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ENC2017-00115OF C4M Ok CHAR CITY OF CAMPBELL Public Works Department October 11, 2018 Brett Hassett 313 W. Campbell Ave. Campbell CA 95008 SUBJECT: PERMIT NO. ENC 2017-00115 313 W. Campbell Ave., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Brett: The City of Campbell has made the final one year maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Sincerely, r, 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 oV c9� 'kCHAK9 CITY OF CAMPBEL,L Public Works Department October 24, 2017 Brett Hassett 313 W. Campbell Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00115 313 W. Campbell Ave. FINAL INSPECTION AND ACCEPTANCE Dear Brett: 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 a:s of October 10, 2017. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of $2,500.00 is enclosed. If you have any questions, please call meat (408) 866-2165. Sincerely, Syed'WAidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00115 70 North First Street ..Campbell, California 95008-1436 • TEL 408.866.2150 • FAx 408.376.0958 • TDD 408.866.2790 i� Print Form CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No: I_:NCIO a/I DEPT. OF PUBLIC WORKS (Non -engineered work within the public right-of-way) X-Ref File 70 North First Street ($10,000.00 maximum value of work) Application Date / Campbell, CA 95008�j I �— Application Expiration t Ph. (408) 866-2150 ISSUED: ` Date 117 I Fx. (408) 376-0958 Permit Expiration Date: APN _ (. APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months if the permit is not issued.) A. Work Address: ! '31 +- �1 P ► Cap `�Ci B. Nature of Work:Mtn C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing become a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance securities. NAME OF_APPLICANT:��� �� cr Telephone: Ij Address: �j 17j....�I�?'0. � _ E-Mail Address: re, C_ 016. , Sse_(:� t d ! �/1(Cj r co INA The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence. The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency, its officers, agents, and employees free, safe and harmless from any claim or demand for damages resulting from the work covered bythis permit. The Applicant hereby acknowledges that they have read and understand both the front and back of this permit, and that they will inform their contractor(s) of the information. 1 ACCEPTED: (Applicant/Permittee) (Sign) Date NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable insurance requirements. The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number (Ticket No.) has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.: Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the design, installation or condition of private improvements in the public right-of-way. SPECIAL PROVISIONS 1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be 3. STANDARD AMOUNT EIP SECURITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.) $ 2S R-1 PERMIT FEE $ APPROVED FOR ISSUANCE: 5 a-51 ity Engineer Date GENERAL PERAM CONDITIONS 1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon completion of the work and written. acceptance by the City. 2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the one-year maintenance period. 3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10 days prior to proposed start of work. Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves. 7. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 8. Sawcut for all. PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 9. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading as specified by the City Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee. 1-0. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during construction. 11. This permit shall be kept at the site of work and must.be shown to any authorized representatives of the City of Campbell or any law enforcement officer upon demand. 12. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline, which would create a hazardous condition to the public. 