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ENC2017-00210pF CA 4 U r r . o` CITY of CAMPBELL Public Works Department. October 1, 2018 Da Vinci Homes, Inc. 2898 Joseph Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00210 2898 Joseph Ave., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Omid: 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. The remaining 25% of your Faithful Security Deposit refund is enclosed. Sincerely,. Syed Wahidi Public works Inspector 70 North First Street • Campbell 'California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 ............................... ............. ........................... . ........... . ................. .. ...... ............................... ........ . ............... ............ . .. ....... ........ .......... ... ...... .............. ......................... ........... -------- ---------- ---- -- ---- - CITY OF CAMPBELL VENDOR NO. 10014585 CHECK NO. ... . ...... . .......... . . . ......... 269958 269958 14 axin a xTa., i mi :1 A I III low I! 3EMM P, ELL. -- BANK, N.A. CHECK CHECK NO, 13-24 Al STREET STREET 11R I ANCISCO, CA 94104 72-1-0 lo o 1/18- 269988 CAMPBEL.' M,CALIFORNIA 9,500.8 AMP t�*7 6 2 ..�::iOlj:�,_AFTER 9 G',,DA: S. y 0 PAY ,THE SUM OF-.S_TXl=NbRED TWENTY FIVE DOLLARS & ZERO CENTS', co DA VINCI HOMES,INC 2898 JOSEPH AVE CAMPBELL CA 95008 Encroachment Permit Final Sign Off .Encroachment Permit # C-NC 17 - 00210 Address: Date of Final Inspection and Acceptance: 9/171 3 - Sw - Inspected by: OK to release, deposits: 100% 75% f Comments: of C4 ORCHARO CITY of CAMPBELL Public Works Department October 9, 2017 Da Vinci Homes, Inc. 2898 Joseph Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00210 910 Emory Ave. FINAL INSPECTION AND ACCEPTANCE Dear Omid: 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. 75% of your Faithful Security Deposit in the amount of $1,875.00 is enclosed. The remaining 25% of your security deposit will be returned after the one-year maintenance period is up. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahldi Public Works Inspector Cc: Inspector/Suspense Files Permit File ENC2017-00210 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2017-00210 Property Address: 910 Emory Ave. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance $625.00 (remaining 25% of FPS) Labor and Material $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: �Ircl Administrator l d Reviewed by: -V Inspector Reviewed by: C lc� ic-f Land Development Engineer 1 l b JAJoAnnaT\Deposit refunds\CHECKLISTS\Emory 910 1yr.doc (Rev. 10/11) Ref undable'- Deposit Cheek. Request C� C To: Finance.Director Check. Payable To: Da Vinci Homes, Inc. N\� C111, Address - Line 1: 2898 Joseph Ave. 0\ Line 2: City: Campbell State: CA Zip: 96008 Description: ENC2017-0021 7-S"' — Account Number: 101.2203 Amount.: $660.00 Account Number: 101.2263 —Amount: Account Number: 1�01.540.7449 Amount: (Finance Depronly) Interest Earned (Finance Dept only) Total Payable: (Exact Amount) Purpose: ENC2017-00210 25% Deposit.Refund Receipt* 271269 Receipt M Permit #: ENC2017-0021G Date: 9/5/2017 Date: Requested by. Title: Inspector Date: -4;M4h?W �� I� l ��Syed Wahidi Approved by: Title: Sr. Engineer Date: � Roger Stor! Finance Dept Only: Verified by: Approved by: Special Ins - Title: Accounting Clerk 11- Date: Title: Accountant Date: muctions For Handlind, Check in'uneCK: Mall AS Is: Mail �in_ AttaChecl Envelope: terim Needed By: Return To: JoAnnA Thomason 1 Public Works., (Name) (Department) �ther: -Please -return check to JoAnn sy :r 10014585 DA VINCI I40MES INC I _ I " i AN SEE A HEXAGON -SHAPED TRUE WATERMARK WHEN HELD TO THE LIGHT -----� --- ' ...._....,_,_._...___....... �...____...__ _ ..__. _ _ _..__.- _ -- _..__..____.. . i ':, ..........._.__."-..........1 i..........................:.....;...:_...._...- .... -_.-... _ - _. - *See Reverse Side For Easy Opening Instructions* - -------- -------------------------------------------- ---------------------- -- - - - i CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 i I I I I DA VINCI HOMES INC 2898 JOSEPH AVE r CAMPBELL CA 95008 -�,/Print:Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit N.o c 2-0 U—oo Z( o DEPT. OFPUB LICWORKS (forworking within the public X-Ref. File 70NorthFirst Street. ri t-of- ay) Application Date ma Campbell, CA 95008 Issued S Application Expiration Date Ph. (408) 866-2150 APN ®=-1 Fx. (408) 376-0958 Permit Expiration Date APPLICATION -Application is hereby made fora Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six "(6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.:F7.- 6<. _._ . /.........� .. Utility Trench Location: B. Nature ofWork: (�j f7/(/ / �/L ���L'' C. Attachfour(4)copiesofanengineeredplanshowingthelocationandextentofthework,andfour(4)copiesofthepreliminaryEngineer's 5f-i-XfG, 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 work shall conform to the City of Cam p4ellStandardSpecificatiom and Detai Is for Public Works Construction; the Genera I 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 startingwolrk. Notice must be given to Public Works atleast24 hours before restarting anywork. Name of Applicant: Telephone: ���^�(o�, �SY-6 Address: I:._ �:G.