Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
ENC2016-00161
OF C4 A U w r" - Cs - 'yF C, UkcHAR'D CITY of CA►MPBELL -Public Works. Department April 17, 2018 Mr. Michael Preston 106 E. Rincon Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2016-00161 106 E. Rincon Ave. Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Michael: 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 Address: C o Date of Final Inspection and Acceptance:I Inspected by: �� f` OK to release deposits: 100% 75% Comments: Print T71 r1Tv nF rARAPRFI I iz_i FNCRnACHMFNT PERMIT Permit No. L l,� Q-?at�_' `6o \� \ DEPT. OF PUBLIC WORKS (Non -engineered work within the public right-of-way) X-Ref File 70 North First Street ($10,000.0Tf1 imum va u/e of work) Application Date Campbell, CA Ph. (4 8) 866-21508 ISSUED: I 0l �Application Expiration Date Fx. (408) 376-0458 Permit Expiration Date: APN APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months if the permit is not issued.) A. Work Address: 1 I O (O B. Nature of Work: I � b N C. Attach three (3) copies of a drawing 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: Address: �1 Telephone: O-Fvo _zu-m-oo w E-Mail Address: _. ......... ............. _............ 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 permitto hold the City of Campbell, Cityof 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 hive read an erstand both the front and back of this permit, and that they will inform their contractor(s) of the information. e CEPTED: (Applicant/Permittee) r (Sign) V' of 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. SECURITY FOR FAITHFUL PERFORMANCE R-1 PERMIT FEE APPROVED FOR ISSUANCE: STANDARD AMUUNy (100% Of Engr's Est.) $ /2&' for City Engineer C.tlf'I N V� Date 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. Ail PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 9. Adequate signing and barricading is required on the job 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 authorizes 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, of 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. Ifthe 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 +plater. A•nnlirant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. Applicant shall be conditions. Applicant for ensurinq ttbA all those providing services under the applicant are aware of and understand all ofthe above /� / 4, 11 /&, Date J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev r»ria of C� A'0 • Ux'CHAR� • CITY OF CAMPBELL Public Works Department April 18, 2017 Mr. Michael Preston 106 E. Rincon Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2016-00161 106 E. Rincon Ave FINAL INSPECTION AND ACCEPTANCE Dear Michael: 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 one year maintenance period stated in the permit begins as of March 23, 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 $2,500.00 is enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, �1 Syed Wahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2016-00161 70 North First Street Campbell, California 95008-1436 • TEL 408.866.2150 • Fax 408.376.0958 • TAD 408.866.2790 PUBLIC VVUKK6 UCF'HK i IVICIV I -1- vL v - , ••• - 1 Effective July 1, 2015 TO: Finance PUBLIC WORKS FILE NO. PROPERTY ADDRESS / ✓ Ci Please collect & receipt for the following monies: AMOUNT ACCT. ITEM LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Major >_$10 000 $395.00 Minor Encroachment Permit <$10,000 $225.00 Initial R-1 Permit N/C Subse uent R-1 Permits within Two Year Period $225.00 Inspection Fee Minimum Charge per Location $390.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree Plan Check Deposit 2% of Engineer's Estimate $500.00 min 22031 Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $275.00 Site < 10,000 s.f. $825.00 Site >_ 10,000 s.f. < 0.5 Acre $1,105.00 Site >_ 0.5 Acre $1 655.00 4722 NPDES .Review C3 Re uirements For projects not required to submit numeric sizing $160.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $690.00 Impervious Area 1 Acre or more $900.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $300 ea Plan Check & Inspection Fee(Non-Utility) 4722 En r. Est. < $250,000 14% of Engineer's Estimate 4722 Engr. Est. >_$250,000 and :5$500,000 $35,000 + 8% of Enqineers Estimate 4722 2203 Enqr. Est. >$500,000 $55 000 + 7% of Engineers Estimate Emergency Cash Deposit 4% of.Engr. Est.