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ENC2017-00217 Print Form CITY OF CAMP,BELL ENCROACHMENT PERMIT Permit No C�y� [��U DEPT.OFPUBLICWORKS (forworkingwithin the public X-Ref. File L� 70North First Street. right-of-way) Application Date 1.- ( Campbell, CA 95008 q% Application Expiration Date 3 l Issued. !'I Al Ph.(408)866-2150 t APN Z ( P Fx. (408)376-0958 Permit Expiration Date APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section11.04. (Applicationex pires in six "(6) months if the permit is not issued. Application Fee is non-refundable.) I` A. Work Address or TractNo.: �iL�Ppl f �! Utility Trench Location` B. NatureofWork: T,��,(� l�` f Fi-12 c 1"—5 77� KfG41c _. ..... -.... C. Attach four(4)copies ofan engi neered plan showi ngthe location and extentofthe work,and four(4)copies ofthe preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part of this permit. D. All workshall conform tothe City ofCampbe.-Il Standard Specifications and Detailsfor Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance.Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two'days before startingwork.sN�otice must be given to Public Works at least24 hours before restarting any work. Name cant: ) _ .. _-.._._. Telephone: �i/he7 ofAppli 1a�C �-p 4P ,n t�C�J Address: ZV' .��'b y .G J.Y°'�-' ►.D ....�.tJ i_ _ l`�- 'QM bYtT�.C `'t -?_►,..... - E-MailAddress: /. T 247HOUR EMERGENCY PHONE NUMBER`. Is this work being done by the property owners at their own residence? FV1 YES ❑ NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit,-and they will inform their contractors) 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 damages arising out of improvements ompleted in the ublicright of-wa . Accepted: ` " '� :.(Applicant Permittee) sign) Date (Contractor) (Print Name) - Date SPECIAL PROVISIONS: 1. Street shall not be open cutfor underground installations.Minimum cuts may be allowed for connections or exploration holes.Suchcuts.maybe 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 NO PERMIT APPLICATION FEE $ 2 L>>,,f U L7 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ - - .� CONSTRUCTION CASH DEPOSIT $ i� PLAN CHECK&INSPECTION FEE $ 0 r, EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE C— - q Fo\it ngineer Date Y Permit Expires 12 Months After Date of Issuance ES 9 3 BRAVA L.&Pp4 L3 Google Earth Pro �ilc. edit :riev. Tools. Add window Hei (;� ` t^ 7 �'?s[y=h Thu Mar 23 2:41:50 PIV,' ARC CONSTRUCTION INC C,' t := G:or Earth: ?ro Swmar avenue,Campueti.CA C� y .,_ �i t Sign in Line Path Circte 313:patn 31D polygon Measure the distance or area of a yeonietric shape on the groundIF - r� Perimeter: 1.168.40 Feel ! Area: 30,1.68.44 Square FeatIF a Mouse'Nay.iga lion Save Clear - w , i JLU P pp 41 f> - fir y r f �; .' - ..+. I ter•- ... ,.� 7 :�-�: �, :�- 14'-: - ,�'�"�:'. ,, ,::. ••�--�+i:,.r „_ �' a _:�.;,,,�„ •�.Y.,M�1-1�1 �*� - � Y LY9 I Y _ r y ® `�i' 76I rl uu�' t l i 1/f y�%W ..,.�' ?� i 5`r•,,Gq - PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 ? 1-7 —OG 2 -7 �--s TO: Finance PUBLIC WORKS FILE NO. \4- PROPERTY ADDRESS 5'725 SALN-flP< AA Please collect&receipt for the followin monies: :ITEM ACCT. AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major>_$10 000 $425.00 Minor Encroachment Permit.<gio,000 $240.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240.00 Inspection Fee Minimum Charge per,Location $420.00 Street Tree Plantinq/Removal N/C 22 33 ($500 per Tree Plantinq Deposit Required) $500.00/tree 2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading &Drainage Plan Review Single Family Lot $295.00 Site< 10,000 s.f. $885.00 Site>_10,000 s.f. <0.5 Acre $1,185.00 Site>_0.5 Acre $1 772.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 4722 For projects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities $315 ea Plan Check& Inspection Fee(Non-Utility) 4722 En r. Est. <$250 000 14%of Engineer's Estimate 4722 En r. Est. >_$250 000 and 5$500,000 $35,000.00+8%of Engineers Estimate 4722 En r. Est. >$500 000 $55 000.00+7%of Engineers Estimate 2203 Emergency Cash Deposit 4% of Enqr. Est.*($500 min/$10 000 Max 2203 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 Parcel Map(4 Lots or Less) $4,200.00+$90/lot 4722 Final Tract Map(5 or More Lots) $5 115.00+$124/lot 2203 Monumentation Security 100%of City's Monumentation Estimate 4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,990.00 4722 Vacation of Public Streets& Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 Certificate of Correction $590.00 4722 Document Recording Fees $15.00/first page$3 ea.Additional 4722 Private Improvement in Public ROW $100.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Payment 22 Assessment egregatlon or eapportlonment First Split $940.00 Each Additional Lot $295.00 511.7424 Postage MISCELLANEOUS Other(Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL NAME OF APPLICANT NAME OF PAYOR _Ukn ADDRESS 3 O �� OY►1 h SV st e, AF�m }' IP FOR RECEIVED Ya CITY CLERK r ,. . r - ONLY Date Receipt 1��y]� J'TORM51T—pla t /� L � _.. . ,�r 1� n�/ --�' �a 1 i i Syed Wahidi From: JoAnna Thomason Sent: Thursday, September 14, 2017 4:54 PM To: Syed Wahidi Cc: 'Keith@tarcinc.com' Subject: RE: 535 Salmar Ave (ENC 2017-00217) Attachments: SKM BT_50117091416480.pdf I reviewed the insurance and I need the following: Waiver of Subrogation for Worker's Comp.