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ENC2017-00182OV C4'ei i •UkCHA60� . CITY OF CABELL Public Works Department September 18, 2018 William Tuttle 39 N. Milton Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00182 39 N. Milton Ave., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear William: The City of Campbell has made the final inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Sincerely, Syed Wahidi Public works Inspector Enc:2017-00182- 70. North "First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 . ra Encroachment Permit Final Sign Off Encroachment Permit # c'c {�2 Address: 3q t\A lam. /fie pate of Final Inspection and Acceptance: 9117 18 Inspected by: J� OK to release deposits: 100% ✓ '75% Comments: �L 1 s OF Q44t ;io� . �kCHARO •. CITY OF CAMPBELL Public Works Department October 9, 2017 William Tuttle 39 N. Milton Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00182 39 N. Milton Ave. FINAL INSPECTION AND ACCEPTANCE Dear .William: 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. The one year maintenance period stated in the permit begin•Cas'of September 13, 2017. The permittee is responsible for the repair and/or replacement of any defective wor or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of $2,000.O0 is enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00182 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.279*0 of C,q4�( � c •�kCHAR�• CITY of CAMPBELL Public Works Department October 9, 2017 William Tuttle 39 N. Milton Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00182 39 N. Milton Ave. FINAL INSPECTION AND ACCEPTANCE Dear William: 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. The one year maintenance period stated in the permit begins as of September 13, 2017. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of $2,000.00 is enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00182 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 , `2 C _ ._-" r f 1 I- ' 4 l y � Check Payable 4To WllliI $. n Address Line 1 39 N; Line 2 City w Camj -. Description , ENE Account Number Account°Number 101 540 7448 mount _ _ Interest-Earned('Finance Dept odly, . _ ;;;� { I ,Z .. � (Exact Amount), =r s :.f f = H Je ,i 117 00182 Deposit Refund y, 4 f C l t o . : n q. ` Permit # ENC2017 00182 r f w ' r. { 270641"e - Date 7/26/2017 . __ Y- y j . Receipt # Date c j ` �' , I, 1 Requested 6y C ,, `Syel L , . i r Approvetl"by Roger Stot ! fi FJnance" ept Only Verified by, C Approved 'by l�s Z Fly M811 AS IrS M 1 1. j, 1 -' Rety n To ' JoA , `' }� :, `;,` ther Please retui e„ t r -' e t ". Y i " m Tuttle r 4 t t l r -, r 7,, m r ry" Ji .. -. ? Milton Ave v - ,'. r K, r K ;, e'er M-•f""". . t - ':. J r c t Y - -rl bell � State MCA Zip 950D8 11- .f i ' ,z 2017 ,00182 ; -;'os � Refund ;i h k 5 F d.Y jz - ] 'I 101- 2203 _ _ 1 Arr%unt = $2;000 00 ` h'. `; 101 2.203 t Amount :i Account Nuirber, R �A (Finance,Dept only) Total .Payable - 1, Purpose t ENC l r , ti , Receipt 4 f a 1 �` i - - l f k t i i ,' r T,itle In"spector Date' 9%26/2`017 + u 1, r . d 4 t t i e k ' � Titles Sr Englneer ` Date_: ` 1` i l i ' - 1 � M '.�, f ,F •1 t ' 11. 5) Title k _,Accountmg;Clerk 11. Date: -°:� > 5"r L,1-.;_7�7I�-., ',,--.. ,1�' "�"" __T'�"'%- �;��_',-',�7" -K- , �_-.�, _,- ', .".;�' �I__�,�, ,',_, '�-"-%:I__",''w1(_1�";.'��- �;"�',_�_I M----'-r. 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"., _;7,-'I_" 1L"_�.'.,- ,�,7,' , .�Z.'; I,.'I-�_--�..% _,-'�'�,,. ,-,-4�.".-_%�1_ �� _� - ,I ;- "."."� _. - � ._-� �':,_-,._'1 --:- 7,- _ ,"I . -, I, -, �,-.-, : :� _"'.,;,,, _'.,'- .-- I "�,�',!,'-'- ��"�.',: _ �''�,- . 1�- '� tra s F:oir� f Hand'I i n Checyk, __ L ilit Attached nvelope ` lnierlm l.neCK 1 , r x { 4 Y NeededrBy ' ` C 4 ;I F l :. 9 �^ na Thomaso'n € `Public Works 2) (Name) } (Department) i r i r check to JoAnna 3 �1 J._.:1 J { r t _ '� r _e Y�-� 4 t ; f IK 1 f -tii r CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00182 Name: William Tuttle Property Address: 39 N. Milton Ave. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance-' 000.00 1 Labor and Material: $$_._____--"�/ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: Reviewed by: Reviewed by: Administrator pector Land Development Engineer I /,zz � r, JA\JoAnnaT\Deposit refunds\CHECKLISTS\Mi1ton39.doc (Rev. 10/11) Encroachment Permit Final Sign Off -Encroachment Permit # '—^I c 2z 17. ooI82 Address: 3�l MIL%ram Date of Final Inspection and Acceptance: Inspected by: OK to release deposits: 100% .y 75% Comments: Print Form ( IV CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No.� �"n®' � DEPT. OF PUBLIC WORKS (Non -engineered work within the public right-of-way) X-Ref File 70 North First Street ($10,000. 0 maximum value of work) Application Date Campbell, CA 95008 (� (7 Application Expiration Ph. (408) 866-2150 ISSUED: 1 1 9 Date Fx. (408) 376-0958 Permit Expiration Date: APN �O� 5— APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months if the permit is not issued.) A. Work Address: 139 N. Milton Avenue B. Nature of Work: Replace driveway curb cut and driveway C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing become 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 securities. NAME OF APPLICANT: William Tuttle Telephone: [408-316-93-31 Address: 139 N. Milton Avenue E-Mail Address: lbill.tuttle@sjwater.com The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence. The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency, 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 hereby acknowledges that they have read and understand both the front and back of this permit, and that they will inform their contractor(s) of the information. ACCEPTED: (Applicant/Permittee) (Sign) Date NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable insurance requirements. The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. 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 (Ticket No.) has been entered hereon. USA Phone: 1-800-227-2600. Ticket No 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 the design, installation or condition of private improvements in the public right-of-way. SPECIAL PROVISIONS 1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 2. a STANDARD A►11 LINT URITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.) $ � o o PERMIT FEE nQ\ a 1 $ ROVED FOR ISSUANCE: for City Engineer Date Permit Expires 6 Months after Date of Issuance. GENERAL PERMIT CONDITIONS 1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon completion of the work and written acceptance by the City. 2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the one-year maintenance period. 3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10 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, fire hydrants and water valves. 7. 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. 8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 9. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading as specified by the City Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee. 10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during construction. 11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any law enforcement officer upon demand. 12. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline, which would create a hazardous condition to the public. 13. 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. 14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 16. 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. 17. 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. 18. 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. 19. 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. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. Applicant J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev. 02/14 Date R MECHANICAL - SEPARATOR SIDEWALK SEE NOTE 5 w w w w �, w WEAKENED PLANE; JOINT � OR CUT JOINT 1 /8" WIDE 2" DEEP+. w w - w w w w R R w i• . w w w w w w PARKSTRIP w w v CONSTRUCTION JOINT _ / -- WEAKENED PLANE JOINT OR CUT JOINT �p 1 /8" WIDE, 2' DEEP 25 `L 1 o - "5 y5 S=1" PER FOOT 5/8" 1"R -1 /2" R 0'-0" �I i4'-6" 5'-0" 6,. +10% MAX CONFORM`SLOPE = 1/ 4" PER FT. —6% MAX .