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ENC2017-00073 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00073 Name: John Kim Property Address: 221 cherry Lane Date of Final Inspection: On File: Bonds CD Cash Labor and Material: $ Construction Cash De sit to be released: $ Faithful Securit eposit: Other overd deposits to be released (Description): 1 Processed by: L—)Administrator l Reviewed by: 1 2,8 j I `r I Inspector Reviewed by: Land Development Engineer J:VoAnnaT\Deposit refunds\CHECKLISTS\Cherry 22LENCpermit.doc(Rev. 10/11) Print Foim CITY OF CAMPBELL ENCROACHMENT PERMIT Permit Nol� � I DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date Campbell,CA 95008 `b Y^ Application Expiration Date Ph. (408)866-2150 Issued < 0 I 1 Fx. (408)376-0958 APN Permit Expiration Date APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04. (Application expires in six (6) months if the permit is not issued. Application'Fee is non-refundable.) A. Work Address or Tract No.: Utility Trench Location: r B. Nature of Work: C. Attach four(4)copies of an engineered plain showing the location and extent ofthe work,and four(4)copies of the 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 ofthis 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 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 starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Telephone: Address: 68 0­31. -Lan -2..... E-Mail Address: I 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 dernand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have-read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all Jdamages arising out of improvements complet d in th ublic i t of way. Accepted: (Applicant Permittee) (sign) Date (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be 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 t6the Public Works Department before starting work. —N,�'4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT 2' p� RECEIPT NO. PERMIT APPLICATION FEE $ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ 3 �.7[,�tFU OI EMERGENCY PERMIT FEE $ ` 1 APPROVED FOR ISSUANCE For ity Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained for the duration of the permit work. 2. A Construction Cash Deposit is required. Charges 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 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. 29. Call back(call out)due to emeregencies 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 otherthan 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. 32. Permitttee 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 phone number. Applicant is hereby responsible or-L1 surin hat all those providing services under the applicant are aware of and abide by all of the above conditions. (ZA Applicant Date: ,\era Mo XbPe, Contractor (Print Name) Date: JAFORMS\Templates\Encroachment Perm its\Encroach ment Permit STATICform2.pdf Rev.05/14 1 f \ PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 21016 TO: Finance PIJ13LIC WORKS FILE NO. Rao 000-�3- PROPERTY ADDRESS Please collect& recei "t for the following monies: ACCT {A, i a } ••• 7i IT .1m pr. ,gre, g ` ,Y x*e N r urc ina t:S 1�*&�"�sa (�bs z x F n za�. ENC�tt?ACI'MENT,PER,'M!T, �' I t lur ItA31 � ... , u 4722 Utility Encroachment Permit Application Fee $434.00 R-1 Encroachment Permit IV/C Emergency Permits $122.00 t Plan Check&Inspection Fee Minimum Charge Per Location $398.00 Conduits/Pipelines up to 500 Feet $2.81/ft Above 500 Linear Feet $1.68/ft Manholes/Vaults/Etc. $179.00/ea Pole Set/Removal 1 $179.00/ea 4760 Storage Container Permit(valid up to 60 days only) $163.00 4760 Project Plans&Specifications Project No. 4760 Standard Specifications&Details $1/Pg$15.50/Bk 4760 Engineering Maps&Plans Aerial Plot 24"x 36" $63.00 Aerial Print 8 1/2"x 11" $31.00 -Map Research(includes max of two 24"x36"copies) $31.00 Maps and Plans 24"x 36" $15.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day(Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4722 Work Without Permits 4 Times Applicable Fee U 1. °p ,1 ap r,IP. TRAF.F C � M n 150, 4728 Traffic Flow Map(Daily Traffic Volumes) $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISOELLANE�JUS 5 " aaa .Nt s at s aE a F,. i,r» a 511.74241 Postage Other(Please Specify) _ TOTAL _ NAME OF APPLICANT )� Xel NAME OF PAYOR PHONE ADDRESS 0XIM11, j ZIP ratio alf 4n d {;xR? + F axe a7; s r3 a �� ° i� ,r�CCa -iB` � +axtn iy W i�aI qa4 &a 'E di kfi f,r. FOR IRECEli�E> Y CITY � - Es �w:YJ ,o; � h,_V ONLY n 7 , f 4 _ a.,a a Iik I�Cn e^.''Ero ap - d7 1ni Ian NOd X 1 c9: � *`� „1 , s p, J:IFORMS\Templates\4dministrative\Receipt Form Utility Encroachment&Misc 16-17.xis \ CITY OF GM §PE [[ 3N FIRST£ aae� Ra� nnn CITY 7 CAMPBELL +q§ BY: 9kla 0100268449 e»G! !mR TOM TODAY': DATE: 03Z9Q7 Rg#S DATE- pG S TIME: m;Q DESCRIPTION UmR eqI S;ate% mq3 AmamG& FILING k7.05 m# D: 1.006 gGam»w FILING gm.m TOTAL TOG 02.00 TENDERED: q£.m mA7; «m . CREDIT QU; $TOG m . «F TOW �A�R CERTIFICATE OF LIABILITY INSURANCE DATE(MM(DD/YYM4i2,i201, THIS CE i