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" , - , 9 0- , - � - . � , � � � , - r CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00127 Name: Lua's Construction Property Address: 1040 Dell Ave. Date of Final Inspection: On File: Bonds CD Cash Labor and Material: $ Construction Cash Deposit to be released: $ Faithful Security Deposit: $2,000.00 Other overdue deposits to be released (Description): Processed by: /2 1/ 7 dministrator Reviewed by: q/2�) I f Inspector Reviewed by: L--<-. i o j Lt Land Development Engineer J:VoAnnaT06posit refunds\CHECKLISTS\Dell 1040.doe (Rev. 10/11) a Rn� CERTIFICATE OF LIABILITY INSURANCE DATE /19/l7YYY) 05/19/17 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 Progressive Tower Insurance Service CONTACT NAME: A/C. No Ext : (818)704-1068 FAX, No): (818)812-7854 A DRESS, EMAIL jason@progressiveins.net 7334 Topanga Cyn Blvd., Suite #108 INSURERS AFFORDING COVERAGE NAIC # Canoga Park, Ca , CA 91303 INSURERA: ASSOCIATED INDUSTRIES INSURANCE COMPANY 23140 Phone (818)704-1068 Fax (818)812-7854 INSURED INSURER B : INSURER C : MT. HAWLEY INSURANCE COMPANY LUA'S BUILDING SERVICES, INC- INSURER D : CALIFORNIA INSURANCE COMPANY 38865 DBA LUA'S CONSTRUCTION & FACILITIES INSURER E : HISCOX INSURANCE COMPANY 3062-3064 Scott Santa Clara, CA 95054 INSURER F : rnVFRnr.FR CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD. INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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 INSR UBR WVD POLICY NUMBER POLICY EFF MMlDD/YYYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 COMMERCIAL GENERAL LIABILITY- - DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000.00 MED EXP (Any one person) $ 5,000.00 A ❑ ❑ CLAIMS -MADE �/❑ OCCUR Y Y AES1023288 04 08/13/2016 08/13/2017 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE s 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000.00 $ ❑ POLICY © PRO ® LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ❑ ANY AUTO BODILY INJURY (Per accident) $ ❑ ALL AUTOS OWNED ❑ SCHEDULED AUTOS NON -OWNED ❑ HIRED AUTOS ❑ AUTOS PRO rac is ";M AMAGE $ $ ❑ ❑ C ❑ UMBRELLA LIAB OCCUR �/ EXCESS UAB CLAIMS -MADE Y EMX0322427 12/01/2016 08/13/2017 EACH OCCURRENCE $ 5,000,000.00 AGGREGATE $ 5,000,000.00 ❑ DED ❑ RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY OFFICER/MEMBORIPARTN RIE?ECUTIVE (Mandatory in NH) �Y .NIA Y - 46-876401-01-04 09/01/2016 09/01/2017 ® WCRSTAITU ❑ OTH- ER E.L. EACH ACCIDENT $ 1,000,000.00 E.L. DISEASE - EA EMPLOYE $ 1,000,000.00 E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 If yes, describe under " DESCRIPTION OF OPERATIONS below E FIDELITY CRIME BOND UC21700253.17 03/03/2017 03/03/2018 $1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS frVEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE 104' ' K ell Ave , CarnbeEl�C 950�ermi't #ENC-200 �7i� The City of Campbell, its officers, employees and volunteers are named as Additional Insured. CERTIFICATE HOLDER. CANCELLATION The City of Campbell 70. N. First Street Campbell, CA 95008 ACORD 25 (2010/05) QF 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 @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IN' PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT I Effective July 1, 2016 TO: Finance PUBLIC WORKS FILE NO. ' {`t PROPERTY ADDRESS Please collect & receipt for the followm monies AMOl�T 3'ACCT _ ITEM -�; , - T �n N1 U IAND.DEVELDPMENT-� .4722 Encroachment Permit Application ee Non-Utilt Encroachment Permit Ma'or 2:$10 000 $403.00 ' Minor .Encroachment Permit <sio,000 $230.00 Initial -1 Permit N/C Subsequent R-1 Permits within Two Year Period $230.00 Inspection Fee Minimum Charge per Location $398.00 Street Tree Plantinq/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% bf Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $281.00 Site < 10,000 s.f. $841.00 Site >_ 10,000 s.f. < 0.5 Acre $1,127.00 Site >_ 0.5 Acre $1 688.00 4722 NPDES Review C3 Requirements) For protects not required to submit numeric sizing $163.00 For projects required to submit numeric sizing 1 Acre $704.00 Impervious Area 10,000 S . Ft to Impervious Area 1 Acre or more $918.