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ENC2018-00029 Of ,C4�� C •UkCHAKp' CITY OF CAMPBE .L Public Works Department May 22, 2019 + Jose Amaya 15245 Murphey Ave. San Martin, CA 95046 SUBJECT: PERMIT NO. ENC 2018-00029 1750 S. Winchester Blvd. Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Jose: 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. If you have any questions,please call me at(408) 866-2165. Sincerely, r 7 Syed Wahidi Public Works Inspector Cc: Permit File ENC2018-00029 70 North First Street • Campbell, California 95008 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 r _ � ti OF C44f Al 4�, GkCHARO• - CITY of CAMPBELL Public Works Department May 18, 2018 r. 5 Jose AmayaV' 15245 Murphey Ave. San Martin, CA 95046 SUBJECT: PERMIT NO. ENC 2018-00029 1750 S. Winchester Blvd. Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Jose: 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 May 18, 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. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector/Suspense Files Permit File ENC2018-00029 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 Encroachment Permit Final Sign Off Encroachment Permit# Address: 176o Date of Final Inspection and Acceptance: Inspected by: 5v\j OK to release deposits: 100% `' 75% Comments: AMAYCON-01 KIM ACtRO°° CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 03/26/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#OK07$68 - CONEACT Kimberly D.White,CISR Pacific Diversified Insurance Services PHO,"N,Ext):(408)842-2131 2179 (FAX Na):(408)842-0867 15005 Concord Circle,Suite 110 408-842-2131 noDRIE :kwhite@pdins.com Morgan Hill,CA 95037 INSURERS AFFORDING COVERAGE NAIC# RECEIVED INSURER A:Security National Insurance Co 33120 INSURED INSURER B: Amaya's Concrete APR 0,2 20# INSURER C: Jose Amaya 15245 Murphy Ave Public Works gdmlalstra URER E:INS URER D: 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 ADDLSUBR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS L R IN SD WVD MM DD M DD/Y YY COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ CLAIMS-MADE 7 OCCUR DAMAGE TO RENTED P a occurrence) $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $, EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY T T ER ANY PROPRIETOR/PARTNER/EXECUTIVE �Y Y/" X SWC1186995 04/01/2018 04/01/2019 1,0001,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I I 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) Jobs As Per Written Contract-Proof of Workers Compensation Renewal Re:Jobs As Per Written Contract-Proof of Workers Compenation Insurance Renewal,City of Campbell,its officers,employees,and volunteers. All other forms&coverages with the general liability are as per previous copies provided. 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 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DATE(MM/Do YYYY® ) .d►`oho CERTIFICATE OF LIABILITY INSURANCE 02/12/2018 PROD*CER THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION N_iKE MURILLO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1449 PARK AVENUE SUITE 3 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR SAN JOSE, CA 95126 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (408) 295-0554 FX (408)295-2147 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:State Farm Fire and Casualty Company 25143 25178 AMAYA, JOSE G DBA AMAYAS CONCRETE 15245 MURPHY AVE INSURERS: SAN MARTIN, CA 95046-9539 INSURERC: INSURER D: INSURER E: COVERAGES 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 O F SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY) DATE MMIDD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE OCCUR MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEML AGGREGATE LIMITAPPUESPER PRODUCTS-COMP/OP AGG $ PRO- POLICY JECT LOC A X AUTOMOBILE LIABILITY 410 8468-Dll-05-001 04/11/2017 04/11/2018 COMBINED SINGLE LIMIT 410 8470-Dll-05-001 04/11/2017 04/11/2018 (Ea accident) $ 1 MILLION X ANY AUTO 410 8472-Dll-05-001 04/11/2017 04/11/2018 X ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY—EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F-I CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS 2000 FORD F450 FLTBD VIN#1FDXF46F6YEE14149 2000 GMC C34 HD FLTBD VIN#1GDJC34ROYF516370 2009 FORD F750SD FLTBD VIN#3FRXF75N49V125438 CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED. THE INSURANCE COVERAGE AFFORDED TO THE ADDITIONAL INSURED IS PRIMARY INSURANCE. ALL WORK IN THE PUBLIC RIGHT-OF-WAY REFERENCE PROJECT LOCATION: 1750 WINCHESTER BLVD. PERMIT# ENC2018-00029 CERTIFICATE HOLDER CANCELLATION ADDITIONAL INSURED: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF CAMPBELL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 70 N. FIRST ST. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL CAMPBELL, CA 95008 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ACORD 25(2001/08) The registration notices indicate ownership of the marks by their respective owners ©ACORD CORPORATION 1988,2007 132849 03-13-2007 All rights reserved a o' IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2018-00029 Name: Jose Amaya Property Address: 1750 S. Winchester Blvd. Date of Final Inspection: wis/18, On File: Bonds CD Cash Faithful Performance: $ Labor and Material: $ Construction Cash Deposit to be released: $r l Other overdue deposits to be released (Description): Processed by: J ( g ( I A inistrator 1 1 Reviewed by: 13 Inspector l Reviewed by: Land Development Engineer JAJoAnnaT\Deposit refunds\CHECKLISTS\Winchester 1750.doc(Rev. 10/11) CITY OF CA PBELL ENCROACHMENT PERMIT Permit No.: Ge o DEPT.OF PUBLIC WORKS (for working within the X-Ref. File 70 North First Street public right-of-way) Application Date o Campbell,CA 95008 /7/� Ph.'(408)866-2150 Issued zl l/j �p Application Expiration Date Fx. (408)376-0958i( Z� �1 APN Permit Expiration Date APPLICATION-Application isherebymadefora Public Works Permitin accordance with Campbell Municipal Code,Section 11.04..(Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. WorkAddress`. �� (� ✓� � - rrr �J Nature of Work/Utility 'i' B. Trench Location: // __ f ❑ No Fee Permit for work related to City Project Project Name: C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part of-this permit. D. All work shall conform to the City of CampbellStandardSpecificationsandDetailsforPublicWorksConstruction;theGeneralPermitConditions _ 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. Na p[alicarit Tele( o e . 00 ��' s V bye t%q CV E-Mail ddre s: 4`}iNBZtIR'_MERGEiJGY I;HC1N Y 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 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 owner's successors, shall be responsible for any and all damages arising out of improvements completed in the public right-of- Accepted: 11 Permitteel/ sign. �{,•: ®(Contrraett�ry® Pri.,�Name)�— C�at'i SPECIAL PROVISIONS: 1. Street shall not be open cutfor underground installations.Minimum cuts maybe allowed for corinktions orexpl oration holes.SuchcutsDja! b cnarifically approved by the Inspector prior to rutting. 2.1 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 startingwork. V4. 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: SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT%/ _ RECE�TI PERMIT APPLICATION FEE $ `�,' PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK& INSPECTION FEE $ � EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE G or City Engineer Date Permit Expires 12 Months After Date of Issuance 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.ofthe permit work. 2. A Construction Cash Deposit is required.Changes will be made against this deposit iftherels 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 ofthe work by the City. 4. A one-year maintenance period and surety are required.Such period will begin on date of written acceptance by the City.Surety posted shall be equal to 25%of the original Faithful Performance Security. S. Submit project schedule 10(ten)days priorto proposed start of work.Additional lead time may be required for workwithin 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. Sawcutfor 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 Contractot 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.gcv/water issues/programs/nodes/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. Gon3 CIO r (Print Name) $amp J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.02/18 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 -�CW(� e7lI TO: FiqAi6e PUBLIC WORKS FILE NO. —4-!rl PROPERTY ADDRESS Please collect&receipt for the following monies: AMOUNT'' DEVELOPMENT 47221 Encroachment Permit Application Fee on- _tilitv Encroachment Permit Major 2:$10,000 $425.00 Minor Encroachment Permit<sio,000 $240.