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ENC2000-00020CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 Fax (408) 376-0958 ENCROACHMENT PERMIT '~ Permit No. ~./~-~-~.~-~ (for working within the X-Ref.~ file .'~,,~' public right-of-w~.) / Issued ~2)/2--'-} l0 ~ Application Date Permi(exl~ires itel2 months Application expires in 6 months APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section I 1.04. (Application expires in 6 months if ~he permit is n~t i~ued. Application Fee is non-refundable.) Utility trench location C. Ay. ach four (4) copies of an engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. All work shall conform to the City of 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 shut-down 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 TIlE PUBLIC WORKS DEPARTMENT AT LE. AST TWO DAYS BEFORE STARTING WORK. NOTIqEdvl U~T.~F4C, JV,~N.T.Q PLIBI,~Q WO P.Y~,~ AT I,.~'mAS1~ 29/cIQUR$_]~F,F. OJ?,E RE, STARTING ANY WORK. ' (pti t name)- -- ~ . ' ~'' ' * Yes '/ No Pb 37~1-7~-:t~o ' Is this work beiag 4on¢ by the property owner a~ thcir own r~idence. The ApplicanffPerm/tlee hereby agrees by affixing their sign~ure to this permit to hold the City of Campbell, its officers, agents and en-~ployees free, safe and harmless from ~ny claim or demand for damages resulting from the work covered by this permit. The Applicant/Permktee hereby acknowledges that they have read and understand both thc front and back of this permit:, and the)~ will inform their contracwr(s) of thc ~2/.~'~' _ ' 2 - 2~- ~_~ ACC~Xl /~-~plican~/P~nnkt~) (sign) f/~ / 0~_.~~ 7-----! Date SPECIAL PRQ,VISIONS 1. Sa~et shall not be open cut for underground installatiorm. Minimum eats ma~ be allowed for cormectiom or exploration holes. Such cut~ may be q~.ifieally __2. approved by the Inspector prior to cutting. Pavement may be cut for underground installations and must be restored in accordance with the Utility Trench Restoration Standard Derails, M~hnd 'A' unless ofl~rwis¢ ~pproved by Inspector. Work to be staked by a lic~tsod Land Surveyor or Civil Engineer and two (2) copi~ of the cut sheets sent to thc Pubfic Work~ Depattm~ before sta~ work Per Section 4215 of ~ Government ~ th~ permit is not valid for excavations un61 Underground Service Alert (USA) has been:notified a~l the inquiry idenfif~aion number has bee~ entered hereon. USA Phone 1-800-227-2600. USA TICKET NO. /.,~' .~'-//,, ~/~/x;,'_ .,4~'J/.,/ ' ,,'2; _~ ~,.~ ~ ~; ~,.~ " : f zS_~->-~-.~Y~,,q ',.~,.,,~.5~ ',, SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CH~CK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR~ MATERIALS CONb~TRUCTION CASH DEPOSIT .,~ /: PLAN CHECK & INSPE i .- : .. , Rov D / ( --__ TYPE ' ~aMOUNT RECEIPT NO. Dnt~ :\ forms\pwpcrm2/rev .6t96 \ GENERAL PERMIT CONDITIONS f I. A CONSTRUCTION CASH DEPOSIT is required. Charges will be made against this deposit if there is an emergency call-out, ovcrtim~ insp~tion or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Perm/tree. 2. A ONE-YEAR MAINTENANCE PERIOD AND SURETY are required. Such period will begin on date of wriuen acceptance by the City. 3. REFUND of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be Lnitiated by the written acceptance of. the work by the City. 4. The Perminee MUST REQUEST IN WRITING a final inspection and acceptance of the work upon completion. Acceptance by the City will be made ia writing to the Perm/tree. 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 is required for all lane closures, detours and street closures. This plan must be REVIEWED and APPROVED prior to any lane closures. ?. The CONSTRUCTION TRAFFIc CONTROL PLAN shall conform with the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type I1 flashing arrow signs if required. 8. REPLACE IN KIND any damaged or removed existing improvements, including planting. 9. Sawcut for all PCC or AC removals. Ail PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. I0. OVERTIME INSPECTION PREMIUM will be charged against the cash deposit for inspection required outside the hours of 8:00 a.m. to 4:00 p.m. at the current overtime rate, minimum one hour charge. I 1. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the current overtime rate with a three hour minimum. Advance payment for the estimated time is required. 12. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and barricading may result in the City's renting such sigmng and barricades and charging the cost (including ail labor and materials) against the cash deposit. I3. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is REQUIRED unless otherwise stated by the City Engineer. I4. The Contractor or Permittee will have a SUPERVISORY REPRESENTATIVE available for contact on the project at all times during consmiction. 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. 15. No STORAGE of materials or equipment will be allowed near the edge of pavement, the ~raveled way, or within the shouiderline which would create a hazardous condition to the public. 16. 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 Permiuee of any obligation to obtain any other permit required by law. 17. This permit does NOT RELEASE the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. I8. This permit is NOT TRANSFERRABLE. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. CALL BACK (call out) due to emergencies regarding this permit, shall be at the current overtime rate with a three (3) hour mini~lum charge per 20. 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 S, anta Cla~ Valley Nonpoint Source Pollution Control Program. Applicant shall be responsible for ensuring that all those providing services under the ~l~plicant are aware of and understand all of the above conditions. -- Applicant Date ' ! D~. OF P~C ~O~S ~ (for wor~g ~in ~c ~-~f. file ~/~ ~ .-~ 70 No~ Fkst St. public fi~tmfiwa~ (408) 866-2150 ~sucd · ~ Applica~n Dam 4 16 O~ .F~376~58 Pe~t expife~ ~ f2 mon~" ~p~ca~on e~cs ~ ~ mo~ ~P~A~O~ - Applicon ~ h~ ~, for a ~li~ Wo~ ~ ~ ~ ~ ~1M~ ~, ~ 11.~. (~ ~ ~ 6 ~ · ~ ~it ~ n~ ~su~. Applicon F~ ~ ~~le.) U~i~ ~ l~on ~ ~t. D. All work shall conform to uhe City of Campbell Standard Specificalions and De~ails for Public Works Coastruc:ion; ~e ~ Pennk Co~d~ listed on the rmterse side; and the Special Provisions for this permiL list~xi below. Failu~ to abide by these conditions and provisions may resuk in job t~m-dowe az~/or forfeiture of Faifl~ful Performanc~ Surely< and cash deposits. ($0~ Genera] Po"mit Congitions 1 a~l 20 E. ~ CONTRACTOR MUST I-IAVE THIS PERMIT AND APPROVED PLANS AT Tt~ SITE AND MUST NO'/t~-Y THE PUBLIC WORK~ DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORK~ AT ~ 2A HOUR~ B£FOP. E RF--Ti'ARTING ANY WORK. Is this work being clone by the proptvO, owns' at their own msidmc~? Yes /// No Th~ Applican~/Ftrmi~:t hereby agrees by affkf~g thek signature to this permit to hold the Ci~/of C..~Ipbetl, i~ officers, age~.s and employees free, rate ~ I~'mJess from any claim or demand for damages resulting from the work covered by this permit., The Applicmm. TPermi=~-'~ hereby 3~knowledges ~m~ they have r:md md ~dersrand ~ ~¢ from and back of ~ ~ a~t they will inform ~:ir co~'-ac~or(s) of d~ im'ormauon. . ...... ~ ..... SPECU~L pROV~S)O~S Wa.,..' i t~oi t-e A ~c r~.~, SE"E PUBLIC WORXS FEE $CI-H~)LrLE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECL'R.rTY FOR FAITKFUL PERFORMANCE/LABOR & MATERIALS 'rv~ ' .,~,,{otmrr ~c~iPr ~o. / I:~torms"pwpcrm2s r~t.6/90 ~ ~ERAL PERMIT CONDITIONS I. A CONSTRUCTION CASH DEPOSIT is required. Cbm'ges will be made agalr~ ~ depo~ ~ there is aa emergency call-out, overtime impection or when City ordered bamcading is required. Any such costs in excess of the deposit will be billed to the Permi~ee. 2. A ONE-YEAR MAINTENANCE PERIOD AND SURETY are required. Such period will begin on date of written accepl~.l~:e by the City. 3. REFUND of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be ini~iatod by the wriuen acceptance of the work by the City. ,L The Perm~r.~'e MUST REQUEST IN WILITING a tirol im'pection and acceptance of the work upon completion. Acc, eptm~e by the Cie/will be made in wri~ng to the Penm~e. 5. MAINTAIN safe pedesman ,nd vehicular crossings and free access to private driveways, bus stops, fi~ hydram~ a~l water valves. 6. A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for all lane closures, demurs and street closures. This plan must be REVIEWED aad APPROVED prior to any lane closures. 7. The CONSTRUCTION TRAFFIC CONTROL PLAN si~Jl conform with the Cal~ Manual of Traffic Controls for Consu"uction and Main~naace Work Zones, dated 1990, available at Caltrans. Traffic comrol equipment ~hal! include Type li flast~g arrow sign~ 8. REPLACE IN KIND any damaged or removed existing improvements, including plaatmg. 9. Sawcut for all PCC or AC removals. All PCC removals ~hall be to nearest scorema~'k and s~.ll be doweled to existing improvemems. I0. OVERTNviE INSPECTION PRE,~ will be charged against the cash deposit for Luspec:ion required outside the hours of 8:00 a.m. to 4:00 p.m. at the current overume rate, minimum one hour charge. I I. SATURDAY I~'S?ECTIONS must be arranged in advaac¢. Saturday in.spec:ion ~me is charged at the current overtime ra~ with a flu~e hour minimum. Advznc: payment for the csurmted time is required. 12. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing aad barricading may result in the City's renting such sig~ng and barricades and charging the cost (including all labor aad materials) agalm't the cash deposit. 13. Compaction testing of subgrade, base rock, aad asphalt concrete by Permim:e is REQUIILED unless otherwi~ stated by the City Engineer. 14. The Contractor or Permmee will have a SUPERVISORY REPRESENTATIVE available for con~act on the project at all times during cons~uc:ion. Comractor or perrmt~e: shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 15. No STOIL~,GE of rnateriaJs or equipment will be allowed near the edge of pavement, the ~raveled way, or within the stlouldeHine which would create a hazardous condition m the public. 16. This pet'mit shall not be construed as authorization for excavation aad grading on private property AD3ACENT to the work. or any other work for which a separate p,rrmt may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does NOT RELEASE r.he Permi~ee from any liabilities contained in other agreements or contracts with the Civy ,nd any other public agency. lt. This pein'ut is NOT TR~u~;SFER2L-LBLE. Work must be performed by the Permi~e or bis designated agent or conlractor a.s specified thereon. 