* ($500 min/$10,000 Max) 2203 Faithful Performance Security (FPS) 100% of ENGR. EST.* 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) $3,930.00 + $85/lot 4722 2203 Final Tract Map 5 or More Lots) $4,775.00 + $116/lot - Monumentation Security 100% of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (includes Certificate of Compliance) $1,856.00 4722 Vacation of Public Streets & Easements $2,480.00 4722 Certificate of Compliance $1,840.00 4722 Certificate of Correction $550.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 4722Segregation or Reapportionment First Split $877.00 Each Additional Lot $275.00 511.7424 MISCELLANEOUS Postage Other (Please Specify) �7 O *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ p NAME OF APPLICANT I�FiiG _ilGG7�S�N - NAME OF PAYOR P: OE' �O� 26 2- ADDRESS a KJ FOR RECEIVED Y A d Y OF t y'AftA HELL CITY CLERK ONLY f _5 7nC/ Date Receipt# ^ � ` CI�Y DF CAMPBELL RECV8 8�: CASHIE8 O1UOO265386 po/UK: MlCHAEL PR[CTON TODAY`S DATE: U8/15/16 REGISTER DATE: U8/15/�6 TIHE� OU:OO 8ESCRlP7ION AMOUNT COT ID:ENC2816-OO161 REF� DEP0SlT - 101 $2`5OO,OO COT ID: 1.000 R-�F DEPOSIT - 1O1 $35O.00 -'_---_--__- TOTAL DUE: $2,85O.00 TENDERED: $2,85O'00 CHANGE: $,OO CHECK : $2,8so. 8O REF NUM: 2592 MICHAEL PRESTON 106.E. RINCON AVE CAMPBELL CA 95008 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2016-00161 Name: Michael Preston Property Address: 106 E. Rincon Ave. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ 2,500.00 Labor and Material: $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: —�L 1 (0 dm istrator Reviewed by: Inspector Reviewed by: Land Development Engineer JAJoAnnaT\Deposit refunds\CHECKLISTS\Rincon 106.doc (Rev. 10/11) Encroachment Permit # Encroachment Permit Final Sign Off T-m c. 2016p - oo 1(, 1 • - Address: �oG �cnlCcdJl= Date of Final Inspection and Acceptance: 3�23�17 Inspected by: Svv OK to release deposits: 100% V 75% Comments: JOSEJAL-01 LTREVINO CERTIFICATE OF LIAEUTY INSURANCE DATE (MMIDD/YYYY) 12/9/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Alliant Insurance Services, Inc. 177 Park Ave, 3rd Floor San Jose, CA 95113 CONTACT NAME, Certificate Request ACNE Ezt : (408) 352-6700 NC, No E-MAIL ADDRESS: sjcertificates@alliant.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Executive Risk Indemnity Inc 35181 INSURED Joseph J. Albanese, Inc. PO BOX 667 Santa Clara, CA 95052-0667 INSURER B : Federal Insurance Company 20281 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE A D INSD WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEry] OCCUR X X 54303129 06/01/2016 06/01/2017 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ® ECT N LOC PRODUCTS - COMP/OP AGG $ 2,000,000 DEDUCTIBLE $ 5,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO X X 54303128 06/01/2016 06/01/2017 ALL OWNED SCHEDULED AUTOS AUTOS JX BODILY INJURY (Per accident) $ X NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB OCCUR / EACH OCCURRENCE $ Id AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YNIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) X 54303130 06/01/2016 06/01/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Re: JJA Job No. 16.1248.01, Preston Residence, 106 E. Rincon Avenue, Campbell, CA 95005 This cancels and replaces certificate issued on 8/31/16. City of Campbell, its officials, employees, agents and volunteers are included as Additional Insured as respects Liability arising out of operations (work) performed by or on behalf of the Named Insured in accordance with the policy provisions of the General Liability and Auto Liability policies. The General Liability and Auto Liability evidenced herein are Primary and Non -Contributory to other insurance available to the Additional Insured, but only in accordance with the policy provisions. Waiver of Subrogation is granted in favor of the Additional insured as required by contract in accordance with the policy provisions of General Liability, Auto Liability and Workers' Compensation. Cancellation notice will be delivered to the certificate holder in accordance with the policy provisions. C I a CERTIFICATE HOLDER CANCELLATION City of Campbell 70 North First Street