(we need the actual waiver) Required wording in the Description of Operations Section including location and permit# ENC2017-00217 City of Campbell is the Certificate Holder I'm attaching a copy of the requirements checklist for your reference. Please let me know if you have any questions. Thank you, JoAnna JoAnna Thomason Office Specialist City of Campbell Public Works Department 70 N. First Street Campbell, CA 95008 www.citvofcampbell.com 408.866.2150 -----Original Message----- From: Syed Wahidi g Sent:Thursday, September 14, 2017 3:42 PM To:JoAnna Thomason Cc: 'Keith@tarcinc.com' Subject: 535 Salmar Ave (ENC 2017-00217) JoAnna, Please review insurance. Thx Syed Wahidi Public Works Inspector City of Campbell Public Works Department 70 N. First Street Campbell, CA 95008 www.citvofcampbell.com 408.866.2165 1 W �v�,a•^C INSURANCE REQUIREMENTS CHECKLIST Permit# 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: t <-$1,000,000 per occurrence-,and ❑ $1,000,000 general aggregate limit applying separately to the project, or ❑ $2,000,060 general aggregate limit. ❑. Policy expiration date Icy 1 5- Automotive Liability: "Any Auto"checked on certificate a $1,000;000 per accident for bodily injury and property damage ❑ Policy expiration date_ ,� iZ11-7 Workers'Compensation and Employer's Liability ❑ Waiver of Subrogation clause -$1;000,0.00 per accident.for bodily injury or disease A-,Policy expiration.date Z 1 1-6 Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date i g!wlredl fiddrsementsadt rra.x ral abilfl and Automr___T_1i4l41111#ywollci'es Additional insured Endorsement(Description of Operations Area) ❑' The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location&Permit NurnberJ r ❑ The insurance coverage afforded to the Additional Insured is primary insurance. FIN Cancellation Area: \� SfiI C2, A ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. \\Honouliuli.cityhall.ci,campbell.ca.us.local\Profile_Qata$\Joannat\Desktop\AII Insurance Requirements.doc(Rev 03/13) Page 1 of 1 CERTIFICATE OF LMILITY INSURANCE V I I I CERMf4CATE 1 ISSVED AS A.MA7`rM- 14 M fi K kM'x* OFIE7-A0M.cot tliMRsM 0 ftfft t 0 b 4 T HEE E!Rt.X'RCAtER0lMfLITiIS.. _(aEi771MCA'M DOES AW AEFTRAl ATIVEL.Y 09 WGArYELY AMkND.lEtf ENO OR ALTER AFPQF*DED BY THE POLMES BELOW. T19a G>rR'I'IF wt dF M;-06ANdE,DOES NOT tSTITi; 'F.A C$ATIRACT BETWNEEM THE WbNG INSURER{St,AUTHORO REPRMNTA7wF o-k i�1 0WC-El•AND THE CEP1.1FICATE HOLDER.. IMPORTANT- It fhe rostiffeate homer an ADbM'ONA L.INSURED,the.po2lc�.i�7 t 'llbj:MOML M.URED vbIbM tJr�sr?dars ed, Ef•S'#9ROGAgtElli is iiSrAIVED 5tt�jeet th ffte tet tsitlfd't�Jt►tlitioY �t the3�potiGy;i rtalit pis3ides riraY reettdte an r I[tt A #atRnttt GrJ tlt s cerhfic detlo4w not confer fthM to the tottifiGa hotdet-ia:tlou ffisuch'entlorst tit pnoodcm Uceme#DE63433 :.CONTACT - O/f'&. SSOGISIf7lit88ilL':6.' 28M Single Oak Dr A.-NS506 5859' S4255 a�Di+'[€ssc�er�rrce(n7orrandass0 tam _ j7enmwI%CA M". aysst RrJ�Jr;Fratm[Nc:c Aoe - ttaJsd :�&iifd►s"s'i�ii:Fri�:�i.�asua�.jfCa �240�G� 1i C¢�sBJ�ttt>rilisc. �aact�e:`t`tartt�A'E3Dgttat��StliLti*a�6[€ilTail�t ' 3 P68ax INSURgkto Avoiesf.b6t,orto 110! Salta CA SM - l, .I�sjG3�hiioIctity Ortai�n'e 0 ; 82__ [ VilS iS TD GERT-IFY TMT T.ME FO-LiCIES•10F INSURA'FitGE'Uli TED.13ELOWi4A%EeSEEN..ISSUEDTEJ EiE-iNSUttED`FAMED kB01/ 6R TME;PLNJGY RERibI? INDIGATEI3., FJOTtI{ATJISTANplNG AlYI;KEGiUIJ3EMENT, ERM:;OR'CONDF7'ION:OF ANY GONTRAG7'L#RDT.IER'bQGUMENtWITJiNESPECT-TtXVMICHTHIS: CER-IWt .AT-E'MAY,'8'E ISSUED: OR MAY PERTAIN,THE INSURANCE;AFFLIRDED " THE POLICJE5 DESCRISEV REREIN.IS:SiJ83ECT'ft7A .tHE.TEl2W4S, _VXCLtaSi1`IftAND.4O14 IT101VSb SUCH;;PoliCIES.uMi SHOWNAAAYt1AVEBEEN•I2FDUCEDSV:PAtQ;CLAIMS: - TADDLSUHR:._ .. PDUCY EFF i fishy l8Y!'EX ' .. . .. _..: YE JN§LRANGE. _... i. A f} �,� fAfd. 3 ��EE{•11.' . . .. i Mj��q�y I fy +y� FAGH_CCCJRF?ENCE' jam. ��lg � i132465806 IYL IVuiG ' {�ItTh3�IRAE&GE.TOR SM-Y�dD #AFD $ I�, I 'j � ` ;,fE623�A1#L8.lilYllS3JL3R9 $ 'I,$.�D•I7a0 [ A33CG✓3 t�ar�n,�s _ � •` �. ;s t�tdi�i.n(�Fi�c�7� j aga rLr !X _{Lac � s. i a . ouGr�=:tkgn . DT[1ER ! ; i i ?RedaGt s C000 i COMBINED SIFi I.MT I S RfifY 14tF11� f 1 6$1 `P' i TM# '�' lw "' f blFffit�D p ! AU'1LYs177`SI:1'• OOCLYJWURYJlasr f i P.GY�J43f1-0 't i 'PROPEE2'T'!DA� - , yJ�pp _ [ iO,IDQO 000 C }x I�StESSJtAt , 1 ?,'0T3Et lLl ;1bF15129ti5 t0i &faM7.; ;£ S,uoata®o �---. KETENTM4 f�EMPtS.£/YERb'iIRB=Y Y3N I1{ , IANYP CORIETOKMAA ! I j7tl II r. H �tn iJnl EN:GLUpSS? MIA i !• —-- - P7f�l L i.Tres.aesc be#ut er ! 4 t F § LIM trt i�0 I I - E i ?+DESCRiPiIONOF03'ERA _. ... _.. . [ L Y jPraRsrty J jBz iSIf2BI7!;C2I9 8;Schi ciuted 5-F.01m i' F. ,Eqpt PkY jBKS &Sf+ &7 (} f�3110ET !l�t912419 : fe SeE'fttm bES�[tt3nitffnP'�RA3ION3FJ,ACA71olV5'IF1BS{,4i�DI7d`#ifef.AtP�a4�1R�rkadu'e, 1irt�sict�aaa?rtmais.regn[�v!} I ' . t Cg;I PICATE ROLEfF ' MOLL AM a _! • ' tll.Lr A�i�1' F T� I3E'R3�SCR1 �S t �� t AUttJo���ps�rraTru.E t 0 i9 CORRPOAiSTON. 