Loading...
ENC2018-001581\ CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.: r_NC_ p&_ Msb DEPT. OF PUBLIC WORKS (for working within the X-Ref. File r ?O1702_ 70 North First Street publi right- f-way) Application Date Campbell, CA95008 Issued V/ Ph. (408)866-2150 Application Expiration Date Fx. (408) 376-0958 �5 I APN Permit Expiration Date APPLICATION -Application is hereby made for a Public Works Permit inaccor ance 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: 1223 Walnut Drive Nature of work/Utility Trench for PG&E joint trench B. Trench Location: ❑ No Fee Permit for work related to City Project Project Name: 1223 Walnut Drive 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 conform tothe City of Campbell Standard Specifications and Details for Public Works Construction; theGeneral Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result 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 Telephone: 408-377-6103 Address: 260 E. McGlincy Lane Campbell, Ca 95008 E-Mail Address: mellopipe@sbcglobal.net 24-HOUR EMERGENCY PHONE NUMBER: 408-761-0585 Is this work being done by the 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 G1/ZZ i�, 6-13-18 Mello Pipelines, Permittee) (sign) Jeff Mello (Contractor) (Print Name) Date 6-13-18 Date SPECIAL PROVISIONS: 1. Streetshall not be open cutfor underground installations. Minimum cuts may be allowed for connections or exploration holes. Suchcuts maybe spRrifirally approved by the R Inc p ctor 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 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 r-- APPROVED FOR ISSUANCE AMO NTT'S•dO s S �n For City Engineer Permit Expires 12 Months After Date of Issuance RECEIPT NO. ?.:`7S72 , R. 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 vaIves. 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. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the construction cash deposit. 14. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit maybe required, nor does it relieve the Permittee of any obligation to obtain any other permit required bylaw. 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 priorto 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. 1(0 ram fees Applicant Contractor (Print Name) J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 04/18 Date: Date: 7 ® ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 11/28/2017 THISCERTIFICATE 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 REI ,RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) mast be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Moore & Miller Insurance 3333 Soquel Drive NAME: Leslie Brown PHONE (83I)462-6900 X108 FAX (831)462-3884 AfC No Ext: C No: noDRess: leslie@mooremiller. com INSURERS AFFORDING COVERAGE I NAIC # ' INSURERA:Colony Insurance Company Soquel CA 95073 _ INSURED INSURER B Nationwide Mutual Insurance Co 23787 INsURERc:State Compensation Insurance Fund Mello Pipelines, Inc. INSURER D American Contractors Indemnity 260 McGlincey Lane INSURER E : - k` Campbell CA 95008 INSURERF: 1.rV V CI'iHl'.LJ 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. LLT R LTR 'n TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICYEFF MMIIDD EXP YYYI UM(I'S ? ( COMMERCIAL GENERAL LIABILITY -EACH OCCURRENCE S 1,000,000 A ' ( CLAIMS-MADEril OCCUR %�!