%SL_F.....,e9. is t/jl f ... E-MailAddress: 24-HOUR EMERGENCY PHONE NUMBER: vw Is this work being done by the property owners at theirown residence? YES ❑ NO The Applicant/ Perm ittee 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 contractors) of the information. Applicant is a ' that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all dam an in o of ovements completed in the public right-of-way. Q � Accepted: l nt Permittee) (sign) ^ Date f/ �•'�r,`ow��lsv� M i U ! ( 7 Contractor) (Print Name) - Date SPECIAL PROVISIONS: ❑ 1. Streetshall not be open cutfor underground installations. Minimum cuts maybe allowed for connections or exploration holes. Suchcutsmaybe 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 N0. ❑ 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 $ AMOUNT RECEIP - NT _'— PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ ° .00#0 2 7®1 CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE, $� 2 EMERGENCY PERMIT FEE APPROVED FOR ISSUANCE (r;�=" v— �� ✓ l I For City Engineer Date_ Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained forth e 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 2S% of the original Faithful Performance Security. 5. Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and 'approved 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 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 may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 21. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to 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 RunoffPollution Prevention Program. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner,in which the same is to be made. 23. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order 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.gov/water issues/programs/nodes/utilityvaults.shtml for more information. APp Contractor for ensuring that all those providing services under the applicant are aware of and abide by all of the abconditions. ove h Date: Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00210 Name: Da Vinci Homes, Inc. Property Address: 910 Emory Ave. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ 1875.00 (75% of $2,500.00) Labor and Material: $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: istrator Reviewed by: Inspector Reviewed by: 9/2,5-/ 1-7 Land Development Engineer n J:VoAnnaT\Deposit refunds\CHECKLISTS\l Checklist -Final Acceptance.doc (Rev. 10/1 1) Encroachment Permit Final Sign Off Encroachment Permit # 2Q 1-7 Address: Date of Final Inspection and Acceptance: 13 I1 Inspected by: OK to release deposits: 100% 7% 00 Comments :'S S� a�57c00o PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2017 TO: Finance PUBLIC WORKS FILE NO. �V G vZQ 0 t� PROPERTY ADDRESS 910 EmoryAvenue Please collect & receipt for the following monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT 4722 Encroachment ermit Application Fee Non -Utility Encroachment Permit Major >_$10,000 $425.00 Minor Encroachment Permit <$10,000 $240.00 $ 240.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240.00 Inspection Fee Minimum Charge per Location $420.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $295.00 Site < 10,000 s.f. $885.00 Site>_ 10,000 s.f. < 0.5 Acre $1,185.00 Site>_ 0.5 Acre $1,772.00 4722 NPDES Review C3 Requirements For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $315 ea Plan Check & Inspection Fee(Non-Utility) 4722 Engr. Est. < $250,000 14% of Engineer's Estimate $ 350.00 4722 Engr. Est. ?$250,000 and <_$500,000 $35,000.00 + 8% of Engineers Estimate 4722 Engr. Est. >$500,000 $55,000.00 + 7% of Engineers Estimate 2203 Emergency Cash Deposit 4% of Engr. Est.* ($500 min/$10,000 Max) 2203 Faithful Performance Security FPS 100% of ENGR. EST.* $ 2,500.00 2203 Labor and Materials Security 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 Paid (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 Cit 's Monumentation Estimate 4920 Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (Includes Certificate of Compliance) $1,990.00 4722 Vacation of Public Streets & Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 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 4722 Assessment Segregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 Postage 511.7424 MISCELLANEOUS Other (Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ 3,090.00 NAME OF APPLICANT Omid Shakeri NAME OF PAYOR �� t//.c/ PHONE e) ADDRESS '. t114, T ' _. FOR RECEIVED BY S. 0 5 17 CITY CLERK ONLY Date Receipt # �p-�-� F ic6 "il !:\FORMS1Template.lAdministret,velR..pt F— Lund Development 17-18 S9 , ®® o&mbl2• eAm, 5 \ 9/G ^m pm.m m2 Am&mpGEk*e7 . i.m ale lmADFyaG�� ,plmSm �J »� �\A - � »__�- Ciou - q,mGa !SK ma glpbm ;go'[Q wm qq ; p1 mdbK ` � e . a7 mu^ INSURANCE 'REQUIREMENTS CHECKLIST Permit # Consultant/Contractor:. t' Cco Ms-e CIP Project # The .following insurance- is required of all consultants/contractors working in the City of Campbell public right-of=way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements. apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits _ Commercial General Liability for bodily, personal injury