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ENC2018-00189CITY of CAMPBELL ENCROACHMENT PERMIT Permit No.:'`�®�V 1 DEPT. OF PUBLIC WORKS (for working within the X-Ref. File 70 North First Street publ(c right f-way) ' Application Date Campbell, CA 95008 Issued C3 Application Expiration Dater—' Ph.(408)866-2150 Fx. (408)376-0958 APN SOS3—O Permit Expiration Date APPLICATION -Application is hereby made fora Public Works Permit inaccor ancewithCampbellMunicipal Code, Section 11.04.(Application expires insix (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address: 125 West Rosemary Lane Nature of Work/Utility Trench for new PG&E gas service B. Trench Location: ❑ No Fee Permit for work related to City Project Project Name: eSemwr— 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. Allworkshall conformtothe Cityof Campbell Standard Specifications and Detailsfor PublicWorks 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 injob 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 starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Mello Pipelines, Inc Address: 260 E. McGlincy Lane Campbell, CA 95008 Telephone: 408-377-6103 E-Mail Address: mellopipe@sbcglobal.net 24-HOUR EMERGENCY PHONE NUMBER: 408-761-0585 Is this work being done bythe property owners at their own residence? ❑ Yes W 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 arising out of improvements completed in the public right-of-way. Accepted: Jeff Mello Mello Pipelines, Inc (Applicant (Contractor) 7/10/18 (sign) Date Jeff Mello 7/10/18 (Print Name) Date 1. Street shal I not be open cut for u nd ergrou n d instal lations. Mi ni m urn cuts may be al lowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector Prior to rutting. 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 startingwork. 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 AMO NT For City Engineer Permit Expires 12 Months After Date of Issuance RECEI17OI. 1 T— '27 1 3 n 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 priorto 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. 11. Sawcutfor all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the construction cash deposit. 14. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement, the traveled way, orwithin 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 beat the current overtime rate with a three (3) hour minimum charge per occurrence. 21. Pursuant to Chapter 14.02 ofthe Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 23. Permittee must provide advance notification to all parties that 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 WQ 2014-0174- DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http://www.waterboards.ca.goy/water issues/programs/npdes/utilityvaults.shtml for more information. Applicant is hereby responsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. Mello Pipelines, Inc Applicant Jeff Mello 7/10/18 Date: 7/10/18 Contractor (Print Name) % "I" G14' Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.04/18 #127 16' 2"HP 16' - 1940 35031532 3412-H4 CP #3412-36 SJ-08-16-C SCALE: 1 "=20' 4'x4'x I8" TAP HOLE 4'x4'x 18- TAP HOLE J 00 UNDER GAS PIPE UNDER GAS PIPE W F- ROSEMARY LN - 60' Lu _ u z EOP P/L - NOTES * BUILDING CONTRACTOR TO TRENCH/BACKFILLALL * BUILDING CONTRACTOR TO DIG Z OFFSITE TAP HOLES AS SHOWN 4'x4'x18" UNDER GAS PIPE * BUILDING CONTRACTOR TO TRENCH APPROX. 16' FROM TAP HOLE TO PROPERTY LINE FOR EACH SERVICE . * BUILDING CONTRACTOR TO TRENCH APPROX. 1 10' AND 32' ONSITE TO GAS METER LOCATION * PG&E TO PERFORM HOT TIE IN EST: JC1 CO: %ADE: JJGJ GAS CONSTRUCTION SKETCH So._ SUPV: EEW6 125/127 ROSEMARY LN NOTIF: REP: JODl OTHER: PLNR: CAMPBELL SHT: SCALE: NTS oa% 51/2018 PACIFIC GAS AND ELECTRIC COMPANY P�� 35031532 REV. .