~ _ -- -QAMAGE TO RENTED PREMISES Ea occurrence)S SO,OOD EXP (Any one person) S 5,000 X Contractual Liability X 103GLOO21100-00 12/1' 2017 12/1/2018 . PERSONAL & ADV INJURY $ 1,000,000 i GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS S 2, 000 000 'X -POLICY PRO LOG JECT �- S OTHER: EOMaccidentCBINED 51NGLE LIMIT (g j., 000, ODD AUTOMOBILE LIABILITY BODILY INJURY (Per person) S B ANY AUTO ' SCHEDULED ALL OWNED X ACP7854805179 12/1/20I7 12/1/2018 BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED y PROPERTY DAMAGE Per accident $ X X AUTOS HIRED AUTOS I is q .... UMBRELLA LIAR 1 OCCUR EACH OCCURRENCE S AGGREGATE is EXCESS LIAB CLAIMS -MADE DED RETENTION S " WORKERS COMPENSATION /� $'... PEROETRH - AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE ❑ OFFICEC E EXCLUDED? NIA .,, � _--. \, E.L EACH ACCIDENT $ 1 000 , 000 (Mandatory (Mandatory In H) 9096ESS17 8/1/201j7 t\ 8/1/2018 E.L.E1SEASE-EA EMPLOYE S 1,000,000 ,/ -E:C. DISEASE -POLICY LIMIT S 1 000 000 Ifyes, describe under '> DESCRIPTION OF OPERATIONS below . D aCon'ractorIs License Bond I `9055069 8/9/2017 8/9/2020 Bond Amount $12,500 D .'Contractor`s License Bond 9055066 1/31/2017 1/31/2020 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 voluriLsers 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. \22� GtK I7tIGA I t IIULUt1Y "^��"'-'-'-^ • "'• " SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 70 North First Street ACCORDANCE WITH THE POLICY PROVISIONS. Campbell, CA- 95008 AUTHORIZED REPRESENTATIVE Leslie Brown/LB"'L'"' n 1988-2014 ACORD CORPORATION. All rights reserved, AGORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS026 (207401) LEGEND — S (1) - 3" PVC SECONDARY DUCT BY APPLICANT — SV (1) - 3" PVC SERVICE DUCT BY APPLICANT [2] 17" X 30" X 26" IVT SECONDARY SPLICE BOX BY APPLICANT [2F3 17" X 30" X 30" FVT SECONDARY SPLICE BOX BY APPLICANT ® EXISTING 17" X 30" X 18" IVT SECONDARY SPLICE BOX NOTES 1. APPLICANT TO TRENCH JOINT WITH ELEC, GAS, TELCO AND CAN 2. APPLICANT IS TO PROVIDE ALL ELECTRIC SUBSTRUCTURES AS SHOWN 3. APPLICANT IS TO PROVIDE MANDREL AND PERFORM MANDREL TEST WITH PG&E INSPECTOR STANDBY 4. THE TOTAL NUMBER OF BENDS IN ANY SECONDARY DUCT RUN IN EXCESS OF 200 FEET SHALL NOT EXCEED 300 DEGREES, ANY SECONDARY DUCT RUN EQUAL TO OR LESS THAN 200 FEET IN LENGTH MAY CONTAIN UP TO A TOTAL OF 315 DEGREES IN BENDS. 5. APPLICANT IS RESPONSIBLE TO ENSURE TRENCHING AND SUBSTRUCTURE INSTALLATION MEET PG&E GREENBOOK STANDARDS. GREENBOOKS ARE AVAILABLE AT YOUR LOCAL PG&E HEADQUARTERS OR CAN BE FOUND ON THE INTERNET 0 WWN.PGE.COM/GREENBOOK 6. FLAME RESISTANT (FR) CLOTHING IS REQUIRED WHEN WORKING ON OR AROUND PG&E FACILITIES AND EQUIPMENT. SEE PG&E GREENBOOK FOR ADDITIONAL DETAILS 7. APPLICANT IS RESPONSIBLE TO COORDINATE WITH TELCO AND CAN FOR THEIR CONSTRUCTION REQUIREMENTS °AFETY SAFETY PLEDGE I ALWAYS PUT VSM MST. I LOOK FOR M ACT TO RESOLVE UNSAFE SIE AMM. I HELP MO DCOURAGE OTHERS TO ACT -LY. DEVELOPER NOTES BEFORE BEGINNING SUBSTRUCTURE WORK, PLEASE CALL THE UNDERGROUND INSPECTOR AT LEAST 46 HOURS IN ADVANCE AT (408) 725-2202 OR FAX (408) 725-7773. (WORK NOT PROPERLY INSPECTED MAY BE REJECTED) IF THERE ARE ANY CONFLICTS BETWEEN SUBSTRUCTURES INSTALLATIONS AND LANDSCAPING CONTACT THE INSPECTOR PRIOR TO INSTALLATION. NOTE LOT 3 (COMMON AREA) AREA=2,433 SF PSE, EVAE, PIEE, PSDE & PSSE UNDERGROUND SERVICE ALERT umelt CONTACT U.S.A. AT LEAST 4B HOURS IN ADVANCE OF TRENCHING OR EXCAVATING. CONTACT PG&E INSPECTOR AT LEAST 48 HOURS IN ADVANCE TO MAKE STANDBY ARRANGEMENTS WHEN WORKING WITHIN 5' OF ENERGIZED FACILITIES. 