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ENC2017-00200of Cq,� •UkcHA0 CITY of CAMPBELL Public Works Department June 11, 2018 Camacho Construction 8121 Jackson St. Paramount, CA 90723 SUBJECT: PERMIT NO. ENC 2017-00200 766 E. Campbell Ave., Campbell, CA FINAL INSPECTION AND ACCEPTANCE To Whom It May Concern: 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, nSvye--'Wahidi Public works Inspector 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAx 408.376.0958 • TDD 408.866.2790 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR_FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00200 Name: Camacho Construction Property Address: E. Campbell Ave. Easterly R/W, SR17 Date of Final Inspection: 6/11/18 On File: Bonds CD Cash Faithful Performance: $ Plan Check Deposit: $ Construction Cash Deposit to be released: R0M D e Other overdue deposits to be released (Description): Processed by: Reviewed by: Reviewed by: inistrator Inspector Land Development Engin er J:VoAnnaT\Deposit refunds\CHECKLISTS\Camacho Construction.doc (Rev. 10/11) Print Form f CITY OF CAMPBELL L ENCROACHMENT PERMIT Permit No _Z6`,'©oZno DEPT. OFPUBLICWORKS (forworkingwithin the public X-Ref. File _ 70 North First Street right- f-way)' Application Date Z 1 Campbell, CA 95008 Issued 'Z Application Expiration Ph. (408) 866-2150 APN Fx. (408)376-0958 !z 1 Permit Expiration Date 1 APPLICATION -Application is hereby made fora Public Works Permitin accord ce wit Campbell Municipal Code, Section 11.04_ (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No-: JEast Campbell Ave at Easterly R/W, SR 17 Utility Trench Location: B. Nature of Work: 7 connected by 75 feet of wire to an Eruv�j ole adjacent to access control fence end p,,,aos��t on the north tide of Campbell Avenue west of SR 17. 1 L,gy1 C�(.t `� , [� Ci -L—OAJS C. Attachfour(4)copiesofan,engineeredplanshowingthelocationandextentofthewor�-endfour(4)copiesoftheprehmmary Engineer's C��r 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. All work shall conformto 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 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 begiven to Public Works at least24 hours before restartingany work. t Name of Applicant: w�l�ry ��` :, Telephone: Address: I P,,- E-MailAddress: 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? ❑ YES �NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbbel-1,--ii?s officers, agents, and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicarit/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 any and all damages arising out of improvements completed in the public right-of-way. Accepted: (Applicant Permittee) (sign) Date Camacho Construction 0 D I 1 �( ( i -7 (Contractor) (Print Name) Date SPECIAL PROVISIONS: ❑ 1. Street shall not be opencutforundergroundinstallations.Minimumcutsmaybeallowedforconnectionsorexplorationholes_Suchcutsmaybe specifically approved by the Inspector prior to cutting. ❑ 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", 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. ❑ 5. 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 PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEP051T PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE AMOUNT RECEIPT NO. 2% '1 CLA,v S 47.6 — 277 1 4`13It I APPROVED FOR ISSUANCE For City Engineer Permit Expires 12 Months After Date of Issuance Date GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained for the 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 theCity'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 shalt 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 Gry 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 maybe 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 WQ2014-0174- DW.Q. Said vault water shall not be discharged into the City of Campbell's storm drain system. See htr)://www.%va terb oa rds.mgov/water issues/programs/nodes/utilityvauits slitml for more information. Applicant isherebyresponsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. Applicant ✓___.