19. CALL BACK (call out) due to emergencies regarding this permit, shall be at the current over0me rate with a th.ree (3) hour mlnirrRl~l ch~i~e per 20. Pur~ant to Chapter la.02 of the Campbell Mumcipal Code, applicator shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST ,V~LNAGEMENT PRACTICES established by the Santa Clara Valley Nonpoint Sour:: Pollution Control Program. Applicant shall be responsible for ensuring that all those providing services under the applicant ~ aware of and understand all of the above conditions. '-7 '~pllLicant ~ Date j:\forms\pwperm2 6/96 01/22/2001 1:47:05 PM PA,"'-MENT HISTORY FOR CASE ENC2000-00020 Fee Type: APP Fee Type: Fee Type: Description: Encroachment Application Fee Date Paid Receipt~ Check~ Recorded By 02/28/2000 128412 3858 JD Total Paid: CASH Description: Construction Cash Deposit Date Paid Receipt# Check~ Recorded By 01/22/2001 136941 3967 JD Total Paid: PCDP Description: Plan Check Deposit Date Paid Receipt~ Check# Recorded By 02128/2000 128412 3858 JD Fee Type: PC I1 Description: Date Paid Receipt-# Check~ 01/22/2001 136942 3967 Fee Type: Total Fee: Amount Paid $236.25 $236.25 Due: Total Fee: Amount Paid $960.00 $960.00 Due: Total Fee: Amount Paid $500.00 Total Paid: $500.00 Due: Non-Util Plan Cldlnsp to $250K Total Fee: Recorded By JD Total Paid: SDA Description: Storm Drain Fee - R-1 Date Paid Receip~ Check~ Recorded By 01/22/2001 136942 3967 JD Total Paid: Totals for ENC2000-00020: $5,071.25 Paid: Fees: Amount Paid $2,880.00 $2,880.00 Due: Total Fee: Amount Paid $495.00 $495.00 Due: $5,071.25 Due: $0.00 $236.25 $0.00 $960.00 $o.oo $500.00 $0.00 $2,880.00 $0.00 $495.00 $0.00 Page I of 1 01/25/2001 8:25:59 AM r YMENT HISTORY FOR CAS'- ENC2000-00020 Fee Type: APP Fee Type: Fee Type: Fee Type: Fee Type: Fee Type: Description: Encroachment Application Fee Total Fee: Date Paid Receip~ Check~ Recorded By Amount Paid 02/28/2000 128412 3858 JD $236.25 Total Paid: $236.25 Due: CASH Description: Construction Cash Deposit Total Fee: Date Paid Receipt~ Check~ Recorded By Amount Paid 01/22/2001 136941 3967 JD $960.00 Total Paid: $960.00 Due: PCDP Description: Plan Check Deposit Total Fee: Date Paid Receip~ Check~ Recorded By Amount Paid 02/28/2000 128412 3858 JD $500.00 Total Paid: $500.00 Due: PCDP Description: Refund - Plan Check Deposit Total Fee: Date Paid Receip~ Check~ Recorded By Amount Paid 01/22/2001 128412 JD ($500 00) Total Paid: ($500,00) Due: PCI1 Description: Non-Util Plan Ck/Insp to $250K Total Fee: Date Paid Receipt~ Check# Recorded By Amount Paid 01/22/2001 136942 3967 JD $2,880.00 Total Paid: $2,880.00 Due: SDA Description: Storm Drain Fee - R-1 Total Fee: Date Paid Receip~ Check~ Recorded By Amount Paid 01/22/2001 136942 3967 JD $495.00 Total Paid: $495.00 Due: Totals for ENC2000-00020: $4,571.25 Paid: $4,571.25 Due: $0.00 Fees: $236.25 $0.00 $960.00 $0.00 $500.00 $0.00 ($5oo.oo) $o.oo $2,880.00 $0.00 $495.00 $o.oo Page 1 of 1 To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Refundable Deposit Check Request WYATT ENTERPRISES, INC. 14630 HORSESHOE DR. SARATOGA Refundable Deposit 101.2203 Amount: Amount: 101.540,7448 Amount: Interest Earned (Exact Amount) Refund construction cash deposit of $960.00. State: CA Zip: 95070 $960.00 (Finance Dept only) Voucher #: Permit #: ENC 2000-00020 Receipt #: 136941 Date: 1/22/01 Requested by:'~~ Syed Wahidi Title: PW Inspector Date: 7/15/03 Approved by: ~ Michelle Quinney Title: City Engineer Date: 7/15/03 Finance Dept Only: Verified by: Title: Accounting Clerk II Date: ApProved by: Title: Accountant Date: Special ];nstructions For Handling Check Mail As Is: X Mail in Attached Envelope: Interim Check: Needed By: Return To: (Name) (Department) Other: h:~permits~000-00020 refund 360 campbell ave(mp) P' ~'C WORKS DEPARTMENT RECEIPT Effective August 1. 2000 To: C~ty C~erk PUBLIC wo~xs F,LE NO. Please collect & receipt for the following monies: 4.35.535.4921 Proiect Revenue (specify proiect) .................................................................. ENCROACI{MENT PERMIT 4722 Application Fee Non-Utility Encroachment Permit ($245.00) Minor Encroachment Permit < $5,000 ($50.00) R-t First Permit (No Fee} Subsequent PermitIYr ($110) Utility Eecro~:hment Permit Arterial/Collector Street ($355.00) Residential Street/Other Areas ($245.00} 2203 Plan Check Deposit - 2% of ENGR. EST. ($500 rain} 22031 FaS hfu Perfo .... Secur Pt {FPS) .,~.~ 6"e~') (100% of ENGR.EST.) ../~)',/~/,~ 2203 Labor and Materials Security -~ff(/'~/~/~.~ (100% of ENGR. EST.) 2203 MonumentationSecurity ~-~ t / -- (100%ofENGR.EST.) 2:03 Deposit (4% of ENOR. .I(S 00 m, $,O,000 2203 Labor and Material Security 000% of ENGR. EST.} Plan Check & Inspection Fee (Non-Utility) 4722 E.gr., st. < $2,0,000 (,2% of E oR. EST.} ** 2203 Engr. Est.>$250,000 (Deposit 8% of ENGR. EST./S30,000 min.)*' 4722 Utility < $100,000 (8%) Minimum Charge Per Location ($130) Conduiu/Pipelines up to 500 Feet ($2.00} Above 500 Linear Feet ($1.25) Manholes/Vaults/Etc. {$115.00/ca} Pule Set/Removal ($115.00/ca} Street Tree Planting/Removal ($11S.00/tree} *- 2203 Utility > $100,000 Actual Cost + 20% ** 4722 Street Tree Planting/Removal Permit ($I 15.00) 4760 Pro}ect Plans & Specifications Proiect No. 4760 Standard Specifications & Details ($1/Pg $12.50/Bk) 4760 Copies of Engineering Maps & Plans Aerial Plot 24' x 36' ($45} Aerial Print 8 1/2' x 11' ($15) Maps and Plans 24' x 36' ($5) 4722] Penalties: Failure to restore public improvements {$100/Calendar Day} {,Mum 4722] Penalties: Failure a~ correct unsafe conditions ($100/Calendar Day) LAND DEVELOPMENT 4722 Lot Line Adiustment ($600.00) 4722 Parcel Map (4 Lots or Less) ($1,170 + $25/LoQ 4722 Final Tract Map (5 or More Lots} {$1,510 + $25/Lot} 4722 Certificate of Compliance {$545.00} 4722 Certificate of Correction ($330.00) 4722 Notary Fee {per signature} ($I0.00} 4.722 Vacation of Public Streets & Easements ($600.00} 4722 Assessment Segregation or Reapportionment First Split ($600.00) Each Additional Lot ($185.00) 4721, Storm Drainage Area Fee Per Acre (R-I, $2,000) (Multi-Res, $2,250} 4920 (All Other, $2,500) Parkland Dedication Fee (75 %/25 % Due Upon Cert. of Occupancy} 4965 Postage TRAFFIC 4728 Intersection Turn Counts (Two-Hour Count} ($65.50} 4728 Imersection Turn Counts (a.m. or p.m. peaks) ($136.50) 4728 Traffic Flow Map (DaiLy Traffic Volumes} ($29.50} 4.728 Campbell Traffic Model {Futl Scope Assessment) ($2,460.00) 4728 Campbell Traffic Model (Reduced Scope Assessment} ($810.00) 4271 Truck Permits ($32.00/rnd trip} 4728 No Parking Signs (SI/each or $25/100) OTHER TOTAL NAME OF ^PPUCANT ~/"'-~/~--C~ .~Z---~-~ - **Actual Cost Plus 20% Overhead (Non-lnterest bearing deposit) h:~forms~r~eiptform~l.xls rev 7-17-~ (mp) City of Campbell - Refundable Deposit Check Request To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Total Payable: Account Number: Account Number: Account Number: (Finance Dept only) Purpose: Wyatt Enterprises 14630 Horseshoe Drive Saratoga Refund Deposit $500.00 101.2203 101.540.7448 Interest Earned Refund Plan Check Deposit State: CA 95070 (Exact Amount) Amount: $500.00 Amount: Amount: (Finance Dept only) Voucher #: Permit #: ENC2000-00020 Receipt 0: t 2841;~ Approved by: ~b;~-,,, -~',''~'~ ~'I~}L Lyn~penoyer- - j Finance Dept Only: Verified by: Date: 02/2812000 Title: Land Dev. Engineer Date: 0~122/2001 Title: Land Dev. Manager Date: 01122/2001 Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special ]:nstructions For' Handling Check Mail As Is: X Mail in Attached Envelope: Interim Check: Needed By: Return To: Other: (Name) (Department) f/n: Forms/excei/chkreq Revised 02JO0 ,2' WORKS DEPARTMENT RECEIPT Effective August 1, 1999 PU, l wOWSFI,_ .o. _ Cky Clerk Please collect & receipt for the following mon es ENCROACHMENT PERMIT 4722l 2203[ ~903~ ~03/ 22O3 2203 Application Fee Non-Utility Encroachment Permit ($236.25) Minor Encroachment Permit < $5~000 ($50.00) R-I First Permit (No Fee) Subsequent Permit/Yr ($105) Utility Encroachment Permit Arterial/Collector Street ($341.25) Residential SIrec~/Other Areas ($236.257 Plan Check Deposit - 2 % of ENGR. EST. ($500 rain) Faithful Performance Security (FPS) Labor and Materials Security Monumentatlon Security Cash Deposit Labor and Material Security Plan Check & Inspection Fee (Non-Utility) Engr. Est.< $250.000 (100% of ENGR.EST.) (100% of ENGR. EST.) (100% of ENGR.EST.) (4% of ENGR.EST.)($500 min/$10,000 maxt (100% of ENGR. EST.) Engr. Est. >$250~000 (Deposit 8% of ENGR. EST./$30,000 min.)'* (12% of ENGR. EST.) Mimmum Charge Per Location ($126) Conduit/Pipelines up to 500 Feet ($1.75/ft) Above 500 Linear Feet ($l. 15/ft) Manholes/Vaults/Etc. ($110.25/ea) Pole Se~Removal i$110.25/ea) SIreet Tree Planting/Removal ($110.25/tree) Utility > $100,000 Actual Cost + 20% ** Street Tree Planting/Removal Permit ($110.25) Prmect No. Standard Specifications & Details ($1/Pg $I2.50/Bk) Copies of Ene eering Maps &Platts ~[ Aerial Plot 2~' x 36' Aerial Print 8 1/2" x 11" Maps and Plaits 24" x 36' 4722 4722 Penalties: Failure to correct unsafe conditions Penalties: Failure to restore public improvemen~ LAND DEVELOPMENT ($42) ($57 ($100/CalendarDay/ ($100/Calendar Day) 4722 Lot Line Ad}ustment ($577.50) 47221 Parcel Map (4 Lots or Less) ($i,125 + $25/Lot) 47221 Final Tract Map (5 or More Lot~) ($1 AS0 + $25/Lot) 4722 [ Certificate of Compliance ($525) 4722 [ Certificate of Correction ($315) 47221 Notary Fee (per signature) ($10} 4722 Vacation of Public Streets & Eaxements {$577.50) 4722 4721 4920 4965 ,TRAFFIC 47281 Assessment Segregation or Reapportionment First Split ($577.50) Each Additional Lot 15178.501 Storm Drainage Area Fee Per Acre Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) Posmge {R-I, $2.000) (Multi-Res, $2,250) (All Other, $2,5007 Intersection Turn Counts (Two-Hour Count) ($63) 4728t 4728I 4728t 4728I 4271[ 4728 OTHER Intersection Turn Counts (a.m. or p.m. peaks} ($131.25) Traffic Flow Map (Daily Traffic Volumes} ($28.35) Campbell Traffic Model (Full Scope Assessment} ($2,362.50} Campbell Traffic Model (Reduced Scope Assessment) ($777) Truck Permits /$36.75/trip) (SI/each or $25/100) No Parking Signs CITY OF C~HPBELL, C~ 0100012~12 TIME: 16:16:!0 DESCRIPTION ENGR & SUBDIU FILING F REF I)EPOSIT$ -101.2203 AHOUNT $236.2~ TOTAL ~E: $~6.2~ $,00 BOND FOR FAITHFUL PERFORi~IANCE PREMIUM: $600.00/2 YRS We, the undersigned JEFFREY L. I4;YATT AND GA YLENE A. WYATT, HUSAND AND WIFE A~' COMMUNITY PROPERTY(hereinafter "Contractor") and OLD REPUBLIC SURETY CO&IPANY a corporation organized under the laws for the State of WISCONSINt and authorized to transact business in the State of California, as Sure~.', are obligated to the City of Campbell, (hereinafter "City "), a municipal corporation under the laws of the State of California, in the sum of TWENTY-FOUR THOUSAND DOLLARS AND NO CENTS($24~O00. 