811 •Blf CALL 1V0 WIKCVG DRYS 06 - RIG *** MINIMUM 3 FOOT SEPARATION FFACILITIES.ANALONG WITH 111 FOOT MINIMUM OF UNDISTURBED EARTH *** j 550 1225 i I 200AM S 120/240 V „•. 3W 10 'PROPERTY LINE" PROPERTY UNE ' �•_ 32 w 548 0 LOT.:.3.•1..' 1223 J N. 200AMS H 120/240 V j 1221 3w10 64'I I PROPERTY LINE I •' N• �IM CURB EDGE OF PAVEMENT 3' S WALNUT DR t 180' TO W HACIENDA AVE SIDEWALK 45' ® �� 4' S PT03672-2 ,or V) ~w L.LJ 00 z F- O N V) Z to J CY) L.LJ a z N J U LLLd c CL 00 mA V) N U m CV gr� U 4 5 6 I 7 I 8 9 I - - -10 r1 n LEGEND r-I EXCAVATE 4418" BELOW PIPE BELL HOLE LJ — c — G — EXISTING GAS FACILITIES — JT — it — PROPOSE ELECTRIC, TEL AND CAN JOINT TRENCH D — — — — — PROPOSE GAS, ELECTRIC, TEL AND CAN JOINT TRENCH P/L PROPERTY LINE r1p. z-1 FDIC FACE OF CURB 'IvpICnL JO.NT {yy �_'EBYLE_IF3EClC}4 CAS ONLYAITFNCH �N CONSTRUCTION NOTES; * APPLICANT WILL TRENCH AND BACKFILL ON -SITE P B , L ti AND OFF -SITE +PGkE INSTALL 1"PL SERVICE AND A BRANCH JOINT TRENCH WITH ELECTRIC, TEL AND CAN G MINIMUM COVER AND CLEARANCES ��C D�Y671[iii6Ti[is'31'i 1'iTi, 6�(]1.�PLCimIlll�I�fF�ifYTi®I�f�fi r - Immeamlmm�;r�r>,a; o[a�ri���IaolgmlmNr�l © � • mlramoao+ ; ", o�� •r;�si'�m+a�mmlaoa� J mF31�i�C3T�[ilmimi6ll'illdCiDii�m -- I. Farm a Inlormaflon, a PG&E UO Standard 5-SASS, Exhibll B, Jaln} Trench & Oeeupanev Guido, Greenbook, Appendix B. Speclflcelly, sou Notes 4, 5, 7, & 13, 2. Sireelllghl circuits not owned by PG&E must be B Inslallod fo meal the requir ..I, in PG&E', Jolnf T h & Oc v G.gg, Spedficclly, appli—I must �evlew the raqulremente tar working wllh c aocand utility company. APPLICANT CHECKLIST ED CONTACT UNDERGROUND SERWCE ALERT'UW AT 811 AT LEAST 2 WORKING DAYS BEFORE EXCAVATION TO HAVE EGSTdh'G UNDERGROUND OBURES MARKED IN FIELD ® 03114 CITY/COUNIY EXCAVATION PERMIT (IF APPU(9IT TO TRENCH) ® FOILOW TRENCH NSTRUCTIONS IF APPUCANT TO TRDJCN) DO M IN 3' OF SEPARATION FROM WEF FAOURES Q.E. W RR, SEWER, STORM), REFER TO U0 STMUD 55453, EY.NIDR B 19 HAVE SUFFICIENT SAND ONSIFE PRIOR TO RNA. INSPECTION, REFER 10 GREENBOOK SECTION 2.3.4 © W(RDDNATE INST&LATION OF T1]EPHONE AND CAOLE 1V FA&IURES PER THOR CONSTRUCTION REOUIRELIENTS GO CA'1 (408) 299-1024 OR FAX (408) 299-1087 FOR PG&E INSPECTION - 2 BUSINESS DAYS ADVANCED NOTICE 19 PLUA3 CAS HOUSELINE TO MEN LOCATION AND HAVE MUNICIPALITY NOTIFY PG&E THAT GAS HOUSEUNE HAS PASSED INSPECIIQ4 A ® GAS VETER GUARDS PER GAS STANDARDS AND SPECIFICATIONS LMUAL SECTION J-95 TO W HACIENDA AVE TIED BELL HOLE BY APPLICANT TEE, EFV PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2017 TO; .Finance ©.t� l S •- PUBLIC WORKS FILE NO. t�-��[�✓ I� — Z�'..�. PROPERTY ADDRESS r ICdJC I.V IIOVI Vc IGI�I.! i ! - rl ITEM jar `, zry,. .„ . s -s ; ' i.�' ``.t.,u k• = F•t- =y "z� {_ .r. v. 4§ , .._. * •- ,f - '� i r.,w.,.trr,'r..,,'n +,.ay�n.�""" •� "� - >t'S".Mz.".'�. Utility Encroachment Permit Application Fee $455.00 { #AM UNi` r .,'� ..._ ' ,EIUCRDACNMENT:1?ER1Vill=.u. 4722 �3 ki e�r_.''�,,.r :.', R-1 Encroachment Permit N/C Emergency Permits $130..00 Plan Check & Inspection Fee Minimum Charge Per Location $420.00 Z© "L 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 476.0 Storage'C.ontainer Permit(validup to 60 days only) $1.7.0.00 4760 Project Plans & specifications. Project No. 4760. Standard .Specifications,& Details $11Pg "$:15 SO/Bk, 4760, Engineering Maps .