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ENC2017-00096 . Print-Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No � DEPT.OFPUBLICWORKS (for workingwithin the public X-Ref. Filed 70 North First Street r'ght-o-way) Application Date �( Campbell,CA 95008 (� ' Application Expiration Dateltqt� rt< Ph.(408)866-2150 Issued i APN Z`�J� n�� Fx. (408)376-0958 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 neon-refundable.) {+ A. Work Address or Tract No.: ,A V ( �yy►QhZ�� , ��T Utility Trench Location: B. NatureofWork: ................._._ .._-........- C. Attach four(4)copies ofan engineered plan showing the location and xtentofthework,and four(4)copies ofthe preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part of this permit. D. All workshall conform tothe CityofCampbell Standard Specifications and Detallsfor PublicWorks 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 begiven to Public Works at least 24 hours before restarting anywork. Name of Applicant: �Qelephone: . �c .�� j )�hrY-� Inc.nc ' _ _ « __ _ ._......_ Address: !� Q, .._... '.._.5.1�'� t. ��1.....5� t�....... ....... q.�:1..1� .._.__,._............... ... E-MailAddress: 24-HOUR EMERGENCY PHONE NUMBER: 79 Is this work being done by the property owners at their own residence? ❑YES NO ilrp l The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit roperty owner, or property owner's successors, shall be responsible for any and all damages ari/sing out of improvements complete RA pu_U* -of-way. ✓ a' >/ l Accepted: 1r�/� (Applicant Permittee) (sign) Date (Contractor) (Print Name) Date SPECIAL PROVISIONS: ❑ 1. Street shall not be open cutfor underground installations.Minimum cuts maybe allowed for connections or exploration holes.Suchcutsmaybe specifically approved by the Inspector prior to cutting. ❑ 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. ❑ 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department before starting work. ❑ 4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET 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 RECEIPT NQ. 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 / For City Engineer D to Permit Expires 12 Months After Date of Issuance f 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 http://www.waterboards.ca.goy/water issues/programs/npdes/utilityvaults.shtml for more information. Applicant is hereby responsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. Applicant Date: �-- Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit STATIC form2.pdf Rev.03/17 PUBLIC WORKS-DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective Jully 1, 2016 TO: Finance \ n( PUBLIC WORKS FILE NO. PROPERTY ADDRESS Please collect & receipt for the following monies: •.ITIE�NIi , s e,A C9111�T ENCRQ/ICIi� 8NT.PER 1�IT. .,, , ,,,, $F4 ,e x { p F 1 1. ..: €w x 3 x A Y 4722 Utility Encroachment Permit Application Fee $434.00 —00 R-1 Encroachment Permit N/C _ Emergency Permits $122.00 Plan Check& Inspection Fee Minimum Charge Per Location $:398.00 _ � Q Conduits/Pipelines up to 500 Feet $2.81/ft Above 500 Linear Feet $1.68/ft Manholes/Vaults/Etc. $179.00/e:a Pole Set/Removal $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/l3k 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 Cade Sec.11.34.010) 4722 Penalties: Failure to correct unsafe conditions $1o0/Calendar Day 4722 Work Without Permits 4 Times applicable Fee TR,4FRIC n5a l,+ a y h dal 4"; : N . . (,:pAi.aw.xry^»-�d•'llrv„qA. .t 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 