-- Camacho Construction Theodore D. Camacho / Contractor (Print Name) J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 03/17 Date: 8/14/2017 Date: PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2017 TO: Finance PUBLIC WORKS FILE NO. C- PROPERTY ADDRESS Please collect & receipt for the following monies. ENCROA;-HMr 4722, Utility Encroachment Permit Application Fee $455.00 R-1 Encroachment Permit N/C .. . ........... Emergency . rmits errnits $130.00 ... . ..... . qqy Pe Plan Check &-Inspection Fee. ------- Minimum Charge Per Location $420.00 Zv CSC — --------- 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 $1 90.00/ea 4760 Storage Container Permit (valid u.0 to 60 days only $170.00 4760 Pr 'ect Plans & Specifications Project No._.___. . . .... 4760 Standard Specifications & Details $1/Pg $15,50/B. 4760 Engineering Maps & Plans Aerial Plot 24" x 36" $65.00 Aerial Print 8 1/2" x 11 $32.00 Map Research (includes max of two 24"x36" copies) $32.00 Maps and Plans 24" x 36" $15.00 4722 Penalties: Failure to restore improvements Sloo/Calendar Day (Muni Code Sec. 11.34.0 10) 4722 Penalties: Failure to correct unsafe conditions $1 OO/Calendar Day 4722 Work Without Permits- 4 Times Applicable Fee/Min. $500 TRAFFIC -7' 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 �78 Signal Timing Information $73-per hour­­­­­ 427-i Truck Permits $16.00 per trip 4.728 No Parking Signs $1 each or $25/100 WS'CEEMNE0 51 1.-MR Postage 1 Other (Please Specify) TOTAL NAME OF APPLICANT ...... ... NAME OF PAYOR y\(, v PHONE . ... ............ . ADDRESS IS01-1 I11<v, 4011, Avf ,JQ zip � S, 1-r FOR RECEIVED CITY CLERK ONLY Date. ... 4pt F.a.0,41y e. ht:. 57-1Z.,ia Policy Number XN1 07583400 Date Entered: 8/9/2017 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 8/9/2017 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 endorsements . PRODUCER NAME:DT Joseph Pappalardo CA Contractors Insurance Services, Inc. 9848 Business Park Drive INCN , EHI, (916) 363-2663 lac, Nop (916) 363-2662 EMAIL JPappalardo@ccisbonds.com ADDRESS: Suite H INSURERS) AFFORDING COVERAGE NAIC # Sacramento, CA 95827 INSURER A: AmTrust International Underwriters, Ltd. AA1780074 INSURED INSURER B: CAMACHO CONSTRUCTION INSURER C: 8121 JACKSON STREET PARAMOUNT, CA 90723 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF THE 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 RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE NSRL WVo POLICYNUMBER (MWDDYIYYYY) (MMIDIDNYM LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR ® ® XN107583400 $/8/2017 $I$J2O18 EACH OCCURENCE 1,000,000 DAMAGE TO RENTED PRE ISES (Ea occurencel $ 10,00 MED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP-AGG $ 2,000,000 POLICY PROJECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO El ❑ BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE (Per accident) $ HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR ❑ ❑ EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N N/A ❑ WC STATU- OTH- TORY LIMITS ER E. L. EACH ACCIDENT $ ANY PROPRI ETOR/PARTNER/EXECUTI VE E. L. DISEASE -EA EMPLOYEE $ (Mandatory in N/H) Ifyes, describe under DESCRIPTION OF OPERATIONS below E. L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONSILOCATIONS NEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Job locations: 766 E Campbell Ave., Campbell CA and 1256 Camden Ave., Campbell Ca. City ofCcampbell, its officers, employees and volunteers are named as Additional Insured. The insurance coverage afforded to the Additional Insured is primary insurance. All work in the public right-of-way. License # 1012599 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Campbell 70 N. First St EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Campbell, CA 95008 tedcamacho1956@gmail.com ACORD 25 (2010/05) 0 1 988-201 0 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERICAL GENERAL LIABILITY CG 20 37 07 04 Policy#: XN107583400 Insured Name: CAMACHO CONSTRUCTION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART