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ENC2017-00092pF Cq, _ � r r- CITY of CAMPBELL Public Works Department October 1, 2018 Millich Commercial, LLC 100 Century Center Ct. San Jose, CA 95112 SUBJECT: PERMIT NO. ENC 2017-00092 595 Millich Dr., Campbell, CA FINAL INSPECTION AND ACCEPTANCE To Whom It May Concern: 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. 10014581 CHECK No. .269988- 100DO NOT ACCEPT THIS CHECK UNLESS'THE PINK LOCK &KEY ICONS FADE WHEN WARMED AND VOU CAN SEE AHEXAGON-SHAPEDTRUE WATERMARK WHEN HELDTO THE LIGHT 14581 MILLICH COMMERCIAL LLC 1111,111 all I I Refundable Deposit Check Request To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Receipt M Receipt #: Millich Commercial, LLC 100 Century Center Ct. San Jose ENC2017-00092 101.2203 101.2203 101.540.7448 Interest Earned' Remaining 25% deposit refund 269592 State: CA Zip: 96112 Amount: $6,000.00 Amount: Amount:. (Finance Dept only) (Exact Amount) Permit M ENC2017-00092 Date: 5/17/2017 Date: �V� ' Or\ Requested by: �� Title: Inspector Date: Syed Wahidi Approved by: ?Y� Title: Sr. Engineer Date: �9 Roger Storz Finance Dept Only: Verified by: Title: Accounting Clerk ll Date: Approved by: Title: Accountant Date: Special Instructions For Check -Handling mall AS IS: Wii In Attached Envelope; Interim l:neCK: Needed By: Return To: JoAnna Thomason ff Public Works (Name) Other: Please return check to_JoAnna (Department) CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2017-00092 Property Address 595 Millich Dr. Date of Final Inspection: 9/17/18 On File: Bonds Faithful Pe f rmance $6,000.00 Labor and Mate a- - Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: A minist for Q Reviewed by: Inspector Reviewed by: Land Development Engineer J:VoAnnaT\Deposit refunds\CHECKLISTS\Millich 595 1 yr.doc (Rev. 10/11) l Encroachment Permit Final Sign Off Encroachment Permit # 2017— 000g2 Address: 575 R`UAW Date of Final Inspection and Acceptance: 1 t71 Inspected by: OK to release deposits: 100% 7.5. Comments: v C C c�- OV C44f 4-Add . U �x tom^ - • pk C}tARO _ CITY OF CAMPBELL Public Works Department October 3, 2017 Millich Commercial, LLC 100 Century Center Ct.- #210 San Jose, CA 95112 SUBJECT, PEWIT NO. ENC 2017-00092 -7--5Millich Dr. , FINAL INSPECTION AND ACCEPTANCE To Whom it May Concern: 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 s of September 13, 2017. The permittee is responsible for the repair and/or replacemen and defective work-0 ork o 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 $18,000.00 and your Construction Cash deposit in the amount of $960.00 are enclosed. The remaining 250/lo 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 Wahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00092 7o North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 w� ttom�.. Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No Ef��,�(g OLDIJ — NO DEPT. OFPUBLICWORKS (forworking within the public X-Ref. File 70 North First Street right-of-way) Application Date Campbell, CA 95008 Issued `(Fi 'J-71 Application Expiration Date Ph. (408) 866-2150 APN Fx. (408) 376-0958 Permit Expiration Date l�9 APPLICATION -Application is hereby made fora Public Works Permit in accor ance tith 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.: Utility Trench Location: B. Natureof Work: tIle �Q C. Attach four (4) copies of an engineered plan showing the location and extent ofthe work, 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 to the CityofCampbell 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 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 must be given to Public Works at least 24 hours before restarting anywork. Name of Applicant: I Telephone: Address: 5� 1 P k Q A l c M1 Gam, � " 4-cam. E-MailAddress: I pp 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 understqnd both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issaaace of rii permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of improvements le d i j public right-of-way. Accepted: 0 rL��r _(�"X(Applicant Permittee) (sign) Date ? �, ram,'_-f9C r^ � .� A w'f r (Contractor) (Print Name) I DIte SPECIAL PROVISIONS: ❑ 1. Street shall not be open cutfor underground installations. Minimum cuts may be 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. " \ . 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. Priorto any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE APPROVED FOR ISSUANCE AMOUNT RECEIPT 0. ?� $ C16 .00 S 3� :`Lita- 3 .co —1 0 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 for the duration of the permit work. 2: A Construction Cash Deposit is required. Changes will be made against this deposit if there is an emergency call -out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. Surety posted shall be equal to 25% of the original Faithful Performance Security. 5. Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved 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 Runoff Pollution Prevention Program. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 23. Permittee must provide advance notification to all parties that 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 for more information. Applicant is hereb s Bible for' ris ri g that all those providing services n er the a plicant are aware of and abide by all of the above conditions. •� Applicant ^ Date: Ken ,� e rd'SA f Contractor (Print Name) /n Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03117 Oc4 v �� r Y r ` •CRCHAR9 ' CITY of CAMPBELL Public Works Department October 3, 2017 Millich Commercial, LLC 100 Century Center Ct. #210 San Jose, CA 95112 SUBJECT: PERMIT NO. ENC 2017-00092 7595 Millich Dr. FINAL INSPECTION AND ACCEPTANCE To Whom it May Concern: 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 $18,000.00 and your Construction Cash deposit in the amount of $960.00 are 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 Wahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00092 70 North First Street • Campbell, California 95008-1436 • TEL 468.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 i I I c •c I N L � � O. I • I I� � t --'' i �• - .- -.tea , r r ? CAA ('1 '� _ CHECK DATE CHECKNO Off',.� Oil" CAMPBEtiL =: yEi•:LL5 FARGO HANK,'N:A 42a MONTGdMERY STREET 1 zio 10 / 0 2 // 17 2 64 611 S 7O NOfiTH FIRST STREET y1 SAfI FRANCISCO JCA 94304 / CAIVIPBELL, CALIFOfiNIA 95008 960 o�tr�tnaQ VOID AFTER 90 DAYS` I PAY THE SUM OF EIGH EEN' CENTSAND, NINE HUNDRED SIXTY DOLLARS & m� r To TxE MIL 'ICH COMMERCIAL LLC f N ORDER lb0 CENTURY` CENTER CTL� �r 1SAN JOSE CA 95112 I ) -'' ��'' -, � iI 264!�LLI► '�:L2i0D0248�:�4L2:18554L5�I' �` I , .. �. . I - ---- --- -- - - -- • I - - . .._._, .... _.......................... f........... ........... _ ......... i ...... .......... t.. ... _ } J .... . *See Reverse Side For Easy Opening Instructions* ----- - --- ------------------------------------------------------------------------- ------ CITY OF CAMPBELL 70 NORTH FIRST STREET ) CAMPBELL, CALIFORNIA 95008 1 MILLICH COMMERCIAL LLC 100 CENTURY CENTER CT: SAN JOSE CA 95112 Ref undnble Deposit, Check Request To: Finance Director Check Payable To ,Millich Commercial,'LLC. Address - Li,ne' 1. 100 Century Center Line 2 City:, San Jose` State;. ,CA Zip 951.12 Description: 595.Millich Dr... . - ' Account Number: 1'01.2203 .. , - . Amount: Account Number : 101.2203 , Amount:'._ 960 00 Account" Number: 101:.540:7448 'Amount:- (Finance Dept only) Interest-Eained- (Finance Dept only)" " Total Pa C�Cb able (EzactAmount) Purpose: EN62017_-00092 Pep Refund. '..-' .. • -P. : ermit#: ,. ENG201740092 Receipt'#`.. `. 269592. Date; 5/17/2017 Receipt #: - Date: Requested by: Title :;Inspector-' Date: 9/21/20.17 - Syed Wahidl Approved by:...t' off( ' Title: '' Sr. Engineer Date' Roger.Storz. ' Finance Dept Only; Ufled by _ _ Title Accounting Clerk -II Date: Approved.by: ._ - Title: Accountant ,. Dated" S ec :al I 'strut. to :For Hdndlir Check mail As iS: , • ," Mail in•Attkne elope interim l.neCK: Needed By:, Return T '. JoAnne Thomason.,`:'° ;- r-: Public :Works : (Name)` = (Department) check to JoAnne. ther: Please return ' :: CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00092 Name: Millich Commercial, LLC Property Address: 595 Millich Dr. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ 24,000.00 Labor and Material: $ Construction Cash Deposit to be released: $960.00 Other overdue deposits to be released (Description): 75% FPS Refund $18,000.00 Processed by: nistrator Reviewed by: 91zr Inspector Reviewed by: I Land Development Engi JAJoAnnaT\Deposit refunds\CHECKLISTS\Millich 595.doc (Rev. 10/11) Encroachment Permit Final Sign Off odC-1, Encroachment Permit #� Address: 1�95 1"1 1LAI .A Date of Final Inspection and Acceptance:I13 Inspected by: OK to release deposits: 100% 75% " Comments: Finance P for the followin DEPARTMENT LAND DEVELOPMEf Effective July 1, 2016 PUBLIC WORKS FILE NO. PROPERTY ADDRESS ENC2017-00092 595 Millich Drive 4722 1 encroachment Permit Appucatfon tee Non -Utility Encroachment.Permit Major>_$10,000 $403.00 $500.00 Minor Encroachment Permit <sio,000 $230.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $230.00 Inspection Fee Minimum Charqe per Location $398.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Plantinq Deposit Required) $500.00/tree Plan Check Deposit 2% of Enqineer's Estimate $500.00 min Utility and R-1 Permits no deposit Gradinq & Drainage Plan Review Sinqle Family Lot $281.00 Site < 10,000 s.f. $841.00 Site ? 