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ENC20017-00184 Of- C44(A U r Nam`k t" y '"?CHAA'o. CITY OF CAMPBELL Public Works Department March 8, 2019 Peter and Melissa Bovenberg 655 E. McGlincy Lane Campbell, CA 950.08 SUBJECT: PERMIT NO. ENC 2017-00184 655 E. McGlincy Lane, Campbell, CA FINAL INSPECTION AND ACCEPTANCE. Dear Peter and Melissa: 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. Your original Maintenance and Faithful Security and Labor/Materials Bonds are enclosed. Sincerely, Syed Wahidi Public Works Inspector Enc: Bonds 44415192 Cc: SureTec Insr. Co. 70 North First Street Campbell, California 95008 • TEL 408.866.2150 • FAx 408.376.0958 TDD 408.866.2790 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2017-00184 Property Address : 665 E. McGlincy Date of Finaljspection: 3/7/19 On File: Bonds CD Cash Faithful Performance $ Labor and Material $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): ro Faithful Performance/Labor —Material Bonds on file. Processed by: Administrator Reviewed by: l� Inspector Reviewed by: pv�� Land Development Engi eer JA\JoAnnaRDeposit refunds\CHECKLISTS\McGlincy 665 final.doc(Rev. 10/11) Encroachment Permit Final Sign Off Encroachment Permit# r 2017-00 kpLv. Address: . Date of Final Inspection and Acceptance: f 1 Inspected by.- OK to release deposits: 100% 75% Cornments' Ov CA •�RCHARO. - CITY of CAMPBELL Public Works Department March 20, 2018 r' John Lyden DP Construction - 852 5t1i St. . Norco, CA 92860 SUBJECT: PERMIT NO. ENC b p\VA 665 E. McGlincy Lane; Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear John: 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 February 13, 2018. 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. Your Cash Deposit in the amount of$1,448.00 is enclosed. If you have any questions,please call me at (408) 866-2165. Sincerely, Syed Wa Public Works Inspector Cc:Peter and Melissa 13ovenberg Inspector/Suspense Files - Permit File:ENC2017-00184 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 BOND FOR FAITHFUL PERFORMANCE ENCROACHMENT PERMIT NO. ENC2017-00184 We,the undersigned Peter Bovenberg and Melissa Bovenberg (hereinafter"Principal")and SureTec Insurance Company a corporation organized under the laws of the . State of Texas and authorized to transact business in the State of California, as Surety, are obligated to the City of Campbell, (hereinafter"City") a municipal corporation under the laws of the State of California,in the sum of Thirty Six Thousand Two Hundred and 00/100 Dollars ($36,200.00 )for the payment of which sum we obligate ourselves and our successors and assigns,jointly and severally by the following provisions: The condition of this obligation is: Because the obligated Principal has, on September 12 2017 entered into written Encroachment Permit with the.City for the Project, a copy of which Encroachment Permit is attached and made a part of this bond, for constriction of Project New Automotive Repair Use(PLN2016-290)at 661-667 East McGliney Lane,Campbell,CA 95008 . Now,therefore, if the Principal shall faithfully perform the work'in accordance with the plans, specifications and permit documents during the original term,and any extensions of the permit which may be granted by the City,with or without notice to the surety,and if it shall satisfy all claims and demands incurred under the permit,and shall fully indemnify and save harmless the City from all costs and damages which it may suffer by reason of failure to do so,and shall reimburse and repay the City all outlay and expense which the City may incur in curing any default,then this obligation shall be void;otherwise to remain in,full force and effect, with surety obligated to secure the full and faithful perfonmance of all of Principal's obligations under the attached Encroachment Permit. If any legal action be filed upon this bond,it shall be filed within one year after final payment has been made under the Encroachment Permit excluding the warranty period, if any, provided for in the Encroachment Permit,and venue shall lie in the County of Santa Clara, State of California, and that surety, for value received stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Encroachment Permit or to the work to be performed under it or the specifications accompanying it shall, in any way affect its obligation on this bond, and it does by this means waive notice of any change, extension of time,alteration or addition to the terms of the Encroachment Permit or to the work or to the specifications,and thereby waives the provisions of Section 2819 of the Civil Code of the State of California. In witness,the parties have executed this agreement as 7,,)' ober 12 12017 nbeftand elissa Bovenberg - SEE ATTACHED ACKNOWLEDGMENT FROM NOTARY' r (Surety reTec Insurance Company M BY Shaunna Roze e O rom,. ttorney-in-Fact Address of Surety:3131 Camino del Rio N.,Suite 1450 San Diego. CA 92108 (Attach Acknowledgements) Surety's Bond Number 4415192 (Accompany this bond with Attorney-in-facts (Both Principal's and authority from Surety to execute the bond, Surety's Attorney in Fact) certified to include the date of the bond.) DFORMSUemplatesTneroachment Permits\Bond for Faithful Performance.doc(Rev.03/08) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of California ) County of � ) Jane Fox, Notary Public On 1, D ZZ!E before me, Date Here Insert Name and Title of the Officer personally appeared Name(s)of Signer(s who proved to me on the basis of satisfactory evidence to be the personSWwhose name is/are- subscribed to the within instrument and acknowledged to me that he/sFmM,er executed the same in his/he k4 ei authorized capacity(ies);and that by his/he##eir-signature(sj on the instrument the person(s), or the entity upon behalf of which the person(s)-acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph JANE FOX is true and correct. Notary Public-California,_ WITNESS my hand and official seal. z%-.-4My Santa Clara CountyzCommission #2161523 Comm.Expires Aug.23,2020 Signature Si nature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Qx?71�) -d(Lr_A � q-Or04VQ6ocument Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) . Signer's Name: Signer's Name: .❑ Corporate Officer — Title(s): ❑Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑General ❑ Partner —. ❑ Limited ❑General Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact ❑Trustee ❑Guardian or Conservator ❑Trustee I]Guardian or Conservator ❑ Other: ❑ Other: Signer Is Representing: Signer Is Representing: 02014 National Notary Association -www.NationalNotary.org - 1-800-US NOTARY(1-800-876-6827) Item#5907 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Orange ) On October 12, 2017 before me, Susan Pugh Notary Public . (insert name and title of the officer) personally appeared Shaunna Rozelle Ostrom , who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to the within instrument and acknowledged to me.that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the .person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. SUSAN PUGH WITNESS my hand and official seal. 10MYCOMM. COMM.