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ENC2017-00045
OF C4 +� U 1p - °kcnak° CITY OF CAMPBELL Public Works Department June 4, 2018 Steelwave 4000 E. P Ave. #500. Foster City, CA 94404 SUBJECT: PERMIT NO. ENC 2017-00045 900-910 E. Hamilton Ave. FINAL INSPECTION AND ACCEPTANCE To Whom It May Concern: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. Your Faithful Security Deposit in the amount of $53,150.00, Your Plan Check Deposit for $1,000.00 and your Construction Cash Deposit in the amount of $2,126.00 are enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Vahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00045 70 North First Street • Campbell, California 95008-1436 ' TEL 408.866,2150 ' FAX 408.376:0958 • TDD 408.866.2790 10014935 STEELWAVE go IA WAN TER91 I a 4 oil R 111:1713 Plif 13•n RX13) %1 -:FARGO..BANK, N.A.. i-24 CHECK 'CHECK "NO. 0 6 /,0 4 /�I, 26PI 6.9�� 'NORTH 'FIRST STREET NTGOMERY STREET 1210 FP-hilCiSCO', CA 94'104 CA cALIFORNIA 95008 m 6� L -5, Z7 6' 664 0, . AmobNT 0 "VOID -AFTEk3l'jQ.' t4�Y d PAY THE SUM OF FIFTY. SIX 'THOUSAND; TWO HUNDRED ,SEVENTY -S Ii,-, DOLLARS & ZERO. CENTS IE TO THE� , STEELWAVE OiDEk 4000, R. 3RD AVENUE, #5 0 0: �; 'FOSTER' CITY CA94464' ..... ..... , If. . Y'- S 5 .. --- - - - -- ------ - - . .... ... 44 . ........................... .............. .............................. ............................ ................................... ............. ............ . ............... . .. .. .............................. ...................................... ................................. J *See Reverse "Side For Easy Opening Instructions* -- ----------- .... -- --- - - - -------------- - - -------- i --- ---- -- - ----- CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 STEELWAVE 40.0.0 E. 3RD AVENUE, #_500 FOSTER CITY CA 94404 r 7- l?rint'Form x' CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First Street right -of -ray) Application Date Campbell, CA 95008 Application Expiration Date i Ph. (408) 866-2150 Issued APN a I e6 IZAL \ li Fx. (408) 376-0958 1 Permit Expiration Date APPLICATION - Application is hereby made for a Public Works Permit in accords ce th 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.: 900 - 910 E. Hamilton Avenue Utility Trench Location: B. Nature of work: Frontage (ADA) Improvements on Hamilton and Creekside ... ........ --_ _. _ _. --- _ - __ _ __ C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the 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. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) 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 starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: 5TC�WA\ Telephone: Address: E-Mail Address:"yth I� �' 5 VVc�Vf:� ��; 24-HOUR EMERGENCY PHONE NUMBER: C 2q z�s Is this work being donproperty owners at their own residence? F-,i YES I 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 any and all damages arisi the condition of �ryy private improvements in the public right-of-way. Accepted: R iittee) (sign) Date (Print Name) A Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be 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 DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE , APPROVED FOR ISSUANCE NT $MOI 0 3. $ i 000, 00 It RECEIPT NO. yp 6 L � (l o (t(11 Z-10O i tv I� 21®o'�i z 1 For Uty tngineer Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS I . A Construction Cash Deposit is required. Charges 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. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation ofthe Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10 (ten) days prior to proposed start of work. Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 7. 