1 ACORD 25 20'I6I03) Air rlgfits reseiyeii, The ACGRb J?a ine attci i'.aRn,ara re&torM marks df Act3Rl3 TARCCON-01 AALCANTAR ,4COR® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 09/19/2017 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#OE63493 NAME CT Orr&Associates Insurance Services PHONE FAX 28780 Single Oak Dr (A/C,No,Ext):(951)506-5859 (vC,No):(800)474-3003 Ste 255 ADDREss:service@orrandassociates.com Temecula,CA 92590 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Associated Industries Insurance Co. 23140 INSURED INSURERB:American Fire and Casualty Co 24066 TARC Construction Inc. INSURERC:Starstone NatlOnal Insurance Company Compairly 25496 PO Box 4226 INSURER D:Everest National Insurance Company 10120 Santa Cruz,CA 95063 INSURER E:Ohio Security Insurance Companies 124082 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X X X PREMISES(Ea occurrence $ OCCUR AES102466806 10/15/2016 10/15/2017 DAMAGERENTED 100,000 MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[X] PRO- LOC. PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: IDeduct $ 5,000 B AUTOMOBILE LIABILITY Ee acBIND ad.n S INGLE LIMIT $ 1,000,000 X ANY AUTO X X BAA56617267 10/17/2016 10/17/2017 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ Deduc $ 3,000 C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB CLAIMS-MADE 77073E164ALI 10/16/2016 10/15/2017 AGGREGATE $ 10,000,000 DED RETENTION$ $ D WORKERS COMPENSATION X STAPERTUTE OERH AND EMPLOYERS'LIABILITY 7600015997171 02/01/2017 02/01/2018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA X E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ E Property BKS56517267 02/19/2017 02/19/2018 Scheduled See Notes E Eqpt Fltr BKS56517267 02/19/2017 02/19/2018 Scheduled See Notes DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Campbell,Its officers,employees and volunteers are named as additional insured per attached endorsement forms. The coverage afforded to the additional insured is primary insurance. Re:Location:535 Salmar Ave.,Campbell,CA 95008-1400 permit#ENC2017-00217 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City P ACCORDANCE WITH THE POLICY PROVISIONS. 70 N.First Street Campbell,CA 95008 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TARCCON-01 AALCANTAR CERTIFICATE OF LIABILITY INSURANCE DATE 09/15/2017Y) 0911512017 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#OE63493 NAMEACT Orr&Associates Insurance Services 28780 Single Oak Dr ( / N PHONE,Ext):(951)506-5859 (A/c,No):(800)474-3003 Ste 255 a DRESS:service@orrandassociates.com Temecula,CA 92590 INSURERS AFFORDING COVERAGE NAIC# - INSURERA:Associated Industries Insurance Co. 23140 INSURED INSURER B:American Fire and Casual Co - 24066 TARC Construction Inc. INSURERC:Starstone National Insurance Company 25496 PO Box 4226 INSURER D:Everest National Insurance Company 10120 Santa Cruz,CA 95063 INSURERE:Ohio Security Insurance Companies 124082 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP - LIMITS LTR INSD WVD MM/DDIYYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR AES102466806 10/15/2016 AlTO 'IR01 lOAMAGETORENTED 100,000 X X PREMISES Ea occurrence $ _ MED EXP(Any oneperson) $ . 1 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY®JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Deduct $ 5,000 B AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT 1,000,000 �,-Ea.accident $ X ANY AUTO X X BAA56517267 10/17/2016 -0777"27 BO-I1RiT NJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ 1 Deduc $ 3,000 C UMBRELLA LIAB X OCCUR - 10,000,000 . +AC1JOCCURRENCE $ X EXCESS LIAB CLAIMS-MADE 77073E164ALI 10/15/2016 %[ 5'/2 17 AGGREGATE $ 10,000,000 DED RETENTION$ - $ D WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE X 7600015997171 02/01/2017 02/01/2018 1,000,Opp OFFICER/MEMBER EXCLUDED? ® N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ E Property BKS56517267 02/19/2017 02/19/2018 Scheduled See Notes E Eqpt Fltr BKS56517267 02/19/2017 02/19/2018 Scheduled See Notes DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Campbell is named as additional insured per attached endorsement forms. Re:Location:535 SalmarAve.,Campbell,CA 95008-1400 permit?O r7� 0Z17� 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 ACCORDANCE WITH THE POLICY PROVISIONS. 70 N.First Street SEtl�vue,WA 98008 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2%of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 02/01/2017 Policy No.7600015997171 Endorsement No. 001 Insured: Tarc Construction,Inc. Premium$INCL. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999. AGENCY CUSTOMER ID:TARCCON-01 AALCANTAR LOC M 1 `4 ®� ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY License#OE63493 NAMED INSURED Orr&Associates Insurance Services TARC Construction Inc. PO Box 4226 POLICY NUMBER Santa Cruz,CA 95063 EE PAGE 1 CARRIER NAIC CODE EE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER' ACORD 25 FORM TITLE: Certificate of Liability Insurance Certificate of Liability Remarks Property: BKS56517267 3230 Darby Cmn, Fremont,CA 94539 Repl Cost $3,090 2315 C Matisson Ln,Santa Cruz,CA 95062 Rplc Cost$5,150 Inland Marine-BKS56517267: 2006 Dynapac CC112 Smooth Drum Roller#60119197$16,857 2006 John Deere 41OG Backhoe loader VIN: T0410GX955899 value$51,223.00 2004 BO Mag Pro Paver Model 813 ID#23497 value$37,305 2007 Bomag BW120-AD Roller SIN 101880025534$22,990.00 2006 Bomag Model 814-2 Paver SIN 91183516-1038$613000 2007 Bomad Roller Model#SW120Ad-4 $17,000 Schwing Model SP 500 Concrete Pump,#5001513 $100,247.00 Writgen Model W120CFI FCS Milling Machine SIN 1810.018 $463,721.00 Hamm Model DH+12-VO Roller SIN H1840295$86,891.75 Wirtgen Model W120CFi FCS Milling Machine SN: 1810.0118 Value: $463,721 Business Auto-BAA56517267 2016 ZIEMAN MODEL A BEAVER TAIL RAMP TRAILER 1ZCE40A28GZ348974 COVERAGE$22,835.13 1985 Cozad Lowboy Trailer,Vln: 1C9G45207F1167174 Coverage$40,400 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy: AES102466806 COMMERCIAL GENERAL LIABILITY CG 20 33 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under.the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured any person or or- additional insureds, the following additional exclu- ganization for whom you are performing