#2105405 M Notary Public-California aORANGE COUNTY LL Expires Apr29,2019 Signature (Seal) Susan Pugh Bond No.4415192 FOAM 510023 SureTec Insurance- Company LLMTED POWER OF ATTORNEY Snow All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly,organized and existing under the laws.of the State of Texas, and having its principal office in Houston, Harris County, Texas, does by these presents make,constitute and appoint Arturo Ayala, Daniel Huckabay, Dwight Reilly, Shaunna Rozelle Ostrom, Michael Castaneda its true and lawful Attorney-in-fact,with full power and authority hereby conferred in its name,place and stead,to execute,acknowledge and deliver any and all bonds,recogaizances,_undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for,providing the bond penalty does not exceed Fifteen Million and 001100 Dollars ($15,000,000.00) and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President,sealed with the corporate seal of the Company and duly attested by its Secretary,hereby ratifying and confirming all that the said Attorney-in-Fact may do in the premises. Said appointment shall continue in force until 9/10/2020 and is made under and.by authority of the following resolutions of the Board of Directors of the SureTec Insurance Company: Be it Resolved, that the President,any Vice-President, any Assistant Vice-President,any Secretary or any Assistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attomey(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and of behalf of the Company,to execute, acknowledge and deliver,any and all bonds,recognizances,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attomey-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved,that the signature of any authorized.officer and seal of the Company heretofore or,hereafter affixed to any power of attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid j and binding upon the Company with respect to any bond or undertaking to which it is attached. (Adopted at a meeting held on 20`h of Aplil, j 19.99) In Witness Whereof, SURETEC INSURANCE COMPANY has caused these presents to be signed by its President,and its corporate seal to be hereto affixed this 24th day of March_ A.D.2017. n SURETEC E ANY By: w w $ John Knox ., resi nt (r State of Texas ss: County of Harris On this240t day of March A.D.2017 before me personally came John Knox Jr.,to me known,who,being by me.duly sworn,did depose and say,that he resides in Houston,Texas,that he is President of SURETEC INSURANCE COMPANY,the company described in and which executed the above instrument;that he knows the seal of said Company;that the seal affixed to said instrument is such corporate seal;that it was so affixed by order of the Board of Directors of said Company;and that he signed his name thereto by like order. � � XENIA CHAVEZ `�t�,q{Y fQN. r=?.. -'$Notary Public,State of Texas 9r Comm.Expires 09-10-2020 Notary ID 129117659 X to avez,Notary Public i 1- y commission expires September 10,2020 i h M.Brent Beaty,Assistant Secretary of SURETEC INSURANCE COMPANY,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney,executed by said Company,which is still in full force and effect;and furthermore,the resolutions of the Board of Directors,set out in the Power of Attorney are in full force and effect. Given under my hand and the seal of said Company at Houston, Texas this 12th day of cteiorZlis2017 A.D. M.B nt Befty,Assistaut Se etary Any instrument issued in excess of the penalty stated above is totally void and without any validity.510023 For verification of the authority of this power you may call(713)812-0800 any business day between 8:00 am and 5:00 pm CST. OP Cq,� A �RCHA1t0 CITY OF CAMPBELL Public Works Department March 20, 2018 Peter and Melissa Bovenberg 655 E. McGlincy Lane Campbell, CA 95008 SUBJECT: PERMIT NO. ENC Xb%_1- 665 E. McGlincy Lane, Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear Peter and Melissa: l 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 February 13, 2018. 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. Your Faithful Performance Security and Labor/Materials Bonds in the amount of $36,200.00 will be kept in force for the one-year maintenance period, unless you wish to replace it with a Maintenance Bond for 25% of the original amount. A Cash Deposit refund in the amount of$1,448.00 is being returned to DP Construction as they are listed as the Payors of the deposit. lam attaching a copy of the letter to DP Construction. If you have any questions, please call me at(408) 866-2165. Sincerely, Syed Wahidi Public.Works Inspector Cc: - Inspector/Suspense Files Permit File: ENC2017-00184 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 Fax 408.376.0958 TDD 408.866.2790 oV ' C4,y " •�k CH ARC• CITY OF CAI BELL Public Works Department March 20, 2018 John Lyden DP Construction 852 5tn St. Norco, CA 92860 SUBJECT: PERMIT NO. ENC :; 0l1— b p*%.0oLk 665 E. McGlincy Lane, Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear John: 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 February 13, 2018. 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. Your Cash Deposit in the amount of$1,448.00 is enclosed. If you have any questions,please call me at (408) 866-2.165. Sincerely, Syed W Public Works Inspector Cc: Peter and Melissa Bovenberg Inspector/Suspense Files Permit File:ENC2017-00184 7o North First Street • Campbell, California 95008-1436 TEL 408.866.2150 •FAX 408.376.0958 TDD 408.866.2790 9 Z BOND FOR LABOR AND MATERIAL ENCROACHMENT PERMIT NO. ENC2017-00184 We,the undersigned Peter Bovenberg and Melissa Bovenberg ,(hereinafter"Principal")and SureTec Insurance Company a corporation organized under the laws of the State of Texas and authorized to transact business in the State of California, as Surety, are obligated to the City of Campbell (hereinafter "City"), a municipal corporation under the laws of the State of California, in the sum of Thirty Six Thousand Two Hundred and 00/100 Dollars ($36.200.00 ) for the payment of which sum we obligate ourselves and our successors and assigns,jointly and severally by the following provisions: The condition of this obligation is that the Principal entered,or is about to enter,into a certain written Encroachment Permit with the City dated September 12 ,2017. which said Encroachment Permit No. is hereby referred to and made a part hereof. *ENC2017-00184 Because Principal is required to furnish a bond in connection with the Encroachment Permit, providing that if Principal,or any of its subcontractors,shall fail to pay for any materials,or other supplies,or for any work or labor on the permitted work of any kind,or for amounts due under the unemployment insurance act with respect to any work or labor on this project,the Surety on this bond will pay for the debt,in an amount not exceeding the sum specified in this bond,and also, in case suit is brought upon the bond,a reasonable attorney's fee to be fixed by the court. Now, therefore, we, Peter Bovenberg and Melissa Bovenberg as Principal, AND SureTec Insurance Company as Surety,are obligated to the City of Campbell,and all contractors,subcontractors,laborers, material men and other persons employed in the performance of the aforesaid agreement in the sum of Thirty Six Thousand Two Hundred and 00/100 Dollars ($36,200.00 ), lawful money of the United States, for the payment of which sums will and truly to be made, we the said Principal and Surety bind ourselves, successors and assigns, jointly and severally,by