Campbell, CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ` ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Policy Number: 54303129 COMMERCIAL GENERAL LIABILITY 10-02-2508 (Ed. 7-15) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSURED (CONTRACTORS) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART 1. SECTION II — WHO IS AN INSURED is amended to include any person or organization that you agree in a "written contract requiring insurance" to include as an insured on this Coverage Part, but: a. Only with respect to liability for "bodily injury', "property damage" or "personal injury'; and b. If, and only to the extent that, the injury or damage is caused by acts or omissions of you or your subcontractor in the performance of "your work" to which the "written contract requiring insurance" applies. The person or organization does not qualify as an insured with respect to the independent acts or omissions of such person or organization. 2. The insurance provided to the insured by this endorsement is limited as follows: a. In the event that the Limits of Insurance of this Coverage Part shown in the Declarations exceed the limits of liability required by the "written contract requiring insurance", the insurance provided to the insured shall be limited to the limits of liability required by that "written contract requiring insurance". This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. b. The insurance provided to the insured does not apply to damages, loss, cost or expense arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders or change orders, or the preparing, approving, or failing to prepare or approve, drawings and specifications; and c. The insurance provided to the insured does not apply to "bodily injury" or "property damage" caused by "your work" and included in the "products -completed operations hazard" unless the "written contract requiring insurance" specifically requires you to provide such coverage for that insured, and then the insurance provided to the insured applies only to such "bodily injury" or "property damage" that occurs before: (1) The end of the period of time for which the "written contract requiring insurance" requires you to provide such coverage; or (2) The end of the policy period; whichever is earlier. 3. The insurance provided to the insured by this endorsement is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the insured for a loss we cover under this endorsement. However, if the "written contract requiring insurance" specifically requires that this insurance apply on a primary basis or a primary and non-contributory basis, this insurance is primary to other insurance available to the insured which covers that person or organization as a named insured for such loss, and we will not share with that other insurance. But the insurance provided to the insured by this endorsement still is excess over any other valid and collectible insurance, whether primary, excess, contingent or on any other basis, that is available to the insured when that person or organization is an additional insured under such other insurance. 4. As a condition of coverage provided to the insured by this endorsement: (2) Supervisory, inspection, architectural or a. The insured must give us written notice as engineering activities. soon as practicable of an "occurrence" or an 10-02-2508 (Ed. 7-15) Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. offense which may result in a claim. To the extent possible, such notice should include: (1) How, when and where the "occurrence" or offense took place; (2) The names and addresses of any injured persons and witnesses; and (3) The nature and location of any injury or damage arising out of the "occurrence" or offense. b. If a claim is made or "suit" is brought against the insured, the insured must: (1) Immediately record the specifics of the claim or "suit" and the date received; and (2) Notify us as soon as practicable. The insured must see to it that we receive written notice of the claim or "suit" as soon as practicable. c. The insured must immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. d. The insured must tender the defense and indemnity of any claim or "suit" to any provider of other insurance which would cover the insured for a loss we cover under this endorsement. However, this condition does not affect whether the insurance provided to the insured by this endorsement is primary to other insurance available to the insured which covers that person or organization as' a named insured as described in paragraph 3. above. 