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ENC2012-00041 s � s'Print Forrn CITY OFCAMPBELL ENCROACHMENT PERMIT Permit No IE'NC 4n\ _rn0 1 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date — Campbell,CA95008 Issued I �� Application Expiration Date VJ! —U _ Ph. (408)866-21 SO APN Fx. (408)376-0958 Permit Expiration Date APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: Utility Trench Location: B. Nature of Work: 3, �r c or..1 ........... C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the prelimidary 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 Campbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Telephone: C%ak I z(f �_� 9 y V 4- L L� eo/(/e �Z 6 \ J Address: f U ZU / , E-Mail Address: �� � 'W /<fGGE`y / - OUR EMERGENCY PHONE NUMBER: 1C .,_C� conk ©Y� ��. 7 _-/G_ � . Is this work being done by the property owners at their own residence. F. 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 the condition of any "�private improvements in the public right-of-way. of Accepted: V4 C i.(—' C6!AJ CAL E / V� e, /,�%GC��_ //2- (Applicant Permittee) (sign) Date VA CaAJ C It --- /0-g, ;7 T� M-'J %4D f (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes, Such cuts may 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 4215 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. i"— a — SEE PUBLIC WOR S FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO, PERMIT APPLICATION FEE $ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR& TER ALS $ . CONSTRUCTION CASH DEPOSIT PLAN CHECK&INSPECTION FEE $ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE Z_ For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required.Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the 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. 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. 5.. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 6. 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. 7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated 1990,available at Caltrans.Traffic control equipment shall include Type II flashing arrow signs if required. 8. 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. 9. Sawcut for all PCC or AC removals.All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 11. Adequate signing and barricading is required on thejob 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 cash deposit. 12. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. 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. 14. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 15. 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. 1 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 19. 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. 20. If the public interest requires a modification of,or a departure from the plans and 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 for City-owned or maintained facilities. 21. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. J � �L �� CCJAJC 6L E-7� �� of/�" / �7 Applicant Date: V4 L CO N C 44,4 /7�`7�r/ Contractor (Print Name) 1 ,,Z� f Date: JAFORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.09/10 ACC) ®!� ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 1 04/05/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEOT Dmitriy Lazarev NE AX All Spectrum Insurance Brokers a1,No, El: (408) 739-8300 (AC No):(866) 826-6701 4300 Stevens Creek Blvd. ADDRESS: dima@asibrokers.com Suite 100 PRODUCER D tl.SBV Concrete, dba Valley Concrete CUSTOMER I San Jose CA 9 512 9- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A :Financial Pacific Ins Company 31453 SBV Concrete, dba Valley Concrete INSURER 8 :Republic Underwriters Ins Co. 1020 Ruff Dr INSURER C :Nationwide Mutual Ins Company 23787 INSURER D INSURER E San Jose CA 95110- IINSURER 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. INISR LTR TYPE OF INSURANCE AI SR WVD POLICY NUMBER IYPOLICY EFF POLICY EXP LIMBS(POLICY (MMIDDIYYYY) A GENERAL LIABILITY y y 175564E 06/19/2011 06/19/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES fEa occurrence $ 50,000 CLAIMS-MADE I—XI OCCUR / / / / IVIED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 [GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: / RODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC / / / / $ `+ AUTOMOBILE LIABILITY Y CPBA7824076279 06/19/2011 06/19/2012 COMBINED SINGLE LIMIT $ 11000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ / / / / BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS / / / / (Per accident) $ NON-OWNED AUTOS / / / / $ $ A UMBRELLA uaB X OCCUR Y 923148E 06/19/2011 06/19/2012 EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE / / / / AGGREGATE $ 11000,000 DEDUCTIBLE / / / / $ RETENTION $ / / / / $ B WORKERS COMPENSATION TW 001047-00 01/09/2012 01/09/2013 WC STATU- OTH- AND EMPLOYERS' LIABILITY YINLi ANY PROPRIETORIPARTNER/EXECUTIVE Y/N / / / / E.L.EACH ACCIDENT OFFICE NH)IMEMSE EXCLUDED? y❑ N/A / / / / $ 11000,000 (Mand / / / / E.L.DISEASE-EA EMPLOYE $ If yes,describe under 11000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1 000 00 0 J / / DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) When required by written contract The City, its officers, employees and volunteers are additional insured per endorsement CG2010 02 10 R attached. Concrete work performed in the State of California. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 N 1st Street AUTHORIZED REPRESENTATIVE Campbell CA 95008- -----"`" � ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD 7 CAMPBELL VETERANS MEMORIAL PHASE I —SPECIAL PROVISIONS 1. The Contractor shall assign a project superintendent. The project superintendent shall be on the job at all times during construction and shall be available and on call 24 hours a day for the duration of the project. The Contractor shall provide to the Engineer and to the Campbell Police Department a 24-hour contact number for the project superintendent. This number shall not direct calls to a recorder or other message taking service. 2. The Contractor shall submit a biweekly project schedule. 3. Contractor shall attend a preconstruction meeting with the City prior to any work beginning on site. 4. Notify the City Engineer 48 hours prior to relocating any utilities; Install necessary sleeves as noted on the plan sheet. Reference Plan Sheet C300. 5. Contractor shall be responsible for material testing and certifying that they are meeting compaction requirements; Submit weed abatement treatment for City's review. Reference Plan Sheet C500. 6. Contractor shall provide continuous temporary HVAC supply to IT Room during construction. Reference Plan Sheet A1.2. 7. Contractor shall pick up "No Stopping Anytime" signs from the City. Reference Plan Sheet A1.5. 8. Notify the City Engineer 48 hours prior to installing electrical conduits, and light fixtures. Resubmit corrected electrical plan sheet addressing comments as shown on plans for review and approval 5 days prior to beginning associated work. Reference Plan Sheet E.O. 9. Campbell Veterans Memorial Foundation shall fully execute the Maintenance Agreement between the Campbell Veterans Foundation and the City of Campbell prior to completion of the construction. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions, and that these Special Provisions are incorporated as part of the City's General Permit Conditions. Applicant Date LL�l Z� A� Contractor Date r , INSURANCE REQUIREMENTS CHECKLIST Permit# Cl 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: X $1,000,000 per occurrence, and ' ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date -\G-x I Automotive Liability: i. "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage '�zf_ Policy expiration date Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease Policy expiration date 1. 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 ❑ The City, t is officers, employees and volunteers are named as additional insured. ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: o Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc(Rev 07/11) Page 1 of 2 ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner 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: �;.na�nc��\ �c��;c NAIC#, ) Rating: Vlll Authorized in CA: &,M SS Name: .\)%Aev NAIC# 'aLAS Rating: - V It l Authorized in CA: Name: ,}; `�,,�p�,�.,,, ,, S�- NAIC# -51j62Rating: Authorized in CA: ,c 3 Name: NAIC# Rating: Authorized in CA: Campbell Business License# � Insurance Certificate Reviewed —� Initial Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc(Rev 07/11) Page 2 of 2 C(. JERCIAL GENERAL LIABLILTY POLICY NUMBER: 175564E CG 2010 Blanket Additional Insured 02 10 R THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (WITH LIMITED COMPLETED OPERATIONS COVERAGE) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART BUSINESSOWNERS COVERAGE FORM SCHEDULE NAME OF PERSON OR ORGANIZATION: Any person or organization to whom or to which DESCRIPTION OF WORK: the named insured is obligated by a virtue of a The type of work performed must be that as written contract to provide insurance that is described under classifications