13.. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or anyother work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 16. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the(current overtime rate. 17. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 18. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City -owned or maintained facilities. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the rrimjcipal stnrrn chain system nthortl-;an storm water_ Applicant shall adhere to the BEST MANAGEMENT PRA(`TIrFC ectahlichc�l by the Santa Clara Valley Urban Runoff Pollution Prevention Program. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above Applicant. Date l•\FnRMS\Temnlatas\Fnrrnarhmant Permits\R-1 Encroachment Permit STATIC form2.pdf OF Cg4t yF 0 'k CHAR CITY of CAMPBELL Public Works Department October 24, 2017 Brett Hassett 313 W. Campbell Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2017-00115 313 W. Campbell Ave. FINAL INSPECTION AND ACCEPTANCE Dear Brett: 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 October 10, 2017. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any_repairs are required. Your Faithful Security Deposit in the amount of $2,500.00 is enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, Sye&W'ahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2017-00115 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 =undable Deposit Check Rec 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: Brett Hassett 313 W. Campbell Ave. Campbell State: CA ENC2017-00115 Zip: 95008 101.2203 Amount: $2,600.00 101.2203 Amount: 101.540.7448 Amount: Interest Earned (Finance Dept only) (Exact Amount) ENC2017-00115 Dep Refund Permit #: ENC2017-00115 Receipt #: 269346 Date: 5/1/2017 Receipt #: Date: Requested by: Title: Inspector Date: Syed Wahidi Approved by: Title: Sr. Engineer Date: Roger Storz Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handlina Check Mall AS IS: Mall in Attachecl Envelope: interim l:neCK: Needed By: Return To: JoAnna Thomason Public Works (Name) (Department) Other: Please return check to JoAnna Encroachment Permit Final Sign Off Encroachment Permit # [wL 2.c�� -Uci �Sr' Address: Date of Final Inspection and Acceptance: fG�.%7 Inspected by: OK to release deposits: 100% 715 Comments- 0 '-- - - I,. - .r , .: 1 i� p'�'-.�' - ''- , - - � ;_,- -,­ ' " -. ,"0 ­,,-- 1�­ _-. ,- ." .- "w� � , . , , . � " 4- :L- .:I " ; , 1 "-. _. j ' - w'; - : '. � L .- . ' -- � 'L � i I ' ' - ' . 7 �- �I1 "_L­' 2 i­7: Mdbe-" DO$iTCheck` iZ44uttt6'" .t, %_ � t �9�j ­"t-it : >+"Z�iy 7 -",',T&l3RI 'y 4 Chddk­Pd�abl6'ToBre it Fasi","�i- . � Address-Uh �313 '.W.0 OOl611AVE) 1 1�'� 4, ti L2 "J" j " 1, d MObOII — lCity:�''�6te_CA96QQO _s .4r,- ,-, " beicH�fi6694p�01 6 a '' ' e,71 Account.JUpn66et _. I0129wA �i kfj,M AbdduhTNOmb6i"4' 401� 203t-AM6unt �j , Account um66 - 04O7448-Amount Fiance 6eft�6fil�A (Fiance Dept interest 69t; Earned (ky Tot!['Piyablq(��ia Amquq�� ,I � I, ' ,te ;.I � ' I�1 I , § PLTPR�6Ob201-115� "df00'1 , � '*. , _ 4 I�w p" , , ,5Permit f gvcg6l776' AbdefpfI 269T4 "' Date. I 01112017 - ,7 s t . j�Ikekii0C# IDate r kequestbdbYInspector 6J' -,� 1' "1� , I ,,•1 AprovedbTitle Srrll7 , ' �­iV&�N- ,py' RogerStqrz -1 " '- ,"i3 a" I"t_" - r ! InardWDept 6nlY Vdn id �4"t�f Title Accounting nRffng ClerkAI 06 1 � , -!'?"­ 7t) , ,LI,Il' tII.I ,..,,'.i Approved byTitle , Accountant 3atq ' 1I!�IIlj� - , l ' , -"­' , i1 •� y 4 , v s9 j*Forfin�a,hdIln _ �_" McMi A s IsdiIj h AttihedEfiveIopeifire. _runedK-s " ,,. 'n, _ Nbddbd y- ' Return p_'���f�n OR' "t Public Works , *, r (Name){ (Department) , _ 7 ''� 1 1e . 4- _ ,. �, l Ofi6rPldatdreturn check td.JoAnn' fi!-�rr e _, f , ' !I� .,. 