5. The following definition is added to SECTION V — DEFINITIONS: "Written contract requiring insurance" means that part of any written contract or agreement under which you are required to include a person or organization as an additional insured on this Coverage Part, provided that the "bodily injury" and "property damage" occurs and the "personal injury" is caused by an offense committed: a. After the signing and execution of the contract or agreement by you; b. While that part of the contract or agreement is in effect; and c. Before the end of the policy period. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., 10-02-2508 (Ed. 7-15) with its permission. Policy Number: 54303129 c. Method Of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method al- so. Under this approach each insurer contrib- utes equal amounts until it has paid its appli- cable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable lim- it of insurance to the total applicable limits of insurance of all insurers. 5. Premium Audit a. We will compute all premiums for this Cover- age Part in accordance with our rules and rates. To the extent that the insured's rights to recover all or part of any payment made under this Cover- age Part have not been waived, those rights are transferred to us.' The insured must do nothing af- ter loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. This condition does not apply to Coverage C. 9. When We Do Not Renew If we decide not to renew this Coverage Part, we will mail or deliver to the first Named Insured shown in the Declarations written notice of the nonrenewal not less than 30 days before the expi- ration date. If notice is mailed, proof of mailing will be.sufficient proof of notice. SECTION V — DEFINITIONS b. We may audit your books and records as they 1 relate to this insurance at any time during the term of this policy and up to three years after- wards. c. The first Named Insured must keep records of the information we need for premium computa- tion, and send us copies at such times as we may request. 6. Representations By accepting this policy, you agree: a. The statements in the Declarations are accu- rate and complete; b. Those statements are based upon representa- tions you made to us; and c. We have issued this policy in reliance upon your representations. 7. Separation Of Insureds Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in this Coverage Part to the first Named Insured, this in- surance applies: a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom claim is made or "suit" is brought. ,Transfer Or Waiver 'Of Rig hts Of Recovery Against Others To Us We will waive the right of recovery we would oth- erwise have had against another person or organ- ization, for loss to which this insurance applies, provided the insured has waived their rights of re- covery against such person or organization in a contract or agreement that is executed before such loss. "Advertisement" means an electronic, oral, written or other notice, about goods, products or services, designed for the specific purpose of attracting the general public or a specific market segment to use such goods, products or services. "Advertisement" does not include any e-mail ad- dress, Internet domain name or other electronic address or metalanguage. 2. "Advertising injury" means injury, other than "bodi- ly injury", "property damage" or "personal injury", sustained by a person or organization and caused by an offense of infringing, in that particular part of your "advertisement" about your goods, products or services, upon their: a. Copyrighted "advertisement"; or b. Registered collective mark, registered service mark or other registered trademarked name, slogan, symbol or title. 3. "Asbestos" means asbestos in any form, including its presence or use in any alloy, by-product, com- pound or other material or "waste". 