V Name of Additional Insured Person(s) or O!ganizatlon(s): Location and Description of Completed Operations CITY OF CAMPBELL INSTALLING CHAIN LINK FENCE POSTS ONLY LOCATION 1:766 E CAMPBELL AVENUE, CAMPBELL, CA. 95008 LOCATION 2: 1256 CAMDEN AVENUE, 70 N FIRST ST CAMPBELL CA. 95008 CAMPBELL CA 95008 Information required to complete this Schedule, if not shown above, will be shown in the declarations Section 11 -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". CG 20 37 07 04 Copyright Iso Properties, Inc.. 2004 Page I of I Insured POLICY NUMBER: XN107583400 COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, AWL 1 11:4- - r : i This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: XN107583400 Endorsement Effective: 8I912017 12:01 a.m. Named Insured: THEODORE DANIEL Counter Signed By: CAMACHO CAMACHO CONSTRUCTION SCHEDULE Nance of Person or Organization: CITY OF CAMPBELL 70 N FIRST ST CAMPBELL CA 95008 Location: LOCATION 1: 766 E CAMPBELL AVENUE, CAMPBELL, CA. 95008 LOCATION 2: 1256 CAMDEN AVENUE, CAMPBELL CA. 95008 (If no entry appears above, information required to complete this endorsementwill be shown in the Declarations as applicable to this endorsement) A. Section II —Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to"bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than services, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed: or (2) 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. The words "you" and "your" refer to the Named Insured shown in the Declarations. NX GL 189 05 11 Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission D. The following are added to SECTION V— DEFINITIONS: "Your work" means work or operations performed by you or on your behalf, and materials, parts or equipment furnished in connection with such work or operations. E. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: Primary Wording With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you underwritten contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. 2. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. NX GL 189 0911 Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission AmTrust International Underwriters, DAC Policy Number: XN107583400 P.O. Box 318004 Cleveland, OH 44131-0880 Named Insured: THEODORE DANIEL CAMACHO FACAMACHO CONSTRUCTION COMMON POLICY DECLARATIONS Policy Number XN 107583400 Policy Period From: 08-08-2017 To: 08-08-2018 12:01 A .M. Standard Time at the Named Insured's Address Transaction NEW BUSINESS Named Insured and Address Producer THEODORE DANIEL CAMACHO BUILDERS & TRADESMEN'S INS SVC CAMACHO CONSTRUCTION 6610 SIERRA COLLEGE BLVD 8121 JACKSON STREET ROCKLIN, CA 95677 PARAMOUNT, CA 90723 Telephone: (877) 649-6682 Business Description Type of Business Audit Period CARPENTRY -CONSTRUCTION OF RESIDENTIAL PROPERTY NOT Individual EXCEEDING THREE STORIES IN HEIGHT IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. COVERAGE PART DESCRIPTION PREMIUM Commercial General Liability Coverage Part Limited Terrorism Premium Minimum Retained Audit Premium $ Forms applicable to all Coverage Parts: See Forms and Endorsements schedule $ 2,847.00 $ Not Covered TOTAL PREMIUM FOR THIS COVERAGE PART $ OTHER CHARGES: POLICY FEE $ STATE TAX $ STAMP FEE $ TOTAL DUE $ Minimum Retained Premium $ 2,847.00 175.00 90.66 6.04 3,118.70 These Declarations together with the common policy conditions, coverage declarations, coverage form(s) and form(s) and endorsements, if any, issued, complete the above numbered policy. Issued Date: 08-09-17 Authorized Representative „ 3'1` Name of Surplus Lines Broker License Number LAE Insurance Services, Inc. OE44215 CPPMDEC CA-B 0212 -INSURED- Page 1 of 1 AmTrust International Underwriters, DAC Policy Number: XN107583400 Named Insured: THEODORE DANIEL CAMACHO CAMACHO CONSTRUCTION FORMS AND ENDORSEMENTS SCHEDULE Coverage Form Ed. Date Description CPPMDEC CA-B 02 12 Common Policy Declarations GL330000 B 01 12 Commercial General Liability Declarations GL33000B B 01 12 Commercial General Liability Extension of Declarations CCP330004 AIUL 12 12 Read Your Policy Carefully CPS33002 1211 Policyholder Notice - Service Of Process D-2 01 /17 California Disclaimer AIUL PN 01 13 Privacy Policy 49-0106 07 15 Policyholder Disclosure Notice Of Terrorism Insurance Cov. 49-0157 06 13 Independent Contractors Limitation Endorsement CG 0001 1207 Commercial General Liability Coverage Form CG 00 55 03 97 Amendment of Other Insurance Condition -Occurrence Version CG 03 00 01 96 Deductible Liability Insurance CG 21 01 11 85 Exclusion.