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240;00 inspection Fee Minimum Charge per Location $420.00 Street'Tree 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 $295.00 Site< 10,000 s.f. $885.00 Site 2! 10,000 s.f. <0.5 Acre $1,185.00 Site 2!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 4722 For Proiects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities $315 ea Plan Check& Ins pection.Fee(Non-UtilitV) 4722 Enqr. Est. <$250,000 14%of Enqineer's Estimate 4722 Enqr. Est.>_$250,000 and:5$500,000 $35,000.00+8%of Engineers Estimate 4722 Engr. Est. >$5D0,000 $55,000.00+7%of Engineers Estimate 2203 Emergency Cash Deposit 4%of Enqr. Est.*($500 min/$1 0,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* 2203 Labor and Materials SecuritV 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) 47221 Parcel Map (4 Lots or Less) $4,200.00+$90/lot 4722 Final Tract Map(5 or More Lots) $5,115.00+$124/lot 2203 Monumentation Securitv - 100%of City's Monumentation Estimate 4920 Parkland Dedication Fee(75%/25%Due Upon Cert.of Occupancy) .4722 Lot Line Adjustment(includes Certificate of Compliance) $1,990.00 4722 Vacation of Public Streets&Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 Certificateof 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 $1 00/sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Payment --- 4722 sessment Segregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 511.7424, Postage 7 Other(Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ NAME OF APPLICANT LOUD ,�Gl NAME OF PAYOR 17 J2 4-2V f jj-� PHONE 1, ADDRESS JJ—h=sPA2 .5 7. ZIP SA- C .4- 71 1)B FOR E El: E 0. Z" CITY CLERK ONLY 7 j ToRm � . . S2E my+w RCUD BY: CASHIER 011m029211 GSQ wGq y++dm TODAY`-'; DATE: 02 de 2qq DATE. 9 dB 9«= Q!m . +S 2AI+ qmq CANTIA yag9 . gmamgD SQmF #a.m mS DRSOSgm+§T gq & gqS SSm £ \«Gm TOTALDw !S&m IGR«m CHANGE: tm CREDIT CARD: A75.00 3E Num. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 04-84) WAIVER Of OUR RIGHT To RECOVER FROM OTHERS ENDORSEMENT-'CALIFORNIA We have the right To recover our payments from anyone liable For.an injury covered by this policy."We vvill Not enforce-our right against the person Or.organization•named In the,Schedule. (This agreement applies only To the extent that you perform work under a written contract that requires you To obtain this'agreement from us.) You must maintain payroll records accurately segregating the remuneration Of your employees While engaged In the work described In the Schedule. The additional premium For this endorsement shall be 5%Of the California workers'compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description City of Campbell Attn.-'Dept of Public Works Permit#ENC201800029 Campbell, CA 95008 This endorsement changes the policy to which it is,attached and is effective on the.date issued unless;ofherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy:) Endorsement Effective 4/1/20.17 Policy No. SWC1144886 Endorsement No. 1 Insured Amaya,Jose Gilardo(An Individual) Premium$ 11995 Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed.04-84) AMAYCON-01 BROOKE AC RO® DATE(MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 12/19/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,-EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License#0504035 CONTACT Brooke Alarcon,CISR NAME: Pacific Diversified Insurance,Inc. PHONE FAX 15005 Concord Circle,Suite 110 (A/C,No,Ext): (A/C,No): AIL 408-842-2131 ADDRESS:balarcon@pdins.com Morgan Hill,CA 95037 INSURERS AFFORDING COVERAGE NAIC# INSURERA:Colony Insurance Company 39993 INSURED - - - INSURER B:Security National Insurance Co33120 Amaya's Concrete INSURER C Jose Amaya 15245 Murphy Ave INSURER D: San Martin,CA 95046 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING-ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR-OT-HEfZ-D000MENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE—POLIICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN EDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF . POLICY EXP TYPE OF INSURANCE POLICY NUMBER LIMITS T I WVD , f�, M DD YY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 103GLOO16187-0 f 11/22/2017 11/22/2018 DAMAGETORENTED 100,000 X t� PREMIS S'Ea occurrence $ S,000 MED-EXP An one person) $ PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: � ..