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $300 ea Plan Check & Inspection Fee(Non-Utility). ci l 4722 En r. Est.. < $250 000 14% of Engineer's Estimate 4722 Engr. Est.>_$250,000 and <_$500,000 $35,000 + 8% of Engineers Estimate 4722 En r. Est. >$500 000 $55 000 + 7% of Engineers Estimate 2203 22031 Emergency Cash Deposit 4% of En r. Est.* ($500 min/$10 000 Max 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 4722 2203 Parcel Map (4 Lots or Less) $4009.00 + $87/lot Final Tract Ma (5 or More Lots) $4,871.00 + $118/lot Monumentation Security 100% of City's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (includes Certificate of Compliance) $1,893.00 4722 Vacation of Public Streets & Easements $2,530.00 4722 Certificate of Compliance $1,877.00 4722 Certificate of Correction $561.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 4722 Private Improvement in Public ROW $50.00 - Approved Plan Revision Fee $100/sheet 4722 4722 Appeal Filing Fee $200.00 Notary Fee (per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $895.00 Each Additional Lot $281.00 Postage - 5117424 110— ther (Please Specify) tP � s Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ t1 0L e� *Engineer ^ NAME OF APPLICANT L V 14�j Cn Iqv NAME OF PAYOR PHONE loa— ADDRESS 3 ZIP FOR ITY CLERK ONLY CITY OF iE_i ._r..rx ... _ RLCr.ii- BY,. .. CASHIER _ �i YD..x L_rr r : REGISTER DAY! ..." r r . iTim: _ EPTIDD 00x v.0 ENT U-MCM79W27 r_fa' R a .___.__. FILMS .. fir, f'91H 1 - .v. x `U Wit! ...�,. xa :'-: •.^r. � CHECK . - rSZ .00 I* i Z ,RECEIVED I Print Form � aid CX� � Z CITY OF CAMPBELL MM 1:1 ENCROACHMENT PERMIT Permit No DEPT.OFPUBLICWORKS (forworking within the public X-Ref. File 7dNorth First Street dministration right-of-way) Application Date '� Campbell, CA §licworks A �� Application Expiration Date Ph. (408) 866-21SO Issued f APN Fx. (408) 376-0958 36 8 Permit Expiration Date _ APPLICATION -Application Is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: 11040 ,SELL AV Crq Mp g ELL t 6 A Utility Trench Location: B. NatureofWork: �iVCnET� p rp �(l�C H )2CAJOVE � Pi- h 0gCLc- C. Attach four (4) copies ofa n engineered plan showing the location and extentofthework, and four (4) copies ofthe preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. All workshall conform tothe City ofCampbellStandard Specifications and Details forPublicWorks Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result In Job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before startingwork. Notice mustbe given to Public Works atleast24 hours before restarting anywork. Name of Applicant: I Ptl r)q FL Lv w Telephone: '5� 0 u Address: 13661-1 5 CCg7 6 1V 4 I -Z�,ctrr7 A C ifui/ CA , ( 1-1 9S 6 5 E-MailAddress: rfoU%UUS<Oi1ST1 VCT1U»' CUNt 24-HOUR EMERGENCY PHONE NUMBER: _ Is this work being done by the property owners at their own residence? ❑ YES NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. 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 compl9ted in the public right-of-way. Accepted: (Applicant Permittee) Date /O/f7 L v LvF►s cr,;v.-��_,��1,�� p-, 1°c�..._1._i-�._r1. L�1i�� (Contractor) (Print Name) 70 l Date SPECIAL PROVISIONS: ❑ 1. streetshall not beopen cut for underground Installations. Minimum cutsMaybe allowed for connections orexploration holes. Such cuts maybe specifically approved by the Inspector prior to cutting. ❑ 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by the Engineer. ❑ 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. ❑ 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. ❑ 6. Public Notification Requirements: ❑ 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT �1 dtr RECEIPTNO.Ir PERMIT APPLICATION FEE PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $.9CA C_— '� (p_�_t CONSTRUCTION CASH DEPOSIT S __ PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE $ // APPROVED FOR ISSUANCE or City Engineer Date Permit Expires 12 Months After Date of Issuance Kidder Mathews April 7, 2017 City of Campbell Building & Permit Department 70 North First Street Campbell, CA 95008 RE: Building Permit for 1040 Dell - Additional Encroachment Permit: To whom it may concern: We would appreciate your assistance with the building permit for 1040 Dell in Campbell, California. As representative for owner of the property, Dell Avenue Properties, LLC the exiting permit had expired due to change in general contractors which occurred back in February, 2017 and then with the additional engineering changes to the exterior driveway ramp per the City Inspector which we are correcting at this time. Please accept this letter as authorization for you to continue to work with our contractor, Lua's Construction. If you have any questions regarding the above please contact me directly at (408) 588-2303. .Sincerely, Nancy Bab,RP Representative for Dell Avenue Properties, LLC Kidder Mathews 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 bf 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 ofthe 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, S. 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 roust be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 2006 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 scoremork 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 shoulderiine 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 wort: 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. Wort: must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 21, Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the 13EST 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 mariner in which the same Is to he made. 29. Permittee roust provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and a phone number. 24. Applicant shall remove water from utility vaults In accordance with the requirements of State Water Resources Control Board Water Quality order WQ 2014-0174- DWQ. Said vault waters all nQ be discharged into the City of Campbell's storm drain system. See htt�(/wwFv.waterfiaar¢s.ca.rov/water Issuasluronmrns/nudes(utlllivvnutts.shtnit 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. V T rjl.f2__ is f"-, I Contractor (Print Name) J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC forn12.pdf Rev.03/17 Date: O�Z0_L7_ Mk pate: AC®® CERTIFICATE OF LIABILITY INSURANCE DATE YY1Y) 05J2312017 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER $I:df£'Fafftl State Farm Insurance -Patricia Medina, Agent Lic.#OF08124 w L (Owl' 2001 Salvio St., Suite 5 Concord, CA 94520 NAONTACT PATRICIA MEDINA, AGENT PHONE , 925-755-1177 No : 925-755-5007 E.R.SS: patricia.medina.ppyr®statefami.com ADD INSURE S AFFORDING COVERAGE NAIC q INSURERA: INSURED Lua's Building Services, Inc, dba Lua's Construction & Facilities 2900 Scott Blvd Santa Clara, CA 95054 INSURER B : State Farm Mutual Automobile Insurance Company 25178 INSURER C : INSURER D : INSURER E: INSURER F: /AVG�A!?GQ f'=0TICICATG W"11MR1=I7• REVISION NUMBER: vTHIS 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 WRH 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 LT TYPE OF INSURANCE �ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL 0 ENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO as RENTED n $ MED EXP An one person) $ j I PERSONAL & ACV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: j GENERAL AGGREGATE S PRODUCTS -COMP/OPAGG f POLICY JET LOC $ OTHER: AUTOMOBILE LIABILITY ; Y Y 293 4742-005-05A 03/05/2017 03/05/2018 O aS N ED NGL r iT 5 1,000,000 BODILY INJURY (Per person) S ANY AUTO BODILY INJURY (Per accident) S B ' OWNED SCHEWLED AUTOS ONLY AUTOS i HIRED NON-0WNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Peracdde