MISCELL`ANEt 511.74241 Postage _ Other(Please Specify) TOTAL NAME OF APPLICANT NAME OF PAYOR 'n (( k F� c, PHONE � 9& ADDRESS S. Jo� ZIP t;M \ ffi' ?'i3 b_ FOR RECEIVE BY CITY CLERK ONLY71, D1tL' ( t r a le 1 ,. t CANWbELL J:\FORMS\TemplatesWtlministrative\Receipt Form Utility Encroachment&Misc 16-17.xls Proposed Gas Line I 2210 S. BASCOM AVE. 6 Ft. Existing PG&E Gas Line I CAM PBELL CA 95008 6'X 4'x 18" Pot Hole 51 Ft. Sidewalk 10' Wide S. BASCOM AVE. NOTES: PG&E gas line is 2 ft.from the edge of sidewalk. TrenchFree will not need to close the sidewalk.Safety Fencing will be used to block off work area. Proposed Gas Line 2210 S. BASCOM AVE. 6 Ft. Existing PG&E Gas Line I CAM PBELL CA 95008 6'X4'x18" Pot Hole 51 Ft. Sidewalk 10" Wide S. BASCOM AVE. NOTES: PG&E gas line is 2 ft.from the edge of sidewalk. TrenchFree will not need to close the sidewalk.Safety Fencing will be used to block off work area. Proposed Gas Line I 2210 S. BASCOM AVE.- 6 Ft. Existing PG&E Gas Line I CA M P B E LL CA 95008 - 6'X 4'x 18" Pot Hole 51 Ft. Sidewalk 10" Wide S. BASCOM AVE. NOTES: PG&E gas line is 2 ft. from the edge of sidewalk. TrenchFree will not need to close the sidewalk. Safety Fencing will be used to block off work area. Pacde Gas&Eleatrie Company ❑Special Facilities ❑(CP 1OW) ❑Existing(10%r) servcee Rena GAS SERVICE RECORD DIas,L ;an:❑1 ❑2 03 04 No..of Floors 1D=9500P-14—FD1 e Agreement Map Na. 3412 Nam. 110097764 PM Order Na 31164554 Led:No. SO.No.—,— Verbal Plat No. 17 Block 56 City 2210 S BASCOM AVE Address 2210 S. BASCOM AVE ®Written Appilcant/rmet Name MASATC QU MIFHARA Lot No. Est LAN 1D RRSS pate issued t t/19/2015 ❑PROPOSED ®EXISTING FACILRY: MAOP 60 PSG/ Man Trench Occupants: Pasted By Mapping Inserted®No ® None �I— OFF:®Hain 27 HP ❑PE®STL❑A1dyl—A in' ❑Yes Cadng size&material: ' ❑Electric ❑service S10 a Preen ❑CI [ICU Cosing❑Double Casing size&matmtah ❑Telephone h Ong Side S BASCOM AVE In Out_� ❑ CAN ❑ Other Date —/— ®PROPOSED ❑EXISTING SERVICE LOCATION: Insert ®No [--]Yes ❑Double JOB TYPE service Ong Sales BASCOM AVE, 123' SIQ APRICOT Casing size&material: NEW SERVICE She 1. ®PE2406 ❑PE3408 ❑Aldyl—A ❑STL ❑L1X Casing size&material: ❑SiUB SERVICE ❑STUB COMPLETION•• SVC Trench Ocaap'hed With ❑BRANCH SERHCE Rlser. She� 4 ❑Inside-00utside❑W/Byposs Curb Volvo: REF.N0. Pre—Fab Non—Corrodible ®Regidar❑Short []Long ❑Metal ❑PL ®None ®None ❑Electric ❑Phone ❑we METER ®Sted Encased—Plastic Insert ❑Steil Riser r ❑CU Riser ❑CATV ❑0thr ❑METER CI NLE MANIFOLD— No.of Outlets 1 Res.Me s Qt. e 1 00 R She e 3 4' 181392 Orifice 3 ❑ Meter(s) y/sh L� Req.Size/Type: L ltrz-- ❑t�NVEr:r TO MAIN Comm Meter(s)Qty./Su Madtor Sue/Type OrrFicsC ❑UPRATEREPLACEMENT C/O Data Ft of In. Yr.nstdl Type ❑SR ❑PL ❑CU Reason: ❑Leakage ❑Other ❑PARTIAL Transfer From Mon On Side in Out 0 COMPLETE ❑iRANSFER Instructions&Cautions ❑ALTER/INSPECTION EXCAVATED BY: PG&E APPLICANT INSTALLED BY: PG&E APPLICANT BORE; OYES ®NO ❑ ❑AT MAIN FRANCHISE/STUB ® ❑ FRANCHISE/MB ® ❑ Remarks ❑AT P/L PRIVATE/COMPLETION ® ❑ PRIVATE/COMPLETION ® ❑ 1 1 ❑AT BRANCH •DATE STUB INSTALLED Foreman LAN ID_Signature WORT(DONE (Show corrections ❑OTHER ❑Electronic Marker installed to service and main data above) Tatd load 1108 SCFH MANUFACTURER DATE MANUFACTURED—// FL Main to PA Pressure 25 -DATE COMPLETED._/^/— Foreman LAN ID_Signature Ft PA to End of Stub TB� MANUFACTURER DATE MANUFACTURED—%/— _r ToFt.alEFt nd of Stub to Rttr Elewtlon TEST DATA: (Per Na Doc.A-34) ❑Soap Test WELDING INSPECTION EFV Brand PERFECTION STUB PSIG for Minutes Appea.Do of main PER