operations sions apply: when you and such person or organization have This insurance does not apply to: agreed in writing in a contract or agreement that such person or organization be added as an addi- 1. "Bodily injury', "property damage" or "personal tional insured on your policy. Such person or or- and advertising injury"arising out of the render- ganization is an additional insured only with re- ing of, or the failure to render, any professional spect to liability for "bodily injury", "property architectural, engineering or surveying servic- damage" or "personal and advertising injury" es, including: caused, in whole or in part, by: a. The preparing, approving, or failing to pre- 1. Your acts or omissions; or pare or approve, maps, shop drawings, opi- 2. The acts or omissions of those acting on your nions, reports, surveys, field orders, change behalf; orders or drawings and specifications; or in the performance of your ongoing operations for b. Supervisory, inspection, architectural or the activities. he additional insured. A person's or organization's status as an additional 2. "Bodily injury" or "property damage" occurring insured under this endorsement ends when your after: operations for that additional insured are com- a. All work, including materials, parts or pleted. equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the additional in- sured(s) at the location of the covered operations has been completed; or b. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontrac- tor engaged in performing operations for a principal as a part of the same project. CG 20 33 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 POLICY NUMBER:AES102466806 I COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ ization s : Location And Description Of Completed Operations ALL PERSONS OR ORGANIZATIONS WHERE WRITTEN CONTRACT WITH THE NAMED INSURED REQUIRES ADDITIONAL INSURED COMPLETED OPERATIONS. THIS FORM DOES NOT APPLY TO YOUR WORK ON "RESIDENTIAL PROPERTY" L 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 sche- dule of this endorsement performed for that addi- tional insured and included in the "products- completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ POLICY NUMBER: AES102466806 COMMERCIAL GENERAL LIABILITY NX GL 093 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT ® AGGREGATE LIMITS OF INSURANCE (PER PROJECT) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Schedule Subject to an Overall Policy Aggregate Limit: $ (Information required to complete this Schedule, if not shown above, will be shown in Declarations.) A. Paragraphs 2. and 3. of SECTION III—LIMITS OF INSURANCE are replaced by the following: 2. The Overall Policy Aggregate Limit is the most we will pay for the sum of a. Medical expenses under Coverage C; b. Damages under Coverage A, except damages because of"bodily injury"or"property damage" included in the"products-completed operations hazard"; and c. Damages under Coverage B. 3. The Products-Completed Operations Aggregate Limit is the most we will pay under Coverage A for damages because of"bodily injury"and "property damage" included in the"products-completed operations hazard"to each of your projects away from premises owned by or rented to you. B. The following is added to SECTION III—LIMITS OF INSURANCE: 8. Subject to Paragraph 2. and 3. above, the General Aggregate Limit is the most we will pay under for the sum Coverage A, Coverage B,or Coverage C to each of your projects away from premises owned by or rented to you. NX GL 093 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission i POLICY NUMBER: ES102466806 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD-PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4. of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of'Insurance Services Office, Inc., with its permission 1 POLICY NUMBER:AES102466806 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Blanket as required by written contract. Information required to complete this Schedule if not shown above will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or ,.your work" done under a contract with that person or organization and included in the "products- completed operations hazard". This waiver applies only to the person 'or organization shown in the Schedule above. r CG 24 04 05 09 ©Insurance Services Office, Inc.,2008 Page 1 of 1 ❑ I / COMMERCIAL AUTO CA 88 10 01 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO COVERAGE ENHANCEMENT ENDORSEMENT This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. COVERAGEINDEX SUBJECT PROVISION NUMBER ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT 3 ACCIDENTAL AIRBAG DEPLOYMENT 12 AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT OR LOSS 19 AMENDED FELLOW EMPLOYEE EXCLUSION 5 AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE 13 BROAD FORM INSURED 1 BODILY INJURY REDEFINED 22 EMPLOYEES AS INSUREDS (including employee hired auto) 2 EXTENDED CANCELLATION CONDITION 23 EXTRA EXPENSE- BROADENED COVERAGE 10 GLASS REPAIR-WAIVER OF DEDUCTIBLE 15 HIRED AUTO PHYSICAL DAMAGE (including employee hired auto and loss of use) 6 HIRED AUTO COVERAGE TERRITORY 20 LOAN / LEASE GAP 14 PARKED AUTO COLLISION COVERAGE(WAIVER OF DEDUCTIBLE) 16 PERSONAL EFFECTS COVERAGE 11 PHYSICAL DAMAGE -ADDITIONAL TRANSPORTATION EXPENSE COVERAGE 8 RENTAL REIMBURSEMENT 9 SUPPLEMENTARY PAYMENTS 4 TOWING AND LABOR 7 TWO OR MORE DEDUCTIBLES 17 UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS 18 WAIVER OF TRANSFER OF