4. "Auto" means: a. A land motor vehicle, trailer or semitrailer de- signed for travel on public roads, including any attached machinery or equipment; or b. Any other land vehicle that is subject to a com- pulsory or financial responsibility law or other motor vehicle insurance law in the state where it is licensed or principally garaged. However, "auto" does not include "mobile equip- ment". 5."Bodily injury" means physical: a. Injury; b. Sickness; or c. Disease; Page 12 of 16 Includes copyrighted material of ISO Properties, Form 10-02-1800 (Rev. 6-09) Inc., with its permission Policy Number: 54303128 COMMERCIAL AUTOMOBILE THIS ENDORSEMENT CHANGES THE POLICE'. PLEASE READ IT CAREFULLY. COMMERCIAL, AUTOMOBILE BROAD FORM ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM This endorsement modifies the Business Auto Coverage Form. 1. EXTENDED CANCELLATION CONDITION Paragraph A.2.b. — CANCELLATION - of the COMMON POLICY CONDITIONS form IL 00 17 is deleted and replaced with the following: b. 60 days before the effective date of cancellation if we cancel for any other reason. 2. BROAD FORM INSURED A. Subsidiaries and Newly Acquired or Formed Organizations As Insureds The Named Insured shown in the Declarations is amended to include: 1. Any legally incorporated subsidiary in which you own more than 50% of the voting stock on the effective date of the Coverage Form. However, the Named Insured does not include any subsidiary that is an "insured" under any other automobile policy or would be an "insured" under such a policy but for its termination or the exhaustion of its Limit of Insurance. 2. Any organization that is acquired or formed by you and over which you maintain majority ownership. However, the Named Insured does not include any newly formed or acquired organization: (a) That is an "insured" under any other automobile policy; (b) That has exhausted its Limit of Insurance under any other policy; or (c) 180 days or more after its acquisition or formation by you, unless you have given us written notice of the acquisition or formation. Coverage does not apply to "bodily injury" or "property damage" that results from an "accident" that occurred before you formed or acquired the organization. B. Employees as Insureds Paragraph A.1. — WHO IS AN INSURED — of SECTION 11— LIABILITY COVERAGE is amended to add the following: d. Any "employee" of yours while using a covered "auto" you don't own, hire or borrow in your business or your personal affairs. C. Lessors as Insureds Paragraph A. I. —WHO IS AN INSURED —of SECTION II — LIABILITY COVERAGE is amended to add the following: e. The lessor of a covered "auto" while the "auto" is leased to you under a written agreement if: (1) The agreement requires you to provide direct primary insurance for the lessor; and (2) The "auto" is leased without a driver. Such leased "auto" will be considered a covered "auto" you own and not a covered "auto" you hire. However, the lessor is -an "insured" only for "bodily injury" or "property damage" resulting from the acts or omissions by: 1. You; 2. Any of your "employees" or agents; or 3. Any person, except the lessor or any "employee" or agent of the lessor, operating an "auto" with the permission of any of 1. and/or 2. above. D. Persons And Organizations As Insureds Under A Written Insured Contract Paragraph A.1 — WHO IS AN INSURED — of SECTION II — LIABILITY COVERAGE is amended to add the following: f. Any person or organization with respect to the operation, maintenance or use of a covered "auto", provided that you and such person or organization have agreed under an express provision in a written "insured contract', written agreement or a written permit issued to you by a governmental or public authority to add such person or organization to this policy as an "insured". However, such person or organization is an "insured" only: Form: 16-02-0292 (Rev. 4-11) Page 1 of 3 "Includes copyrighted material of Insurance Services Office, Inc. with its permission" 3. 4. 