10,000 s.f. < 0.5 Acre $1,127.D Site >_ 0.5 Acre $1,688.0( NPDES Review (C3 Requirements) For projects not required to submit numeric sizing $163.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $704.00 Impervious Area 1 Acre or more $918.00 For projects sent to Consultant for review Consultant -` ""'s`' ..•: .:-. ;.; Additional treatment facilities $300 ea - ` `"''t'" - Plan Check & Inspection Fee (Non -Utility) Enqr. Est. < $250 000 14% of Eng q=, -1. ;:: _�... • _ ;.,'-- ' Enqr. Est. >_$250,000 and s$500,000 $35,000 + 8 _ Enqr. Est. >$500,000 $55,000 + 7`�" _ -- Emergency Cash Deposit 4% of Enqr. ; " y!'• - - '''" LL - °, r: Faithful Performance Security (FPS) 100% of ENt'''---- Labor and Materials Security 100% of EN( -': _U Storm Drainage Area Fee Per Acre R-1 $2,120.0 (Multi -Res $2 ;31i 4sv: All Other $2,1 3434 Parcel Map (4 Lots or Less) $4009.00 + $t =v ° -• Final Tract Map (5 or More Lots) $4,871.00 + $ - Monumentation Security 100% of City's -'"'}` . i -.1- Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) Lot Line Adjustment (Includes Certificate of Compliance) $1,893.00 Vacation of Public Streets & Easements $2,530.00 Certificate of Compliance $1,877.00 22031 4722 4722 4722 4722 4722 4722 4722 2203 2203 2203 4721 4722 4722 2203 4920 4722 4722 4722 4722 Certificate of Correction .$561.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per siqnature) $10.00 4722 Assessment Seqreqation or Reapportionment First Split $895.00 Each Additional Lot $281.00 511.7424 Postage - Other (Please Specify) 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $500.00 NAME OF APPLICANT NAME OF PAYOR PRONE;t, ADDRESS ZIP FOR fY CLERK ONLY J-\Land Oev Plan Check Comments\1 - Specific Projects -Active Project m Progr..Willich Or 595\F—Fees xls ,..'I I-Y OF CAPAPbELL J %L ... D.-- c.- c.—I.—Il - 5...... P,.".,. - A., - P-.- P ...... M.- V. 5%11 ... 11 ....... ~*'° ' .� ClTYOF CAMPBELL RECVD BY� CASHIER 01000269592 PAYOR; MILLICH COMMERCIAL TODAY`S DATE. 05/17/17 REGISTER DATE: 05/17/17 TIME� OO:OO DESCRIPTION AMOUNT CUST 1DrENC2017-00092 ENGR 8 SUBDIV FILING F $3r263.00 CUST ID: 1.0110-111--i REF DEPOSIT - 181 $96O.OD CUST ID: 1.0O31 REF DEPOSIT - 1O1 $24`010O.00 ----------'---- TOTAL DUE: $28,223.00' TENDERED: $28,223.08 CHANGE: $.OG OTHER $281223.00 REF NUM: 331 INSURANCE REQUIREMENTS CHECKLIST Permit # C oZOi 0�1� 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 7mercial General Liability for bodily, personal injury and property damage: ,000,000 per occurrence, and - f $1,000,000 general aggregate limit applying separately to the project, or IL/ $2,000,000 general aggregate limit. P/Policy expiration date _ �4 ((% Automotive Liability: \":`l er,t' S6,te�v `�P— ` V\1z;'N-y„0-N ❑ "Any Auto" checked on certificate V$1,000,000 per accident for bodily injury and property damage Policy expiration date Workers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident for bodily in'ury ,or disease Policy expiration date LF f Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) )4a The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) �; ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\loannat\Desktop\Insurance Requirements Checklist.doc (Rev 03/13) Page 1 of 2 A � ❑ 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.cityhall.ci.campbell.ca.us.local\Profile_Data$\loannat\Desktop\Insurance Requirements Checklist.doc (Rev 03/13) Page 2 of 2 May 25, 2017 City of Campbell Building Division 70 North First Street Campbell, CA 95008 Re: Building Permit #2016-01507 595 Millich Drive, Campbell City of Campbell, This letter shall serve as authorization that my general contractor, Willow Glen Construction - License #B-698627, may pick up the permit for the job site located at 595 Millich Drive, Campbell, CA. Regards, Millich Commercial, LLC A California limited liability company By: Briggs Development Corporation, A California. Corporation Its: Managing Member �P Jeffrey L. Rogers, President 100 CENTURY CENTER COURT, SUITE 210 SAN JosE, CA 951 12 408.441 .8050 Memo 2450 Scott Blvd., Suite 308 Santa Clara, Ca 95050 Office phone: 403 970-9131 Office fax: 408 970-9136 City of Campbell Dept of Planning, Building & Code Enforcement Building .Division Re: Permits Project. MILLICK Address: 595 MILLICK DRIVE, CAMPBELL, CA 95008 Date: May 31, 2017 Please allow Rick Bauer to procure this permit in behalf of Willow Glen Construction Signature. - -� Printed name: Scott Essary Title:. General Partner Business name: Willow Glen Construction Phone A 408-970-9131 scott@wgconstcom Contractors are required by law to be licensed and regulated by the Contractors' State License Board. Any questions concenft a contractor may be referred to the Registrar, Contractors' State License Board, 9835 Goethe Road, Sacramento, California 95826. Mailing Address: PO Box 26000, Sacramento, Califomia 95826. (www.cslb.ca.gov.) SILICON VALLEY SOIL ENGINEERING GEOTECHNICAL CONSULTANTS firm DAILY REPORT services for the Project Number: _>�V Project Name: '`7 _ Date: ) of-, Field Engineer:,S V� \j ❑� GRADING OPERATION: 0 SOIL MATERIAL: ❑ Building Pad ❑ Original Subgrade ❑ Native Parking Area ❑ Excavated Grade ❑ On -Site 0 -� Driveway / Sidewalk y ;n ❑ Subgrade ® Import ❑ Other: U Baserock ❑ Engineered Fill ❑ Other: ❑ Other: ❑ BACKFILLING OPERATION: ❑ BACKFILL SOIL -MATERIAL- -'° ❑ Storm Drain Trench ❑ Excavated Pit Area------'`-0 Native ❑ Sanitary Sewer Trench 0,..-Abandoned Trench ❑ Import ❑ Fire/Water Line Trench �-- �,, ❑ Other: ❑ Baserock ❑ Electrical Utihty r - ❑ Other: -Gas Li a Trench ❑ FOUNDATION SYSTEM: ❑ WATERPROOFIN�O" SHORING SYSTEM: ❑ Perimeter Footing ❑ Grade Beam ❑ Membrane ❑ Pier Holes ❑ Continuous Footing d Drain Mat ❑ Soldier Beams ❑ Interior Footing �U-Pie.-r Holes ❑ Subdrain System ❑ Wood Lagging ❑ Isolated Footing-'J ❑ Filter Fabric ❑ Soil Nails/Tie-Backs ❑ Other:,----- ' ❑ Other: ❑ Shotcrete As a result of our inspection services: ❑ Field tests revealed that the material was compacted to at least 90% relative maximum density. C7 Field tests revealed that the �'� material was compacted to at least 95% relative maximum density. ❑ Inspection revealed that the foundation footing bottoms were firm and free of loose material. ❑ Inspection revealed that the pier holes were drilled to the recommended depth and free of loose material. ❑ Additional inspection services will be required at a later date. eUyThe inspected area(s) is (are) complete and ready to receive further improvements. NOTE: ��.�.�-fir. - �,• - _._.__.__.�._... 2391 Zanker Road, Suite 350 o San Jose; California 95131 o (408) 324-1400 0 F (408) 324-1404 .YIMJ 1 cfl V . c THIS IS TO CERTIFY THAT THE FOLLOWING DESCRIBED COMMODITY WAS WEIGHED, MEASURED, OR COUNTED BY A WEIGHMASTER, WHOSE SIGNATURE IS ON THIS CERTIFICATE, WHO IS A RECOGNIZED AUTHORITY OF ACCURACY, AS PRESCRIBED BY CHAPTER 7 (COMMENCING WITH SECTION 12700) OF DIVISION'S OF THE CALIFORNIA BUSINESS AND PROFES- SIONS CODE, ADMINISTERED BY THE. DIVISION OF MEASUREMENT STANDARDS OF THE CALIFORNIA DEPARTMENT OF FOOD AND AG I�IR,d�U�LTURE. LOADING RELEASE 1 SOLDBYCONCRETE READY MIX INC.. -, �' t% 1\`�-r' �NI_!, 0 0 WEIGHED / MEASURED AT 33 HILLSDALE AVE., SAN JOSE, CA 95136 1. Concrete Ready Mix, Inc. is not responsible for any OPEN 7 DAYS A WEEK PHONE (408) 224-2452 damages to sidewalks, driveways, buildings, trees, rubbery, etc. when delivery is made inside the curb CAUTION �� d on lot at the customer's request. May cause eye or skin injury. Contains Portland cement. Freshly mixed VISA 2. Contractor does hereby indemnify and hold harmless cement, mortar, grout may cause skin injury. Concrete Ready Mix, Inc. from any said damages TAKE THESE PRECAUTIONS claimed by property owner. 1. Avoid all contact with eyes. Wear rubber boots and gloves, and avoid prolonged contact directly with skin or through porous materials 3. Signature below authorizes Concrete Reader Mix, Inc. DISCOVER' 2. In case of contact with eyes or skin, FLUSH THOROUGHLY WITH 'AMERICANI t0 use private driveway for making delivery and WATER. EowREss customer assumes full responsibility. 3. If irritation persists, get medical attention' promptly. o V 4. Keep children away. A LOAD NO. SLUMP C.O.D. MAP NO. TRUCK DRIVER DATE TIME PURCHASE ORDER /JOB NO. DELIVERY TICKET' `IA t_ r-fc, s 1 Zl, .2,, ' 7+ SOLD TO DELIVER TO DFZV(,:! I f-..,t.-+., B. `{ :fflD (;.ta 96 --r.7'vt f; l 'I"'r' QUANTITY TOTAL PRODUCT '• PRODUCT _ UNIT EXTENDED THIS LOAD DELIVERED CODE DESCRIPTION ' PRICE PRICE :l. 1€+4{1 4RRIVE START POUR END POUR WATER ADDED AT CONCRETE READY MIX -(NC. WEIGHMASTER JOB CUSTOMER REQUESTyl,; - -. SUBT07AL. TAX GALLONS BY DEPUTY TOTAL MIN, ALLOWED CHARGED MINUTES I HEREBY ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND MISCELLANEOUS AGREE TO THE TERMS OF THIS,INVOICE. STAND BY CHARGED MIN. STAND BY CHARGE .,HARGE10' /MIN --poi ByXr—f'Y r_„ ' '`; ' f' ' :' "' Five minutes per yard unloading time is allowed. GRAND TOTAL 'INANCE CHARGES will be charged at THE RATE of 18% per annum. (11/z% per mo0th). If it becomes necessary to file suit for the collection of any amount, costs, including collection and ►ttorney's fees shall be paid by the buyer, with venue in Santa Clara County. We•do not guarantee against discoloration of concrete, whether color is added or not. We also do not guarantee against cracks in concrete. It is agreed that the above described materials and labor are to be paid for from funds received from the above described job in any event not later than 30 days rom date of delivery. -Water or other ingredients added may reduce strength and quality, and are added only at customer's request. 