-�o. :";;$'.' .•`.i;?, i...,a, .:. �. :•:o.- :'•e.• 8 6 SS A CONCRETE, TYP. ° '':' o:.. :• s >;;;;: t•.4: I 8 , 6. CLA" 6" CLASS 2 AGGREGATE BASE, TYP. NOTES SECTION . A -A DOWEL 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF- NO. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC-3- ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. " 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING' SIDEWALK, THE NEW SIDEWALK. SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. c CITY OF CAMPBELL REV. DATE BY SCALE: -t °� �jD� PUBLIC WORKS DEPARTMENT � Residential _ N.T.S. DRAWN BY: EA DATE 02/04 DI'1VeW$y Detail -Yo.9 DETAIL • "'`'q�'° CHECKED, BY: DAB (Detached Sidewalk .) NO. APPROVED BY: �RCgAR9 W� 4 GINEER d:/Drawings/Std_•Details/D14.2 D-14.2 NOTE: REMOVE EXISTING PAVEMENT FULL DEPTH TO CLEAN, - REMOVE EXISTING STRAIGHT EDGE AC SECTION AND BASE (12" MIN) REPLACE AS SHOWN GRIND 2" DEEP PAVEMENT KEY TYPE A Y2"-MAX-MED AC (95% COMPACTION) NEW PCC IMPROVEMENTS CURB, GUTTER,' DRIVEWAY 1211 9i1 - 12" APPROACH OR ACCESSIBILITY RAMP EXISTING PAVEMENT \ o e TO REMAIN Opt DOWEL TO EXISTING PCC IMPROVEMFNTS WITH 44 REBARE6" EMBEDMENT ^� I=i I I I I I I I I I LI I I I I I I I IO" MIN 2 SACK SANDICEMENT SLURRY BACKFILL, 2 SACK CEMENT PER CUBIC YARD OF MATERIAL 6" CLASS 2 AGGREGATE BASE (95% RELATIVE COMPACTION) COMPACTED NATIVE NOTE: APPLY TACK OIL TO ALL (95% RELATIVE COMPACTION) SURFACES PRIOR TO PLACING NEW A.C. ��•�d• A.C. PAVEMENT REMOVAL & RESTORATION :t� a DRAWN BY: DETAIL CHECKED BY: AT NEW PCC IMPROVEMENTS sd 1,141 APPROVED BY: T A-3 REVISED DAIE& MAY 2012 �RCB►R9 ' J:\DRAWINGS\STD DETAILS\A-3 F Effective July 1, 2017 PUBLIC WORKS FILE NO. G A PROPERTY ADDRESS Ina monies: U i' i t OF Ct";i'ti''1ZGii RECVD BY; C:saHT-EROi,00027 64t lla or>_$10 000 $425.00 ulLi IAI1 ;Cf`I;L oo $240.00 TODAY'S DATE: 07 26 17 to Year Period $24 $240.00 REGISTER DATE: 07/26/17 TIRE— 00:0(v er Location $420.00 DESCRIPTION AM011UIN T N/C COST ID:WILLT4M TUTTLE bositRequired) $500.00/tree REF DEPOSIT - 101 $2e000.00 Dr's Estimate $500.00 min ----------------no deposit required TOTAL DUE: $2., 000.01111 $295.00 TENDERED: v2.000.0II $885.00 CHANGE: $1,185.00 CHECK $2.000.00 $1 772.00 - REF svilft" 1569 numeric sizing $175 00 . heric sizing Ft to 1 Acre $740.00 Impervious Area 1 Aui, lore $965.00 4722 For ro'ects sent to Consultant for review Consultant Cost +20% 4722 . Additional. treatment facilities $315 ea Plan Check & Inspection Fee(Non-Utility) 4722 En r. Est. < $250 000 14% of Engineer's Estimate 4722 Engr. Est. >_$250,000 and <_$500,000 $35,000.00 + 8% of Engineers Estimate 4722 En r. Est. >$500 000 $55 000:00 + 7% of Engineers Estimate 2203 Emergency Cash Deposit 4% of Enqr. Est.* ($500 min/$10,000 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 Citv's Monumentation Estimate 4920 Parkland Dedication Feb (75%/25% Due Upon C_ ert. 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 Certificate of 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 4122 Assessment Segregation or Keapportionment First Split $940.00 Each Additional Lot $295.00 511.74241 Postage Other (Hlease 5peclty) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ NAME OF APPLICANT L. W.-ex- NAME OF PAYOR L< 0 + f, PHONE j ADDRESS n C ZIP FOR ITY CLERK ONLY To: Page 4 of 4 2017-08-15 22:56:32 (GMT) /V19169141313 From: Tony Clark FD /4 1JG 1 16 �� DATE (MM.'DOIYYYY) Aco�r®" CERTIFICATE OF LIABILITY I CEO 08/15/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP Rbil *ARTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFF&QED 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(les) 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 certliJcate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER Phone: (800)750-2663 Fax: (916) 914-1313 CONTACT Contractors Brokerage Service, Inc, CONTRACTORS BROKERAGE SERVICE, INC. PHONE Fax !A!C.N..EA:-. 