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ENC2017-00294
Encroachment Permit Final Sign Off Encroachment Permit# C 2,017—0029 Address: 2--0 2i9 S ,�1SCcl�t vt Date.of Final Inspection and Acceptance: 5 JIS116t Inspected by: %�>*j OK to release deposits: 100% 75% Comments: I .......................... .............................. ........................................ V* ........ ........ ................................. ................. ..................................... .......................... ............ ...................................... ..................-................ ........................... ................................ ............................... CITY OF CAMPBELL VENDOR NO. 10014886 CHECK NO. 273647 Account ':l::Pu'rcha's' r Avbice:Nlithb& 101 2203 CRO52319 1,250.00 REMAINING FPS REFUND 4, 10014886 GALILEI PROPERTIES CHECK DATE CHECK NO. CITYOY:CAMPBELL w 1 9.L.r s.1 FARGO BANK, N.A. -24 FIRST STREET 06/03/19 273647 7.6 N 60 3-20'MONTGOMERY STREET, 1210 .:SAN.FRANCISCO, CA 94104 CAMPBELL, CALIFORNIA 95008 0 AMOUNT ***1, 250 . 00* °ROIIARO0 :::::!VOID AFTER 90 DAYS -n PAY THE .SUM OF ONE THOUSAND, TWO HUNDRED FIFTY DOLLARS & ZERO CENTS TO THE GALILEI PROPERTIES ORDER F 1425 FOXWORTHY AVE. , #E SAN JOSE CA 95118 iil2 ? 3G1, ?o i: 12LD0021.8i: It 12 18 S 54 I'Sil I Oil 'D I - --------- H ................................. I. . ...................-............... ............I................... ..................................... ................................... ................................. ......... .............. .................. ............. .. ....................... *See Reverse Side For Easy Opening Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 GALILEI PROPERTIES 1425 FOXWORTHY AVE. , #E ,, SAN JOSE CA 95118 yr _,__ CITY OF CAMPBELL Public Works Department June 4, 2019 Biagio Passaro Galilei Properties, Inc. 1425 Foxworthy Ave. #E San Jose, CA 95118 SUBJECT: PERMIT NO. ENC 2017-00294 2089 S. Bascom Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Passaro: 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 remaining 25% of your Faithful Security Deposit in the amount of$1,250.00 is enclosed. If you have any questions, please call me at(408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Permit File ENC2017-00294 7o North First Street Campbell, California 95008 TEL 408.866,2150 • Fax 408.376.0958 TDD 408.866.2790 Refundable Deposit Check Request To: Finance Director Check Payable To: Galilei Properties Address - Line 1: 1425 Foxworthy Ave.#E Line 2- City: San Jose State: CA Zip: 95118 Description: 2087 S. Bascom Account Number: 101.2203 Amount: $1,250.00 Account Number: 101.2203 Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: (Exact Amount) Purpose: Remaining 25% FPS Refund Permit#: ENC2017-00294 Receipt#: 272947 Date: 12/20/2017 Receipt#: Date: Requested by: t Title: Inspector Date: 6/2-3 Syed W Approved by: — Title: Sr. Engineer Date: Roger Stolz Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handlinq Check Mall As Is: Mail in Attached Envelope: Interim Gheck: Needed By: Return To: JoAnna Thomason Public Works (Name) (Department) CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2017-00294 Property Address 2089 Bascom Ave. Date of Final Inspection: 5/15/19 On File: Bonds CD Cash Faithful Performance $1,250.00 (Remaining Z5 /o Labor and Material $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: y Z2 i q Ad inistr for Reviewed by: Inspector 1 Reviewed by: Land Development Engineer JAJoAnnaT\Deposit refunds\Checklist-Clearance One Year Maintenance Acceptance.doc(Rev. 10/11) of 'c��° - •UkCHAR�• CITY of CAMPBELL Public Works Department May 16, 2018 Biagio Passaro Galilei Properties, Inc. 1425 Foxworthy Ave. #E San Jose, CA 95118 SUBJECT: PERMIT NO. ENC 2017-00294 2089 S. Bascom Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Passaro: 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 1, 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. 75% of your Faithful Security Deposit in the,amount of$3750.00 and your Construction Cash Deposit in the amount of$500.00 are enclosed. If you have any questions,please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector/Suspense Files Permit File ENC2017-00294 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790 ....................................... I . E y ........................................ - / 1 i :............_.._._._. ..._............................._..,, v......................................... ............. .......... :............_..._._.............._., ..............1 _ ___________ __ ____ _ _____ _ -.__... t CITY OF CAMPBELL VENDOR No. 10014886 CHECK NO'. 267790 Account 101 2203 CRO',50418 4,250.00 2087 S BASCOM I j I % I 10014886 CALILEI PROPERTIES i I � 1 CHECK DATE' CHECK NO I a�'� r, : CITY OP CAMPBELL W � FARqq B K;:N.A -24 1 -.,i •, + 420 MONTGOMERY STREET ., 2210 0 5/'14/1 B 2 6 77 9 0 NORFii:'FIRST STREET\ srN FRxcss c 4104 CA( PL .CALIFORNIA 95008 AM oVL * j I _ 01 �Rr R9 VOID AFTER 9,0 DAYS m 1II \. \I PAY THE" SUM: OF FOUR THOUSAND, TWO HUNDRED'FIFTY DOLLARS &- ZERO lim�l I t CENTS ` TO THE GALILE.I PROPERTIES _, ORDER 1425.t FOXWORTHY AVE , #E � AN JOSE CA? I � �� � S 95118 f� � � �j � •;� � l' 2,6L��wjll" .7 T9,Q�iI' . ,':• L 2 L.0 0 0"2�4 8�: 4 1 2 L 8 5.5 4 L SII' ifelml m1gjulAil • 1 / i..............__...._...........__ '1........................._.._......._3 ......._......,.._......_............. .....................-. _ - - ......... ._...._._..... ...._.....__........ - ........ ............. ;... l i See Reverse Side For Easy Opening Instructions* - - I � I CITY OFF CAMPBELL 70 NORTH FIRST STREET CAMPBELL\, CALIFORNIA 95008 J • I l � _ _ I J / .I I I , i I GALILEI PROPERTIES 1425 FOXWORTHY AVE. , #E SAN JOSE CA 95118 - - .� F - H Ref undnble Deposi# Check Request f' v _ J ',,-.I.';.-,:,I�-�.;c..,�-,I-:.,,�1�.�.-1.��,-1-,.--.C,-1.�.-..� ..,1-,,-�-.I,�-.-,,I,,-,�"�.�.,.I.:.I---,�-'"t-.'�.a.�-,-".""-..I--.-�(--Ip,--.,.�,,.4,--.�.1,-�,.1--'bI:',�.--.:�....� To Finance D-�,-:,,"-�..."--..`...''