ENC2017-00057of, C,q y
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CITY of CAMPBELL
Public Works Department
... April 17, 2018
Mr. Mark Anenberg
1237 E. Campbell Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2017-00057
1237 E. Campbell Ave., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear Mark:
The City of Campbell has made the final inspection of the subject Public Works
improvements and finds that no remedial work is required.
Your warranty requirements and any surety, therefore, are hereby released.
Sincerely,
Syed Wahidi
Public works Inspector
70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAx 408.376.0958 • TDD 408.866.2790
Encroachment Permit Final Sign Off
Encroachment Permit #
[ c 2v1'7 -000j7�_
Address: �AU� I
Date of Final Inspection and Acceptance:
Inspected by. -
OK to release deposits: 100% 75
Comments:
Print Form
CITY OF CAMPBELL R-'I ENCROACHMENT PERMIT Permit No. 9,3C 2,�'17-coc 57
DEPT. OF PUBLIC WORKS X-Ref File
(Non -engineered work within the public right-of-way)
70 North First Street ($10,000.00 maximum value of work) Application Date 2/11?
Campbell, CA95008 / Application Expiration
Ph. (408) 866-2150 ISSUED: 2/ 1 a A 7 Date S
/16
1-7
Fx. (408) 376-0958 Permit Expiration Date: 'L (fo Imo_ APN
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell MunicgipO Code, Section 11.04.
(Application expires in 6 months if the permit is not issued.)
A. Worl<Address: 12,2r7 -E' , C0.MP I I V , cac, -j =i
B. Nature of Work: R-r(_-N STr2-V(T ADA, C M9LkAr A l DW Y t�j�G�Cl )
C. Attach three (3) copies of a drauuiiag showing the location, extent and dimensions of the work. The drawing shall show the relation of
the proposed work to existing improvements. When approved by the City Engineer, said drawing become a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit
Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and
provisions may result in job shutdown and/or forfeiture of Faithful Performance securities.
NAME OF APPLICANT: Ct ��'� ►'C112h Telephone:
Address: 1,2 2 r E i CQr \? 6Q_(1 4v e— C<RLo,? 6-o-11 CA 9 S0o)�
E Mail Address: jY1G(^ k , a ine r1 b er�c
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency, its
officers, agents, and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant hereby acknowledges that they have read and understand both the front and back of this permit, and that they will inform their
contractor(s) of the inform do .
�j�/201
ACCEPTED: C
n)
Date
NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable
insurance requirements.
The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days
before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the
inquiry identification number (Ticket No.) has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.:
Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all
damages arising out of the design, installation or condition of private improvements in the public right-of-way.
SPECIAL PROVISIONS
1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be
recorded.
2.
3.
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.) $ 2000 26e 14 c,
R-1 PERMIT FEE $
APPROVED FOR ISSUANCE:
for CityEngineer Date
Permit Expires 6 Months after Date of Issuance.
GENERAL PERMIT CONDITIONS
1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon
completion of the work and written acceptance by the City.
2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's
responsibility to remove and replace unacceptable improvements within the one-year maintenance period.
3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City.
4. Submi pYialect sche. u 1;0 a, prior o proposed start of work. Special provisions may be required for work within City facilities
and downtown Campbell.
5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be
made in writing to the Permittee.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
7. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and
Specifications at the sole expense of the Permittee.
8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
9. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading as specified by the City
Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee.
10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any
law enforcement officer upon demand.
12. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline,
which would create a hazardous condition to the public.
13. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other
work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit
required by law.
14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require
reimbursement of inspection costs at the current overtime rate.
17. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum
charge per occurrence.
18. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to
require or approve any, modification or departure and to specify the manner in which the same is to be made for City -owned or
maintained facilities.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the
municipal storm drain System other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by
the Santa Clara Valley Urban Runoff Pollution Prevention Program.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above
conditions.
Applicant n Date
J:\FORMS\Templates\Encroachment PermitAR-1 Encroachment Permit STATIC form2. pdf
Rev. 02/14
GENERAL PERMIT CONDITIONS
1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon
completion of the work and written acceptance by the City.
2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's
responsibility to remove and replace unacceptable improvements within the one-year maintenance period.
3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City.
4. Submit project schedule 10 days prior to proposed start of work. Special provisions may be required for work within City facilities
and downtown Campbell.