t S $ UUMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS Ulm DED I I RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE PER TH. TAT UTER AC E.U. EACH ACCIDENT f E.L. DISEASE - EA EMPLOY • f OFFICERIMEMBER EXCLUDED? NIA (Mandatory in N141 E.L. DISEASE -POLICY LIMIT f If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Addillonal Remarks Sehedule, may,6 attached If more apace Is required) RE: 1040 Dell Ave., Cambell, CA 95008 / Permit #ENC-2017-00127 - The City of Campbell, its officers, emPtgvegs.and-volonnteers are named as Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70. N. First Street Campbell, CA 96008 AUTHORIZED REPWENTATIVE © V 988-2015 ACO D CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered ma s of ACORD 1001486 132649.12 03-1&2016 CITY OF CAMPBECU' ' w (408) 866-2174 ��':a ESTABLISHED: 02/10/2017 EXP'`DATE: �02110t2018, LICENSE NO. 030615 S 3Y LOCATION: 1750 E MAIN ST MORGAN HILL, CA 95037 '^ BUSINESS: LUA'S BLDNG SVC INC .�DB'A ,LUA'S�CONS TYPE OF BUSINESS OWNER: RAFAEL G LUA �:r CONTRACTOR -SPECIAL TRADE -OUT OF ,. TOWN The person, firm, or.corporation nained:above is gjanted this business license pursuant to the provisions of the City: Business License Ordinances to engage in, carry on, or conduct the`business, trade, calling, profession, --exhibition, or occupation described above. Issuance of the license is not an end'oisement, nor'certification of compliance with other ordinances or laws, nor, an; assurance that,the proposed uses In conformance with the. city zoning regi'tlattons. This license is issued without verification, that the"license'e��is:subject to or exempt from the 11censing by the State of California. Vaiil"oniy within°the "City of Campbell city. limits. CITY MUST13E.NOTIFIED. ON ANY CHANGE IN OWNERSHIP, LOCATION, OR CLOSURE. ANNUAL TAX PAYMENT DUE ON OR BEFORE THE EXPIRATION DATE. RENEWAL NOTICE NOT REQUIRED. av �� CERTIFICATE OF LIABILITY INSURANCE FDA 05MIDD/YYY() 05/19/17 T IIS 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 Progressive Tower Insurance Service CONTACT NAME: a/co No Ext : (818)704-1068 FAX No): (818)812-7854 E-MAIL Jason@progressiveins.net 7334'Topanga Cyn Blvd., Suite #108 INSURERS AFFORDING COVERAGE NAIC # Canoga Park, Ca , CA 91303 INSURERA: ASSOCIATED INDUSTRIES INSURANCE COMPANY 23140 Phone (818)704-1068 Fax (818)812-7854 INSURED INSURER B : INSURERC: MT. HAWLEY INSURANCE COMPANY LUA'S BUILDING SERVICES, INC INSURER D : CALIFORNIA INSURANCE COMPANY 38865 DBA LUA'S CONSTRUCTION & FACILITIES INSURER E : HISCOX INSURANCE COMPANY 3062-3064 Scott Santa Clara, CA 95054 INSURER F : COVERAGES CERTIFICATE NUMBER: KtVI51UN NUMULK: 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 INSR UBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY) POLICY EXP I (MMIDDIYYYYI LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE 0 OCCUR ❑ Y Y AES1023288 04 08/13/2016 08/13/2017 EACH OCCURRENCE $ 1,000,000.00 AGE TQ PREM SESOEa .Nccu ence $ 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY d❑ PRO ® LOC PRODUCTS -COMP/OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL AUTOS OWNED ❑ SCHEESULED ❑ HIRED AUTOS ❑ ANON -OWNED ❑ ❑ COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PUTOSe�ac.,dZl)AMAGE $ $ C ❑ UMBRELLA LIAB OCCUR EXCESS LIAR Q El Y EMX0322427 12/01/2016 08/13/2017 EACH OCCURRENCE $ 5,000,000.00 AGGREGATE $ 5,000,000.00 ❑ DED ❑ RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) F—Y] If yes, describe under DESCRIPTION OF OPERATIONS below NIA Y 46-876401-01-04 09/01/2016 09/01/2017 WC STATU- OTH- TOR LIMITS ❑ E E.L. EACH ACCIDENT $ 1,000,000.00 E.L. DISEASE - EA EMPLOYE $ 1,000,000.00 E.L. DISEASE -POLICY LIMIT $ 1,000,000.00 E FIDELITY CRIME BOND UC21700253.17 03/03/2017 03/03/2018 $1,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: 1040 Dell Ave., Cambell, CA 95008 / Permit #ENC-2017-00127 The City of Campbell, its officers, employees