in the CGL afforded by this policy. Where required by Coverage Part Declarations, contract the officers, officials, employees, directors, subsidiaries, partners, successors, 1) DRIVEWAY/PARKING... PAVING/REPAVING parents, divisions, architects, surveyors and engineers are included as additional insureds. All other entities, including but not limited to agents, volunteers, servants, members and partnerships are included as additional insureds, if required by contract, only when acting within the course and scope of their duties controlled and supervised by the primary (first) additional insured. If an Owner Controlled Insurance PRIMARY CLAUSE: Program is involved, the coverage applies to off- site operations only. If the purpose of this When this endorsement applies and when endorsement is for bid purposes only, then no required by written contract, such insurance as coverage applies. is afforded by the general liability policy is WHO IS AN INSURED:(Section II) primary insurance and other insurance shall be excess and shall not contribute to the insurance This section is amended to include as an insured afforded by this endorsement. the person or organization shown on the EXCLUSION: Certificate of Insurance, but only to the extent that the person or organization is held liable for The insurance provided to the additional insured your acts or omissions in the course of "your does not apply to "bodily injury", "property work" for that person or organization by or for damage" or "personal and advertising injury" you. The "products-completed operations arising out of an architect's, engineer's or hazard" portion of the policy coverage does not surveyor's rendering or failure to render any apply to any work involving or related to professional services, including: properties intended for residential or habitational 1. The preparing, approving, or failing to occupancy(other than apartments). prepare or approve, maps, designs, shop drawings, opinions, reports, surveys, WAIVER OF SUBROGATION: field orders, change orders, or drawings We waive any right of recovery, when required and specifications; and by written contract, that we may have against 2. Supervisory, inspection, architectural or the person or organization shown in the engineering activities. Certificate of Insurance because of payments we make for injury. LOCATION OF JOB: Endorsement EFFECTIVE DATE: 06/19/2011 The job location must be within the State of domicile of the named insured, or within any Endorsement contiguous State thereto. EXPIRATION DATE: 06/19/2012 CG 20 10 Blanket Additional Insured 02 10 R Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission COMMERCIAL GENERAL LIABLLLTY POLICY NUMBER: 175564E CG 20 10 Blanket Additional Insured 02 10 R THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (WITH LIMITED COMPLETED OPERATIONS COVERAGE) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART BUSINESSOWNERS COVERAGE FORM SCHEDULE NAME OF PERSON OR ORGANIZATION: Any person or organization to whom or to which DESCRIPTION OF WORK: the named insured is obligated by a virtue of a The type of work performed must be that as written contract to provide insurance that is described under classifications in the CGL afforded by this policy. Where required by Coverage Part Declarations. contract the officers, officials, employees, directors, subsidiaries, partners, successors, 11 DRIVEWAY/PARKING... PAVING/REPAVING parents, divisions, architects, surveyors and engineers are included as additional insureds. All other entities; including but not limited to agents, volunteers, servants, members and partnerships are included as additional insureds, if required by contract, only when acting within the course and scope of their duties controlled and supervised by the primary (first) additional insured. If an Owner Controlled Insurance PRIMARY CLAUSE: Program is involved, the coverage applies to off- site operations only. If the purpose of this When this endorsement applies and when endorsement is for bid purposes only, then no required by written contract, such insurance as coverage applies. is afforded by the general liability policy is WHO IS AN INSURED:(Section II) primary insurance and other insurance shall be excess and shall not contribute to the insurance This section is amended to include as an insured afforded by this endorsement. the person or organization shown on the EXCLUSION: Certificate of Insurance, but only to the extent that the person or organization is held liable for The insurance provided to the additional insured your acts or omissions