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ENC2018-00114-V Permit No.. 0 18 - oc (, a CITY OF CAMPBELL ENCROACHMENT PERMIT Perm -- '- - DEPT. OF PUBLIC WORKS (for working within the X-Ref. File � 70 North First Street public right-of-way) Application Date Campbell, CA 95008 Issued A F 1© EDate Ph. (408)8ee-2150 ✓� O Application Expiration Fx. (408) 376-0958 �(/1,� 6 - APN �- Z._ C� Z� Permit Expiration Date APPLICATION -Application is herebymade fora Public Works Permitin accordance with 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: 354/360 Campbell Ave., Campbell, CA 95008 Nature of Work/Utility /r � /� / 0 r B. Trench Location: N C( (�0 616Js L ! bG L /K 4- gi� �I�i Gi�j � v ❑ No Fee Permit for work related to City Project Project Name: 354/360 Campbell 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 workshall conform tothe City ofCampbellStanclard Specifications and Details forPublicWorks 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 leasttwo days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Method Construction, Inc. Telephone: 408-842-0054 Address: P.O. Box 2702, Gilroy, CA 95021 E-Mail Address: lave CI method-COnStruction.c0111 24-HOUR EMERGENCY PHONE NUMBER: 408-590-4074 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 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. Applic is advise( IT) that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all da .age arising out of im rovemerits complekd in the public right-of-way. 9 Accepted: ' V lb-t- W ( Iic ermittgeee) (sign) Date o David Method 5f- j (Contractor) (Print Name) Date SPECIAL PROVISIONS: -- 1. Street shall not be open cut for underground installations. Minimum cutsl-aaabe allowed for connections orexploration holes, Suchcutsmaybe spec finally ar, rover! h, t� hP InSncacinr nrior In rCttt nfr. 2. Pavement may be Cut for underground snstaiiaLion., 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 Ilcemcd 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. i 5. Prior to any work, the property owner snailleexe.cu'e pee etst for' Fr va, t2 improvements in the Public Right -of -Way, which shall be recorded. f . . C NotifRequirements, a I� ut _ " . / SEE PUBLIC WORKS FE CHEDULE FOR CURRENT FE S AMOUNT RECEIPT,N . PF:Riv1iT APPLtCr1TION FFE ��� �_ �-� �_ � - $— ('r7 PLAN CHECK DEPOSIT S SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS -- CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE ----- — APPROVED FOR ISSUANCE �--� -� 45/6 - For C_ityE:r'q;int=trr Date Permit Expires 12 Month: Aft r Dace of Issuance GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Add itionai 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 ofthe Faithful Performance Surety will be initiated by the written acceptance ofthe 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% ofthe original Faithful Performance Security. 5. Submit project schedule 10 (ten) days prior to proposed start ofwork. 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 most recent version of the 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. 1.1. 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 workir:g 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 ofthe 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 he discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACT!CES 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 WQ2014-0174- DWQ, Said vault water shall not be discharged into the City of Campbell's storm drain -system. See http://www.waterboards.ca.Rovlwater issues/programsLnpdes!utilityvaukssht_ml for more information. is hereby responsible for ensuri6e thlIiit all those providing services under the applicant are aware of and abide by all of the above conditions. Applicant /I- A J -"`� �ti��� (.��✓.S C i�' �t� � "�,,U cam) Contractor (Print Name) J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.04/18 Date: Date: PUBLIC WORKS :5DEPARTMENT LAND DEVELOPMENT Effective July 1, 2017 TO: Finance PUBLIC WORKS FILE NO. 9QC PROPERTY ADDRESS CAKl-ST_-'_L_ AVE Please collect & receipt for the following monies: . . . . . . . . . . . AMOUNT � LA 6 _.EVELdPMMV,---�',:,., 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Major 2!