80( 0) 750-2663 9940 BUSINESS PARK DRIVE, SUITE 150 _ (a�•AN,�. (918) 914-1313 e4AAI'_ WWW.cbsbond.com SACRAMENTO CA 95827 ADDRESS INSURER(S) AFFORDING COVERAGE NAIC # Agency Lich: OD58571 INSURERA : AmTrust international Underwriters Ltd. IusURERD : United Financial Casualty Company 11770 K 8 S BAY CONCRETE 2575 CANVASBACK DR INSURER LOS BANOS CA 93635 INSURER D: INSURER E ' INSURER F n nvoown_rc f1C0TICIt`A'Te KIIIRACCC• 99I1A f1 GP\/LCIAIJ AIIIIUIRRR- 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 P ID CLAIMS. INSR TYPE OF INSURANCE ADD, SUER INS_... �ti^..!G._ I POLICY EFF POLICY NUMBER POLICY EXP LIMITS A GENERAL LIABILITY X X XN107600800 08115/17 08115/18 EACH OCCURRENCE ' S 1,000,000 X COMMERCIAL GENERAL LIABILITY ! GE TO RENTED PRE al ES ;Ea aurcnca) i S 100,000 CLAIMS -MADE X OCCUR _ MED. EXP (Any one person) S 5,000 PERSONAL & ADV INJURY 5 2,000,000 GENERAL AGGREGATE j S 2,000,000 ( i I GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMPiOP AGE, I S 2,000,000 r--- __X I POLICY J� i LOC E I ! I --------..----------....--+------.__.......... - S B AUTOMOBILE LIABILITY X X 040743130 08115M 7 08/15/18 COMBINED SINGLE LIMIT 6 1,000,000 )(�ANYAUTO BODILY INJURY (Per person) S IALLOWNED SCHEDULED )t --------_..--------_a_.._...._.-.._...---.__.---- BODILY INJURY (Per aoddem) S AUTOS AUTOOTNOSOWNED i HIRED AUTOS N I PF20PER'Y`DAA1A E _- --_ _.._I.......................................................................:: i 5 I AUTOS (ner occident? - I S UMBRELLA UAB OCCUR I i EACH OCCURRENCE i6 ;EXCESS UAB �— CLAIMS•MADEI I AGGREGATE -� 5 DED RETENTION S , 5 ........ -- ---- :.._._. - - --- - -- 1 _...-- . _ . . WORKERS COMPENSATION AND EMPLOYERS' LIABILITY VC ST O H TORY LIMII;S ER f 5 ANY PROPRIETOWPARTNERJEXECUTNE YIN OFFICER;MEMBER EXCLUDED? F E.L. EACH ACCIDENT i y NIA (Rlandetory In NH) '----- I j E.L. DISEASE -EA EMPLOYEE ; S If ycS. desc-ibe under 1 -DESCRIPTION OF OPERATIONS beK,w i E.L. DISEASE -POLICY LIMIT S \ I i I 9 JI DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Addition.. Remarks ScFP6 We, if more space is required) City of Campbell, its officers, employees and volunteers are named as additional insured The Insurance coverage afforded to the Additional Insured is primary Insurance All work in the public right-of-way, Reference Project Location and Permit Number CERTIFICATE HOLDER CANCELLATION City of Campbell ( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 N. First St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Campbell, CA 95008 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESEN?AMIE Attention: rµ., I Jason March ACORD 25 (2010105) (D1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD To: Page 1 of 4 e 2017-08-15 22:56:32 (GMT) FAX COVER SHEET TO COMPANY FAXNUMBER 14083760958 FROM TonyClark DATE 2017-08-15 22:56:20 GMT RE Certificate of Insurance - K & S Bay Concrete COVER MESSAGE Insured: K & S BAY CONCRETE Company: AmTrust International Underwriters Ltd. Policy Number: XN107600800 Policy Period: AUG 15 2017 To AUG 15 2018 Please see attached COI for K & S Bay Construction, Sincerely, Sarah Otto Contractors Brokerage Service, Inc. 9940 Business Park Dr., Suite 150 Sacramento, CA 95827 (800) 750-2663 ext. 205 (916) 368-4747 ext. 205 Fax (916) 914-1313 (main) sarah@cbsbond.com www.cbsbond.com 19169141313 From: Tony Clark Specializing in the License, Bond and Insurance requirements for the Construction Industry. General Liability - Workers' Compensation - Auto - Bonds - License Exam Preparation WWW.METROFAX.COM To: Page 3 of 4 2017-08-15 22:56:32 (GMT) 19169141313 From: Tony Clark POLICY NUMBER: COMMERCIAL GENERAL LIABILITY NX GL 189 0611 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. D. The following are added to SECTION V — DEFINITIONS: "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. E. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: Primary Wording With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. 2. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "you work" done under a contract with that person or organization. NX GL 189 0511 Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc.: with its permission To: Page 2 of 4 2017-08-15 22:56:32 (GMT) 19169141313 From: Tony Clark POLICY NUMBER: XN107600800 COMMERCIAL GENERAL LIABILITY NX GL 189 05 11 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modes insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: XN107600800 Endorsement Effective: 8/15/2017 12:01 a.m. Named Insured: Counter Signed By: K & S BAY CONCRETE, DBA: K & S BAY CONCRETE,, SCHEDULE Name of Person or Organization: Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (if no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II —Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than services, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed: or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. NX GL 189 05 11 Page 1 of 2 Includes copyrighted material of Insurance Services Office, Inc., with its permission PLEASE POST IN A CONSPICI; )US PLACE ..NOT TRANSFERABLE -BU81NESS, LICENSE 6,6w"Op CA,b P BELL0 31 (408) 866-2174 ESTABLISHED: 07/2712017 EXP�,DATE: 0.6/3012018 LICENSE NO. 030946 LOCATION: 1169 KEYSTONE CT SAN JOSE, CA 951320-. -V �2 BUSINESS: K & S BAY CONCRETE TYPE OF BUSINESS IR -CONCRETE-OUT OF TOWN. ��CTIDR OWNER: KIPILOTI KUILA CONTRACTOR-CONCRETE-OUT i6d§sAcens p toth provisions of the City Business License the person, firm, or corporation named above .is.g ranted this 11-1-111 "Plysuan RA , . '�h-bition, or occupation described above. Ordinances to engage in, carry on, or conduct the business., 'c"a-iii'n-g",-'�r6fessiion,,,ex i `�brtifiicaii,n of compliance with o her"ordinances or laws, nor an assurance that the , f� Issuance of the license is not an endorsement no . T proposed use is in conformance with the city zoning regulations. This license is issue" without verification that the licensee is subject m the licensing by State of California .Valid only within thwCity� of Campbell city limits. CITY MUST BE NOTIFIED to or exempt from '�r' i�, ��, - , --', i� - ON ANY CHANGE IN OWNERSHIP, LOCATION, OR CLO UR_,-�,, r'i 14�,,- I ANNUALTAX PAYMENT DUE ON OR BEFORE THE,EXPIRATION''-DALF'E..RENEWAL NOTICE NOT REQUIRED. INSURANCE REQUIIIEMENTS CHECKLIST Permit # �'�"17'Y 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 general aggregate limit applying separately to the project, or $2,000,000 general aggregate I' it p olicy expiration date '-D� Automotive Liability: 0- "Any Auto" checked on certificate �... $1,000,000 per accident for bodily injury and property damage Policy expiration date Workers' Compensation and Employer's Liabi ' -`,Je' ❑ Waiver of Subrogation clause ❑ $1,000,000 per accident for b erinjury or disease IC ❑ Policy expiration date Course of Constr ion (if required in Special Provisions) ®� - ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) i The City, its officers, employees and volunteers are named as additional insured. _ (Reference Proiect Location & Permit Number) < �\e-ec dk- ❑ The insurance coverage afforded to the Additional Insured is primary insurance. i i Cancellation Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read 4-0 Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. \\Honouliuli.cityhaII.ci.campbell.ca.us. loca[\Profile_Data$\loannat\Desktop\All Insurance Requirements.doc (Rev 03/13) Page 1 of 1 i s ❑ Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: v\� ` AIC # Rating: Authorized in CA: Name: �vu w�`IAIC # P A- R a t i n g: Authorized in CA: Name: Uv��e� .np.y\_cic.\ NAIC.# 111 Q Rating: k Authorized in CA: Name: CG`S`� NAIC # Rating: Authorized in CA: TAM r�G_ ❑ Campbell Business License # Insurance Certificate Reviewed Initia 4\-A4 7(v6�\% ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. t� i U0_`-aa0 GX�ij �kl3dll`� L 7 C:\Documents and Settings\loannat\Desktop\Insurance Requirements 2 pgs.doc (Rev 03/13) Page 2 of 2 r WORKERS' COMPENSATION INSURANCE INFORMATION The following worker's compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit or contract. WORKERS' COMPENSATION INFORMATION: Name of Contractor/Applicant ❑ A Certificate of Consent to Self -Insure issued by the Director of Industrial Relations: OR ❑ A Certificate of Workers' Compensation