1O.D. - A $100 fee wil[,be charged to all C.O.D. orders not paid for at the time of delivery. 1 a t; c,--h f.'. i1 cf f't ° ! -' 1 ..t e3 (• :i Fees Associated With Case #: ENC2017-00092 l/GV/GV 1 / 9/20/2017 4:16:48PM AF02 7/l/2016 6/30/2017 PrmtAppFee-Major-Eng E 101.730.4722 JT 5/15/2017 560.00 0.00 PCI1 7/l/2015 6/30/2017 Non-Util Plan Ck/Insp < $ 101.740.4722 JT 5/23/2017 3,263.00 0.00 FPSD 7/1/2016 6/30/2017 Faithful Per£ Security/De 101.2203 JT 5/23/2017 at.d' 0.00 CASH 7/1/2016 6/30/2017 Construction Cash Deposi 101.2203 JF 5/23/2017 emobArly 0.00 Total Due: $0.00 Page 1 of 1 CneFees..rpt May 10, 2017 Roger Storz City of Campbell Department of Public Works 70 N. First St Campbell, CA 95008 Re: 595 Millich Ave Encroachment Permit Application ENC2017-00092 Dear Roger, Attached please find: • Four (4) copies of Street Improvement Plans • One (1) copy Public Works Submittal Requirements checklist • One (1) copy of Encroachment Permit Application • One (1) copy of Checklist for Street Improvement Plans • One (1) copy of Engineer's Estimate • One (1) copy of Grant Deed for the subject property If you have any questions, feel free to call me at (408) 236-2400. Since el Stephen Sherman P.E. Senior Project Engineer R+G Job No. 17-908A Ruth and Going, Inc. Engineering Planning Mailing Address: P.O. Box 26460 San Jose CA 95159-6460 2216 The Alameda Santa Clara CA 95050 Ph: (408) 236-2400 Fax: (408) 236-2410 M:\17-908A Millich Drive ADA\may 10 2017 transmittal.docx PUBLIC WORKS SUBMITTAL REQUIREMENTS City of Campbell Department of Public Works www.cityofeampbell.com 4 Public Works -> Land Development **A. ITEMS REQUIRED FOR PARCEL OR TRACT MAP SUBMITTAL: 1. Utility clearance letters from public utilities or copies of letter requests (see page 5 of item 7 below for sample) 2. Two (2) copies of the Preliminary Title Report (current within the last 6 months) 3. Two (2) copies of the Grant Deed(s) for the subject property(ies) 4. Two (2) copies of all referenced maps and documents used to prepare the Parcel or Tract Map (deeds, maps ,etc.) 5. Map Plan Check Fee paid 6. Four (4) Sets of Parcel or Tract Map 7. Check List for Parcel Maps and Tract Maps 8. Two (2) copies of Closure/Area Calculations 9. Soils Report 10. Submittal appointment time scheduled with Public Works Project Engineer **B. ITEMS REQUIRED FOR STREET IMPROVEMENT PLAN SUBMITTAL: I . X Preliminary Title Report (current within the last 6 months; proof of ownership may be substituted with City's approval.) 2. K Encroachment Permit Application complete 3. X Applicant signature and date on Encroachment Permit (front and back) 4. Permit Application Fee paid 5. Plan Check Deposit paid (2% of Engineer's Estimate, $500 min) Receipt Number 6. % City Engineer's Estimate Completed and Submitted 7. X Four (4) Sets of Street Improvement Plans with City Standard Title sheet and standard border on all sheets. 8. Check List for Street Improvement Plans 9. -� Submittal appointment time scheduled with Public Works Project Engineer **C. ITEMS REQUIRED FOR GRADING & DRAINAGE PLAN SUBMITTAL: 1. Four (4) Sets of Grading & Drainage plans (24" x 36" size sheets) submitted to the Public Works Department with City Standard Title sheet and standard border on all sheets. 2. -Grading Plan Review Fee paid 3. NPDES Review Fee paid 4. Check List for On -Site Grading & Drainage 5. Soils Report 6. Stormwater Management Plan, = C.3 Regulated Projects Only 7. Submittal appointment time scheduled with Public Works Project Engineer **Response Letter: Upon submittal of the Parcel/Final Map, the Street Improvement Plans and the Grading and Drainage Plans, the applicant shall provide an itemized response letter verifying that all the Public Works Conditions of Approval have been met or addressed. J:\FORMS\Templates\Land Development\Public Works Submittal Requirements rev. 12/16 RECORDING REQUESTED BY: Chicago Title Company Order No.: FWPS-2982160065 When Recorded Mail Document To: MILLICH COMMERCIAL LLC 2323 SOUTH BASCOM AVE, STE 100 CAMPBELL, CA 95008 ATTN: JEFFREY ROGERS APN/Parcel ID(s): 305-15-011 DOCUMENT: 23331391 Pages: 6 Fees.... 30.00 Taxes... 5692.50 Copies.. AMT PAID 57 522 0 REGINA ALCOMENDRAS RDE # 007 SANTA CLARA COUNTY RECORDER 6/10/2016 Recorded at the request of 8:00 AM Chicago Title GRANT DEED 0WILTAX5TATEMEMAS DIRECTMDABOW SPACE ABOVE THIS LINE FOR RECORDER'S USE THIS PAGE ADDED TO PROVIDE ADEQUATE SPACE FOR RECORDING INFORMATION (Additional recording fee applies) Recording Document Cover Page Printed: 06.07.16 @ 03:38 PM SCA0000079.doc / Updated: 09.30.15 Page 1 CA-CT-FWPS-02180.052982-FWPS-2982160065 RECORDING REQUESTED BY: Chicago Title Company 675 North First Street, Suite 900 San Jose, California 95112 WHEN RECORDED RETURN AND ADDRESS TAX STATEMENTS TO Millich Commercial, LLC 2323 South Bascom Avenue, Suite 100 Campbell, California 95008 Attn: Jeffrey Rogers (Above Space for Recorder's Use Only) APN: 305-15-011 GRANT DEED THE UNDERSIGNED GRANTOR DECLARES: SANTA CLARA COUNTY DOCUMENTARY TRANSFER TAX is $5,692,50. CITY OF CAMPBELL DOCUMENTARY TRANSFER TAX is $00.00, Computed on full value of property conveyed. Declarant FOR VALUE RECEIVED, Millich Office Associates, LLC, a California limited liability company ("Grantor"), hereby grants to Millich Commercial, LLC, a California limited liability company ("Grantee"), all that certain real property ("Property") described on Exhibit A attached hereto and incorporated herein by reference, together with all buildings and improvements located thereon and any and all improvements, easements, privileges and rights appurtenant thereto. THE PROPERTY IS CONVEYED TO GRANTEE SUBJECT TO: (a) A lien not yet delinquent for taxes for real property and personal property, and any general or special assessments against the Property; and (b) All liens, encumbrances, easements, covenants, conditions and restrictions set forth on the attached Exhibit B. [signature follows on subsequent page] Grant Deed Page 1 of 3 IN WITNESS WHEREOF, Grantor has executed this Grant Deed as of this of June, 2016. GRANTOR: Millich Office Associates, LLC a California limited liability company By. Name: Allen Guggenh Title: Manager Grant Deed Page 2 of 3 CALIFORNIA ALL-PURPOSE ACKNOWLEDGEMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF Nt.6( 6'/l(0 )SS COUNTY OF o ,{.,c(((,I'n } On U ! 7 11() before j-� VC-'t (e"' , NotaryPublic, personally who proved to me-M the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and Signature . S. KELLER Committlon 0 2130378 e notary a C re County n Comm. Noy 1 am 201li Affix appropriate seal above r. Grant Deed Page 3 of 3 EXHIBIT A LEGAL DESCRIPTION THE LAND REFERRED TO HEREIN BELOW IS SITUATED IN THE CITY OF CAMPBELL, COUNTY OF SANTA CLARA, STATE OF CALIFORNIA AND IS DESCRIBED AS FOLLOWS: PARCEL ONE: ALL OF PARCEL "2", AS SHOWN UPON THAT CERTAIN MAP ENTITLED, "PARCEL MAP CONSISTING OF ONE (1) SHEET BEING A PORTION OF PARCEL "B" AS SHOWN ON THAT CERTAIN PARCEL MAP, RECORDED IN BOOK 341 OF MAPS, AT PAGE 34, SANTA CLARA COUNTY RECORDS", WHICH MAP WAS FILED FOR RECORD IN THE OFFICE OF THE RECORDER OF THE COUNTY OF SANTA CLARA, STATE OF CALIFORNIA ON SEPTEMBER 11, 1975 IN BOOK 361 OF MAPS, AT PAGE 20. PARCEL TWO: AN EASEMENT FOR INGRESS AND EGRESS BEING AN EASEMENT 25 FEET IN WIDTH, MORE PARTICULARLY DESCRIBED AS FOLLOWS: THE NORTHERLY 25 FEET OF PARCEL ONE AS SAID PARCEL IS SHOWN UPON THAT CERTAIN PARCEL MAP RECORDED IN BOOK 361 OF MAPS AT PAGE 20 IN THE OFFICE OF THE COUNTY RECORDER OF SANTA CLARA COUNTY. APN: 305-15-011 Exhibit A to Grant Deed Page 1 of 1 EXHIBIT B PERMITTED EXCEPTIONS 1. Property taxes, which are a lien not yet due and payable, including any assessments collected with taxes to be levied for the fiscal year 2016-2017. 2. The lien of supplemental or escaped assessments of property taxes, if any, made pursuant to the provisions of Chapter 3.5 (commencing with Section 75) or Part 2, Chapter 3, Articles 3 and 4, respectively, of the Revenue and Taxation Code of the State of California as a result of the transfer of title to the vestee named in Schedule A or as a result of changes in ownership or new construction occurring on or after the recording of this Deed. 3. Special Tax for Santa Clara County Library District Joint Powers Authority Community Facilities District No. 2013-1, under the Mello -Roos Community Facilities Act of 1982, as disclosed by a Proposed Boundary map filed for record on April 26, 2013 in Book 48 of Assessment Maps, page(s) 36-37, as Instrument No. 22194943, Official Records, and further disclosed by Notice of Special Tax Lien recorded January 22, 2014, Instrument No. 22502535, Official Records, payable in continuing installments collected with the real property taxes. 4. The ownership of said Land does not include rights of access to or from the street, highway, or freeway abutting said Land, such rights having been relinquished by the document, recorded August 13, 1975, as document number 5075011, Book B558, Page 593, of Official Records. 