these provisions. The condition of this obligation is that if Principal, its successors or assigns, or its subcontractor, or subcontractors,shall fail to pay for any labor, materials, or other supplies, used in the performance of the work permitted to be done, or for amounts due under the unemployment insurance act with respect to this work or labor,then the Surety on this bond will pay for them,in an amount not exceeding the sum specified in this bond,and in case suit is brought upon this bond will also pay a reasonable attorney's fee,to be fixed by the court. Venue for any action arising out of this obligation shall lie in the County of Santa Clara,State of California. It is expressly stipulated and agreed that this bond shall inure to the benefit of any and all persons, companies and corporations entitled to file claims under Title 15(commencing with Section 3082)of Part 4 of Division 3 of the Civil Code,so as to give a right of action to them or their assigns in any suit brought upon this bond. Should the condition of this bond be fully performed,then this obligation shall become null and void,otherwise it shall be and remain in full force and effect. No prepayment or delay in payment and no changes,extensions, addition or alteration of any provision of said Encroachment Permit or in any plans and specifications referred to herein,and no forbearance on the part of the City shall operate to release the Surety from liability on this bond, and consent to make such alterations without further notice to or consent by the Surety is hereby given, and the Surety hereby waives the provisions of Section 2819 of the Civil Code of the State of California. In witness,the parties have executed this agreement as of October 12,2017 (Princi al) P ter ovenber n elissa Bov n erg By SEE ATTACHEII) ACKNOWLEDGMENT Title 6 FROM NOTARY (Sureg reTec Insurance mpany By �1/� Shaunna Rozelle.Ostrom, ttorney-in-Fact Address of Surety: 3131 Camino del Rio N., Suite 1450 (Attach Acknowledgments San Diego, CA 92108 Both Principal's and Surety's Attorney in Fact) Surety's Bond Number 4415192 (Accompany this bond with attorney-in-fact's authority from Surety to execute the bond,certified to include the date of the bond.) J:\FORMS\Templates\Encroachment Permits\Bond for Labor&Materials.doc(Rev.03/08) r CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 -A notary public or other officer completing this certificate verifie&only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of Californi ) County of ) Jane Fox, Notary Public On o S O/ before me, - -- ate Here Insert Name and Title of the Officer personally -appeared /9 Ael- A0 V rZ U /�� Name(s)of Sign r(s) who proved to me on the basis of satisfactory evidence to be the person whose name is/afe subscribed to the within instrument and acknowledged to me that he%sbeA eq executed the same in his/heatheii,authorized capacity(iesj;and that by his/heetheir-signature(*oh the instrument the person(#, or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. JANE FOX, WITNESS my hand and official seal. Notary Public-California Santa Clara County z Commission-�2161523 Signature M Comm.Expires Aug 23.202o gnature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Q Cmp FC-A- LAST+�ocument Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) C i ed by 9ner(s) Signer's Name: l CV � � Signer's Name: ❑Corporate Officer — Title(s): ❑Corporate Officer —Title(s): ❑ Partner — ❑ Limited ❑General ❑ Partner = ❑ Limited ❑General `Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact ❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator ❑Other: ❑ Other: Signer Is Representing: Signer Is Representing: ©2014 National Notary Association -www.NationalNotary.org - 1-800-US NOTARY(1-800-876-6827) Item#5907 • 1 r , ' S ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies.only the identity of the individual who signed the document to which this certificate is attached, and not the.truthfulness, accuracy, or validity of that document. State of California County of Orange ) On October 12, 2017. before me, Susan Pugh'Notary Public (insert name and title of the officer) personally appeared, Shaunna Rozelle Ostrom who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. su_saN PUGH COMM.#2105405 �+ Notary Public-California a ORANGE COUNTY a, My COMM.Expires Apr29,2019 Signatur (Seal) Susan Pugh Bond No.4415192 POA#: 510023 SureTec Insurance Company LBUTED POWER OF ATTORNEY Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State of Texas, and having its principal office in Houston, Hams County, Texas, does by these presents make,constitute and appoint Arturo Ayala, Daniel Huckabay, Dwight Reilly, Shaunna Rozelle Ostrom, Michael Castaneda its true and lawful Attorney-in-fact,with full power and authority hereby conferred in its name,place and stead,to execute, acknowledge and deliver any and all bonds,recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for,providing the bond penalty does not exceed Fifteen Million and 00/100 Dollars($15,000,000.00) and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President,sealed with the corporate seal of the Company and duly attested by its Secretary,hereby ratifying and confirming all that the said Attorney-in-Fact may do in the premises. Said appointment shall continue in force until 9/10/2020 and is made under and.by authority of the following resolutions of the Board of Directors of the SureTec Insurance Company: Be it.Resolved, that the President,any Vice-President,any Assistant.Vice-President,any Secretary or any Assistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attomey(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and of behalf of the Company,to execute, acknowledge and deliver,any and all bonds,recognizances,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attomey-in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. Be it Resolved that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid i and binding upon the Company with respect to any bond or undertaking to which it is attached. (Adopted at a meeting held on 206 of April, j 1999.) In Witness Whereof, SURETEC INSURANCE COMPANY has caused these presents to be signed by its President,and its corporate seal to be hereto affixed this 24th day of March_,A.D.2017. 