Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
ENC2017-00193
V L\Z111 CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No 01 1 —0 CiL 4 DEPT.OFPUBLICWORKS (forworkingwithin the public X-Ref. File 70 North FirstStreet righ tt-of-way) Application Date l71 1 b1 ( Campbell, CA 95008 fA ` %/-� AAppplication Expiration Date Ph. (408)866-2150 RFC Issued ZJ� I �' Fx. (408) 376-09S8 �� AUIrff;; %] Permit Expiration Date APPLICATION-Applicati n s`hefe,l4 r or a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if th it is not issued. Ap lication Fee is non-refundable.) I 1C works Ad minisrr j aG; 5 C t�L,_l FP (� r A L Gh s A. Work Address or Tract No.: ail n r c 1Z...............�.......................................................�.......................F�.........................................._ ..J......._.....................................-_: Utility Trench Location: B. NatureofWork: C. Attach four (4) copies of an engineered plan showingthe location and extent of ework, and four (4) copies ofthe preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. Allworkshall conform to the Cityof Campbell Standard Specifications and Detailsfor PublicWorks Construction; theGeneral 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 Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before startingwork. Notice must be given to Public Works at least 24 hours before restarting a nywork. Name of Applicant: I nd,/' Address: I Telephone: b b E-MailAddress: 24-HOUR EMERGENCY PHONE NUMBER: ase ........... qc.�.f �c►.m�i.rj i c• (, y0 �Cn �fl 8 OQ Is this work being done by the �roperty owners at thei own residence? ❑ YES v NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, 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/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for anyaLnages aris}ng out of improvements completed in the public right-of-way. Accepted: (Applicant Permittee) , (sign) Date t. MER4 OMWAT1 2 — 01 ^ 11 (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Streetshall not be.open cutfor underground installations. Minimum cuts may be allowed forconnections orexploration holes. Such cuts may be 2. specifically approved by the Inspector prior to cutting. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A" f unless otherwise approved by the Engineer. ❑ 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. 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 has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. ❑ S. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 6. Public Notification Requirements: ❑ 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE AMOUNT s PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE ^ EMERGENCY PERMIT FEE // ' J% $ APPROVED FOR ISSUANCE For City Engineer Expires 12 Months After Date of Issuance RECEIPT NO. Z70 � Z'7 GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained forth e duration of the permit work. 2. A Construction Cash Deposit is required. Changes will be made against this deposit if there is an emergency call -out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. Surety posted shall be equal to 25% of the original Faithful Performance Security. 5. Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. 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. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices (MUTCD). 10. 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 as expeditiously as possible. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the construction cash deposit. 14. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 17. 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. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. 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. 21. 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. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or 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. 23. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order WQ 2014-0174- DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http://www.waterboards.ca.gov/water issues/programs/npdes/utilitvvaults shtmi for more information. Applicant is hereby responsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. MPP11Ld1JL �.Tr��. E®� g J v` l ` t.J�t Vv Date: Contractor (Print Name) Date: j(J J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2017 TO: Finance _ PUBLIC WORKS FILE NO. tr(n 201'1-6011rl>�p PROPERTY ADDRESS -2- t • cLa.(1� llTns+ eL+.�I '' Please collect & receipt for the followinq monies: 4722 Utility Encroachment Permit Application Fee $455.00 95 '— R-1 Encroachment Permit N/C Emergency Permits $130.00 Plan Check & Inspection Fee Minimum Charge Per Location $420.00 Zp — Conduits/Pipelines up to 500 Feet $2.95/ft Above 500 Linear Feet $1.75/ft Manholes/Vaults/Etc. $190.00/ea Pole Set/Removal $190.00/ea 4760 Storage Container Permit (valid up to 60 days 4760 Project Plans & Specifications 4760 Standard Specifications & Details 4760 Engineering Maps & Plans Aerial Plot 24" x 36" Aerial Print 8 1/2" x 11" Map Research (includes max of two 24"x36" ci Maps and Plans 24" x 36" 4722 Penalties: Failure to restore public improvemer 4722 Penalties: Failure to correct unsafe conditions 4722 Work Without Permits 5 r r 4728 Traffic Flow Map (Daily Traffic Volumes) 4728 Signal Timing Information 4271 Truck Permits 4728 No Parkina Sians Other (Please S Project No. $1/Pq $15.50/13k �+ NAME OF APPLICANT �: -A,1 VO -6lam/ ,� I V� Ci NAME OF PAYOR�� N A)6,() p� ADDRESS ; q j�A A)6,() LL FOR rY CLERK ONLY $65.00 $32.00 $32.00 $15.00 $100/Calendar Day (Mu $100/Calendar Day Code Sec. 11.34.010) 4 Times. Applicable Fee/Min. $500 fa i u5§: x d $35.00 $73 per hour $16.00 per trip $1 each or $25/100 TOTAL r PHONE ZIP J \FORMS\Templales•AdministratweUReceipl Form Utility Encroachment & Miso 17-18A, CITY OF CAMPBELL RECVD BY. CASHIER 0100,3270896 PAY'OR, MARIO VODENNI.CANEVI TOI:faY''S DATE: 08/10/1. i REGISTER DATE: 00/10/17 TIME, 00.00 DESCRIPTION AMOUNT CUST ID:ENC2017-00193 ErdGR 8 SUBDIV FILING F e00 CRUST ID: 1.000 E N GR f, SUBDI a° FILING E $4 O.00 TOTAL. DUE, $875.00 TENDERED: CREDITC;ARDg : 8'751.00 REF NUM: ' CAMPBELL MIDDLE SCHOOL Great DNiw swoop wsma o urt NJw xs-u-mz tC y ;�`eRotigro PH Tpe;r�y`.::'.:'::j.