$10,000 $425.00 Minor Encroachment Permit <sio.000 $240.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240.00 Inspection Fee Minimum Charge per Location $420.00 Street Tree Plantinq/Removal NZ q 2- C, 2203_ 22031 ($500 per Tree Plantinq Deposit Required) 00.00/tree Plan Check Deposit 2% of Engineer's Estimate $500.00 min 4722 Utility and R-1 Permits no deposit required Grading & Drainage Plan Review 0� fl L. A CaU1, L4_ 1 - Single Family Lot $295.00 Site < 10,000 s.f. $885.00 Site 10,000 S.f. < 0.5 Acre $1,185.00 Site 0.5 Acre $1,772.00 Ad 4722 NPDES Review (C3 Requirements) For protects not required to submit numeric sizing $ 75.00 OF GANOFUELL­ For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $740.00 `7s Impervious Area 1 Acre or more $965.00 4722 For promects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $315 ea Plan Check & Inspection -Fee (Non-Lltility) 4722 Engr. Est. < $250,000 .14% of Engineer's Estimate 4722 Enqr. Est. �t$250,000 and:5$500,000 $35,000.00 + 8% of Engineers Estimate 4722 Engr. Est. >$500,000 $55,000.00 + 7% of Engineers Estimate 2203 Emergency Cash Deposit 4% of Enar. Est.* ($rnn min/5;1 0.000 Max) 2203 Faithful Performance Security (FPS) 100% of ENGR. EST.* 2203 Labor and Materials Security 100% of ENGR. EST.* - 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi -Res $2,385.00) (All Other $2,650.00) 4722 Parcel Map (4 Lots or Less) $4,200.00 + $90/lot 4722 Final Tract Map (5 or More Lots) $5,115.00 + $124/lot 2203 Monumentation Security 100% of City's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (includes Certificate of Compliance) $1,990.00 4722 Vacation of Public Streets & Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 Certificateof Correction $590.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $100.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Payment 47Z2- Assessment Segregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 511.7424 MISCELLANEOUS Postage 7_7_7 _�' Other (Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ GGO NAME OF APPLICANT c UW i!�61vST NAME OF PAYOR yw__z-PHON4 5 141 e,4 ?LOZJ ZIP ADDRESS Z, ZcgL _LLAa,�> r FOR r 'RE EIVEP W. CITY CLERK ONLY t: d a te� ei 3 J %FORMS\T­Plz �,l i,; I .p -,p W F FLAGGERS WILL BE IN CONSTANT 2 WAY COMMUNICATION. 25- MAX CONE SPACING. ( TAPER) 50' MAX CONE SPACING. ( TANGENT) 12' MAX CONE SPACING. ( CONFLICT ) NOTALL ITEMS ARE SHOWN TO SCALE. NO PARKING SIGNS MUST BE IN PLACE 72 HRS PRIOR TO THE START OF WORK. AHitiAO° 48" Plan Scale 1 1 1 I_ 1 24" W20-1 1" 92.64' 28 tf, CONSTRUCTION HOURS: Too AM TO 4:00 PM PLAN # 2390 ���pyl0t S DATES&16 ® Work Area �{, CONE2 'F-- FLAGGER Ill` Sign 10C9A(CA) CONTRACTOR JOB LOCATION: W20-4 ® W20-1 R26K )--( TYPE I BARRICADE �--'—j R9-11R LICENSE#976518� METHOD �"�T' _ �, _,_ ��—J t1 /� E. CAMPBELLAVE� � R9-9 R9-11L Q R9-10 w��p�Tom Swana'on �® CONSTRUCTION, PHONE# N. CENTF ALAVE, K,C0����F�r�fQ'y INC , N CAMPBELL, CA METHCON-01 VCASTRO CERTIFICATE OF LIABILITY INSURANCE ATE (MMIDDlYYYY) D05/02/2018 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 statement on this certificate does not confer rights to the cel>tIt ' lieu of such endorsement(s). PRODUCER License # 0665907 The J. Morey Company, Inc. MAY qp SanJackson 9 201(J San Jose, CA 95112 Public Wo fps Administration CONTACTVeronica Castro HO No, Extj: (408) 280�551 (FAX PHONE No): E-MAIL rcastro more ins.com AnORE s: Ca?J Y INSURERS AFFORDING COVERAGE NAIC 0 INSURER A: Kinsale Insurance Company INSURED Method Construction, Inc, P.O. Box 2702 Gilroy, CA 95021 INSURER B : West American Insurance Co. INSURER C : Topa Insurance Company INSURER D : Midwest Ins. Co INSURER E INSURER F : r`nVFRAI,FC r:FRTIFIr:ATF NI IMRFR- 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 INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP M IDD _ LIMITS A I X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X �( 1 0100046859-1 I 112130/2017 � 1213012018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence 100,DD0 $ MED EXP An one person)$ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY EG LOC OTHER: GENERAL AGGREGATE $ '000,000 PRODUCTS -COMPIOPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED A�U�TOS ONLY AUTOS AUTOS ONLY AUTOS ONL� X X BAW581971-92 08105/2017 08/05/2019 EO.'w" 6.n SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PerOaoEodentDAMAGE $ + J1 $ C X , UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE _I XL6607596-02 12130/2017 12/30/2018 EACH OCCURRENCE $ S,000,ODO AGGREGATE $ DED I I RETENTION$ 15,000,DOD $ 6,000,000 D I WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRiETORiPARTNERlEXECUTIVE Y 1 N OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA XEE.L.1,ODO,OO �BNUWC0137522 08/01/2017 08/0112018 PER OTH- STAT T ER EACH ACCIDENT $ � E.L. DISEASE - EA EMPLOYEE 1 ODD Owo $ , , E.L. DISEASE - POLICY LIMIT _ 1,000,000, $ i-� 1 I yII� DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 104, Additional Remarks Schedule, may be attached if more space is required) City Of Campbell, is officers; emN oyees and volunteers are named as additonal insured. The insurance coverage afforded to the Additional insured is 'Primary Insurance. All Work in the public right-of-way, iI (Project: 354/360 Campbell Ave, Campbell, CA 95008, Permit#BLD2017-01353 f SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE w1LL BE DELIVERED 1N ty P ACCORDANCE W TH THE POLICY PROVISIONS. 70 N. First Street i Campbell, CA 95008 j AUTHORIZED REPRESENTATIVE I _ } i ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. r The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY Attached Tv: and Forming Part of ftiicy Effective Date affndarsenienr Nari?,,-d Insured 12/30%20R712;01AM.at the Named Insured 1, Methad Cartaruction hic Mdre§s -th6" on the Deciaratiom Addibonol Premium: Retvrn Premium. This endorsement modifies, Insurance provided under flte fdfibiu - OMMERCUAL GENERAL LIABIL"Y COVER AGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE ENVIRONMENTAL CONTRACTING AND PROFESSIONAL SERVICES LIABILITY COVERAGE. PROKHJCTS POLWTION LIABILITY COVERAGE The insurance provided to Addffi=i Insureds shall beekcess with respect- to any other vaiiO and cbltecUble insurance: available to the Additional Insured* unless the wriften, coOrkt r? p0j?*'Q0. r1 A 0 i th.atthis.i.ns.0 aaa. mary and non-contributory bags, to which,.case this insuranbeshall be prIMary aftd non-ontributory. ALL OTHERTERMS.AND CONDITIONS OF THE POLICY REMAIN UNCHANGED_ CASS003 0717 Page I of 1 I f THIS ENDORSEMENT CHANGES T.HE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS., LESSEES OR CONTRACTOZ SCHEDULED PERSON. OR ORGANIZATION Attached To and Formitig F"aft of plicy Effectlue stateNOOL0 Ihk"d .12/90/2%7 IMAM at the Named Insured Methad Construction Inc addressshoran on the D eciarations Additional Pr&nium., ftun, This endorsement m0dlfieg lnsuf.artce provided under the following. COMMERCIAL GENERAL LIAMLITY COVERAGE PART I NaMe of Additional Insuted Person(SI or organizatlo"(s). Loca*m(s)- of Covered Operarwns i1lank fred by written contract- . etas eeqw A. SMlon if —Who Is An Insured is amended to Indude as on. additional. insured the, person(s) or organization(si Sh6w,ri in*t,h*e Schedule, but only with revect to liability for "bodily Injury". "property damage" or "persona and.,advertising. inprVm caused, in Wholeor in part; by- L your acts or omissions; or _2. The, a , ci5 or omissions of those acting an yo . u . r in the Performance of your bilgoing operations far the -additional insured(s) at the locallon(s) desi gnated abort. be show'n in Bi With respect to the insurance. affortied to: these ,additional insureds;. the following addjfaht1..6xrAu,5Icq15 "is insurance doeis. not 0P0 . ly to "bodily Injury' or "property damage" occurring .L All work, fricludin9 mater!4&, parts, or eqUipMetit . futh.1shed in cOntm Olon vVith such work, on the Project (other thaw service, maint . *1 - 1 enance or repairs) W bi PLeffortiled' by or or.; beh .1. . alf of !he additional iris.uridfs) it: the location of the covered operadons has been comipleteit; dr Z- That PoftiOh Of "Your Work" Out of which the injury or damage arlt0n has been put to its intended .use by any person or organization other than another , contractor oespbt4nj ,rl �p ct r engaged in perfa".ng . operation's for a principal aS a Part of the same project. ALL. OTHER TERMS.AND