00), fbr the payment of which sum we obligate ourselves and our successors and assigns, jointly and severally by the following provisions.. The condition of this obligation is: Because the obligated Contractor has, on December 19'h' 2000 , entered into written Contract with the City J~br the project, a copy which contract is attached and made part of this bond, fbr construction of ' Project S 98-17~ UP 98-11, 368 E. Campbell Avenue, Encroachment Permit ENC 2000-00020. Now therefore, if the Contractor shall faithfidly perform the work in accordance with the plans, specifications and contract documents during the original term, and an3, extensions of the contract which may be granted by the CIO,, with or without notice to the Sure~, and if it shall satisff all claims and demands incurred under the contract, and shall fully indemnifS, and save harmless the CiO, from all costs and damages which it may suffer bv reason of failure to do so, and shall reitnburse and repay the City outlay and expenses which the CRv mav incur in making an.;, default, then this obligation shall be void; otherwise to remain in full force and effect, r~,~ith the Surety obligated to secure the full and faithful perJbrmance o fall of Contractor %. obligations under the attached contract. [./'any legal action be filed upon this bond, it shall be filed rvithin one year after final payment has been made under the Contract excluding the warranty period, if any, provided for in the Contract, and venue shall lie in the County of Santa Clara, State of California, and that Surety, jbr value received stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Contract or to the work to be performed under it or the specifications accompanying it shall m any way affect its obligation on this bond, and it does by this means waive notice of any change, ext~ension of time, a/terat~'on or addition to the terms of the Contract or to the work or to the ?ecifications, and thereby waives t'he provisions of Section 2819 of the Civil Code of the State of CaliJbrnia. In witness, the parties have executed this agreement as el' December 19th . 2000 JEFFREY L. ~TA TT AND GA YLENE A. WYATT, HUSBAND AND WIFE AS COMJIUNITy PROPERTY JEFFREY,~.. ~'ATT / - GAYLENE ~ E T (A TTA CH A CKNO ti/LED GMENTS) (BOTH PRL¥CIPAL 'S AND SURETY'S .4 TTORNEY IN FACT) (SURETD Ol_~d~ Republic Stodet}, Company //./ ARIrA Z aPj nrro CVEY, tN. FAcr ~(DDRESS OF SURErY: 300 N. SEP~:L VEDA BL VD. STE. #1070 EL SEGUNDO~ CALIFORNIA 9024g SURETY'S BOND NOSIIBER WCN1208858 (ACCOMPANY THIS BOND W1TH A TTORNE Y-IN-FACT'S AUTHORITY FROM THE SURETY TO EXECUTE THE BOND, CERTIFIED TO INCLUDE THE DATE OF THE BOND) POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That OLD REPUBLIC SURETY COMPANY. a Wisconsin stock insurance corporation. does make. constitute and appoint: MARGARITA t. LOPEZ, CAS$tE J BERRtSFORD, ELIZABETH T. LEM, OF EL SEGUND0 CA :ts true and lawful Attor?ey(s~-~n-Facl ,'¢~n full ¢~owef ]nd authority for and on ~ehaif of the company as surety, to execute and aet~ver and affix ~he sea[ of me company mereto (~f a sea~ :s reau~red~ COHOS. undertakings, recognizances or other written obfigat~ons ;n the nature thereof. (oder titan bait bonds, bank del)osaon/ bonds, mortgage deficiency bonds, moagage guaran%' bonds, guarantees of installment pape~ and note guarant~ bonds, setf4asurance workers compensation bonds guaranteeing payment of benefits asbestos abatemenrcontract bonds, waste management cohos, hazardous waste remediat~on bonds or black tung bonds), as follows: ALL WRITTEN INSTRUMENTS and to olnd OLD REPUBLIC SURETY COMPANY thereby, and alt of the acts of sa~ctArtorneys.m-Fact, pursuant to these aresef~ts are ratified and confirmed. This documem ;s not valid unless punted on colored background and ~s muC>cotored. Th~s aapomtment ismade under and by author:tv o¢ ;he boarC of directors at ~ soec~at meeting held on February 'tS. t982. Th~s Power of Attorney -S s~gned and sealed 2v facsimile under ancr 3y the authority cr the foilowmg resolutions adopted by tn'e board- of d~rectors Of ,'.ne L,~u'-"~ REPUBLi'C SURETY COMPANY on Febr'uaw !8. ~982 RESOLVED :hat the ores[dem, any v~ce 3res~oenL ,or assistant ',/roe Dresldertt ~n conjunouon w~th the secretary or any assistant secretary, may a[:)ootnl a~ornevs-,nLfac! :r agents w~th autnonb/ as defined or ~:m~(ed in :he ,ns~rumem ewdenoing the a~)oointment ~n each case. rot and 3n bertalf of 'he company .',o execute and de,ver and affix (he seat of me comaanv to annas dPrdertaKJngs? recodnlzances. ARQ sure~vsr:o 3Dliga[~on$ of att ~qP..dS: 3nC sald officers may remove any SUCh a~tomey-m-'act or aged aaa revoke any ~ower of .47,Cdev Dr~v~ous;~, ]ramec :o such Demon RESOLVED TM ,. ,,~ o .s,ce, ,,. an.~ /ice .r~s,d~pt v, aSSlS,~m lt.~ president, and a,'tested atto sealed' ff a seat be .~equ~redl 2v any secre~a¢,, or ~ss~smn~ ~ecretap.,: or when sicnec, ov :ne. ~LSlde ..~. any ',;ed oresiaem 3r ]ss[stent vlce ores~aem secret, aW or assistant secre:~p/, and :oumers gnea ann sealed if a sea~ ce "equtrec 3v a :u?/afJt~c~qzeg a~omev-.r'-[act or Iccp[: or zvflen dun executed ar, q sea,ed "a ~ea~ 3e recu~rec~] bY ape )r more ~orneys-,n-fac: 3r agents pursuant :o and ~E?.fi 'he qmJts 3; :ne au~orlty avJoencea 3v .-_ne Power c,~ ~,~orney ,ssued by the compa[]y (a such oerson or gersons. RESOL'/ED FUFTHE,~ ;~[ :ne _~,qp~ture of ~nv Authorized o~cer and 'ne ~ai ,~ the ~Dan,, may ce affixed nv f~lm~ e :o ~nv Power ~ A~omev Dr confiscation [Pere:7 ~uthor~z.nc 'ne ~xecLucn an~ :¢~en~ of ~ny gone. undeda~, r~c~ or ~ther sura[vsnJ~ gbli~tJccs :f ~e cfm2af¢: and ~ucn iN NITNESS W~ERECF OLD REPUBLIC SURETY COMPANY has caused ~ese oresents :o be signed bv ts 3rocer ~icer. and ~s :3rocrate sea~ t.o ~e affixed :nfs 2 6 T R' STATE OF WISCONSIN. COUF['-'; OF WAUKESHA - SS 2O0O OLD REPUBLIC SURETY COMPANY On this 26TEt_ ~av 3r S~PTRI~t~RI~ 2¢]f~0,,oersona{lycame before me JAMES E. LEE and DAVID G. MENZEL cc me <t, own ~o oe ~he na~v,cuals and officers of the OLD ~EPUBL~C SURETY COMPANY who execu~d the acove ns[rodent. ~nd the/ adc~ ~c<now,edgec the execution of ~e same. and De[pa 3v me duly ~worn. did severally dispose and say' :nat :hey 9re the sa~d OTT'ce's 3= -"e core.star,on ]foresald. and That [ne seal affix~ :o-:n~ above ¢strumem ,s [ne 8eat of the :orDoration. aPO *ha~ ~a~c .:orDcrate:~.,-¢~: ~n.: :?e~r s~nalbres ~s such officers were du~y affix~ apo sdosCnbed :O t~e said Ps:Foment bv the authorfw 3r the Board of ~treczors )f 5a~e ':2roora(i,sp ' ' CER%FiCATE I. ~e unaers~gr~ea ass,s~am .--ecretat7 o~ :ne OLD REPUBLIC SURETY COMPANY a Wisconsin coroora:,cn. CERTIFY ~at the foregoing anc attached Power of a.~ornev rema,']s .~ ,o, ~e and has not ~:een revo~ec]: and furthermore, that me Peso uuons of the board of directors se~ fon~ n :ne Power ~f Attorney ~re now ~ force 74-3544 Signed ar.c] sealed at the City of Brookfield. Wt th~s lc~ITI aay of ~i~.Cl~4~:~,~-~,. 2~ .Assistant CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of County oi LOS ANC~.F.~ On n~,l~m~ 1 Q personally appeared before me, ROSALYN JORDAN-MILI.~, NOTARY PUBLIC NAME. TITLE OF OFFICER - E.G., 'JANE DOE, NOTARY PUBLIC' MARGARITA I. LopEZ NAME(S) OF SIGNER(S) [] personally known to me - OR - [] proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and ac- knowledged to me that he/she/they executed the same in his/her/their authorized capacity(les), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. ~ROSALYN JOi:IDAN-NIIU,~ Ii: COMM. 1262858 ~ NOTARY PUBLIC - CALIr-ORNIA "~ LOS ANGELES COUNTY ~ My comm. E~lr,, M,,¥ S, 2004 I WITNESS my hand and official seal. OPTIONAL Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER [] INDIVIDUAL [] CORPORATE OFFICER Tm~(S) [] PARTNER(S) ~ LIMITED -_r: GENERAL [] ATTORNEY-tN-FACT ~ TRUSTEE(S) [] GUARDIAN/CONSERVATOR ?] OTHER: DESCRIPTION OF ATTACHED DOCUMENT BOND FOR FAITHFUL PERFORM. ~WCN1208858 TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT SIGNER IS REPRESENTING: NAME (DC PERSON(S) OR EN33TY(IES) SIGNER(S) OTHER THAN NAMED ABOVE NOTARY ACKNOWLEDGMENT STATE OF CALIFORNIA COUNTY OF Santa Clara }ss On March 18, 2002, before me, Susan E. Taylor, a Notary Public in and for said State, personally appeared Jeffrey L. Wyatt and Gaylene A. Wyatt, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(les), and that by his/her/their signature(s) on the instrument the person(s) or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. / J (This area for official notanal seal) OPTIONAL: DESCRIPTION OF ATTACHED DOCUMENT NOTARY.DOC (Rev 6/94) BOND FOR LABOR AND MATERIAL PREM£UM'.'INCLUDED IN PERFOR3[ANCE BOND We, the undersigned Jeffrey L. Wyatt and Gaylene A. Wyatt, Husband and Wife as Community Pro#ertl. (hereinafter "Principal ") andOLD REPUBLIC SURETY CO&IPANY a corporation organized under the laws of the State of. WISCONSIN and authorized to transact business in the State of California, as SureO,, are obligated to the Cit~' of Campbell(hereinafter "Cio' a municipal corporation under the laws of Cal~brnia,'in the sum of.Twent;,-Four Thousand dollars and no cents ($24, 000) for the payment ~vhich sum we obligate ourselves and our successors and assigns, jointly and severally by the following provisions.. ' - ?he condition of this obligation is that the Principal entered, or is about to enter, into certain written Contract with the City dated jfld,'v',,o~ /9 e',r~ /q .20 :'£~ , a true and correct copy of which is presently on file in the office of the City Clerk of the City' Of Campbell, which said Contract is hereby referred to and ~nade a part hereq7 The contract is entitled.'S 98~1 ~ ap 98-11, 368 E. CAMPBELL AVENUE ENCROACHMENT PERi,lIT ENC 2000-00020. Because Principal is required to furnish a bond m connection with the contract. providing that if Principal, or any o fits subcontractors, shall fail to pay./hr any materials, or other supplies, or for any work or labor on the contracted work of any kind, or for amounts due under the unemployment insurance act with respect to any work or labor on this project, the Surety' on this bond will pay for the debt, in an amount not exceeding the sum spec~ied in this bond, and also, in case suit ia' brought upon the bond. a reasonable