'i l; Ij,:trt '; " 'f , _ " T Il "1-1- � - �" 1,�� , I � - , CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00115 Name: Brett Hassett Property Address: 313 W. Campbell Ave. Date of Final Inspection: On File: Bonds CD Cash Labor and Material: $ Construction Cash Deposit to be released: $ Faithful Security Deposit: $2,500.00 Other overdue deposits to be released (Description): Processed by: Yv l l -1 Admin trator Reviewed by: Inspector Reviewed by: ib kj kl Lanh Development Engineer JA\JoAmmaT\Deposit refunds\CHECKLISTS\W. Campbell 313.doc (Rev. 10/11) PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2016 5J TO: Finance PUBLIC WORKS FILE NO. 115 PROPERTY ADDRESS (law jobe. b/ Please collect & receipt for the followinQ monies: -7, __jAM0UNT t7 A OCC LA_ ND_ :DEVELOPMENT �4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Mapor ��$l 0,000 $403.00 MinorEncroachment Permit <sio,000 $230.00 INPermit N/C Subsequent R-1 Permits within Two Year Period $230.00 Ins ection Fee Minimum Charge per Location $398.00 Street Tree Planting/Removal N/C - 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $281.00 Site < 10,000 s.f. $841.00 - Site 10,000 s.f. < 0.5 Acre $1,127.00 Site 0.5 Acre $1,688.00 4722 NPDES Review (C3 Requirements) For protects not required to submit numeric sizing $163.00 For projects required to submit numeric sizing Im ervious Area 101000 Sq. Ft to 1 Acre $704.00 Im ervious Area 1 Acre or more $918.00, 4722 For projects sent to Consultant for review Consultant Cost +20% _47_22 Additional treatment facilities $300 ea Plan Check & Inspection Fee (Non -Utility) 4722 Engr. Est..< $250,000 14% of Engineer's Estimate 4722 Enqr. Est. __t$250,000 and 5$500,000 $35,000 + 8% of Engineers Estimate 4722 EnqF. Est. >$500,000 $55,000 + 7% of Engineers Estimate 2203. 2203 Emergency Cash Deposit 4% of Enqr. Est.* ($500 min/$1 0,000 Max) Faithful Performance Security (FPS) 100% of ENGR. EST.* 2203 Labor and Materials Security 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi -Res $2,385.00) (All Other $2,650.00) 4722- 4722 2203 Parcel Map (4 Lots or Less) $4009.00 + $87/lot Final Tract Map (5 or More Lots) $4,871.00 + $118/lot-- Monumentation Securitv 100% of Citv's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (includes Certificate of Compliance) $1,893.00 4722 Vacation of Public Streets & Easements $2,530.00 4722 Certificate of Compliance $1,877.00 4722 Certificate of Correction $561.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 4722 Private Improvement in Public ROW $50.00 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 4722 ---Assessment begregation 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 an . d shall include all items of work. TOTAL $ 2,600 NAME OF APPLICANT ✓ ]t &CU4 NAME OF PAYOR �JAH H �CU4W�,� ADDRESS CA MVA ZIP 500 C,h - [JAY 0 2fij w FOR A • 6�. RECEIVED. BY _:- CITY CLERK ONLY . L Da e-# t6. R ilpl ~ ' � - CITY OF CAMPBELL RECVD � CASHIER 81OOO269346 BY PAYOR: BRETT HASSETT O5/O1/17 TODAY`S DATE; TIM£� OO OU � DkTE: O5/D1/17 ` REGISTER AMOUNT, DESCRIPTl8H COST ID;ENC2017-115 $2,00.OO , TOTAL VuE" $2 ,500.Du TENDERED. $,OO CHANGE` CHECK � r- MARIHER-04 MGALANG ACO/�0� CERTIFICATE OF LIABILITYINSURANCE FDATE(MM/DD/11YY) 06/09/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # OF82764 Inszone Insurance Services, Inc. 2701 Citrus Road Suite C Rancho Cordova, CA 95742 " CONTACT Laurie Graves (AJC, No, Ext): (916) 503-4813 (AHO/C, No):(916) 636-0134 E-MAIL ADDRESS:l9raVES@ir1SZOneinS.COm INSURERS AFFORDING COVERAGE NAIC # INSURER A: National Insurance Company 19879 INSURED Maria Hernandez DBA: Hernandez Concrete POB 730214 San Jose, CA 95148 INSURER B INSURER C : INSURER D : INSURER E INSURER F : ..�� r=oTirirArC Ku Inncco• RFVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SU D WVD POLICY NUMBER POLICY EFF MMIDDlYYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ GEN'L PRODUCTS -COMP/OP AGG 1 $ POLICY ❑ jE LOC Is OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT jEa accident $ BODILY INJURY Perperson) $ ANY AUTO BODILY INJURY Per accident $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY AMAGE Per accident $ $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE - DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE X SWC1119839 09/2912016 09/29/2017 PER X STATUTE EORH