ENC2016-00181 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) Appl
ication Date
Campbell,CA 95008 _ Application Expiration Date _-
Ph. (408)866-2150 Issued APN 41 zt�n�
Fx. (468)376-0958
Permit Expiration Date
APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04. (Application expires in six
(6) months if the permit is not issued. Application Fee is non-refundable.)
II /�
A. Work Address or Tract No.:
Utility TrencWLocation:
B. Nature of Work: i�e
C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four( )copies of the preliminary Engineer's
I
Estimate of work. The plans shall show the relation of the propo d worktgexisting e aTGA_
erground improvements. When approvedby the City Engineer,said plan becomes a part of this permit. q Des
D. All work shall conform to the City of Campbell Standard Specifications and 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: L-46 J ! Telephone;
Address: 35 �Lg/` W,• .'.-. _
E-Mail Address: TtqI�I EMERGENCY PHONE NUMBER:
Is this work being done by the property owners at their own residence? F_ YES I 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. I
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owners successors, shall be I
responsible for l damages ansi j of im vements completed in the public right-of-way.
Accepted: � /IXIVGcr ��/) ( l/7V / / ✓ �(O i
� (App• nt Permittee) (sign) D41t I
Phut- A%,1T4 W Y L'f, s g I Ca
(Contractor) (Print Name) Dale
SPECIAL PROVISIONS:
1. Street shall not be open cutfor underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be.
specifically approved by the Inspector prior to cutting.
2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
"A",unless otherwise approved by the Engineer.
3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent 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. FublicNotification Require nts:
7.
SEE PUBLIC' R 5��`Z i-i E FOR CI�iPE'S T' "InL AMOUNT RECEIPT Nn
PERMIT APPLICATION FEE L $ zaQ
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $ SOO-�
PLAN CHECK&INSPECTION FEE $ 3$O
-E_ _ .E .... FEE k $ 2y1'_ 2(0 SZln
S-1'VIAA qla
APPROVED FOR ISSUANCE �O
For Citv Engineer Date
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 ifthere 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.Perm ittee.
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%ofthe 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 Controi 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 Inay 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 reauired 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
rfto distribution and include dates of work and a contact name and phone number.
Appl'c is h eby responsible f uring If those providing services under the applicant are aware of and abide by all of the above conditions.
a,
pplicant Date:
PAU I� /-)TM OgH cl /2 9 l b
Date:
Contractor (Print Name)
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PUF° WORKS DEPARTMENT LAND DEVELOPM6 r
Effective July 1,2016
TG',Finance PUBLIC WORKS FILE NO.
PROPERTY ADDRESS 35 D� ll�n
Please collect&receipt for the following monies:
ACCT. ITEM - ..AMOUNT
LAND DEVELOPMENT
4722 Encroachment Permit Application Fee
Non-Utility Encroachment Permit Ma'or 2: 10,000 $403.00
Minor Encroachment Permit<$to,000 $230.00
Initial R-1 Permit N/C
Subsequent R-1 Permits within Two Year Period $230.00
Inspection Fee Minimum Charge per Location $398.00
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 Gradinq&Drainage Plan Review
Single Family Lot $281.00
Site<10,000 s.f. $841.00
Site>_ 10,000 s.f. <0.5 Acre $1,127.00
Site>_0.5 Acre $1 688.00
4722 NPDES Review C3 Requirements)
For projects not required to submit numeric sizing $163.00
For projects required to submit numeric sizing
Impervious Area 10,000 S . Ft to 1 Acre $704.00
Impervious Area 1 Acre or more $918.00
4722 For ro'ects sent to Consultant for review Consultant Cost+20%
4722 Additional treatment facilities $300 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_<$500 000 $35,000+8%of Enqineers Estimate
4722 En r. Est. >$500 000 $55 000+7%of En ineerc Estimate
2203 Emergency Cash Deposit 4%of Enqr. Est.*($500 min/$10 000 Max)
2203 Faithful Performance Security FPS 100%of ENGR. EST.* ROD
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) $4009.00+$87/lot
4722 Final Tract Ma (5 or More Lots) $4,871.00+$118/lot
2203 Monumentation Securit 100%of Citv's Monumentation Estimate
4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy)
4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,893.00
4722 Vacation of Public Streets&Easements $2,530.00
4722 Certificate of Compliance $1,877.00
4722 Certificate of Correction $561.00
4722 Document Recording Fees $15.00/first page$3 ea.Additional
4722 Private Improvement in Public ROW $50.00
4722 Approved Plan Revision Fee $100/sheet
4722 Appeal Filing Fee $200.00
47221 Notary Fee (per signature) $10.00
4722 Assessment Segregation or Reapportionment
First Split $895.00
Each Additional Lot $281.00
511.7424 Postage
MISCELLANEOUS--_.._._ .__ ". - • _
Other(Please Specify) Q
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ !9l I '—"'
NAME OF APPLICANT
NAME OF PAYOR CC ��p , e bL �T(U PHONE
ADDRESS �J o 4 ZIP
SEP 1 5 affi
FOR RECEIVED Y .