5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be
made in writing to the Permittee.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
7. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and
Specifications at the sole expense of the Permittee.
8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
9. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading as specified by the City
Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee.
10. ' The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any
law enforcement officer upon demand.
12. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline,
which would create a hazardous condition to the public.
13. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other
work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit
required by law.
14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require
reimbursement of inspection costs at the current overtime rate.
17. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum
charge per occurrence.
18. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to
require or approve any modification or departure and to specify the manner in which the same is to be made for City -owned or
maintained facilities.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the
municipal storm drain system other that; storm ;neater. Applicant shall adhefe to the REST MANAGEMENT PRACTICES established by
the Santa Clara Valley Urban Runoff Pollution Prevention Program.
Applicant shall be responsible for ensuring that all those'providing services under the applicant are aware of and understand all of the above
conditions.�
Applicant Date
J.\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev. 02/14
°V C4
U r
ORCHAR9
CITY OF CAMPBELL
Public Works Department
April3, 2017
Mr. Mark Anenberg
1237 E. Campbell Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2017-00057
1237 E. Campbell Ave.
FINAL INSPECTION AND ACCEPTANCE
Dear Mark:
The City of Campbell has made a final inspection of subject Public Works improvements
and finds the work to be acceptable and in conformance with City standards.
Accordingly, the City Engineer accepts the improvements.
The orie year maintenance period stated in the permit begins as of March 13, 2017. The
permittee is responsible for the repair and/or replacement of any defective work or
failures that occur within one year. The City will inspect the improvements within one
year and notify you, in writing, whether or not any repairs are required.
Your Faithful Security Deposit in the amount of $2,000.00 is enclosed.
If you have any questions, please call me at (408) 866-2165.
Sincerely,
h '
Sy�d Wahidi
Public Works Inspector
Cc: Inspector /Suspense Files
Permit File ENC2017-00057
7n KT. 41, F;—t Qf—t . C-6n11 Califnrnin 9500R-1436 • TFL 408.866.2150 • Fu 408.376.0958 • TDD 408.866.2790
r
Encroachment Permit Final Sign Off
Encroachment Permit # 911 C 2Ea
Address: 237 IE— IN
Date of Final Inspection and Acceptance:
Inspected by:
OK to release deposits: 100% V 75%
Comments:
PUBLIC WORKS ED id?, I NIE11,11: LAND DEVELOPMENT
Effective July 1, 2016 1 7 '_00C'E3 -7
TO: Finance PUBLIC WORKS FILE NO. ANC
PROPERTY ADDRESS 12 3 7 QP
Please collect & receipt for the following monies:
-AMOUNT
ACCT._j ITEM
L NND'DEVtL0PMtkT- -r.4722
Encroachment Permit Application Fee —
Non -Utility Encroachment Permit Major 2!$10,000 $403.00
Minor,Encroachment Permit <sio,000 $230.00
Initial l 1 Permit N/C
Subse nt R-1 Permits within Two Year Period $230.00
Inspection Fee Minimum Charge per Location $398.00
Street Tree Plantinq/Removal
2203
($500 per Tree Plantinq Deposit Required) $500.00/tree
2203
Plan Check Deposit 2% of Engineer's Estimate $500.00 min
4722
Utility and R-1 Permits no deposit required
Grading& Drainage Plan Review
Single Family Lot $281.00
Site < 10,000 s.f. $841.00
Site 10,000 s.f. < 0.5 Acre $1,127.00
Site 0.5 Acre $1,688.00
4722
NPDES Review (C3 Requirements)
For projects not required to submit numeric sizing $163.00