in the course of "your does not apply to "bodily injury", "property work" for that person or organization by or for damage" or "personal and advertising injury" you. The "products-completed operations arising out of an architect's, engineer's or hazard" portion of the policy coverage does not surveyor's rendering or failure to render any apply to any work involving or related to professional services, including: properties intended for residential or habitational 1. The preparing, approving, or failing to occupancy(other than apartments). prepare or approve, maps, designs, shop drawings, opinions, reports, surveys, WAIVER OF SUBROGATION: field orders, change orders, or drawings We waive any right of recovery, when required and specifications; and by written contract, that we may have against 2. Supervisory, inspection, architectural or the ,person or organization shown in the engineering activities. Certificate of Insurance because of payments we make for injury. LOCATION OF JOB: Endorsement EFFECTIVE DATE: 06/19/2011 The job location must be within the State of domicile of the named insured, or within any Endorsement contiguous State thereto. EXPIRATION DATE: 06/19/2012 CG 20 10 Blanket Additional Insured 02 10 R Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,with its permission WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.4-84) 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 will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) 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 2.5% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all California jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement Effective 1/9/2012 Policy No. ATW 001047-00 Endorsement No. 1 Insured Insurance Company SBV Concrete, Inc. Republic Underwriters Insurance Company Countersigned By ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. 16�l CAMTBELL VETERANS MEMORIAL PHASE I—SPECIAL PROVISIONS �- 1. The Contractor shall assign a project superintendent. The project superintendent shall be on the job at all times during construction and shall be available and on call 24 hours a day for the duration of the project. The Contractor shall provide to the Engineer and to the Campbell Police Department a 24-hour contact number for the project superintendent. This number shall not direct calls to a recorder or other message taking service. 2. The Contractor shall submit a biweekly project schedule. 3. Contractor shall attend a preconstruction meeting with the City prior to any work beginning on site. "S Submit detail for CVMF walkway entrance treatment for review and approval 5 days prior to beginning associated work Reference Plan Sheet C200. 5. Notify the City Engineer 48-hours prior to relocating any utilities;Install necessary sleeves as noted on the plan sheet. Reference Plan Sheet C300. Submit concrete finish treatments for review and approval 5 days prior to beginning associated work. Reference Plan Sheet C401. 7. Contractor shall be responsible for material testing and certifying that they are meeting compaction requirements; Submit weed abatement treatment for City's review. Reference Plan Sheet C500. XResubmit 1,100 plan sheet per directions from the Public Works Superintendent Larry Iaquinto for review and approval 5 days prior to beginning associated work. Reference Plan Sheet L100. Submit curb bridging detail over roots where tree is to remain for review and approval 5 days prior to beginning associated work. Reference Plan Sheet Al.1. 10. Contractor shall provide continuous temporary HVAC supply to IT Room during construction. Reference Plan Sheet A1.2. 11. Contractor shall pick up"No Stopping Anytime"signs from the City. Reference Plan Sheet A1.5. Submit PCC flag ring pole foundation detail for review and approval 5 days prior to beginning associated work. Reference Plan Sheet S.1. Submit flag pole detail for review and approval 5 days prior to beginning associated work. Reference Plan Sheet 5.2. n ��' 14. Resubmit corrected electrical plan sheet addressing comments as shown on plans for review and approval 5 days prior to beginning associated work. Reference Plan Sheet E.O. 15. Campbell Veterans Memorial Foundation shall fully execute the Maintenance Agreement between the Campbell Veterans Memorial Foundation and the City of.Campbell prior to completion of the construction. Applicant shall be responsible for ensuring that all those providing services under the a plicant are aware of and understand all of the above conditions - eye- �� v.s�o�� ate_ ^Qv�2ra� Ltr-� Applicant Date 1 000-1790aro- Q1roSI7-n-pti lu6w 'T I1yL. 1�. 