-.,�,-'-�-�.��-I-.--.I..,r-.-".-;�:,,.--.,,�.�;.I.,:,.-e,--,-.,�,,I.-..-",,,.f-`,,,!.,.:l.P4,..,.-�-,-:,".-.�,'--,-.,,,�r:,,�,,."."�-irec,.�.I,.'.,'..�,-...'�.-''"�.,�':�:-.-'--,�,',',,.-.-1�--I1-,-,-,�:.-',�,-,to.,r..�-.I.-.'-,.,I_..�:-�--..,,...,�.,,�'-':.,,r..�,,'.'-.,-.I-.-�-,-.-.--,--.,'-.----P-,.�,l,I,,,--.,.I.-1,.:-�,,-:--�I.--',.�--,-,,.."�"I%,--,I_:.r ,-`-����,--,:'F_-��,."�,-"�--�,.;.--..�'''-.-I- :-�"�!1----�!,.-..-�..:��---.----.,c--I�-,-1- rt1 �-:-I:.-.,-.....,':-.`--I.-,I."I.':,.�-.,-.,-��1-",.'--,-,-"-,�.-*:-,.-,.--f-I..-'..`.-':'�":-..,",;I-.,��.,---,.1-,.-�--,,'-::,:�---.,;:,--,.,,,'-,.,.--1--�.-,F"--"--,1,.--.-,--��!--"�,---.'�'"--."-,..�.---.-:--I.,.-- ,.:.1',I-,,�:'�.;,_,,-,1-.�1:--.-.-.1.11.-',,.-",�.,'.-1..,I-:,I,:.!2:.,..:�-.I-1 t,..1 I-,.l;�-,I...t.-�I-,.,�..I.,,-,,,'..I..,1,,---�1.. 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I - !1 ,Pu[pose FPS.and Construction Degoslt-Refunds. i - . ,;{ , , , Permit# ENC2017 00294 , Receipt# 272947 Date _ 12/20/2017, I IZecelpt,# _ _ Date.: 2/14/2014 I . l... .. „ r' -4 ,. 5 - - { -, I-- I Requested by ,A Tithe Inspector Date 5 - Syed Wahidi , , �,,:;--1.-,."---..t:�-,:,.,,.�I.,!,.,,-l"-,.;..,-'�-.-.;.I',-�,.1...1..�.-''.:._-.�1-,-,,,;:.�,-,"�-1,,..._-.�.:l�,".-�,,�''t,-�,,�-..-p;---,:-,r,,.�-.._,d�---��-2..,---,--���,-���-�.I'--,.-�--:,---.�",--�:�.-,,-I I,':'"-"-,.-,,.,,,.1.,-..,,�,..,-I-'.,1,...�.,�.����'�-�-.--"------�-..-,--I-,--.;I,�I..lI.--,.-,-'`,.-e-�.�I�z!,�,l-0,,',',,-I,. -,.''-,"...-��;1�.:,---.-.1,-�'�.-'.-,,l-,�-.,-,.:..I'.-,,.-�%-,.,-�"-.�,Il�-,,,---�_',,...,-�-,.,-I-.--.-,-'-'-6,�,,.--'--,,�,.:-,-.-�I.--'�,�-,��.,�,,�..--..--,.,-'-,'�--.,�.'-�-t..7I,.,....;,,.,:.-,�-"-.,..''--..�..7-.-i.-,:-.--,,....--I-',_-I,'.,:.I-..-,'��:�-,:,,.�-,_,-1�-,-.1,.-,I.-.��,,,.' - I Approved by .I-�-,..1:7-:'-,,".-�'--,--.-..,�.]--�,.".-.�-,,::,--`"�"."I-1�-'.-,",,.,,t,---'--�-,.---�.I�-:.-.,-..�;�,��I1,--:,l-;.,.e."�,'.'-p-;..,�,.:,*.�I,��,,-'.,.I,-.�C,I;,,.l I.-,.'I-,�-,.-7*l`I,",,�"I---'.I"-,-..,..,,,."-.-..-:-_�,i�.1,---p..I',,..:,�--:;.�-..-��,-,...-;�,,�,,..-;I I.,II�.-, - Title Sr.`Engineer _ Dafe - Roger Storz �---:��.,--I,-,.,--,-�-:�,,._,.-.-.r 7I-`,--,I.,--,�."-�,,-i:--i.--1,,,---:�.--,",,-�,--�,,--",�Z�-,:'-.]---,-��--�-----,-,-.---,-�--1I--,:-..",",-,',1�.-�.-,-z,-.�:,,--"Z-,,t,:-..-,�!t-L,.-- ,-.,.l.,�--%:,,..-.--,--� ,I , I - ,i Finance Dept Only i ;` Verified by --- . - Tithe Accounting.Opp,II., Date - . - - 4 Y_. i Title __ Acco ant Date . _ Approved t -. . , _ . -. - ,rig. - t t ! S caj,,I1ttpUct46h-1 For:_ Handlin Check /. - r *. '!///INiall ' s IS , Mail m Attached'Envelope Ini2-iA l+ne,k {" } '.c ,I Needed:Bq _ , Return To ' JoAnna Thomason _ Public Wog s _ (Name) (Department) .I. ' } d �,. ,S'' I' .!, Other Please return check to Jo Anna; f - ._ R.- - - , , - - CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2017-00294 Name: Biagio Passaro Property Address: 2089 S. Bascom Ave. Date of Final Inspection: 4/30/18 On File: Bonds CD Cash Faithful Performance: $ 5,000.00 Q5Wb-= i,59-�0,0-) Labor and Material: $ Construction Cash Deposit to be released:Q$5OD..S10 Other overdue deposits to be released (Description): Processed by: S Ad inist for Reviewed by: Ins13 ctor Reviewed by: Land Development Engineer J:VoAnnaT\Deposit refunds\CHECKLISTS\Bascom 2089.doe(Rev. 10/11) Encroachment Permit Final Sign Off Encroachment Permit# tNC 9-104 Z �'o 2 '-} Address: Date of Final Inspection and Acceptance: 413C-A& n Inspected by: OK to release deposits: 3-00% 75% Y Comments: CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No ENC2017-00294 DEPT.OF PUBLICWORKS (for working within the public X-Ref. File 70 North First Street right f-wa Application Date 12/13/17 Campbell,CA 95008 l Application Expiration Date Ph.(408)866-2150 Issued APN 41 9-10-045 Fx. (408)376-0958 I's Permit Expiration Date APPLICATION-Application is hereby made for a Public Works Permit in accord ce 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.: 2089 S Bascom Avenue Utility Trench Location: B. NatureofWork: Driveway Reconstruction (ADA) C. Attach four(4)copies ofan engineered plan showingthe location and extent ofthe work,and four(4)copies ofthe preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part of this permit. D. All workshall conform to the City ofCam pbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below.Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before startingwork.Notice must be givento PublicWorks at least 24 hours before restarting anywork. Name of Applicant: Telephone: 4082692376I Address: F2q789S BASCOM AVENUE E-MailAddress: PNOPASSARO@GMAIL.COM 24-HOUR EMERGENCY PHONE NUMBER: 40$4497475 ................................................_........... .............__ Is this work being done by the property owners at their own residence? ❑YES F 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 I ublic right-of-way. Accepted: BIAGIO PASSARO (Applicant Permittee) (sign) Date �a� ,r Pi VI(II far Lo e2 A, 10 - �3�-Gy991r�- (Contractor) (Print me) Date SPECIAL PROVISIONS: ❑ 1. Streetshall not be open cutfor underground installations.Minimum cuts maybe allowed for connections or exploration holes.Suchcutsmavbe specifically approved by the Inspector prior to cutting. ❑ 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. ❑ 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department before starting work. ❑✓ 4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. ❑ 5. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. ❑ 6. Public Notification Requirements:, ❑ 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $A25.00 � PLAN CHECK DEPOSIT $__ 7Sll SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ 5000.00 ,Z CONSTRUCTION CASH DEPOSIT $ �Z PLAN CHECK&INSPECTION FEE $_ —77-9 EMERGENCY PERMIT FEE $_ APPROVED FOR ISSUANCE ForCity Engineer D to 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 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.gov/water issues/programs/npdes/utilitwaults.shtml for more information. Applicant is le for ensuring that all those providing services under the applicant are aware of and abide by all of the abov conditions. I2 � f� AppilcAt H-77: � r P�V I ` Date: 9 . Cq 6d;nI ZnG Contractor (Print Name) '( LG� Date: J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit STATIC form2.pdf Rev.03/17 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finance PUBLIC WORKS FILE NO. ENC2017-00294 PROPERTY ADDRESS 2087 S.Bascom Avenue Please collect-&receipt for the following monies: tzTE _ AMC111dfi LA110.. iILM #I .._.. 