119, SURETEC E ANY \�SURAfVQFC AuQ'f X 9 tog' By w w ;D John Knox resi nt State of Texas ss: 7s% ,IW yi�a County of Harris On this Zt&day of March A.D.2017 before me personally came John Knox Jr.,to me known,who,being by me,duly sworn,did depose and say,that he resides in Houston,Texas,that he is President of SURETEC INSURANCE COMPANY,the company described in and which executed the above instrument;that he knows the seal of said Company;that the seal affixed to said instrument is such corporate seal;that it was so affixed by order of the Board of Directors of said Company,and that he signed his name thereto by like order. �p��YPb XENIA CHAVEZ irGc_Notary Public,State of Texas Comm.Expires 0901 -10-2020 Notary ID 129117659 X is avez,Notary Public I y commission expires September 10,2020 I I,M.Brent Beaty,Assistant Secretary of SURETEC INSURANCE COMPANY,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney,executed by said Company,which is still in full force and effect;and furthermore,the resolutions of the Board of Directors,set out in the Power of Attorney are in full force and effect. Given under my hand and the seal of said Company at Houston, Texas this 12th d4Y of A OC r 2017 A.D. '54.Art&Beity,Assistant Se etary Any instrument issued in excess of the penalty stated above is totally void and without any validity.510023 For verification of the authority of this power you may call(713)812-0800 any business day between 8:00 am and 5:00 pm CST. CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00184 Name: DP Construction Property Address: 665 E. McGlincy Ln Date ofCFinal ection: 2/13/18 On Filends CD Cash FP ormance: $ Labor and Material: $ Bonds #4415192 - $36,200.00 Construction Cash Deposit to be released: $1,448.00o c�1 �qCt o Other overdue deposits to be released (Description): Processed by: a� -O l dministrator Reviewed by: Inspector Reviewed by: 21�L Land Development Engineer J:UoAnnaT\Deposit refunds\CHECKLISTSWeGlincy 665.doc(Rev. 10/11) Encroachment Permit Final Sign Off Encroachment Permit# '6QC- �,) 1-7— 0618 1 Address: �Jr G j-I OCY LN Date of Final Inspection and Acceptance: l Inspected by.- OK to release deposits: 100% 7.5 Comments: �''�`n � �-a��` peg C�.��J•cv�C..-e.. . Cb�,�,�s v b0, Refundable De-posit Check 'Request „ To: Finance'Direcfor'- 'Check Payable To: DP:donstruction a ' Address Line 1:• 852 5th Street Line 2:. City: Norco, State: CA' Zip: 02860 .Description: 665 E. McGlihdy Lane Account Number: 101.2203_ Amount: $1,,448.00 Account Number: . 101:2203 Amount: Account Number: 101.540"'7448 Amount: (Finance Dept only) Interest,Earned (Finance Dept only) , Total Payable: (Exact Amount) ' Purpose: _ Deposit Refund Permit M ENC2017-00184 Receipt#: - 271058. Date: 8/22/2017. Receipt,#: Date: Requested.by: �— Title: Inspector Date:. ��' - Syed' ldi Approved by: Title: Sr. Engineer Date: 2 Zt cg. Roger Storz -Finance Dept Only: Verified by: Title: Accounting.Clerk II Date: App"roved by:. Title: Accountant - Date! Special Instructions_ For 'Handling Check man AS IS: man In Attached Envelope: Inierlm tme= Needed By: Return,To: JoAnna Thomason Public-Works (Name) (Department) Other: Please return check to JoAnna [E ' r _ -... ....._...... ......_......_ .._....I - ..—...._............ ___..................._—... t i CITY OF CAMPBELL VENDOR NO. 10014797 CHECK NO. 266759 `•I 101 2203 CR022218 1,448.00 665 E.�MCGLINCY LANE i m i i I 10014797 DP CONSTRUCTION I I • C ECK DATE= CHECK NO. CAMPBELL. ,,, � rvs FaRco B> NK, N.A . 11.24 y t6�, 7Q NOR7H FIRST STREET ERy STREET 1-210 03/-05/18 2663 5 + aso t4orrraoM OQMPBELL,,CALIFORNIA 95008 FR�xC SDI ISCO CA 94104 - - � TS AMOUN r- i �+ 1� s �� o * 1 i °RCIiAao ( - f VOID AFTER 90 DAYS'v �. I > I ' PAY THE SUM-.OF ONE THOUSAND, FOUR HUNDRED. .FORTY EIGHT DOLLARS & m `/ ZERO CENTS. � I To TxE DP CONSTRUCTION ORDER 852 /5TH STREET 8,F2NORCO `CA 92860 , � n , l n' 26- 7 59I' �: L 2 L000 '2;48�: 4 L° 2 L8 5'S4 15�I' t >...... i - _ ! I - __...._....- _...... ._............. _.._...... ......... ............................._. ............_.._ ....._.. `� ==:_.................; _. ....................... 1..................................._... :.:. .. ............ *See Reverse Side F6r'Easy Opening/instructions*. --k---- -- --------- - - ----------------------- - -- -'---- - --- --- ----- CITY OF CAMPBELL 70 NORTH -FIRST STREET r j CAMPBELL, CALIFORN-IA 95008. 1 i I DP CONSTRUCTION 852 5TH STREET _ NORCO CA 92860 — Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No Zz-1 1 —C® ,+ DEPT.OFPUBLICWORKS (forworkingwithin the public X-Ref. File G 70 North First Street right- of-wa ) Application Date l Campbell,CA 95008 Application Expiration Date ( ` Issued , il Ph.(408)866-2150 r APN `41 Fx. (408)376-0958 Permit Expiration Date too APPLICATION-Application is hereby made fora Public Works Permit in accordan a with ampbell 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.: 665 E. Mc GLINCY Utility Trench Location: B. Natureofwork: NEW SIDEWALK, DRIVEWAY, AND STREET TREES C. Attach four(4)copies of an 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. Allworkshall conform to the City ofCa mpbell Standard Specifications and Detailsfor PublicWorks Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below.Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before startingwork.Notice must be given to Public Worksatleast24hoursbeforerestartinganywork. Name of Applicant: I MICHAEL BATES Telephone: 562.426.3453 Address: P.O. BOX 9130 LONG BEACH, CA 90810 E-MailAddress: mb@mbtechnicalservices.com 24-HOUR EMERGENCY PHONE NUMBER: 310.283.6197 __at - si - 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 read a erstand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon isU61 f this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of improve Me completedAntth�e pu-bl�ic`right-of-way. Accepted: A `!�6 �— v� � qj,�R_o 7?_ -ice plicagt Permittee) (sign Date Asphalt Maintenance Systfi P 2 z f 1- 7 (Contractor) (Print Name) Date SPECIAL PROVISIONS: ® 1. Streetshall not be open cutfor underground installations. Minimum cuts may be allowed for connections or exploration holes.Suchcuts.maybe specifically approved by the Inspector prior to cutting. F 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. p✓ 4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. ® 5. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. 6. Public Notification Requirements: ❑ 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $425.00 -�� r( PLAN CHECK DEPOSIT 51 1 - 1)0 SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ ' — eM t CONSTRUCTION CASH DEPOSIT $ 50 S c' 2 (1 PLAN CHECK&INSPECTION FEE $ �� V i, EMERGENCY PERMIT FEE $ -7 APPROVED FOR ISSUANCE pv_�< For City Engineer A. Permit Expires 12 Months After Date of Issuance 0 • GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained forth e duration of the permit work. 2. A Construction Cash Deposit is required.Changes will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required.Any such costs in excess of the deposit will be billed to the Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. A one-year maintenance period and surety are required.Such period will begin on date of written acceptance by the City.Surety posted shall be equal to 25%of the original Faithful Performance Security. 5. Submit project schedule 10(ten)days prior to proposed start of work.Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion.Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures.This plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices(MUTCD). 10. Replace,as directed by the City Engineer,any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee as expeditiously as possible. 11. Sawcut for all PCC or AC removals.All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards.Adequate signing and barricading is required on the job site.Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost(including all labor and materials)against the construction cash deposit. 14. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction.Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m.and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. Call back(call out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 21. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water.Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 22. If the public interest requires a modification of,or a departure from the permit,plans,special provisions and/or specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 23. Permittee must provide advance notification to all parties that may be affected by the permit activities.Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order WQ 2014-0174- DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system, See http://www.waterboards.ca.goy/water issues/programs/npdes/utilityvaults.shtml for more information. Applicant is hereby responsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. Michael Bates 8/7/17 Applicant //) Date: AMphall Mainte5ptl ,Mn %AY1� Q\ ✓� (y�) Contractor (Print Name) c Date: / J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finance PUBLIC WORKS FILE NO. ENC2017-00184 PROPERTY ADDRESS 665 East McGlincy Lane Please collect&receipt for the following monies: ACCT. ITEM - AMOUNT LAND DEVELOPMENT 47221 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major?$10,000 $425.00 $425.00 Minor Encroachment Permit<sio,000 $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 Sq. Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 t 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 Engineer's Estimate $5,068.00 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) $1,448.00 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* Separate Bond 2203 Labor and Materials Security 100%of ENGR.EST.* Separate Bond 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) All Other$2;650.00 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 $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 i clude all items of work. TOTAL $6,941.00 NAME OF APPLICANT NAME OF PAYOR PHONE ADDRESS C C C� ZIP �`tp FOR RECEIVED Y' -'( � , '.t, F1 ; - — - - CITY CLEP,K - ONLY Date Receipt.# a )tsy �� cj+ \ . CITY 7C+Rw G7§ 7: Gmlq 0 1000271358 PA mR DPJlJ6«k2A . § q+«G DATE. meS . 3#a b«: m d7 TIME: m;m DESCRIPTION . Um4 . . . m» 3;g91017-50184 Daaq»D SG0.1 mA R: ilmG GmaRA& SGmF «!«Cm ma 3; Smo 4E DEPOSIT - !g ----------------- . +GE ma . k191.00 RADO: #.91.00 CHANGE: _ %m . . PODS U: 4F AR AC® OR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/05/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellie O'Connell NAME: DeSando Insurance Services,LLC. PA cNNo Ext (650-453-8552 ac No): (408)264-7016 6081 Meridian Ave Ste 70-125 E-MAIL-ADDRESS: ellie@desandoins.com INSURERS AFFORDING COVERAGE NAIC# San Jose CA 95120 INSURERA: ROCKINGHAM INSURANCE CO 42595 INSURED INSURERB: UNITED FINANCIAL CASUALTY CO 11770 Acero Builders Inc INSURERC: 12235 Foothill Ave INSURER D: INSURER E: San Martin CA 95046 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 LTR POLICY NUMBER MM/DDIYYYY MM/DDfYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE To RENTED CLAIMS-MADE [X7 OCCUR PREMISES(E.occurrence) $ 100,000 X Primary&Non Contributory MED EXP(Any one person) $ 5,000 A X RCAG3000418-00 09/22/2017 09/22/2018 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 1 PRO JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED X 06314336-0 11/09/2017 11/09/2018 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY 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 ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Caliber Collision,Campbell,CA �O —1_ ^ ��E ov/ � a Per written contract,the City of Campbell,it's officers,employees and volunteers are named as additional insureds per attached General Liability endorsement CG20100413 and Commercial Auto endorsement Form 1198 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 St AUTHORIZED REPRESENTATIVE Campbell CA 95008 `I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: RCAG300418-00 COMMERCIAL GENERAL LIABILITY CG20100413 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) Locations Of Covered Operations City of Cambell; It's officers, employees and volunteers Caliber Collison, 665 E McGlincy Ln, Campbell, CA 70 N First St, Campbell, CA 95008 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 organization(s) shown in the Schedule, but only exclusions 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 equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 20 10 04 13 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 PAOG�9Ell/�/E y Additional Insured Endorsement Name of Person or Organization CITY OF CAMPBELL Its Officers Employees and Volunteers 70 N FIRST ST CAMPBELL, CA 95008 The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability.We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodily Injury each person/ each accident Property Damage each accident Combined Liability 1,000,000 each accident All other terms,limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 6314336-0 Issued to(Name of Insured): OMAR AMONS ACERO BUILDERS INC Effective date of endorsement: 11/09/2017 Policy expiration date: 11/09/2018 Form 1198(01/04) 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change Number 0001 POLICY NUMBER POLICY CHANGES COMPANY EFFECTIVE RCAG300418-00 11/14/2017 Rockingham Insurance Company 12:01AM NAMED INSURED AUTHORIZED REPRESENTATIVE ACERO Builders Inc 12235 Foothill Ave. Atlas General Insurance Services, LLC San Martin, CA 95046 COVERAGE PARTS AFFECTED Commercial General Liability CHANGES 1. PREMIUM 8. ❑INCEPTION DATE 15. ❑CANCELLATION 2. ADVANCE PREMIUM 9. ❑EXPIRATION DATE FLAT 3. ❑MINIMUM PREMIUM 10. FTERMS ❑SHORT RATE 4. ❑RATE 11. ❑NAME OF INSURED ❑PRO RATE 5. ❑INSTALLMENT 12. ❑INSURED'S ADDRESS MINIMUM EARNED PREMIUM 6. AUDIT 13. COVERAGE EXTENSION 16. ❑CLASSIFICATION/CLASS CODE 7. ❑COVERAGE/LIMITS 14. ❑REINSTATEMENT 17. X❑OTHER POLICY CHANGES ENDORSEMENT DESCRIPTION Adding Additional Insured The above amendments result in a change in the premium as follows: NO CHANGES TO BE ADJUSTED ADDITIONAL PREMIUM PRETURN PREMIUM ATAUDIT $0.00 So( 0.00 Countersigned by: (Authorized Representative Signature) IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 p Copyright, ISO Commercial Risk Services, Inc., 1983 l ® DATE(MM/DDIYYYY) ACOR>D CERTIFICATE OF LIABILITY INSURANCE 12/05/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellie O'Connell NAME: Berry Francis Integrity Insurance Broker,LLC AID"No Ext: (650)453-8552 FAX Nc; (650)453-2398 557 Creekside Lane ADDARESS: ellie@integrityinsurancebroker.net INSURERS AFFORDING COVERAGE NAIC# Morgan Hill CA 95037 INSURERA: STATE COMPENSATION INSURANCE FUND 35076 INSURED INSURER B: Acero Builders Inc INSURERC: 12235 Foothill Ave INSURER D: INSURER E: San Martin CA 95046 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM DDIIYYYY) (MMIDDNYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES (E.occurrence) ccurrrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGO $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X SPERTATUTE EORH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA 9221249-17 11/10/2017 11/10/2018 (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/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re:Caliber Collision,Campbell,CA Per written contract,the City of Campbell,it's officers,employees and volunteers are named as certificate holders Work Comp waiver of subrogation applies per attached endorsement �SLA ox 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. 