- Athletic or Sports Participants CG 21 16 07 98 Exclusion - Designated Professional Services CG 21 32 05 09 Communicable Disease Exclusion CG 21 34 01 87 Exclusion - Designated Work (in New York and Colorado) CG 21 34 10 12 Exclusion - Designated Work CG 21 34 ES 01 87 Exclusion - Designated Work CG 21 36 0305 Exclusion - New Entities CG 21 46 07 98 Abuse or Molestation Exclusion CG 21 49 09 99 Total Pollution Exclusion Endorsement CG 21 53 01 96 Exclusion - Designated Ongoing Operations (NY and CO) CG 21 54 01 96 Exclusion - Designated Operations Covered By a Consolidated (Wrap-up) Insurance Program CG 2243 07 98 Exclusion - Engineers, Architects or Surveyors Professional Liability CG 22 79 07 98 Exclusion - Contractors - Professional Liability CG 2426 07 04 Amendment of Insured Contract Definition ID THEFT PROT Personal Internet & Identity Coverage IL 00 03 09 08 Calculation Of Premium IL 00 17 11 98 Common Policy Conditions NX GL 004 0809 Amendment - Common Policy Conditions NX GL 005 11 10 Policyholder's Guide to Reporting a Casualty Claim NX GL 014 08 09 Temporary and Volunteer Worker Exclusion NX GL 053 08 09 Exclusion - Continuous, Progressive or Repeated Offenses NX GL 066 08 09 Exclusion - Prior Work Completed, Sold or Abandoned NX GL 080 0809 Exclusion - Residential Conversion NX GL 089 08 09 Exclusion - Subsidence NX GL 114 08 09 Non -Duplication of Limits of Insurance Endorsement NX GL 147 05 10 Exclusion - Open Roof NX GL 164 09 10 Exclusion - Action Over NX GL 182 05 11 Exclusion - Alarm Monitoring NX GL 183 05 11 Exclusion - Designated Work Construction Management for a Fee NX GL 184 05 11 Wrecking of Buildings or Structures Limitation NX GL 189 05 11 Blanket Additional Insureds - Owners, Lessees Or Contractors NX GL 190 05 11 Additional Exclusions CG 21 73 01 15 Exclusion of Certified Acts of Terrorism NX GL 062 01 12 Exclusion - Designated Residential Construction Work Issued Date: 08-09-17 Page 1 of 1 CPPMFORMSCHED FAAmTrust International Underwriters, DAC P.O. Box 318004 Cleveland, OH 44131-0880 Policy Number XN107583400 Transaction NEW BUSINESS Named Insured and Address THEODORE DANIEL CAMACHO CAMACHO CONSTRUCTION 8121JACKSON STREET PARAMOUNT, CA 90723 GENERAL LIABILITY COVERAGE PART Policy Period From: 08-08-2017 To: 08-08-2018 12:01 A .M. Standard Time at the Named Insured's Address Producer JE072 J E P CAPITAL INC CALIFORNIA CONTRACTORS INS SRVCS INC PO BOX 278238 SACRAMENTO, CA 95827 Telephone: (916) 363-2663 Business Description Type of Business Audit Period CARPENTRY -CONSTRUCTION OF RESIDENTIAL PROPERTY NOT Individual EXCEEDING THREE STORIES IN HEIGHT IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. LIMITS OF INSURANCE General Aggregate Limit (Other than Products -Completed Operations) Products - Completed Operations Aggregate Limit Each Occurrence Limit Personal and Advertising Injury Limit Medical Expense Limit, any one person Damage to Premises Rented to You Limit, any one premises AMENDED LIMITS OF LIABILITY Refer to attached schedule. LOCATIONS OF ALL PREMISES YOU OWN, RENT OR OCCUPY Refer to attached schedule. CLASSIFICATIONS Refer to attached schedule. $ 2,000,000 $ 2,000,000 $ 1,000,000 $ 1,000,000 $ 5,000 $ 100,000 These Declarations together with the common policy conditions, coverage declarations, coverage form(s) and form(s) and endorsements, if any, issued, complete the above numbered policy. Issued Date: 08-09-17 GL330000 B 0112 Page 1 of 2 -INSURED- FiAmTrust International Underwriters, DAC P.O. Box 318004 Cleveland, OH 44131-0880 COMMERCIAL GENERAL LIABILITY EXTENSION OF DECLARATIONS Policy Number: XN107583400 Named Insured: THEODORE DANIEL CAMACHO CAMACHO CONSTRUCTION LOCATION OF PREMISES Location of All Premises You Own, Rent or Occupy: 1-1. 