5. (1) with respect to the operation, maintenance or use of a covered "auto"; and (2) for "bodily injury" or "property damage" caused by an "accident" which takes place after: (a) You executed the "insured contract" or written agreement; or (b) The permit has been issued to you. FELLOW EMPLOYEE COVERAGE EXCLUSION B.5. - FELLOW EMPLOYEE — of SECTION II — LIABILITY COVERAGE does not apply. PHYSICAL DAMAGE — ADDITIONAL TEMPORARY TRANSPORTATION EXPENSE COVERAGE Paragraph A.4.a. — TRANSPORTATION EXPENSES — of SECTION III — PHYSICAL DAMAGE COVERAGE is amended to provide a limit of $50 per day for temporary transportation expense, subject to a maximum limit of $1,000. AUTO LOAN/LEASE GAP COVERAGE Paragraph A. 4. — COVERAGE EXTENSIONS - of SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add the following: c. Unpaid Loan or Lease Amounts In the event of a total "loss" to a covered "auto", we will pay any unpaid amount due on the loan or lease for a covered "auto" minus: 1. The amount paid under the Physical Damage Coverage Section of the policy; and 2. Any: a. Overdue loan/lease payments at the time of the "loss"; b. Financial penalties imposed under a lease for excessive use, abnormal wear and tear or high mileage; c. Security deposits not returned by the lessor: d. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease; and e. Carry-over balances from previous loans or leases. We will pay for any unpaid amount due on the loan or lease if caused by: 1. Other than Collision Coverage only if the Declarations indicate that Comprehensive Coverage is provided for any covered "auto"; 2. Specified Causes of Loss Coverage only if the Declarations indicate that Specified Causes of Loss Coverage is provided for any covered "auto"; or 3. Collision Coverage only if the Declarations indicate that Collision Coverage is provided for any covered "auto. 6. RENTAL AGENCY EXPENSE Paragraph A. 4. — COVERAGE EXTENSIONS — of SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add the following: d. Rental Expense - We will pay the following expenses that you or any of your "employees" are legally obligated to pay because of a written contract or agreement entered into for use of a rental vehicle in the conduct of your business: MAXIMUM WE WILL PAY FOR ANY ONE CONTRACT OR AGREEMENT: 1. $2,500 for loss of income incurred by the rental agency during the period of time that vehicle is out of use because of actual damage to, or "loss" of, that vehicle, including income lost due to absence of that vehicle for use as a replacement; 2. $2,500 for decrease in trade-in value of the rental vehicle because of actual damage to that vehicle arising out of a covered "loss"; and 3. $2,500 for administrative expenses incurred by the rental agency, as stated in the contract or agreement. 4. $7,500 maximum total amount for paragraphs 1., 2. and 3. combined. 7. EXTRA EXPENSE — BROADENED COVERAGE Paragraph A.4. — COVERAGE EXTENSIONS — of SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add the following: e. Recovery Expense We will pay for the expense of returning a stolen covered "auto" to you. 8. AIRBAG COVERAGE Paragraph B.3.a. - EXCLUSIONS — of SECTION III — PHYSICAL DAMAGE COVERAGE does not apply to the accidental or unintended discharge of an airbag. Coverage is excess over any other collectible insurance or warranty specifically designed to provide this coverage. 9. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT - BROADENED COVERAGE Paragraph C.2. — LIMIT OF INSURACE - of SECTION III - PHYSICAL DAMAGE is deleted and replaced with the following: 2. $2,000 is the most we will pay for "loss" in any one "accident" to all electronic equipment that reproduces, receives or transmits audio, visual or data signals which, at the time of "loss", is: a. Permanently installed in or upon the covered "auto" in a housing, opening or other location that is not normally used by the "auto" manufacturer for the installation of such equipment; b. Removable from a permanently installed housing unit as described in Paragraph 2.a. above or is an integral part of that equipment; or c. An integral part of such equipment. Form: 16-02-0292 (Rev. 4-11) Page 2 of 3 "Includes copyrighted material of Insurance Services Office, Inc. with its permission" 10. GLASS REPAIR —WAIVER OF DEDUCTIBLE Under Paragraph D. - DEDUCTIBLE — of SECTION III — PHYSICAL DAMAGE COVERAGE the following is added: No deductible applies to glass damage if the glass is repaired rather than replaced. 11. TWO OR MORE DEDUCTIBLES Paragraph D.