RIGHTS OF RECOVERYAGAINST OTHERS TO US 20 SECTION II -LIABILITY COVERAGE is amended as follows: ° 1. BROAD FORM INSURED SECTION II - LIABILITY COVERAGE, paragraph A.1. - WHO IS AN INSURED is amended to include the following as an insured: d. Any legally incorporated entity of which you own more than 50 percent of the voting stock during the policy period. However, "insured" does not include any organization that: (1) Is a partnership or joint venture; or (2) Is an insured under any other automobile policy; or (3) Has exhausted its Limit of Insurance under any other automobile policy. Paragraph d. (2) of this provision does not apply to a policy written to apply specifically in excess of this policy. e. Any organization-you newly acquire or form, other than a partnership or joint venture, of which you own more than 50 percent of the voting stock. This automatic coverage is afforded only for 180 days from the date of acquisition or formation. However, coverage under this provision does not apply: (1) If there is similar insurance or a self-insured retention plan available to that organization; © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 1 of 7 (2) If the Limits of Insurance of any other insurance policy have been exhausted; or (3) To "bodily injury" or "property damage" that occurred before you acquired or formed the organization. 2. EMPLOYEES AS INSUREDS SECTION II - LIABILITY COVERAGE, paragraph A.1. -WHO IS AN INSURED is amended to include the following as an insured: f. Any "employee" of yours while using a covered "auto" you do not own, hire or borrow, but only for acts within the scope of their employment by you. Insurance provided by this endorse- ment is excess over any other insurance available to any "employee". g. An "employee" of yours while operating an "auto" hired or borrowed under a written contract or agreement in that "employee's" name, with your permission, while performing duties re- lated to the conduct of your business and within the scope of their employment. Insurance provided by this endorsement is excess over any other insurance available to the "employee". 3. ADDITIONAL INSURED BY CONTRACT, AGREEMENT OR PERMIT SECTION II - LIABILITY COVERAGE, paragraph A.I. -WHO IS AN INSURED is amended to include the following as an insured: h. Any person or organization with respect to the operation, maintenance or use of a covered "auto", provided that you and such person or organization have agreed in a written contract, agreement, or permit issued to you by governmental or public authority, to add such person, or organization, or governmental or public authority to this policy as an "insured". However, such person or organization is an "insured": (1) Only with respect to the operation, maintenance or use of a covered "auto'; (2) Only for "bodily injury" or "property damage" caused by an "accident" which takes place after you executed the written contract or agreement, or the permit has been issued to you; and (3) Only for the duration of that contract, agreement or permit 4. SUPPLEMENTARY PAYMENTS SECTION II - LIABILITY COVERAGE, Coverage Extensions, 2.a. Supplementary Payments, para- graphs (2) and (4) are replaced by the following: (2) Up to $3,000 for cost of bail bonds (including bonds for related traffic violations ) required because of an "accident" we cover. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the insured at our request, including actual loss of earn- ings up to $500 a day because of time off from work. 5. AMENDED FELLOW EMPLOYEE EXCLUSION In those jurisdictions where, by law, fellow employees are not entitled to the protection afforded to the employer by the workers compensation exclusivity rule, or similar protection, the following provision is added: SECTION II - LIABILITY, exclusion B.5. FELLOW EMPLOYEE does not apply if the "bodily injury" results from the use of a covered "auto" you own or hire. SECTION III -PHYSICAL DAMAGE COVERAGE is amended as follows: 6. HIRED AUTO PHYSICAL DAMAGE Paragraph A.4. Coverage Extensions of SECTION III - PHYSICAL DAMAGE COVERAGE, is amended by adding the following: If hired "autos" are covered "autos" for Liability Coverage, and if Comprehensive, Specified Causes of Loss or Collision coverage are provided under the Business Auto Coverage Form for any "auto" you own, then the Physical Damage coverages provided are extended to "autos": a. You hire, rent or borrow; or © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 2 of 7 b.' Your "employee" hires or rents under a written contract or agreement in that "employee's" name, but only if the damage occurs while the vehicle is being used in the conduct of your business, subject to the following limit and deductible: A. The most we will pay for "loss" in any one "accident" or "loss" is the smallest of: (1) $50,000; or (2) The actual cash value of the damaged or stolen property as of the time of the "loss"; or (3) The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality, minus a deductible. B. The deductible will be equal to the largest deductible applicable to any owned "auto" for that coverage. C. Subject to the limit, deductible and excess provisions described in this provision, we will provide coverage equal to the broadest coverage applicable to any covered "auto" you own. D. Subject to a maximum of $1,000 per "accident", we will also cover the actual loss of use of the hired "auto" if it results from an "accident", you are legally liable and the lessor incurs an actual financial loss. E. This coverage extension does not apply to: (1) Any "auto" that is hired, rented or borrowed with a driver; or (2) Any "auto" that is hired, rented or borrowed from your "employee". For the purposes of this provision, SECTION V-DEFINITIONS is amended by adding the following: "Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value. 