1 Contractor (Print Name) DQate�`- 6� "wY- S., �rwr l'nS'c7�� U r �r .Pri 'Forii, CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No E M ,2,O 11— [)0 1-�1 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street Aht-of-way) Application Date i D ZA f 1 i Campbell,CA 9S008 Issued o-is-t Application Expiration Date "-/4 r 12 , Ph.(408)866-21 S0 APN 2,7 9 1-1 n Co7 Fx. (408)376-0958 Permit Expiration Date t 0 — APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04.(Application expires in ix (6)months If the permit Is not issued.Application Fee is nori-refundable) A. - Work Address or Tract No;: 70 North First Street,Campbell,CA 95008 UtilityTrench Location: Work Area Is East of City Hall,ClockTower Plaza 1 B. Nature of Work: Construction of Phase 1 of a(N)Veterans Memorial and pathway C. Attach four(4)copies of an engineered plan showing the)ocatlon 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 workto existing surface and underground Improvements.When approved by the City Engineer,said plan becomes a part ofthls permit. D. All work.shail conform to the Chy of Campbell Standard Specifications and.Details for Public Works Construction;the General Permlt Conditions listed an the reverse side;andthe Special Provisions forthis permit,listed below.FM]ureto abide.bytheseconditions and provisions may result in Job shutdown.and/orforfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the PublicW.orks Department at least two days before starting work. Notice must be given to Public Works of least24 hours before restarting any work. II Name of Applicant: T81 Construction&Construction Management,Inc. Telephone: 408-246-3691 1 -.....__...------- Address: 1960 the Alameda,Suite 100,San Jose,CA 95.126 E-Mail Address: bpetty@tbionline.com 24-HOUR EMERGENCY PHONE NUMBER: 408-206'-5605 Is this work being.done by the property owners attheir own residence? — YES r No The Applicant/Permlttee hereby agrees by affixing their signature to this permit to hold.the City of Campbell,Its officers,agents;and employees(ree,safe and harmless from any claim or demand fordamages 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 contractors)of the Information. Applicant is advised that upon Issuance of this permit, property owner, or property owner's successors,shall be responsible for anyand all damages art ut of the condition improvements in the public right-of-way, Accepted (Applicant Pennittee) (sign) Date ! n 9 '7'rz! i t bnt4Tr?-t.Z'M064 &N�,_1 cn t lliltvrld'T .1.NL, (Con clod (Print Name) Date SPECIAL PROVISIONS: l 1. Street shall not be open cut for underground Installations Minimum cuts may.be allowed for connections or exploration holes.Such cuts maybe specifically aotiroved by the Inseiector prior to cutting. 2. Pavement may becutfor underground.Installationsand 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 cutsheets sent to the Public Works Department before starting work. 4. Per Section 4215 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.USAPhone: 1-800-2272600. USATICKETNO. _�. Pi for 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 at iat fC WORKS FEE SCHEDULE FOR CURRENT FEES_ AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $ PLAN CHECK DEPOSTf $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS' $ CONSTRUCTION CASH DEPOSIT S PLAN CHECK&INSPECTION FEE $ EMERGENCY PERMIT FEE $� APPROVED FOR ISSUANCE Forci glneer Date Permit Expires 12 Months After Date of Issuance o � (9�►[(� ir'ZR C"�r�CtC Qf so+_Zf t , GENERAL PERMIT CONDITIONS. I. A Construction Cash Deposit is required.Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading Is required.Any such costs In excess ofthe deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required.Such period will begin on date ofwritten acceptance by the City. 3. Refund or the 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. The Permittee mustrequest in writing a final Inspection and acceptance of the work upon completion.Acceptance by the City will be made in writing tb the Permittee. S. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 6. A Construction Traffic Contra Plan and a Construction Schedule are required for all lane closures,detours,and street closures.This plan must be reviewed and approved prior-toany lane closures, 7. A Construction Traffic.Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated 1990,available atCaltrans.Traffic control equipment shall IncludeType II flashing arrow signs if required: 8. Replace.a9 directed by the Clty Engineer any damaged or removed Improvements in accordancewith City Standards and Specifications at.the sole expense ofthe Permittee. 