attorney's fee to he fixed by the court. - Non,, therefore, we, Jeffrey: U WFatt anf Gay'lene A. W~,att, Husband and Wife as Communily Property', as Principal AND OLD REPUBLIC SURETY C03IPANY Surety, are obligated to the CiO, qf Campbell, in the sum of TIVENTY-FOUR THOUSAND DOLLARS CENTS($24,000. O0), [awjid money of the United States, £or the pavment of which sums will and truly be made, we the said Principal and SureO; bind ourselves, successors ~nd assigns, jointly and severally, by theses provisions. The condition of this obligation is that if PrincitJal, its successors or assigns, or its subcontractor, or subcontractors, shall fail to pay for any labor, materials, or other supplies, used in the petJbrmance of the work contracted to be done. orjbr amounts due under the unemplo),ment insurance act with respect to this work or labor, then the Sure~, ' on this bond will pay for them, in amount not exceeding the sum specified in this bond. and in case suit is brought upon this bond will also pay a reasonable attorney's fee, to be fi. Yeti by the court. ' ' No prepayment or delay in payment and no changes, extensions, addition or alteration of atf .pro._¥isio.n of. said Cont,'act o; in any plans and specifications referred to herein, and no Jarbearance on the part olthe Lztv shall operate to release the Suret~Jkom liability on this bond, and consent to make such alterations without further notice to or consent by the Surety is hereby given, and the Surety hereby waives the provisions of Section 2819 of the Civil Code of the State of C~lifornia. In witness, the parties/rave executed this agreement as of December ] 9, 2000 JEFFREY L. WYA-TT AND GA YLENE A. WYATT, HUSBAND AND WIFE AS COMj~I~?yI~PROPERT SEFff~EY L. WY~T / Old Republic Sure~ Companv (~ttach Acknowledgments) ,.fAddress of ~urety 30~k Xepul~eda Blvd. Ste. ~Both Principal's and El Se~undo~ California 902~5 Sure~' 's Attorney in FacO Sure~ 's Bond Number WCN1208858 Llccompany this bond with attorney-in-fact's authori~ from the Sure~ to execute the bond, certified to include date of bond) KNOW ALL MEN BY THESE PRESENTS: Thai OLD REPUBLIC SURETY CObIPANV a Wisconsin stockEnsurance corpor~ior~ - does make copstKute and MARGARITA I. LOPEZ, CA$$IE $ BERRISFORD, ELIZABETH T. LEM, OF EL SEGUND0. CA :s 7ua 3n~ a',~".,~ Attorney sl-,n-Fgc:..,~En c,[ Dower lcd aumon.'.v for ~n,: on 'Dena,+ af :ne coF', Deny as surety, ~o e×ecu~e and de!,ver ~no affix .~he seal of the C0~¢8.RV :P, ers~c f 3 $8,3 S :equ~red} 3oDds under, ak ngs recogmzances )r omar wn~en oolloa~loRs ¢~ ;~e ~atur8 ~hereof. (other than bail bonds, bank depository bonds, mortgage deficiency bonds, mortgage guaranty bonds, gu~ramees of installment paper and no[e guaranty bonds, self-insurance workers con'censa~n bonds guaranteeing payment of benefits, asbestos abatement con~ract bonds, waste managemem oon~s, hazardous waste remediation ~onds or bfacktung bonds), IS !0!lOWS ALL WRITTEN INSTRUMENTS ~r'd 'c 9u% ~"_._~.-' REPUBLIC SUREYV CCMP~?,I', ':~e,~.r:~v 3pc 2ii 3r :Re 3c;s 3T Said rA~OrPeys-!n-F~cL pursuam :o these presents, are '3U¢18c AP~ gOgT:r~eQ %h~s dOCU~R~ SRC( ,'A!iO dRieSS Dr?,'.e~ OR COlOred 380KSrOURJ and s mum-coiore~. Th~s aPPointmem ~S made' sneer 3nE gv 3u;~or~v 3f ;~e goer= 3~ direc:om ~( a sDec~81 mee~!Rg neid DR F~bruaP¢ ~8. *982 Th~s ~ower of A~omev's signed and ?':~tP-~Nv :n :eorbar'./ '8 1982 ,,rec,~ , of me OLD REPUBLIC SURE~ ~--C~L,ZU 'Re; :ne ores~dent any vrce urssldenL ,or ~ss~s;am xc~ 3res~cem :n con MPC[iOn Nlm',h~ secre~arz or 8n~ ev'zer'o~a :v :De :ewer 2f 4ttcrne,, ssuee :v :ne :omcanv T3 5bcp gordon :r ........ b~m~.. CCMPAN'f '*as :ausea :beDe cresec:s .o De s~gne.s Dy ts groper officer. ~d ::'~:-'-t:a ~ea o':e tffxec c~s2_6~ .:ay ;f.[EPTEMBER 2000 S-;-'S-_ S:-- ,",,",SCCNSiN COUN"~Y CF /VAuX£ShA -SS ............... L,., REPUBLIC SURETY COMPANY C'~'r's .2_6TH .... :ac :r SEPTEMBER 2000 cerscca~,,cama befcreme :AMES E._SE ~L -'z .... ~ ',~x.~' Fe ~2OWF -O Oe '~ PC,',:CUa;5 3;*~ ;ff~cErs }r ;Re 2LD :E=Ua_,C S~RET'" 'DCMc~N'/ who executed the 2LJC. ve ~S:' ..'~?'. ~F'C '~e'..' ~C'* 3"]<~C,V,~'~C~2 [r~ 3x~c2[c~ )r -~ 38~ .gpd De,nc s.. '~o Dui'_ s',vcrp. 7~c se era:F/ discos8 ~Rd sav ?'] '~.~[ ~3'c :'} c,3rate seai ~2~ '~e., ],'];Pa~L,'~S_ _tS amen Df ce-s ~ere du',v .3ff;xem 3¢d Suoscr.ced 'O '~e 9a,d ~"~b .... ~;eR,t Dy the authoPty "'~'= DOerS 2' .u~eclors Si sat~ ?3rccrg:.o¢ '2E=7'~ C,z-E ; :ne _,'cers~gnec. ass;sta,~ secre~.a~*/ c= :ne SLD ,qESUBL,C ~,sm: ¢'r ,~¢~r.,-~ a .,'1 scons;n CQfCCr2ECs r~E~TiFV that the -.an(.. -~ ..r'q_ ?'2 .... ='"'~"~a~, '.~a Po',~er s: a:tomay '~m=:n~ .... n % 'orca ~pd Pas ~ci oeec re,..c~ea: ~n~. fi.,nhermor~. ',ha.' + t~s ~eso ut;ocs c~ ;ne board 74-3544 S ghee acc sea,ed at 'ne Oily s..f Srookfie,c Wt th;s i~']~:L~_ oay of ~._._~ 2000 .,. V A $$iStarq'~ CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of CALIFOP~fA County of la:)S On DECMMBER 19, 2000 before me, ROSALYN JORDAN-MII.I-~, NOTARY PUBLIC , DATE NAME, TITLE OF OFFICER - E,G, 'JANE DOE, NOTARY PUBLIC' personally appeared MARGARZTA T. LDPF2.. , NAME(S) OF SIGNER(S) ~ personally known to me - OR - [] proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and ac- knowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. ]1 ~ROSALYN JORDAN-MILLS ~..~~ COMM. 1262856 ~'1 [=~"~1 NOTARY PUBLIC - CALIFORNIA L~ \ ~'~L~f'~// LOS ANGELES COUNTY My co,,. ,..,,,, WITNESS my hand and official seal. Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent reattachment of this form. CAPACITY CLAIMED BY SIGNER [] INDIVIDUAL [] CORPORATE OFFICER 'RTLEfS) ~ PARTNER(S) r-- LIMITED ~ GENERAL [] ATTORNEY-IN-FACT [---J TRUSTEE(S) [] GUARDIAN/CONSERVATOR [] OTHER: DESCRIPTION OF ATTACHED DOCUMENT BOND FOR LABOR & MATERIALS -~/CN12088~ TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT SIGNER IS REPRESENTING: NAME OF PERS4~(S) OR ENTfTY(IES) SiGNER(S) OTHER THAN NAMED ABOVE NOTARY ACKNOWLEDGMENT STATE OF CALIFORNIA COUNTY OF Santa Clara }SS On March 18, 2002, before me, Susan E. Taylor, a Notary Public in and for said State, personally appeared Jeffrey L. Wyatt and Gaylene A. Wyatt, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature f . , . . (This area for official notarial seat) OPTIONAL: DESCRIPTION OF ATTACHED DOCUMENT NOTARY.DOC (Rev 6/94) INSURANCE REQUIREMENTS CHECKLIST Permit # (¢-K[C--2~OO--CL)0'2 CIP Project # The following insurance is requirecfof 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 uniter an Encroachment Permit and work being pertbrmed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury, and property damage: ~ $1,000.000 per occurrence, and -n $1,000.000 general aggregate limit applying separately to the project, or $2.000,000 general aggregate limit. Policy expiration date $],-,~'] Automotive Liability: "Any Auto" checked on certificate $1,0~)0,000 per accident for, bodily injury, and property damage ),5. Policy expiration date .'~/~ Workers' Compensation and Employer's Liability ~t, Waiver of Subrogation clause '~ $1,000,000 per accident fo~ bqdily injury or disease Policy expiration date k2 ! ]/~_~'rO~__ Course of Construction (if required in Special Provisions) '~ Completed value of the project a Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement "~ The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. 11:' The insurance coverage afforded to the Additional Insured is primary insurance. 3if., 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". a Workers' Compensation Insurance Sheet Submitted .a For General Contractor 6e'oe(',4 ~'c~r~'~ b~- ~,~X~, C~ ~ a For Developer or O~vner ~ ~~ ~' ~ I fl~ '~ O~ ~ c~ Acceptability of Insurer(s) ~ ~,d' ~W~ ~. ~ ~g:~g G~ c~ O& ~,' Insurer(s) has cu~ent A.M.~ Best Ratin= of A:VII and is authorized to transact business in the State of California. Insurance Ce~ificate Revie~ ~ I O~ Initials D~te CopyInsurance Ce~ificate placed in tickler file for month of expiration. 0f j:\forms\inscklst (rev 11/99) FAX I Date 3/15/2002 I Number ofpases including cover sheet 4 TO: Phone Fax Phone CC: Daniel Fuentes Insurance 2375 Forest Avenue San Jose, CA 95128 (408) 246-0800 (408) 246-0899 FROM: Phone Fax Phone Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 (408)866-2701 (408)376-0958 REMARKS: [] Urgent [] For your review [] Reply ASAP [] Please Comment Re: Insured: Benitez Concrete Construction Work Site: 368 E. Campbell Avenue, Campbell Permit No: ENC2000-00020A We recently received the insurance certificate from you in connection with the above permit. After reviewing the certificate, we find that we must ask you to provide the following additional items or make the following changes to meet our minimum insurance requirements: /1. Under Automobile Liability coverage, on the insurance certificate, we require that "Any Auto" be checked. We require a Waiver of Subrogation clause in connection with the Workers' Compensation coverage. o The cancellation area of the certificate needs to be 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. 4. We require a 10 day notice for cancellation due to non-payment of premium. A copy of your certificate as well as applicable sections of our insurance requirements follow for your reference. You may forward the requested items to us by fax for approval. Please call me if you have any questions. Thanks for your help in this matter. Daniel Fuentes 2375 Forest Ave San Jose,Ca.95128 Phone Fax (408)246-0899 TO' ATTENTION · SENT BY - MESSAGE - / ! REPLY HAVE A NICE DAY~ PAGE i OF ~ '-AG_ORD. CERTIFICATE OF UABIUTY INSURANCE o. ' · ~ ~ THI~ CER%IFICATE I~ I~U~D A~ A MATTER OF INFORMATION 2~t75 frj~;; A-~. I HOLDE]~. ~14,1 CERTIFICATE DOF~ NOT AMEND, EXTEIO SA~ aO,,,,.r.J..gsl.2e ALTER THE (X)Y~RAGE AFFORDED BY THE P~LK3E~ BELOW. COW)AmES AF~O~D~ (4oe)~46-oeoo I ~M~GENERAL SECURITY INSURANCE ! ~ t °~'w~FARMERS INSURANCE EXCHANGE BENi'£~:7, UL)N~K.~'i'.~ UUL~$TRUCTION · - 2075 DELA CRUZo,,vu.~u~=""~"~ ~,04- I i ~m~''"CLARENDON NATIONAL INSURANCE SANTA CLARA,"~ua. o=n=a .i.. ( ~VMiD CENTURY iNSURANCE IJDICATIED, NOI~tNt'~TA~ ANY REQUIRBdiBIT, 1ERM O R COM)ITION OF ANY ~ O~ Oq'H~ DOC(.M~i* %%n~"rt RE,gP EG; , ~ ,~,.'.,- , r.,, ~--------'iFiC~TE ~Y ~c. ,(~U~D ~ f,~Y -e'~R.T~,NN. ~ !~I,,-~.N'~.