='- . . . . . . .... l N OD'19900' W 6➢AO' Al m n K I yy ! \ \\\`\` \ ��Y S' •��`.}per\� 0 I 0 1.0 9 ' N6 m_ rY y 7-7 9 r� tl ioj. _--_--_—_— �f <<• Ap'�, O 4S,f�J✓ I 7 -� Tj C z :1 m =1 da n m Imp LI ORtIA Sl"D m k Z a' 1 rn 1 I m l g `D mO E � uVI�II�R'/ { Z I�A¢� +n D 1 j rn ay m SITE PLAN j„shCma�TNp Ec' De4: D-19-16 Na. Revleian Date H Chkd GRADING AND DRAINAGE PLANS SnN �OSE,G e51f0 Drem By: D. 285 & 295 CALIFORNIA STREET CAMPBELL, CA 95008 APN: 305-35-020 k 021 BUILDING PERMIT NO. I DeeiQDed HY TJs D9/13/2016 10:23— - N:\2015 JOB5\15-243\d.9\15-243 MWE C3 517E PUN.dw9 - C3 LEGEND: • CHANNELIZI:.., e SIGN m WORK ZONE y DIRECTION OF TRAFFIC H TYPE 3 BARRICADE FR TYPE 3 BARRICADE W1 .................... ...-.�.._..-... ® CRASH BARRELS R2 MESSAGE BOARD(PCmS) •iENARIIii%k KINGS16K FLASHING ARROWBOARD ❑% ON ttPOSTPE18APORRRIMC72HRS IN ADVANCED. (mJ TEMP NO PARKING SIGNS NOiE: Please mntaciRAi,S721r0-d.—incase SIGN 4� FLASHING BEACON If we are to lmtall"iENPORARYNGPARKING"slins. -Tmf,. control sball cronform with MUTCU andbr Caltrans Standards section 6 dated 2014. -one lane f imffic h, n and all high ou l n 9I.—Mll De mainlainetl at eR times on all strew al a minlmam lane width o110 feel. ®-Canlrzclor Mall nmily local aalhoHh- once signs are Posted. - Al wit ad--d warning signs shell be equipped h 2 (18' orange flags) - Gadded T. Mc Convol workers shall nave Type 11 vests, wode shoes, and hard has. Temporary no parking signs Mail be placed a min of 72 hrs prior of work Ddeewa span bo momigrea and mainainea al an times dune .vork hpprs. n e Distance bcnveen si n and work area w111 be tlel—In Ped d - s enmlt. 21 9 Roadway —11 not be opened until safe for public use. All open benches most ba plated or wt. beckfiled prior to public usage. Al Devices Mali be removed -- no longer required. ti"m �M0©D NOTTO SCAL E 295 CALIFOBNIA 5T. JOSEPH BECHWATI DAiE Copp: CAMPBELL, CA PACIFIC PLUMBING 8-e-i7 PAGED PRtI 408 -1111121 e» 10SEPH@PACIFICPLUMBINGINC@ICOM D awn B AFTER HOURS DrewpalYel EMERGENCY Ds1Da 9170M 510-299-56b6 OHiee: 51-57-Z5a3 far510.650NS.0 "BOO Industrial Drive Fremont CA 4538 9 W W W.BATDTFAEFICSOLUTIONS.COM BA.T.S. TRAFFIC SOLUTIONS NOTTO SCAL E 295 CALIFOBNIA 5T. JOSEPH BECHWATI DAiE Copp: CAMPBELL, CA PACIFIC PLUMBING 8-e-i7 PAGED PRtI 408 -1111121 e» 10SEPH@PACIFICPLUMBINGINC@ICOM D awn B AFTER HOURS DrewpalYel EMERGENCY Ds1Da 9170M 510-299-56b6 OHiee: 51-57-Z5a3 far510.650NS.0 "BOO Industrial Drive Fremont CA 4538 9 W W W.BATDTFAEFICSOLUTIONS.COM BA.T.S. TRAFFIC SOLUTIONS ESf ailer .w � Sanibdon Ois ri[i OFFICE HOUR'S $ CONTACTS. 7:30 a.m. to 4:30 p.m. Monday thru Friday 100 E. Sunnyoaks Ave., Campbell, CA 95008 • Phone: (408) 378-2407 • Information Services Department LOCATION: APN :�r57 d,2,_5—C, Z I Sewer Map Book Page Tract Lot Project Assmt Address �`7 e::; �;� A Jurisdiction BUILDING TYPE: — -Single Family Condo/Town House Multiple Dwelling Units Industrial Commercial REMARKS:. Wit( Arl'i We— OLD PERMIT No.; Sub NO.. Original —Applicant Sewer Connection Permit FEES: Connection Capacity Processing Service Advance Total Due: Paid by Check No $ q�'k°��rr 7✓�4 $�- vv6',iz ) 7 Hillside: Yes_ No 4�1 INSTRUCTIONS: • Permit is invalid if work is not completed within 12 months of issue. • Do not connect until the main sewer is accepted by the District. • Obtain a building or plumbing permit from the Jurisdiction listed above. Street encroachment permit is required from Keep 3' radius around cleanout clear of vegetation or obstruction. i �2 t` No: Issue Date: By: BACKFLOW PROTECTION tit Field check required ),,/L> Basement Check valve required: `test --No BUILDING SEWER CONNECTIONS - Total numT f connections to this property: 1. Lateral ID No. is located feet of property line, feet from main sewer and feet deep. Pink - Accounting Yellow -- City/County Bldg. Inspector Connection to Main Sewer fleet US from DS MH US MH Pipe Type List any additional connections on reverse side of this form. Card — District File P�tl�lt �UUH� ;> & Underground Construction 329 Sango Court Milpitas CA95035 (408) 894-9120 Email: info@pacificplumbinginc.com License: Class A & C-36 Lic#745976 Billed To: Le 295 California Street Campbell CA 95008 Proposal Proposal/Contract #:338112 Date: 07/27/17 Project: 295 California Street 295 California Street Campbell CA 95008 Pacific Plumbing & Underground Construction will perform the following work: AMOUNT Proposal Work 14,020.00 Will setup traffic control, saw cut pavement, trench and install 4" sewer lateral with 1 property line cleanout per sanitation district standard. Will restore trench, compaction and pavement per city standard. Will assist with encroachment permit. Permit fees and cost not included on this quote. Labor and parts $14,020 Grand Totals: 14,020.00 to czli rion I Payments: Owner shall pay Contractor sums listed above, subject to additions & deductions provided herin, installments as follows: * 10% down payment upon acceptance of proposal. Progress invoices relative to the percentage of completed work will be generated and are due upon receipt. Final payment is due upon completion. Payments due and unpaid under the contract shall bear interest of 18% per annum. NOTICE ' Contractor, subcontractors, suppliers and other persons who help to improve your property have the right to enforce a lien against your propert for unpaid balance (Mechanics' Lien Law - California Code of Civil Procedure, Section 1181 et seq.) Owner(s): SIGNATURE: PRINT NAME: TITLE & DATE: Contractor: Pacific Plumbing & Sewer Service, Inc. DBA Pacific Plumbing & Underground Construction SIGNATURE: PRINT NAME: TITLE & DATE: CAMPBELL MIDDLE SCHOOL REA g� u lmnxc � CW��i1PNUw]IaLs-� p�p20151WCf � � a -------- :7 f N 0718'00• W _ 110A0' - -"---- —A A --- ti L, N arip'oo• W 50.00'- a 5gg-t 1J lok y� m< o m 1 9 ,erg Jam,: N u 8, S m � -' ,'6 ~ ��(. as I{� .- U �. � N 5 :!,•'',ey+,F�'" Y —Y�VV--- ----------`5<2N'aou3o'.w a.: ..� •'up.00'...- i � �= � �. 