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. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 9. 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. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on thejob 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 cash deposit. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. 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. 15. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 16. 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. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 20. 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. 21. If the public interest requires a modification of, or a departure from the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City -owned or maintained facilities. 22. Permitttee 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 phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Date: Date: JAFORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 02/14 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE'FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2017-00045 Property Address 900-910 E. Hamilton Ave. Date of Final Inspection: On File: Bonds CD Cash 4 Fa thf �P'e-fo%�iarz ,.15:00,00 --q6 `� Labor and Material $ IT Cons ruction a '$D pa Utz �I r l as f� 2,1e6.'t r� .rye e Other overdue deposits to be released (Description): 'elan (hec< ep+asit0�,.�p Processed by: Reviewed by: Admi`Wii 't at-vr Ins Cj�vP l�� [] Reviewed by: \` � IZ,ZIvq) ` Land Development Engineer 0 JAJoAnnaT\Deposit refunds\CH ECK L I STS\Steelwave. doc (Rev. 10/11) PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 201.6 TO: Finance PUBLIC WORKS FILE NO. ENC2017-00045 PROPERTY ADDRESS 900-910 E Hamilton Avenue Please collect & receipt for the following monies: ACGT ' LA it '43E ELClP k w r h OU` AM S IEI�T 4722 Encroachment Permit APPlication Fee Non -Utility Encroachment ermit Majdr >_$10,000 $403.00 $403.00 Minor Encroachment Perrrrit <$io,000 $230.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $230.00 Inspection Fee Minimum Charge per Location $398.00 _ Street Tree Plantinq/Removal N/C 2203 ($500 per Tree Plantinq Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Engineer's Estimate $500.00 min $1,000.00 4722 Utility and R-1 Permits Gradinq & Drainage Plan Review no deposit required Single Family Lot $281.00 Site < 10,000 s.f. $841.00 Site >_ 10,000 s.f. < 0.5 Acre $1,127.00 Site >_ 0.5 Acre $1,688.00 NPDES Review (C3 Requirements For projects not required to submit numeric sizing $163.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $704.00 Impervious Area 1 Acre or more $918.00 For projects sent to Consultant for review Consultant Cost -f Additional trLdatment facilities $300 ea Plan Check & Inspection Fee (Non -Utility Enqr. Est. < $250,000 14% of Engineer': Enqr. Est. >_$250,000 and <_$500,000 $35,000 + 8% of I Enqr. Est. >$500 000 $55,000 + 7% of "t" ` ? ` `i'` U. — Emergency Cash Deposit 4% of Enqr. Est.' A. 1," R° S T FE? 1^1AVE Faithful Performance Security (FPS) 100% of ENGR. E iilli?h'!' DATE, Labor and Materials Securi 100% of ENGR. E ;;( LI J I L ; L?AT v iJ ', Storm Drainage Area Fee Per Acre R-1 $2,120.00 r+EtiiF`Tii1f %y;"iiif-T (Multi -Res $2,38,r. _._ AllOther$2,650"t `iC`:'?.t"�"''zA'' Parcel Map (4 Lots or Less) $4009.00 + $87/li 11""'GR I :LIBE111V F f=•1t'G FTi; `ta Final Tract Map 5 or More Lots) $4 871.00 + $11E 00 Monumentation Security 100% of City's Mi },CP 4im, n.,T T _ in, $j 0e00 Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) Lot Line Adjustment (Includes Certificate of Compliance) $1,893.00 Vacation of Public Streets & Easements $2 530.00 T;?} AL DUE: $ —in- '� ��. Certificate of Compliance $1 877.00 Tr UEt `d?n ti =; u,OU Certificate of Correction $561.00 CHANGE.