PG&E No. Doc. D-40 Connection TWO PERMASERT Foreman LAN ID_Sghatum Date�� sbeum. Flow Shies HIGH FLOW 1800 COMPLETION—PSIG for Minutes Aopo<•Doth dEs Svc•. hM a Material: ®Plastic ❑sted Foreman LAN ID_9gnature Date For services operating math an MACP above 60 PSG, —Depth of n.. Size❑1/2' ❑3/4' 01' ❑1-1/4' ❑2' attach a copy of the Strength Test Pressure Report RISER VALVE MFG: N/A Reason: CATHODIC PROTECTION: CPA Na 3412-29 GALVANIC CP SYSTEMS LOCATING WIRE CONNECTIONS SVC Were Size Main under protection ®YES ❑NO ❑RISER Readmg Date—/—/ TERM.AT.®MAIN ❑WtAt4CH TE U AT: ®RISER ❑SVC Instal cathodic protection(Pr No.Doc D-16) 0� Reading Date—/—/ ®Bonded ❑Banded ®Exciting ❑New Na metalled_ ❑MAINReading Dote—/_./ ❑Wrapped around'Tee ®Strapped to R'hsr Sirs Lb.Mode Typo ❑NAG ❑21NC anwAeE„ratjw,swaiwo s[.ao ❑N/A ❑N/Ainated Slitcih Notes lazk LOAD-1.108 MCFH PM 31164554 a MAP 3412-17 //tom CPA 3412-29 (a D 60 PSIG SDp 08-51-C APRICOT AVE. cAMPBELL PA NORTH 4 618'MON GAS-WE v BELL 01 BY PQE 01'x 3/4'NC116tR PG&E NOTES _ BY PGdE - PG&E TO INSTALL PIPE - PG&E TO TRENCH AND BACKFILL ALL PA N #2210 PG&E MATERIALS: S.BASCOY AVE, - 3/4'x1' STL TO PL SVC TEE- 020928 - 50'1'PL PIPE- 01BOW - 70' OF#10 LOCATING WIRE-294414 - (1) 1'X 3/4,NC RISER- 041062 L,, l _ I — 1 3/4"SVC VALVE- 447596 > - 1 1 HIGH FLOW 1800 EFV- 020956 a --------------- - v r PL SVC DB 5 TRASH ENCLOSURE O se N rn�.t a er cavomws STAMP Q 120' per►.a.v.. m pwrx h a auwmm C Am.n panne mPPwme a..x+..M t/T ❑axw w RPM I ❑rrwmx puawmm ❑anax DA T E(MMDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4/4/2017 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 NEACT Cheryl Trusler HUB Int'I-CAL Bronson AMPHONE 916-480-4171 F"X 916-993-7271 3636 American River Drive rttt A/c "° Suite 200 E'N�IL .Cheryl.Truster@hubinternational.com Sacramento CA 95864 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Ironshore Specialty Company 25445 INSURED JDPLUMB-02 INSURERB:Natlonal Union Fire Insurance Co Trenchfree INSURER C:Cypress Insurance Company 10855 P.O. Box U San Jose CA 95111 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1727282559 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DDIYYFF MM DD/Y POLICY P LIMITS A X COMMERCIAL GENERAL LIABILITY Y AGS0078402 9/25/2016 9/25/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X❑ OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY I 7X PRO- JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$ Ea accident ANY AUTO BODILY INJURY(Per person) j$ !AUTOS OWNED SCHEDULED BODILY INJURY(Per $ ,AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED - PROPERTY DAMAGE $ AUTOS Per accident $ B UMBRELLA LIAB X OCCUR EBU017149450 3/2/2017 9/25/2017 EACH OCCURRENCE I$3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE I$3,000,000 I DED RETENTION$ is C WORKERS COMPENSATION y JDWC704207 4130/2016 4/30/2017 X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICEWMEMBER EXCLUDED? ❑ N!A (Mandatory in NH) E.L.DISEASE-EA EMPLOYER$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 ---—L] DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Work performed by the named insured under written contract for the certificate holder. Additional Insured: City of Campbell,its officers,employees and volunteers where required by written contract. Waiver of Subrogation in favor of City of Campbell, its officers,employees and volunteers where required by written contract. Form: CG2010 0413,WC990410B Z 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 N.First St. ACCORDANCE WITH THE POLICY PROVISIONS. Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER:AGS0078402 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES CAR CONTRACTORS -- SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations As required by written contract. If required by your Any Location agreement with such Additional Insured. Additional Insureds shown in a written contract, or written agreement that includes primary and non-contributory wording where required. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insurance will apply as outlined in SECTION IV — COMMERICAL LIABILITY CONDITIONS, paragraph 4. Other Insurance,subparagraph c. Method of Sharing. The inclusion of one or more Insured(s) under the terms of this endorsement does not increase our limits of liability. All other terms and conditions remain unchanged Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section li — Who Is An Insured is amended to 1. The insurance afforded to such additional include as an additional insured the person(s) or insured only applies to the extent permitted by organization(s) shown in the Schedule, but only law; and with respect to liability for"bodily injury", "property 2. If coverage provided to the additional insured is damage "personal personal and advertising injury required by a contract or agreement, the caused,in whole or in part, by: insurance afforded to such additional insured 1. Your acts or omissions; or will not be broader than that which you are 2. The acts or omissions of those acting on your required by the contract or agreement to behalf; provide for such additional insured. in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However, CG 2010 0413 ©Insurance Services Office, Inc.,2012 Page 1 of 2 fA ti B: With respect to the insurance.afforded to these 2. Available under the applicable Limits of additional insureds, the following additional Insurance shown in the Declarations; exclusions apply: whichever is less. This insurance does not apply to "bodily.injury" or This endorsement shall not increase the "property damage"occurring after: applicable Limits of Insurance shown in the 1. All work, including materials, parts or Declarations. equipment 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 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. C. 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 most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 @ Insurance Services Office, Inc.,2012 CG 2010 04 13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 990410B (Ed.A44) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS VVe 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 nr organization nmmodintheGobedu|e. (Tmaogreementapp|iouon|yuothuaxtont that you perform work under awritten contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be 2%of the total manual premium otherwise due on such remuneration. The minimum premium for this endorsement\o $35O. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE BLANKET WAIVER Person/Organization Blanket Waiver—Any person o,organization for whom the Named Insured has agreed by written contract*o furnish this waiver. Job Description Waiver Premium All CAOperations 2281.00 This endorsement changes the policy 10 which it is attached and is effective cm the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent mo preparation ov the pnncp) Endorsement Effective 04/302016 Policy No. JDVVC704207 Endorsement No. Premium|no�no� Insurance Company Cypress Insurance Company Countersigned by WC 9904108 (Ed'9'14) CERTIFICATE. OF LIABILITY INSURANCE DATE 4105/IOO�YYY} ,�� 0105J20'17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING. INSURER(S), AUTHORIZED REPRESENTATIVE OR.PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the-policy(ies)must 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 Berm Insurance Agency nCOONTACT 5328 Montere Rd PHONE ...... _ "Fwc ,...._.. .. ..... Y 408-36i 0.121 n:c No:408 361.0123 San Jose.CA 951.11 EMAIL ppRESS: Y ...y fredd bermu ndez ahbo:com _....