7 Encroachment Permit Applitation ee Non-UtilityEncroachment Permit Major>_$10 000 $425.00 $425.00 Minor Encroachment Permit<$10 000 $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 Grading&Drainage Plan Review Single Family Lot $295.00 Site< 10,000 s.f. $885.00 Site>_10,000 s.f.<0.5 Acre $1 185.00 Site>_0.5 Acre $1 772.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Impervious Area 10,000 S .Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 4722 For projects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities 315 ea Plan Check&Inspection Fee(Non-Utility) 4722 Encir.Est.<$250 000 14%of En ineer's Estimate $700.00 4722 En r. Est.>:$250 000 and<_$500,000 35 000.00+8%of Engineers Estimate 4722 En r. Est. > 500 000 $55,000.00+7%of Engineers Estimate 2203 Emergency Cash Deposit Refundable Deposit) 4%of En r.Est.* $500 minl$10 000 Max $500.00 2203 Faithful Performance Security(Refundable De osi+100%of ENGR.EST.* $5,000.00 2203 Labor and Materials Security 100%of ENGR.EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) All Other$2,650.00 4722 Parcel Ma 4 Lots or Less 4 200.00+$90Hot 4722 Final Tract Map(5 or More Lots) $5,115.06+$124/lot 2203 Monumentation Security 100%of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee 75%/25%Due Upon Cert.of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) $1 990.00 4722 Vacation of Public Streets&Easements $2 700.00 4722 Certificate of Compliance $1 970.00 4722 Certificate of Correction $590.00 4722 Document Recording Fees $15.00/first page$3 ea.Additional 4722 Private Improvement in Public ROW $100.00 - 4722 Approved Plan Revision Fee 1 DO/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 51.1..7424 _.. Postage Other'Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $6,625.00 NAME OF APPLICANT NAME OF PAYOR PHONE ADDRESS ZIP 61 FOR _.s CITY CLERK ONLYMft jai an,lrY11 Ian c n¢r W.,-nc@ a'-�W I11't1j- .i\'I--XaCD 4roT.l^a>J4 i s. PITY -Df D4 RESISTER Irk.. REF DEPOSIT W! 1506.65 __...r ED.. ..a_li il.: - P._i__._.r _ ._�.... _:1.i�'n �.' oc) INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: 154 $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. )r, Policy expiration date Lrll Automotive Liability: 4- "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage Policy expiration date Workers'Compensation and Employer's Liability -�67 Waiver of Subrogation clause 'sk $1,000,000 per accident for bodi y in'ury or disease ❑ Policy expiration date Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement �\ -e The City, its officers, employees and volunteers are named as additional insured. Ae (Reference Project Location/Permit Number) ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind � I upon the company, its agents or representatives". OR should say: C:\Documents and SettingsVoannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) -1- •'Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: \ NAIC# Rating: Authorized in CA: Name: &� 14 cc NAIC# t q:553 Rating: Authorized in CA: Name: "",-'`' ONAIC# Rating: Authorized in CA: Name: ��o��� C'�,r��NAIC#��—V Rating: Authorized in CA: ❑ Campbell Business License# Expiration: 14, Contractors License# Z Class: Expiration: Insurance Certificate Reviewed 1Z (� Initi Is Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 DATE(M A16. " CERTIFICATE OF LIABILITY INSURANCE 12/2MIDD/Y17 12/20/2017 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 pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endoreement(s). PRODUCER CONTACT Tammie Stamp -NALeavitt Pacific Insurance Brokers, Inc. PHONE (408)288-6262 FAX Na:(408)298-7635 License #OD79674 ADDRESS:tammie-stamp@leavitt.com 1330 S Bascom Ave INSURE S AFFORDING COVERAGE NAIL0 San Jose CA 95128 INSURERA:Ohio Security Insurance Company 24082 INSURED INSURERB:West American Insurance Company 44393 Black Bear Paving and Grading INSURERC:State Compensation Insurance Fund 35076 1160 D Street INSURERD• INSURER E: Hayward CA 94546 INSURERF: COVERAGES CERTIFICATE NUMBER:17-18 GL/AU/WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MYID Y E� POLICY LIMA LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGERENTE A CLAIMS-MADE ❑X OCCUR PREM SESOEa occur ence $ 500,000 X BKS57256267 4/4/2017 4/4/2018 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 NPOLICY JECTPRO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- OTHER: $ AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS AUTOS BAW57243350 4/1/2017 4/1/2018 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Uninsured motorist combined $ 1,000,000 UMBRELLA LUIS OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'L1IA3ILRY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ 1,000,000 C (ManddatRMinNH EXCLUDED? Y 9160860-17 6/15/2017 6/15/2018 ( ry ) 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 I LOCATIONS/VEHICLES(ACORD 101,Additional Ramada SchaduN,ray be attached It more apaco Is required) Re: 2089 S. Bascom Avenue, Campbell, CA 95008. The City of Campbell, its officers, employees and volunteers are named as additional insureds as respects to General Liability as respects to work performed by the named insured as required by written contract. Workers Comp Waiver of Subrogation Applies and attached. 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 70 N. First Street ACCORDANCE WITH THE POLICY PROVISIONS. Campbell, CA 95008 AUTHORIZED REPRESENTATIVE Fred Stafford/CHDUEN ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) ENDORSEMENT AGREEMENT BROKER COPY STATECOMPENSATION WAIVER OF SUBROGATION INSURANCE 916.0860-17 RENEWAL NA HOME OFFICE SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 1201 AM PACIFIC EFFECTIVE DECEMBER 19, 2017 AT 12.01 A.M. STANDARD TIME OR THE TIME INDICATED AT AND EXPIRING JUNE 15, 2018 AT 12.