- GE.- t D0, Document Recording Fees $15.00/first paqe n1,F:i?.i; t•s�l_L,a H e-irtia ll+ Private Improvement in Public ROW $50.00 Approved Plan Revision Fee $100/sheet RE-- NUM.- Appeal Filing Fee $200.00 Notary Fee (per signature) $10.00 Assessment Segregation or Reapportionment First Split $895.00 Each Additional Lot $281.00 Postage .`U., ...f'E s..?, 4722 4722 4722 4722 4722 _4722 2203 2203 2203 4721 4722 4722 2203 4920 4722 4722 4722 4722 4722 4722 4722 4722 4722 4722 _ 5117424 p11tb1'ELflCNEOtu Other (Please Specify) 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $1,403.00 NAMEOF APPLICANT ST LWAV NAME OF PAYOR _ PHONE' ' ADDRESS � �� .. I � ZIP 44L) Q FOR CITY CLERK \I C�hll_ j r 'Y � 1. -� - �+ � � � 9 d' � 3iai ,�^ *'k Ei" S:i i •5.4' �$ i S U � �P^ � � ,'Y � q}` 1S r Date J'LandDev:Plan Check Commenlsll - Spedr, Projects - Active Project in ProgresslNamitlon Ave. E 900-91ffeesWees.tls 5/16/2018 < Fees Associated With 5:02:07PM CEL;Op Case #: ENC2017-00045 ee°' Start Epd ; T raps'. Revenue Created y date P : Date Dept- = = Description Code Account Number y" By Date Amoupf Due: _. , , . . AF02 7/1/2016 6/30/2017 PrmtAppFee-Major-Eng E 101.730.4722 JT 2/2/2017 403.00 0.00 PCDP 7/1/2016 6/30/2017 vRIOTT ec < Depos- 101.2203 JT 2/2/2017 1�00-0 0.00 PCI1 7/1/2015 6/30/2017 Non-Util Plan Ck/Insp < $ 101.740.4722 JT 6/12/2017 7,441.00 0.00 CASH 7/1/2016 6/30/2017 structo�Eras D.eposie 101.2203 JT 6/12/2017 2,1 6OOa� 0.00 FPSD 7/1/2016 6/30/2017 F fulzBerfa-Secant-0De 101.2203 JT 6/12/2017 1-050�t°iw 0.00 Total Due: $0.00 Page 1 of 1 CaseFees..rpt .f PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2016 TO: Finance PUBLIC WORKS FILE NO. ENC2017-00045 PROPERTY ADDRESS 900-910 E Hamilton Avenue Please collect & receipt for the following_monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Ma'or>_ 10 000 $403.00 Minor Encroachment Permit <$io oo0 $230.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $230.00 Ins ection Fee Minimum Char a per Location $398.00 Street Tree Planting/Removal N/C 2203 500 per Tree Planting Deposit Required) 500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Gradinq & Drainage Plan Review Single Famil Lot $281.00 Site < 10,000 s.f. $841.00 Site >_ 10,000 s.f. < 0.5 Acre $1,127.00 Site >_ 0.5 Acre $1,688.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $163.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $704.00 Impervious Area 1 Acre or more $918.00 4722 For promects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities 300 ea Plan Check & Inspection Fee(Non-Utility) 4722 En r. Est. < $250 000 14% of Engineer's Estimate $7 441.00 4722 En r. Est. z$250 000 and <_ 500 000 $35,000 + 8% of Engineers Estimate 4722 En r. Est. > 500 000 $55,000 + 7% of Engineers Estimate 2203 Emergency Cash Deposit 4% of En r. Est.* $500 min/$10 000 Max $2 126.00 2203 Faithful Performance Security FPS 100% of ENGR. EST.* $53 150.00 2203 Labor and Materials Securi 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi -Res $2,385.00) All Other 2 650.00 4722 Parcel Ma 4 Lots or Less 4009.00 + 87/lot 4722 Final Tract Ma 5 or More Lots 4 871.00 + 118/lot 2203 Monumentation Security 100% of Ci 's Monumentation Estimate 4920 Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) 1 893.00 4722 Vacation of Public Streets & Easements $2,530.00 4722 Certificate of Compliance $1,877.00 4722 Certificate of Correction $561.00 4722 Document Recording Fees 15.00/first page 3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee 100/sheet 4722 Appeal Filing Fee $200.00 4722 NotarV Fee(per signature) 10.00 4722 Assessment Segregation or Reapportionment First Split $895.00 Each Additional Lot $281.00 511.74241 Postage P MISCELLANEOUS ------- - -- -- - - - - - - - - Other Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $62 717.00 NAME OF APPLICANT NAME OF PAYOR S PHONE �y ADDRESS 4000 etq�� 3m N& ct,.,- ZIP t - FOR RECEIVE BY g e 9 .