8121 JACKSON STREET, PARAMOUNT, CA 90723 PREMIUM Rate Advance Premium Location Classification Code No. Exposure Basis Prem. Ops. Prod/Comp Prem.Ops. Prod/Comp Ops. 1- 1 CARPENTRY -CONSTRUCTION 91340 52,000 (p) INCL 51.212 INCL 2,663 OF RESIDENTIAL PROPERTY NOT EXCEEDING THREE STORIES IN HEIGHT 1- 1 CONTRACTORS -SUBCONTRACT 91585 35,000 (C) INCL 5.271 INCL 184 WORK-IN CONNECTION WITH CONSTRUCTION, RECON- STRUCTION, REPAIR OR ERECTION OF BUILDINGS Extension of Declarations — Total Advance Annual Premium 2,847.00 Includes copyrighted material of Insurance Services Off ice, Inc., w it h it s permission. Copyright, Insurance Services Off ice, Inc. Issued Date: 08-09-17 GL33000B B 0112 -INSURED- Page 2 of 2 THEODCA-01 CHCA A4C-wJr15n CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) 8122/222/2017 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 CONTACT NAME: Automatic Data Processing Insurance Agency, Inc 1 ADP Boulevard Roseland, NJ 07068 PHONE FAX Alc No Ext : A/c No: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:WeSCO Insurance Company INSURED THEODORE D CAMACHO INSURERB: INSURERC: CAMACHO CONSTRUCTION INSURER D : 8121 Jackson St Paramount, CA 90723 INSURER E : INSURER F : 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 ADDL S SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DDIYYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ KEN'LAGGREGATELIMITAPPLIESPER: POLICY PRO-LOC Jr PRODUCTS -COMPIOPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SINGLE LIMIT Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ S UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WWC3275757 4/13/2017 4/13/2018 X WC STATU- OTH- TORY LIMITS ER E.LEACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) A waiver of subrogation in favor of certificate holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell Y P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 70 N. First St Campbell, CA 95008- AUTHORIZED REPRESENTATIVE ........... _... y. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Wesco Insurance Company 800 Superior Avenue East, 21st Floor Cleveland, OH 44114 Policy Change Endorsement CAMACHO, THEODORE D. (AN INDIVIDUAL) ADP Insurance Services - Pittsburgh DBA: CAMACHO CONSTRUCTION 1 ADP Blvd. 8121 JACKSON ST Roseland, NJ 07068 PARAMOUNT, CA 90723 Enclosed is a Policy Change Endorsement for Policy Number: WWC3275757 For Policy Change Endorsements, please retain one copy for your files and provide the second to the policyholder. For questions, please contact our Underwriting Office at: 877-528-7878. 8/22/2017 AmTrust North America An Amirust Financlal':Company WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B POLICY INFORMATION PAGE ENDORSEMENT Insured: Camacho, Theodore D. (An Individual) Policy No: WWC3275757 DBA: Camacho Construction Policy Period: 4/13/2017 to 4/13/2018 Endorsement No: 7 Carrier Name: Wesco Insurance Company Endmt Effective: 8/7/2017 Authorized Rep: The following item(s) ❑ Insured's Name (WC 89 06 01) ❑ Policy Number (WC 89 06 02) ❑ Effective Date (WC 89 06 03) ❑ Expiration Date (WC 89 06 04) ❑ Insured's Mailing Address (WC 89 06 05) ❑ Experience Modification (WC 89 04 06) ❑ Producer's Name (WC 89 06 07) ❑ Change in Workplace of Insured (WC 89 06 08) ❑ Insured's Legal Status (WC 89 06 10) ❑ Item 3.A. States (WC 89 06 11) is changed to read: ❑ Item 3.13. Limits (WC 89 06 12) ❑ Item 3.C. States (WC 89 06 13) ® Item 3.D. Endorsement Numbers (WC 89 06 14) ® Item 4.