-01 A.M. PACIFIC STANDARD TIME BLACK BEAR PAVING & GRADING 1160 D ST HAYWARD, CA 94541 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;, BLACK BEAR PAVING &GRADING 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 20, 2617 2570 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCI F FORM 10217 IREV.7.201,0 OLD DP 217 Policy Number: BKS57256267 COMMERCIAL GENERAL LIABILITY CG88100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART INDEX SUBJECT PAGE NON-OWNED AIRCRAFT 2 NON-OWNED WATERCRAFT 2 PROPERTY DAMAGE LIABILITY-ELEVATORS 2 s EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) 2 MEDICAL PAYMENTS EXTENSION 3 EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 3 " ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 3 PRIMARY AND NON-CONTRIBUTORY- ADDITIONAL INSURED EXTENSION 5 ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" 6 WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES 6 NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES 7 FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES 7 KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT 7 LIBERALIZATION CLAUSE 7 BODILY INJURY REDEFINED 7 EXTENDED PROPERTY DAMAGE 8 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - 8 WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU 4 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 1 of 8 With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I - Coverage A =Bodily Injury And Property Damage Liability, exclusion g.Aircraft, Auto Or Watercraft does not apply to an aircraft provided: 1. It is not owned by any insured; 2. It is hired, chartered or loaned with a trained paid crew; 3. The pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. NON-OWNED WATERCRAFT Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury And Property Damage Liability, Subparagraph (2) of exclusion g.Aircraft, Auto Or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 52 feet long; and (b) Not being used to carry persons or property for a charge. C. PROPERTY DAMAGE LIABILITY -ELEVATORS 1. Under Paragraph 2. Exclusions of Section I -Coverage A - Bodily Injury And Property Damage Liabil- ity, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply if such "property damage" results from the use of elevators. For the purpose of this provision, elevators do not include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV - Commercial General Liability Conditions, Condition 4. Other Insurance, Paragraph b. Excess Insurance: The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part: 1. Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph of exclusion j. Damage To Property is replaced by the follow- ing: Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire, lightning, explosion, smoke, or leakage from an automatic fire protection system) to: (1) Premises rented to you for a period of 7 or fewer consecutive days; or (ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in Section III - Limits of Insurance. 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 2 of 8 b. The last paragraph of subsection 2. Exclusions is replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section III -Limits Of Insurance. 2. Paragraph 6. under Section III -Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of"property damage" to: a. Any one premise: (1) While rented to you; or (2) While rented to you or temporarily occupied by you with permission of the owner for damage by fire, lightning, explosion, smoke or leakage from automatic protection sys- tems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) -Paragraph 9.a. of Definitions is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage to contents of such premises that are included in your premises rental or lease agreement, is not an "insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy are amended as follows: Under Paragraph 1. Insuring Agreement of Section I -Coverage C-Medical Payments, Subparagraph (b) of Paragraph a. is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 1. Under Supplementary Payments -Coverages A and B, Paragraph 1.1b. is replaced by the following: b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: ° d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. ° G. ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under Section II -Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your on going operations for the additional insured that are the subject of the written contract or written agreement provided that the "bodily injury" or "property damage" occurs, or the "per- sonal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 3 of 8 b. Premises or facilities rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions: (1) This insurance does not apply to "bodily injury", "property damage", or "personal and ad- vertising injury" arising out of the operations performed for the state or political subdivision; (2) This insurance does not apply to "bodily injury" or "property damage" included within the "completed operations hazard". (3) Insurance applies to premises you own, rent, or control but only with respect to the following hazards: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, street banners, or decorations and similar expo- sures; or (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. 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 is required by a contract or agreement, the insur- ance 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. With respect to Paragraph, 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to Paragraph 1.b. above, a person's or organization's status as an additional insured under this endorsement ends when their written contract or written agreement with you for such d premises or facilities ends. With respects to Paragraph 1.c. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Suit under Section IV - Commercial General Liability Condi- tions. 