70 `A -a-- (n m i i tic. / CALIFORNIA` ST RIEE—T 1 m I �r — ------ ---- ------ ---- — I Z m qm m A Y (n 1I�III i/ C s; z _ D �4cFRF c D b m a� Ny X F m s n s SITE PLAN 5 N6ErvGWEEarvo,luc. Deto: 8-13-18 No. Radeion Bcln B cnla marecnrvaacroarvE GRADING AND DRAINAGE PLANS I� SAII �OSE,G BSi 10 Bium BA71 285 & 205 CALIFORNIA STREET CAMPBELL, CA 95006 J`Z-CIVIL M;!E � 6 APN: 305-35-020 & 021 BUILDING PERMIT NO. w B..igoea By: r3s 09/13/20M 16.23vn - N:\2015 JOBS\15-243\d.g\15-243 UNSNE C3 SITE 7LAN.d.9 - C3 PACIF-5 OP ID: Z1 ACOR® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDmvY)08/10/2017 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 Bozzuto & Associates Insurance 34 S. Second St Campbell, CA 95008 Linda Ellis CONTACT NAME: Lisa Malvido PHONE g00-989-8712 FnAX No): 408-429-8460 A/c No Ext E-MAIL ADDRESS: lisam@dbinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Navigators Specialty Insurance 36056 INSURED Pacific Plumbing & Sewer Service, Inc 329 Sango Ct Milpitas, CA 95035 INSURER B: American Fire and Casualty Corn 24066 INSURER C: Mercer Insurance Company 14478 INSURER D: Cypress Insurance Company 10855 INSURER E: Ohio Casualty Insurance Co 124074 INSURERF: Homeland Insurance Company of 134452 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 INSD WVD POLICY NUMBER POLICY MMIDD/YYYY MM/DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS -MADE FX] OCCUR X SF17CGLO196271C 02/19/2017 02/19/2018 PREMISES Ea occED urrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY � PEt° 7 LOC PRODUCTS- COMP/OP AGG $ 2,000,000 Emp Ben. $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) S B X ANY AUTO X BAA56378613 02/24/2017 02/24/2018 ALL OWNED SCHEDULED AUTOS AUTOS NON --OWNED HIRED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 C EXCESS LIAB CLAIMS -MADE 27304874 02/19/2017 02/19/2018 DED RETENTIONS $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A X PAWC811288 02/19/2017 02/19/2018 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 E Equipment BM056378613 02/01/2017 02/01/2018 Schd Tool 114,19 F Pollution 793-00-56-49-0000 12/30/2016 12/3012017 Liability 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) . Re: Capital Improvement Projects, 295 California Street, Campbell. City of Campbell, its officers, employees and volunteers are included as an additional insured on General Liability and Automobile Liability policies per the attached endorsements.General Liability policy is primary and non- contributory per the attached endorsement. Waiver of Subrogation <<Cont'd>> �"h �1•�� ,�� l;tK I It -I ;A I t MULUtK CITYOFC City of Campbell 70 N. 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 (2014101) The ACORD name and logo are registered marks of ACORD 4. 5. READ INSTRUCTIONS. ON REVERSE SIDE BEFORE C MAIUNG NAME AND ADDRESS (OPTIONAL) E NAME Anita Adams ADDRESS 599 College Avenue _ D,,, Palo Alto STATE CA Lp 94306 FICTITIOUS BUSINESS NAME STATEMENT FILED WITH THE COUNTY. CLERK -RECORDER OF SANTA CLAM COUNTY ON THE DATE IDENTIFIED ON THE FILING LABEL allowing corson toarsons) Is (are) doing business as: (Use the ADDENDUM page to listadditional File Number: 560454 No. of Pages: 1 File Date: 1/24/2012 Expires: 1/24/2017 Fee Total: 44.35 ■ 560454m Clerk ID: 012 REGINA ALCOMENDRAS, County Clerk —Recorder SANTA CLARA COUNTY CLERK —RECORDER'S OFFICE business 119 College Avenue Palo Alto CA 94306 Santa Clara Ifthe principal place of business Identified In 02 above Is not In Santa Clara County, a current fictMous business name statement for the fictitious ous business name(s) Identified In it above @half be on file at the above4denBMd County that Is the principal place of business. If applicable, please complete 03 below: THE PRINCIPAL PLACE OF BUSINESS 15 IN Santa Clara COUNTY AND A CURRENT FICTITIOUS BUSINESS NAME STATEMENT IS ON FILE AT THE COUNTY CLERK -RECORDER'S OFFICE OF SAID COUNTY. This business is owned b)r (An asterisk(*) item requires proof of registration with the California Secretary of State's Office) AN INDIVIDUAL Q A GENERAL PARTNERSHIP Q 'A LIMITED PARTNERSHIP U 'A LIMITED LIABILITY COMPANY Q AN UNINCORPORATED ASSOCIATION OTHER THAN A PARTNERSHIP XQ 'A CORPORATION Q A TRUST Q COPARTNERS Q HUSBAND AND WIFE Q JOINT VENTURE Q STATE OR LOCAL REGISTERERED DOMESTIC PARTNERS Q -LIMITED LIABILITY PARTNERSHIP The name and residence address of the owner(s) I registrangs) Is (are): (DO NOT USE P.D. BOX, PKIVA It MPAL DVAAUUKC =D) NOTE: General Partnerships, Copartnership, Joint Venture, Umged Liability Partnership, Unincorporated Association, and limited Partnership - Insert name and residence address of each General Partner, Trusts- insert the full name and residence address of each trustee; United Liability Company and Corporation - Insert fug name and address of Lbrdted Liability Company or Corporation as registered with the California Secretary of State'@ Office; State or local registered Domestic Partners - Insert tug name and residence address of each Domestic Partner. NAME ADDRESS CITY STATE - ZIP RaghnnardlOwnerbegen transacting business under the fictitious business nea)@(@) aseu Reeve 6. Q DATE: i i/n'I /ZOi i _ Q NOT APPUCA 7. 0 First Filing (Publication Required) ., Q Refile of previous Ne It558756 (chick appropriate boxes, be" s � A,[�4{ Q Refiled prior to expiration or within 40 days past expiration, with NO CHANGES 10 0 1�, • nO o, Q With changes (Pubkotion Required) SG / Q After 40 days of expiration date (Publication Required). s M Q Due to publication requirement not rret on previous Sing (Publication Required) % 1 hereby certify that this copy Is a correct copy of the original rI i\ �J')♦i� Fictklous Business Name Statement on file In my office. RegIna Aleomendras, n Cie ERK-RECORDER SEAL E- a. I declare that all irdorma I his statement is hire end correct (A registrant who declares as true Information which he or she knows to be false is guilty of a crime.) SIGNED x PRINTED NAME John Suppes M a CORPORATIOON, L)M. SUABILITY COMPANY, LIMITED PARTNERSHIP or LIMITED LIABIUTY PARTNERSHIP, Me following must be completed: ENTRY NAME 13 Id CD oration TITLE/CAPACITY OF SIGNER President ARTICLE I REG i C 1 (from CA Sac of State's Office) ABOVE ENTRY WAS FORMED IN THE STATE OF (`alifornia NOTICE.IN ACCORDANC WITH SUBDIVISION (a) OF SECTION 17920. A FICTITIOUS BUSINESS NAME STATEMENT GENERALLY EXPIRES AT THE END OF FIVE YEARS FROM THE DATE ON WHICH IT WAS FILED IN THE OFFICE OF THE COUNTY CLERK EXCEPT, AS PROVIDED IN SUBDIVISION (b) OF SECTION 17920, WHERE IT EXPIRES Q DAYS AFTER ANY CHANGE IN THE FACTS SET FORTH IN THE STATEMENT PURSUANT TO SECTION 17913 OTHER THAN A CHANGE IN THE RESIDENCE ADDRESS OF A REGISTERED OWNER. A NEW FICTITIOUS BUSINESS NAME STATEMENT MUST BE FILED BEFORE THE EXPIRATION. THE FILING OF THIS STATEMENT DOES NOT OF ITSELF AUTHORIZE THE USE IN THIS STATE OF A FICTITIOUS BUSINESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER FEDERAL, STATE, OR COMMON LAW (SEE SECTION 14411 ET SEO., BUSINESS AND PROFESSIONS CODE). _ INSURANCE REQUIREMENTS CHECKLIST Permit # �►-�c "aC) .