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ENC2017-00225
OF C4�A A. 6, CITY OF CAMPBELL Public Works Department January 8, 2019 Barre Bonds 2175 De La Cruz Blvd. #C Santa Clara, CA 95050 SUBJECT: PERMIT NO. ENC 2017-00225 - 173 Carlyn Ave., Campbell, CA 95008 MAINTENNACE INSPECTION AND ACCEPTANCE Dear Barre: The City of Campbell has made the final maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety,therefore, are hereby released. Sincerely, Syed Wahidi Public works Inspector Cc: 70 North First Street Campbell, California 95008-1436 TEL 408.866.2150 FAx 408.376.0958 TDD 408.866.2790 Encroachment Permit Final Sign Off Encroachment Kermit# C17— Uci22j Address: t'Z C w l7� Date of Final Inspection and Acceptance: Inspected by: OK to release deposits: 100% 75% Comments: OF CqA6 r UkCHA&9 CITY OF CPBELL Public Works Department January 25, 2018 Barre Bonds 2175 De La Cruz Blvd. #C Santa Clara, CA 95050 SUBJECT: PERMIT NO. ENC 2017-00/225 173 Carlyn Ave. Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear Barre: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of December 20, 20.17. The permiftee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of$2,500.00 and your Construction Cash Deposit in the amount of$500.00 are enclosed. If you have any questions,please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Permit.File ENC 2017-00225 Suspense File 70 North First Street • Campbell, California 95008-1436 TEL 408.866,2150 FAX 408.376.0958 TDD 408.866,2790 ................................... ...................................... ....................... ............ ....................................... ..................................... ......................... ........................................ ............................... +I----- - ------------------------------ --------- CITY OF CAMPBELL VENDOR NO. 10014720 CHECK NO. 266135 ........... Account P ..... .... ........ ....... on 102: 2203 CRO10918 3,000.00 REF DEP ENC17-225 > i 10014720 1 F R'ENTERPRISES LLC MIT". RUIR61,00 1131,11-.14,11ml. CHECK DATE CHECK NO'. C TY. �i.:i�i0f'�AMPBELL 'Wk.ES FARGO BANK, N.A. -24 01/22/1, 8' 266135' MD MONTGOMERY STREET SCO, C 941 NORTH FIRST�TREET - 1210 SAN FRANC1 A 4 CALIFORNIA 9 008 10 AMOUNT 00 0 o ,VOID AFTER 90 DAYS PAY THE SUM OF 'THREE _THOUSAND DOLLARS -&: ZERO CENTS 1E 9 TO THE F PCENTERPRISES! LLC ORDER113 CARLYN AVE" < > of SANTA,,CLARA CA�, . 950501 ttt 2 66115 112 is L"2 10 0 0 IvEl i 5115 • • • ---------------------------------------- -------- ------------------------------- ------- ------ ----------------------------------------------------------------------------------------------- ------ .............. ............ ............. ........................... ...... ....................... ......................... ..................................... ........................................ ................................ ................................. ........................... ............................. ........................... *See Reverse Side For Easy Opening Instructions* ------------- ----------- ----------------------- ---------------- _ -- ------------------ --- - --- ------- - CITY OF CAMPBELL 70 ,NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 Ac I F R,ENTERPRISES LLC 173 CARLYN AVE SANTA CLARA CA 9505.0 l OF CA.y •Ok CH AKA - CITY ®F CAMPBELL Public Works Department January 25, 2018 Barre Bonds 2175 De La Cruz Blvd. #C Santa Clara, CA 95050 SUBJECT: PERMIT NO. ENC 2017-00/225 173 Carlyn Ave. Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear Barre: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of December 20, 2017. The permiftee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of$2,500.00 and your Construction Cash Deposit in the amount-of$500.00 are enclosed. If you have any questions,please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Permit,File ENC 2017-00225 Suspense File 7o North First Street Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finance PUBLIC WORKS FILE NO. ENC2017-1C)C) PROPERTY ADDRESS 173 Carlyn Avenue Please collect&receipt for the following monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT 4722 Encroachment ermlt Application ee Non-Utility Encroachment Permit Major>_$10,000 $425.00 Minor Encroachment Permit<$10,000 $240.00 $ 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 Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review Single Family Lot $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 Engr. Est. <$250,000 14%of Engineers Estimate $ 350.00 4722 Engr. Est.>_$250,000 and:5$500,000 $35,000.00+8%of Engineers Estimate 4722 Engr. Est. >$500,000 $55,000.00+7%of Engineers Estimate 2203 Emergency Cash Deposit 4%of Engr. Est."($500 min/$10,000 Max) $ 500.00 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* $ 2,500.00 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 Ma 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 Cit '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 47221 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 4722 Assessment Segregation or Reapportionment First Split 1 $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 $ 3,590.00 NAME OF APPLICANT Barre Barnes NAME OF PAYOR PHO.NE,_,_, 408-234-9061 ADDRESS 2175 De La Cruz Blvd#C Santa Clara 95050 FOR RECEIVED BY S-EF 27 20V ITY CLERK �A Y OF �a����� � � ONLY Date Receipt# G J:LLeermeNPlan Check Cvn 11-Specific P,ojecw-Active P,.jml in PmyeeslC Hp Ave 173U - »qeS= CASHIER gm«sQ? . . eqm: TER ae»gee we . . . \ TDgs bE: 9Q»g . . REGISTER +«: 09»g 2«: m!m DESCRIPTION q+» . . . . < my ?:g9G7 mG5 ' . . . < gR & mgR SSmF M.m . \ § . m R! 1.000 « . . . 9mamSD FILING l3Gm . mS D: s mo . . RF kmgT - lm «m.L . £CHI D: b ) RF RmgT - ------------------ TOTAL ma q!9&m E GQ i3.590.00 ' CHAR: tD . . . CHECK . $ .&G m \ : EGA mm Refundable beposif. ,Check-. Reguestf--f To: 'Finance Director—' Check Payable To; IFR Enterprises,-LLC, Address,-..'Line;1;' 21.75,de.La Cruz Blvd'.#C Line 2 City: Santa.Clara.. State: CA Zip: 95050 Description:, 173,Carlyn,Ave: Account Number: 101.2203. Amount: $2,500.00 Account Number: IM.'2203 Amount: ' 5.00:00 Account Number: 101.540.7449 Amount:. (Finance Dept only) Interest Earned (Finance Dept only) To tal'Payable (Exact Amount) Purpose: 173 Carlyn .i Permit#: ENC201.7-00225 Receipt-M. = 271627 ' Date: -_ 9/27/2017 i Receipt'M Date: Requested'by 'Title: Inspector Dafe: I -L. [b Syed Wahidr Approved.by: Title: Sr. Engineer Date: q l Roger"S orz,. Finance Dept Only:` Verified by: . Title: Accounting Clerk II :_ Date: 'Approved by;., Title: , Accountant Date: Special _Instructions For Ha�ndliflg .Check mail As Is: mau:in Attachety,Envelope:- Interim't;necK: Needed By: Return To;: :JoAn.na Thomason_ Public Works, (Department) _ Oth r..Please return;check.to.JoAnna CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00225 Name: Barre Barnes Property Address: 173 Carlyn Ave., Campbell CA Date of Final Inspection: On File: Bonds CD Cash Labor and Material: Construction Cash Deposit to be released: $500.00 Faithful Security Deposit: $2,500.00 Other overdue deposits to be released (Description): Processed by: �f d m i n istrabar Reviewed by: \ Inspector Reviewed by: lJet Land bevelopment Engineer J:\JoAnnaT\Deposit refunds\CHECKLISTS\Carlyn 173.doc(Rev. 10/11) i; Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No ENC2017-Oa Z.ZS DEPT.OFPUBLICWORKS (for working within the public X-Ref.File 70 North First Street right-of--way) Application Date 9-18-17 Campbell,CA 95008 Issued 1X Application Expiration Date 10-11-17 Ph.(408)866-2150 APN 305-23-029 Fx. (408)376-09SS Permit Expiration Date APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04.(Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: 173 Carlyn Avenue Utility Trench Location: NSA B. NatureofWork: Relocate Dwy approach 5 ft N of (E) Dwy and remove hardscape. C. Attach four(4)copies ofan engineered plan showingthe location and extent ofthe work,and four(4)copies ofthe preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part of this permit. D. All workshall conform to the CityofCampbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below.Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before startingwork.Notice must be given to Public Worksatleast24hoursbeforerestartinganywork. Name of Applicant: I Barre Barnes I Telephone: 408-234-9061 Address: 2175 De La Cruz Blvd #C, Santa Clara 95050 j E-MailAddress: barrebarnes@mac.com 124-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? ❑YES NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have r ad a front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised at uponp� tMis�ermit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of i pr menmp ted in he pub i ht-of-way. Accepted: Barre Barnes (Applicant Permittee) si Date Rodriqez Concrete Construe ZA 14K �Z (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 Pubic 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 RECEIPTNO. q PERMIT APPLICATION FEE $240.00 Z�\(��—7 l/Z-J) PLAN CHECK DEPOSIT $_0.00 _ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS ��$2500.00 CONSTRUCTION CASH DEPOSIT $.900.00 PLAN CHECK&INSPECTION FEE $350,00 EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE <i 11-7 For City Engineer ID o Permit Expires 12 Months After Date of Issuance ® - DATE(MM/DD/YYYY) ,d►co�o CERTIFICATE OF LIABILITY INSURANCE �. 09/26/2017 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 endorsement(s). PRODUCER CONTACT NAME: Adlemi Trucking Insurance Services a/c°NIv Ext: 562-923-0333 FAX No:562-923-8111 P O Box 2371 E-MAIL ESS: adlemitruckinginsurance@yahoo.com Downey, CA 90242 INSURERS AFFORDING COVERAGE NAIC# INSURERA:Century National Insurance Company INSURED INSURERB: Pennsylvania Manufacturers Association Javier Rodriguez DBA Rodriguez Concrete INSURERC: 174 N.24th St. INSURER D: INSURER E: San Jose CA 95116 INSURERF: 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 EFF POLICY EXP LIMITS LTR I S D WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE OCCUR PREMISES R M SES Ea RENTED cur snce $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT PRO ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A AUTOMOBILE LIABILITY BAP0183669 12/29/201512/29/2016 COMBINED SINGLE LIMIT $ $1 000 000 Ea.cadent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED x SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B CARGO 811601-0716563Y 12/29/15 12/29/16 Limit $100,000 Deductible $1,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) A - 2007 Volvo Tractor VIN# 4V4NC9TG97N445641 Physical Damage $ACV Deductible $1,000 - Non Owned Trailer Physical Damage $ACV Deductible $1,000 ***CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED ON POLICY*** CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 North First Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Campbell, CA 95008-1423 ACCORDANCE WITH THE POLICY PROVISIONS. Fax-408-376-0958 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. 9RD 25(2014101) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) AcoRO . CERTIFICATE OF LIABILITY INSURANCE ��- 09/26/2017 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 IN the policy(ies) must be endorsed. If SUBROGATION IS WAIVED;subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the "certificate holder in lieu of such-endorsement(s). PRODUCER CONTACT NAME: Adlemi Trucking,Insurance Services PH0A/C N Ext: 562-923-0333 a/c No:562-923-8111 P O Box 2371 ADDRESS: adlemitruckinginsurance@yahoo.com Downey, CA 90242 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Century National Insurance Company INSURED l INSURERB: Pennsylvania Manufacturers.Association Javier Rodriguez DBA Rodriguez Concrete INSURERC: 174 N.24th St. INSURER D: INSURERE: i San Jose CA 95116 INSURERF: i 