~E .afF. --~'~J~('~=O ~ ~ POklC:_~'~ (]~ _9CRleEZ) ~RE~t IS ~I.M, JE~T ~ ALL TH;3 EXC/u~IONSAND CoIomONS OF ~ POUCIES. UI~t'~ ~H~WN MAY HAVE ~NPF~;C~ ~P~ ~ ' 2'4007858' pa-10!02003 S y , LJ529 ~v T,vc, OFFICERS~EMPLOY CITY OF CAMPBELL,CITY O~ CAMPB~n,~ REDEVELOPMENT EES,AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS LIABILITY PER CG2010 G~TFIG&TE HO(.DEA CITY OF CAMPBELL ATTN: DE~T- u~ 70 NORT~ FIRST cAMPBELL, ua · ~ ~ v v CAH~..U.ATi~N poii%~ #; 22- L24007858 I~red: BENiTEZ CONCRETE ADDITIONAL INSURED - OW~iERS, OR CONTRACTORS (FORM B) Thi~ endorsement modifie~ ineuranGe provided under the rollowlng: COMMERCIAL GENERAL liABILITY COVF. RAGE PART. ~T~V OF NAME OF PERSON OR ORGAHIZA~ON: ~ ~ - CAMPBELL 70 NORTH FIRST STREET CAMPbELL,CA.95008 RE:ALL WORK ........X~uBDI%'DR~=~LAT~'~ O~. ~ ~W..,.. ~T~Y~ ........ OF ~aMP~ELL.CITY. OF -'C~%MPBELL REDEVELOPMENT A~ENC'Y, ITS OFFICERS,EMPLOYE~S AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS LIABILITY PZR CC20~0. (1! no en_t~ !ppeam above Information ruquimd to Gomplem mb en(/or~lm, ent will be ,how in the Declirlit~on~ il applicable to endo~em,~t) pemon or 6~lniz~tia~ihown lfi ~,® ,fi~t~-a~u!-% but o~.h,, ~. ~,~_p~c~ _t iiibiiity i~i~ing out of 'your wo[-4~ ,'or the I .n~,u.%md by or ~; you, E9 .-Rg~d 3:DN~,dlqSNI S3±N31q-i 66809t:'J_.80i~ 8i ;91 J, ooa/a~/£0 INSURED NAME: BENiTEZ ~u~'~ CONSTRUCTION POLICY ~22-L24007858 PRIMARY WORDING: SUBJECT TO ALL OTHER TERMS AND PROVISIONS OF THE POLICY, SUCH INSURANCE A~ ~Kovzu~ BY 'rnz~ ~muORSEMENT SHALL BE DEEMED PRIMARY.BUT ONLY WITH RESPECT TO WORK PERFORMED BY OR FOR THE NAMED iNSURED iN CONNECTION WITH THE ABOVE DESCRIBED CONTRACT. ~--I/1 ~/'~fl¢~':;' 14: 4q 40R?4fiORq'::l FIIFNTFq 'fNC:,l IF?~,Nf';.F PC. GF ~1 Daniel Fuentes San ,~os¢, Ca. 95 i 28 Phone (408)246-0800 TO' /q ! .,/ ATTENTION: SENT BY ' / '? I Z /Z/ /' '/,,CL. 0,o,o~' '. / / .... // ,¢"Y~'///,/ FAX COVER SHEE'I /',,d v, ,,.., [ / ~ /.,~t '".. I I REPLY: PAGE 1 OF d~R?dgoRqq [ ,a~F~/N'~ CEI~TII::It~A', FI IFNTF~ TNql IF~.N(':F PAGF R? OF LIABILITY INSUKANC~ ~/'°' ~""'~ 1 '! THI~, CERTIFICATE 19 BSUED AS A MATTER OF INFORIIATI3N I ONLY ANO OONFEI~ NO mGHT~ UF'C~ ~--HE C:~TFEA~ nuu-~--A T,.,,e /'m~'~nr*TE n~:~ M(tT &ME#Q. EXTEHD ALTER THE COVERAGE AFFORDED BY T)f- IK)UCli~ COMPANIES AF FOROBIG COVERAGE n;t4T'PF.Z CONCRETE CONSTRUCTION I]~:~-~LA CRUZ ~LVD.SUIT~. SANTA CLARA,CA.95050 ~ coM'MYGENERAT_. SECURITY INSURANCE I co~"'~FARMERS INSURANCE EXCHANGE l I c~.'~"CLARENDON NATIONAL INSURANCE ) c°u~DA'~MID CENTURY INSURANCE l, 96-601660966 PA-10102003 : 1 ~000,O0C ( JI . ~ ,,: ~ -.- ~ ~R:PERHIT ~ENC2000-00020A368 EAST CAMPBELL.ALL WORK IN. PUBLIC RIGHT OF WAY.J J~+Y OF CAMPBELL.CITY OF CAMPBELL REDEVELOPMENT AGENCY,ITS OFFICERS,EMPLOY J J BES.AND VOnUNTEB~8 aRE NA~BD' aS ADDITIONAL INSUREDS AS RESPECTS LIABILITY J IPE~' c~20~ 0 ! JC~, ~,~TE H~ ~ ~ ~T~H J CITY OF CAMPBELL ~411g~, #: 22- L2 4 00 7 8 58 .*- .... a. n~Tm~,~. CONCRETE CONSTRUCTION INSURED - OWNERS, OR CONTRACTORS under the follOw, nM: ............... ~'~;~m.OF PUBLIC WORKS 70 NORTH FIRST STREET "'~MPB~LL REDEVELOPMENT A~NC'Y~I~ O~FICERS,~MPLOY~ES AND ~I~TT1~q ~0~ ~aM~D AS ADDITIONAL INSUREDS AS RESPECTS LIABILITY PER CG2010. ~,?~ CG201 el 1 II ~,~uR~,",,..,-,~.~'~"=: u,~T,l~. ~'ONC. RETE ......... CONSTRUCTION POLICY #99--T.74007858 PRIMARY WORDING: SUBJECT TO ALL OTHER TERMS AND PROViSiONS OF THE POLICY, SUCH INSURANCE AS PROVIDED BY THIS ENDORSEMENT SHALL n~ u~n~mu =~.~R ................ RESPECT TO WORK PERFORMED BY OR FOR THE NAMEDx~u~~""""~ IN ~mO~TON~.. .......... WITH THE ABOVE DESCRIBED CONTRACT. ~AR-Z?-ZOO2 01:0ZPM FROM-FARMERS INSURANCE FARME To Company/Dept. Fax number (Including this cover~heeO +805-~B3-?Z19 T-BBB POO1/OOZ F-~84 Pax From Company/Dept. Fax Nuanber WCC f88-329-9922 (cahf and poco) LEGON- 1-866-28-1-1894 Pages Message Phone Number 300-362-6170 Signed Dace MAR-2?-Z00Z 01:02PM FROM-FARMERS INSURANCE +$05-553-TZ1 g NCCI CO, NO. ! 8Z4-~ NCCI C~), ,qO. 177~ W~R~ERS' CQMP~NSATiON ANg EMPLQYE LIABILI~ iNSURANCE POLICY BENIT£Z, PAUL (IND) [ . DBA: BENITEZ CONCI~ETE · 30Z1 ~ 96 ~ S~ JOSE CA 95~2~ Effcc',ive Oatc 03/20/02 WAIVER OF OUR RIGHT TO ,::?ECOVER FROM OTHERS ~uims ,~u to cbtain ~is ~gmoment ~mm us.) 'fcu must maintlin paymil ~ccn~s sccum(=!'f scgr:;ating thc .':.-.,uneraUcn oi' '/(:ur tm;It'!ce Schedule. The ;)dditicnal ,cr':mium [cr this e,":¢c:'s.."me~t shall ~.; such ..~mune~,cn. $200. )(~ CtIA~GE Person or Organiz-',tion DEPARTMENT OF PUBLI¢I~DRKS C~T~ O~ CA. BELL 70 NORTH FIRST ST CAHI~BELL CA 95008 Schedule CO~ 520! 20,000 P/R T-606 P OOUOOZ F-56, ~.fld EdiUo,~ 3/+6 &1912 35 29 O1 2003. Felic! Num,'er Polio: the Comr.~n,/ Year ZNT - CALIFORNIA '. ',Ye will nc: enfc:~- CUr JoD Oe~cripdcn ~ $ I:DEla~T.X. Thli endorscmcPt Is part o! your ~.Cl~C,/ Il, ~ul:e~t¢;$ 3nd ¢:~t::{~ :mnyhtl~C2 to t/~: contrar i~ciic7. is olner,'dse Sc:l'.ct [o all lb.. :;Fins ¢( &~e Coun:c~igne'J Apr-02-02 10:52A FARMERS' From Company/Dept. number P~ges Stablcc: Message Apr-02-02 Named [~ FARMERS INSURANCE [~ MI' q'URY INSUP~NC~. EXCHANGF. CO,. .aY NCCf CO, NO. ~77~ NCC~ CO. ~0. ~2~ WORKERS' COMPENSATION AND EMPLOYERS' LIABILI~ INSURANCE POLICY BENITEZ, PAb~L (IND) DBA: BENITEZ CONCRETE 3021 FRANELA SAN JOSE CA p.o2 sg026B CALIFORNIA 2nd Edition Oate 03-18-02 93124 Agent 96 62 346 i }A1912 3..5 29 01 ¢[ Ihe Corn:any 'X'd' acove 2001 ?cticv Ye:ir WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA ;emcn er c~niz~[cn name~ ~n '.he ~c.~edu~e. (This agreement acches ~,l~ '.o the e~ent ~hat you 2edo~ ,om ,:n~er .~ .~ * -- '.ba~ Scne~ute ,3 o C,q ~mu ~e."atic ~ Yo ci !~C ~,)li!c~ia Wc~rs' Com~er. salicn ~remium ¢ICS,*,vi,.e :u~. Person or Org:,niz;tion CTTY OF C.~PBELI, ATTN: PUBi.[C WORKS 70 NORTH Y[RST STREET CAMPBEI,L, CA 95008 Schedule PAYROLL $20,000. NEW JOB SIDEWALK 368 E. CAMPBELL AVENUE INSURANCE REQUIREMENTS CHECKLIST Permit #,{~XS',,~O/ ~ ~_.,O CIP Project # The followin= insurance is required of ail cdntractors worK~ in the City 4f C~pbell ~blic right-otLway. Insurance certificates must be accepted by CiW staff betbre work c~ begin. These insurance requirements apply to work being perfo~ed under ~ Encroac~ent Pe~it ~d work being pertbrmed under contract tbr Capital improvement Projects. Limits Commercial General Liability tbr bodily, personal injury, and property damage: ~ $1,000.000 per occurrence, and -~ $1,000.000 general aggregate limit applying separately to the project, or '~, $2.000,000 general aggreaate~limit. ~ policy expiration date i--b~.l Automotive Liability: ~ "Any Auto" checked on certificate -~ $1.000.000 per accident rbr bodily injury, and property, damage '~ Policy expiration date ~'j I t Workers' Compensation and Emplover's Liability '5~ Waiver of Subrogation clause ~ CbS b."hD. /~ $1,000.000 per accident forbodilv injury or disease ~ Pohcy exp,ratlon date ~/i l O, 0_/a~-e-~ Course of Construction (it' required in Special Provisions) ~ Completed value of the project -n Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional insured Endorsement '~' The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. The insurance coverage afforded to the Additional Insured is primary, insurance. Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail Acceptability of Insurer(s) ~ Insurer(s) has current A.M. Best Rating of A:V[I and is authorized to transact business in the State of California._ ? Insurance Certificate Reviewed ~/'L'~~'~ ' 'Initials :~/~'D'-'-~/O ' Date Copy of Insurance Certificate placed in tickler file for month of expiration. such notice shall impose ,no obligation or liability of any. kind upon the company, its agents or representatives'. Workers' Compensation Insurance Sheet Submitt~Wl] -J ~ For General Contractor n For Developer or Owner , l..bb~ j:\forms\inscklst (rev 11/99) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FEDERATED MUTUAL INSURANCE COMPANY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2400 W. Dunlap Ave., Suite 250 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phoenix, AZ 85021 COMPANIES AFFORDING COVERAGE Phone: 602-944-5566 COMPANY FEDERATED MUTUAL INSURANCE COMPANY OR Home Office: Owatonna, MN 55060 A FEDERATED SERVICE INSURANCE COMPANY INSURED 309-148-5 COMPANY ' ....... ' WEST VALLEY PLUMBING & HEATING B -.~.. ~... ! ~: 1260 DELL AVE COMPANY CAMPBELL CA 95008 c i ' ~ COMPANY .. ~ ~;.,¢ C.~ ~ ~: i, 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 RE 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. POLICY EFFECTIVE POLICY EXPIRATION CO TYPE OF INSURANCE POLICY NUMBER LIMITS LT" DATE (MM/DD/YY) DATE (MM/DD./YY) GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS- COMP/DP AGG $ 2~000,000 A 1 CLAIMS MADE [] OCCUR 9271600 04/01/02 04/01/03 PERSONAL & ADV INJURY $ 1,000,000 OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 100,000 MHD EXP (Any one person) $ ~ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ A SCHEDULED AUTOS 9271600 04/01/02 04/01/03 IPe, p ..... ~ _ HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE S2,000,000 A XOTHERUMBRELLATHANFORMuMBRELLA FORM 9271601 04/01/02 04/01/03 AGGREGATE $$ 2,0001000 WORKERS COMPENSATION AND I WC STATU- OTH-i TORY LIMITS I ER ,,; ,, ,,. EMPLOYERS' LIABILITY EL EACH ACCIDENT $ THE PROPRIETOR/ ~1 INCL EL DISEASE - POLICY LIMIT $ PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE - EA EMPLOYEE$ OTHER DESCRIPTION OF OPERATIONSlLOCATIONSNEHICLESlSPECIAL ITEMS SEE ATrACHED PAGE 309148,5 CITY OF CAMPBELL 229 SHOULD ANY OF THE ABOVE DESCmBED POUCHES BE CANCELLED BEFORE THE 70 NORTH FIRST STREET EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~4~)~O~I~XMAIL CAMPBELL CA 95008 30DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, PERMIT #ENC2000-00020 A TTN JOANN D AMBROSIA AUTHORIZED ,EPRESENTATI,~~ CEI-, ,'IFICATE OF INSURAE..;E INSURED WEST VALLEY PLUMBING & HEATING INC 1260 DELL AVE CAMPBELL CA 95008 309-148-5 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS THE CERTIFICATEHOLDER IS ALSO AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE CG-F-48 ADDITIONAL INSURED BY CONTRACT ENDORSEMENT. RE: 368 EAST CAMPBELL AVE., #21023, CAMPBELL CA 95008. ADDITIONALLY INSURED: THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGNCY,ITS OFFICERS, EMPLOYEES, AND VOLUNTEERS. IT IS FURTHER AGREED THAT THE INSURANCE PROVIDED BY THIS ENDORSEMENT IS PRIMARY. OTHER INSURANCE AFFORDED TO THE INSURED SHALL BE EXCESS OF, AND DOES NOT CONTRIBUTE WITH, THE INSURANCE PROVIDED BY THIS ENDORSEMENT. CERTIFICATE HOLDER CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL CA 95008 PERMIT #ENC2000-00020 ATTN JOANN D AMBROSIA 229 L_COPY A.DDITI~L INSURED BY CON'I'RA~ 04X)RSEMEMT OWNERS AND ~u. IP. ACI-OR$ COVERAGE PART -------.--,,--,.,1- mv.~ do.. ~ ~ ~--~ ,..-,--.. pmmm. ~ ~., m ~,?,r~,~ · ..aoeouleOofi ....q"~ 0~ moor ,011Oll e~ oleiel~ ...... 4...1~ c.y.. sub=,,,.,~.. 0, .,~ ..h~. om.,. ~,.,. ,.q~...~...h.' - e. ~ C~over~~~a~~~~ ~ . __....