FICA ' IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIF ATE ES NOT.AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO THI; CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING-INSURER($), AUTHORIZED REP ! SENT VE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPO` If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Leslie Brown NAME: Moore & Miller Insurance PHONE. (831)462-6900 x108 a�c No:(831)462-3884 3333 Soquel Drive ADDRE E-MAIL SS::LeSlie@mooremiller.com INSU S AFFORDING COVERAGE NAIC# Soquel CA 95073 INSURERA:f—ini Insurance Co. INSURED INSURER B Nationwide Mutual Insurance Cc 23187 Mello Pipelines, Inc. INSURERC:State Compensation Insurance Fluid 2 60 McGlIncey Lane INSURER D American Contractors Indemnity INSURER E: J Campbell CA 95008 1 INSURER F: COVERAGES CERTIFICATE NUMBER;CL1733007885 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER MIDD mwnpryyyyj LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g 1,000,000 A CLAIMS-MADE �OCCUR E I To C D occurrence $ 50,000 P EMI E.Ea X Contractual Liability X VCGB022066 12/1/2016 12/1/2017 MEDEXP(AM one person) $ 5,000 PERSONALBADVINJURY $ 1,000,000 GE_N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $' 2,000,000 POLICY F jECT F LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: I $ AUTOMOBILE LIABILITY COMMUNaccident)SI NGLE LIMITMe $ 1,000,000 B ANY AUTO BODILY INJURY(Perperson) $ ALL AUTOS OWNED X AUTOSULED ACP7854805179 12/1/2016 12/1/2017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS _ Peraccident $ UMBRELLA L1AB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAII&MADE AGGREGATE S DEC) I I RETENTIONS $ WORKERS P COMPENSATION X R OTH- AND EMPLOYERS'LIABILITY YIN STA ER ANY PROPRIETORIPARTNER/E(ECUTIVE E.L.EACH ACCIDENT $ 1 000 )00 OFFICER/MEMBER EXCLUDED? N I A C (Mandatory In NH) 909655516 8/1/2016 EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below - EL DISEASE-POLICY LIMIT $ 11000,000 D Contractor's License Bond 9055069R2014 8/9/2016 .8/9/2017 $15,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddWonal Remarks Schedule,may be attached if mom space is required) - - The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured with respect to liability arising out of autos owned, leased hired or borrowed. This insurance is primary. There will be ten (10) days notice of cancellation for non payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION; DATE THEREOF, NOTICE WILL BE DELIVERED IN 70 North First Street ACCORDANCE WITH THE POLICY PROVISIONS. Campbell, CA 95008 - AUTHORIZED REPRESENTATIVE Leslie Brown/LB ©4988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 i2ouniv a Policy:VCGP022066 CG 20 0104 13 Insured Name:MEMO PIrELINES INC Number:1.4 THIS ENDORSEMENT CHANGES THE POLICY,PLEASE READ IT CARMLLY. PRIMARY NONCONTRIEBUTORY-- = .OTHER INSURANCE CONDITION . = This endorsement modifies insurance provided under the followiing: Commercial General Liability Coverage Part The following is added.to the Other Insurance Condition and supersedes any provision to the contrary: , Primary And.Noncontribato_ry,lusurance Tbis insurance is primary, to and will not-seek contributions from any other insurance available-to an additional-insure under your policy provided that: (i) The additional insured-is aNamed Insured under such other insurance;and (2) You have agreed.in writutg in a contract or agreement that this insurance would be-primary-aad would slot seek contribution fir any other insurance available to the additional.insured. CO 20 0104 13. l of 1 Policy:VCGP022666 CG-2033..0413 Insured Dame:MIELLO PIPELLNES LNI C Number:15 THIS EIDGRSFWNT CHANGES THE POLICY.PLEASKREAD IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED CONSTRUCTION AGREEMENT WITH.YOU This endorsement modifies insurance provided under the following: Commercial General Liability Coverage Part A. Section 11—Who Is An Insured is amended to include as an additional insured any person or organization for whom you are perfonning.operations when you and such person-or organization have agreed in writing`in a contractor .. agreement that such person or organization be added as an additional insured on your policy.Such persom or organization is an additional insured only with respect to liability for"bodily injury","property damage"or"personal and advertising injury"caused,in whole or in part,by: - 1, Your acts or omissions;or 2. The acts or omissions of those acting on your behalf; in the performance ofyour 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. w.ill'not be broader than that which you are required by the contractor agreement to-provide for-such additional insured. A persons or organisation`s status as an additional insured underthis endorsement ends when your operations.forthat additional insured are completed. B. with respect to the insurance afforded to these additional insureds,the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury","property damage"or".personal and advertising injury"arising out of the rendering of,or the failure to render,any