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. ILTR TYPE OF INSURANCE INNR D WVD POLICY NUMBER MM DIDY/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE CLAIMS-MADE OCCUR PREM SES�RE a oocur TE ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ - JECT OTHER: $ A AUTOMOBILE LIABILITY BAP0183669 12/29/201512/29/2016 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Fy SCHEDULED AU BODILY INJURY(Per accident) $ To AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? -� N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS belowi E.L.DISEASE-POLICY LIMIT I$ - B CARGO 811601-0716563Y 12/29/15 12/29/16 Limit $100,000 Deductible $1,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) A - 2007 Volvo Tractor VIN#4V4NC9TG97N445641 Physical Damage $ACV Deductible $1,000 - Non Owned Trailer Physical Damage $ACV Deductible $1,000 3on _o\(c) z S✓ ***CERTIFICATE HOLDER'IS NAMED AS ADDITIONAL INSURED ON POLICY*** CERTIFICATE HOLDER CANCELLATION City Of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 North First-Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Campbell, CA 95008-1423 ACCORDANCE WITH THE POLICY PROVISIONS. Fax-408-376-0958 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 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. S. 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. Barre Barnes Y__ !n_C Applicant f^ Date; C Contractor (Print Name) IY/r r/ `f Date: J:\FORMS\Templates\Encroachment Perm its\Encroachm ent Permit STATIC form2.pdf Rev.03/17 8• Soh �O„ P Qp�C��S � ILI ILI PARKSTRIP W y w / I w �—MECHANICAL R SEPARATOR -CONSTRUCTION JOINT SIDEWALK SEE NOTE 5 WEAKENED 4�Oy PLANE JOINT OR CUT JOINT W �p 1/8" WIDE, p 2' DEEP WEAKENED Ev JOINT q OR CUT 1/8" WIDE 2" D IV �11, � �. .!, I 3/4" S=1„ o; \\1 P PERFOOT 5/8" 1"R 1/2" R 8'-0" 4'-0" 4'-0" 2'-0" +10% MAX 6" CONFORM SLOPE = 2.0% —6% MAX '�'° .:d;' :d;' a:�;' a.o-•. 6" CLASS A CONCRETE, TYP. 6" CLASS 2 AGGREGATE BASE, TYP. •':•°•�."�`�•:•a.;'.;�:.•:a. NOTES SECTION A—A DOWEL 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF NO. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. OV C A Af p CITY OF CAMPBELL REV. DATE BY SCALE: -� s PUBLIC WORKS DEPARTMENT 1 02/17 HE .� Residential N.T.S. " DRAWN BY: EA DATE 10/04 Driveway Detail •Qo.9�1' DETAIL • .:�:o.�d°' CHECKED BY: DATE (Detached Sidewalk ) NO. ti APPROVED BY: A��0RcEAVO�� AMY °G � J:/Drawings/Std_Details/D14.1 D— 14•�• v • • p • S a I I• 91 �— I r n • -I I__ I f D A tz, ------------------- ------------ }+T I • i I E--sm . . . . . . . . . . . . . s ir-. . \I 1 IIww I I b 8 A � 5 ©� awl I Il 11 lzHa bx012@G. I I < I I - III I III III � 11 111111.11i gs01 �• I I I I lal ; � � Y0 b ®Q QT E® °o 1 II IIIIIII 1 Je2� HARDY VE s y r QI 3 II 1 I I I I IL I I I I 1 I I I I y - e ��3 � �j �' �.• ��� 3 1-+-+-r--+ li-- -11TJr-I m $ sea2g� �R �gJ P I I I I I I I I I I I II I I I I D9^- D I I I I I I I 1 II I I 9.�L�-1-L-1-LJ-1J-J-1--LLJ-1J ^' U i nI Sqg LYNAVE e � n- ® �9 9elf g =g 3p �T OCi 9 $iV V� AY�$�•' b �g� E m I$� s g bb�b��o�e�eS�o R V»mGwGmpXSIR: - PUP go PoA P N Pell oil � � sna� n•a � § 0 DMGN MR MVBION PARTNOM WITH 91 416, AL J, J SGD 0�'S tioG lie v PARKSTRIP v ..O�MECHANICAL R SEPARATOR CONSTRUCTION JOINT SIDEWALK SEE NOTE 5 WEAKENED w PLANE JOINT OR CUT JOINT 1/8" WIDE, 2' DEEP WEAKENED PLANE,JOINT 2R DCUT EEPS'OINT�1/8'� WIDE v `L 3/4„ S=1" ''a; '• 0 PER FOOT 5/8" O 1"R 1/2" R R go-o" 4'-6" 4'-6" 2'_on +10% MAX 6" CONFORM\ SLOPE = 2.0% _ a. ' .a. ..• .a. a. .+• 1. —6% MAX °..'. _ °. ..:o-.. :a.. :°.:a..• °..a,.. ' O•V'.'.1 .4 :• 1 .4.O.•..1 Q. 6'i CLASS A CONCRETE, TYP. 6" 6" CLASS 2 AGGREGATE BASE, TYP. g oa o a NOTES SECTION A—A DOWEL 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF NO. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. of CA AfA CITY OF CAMPBELL REV. DATE BY SCALE: PUBLIC WORKS DEPARTMENT 1 02/17 HE a Residential 7 N.T.S. DRAIN BY: EA DATE 02/04 Driveway Detail DETAIL :a•SJd" CRECKED BY: DATE (Detached Sidewalk ) C NO. APPROVED BY: �h oII Att9 TE GINEER J:/DrawingslStd_DetallslD14.3 D---14°3 8• p� a.