CITY CLERK 1I w Y OF GAMF8ELL.
ONLY Date Receipt# ( iCJJ U. a
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CIT'Y of CAMPBELL
Public Works,Department
February 6, 2018
Liane and Steve Burton
35 Dillon Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2016-00181
35 Dillon Ave., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear Liane and Steve:
The City of Campbell has made the final 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.
The remaining 25% of your Faithful Security Deposit in the amount of$625.00 is
enclosed.
Sincerely,
Syed Wahidi
Public works Inspector
7o North First Street•Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 •TDD 408.866.2790
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AMPBELL 'CA
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CITY OF CAMPBELL
70 NORTH FIRST STREET
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COPPER BlosroN
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CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR ONE YEAR MAINTENANCE
ACCEPTANCE LETTER
Encroachment Permit # ENC2016-00181
Property Address
35 Dillon Ave.
Date of Final Inspection: -b1*6qtT7—
On File: Bonds CD Cash
Faithful Performance $6`42 @@(0 (R rtia ng 5%0)
Labor and Material $
Construction Cash Deposit to be released: $
Other overdue deposits to be released (Description):
Processed by:
ml ' trator
Reviewed by:
Inspector
Reviewed by: V\ 4:5- I
Land Development Engi eer
J:VoAnnaMeposit refunds\Dillon 35..doc(Rev. 10/11)
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Encroachment Permit Final Sign Off
Encroachment Permit# L.
Address:
Date of Final Inspection and Acceptance:
Inspected.by: 5�j
OK to release deposits: 100% v 75%
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Comments:
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CITY OF CAMPBELL
Public Works Department
January 25, 2017
Liane and Steve Burton
35 Dillon Ave.
Campbell, CA 95038
SUBJECT: PERMIT NO. ENC 2016-00181
35 Dillon Ave
FINAL INSPECTION AND ACCEPTANCE
Dear Liane and Steve:
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 21, 2016.__
The permittee 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.
75% of your Faithful Security Deposit in the amount of$1,875.00, and your Emergency
Cash Deposit in the amount of$500.00 is enclosed. We will continue to hold 25% of
your Faithful Performance Security cash deposit for one year as a maintenance surety.
If you have any questions,please call me at(408) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Inspector/Suspense Files
Permit File
70 North First Street • Campbell, California 95008-143.6 TEL 408.866.2150 • FAx 408.376.0958 TDD 408.866.2790
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Refundable. De osit. Check..Re ues
To: Finance Director:.
Check Payable To Copper Burton..
Address-Line,1:: 35 Dillon Ave:. _
Line 2:. -
City: Campbell' State: CA Zip:;95008
Descnptlon:, ERC2019,`00161
-Account Number: - 101 2203 Amount _,$525 00
Account Number:` `'.. Amount:.
Account 101°.540 7448 Amount:
,'{(Finance Dept only)'• Interest Earned ... (Fmence,Dept only)
.'Total Payable:,. i_ (Exact Amount) .