* Class, Rate, Other (WC 89 04 15) ❑ Interim Adjustment of Premium (WC 89 04 16) ❑ Carrier Servicing Office (WC 89 06 17) ❑ Interstate/Intrastate Risk ID Number (WC 89 06 18) ❑ Carrier Number (WC 89 06 19) ❑ Issuing Agency/Producer Office Address (WC 89 06 25) Specific Waiver of Subrogation is added to the policy in favor of: City of Campbell 70 N. First St, Campbell, CA 95008 Class code 5146 - $7,500 Adding form WC040306 Wesco Insurance Company WC 99 00 01 C 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Insured: Camacho, Theodore D. (An Individual) Policy Number: WWC3275757 EXTENSION OF INFORMATION PAGE FOR ITEM #4 ITEM 4: SCHEDULE OF PREMIUMS Premium Basis Rate Per $100 Estimated # of Code Total Est. Annual of Annual Classification Emps No. Remuneration Remuneration Premium California Cabinet or Fixtures 1 5146 25,000 15.19 3,798 Manual Premium 3,798 Total Manual Premium 3,798 Waiver of Subrogation: City of Campbell 70 N. First St, Campbell, CA 95008 0930 250 Total Premium Subject To Experience Modification 4,048 Experience Modification N/A 4,048 California Territorial Factor 1.2 810 Terrorism 9740 8 Catastrophe (other than Terrorism) 9741 2 Expense Constant 0900 200 Total CA Premium 5,068 CIGA 2% 9999 101 WCARF 0.3128% 9999 16 UEBTF 0.0721% 9999 4 SIBTF 0.1335% 9999 7 OSHAF 0.2305% 9999 12 LECF 0.1918% 9999 10 FRAUD 0.1675% 9999 8 Total CA Cost 5,226 TOTAL ESTIMATED ANNUAL PREMIUM 5,068 STATE ASSESSMENT 158 TOTAL COST 5,226 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER Of OUR RIGHT To RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA 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. (This agreement applies only To the extent that you perform work under a written contract that requires you To obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration Of your employees While engaged In the work described In the Schedule. The additional premium For this endorsement shall be 5% Of the California workers' compensation premium otherwise due on such remuneration. Person or Organization City of Campbell Campbell, CA 95008 Schedule Job Description Specific waiver per written contract This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 4/13/2017 Policy No. WWC3275757 Endorsement No. 7 Insured Camacho, Theodore D. (An Individual) Premium $ 5068 Insurance Company Wesco Insurance Company Countersigned by WC 04 03 06 (Ed. 04-84) Amtrust North America, Inc. Wesco Insurance Company 800 Superior Avenue East, 21st Floor Cleveland, OH 44114 PAYO Net Rate Schedule Payroll Company: ADP Insurance Services Payroll Co Phone: One ADP Blvd, MS 325 Payroll Co Email: Roseland NJ 70680 Print Date: 9737123500 SBSIS_Implementation@adp.com 8/22/2017 Policy Insured Fein New/Renew Effective Expiration Agent ADP Insurance Services - WWC3275757 Camacho, Theodore D. (An Individual) 272780614 New 4/13/2017 4/13/2018 Pittsburgh Eff Date State Class Classification Net Rate 4/13/2017 CA 5146 Cabinet or Fixtures 0.196574 [PolicyListPayoByPayrollCo] INSURANCE REQUIREMENTS CHECKLIST Permit # 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 c7hG 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 16 l � I R, •� 1 Automotive Liability:. .id —"Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage * Policy expiration date 1 �q Workers' Compensation and Employer's Liability Z� Waiver of Subrogation clause $1,000,000 per accident for bodily i jury or disease (� ,cP`—Policy expiration date V3 Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies U` `t P> ( Yel4te& CpS Lp'CCA- 0 2k Additional Insured Endorsement (Description of Operations Area) ❑ The City, its officers, employees and volunteers are named as additional insured. 77- I (Reference Project Location & Permit Number) V1 The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read ❑ Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. \\Honouliuli.cityhall.d.campbell.ca.us.loca[\Profile_Data$\ioannat\Desktop\All Insurance Requirements.doc (Rev 03/13) Page 1 of 1 ❑ Workers' Compensation Insurance Sheet Submitted ❑ For 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. Name: �,)SeSCD CO NAIC # Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License # �Z r'✓�x ��� l 0 Insurance Certificate Reviewed Date o Copy of Insurance Certificate placed in tickler file one month prior to expiration. \ q I o' Z- ( q 1 1 �.d C] I&t 5S �.5 C:\Documents and Settings\ioannat\Desktop\Insurance Requirements 2 pgs.doc (Rey 03/13) Page 2 of 2 AIIt_ ® CERTIFICATE OF LIABILITY INSURANCE F77om8/24/2017 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 pollcy(les) must be endorsed. If SUBROGATION IS WANED, 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 ESNJ Financial & Insurance Services LIC# OF52947 7018 Dove Valley Way CONTACT Eder Sanchez NAME: ac No Ent : (909) 962-0102 ac Ne : (888) 787-5927 E-MAIL Eder@ESNJfinancial.