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ENC2016-00193 "Print Form Permit No — CITY OF CAMPBELL ENCROACHMENT PERMIT — DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File _. 70 North First Street right-of-way) Application Date Campbell,CA 95008 Application Expirations ate _ Ph. (408)866-2150 Issued APN �� Fx. (408)376-0955 7 Permit Expiration Date .G / APPLICATION-Application is hereby made for a Public Works Permit in c ordance with Campbell Municipal Code,Section 11.04. (Application expires in six (6) months ifthe permit is not issued. Application Fee is non-refundable.)da A. Work Address or Tract No.: ' �j 1 ) ' i Utility Trench Location: 6.11 2 d � ^� B. ,' Nature of Work: ._.. ... C. Attach four(4)copies of an engineered plan showing the location,and f tnd extent ohe woF,a(,J,d,oVr(4)copies of the preliminary Engineer's Estimate of work, The plans shall show the relation ofthe proposed work to existing surface and underground improvements. When approved i by the City Engineer,said plan becomes a part ofthis permit. i D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Telephone: Address: ............j A-4_ E-Mail Address: ` f 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by th2 property owners of thr own reside V �� )� 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 contractor(s) of the information. Appf ant is, advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages a 1ng out of improvements completed in the public right-of-way. A Accepted: -5?7x0imoc ?h_9 11, 6 (Applicant Permittee) (sign) Cfa4e- z te (Contractor) (Print Name) ate SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be. specifically approved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two(2)copies ofthe cut sheets sent to the Public Works Department before starting work. 4. . Per Section 4216 ofthe 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: 1-80.0-227-2600. USA TICKET NO. 5. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Ri t-of-Way,which shall be recorded. 6. P lie Notif. tion ,27 Re uireme ts: SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES Ali iT RP(-F7!pl- n_ (� PERMIT APPLICATION FEE $ � 7J PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE i For City Engineer ate GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained for the duration of the permit work. 2. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City.Surety posted shall be equal to 25%of the original Faithful Performance Security. 5. Submit project schedule 10(ten)days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures. This plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices(MUTCD). 10. Replace,as directed by the City Engineer,any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee as expeditiously as possible. 11. Sawcut for all FCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed.after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards.Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost(including all labor and materials)against the construction cash deposit. 14. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. .15. The Contractor or Permittee will have a supervisory representative available.for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m.and on weekends. 16. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 29. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge.per occurrence. 21. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system 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. 32. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant is here responsible for ensuring that all those providing services under the applicant are aware of and abid by all f the above conditions. Applicant ••���� Date/ ', TAI Z Contractor (Print Name) Da J:\FORMS\Templates\Encroachment Perm its\Encroach ment Permit STATIC form2.pdf a Rev.05/14 - PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2016 TO: Finance PUBLIC WORKS FILE NO. PROPERTY ADDRESS Please collect& receipt for the following monies: ACCT., ITEM AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $434.00 9-1 Encroachment Permit N/C Emergency Permits $122.00 Plan Check&Inspection Fee Minimum Charge Per Location $398.00 Conduits/Pipelines up to 500 Feet $2.81/ft Above 500 Linear Feet . $1.68/ft ManholesNaults/Etc. $179.00/ea Pole Set/Removal $179.00/ea 4760 Storage Container Permit(valid up to 60 days only) $163.00 4760 Project Plans&Specifications Project No. 4760 Standard Specifications&Details $1/Pg$15.50/13k 4760 Engineering Maps&Plans - Aerial Plot 24"x 36" $63.00 Aerial Print 8 112"x 11" $31.00 Map Researc�(indrudes max of two 24'x36"copies-$34-00 -- Maps and Plans 24"x 36" $15.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day(Muni Code Sec.11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/calendar Day 4722 Work Without Permits 4Times Applicable Fee TRAFFIC. ; 4728 Traffic Flow Map(Daily Traffic Volumes) $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 47281 No Parking Signs $1 each or$25/100 IIt11S:CELLANEOUS >. ` ;r n 511.7424 Postage Other(Please Specify) TOTAL NAME OF AIPPLICA,NT om 6 arIA— NAME OF PAYOR III d PHONE ADDRESS f'0 r '. ZIP D,3 a� FOR RECEIVED BY� (� �� OF �-t, A_n a .o u u G MPH- CITY E �., CLERK ONLY at� Receipt# 'a .0 i0 . . .?1LiiSe ie11� v<. i'i '-' DESCRIPTION AMOUNT w.,... It a-—_:I FILING lit a ry _,._.. TOTAL DUEs TENDERED: $832.00 RE NUM. i 4r a CERTIFICATE OF LIABILITY INSURANCE r ATE(MM/DD/YYYY) 09/26/2016 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: GRAND COMMERCIAL INSURANCE PH, ONpj 866 925-6288 pC No:866 519 6288 BROKERAGE E-MAIL ADDRess:GRANDINSURANCE ATT.NET GRANDINSURANCE(o)ATT.NET INSURERS AFFORDING COVERAGE NAIL FAX 866-519-6288,DIRECT 866-925-6288 INSURERA:AMTRUST INTERNATIONAL INSURED INSURER B: MID PENINSULA PLUMBING INSURER C THOMAS GARA III INSURER D:NATIONAL UNION FIRE INSURANCE P.O.BOX 7033 SAN MATEO,CA 94403-7033 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE INSD WVD POLICY NUMBER MMMD/YYYY MM/DD/YYY LIMITS A X COMMERCIAL GENERAL LIABILITY X X XN103756603 3/14/2016 3/14/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I OCCUR PREMISE, Eao"ccurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PRO LOG PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident D UMBRELLA LIAB X OCCUR EBU 028257922 3/14/2016 3/14/2017 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CIT OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED ADDITIONAL INSURED. THE INSURANCE COVERAGE AFFORDED TO THE ADDITIONAL INSURED IS PRIMARY INSURANCE. ALL WORK IN THE PUBLICK RIGHT-OF-WAY. FILE#ENC2016-00181 PROJ:35 DILLON AVE 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 N.FIRST STREET CAMPBELL,CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/011 The ACORD name and loao are registered marks of ACORD POLICY NUMBER: XN103755603 COMMERCIAL GENERAL LIABILITY NX GL 1 B9 0511 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided underthefollowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: XN103756603 Endorsement Effective: 3/14/2016 1201 a.m. Named Insured: Counter Signed By: THOMAS LAWRENCE GARA,DBA:MID PENINSULA PLUMBING .i. 24 SCHEDULE Name of Person or Organization: Any person or organization that the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above,information required to complete this endorsementwill be shown in the Declarations as applicable to this endorsement.) A. Section II—Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule,but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds,the following exclusion is added: 2. Exclusions This insurance does notapply to"bodily injury'or"property damage'occurring after: (1) All work,including materials,parts or equipment furnished in connection with such work,on the project(other than services,maintenance or repairs)to be performed by or on behalf of the additional insured(s)at the site of the covered operations has been completed:or (2) That portion of"your work"out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words'you'and"your"refer to the Named Insured shown in the Declarations. NX GL 189 0511 Page 1 of 2 Includes copyrighted material of Insurance Services Office,Inc.,with its permission POLICY NUMBER: COMMERCIAL GENERAL LIABILITY NX GL 189 0511 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. D. The following are added to SECTION V—DEFINITIONS: "Your work"means work or operations performed by you or on your behalf,and materials, parts or equipment furnished in connection with such work or operations. E. The following additional provisions apply to any entity that is an insured by the terms of this endorsement: 1. Primary Wording 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. 