E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE 1,000,000 $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA E.L. DISEASE - POLICY LIMIT 1,000,000 S If yes, describe under DESCRIPTION OF OPERATIONS below _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage inlcudes Waiver of Subrogation applies to Workers Compensation per attached endorsement. Should the above described policy be cancelled before the expiration date, notice will be delivered in accordance with the policy provisions. RE: 313 W. Campbell Ave., Campbell CA 95008 - Permit number ENC2017-00115 " 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 ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD N WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 01-84) 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 0% of the California workers' compensation premium otherwise due on such remuneration. Person or Organization City -of Campbell Campbell, CA 95008 Schedule Jots Description Residential driveway Approach This endorsement changes the policy to which it is attached and is effective an 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 9/29/2016 Policy No. ' SWC1119839 Endorsement No. Insured Hernandez, Maria (An Individual) Premium $ Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed. 01-84) 1 9484 ri INSURANCE REQUIREMENTS CHECKLIST 3\3 Permit # �C��U O\�1-�S CIP Project # w. cG..N.phe« AIJe. The following insurance is required of all contractors working in the 'City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date %-I Automotive Liability: %"Any Auto" checked on certificate s�ti��� e(� 6 �A13S �.S l�S� ©� ��A0 ❑ $1,000,000 per accident for bodily injury and property damage Policy expiration dateMB§jJ9l \$ Workers' Compensation and Employer's Liability Waiver of Subrogation clause e $1,000,000 per accident for bodily injury or disease Policy expiration date G \ 7_0 1 �'1 Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) The City, its officers, employees and volunteers are named as additional insured. (Reference Proiect Location & Permit Number) ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\loannat\Desktop\Insurance Requirements Checklist.doc (Rev 03/13) Page 1 of 2 m Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. _�.� .cv�� �\(�'A v. \� L\ �- \aVX&G& ",Jc� ��QCC�c.1 � G� . Name: D(ne���S5��1 NAIC # ik-110 Rating: Authorized in CA: Name: eC�s� ���\ NAIC # IA�Rating: Authorized in CA: Name: \J o NAIC # �R q� Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: eW�-- ❑ Campbell Business License #� Expiration: Contractors License # Class: l_ Y Expiration: Insurance Certificate Reviewed Initials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 s PR98RE.i YE0 OASIS INS AGENCY 001W -RC/AL PO BOX 1028 SAN JOSE, CA 95108 1-408-294-6222 Policy number: 02565626-9 Underwritten by: United Financial Cas Co —IGTay 24, 2017 Page 1 of 2 Certificate of Insurance Certificate Holder ...................................................................................................................... Additional Insured THE `CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CA 95008 Insured Agent ................................................................................................................................................ MARIA HERNANDEZ OASIS INS AGENCY HERNANDEZ CONCRETE PO BOX 1028 P 0 BOX 730214 SAN JOSE, CA 95108 SAN JOSE, CA 95173 This document certifies that insurance policies identified below have been issued by the designated insurer to the insured named above for the period(s) indicated. This Certificate is issued for information purposes only, It confers no rights upon the certificate holder and does not change, alter, modify, or extend the coverages afforded by the policies listed below. The coverages afforded by the policies listed below are subject to all the terms, exclusions, limitations, endorsements, and conditions of these policies, ...........................:.......................................................................................I......... y............. ................................ Policy Effective Date: Mar 14, 2017 Policy Expiration Date: Mar 14, 2018 Insurance coverage(s) Limits ............................................................................................................................................................................ Bodily Injury/Property Damage $1,000,000 Combin ed'Sin gle Limit ............................................................................................................................................................................. Uninsured/Underinsu red Motorist $750,000 Combined Single Limit Description of LocationNehicles/Special Items Scheduled autos only ............................................................................................................................................................................. 2006 FORD F550 SUPER DUTY 1 FDAW56PO6EA92674 Fire and Theft w/ CAC $500 Ded Collision ............................................................................................................................................................................. $500 w/Waiver Ded 2015 DODGE DURANGO IC4SDJCTOFC927418 Comprehensive $500 Ded Collision $500 w/Waiver Ded ............................................................................................................................................................................. 2005 FORD F250 1 FTSW21 P35EA29694 Comprehensive $500 Ded Collision $500 w/Waiver Ded Rental Reimbursement $30 Per Day ($900 Max) Attention department of public works Job Site: 313 w cambell ave cambell, ca 95008 Continued Policy number: 02565626-9 Page 2 of 2 Certificate number 14417A10626 Please be advised that additional insureds and loss payees will be notified in the event of a mid-term cancellation. Form 5241 (10/02) MARIHER-04 KDULIN � 1 CERTIFICATE OF LIABILITY INSURANCE DATE 04/28/2017Y) (MM/ 017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # OF82764 NAMEACT LBUYIe Graves Inszone Insurance Services, Inc. PHONE 91-6 503-4813 FAX 916 636-0134 2701 Citrus Road (A/C, No, Ext): ( ) 1 (A/C, No):( ) Suite C E-MAIL (graves@inszoneins.com Rancho Cordova, CA 95742 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Security National Insurance Company 19879 INSURED ONSURER B : Maria Hernandez DBA: Hernandez Concrete INSURER.0 : _ POB 730214 INSURER D : San Jose, CA 95148 INSURER E : j INSURER F : rnvoonr_re r FRTIFIr_ATE 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 VVITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE IADDL IINSD SUBR WVD - POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS -MADE OCCUR DAMAGE( RENTED PREMISES �Ea occurrences I $ MED EXP (Any oneperson) ; $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY PRO ❑ LOC JECT I I i $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ BODILY INJURY Perperson) $ ANY AUTO j BODILY INJURY Per accident $ OWNED !—� SCHEDULED AUTOS ONLY AUTOS HIRED NON-OWNEp AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ �$ UMBRELLA LIAB OCCUR ( EACH OCCURRENCE $ AGGREGATE i $ EXCESS LIAB CLAIMS MADE' DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE X SWC1119839 09/29/2016 09/29/2017 X STATUTE _ _�RH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE! $ 1,000,000 FFICER/MEMBER EXCLUDED? rI Mandatory in NH) N /A E.L. DISEASE - POLICY LIMIT 15000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below I i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Waiver of Subrogation applies to Workers Compensation per endorsement to follow from carrier. City of Campbell 70 N. First St. 