Purpose:,_" Remaining 25%'of FPS
:Permit'#: - ':ENC2016.001;8.1
Receipt'#. ;:265070 _ Date: 8/2/2016
Requested by.:• Title. Office:$"pec Date; 1/22/2018.
JoA na Tho on
Approved by, Title Sr.,Engi'neer Date:
:Roger Storz "
:.. Finance Dept Only
Verified by; :, Title: . _ Accounting,Clerk II. Date:
Approved by' Title ; . '. Accountant. Date:,
S eci:al Lnstr ict on Fo`r y:Hand:H-6 Check
Mail As Is Maii,in Attached Envelope: Interim Check
eeded 13y `
Refur To. JoAnna Thomason „' Public Works
(Name) (De'partment)
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6:Forms/excel/chkreq Revised 05/Oo..
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CITY OF CAMPBELL
Public Works Department
January 25, 2017
Liane and Steve Burton
35 Dillon Ave.
Campbell, CA 95038
SUBJECT: PERMIT NO. ENC 2016-00181
35 Dillon Ave
FINAL INSPECTION AND ACCEPTANCE
Dear Liane and Steve:
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 21, 2016.
The permittee 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.
75% of your Faithful Security Deposit in the amount of$1,875.00, and your Emergency
Cash Deposit in the amount of$500.00 is enclosed. We will continue to hold 25% of
your Faithful Performance Security cash deposit for one year as a maintenance surety.
If you have any questions,please call me at (408) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Inspector/Suspense Files
Permit File
70 North First Street • Campbell, California 95008-143.6 •TEL 408.866.2150 • FAx 408.376,0958 -TbD 408.866.2790
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CITY OF CAMPBELL VENDOR No: 10014188 CHECK NO. 260841
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CITY OF`�AMPBELL
70 NORTH FIRST STREET j
CAMPBELL., CALIFORNIA 9SO08
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COPPER BURTON
35 DILLON AVE.
CAMPBELL CA 95008
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Refundable . Deposit Check Request
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Address Line 1 .35 Ullon Ave
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'City Campbell ,State CA Zip 95008
Descnpfion ENG2016.-00181:, '";
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Account Number 101 2203 Amount ;$2 375.00 1.
Account Number ,
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Account Nunbe, 101 540 7448 y Amount
(Finance Dept only) ;interest Earned (Finance Dept only)
Total Payable _ (Exeot.nmount) I --
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Purpose FPS>�Emea 'n Cash refunds
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, Permit# ENC2016=00181:-
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Receipt.* .. 265070• 'Date 8/2/2016
Requested by r } Title PW Inspector` Date F
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Encroachment Permit Final Sign Off
Encroachment Permit# ` -N -
Address: �S t 1 cnr, /fie
Date of Final Inspection and Acceptance: 2/2� /I Co
Inspected by:
OK to release deposits: 100% 75%
Do_
Comments: �� ~
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CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2016-00181
Name: Liane and Steve Burton
Property Address: 35 Dillon Ave.
Date of Final Inspection:
On File: Bonds CD Cash
Faithful Performance: $ 1,875.00 (750/a of 2,500.00)
Labor and Material: $
Construction Cash Deposit to be released: $500.00
Other overdue deposits to be released (Description):
Processed by: ,Q- o0
Ad im�ni rator
Reviewed by:
Inspector
Reviewed by:
Land b evelopment Engineer
J:VoAnnaT\Deposit refunds\CHECKLISTS\Dillon35..doc(Rev. 10/11)
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.a►`�o�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
6/30/2017
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 Sarah Mattos
NAME:
Dorsey, Hazeltine & Wynne PHONE (650)858-2375 A/C No:(650)856-1023
License # : 0281413 E-MAIL smattos@dhw-ins.com
400 Seaport Court, Suite 105 FCEFIVE�o ADDRESS: INSURERS AFFORDING COVERAGE NAIC#
Redwood City CA 94063 INSURERA:ROckhill Insurance Company
INSURED VU 11 INSURERB:OhiO Security Insurance
P.A. Lewis Construction, Inc. Pablfc wO'kS INSURERC:Financial Pacific Insurance C
P.O. Box 2003 adrninistrwI INSURERD:State Compensation Ins. Fund 35076
NSURERE:CNA Surety
Menlo Park CA 94026 INSURERF:
COVERAGES CERTIFICATE NUMBER:17-18 WC. 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.