7. TOWING AND LABOR SECTION III - PHYSICAL DAMAGE COVERAGE,paragraph A.2. Towing, is amended by the addition of the following: We will pay towing and labor costs.incurred, up to the limits shown below, each time a covered "auto" classified and rated as a private passenger type, "light truck" or "medium truck" is dis- abled: a. For private passenger type vehicles, we will pay up to $50 per disablement. b. For "light trucks", we will pay up to $50 per disablement. "Light trucks" are trucks that have a gross vehicle weight (GVW) of 10,000 pounds or less. c. For "medium trucks" ,we will pay up to $150 per disablement. "Medium trucks" are trucks that have a gross vehicle weight (GVW) of 10,001 -20,000 pounds. However, the labor must be performed at the place of disablement. 8. PHYSICAL DAMAGE -ADDITIONAL TRANSPORTATION EXPENSE COVERAGE Paragraph A.4.a., Coverage Extension of SECTION III - PHYSICAL DAMAGE COVERAGE, is amend- ed to provide a limit of $50 per day and a maximum limit of$1,500 © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 3 of 7 9. RENTAL REIMBURSEMENT SECTION III -PHYSICAL DAMAGE COVERAGE,A. COVERAGE,is amended by adding the following: a. We will pay up to $75 per day for rental reimbursement expenses incurred by you for the rental of an "auto" because of "accident" or "loss", to an "auto" for which we also pay a "loss" under Comprehensive, Specified Causes of Loss or Collision Coverages. We will pay only for those expenses incurred after` the first 24 hours following the "accident" or "loss" to the covered "auto." b. Rental Reimbursement will be based on the rental of a comparable vehicle, which in many cases may be substantially, less than $75 per day, and will only be allowed for the period of time it should take to repair or replace the vehicle with reasonable speed and.similar quality, up to a maximum of 30 days. C. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove and replace your tools and,equipment from the covered "auto". d. This coverage does not apply unless you have a business necessity that other "autos" avail- able for your use and operation cannot fill. e. If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided under Paragraph 4. Coverage Extension. f. No deductible applies to this coverage. For the purposes of this endorsement provision, materials and equipment do not include "personal effects" as defined in provision 11. 10. EXTRA EXPENSE-BROADENED COVERAGE Under SECTION III -PHYSICAL DAMAGE COVERAGE,A. COVERAGE,we will pay for the expense of returning a stolen covered "auto" to you. The maximum amount we will pay is $1,000. 11. PERSONAL EFFECTS COVERAGE A. SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the following: If you have purchased Comprehensive Coverage on this policy for an "auto" you own and that "auto" is stolen, we will pay, without application of a deductible, up to $600 for "personal effects" stolen with the "auto." The insurance provided under this provision is excess over any other collectible insurance. B. SECTION V-DEFINITIONS is amended by adding the following: For the purposes of this provision, "personal effects" mean tangible property that is worn or carried by an insured." "Personal effects" does not include tools, equipment, jewelry, money or securities. ° 12. ACCIDENTAL AIRBAG DEPLOYMENT SECTION III - PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS is amended by adding the follow- ing: If you have purchased Comprehensive or Collision Coverage under this policy, the exclusion for "loss" relating to mechanical breakdown does not apply to the accidental discharge of an airbag. Any insurance we provide shall be excess over any other collectible, insurance or reimbursement by manufacturer's warranty. However, we agree to pay any deductible applicable to the other cov- erage or warranty. 13. AUDIO, VISUAL AND DATA ELECTRONIC EQUIPMENT COVERAGE SECTION III - PHYSICAL DAMAGE COVERAGE, B. EXCLUSIONS, exception paragraph a. to exclu- sions 4.c. and 4.d. is deleted and replaced with the following: © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 4 of 7 Exclusion 4.c. and 4.d. do not apply to: a. Electronic equipment that receives or transmits audio, visual or data signals, whether or not designed solely for the reproduction of sound, if the equipment is permanently installed in the covered "auto" at the time of the "loss" and such equipment is designed to be solely operated by use of the power from the "auto's" electrical system, in or upon the covered "auto" and physical damage coverages are provided for the covered "auto'; or If the "loss" occurs solely to audio, visual or data electronic equipment or accessories used with this equipment, then our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by a$100 deductible. 