- DEDUCTIBLE — of SECTION III — PHYSICAL DAMAGE COVERAGE is amended to add the following: If this Coverage Form and any other Coverage Form or policy issued to you by us that is not an automobile policy or Coverage Form applies to the same "accident", the following applies: 1. If the deductible under this Business Auto Coverage Form is the smaller (or smallest) deductible, it will be waived; or 2. If the deductible under this Business Auto Coverage Form is not the smaller (or smallest) deductible, it will be reduced by the amount of the smaller (or smallest) deductible. 12. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS Paragraph A.2.a. - DUTIES IN THE EVENT OF AN ACCIDENT, CLAIM, SUIT OR LOSS of SECTION IV - BUSINESS AUTO CONDITIONS is deleted and replaced with the following: a. In the event of "accident", claim, "suit" or "loss", you must promptly notify us when the "accident" is known to: (1) You or your authorized representative, if you are an individual; (2) A partner, or any authorized representative, if you are a partnership; (3) A member, if you are a limited liability company; or (4) An executive officer, insurance manager, or authorized representative, if you are an organization other than a partnership or limited liability company. Knowledge of an "accident", claim, "suit" or "loss" by other persons does not imply that the persons listed above have such knowledge. Notice to us should include: (1) How, when and where the "accident" or "loss" occurred; (2) The "insured's" name and address; and (3) To the extent possible, the names and addresses of any injured persons or witnesses. 13. WAIVER OF SUBROGATION Paragraph A.S. - TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US of SECTION IV — BUSINESS AUTO CONDITIONS is deleted and replaced with the following: 5. We will waive the right of recovery we would otherwise have against another person or organization for "loss" to which this insurance applies, provided the "insured" has waived their rights of recovery against such person or organization under a contract or agreement that is entered into before such "loss". To the extent that the "insured's" rights to recover damages for all or part of any payment made under this insurance has not been waived, those rights are transferred to us. That person or organization must do everything necessary to secure our rights and must do nothing after "accident" or "loss" to impair them. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. 14. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS Paragraph B.2. —CONCEALMENT, MISREPRESENTATION or FRAUD of SECTION IV — BUSINESS AUTO CONDITIONS - is deleted and replaced with the following: If you unintentionally fail to disclose any hazards existing at the inception date of your policy, we will not void coverage under this Coverage Form because of such failure. 15. AUTOS RENTED BY EMPLOYEES Paragraph B.S. - OTHER INSURANCE of SECTION IV — BUSINESS AUTO CONDITIONS - is amended to add the following: e. Any "auto" hired or rented by your "employee" on your behalf and at your direction will be considered an "auto" you hire. If an "employee's" personal insurance also applies on an excess basis to a covered "auto" hired or rented by your "employee" on your behalf and at your direction, this insurance will be primary to the "employee's" personal insurance. 15. HIRED AUTO — COVERAGE TERRITORY Paragraph 13.7.b.(5).(a) - POLICY PERIOD, COVERAGE TERRITORY of SECTION IV — BUSINESS AUTO CONDITIONS is deleted and replaced with the following: (a) A covered "auto" of the private passenger type is leased, hired, rented or borrowed without a driver for a period of 45 days or less; and ' 17. RESULTANT MENTAL ANGUISH COVERAGE Paragraph C. of - SECTION V — DEFINITIONS is deleted and replaced by the following: "Bodily injury" means bodily injury, sickness or disease sustained by any person, including mental anguish or death as a result of the "bodily injury" sustained by that person. Form: 16-02-0292 (Rev. 4-11) Page 3 of 3 "Includes copyrighted material of Insurance Services Office, Inc. with its permission" WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 99 03 04 (Ed. 7- 08) WAIVER OF OUR RIGHT TO RECOVER FROM. OTHERS ENDORSEMENT— CALIFORNIA I This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" need to be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 06/01/16 Policy No. 