-�'� GENERAL AGGREGATE $ 2,000,000 X POLICY jE O LOC \\\� --- PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accide t $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON0WNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN - X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE .X SWC1144886 04/01/2017 04/01/2018 1,000,000 OFFICER/MEMBER EXCLUDED? ❑Y N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,-describe under - - 1,000,000DESCRIPTION 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) City of Campbell,its officers,employees,and volunteers,are hereby listed as additional insureds in regards to the General Liability Policy where required by written contract.Insurance is primary and noncontributory.Waiver of Subrogation in favor of the Workers Compensation applies. W Q-1 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 tY P ACCORDANCE WITH THE POLICY PROVISIONS. Attn:Dept of Public Works 70 N.First St Campbell,CA 95008 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) @ 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD INSURANCE REQUIREMENTS CHECKLIST , 177 S0 Permit# CIP Project# Consultant/Contractor: c s C(-) `rcce The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: X $1,000,00.0 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date Automotive Liability: © y6- ."Any Auto" checked on certificate $1,000,000 per accident for bodily injury and,property damage Policy expiration date AA 1l Workers' Compensation and Employer's Liability C Waiver of S"ubrogation clause S s $1,000,000 per accident for bodily injury or disease _ ,p. Policy expiration date t 1711. `C P Course of Construction (if required in Special Provisions) ❑ -Completed value of the.project ❑ Policy expiration date l Required Endorsements to General Liability and Automobile Liability Policies \ditional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area 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 Jan 2018) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of.A:Vll.and is authorized to transact business in the State of California. i f �)9ct Name: ��(�� �� NAIC# Rating: A— X\\' Authorized in CA: Name: �,,1.�`I �'� NAIC# MI ZORating: ' 7C Authorized in CA: V Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: 3/ zci cl X ` ❑ Campbell Business License Expiration: ❑ Contractors License# Class: Expiration: YInsurance Certificate Reviewed 2 ' Ini ials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. - O x Yn J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 Feb, 9. 2018 3: 36PM No, 4666 P. 1 �y AMAYCON-01 EBECK DATE(MMIDD1YYYY) CERTIFICATE OF LIABILITY INSURANCE 1. 02109120'I8 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 1NSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder IS an ADDITIONAL INSURED,the policy()es)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, Subject to the terms#and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER License#0504036 ROANTACT Brooke AlarconEr ' Paciflc DiVersified insurance Services PHONE 15005 Concord Circle Suite 110 A(c No FJd:(408)842-2131 --�FuU6,y 40B 842-0867 408.842-2131 hngs.balarcon dlns.com :-- Morgan Hill,CA 95037 AFFORDING COVE E _.NAIL _.... _...._...._....•.. ...._—__—..__..__ RERA:Colony insurance COmpany—... 