� CITY CLERK ONLY 84 Date Receipt # d (} '- 1\I a,d U eNP lan CI— C— m[nssrl spe C., Pr,-, A,,,r Prgj in Progress\IldmillOn Are Ian0 ,reef\r ads rls SteelWave CDS, LLC Vanrinrr`ITV nIZ 0AHA1)0CI I 42709 Check Date: ---June 8. 2017 INVOICE DATE wINVOICE No .: DESCRIPTION INV. AMOUNT 62717.00 DISCNT TAKEN BALANCE 62717.00 5-04-17 i ENC2017-00045 HP Common Area Upgr Chk Date: 6-08-17. Chk No' 42709 Totals 62717.00 62717.00 THE FACE O0 _F THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER - SteelWave CDS, LLC 4000 East 3rd Ave. Suite 500 Foster City, CA 94404-4805 Bank of America 16-66/1220 PAY . 60 ONLY `S PAY Sixty -Two Thousand Seven Hundred Seventeen and 00/100 Dollars TO THE CITY OF CAMPBELL ORDER 70 N FIRST ST OF CAMPBELL; CA 95008 •-^-+r�•^' '�'ty'•'`'•"""'''`""i"'�'""1"•'l<um;�^! THIS DOCUMENT CONTAINS A WATERMARK - HOLD UP TO A LIGHT TO VIE II■011, 2 40911' 1: 12 200066 L1: 14 59 L 3980 3111, 42709 DATE: June 8, 2017 $*****62,717.00 THIS IS TO CERTIFY THAT THE FOLLOWING DESCRIBED COMMODITY WAS WEIGHED, MEASURED"OR COUNTED BY A WEIGHMASTER, WHOSE SIGNATURE IS ON THIS CERTIFICATE, WHO IS A RECOGNIZED AUTHORITY OF ACCURACY, AS PRESCRIBED BY CHAPTER 7 (COMMENCING WITH SECTION 12700) OF DIVISION'S OF THE CALIFORNIA BUSINESS AND PROFES- SIONS CODE, ADMINISTERED BY THE DIVISION OF MEASUREMENT STANDARDS OF THE CALIFORNIA DEPARTMENT OF FOOD AND AGRICULTURE. SOLD BY.CONCRETE READY MIX, INC. UNLOADING RELEASE .��" 7?01 WEIGHED / MEASURED AT 33 HILLSDALE AVE., SAN -JOSE, CA 95136 1. Concrete Ready Mix, Inc. is not responsible for any damages to sidewalks, driveways, buildings, trees, OPEN 7 DAYS A WEEK PHONE (408) 224-2452 shrubbery, etc. when delivery is made Inside the curb CAUTION and ra lot at the customer's request. May cause eye or skin injury. Contains Portland cement. Freshly mixed visa 2. Contractor does hereby Indemnify and hold harmless cement, mortar, grout may cause skin injury. Concrete Ready Mix, Inc. from any said damages TAKE THESE PRECAUTIONS — claimed by property owner. 1. Avoid all contact with eyes. Wear rubber boots and gloves, and avoid prolonged contact directly with skin or through porous materials 3. Signature below authorizes Concrete Ready Mix, Inc. DISCOVER 2. In case of contact with eyes or skin, FLUSH THOROUGHLY WITH AMERICAN to use private driveway for making delivery and WATER. '2#E%PRESS customer assumes full responsibility. 3. If irritation persists, get medical attention promptly. o 4. Keep children away. LOAD NO. SLUMP C.O.D. MAP NO. TRUCK DRIVER DATE TIME PURCHASE ORDER / JOB NO. DELIVERY TICKET f'Pl \)(., Y. 1f ('( !. C`. r 1 -�I- / 17 i 1 �' SOLD TO DELIVER TO r : - , `eE_. , r' l l'it I) ^••r Ai „li 1:.�1" �.Y`}if P'�.�a }�f... P._. L. QUANTITY TOTAL PRODUCT PRODUCT UNIT EXTENDED THIS LOAD DELIVERED CODE DESCRIPTION PRICE PRICE LJ'[I �.., lid lji �. ,. 'i {('i F-J.':i! .I.'N Li e:.?':k •. .d t..a.!V'ikr.r '.iv { (... (-#�.% :.'I'�iv ':'i i;'! .'art,.. .ii.•r. ARRIVE START POUR END POUR WATER ADDED AT CONCRETE READY MIX•INC'- WEIGHMASTER JOB_ _ t CUSTOMER REQUEST=!