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ADDLSUBRTYPE OF INSURANCE INSD WVD POLICY NUMBER MWDDNYYY POLICY
Y LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X�OCCUR PREMISES Ea occu ence $ 50,000
X RCGLPGO114702 9/23/2016 9/23/2017 MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY PRO ❑LOC PRODUCTS-COMP/OPAGG $ 2.000,000
X JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
B X ANY AUTO BA57581258 09/29/2016 09/29/2017 BODILY INJURY(Per person) $
ALLOWNED SCHEDULED X BODILY INJURY(Per accident) $
AUTOS AUTOS NON-OWNED PROPERTY
eO accident)PERTDAMAGE $
HIRED AUTOS AUTOS
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000
DED I I RETENTION �2730361102 9/23/2016 9/23/2017 $
WORKERS COMPENSATION X
AND EMPLOYERS'LIABILITY Y/NTATUTE ER
ANY PROPRIETORIPARTNERIEXECUTIVE E.L.E.L EACH ACCIDENT $ 1,000,000
OFFICEPJMEMBER'EXCLUDED? N/A
D (Mandatory In NH) 9138403-17 7/27/2017 7/27/2018 E.LDISEASE-EAEMPLOYE $ 1,000,000
IfyS describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY umrr I$ 1 000 000
E Contractors License Bond 62127122 08/14/2014 08/14/2017 Bond Limit 15,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required)
RE: ENC2016-00181 - 35 Dillon Avenue
City of Campbell, its officers, employees and volunteers are named additional insured per attached
General Liability and Business Auto endorsement forms. Primary and non-contributory wording applies.
Waiver of subrogation for General Liability and Workers, Comp are included. Notice of cancellation
provided per policy condition form.
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
Attn: Dept. of Public Works ACCORDANCE WITH THE POLICY PROVISIONS.
70 N. First St.
Campbell, CA 95008 AUTHORIZED REPRESENTATIVE
Cherryl Castano/CP
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(201401)
-s"�ENDORSEMENT AGREEMENT �� BROKER COPY
,mum,
COMPENSATION WAIVER OF SUBROGATION
INSURANCE
BLANKET BASIS 9138403-17
RENEWAL
NA
HOME OFFICE
SAN FRANCISCO EFFECTIVE JULY 27, 2017 AT 12.01 A.M. PAGE 1 OF 1
ALL EFFECTIVE DATES ARE AND EXPIRING JULY 27, 2018 AT 12.01 A.M.
AT 12.01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
P.A. LEWIS CONSTRUCTION, INC.
PO BOX 2003
MENLO PARK, CA 94026
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.
THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE
2.00% OF THE TOTAL POLICY PREMIUM.
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ANY PERSON OR ORGANIZATION BLANKET WAIVER OF
FOR WHOM THE NAMED INSURED SUBROGATION
HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS
WAIVER
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JUNE 19, 2017
2572
AUTHORIZED REPRESENT IVE PRESIDENT AND CEO
SCIF FORM 10217 (REV.7-2014) OLD DP 217
1 .
POLICY NUMBER: RCGLPGO1 147-02 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE.READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
Any person or organization to which you. are obligated by virtue of a written contract to
provide insurance ;such as is afforded by this policy, but only with respect to (1) occur
rences taking place after such written contract has been executed and (2)-occurrences.re-
sulting from work performed by you during the policy period, or occurrences resulting from
the conduct of your business during the policy period.