-��. o ■R elf-r7 ARICnl IC DCr`1=113T PUBLIC WORKS DEPARTMENT UTILITY ENCKUAUt1IVII=N 1, 1 MNrrly. a Ivll.w���r+�a���•� Effective July 1, 2017 TO:.Einance PUBLIC WORKS FILE NO. v W PROPERTY ADDRESS ZS W Please collect & recel t for the followin I monies L.�rmA,'If!'fi .ACCT'y. t, s 1 i N 4 k 4;,5'Z:t' yt} 4n=�k a{1,.t. .o-,p1J�«+-ir(•.1'.S. ENCRDi4CHIVIENT,PERMI'I'_. _:. _ n-._.- t. _. M 4722 Utility Encroachment Permit Application Fee $455.00 f f69 LN dti+E`��l�'4IMIQNTk 'r �''f�4� tik �Ljk�-S.'ef4tds r �,��1�:�3'4R m ,. O� R-1 Encroachment Permit N/C .Emergency Permits $130.00 Plan Check & Inspection Fee Minimum Charge Per Location $420.00 • 610 Conduits/Pipelines up to 500 Feet $2.95/ft Above 500 Linear Feet $1.75/ft Manholes/Vaults/Etc. $190.00/ea Pole Set/Removal $190.00/ea 4760 Storage Container Permit -(valid, up to 60 days only) $170.00 .4760 Project Plans & S,pecifications, Project No. 4760 Standard Specifcations.& Details 47.60 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"xW" copies) $32::00 .: Maps and Plans 24" x 36".. $15.00 4722 Penalties: Failure to restore.p;ub.lic improvements $100/Cafendar Day (Muni Code Sec, 11.34.010) 4722 Penalties: Failure "to .correct unsafe conditions Si66italendar Day 4722 Work Without Permits 4 Times Applicable Fee/Min$500 i., 4128 Traffic Flow Map (Daily Traffic Volumes) $35.D0 472.8 Signal Timing Information $7:3 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or $25/100 � �� � t �,, ex - sz�-, � �' rv� ���{ � :rr ii b �� ;� � �"�,.. �'rd� I J 'j��,e' �"�. �"'4, i o, asr✓ :� �.. �� t Postage Other (Please Speci ) i, r�„d.�`l �.. T_,..n".t Ifm�o.,�°.. �".J�.-. ,,�,�n 6U^. 511.742,41 TOTAL �: 010 NAME OF APPLICANT NAME OF PAYOR PHONE ADDRESS ZIP FOR CITY CLERK. ONLY RECEIVED BY x y s� s I. "NA Hr , Date Recelpt#Y " �� �� A EV CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 11/28/2017 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 Moore & Miller Insurance Soquel Drive Soquel CA 95073 CONTACT Leslie Brown NAME: FAX PHONnE o. Ext (831) 462-6900 X108 Nd : (831) 462-3884 fAIC,3333 ADDRESS:leslie@mooremiller.com INSURERS AFFORDING COVERAGE j NAIC 9 INSURERA:CO10PY Insurance Company _ kNSUF2ED Mello Pipelines, Inc. 260 McGlincey Lane Campbell CA 95008 INSURERB:Nat1.OnW].de Mutual Insurance Co 23787 INSURERC:State Compensation Insurance Ftmd INSURER D -American Contractors Indemnity1 INSURER E - i INSURERF:. I COVERAGES CERTIFICATE NUMBER:CL17112808435 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 SUBRI POLICY NUMBER POLICY EFF MMlDD POUCY EXP .MIDD= UMITS a COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE $ 1,000,000 A -1 CLAIMS -MADE L. � 1 OCCUR i i I DAMAGE TO RENTED PREMISES Ea occurrence . S 50,000 MED EXP (Any one person) $ 5, Goo - X I Contractual Liability X 1103GL0021100-00 12/1/2017 12/l/2018 PERSONAL&ADV INJURY $ 1, 000,000 I!I GENI AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE S 2,000,000 PRO ❑ LOC POLICY ❑ JECT _ PRODUCTS -COMPIOP AGG 6 2,000,000 S OTHER: AUTOMOBILE LIABILITY I ! I COMBINED SINGLE LIMIT Ea accident (S 1,000,000 BODILY INJURY (Per person) S ANY AUTO ij I{ B i ALL OWNED SCHEDULED AUTOS �' AUTOS 12/1/2017 12/1/2018 BODILY INJURY (Per accident) S PROPERTY DAMAGE Peracciden' S NON -OWNED y' JAC27854805179 - HIRED AUTOS AUTOS IS UMBRELLALIAB OCCUR I I EACH OCCURRENCE - S EXCESS LIAB CLAIMS -MADE l!I AGGREGATE j S DED RETENTION S S I i WORKERS COMPENSATION PER OTH- STATUTE ER C 'AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ (Mandatory in NH) N ! A , ` J 1909655517 8/1/2017 8/1/2018 E-L EACH ACCIDENT S 1,000,000 E.L.DISEASE - EA EMPLOYE S 1,000,000 Ifyes, describe under ` DESCRIPTION OF OPERATIONS below € E.L. DISEASE --POLICY LIMIT S 1,000,000 D Contractor's License Bond 8/9/2017 8/9/2020 Bond Amount $12,500 D Contractor's License Bond t�9055069 19055068 III 1/31/2017 1/31/2020 I Bond Amount $15 , 000 DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) � The City, the City of Campbell Redevelopment Agency, its officers employees and volutmeers-are named as additional insured for General Liability per attached forms. Waiver of subrogation & primary working applies to General Liability, Auto Liabiltiy & Workers Compensation forms attached. This insurance is primary. There will be ten (10) days notice of cancellation for non payment of '!premium. l; la 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 Leslie Brown/LB A `-o i v 1�6o-ev ru t�t.urcu �vrer�ne� a c+rlis. AfI rlgnts reserveca. ACORD 29 (2014101) The ACORD name and logo are registered marks of ACORD INS026 (201401) 103GL0021100-00 COMMERCIAL GENERAL LIABILITY CG 20 010413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND N®NCONTRIBUTARY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in contract or Condition and supersedes and provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary and Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not additional insured. seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is aNamed Insured under such other insurance; and POLICY NUMBER: 103GL0021100-00 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 TIIIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ,� �'f ��� i 2 �M1,F �4 ��' � L � 4 ry. �•4 � ��� �� � 5� � k �x 1 X 3 +� ^� - This endorsement modifies insurance provided under the following: COMMIERCUL GENERAL LIABILITY COVERAGE PART CY4311104 1/ Name or person or Organization: American Technologies, Inc. and all of their officers, directors, agents, representatives, servants, employees, divisions, subsidiaries and all related entities or individuals whether specifically scheduled herein and the project owners. (if no entry appears above, information required to complete this endorsement will be shown in the Declaration as applicable to this endorsement.) WHO IS AN INSURED (Section II) 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". The insurance provided shall be primary and any other insurance maintained by the additional insured is excess and non-contributory. Copyright, Insurance Services Office, Inc.,1992 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION: JOB DESCRIPTION: s City of Campbell 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.) Policy No. 9096555-17 Insured: Mello Piplines Inc Insurance Company: SCIF -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999 POLICY PLUMBER: 103GL0021100-00 NAMED INSURED: Mello Pipelines, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE® e OWNERS, LESSERS OR CONTRACTORS ® SCHEDULE® PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following_ COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: City of Campbell 70 North First Street Campbell Ca 95008 Any Person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A, 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 ongoing operations performed for that insured. CG 2010 3197 Copyright, Insurance Services Office, Inc.,1992 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVEROF TRANSFER OF RIGHT'S OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM ti With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. SCHEDULE Name(s) Of Person(s) Or Organization(s): I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization_ CA 04 44 1013 O Insurance Services Office, Inc., 2011 Page 1 of 1 Permit # Consultant/Contractor: i s KP5-e INSURANCE REQUIREMENTS CHECKLIST CIP Project # 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: 1.1000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or El$2,000,000 general aggregate limit. - Policy expiration date k-7-1 k Automotive Liability: '(!