700 N First St AUTHORIZED REPRESENTATIVE Campbell CA 95008 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD _ TE ENDORSEMENT AGREEMENT BROKER COPY COMPENSATION WAIVER OF SUBROGATION 9221249-17 FUND NEW NA HOME OFFICE SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE ;DECEMBER 1, 2017 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING NOVEMBER 10, 2018 AT 12.01 A.M. PACIFIC STANDARD TIME ACERO BUILDERS INC 12235 FOOTHILL AVE SAN MARTIN, CA 95046 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF CAMPBELL WHICH MIGHT ARISE BY REASON 'OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, ACERO BUILDERS INC ,r IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. 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: DECEMBER 4,/2017 2570 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217 f® DATE(MM/DD/YYYY) A400 Ro CERTIFICATE OF LIABILITY INSURANCE 10/20/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ellie O'Connell NAME: DeSando Insurance Services,LLC. A/cN o E . (650-453-8552 FAX No: (408)264-7016 6081 Meridian Ave Ste 70-125 ADDRESS: ellie@desandoins.com INSURERS AFFORDING COVERAGE NAIC# San Jose CA 95120 INSURERA: ROCKINGHAM INSURANCE CO 42595 INSURED INSURER B: Acero Builders Inc INSURER C: 12235 Foothill Ave IINSURER D: INSURER E: San Martin CA 95046 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 ADDLITYPE OF INSURANCE INSD WVD SUER POLICYNUMBER MMIDIDYEFF MMIDD� LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE CLAIMS-MADE ®OCCUR PREMISES(Ea occurrence) $ 100,000 X Primary 8r Non Contributory MED EXP(Any one person) s 5,000 A X RCAG3000418-00 09/22/2017 09/22/2018 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODI LY INJU RY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN SPTER ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 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) Re:Caliber Collision,Campbell,CA Per written contract,the City of Campbell,it's officers,employees and volunteers are named as additional insureds per attached General Liability endorsement CG20100413 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 St AUTHORIZED REPRESENTATIVE Campbell CA 95008 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD t AG 19 60 05 15 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU TO INCLUDE WAIVER OF SUBROGATION PROVISION AND PRIMARY AND NONCONTRIBUTORY PROVISION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Additional Insured Status—Ongoing Operations 1. "Section II-Who is an Insured" is amended to provide automatic coverage as an Additional Insured in conformity with the terms and conditions of the CG 20 10 04 13 endorsement, a copy of which is attached hereto and incorporated by reference. Automatic Additional insured coverage provided by this endorsement only applies to the extent permitted by law; and if coverage provided to the additional insured is required by and agreed in writing in a contract or agreement, the insurance afforded such additional insured will not be broader than that which you are required by the contract or agreement, only if such contract agreement is executed by each party prior to the start of your work to provide for such additional insured. B. Additional Insured Status—Completed Operations 1. "Section II-Who is an Insured" is amended to provide automatic coverage as an Additional Insured in conformity with the terms and conditions of the CG 20 37 04,13 endorsement, a copy of which is attached hereto and incorporated by reference. Automatic Additional insured coverage provided by this endorsement only applies to the extent permitted by law; and if coverage provided to the additional insured is required by and agreed in writing in a contract or agreement, the insurance afforded such additional insured will not be broader than that which you are required by the contract or agreement, only if such contract agreement is executed by each party prior to the start of your work to provide for such additional insured. 2. The coverage provided to the additional insured as outlined in paragraph B. Additional Insured Status — Completed Operations does not apply to Any "bodily injury", "property damage" or "personal and advertising injury" arising out of, related to, caused by, or associated with, in whole or in part, to operations and "your work", conducted by you or on your behalf, or work or operations conducted by an unrelated party, involving"residential property". C. Primary and Noncontributory Provision 1. Insurance afforded the Additional insured, when required by written contract or agreement, is primary and noncontributory in the event of an 'occurrence" caused, in whole or in part, by your acts or omissions, or the acts or omissions of those acting on your behalf that occurs while performing ongoing operations for the additional insured, or in connection with premises owned by or rented to you. Page 1 of 5 AG 19 60 05 15 D. Waiver of Subrogation Provision 1. "Section IV-Commercial General Liability Conditions Paragraph 8 The Transfer of Rights Of Recovery Against Others To Us" is amended to add the following: We waive any right of recovery we may have against those added as Additional Insured by this endorsement because of payments we make for injury or damage arising out of your ongoing operations or "your work" performed under written contract or agreement with them. This waiver applies only when you are solely negligent. This waiver shall not apply to claims, "suits" and/or damages arising in whole or in part out of the acts, omissions and/or negligence of those added as Additional Insured by this endorsement. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. E. The following are added to SECTION V—DEFINITIONS: "Residential property" means structures intended for use or used for human dwelling, in whole or in part, including but not limited to single family dwellings, multi-family dwellings, townhomes, condominiums, and appurtenant structures. Page 2 of 5 AG 19 60 05 15 COMMERCIAL GENERAL LIABILITY CG20100413 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) Locations Of Covered Operations See Terms and Conditions of Coverage on page 1 of All his endorsement Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section 11 —Who Is An Insured is amended to 1. All work, including materials, parts or include as an additional insured the person(s) or equipment furnished in connection with such organization(s) shown in the Schedule, but only work, on the project (other than service, with respect to liability for "bodily injury", maintenance or repairs)to be performed by or "property damage" or "personal and advertising on behalf of the additional insured(s) at the injury"caused, in whole or in part, by: location of the covered operations has been 1. Your acts or omissions; or completed; or 2. The acts or omissions of those acting on your 2. That portion of "your work" out of which the behalf; injury or damage arises has been put to its intended use by any person or organization in the performance of your ongoing operations other than another contractor or subcontractor for the additional insured(s) at the location(s) engaged in performing operations for a designated above. principal as a part of the same project. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured C. With respect to the insurance afforded to these is required by a contract or agreement, the additional insureds, the following is added to insurance afforded to such additional insured Section III—Limits Of Insurance: will not be broader than that which you are If coverage provided to the additional insured is required by the contract or agreement to required by a contract or agreement, the most we provide for such additional insured. will pay on behalf of the additional insured is the B. With respect to the insurance afforded to these amount of insurance: additional insureds, the following additional 1. Required by the contract or agreement; or exclusions apply: This insurance does not apply to"bodily injury"or "property damage"occurring after: CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 3 of 5 AG 19 60 05 15 2. Available under the applicable Limits of This endorsement shall not increase the Insurance shown in the Declarations; applicable Limits of Insurance shown in the whichever is less. Declarations. CG 20 10 04 13 ©Insurance Services Office, Inc., 2012 Page 4 of 5 AG 19 60 05 15 COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations See Terms and Conditions of Coverage on page 1 of This endorsement does not apply to your work on his endorsement "residential property" 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 is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage" caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the"products-completed operations hazard". 1. Required by the contract or agreement; or However: 2. Available under the applicable Limits of 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law; and This endorsement shall not increase the 2. If coverage provided to the additional insured is applicable Limits of Insurance shown in the required by a contract or agreement, the Declarations. insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 ©Insurance Services Office, Inc., 2012 Page 5 of 5 JoAnna Thomason 5 ��A From: JoAnna Thomason Sent: Friday, November 03, 2017 9:27 AM To: 'Ellie@desandoins.com' Subject: Required info for Acero Attachments: COI Sample.pdf,Insurance Requirements Cklist.pdf Hi Ellie, attached is the information checklist regarding the City's insurance requirements. I am also attaching a sample of a COI. The project location is 655 E. McGlincy Lane, Campbell CA The permit number is ENC2017-00184 Let me know if you have any questions or need any additional information. Thanks JoAnna J D •CAtijA .JoAnna Thomason �� O Office Specialist U r City of Campbell ; Public Works Department 0 0 70 N. First Street I Campbell,CA 9-5008 «,N�•«.,.citvofcampbell.coni 1 408.866.21 50 11RCHAR1 c ec o 1 JoAnna Thomason From: JoAnna Thomason Sent: Thursday, November 02, 2017 9:51 AM To: Roger Storz Subject: Insr. for 665 E. Mcglincy I reviewed the insurance for Acero Builders, Inc.The insurance is incomplete, and we need the following: Auto Insr. Info Worker's Comp Campbell business license Location and permit number referenced on certificate Additional insured/primary insurance wording on certificate Thanks JoAnna pV•CAi f JoAnna Thomason office Specialist U r C;itti oPCampbcll I Public Works Depariinent 0 o 70 N. First Street Campbell,CA 95008 z.i.i7.t�ell_,cori�1 4108,866.2150 •�RCHAR� . 1 INSURANCE REQUIREMENTS CHECKLIST Permit#i5�1 h, 'RZ)t 7 (20 IC6 -A 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 141 $2,000,000 general aggregate limit. Policy expiration date 2, ) Z.,--11 � Automotive Liability: e Any Auto" checked on certificate ❑- $1,000,000 per accident for bodily injury and property damage Policy expiration date l c� Workers'Compensation and Employer's Liability waiver of Subrogation clause -W $1,000,006 per accident for bodily i jury or disease 4,Policyexpiration date W 6 C Course of Construction (if required inSpecial Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement oL a The City,its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) C—J,\r,, \';Z�bL Ne? ❑ The insurance coverage afforded to the Additional Insured is primary',insurance. Cancellation area: ❑/Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: C:\Documents and Settings\ioannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) -1- 4 &�ceptabilitV 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. n Name: vac NAIC# `I ZS Rating: !'� �l 1 Authorized in CA: Name: v Nrt-A cL NAIC# '�k Rating: Authorized in CA: ✓ Name: C_c6,3etki- I NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: n i❑ Campbell Business License#dam' Expiration: Io pV j Contractors License# �OZ�I�C�� Class: Expiration: n Insurance Certificate Reviewed Initials Date f Copy of Insurance Certificate placed in tickler file one month nor to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8/15 ENGINEER'S`ESTI MATE FOR ` LAND DEVELOPMENT PROJECTS Date: August 7,2017 For File No(s): Site Address: 655 E.Mc Glincy Ln. ENC. No. 2017-00184 Estimated Cost of Improvements $50,000 ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION QTY UNIT <$100 K >$100 K S AMOUNT I. DEMOLITION/CLEARING 1. CLEARING&GRUBBING 0 LS $2,750.00 $2,000.00 $ - 2. SAWCUT P.C.C./A.C.(UP TO 6") 40 LF $5.75 $4.25 $ 230.00 3. P.C.C.REMOVAL 0 SF $4.00 $3.00 $ - 4. CURB AND GUTTER REMOVAL 0 LF $11.00 $7.00 $ 5. MEDIAN REMOVAL 0 SF $7.00 $5.50 $ 6. DEMOLISH EXISTING INLET/PLUG RCP'S 0 EA $2,250.00 $1,750.00 $ IL STORM DRAINAGE 1. 12"R.C.P.(CLASS V) 0 LF $275.00 $225.00 $ 2. 15"R.C.P.(CLASS III) 0 LF $300.00 $250.00 $ - 3. 18"R.C.P.(CLASS III) 0 LF $325.00 $275.00 $ - 4. 24"R.C.P.(CLASS 111) 0 LF $350.00 $300.00 $ - 5. 30"R.C.P.(CLASS III) 0 LF $400.00 $350.00 $ - 6. T.V.INSPECTION(12") 0 LF $1.60 $1.25 $ 7. STD.DRAINAGE INLET(C.C.DETAIL 5) 0 EA $3,600.00 $3,000.00 $ 8. FLAT GRATE INLET(C.C.DETAIL 6) 0 EA $2,125.00 $1,700.00 $ 9. STD MANHOLE(C.S.J.DETAIL D-11) 0 EA $6,500.00 $5,250.00 $ 10. STD MANHOLE(C.S.J.DETAIL D-12) 0 EA $8,000.00 $6,500.00 $ 11. BREAK AND ENTER M.H./D.I. 0 EA $1,300.00 $1,000.00 $ - III. CONCRETE IMPROVEMENTS 1. SIDEWALK 1674 SF $10.00 $8.00 $ 16,740.00 2. DRIVEWAY APPROACH 276 SF $14.00 $10.00 $ 3,864.00 3. CURB AND GUTTER 0 LF $60.00 $47.00 $ - 4. VALLEY GUTTER 0 SF $35.00 $30.00 $ - 5. CURB RAMP 0 EA $4,500.00 $3,500.00 $ - 6. TYPE B-1 CURB 0 LF $50.00 $40.00 $ - 7. TYPE A]-B3 CURB 0 LF $25.00 $20.00 $ - 8. COBBLESTONE MEDIAN SURFACE 0 SF $25.00 $20.00 $ - 9 BUS STRESS PAD 0 EA $12,000.00 $12,000.00 $ - D:\MICHAE-1\Dropbox\MBTDOC-1\CALIBE-1\CAMPBE-1\EXISTI-1\NEWCON-1\PROPOS-1\PRELIM-1\SUBMIT-1\BLDG-1.COR\As- built\REVISE-1\CURBAN-1\1STSUB-1\Completed Engineers Estimate 2015(Rev.03/08) Page 1 of 4 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8/15 ENGINEER'S ESTIMATE FOR, a LAND DEVELOPMENT PROJECTS Date: August 7,2017 For File No(s): Site Address: 655 E.Mc Glincy Ln. ENC. No. 2017-00184 Estimated Cost of Improvements $50,000 ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION QTY UNIT <$100 K >$100 K $AMOUNT IV.PAVEMENT 1. ASPHALT DIGOUT AND REPLACE 300 CF $6.25 $5.25 $ 1,875.00 2. PAVEMENT WEDGE CUT(6) 16 LF $5.50 $3.00 $ 88.00 3. PAVEMENT GRINDING 0 SF $1.10 $0.75 $ - 4. PAVEMENT FABRIC(PETROTECH) 0 SY $2.50 $2.25 $ - 5. ASPHALT CONCRETE(TYPE A) 0 T $225.00 $180.00 $ 6. AGGREGATE BASE(CLASS 2) 0 T $90.00 $50.00 $ - 7. SLURRY SEAL(TYPE II) 0 SF $0.30 $0.25 $ 8 AC REMOVAL/OFFHAUL/DISPOSAL 0 CF $15.00 $13.50 $ V.TRAFFIC SIGNALS/LIGHTS I. DETECTOR LOOP(6'ROUND) 0 EA $650.00 $520.00 $ 2. DETECTOR LOOP(6'x 30') 0 EA $950.00 $750.00 $ 3. DETECTOR LOOP(6'x 50') 0 EA $1,300.00 $1,025.00 $ 4. ELECTROLIER 0 EA $10,000.00 $6,000.00 $ 5. 