9. Sawcvt for all FCC or AC removals.All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. Priorapprovaf of inspectoris required for any work done after normal working hours,on weekends or holidays and may require reimbursement of rnspection costs at the current overtirile rate. 11. 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 Arid charging the cost(including all labor and materials)against the cash deposit 12. Compaction testing of subgradg,base rock,and asphaitconcrete by Permittee is required unless otherwise stated bythe City Engineer.. 13. The Contractoror 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 4:00p:m. 14. No storage of materlals or equipment•will be allowed near the edge of pavemeritthe traveled way,orwithin the shoulderllne which would create a hazardous condition to the public. Is, This permit shall not be construed as authorization for excavation and grading on pilvateproperty adjacent to the work orany other workfor which a separate permit may be required,hor does it relieve the Permittee ofanyobiigation to obtain any other permit required by law. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contractswlth the City and anyother public agency. j i 17. This pennlfis not transferable.Work must be performed bythe Permittee or his designated agent or contractor as sphdfled thereon. I 18. Call back(call out)due to emeregencies regarding thispermit shall be at the current overtime ratewlth athree(3)hour minimum charge per occurrence. 19. Pursuant to Chapter'14.02 ofthe Campbell Municipal Codii,applicant shall not cause to be discharged any material Into the municipal storm drain systemotherttianstormwater.Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff ; Pollution Prevention Program. I 20. if the public Interest requires.a modification of,dra departure from the plans and''spedflcatfons,the City shall have theauthorityto require or approve any modification ordeparture and to specify the mannerin which the same is to be made for City-owned ormaintained facilities. S 21. Permitttee mustprovlde advance notification to all parties that may be affected by the permit activities.Notification shall be reviewed by the City.prior to distribution and Include dates of work and a contact name and phone number: Applicant shall be responsible for ensuring that all those providing services under the appf icant are aware and understand all ofthe above conditions. i 4d• LV•<< Applicant. Date: • �,��} ..�fi' �1 C�NS'7nN�•T-t.� � GON�Tt?�tJ(.i'Z�nl ri?+�1Ni(�Eytrt�r� t�G. Contractor 1 (Print Name) Date: J:\FORMS\Templates\Fncmachment Permfts\Encroachment Permit STATIC f6rm2.pdf Rev.09/10 I % RECEIVE CORNERSTONE APR 3 0 2012 Daily Field Deport EARTH GROUP PUBLIC WORKS -(DTP,-?ClN Project Number Client Name Client Contact Daily Field Report Number 6W „ I_I Campbell Veterans Mr. Jim Free a Memorial Foundation, Inc Project Name Project Location Client Contact Phone Page Date/Day of Week Campbell Veteran Memorial Campbell, CA 408-370-2200 t D 1 3 04-1a-Ix v�sdQ General Contractor Grading Contractor Other,Specialty Contractor Technician/Assistant FK Superintendent Contractor Foreman Contractor Foreman Engineer of Record Operations Observed and Equipment on Site DSA Information Time Arrived/Time Left Weather -16A Nuclear Density Testing Summary Description of Fill Materials Used and Source(s): Max.Dry Density(pcf) Optimum Moisture(%) �- C(at1 bade yoa(( �ro.,. J1,-vanJ Approx. Remaining Test Test Location Test Fill Depth Fill Depth/ Curve Compaction/ Relative Pass/ No. Description Location Beneath Reference Number Moisture Compaction Moisture Fail Elevation Test Grade Requirements A A,A 4" o.o/Fi113 I �t5 �6 10.E I (LM-;r of TEST 7 Legend:BSG=Below Subgrade;FAB=Final AB Follow-up Information This Field Report is Preliminary ❑Final List any failing test nos. List any previous tests GC/Contractor Notified Person/company Previous Report Reviewed from this site visit nos.still needing re-tests of any failing tests notified of results ❑Yes ❑ No ❑Yes ❑No List task(s)of previous GC/Contractor notified Person/company tests still needing re-tests of remaining failing notified of results tests ❑Yes [:] No Items to be checked next site visit and date of next scheduled visit: 1259 Oakmead Parkway I Sunnyvale,CA 94085 1 T 408.245 4600 I F 408 245 4620 I www.cornerstoneearth.com C.LCORNERSTONE EARTH GROUP Daily Field Report Project Number Client Name Client Contact Daily Field Report Number Campbell Veterans 2 Memorial Foundation, Inc Project Name Project Location Client Contact Phone Page Date/Day of Week Campbell Veterans Memorial Campbell, CA z �3 ott-t4-ij.J(�,d4 Field Observations) 2 Oradl-1 �nelraGi�r irecoo"PacA ) J( , Qre4 .