- CIP Project # The following insurance is required of all 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: ,D1[-❑ $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 Zl I f Automotive Liability: I ❑ "Any Auto" checked on certificate b\�❑ '$1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and Employer's Liability �-71ic<<6-'❑ Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease ❑ Policy expiration date a Course of Construction (if required in Special Provisions) ❑ `Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) s� 7 ❑ The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Numberl `i /�-7 ❑ The insurance coverage afforded to the Additional Insured is primary insurance. C Cancellation Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of anv kind upon the company, its agents or representatives". OR Should Read (� ❑ Should any of the above described policies be cancelled before the expiration date v thereof, notice will be delivered in accordance with the policy provisions. \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\joannat\Desktop\All Insurance Requirements.doc (Rev 03/13) - Page 1 of 1 ❑ Workers' Compensation Insurance Sheet Submitted VFor General Contractor ❑ For Developer or Owner 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. 'NgQi jG tad S � fI Name: ' S _��_ NAIC # S Rating: -I",-� Authorized in CA: Name: 'N e.i,<cL-yl .{ e NAIC # 2L10 ,v Rating: Authorized in CA: Name: Cct��c� �� NAIC # Rating: Authorized in CA: Name: C-k y �IeSS CQ. NAIC # Z Rating: W ?,� Authorized in CA: `a, Campbell Business License #. Insurance Certificate Reviewed Ini Date Copy of Insurance Certificate placed in tickler file one month prior to expiration. c.eVLS� �Ce I� C:\Documents and Settings\joannat\Desktop\Insurance Requirements 2 pgs.doc (Rev 03/13) Page 2 of 2 COMMERCIAL GENERAL LIABILITY CG 20 38 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS FOR OTHER PARTIES WHEN REQUIRED IN WRITTEN CONSTRUCTION AGREEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II - Who Is An Insured is amended to include as an additional insured: 1. Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy; and 2. Any other person or organization you are required to add as an additional insured under the contract or agreement described in Paragraph 1. above. Such person(s) or organization(s) is an additional insured only with respect to liability for "bodily injury", "property damage" or 'Personal and advertising injury" caused, in whole or in part, by: a. Your acts or omissions; or b. Tf e acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured described above: a. Only applies to the extent permitted by law; and b. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for the person or organization described in Paragraph 1. above are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or CG 20 38 04 13 C Insurance Services Office, Inc., 2012 Page 1 of 2 b. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement described in Paragraph A.1.; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 38 04 13 0 Insurance Services Office, Inc., 2012 Page 2 of 2 POLICY NUMBER:SF17CGL0196271C COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) - Or Organization(s) Location And Description Of Completed Operations' Any person or organization for whom you are performing "commercial construction" during the period of this policy and have agreed in a written contract to add as an additional insured for products -completed operations. "Commercial construction" does not include any habitational or residential construction other than hotels or apartments. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are B. With respect to the insurance afforded to these additional insureds, the following is added to Section III Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 COMMERCIAL AUTO CA 88 10 01 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE ENHANCEMENT ENpORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverageafforded by this endorsement, the' provisions. of'the policy.apply unless: modified by the endorsement. COVERAGEINDEX SUBJECT PROVISION,NUNIBER ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR. PERMIT 3 .ACCIDENTAL AIRBAG DEPLOYMENT 12 .AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS 1`9 AMENDED FELLOW EMPLOYEE EXCLUSION 5 AUD10, VISUAL AND,DATA ELECTRONIC EQUIPMENT` COVERAGE 13 BROAD FORM INSURED 1 BODILY INJURY REDEFINED '22 EMPLOYEES AS INSUREDS (including employee: hired auto) 2 EXTENDED CANCELLATION CONDITION .23 EXTRA EXPENSE - BROADENED COVERAGE 1.0 GLASS REPAIR - WAIVER OF DEDUCTIBLE 15 HIRED AUTO PHYSICAL DAMAGE (including employee hired'auto and loss of ,use) 6 HIRED AUTO COVERAGE TERRITORY 20 LOAN / LEASE GAP 14 PARKED AUTO -COLLISION COVERAGE (WAIVER OF DEDUCTIBLE), 16 PERSONAL EFFECTS COVERAGE 11 PHYSICAL DAMAGE -ADDITIONAL TRANSPORTATION EXPENSE COVERAGE 8 RENTAL REIMBURSEMENT 9 SUPPLEMENTARY PAYMENT_ S 4 TOWING AND LABOR 7 TWO OR MORE DEDUCTIBLES 17 UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS 18 WAIVER OF TRANSFER OF'RIGHTS OF RECOVERY AGAINST OTHERS. TO US 20 SECTION ii - LIABILITY COVERAGE is amended as follows: 1. BROAD FORM INSURED SECTION 11 - LIABILITY COVERAGE,. paragraph A.1.., - WHO IS AN INSURED is ambMed.to iFicl de the following as an insured: d. Any legally incorporated :entity of which you own ;more than, 50 percent. of the: eating, stock during the policy period. However, "insured" does not ihelude.any organisation that: (1) Is a partnership or joint venture; or (2) Is. an insured under any other automobile