( • OA \OA W W v P� `04 w PARKSTRIP W w w W MECHANICAL SEPARATOR CONSTRUCTION JOINT SIDEWALK WEAKENED SEE NOTE 5 4"0A PLANE JOINT W OR CUT JOINT �pl 1/8" WIDE, 2 DEEP ti WEAKENED EW JOINT W p. 2R DCUT w 1/8'*WIDE f . w W w w t W y`Z w v• W .ifi -..s{ 3/4" S_1" PER FOOT 5/8" 1"R 1/2" R 4'-0" 4'-0" 2'-0" +10_% MAX 6" CONFORM SLOPE = 2.0% :. —CR.—MAX �:a:' 6" CLASS A CONCRETE, TYP. " 6" CLASS 2 AGGREGATE BASE, TYP. NOTES SECTION A—A DOWEL 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER. 12" OF NO. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. 01 C$Arp CITY OF CAMPBELL PXV.1 DATE BY SCALE: 1 02/17 A,A, � PUBLIC WORKS DEPARTMENT 8$ Residential N.T.S. o:. g•. r nRAfnv BY: Ea DATE io/o¢ Driveway Detail DETAIL :Qo ors :'p n64 clom D BY: DATE (Detached Sidewalk ) NO.APPROM Br: °$ Ag° E°G� J:/Drawings/Std—DeW1s/D14.1 D—14-•1 I [�LIMQ3lDii[IIVd I I NOISM I I EQI.NJsia U I� It K o g�g f �� S G lie. u, n a 3 $alb 13AR MR�eH jjj• ,�g{sa4.�'c.R..: QQ ��«�<KK cma —tB6 Q i 'a 0 q� 3ANAIV rTT I--r $ > > y > I I I I I I I I 1 I I I I I I 1 I I Q a 11 I 1 I JI I I ! 1 I I I I I I I e $ 81 3 � II Jr1rLr�r —+_l 1_+-4,7 7L-T � LY m p p t= I I I I I I I I I I I 1 1 I , Q '{• 8a �'� S gg g� 3nv raav I I 1 1 I IL—J lJ cC 9 2 y s� _ ►'I 3 gg5t6R W _ � I �- Q w aoQpIgo%ade0 e e \ m , I I I I I I � I I I.I I I �� �` � • c sZ. I I h a I FI' a j • •J a¢vrt �K _ i I . . .1 1. • I !U h J j iL_._. ----------------- ---------- - -- - - -;-. - — �h • � . . ro. r • r • r . rh I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY MWC 1400 0510 BLANKET 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 any 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. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule I. Blanket Waiver Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. 2. Premium: The additional premium charge for this endorsement shall be 3 percent of the California Workers, Compensation pre-mium otherwise due subject to a minimum premium of$750 per policy. 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 07/05/2017 Policy No. MWC0052320-05 Endorsement No. Insured: Rodriguez,Javier Premium(See Attached) Insurance Company: Markel Insurance Company Countersigned by MWC14000510 Includes copyrighted material of National Council on Compensation Insurance smith its permission Copyright 1983 National Council on Compensation Insurance. 12of12 cof\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: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or -$2,000,000 general aggregate limit. lly Policy expiration date 7— b Automotive Liability: ❑ "Any Auto"checked'on certificate ❑ $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and.Employer's Liability >6- Waiver of Subrogation clause -4 $1,000,000 per accident for bodily injury or disease Policy expiration date nilla Course of Construction (if required in Special Provisions) ❑. Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement(Description of Operations Area) The City, its officers,-employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) N4 The insurance coverage afforded to,the Additional Insured is primary insurance. Cancellation.Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read 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$\)oannat\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. �5 Name: US 51pec�O,�--1 NAIC# 2 Rating: Authorized in CA: Name: �M ,j\/xcV NAIC# 3VVIORating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: -NAIC# Rating: Authorized in"CA: �.� ❑ Campbell Business License# Insurance Certificate Reviewed Initial Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. W-K C:\Documents and settings\joannat\Desktop\Insurance Requirements-2 pgs.doc(Rev 03/13) Page 2 of 2 RODRIA OP ID: FF DATE(MMIDDIYYYY) ACORO' CERTIFICATE OF. LIABILITY INSURANCE 09/2512017 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 endorsement(s). PRODUCER CONTACT NAME: Jesus Rojas Business Owner's Ins.Agency PHONE FAX Genesis Ins.Svcs USA,Inc. Arc No Ext:858-874-0101 Arc No): 858-874-3801 3914 Murphy Canyon Rd.