139983 INSURE! imsuRERe,Securiiy National Insurance Co 33120 Amaya's Concrete INsuRERc.Jose Amaya 16245 Murphy Ave D: —•----_ --......... -- San Martin,CA 96046 INSURER E: INSURER F• ' COVERAGES CERTIFICATE NUMBER: REVISIbN N THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW tIAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH•RESPECT 70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- INSR, ADDL TYPE OF INSURANCE NEW POLICY NUMBER POLIC,y E F POLICY EXP LIMITS — A X COMMERCIAL GENERAL LIABILITY 1000,000 � i 9RRENCE �. — CLAIMS-MADE L^I OCCUR 103GL0016137-01 1112212017 11122/2010 DAMAGE TORENTEo 160,000 .l.. crs+rt�n�91.._._ ... _.... ---'---'-••— Q FJ(P(Any OYYe Qerson� >� 6,600 PERS�NAL ,ADV INJURY_....;. GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREQATF 2,000,000 POLICY D jPteT PRODUCTS-COMPlQP AGO2,000,000 OYHER: -- 'AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 'ANY AUTO ' I OWNED SCHEDULED BODILY INJ ,— .... ...... .. .. AUTOS ONLY AUTO$ ` �i) i •1 ILYINJURY Pbra=ide _ NOPI WNED TOPER AMAGE " I...._j A S ONLY _— AUTO ONLY er accn , I UMBRELLA LIAa OCCUR I— lAr}10CCURRENCE _ EXCESS LIAR CLAIMS-MADE AGG E -- i DED M1 RETFNTIDN$ I3 ,WORKERS COMPENSATION PER 07N- AND EMPLOYERS'LIABILITY LEE— ANY PROPRIETOR/PARTNER/EXECUTIVE 7!N X SWC1144886 04/01/2017 04/0112018 1000000 OFFICER/MEMBER"'LUDED? NIA E.L.E CIDENT _•___ —,_-• + _ _ + an lery nNH) E.L DISEASE.E LOYit _ _1-006,666 ious-dde;rrme,n+tlor _ 1,000,000 IDES OF OPERATIONS below DISEASE-POLICYL g • I I 1 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101.Additional Remift 9chadde may be aftwhed R more apace Is requlmd) RE:Job located at:17SO Winchester Blvd.,Campbell,CA 96008;Permit N ENC2RI300029 • City of Campbell,Its officers,employees,and voluntaere;are hereby listed as additional Insureds In-regards to the General Liability.Policy where required by written contract.Insurance Is primary and noncontributory.Waiver of Subrogation In faVor of the Workers Compensation appflee;copy of policy farm WC 04 03 06 to follow. CERTIFICATE HOLDER CANCELLATION SHOULDANY'OF THE ABOVE DESCRIfto 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 95006 AUTHORZFDRSPRESENTATNE LI;2 L-- I . �i ACORD 25(2016/03) O 1988.2015 ACORID CORPORATION- All rights reserved. Tho ACORD name and logo are registered marks of ACORD 02/09/2018 16:27 4082952147 MIKE MURILLO PAGE 03/03 4f S TE PORARY AUTO ID►• IV IFICATION CARD STATE FARM This card is invalid if the po icy for which it was issued lapses or , terminated. CALIFORNIA CAR INSURANCE CARD N IF YOU HAVE ANO CC.ICEN'r- ._�. .�... NOTIFY POLICE IMMEDIATELY POLICY NUMBER 410 8472�D11-05 001 INSURED v I.Get names, addreases, and prune m rs of persons Involved and witnaeass.Also gat driver licanse numb6i f3 of persona involved and Ifoansa AMAYA,J03E G )4 URPbIY AVE plate numbars/states of wiftles. 1525 M SAN MARTIN,CA 25046-9539 2•pmMpfly notify your agent,lag an to st(,frdrm.aoA or visit State Farm EFFECTIVE DATE OCT-17-2o77 EXPIRATION DATE AJ�R-11-2010 Pooknt Awim to foe n clrtlm, CAR-YEARAVIAISEIV&HICLE IGEN71P1CATION NUMBER 3,Don't admit fault ar diaeusa the acdderl vlth anyone but State Farm yr 2009 FORD F75OSD FLTBDTRK police, 3FRXF75N49Vg26430 COVERAGES + For Emergency Road Servld I 1-677-627-5757 A,C,D500,G500,U.U1 � � A The coversgga ravlded by the policy meat9 the w minimum Ile H tty limits prescribed by law, SEE POLICY FOR FULL.NA ,AND DEFINITION and Is 9 commerelal ar fl4et vehicle, NAIL 1#25143 A Liability R1 Cor Rental and Travel Expense StataFallti'FTId'Artd °t71391i51tSi'COr$�j311n '+ ;, i ':{t"i:!`" a edIMI Payments S heath,Dismemberment and 900 OLD c M i+.E ". :.j,,;;i ';'; ;i; i D Comprehensive Loss of Bight BAKERS IF 51DbR'334-4807 I" s G Collision U Uninsured Motor Vehlole AGENT H Emergency Road Sorvice 1-11 Uninsured MotorVehitio-PD MICHAEL P MURILLO,AGENT ? L Phyalcaf Damage z LOse of Eaminga 1449 PARK AVE,GTE 3 SAN JOSE,CA 65126 PHONEt#408.29"554 STATE FARM0 Submit this card or a photocopy of this with your vehicle regial lation renewal. One copy of this form�!should be carried in the vehicles at a I times. The form may be needed as evidence of insurance in c0urt. A toll free number is availabl4for Emergency Road Service and is 10cated on your insurance card. 70017a0 20M 144750 200 01.OM017 d S 02/09/2018 16:27 4082952147 MIKE MURILLO PAGE 02/03 r 'i TEII PORAR'Y AUTO IDEN IFIDATION CARD STATE FARM@ This card is invalid if the pliilicy for which it was issued lapses or is terminated. i CALIFORNIA,CAN INSURANCE CARD s[aterenn t fie. IF YOU HAVE A OCCIDENT- NOTIFY