___. A INSURERS)AFFORDING COVERAGE w w y I_NAIC it ......... ...... ._ --. .-..__. INSURER A.,Foremost Insurance Group 41513 INSURED JD Plumbing.ITrenchFreetJuan Diaz INSURER6: 17660 Laurel Rd .....-- Morgan Hill CA 95037 iNsurtER c s- INSURER D INSURER E a 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. `NOTWITHSTANDIN,G 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 HAVEBEEN REDUCED BY PAID CLAIMS. ...,. NSR( i 114 i tSl76Rh ` POLICY'NUMBER� MMIDONYYY .MM/ /YYYY 2� �� LTRi TYPE OF INSURANCE LIMITS -..,... COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE .00CUR bAMAGEToRENTED I ( PREMISE iEa ocarrence) S_. MED EXP(Anoneea,an) { PERSONAL 8 ADV INJURY �S GEITL AGGREGATE LIMIT APPLIES PER: E GENERAL AGGREGATE I S POLICY JECT LOtI I PRODUCTS-COMPIOP AGG ,S _. .._._.._:. PRO• OTHER: ; 5 AUTOMO BILE IJAWLiTY € COMBINED SINGLE LIMIT S1,000,000 4 iEa acadentj H Y AUTO BODILY INJURY iPor person) 1 S (� OWNED SCHEDULED ! -. _-. AUTOS ONLY AUTOS SCP 12$92533 12J16120.1 t3 C121'16120"17 1~BODILY INJURY(Per ucctdent)�s HIRED ✓ NON-OWNED: PROPERLY DAMAGc AUTOS ONLY AUTOS ONLY (Pnr acutj- { is UM BRELLA LIAR OCCUR ! I µEACH OCCURRENCE _ S M ....... _ EXCESS CIAB CLAIMSWADE } I AGGREGATE I s OEO RETENTIONS- i � {_ �$ ........ WORKERS COMPENSATION STATUTE ERH PAND EMPLOYERS'LIABILITY I {ANYPROPRtETORtPARTNER EXECUTIVE Y!N — - (OFFtCERPAEMBEREItC1UDED? N-!'Ar ;E.L EACH ACCIDENT $ m I(Mandatory in NH). ' 3 YEE EA EMPLO S If yes,describe under � � � ..E.L DISEASE.< ---_ — �------_� ___ DESCRIPTION OF OPERATIONS tiataiv E.L.DISEASE-POLICY LIMIT IS F )ESCROTION OF OPERATIONS I LOCATIONS t VEHICLES(ACORD 101,Additional Remarks Schedule,may be attachod If more space is required) aty of Campbell.Its'officers,employees and Volunteers are named as additional insured.The Insurance coverage affordedto the Additional Tsured is primary lnsurance.,All work in the public`.right-of-Way;; CERTIFICATE HOLDER CANCELLATION ;ity of Campbell '0 N. First St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE :ampbell:CA.95.008 THE EXPIRATION DATE THEREOF, NOTICE .WILL BE DELIVERED IN ACCORDANCE WITH THE POLICYRROVISIO AUTHORIZED REPRESENTATIVE Freddy Bermudez 01988-2015 ACORD CORPORATION. All rights reserved. kCORD.25(2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms.Boss.web.5oftwara.www FormsBoss.com fcl lmoronedwi P„hitshinn ann:911R:1o77 $7 FOREMOST 41.52017 INSURANCE GROUP Ghost Transaction .Activity i12/,16/2016, Transaction.Type;. ENDORSEMENT User-Ids: . freddy(M) Transaction Effective D"ate: 4/5/2017 Processing Date: 4/5/2017 ADDED DESIGNATED INSURED CITY Or CAMPBELL 70 N 1 ST ST CAMPBEL.L CA 95008- 1458 1 INSURANCE REQUIREMENTS CHECKLIST Permit# R(� 1' CIP Project# Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance -requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $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 2 \� Automotive Liability: "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage Policy expiration date \z l(oIT Workers' Compensation and Employer's Liability Waiver