5. Easement(s) for the purpose(s) shown below and rights incidental thereto as delineated or as offered for dedication, on the map of said tract/plat; Proposed Sanitary Sewer Easement, Affects: Portions of said land; Purpose: Proposed Ingress and Egress; Affects: Portions of Said Land. 6. Easement(s) granted to Vista Construction Company, a California Corporation, per document recorded September 22, 1975, recorded in Book B623, Page 714, of Official Records. 7. Rights of the following tenants as tenants only with no options to purchase or rights of first refusal: Peter Cirivilleri, Alacrity Medical Systems, Inc., Process Therapy Institute, ABL Properties, Inc., Twelveacres, Inc., Marilyn Bird & Carolyn Kern, Guggenheim Realty Group, Inc., Arteris, Inc., Synergy Infoconnect, Richard Waterman, Coventor, Inc. Exhibit B to Grant Deed Page 1 of 1 CITY OF CAMPBELL _ __ __..___ ____ Print Form DEPARTMENT OF PUBLIC WORKS ENGINEERING DIVISION 70 North First Street, Campbell, CA 95008 Ph. (408) 866-2150; Fx. (408) 376-0958 CHECKLIST FOR STREET IMPROVEMENT PLANS APPLICATION NO(S): ADDRESS: D r; V2 Instructions: This checklist provides advance notification to applicants of the City of Campbell's final street improvement plans and submittal requirements. Using this checklist will expedite your application through the City's review process. Prior to submitting a final street improvement plan list to the City Engineer, please place an "X" in the space to the right of each item below to indicate you have complied with, or place "N/A" to indicate that the particular item doesn not apply. Review applicable sections, which are referenced in parentheses, before checking off each item. SEAL AND SIGNATURE OF ENGINEER OF WORK I HEREBY DECLARE T T I AM THE ENGINEER OF WORK FOR THIS PROJECT, THAT I HAVE EXERCISED RESPONSIBLE CHARGE OVER THE DESIGN OF TH� PR CT, COMPLETION OF THIS CHECKLIST, AS DEFINED IN SECTION 6703 OF THE BUSINESS AND PROFESSION CODE, AND THAT THE D SI IS S TENT WITH CURRENT STANDARDS. 5 9 /P-7 Signature `- Date Printed Name: S+e o'eo J� -rmarl RCE#: Expiration Date: O n ' 30 4 (SEAL) ITEMS COMPLY NOT APPLY CITY COMMENTS I. GENERAL OK 1. City standard off -site title sheet with applicable notes. 2. 24"X36" sheet size used, including City Standard �?C] OK borders and Blueprint for a Clean Bay Plan Sheet. ® OK 3. Title Block/Scale/North Arrow Shown. 4. Plans capable of microfilm reproductions - minimum [X] OK 1/8 inch lettering. 5. Engineer's name, number, expiration date and r4j OK signature included on all sheets. 6. Vicinity Map shown (must be microfilmable). ® OK 7. Sheet Index and key map included for 3 or more OK CI N/A sheets. 8. Limits of Public Works inspection clearly shown OK on plan, typical section, and bond estimate. 9. Street Light locations/legend/Electric Service G OK N/A Connection Location shown. 10. Elevation tied to City benchmark. OK Reference City benchmark. Page 1 of 6 COMPLY NOT APPLY CITY COMMENTS 11. Curb grade plans prepared by Public Works have been incorporated into improvment plans and [I OK � N/A verified as adequate. 12. Curb grade plans prepared by Engineer for review by Public Works and cross -sections @ 50' max. intervals ❑ OK N/A along road frontage and extending 150' min. beyond limits of work. Profile line, centerline, & EP 13. Signing and striping plan plus existing striping ❑ OK N/A included in improvement plans. 14. Development No. (SUB, MS, LUP, DP) shown on each sheet. [ OK N/A 15. Verification and land rights for off -tract work (title OK ® N/A report, recorded easement, etc.) 16. Permits required from other agencies (Fish & Game OK © N/A CalTrans, Army Corps of Engrs, Flood Control, etc.) 17. Right of entry submitted for review for all off -tract F7 OK © N/A work. 18. Landscaping within the public right-of-way OK N/A included in improvement plans. 19. Fence required along water district canals. ❑ OK N/A II. ROADS A. TYPICAL SECTIONS 1. Street cross-section shown at 50' intervals maximum (closer intervals may be necessary per OK n N/A the City Engineer). Cross sections slopes shown. 2. Structural pavement design calculations submitted (per Caltrans Highway Design Manual) and Fj OK N/A correspond to plans. 3. Sidewalk, curb and gutter indicated with details OK (—j N/A included on plans. 4. Right -of -Way and street width dimensions shown. OK 5. 2:1 max. cut/fill slopes shown beginning at R/W G OK C N/A lines - Soils Report verifying exceptions. 6. Crown Slope indicated. G OK F N/A 7. Pedestrian or bike paths shown. OK Ln N/A 8. Pavement Design Chart shown with T.I. and R-values F. OK FZj N/A for review. Page 2 of 6 B. PLAN VIEWS COMPLY 1. Radius of curvature shown on all curves. F! OK 2. 20' curb return radii shown for major thoroughfares F OK and industrial streets. 3. 24' min. curb opening for private road intersection. ❑ OK 4. Horizontal curves and sight distance designed per Highway Design Manual. ❑ OK 5. Cul-de-sac radii (35' min.) shown. F-1 OK 6. Private road turnarounds shown. ❑ OK 7. R/W and street width dimension shown. ❑ OK 8. Centerline stationing shown at 50' intervals. ❑ OK 9. Curve info provided in table format (i.e. BC/EC station, offset, radius, and delta). ❑ OK 10. Lot/parcel lines and numbers/letters indicated. ❑ OK 11. Valley gutters indicated. Flag flow line elevations at quarter points on curb returns and valley gutter [, OK centerline. ❑ OK 12. Stationing and offsets of all drainage structures shown. 13. TC/RIM elevations at all drain structures w/ invert and ❑ OK FL elevations shown. (Invert and FL elevations may be shown on profile if preferred. If profile is not on same sheet as plan view, TC/RIM, invert, and FL elevations must be shown on plan and profile.) 14. Drainage easements shown and dimensioned. ❑ OK 15. Location of underground pipes and utilities shown for laterals and main lines (i.e. sanitary sewer, gas, ❑ OK water, etc.). 16. Street monuments shown. ❑ OK 17. Off -tract slope easement shown, with x-sections, topo and offer of dedication for slope easement ❑ OK submitted for review. 18. Pedestrian Paths shown. Basic grade shown. (—f OK 19. Wheelchair ramps shown at returns with details. OK C. PROFILES 1. Vertical curves designed for proper speeds per L7 OK Highway Design Manual. 2. Minimum vertical curve lengths observed. [f OK 3. Curb returns and cul-de-sac profiles shown (high ❑ OK and or low points indicated when vertical curve is used. NOT APPLY N/A r N/A LKJ N/A N/A N/A N/A M N/A ® OK N/A N/A C N/A F] N/A [j N/A N/A N/A N/A N/A Xj N/A N/A N/A N/A N/A CITY COMMENTS Page 3 of 6 COMPLY NOT APPLY 4. Vertical curve used for grade breaks greater than 2%. (3% on sag curves). OK N/A 5. 6% maximum gradient observed @ intersecting streets. OK N/A 6. 6% maximum grade observed across intersections. ❑ OK F N/A 7. 1% minimum grade observed on all streets. [j OK ® N/A 8. Maximum street grades per ordinance. ❑ OK N/A 9. Underground pipes and utilities shown. ❑ OK VN N/A 10. Existing ground at centerline shown. Where OK i N/A topography is steep, existing ground left and right of centerline has been shown. 11. Finish grade profile for centerline and for top of curb shown (left & right) if special grades required. ❑ OK N/A 12. Cul-de-sacs all have 1 % to 4% cross slope between OK N/A gutter lip and high point. 13. Super elevation grades shown where required by OK N/A Highway Design Manual. 14. Back of curb flow diverters indicated on proposed county streets with grades over S% when no sidewalk ❑ OK F-,� N/A installed. 15. Centerline profiles of intersecting streets shown to their point of intersection. (Showing curb return or [J OK R] N/A other profiles in lieu of the centerline profile is not an adequate or correct representation.) 16. Off -tract profile to catch point shown where road is OK N/A constructed to subdivision boundary. 17. Centerline stations and elevations shown @ 50' OK FT, N/A minimum intervals and @ all BVC, EVC, PIVC, and grade breaks. 18. Profile slopes indicated. ❑ OK (Z N/A III. DRAINAGE A. HYDROLOGY -HYDRAULICS 1. Contours shown for 100 feet + beyond property. OKl N/A 2. 100 year water surface calculations completed when natural watercourse or drainage facility flows through C OK N/A or adjacent to subdivision or the property lies within flood hazards or flood prone area and water surface shown on plans. 3. EGL, HGL, F1, E1, Q, A, S, V, freeboard at structures, ❑ OK N/A structure losses, tailwater assumptions, super or subcritical flow all indicated. 4. Adequacy of in -tract drainage system verified. n OK N/A 5. All starting water surface calculations adequately verified. (When computing beginning water surface in ❑ OK N/A natural watercourse and no obvious point of control is available, begin 500' downstream and work up to point in question.) CITY COMMENTS Page 4 of 6 COMPLY NOT APPLY 6. ' Adequacy of off -tract drainage system verified. ❑ OK N/A CITY COMMENTS B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. C. 1. 2. 3 4. 5. 