~ ..... - D. ~ mcckiskms. The insurance alfoi, d~ Io lu~ pm'son m* orga~zelkm B8 an insurKI UrKIm' IMB mldar~ merit cbes not apply: 1. To 'bcxJly in/my' cw 'property dmnage' which occm= I~im' lo ~m, dab al'your conb'm wflh .uch I)mmm or ar 2. To ~)od~ i~lur~' o~ "lxoperty damage' b~ucled ndOdn the ' 3..T..o~_--bo~?..i.njup/_" of "l~opefly damage" adsingout~flh."l~~eted°peral/°nshaziu~" v,mou rnx ~)e an Irmu~ed excepl fo~ this encIofamn,r~ me n,gigence of any per~)n or mgank~llon that 3-27-01; 9:38AM; ;60Z94455~115 moouc~ ~IS C~CA~ I$ ~SU~ AS A MA~ OF IN~ON ~LY ~ CONF~ NO RI~TS UPON THE C~TIRCATE ~~ ~L INSU~ ~Y HO~. ~ C~TIRCATE DO~ NOT ~, ~T~ OR 2400 W. Dunlap Ave., Suite ~O __~LT~ ~E COV~ AFF~ 6Y ~E PO~ ~L~. r P~enix. ~ 85021 _. coMP~lES A~ORDING COV~E P~ne: ~2-~-5~ co~.A~ ~DE~TED ~T~ INSURE COMPLY OR Home ~ce: Owatonna, MN 55~ A ~DE~TED ~ERV[CE ~SU~CE ~ANY WEST VALLEY PLUMBING & HEATING INC 1~ DELL AVE CAMPBELL CA 95008 c TH~ IS TO C~ TBT THE PO~IES OF IBBANCE L~YED BOW ~VE EEN ~UED TO THE IN;~ED ~B ~OV[ ;OR THE POLICY P~IOD INDiTe, ~HSTANDING A~ REQU~, TE~ ~ COND~N OF ANY CONTACT OR OTH~ DOCUMENT ~TH RESPECT TO ~ICH THIS C~TIFI~TE ~Y BE tSSU~ ~ ~Y ~TAIN, T~ ~E ~FO~ BY THE ~1~ DE~IB~ H~EIN ~ ~ECT TO ~ THE EXCLU~ A~ ~ONDIT~N$ OF $~H P~. L~TS SHOWN ~Y ~VE ~EN REDUC~ BY PAiD C~S. LTR DATE IM~D~} ~q ~A0~) urns A [ ~,MS M~ ~ OCC~ 9271 ~ 0~01101 0~01~2 ~*~.~ ~ AOV ,~ ~ 1.000.~0 m...WA~[ ~.~.~ ~ .... 1~,000 AUYOM~ X A~ A~O A ~.~o~ AuT~ 9~1 ~0 0~1/01 0~1~2 m. ~HI~O A~O~ 8~Y INJ~ ~ NO~WNED A~O~ {~ O~ ~ AUYO ONLY . EA ACC~E~ ~CHACCI~NT ~ ~ AGG~GA~ t A .X]J uu~ ~ ~71~1 0N01/01 04/01 ~2 ~o;.~z, ; 2,0~.000 WO~ CO~TION AND TORY ~ITS I ~LO~' ~ EL ~CH ACCIDE~ THE ~OW t ~ I~L EL DISEA~ - ~LICY L~ DI~ON oF ~Q~QCA~ICL~C~ I~ CITY OF CAMPBELL ~ sHou~ ~v o~ r~ ABOVE DESCenD POUaa BE C*.C[~ BE~ 70 NORTH FIRST STREET ~.oN OAT[ ~i~o~. 1~ $$ co~.y w~ ~ ~ll CAMPBELL CA ~08 30 DAYS WmTT~ NQTICl TO ~i ~mRCAT[ "0~ ~ TO T~ PERMIT ~ENC~O-~ e~x~~~~ .... A TTN JOANN D AMBROSIA .UTHO~ 3-27-0~; 9t38AM; ;50294455666115 # 6/ 7 CERTIFICATE OF INSURANCE IItSLIRED WEST VALLEY PLUMBING & HEATING INC 1260 DELL AVE CAMPBELL CA 95008 309-148-5 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS THE CERTIFICATEHOLDER IS ALSO AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE CG-F-48 ADDITIONAL INSURED BY CONTRACT ENDORSEMENT. RE: 368 EAST CAMPBELL AVE., #23023, CAMPBELL CA 95008. ADDITIONALLY INSURED: THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGNCYJTS OFFICERS, EMPLOYEES, AND VOLUNTEERS. IT IS FURTHER AGREED THAT THE INSURANCE PROVIDED BY THIS ENDORSEMENT IS PRIMARY. OTHER INSURANCE AFFORDED TO THE INSURED SHALL BE EXCESS OF, AND DOES NOT CONTRIBUTE WITH, THE INSURANCE PROVIDED BY THIS ENDORSEMENT. CERTIFICATE HOLDER CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL CA 95008 229 PERMIT #ENC2000-00020 ATTN JOANN D AMBROSIA 3-27-01; 9:38AM; ;60294455656115 # 7/ 7 ADDITIONAL INSURED BY COHTRACT ENDoRsEMENT This endm~ement mod~es insurance provided under the following: COMMERCIAL GENERAL LI)J~ILITY-COVERAGE PART OWNERS AND CON~I:~CTORS COVERAGE PART ^. WHO IS AN INSURED f~ 'b<~'ly inN~y" and "properly damage' liabilily is amended to include': person of organization oU'~ thana ~nt venture, ~e~, ~s ~~ ~e ~s ~ ~ lo: 1. An employee, association of employees or lalxx ~ion, except with respect to work performed by o~ for you for such employee, association of emNg~..e_es g[ labm ~ under direct contract between you as c'ordme- tot and such employee, as~c~ialion of %riil~ees of labor unton as owning, ~ r~ conq)any exeePt~dth respect to wink pertornmd by of for you for ~uch railroad con,tony under direct contract M agreement ~tween you and such. railroad ~ompany; m :- 3. mr,/ person o~ orgard'za#on .whose i~ofesslon, business ~er ~ fe~ ~ ~ ~i~M~~a~ se~ee ~ su~ ~r~ M ~n; B. The Coverage extended to arty acl~! Insured by this endorsement is limited to, and subject to all terms, con- dilion~ and exclusions ol' the Covomge part to which this endorsement is attached. In addition Coverage shall nol exceed Ihe terms and condittom lhat are required by the terms ol the Mitten ag~eemenl Io add any insured, or to procure insurance. .. C. The limits of insurance applicabto to sum insurance shall be Ihe less~ of the limits requi~ed by the agreeme~ between the parties or ltm limits provided by this policy. D. Additional exctuuMn~.-. The insurance afforded to ar~ I~son or orl;larJzatkm as an insured under INs efld~'se- men! does not apply: ' 1. To "bodily injurY*", or, "property damage" Which occur~ Pr'mr to ttte date of yom conbact with such person: <x or- ganization; 2.. To'"bod~ly injury' o~ *property damage" included within the 'Moducts/completed operations hazard.' 3. To 'bodily 'injury" or "Mopefty damage' arising out of Ihe sole negligence of a~Y person or organization that would r~ be an inSUred except for this endorsement. : Includes copyrighted material o1' Insurance Services Office. Inc. with ils permission. CG-F-48 (06-92) 3-27-01; 9~38AM; ;60294455666115 # Z/ 7 I ~LY AND CONF~ NO RIGHTS UPON ~E C~TIFICA~ ] 2~0 W. Dunlap Ave., Suite ~0 AL~ ~E COV~ AFFORD~ BY ~E ~klCIES BELOW. Ph~e: ~2-~-55~ co~,.~ FEDE~TED MUT~ INSURE COMPLY OR Home Office: Owatonna, MN 55~ A FEDE~TED SE~E INSU~NCE CO~Y WEST VALLEY PLUMBING & HEATING INC B .... 12~ DELL AVE coM.A~ CAMPBELL CA ~008 c COMPANY THIS IS TO CE~ T~T THE POLICIES OF INS~NCE LIS~D ~OW ~VE BE~ I~ TO THE INSURED ~MED A~VE FOR ~E POLICY P~IOD ~.D~T[O..O~H~O~N~ ~ ~[OUm~. T~ OR common o; ANY CO~CT OR OT~ DOC~Em ~H RE~ TO WINCH C~T~F~TE ~Y M ~U[P OR ~Y ~T~. THE ~NS~ AFFO;DED SY THE POUC~ DE~R~EO HERaN m S~E~ TO A~ THE T~S. EXCL~IONS AND COmmON6 OF SU~ ,p~lES. LIM~S ~OWN ~y ~VE BEEN REDUCEO BY PAID co TY~ OF ~U~N~E ~ ~R FQU~ ~E POLICY ~N ~A~ L~TY A~O O~Y - GA ACC;DENY ~ OTHER THAN ~L~A ~RM , ,, , WC ,TATU- IO~H. E~P~o~' LIAB~I~ EL ~H ACC~OE~ T~ ~OPRI~O~ ~ tN~ EL DISE~ · ~UCY UM~ 70 NORTH FIRST STREET ~,~oN ~ ~F. T~ ,s~m co.,~.Y w,~ ~,~ CAMPBELL CA ~08 30 ~AY~ W~N ~T,c~ To ,~ ~.,.~ Hoop[. ~ TO PERMIT ~ENC2000-000~ 3-27-01; 9:38AM; ;60294455656115 CERTIFICATE OF INSURANCE # 31 I#&URED WEST VALLEY PLUMBING & HEATING INC 126O DELL AVE CAMPBELL CA 95008 DESCRIPTION OF OPERATIONS/LOCATION$/YEHICLES/SPECIAL ITEMS THE CERTIFICATEHOLDER IS ALSO AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE CG-F~I8 ADDITIONAL INSURED BY CONTRACT ENDORSEMENT. RE: 368 EAST CAMPBELL AVE., #21023, CAMPBELL CA 95008. ADDITIONALLY INSURED: THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGNCY, ITS OFFICERS. EMPLOYEES, AND VOLUNTEERS. IT IS FURTHER AGREED THAT THE INSURANCE PROVIDED BY THIS ENDORSEMENT IS PR[MARY. OTHER INSURANCE AFFORDED TO THE INSURED SHALL BE EXCESS OF. AND DOES NOT CONTRIBUTE WITH. THE INSURANCE PROVIDED BY THIS ENDORSEMENT. CERTIFICATEHOLDER CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL CA 95008 229 PERMIT #ENC2000-00020 ATTN JOANN D AMBROSIA 3-27-01; 9t3~AM; ;50294455665115 # 4/ 7 'rmS I; Do. CHM $ OUCY. REN A ITIO L I URED BY E ORS ~ ~rsem~t ~es ~e pr~ed ~er ~ ~: C~MERC~ GENE~ ~IL~ CO~ P~T ~ERS ~D C~CT~$ CO~E P~T A. ~ ~ ~ ~S~ED ~ "~ ~" ~ '~ ~' ~ ~ ~ ~ 1. ~ e~ee. a~~ ~ e~ees ~ ~m ~ exc~t ~ re~t ~ ~ ~~ ~ m for you 2. ~ railroad company except with respect to wod( performed by or for you for mJch railroad ~mparpj urp:ler ~ed cor~rad or agreement between you and such.raCom] r, ompany; or 3. Ary person or orgarizaltofl .whose. .profession, business or occup~tien is.ltmt of an archilect, survey~ or engiheer with respect to rut)Fay arin~g out of the i~el~a#on o~ approval of 'mal~, d~aW~gs, opinior~. reports, surveys, change, o~ders, designs, apecifmations or the performance of arff other profesSiOnal sewices by such per~on or organization: 4. ,4~y'of your Subconlrac~ms, m any partner, officer, agent or empbyee of such B. ]'he Coverage extended Io any additional Insured by ~ endmsement is limited to, a~d subject to all terms, ditior~, and exclusions of the Coverage part to which this endorsement js attached. Irt &ckfllio~ Coverage shad m~ exceed the terms and col'lditior~ Ihat are re(~lJred by the te~m$ of Ihe w~itten agreemerd to add any insured, or to procure insurance. · . ~ C. The limlt~ of insurance epph~abte to such rUufanc· Shall t~e the lesser of the limits required by the agreement between the parties or the limits provided by this policy. D, Add#Jonal exclu~3rm; The insurance afforded to ary pef~on or (3rgaflizatJen as an insured under this endorse- ment does not apply: ' 1. To 'bodily injujy,', of .~'property damage" which occur~ Prtdr to the dale of your contract with such per$or~' or- ganization; ?.. To"lxH:lily injury' or "property. damage" included withal the "pToducts/comJ:deted operations hazard.' 3. To 'bodily injury' or "property damage' arising out of the sole negligence of any person or organization that would not b~ an insured except for this endorsement. Includes copyrighted maleria; of Insurance Services Office. ;nc. with its permission. CG-F-48 (06-92) 3-27-01; 9:38AM; ;60294455566115 # 1/ 7 De[ay senti FEDERATED LIFE INSURANCE COMPANY FEDEI:;~TED SERVICE INSURANCE COMPANY ~o,~ o.,o.~ ow~.o..~ ~,. ~.~., INS URANCE[~ FACSIMILE COMMUNICATIONS COVER SHEET Date o3/27//01 Number ot pages sent (Including cover sheet) To: Name JOANNF. D'AHROSIA From: Name MAKCI NEZ Company CITY OF CAI~PBELL Fax No. (602) 395-066~ FaxNo. ¢08- 376-0958 Ext. No. Telephone No. (602) 9c~.-5566 ~XT 6312 NOTE: It any of the pages are not legi'ole, or you do not receive all Ihe pages, contact Federated at the above telephone o[ fax num~L Subject: CEKTIFICATI~ OF INSURANCE AND ADDITIONAL INSLrRED ENDORSEHENT }Message: HAleD COPY TO FOLLOW MM-Eg(c) Ed. 5-90 Printed in U.~;.A. pRo~uc~ THI~ CERTIFICATE I$ ISSUED AS A MATTER OF INFORMATION ONLY AND CO~ NO flI~TS UPON ~[ C;TlflCA; ~T~ ~UAL INSU~N~ ~fA~ Ho=re. ~ C~TIFIcATE DO~ NOT J~D, ~mD OR 2400 W. Dunlap Ave.. Suite 250 ALT~ ~E COV~GE AFFO~ BY ~E PO~I~ B~OW. Phoen~. ~ 8~21 C~PA~I~ AFFORm~G COV~ Phone: ~2-~-55~ =o~,~ FEDE~TED MUT~L IN~U~CE CO~Y Home 0~ce: Owa/onna. MN 550~ A FEDE~TED SERV~E ~SU~CE CO,ANY WEST VALLEY PLUMBING & HEATING INC C~PBELL CA ~08 C CO~A~ ~DI~, NO~TAND~N6 ANY R~M~, TeRM ~ CoNDmoN OF ~Y CO~C? ~ OT~ D~UME~ ~H R~CT TO ~ICH C~I~TE ~Y 8E I~UED OR ~Y ~AIN, THE I~U~NCE AFAO~D~D BY TH~ POCICIB D~R~ H~[IN ~ 6~ECT TO ~ THE T~, [XCL~ONS AN~ CON~ITIOB O~ $~CN ~AICI[S, C~T$ S~ MAY HAVE 6EEN ~EDUCED ~Y PAID A~ OWeD AUTOS ~[Y I~ A~ A~ OT~R T~N A~O ONLY: ~CH ACCIDE~ AGGRE~ CITY OF ~ ~~ ~ ............................................................................................................... ~9 ~ou~ ANY OF ~ AB~ ~GAi POLICIES BE ~N~ 70 NORTH FIRST STREET i~.o. ~ ~.