A person or organization that qualifies as an "insured" under the above paragraph of this
Endorsement shall be an additional insured solely with respect to such additional insured's
liability for. "bodily injury," property damage" or "personal and advertising injury" caused in
whole or in part by your acts or omissions in the performance of "your work" for the addi-
tional insured on-or at-"commercial construction projects." - - -
For the purposes of this Endorsement, "commercial construction projects" are defined as
buildings or structures constructed for commercial use and also include apartments, hotels,
homes for the aged, dormitories or barracks. However, "commercial construction projects"
shall not include any building or structure which, in whole or in part, contains 'individual
owner occupied units or dwellings.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
IWHO IS AN INSURED (Section II) is amended to include as.an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of 'your work"for that insured by or for you.
Coverage provided by this policy to the Additional Insured(s) shown in the Schedule
shall be primary insurance and any other insurance maintained by the Additional
Insured(s) shall be excess and non-contributory, but only if required of the Named
Insured and by written contract.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 , Page 1 of 1 0
COMMERCIAL GENERAL LIABILITY
CG'20 33 07 98
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 these addi-
include as an insured any person or organization tional insureds, the following additional exclusion
for whom you are performing operations when you applies:
and such person or organization have agreed in This insurance does not apply to:
writing in a contract or agreement that such person
or organization be added as an additional insured "Bodily injury', "property damage" or"personal and
on your policy. Such person or organization is an advertising injury"arising out of the rendering of, or
additional insured only with respect to liability aris- the failure to render, any professional architectural,
ing out of your ongoing operations performed for engineering or surveying services, including:
that insured.A person's or organization's status as 1. The preparing, approving, or failing to prepare
an insured under this endorsement ends when or approve, maps, shop drawings, opinions, re-
your operations for that insured are completed. ports, surveys, field orders, change orders or
drawings and specifications;and
2. Supervisory, inspection, architectural or engi-
neering activities.
Coverage provided by this policy to the Additional Insured(s) shall be primary insurance and any other
insurance maintained by the Additional Insured(s) shall be excess and non-contributory, but only if required of
the Named Insured and by written contract.
CG 20 33 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 0
POLICY NUMBER: RCGLPGO1147-02 COMMERCIAL GENERAL LIABILITY
CG 24 0410 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
Any person or organization to which you are obligated by virtue of written contract to provide insurance
such as is afforded by this policy, but only with respect to(1)occurrences taking place after such written
contract has been executed and (2) occurrences resulting from work performed by you during the policy
period,or occurrences resulting from the conduct of your business during the policy period.
(If no entry appears above,information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV —
COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:
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,
CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 0
` NDORSEMENT AGREEMENT BROKER COPY
COMPENSATION WAIVER OF SUBROGATION
BLANKET BASIS 9138403-16
NEW
NA
HOME OFFICE
SAN FRANCISCO EFFECTIVE JULY 2 7, 2016 AT 12.01 A.M. PAGE 1 OF 1
ALL EFFECTIVE DATES ARE AND EXPIRING JULY 27, 2017 AT 12.01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
P.A. LEWIS CONSTRUCTION, INC.
50 JENNINGS LANE
ATHERTON, CA 94027
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.
THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE
2.00% OF THE TOTAL POLICY PREMIUM.
SCHEDULE
PERSON OR ORGANIZATION JOB DESCRIPTION
ANY PERSON OR ORGANIZATION BLANKET WAIVER OF
FOR WHOM THE NAMED INSURED SUBROGATION
HAS AGREED BY WRITTEN
CONTRACT TO FURNISH THIS
WAIVER
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS 'STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUGUST 11, 2016
2572
AUTHORIZED REPRESENT/IVE PRESIDENT AND CEO
SCIF FORM 10217 (REV.7-2014) OLD DP 217
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.
COVERAGE INDEX
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 LI - 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;
U 2013 Liberty Mutual Insurance
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(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.1. - 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
g "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.
S. 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.S. FELLOW EMPLOYEE does not apply if the "bodily injury"
results from the use of a covered "auto" you own or hire.
h 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
O 2013 Liberty Mutual Insurance
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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 AA.a., Coverage Extension of SECTION Ill - PHYSICAL DAMAGE COVERAGE, is amend-
ed to provide a limit of $50 per day and a maximum limit of $1,500
N
2013 Liberty Mutual Insurance
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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 astolen covered "auto" to you. The maximum amount we will pay is $1,000.