2. Waiver of Subrogation If required by written contract or agreement:We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of'you work"done under a contract with that person or organization. NX GL 189 0511 Page 2 of 2 Includes copyrighted material of Insurance Services Office,Inc.,with its permission zCJ Ff MSL DATH(MIIMD/YYYY) .4 � CERTIFICATE OF LIABILITY INSURANCE R002 9/27/2016 THIS CERTIFICATEIS 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 CONTACT NAME. COUCH-BRAUNSDORF INS GROUP INC/PHS (PIC,,"No,E)t): (866) 467-8730 FAX (888) 443-6112 650672 P: (866) 467-8730 F: (888) 443-6112 ADDRESS: 301 WOODS PARK DRIVE INSURER(S)AFFORDING COVERAGE NAICa CLINTON NY 13323 INSURER A: Hartford Casualty Ins Co 29424 INSURED INSURER B: INSURER C: TOM GARA DBA MID PENINSULA PLUMBING INSURER D: 138 .S B .S T INSURER E: SAN MATEO CA 94401 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. LNSR TYPE 0FLNSVR4NCE ADDL SVRR POL7CYNUMBER PO CYEFD/PYF POL7CPEXP LUIM COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE❑OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) PERSONAL&ADV INJURY GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY PRO LOC PRODUCTS-COMP/OP AGG OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANYAUTO BODILY INJURY(Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Peraccident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Peraccident) S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ WORNERSCOMPENS41701V X PER OTH- ANDEMPLOFER4'LIABILErY STATUTE ER ANY PROPRIETOR7PARTNER/EXECUTIVE YIN E.L EACH ACCIDENT $1, 0 0 0, 0 0 0 OFFICER/MEMBER EXCLUDED? A (Mandatory in NH) ❑ WA 13 WEC BK7020 03/09/2016 03/09/2017 E.L DISEASE-EA EMPLOYEE $1, 000, 000 If yes,describe under $1 0 0 0 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT Q DESCRIPITON OF OPERA77ONS ILOCAT70NS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. City of Campbell, its officers, employees and volunteers are included in the Waiver of Suborgation. All work in the public right of way at 35 Dillon. File Number: ENC-201600181 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED The City of Campbell BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE y p DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RE• Public Works AUTHORIZED REPRESENTA17VE 70.N 1ST ST CAMPBELL, CA 95008 � � f 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Zol9 .4►Co CERTIFICATE OF LIABILITY INSURANCE 09/( i20 2•r 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 policylles)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 endorseme S. PRooucER CONTACr STATE FARM INSURANCE NAMe: SHERRI WARMAN Shiftfiam BRIAN TAKEMOTO-AGENT PHONE 650-340-6955 FAX 1516 EL CAMINO REAL,SUITE 220 oRess SHERRI@8RIANTAKEMOTO.COM . SAN MATEO, CA 94402 INsu s AFFORINNG COVERAGE NAIc s MBURERA:State Farm Mutual Automobile lnsuranceCompany 251" INSURED TOM GARA, III INSURERS: DBA:MID PENINSULA PLUMBING INC; PO BOX 7033 INSURER 0: SAN MATEO. CA94403 INSURERE: 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. LTR TYPE OF INSURANCE POLIGYRUMBER POLICY EFF LfbRT8 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIM84AADE FI OCCUR PREMISES Ea occurrersoe $ MED EXP(Arse one person) 3 PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY ElJER T LOC PRODUCTS-COMP/OP AGG $ OTHER L S A AUTOMOBILE UABILrrY COMaMMINGLE LIMIT Y 322 2330-1002.0 091021201s ONOM17 Ea McIft t s 1,000,E ANY AUTO 322 2331-Ce2-05 09102/20/6 09►0212017 BODILY INJURY(Per person) S ALL