14. LOAN /LEASE GAP COVERAGE A. Paragraph C., LIMIT OF INSURANCE of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by adding the following: The most we will pay for a "total loss" to a covered "auto" owned by or leased to you in any one "accident" is the greater of the: 1. Balance due under the terms of the loan or lease to which the damaged covered "auto" is subject at the time of the "loss" less the amount of: a. Overdue payments and financial penalties associated with those payments as of the date of the "loss", b. Financial penalties imposed under a lease due to high mileage, excessive use or ab- normal wear and tear, c. Costs for extended warranties, Credit Life Insurance, Health, Accident or Disability Insurance purchased with the loan or lease, d. Transfer or rollover balances from previous loans or leases, e. Final payment due under a"Balloon Loan", f. The dollar amount of any unrepaired damage which occurred prior to the "total loss" of a covered "auto", g. Security deposits not refunded by a lessor, h. All refunds payable or paid to you as a result of the early termination of a lease agreement or as a result of the early termination of any warranty or extended service agreement on a covered "auto", L Any amount representing taxes, j. 'Loan or lease termination fees; or 2. The actual cash value of the damage or stolen property as of the time of the "loss". An adjustment for depreciation and physical condition will be made in determining the actual cash value at the time of the "loss". This adjustment is not applicable in Texas. B. ADDITIONAL CONDITIONS This coverage applies only to the original loan for which the covered "auto" that incurred the loss serves as collateral, or lease written on the covered "auto"' that incurred the loss. C. SECTION V-DEFINTIONS is changed by adding the following: As used in this endorsement provision, the following definitions apply: "Total loss" means a "loss" in which the cost of repairs plus the salvage value exceeds the actual cash value. A "balloon loan" is one with periodic payments that are insufficient to repay the balance over the term of the loan, thereby requiring a large final payment. © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 5 of 7 15. GLASS REPAIR-WAIVER OF DEDUCTIBLE Paragraph D. Deductible of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: No deductible applies to glass damage if the glass is repaired rather than replaced. 16. PARKED AUTO COLLISION COVERAGE(WAIVER OF DEDUCTIBLE) Paragraph D. Deductible of SECTION III - PHYSICAL DAMAGE COVERAGE is amended by the addition of the following: The deductible does not apply to "loss" caused by collision to such covered "auto" of the private passenger type or light weight truck with a gross vehicle weight of 10,000 lbs. or less as defined by the manufacturer as maximum loaded weight the "auto" is designed to carry while it is: a. In the charge of an "insured'; b. Legally parked; and c. Unoccupied. The "loss" must be reported to the police authorities within 24 hours of known damage. The total amount of the damage to the covered "auto" must exceed the deductible shown in the Declarations. This provision does not apply to any "loss" if the covered "auto" is in the charge of any person or organization engaged in the automobile business. 17. TWO OR MORE DEDUCTIBLES Under SECTION III PHYSICAL DAMAGE COVERAGE, if two or more company policies or coverage forms apply to the same accident, the following applies to paragraph D. Deductible: a. If the applicable Business Auto deductible is the smaller (or smallest) deductible it will be waived; or b. If the applicable Business Auto deductible is not the smaller (or smallest) deductible it will be reduced by the amount of the smaller (or smallest) deductible; or c. If the loss involves two or more ,Business Auto coverage forms or policies the smaller (or smallest) deductible will be waived. For the purpose of this endorsement company means any company that is part of the Liberty Mutual Group. SECTION IV -BUSINESS AUTO CONDITIONS is amended as follows: 18. UNINTENTIONAL FAILURE TO DISCLOSE HAZARDS SECTION IV-BUSINESS AUTO CONDITIONS, Paragraph B.2. is amended by adding the following. If you unintentionally fail to disclose any hazards, exposures or material facts existing as of the inception date or renewal date of•�the Business Auto Coverage Form, the coverage afforded by this policy will not be prejudiced. ° However, you must report the undisclosed hazard of exposure as soon as practicable after its discovery, and we have the right to collect additional premium for any such hazard or exposure. 19. AMENDED DUTIES IN THE EVENT OF ACCIDENT, CLAIM, SUIT, OR LOSS SECTION IV - BUSINESS AUTO CONDITIONS, paragraph A.2.a. is replaced in its entirety by the following: a. In the event of "accident", claim, "suit" or "loss", you must promptly notify us when it is known to: 1. You, if you are an individual; 2. A partner, if you are a partnership; 3. Member, 'if you are a limited liability company; 4. An 'executive officer or the "employee" designated by the Named Insured to give such notice, if you are a corporation. © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 6 of 7 1 To the extent possible, notice to us should include: (1) How, when and where the "accident" or "loss" took place; (2) The "insureds" name and address; and (3) The names and addresses of any injured persons and witnesses. 20. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US SECTION IV - BUSINESS AUTO CONDITIONS, paragraph A.5., Transfer of Rights of Recovery Against Others to Us, is amended by the addition of the following: If the person or organization has waived those rights before an "accident" or "loss", our rights are waived also. 21. HIRED AUTO COVERAGE TERRITORY SECTION IV- BUSINESS AUTO CONDITIONS, paragraph B.7., Policy Period, Coverage Territory, is amended by the addition of the following: f. For "autos" hired 30 days or less, the coverage territory is anywhere in the world, provided that the insured's responsibility to pay for damages is determined in a "suit", on the merits, in the United States, the territories and possessions of the United)States of America, Puerto Rico or Canada or in a settlement we agree to. This extension of coverage does not apply to an "auto" hired, leased, rented or borrowed with a driver. SECTION V -DEFINITIONS is amended as follows: 22. BODILY INJURY REDEFINED Under SECTION V-DEFINTIONS, definition C. is replaced by the following: "Bodily injury" means physical injury, sickness or disease sustained by a person, including mental anguish, mental injury, shock, fright or death resulting from any of these at any time. COMMMON POLICY CONDITIONS 23. EXTENDED CANCELLATION CONDITION COMMON POLICY CONDITIONS, paragraph A. - CANCELLATION condition applies except as fol- lows: If we cancel for any reason other than nonpayment of premium, we will mail to the first Named Insured written notice of cancellation at least 60 days before the effective date of cancellation. This provision does not apply in those states which require more than 60 days prior notice of cancella- tion. 0 1 © 2013 Liberty Mutual Insurance CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 7 of 7 4 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury,covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while-engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2%of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 02/01/2017 Policy No. 7600015991171 Endorsement No. 001 Insured: Tarc Construction,Inc. Premium$INCL. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999. TARCCON-01 AALCANTAR CERTIFICATE OF LIABILITY INSURANCE DATE 09/ 5/2 1512MM/D /Y017 7 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#OE63493 CONTACT . NAME: Orr&Associates Insurance Services PHONE,E:t):(951)506-5859 (FAX. No);(800 474-3003 28780 Single Oak Dr ) Ste 255 E-MAIL ADDRESS:service@orrandassociates.com Temecula,CA 92590 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Associated Industries Insurance Co. 23140 INSURED INSURER 13:American Fire and Casualty Co 24066 TARC Construction Inc. INSURERC:Starstone National Insurance Company 25496 PO Box 4226 INSURER D:Everest National Insurance Corripariv 110120 Santa Cruz,CA 95063 INSURER E:Ohio Security Insurance Companies 124082 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MM/DD/YYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR AES102466806 10/15/2016 10/15/2017 DAMAGE TO RENTED 100,000 X X PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: IDeduct $ 5,000 B AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT 1,000,000 Ea accident - $ X ANY AUTO - X X BAA56517267 10/17/2016 10/17/2017 BODILY INJURY Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS - BODILY INJURY Per accident $ HIRED NON-OWNED PROPTY DAMAGE AUTOS ONLY AUTOS ONLY _ Per acciERdent $ 1 Deduc $ 3,000 C UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB CLAIMS-MADE 77073E164ALI 10/15/2016 10/15/2017 AGGREGATE $ 10,000,000 DED RETENTION$ $ D WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE_ ER ' ANY PROPRIETOR/PARTNER/EXECUTIVE Y�IN X 7600015997171 02/01/2017 02/01/2018 1,000,000 OFFICER/MEMBER EXCLUDED? N/A _ E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ E Property BKS56517267 02/19/2017 02/19/2018 Scheduled See Notes E Eqpt Fltr BKS56517267 02/19/2017 02/16/2018 Scheduled See Notes DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) City of Campbell is named as additional insured per attached endorsement forms. Re:Location:535 SalmarAve.,Campbell,CA 95008-1400 permit#ENC2017-00217 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p 70 N.First Street ACCORDANCE WITH THE POLICY PROVISIONS. Rpllor.ue,-WA 98008 AUTHORIZED REPRESENTATIVE . ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks:of ACORD INSURANCE REQUIREMENTS CHECKLIST Permit# 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: �<—$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 '® 15-11, Automotive Liability: "Any Auto"checked on certificate 6—$1,000,000 per accident for odily injury and property damage ❑ Policy expiration date `o (-1 ��. Workers'Compensation and Employer's Liability Waiver of Subrogation clause -$1,000,000 per accident for bodily injury or disease A,Policy expiration date 2 1 Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies k_ek `Additional Insured Endorsement(Description of Operations Area) ❑ The City, its officers, employees and volunteers are named as additional insured. r rV� (Reference Project Location& Permit Number) . "�a 7 ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: Ake, C� -.n��1\, C ��� ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\ioannat\Desktop\All Insurance Requirements.doc(Rev 03/13) Page 1 of 1 ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner 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: t' ��`-° ����S�J�E'S NAIC# Rating: -,/ Authorized in CA: Name: hlMPv�cc�_,. ';F\(e k NAIC#.D+06� Rating: ><N4,' Authorized.in CA: . Name: Cci")Q`�ltl NAIC# Rating: p� 11 Authorized in CA: Name: ��rC��l�� Y 1�1 -1 _NAIC# 10 1� Rating: I `'� 7��/ Authorized in CA: CO -Campbell Business License# Insurance Certificate Reviewed 4nlls Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. (�C)A�KOMCAIO,� S7 � 1 C:\Documents and Settings\)oannat\Desktop\Insurance Requirements 2 pgs.doc(Rev 03/13) Page 2 of 2