professional architectural,engineering or surveying services,including: a. The preparing;approving,or failing to prepare or approve;maps,-shop drawings,opinions,reports,surveys,field orders,change orders or drawings and specifications;or b. Supervisory,inspection,architectural or engineering activities. This exclusion applies even ifthe 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.in or"property damage",or the offense which caused the"personal and advertising injury";involved-ibe 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 equipment furnished tit connection with suchwork,on the project(other than service,maintenance or repairs)to be performed by or on behalf ofthe additional insured(g)at the location of the covered operations has been completed;.or b, That portion of"your work"out of which the injury or damage arise.$has=been put to its intended use by:any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project - CG 20 33 0413 1 of 2 - C. With respect to the insurance afforded to these additional insureds,the following is added to Section II —Limits Of. Insurance: The•mostwe will pay-on behalf of the additional insured is the amount ofinsurance: I. Required by the contract or 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 Deblaratioas. CO 20 33 04 13 2 of 2 Policy:VCGPO22068 - CG 20 37 04 13 Insured Name*MELLO PIPELINES INC Number:16 THIS E t ENDORSEMENT CHANGES THE POLICY. PLEASE READ m IT.CAREFULLY. ADDITIONAL INSURED -' OW HERS, LESSJEES OR CONTRACTORS o COMPLETED OPERATIONS. This endorsement modifies insuiaiioe provided under the following:. Commercial General Liability Coverage Part SCHEDULE Plante Of Additional Insured Person(s) Or O anizatiori s Location And-Descrl on Of Corn-feted C3 orations For non-residential and non-mixed use For non-residential and-non-mixed:use projects only. Any person.or organization . projects oniy. All locations for which yau.and when you-and such person or organization the additional insured-have agreed in vMting have agreed in-writing in.a contract, prior to in a-contract prior to an occurrence that an-.ocqurrence that causes"Bodily Injury", causes"Bodily Injury", "Property Damage"or 'Property D!3mage"or"Personal and "Personal and.Adverlising.Ir jury"Z Advertising Injury",that such person or = organization be added as an.additionai insured on.your ppticy> Information required to complete this Schedule,if not shown above,will.be shown in the Declarations.. A. Section It—Who Is An Insured is amender to include as an additional insured the person(s)or brganization(s)shown in the Schedule,but only with respect to liability for"bodily injury"or"propettjr damage". caused,in whole or in-part;by"your vroW"at the location-designated and described-in the Sche.duWoftbis endorsement performed for that additional insured and.included in the"products=completed operations hazard„ However 1. 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-insuranee afforded to such additional insured will not be broader than that which you-are required bythe caoritractor. agreement to provide for such additional insured. 13._With respect to-the insurance afforded to these additional insureds,the following is added to Section III Limits Of insurance: If coverage provided to the additional insured is required by a contract or agreement:the-nosteiipyuwa oil behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement;or - 2. Available under the applicable.Limits of Insurance shown in the Deal arations; whichever is less: CG 20 37 0413 1 of 1 IN 52 23 0310 IMPORTANT INSURANCE INFORMATION Please read this Notice carefully. No coverage is provided by this notice nor can it be construed to replace any provision of your policy. You should read your policy and review your declarations page for complete information on the coverages you are provided.If there is any conflict between the policy and this notice,the provisions of the policy shall prevail. BUSINESS AUTO ADVANTAGE ENDORSEMENT ® • Our Business Auto Advantage Endorsement Form has been included as a part of your policy. This endorsement broadens your coverage in a number of areas. Here is a summary of the provisions included in the form with a comparison to the base coverage form CA0001 � es�i� az tt# $ 5r�r "d.. £r y. g''.` � z�'s: -1 s� -t-�F �..,� ,- - tom' _-.:•<xr uy+"06 `^ NNW 1... „_r ,y'?. .. ';,.;� :,. >, —, . I zV F. i��. �..F. ,. >.:u.zr ;.t. ....x ' ,.Q�~ ,.. Newly Acquired or No automatic coverage for new entities. Coverage for newly acquired or formed Formed Entities entities for 180 days or until the end of the policy period,whichever is later. Temporary Substitute Coverage for temporary substitutes Coverage for temporary substitutes Autos—Physical provided for Liability. provided for both Liability and Physical Damage Damage. Employees As An employee is not considered an insured Equivalent coverage to CA9933— Insureds while driving a vehicle he or she owns employee provided excess coverage while unless endorsement CA9933 is added to driving a vehicle he or she