policy; or (3) Has exhausted its Limit of Insurance under any other automobile policy. Paragraph d. (2) of -this- provision does not apply to a policy Written to apply specifically in excess of this policy. e. Any organization younewly acquire. or form,, other than a partnership,orjoint venture, of which, you own more than 50'percent of the voting stock. This automatic coverage is afforded:6nIy f& 180 days from the date ,of acquisition or formation.'However, coverage under this provision does notapply (1) If there is similar insurance,or a. self -'Insured retention -plan available to that organization; © 2013 Liberty Mutual Insurance CA $8 10 01 13 Includes copyrighted material of Insurance Services office; Inc., with.its permission. Pa9e 1 of (2) if the Limits of Insurance of any other insurance policy have been` exhausted;: or (3). To "bodily injury" or ""property damage:" that occurredbefore you acquired'o -formed the organization. 2. EMPLOYEES AS INSUREDS SECTION 11 - LiABiLITY`COVERAGE'pa.ragraph A.1: - WHO IS AN INSURED is amended'to, include the following as an insured: f. Any "employee" of yours while using a covered "auto" you do not own, .hire or borrow, but only for acts within:the scope of their employment by you..lnsurance provided by thiis,endo.rse- ment is excess over any other insurance available to any "employee". g. An "employee" of yours while operating an "auto" hired or borrowed under a written contract or agreement in, that "employe.e's" name; with your permission; vJh e.performng duties re- lated to the. conduct of your business and within the scope `of their employment. Insurance provided by this endorsement is excess over any other- insurance available to the "employee". 3. ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT SECTION 11 - LIABILITY COVERAGE, paragraph A.1. WHO IS AN INSURED 'is.bmendedto include the following as an insured: tt. 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 hT a written' contract, agreement, or permit issued to you:by governmental, orpublic.authority, to add such person, or organization;°or governmental'or public. -authority to this policy as°an "insured However, such person or organization is an. "insured": (1) Only with respect to the operation, maintenance -or use.of a covered "auto' (2) Only for, "bodily injury" or "property damage" caused by on "accident" which takes place after you executed the, written contractor agreement, or the permit has been issued to you; and (3) Only for the duration of that contract,:agreement or permit 4. SUPPLEMENTARY PAYMENTS SECTION II - LIABILITY COVERAGE, Coverage Extensions, 2.a. 'Supplementary Payments, para- graphs (2) and (4) are replaced by the following: (2) Up to $3,000 for cost .of bail bonds (including `bonds forreiated `traffic violations) required. because of an "accident" we cover. We do not -have to furnish these bonds. (4) All reasonable expenses incurred by the.insured at our request, inciuding:actuai' loss of earn- ings up to.$500 a day.be.cause of time "off from work. 5. AMENDED FELLOW EMPLOYEE. EXCLUSION in those jurisdictions where; by law, fellow employees are not.entitled."to ttie protection'afforded to the employer .by the workers compensation exclusivity rule, .or .similar, protection,. the following provision is added: SECTION 11 - LIABILITY; exclusion B.5. FELLOW EMPLOYEE does not apply if the; "bodily Injury. results from. the.use of a covered "auto" you own or hire. SECTION [if - PHYSICAL DAMAGE COVERAGE is amended as follows: 6. HIRED AUTO PHYSICAL DAMAGE Paragraph A.4.:Coverage,'Extensions of SECTION IIi PHYSICAL ,I?AMAGE"COVERAGE,'is ;amended by adding the following: If hired "autos" are covered ":autos" for Liability Coverage, and if Comprehensive.,. Specified Causes of Loss or Collision coverage are provided under the 8uusiness Auto Coverage Form for -any "auto" you own, then the Physical,Damage coverages provided are extended to "autos a. You hire, rent or borrow; or. 2,013 ;Libegy:Mutual: Insurance, CA 88 10 0.1 13 Includes copyrighted material of Insurance Services Office, Inc., w th.its permission. Page'2 of 7 b.. Your ".employee." hires or rents under a written contract -or -agreement in,that'"employee's" name, but only if the damage occurs while the vehicle is being used in the conduct, of .your business, subject to the following limit and deductible:. A. The most we will pay -for "loss" in any. one "accident" or "lass'' is the smallest of: (1) $60,000; or, (2) The: actual cash value.of the damaged or stolen property as of the time'of the:"loss"; or (3) The cost of repairing or replacing the damaged or stolen property'with other:property;of. like'kind and qual'rty,.minus a deductible. B. The deductible will be equal to. the largest deductible applicable to any. owned "auto" for that coverage, C. Subject to the limit, deductible and excess provisions described in this :provision, we Will, provide coverage equal to the broadest coverage applicable to any covered "-auto" you own. D. Subject to.a maximum of $1,000 per "accident", we .will also cover the."actual loss of use of the: hired "auto" if it results from an "accident", you are legally liable and the lessor incurs 'an actual financial loss. E. This coverage extension"does not apply to: (1) Any "auto" that is hired; rented or borrowed with.a driver; or, (2) Any "auto" that is hired, rented or bo.rrowed:from your"employee". For the purposes of this provision, SECTION V - DEFNITIONS is amended byadd'ing the -following:. "Total loss" means a "loss" in which the. cost of repairs plus the:salvage value exceeds the'actual cash value. 7. TOWING AND LABOR SECTION III - PHYSICALDAMAGE COVERAGE, paragraph A.2: TowingJs amended,by the addition of the following: We will pay tovving and labor:costs incurred, up toth°e limits shown below; eachtime -a covered: "auto" classified .and rated as a private passenger type, w1ight truck" :or "medium truck" is dis- abled: a. For private. passenger type vehicles, we will'.pay up to $50,per.disablement.. b. For "light trucks",.we will pay up -to W per,disablement. "Light trucks are trucks that have -.a: gross vehicle weight (GVW) of 10;000 pounds or less. c. For "medium trucks" , we will'payup to$150 per disablement. "Medium trucks" are.truck$ that, have a gross vehicle weight (GVW) of 1.0,001 - 20,000 pounds. However, the labor must be performed at the place of disablement. 