#A239 EMAILADDRESS: San Diego,CA 92123 Francisco Flores INSURER(S)AFFORDING COVERAGE NAIC tY INSURER A:U.S.Specialty Ins.Co. INSURED RODRIGUEZ CONCRETE INSURER B:Markel Insurance Company 38970 JAVIER RODRIGUEZ 174 NORTH 24TH STREET INsuRERc: SAN JOSE, CA 95116 INSURERD: f INSURER E: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F3(1 OCCUR X U15AC88161-02 07/07/2017 07/07/2018 DAMAGETO R N ED PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JECOT PR ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident 11 $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STER ATUTE ER H AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNERIEXECUTIVE Y 1 N X MWC0052320-05 07/01/2017 07/01/2018 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMSER EXCLUDED? N r A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Cityof Campbell,its officers,employees and volunteers are named as addiional insured for Project#173 Carlyn. Coverage is Primary and Non-Contributory if required by written contract per the attached as S endorsement. 10 days notice of cancellation if for nonpayment130 days l� notice for all other reasons.Workers Compensation Waiver of Subrogation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 North First Street Campbell,CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: U17AC813161-02 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR 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): Location(s)Of Covered Operations Any person or organization for whom you are performing operations during the policy period when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II —Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury', "property This insurance does not apply to "bodily injury' or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. Your acts or omissions;or 1. All work, including materials, parts or equip- ment fumished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insureds) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed;or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: U 1 7AC88161-02 COMMERCIAL GENERAL LIABILITY HCS 040 06 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY AND BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO B. WAIVER OF SUBGROGRATION —BLANKET OTHER INSURANCE Under SECTION IV — COMMERCIAL GENERAL With respect to any person or organization that is LIABILITY CONDITIONS, The Transfer Of an additional insured under this Coverage Part, Rights Of Recovery Against Others To Us the following is added to paragraph 4. of Condition is amended by the addition of the SECTION IV — COMMERCIAL GENERAL following: LIABILITY CONDITIONS: We waive any right of recovery we may have If you have agreed in writing in a contract or against any person or organization because of agreement that this insurance is primary and non- payments we make for injury or damage arising contributory relative to an additional insured's own out of: insurance, then this insurance is primary and we a. Your ongoing operations; or will not seek contribution from that other insurance. For the purpose of this endorsement, b. "Your work" included in the "products- the additional insured's own insurance means completed operations hazard". insurance on which the additional insured is a However, this waiver applies only when you have Named Insured. agreed in writing to waive such rights of recovery . When this endorsement is attached to the policy it in a contract or agreement, and only if the contract supersedes all other insurance conditions within. or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. HCS 040 06 10 13 Page 1 of 1. . Includes copyrighted material of Insurance Services Office,Inc.,with its permission.