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 4 of 8 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I-Coverage A-Bodily Injury And Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or "property damage" arising from the sole negligence of the additional insured. b. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or "property damage" occurs. c. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render- ing of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, _field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occur- rence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. d. "Bodily injury" or "property damage" occurring after: "-- (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. e. Any person or organization specifically designated as an additional insured for ongoing operations by a separate ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS endorsement is- sued by us and made a part of this policy. 3. With respect to the insurance afforded to these additional insureds, the following is added to Section III -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declaratio ns. H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. Condition 4. Other Insurance of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS is amend- ed as follows: a. The following is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 5 of 8 b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement, or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the addi- tional insured is designated as a Named Insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. 1. ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. 1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Suit: An additional insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us; b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a"suit" by the additional insured. 2. The limits of insurance applicable to the additional insured are those specified in a written contract or written agreement or the limits of insurance as stated in the Declarations of this policy and defined in Section III - Limits of Insurance of this policy, whichever are less. These limits are inclusive of and not in addition to the limits of insurance available under this policy. J. WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/MALPRACTICE WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II -Who Is An Insured is replaced with the following: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), to a co-"employee" while in the course of his or her employ- ment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1) (a) above; Z (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1) (a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. However, if you are not in the business of providing professional health care services or providing profes- sional health care personnel to others, or if coverage for providing professional health care ser- vices is not otherwise excluded by separate endorsement, this provision (Paragraph (d)) does not apply. Paragraphs (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employ- ees" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and ©' 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 6 of 8 advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury", or caused in whole or in part by their intoxica- tion by liquor or controlled substances. The coverage provided by provision J. is excess over any other valid and collectable insurance available to your "employee". K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3. of Section II -Who Is An Insured is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. d. Records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies as an insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV -Commercial General Liability Conditions, -the following is added to Condition 6. Repre- sentations: 0 " Your failure to disclose all hazards or prior 'occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or prior 'occurrences" is not intentional. M. KNOWLEDGE OF OCCURRENCE, OFFENSE,CLAIM OR SUIT Under Section IV -Commercial General Liability Conditions, the following is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Suit: Knowledge of an 'occurrence", offense, claim or "suit' by an agent, servant or "employee" of any insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph 1. of Section II -Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the day the revision is effective in your state. O. BODILY INJURY REDEFINED Under Section V -Definitions, Definition 3. is replaced by the following: 3. 'Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright or death that results from such physical injury, sick- ness or disease. n5 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 7 of 8 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. . Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under Section IV - Commercial General Liability Conditions, the following is added to Condition 8. Trans- fer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" 'done under a contract with that person or organization and included in the "products-completed operations hazard" provided: 1. You and that person or organization have agreed in writing in a contract or agreement that you waive such rights against that person or organization; and 2. The injury or damage occurs subsequent to the execution of the written contract or written agree- ment. A`D P 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 8 of 8 • 73/29/2018 E(MM/DD/YYYY) ACC" CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Tammie Stamp P Leavitt Pacific Insurance Brokers, In �1� PHfAlONE u (408)288-6262 FAX No:(400)296-7635 License #OD79674 � ADE-MAIL RESS:tammie-stamp@leavitt.com 1330 S Bascom Ave ;(215[gUclll INSURERS AFFORDING COVERAGE NAIC# San Jose CA 951 y4e1V1'3 INSURERA:Ohio Security Insurance Company 24082 INSURED 9. INSURERB:West American Insurance Company 44393 Black Bear Paving and Grading,Inc. INSURERC: 1160 D Street INSURERD: INSURER E Hayward CA 94546 1 INSURERF: COVERAGES CERTIFICATE NUMBER:18-19 