8. PHYsicAL.DAMAGE'; ADDITIONAL TRANSPORTATION EXPENSE COVERAGE Paragraph AA.a., Coverage Extension of SECTION III - PHYSICAL DAMAGE COVERAGE,, is amend ed toprovide a Limit of $50 per day and a maximum limit of$1,50,Q 20113,Uberty Mutual` Insurance CA 88 10 0119 9 Includes copyrightedmaterial of Insurance Services offioe,.Inc., with its -permission. 'Page 3 bf 7 9 RENTAL REIMBURSEMENT SECTION III - PHYSICAL DAMAGE COVERAGE, A: COVERAGE,,,is amended by adding the following,; a. We will pay up to $75 per day for rental reimbursement expenses- incurred by you for the rental of an "auto" because of"accident" or loss , to an .auto for which we also pay a "loss!' - under Comprehensive, Specified Causes of Loss or Collision Coverages. We will pay only for those .expenses incurred after the first 24 hours following. ,the "accident" or ",foss" to the covered "auto:" b. Rental Reimbursement will be based on the rental of a comparable vehicle; which 'in many cases may be substantially less than $75 per: day, and will only be aliowe.d: for the period -of time it should take to repair or replace the vehicle with reasonable speed arid .similar quality, up to a maximum.of 30 days. c. We will also pay up to $500 for reasonable and necessary expenses incurredby,you,to remove and replace your tools and equipmentfrom the covered "auto": d. This coverage does not apply unless you have a business necessity that other "autos" avail- able for your use and operation cannot fill. e. If "loss" results from the total'theftof a covered "auto" of the private passenger"type, we will pay under this coverage only that amount of your rental reimbursement expenses- which is not already.provided under Paragraph 4. Coverage Extension. C No deductible appliesto this coverage. For the -purposes of this endorsement provision, materials and equipment.do not.inc.{ude "personal effects as defined in provision 11. 10. EXTRA EXPENSE - BROADENED COVERAGE Under SECTION III - PHYSICAL DAMAGE COVERAGE, A: COVERAGE, we.wili "pay for the expense of returning a stolen covered "auto" to you, The maximum amount we"will pay'is $1,000. 11. PERSONAL EFFECTS COVERAGE A. SECTION iII - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended. by adding the following: If you havepurchased Comprehensive Coverage on this policy for an "auto" you own and, that "auto it. stolen, we will pay,. without application of a deductible, up -to $600 foe "personal effects" stolen with the "auto," The insurance provided under this provision. is, excess over any other collectible insurance:_ B. SECTION V DEFINITIONS is amended ..by adding the following: .For the purposes of this provision " " personal effects mean tangible, property that. is worn or carried by an insured." "Personal effects" does not include. tools,, equipment, jewelry, money or securities. 12. ACCIDENTAL AiRBAGDEPLOYMENT SECTION Ili - PHYSICAL DAMAGE COVERAGE, 13. EXCLUSIONS is amended by°addin.g°the follow-s ing: If you have purchased Comprehensive or ;Collision Coverage'" under this policy, the, exclusion for ".lass" relating..to mechanical breakdown does not -apply to the accidental .discharge"ofanairbag. Any insurance we provide shall be excess over any other collectible insurance or reimbursementby manufacturer''s warranty: However, we agree to pay any deductible applicable, to, the :other cov= erage. or warranty. 1.3. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE' SECTION III - PHYSICAL DAMAGE COVERAGE, B: EXCLUSIONS, .exception paragraph a.:to.,exclu7. sions 4.6. and 4.d. is deleted and .replaced -with the following,: O 2013.Liberty Mutual insuranpp: CA 88 10"Di 13 Includes copyrighted material. of Insurance Services Office, Inc., with it -permission., Page'A of 7 Exclusion 4.c. and 4.d. do not apply to: a. Electronic equipment that receives or transmits audio, visual or data signals, whether or not designed solely for the reproduction of sound, if the equipment. is. permanently installed in the covered "auto" at the time of the "loss" a.nd such equipment is designed to be solely operated by use of the. power from the "auto's" electrical system, in or upon the covered "auto" and physical damage coverages are provided forth'e,covered "auto";.or If the "loss" occurs solely to audio, visual or data electronic equipment or accessories used with this equipment, then our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by a $100 deductible. 14. LOAN / LEASE GAP COVERAGE A. Paragraph C., LIMIT OF INSURANCE of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by adding the following: The most we will pay for a "total loss" to a covered "auto" owned by or leased to you in any one "accident" is the greater of the: 1. Balance due under the terms of the loan or lease to which the damaged covered "auto" is subject at the time of the "loss" less the amount of: a. Overdue payments and financial penalties associated with those payments as of the date of the "loss", b. Financial penalties imposed under a lease due to high mileage, excessive use or ab- normal wear and tear, c. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease, d. Transfer or rollover balances from previous loans or leases, e. Final payment due under a "Balloon Loan".., f. The dollar amount of any unrepaired damage which occurred prior to the "total loss" of a covered "auto", g. Security deposits not refunded by a lessor, h. All refunds payable or paid to you as a result of the early termination of a lease agreement or as a result of the early termination of any warranty or extended service agreement on a covered "auto", i. Any amount representing taxes, j. Loan or lease termination fees; or 2. The actual cash value of the damage or stolen property as of the time of the "loss". An adjustment for depreciation and physical condition will be made in determining the actual cash value at the time of the "loss". This adjustment is not applicable in Texas. B. ADDITIONAL CONDITIONS This coverage applies only to the original loan for which the covered "auto" that incurred the loss serves as collateral, or lease written on the covered "auto" that incurred the loss: C. SECTION V - DEFINTIONS.is changed by adding the following: As used in this endorsement provision, the following definitions apply: "Total loss" means 'a "loss" in which the cost of repairs plus thesalvage value exceeds the actual cash value. A "balloon loan" is one with periodic payments that are insufficient to repay the balance over the term of the loan, thereby requiring a large final payment. © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 7 15. GLASS REPAIR -: WAIVER OF DEDUCTIBLE Paragraph D. Deductible of SECTION 'ill - PHYSICAL DAMAGE. COVERAGE is amended. by the addition &Ahe following: No deductible applies to glass damage if the glass is repaired rather than replaced. 16. PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) Paragraph D. Deductible of .SECTION III - PHYSICAL DAMAGE .COVERAGE is amended by the addition of the following: The deductible does not :apply to "loss" caused by collision to such covered "auto of'the private passenger type or, fight weight'.truck with a gross vehicle weight,of 14,000 lbs..or less'as defined by the manufacturer -as maximum loaded weight the "auto" is designed to carry while it is: a. In the charge of an "insured% b. Legally parked; -and c. Unoccupied. The "loss" must be reported to the police authorities within 24 hours of known damage.. The total amount of the damage to the covered "auto" must exceed the deductible shown in the Declarations. This provision does not apply to any "loss" if the covered "auto" is in the charge of:any person or organization engaged in the automobile business. 17. TWO OR MORE DEDUCTIBLES. Under SECTION III PHYSICAL DAMAGE. COVERAGE, if two or more company policies or coverage, forms apply to the same accident,.thefollowing applies to paragraph D: Deductible: a. If the. applicable Business Auto deductible is the srnaller (or smallest) deductible it will. be; waived; or b. If the applicable Business Auto deductible is not the smaller (or smaliest)`-deductible it will. `be reduced by the amount of the smaller (or smallest)'deductible; or c. If the loss involves two or. more .Business Auto coverage forms or poll -Gies the smaller (or smallest) deductible will be waived. For the purpose of this endorsement company means any. company that is part of the Liberty Mutual Group: SECTION IV - BUSINESS AUTO CONDITIONS is amended as follows: 18. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV- BUSINESS AUTO. CONDITIONS, Paragraph B.2..is amended by adding the following: If you unintentionally. fail to disclose any hazards, exposures .or. material 'facts existing as of the inception date or renewal date of the Business Auto Coverage Form,:the coverage -afforded by this policy will not be prejudiced. However, you must report the undisclosed hazard of exposure as soon :as practicable. after: its discovery, and we have the right to collect additional premium for any such hazard or exposure. 19. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT, OR LOSS SECTION IV - BUSINESS AUTO CONDITIONS;. paragraph' A 2:a: is replaced in. its entirety by the following: a. In the event of "accident", claim,_ "suit" or ",loss", you must promptly notify ps when it is known to: 1. You, if -you areAn individual; 2. A partner, if you are a partnership 3. Member, if you area limited liability company; 4. An executive officer or. the "employee" designated by the- NamedInsured to ;give suet notice, if you are a.corporation. 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc.,,witti.its_permission.. 0age`6 of 7 To the extent possible, notice to us should include' (1) How, when and where the 'accident" or "doss" took place; (2) The "insureds" name and -address; and (3) The names. and addresses.of any injured persons and witnesses:- 20. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS;'TO US SECTION IV BUSINESS AUTO CONDITIONS,. paragraph A.S., Transfer of .Rights .of. Recovery Against Others to Us; is amendedby the addition of the-fd o.wing: If the person or organization. has waived those. rights before an "accident" or "loss.'%.ourrights are waived also. 21..HIRED AUTO COVERAGE TERRITORY SECTION IV BUSINESS AUTO CONDITIONS, paragraph 0.7., PQIicy. period,. Coverage. Territory, is amended by the addition of the following: f. For "autos" hired 30 days or less, the coverage territory is anywhere in.the world, provided that the iinsured's responsibility to -pay for damages is determined in a "suit",,on the merits, in the United States, the territories. and possessions of the United States of America, Puerto Rico or. Canada or in a settlement we agree to. This extension. of coverage does not apply to an "auto" hired, leased, rented or borrowed with a driver. SECTION V - DEFINITIONS is amended as follows: 22. BODILY INJURYREDEFINED Under SECTION V.= DEFINTIONS, definition C. is replaced by,the.foll'owing , "Bodily, injury" means physical injury, sickness or disease.sustained by a person, including mental anguish, mental injury, shock, fright or death resulting .from. any.af these at any time. COMMMON POLICY CONDITIONS 23. EXTENDED CANCELLATION :CONDITION COMMON. POLICY CONDITIONS, paragraph A. —CANCELLATION. condition applies except as fol- lows: If we cancel for any reason other than nonpayment of premium, we wifl mail to the first 'Narned Insured written notice of cancellation at least 60 days before the effective date of cancellation: This provision does not'apply'in those states which require more.than 6.0 days prior noticevfco ceila- tion. O- 2019 Liberty Mutual Insurance CA 8810 01 13 Includes copyrighted,niaterial of Insurance. Services dffice,•inc., with its permission. Page, 7 of COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be primary contrary: and would not seek contribution from any other Primary And Noncontributory Insurance insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WG 99 04`16M (Ed., 9-14) WAIVER'OF OUR RIGHT TO: RECOVER FROM .OTHERS ENDORSEMENT- CALIFORNIA BLANKET BASIS 'We have the right to,recover our payments from anyone liable for an injury -covered by this policy:.Weswill not enforce our right against.the person:or organization. named in the Schedule. (This.agreementapplies only to the extent.that you: perform work under'a written contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be 2% of the -total manual premium otherwise due on such remuneration. The, minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE BLANKET WAIVER PersonfOrganization Blanket Waiver— Any_person�or organization; for whom thel Named :Insuredhas.. 