For projects required to submit numeric sizing
Impervious Area 10,000 Sq. Ft to 1 Acre $704.00
Impervious Area 1 Acre or more $918.00
4722,
_
For projects sent to Consultant for review— Consultant Cost +20%
4722
Additional treatment facilities $300 ea —
4722
4722
Plan Check & Inspection Fee (Non -Utility)
Enqr. Est..< $250,000 14% of Engineer's Estimate
Enqr. Est. ?$250,000 and 5$500,000 $35,000 + 8% of Enqineers Estimate
4722
EnPF. Est. >$500,000 $55,000 + 7% of Engineers Estimate
2203
—
Emergency Cash Deposit 4% of Enqr. Est.* ($500 min/$10,000 Max)
2203
Faithful Performance Security (FPS) 100% of ENGR. EST.*
ZG
2203
Labor and Materials Security 100% of ENGR. EST.*
4721
Storm Drainage Area Fee Per Acre R-1 $2,120.00
(Multi -Res $2,385.00)
(All Other $2,650.00)
4722
Parcel Map (4 Lots or Less) $4009.00 + $87/lot
4722
Final Tract Map (5 or More Lots) $4,871.00 + $118/lot
2203
Monumentation Security 100% of City's Monumentation Estimate
4920
Parkland Dedication Fee (75%125% Due Upon Cert. of Occupancy)
4722
Lot Line Adjustment (includes Certificate of Compliance) $1,893.00
4722
Vacation of Public Streets & Easements $2,530.00
47221
Certificate of Compliance $1,877.00
4722
Certificate of Correction $561.00
4722
Document Recording Fees $15.00/first page $3 ea. Additional
4722
Private Improvement in Public ROW $50.00
4722
Approved Plan Revision Fee $1 001sheet
4722
Appeal Filing Fee $200.00
Fq_W
4722
Notary Fee (per signature) $10.00
4722
Assessment SI-e—gregation or Reapportionment
First Split $895.00 Oily GF
Each Additional Lot $281.00
511.74241
Postage
7 ,
Other (Please Specify)
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ 0 C,
NAME OF APPLICANT
NAME OF PAYOR a r AV)(, lA6,er- J PHONE QDq
ADDRESS 1-23 . 7 -E - CCIM126QJI J
4Ve- ZIP 95002
FOR
CITY CLERK
ONLY
D ;
REdtIV_1EBY
'bate. A ecelp
................. ..............
................. ............... . ............ . ......... ............ ...... . ..... .................... . ...... ........... . . .. . ......
............... . . ..................... . ..........
I 0014291 CHECK IM 261827
CITY OF CAMPBELL VENDOR NO.
. .........
Account....-.'
...........
101 2203 CR032717 2,000.00 1237 CAMPBELL AVE
10014293 MARK ANENBERG
-- ----- ------------------ --- ----------------- ------ ---- -------------- ----- --- --------------- - ------ --
.......... . ... . ............... . ..... .. ...... ........ ....... . . . .............. ............ ..... .......
. . ................ . .......... ..
........ ......... . . ........... .. . .............. ........... ................. . . . ......... ... ............ .. .... ................... .........
*See Reverse Side For Easy Opening Instructions*
-- ------------------------------- - - ---- ------- -
- -- --------- ------ ------------------------------------------
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBELL' CALIFORNIA 95008
MARK ANENBERG
1237 E CAMPBELL AVE
CAMPBELL CA 95008
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR ONE YEAR MAINTENANCE
ACCEPTANCE LETTER
Encroachment Permit # ENC2017-00057
Property Address
1237 E. Campbell Ave.
Date of Final Inspection: 3/13/17
On File: Bonds CD Cash
Faithful Performance $2,000.00
Labor and Material $
Construction Cash Deposit to be released: $
Other overdue deposits to be released (Description):
Processed by:
Reviewed by:
3/zZi o
"�f 3f 1-7
Inspector
Reviewed by: �{~ -Zq
l I
Land Development Engineer
J:VoAnnaT\Deposit refunds\CHECKLISTS\Campbe111237.Anenberg.doe (Rev. 10/11)
To: Finance Director
Check Payable To.
Address - Line 1:
Line 2:
City:
j Description:
Account Number:
Account Number:
Account Number
(Finance Dept only)'
Total Payable:
Purpose:
Refundable Deposit Check-, Request
Mark Anenberg --
i.
1237 E. Campbell Ave. N
Campbell State: CA Zip: 9.6008
1237 Campbell Ave.
101.2203Amount: - $2,000.00
101.2203, Amount:
10.1.540.7448 Amount
Interest Earned (Finance Dept only)
Faithful Security Deposit Refund
Receipt #: 2681,60.