and volunteers are named as Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Campbell 70. N. First Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Campbell, CA 95008 AUTHORIZED REPRESENTATIVE @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) QF The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 01 03 03 r WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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, but this waiver applies only with respect to bodily injury arising out of the operations described in the Schedule where you are required by a written contract to obtain this waiver from us. This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule. The premium for this endorsement is shown in the Schedule. Schedule 1. () Specific Waiver Name of person or organization: Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Operations: 3. Premium 1500 The premium charge for this endorsement shall be of the premium developed on payroll in connection -with work performed for the above person(s) or organization(s) arising out of the operations described. 4. Minimum Premium 5. Advance Premium This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 09/01/16 Policy No. 46-876401-01-04 Endorsement No. 9 Insured LuaIs Building Services, Inc. Premium$ 11500.00 Insurance Company California Insurance Company Countersigned by �I��— POLICY NUMBER: AES1023488 04 COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to include as an additional insured any person or or- ganization 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 addi- tional insured on your policy. Such person or or- ganization is an additional insured only with re- spect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are com- pleted. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render- ing of, or the failure to render, any professional architectural, engineering or surveying servic- es, including: a. The preparing, approving, or failing to pre- pare or approve, maps, shop drawings, opi- nions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sureds) at the location of the covered operations has been completed; or b. 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 subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: AES1023288 04 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Location And Description Of Completed Operations All persons or organizations where written contract with the Named Insured requires additional insured completed operations coverage. This form does not apply to your work on "residential property". Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured 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 dam- age" caused, in whole or in part, by 'your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products - completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: AES1023288 04 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV —Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 0 POLICY NUMBER: AES1023288 04 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD -PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured .(Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4. of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: 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. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission n INSURANCE REQUIREMENTS CHECKLIST Permit # CEg _ Ao a-1' d d Az-1 CIP Project # C� `� 50�� 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 limit. 0 �� Policy expiration date �I l3jli ,� Automotive Liability: 0 "Any Auto" checked on certificate p ❑ $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and Employer's Liability Waiver of Subrogation clause p\L $1,000,000 per accident for bodily injury or disease ❑ Policy expiration date Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) b�. The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read Q \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\loannat\Desktop\I,nsurance Requirements Checklist.doc (Rev 03/13) Page 1 of 2 I . M 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 V S Name: SG'-tVk\L, k A -S NAIC # a3\WO Rating: Avl )<V Authorized in CA: f Name: Cis .,\A5<-. 