_' SUBTOTAL ; I,I T T) ' •' GALLONS I BY DEPUTY TOTAL MIN. ALLOWED CHARGED MINUTES I HEREBY ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND MISCELLANEOUS AGREE TO THE TERMS OF THIS INVOICE. Received / / CHARGED STANDBY MIN. CHARGE , STAND BY CHARGE @ /MIN ` _ H;.7•"''' Five minutes per yard unloading time is allowed. GRAND TOTAL FINANCE CHARGES will be charged at THE RATE of 18% per annum. (11/2% per month). If it becomes necessary to file suit for the collection of�a`ny amount; costs, including collection and attorney's fees shall be paid by the buyer, with venue in Santa Clara County. We do not guarantee against discoloration of concrete, whether color is added or not. We also do not guarantee against cracks in concrete. It is agreed that the above described materials and labor are to be paid for from funds received from the above described job in any event not later than 30 days from date of delivery. Water or other ingredients added may reduce strength and quality, and are added only at customer's request. C.O.D. - A $100 fee will be charged to all C.O.D. orders not paid for at the time of delivery. ', (.'.ri, i:; CII'i l: Cl C! i`l �•` .I. c8 f4 l THIS IS TO CERTIFY THAT THE FOLLOWING DESCRIBED COMMODITY WAS WEIGHED, MEASURED, OR COUNTED BY A WEIGHMASTER, WHOSE SIGNATURE IS ON THIS CERTIFICATE, WHO IS A RECOGNIZED AUTHORITY OF ACCURACY, AS PRESCRIBED BY CHAPTER 7 (COMMENCING WITH SECTION 12700) OF DIVISION'S OF THE CALIFORNIA BUSINESS AND PROFES- SIONS CODE, ADMINISTERED BY THE DIVISION OF MEASUREMENT STANDARDS OF THE CALIFORNIA DEPARTMENT OF FOOD AND AGRICULTURE. SOLDBYCONCRETE READY MIX, INC. I WAAUNLOADINGRELEASE 131306 WEIGHED / MEASURED AT 33 HILLSDALE AVE., SAN OPEN 7 DAYS A WEEK PHONE (408) 224-2452 CAUTION May cause eye or skin injury: Contains Portland cement. Freshly mixed cement, mortar, grout may cause skin injury. TAKE THESE PRECAUTIONS 1. Avoid all contact with eyes. Wear rubber boots and gloves, and avoic prolonged contact directly with skin or through porous materials 2. In case of contact with eyes or skin, FLUSH THOROUGHLY WITH WATER. 3. If irritation persists, get medical attention promptly. 4. Keep children away. JOSE, CA 95136 �ERIfAN ...EXPRESS a G4,L-7 Concrete Ready Mix, Inc. is not responsible for any "damages to sidewalks, driveways, buildings, trees; shrubbery, etc. when delivery is made inside the curb and on lot at the customer's request. vISA DISCOVER' X 2. Contractor does hereby indemnify and hold harmless Concrete Ready Mix, Inc. from any said damages claimed by property owner. 3. Signature below authorizes Concrete Ready Mix, Inc. to use private driveway for making delivery and customer assumes full responsibility. LOAD NO. SLUMP C.O.D. MAP NO. TRUCK DRIVER DATE TIME PURCHASE ORDER / JOB NO. DELIVERY TICKET `.-.,; "'F 1 ,};. 1 �lj •-'-_"+ SOLD TO DELIVER TO RO I"1I-..j_. 1�•'PREP i':.'Lst-�^.fi.l _i.:'7L..'s? Cfi+71L1 1=. I"Il�aj•'I.I_L.�CJI�'A Ill'I"-�u QUANTITY TOTAL PRODUCT - PRODUCT UNIT EXTENDED THIS LOAD DELIVERED CODE - - -` DESCRIPTION '' PRICE PRICE I'lll - (ill ti •li - l,y(;I(^l4it:'ts j, i j Ltd}a ID i 15i-; 00 1 [:1`1 '3 ( CI !'W r 'T •• r_' . , 1L_ E t_.<. �'i io !?Izz► !'(I;,i ARRIVE START POUR END POUR WATER ADDED AT CONCRETE READY MIX INC. WEIGHMASTER SUBTOTAL JOB CUSTOMER REQUEST GALLONS BY - DEPUTY TAX TOTAL MIN. ALLOWED CHARGED MINUTES I HEREBY ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND MISCELLANEOUS — AGREE TO THE TERMS OF THIS INVOICE. Received STAND BY; CHARGED MIN. STAND BY CHARGE CHARGE C�3 /MIN v By �X Five minutes per yard unloading time is allowed. GRAND TOTAL FINANCE CHARGES will be charged'at THE RATE of 18% per annum. (11/z% per month). If it becomes necessary to file suit for the collection of any amount, costs, including collection anc attorney's fees shall be paid by the buyer, with venue in Santa Clara County. We do not guarantee against discoloration of concrete, whether color is added or not. We also do not guarantee against cracks in concrete. It is agreed that the above described materials and labor are to be paid for from funds received from the above described job in any event not later than 30 day: Tom date of delivery. Water or other ingredients added may reduce strength and quality, and are added only at customer's request. C.O.D. - A $100 fee will be charged to all C.O.D. orders not paid for -at the time of delivery,.