'agreed by written contract.to furnish this ,waiver:. Job Description Walver Ptemlum All CA Operations 30.41.00 This endorsement changes the policy to which it is attached and is effective on the date Issued uniess otherwise stated. (The Information below Is required only when this endorsement Is Issued subsequent to preparstlon;of the pollcy.)` Endorsement Effective 02/19/2017 Insured Insurance Company Cypress Insurance Company WC 99 04105 (Ed. 9A 4) Policy No: PAWC811288 Countersigned by Endorsement -No. Premium.$. PACIF-5 OP ID: Z1 '4�a►sz® CERTIFICATE ®F LIABILITY INSURANCE FDATE(MMIDDIYYYY, �� 08/10/2017 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.feu of Such endorsement(s). PRODUCER NAMEACT Lisa Malvido Bozzuto & Associates Insurance PHONE 800-989-8712 FAX No:408-429-8460 34 S. Second. St. Arc No Exc Campbell, CA 95008 E-MAIL ADDRESS: V lisam//��dbinsurance.com P Linda Ellis - - INSURERS) AFFORDING COVERAGE NAIC # INSURED Pacific Plumbing & Sewer Service, Inc 329 Sango Ct Milpitas, CA 95035 u, r��ovM. INSURERA:Navigators Specialty Insurance 36056 INSURERB:American Fire and Casualty Com 24066 INSURER C: Mercer Insurance Company 14478. INSURER D: Cypress Insurance Company 10855 INSURER E: Ohio Casualty Insurance Co 24074 INSURER F: Homeland Insurance Company of 134452. RFVlglOKI Nil IMRFR- l+V V r_mm V GJ 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. ILNSIRTR TYPE OF INSURANCE R - POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 'REMISES Ea occurrence $ 50,000 CLAIMS -MADE ❑X OCCUR X SF17CGL0196271C 02/19/2017 02/19/2018 MED EXP (Any one person) $ 5,000 ' PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 PRO- POLICY JECT ❑ LeC Emp Ben. $ . 1,000,000 POTHER: Ea acccideDISINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ X X BAA 56378613 02/24/2017 02/24/2018 B ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED PROPERTY DAMAGE Peracciden' $ HIREDAUTOS - AUTOS X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB - CLAIMS -MADE 27304874 02/19/2017 02/19/2018 AGGREGATE $ 5,000,000 DED RETENTION$ $ COMPENSATION - X PER OTH- STATUTE ER D WORKERS AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ X PAWC811288 02/19/2017 02/19/2018 E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below _ E Equipment BM056378613 - 02/01/2017 02/01/2018 Schd Tool 114,19 F Pollution 793-00-56-49-0000 12/30/2016 12/30/2017 Liability .1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Capital Improvement Projects, 295 California Street, Campbell. City of Campbell, its officers, employees and volunteers are included as an additional insured on General Liability and Automobile Liability policies per the attached endorsements.General Liability policy is primary and non- contributory per the attached endorsement. Waiver of Subrogation <<Contld>> 1ir� CERTIFICATE CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 N. First Street Campbell, CA 95008 AUTHORIZED REPRESENTATIVE IJ 1968-ZU14 ACUKU L:UKVUKA I IUIV. An rignts reservea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD PACIF-5 - OP ID: Z1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/10/2017 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 BOZZuto & Associates Insurance 34 S. Second St Campbell, CA 95008 CONTACT NAME: Lisa Malvido " PHONE g00-989-8712 A/X, No : 408-429-8460 A/C No Ext E-MAIL, S: l_+ ADDRESS: lisam/� dbinsurance.com Linda Ellis INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Navigators Specialty Insurance 36056 INSURED Pacific Plumbing & Sewer Service, Inc 329 Sango Ct Milpitas, CA 95035 INSURER B: American Fire and Casualty Com 24066 INSURER C : Mercer Insurance Company 14478 INSURER D:Cypress Insurance Company 10855 INSURER E: Ohio Casualty Insurance Co 24074 INSURER F: Homeland Insurance Company of 34452 ! _ IrfmAI =c - r`GaTIGICATE NUMBER: REVISION NUMBER: l.V V LI�AVLV 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 SHOW_ N MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE L - POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDlYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE S " 1,000,000 CLAIMS -MADE OCCUR' ' X SF17CGLO196271C _ 02/19/2017 02/19/2018 ' PREMISES Ea occurrence $ 50,000 _ MED EXP (Any one person) $ - 5,000 PERSONAL & ADV INJURY $ 1,000,000 _ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 $ 2,000,000 PRO- F-]PRODUCTS-COMP/OPAGG :.POLICY ®JECT LOC OTHER: - �- Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY Ea aBINEDISINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ 13 X ANY AUTO X BAA56378613 02/24/2017 02/24/2018 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ $ X' UMBRELLA LIAB "X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 C EXCESS LIAB CLAIMS -MADE 27304874 02/19/2017 02/19/2018 DED RETENTIONS $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ' ❑NIA (Mandatory in NH) X PAWC811288 02/19/2017 02/19/2018 X PER STATUTE EORH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 -E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E Equipment BM056378613 02/01/2017 02/01/2018 Schd Tool 114,19 F Pollution 793-00-56-49-0000 12/30/2016 12/30/2017 Liability 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) " Re: Capital Improvement Projects, 295 California Street, Campbell. City of Campbell, its officers, employees and volunteers are included as an additional insured on General Liability and Automobile Liability policies per the attached endorsements.General Liability policy is primary and non- contributory per the attached endorsement. Waiver of Subrogation <<Cont'd>> CERTIFICATE HOLDER — GANI.tLLA I IUN CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 N. First Street Campbell, CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (20114/01) . The ACORD nacre and logo are registered miarks Of ACORD