owns. the policy which provides excess coverage. Supplementary Up to$2,000 limit. Up to$2,500 limit Payments—Bail Bonds Supplementary Up to$250 per day. Up to$500 per day. Payments—Loss of Earnin s Fellow Employee Coverage is excluded for bodily injury to a Fellow employee exclusion does not fellow employee. apply to an"insured"who occupies a position as an officer, manager,or supervisor. Personal Effects of No coverage. Up to$250 of coverage for property of Insured and Property others.in Care,Custody or Control. of Others Up to$500 of coverage for your property that is lost or damaged as a result of a covered"toss",with no deductible. Hired Auto Physical For an additional premium,coverage can Coverage is provided for leased,hired, Damage be provided for leased or rented vehicles. rented or borrowed vehicles with no limit if hired auto Liability Coverage is provided. The deductible applied will be equal to the largest deductible applicable to any owned auto. Towing Coverage For additional premium,coverage can be Coverage is provided for$100 for private provided for up to$50 for private passenger type and for$250 for other passenger type autos. than private passenger type if vehicle has Comprehensive or Specified Causes of Loss Coverage and Collision Coverages. IN 52 23 0310 Page 1 of 2 ACP BA 7MA805179 L19T 15301 INSURED COPY IN5223031000 0001 78 0028056 IN52 23 03 10 Layygq ��� Ly a� yyL J>i,x.ak„s`L,..y, RRitt �,_:j.^, -.,.v+.�;.�'. ?s ,«..r..,. :.•r:....... iR/Ysb .,.-,,-..--'� ... .,-.z., ,..,.. ...,_ � .-.v.zf_ - Auto Loan or Lease For additional premium,coverage can be In the event of total loss which is covered Coverage provided with endorsementAC2071. under Comprehensive,Specified Causes of Loss,or Collision,we will also pay any unpaid amount due on the loan or lease plus additional miscellaneous expenses. Rental For additional premium,coverage can be For a vehicle which is covered for Physical Reimbursement provided by endorsementCA9923. Damage Coverage we will pay for rental Coverage reimbursement expenses with a limit of $75 per day for a maximum of 30 days unless coverage is provided by endorsement form CA9923. Extended Coverage provided for up to$20 per day Coverage provided for up to$50 per day Transportation to a maximum of$600 for total theft of to a maximum of$1,000 for total theft of Expense private passenger type autos if private passenger type autos if Comprehensive or Specified Causes of Comprehensive or Specified Causes of Loss are provided. Loss are provided. Extra Expense— No coverage provided. Up to$5,000 for the expense of returning Stolen Autos a stolen covered'auto"to you if Comprehensive or Specified Causes of Loss Coverage are provided. New Vehicle Coverage is provided on an actual cash In the event of a total loss, replacement Replacement Cost value basis. cost(no depreciation)applies to a private passenger type vehicle or a vehicle with a gross vehicle weight of 20,000 pounds or less which is less than one year old. Blanket Waiver of No person or organization can do anything We waive any right of recovery we may Subrogation to impair our rights of subrogation after have against any person or organization to accident or toss. the extent required of you by a written contract executed prior to an accident. Page 2 of 2 IN 52 23 0310 ACP BA 78-54805179 LIST 15301 INSURED COPY IN5223031000 0001 78 0028057 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: JOB DESCRIPTION: City of Campbell,70 North First St., Campbell CA 95008 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.) Insured: Mello Pipelines, Inc. Insurance Company: SCIF., Policy No.909655516 -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999. INSURANCE REQUIREMENTS CHECKLIST Permit# e/Q CIP Project# The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: 5zC-$1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or ❑ $2,000,000 general aggregate limit. Y Policy expiration date Z l Automotive Liability: -0 S "Any Auto" checked on certificate -lea— $1,000,000 per accident for bodily injury and property damage Policy expiration date 1Zf ' k1 Workers' Compensation and Employer's Liability Waiver of Subrogation clause - _$1,000,000 per accident for bodily injury or disease Policy expiration date c61 lQ Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement(Description of Operations Area) The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) 3 The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: 176'Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\)oannat\Desktop\Insurance Requirements Checklist.doc (Rev 03/13) Page 1 of 2 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: G,e Y NNAIC�# Rating:i X" Authorized in CA: Name: l en`��O�WyLie ;My�"NAIL# _Z3_740Rating: Y Authorized in CA. Name: ;'j NAIC# Rating: Authorized in CA: Name: NAIC# / ' Rating: Authorized in CA: Campbell Business License# Expiration: p Contractors License # S Class: Expiration: J 3< « Insurance Certificate Reviewed (K fT Init Is 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