6. EASEMENTS Easements shown on map are shown on plans. ❑ OK Off -tract drainage improvements (plan and profile) ❑ OK and accompanying easements shown. Off -tract offers of dedication for drainage easement submitted for review. Off -tract work to be done but no easement ❑ OK requirements. Right of entry submitted for review. Easement widths indicated for (a) closed conduits, ❑ OK (b) open channels. Sufficient X-sections submitted to verify easement width and Development rights for open channels. ❑ OK Access and ingress easements shown, graded to be ❑ OK useable. Minimum 12' ingress easement to public way provided to all access easements. ❑ OK Minimum 40' centerline radius for access easements ❑ OK shown. Structure setback line indicated and location verified ❑ OK with X-sections for unimproved channel. Fences shown as required where street crosses ❑ OK watercourse or drainage structure. Fences shown as required at outside boundaries of ❑ OK open lined channel easements and water district canals. STRUCTURES Inlet detail shown for new inlet installation. ❑ OK Inlet depths without manhole bases and max. dia. ❑ OK Pipes through inlets observed. Type A 6' CC 3011 36" front 30" side Type B 12' CC3012 36" front 30" side Type C 4' CC3013 36" front 24" side Type D 6' CC3016 36" front 24" side Type E 4' CC3017 36" front 24" side Max. diameter pipes through manholes observed. Type 24" CC 3020 ❑ OK Type II 42" CC 3021 Type III 60" CC 3022 1.25" minimum freeboard in inlets and manholes. ❑ OK OK HGL shown in all structure profiles. Structure type indicated on plan or on structure list [ OK on same plan sheet. N/A ® N/A w, N/A N/A N/A ® N/A N/A N/A N/A N/A N/A JK N/A R N/A L N/A N/A Page 5 of 6 COMPLY NOT APPLY CITY COMMENTS D. PIPES 1. Closed conduit minimum slope of 0.005 observed. F-! OK F N/A 2. Natural watercourses are placed in closed conduits for flows less than 80 cfs. ❑ OK VI N/A 3. Storm drain calculations submitted and correspond ❑ OK N/A with plans. 4. Water directed into inlet does not reverse the ❑ OK N/A direction of flow. 5. Minimum centerline radii of pipe checked. Beveled RCP lengths specified (bevel one or both ❑ OK ® N/A ends) and stationing of EC and BC indicated. 6. Outlet protection for closed conduits or lined ❑ OK N/A channels provided. 7. 2' minimum cover over pipe observed (provided ❑ OK N/A manufacturer specs does not require more) unless special design and calcs. 8. Design Q shown on pipe profile. ❑ OK ® N/A ❑ OK N/A 9. Minimum cleansing velocity of 2 FPS with half design flow observed. ❑ OK N/A 10. 18" minimum pipe size. E. CHANNELS 1. Maximum velocity in earth channel verified by ❑ OK I N/A soils report - minimum velocity 3 FPS. 2. Improved earth channel side slopes shown to be 2:1 or less steep as specified by soils report. ❑ OK N/A 3. Lined channel side slopes as specified by soils ❑ OK N/A report. 4. Areas noted to be cleared of structures, trees, ❑ OK N/A brush, and debris within natural channel and watercourses. J:\FORMS\Templates\Land Development\Street Improvements\Checklist for Street Improvement Plans STATIC form2.pdf Rev. 1/ 12 Page 6 of 6 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8/15 ENGINEER'S ESTIMATE FOR LAND DEVELOPMENT PROJECTS Date: Mav 8 2p 17 For File No(s): Site Address: ,5_,95 Mrll�ich Drv_e ENC. No. NC�OQ.092 Estimated Cost of Improvements R5Q 000 ITEM UNIT PRICES FOR PROJECT AMOUNT < $100 K > SI00 K S AMOUNT NO. DESCRIPTION QTY UNIT I. DEMOLITION/CLEARING 1. CLEARING & GRUBBING 0 LS $2,750.00 $2,000.00 $ - 2. SAWCUT P.C.C./A.C.(UP TO 6") 100 LF $5.75 $4.25 $ 575.00 3. P.C.C. REMOVAL 0 SF $4.00 $3.00 $ 2,424.00 4. CURB AND GUTTER REMOVAL 58 LF $11.00 $7.00 $ 748.00 5. MEDIAN REMOVAL 0 SF $7.00 $5.50 $ - 6. DEMOLISH EXISTING INLET/PLUG RCP'S 0 EA $2,250.00 $1,750.00 $ If. STORM DRAINAGE 1. 12" R.C.P. (CLASS V) 0 LF $275.00 $225.00 $ 2. 15" R.C.P. (CLASS III) 0 LF $300.00 $250.00 $ 3. 18" R.C.P. (CLASS III) 0- ° LF $325.00 $275.00 $ 4. 24" R.C.P. (CLASS III) 0 LF $350.00 $300.00 $ 5. 30" R.C.P. (CLASS 111) `0' t LF $400.00 $350.00 $ 6. T.V. INSPECTION (12") 0 LF $1.60 $1.25 $ - 7. STD. DRAINAGE INLET (C.C. DETAIL 5) 0 EA $3,600.00 $3,000.00 $ - 8. FLAT GRATE INLET (C.C. DETAIL 6) 131KOM EA $2,125.00 $1,700.00 $ - 9. STD MANHOLE (C.S.J. DETAIL D-11) 0 EA $6,500.00 $5,250.00 $ - 10. STD MANHOLE (C.S.J. DETAIL D-12) 0 EA $8,000.00 $6,500.00 $ - 11. BREAK AND ENTER M.H./D.I. 0 EA $1,300.00 $1,000.00 $ - III. I. CONCRETE IMPROVEMENTS SIDEWALK 20 SF $10.00 $8.00 $ 3,200.00 2. DRIVEWAY APPROACH - i[95 SF $14.00 $10.00 $ 2,730.00 3. CURB AND GUTTER &8 LF $60.00 $47.00 $ 4,080.00 4. VALLEY GUTTER 0 SF $35.00 $30.00 $ - 5. CURB RAMP EA $4,500.00 $3,500.00 $ 4,500.00 1 .6. TYPE B-1 CURB LF $50.00 $40.00 $ - 7. TYPE Al-B3 CURB 0 LF $25.00 $20.00 $ - 0 8. COBBLESTONE MEDIAN SURFACE SF $25.00 $20.00 $ - 9 BUS STRESS PAD 0 EA $12,000.00 $12,000.00 $ - Q:\Civil\17908A\Calcs\Engineers Estimate FRONTAGE IMPROVEMENTS (Rev. 03/08) Page 1 of 4 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8/15 ENGINEER'S ESTIMATE FOR LAND DEVELOPMENT PROJECTS Date: �Iay�20a 7: For File No(s): Site Address: SMil1ichDriue ENC. No. EC+201a7-04092rl Estimated Cost of Improvements -15 O00 ITEM UNIT PRICES FOR PROJECT AMOUNT < $100 K > $100 K $ AMOUNT NO. DESCRIPTION QTY UNIT IV. PAVEMENT 1. ASPHALT DIGOUT AND REPLACE CF $6.25 $5.25 $ 2. PAVEMENT WEDGE CUT (6) LF $5.50 $3.00 $ 3. PAVEMENT GRINDING 0 SF $1.10 $0.75 $ 4. PAVEMENT FABRIC (PETROTECH) b Sy $2.50 $2.25 $ S. ASPHALT CONCRETE (TYPE A) 0 T $225.00 $180.00 $ 6. AGGREGATE BASE (CLASS 2) 0 T $90.00 $50.00 $ 7. SLURRY SEAL (TYPE II) 0 SF $0.30 $0.25 $ - 8 AC REMOVAL/OFFHAUL/DISPOSAL CF $15.00 $13.50 $ V. TRAFFIC SIGNALS/LIGHTS I. DETECTOR LOOP (6' ROUND) ". 0,. ' EA $650.00 $520.00 $ 2. DETECTOR LOOP (6' x 30') EA $950.00 $750.00 $ 0,_ 3. DETECTOR LOOP (6' x 50') EA $1,300.00 $1,025.00 $ 4. ELECTROLIER 0 :r , EA $10,000.00 $6,000.00 $ 5. 1 1/2" RIGID CONDUIT 0 LF $13.00 $10.00 $ 0 6. 2" RIGID TRAFFIC SIGNAL CONDUIT LF $24.00 $20.00 $ 7. CONDUCTOR 0 LF $1.05 $0.85 $ 8. PULL BOX (NO. 3 1/2) 0 EA . $425.00 $350.00 $ - 9. TRAFFIC SIGNAL PULL BOX (NO. 5) 0 EA $580.00 $460.00 $ - 10. PULL ROPE 0 LF $0.60 $0.60 $ - 11. NEW SIGNALIZED INTERSECTION 0 LS $380,000.00 $ - VI. STRIPING AND SIGNS 1. REMOVE PVMT. MARKINGS (PAINT) 0 SF $3.00 $2.65 $ - 2. REMOVE PVMT. MARKINGS (THERMO) 0 SF $4.25 $3.70 $ - 3. REMOVE PVMT STRIPING 0 LF $1.85 $1.50 $ - 4. STRIPING DETAIL 9 0' LF $3.60 $3.00 $ - 5. STRIPING DETAIL 22 0 LF $3.60 $3.00 $ - 6. STRIPING DETAIL 29 0' LF $4.75 $4.00 $ - 7. STRIPING DETAIL 32 0 LF $4.75 $4.00 $ - 8. STRIPING DETAIL 37 (THERMO) 0 SF $6.00 $5.00 $ - 9. STRIPING DETAIL 38 (THERMO) 0 SF $6.00 $5.00 $ - Q:\Civil\17908A\Calcs\Engineers Estimate FRONTAGE IMPROVEMENTS (Rev. 03/08) Page 2 of 4 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION ENGINEER'S ESTIMATE FOR LAND DEVELOPMENT PROJECTS Date: ;May 8 '2017 T- Site Address: '595 Mlllich Dr1va. f Revised 8115 For File No(s): -7- ENC. No. '.ENQ '7 y00092 - Estimated Cost of Improvements I $50,000_ ITEM NO. DESCRIPTION QTY UNIT UNIT PRICES FOR PROJECT AMOUNT <$100 K > $100 K $ AMOUNT 10. II. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. VII. 1. 2. 3. 4. 5. 6. STRIPING DETAIL 39 LIMIT LINE CROSSWALK, 12" WHITE PAVEMENT MARKINGS (PAINT) PAVEMENT MARKINGS (THERMO) PAVEMENT MARKER (NON-REFL.) PAVEMENT MARKER (REFLECTIVE) TYPE K MARKER TYPE N MARKER SALVAGE ROAD SIGN RELOCATE ROAD SIGN (W81 ON NEW POST) INST. RD. SIGN ON EXIST. POLE ROAD SIGN WITH POST INSTALL 1226S SIGN WITH POST STANDARD BARRICADE LANDSCAPING STREET TREE STREET TREE (36" BOX) PRUNE TREE ROOTS TREE REMOVAL PLANTINGS IRRIGATION LF LF LF SF SF EA EA EA EA EA EA EA EA EA LF EA EA EA EA LS LS $6.00 $7.50 $7.50 $4.00 $8.00 $6.50 $8.25 $125.00 $125.00 $115.00 $145.00 $265.00 $400.00 $400.00 $25.00 $650.00 $900.00 $200.00 $800.00 $1.00 $1.00 S5.00 $6.00 $6.00 $3.25 $6.60 $5.20 $6.95 $109.50 $109.50 $99.00 $115.75 $231.55 $347.30 $350.00 $19.50 $500.00 $750.00 $150.00 $650.00 $1.00 $1.00 $ $ $ $ $ $ S $ $ $ $ $ $ $ $ $ $ $ $ $ $ Q' "0' r" 0, 'Ol 0;_ _ 0, 0 0: Q. 0 0: 0 0 �-� - 0,- 0 :: - 0 4' 0 0 - d '0 -` .' Q:1Civil\17908A\Calcs\Engineers Estimate FRONTAGE IMPROVEMENTS (Rev. 03/08) Page 3 of 4 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8115 ENGINEER'S ESTIMATE FOR LAND DEVELOPMENT PROJECTS Date: Mayy$„ 20117_ .„$'': L `t, x ." <...yb For File No(s):�.fxh- �a Site Address:9.5_wMlllieh3Drlve�� ____ z,,,,d y ENC. No. �ElNC20a17000.92 Estimated Cost of Improvements 5fl 00 ITEM NO. DESCRIPTION QTY UNIT UNIT PRICES FOR PROJECT AMOUNT <$100 K > $100 K $ AMOUNT Vill. 1. 2. 3. 4. 5. 6. MISCELLANEOUS PEDESTRIAN BARRIER CHAIN LINK FENCE (6) RAISE MISC. BOX TO GRADE RAISE MANHOLE TO GRADE INSTALL MONUMENT BOX MEDIAN BACKFILL arm—,"_. .0 3_.;, LF LF EA EA EA CY $86.85 $30.00 $600.00 $850.00 $3,000.00 $26.00 $69.45 $25.00 $500.00 $700.00 $3,000.00 $22.00 $ $ $ $ $ - $ 0,; ;= 0 I ;' 0 , `''" K6'.77 PREPARED BY: r<nFaa' REVIEWED BY: pS 4L x APPROVED BY: _•7 J.'