GL/AU REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER 1MM1DDfYYYY1 IMMfDDfYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A AGE TO RENTED A CLAIMS-MADE I—XI OCCUR PREM IS ES Ea..0 ence $ 500,000 X BKS57256267 4/4/2018 4/4/2019 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 0 PRO ❑ JECT LOG PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ MBINED SINGLE LIMIT AUTOMOBILE LIABILITY (CEO, c dent $ 1,000,000 ar B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BAW57243350 4/1/2018 4/1/2019 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Uninsured motorist combined $ 1,000,000 UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABIL IFY „/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENIT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Re: 2089 S. Bascom Avenue, Campbell, CA 95008. The City of Campbell, its officers, employees and volunteers are named as additional insureds as respects to General Liability as respects to work performed by the named insured as required by written contract. ec",�c 0aa� L� 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 70 N. First Street ACCORDANCE WITH THE POLICY PROVISIONS. Campbell, CA 95008 AUTHORIZED REPRESENTATIVE Fred Stafford/CHDUEN (c)1988-2014 ACOR❑CORPORATIAN_ All rinht•c racPrvorl Policy Number: BKS57256267 COMMERCIAL GENERAL LIABILITY CG88100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COMMERCIAL GENERAL LIABILITY EXTENSION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART INDEX SUBJECT PAGE NON-OWNED AIRCRAFT 2 NON-OWNED WATERCRAFT 2 PROPERTY DAMAGE LIABILITY -ELEVATORS 2 EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) 2 MEDICAL PAYMENTS EXTENSION 3 EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 3 " ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 3 PRIMARY AND NON-CONTRIBUTORY- ADDITIONAL INSURED EXTENSION 5 ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" 6 WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES 6 NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES 7 FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES 7 KNOWLEDGE OF OCCURRENCE, OFFENSE,CLAIM OR SUIT 7 LIBERALIZATION CLAUSE 7 BODILY INJURY REDEFINED 7 EXTENDED PROPERTY DAMAGE 8 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - 8 WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 1 of 8 With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by the endorsement. A. NON-OWNED AIRCRAFT Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liability, exclusion g.Aircraft, Auto Or Watercraft does not apply to an aircraft provided: 1. It is not owned by any insured; 2. It is hired, chartered or loaned with a trained paid crew; 3. The pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating her or him a commercial or airline pilot; and 4. It is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this policy), contingent or on any other ;basis, that would also apply to the loss covered under this provision. B. NON-OWNED WATERCRAFT Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury And Property Damage Liability, Subparagraph (2) of exclusion g.Aircraft, Auto Or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) Less than 52 feet long; and (b) Not being used to carry persons or property for a charge. C. PROPERTY DAMAGE LIABILITY -ELEVATORS 1. Under Paragraph 2. Exclusions of Section I -Coverage A - Bodily Injury And Property Damage Liabil- ity, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply if such "property damage" results from the use of elevators. For the purpose of this provision, elevators do not include vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations. 2. The following is added to Section IV - Commercial General Liability Conditions, Condition 4. Other Insurance, Paragraph b. Excess Insurance: The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) 0 If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part: 1. Under Paragraph 2. Exclusions of Section I-Coverage A-Bodily Injury and Property Damage Liability: a. The fourth from the last paragraph of exclusion j. Damage To Property is replaced by the follow- ing: Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage by fire, lightning, explosion, smoke, or leakage from an automatic fire protection system) to: (i) Premises rented to you for a period of 7 or fewer consecutive days; or (ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of more than 7 days. Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" to contents of premises rented to you for a period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in Section III - Limits of Insurance. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 2 of 8 b. The last paragraph of subsection 2. Exclusions is replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to Damage To Premises Rented To You as described in Section III -Limits Of Insurance. 2. Paragraph 6. under Section III -Limits Of Insurance is replaced by the following: 6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will pay under Coverage A for damages because of"property damage" to: a. Any one premise: (1) While rented to you; or (2) While rented to you or temporarily occupied by you with permission of the owner for damage by fire, lightning, explosion, smoke or leakage from automatic protection sys- tems; or b. Contents that you rent or lease as part of a premises rental or lease agreement. 