Receipt'#: -
(Exact Amount)
Permit#: ENC2017-00057
Date: 2/16/2017
Date:
Requested by: I- Title: Inspector Date:
Syed Wahidi (�
Approved by: Title: Sr. Engineer Date:
Roger Storz'
Finance Dept Only.:
Verified by:
Approved by:
Spec i a Instructs
Mail As Is Mail in Attached Envelope:
Return To: JoAnna Thomason_
(Name),
Other: Please return check to JoAnna
Title: Accounting Clerk li..,,_ Date:
Title: Accountant Date:
3/22/2017
i na Chec
Interim'Chedk:
Needed -By:
Public Works -
' (Department)
A 70,
�6 moo•• -
P�
4 -0"
6 O�
SIDEWALK
�- MECHANICAL
R SEPARATOR CONSTRUCTION
JOINT
SIDEWALK
SEE NOTE 5
WEAKENED
PLANE JOINT
OR
CUT JOINT
SIDEWALK
1/8" WIDE,
�pf
p
2' DEEP
WEAKENED PLANE' -.JOINT
OR CUT JOINT 1/8",;WIDE,
2" DEEP
N
�O
1
3/4"
PER FOOT 5/8"
1 R
T — 1 /2" R
10'-0"
4'-6"
5'-6" 2'-0"
+10% MAX
6
CONFORM` SLOPE = 1/ 4" PER FF.
—67. MAX : , a o,..... • a.. ••: o-;..:
• ,: o-;. •.. • s.. o.;:.: • °.. o-,... ,
6" CLASS A CONCRETE, TYP.
6"
6" CLASS 2 AGGREGATE BASE, TYP.
o' o
X.
SECTION A —A
DOWEL
NOTES
1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF NO. 4 REBAR AT 4'
INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE
BENT DOWN AND COVERED UNTIL USED).
2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER
SCORE MARK.
3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL
-
HAVE A 6"X6"X10/10 WELDED -WIRE FABRIC
3" ABOVE
BOTTOM OF CONCRETE.
4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING
CONCRETE IMPROVEMENTS.
5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS
AN EXISTING SIDEWALK, THE NEW SIDEWALK
SHALL
TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER.
og CAj
CITY OF CAMPBELL.
REV.
DATE
BY
SCALE:
PUBLIC WORKS DEPARTMENT
Residential
N.T.S.
DRAWN BY:
DATE 02/04
'�'D�°�"
DetailDrZVewaDetailDETAIL
CHECKED BY:
DATE
•
a��
(Attached Sidewalk
)
N0.
APPROVED BY:
���'•
�RCHAR9
MCITTYY ENGINAI ENREY
D — 15
jJ:/Drawings/Std_Details/D15
Next Generation Homeowners Declaration FARMERS
Page INSURANCE
Policy Number: 93973-62-27
Effective:
6/16/201612:01 AM
Expiration:
6/16/201712:01 AM
Namedlnsured(s): Mark Anthony Anenberg &Vikki Lynn Essert
1237 E Campbell Ave
Campbell, CA 95008-2421
e-mail
mark.anenberg@gmail.com
Address(es):
Property Insured:
1237 E Campbell Ave
Campbell, CA95008-2421
Underwritten By:
Mid -Century Insurance Company
6301 Owensmouth Ave.
Woodland Hills, CA 91367
Description of Property
Year of Construction Construction Type
1946 Frame W/ 0%-33% Masonry Veneer
Property Coverage
Coverage
Limit
Coverage A - Dwelling
$463,000
Extended Replacement Cost
.......
$115,750
_... ...... ........... .................... .............
Coverage B - Separate Structures
$46,300
-
- I ................... ......... ..... ... ........... .... .--------- ....-----
Coverage C - Personal Property
.... - - -
$347,250
Contents Replacement Cost
Covered
Premiums
.....................................................
011' Policy Premium $1,078.89
*also see Information on Additional Fees below
This is not a bill.
Your bill with the amount due will be mailed separately.
Roof Type Number of Units Occupancy
Composition - 3 Tab Shingle 1 - Owner
Occupied
(Primary Res.)
Coverage Limit
Coverage D - Loss of Use $185,200
_._...__....... - ............... ... ...... ---- _.._--------
Identity Fraud Coverage $30,000
..-.... -- - ----- --I..................._ ..._.._.. - ..... - --- - - -
Building Ordinance or Law 10%
Liability Coverage
Coverage Limit Coverage Limit
- - ---- _ ----- - --- ---- -..-- - ---- ---- - ---- - — _ -- ,_._._ - - --- _.._ _....-._._....-_.
Coverage E - Personal Liability $300,000 Coverage F - Medical Payments To Others $1,000
---.........- _------------------------------------ .............. ....-.__-----_------ -----............