and property damage: o' $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or . *"'$2,000,000 general aggregate Iim�'jt. ❑ Policy -expiration date -,S 1( � d -7 Automotive Liability: ❑ Any Auto checked on certificate ❑ $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and Employer's Liability _�- v Waiver of Subrogation clause �$1,000,000 per accident for bodily injury or disease ❑ Policy expiration date�U1 Course o onstru i (if rn"d n Spe ' Provisions) ❑ Co ple ed va ue o the ❑ Polj�cy a ira ion dat Required Endorsements to General Liability and Automobile Liability Policies A itional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) 'i The insurance coverage afforded to the Additional Insured is -primary insurance. Cancellation area: o 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 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. ❑ Wo ers' Compensation Insurance Sheet Submitted 'For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Acceptability of Insurers) " ❑ Insurer(s) has current A.. Best Rating of A:VII a d is authorized to transact business in the State of California. Name: ""� �\ s ��c,+A��i � Rating: L_:�_ Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License # Expiration: \ l 3\\ `\ I1 ❑ Contractors License # -Class: ,,� Expiration: 1� Insurance Certificate Reviewed als Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 Policv Number20917003 Date Entered2/16/2017 Ae"® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 9/1/2017 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 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 endorsement(s). PRODUCER Professional Insurance Associates, Inc. ORCA Insurance Services, Inc. 6017 Snell Ave., PMB# 326 CONTACT NAME: n/c Ne Eli: (408)365-1700 FAIIX No): (408)365-1710 E-MAIL ADDRESS, orcains@aol . com San Jose, CA. 95123-4217 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Capital Specialty Ins. CorP • (AmWin ) INSURED E C C O Builders, Inc. INSURER B : STATE COMPENSATION INSURANCE FUND ( IA) INSURER C: INSURER D: 2898 Joseph Ave. INSURER E: Campbell, CA 95008 INSURER F : COVERAGES 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 INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 r 000 r 000 A CLAIMS -MADE ® OCCUR 2 0 917 0 i) 01 02/15/2017 02/15/2018 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 ($2,500 BI/PD Ded PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $ 2,000,000 PRO LOC POLICY JECT PRODUCTS -COMP/OP AGG $ 1 r 000 r 000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPER'ZDAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION OTH- X AND EMPLOYERS' LIABILITY Y / N SPER TAT UTE ER E.L. EACH ACCIDENT $ 1 r 000 r 000 B ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA 9129861-2017 4/9/2017 4/9/2018 E.L. DISEASE - EA EMPLOYEE $ 1 r 000 r 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 r 000, 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) *-10 day notice for non-payment of premium It is hereby agreed and understood that the policies listed are subject to 30 day cancellation notice from the carrier Re: 901 Emory Ave. Campbell, CA. 95008 See additional insured endorsement attached GEKI11-IGAIE MULUEK City of Campbell 70 N. 1st Street Campbell, CA. 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE .........._._..._ __...._.'--_Y.......... © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Produced usina Forms Boss Plus software. www.FormsBoss.com: Impressive Publishing 800-208-1977 COMMERCIAL GENERAL LIABILITY CG 20 33 04 13 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 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. Such person or organization is an additional insured only with respect 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. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not -be broader than that which you are - required by the contract or agreement to provide for such 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 completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: a. The preparing,, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, engineering or surveying services. CG 20 33 04 13 © ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: CT20171619-01 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization when you have agreed in writing in a contract or agreement to waive your right of recovery against such person or organization. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: 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 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 0 tf ORKERS' COMPENSAiTION lf• URANCE 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 EbCQ Builders Inc 0 A Certificate of Consent to Self -insure issued by the Director of Industrial Relations: OR 0 A Certificate of Workers' Compensation Insurance insurance Co. State Fund Insurance a Policy No, 9129061 Expiration Date 04/09/2018: OR 0 A signed Certificate of Exemption from the Workers' Compensation laws as printed below. 4 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. e Signed Rate 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. 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