&. Plans. Aerial Plot 24'' x 36" $65.00 - Aerial Print 8 1/2" x 1,1" $32:00 Map Research (includes max of two 24"x36" copies) $310.0 Maps and Plans 24 x 36".. $15-06:- 4722 Penalties:_ Failure -to restore public irimproveri nts. $ioDicaienaar oay,{Muni code Sec,11.34&010) 4722 Penalties: Failure. to correct unsafe ons. $1 Oolcalendar day ,condit 4722 WOfk Without Permits 4 Times Applicable Fee/Min $500 a-.0. R I i i Sir '�' C,1 ( , .vim• d �y F�j, 1 sl t.3 ��F; h Y f3 .�• -' i�y+�3f Gyy rrW "Ij„fat-rtiy'A .�.���F,aM•;,�1 �t1F I�'�...1.�i9� .{.�aM'�, �,3 �.�•,..-a��, t k. ?vy, 97 4728 Traffic Flow Map (Daily Traffic Volumes) rtav , _ �.S �:N ; - 4728 Signal Timing Information $73„per. hour , 4271 Truck Permits $16:0.0.per trip 4728 MISCEL1AiNElO,US;r. No Parking Signs ns $1 each or $25/100 it Y.F� .... a_r..._..; 511.7424 Posta e Other (Please Specify) TOTAL Cj� S s CCU NAME OF APPLICANT NAME OF PAYOR PHONE ADDRESS FOR CITY CLERK ONLY _ fiR r.a .� .i..y ; ,r ,er}.,y �_. T-'"•,_,r•t ,�{'s$ K Fkxw� Y-- w �'ir *��r`�-4'ke'��r t-`. '� EK�-..�.r�,-+�lx" .u,..'Plr ,rW-ill ��.wgg_mum R1rCE1VEDBY �� ix-,vK'S '"W li:... m f 1 ��. C ..{✓ 5!$'t E� 7 /4�}� 11 T ill`:yft +ile -yr ;EV ;,���r�ryl ffr Dafie Reeept s x�r + ' U.J 15 9 ®- 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 poiicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the Yerms 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 Soquel Drive Soqu91 CA 95073 NAMEACT Leslie Brown AMO Exit. (831) 462-6900 X108 PAic No: (831)462-3884 E-MAIL ADDRESS-leslie@mooremiller.com INSURER(S) AFFORDING COVERAGE I NAIC # INSURERA:CO10 Insurance Company _ INSURED Mello Pipelines, Inc. 260 {McGlincey Lane Campbell CA 95008 INSURER B:Nationwide Mutual Insurance Co 23787 INSURERC:State Compensation Insurance E'und INSURER D American Contractors Indemnit INSURER E . 1 INSURERF: rnvr=nar cc C-r-PTIGIf_eTF All1tVlRFP-CL17112808435 REVISION NUMBER: v THIS 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. IN TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MIDDY EFF MPMI Dr EXP LIMITS ! COMMERCIAL GENERAL LIABILITY ` EACH OCCURRENCE S 1,000,000 I DAMAGE TO REN I L:D PREMISES Ea occurrence S 50,000 ',' CLAIMS -MADE a OCCUR I MED EXP (Any one person) S 5,000 X Contractual Liability t X 103GLOO21100-00 12/1/2017 12/1/2018 PERSONAL & ADV INJURY $ 1,000,000 1 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE , S 2,000,000 PRODUCTS-COMP/OPAGG S 2,000,000 { POLICY PRO ❑ LOC I JECT S `. OTHER: AUTOMOBILE LIABILITY I COMBINED SINGLE LIMITS Ea accident 1,000,000 BODILY INJURY (Per per -son) S ANY AUTO B ALL OWNED SCHEDULED y' ACP7854805174 12/1/20I7 12/1/2018 BODILY INJURY (Per accident) $ AUTOS AUTOS � Per PERT ntDAMAGE S -" HIRED AUTOS AUTOSWNED N ;',.... UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADEI AGGREGATE , S DED RETENTIONS $ WORKERS COMPENSATION XI PER OR STATUTE ER EMPLOYERS' LIABILITY YIN _ ANY PROPRIETOR/PARTNERlEXECUTIVE E.L.EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYEJ S 1,000,000 C OFFICERIMEMBER EXCLUDED? (Mandatory In NH) N / AJ 8/1/20I7 8/1/2018 E.L. DISEASE - POLICY LIMIT S 1,000,000 Ifyes, describe under DESCRIPTION OF OPERATIONS below ( I 1409655517 t II 