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC q Eastvale CA 92880 INSURER A: Intinity Auto insurance Company 11738 INSURED Coastline Installation INSURER B: INSURER C: INSURER D: 4216 South Olive Street INSURER E• Los Angeles CA 90037 INSURER F: COVERAGES CERTIFICATE NUMRFRr RFVICInPJ NI IMRFR- 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. NSR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED MED EXP(Anyone person) $ CLAIMS -MADE OCCUR PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENLAGGREGATE LIMIT APPLIES PER PRODUCTS- COMPIOPAGG $ POLICY PROJ- ECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO BODILY[NJ URY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON -OWNED 504610094818001 08/07/2017 08/07/2018 PROPERTYDAMAGE AUTOS Per accident $ UM/UIM $ 100,000 UMBRELLALVIB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY YIN TORY LIMITS ER E.L. EACH ACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? NIA E.L DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, U mom apace Is required) The City of Campbell its officers, employees, and volunteers are named additional insured. The insurance afforded to the additional insured is primary insurance. All work in the public right of way. 30 days notice of cancellation 110 days notice for non-payment of premiuim City of Campbell Department of Public Works 70 N. First Street Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORED REPRESENTATIVE CA 95008 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD CITY OF CAMPBELL ANNUAL STREET MAINTENANCE PROJECT 18-BB: AUDREY AVE AND HACK AVE " DIGOUT LOCATIONS AND QUANTITIES FOR OBURN COURT (as of 05/29/18) Number Location Description Length (LF) Width (LF) Area (SF) 1 In front of 1510 Oburn 6.5 6.5 42.25 2 In front of 1509 Oburn 6.5 6.5 42.25 3 In front of 1506 Oburn Driveway 18 6.5 117 4a In front of 1504 Oburn 76 6.5 494 4b 24 4 96 f 5a In front of 1106 Audrey Ave (Oburn Ct Side) 6.5 6.5 42.25 5b 6.5 6.5 42.25 6 ".. SE corner ofi0burn Ct at Audrey Ave 19 6.5 123.5 999.5 L-ovL tom-` 00 i o 86 L L D c �(o ito t'o � 5' 4 (2 5 3 L'" ( Ywc)L t' ax-L S 41 ( z s 1 Ak� C_ �. 4-$ -V C. --;7 r J "" 1'p � me+ l�Z �s � 35' too 5-13. go 4CIF fly ®4 3l8 - j—_ -4t,4,Z,F3 CITY OF CAMPBELL ANNUAL STREET MAINTENANCE PROJECT 18-BB: AUDREY AVE AND HACK AVE REVISED DIGOUT/SKIN PATCH LOCATIONS AND QUANTITIES (as of 05/22/18) NumberlLocation Description Length (LF) Width (LF) Area (SF) 1 In front of 1248 Audrey Ave 30 13 390 2 In front of 1240 Audrey Ave t9- to -7' (0 G3'0 3 In front of 1240/1230 Audrey Ave 44 7 308 4 In front of 1230/1220 Audrey Ave 12 7 84 5 In front of 1210 Audrey Ave 33 7 231 6 7 In front of 1206/1200 Audrey Ave NUMBER In front of 1197 Audrey Ave 122 NOT IN USE 33 7 _M. 6.5 854 214.5 8 9 In front of 1044 Audrey Ave 87 5 435 10 At the intersection with Vale Ave 70 7.5 525 11 In front of 998 Audrey Ave 12 6.5 78 12 In front of 1009/1019 Audrey Ave 29 44 &(0.5" 130.5 13 In front of 1027 Audrey Ave 10 7 70 14 In front of 1027 Audrey Ave 51 -6:s- 153 15 In front of 1051 Audrey Ave 30 15-13, 16 In front of 1079 Audrey Ave 31 6, 42� 17 In front of 1089 Audrey Ave 25 7 175 18 In front of 1159 Audrey Ave 6 6., ' &.57 30- 19 In front of 1550 Hack Ave 8 3 24 _ 20 In front of 1543 Hack Ave 5 3 15 21 In front of 1566 Hack Ave 11 3 33 22 In front of 1584 Hack Ave 6 2 12 23 Near the SW corner of Hack at W. Parr 4 4 16 24 In front of 1235 Audrey Ave 17 &-.,a �- 1$2- 25 In front of 1225 Audrey Ave 29 6-.