~. ~ ~ COM.~ ~ CAMPBELL CA 95008 30 ~ w.~ ~o~ ~o ~ c~.~T~ .~. ~ To ~[ ~.. A~N JOANNE DAMBROSIA ................ ~ ......... ~ ~ ~~ ~, FAX TO: Marci Nez Federated Insurance. Phoenix, AZ Phone (602) 944-5566 ext. 6312 Fax Phone (602) 395-0664 CC: I Date 3/26/2001 I Number of pages including cover sheet FROM: doanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 REMARKS: [] Urgent [] For your review [] Reply ASAP [] Please Comment Re: Permit No. ENC2000-00020 Work Address: 368 ~. Campbell Avenue, Campbell, CA We recently received an insurance certificate by fax in connection with the above permit and need to request the following additional changes be made to the certificate to meet our minimum insurance requirements: 1. The additional insurance endorsement needs to be edited to show THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGENC7, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS. 2. Please also refer to the above permit number on the face of the certificate (PERMIT No. ENC2000- 00020). 3. The certificate holder box in the lower left corner of the certicate shows City of Concord but should show City of Campbell. The address shown is correct. A copy of your certificate follows for your reference. You may forward the requested items to us by fax for approval. Please call me if you have any questions. Thanks for all your help in this matter. CEh 'IFICATE OF INSURANCE WEST VALLEY PLUMBING & HEATING INC '1260 DELL AVE CAMPBELL CA 95008 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS THE CERTIFICATEHOLDER IS ALSO AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE CG-F-48 ADDITIONAL INSURED BY CONTRACT ENDORSEMENT. RE: 368 EAST CAMPBELL AVE., #210L::r3, CAMPBELL CA 95008. ADDITIONALLY INSUREDYTHE CFI'Y OF CAMPBELL REDEVELOPMENT AGENCY, rTS OFFICERS, OFFJCALS, EMPLOYEES, AND VOLUNTEERS. IT IS FURTHER AGREED THAT THE INSURANCE PROVIDED BY THIS ENDORSEMENT IS PRIMARY. OTHER INSURANCE AFFORDED TO THE INSURED SHALL BE EXCESS OF, AND DOES NOT CONTRIBUTE WITH, THE INSURANCE PROVIDED BY THIS ENDORSEMENT. CERTIFICATE HOLDER, 70 NORTH FIRST STREET CAMPBELL CA 95008 ATTN JOANNE DAMBROSIA 229 ADDITIONAL INSURED BY' CONTRACT ENDORSEMENT This endorsement modifies ir..su~ance I~m/ided under t~e followirtg: COMMERCIAL GENERAL IJABILITY COVERAGE PART OWNERS AND CON'FRACTORS COVERAGE PART k WHO IS AN INSURED for 'lxtdily injuff' and 'property damage' liability i~ amended to include: Any person or organization other Iha~a jo~ vent~e, fo~ which you have a~'eed t,/ Mitten conb'act to procure bodily k~jufy o~ propert3t demage aaar, y insurance, arising out of operatiom; performed by you or on your behalf; however, this addifJonai In.~artce does not apply lo: 1. An employee, association of employees or labm union, except with respect to Work pedormed by (x fo~ you lot such employee, associati~..~ e .m~..ees of ~ ~ unlle! alii'ecl contract between you as contrae- tof and such employee, assoaaaon o~'employees o~ labor union as owners:. 2. Any rai~d con'q=eny .ex,~pt with respect to work performed by o~ for you for such railroad company U~ldef direcl con~act o~ agreement between you and such railroad c. ofnpm~; of 3. Any.,person.. or organizat~...whose .l~.ofesston, business eng~n~er m~ tespecl to liability reports, s~Jrvey$, el'lille.orders, designs, spectficaltorts or lhe perfo/rnaf3ce of services by such person o~ organization; 4. Any'of your Subcontractors. or any partner, offl=m, ager~ or emlXoyee of such Subconbactor. B. The Goverage extended to any add~onal Insured by this enc~sement is limited to. and sul~ect to all terms, con- di#or~. ~ exclusions of the Coverage I~rt to In adclRk~ Coverage shall nof exceed the te~ms and ~ that me recited by the terrr~ of the vwilten agreement to add any insured, or tO procure insurance. C. The ~ of insurance ~cable to such insurance Sba# be the tesse~ o~ the #mits required by the agreement betwe~ the parties or the limits provi~d by ~s I~#c'y. D.' Addlfiortal exclu.~.~ The insurance allorded to ar~ per,on or orgariization as an insured ur~de~ ~his endorse- ment ¢~e$ not apply: 1. To "bodily irgury", or. 'property damage' which occurs: p~ior lo the dale of your contract with such person: Of gardzation; 2. To 'bodily injury' or "l~operty damage' included within the 'products/completed ol~eratiom hazard.' 3. To 'bodily i!3jury' o~ 'property ~larfmge' arising out o1' the sole negligence of any person or organizaliort that WOtlld not be an Insured except for this endorsement. Includes copyrighted material o! insurance Services Office. Inc. wfth its permission. CG-F-48 (06-92) 3-26-01; 4:40PM; ;50294455666115 # 2/ 7 P~o~uc~ THB C~TIF~ATE Il I~UB ~ A MA~ OF INFORMA~ON ~LY A~ CON~ NO RI~ UPON ~T~ ~UAL INSU~NCE ~ANY .o~m. ~ c~TIFIcATE DO~ NOT ~. ~T~D OR - 2400 W. Dunlap Ave.. Suite 2~ ALT~ ~E COV~GE AFFO~ BY ~E POUCI~ ~LOW. ~ Phoen~. ~ 8~2] C~PANI~ AFF~DING COV~ Phone: ~2-~-55~ co~,~ FE~TED ~T~L INSU~CE CO~Y OR Home ~ce: ~atonna. MN 5~ A FEDE~TED SERV~E NSU~CE CO.ANY WEST VALLEY PLUMBING & HEATING iNC 1 ~ DELL A~ CAMPBELL CA ~08 c CO~A~ j ~ THiS IS TO CBIR T~T T~ PO~IES OF I~MUNCE ~IST~D ~ ~ ~[~N I~M[~ TO THE IN~B~B ~MED ABOVE FOR T~ P~ICY P~IOB ~Ol~J~, ~O~A~BIN6 ANY R~O~[M~, TERM ~ ~O"BEIO~ OF A~f CO~CT ~ OTH~ D~UME~ ~H R~ECT TO ~ICH THIS 6~IUTE ~f ~E I~UED OR ~Y ~TAI~, THE INSU~NCE AF~ORD~O BY THE PO~ICIB B~RI~P ~[IN I~ 8U~ECT TO ~ THE T~, ~XCL~SIONS A~ CONBITIO~ OF SUCH P~ICI~8, ~f$ $~ MAY ~A~[ BEEN REDMCED BY PAID L~ DA~ ~M~O~) DA~ G~L L,~U. ~ GGG"~ ~ 2.000.000 A ~ ~*,MS.A~ ~ ~CU. 9271~ ~1t~ 04/01/01 ~o~*~v.~u~ . 1,000,~0 owen'S & co,~c~'s P~r t,c, OCC~NC[ s 1 ,~0~000 &~ OWeD A sc~ou~ ,~os 9271 ~0 0~01/00 0~01/01 ~' ~ ~0~R~ 0~AGE 8AUOE L~BLITY AUTO ONlY - ~ ACCIDE~ A~A~G 0THEft T~N A~O O~Y: ~ : ~CH ACCIDE~ ~cm ~L,~ ~AC. OCC~.C~ ~ 2,000,000 A ~ UM~b* ~0W 9271~1 0~1~0 0~01~1 &G~*~. , ~ E.000,000 / ~O~' ~ E~ EACH ACCIDENT PARTNE~C~ 0~ CITY OF CONCORD ~9 s. ou~ ~.Y o~ ~ ~.~ ~.~ ~oucms ~E ~.c~ 70 NORTH FIRST STREET ~.o. ~ r.i~. ~ ~mo co~ w~ CAMPBELL CA ~008 30 ~,Ys w.T~ "~"CE TO ~E C~.~TE .~ ATTN JOANNE DAMBROSIA 3-26-01; CERTIFICATE OF INSURANCE INS'URED WEST VALLEY PLUMBING & HEATING INC 1260 DELL AVE CAMPBELL CA 95008 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/~PECIAL ITEMS THE CERTIFICATEHOLDER IS ALSO AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE CG-F-48 ADDITIONAL INSURED BY CONTRACT ENDORSEMENT. RE: 368 EAST CAMPBELL AVE., #Z1023, CAMPBELL CA 95008. ADDITIONALLY INSURED: THE CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS OFFICERS. OFFJCALS. EMPLOYEES. AND VOLUNTEERS. IT IS FURTHER AGREED THAT THE INSURANCE PROVIDED BY THIS ENDORSEMENT IS PRIMARY. OTHER INSURANCE AFFORDED TO THE INSURED SHALL BE EXCESS OF, AND DOES NOT CONTRIBUTE WITH, THE INSURANCE PROVIDED BY THIS ENDORSEMENT. ~-.ERTIFICATE HOLDER CITY OF CONCORD 70 NORTH FIRST STREET CAMPBELL CA 95008 ATTN JOANNE DAMBROSIA 229 3-26-01; 4~40~M; ;60294455666115 ~ 4/ 7 11118 ENDORSEMENT OHANGGS THE POLICY, PI.EA~ READ IT cA.q~Y. ADDITIONAL INSURED BY CONTRACT ENDORSEMENT This endorsement modifies insurance p~ided unde~ the ~ollowirtg: COMMERCIAL GENERAL LIABILITY COV~GE PART OWNERS AND CON'FRACTORS COVERAGE PART k WHO IS AN INSURI:;D for ~ init/" ~ 'prOl~fly damage' liabilily is amended to include: An employee, association of empioyefl or labm union, except with respect to work performed by of for you /or such employee, assoemtian ~f eml~!~ees o[.labm ~ under d~ed cona~cl between you as contrac-- for and such employee, assodation ol ~hililoyees or labor union as owners: 2. Any miboad compav except with respect to work perforated by of for you for such railroad company under direct contract of agreement between you and such. railroad company; of 3. Ar~ person o~ mgen~tien whose ?.oflsslen, business 0c .occupatio~ i~ Ihat ~f an mc:hitect, mJrveyor of enoif~eer ~th resl)e~ to #ab,#y raising out of Ihe per,~anon o~ approva~ ol -maps. drawings, opinions. reports, surveys, change, orders, designs, specifications of the performance of any otheT professional services by such person or m'gani2ation; 4. Any'of your Subcontractors, m any partner, oflicef, agen[ o~ employee of such Suheon~actor. B. The C-overage extended to any additional Insured by th~ erxaxsement is ,mired to. are ~uNect to aa terms, coh- dilion~, and exclusions of the Coverage part to which I~s endorsement is attached. In addition Coverage shall not exceed Ihe te~ms and comltton$ that me requked by the terms of the Mitten a~'eeme~ to add a~ i~su~ed, or tO I~OCU~e insurance. : C. The limits of insurance applicable to such ins~ance Shall tie the lesser of the limits required by the agfeemeht between the parties or the limits provided by this polio/. D. Addltiorml exchJ~,k)r~.~ The imufance afforded to arly Person or orgar~L, ation as an insured urlder this endcJrse- ment does not app.: ' 1. To "bodily iniUry.", or .-'property damage' which occur,~pridr lo the dale of yom conbacl with such persen:O~ garlzation; 2. To 'bodily injury' or "property damage' included within the 'products/completed ~e~ations hazard.' 3. To "bodily '.~fy' or "properly. darhage' arising out of the ~31e negligence of any person or o~genization that Would not be an in~ured except for this endorsement. Includes copyrighted matedat Of insurance Services Office. Inc. with its permission. CG-F-~8 (06-92) 3-26-01; 4:40PM; ;60294455666115 # 1/ 7 FEDERATED MUTUAL INSURANCE COMPANY FEDE~TEp FEDERATED LIFE INSURANCE COMPANY FEDERATED SERVICE INSURANCE COMPANY .o,~E OFF,OE: OW, TO..,,. ,~. ~0.0-.,, INS U.gA NCE [~ FACSIMILE COMMUNICATIONS COVER SHEET Date 03/26/01 Numl~r of pages sent '~, (Including cover sheet) From: Name F. Agc'r h-gZ FaxNo. (602) 395-0664 Ext. No. Telephone No. (602) 9o,.&-5566 ;--ZT 63:1Z I~TE: If any 0t the gages are not legible, or you do not receive all the pages, conlact Federated at the above telephone or fax hurter. Subjecl: CEETIFICAT[ OF INSURANCE AND ADDITIONAL INSUKED ENDORSEMENT To:Name CITY OF CA~?BELL Company, F~No. 408-376-095S ,Message: HARD COPY TO FOLLO~ MM-29(c) Ed. 5-90 Primed in U.;A 3-26-01; 4:40PM; ;60294455556115 # 5/ ~vca ~ CER~FICATE ~ ~U~ ~ A ~ OF INFORMA~ ONW A~ CON~S NO RIGHTS UP~ ~E C~TIRCATE ~~~L INS~~ANY HO~. ~ CERTIFICATE DO~ NOT AM~, ~ OR 24~ W. Du~ap Ave., Suite ~ A~ ~E COV~A~E AFFO~ BY ~E PoucIES BELOW. ~ Phoenix, ~ 8~1 COMP~IES AFFORDING .COV~AGE Phone: ~2-~5~ c~ F~D~T~D ~T~ IN~NCE C~Y OR Home Office: OwMonna, MN ~ A FEDE~TED ~ERVICE INS~NCE CO~ANY WEST VALLEY PLUMBING & HEATING [NC 1~ DELL AVE CAMPBELL CA ~08 C C~FANY I D THIS ~ TO c~l~ T~T THE ~L~IES OF INS~NCE LISTED 6~OW ~VE BE~ I~UED TO THE INSURED ~MED ABOVE FOR THE POLICY P~IOD INDICTED. NO~TANDING ANY RE~U~, T~ ~ COND~ION OF ANY CO~ ~ OT~ DOCUM~T ~TH RE~T TO ~CH THIS CERTIFI~TE ~Y BE ~U~ OR ~Y ~TAIN, THE I~E AFF~ ~ THE POUClES DESCRIBED HERE~ ~ SU~ECT TO ALL THE EX~USlONS A~ CO~ff~ OF S~H POL~IES. UM~S SHOWN ~Y HAVE ~EN REDUCED BY PAl0 ~T[ ~M~D~} DA~ (~D~YI ~lTi X A ' ]c~A,M~ ~occ~ 9271~0 0~01~1 ~1/02 ~t~v,m~ * 1,000.0~ A~OMOB~ ~1~ A s~o~.u~os 9271 ~0 0~01~1 0~01102 ~"""~"~ NON~W~O AUkS ~r ~) ' ~O~R~ 0AMAZE ~QE ~U~ AUTO O~Y - ~ ACCI~NT A~ AUTO OTHER T~N A~O EACH ACCIDENT ....................... ~GK~YK ~ .... A ~.