POLICE I V MEDIATEL,Y POLICY NUMBER 410 8488-D11.05 001 1.Gel namos, addresses, and i3hoha t it Tibem of persons Involved and INSURED whnesses,Also get driver 110006e WWI 0ts of persons Involved and Ilaense AMAYA,JOSE G plate numbers/sUtee of vohiclo9, 18246 MURPHY AVE ; SAN MARTIN,CA 99048-9530 2,Promptly notify your agent,lag on to P.A lafarmROn1l,or vlalt State Farm EFFECTIVE DATE OCT-11-2017 EXPIRATION DATE�PR-l1-2015 Pocket Agont'G to file a claim. I CAR•YEARIMAKENEHICLE IDENTIFICATION NUMBER 3,laon't admit fault or dlaouns tht aooldt}r wlth anyone but State Form or 2000 FORD F450 FLTBDTRK police. II 1FDXF46FGYEE14149 For Emergency Ford SerV vit i call 1-877-627.5757 COVERAGES A,C,U.U1 y p B The eovar096 pprovided by the policy meets the minimum llablllty limits greserlbed by law, SEE POLICY F'OR PULL,NI! @ AND DEFINITION and Is a commercial or flebt voltlale" NAIL 425143 A Liability R I Car Rental and TrAval Expense State FarrW1901%U8 w"f;sif� oMl3hny'`;' .. ........ ....W i C Medical Payments S . Death,DfsmernDeiment and ,.7 1 96�OLDI+1!.:"li .:f);;"�,,. •;:.r,,,.`c!, ;t 0 Comprehensive La98 Of Sight RA ERR IELD 1�ti5J.l I' ,,,••• ..,,•; ... , G collision U Uninsured Motor Vehicle gAKER3FIELD'C11'9$9'11+•$�01 y AGENT H Emergency Road Service- U'1 Uninsured Motor Vehicle PD MICHAEL R MURILLO,AGENT ? L Physical Damage Z. Lo9tt of Earnings 1449 PARK AVE.STE 3 SAN-JOSE,CA 09128 ` PHONES 408-295.0554 STATEFARM0 I •` I k Submit this card or a phot opy of this with your vehicle regi ,ration renewal, i One copy,of this fo4 should be carried in the vehicles at, 8 times. The form may be )�ineeded as evidence of insurance in '�aurt. A tall free number is availab� for Emergency Road Service and N located on your insurance card. 10017a6 t =03 IU750 200 O1-03-2017 , 'r 5 t 02/09/2018 16:27 4082952147 MIKE MURILLO PAGE 01/03 t k TE PORARY AUTO IDEN IFI ATION CARD STATE FARM I I This card is invalid if the p�hlicy for which it was issued lapses of 6s terminated. r� 3 f I CALIFORNIA CAR INSURANCE CARD ! SY�te6nrm u IF YOU HAVE AN ACCIDENT- NOTIFY N( TIFY POLICE 1 .MEDIA"fil LY POLICY NufNSER 410 8474-01 t-OS 061 f 1I INSURED 1.Get names, addresses, and phone I1rb'q limbers of persons Involvad and AMAYA,JOSF.G ° wlinessec.Also gat driver lfaen9e num of persons Mvolvad axnd Ilcanaa 15245 MURPHY AVE ' plate numberslstntes of vehicles. SAN MARTIN,CA 95040.0539 2.Promptly notify your agisnt,log an to It.terarm.carrP,or visit State Farm EFFECTIVE DATE OCT-11-2017 EXPIRATION DATE P%PR-11-201a PockotAgentO to file a claim, CAR-YEARIMAKENEHICLE IPENTIFICATipN NUMBER 3,Don't admit fault at discuss M4 accld r t with anyone but State Farm or 2000 GMC C34 HD FI,TBDTRK police, 1GDJC34ROYPS16370 t COVERAGES For Emerg0noy Ro d$e ip call 1-877-t327-5757 A,C,U.U1 R The coverage pprovided by the policy meets tho 4t minimum Ilnoliity limits prescribed by law, a SRE POLICY FOR FULL W ih1E AND DEFINITION and Is a commarclnl or fleet vahiclo. F NAIC*25143 A LIablllty FY I Gar Rental end Travel Expanse State Farrrilh Wild G"�ali'hIE Xi0fi1}�hn�,`;; tr ;� ".i's a ' �1 C Medical Paym9nt9 g Death,6iamambemleflf and r ¢+, irr.,,,, a�.,..,,,• :•..,JS " ";: 906 OLD RI ,EF�IJ�arl'�Iti 'I': .. �`� 4 Com rehenslve 1 ,:.;v•�••, P Los,;of Sight SAKERSFIELD C%C'4�3$1�(=9�01 n G Collision U Unlnsurad Motor Vehldo AGENT H Emargoncy Road Service U I Unlnsurod Motor Vehicle-PO MICHAEI,P MURILLO,AGENT IL Physical Dsmsge �_ Loaa of Earnings 1449 PARK AVE,GTE 3 SAN JOSE,CA 90126 y PHONE#405.295.0554 6 STATE FARM" i Submit this card or a photc,hcopy of this with your vehicle oregi, tration renewal. One copy of this fbr i should be carried in the vehicles at II times. The form may bo needed as evidence of insurance in c ourt„ A toll free number is availage for Emergency Road Service and i •r located on your insurance card. 1001188 2003 144150 200 01.003017 V I r I - } ' CITY O4 r���ulf�I Rri M:3a CASHIER 01000173710 vy j.E... .-'Life£CONCRETE 1` � .. if ANAYA !]IftT }F1 F 1.2 �?.i.��}f#-tv rf� 1}j.�},1911 i.i f'ifw'_° L.}}U,",t'#�i i D99CRIPTION AMOUNT • - - "" ji{JJ :i}.:.`SS "%.S:.+r{��:.ir REP _._...�...._._....._4 WCT{,I».M1<t.i IZ f.:r�Ty}F¢ti;u CREDIT CARD: $MO.50 REF NUM9 y