54303130 of the issued to JOSEPH, J ALBANESE, INC. Endorsement No. at 12:01 A. M. standard time, forms a part of Federal Insurance Coinpany (NAME OF INSURANCE COMPANY) We have the right to recover our payments from anyone liable for an injury covered by this policy. We Will not enforce our right against the person or organization named in the Schedule. The additional premium for the blanket waiver offered by this endorsement shall be 0.00 % of total California premium. Schedule Person or Organization WHERE REQUIRED BY WRITTEN CONTRACT. Authorized Representative WC,99 03 04 (Ed. 7-08) Job Description LEA5E F'U5I IN A (iUNSF I ;UL)Ub VLAUh "1 BUSINESSILICENSE`, •. CITY OF CA&B&L-�;`' ` •(408) 866-2174 ESTABLISHED: 07/14/1983 EXP DATE: 06130/201.7.. LOCATION: 840PARKER ST SANTA CLARA, CA 95050: BUSINESS: JOSEPH J ALBANESE INC '`�' n OWNER: JOHN ALBANESE TRUST ir; ` '"+ ' '` .",c .,LICENSE NO. TRANSFERABLE 000145 TYPE OF BUSINESS OF TOWN The person, firm, or corporation named above is granted this^busjQess liee•�se 8yrsuant to tF a provisions of the City Business License Ordinances to engage in, cant' on, or conduct the:blsiness, trade, calling, profession, exhibition, or occupation described above. Issuance of the license is not an endorsement, nor'ceitfication of compliance with othei ordinances or laws, nor an assurance that the proposed use is in conformance with the city zoning regulations. This license is issued`without verification that the licensee is subject to or exempt from the licensing by the State of California.:Z(alid,only within the :City of Campbell city limits. CITY MUST BE NOTIFIED ON ANY CHANGE IN OWNERSHIP, LOCATION, OR CLOSURE.' ` ANNUAL TAX PAYMENT DUE ON OR BEFORE THE EXPIRATION DATE. RENEWAL NOTICE NOT REQUIRED. V .���C1S •�vS- L�cevtS�. INSURANCE REQUIREMENTS CHECKLIST Permit # CIP Project # Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date t Automotive Liability: Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage Policy expiration date it Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause —'`n ��J '`����v�c— $1,000,000 per accident for bodily injury or disease .Policy expiration date (iP I I� Course of Construction (if required in Special Provisions) o Completed.value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: ❑ The City, its officers, employees and volunteers are named as additional insured. ' (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of anv kind upon the companv. its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. j - r ❑ Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Insurance Certificate Reviewed _ t C �.2 OO �Gy Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. �( Name: c ,31eC ,�� NAIC#,5Sl-6k Rating: Authorized in CA:_Z Name: NAIC # doZ�k Rating: Authorized in CA: 'Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: L �b �} Campbell Business License #MD \ 1 � Expiration: (3 Contractors I icense # Clads: _ — Expiration. z� 10 Init Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. S S L� cz(S `� n- A / C-DA ). J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 d lu It fU <z lu q)-j IL ()kcj Z z lu E 2 2 ROL-M ON IL o <fl lu ck 7- ul I -lu lu v, ul I W-ciz \9 lo ft OL Ul OL :1 ft 0) Ul ILI lu DIF OL 0 fl lu d) lu U- IL IL l 0) IL . . . � Lo Zzw E-4 < LJ550CL ul z --.,> 71) < > m wU-j Lu �-z Of YZ:D "f m ui o< uj 0 < Of (-) -. V) 3: a- cr U) V) 0 w C) y rat Ld Z M < uj C-4 d UJ C) V) C) 5 ui M ty UJ - j z 0 z 00 -D F- Lj m < Lli co Lli 0 a: Ld X L'i F- ry -j 0 Ld F-< wow < CO > -J 00 Z 0 < LLI z < 0 Uj C) 0 9 ILLJ Z 4� ct (j) LL, ice s LLI m z x a_— co < V) 0 D uj < z X 2 Z z uj 3:: 0 < Ld CO f— j= UJ 0 (f) of FF- - Q�— LAJ w z w =)z U) z (10 LJ 0 z :2 m LliD ZU) LLJ bZ C) 0 < F-- Lj 0 (,o W ILP - z (f) T< :2 w< < tu M - t o Z 0 0- rl� C) LLi < c) =:: �- < E- 10 (f) LLJ < Mi V) U) < �- ui m V) Z 1 Of U- pa ' LJ < -o w Lil LU -j < m 0 Gi :2 Y- 3: W P4 z C) LLi 0 Z > -j w z UJ m 0 0<0 -.4 cr cro M 0 U) w cr- 3i. -j (0 LLJ C) 0 W CL W z < a- Mo( 00, 0 CL CL -5 —oz < ui < x LAJ urn 2 m LLI z U) 0 00 X W x tAi (() —i M 0 u => tozww tj...% z Z < V) w 0- r W"OD U') V) 0 > M xmw 3: if P4 w z O-JYCLZ ZM W W<< O-JO wz Z G- 0 w 0 U) < (n LJJ w 3:L--Joz W Z�-w x x ZWXWOWOO M o I- YOO m / i5 0 W w Z . 3:ON LL- to < *. ci Z 0 (D 0 z +