3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage) -Paragraph 9.a. of Definitions is replaced with the following: 9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or leakage from automatic fire protection systems to premises while rented to you or temporarily occupied by you with the permission of the owner, or for damage to contents of such premises that are included in your premises rental or lease agreement, is not an "insured contract". E. MEDICAL PAYMENTS EXTENSION If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy are amended as follows: Under Paragraph 1. Insuring Agreement of Section I -Coverage C -Medical Payments, Subparagraph (b) of Paragraph a. is replaced by the following: (b) The expenses are incurred and reported within three years of the date of the accident; and F. EXTENSION OF SUPPLEMENTARY PAYMENTS -COVERAGES A AND B 1. Under Supplementary Payments -Coverages A and B, Paragraph 1.b. is replaced by the following: b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time off from work. G. ADDITIONAL INSUREDS -BY CONTRACT, AGREEMENT OR PERMIT 1. Paragraph 2. under Section II -Who Is An Insured is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your on going operations for the additional insured that are the subject of the written contract or written agreement provided that the "bodily injury" or "property damage" occurs, or the "per- sonal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 3 of 8 b. Premises or facilities rented by you or used by you; or c. The maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or d. Operations performed by you or on your behalf for which the state or political subdivision has issued a permit subject to the following additional provisions: (1) This insurance does not apply to "bodily injury", "property damage", or "personal and ad- vertising injury" arising out of the operations performed for the state or political subdivision; (2) This insurance does not apply to "bodily injury" or "property damage" included within the "completed operations hazard". (3) Insurance applies to premises you own, rent, or control but only with respect to the following hazards: (a) The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away .openings, sidewalk vaults, street banners, or decorations and similar expo- sures; or (b) The construction, erection, or removal of elevators; or (c) The ownership, maintenance, or use of any elevators covered by this insurance. 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 is required by a contract or agreement, the insur- ance 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. With respect to Paragraph 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to Paragraph 1.b. above, a person's or organization's status as an additional insured under this endorsement ends when their written contract or written agreement with you for such premises or facilities ends. With respects to Paragraph 1.c. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage". We have no duty to defend an additional insured under this endorsement until we receive written notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the Event Of Occurrence, Offense, Claim Or Suit under Section IV -Commercial General Liability Condi- tions. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 4 of 8 2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2. Exclusions under Section I -Coverage A-Bodily Injury And Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or "property damage" arising from the sole negligence of the additional insured. b. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the location where such "bodily injury" or "property damage" occurs. c. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render- ing of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occur- rence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services. d. "Bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. e. Any person or organization specifically designated as an additional insured for ongoing operations by a separate ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS endorsement is- sued by us and made a part of this policy. 3. With respect to the insurance afforded to these additional insureds, the following is added to Section III -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declaratio ns. H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. Condition 4. Other Insurance of SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS is amend- ed as follows: a. The following is added to Paragraph a. Primary Insurance: If an additional insured's policy has an Other Insurance provision making its policy excess, and you have agreed in a written contract or written agreement to provide the additional insured coverage on a primary and noncontributory basis, this policy shall be primary and we will not seek contribution from the additional insured's policy for damages we cover. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 5 of 8 b. The following is added to Paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreement, or permit issued by a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non-contributory, this insurance is excess over any other insurance for which the addi- tional insured is designated as a Named Insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional insured has been added as an additional insured on other policies. I. ADDITIONAL INSUREDS -EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE" This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this policy. 1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claire or. Suit: An additional insured under this endorsement will as soon as practicable: a. Give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us; b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the additional insured; and c. Agree to make available any other insurance which the additional insured has for a loss we cover under this Coverage Part. d. We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a"suit" by the additional insured. 2. The limits of insurance applicable to the additional insured are those specified in a written contract or written agreement or the limits of insurance as stated in the Declarations of this policy and defined in Section III - Limits of Insurance of this policy, whichever are less. These limits are inclusive of and not in addition to the limits of insurance available under this policy. J. WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS/MALPRACTICE WHO IS AN INSURED -FELLOW EMPLOYEE EXTENSION -MANAGEMENT EMPLOYEES Paragraph 2.a.