�i K° =t: SUBTOTAL 10% MOBILIZATION, CONSTRUCTION TRAFFIC CONTROL/PHASING, CONSTRUCTION STAKING, CONSTRUCTION TESTING 10% CONTINGENCY 10% SECURITY ENFORCEMENT TOTAL FAITHFUL PERFORMANCE SECURITY USE THIS AMOUNT FOR SECURITY $ 18,257.00 $ 1,825.70 400 00 400.0- $ 1,825.70 $1,825.70 $ 24.534.10 Q:\Civil\17908A\Calcs\Engineers Estimate FRONTAGE IMPROVEMENTS (Rev. 03/08) Page 4 of 4 WILLGLE-01 AALCANTAR CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/15/2017 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(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 endorsement(s). PRODUCER License # OE63493 - Orr & Associates Insurance $efVIC@S Orr & Single Oak Dr Ste 255 Ste CONTACT NAME: (A//CCNo, Ext): (951) 506-5859 FAX No):(800) 474-3003 E-MAIL service@orrandassociates.com Temecula, CA 92590 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Mt. Hawley Insurance Company, 37974 INSURED INSURER B : West American Insurance Company INSURER C: National Union Fire of Pittsburg 19445 Willow Glen Construction INSURER D : Everest National Insurance Company 10120 2450 Scott Blvd. Ste. 308 Santa Clara, CA 95050 INSURER E : Sentinel Insurance Company LTD 11000 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 LT TYPE OFINSURANCE ADDL INSD SUBR WVD POLICY NUMBER -POLICY EFF MM/DD/YYYY POLICY EXP D/YYYY LIMITS A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X occuR X X MGL0186057 04/14/2017 04/14/2018 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED P EMI$ES�Ea occurrence] 50,000 $ S 5,000 MED EXP (Any oneperson) PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY �X SECT LOC GENERAL AGGREGATE S 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER:. B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea_accident) $ 1,000,000 $ ANY AUTO X X BAW56242336 12/01/2016 12/01/2017 BODILY INJURY Per person OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY BODILY INJURY Per accident S Pe0accRd DAMAGE _ $ p X AUTOS ONLY X AUTOS ONEY S C UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 10,000,000 X EXCESS LIAR CLAIMS -MADE BE060703306 04/14/2017 04/14/2018 AGGREGATE $ 10,000,000 DED RETENTION $ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? (MandatoryinNH) It yes, describe under, DESCRIPTION OF OPERATIONS below N/A X 7600013036171 04/01/2017 04/01/2018 X $TAT_UTE EERH - E.L. EACH ACCIDENT 1;000,000 S E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 E Property 72SBAAR7136 12/18/2016 12/18/2017 BPP 26,100 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached i1 more space Is required) City of Campbell, its officers, employees and volunteers are named as additional insured per attached endorsement forms. The insurance coverage afforded to the additional insured is primary insurance. All work in the public right-of-way. RE: 595 Millich Drive Campbell, CA 95008 Permit# ENC 2017-00092 V City of Campbell 70 N. First Street Campbell, CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE d91 L 6jU,&V-Fnk ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: MGL0186057 Mt. Hawley Insurance Company 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, signed by both parties prior to the date of "occurrence" or offense, 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 by: 1. Your negligence; or 2. The negligence 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 re- quired by the written contract or written agree- ment to provide for such additional insured. A person's or organization's status as an additional insured under this endorsement ends when your oper- ations for that additional insured are completed. B. With respect to the insurance afforded to these ad- ditional 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 archi- tectural, 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 engi- neering 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. 2. "Bodily injury" or "property damage" occurring after: a. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on behalf of the additional insured(s) at the loca- tion 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 subcontractor engaged in performing operations for a princi- pal as a part of the same project. C. With respect to the insurance afforded to these addi- tional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is: CGL 20 33 08 15 Contains copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 2 Insured 1. The minimum amount required by the written contract or written agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CGL 20 33 08 15 Contains copyrighted material of Insurance Services Office, Inc. with its permission. Page 2 of 2 Insured Policy Number: MGL.0186.057 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES.THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR. CONTRACTORS - COMPLETED OPERATIONS Thisendorsement modifies insurance provided under the -following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured, Persons) Or Organization(s) (Vendor) Location And Description Of Completed Operations All persons or organizations where required bywritten contract. All Locations and All Projects Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II Who Is An Insured is amended to in B. With, respect to the insurance afforded to these clude as an additional insured the person(s) or organi- additional insureds, the following is added to Section zation(s) shown in the Schedule, but only with respect III — Limits Of Insurance: to liability for "bodily injury" or "property damage" caused, by your negligence at the location: designated The most we will pay on behalf of the additional in - and described in the Schedule of this endorsement sured is' performed for that additional insured and included in the "products -.completed operations hazard". However: T. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insur- ance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 1. The minimum amount required by any contract or agreement you have entered into to provide addi- tional insured coverage; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations: ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 20 37 08 16 Contains copyrighted material of Insurance Services Office, Inc. with its permission. Page 1 of 1 Insured Policy Number: MGL0186057 .. Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition (2) You have, agreed in writing in a contract or agree - and supersedes any provision to the contrary: ment that this insurance would- be primary and would not seek contribution from any other in - Primary And Noncontributory Insurance surance available -to the additional insured. This insurance is primary to and will not seek con- tribution from any other insurance available to an . additional insured under your policy provided that: (1) The additional insured is a Named'Insured under such other insurance; and CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Insured Page 1 of 1 Policy Number: MGL0186057 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) - GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following:. COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): All projects. General Aggregate Capped At: $10,000,000 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally obligated to pay as damages caused by "occur- rences" under Section I — Coverage A, and for all Medical expenses caused by accidents under Section I — Coverage C, which can be attributed only to ongoing operations at a single designated construc- tion project shown in the Schedule above: 1. A separate Designated Construction Project Gen- eral Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products -completed op- erations hazard",, and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits." 3. Any payments made under Coverage A for dam- ages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated con- struction project. Such payments shall not reduce the General Aggregate Limit shown in the Declarations nor shall they reduce any other Designated Construction Project General Aggre- gate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Oc- currence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. B. For all sums which the insured becomes legally obli- gated to pay as damages caused by 'occurrences" under Section I — Coverage A, and for all medical expenses caused by accidents under Section I — Coverage C, which cannot be attributed only to on- going operations at a single designated construction project shown in the Schedule above: CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 2 Insured 1. Any payments made under Coverage A for dam- D. If the applicable designated construction project has ages or under Coverage C for medical expenses been abandoned, delayed, or abandoned and then shall reduce the amount available under the restarted, or if the authorized contracting parties devi- General Aggregate Limit or the Products- ate from plans, blueprints, designs, specifications or completed Operations Aggregate Limit, whichever timetables, the project will still be deemed to be the is applicable; and same construction project. 2. Such payments shall not .reduce any ,Designated Construction Project General Aggregate Limit. C. When coverage for liability arising out of the "products -completed operations hazard" is provided, any payments for damages because of "bodily injury" or '.'property damage included in the. "products - completed operations hazard" will reduce the Products -completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. CG 25 03 05 09 © Insurance Services Office, Inc., 2008 Page 2 of 2 Insured Policy Number: MGLO186057 Mt. Hawley Insurance Company 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 PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization -- All persons or organizations where required by written contract. 