CONDITIONS OF THE POLICY REMAIN .UNCHANGM CG 20 20 07 04 (9 50 Properties, Inc., 2004 Page -lofl THIS ENDOASE114ENT CHANGES THE POM. PLEASE READ IT CAREfULLY. ADDITIONAL INSURED - OWNERS;.. LESSEES OR CONTRACTORS - COMPLETED:OPERATIONS - A ttac:h;d-7*md F0tFnfR9:P0rt Of Policy lVanwdigsurgd Effective Date of Enddrswr4erwt 121300017 12-.61AM at the Named Insuitil Methrid Consvu&ibn iric. address shovM on the aeclarations Additional Premium- Reurn Premium., This endorsement modiAes insumnce Provitied under the fonowing., COMMERCIAL GENERAL LIABILITY CMERAdE PART SCHEWLE Section R — Who Is An 11*ured fs amended to include as an additiorml irsbred the person(s) or organization(t) shown in tie Stbiedole, Wttinily with respect to liability for "bodily injury' or "propOty. d6niageo caused, in WWe or in part, by. "your work"` At the local tion desig- nated and desciibed- in the %hedule 4f- this eodorse- mient performed for that additional insured. and 1n*- ;luoed.in the "praduas-complete ope atim. s haurd?, ALL 01"NERTERMS AND COW)VIONS O� THE POLICY REMAIN UNC-HANGED-, CG 20 37 07 (34 0 MO Properties, Inc., 2004 Page 1 of 1 THIS ENDOMEMENTCHAWES THE POUCY. PIXAg g!EAci.IT.CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US. -BLANKET Attached To and Farming P&t of policy Effeaim Date of Ehdarst!ment Named insured a= 12/30/2017 12iDIAM at the VNamed. insured metbod Gonstructid n frit _.�j Insured address shown an the Detfar-iflads Additiantal Premium. I Return Premium; This endarsernent modifies Insurance prwkled under the foilowing: COMMERCIAUGENER '. IkAaE . AL LIABI]LITY toW PRODUM/COMPLETED OPERADOW LtAFULrrl WYERAGE SECTION IV - CONDITIONS,: 8, Transfer of bights of ftcovery against Others . to: Us Is amended by the addition of the forI1.0wing: We Waive any fight. ofrecovery we may 6ecause of payments w,e.,ft*6 for injury or damage arising out of "your work" done under a written contract with that pers()n or or9pnization wherein you have agreed to provide this waiver.. ALL OTHER TERMS AND CONDMONS OF THE PbLICY REMAIN QkHANGED, cmou mo page 1 of 1 POLICY NUMBER: BNUWC0137522 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA (Blanket) 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 0.020000 % of the California workers' compensation premium otherwise due on such remuneration. State CA Schedule Description Any party with whom the insured agrees to waive subrogation in a 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 Date: Policy Number: BNUWC0137522 Endorsement No.: Insured Name: Method Construction, Inc. Insurance Company: Midwest Employers Casualty 'Company Countersigned By �� Acceptability of Ihsurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: �� d1 S NAIC # Rating: V !"Authorized in CA: N Name: W eSI�7 t�u�Rating: Authorized in CA: Name: \J3e % AIC # : ating XV Authorized in CA: . Name: NAIC # Rating: Authorized in CA: Campbell Business License # Z1 '6k le Expiration: ❑ Contractors License # ?(0 Class: Expiration: c �6 Insur nce Certificate Reviewed `- InitWs Date ❑ /Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) . Page 2 INSURANCE REQUIREMENTS CHECKLIST Permit # ab ��� CIP Project # Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being'performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and -- -- — 0--$3;000,fl00-gene-ral-aggregat-e limit applying-separ-atelyt-o the -project ppr---- $2,000,000 general aggregate limit. gK—Policy expiration date vz�.30 Automotive Liability: "Any Auto" checked on certificate E $1,000,000 per accident, for bodily injury_ and property damage Policy expiration date Workers Compensation and Employers Liability Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease Policy expiration date 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: )10 The City, its officers, employees and volunteers are named as additional insured. . (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance: Cancellation area should say: Should any of the above described policies be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. WorkersCompensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner 0 J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev Jan 2018) Page 1