�•=, -I, - p-i ., ti c ; l ! , j a 31 (; 4i-:' ALLPROP-01 DEACHUS 'ac®�zn CERTIFICATE OF LIABILITY INSURANCE DATE 08/10/2017 ) (MM/ 017 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statemerit•on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER coNTACT Denise Eachus NAME: HONK , Ext): (209) 856-8841 FAXJAIC, No):(209) 854-2520 Rico Pfitzer Pires and Associates Insurance P.O. Box 129 Gustine, CA 95322 E-MAIL ADDRESS: deachus@rppins.com INSURERS AFFORDING COVERAGE NAIC # INSURER A:Rockhill Insurance Company 28053 INSURED INSURER B : West American Insurance Company 44393 INSURERC:State Compensation Ins Fund 35076 All Pro Preparation, Inca INSURER D:The Ohio CasualtV Insurance Co. 24074 P.O. Box 1404 French Camp, CA 95231-1404 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 CONTRACTOR 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 INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD/YYYY LIMITS ' A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X - RCGLPGO1718-02 01/17/2017 01/17/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISESEa occurrence 100,000 $ X MED EXP (Any oneperson) $ 5,000 Owners & Contractors PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JECOT- LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 $ BODILY INJURY Per erson $ ANY AUTO BAW(18)55933164 02/01/2017 02/01/2018 JX OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ PROPERTYDAMAGE Per accident $ HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY Comp Ded $500 X Coll Ded $500 A - UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE RXSLPGO0152-02 01/17/2017 01/17/2018 DED I X I RETENTION $ 0 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A X - 9006541-17 03/06/2017 03/06/2018 X STATUTE TE EERH E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 D Inland Marine/Equip BMO(18)55933164 02/01/2017 02/01/2018 Rented/Leased Eq 50,000 D Inland Marine/Equip BMO(18)55933164 02/01/2017 02/01/2018 Deductible 2,500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Job ENC2017-00045 City of Campbell, its officers, employees, and volunteers are included as Additional Insured with respect to General Liability in regard to work contracted with and performed by the Named Insured, per attached endorsement. The insurance coverage afforded to the Additional Insured is primary insurance. All work in the public right-of-way. RE: Hamilton Plaza, 900-910 E Hamilton Avenue, Campbell CA City of Campbell 70 North First Street Campbell, CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SAN FRANCISCO EFFECTIVE MARCH 6, 2017 AT 12.01 A.M. AND EXPIRING MARCH 6, 2018 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME ALL PRO PREPARATION, INC. PO BOX 1404 FRENCH CAMP, CA 95231 RE P A2 9006541-17 RENEWAL NF 5-14-80-73 PAGE 1 OF 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MARCH 1, 2017,/ ;ezi;Ae! AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 1 2572 OLD DP 217 C bji`"�ro• T"" a �; • {jhrlwy.�� � ? y{ ri, y�i A � I'��:• `i�. •� (}y�•w.• �tL*J� d w. r•IIR �� �Q' r! W' K MI i P •N J i ~ M. Mb♦♦ S•• �.J•r� �•. Ni. •tl � 7•. •• M= i.i PI � O � ALL Ply P REPS RA ION DA! "E tt .1181; t 1 l:: / 1 F • : �M i.1I DOJ+p q �j �•# tom` �_• �""• t'•C `% %'�' ��..g t � , '. ���rr�.=t •& �. �• .�. S Chr fd ° � y �O y •.. . o � t I � RS4�;�°'ft�•ij•�'isj'•� .° s T : ?:« �� "�: � �.. s.....� � " ,�•.... .. . E) ,. •.:•r�zr• -• aSR.+{ Y S =t V I Sin K/1 1�ENSE i ••�� rw :r• w �..• swi! wr •w w r.. ++. •.r o•. •w ....« •w N i •� i �1.�•{ � y � }� j• � 1 rj TENDERED: 50 �••• t••�{Rr4� D COO •!" S tU t # _ • ... . i 2 J j ,.i i Jul J. _j i �, L 1. 