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 © Insurance Services Office, Inc., 2008 Page 1 of 1 Insured COMMERCIAL AUTO CA 88 10 01 13 THIS :ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. COVERAGEINDEX SUBJECT ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT ACCIDENTAL AIRBAG DEPLOYMENT AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS AMENDED FELLOW EMPLOYEE EXCLUSION AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE BROAD FORM INSURED BODILY INJURY REDEFINED EMPLOYEES. AS INSUREDS (including employee hired auto) EXTENDED CANCELLATION CONDITION EXTRA EXPENSE -BROADENED COVERAGE GLASS REPAIR - WAIVER OF DEDUCTIBLE HIRED AUTO PHYSICAL DAMAGE (including employee hired auto and loss of use) HIRED AUTO COVERAGE TERRITORY LOAN / LEASE GAP PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) PERSONAL EFFECTS COVERAGE PHYSICAL DAMAGE - ADDITIONAL TRANSPORTATION EXPENSE COVERAGE RENTAL REIMBURSEMENT SUPPLEMENTARY PAYMENTS TOWING AND LABOR TWO OR MORE DEDUCTIBLES UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS WAIVER OF TRANSFER OF RIGHTS OF RECOVERYAGAINST OTHERS TO US PROVISION NUMBER 3 12 19 5 13 1 22 2 23 10 15 6 20 14 16 11 8 9 4 7 17 18 20 SECTION II - LIABILITY COVERAGE is amended as follows: 1. BROAD FORM INSURED SECTION II - LIABILITY COVERAGE, paragraph A.1. - WHO IS AN INSURED is amended to include the following as an insured: d. Any legally incorporated entity of which you own more than 50 percent of the voting stock during the policy period. However, "insured" does not include any organization that: (1) Is a partnership or joint venture; or (2) Is an insured under any other automobile policy; or (3) Has exhausted its Limit of Insurance under any other automobile policy. Paragraph d. (2) of this provision does not apply to a policy written to apply specifically in excess of this policy. e. Any organization you newly acquire or form, other than a partnership or joint venture, of which you own more than 50 percent of the voting stock. This automatic coverage is afforded only for 180 days from the date of acquisition or formation. However, coverage under this provision does not apply: (1) If there is similar insurance or a self -insured retention plan available to that organization; © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 7 (2) If the Limits of Insurance of any other insurance policy have been exhausted; or (3) To "bodily injury" or "property damage" that occurred before you acquired or formed the organization. 2. EMPLOYEES AS INSUREDS SECTION II - LIABILITY COVERAGE, paragraph A.1. WHO IS AN INSURED is amended to include the following as an insured: f. Any "employee" of yours while using a covered "auto" you do not own, hire or borrow, but only for acts within the scope of their employment by you. Insurance provided by this endorse- ment is excess over any other insurance available to any "employee". g. An "employee" of yours while operating an "auto" hired or borrowed under a written contract or agreement in that "employee's" name, with your permission, while performing duties re- lated to the conduct of your business and within the scope of their employment. Insurance provided by this endorsement is excess over any other insurance available to the "employee". 3. ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT SECTION II - LIABILITY COVERAGE, paragraph A.1. - WHO IS AN INSURED is amended to include the following as an insured: h. Any person or organization with respect to the operation, maintenance or use of a covered a "auto", provided that you and such person or organization have agreed in a written contract, agreement, or permit issued to you by governmental or public authority, to add such person, or organization, or governmental or public :authority to this policy as an "insured". However, such person or organization is an "insured": (1) Only with respect to the operation, maintenance. or use of acovered "auto"; (2) Only for "bodily injury" or "property damage" caused by_ an "accident" which takes place after you executed the, written contract or agreement, or. the permit has been issued to you; and (3) Only for the duration of that contract, agreement or permit 4. SUPPLEMENTARY PAYMENTS SECTION Il - LIABILITY COVERAGE, Coverage Extensions, 2.a. Supplementary Payments, para- graphs (2) and (4) are replaced by the following: (2) Up to $3,000 for cost of bail bonds (including bonds for related traffic violations ) required because of an "accident" we cover. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the insured at our request, including actual loss of earn- ings up to $500 a day because of time off from work. 5. AMENDED FELLOW EMPLOYEE EXCLUSION In those jurisdictions where, by law, fellow employees are not entitled to the protection afforded to the employer by the workers compensation exclusivity rule, or similar protection, the following provision is added: SECTION II - LIABILITY, exclusion B.5. FELLOW EMPLOYEE does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire. SECTION III - PHYSICAL DAMAGE COVERAGE is amended as follows: 6. HIRED AUTO PHYSICAL DAMAGE Paragraph A.4. Coverage Extensions of SECTION III - PHYSICAL DAMAGE COVERAGE, is amended by adding the following: If hired "autos" are covered "autos" for Liability Coverage, and if Comprehensive, Specified Causes of Loss or Collision coverage are provided under the Business Auto Coverage Form for any "auto" you own, then the Physical Damage coverages provided are extended to "autos": a. You hire, rent or borrow; or © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 7 b. Your "employee" hires or rents under a written contract or agreement in that "employee's" name, but only if the damage occurs while the vehicle is being used in the conduct of your business, subject to the following limit and deductible: A. The most we will pay for "loss" in any one "accident" or "loss" is the smallest of: (1) $50,000; or (2) The actual cash value of the damaged or stolen property as of the time of the "loss"; or (3) The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality, minus a deductible. B. The deductible will be equal to the largest deductible applicable to any owned "auto" for that coverage. C. Subject to the limit, deductible and excess provisions described in this provision, we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. D. Subject to a maximum of $1,000 per "accident", we will also cover the actual loss of use of the hired "auto" if it results from an "accident", you are legally liable and the lessor incurs an actual financial loss. E.. This coverage extension does not apply to: (1) Any "auto" that is hired, rented or borrowed with a driver; or (2) Any "auto" that is hired, rented or borrowed from your "employee". For the purposes of this provision, SECTION V - DEFINITIONS is amended by adding the following: "Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value. 7. TOWING AND LABOR SECTION III - PHYSICAL DAMAGE COVERAGE, paragraph A.2. Towing, is amended by the addition of the following: We will pay towing and labor costs incurred, up to the limits shown below, each time a covered "auto" classified and rated as a private passenger type, "light truck" or "medium truck" is dis- abled: a. For private passenger type vehicles, we will pay up to $50 per disablement. b. For "light trucks", we will pay up to $50 per disablement. "Light trucks" are trucks that have a gross vehicle weight (GVW) of 10,000 pounds or less. c. For "medium trucks" , we will pay up to $150 per disablement. "Medium trucks" are trucks that have a gross vehicle weight (GVW) of 10,001 - 20,000 pounds. However, the labor must be performed at the place of disablement. 8. PHYSICAL DAMAGE -ADDITIONAL TRANSPORTATION EXPENSE COVERAGE Paragraph AA.a., Coverage Extension of SECTION III - PHYSICAL DAMAGE COVERAGE, is amend- ed to provide a limit of $50 per day and a maximum limit of $1,500 © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 7 9. RENTAL REIMBURSEMENT SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the following: a. We will pay up to $75 per day for rental reimbursement expenses incurred by you for the rental of an "auto" because of "accident" or "loss", to an "auto" for which we also pay a "loss" under Comprehensive, Specified Causes of Loss or Collision Coverages. We will pay only for those expenses incurred after the first 24 hours following the "accident" or "loss" to the covered "auto." b. Rental Reimbursement will be based on the rental of a comparable vehicle, which in many cases may be substantially less than $75 per day, and will only be allowed for the period of time it should take to repair or replace the vehicle with reasonable speed and similar quality, up to a maximum of 30 days. 6. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove and replace your tools and equipment from the covered "auto". d. This coverage does not apply unless you have a business necessity that other "autos" avail- able for your use and operation cannot fill. e. If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided under Paragraph 4. Coverage Extension. g f. No deductible applies to this coverage. For the purposes of this endorsement provision, materials and equipment do not include "personal effects" as defined in provision 11. 10. EXTRA EXPENSE - BROADENED COVERAGE Under SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, we will pay for the expense of $ returning astolen covered "auto" to you. The maximum amount we will pay is $1,000. 11. PERSONAL EFFECTS COVERAGE A. SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the following: If you have purchased Comprehensive Coverage on this policy for an "auto" you own and that "auto" is stolen, we will pay, without application of a deductible, up to $600 for "personal effects" stolen with the "auto." The insurance provided under this provision is excess over any other collectible insurance. B. SECTION V - DEFINITIONS is amended by adding the following: For the purposes of this provision, "personal effects" mean tangible property that is worn or carried by an insured." "Personal effects" does not include tools, equipment, jewelry, money or securities. 