_ "Any Auto" checked on certificate ��de �L 1,000,000 per accident for bodily injury and property damage Policy expiration date I Workers' Compensation and Employer's Liability �- Waiver of Subrogation clause $1,000,000 per accident for bodily injury or -disease Policy expiration date c. Course of Construction (if required in Special Provisions) ❑ Completed value. of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: ^The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area should say: Should any of the above described policies be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted �- br General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev Jan 2018) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the �- State of California. �j Name: NAIC #3 ` sting: � `l`Authorize CA: Name: -"e c;!► NAIC # Z?$Rating: Authorized in CA: Name: , , d ��� NAIC # a� Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License #- M L Expiration: Z 3 � ❑ Contractors License # 'b%Q Class Expiration: 3� I Insurance Certificate Reviewed ' Initials Date ❑ Copy of Insurance Certificate placed in tickler file one mo rior to expiration. w J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 •��®�� CERTIFICATE OF LIABILITY( INSURANCE DATE (MMIODNYYY) 11/28/2017 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. It 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' � � Moore & Miller Insurance - 3333 Socluel Drive CONTACT Leslie Brawn NAME:. NE (g31)462-6900 x108 pAX No.L831)462-3884 No Ext : LL leslie@mooremiller. com RESS: INSURER(S) AFFORDING COVERAGE j tINSURERA:C010171Y NAIC # Insurance Com anINSURED Soquel CA- 95073 _ Mello Pipelines, Inc.. URERB:Nationwide Mutual Insurance Co 23787 wsURERC:State Compensation Insurance Fund INSURERD:American Contractors Inddrah1tV. 260-McGlincey Lane INSURER E : INSURERF: ^ ^A — - — — •. [All 1tdA�tC9. Campbell CA 95008 _ — _ _ _ � COVERAGES tLCtt I it -It A t G ttlUtntorr%.__ • --•--- - --- — - 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. INSft LT R ,. TYPE OF INSURANCE ADDL SUB11 POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD 12/1/2018 uNll.m EACH OCCURRENCE 5 1,000,000 A COMMERCIAL GENERAL LIABILITY F-71GLAINIS-MADE o OCCUR X Contractual Liability X 1 103GL0021100-00 12/1/2017 DAMAGE TO RENTED PREMISES Ea occurrence $ _ 50,000 MED DIP (Arty one person) S 5,000 PERSONAL BAOV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 - GEN'L AGGREGATE LIMIT APPLIES PER: ` PRO ❑ LOG 'Y POLICY ❑ JECT PRODUCTS-COMPIOP AGG $ 2, 000., 000 S OTHER: AUTOMOBILE LIABILITY (CEO aBtcNdeDLSINGLE LIMrf I $ 1,000,000 BODILY INJURY (Per person) $ $ ANY AUTO ALL OWNED L ULED AUTOS WNED HIRED AUTOS ACP7854605179 12/1/2017 12/1/2018 BODILY INJURY (Per accident) S' PROPEP.TY DAMAGE Per accident s I$ UMBRELLA LIAR OCCUR EACH OCCURRENCE Is HCLAIMS-MADE AGGREGATE S. EXCESS LIAR �K / PER OTH- � STAME ER S DED Tj RETENTION S WORKERS COMPENSATION EL EACH ACCIDENT S 1,000,000 C �AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIMEMSER EXCLUDED? (Mandatory in NH) NIA � - _ 1 909655517 8/1/2017 .. 8/1/2018 E.LDISEASE- EAEMPLOYE S 1,000,000 E.L. DISEASE -POLICY LIMIT S 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below D D Contractor's License Bond Contractor's -License Bond I9055069 19055068 8/9/2017 1/31/2017 8/9/2020 1/31/2020 Bond amount $12,500 Bond Amount $15,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured for General Liability per attached forms. Waiver of subrogation & primary working applies to General Liability, Auto Liabiltiy & Workers Compensation forms attached. This insurance is primary. There will be ten (10) days notice of cancellation for non payment of premium. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 70 North -First Street Campbell, CA 95008 AUTHORIZED REPRESENTATIVE Leslie Brown/LB .4-'"L��� W t.7OV�LV fY P1V Vflv,vVry ,v. „Le •.�..w ....--..-- Ac6RD 29 (20'14101) The ACORD name and logo are registered marks of ACORD INS025 (201401)"