1 1 l 0 — `• 1<i.1 Ai1. � • Scanned by CamScanner POLICY NUMBER: RCGLPGO1718-02 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Any person or organization to which you are obligated by virtue of a written contract to provide insurance such as is afforded by this policy, but only with respect to (1) occur- rences taking place after such written contract has been executed and (2) occurrences re- sulting from work performed by you during the policy period, or occurrences resulting from the conduct of your business during the policy period. A person or organization that qualifies as an "insured" under the above paragraph of this Endorsement shall be an additional insured solely with respect to such additional insured's liability for "bodily injury," property damage" or "personal and advertising injury" caused in whole or in part by your acts or omissions in the performance of "your work" for the addi- tional insured on or at "commercial construction projects." For the purposes of this Endorsement, "commercial construction projects" are defined as buildings or structures constructed for commercial use and also include apartments, hotels, homes for the aged dormitories or barracks. However, "commercial construction projects" shall not include any building or structure which, in whole or in part, contains individual owner occupied units or dwellings. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. Coverage provided by this policy to the Additional Insured(s) shown in the Schedule shall be primary insurance and any other insurance maintained by the Additional Insured(s) shall be excess and non-contributory, but only if required of the Named Insured and by written contract. CG 20 10 1185 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 0 INSURANCE REQUIREMENTS CHECKLIST Permit # C-gQ_ 30\-1 —00045, 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: $1,000,000 per occurrence, and ❑ $1,000,000 gene ral 'aggregate limit applying separately to the project, or Vd— $2,000,000 general aggregate limit. Policy expiration dated Automotive Liability: "Any Auto" checked on certificate -,qv, $1,000,000 per accident for bodily injury and property damage Policy expiration date 2 l Workers' Compensation and Employer's Liability Waiver of Subrogation clause - $1,000,000 per accident for bodily injury. or disease ;9. Policy expiration date Course of Construction (if required in Special Provisions) o Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) X'The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and -"but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\joannat\Desktop\All Insurance Requirements.doc (Rev 03/13) Page 1 of 1 ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor , -❑ For Developer or Owner Acceptability of Insureds) ❑ Insurer(s) has current A.M. Best Rating of A:Vll,and is authorized to transact business in the State of California. -� �� D5 Name: _ C)CY V'k \� � 1�.�� NAIC # RatinAuthorized in.CA: Name:, \QeSt- kr�ne4 \c --- NAIC # L1��3 Rating: Authorized in CA: r ' Name: tAcx,, e_ co-n��_ NAIC # 3 o ating: Authorized in -CA: Name: NAIC # Rating: Authorized in CA: .Campbell Business License !�� `S�l Insurance Certificate Reviewed « 7 tials Date o Copy of Insurance Certificate placed in tickler file one month prior to expiration. 72 1 C:\Documents and Settings\joannat\Desktop\Insurance Requirements 2 pgs.doc (Rev 03/13) Page 2 of 2 I I I- I - - I I -1 I , I I I I'll - I I 1-1 I 11 I I 11-1 I I . I I I I I 11 I I I I I . I . I - I � I I I . I � I I I I I � I � I � . I I I I I I - I � I . I I I I I I I I I I I . . . I I � � I I I I . I I � I I I . I � � I . I I I I � I I I I I � . I I I I I I I . � � I I I . � 11 - -- ---- - I I I I I . . I � I I I � I . . . I . I � I � I I I I I I "I . 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