12. ACCIDENTAL AIRBAG DEPLOYMENT SECTION III - PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS is amended by adding the follow- ing: If you have purchased Comprehensive or Collision Coverage under this policy, the exclusion for "loss" relating to mechanical breakdown does not apply to the accidental discharge of an airbag. Any insurance we provide shall be excess over any other collectible insurance or reimbursement by manufacturer's warranty. However, we agree to pay any deductible applicable to the other cov- erage or warranty. 13. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS, exception paragraph a. to exclu- sions 4.c. and 4.d. is deleted and replaced with the following: © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 7 Exclusion 4.c. and 4.d. do not apply to: a. Electronic equipment that receives or transmits audio, visual or data signals, whether or not designed solely for the reproduction of sound, if the equipment is permanently installed in the covered "auto" at the time of the "loss" and such equipment is designed to be solely operated by use of the power from the "auto's" electrical system, in or upon the covered "auto" and physical damage coverages are provided for the covered "auto"; or If the "loss" occurs solely to audio, visual or data electronic equipment or accessories used with this equipment, then our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by a $100 deductible. 14. LOAN 1 LEASE GAP COVERAGE A. Paragraph. C., LIMIT OF INSURANCE of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by adding the following: The most we will pay for a "total loss" to a covered "auto" owned by or leased to you in any one "accident" is the greater of the: 1. Balance due under the terms of the loan or lease to which the damaged covered "auto" is subject at the time of the "loss" less the amount of: a. Overdue payments and financial penalties associated with those payments as of the date of the "loss", b. Financial penalties imposed under a lease due to high mileage, excessive use or ab- normal wear and tear, c. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease, d. Transfer or rollover balances from previous loans or leases, e. Final payment due under a "Balloon Loan"; f. The dollar amount of any unrepaired damage which occurred prior to the "total loss" of a covered "auto", g. Security deposits not refunded by a lessor, h. All refunds payable or paid to you as a result of the early termination of a lease agreement or as a result of the early termination of any warranty or extended service agreement on a covered "auto", i. Any amount representing taxes, j. Loan or lease termination fees; or 2. The actual cash value of the damage or stolen property as of the time of the "loss". An adjustment for depreciation and physical condition will be made in determining the actual cash value at the time of the "loss". This adjustment is not applicable in Texas. n B. ADDITIONAL CONDITIONS This coverage applies only to the original loan for which the covered "auto" that incurred the loss serves as collateral, or lease written on the covered "auto" that incurred the loss. C. SECTION V - DEFINTIONS is changed by adding the following: As used in this endorsement provision, the following definitions apply: "Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value. A "balloon loan" is one with periodic payments that are insufficient to repay the balance over the term of the loan, thereby requiring a large final payment. © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 7 15. GLASS REPAIR- WAIVER OF DEDUCTIBLE Paragraph D. Deductible of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: No deductible applies to glass damage if the glass is repaired rather than replaced. 16. PARKED AUTO COLLISION COVERAGE (WAIVER OF DEDUCTIBLE) Paragraph D. Deductible of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: The deductible does not apply to "loss" caused by collision to such covered "auto" of the private passenger type or light weight truck with a gross vehicle weight of 10,000 lbs. or less as defined by the manufacturer as maximum loaded weight the "auto" is designed to carry while it is: a. In the charge of an "insured"; b. Legally parked; and c. Unoccupied. 4 The "loss" must be reported to the police authorities within 24 hours of known damage. The total amount of the damage to the covered "auto" must exceed the deductible shown in the Declarations. This provision does not apply to any "loss" if the covered "auto" is in the charge of any person or 0 organization engaged in the automobile business. 17. TWO OR MORE DEDUCTIBLES Under SECTION III PHYSICAL DAMAGE COVERAGE, if two or more company policies or coverage forms apply to the same accident, .the following applies to paragraph D. Deductible: a. If the applicable Business Auto deductible is the smaller (or smallest) deductible it will be waived; or b. If the applicable Business Auto deductible is not the smaller (or smallest) deductible it will be reduced by the amount of the smaller (or smallest) deductible; or c. If the loss involves two or more Business Auto coverage forms or policies the smaller (or smallest) deductible will be waived. For the purpose of this endorsement company means any company that is part of the Liberty Mutual Group. SECTION IV - BUSINESS AUTO CONDITIONS is amended as follows: 18. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV- BUSINESS AUTO CONDITIONS, Paragraph B.2. is amended by adding the following: If you unintentionally fail to disclose any hazards, exposures or material facts existing as of the inception date or renewal date of the Business Auto Coverage Form, the coverage afforded by this policy will not be prejudiced. ° However, you must report the undisclosed hazard of exposure as soon as practicable after its discovery, and we have the right to collect additional premium for any such hazard or exposure. 19. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT, OR LOSS SECTION IV - BUSINESS AUTO CONDITIONS, paragraph A.2.a. is replaced in its entirety by the following: a. In the event of "accident", claim, "suit" or "loss", you must promptly notify us when it is known to: 1. You, if you are an individual; 2. A partner, if you are a partnership; 3. Member, if you are a limited liability company; 4. An executive officer or the "employee" designated by the Named Insured to give such notice, if you are a corporation. © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 7 To the extent possible, notice to us should include: (1) How, when and where the "accident" or "loss". took place; (2) The "insureds" name and address; and (3) The names and addresses of any injured persons and witnesses. 20. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US SECTION IV - BUSINESS AUTO CONDITIONS, paragraph A.5., Transfer of Rights of Recovery Against Others to Us, is amended by the addition of the following: If the person or organization has waived those rights before an "accident" or "loss", our rights are waived also. 21. HIRED AUTO COVERAGE TERRITORY SECTION IV - BUSINESS AUTO CONDITIONS, paragraph 13.7., Policy Period, Coverage Territory, is amended by the addition of the following: f. For "autos" hired 30 days or less, the coverage territory is anywhere in the world, provided that the insured's responsibility to pay for damages is determined in a "suit", on the merits, in the United States, the territories and possessions of the United States of America, Puerto Rico or Canada or in a settlement we agree to. This extension of coverage does not apply to an "auto" hired, leased, rented or borrowed with a driver. SECTION V - DEFIMITIONS is amended as follows: 22. BODILY INJURY REDEFINED Under SECTION V - DEFINTIONS, definition C. is replaced by the following: "Bodily injury" means physical injury, sickness or disease sustained by a person, including mental anguish, mental injury, shock, fright or death resulting from any of these at any time. COMMMON POLICY CONDITIONS 23. EXTENDED CANCELLATION CONDITION COMMON POLICY CONDITIONS, paragraph A. - CANCELLATION condition applies except as fol- lows: If we cancel for any reason other than nonpayment of premium, we will mail to the first Named Insured written notice of cancellation at least 60 days before the effective date of cancellation. This provision does not apply in those states which require more than 60 days prior notice of cancella- tion. © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 7 of 7 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION ANY PERSON OR ORGANIZATION FOR WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER JOB DESCRIPTION BLANKET WAIVER OF SUBROGATION This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only When this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 04/01/2017 Policy No. 7600013036171 Endorsement No. 001 Insured: Essary, Kevin Scott; Anderson, David Carl Premium $ INCL. Insurance Company: Everest National Insurance Company Countersigned By: - 1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999.