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 ACORD 25 (2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number U16AC83189-02 Date Entered: 5/2/2017 Ammon CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 5/2/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: Joseph Pappalardo ,,-c,"E,.,I, (916) 363-2663 a N„ (916) 363-2662 CA Contractors Insurance Services, Inc. &MAIL JPappalardo@ccisbonds.com ADDRESS: 9848 Business Park Drive Suite H INSURER(S) AFFORDING COVERAGE NAIC # Sacramento, CA 95827 INSURER A: U.S. Specialty Insurance Company 29599 INSURED INSURER B: HERNANDEZ CONCRETE INSURER C: PO Box 730214 San Jose, CA 95173 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF THE 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L.� TYPE OF INSURANCE NSR ADDLIWVD POLICY NUMBER MOLIC (UBRI POLICY) POLICY EXP (MWDDNYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX OCCUR ® FX1 U16AC83189-02 8/5/2016 8/5/2017 EACH OCCURENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea oc u e ce $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP-AGG $ 2,000,000 POLICY PROJECT 7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ❑ ❑ BODILY INJURY (Per accident) $ ALLOWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE Per accident $ HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB OCCUR ❑ ❑ EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION Y/N AND EMPLOYERS' LIABILITY NIA ❑ TG STATU- ORY LIMITS OTH- ER E. L. EACH ACCIDENT $ ANY PROPRI ETOR/PARTNER/EXECUTI VE E. L. DISEASE- EA EMPLOYEE $ (Mandatory in N/H) If yes, describe under DESCRIPTION OF OPERATIONS below E. L. DISEASE- POLICY LIMIT $ El DESCRIPTION OF OPERATIONS/LOCATIONS NEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Campbell, its officers, employees and volunteers are named as additional insured. Project: 313 W. Campbell Ave., Campbell CA 95008. Permit number: ENC2017-00115 License # 833621 CERTIFICATE HOLDER I CANCELLATION The City of Campbell 70 N. First St. 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 O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks ofACORD POLICY NUMBER: U16AC83189-02 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO OTHER INSURANCE With respect to any person or organization that is an additional insured under this Coverage Part, the following is added to paragraph 4. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If you have agreed in writing in a contract or agreement that this insurance is primary and non- contributory relative to an additional insured's own insurance, then this insurance is primary and we will not seek contribution from that other insurance. For the purpose of this endorsement, the additional insured's own insurance means insurance on which the additional insured is a Named Insured. When this endorsement is attached to the policy it supersedes all other insurance conditions within. HCS 040 06 10 13 B. WAIVER OF SUBGROGRATION — BLANKET Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, The Transfer Of Rights Of Recovery Against Others To Us Condition is amended by the addition of the following: We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" included in the "products - completed operations hazard". However, this waiver applies only when you have agreed in writing to waive such rights of recovery in a contract or agreement, and only if the contract or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. POLICY NUMBER: U16AC83189-02 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL PERSONCONTRACTORS - SCHEDULED ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Orcianization(s): I Location(s) Of Covered Operations Any person or organization for whom you are performing operations during the policy period when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: U16AC83189-02 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE® - OWNERS, LESSEES OR CONTRACTORS - COMPLETE® OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location And Description Of Completed Operations Any person or organization, when you and such parties have agreed in writing in a contract or agreement pertaining to "your work" performed during the policy period. This additional insured coverage does not apply to "excluded residential construction". "Excluded residential construction" means: a) the ground -up construction of any building whose units will be individually owned and titled; and, b) "your work" performed on the conversion of any building into a condominium or townhome. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ Campbell Finance beparment Licen:e tvo. 0 N <—_ 70 NOrth Nut Streot — Campholl, CA 950a8 SICJC ,tssod (408) 866=1174 - FLA a' FEE: $96.00 CITY O1' CAWBELL X `"ERiSHr h l�-PI,TCATIGN FOR AN oti7' o , T.!Dw � I , rill queallogs or( [his form trust be a7t,ve-re'd o? alr_ lgaamd nal applicable ;(v.�rt), ar 7.. Addltionk] infot Wdott mtty t,,% requirrd pursuant, tc C;ity of Campbell I'll]'! ti. -t.- Applicants are req,-"red to declare, unuzr penalty' X per,''�ry, that the statements made h©rt'n 9r: true. 4. In order to comply with requ'u meats Of the ' :;.s�trol;e�'s OffiOffice undtr Revenue & T-r, C ode Sec MKS, business licenses i.Rnnot bs icsurd without this .;tforninun, INFO MUM 1, BVSINESS NAME. ~ L71 0 iM�� ;S n, BUSINf.SS ADDRESS; � Y� fjvfm: ery ($r:ea:J Nulr;r,rp: f rcljyJ f9d(r) f7w 3. MAILING ADDRESS: _ (((,1111e:rr„r frv,�., NhuprJ _ (%r/mr•�+C!/ (S/rytrl T (.u.(rr �lp(•�J � (('ruv �-'�'�� f�+ulc,� .. l�tAt ..--,--'- 4. BUSINF,5S TELEPHONE NUMBER: �35. nItIV )t'$ LIC:EKSF. N:�.619 5. FED EMPLOYER IP �': � �. 7 SOCIAIr SECURITY �'�� ti. STATE�ntP[rCtYE]a ID �F �.v� fi. Rt;TAiG SAi.1;'4 7-A:Y F!: 7O%Vh'M.SNAtv1Et k�C�G. _ f-tO-CAando, Z- _11.OUtvEW1' PH0NEN0jACrj (Jdh,rled J,S GIiBhrdL'Y.f S.OWNER'$AVDRESSt (Numb«! (.S(rrrvJ 9. ri'PE ()F OivN[ RSHIf (C.hack one); Note Proprietorship [ ] Parincrshlp [ j Corpurxtlon j) TcuAt () LLC 10. rs'P1; OF BLIS)IVR59 (Bc Sptclflc):_C) r� i t,CON rRACTOR STATE LICENSE NU?VffjER; �� � j irtASS: 1•! ��Expiratictt Y Vtriticd. EVLARATION f DECLARE UNt)ER PENAI,TV OI: PERJURY that the foregoing is�trru�e a id cormaot und.]IcalInd cs,,isvrtnae& I_o)uld cunlpc knt)y:testify to the thcts contAined herein. P.xeeuted this i-Say or�. t " 70117iq ;he Tgwu/City of / -- - -- i a„rtty of . •�(_, Stntc of_yl ; _ _. /• rn��ot c•�"'t - —• FOR OFFICE USE ONLY: Receipt # State .ADA Fet S_,_,_Lo —, Amt• Paid- l3ustnas.K Lio,1'tur;�•_ x, 95.t7G 'i'ortl: S 96A0 Date Paid: � A _ tJ I 7 / w 1 / w v^• w w w w PARKSTRIP w w w / MECHANICAL SEPARATOR CONSTRUCTION / JOINT SIDEWALK SEE NOTE 5 WEAKENED w PLANE JOINT w w OR CUT JOINT 1 /8" WIDE, 0 2 DEEP w w w tj' 2 WEAKENED RLANEw JOINT w p OR DCUT EEP"" JOINT 1 /8"'Llw WIDE 1 w w w 3/4" PER FOOT 5/8„ Q 1"R _1 /2' R 5a-0" 2a—On 6.. +10% MAX CONFORM�SLOPE = 2.0% fj 6" CLASS A CONCRETE, TYP. ` ' :. °. 6" 6" CLASS 2 AGGREGATE BASE, T'+P. NOTES SECTION A -A DOWEL 1. WHEN THE DRIVEWAY IS NOT POURED AT T i°ic SAME TIME AS THE CURB AND GUTTER, 12" OF NO. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (RE[, ARS TO BE BENT DOWN AND COVERED UNTIL USED;. 2. SCORE MARKS SHALL NOT EXCEED 4'-0" '0,'.., AND USE MECHANICAL SEPARATOR' AT EVENY OT iER .SCORE i i,". K. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. ag C A jp CITY OF CAMPBELL REV. DATE BY SCALE PUBLIC WORKS DEPARTMENT 1 02/17 HE Residential N.T.S. nR®irx BY: EA DATE 02/04 Driveway Detail DETAIL • qa°j`" CHECKED BY: DAi (Detached Sidewalk ) NO. A�� GtiR'� APPROVED BY: �kese� C1T Y 01LAYER J:/Drawings/Std_Details/D14.2 ID-14.2 REMOVE EXISTING AC SECTION AND BASE (12" MIN) REPLACE AS SHOWN NEW PCC IMPROVEMENTS CUPM, QUTTER, DrIVEWAY —� 1211 APPROACH OR ACCESSIBILITY RAMP U&4- DONVELEXISTING WITH ##44 REBAR,6 IMPROVEMENTS l--I 11=t 11-1 f 1=1 6" CLASS 2 AGGREGATE BASE (95% RELLATIVE COMPACTION) MOTE: REMOVE EXISTING PAVEMENT FULL DEPTH TO CLEAN, STRAIGHT EDGE GRIND 2" DEEP PAVEMENT KEY TYPE A I/2" MAX MED AC (95% COMPACTION) 911 - 12" EXISTING PAVEMENT TO REMAIN I (I 10" MIN 2 SACK SAND/CEMENT SLURRY BACKFILL, 2 SACK CEMENT PER CUBIC YARD OF MATERIAL COMPACTED NATIVE NOTE: APPLY TACK OIL TO ALL (95% RELATIVE COMPACTION) SURFACES PRIOR TO PLACING NEW A.C. cA J`A�� A.C. PAVEMENT REMOVAL & RESTORATION DRAWN BY: DETAIL • CHECKED BY: AT NEW PCC IMPROVEMENTS A-3 eoAo$1R9 c APPROVED BY: J:IDPA.WINC3S\STD DETAILS%A-3