OWNED x71 AUTOS LED BODILY INJURY(PereoadwA) AUTOS $ HIREDAUTOS X NON-0wNED 3� 7'�2'� 08102/2018 091021201T PROPERTY DAMAGE $ AUTOS 327 2477-D1346 0910=16 0910=17 � s UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR HCLAJUS44ADE AGGREGATE S DED I I R I S WORKERS COMPENSATION AND EVIPLOVERS'LIABILITY YIN 9MTAKTUTE ER ANY PROPRIETORIPARTNEWEXECUTIVE = E.L.EACH ACCIDENT S OFFICERIMEMBEREXCLUDED? NIA In E.L.DISEASE-EA MEIP S 9weswft under IPTION OF OPERATKM below E.L DISEASE-POLICY LIMIT I$ A AUTOMOBILE PHYSICAL DAMAGE COVERAGE SAME POLICIES AS ON0212016 0910212017 COMPREHENSIVE DEM SIXIM.WD ABOVE&BELOW COLLISIONOEDUcMUES5om1,000 OESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddWoml Rwarke Schadul%my be aftelud U awre apme Is required) AS RESPECTS:PLUMBING SERVICES RE:City of Campbell,Irs offmrs,employees and volunteers are names as additional insured coverage extends to following list of vehicles:l)1994 FORD E260 VAN POLAI 322 2330-CO2405;2)1999 FORD F250 SD PU#322 2331-0O2-05;3)2009 GMC YUKON SPORT WG #322 2347-0O2-05; 4)2002 FORD F450 SD DMP SGL#327 2477-013-05;5)1998 CHEV C3500 UTIL TRK*326 W52-D13-05 / V CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE VRLL BE DELIVERED IN 70 N First St ACCORDANCE WITH THE POLICY PROVISIONS. Campbell,Ca 95008 ALrtxoRLZFa ATnrE 0 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 CERTIFICATE OF LIABILITY INSURANCE Roo 927/2Do1166 THIS CERTIFICATEIS 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 endorsements. PRODUCER CONTACT NAME: COUCH-BRAUNSDORF INS GROUP INC/PHS �AC,,No,E,n): (866) 467-8730 x.No): (888) 443-6112 650.672 P: (866) 467-8730 F: (888) 443-6112 ADDRESS: 301 WOODS PARK DRIVE INSURER(S)AFFORDING COVERAGE NAIC# CLINTON NY 13323 INSURERA: Hartford Casualty Ins Co 29424 INSURED INSURER B: INSURER C: TOM GARA DBA MID PENINSULA PLUMBING INSURERD: 138 S B ST INSURER E: SAN MATEO CA 94401 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. Imm TYPEOFJNSVRANCE ADDL SUER P0LR7YNVMBER PM�D EFF POLICYEXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE ❑OCCUR DAMAGE TO RENTED $ PREMISES Ea occurrence MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OPAGG $ JECT El OTHER: $ AUTOMOBILE LIABILITY CEa acciOMBINED dent)SINGLE LIMIT $ ( ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- ANDEMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN EL.EACH ACCIDENT 11, 000, 000 OFFICER/MEMBER EXCLUDED? A (MandarorylnNH) ❑ wA 13 WEC BK7020 03/09/2016 03/09/2017 E.L DISEASE-EA EMPLOYEE 1, 000, 000 If yes,describe under E.L.DISEASE-POLICY LIMIT 11000 DESCRIPTION OF OPERATIONS below / , 000F DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The City of Campbell AUTHORIZED REPRESENTATIVE ` 10 N 1ST S T CAMPBELL, CA 95008 / f ©1988-2016 ACORD CORPORATION.All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD IN URANCE REQUIREMENTS CHECKLIST Permit# ��`�'��%%"'� ChP Project# Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and'property damage: $1,000,000 per occurrence, and ❑, $1,000,600 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. d-Policy expiration date Automotive Liability: ❑ "Any Auto" checked on certificate -22f $1,000,000 per accident for bodily injury and property damage Y- Policy expiration date kers' Compensation and Employer's Liability D� Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease -Rolicy expiration date g 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: r / The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". r OR should say: ❑ Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner 1:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Acceptability of insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: `�`�'}5 NAIC# Rating: 1"\ Authorized in CA: Name: NAIC# 25-05 Rating: �` V Authorized in CA: Name: a• NAIC# '�`�L W_6ting: t Y\/ Authorized in CA: Name: NAIC# Rating: Authorized in CA: GI'Campbell Business License# C�� 1 Expiration: \rt- `g( Contractors License# `�� l ( 1 Class: Expiration: Insurance Certificate Reviewed I iti Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2