Insurance Insurance Co. Policy No. Expiration Date •m ❑ A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that in the performance of the work for this contract, I shall not employ any person in a manner so as to become subject to the Workers' Compensation Laws of California. Signe Date% f a Title NOTICE TO'APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the {permit or Contract will be cancelled or revoked. J:\FORMS\Templates\Insurance Requirements\Workers Comp information sheet.doc (Rev 9/11) 1 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 08/15/2017 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 Phone: (800) 750-2663 Fax: (916) 914-1313 CONTRACTORS BROKERAGE SERVICE, INC. 9940 BUSINESS PARK DRIVE, SUITE 150 SACRAMENTO CA 95827 CONTACT Contractors Brokerage Service, Inc. NAME: 9 PHONE FAX (916) 914 No Ex,: 800 750-2663 Ac No: E-M-1313 -M AIL wWw.Cbsbond.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER : Arri International Underwriters Ltd. Agency Lic#: OD58571 INSURED K & S BAY CONCRETE INSURER B :United Financial Casualty Company 11770 INSURER 2575 CANVASBACK DR INSURER D: LOS BANOS CA 93635 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 22040 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 ADD'L INSR suBR WVD POLICY NUMBER MM DDPOLICY/YYYY MM DDM/YY LIMITS A GENERAL LIABILITY X X XN107600800 08/15/17 08/15/18 EACH OCCURRENCE $ 1,000,000 X, COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurence) $ 100'000 CLAIMS -MADE A OCCUR MED. EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 P $ X POLICY C LOC B AUTOMOBILE LIABILITY X X 040743130 08/15/17 08/15/18 CO(Ea aMBNGLELIMIT dent) ccident) $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO ULED ALL OWNED X AUTOS BODILY INJURY (Per accident) $ AUTOS NON -OWNED HIRED AUTOS PROPERTY DAMAGE $ UTOS (per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH TORYLIMITS ER $ AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVEY^N E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ICI N iA (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ If yes,describe under DESC DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) City of Campbell, its officers, employees and volunteers are named as additional insured The insurance coverage afforded to the Additional Insured is primary insurance All work in the public right-of-way, Reference Project Location and Permit Number Job Location - 39 N. Milton Ave., Campbell, CA 95005 CERTIFICATE HOLDER CANCELLATION City of Campbell 70 N. First St. Campbell, CA 95008 Attention: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE Jason March ACUKU Z5 (Zu1u/U5) (9 1blUB-211110 AGORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Al y r e` D ;p. LoveuAve San Tomas Aquino Bucknam Ave Creek Turne WaY m y, reek Trail Project ientary School Cafeteria vember 9, 2016, at 7:30-9:00 p.m. fional information at ks@cityofcam pbell, com includes the presentation of the iil along San Tomas Aquino Creek ?sign are the first stages of the project. 1 Unjta �,O(A FW 2cnJ �'n�i s i�sv�wc� else , (Uvredua - v�tQ� San I omas Aquino Bucknam Ave Creek iutner WaY m > U m o Creek Trail Project ementary School Cafeteria November 9, 2016, at 7:30-9:00 p.m. Iditional information at vorks@cityofcampbell.com ting includes the presentation of the trail along San Tomas Aquino Creek nue. 1 design are the first stages of the project. �So 3(oq 333� �j �v� CnSv�-�- �ie• a� "� San-iomas Aquino F . Bucknam Ave Creek ' Turner N]aY- D m ® Creek Trail Project ementary School Cafeteria November 9, 2016, at 7:30-9:00 p.m. Witional information at forks@cityofcampbell.com ing includes the presentation of the trail along San Tomas Aquino Creek we. design are the first stages of the project. EX. 2 CAR GARAGE 39 31 PORCH 49 9' EX. no - - - - D/lY TWIN TON AVENUE 60o/CZ IYATER N s MIL 0 0 o Q:.. CS 0/� l 30 40 j-,�HkCVE 50 FOR CONSTRUCTION ity ®f Campbell Public Works Permit contractor trust have Whose Plans ,, +he job sire during oanstrucHon. 39 Ns MILTON AVENUE DRIVEWAY WIDENING PLAN SC,4L E- /" = 20' so