` e(I tea' T (CS,,I G (U••a ()1�^J iTaC� . T had 0-4 VA4x"t"+f"4 ,l_r-f akgs.', l G fje roc(G r--J '00(Jt' 3, 5 w—� `►� fir% .,»f a15 jt.A. %,A:h I wIK..,.� YliaYl'✓e? �e1 r IIe✓ � o` l Y� gfew M- t13 (✓,'(� �''�7 Z~'n�,�n�er� �� fa,s/ (� a,r.a� -� �[.,l, 1 4-d � w:�ll.+e ,'i.F,�r�✓ /o..-d IXd4 G�_-el me eo C�40 j C wo r le-d1" A L ret u.- Q,.a o f [elf i) lS , --loCe 6-le- rook a-d CJ4— C1-a �.'((a 5L a.re4 halt ro{-K C a-d »Ij��ekr/ ��� Iw w.•ll( ��o Fti><� cl �� l' 1259 0akmead Parkway I Sunnyvale,CA 94085 1 r 408 245 4600 1 F 408 245 4620 1 www.cornerstoneearth.com Ili Jj ' IN�! \V i� CAL1Pt3ELL �/ VF.TERAIJS Id[h10RIAL S CAM ELL VETERANS MEMORIAL FOUNDATION, INC 11 � 11 � 11 - - RECEIVER CORNERSTONE APR 10 Z', Ego EARTH GROUP PUBLIC Field Report PUBLIC WORKS Project Number Client Name Client Contact Daily Field Report Number Campbell Veterans Mr. Jim Free t Memorial Foundation, Inc Project Name Project Location Client Contact Phone Page Date/Day of Week Campbell Veteran Memorial Campbell, CA 408-370-2200 1 4 3 04-I$-I -(Glcdne�c)w General Contractor Grading Contractor Other,Specialty Contractor Technician/Assistant FK Superintendent Contractor Foreman Contractor Foreman Engineer of Record Operations Observed and Equipment on Site DSA Information Time Arrived/Time Left Weather //tt3o f.,4•`14aeo 1 1-t• CQo�ccl Nuclear Density Testing Summary Description of Fill Materials Used and Source(s): Max.Dry Density(pcf) Optimum Moisture(%) {_ CL�ts TI bwe YccIC Am. � ,kv t?j CeoGIc QAMrr-1 ILt,a.s 3.S Approx. Remaining Test Test Location Test Fill Depth Fill Depth/ Curve Compaction/ Relative Pass/ No. Description Location Beneath Reference Number Moisture Compaction Moisture Fail Elevation Test Grade Requirements (%) (%) t scfi Wa Ile, o.o A:YJ? 4•" 000ln4a 1 9 y F �.� -14 5 6,. F d 4" ClG 9.4 P. Legend:BSG=Below Subgrade;FAB=Final AB Follow-up Information This Field Report is Preliminary ❑ Final List any failing test nos. List any previous tests GC/Contractor Notified Person/company Previous Report Reviewed from this site visit nos.still needing re-tests of any failing tests notified of results ❑Yes ❑No ❑Yes ❑ No List task(s)of previous GC/Contractor notified Person/company tests still needing re-tests of remaining failing notified of results tests ❑Yes ❑ No Items to be checked next site visit and date of next scheduled visit: 1259 Oakmead Parkway I Sunnyvale,CA 94085 1 T 408 245 4600 1 F 408 245 4620 1 www.cornerstoneearth.com CORNERSTONE Daily Field Report r EARTH GROUP Project Number Client Name Client Contact Daily Field Report Number Campbell Veterans 1 Memorial Foundation, Inc Project Name Project Location Client Contact Phone Page Date/Day of Week Campbell Veterans Memorial Campbell, CA 2 43 04_IY-I2 Ae4fleAa Field Observations 6 Wrn v-J.a} -%1,, aob e u r� e4 o - 4" To G " .� cQa�l � ynrG e4— rw¢ rr� ro�I Q /Q�}ev.¢n1 C' 1 Qua ( � uj�o/ MenoJ L oCd Mo Itr:Vc It-L eurva T� ,. 6 N!e- roc caaJd �oa�= a rr Py7.�t'l -` ep"If'4-/ a,-.d hwe @ 71,,. awwe /A e o c i;r,ee) e rto -�� S1�k Q_cl {a1�d. t✓:�1, e' �� E11�IrJee/ a6ow (-ow" 1)4L�Ad ��RLt��!<Wa�l) Goj WAS L �-- I� d J-oItl �,w 1'� l I pw Mu�' NuYG ` Qa,�Y2 ..�� �.✓< �./..�1 �yyOL� 4�iO4/� Ik4 1259 Oakmead Parkway I Sunnyvale,CA 94085 1 T 408 245 4600 1 F 408 245 4620 I www.cornerstoneearth.com i 3 - + y t _ •� . } �� +I Yy '-�i iti`'• `� f ' •,rw . �y :. a ``�•t,,' �• 4 ;` •' ¢� �Y }�i. L� Post iY ; _ �~ , N , /M'y • -IJ lM RECEIVED Vv .__ APR 18 2` i12 Particle Size Distribution Report PUBLIC \N ORKS , E 5 - 70 UJ 60 Z L Z 50 Lu U w ap '0, 0 500 i 0o 10 1 0.1 0:01 0.001 GRAIN SIZE-mm °i°COBSLES %GRAVEL %SAND' °/u SILT %CLAY !) 51 40 9 SIEVE PERCENT SPED* PASS? 1 Snit Description SIZE FINER PERCENT (X=tJOj Class 13 Aggregate Base with 1.5%Lime,sampled 6/2W201 1 1 in. 100 3:4 ill. 97 I ? in. Jet 3>S 74 Atterberi Limits sra 49 PL= LL= Pl= 29, 21: Coefficients 16 D85= 13.1 D50= 6.45 D50= 4.19' =;rr 12 p = 48 D 0.517 0 = 0.150 100 lo! Cu= 43.03 cc= 6.35 i j Classification j USCS= AASHTO= 11 ; .Remarks'. I ! 'Sand Equit alenr-.33 Durabililytc)-43,Durabiiity(I)=30,Durability Index--30 I R Valuc=91 (n)specification provided)' Sample No.: 4202(SL1045) Source of Sample; Date: 6i40.'2tt11 Location: `tevenSCreek.Quarry.112314 Elev./Depth: Client- SC 1-Ruch Voss, SIGNET t Project: Ste%ei)s Creek(hiarrr Nhse,'Testing 773SdAgLaGts ! ` ^__� Project No: 4622478Q Plate