--5,6 S 1.4-7' 26 In front of 1215 Audrey Ave 5 27 In front of 1525 Hack Ave 31 3 93 28 In front of 1235 Audrey Ave 14 4 56 29 In front of 1056 Audrey Ave 7 6 42 30 In front of 1032 Audrey Ave 5 5 25 31 In front of 1032 Audrey Ave 12 3 36 -'21E6LLAar Aijreg @ 8. 1�Z NEW TOTAL: 4634 SF Bid Item #8 Bid QTY: 3992 SF Difference 642 SF Percent QTY Above Bid: 16.08% SEE EN BAR GEM EN ftuS '^ h This encroachment permit (EINC2017-00200) is approved only for the placement of the wire over East Campbell Avenue as shown on this plan. Installation of the poles requires a separate permit from Caltrans for working in their right-of-way. i ERU V POLE ADJACENT ACCESS CONTROL FENCE END POST. ., PH=20 ±, POLE TO FC = 21 ±__-- "� ERUV POLE ADJACENT ACCESS 'R -CONTROL FENCE END POST. : PH=20'±, POLE TO FC = 46'± I EXISTING ELECTROLIER r EXISTING ELECTROLIER� (OVER CAMPBELL AVE.) WS=130'± C rn ■ GRAPHIC SCALE 1" = 10' i l I y Mn Of = m mF0 Y Ul = N a o a 5i � a= mY a@ V J U r�i V7 TVA C � ao 83 c a a� a C m r n` — � 1 o+ W N 3�K � o0 w �S 3 + �o SS A6 Q eg�g F- J m a se = Z U 46 6 W D oa W C 9e 0 J ® > $s �- W () s" W a°7 cr s ° W < W W e� U U) 7s z O, (n os W Z a �( W - K 0 60 cn '^ .G C/, Z eg (n Scale NTS 5s Date 04-20-2017 as 5= 6$ d of 3 Sheets 3? ge Job No.12044A W O H Drawing SH01 O 1 Orating Fla: Q\Ci„1\12044A\DMg\Exhibits\CSJ ERUV\CAD\CITY OF CAMPBELL\ ELECTROLIER WIRE FOR ROGER.tl„g A,, 20. 2017 — 9: 51am FRII C—\— OF C"PREL \ ELECTROUER WIRE FOR ROGER.d.a ' EGEND : r WORKAREA 'k CONE CITE: WORK WILL NOT IMPEDE INTO ROADWAY OR SIDEWALK 'EED LIMIT:_ _ __.. SHOULDER TAPER LENGTH: I SIGN SPACING: _ I CONE SPACING:_ ALL PLANS MUST BE CHECKED AND APPROVED BY THE GOVERNMENTAL AGENCY, ORAGENCIES, HAVING JURISDICTION OVER THE ROADWAYS SHOWN ON THIS PLAN PRIOR TO THE PLAN BEING PUT INTO EFFECT. ALL PLANS ARE INTENDED TO CONFORM TO THE MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES (M.U.T.C.D. THE CUSTOMER / CONTRACTOR IS RESPONSIBLE FOR ASCERTAINING ADDITIONAL AGENCY REQUIREMENTS FOR WORK HOURS ALLOWED, NOISE ABATEMENT, AND OTHER RULES AND REGULATIONS. THE TEMPORARY TRAFFIC CONTROLS MUST BE INSTALLED PER THE AGENCY APPROVED PLAN TO BE EFFECTIVE. FIELD CHANGES, OTHER THAN MINOR ADJUSTMENT, MUST BE AUTHORIZED IN WRITING BYA REPRESENTATIVE OF THE GOVERNMENTAL AGENCY, OR AGENCIES, HAVING JURISDICTION OVER THE ROADWAY. PLAN IMPLEMENTATION AND DEVICE PLACEMENT SHOULD BE PERFORMED BY EXPERIENCED /TRAINED PERSONNEL. TEMPORARY TRAFFIC CONTROLS MUST BE MONITORED AND MAINTAINED BY THE CUSTOMER / CONTRACTOR TO REMAIN EFFECTIVE. MONITORING AND MAINTENANCE FREQUENCY IS DICTATED BY FIELD CONDITIONS, BUT NOT LESS THAN DAILY. STATEWIDE SAFETY & SIGNS HAS NO CONTROL OVER, OR RESPONSIBILITY FOR, TRAFFIC CONTROL PLAN IMPLEMENTATION AND INSPECTIONS PERFORMED BY OTHERS. USERS AGREE TO INDEMNIFY STATEWIDE SAFETY & SIGNS FOR CLAIMS MADE REGARDING FAILURE TO INSTALL, MAINTAIN OR REMOVE CONTROLS PER APPROVED TRAFFIC CONTROL PLAN STATEWIDE TRAFFIC SAFETY AND SIGNS ('STATEWIDE-) SHALL NOT BE RESPONSIBLE FOR, AND jCOASTLINE INSTALLATIONI (SHALL INDEMNIFY, DEFEND AND HOLD HARMLESS STATEWIDE AND ITS AGENTS, REPRESENTATIVES AND EMPLOYEES FROM AND AGAINST, ANY CLAIMS, COSTS, DAMAGES, LIABILITIES, EXPENSES, DEMANDS AND LOSSES (INCLUDING ATTORNEYS' FEES AND COSTS AND EXPENSES) ARISING OUT OF OR RELATING TO THE FAILURE OF ANY TRAFFIC CONTROL PLAN APPLICABLE TO STATEWIDE'S WORK OR SERVICES TO COMPLY WITH ANY LOCAL, STATE OR FEDERAL RULE, REGULATION, ORDINANCE, OR STATUTE. STATEWIDE DOES NOT WARRANT THAT ANY TRAFFIC CONTROL PLAN APPLICABLE TO STATEWIDE'S WORK OR SERVICES IS ACCURATE, CORRECT OR COMPLIES WITH ANY LOCAL, STATE OR FEDERAL RULE, REGULATION, ORDINANCE, OR STATUTE. (NANF n;: rPNFRAI mNTRA(:T(IR (IR DI IRI I(: A(:FN(:)n A(:RFPC THAT THG CTATFWIIIF I.0 FNTITI FI1 Tn ANTI Wn I RFI V (1N THE WRITTFN TRAGFI(: (.nNTR(lI PI AN(Cl Ppn%/i r:n Tn CTATFWN7F RV 1% PLAN APPROVED BY: DRAWN BY COLTON GEORGES DAlEDRAWN:,' SCALE; E CAMPBELLAVE 622 Lindon Ln. Nlpop 3444 tong) a , CA 7l) flA 1 8AGi 8(ilY reno� o,CA9n