1 1/2"RIGID CONDUIT 0 LF $13.00 $10.00 $ 6. 2"RIGID TRAFFIC SIGNAL CONDUIT 0 LF $24.00 $20.00 $ 7. CONDUCTOR 0 LF $1.05 $0.85 $ 8. PULL BOX(NO.3 1/2) 0 EA $425.00 $350.00 $ 9. TRAFFIC SIGNAL PULL BOX(NO.5) 0 EA $580.00 $460.00 $ 10. PULL ROPE 0 LF $0.60 $0.60 $ 11. NEW SIGNALIZED INTERSECTION 0 LS $380,000.00 $ VI. STRIPING AND SIGNS I. REMOVE PVMT.MARKINGS(PAINT) 0 SF $3.00 $2.65 $ 2. REMOVE PVMT.MARKINGS(THERMO) 0 SF $4.25 $3.70 $ 3. REMOVE PVMT STRIPING 0 LF $1.85 $1.50 $ 4. STRIPING DETAIL 9 0 LF $3.60 $3.00 $ 5. STRIPING DETAIL 22 0 LF $3.60 $3.00 $ 6. STRIPING DETAIL 29 0 LF $4.75 $4.00 $ 7. STRIPING DETAIL 32 0 LF $4.75 $4.00 $ 8. STRIPING DETAIL 37(THERMO) 0 SF $6.00 $5.00 $ 9. STRIPING DETAIL 38(THERMO) 0 SF $6.00 $5.00 $ - D:\MICHAE-1\Dropbox\MBTDOC-1\CALIBE-1\CAMPBE-1\EXISTI-1\NEWCON--1\PROPOS-1\PRELIM-1\SUBMIT-1\BLDG-1.COR\As- built\REVISE-1\CURBAN-1\1 STSUB-1\Completed Engineers Estimate 2015(Rev.03/08) Page 2 of 4 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8/15 �ENGINEER'S ESTIMATE FOR LAND DEVELOPMENT PROJECTS ' . Date: August 7,2017 For File NOW: Site Address: 655 E.Mc Glincy Ln. ENC. No. 2017-00184 Estimated Cost of Improvements $50,000 ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION QTY UNIT <$100 K >S100 K $AMOUNT 10. STRIPING DETAIL 39 0 LF $6.00 $5.00 $ - 11. LIMIT LINE 0 LF $7.50 $6.00 $ 12. CROSSWALK,12"WHITE 0 LF $7.50 $6.00 $ - 13. PAVEMENT MARKINGS(PAINT) 0 SF $4.00 $3.25 $ - 14. PAVEMENT MARKINGS(THERMO) 0 SF $8.00 $6.60 $ - 15. PAVEMENT MARKER(NON-REFL.) 0 EA $6.50 $5.20 $ - 16. PAVEMENT MARKER(REFLECTIVE) 0 EA $8.25 $6.95 $ - 17. TYPE K MARKER 0 EA $125.00 $109.50 $ - 18. TYPE N MARKER 0 EA $125.00 $109.50 $ - 19. SALVAGE ROAD SIGN 0 EA $115.00 $99.00 $ - 20. RELOCATE ROAD SIGN(W81 ON NEW POST) 0 EA $145.00 $115.75 $ - 21. INST.RD.SIGN ON EXIST.POLE 0 EA $265.00 $231.55 $ - 22. ROAD SIGN WITH POST 0 EA $400.00 $347.30 $ 23. INSTALL 1226S SIGN WITH POST 0 EA $400.00 $350.00 $ 24. STANDARD BARRICADE 0 LF $25.00 $19.50 $ - VII. LANDSCAPING 1. STREET TREE 3 EA $650.00 $500.00 $ 1,950.00 2. STREET TREE(36"BOX) 0 EA $900.00 $750.00 $ - 3. PRUNE TREE ROOTS 0 EA $200.00 $150.00 $ - 4. TREE REMOVAL 1 EA $800.00 $650.00 $ 800.00 5. PLANTINGS 0 LS $1.00 $1.00 $ - 6. IRRIGATION 0 LS $1.00 $1.00 $ D:\MICHAE-1\Dropbox\MBTDOC-1\CALIBE-1\CAMPBE-1\EXISTI-1\NEWCON-1\PROPOS-1\PRELIM-1\SUBMIT-1\BLDG-1.COR\As- built\REVISE-1\CURBAN-1\1 STSUB-1\Completed Engineers Estimate 2015(Rev.03/08) Page 3 of 4 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Revised 8/15 ENGINEER'S ESTIMATE FOR LAND DEVELOPMENT PROJECTS Date: August 7,2017 For File No(s): Site Address: 655 E.Mc Glincy Ln. ENC. No. 2017-00184 Estimated Cost of Improvements $50,000 ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION QTY UNIT <$100 K >$100 K $AMOUNT VIII. MISCELLANEOUS 1. PEDESTRIAN BARRIER 0 LF $86.85 $69.45 $ 2. CHAIN LINK FENCE(6) 0 LF $30.00 $25.00 $ 3. RAISE MISC.BOX TO GRADE 0 EA $600.00 $500.00 $ 4. RAISE MANHOLE TO GRADE 0 EA $850.00 $700.00 $ 5. INSTALL MONUMENT BOX 0 EA $3,000.00 $3,000.00 $ 6. MEDIAN BACKFILL 0 CY $26.00 $22.00 $ - SUBTOTAL $ 25,547.00 PREPARED BY: - 10%MOBILIZATION,CONSTRUCTION $ 2,554.70 TRAFFIC CONTROL/PHASING, $ 1,000.00 REVIEWED BY: CONSTRUCTION STAKING, $ 1,000.00 CONSTRUCTION TESTING $ 1,000.00 APPROVED BY: 10%CONTINGENCY $ 2,554.70 10%SECURITY ENFORCEMENT $2,554.70 TOTAL FAITHFUL PERFORMANCE SECURITY $ 36,211.10 USE THIS AMOUNT FOR SECURITY D:\MICHAE-1\Dropbox\MBTDOC-1\CALIBE-1\CAMPBE-1\EXISTI-1\NEWCON-1\PROPOS-1\PRELIM-1\SUBMIT-1\BLDG-1.COR\As- built\REVISE-1\CURBAN-1\1STSUB-1\Completed Engineers Estimate 2015(Rev.03/08) Page 4 of 4 - vvcwmm�o�cn a,cn��rwr.. THIS IS TO CERTIFY THAT THE FOLLOWING DESCRIBED COMMODITY WAS WEIGHED, MEASURED, OR COUNTED BY A WEIGHMASTER,WHOSE SIGNATURE IS ON THIS CERTIFICATE, WHO IS A RECOGNIZED AUTHORITY OF ACCURACY,AS PRESCRIBED BY CHAPTER 7(COMMENCING WITH SECTION 12700)OF DIVISION'S OF THE CALIFORNIA BUSINESS AND PROFES- SIONS CODE,ADMINISTERED BY THE DIVISION OF MEASUREMENT STANDARDS OF THE CALIFORNIA DEPARTMENT OF FOOD AND AGRICULTURE. SOLD BY-CONCRETE RiADY MIX, INC,-. UNLOADING RELEASE 134679 WEIGHED/ MEASURED A7: 33 HILLSDALE AVE., SAN JOSE, CA 95136 1. Concrete Ready Mix, Inc. is not responsible for any s4 damages to sidewalks, driveways, buildings, trees, OPEN 7 DAYS A WEEK PHONE (408)224-2452 I shrubbery,etc.when delivery is made inside the curb and on lot at the customer's request. CAUTION ; May cause eye or skin injury.Contains Portland cement.Freshly mixed VISA 2. Contractor does hereby indemnify and hold harmless cement,mortar,grout may cause skin injury. ;i Concrete Ready Mix, Inc. from any said damages TAKE THESE PRECAUTIONS claimed by property owner. 1. Avoid all contact with eyes.Wear rubber boots and gloves,and avoid 3. Signature below authorizes Concrete Ready Mix,Inc. prolonged contact directly with skin or through porous materials WE DISCOVER to use 'private driveway for making delivery and 2. In case of contact with eyes or skin,FLUSH THOROUGHLY WITH AIfAN P Y 9 rY WATER. ornREss customer assumes full responsibility. 3. If irritation persists,get medical attentiei promptly. o 4. Keep children away. LOAD NO. SLUMP C.O.D. MAP NO. TRUCK DRIVER DATE TIME PURCHASE ORDER/JOB NO. DELIVERY TICKET Y 53-4 ;° Ca i t_.,E F-.,'' J 1.t r E-_- /17 E, 5G'I 232302 SOLD TO DELIVER TO AC E:R 1 likUlL.DERE-- 4i:,:l.•--:IR'IZ11C, (-,C-5 E,. r*;,,,:aI_I \1C.Y I..ru.. I �� o QLANTITY TOTAL"'--�� - PRODUCT j PRODUCT- _ UNIT EXTENDED THIS LOAD DELIVERED _ CODE '. DESCRIPTION PRICE PRICE v. 4"i!„I 13. ftlfl i:: t !,._� :� '.I�:'.f•,}1'.. 144. !r'ill;( 1 .`�J2o 0I- - �..5., 0 L 5::,. t-0 itil'+r• w.7..,`�e > _ 1'J � .l".d. ::.1.... {`71..1. F L - a 'Af.E'J f'4 De 4i 0 7\�Je LA(jt i, I 's""� I i< 11 ,iC�i,U';i=1"i;j. l % . c7 41., r I, 00 O F° _ 4RRIVE A T PO U .E,al3 POU F� WATER ADDED AT .CONCRETE READY MIX INC. - WEIGHMASTER ,.. or; `"f CUSYOMER REQUEST R „ SUBTOTAL f ot'b J i 6 GALLONS BY DEPUTY T TOTAL MIN. ALLOWED CHARGED MINUTES AX I HEREBY ACKNOWLEDGE THAT I HAVE READ,UNDERSTAND,AND AGREE TO THE TERMS OF THIS INVOICE. MISCELLANEOUS r� CHARGEY, CHARGED -•,.- MIN Received ', I STAND BY CHARGE Five minutes per yard unloading time is allowed. By--*-X '''I,' GRAND TOTAL -INANCE CHARGES will be charged at THE RATE of 18%per annum.(11/2%per month).If it becomes ecessary to file suit for the collection of any amount,costs,including collection and ittorney's-fees shall be paid by the buyer,with venue in Santa Clara County.We do not guarantee against discoloration of concrete,whether color is added or not.We also do not guarantee against cracks in concrete. It is agreed that the above described materials and labor are to be paid for from funds received from the above described job in any event not later than 30 days rom date of delivery. Water or other ingredients'added may reduce strength and quality,and are added only at customer's request. C.O.D.-A$100 fee will be charged to all;C.O.D.orders not paid for at the time of delivery. - I I . 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