of Subrogation clause i $1,000,000 per accident for bodily injury or.disease ---Policy expiration date Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: 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 say: �Should any of the above described policies be cancelled before the expiration date thereof, otice will be delivered in accordance with the policy provisions. ❑ Workers' Compensation Insurance Sheet Submitted or General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 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: rLD�I S�Ad(2 NAIC# Rating: Authorized in CA: Name: �t�«_ y"�°HIC# — Ratin Authorized in CA: g� Name: �P{ASS NAIC �Rating: Authorized in CA: v/ Name: NAIC# Rating: Authorized in CA: ❑ Campbell Business License#�Nn - (ot� Expiration: eVe i t`'Z- 3 Contractors License# �� t w Class: C-Lkz. Expiration: Insurance Certificate Reviewed 1 AI Ini is Date 04/ 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 ,,..� ACC2jRD CERTIFICATE OF LIABILITY INSURANCE FDATE(MM)DDrYYYYI ,.-- 04105/2017 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}folder 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 Berm Insurance Agency CONTACT 5328 MontereyRd PHONE F IAI �,e> 408,361-0.121 IArc Net:448 361-0123 San Jose-CA 95111 EMAIL `..E-MAIL s:freddy:bermudez@yahoo.com INSURER(S):AFFORDING COVERAGE f NAIC k INSURER A:Foremost Insurance Group 141513 INsuRED JE}#'lumbmg/TrenchFree]Juan Diaz wsuRERs: 17660 Laurel Rd _. ......,...__..__. w.._.. __.,,._ Morgan Hill CA 95037 �NsuRErz c, INSURER D - INSURER E t 1NSURER'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 CONDITIMOF ANY CONTRACTOR 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.. POLICY EFF' ( POLICY EXP LTR . TYPE OF INSURANCE i I POLICYNUMBER 4 MM)DDIYY 1 MM/DDrM. Y I LIMITS COMMERCIAL GENERAL.LIABILITY # � EACH OCCURRENCE 5 ❑ DAh-1AGE TO RENTED CLNMS�MADE OCCUR PERSONAL&ADV INJURY is GENL AGGREGATE L1411T APPLIES PER: I GENERAL AGGREGATE 15 POLICI JECT LOG PRODUCTS-.COMPIOPAGG I S OTHER; _ S AUTOMOBILE LIABILITY ✓ ti�.I - - - I `COAiBiNED'INGLE LIMIT I S,1'.404'00.0 . ANY'AUTO (Ee acadort € BODILY INJURY(Per person) S 4 OWNED SCHEDULED i AUTOS ONLY AUTOS ? SCP I 12592533 12/16/2016 12/16/2617 BODILY INJURY(Peracddent) S HIRED NON•O+ANED: i AftOPERTY[1AMAG AUTOS ONLY AUTOS ONLY i UMBRELLA LIAR OCCUR 3 EACH OCCURRENCE it DXCDEiS.CIAB HCLAIMSP.dA E I I r. 1I IAGGREGATE IS RETENTIONS JWORKERS COMPENSATION ANDEMPLOYERS'L'tABILITY STATUTE_• ERH IANYPROPRIETORIPARTNER;EXECUTIVE (Y--)' E.L.EACH ACCIDENT 5 ?OFFICERIMEMBERECCLUDED? JiN(Jt { E.L.(Mandatory in NH). i EA EMPLOYEES Nyyns;'tltscriba untlar i (( _.._ DISEASE DESCRIPTION.OF OPERATIONS twlo�v E.L.DISEASE POL1CYlIP,t1T r �I i I 3ESCRIPTION OF'OPERATIONS I LOCATIONS I VEHICLES (ACORO 101.Additional Remarks Schedule,maybe attachod if more space-is requirod) :ity of Campbell:its officers;employees and Volunteers.are named as.additional insured.The Insurance coverage.affordedto'the Additional isured is-primary insurance,All work in the;pubiic.right-of-way: ?�ct�dCSS C— \'-l—C��Uri IF CERTIFICATE HOLDER. CANCELLATION Nty of Campbell 'D N.First St- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE :ampbell.CA.95008 THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY:PROVISION AUTHORIZED REPRESENTATIVE Freddy Bermudez L (1 01988-2015'ACORD CORPORATION. All rights reserved. aC.ORD.25.(2016103)_ The ACORD name and logo are registeredmarks of ACORD Produced using Farms-Boss Web Software.www.Formsaoss.com tel Imnra—i-i Puhlia h;nn Ann-onA_1OT9