Association Loss Assessment Not Covered
Deductible
Deductible
Applicable to each covered loss - $500
farmers.com Policy No. 93973-62-27
Questions?
Call your agent Anthony L Mangiameli
at (408) 247-7833 or email
tmangiameli@farmersagent.com
Manage your account:
Go to www.farmers.com to access
your account anytime!
56-6177 1st Edition 4-15 4/25/2016 Page 1 of
Declaration Page (continued)
Discounts Applied to Policy
Discount Tvoe
Auto/Home
__.............._ ...---- --------------------------- -- - ----- - -- - - - ------ --- _ -
Non Smoker
Mortgagee / Other Interest
1st Mortgagee _ _ Loan Number
Jpmorgan Chase Bank NA _ 1313381175
I SAOA ATI MA
PO Box 47020
Doraville, GA 30362-0020
Mortgagee Deductible Clause
Discount Type
Experience Rating Plan
Home/Umbrella
The following provision applies only if a mortgagee is named in the policy:
For any loss in which only the mortgagee's interest is adjusted and settled, not including any interest you may have in the property or
loss, the applicable deductible will be the smallest of the following amounts:
1. The deductible stated in the declarations or renewal notice, or
2. $1,000.
The policy deductible stated in the declarations or renewal notice will apply to settlement of any interest you may have in the property or
loss.
Policy and Endorsements
This section lists the policy form number and any applicable endorsements that makeup your insurance contract. Any endorsements
that you have purchased to extend coverage on your policy are also listed in the coverages section of this declarations document:
56-55323rd ed.; 25-8531 10-12; 438BFUNS 5-42; J6965A 1st ed.
Other information
• Mortgagee pays premium for this policy.
• The limit of liability for this structure (Coverage A) is based on an estimate of the cost to rebuild your home, including an approximate
cost for labor and materials in your area, and specific information that you have provided about your home.
farmers.com
Policy No. 93973-62-27
Questions?
Call your agent Anthony L Mangiameli
at (408) 247-7833 or email
tmangiameli@farmersagent.com
Manage your account:
Go to www.farmers.com to access
your account any time!
56-6177 1st Edition 4-15
Page 2 of 3
i
®L
FARMERS
Personal Umbrella Declaration Page INSURANCE
Policy Number: 60566-50-83
Effective: 6/16/201612:01 AM
Expiration: 6/16/201712:01 AM
Namedlnsured(s): Mark Anenberg
1237 E Campbell Ave
Campbell, CA95008-2421
e-mail mark.anenberg@gmail.com
Ad dress(es):
Underwritten By: Truck Insurance Exchange
6301 Owensmouth Ave.
Woodland Hills, CA91367
Rated Exposures (Item 2)
Exposure Type
Quantity
Owner Occupied Residence 1
---- ------------------- --------------- - -- ------------------------------ --- --- ------ ----------- ---
Youthful Driver 2
Premiums (Item 1 )
.....................................................
Policy Premium $846.00
This is not a bill.
Your bill with the amount due will be mailed separately.
Exposure Type
Motorized Vehicle
Quantity
5
Schedule of Underlying Insurance (Item 3)
You havetold usyou have underlying insurance policieswith liability limits listed below. If the underlying policies terminateorthe
liability limits are less than shown below, in the event ofa covered loss we will only pay those damages we would have paid if the limits
and policies were in place as scheduled. You must keep the coverages and limits below in effectto avoid gaps in your protection.
Insurance Carrier_
Policy Number
Farmers Insurance Exchange
128507668
Mid -Century Insurance Company
176891613
Farmers Insurance Exchange
190262954
Mid -Century Insurance Company
939736227
Limits (Item 4)
Limit of Insurance
Coverage _ (in thousands of dollars)
Auto Liability 250/500/100
--- --
Auto Liability 250/500/100
Auto Liability 250/500/100
Homeowner 300
1237 E Campbell Ave, Campbell, CA
Limit
Coverage Type _ _(each occurrence)
General Liability A $1,000,000
Retained Limit $250
Limit
Coverage Type _ (each occurrence)
Uninsured/Underinsured Motorist Not Covered
farmers.com Policy No. 60566-50-83 Questions? Manage your account:
Call your agent Anthony L Mangiameli Go to www.farmers.com to access
at (408) 247-7833 or email your account any time!
tmangiame!i@farmersagent.com
56-6178 1st Edition 4-15 4/20/2016 Page 1 of