0-0. NAIC #1S'Rating: X, Authorized in CA: N,--' Name: 5V e —1L%-4VIJtUvA- NAIC # a--\ Rating: Authorized in CA: �Z Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License # �,1'J Expiration: lO 0 ❑ Contractors License #1 ' 1-1 (n� �- Class: Expiration: I 1c� Insurance Certificate Reviewed Qom- . -5- 1 In Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. b J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 REID LERNER ARCHITECTS 30 May 2017 Syed Wahidi Public Works Department City of Campbell 70 North First Street Campbell, CA 95008 Subject: Transmittal of Driveway Improvement Plans Project: Alterations to former Grand Dell Saloon 1040 Dell Avenue, Campbell, CA 95008 APN: 421-01-063 Greetings, One. set of driveway improvement plans is attached in support of our application for an encroachment permit, per our telephone conversation. Please contact Oscar Osuna, CE at GreenBluEarth of me if questions or comments are regarding this assignment. i Than 'u, R Id Lerner, AIA REID LERNER ARCHITECTS 7680 Monterey Street #105 Gilroy, CA USA 95020 Phone (408) 842-9942 Fax (408) 842-9971 reidlerner@yahoo.com Copy: Miguel Lua, Lua's.Construction & Facilities, 3064 Scott Boulevard, Santa Clara, CA 95054 California License No. C19293 Hawaii License No. AR7007 Indiana License No. AR19800066 NCARB Certificate No. 40,835 Idaho License No. AR-1871 New Mexico License No. 3043 Guam Certificate No. 240 CNMI Certificate No. A085 Arizona License No. 34778 �Qy CR 117 8&47 FL tie 9e.9e TIC RET f / 7 EX. FACE OF CURB — 29e g&' x Vn x w� 213 99.13 z 08 x 7RFY COR 99.14 T wv 2177 F1�EX x 99.'50 wv 212 J 99.17 211 TFUM COR 99.10 T " `°R CITY ROW 01* xa +e2— teo.t4 FL BER 00 153 10037 FL so te4 t0052. Ut t55 FLBER — tBo.50 FL 9ER 126 121 �' `p °8up1 / P— 18.00' foaot 700 I TREE 101 99 eB STRIP BFP t cq 1K co 19 l9FP +� FL�BER 4 nM/O� 99Q AC Pv �"ea 9B5B 4 �-- UGr IVY - - FL eFx EL Sox oR PST 149 - — 14E 0.69 9f147 FFLL BM 5 FL 99.78 FL BEx 175 174 UG 'AT E UC RPPCE ne - 1481 99.72 99.73 U9 ATF FL BER 177 178 99 0 uc Air �c x TuEr *ifT UG RID POE CONFORM TO EX PAVEMENT x'ino= 1m SEE ON —SITE PLANS oo� vi x vv CONSTRUCTION NOTES .I SEE AC PAVEMENT REMOVAL/RESTORATION _ I xa� DETAIL ON SHEET 4 - - - - 99 ��' I O ice/ X-1 I 01 ry I — 130 O N I — — 9e.sz `P °m I +� 56.10' x 9Es 131 `G TIC 98.80 �B 4 I 1°2 FL 98.32 '� m 7 I221 , I ee Will sa Lp 42 197 '98.7e p I 220 9 GAS lC F]ID CJ I 222 9eu72 0.4% is � 2ze 99.7E ,c D A '� o �t +E� LANDING NOT TO 13S X w w EXCEED 2% ANY f11o�e PA° / DIRECTION m ME MATCH EX. u I� II, IIIIII i Foe Ra � PAn o noaR 139 x1v r 190 =21 w E� UO w FF 100.47 , e DOOR V x 133 AC _ _,o %.� ��' Es°r FIX R� G FjF!!o% G �`� 12, 100.49E / odo ��,uc A7i V Y �ob PAVEMENT RESTORATION NOTE: O1 REPLACE DRIVEWAY WITH NEW 18.0' CITY STANDARD DRIVEWAY APRON, PER CITY STD DETAIL D-18 ON SHEET 4 O O3 4O 5O 6 0 O O THE CITY ENGINEER RESERVES THE. RIGHT TO, AMEND OR _CHAP REMOVE EX AC PAVEMENT SIDEWALK & REPACE WITH NEW SIDEWALK TO NEAREST THE PAVEMENT RESTORATION'AREA.SHOULD�ANY UTILITY "TREI EXPANSION JOINT PER CITY STD. DETAIL D-20 ON SHEET 4. CONNECTIONS, FACILITIES, ETC CHANGE IN=LOCATION FROM, CONFORM TO EXISTING IMPROVEMENTS. ARE SHOWN ON THESE PLANS, OR FOR PAVEMENT DAMAGE Ci BY -THE CONTRACTOR'S CONSTRUCTION EQUIPMENT ANY CHAP! EX.. POLE &GUY WIRE TO REMAIN THE CITY.ENGIIVEER REQUIRES CAN INCLUDE BUT ARE NOT:LIMI - PA = TO -FULL REMG�VAL OF EXISTING PAVEMENT STRUCTURq4s EXISTING TREE TO REMAIN. EC7 - INSTALLATtON,UF PA�/EIVIEN`STRUCTUR,gL SECTION, GRINDIN EXISTING CURB AND GUTTER TO REMAIN '_ ;,� rv:INSTkLLAT1ONEF PAVEMENT, p► f G K t... 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