'Contractor's License Bond I I j9055069 8/9/2017 8/9/2020 Bond Amount $12,500 D �Contzactor's License Bond f 19055068 I 1/31/2017 1/31/2020 Bond Amount $15,000 DESCRIPTION OF OPERATIONS / LOCATIONS / 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 volunT_eers--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. \223 City of Campbell 70 North First Street Campbell, CA 95008 CANCELLATION 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 lie Brown/LB :r ) 25 (2014101) (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 103GL0021100-00 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTARY - OTBER 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 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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.) O IS AN INSURED (Section 11) 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 ilflC OY 03 06 WAIVER OF OUR RIGHTRECOVER 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 €, ERSON OR OROAMIZATION: City of Campbell JOB DESCRIPTION. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The infonnation 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 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. :� f�'a L F ' R`� S�, y�" � �i: ,...� .. ¢.. � a 3 4� 5y �_ nm'' t _Ax ..�3 $ 1 ,•--. � � e. l This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. SCHEDULE N2me(s) Of Person(s) Or Organization(s): Information required to complete this Schedule, if not shown above, will be shown in the Declarations. f 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 3 of 1 POLICY NUMBER: 103GL0021100-00 NAMED INSURED: Mello Pipelines, Inc. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL I}a'URa-- D - OWNERS, a E i e,,,, E RC.;' OR CONTRACTORS SCHEDULED ' i,...PEDi .l — PERSON O 1' t`y few N'. ! r h M 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.) 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 20 I0 3197 Copyright, Insurance Services Office, Inc., 1992 Acceptability of Insurers) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: o(t NAIC # J Rat g: X\l Authorized in CA: ✓ i Name: - %c A cJ.�� NAIC # 231fl Rating: Authorized in CA: V Name: :nA-tite.. Co.. -V NAIC # ' O7 ating: r7,, Authorized in CA: Name: NAIC # Rating: Authorized in CA: Campbell Business License # �--I Expiration, Contractors License # -11 S- 96 6 Class: Expiration: n Insurance Certificate Reviewed Initials Date ❑ - Copy of Insurance Certificate placed in tickler file one month prior to expiration. ®m J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 INSURANCE REQUIREMENTS CHECKLIST Permit # i��C. �o -Col s 'w CIP Project # Consultant/Contractor: V\&e. Ao o-e- / e� 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: >4 $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date Automotive Liability: \ �[C_6 a 5 Any Auto checked on certificate - 4L$1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date i Z l c6 Workers' Compensation and -Employee's Liability 9- Waiver of Subrogation clause VI$1,000,000 per accident for odilyciinjury or disease j� Policy expiration date �6 r �5 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) - 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. Workers' Compensation Insurance Sheet Submitted X3_ 6r General Contractor ❑ For -Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev Jan 2018) Page 1