N
11, PERSONAL EFFECTS COVERAGE
A. SECTION III - PHYSICAL DAMAGE COVERAGE, A. COVERAGE, is amended by adding the
fol lowing:
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
15
`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:
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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 1 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 lease's,
e. Final.payment due under a"Balloon Loan",
f. The dollar amount of any unrepairdd 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",
1. 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 Ahe balance over
the term of the, loan, thereby requiring a"large final payment.
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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
0 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
c' 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 9.2. 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.
b 2013 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 6 of 7
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, w AVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US
SECTION IV - BUSINESS AUTO CONDITIONS, paragraph A.S., 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 6.7., 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.
2013 Liberty Mutual Insurance
CA 88 10 01 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page-7.of 7
3'S f-Y\ INSURANCE REQUIREMENTS CHECKLIST
Permit# f--=" a of(42 ' �L�\ CIP Project#
Consultant/Contractor: C_\ 0\/--_
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 rl
being performed under contract for Capital Improvement Projects. -
Limits
Commercial General Liability for bodily, personal injury and property damage:
10 $1,000,000 per occurrence, and
❑ $1,000,000 general aggregate limit applying separately to the project, /
�e5 $2,000,000 general aggregate limit.
pr_ Policy expiration date zaj 1
Au omotive Liability:
"Any Auto" checked on certificate
$1,000,000 per accident for bodily injury and proper damage
6 K
o Policy expiration date �kn I t T
Workers' Compensation and Employer's Liabilit
Waiver of Subrogation clause
$1,000,000 per accident for bodily inju/re or disease
o\k )zf Policy expiration date 7/a7 /6l
Course of Construction (if required i Special Provisions)
o Completed value of the projec
❑ Policy expiration date
Required Endorsements to General Liability and Automobile Liability Policies
Additional Insured End fsement:
i
>6- The City, its offic s, employees and volunteers are named as additional insured.
(Reference Pr 'ect Location/Permit Number)
The ins, ance coverage afforded to the Additional Insured is primary insurance.
Cancellati��o area:
❑ CaZ
llation area of certificate edited to delete "endeavor to" and "but failure to mail such
no shall impose no obligation or liability of any Kind up on the companV, its agents or
epresentatives".
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
J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1
Acceptability of Insurer(s)
❑ insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the
State of California.
Name: R[Ky,�k\A �—� NAIC# RatingA — \\ Authorized in CA:
Name: S ee. C"_.G"",z) NAIC# Rating: Authorized in CA:
Name: �,2 C� NAIC# Rating: 2 X� Authorized in CA:
Name: NAIC# Rating: Authorized in CA:
Campbell Business License# ���-3 a0 I Expiration: �I r
Contractors License Class Expiration:
Insurance Certificate Reviewed
Initials 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
10/3/2016
1:40PM
C E L; Payment History For
Case#: ENC2016-00181
.� Recorded
Type Fee Tl)# Description " Rees -I'a�d Date'Paid '. 'Check# Receipt# ' RY Due History
> Z
FPSD 201609191530073130 Faithful Perf. Security/Dep 2,500.00 2,500.00 9/15/2016 265868 JF 0.00
AF01 201609201147558460 PrmtAppFee-Minor-Eng 230.00 230.00 9/15/2016 265868 JF 0.00
Est<10K
CASH 2O1609201149058120 Construction Cash Deposit 500.00 500.00 9/15/2016 265868 JF 0.00
PCI1 201609201149435790 Non-Util Plan Ck/Insp< 350.00 350.00 9/15/2016 265868 JF 0.00
$250K
SDC 201609201150280550 Storm Drain Fee-All 239.00 239.00 9/15/2016 265868 JF 0.0n
Others
Total Fees:$3,819.00 Paid:$3,819.00 TOTAL REMAINING DUE: $0.00
Page I of 1 CasePaymentHistory..rpt