(1) of Section II -Who Is An Insured is replaced with the following: (1) "Bodily injury" or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability. company), to a co-"employee" while in the course of his or her employ- ment or performing duties related to the conduct of your business, or to your other "volunteer workers" while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co-"employee" or "volunteer worker" as a consequence of Paragraph (1) (a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1) (a) or(b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. However, if you are not in the business of providing professional health care services or providing profes- sional health care personnel to others, or if coverage for providing professional health care ser- vices is not otherwise excluded by separate endorsement, this provision (Paragraph (d))does not apply. Paragraphs (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employ- ees" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 6 of 8 advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury", or caused in whole or in part by their intoxica- tion by liquor or controlled substances. The coverage provided by provision J. is excess over any other valid and collectable insurance available to your "employee". K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES Paragraph 3. of Section II -Who Is An Insured is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. d. Records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint .venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies as an insured under this provision. L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES Under Section IV -Commercial General Liability Conditions, the following is added to Condition 6. Repre- sentations: Your failure to disclose all hazards or prior "occurrences" existing as of the inception date of the policy shall not prejudice the coverage afforded by.this policy provided such failure to disclose all hazards or prior "occurrences" is not intentional. M. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT Under Section IV -Commercial General Liability Conditions, the following is added to Condition 2. Duties In The Event of Occurrence, Offense, Claim Or Suit: Knowledge of an "occurrence", offense, claim or "suit" by an agent, servant or "employee" of any insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph 1. of Section II -Who Is An Insured or a person who has been designated by them to receive reports of "occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or "employee". N. LIBERALIZATION CLAUSE If we revise this Commercial General Liability Extension Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the day the revision is effective in your state. O. BODILY INJURY REDEFINED Under Section V-Definitions, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes mental anguish, mental injury, shock, fright or death that results from such physical injury, sick- ness or disease. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 7 of 8 P. EXTENDED PROPERTY DAMAGE Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the following: a. Expected Or Intended Injury "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of reasonable force to protect persons or property. Q. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU Under Section IV -Commercial General Liability Conditions, the following is added to Condition 8. Trans- fer Of Rights Of Recovery Against Others To Us: We waive any right of recovery we may have against a person or organization because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard" provided: 1. You and that person or organization have agreed in writing in a contract or agreement that you waive such rights against that person or organization; and 2. The injury or damage occurs subsequent to the execution of the written contract or written agree- ment. © 2013 Liberty Mutual Insurance CG 88 10 04 13 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. Page 8 of 8 SOLD BY: MILPITAS MATERIALS COMPANY MEA URED/DAT-1125 N. MILPITAS BLVD. MILPITAS, CA 95035 'a0(,2d' 7 PHONE: 408-262-0656 510-656-2619 650-969-4401 TRUCK# DRIVER FAX: 408-942-0826 ;!n R.1.L:�1 WE MAKE ALL DELIVERIES INSIDE CURB AND ON LOT AT CUSTOMERS RISK ONLY TIME LOADED AND ACCEPT NO RESPONSIBILITY FOR DAMAGES RESULTING FROM SUCH DELIVERY. 7 g 3; (•,.N IT IS CUSTOMERS RESPONSIBILITY TO HANDLE THESE MATERIALS SAFELY AND ARRIVE JOB PROPERLY. WARNING: Materials are irritating to the skin and eyes because they contain Portland Cement,so wear rubber boots and START POUR gloves. Prolonged contact may cause burns. Avoid contact with eyes and prolonged contact with skin. In case of contact with skin or eyes flush thoroughly with water. If irritation persists,get medical attention. Precaution must be observed because alkali burns occur with little warning and little heat is sensed. END POUR WEIGHMASTER CERTIFICATE 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 5 of the California Business and Professions Code, ARRIVE PLANT administered by the Division of Measurement Standards of the California Department of Food and Agriculture. WATER ADDED AT JOB: GALLONS MILPITAS MATERIALS CO. i t; yf �tl 1.4r;r, i__ 1t DEPUTY WEIGHMASTER CUSTOMER ID PHONE NUMBER JOB/P.O.NUMBER DATE TICKET C O{J i"I Ill ../:a c_� ';U"!I ,. F.1 I'A- ..7': - FA Cl I,)L, 'i ra, .b_ .":{ -"_ _'7 7 SOLD TO DELIVER TO LOAD# SLUMP i.:;i��i'�'IF'EsE:L...I-_ Ci=)I• FIDIELL AVE— QUANTITY QUANTITY PRODUCT PRODUCT UNIT OF UNIT EXTENDED THIS LOAD DELIVERED CODE DESCRIPTION MEASURE PRICE PRICE . 17117f v• 4210 ri F3 0 1' 0 0 0 F:!5? 'Sr d 3 1145. 00 .s>I q I-ES t'I< iZ'I l'i 1. 0171 .1 y G.r'.i•4 E11'•;I.7''i7fl(➢eFlt,-AZ F" at? a_' jy•^ec- 1 ) t,.'',. I; STAND BY TOTAL MINUTES ALLOWED MINUTES MINUTES .1 '',4� h'i1,!;SUBTOTALj.1 f..• , ;_ CHARGE @ 0174MINUTE If bu er fails to a the amount owed when due,buyer agrees to a month) service charges equal to 11/2% er z i�l , 1_,: SALES TAX ` Y P Y Y 9 pay Y 9 q P month (18%per annum)of the outstanding balance of principal due as liquidated damages. A SERVICE CHARGE of$20 will be charged on any returned check. 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