~ r~ ~71 ~1 0~1/01 0~01/02 *Get.T; ~ 2,000,~ I WC¢~T~ I IOT~- EL EACH ACCID[~ THE PR~T~ J J ~ ~ Oi~ - POLICY L~ P~NER$~EC ~lV[~ ' o~ ~P~N OF O~O~~CL~C~ I~S ~ A~ P~ 70 NORTH FIRST STREET ~.o. ~ ~o~. ~ m~o c~.~ w~ ~~ ~ CAMPBELL CA ~08 30 ~*. w~ .o~c[ ~ ~ c~.c~= .om~ ~ ~ ~ ATTN JOANNE DAMBROSIA ~~x~~~~ 3-26-01; 4t40PM; ;60294455656115 CERTIFICATE OF INSURANCE IN:~UR~ WI=ST VALLEY PLUMBING 8, HEATING INC 1260 DELL AVE CAMPBELL CA 95008 ,30~J- 148-5 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS THE CERTIFICATEHOLDER IS ALSO AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE CG-F-48 ADDITIONAL INSURED BY CONTRACT ENDORSEMENT. RE: 368 EAST CAMPBELL AVE., #21023, CAMPBELL CA 95008. ADDITIONALLY INSURED: THE CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS OFFICERS, OFFICALS, EMPLOYEES, AND VOLUNTEERS. IT IS FURTHER AGREED THAT THE INSURANCE PROVIDED BY THIS ENDORSEMENT IS PRIMARY. OTHER INSURANCE AFFORDED TO THE INSURED SHALL BE EXCESS OF. AND DOES NOT CONTRIBUTE WITH. THE INSURANCE PROVIDED BY THiS ENDORSEMENT. CiTY OF CONCORD 70 NORTH FIRST STREET CAMPBELL CA 95008 ATTN JOANNE DAMBROSIA 229 3-26-~1; 4:4OPM; ;602944556661~5 # 7/ 7 THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT C, AREiq, JLLY. ADDITIONAL INSURED BY CONTRACT ENDORSEMENT This endorsement modifies insurance prOVided unde~ the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS COVERAGE PART WHO IS AN INSURED fm 'bddily injury" azxl 'property damage' liability is amended to include': Any person or o~ganization other thaAa joint venue, for whichyou have agroed~ written contract to procure badity injury o~ I:)fopert~ ~ge liability insurance, arising out of operations performed by you or on your ,behalf; however, this additional jrJeurance does riot apply to: An employee, association of employees or labor union, except with respect lo work performed by or for you rr such err?eye.e, associat' .mn..of e~e. es or lal~r, urd~m under dh'ect contract between You as em-itrac- arm suc~ empJoyee, &~)cJelton ow employees ~f ~ union as owners; . Any railroad company except with respect to work performed by or for you fo~ such ra~road company under direct contract o~ agreement between you and such. railroad company; or Bo 3. Arqt .pers~. or orgafliza .tl~t..._.w~Jo. se .l~.ofessJon, business m- occupation is.that of an a~chilect, surveym or engineer with respect to Imbility arising out of the preparation or approval of -maps, ~awing8, opinions, reports, sulvey$, change, orders, designs, specifications or the performance of any other professional · ervices by such person or organization; 4. Any'of you~ Subconbactors, of any partner, officer, agent oi' employee of such Subcontractm. The Coverage extended to any additional Insmed by this endmsement is limited to. and subject to all terms, con- dition% and exclusions of the Coverage part to which this endorsement is attached. In addition Coverage shall nM exceed the terms and conditions that are required by the terms of the written ag~eemenl lO add any insul'ed, o~ to procure insu~anGe. The limits of insurance applicable to such insurance ~halt be the lesser of the limits required by the agreemel~t between the parties or ~ limits provided by this policy. D. Additional exclusk)ns,.. The insurance alluded to any person or orgalli2atiun as an insured under ti:fi. 's endorse- ment does not apply: 1. To 'bodily iniurY.','~r. 'property damage' which occurs pddr to the date of your contract with such persen:'or or- ganization; 2, To "bodily injury" of "property damage" included within the "products/completed operations hazard." 3. To 'bodily injury' or "property damage- arising out of the sole negligence of any person or organization that would not be an insured except for this endorsement, Includes copydghled material of Insurance Services Office. inc. with ils permission. CG-F-48 (06-92) 03/26/2001 MON 15:27 FA~ 408 297 4949 MIC~LEL~TTI & ASSOCIATES ~001/003 heletti & AssocMtes ImmmSe~vlm · Risk 700 Meridian Way, P.O. Box 25620, Gan Jo~e, CA 95159 408-292.4900 Fax 406.2974949 To; City of Campbell Frerm Sylvia So Sax= ¢08-376-0958 Pa~a~: 3 __ Att: Ioanne D'ambrosia Date: D3/26/01 ~ West Valley Plumbing and Heating Inc. of ¢{3: Los Gatos Attached Certificate 03/26/2001 MON 15:27 FAX 408 297 4949 ~ICEEI.~TTI & ASSOCIATES ~002/003 ACORD. ~05¥ CERTIFICATE OF LIABILITY INSURANCI= Xichele~ti & Aseoeia~es 760 br~d~a~ Way P, O, Box 26620 S~ ~oee ~ 95159- I~U~D (408) 292-4900 ,1 COVF. RA~E~ West Valle~ ~lmabing & Heating o~ Lee 1260 Dell Avonve C~'-~.~ell CA 95008 ,, THIS CERTIFICATE iS ISSUED A8 A MAi; ~-R OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR A~._ TER THE COVERAGE AFFORDED_B_Y THE_POUGIE~ BELOW. ]NSURER$ AFFORDING COVERAGE INSURER B: : IN~URERC; 1N~URER O: THE POLICIES OF INSURANCE LISTED BELOW I'tAVE BEEN I~$UED TO THE IN$URED N~ED ABOV~ 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 P~II['rAIN, THE INS~E AFFORDED BY TI-IE POLICIES DE,,~CRIBED HEREIN IS SUBJECT TO ALL TI-~ TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !msR " ' pm. Ct EF~c'n~ POUGY tbmeA'nON ~TR TYPE, Of; INSURANCE ~ NU~IER ~T~ 6VIM/~]~t~t.1 DATE IMIWDD/Y~i ,UMJTS GENERAL ~ EAC~ C3CCU~f'~CE . S .. COMMERCIAL OEI'qERAL LM&IU'rV FrR~ ~C~ (kw o~ rrr.) $ PCRSOI~L & ADV INJURY S GENER&L AGGREGATE , S OEN'L AGGREGAT~ LtM~T APPLIES ~ Pf~UG ~$ · ~OMP/OP AGG AUTOMOB~E Ui~U'T~ CO~G8NED S~GLE LWrr S ' -- ~ ANY'AUTO I AI~ OWIq~ Au'r~ ~ODILY II~LJURY S ..RCHEDULED AUTOS (Per pemo~) HIRED AUTOS BODILY II~ URY PROPERTY ~.2AMAOE , GAJf,/~E UA~I,n"Y AUIO ~LY · EA &CCA~NT S i ANYAUTO OTHERTHAN ~ S &UTO ONLY AO0 $ EXCESS UAI~LJ~Y F-&C~ OCCURRENCE $ -- J OCCUR ~ ~,M~ MAGE ~a~(~?E s _ S DEDUCTIBLE RE?ENT;ON $ $ A EMPLOYE. RG'LIA~i~I'Y 151~?.~0& 04/02/2000 04/01/2001 EL.I~ACHACCtDENT $ 1,O00,O0O E_L [:h'leAae - ~ r~dPCOYeF S 1,000,000 F_L OtSEASE-POLICYLIMIT $ 1,000,000 OTH~;R OeSOmenON OF O~e eATJONM. OCA~ONS~I)MC Le~Ex~.ue~N~ aDOED eY ~oomm~p~m~ PI~0V~0N$ Pcr'm~ ffENC2001- 368 E Camp~ll Avenue fl21025, CalmDb~l, ~ 95006 Ten ~ n;~ce of cancellation for nonp~ymenl of premium. ,CERTIFICATE HOLDER I [ ~,~um;a; m~u~, LLe~f,: CANCELLATION SHOULD &NY OF TH~,,I~OVE DESCRllED POUClES B~ P.,ANG F..LLED IF. FORE TNE EXRRATION City o£ Cma~bell Campbell ~ 9500a-1423 1 ACORD 25-8 ~?) 03/26/2001 MON 15:27 FAX 408 297 4949 MICHELETTI & ASSOCIATES ~005/003 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy{les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such etldOrsement(s). If SUBROGATION IS WAIVED, subject to the ~erms 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 enclomement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing Insurer(s), authorized representative or producer, and the certificate holder, nor does It affirmatively or negatively amend, extend or alter the coverage afforded by the pollcles listed thereon. ACORD 25-~ ~'/97) PRODUCER ;NSURED FEDERATED MUTUAL INSURANCE COMPANY 2400 W. Dunlap Ave,, Suite 250 Phoenix, AZ 85021 Phone: 602-944-5566 Home Office: Owatonna, MN 55060 WEST VALLEY PLUMBING & HEATING INC 1260 DELL AVE CAMPBELL CA 95008 309-148-5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE COMPANY FEDERATED MUTUAL INSURANCE COMPANY OR A FEDERATED SERVICE INSURANCE COMPANY COMPANY B COMPANY C COMPANY D 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. TYPE OF INSURANCE GENERAL LIA~UTY COMMERCIAl. GENERAL LIABILITY __ CLAIMS MADE ~ OCCUR OWNER'S & CONTRACTOR'S PROT AUTOMOBILE LIABILITY ANY AUTO ALt. OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OW.NED AUTOS GARAGE LIABIUTY ANY AUTO EXC E~S UABIUTY UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPEN~ATION AND EMPLOYF. R~' LIABJUTY THE PROPRIETOR/ ['~ INCL PARTNERS/EXECUTIVE OFFICERS ARE: EXCL OTHER '~CRIPTION OF OPERATION~I,0CATIONS/VEHICLESISPECiAL ITEMS ~E CERTIFICATEHOLDER 16 ALSO AN ADDmONAL INSURED :IR GENERAL UABILITY COVERAQE PER CQ-F..4~ ENDORSEMENT. POUCY NUMBER 9271600 9271600 9271601 POLICY EFFECTIVE DATE (MM/DD/YY 04~01/00 04/01/00 04/01/00 POLICY EXPIRATIOh DATE (MM/DD/YY) 04/01101 04/01/01 04/01/01 LIMITS GENERAL AGGREGATE PRODUCTS - COMPIOP AGG PERSONAL & ADV INJURY EACH OCCURRENCE FIRE DAMAGE (Any one fireJ MED EXP {Any one peck, nj 2,000,000 2,000,000 1,000,000 1,000,000 100,000 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per pereon} BODILY INJURY (Per icc~dent) $ PROPERTY DAMAGE AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: EACH ACCIDENT AGGREGATE EACH OCCURRENCE AGGREGATE 2,000.000 TORY LIMITS EL EACH ACCIDENT $ EL DISEASE - POLICY LIMIT $ EL DISEASE - EA EMPLOYEE $ 2,000,000 POLICY OR ENDORSEMENT ATTACHED THERETO ALL OPEARATION8 OF THE NAMED INSURED A.S COVERED BY THE · CITY OF CAMPBELL to J SHOULD ANY OF THE ABOVE DESCPJBED POLICIES SE CANCELLED BEFOAE THE BUILDING DEPARTMENT I EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 75 NORTH CENTRAL AVENUE' I 30 DAYs WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. CAMPBELL CA 95008 I ~--~T ;-A,LURE TO W~I. SUC..OT~CE S.A,L IMPOSE .O OBL,OAT, O. OR U~BILITY , ACORD. ~o_~,_,c_~_r (408) 292-4900 icheleCti & Associates arrell E. Dukes 60 Meridian Way O. Box 26620 an Jose CA 95159- West Valley Pl,,m~ing & Heating Sylvia So CERTIFICATE OF LIABILITY INSURANCE 104/06/2000 (' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BF[_OW. of Los Gatos 1260 Dell Avenue I Campbell CA 95008 )VERAGES INSURERS AFFORDING COVERAGE INSURERA: Republic Indemni~y Co. of Amer. INSURER B: INSURER C: INSURER D:. INSURER E: 7HE POUC!E$ OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING d~Y REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ,~Y PERTAIN, THE INSURANCE AFFORDED BY THE POUClES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH :OLIClES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. i t~.~ OF INSURANCE POUCY NUM_R;_R POLICY I:H'ECTNi POLICY EXPIRATIO~ DATE IMM/OO/YYI DATE/MMIODfYYI uMrr~ GENERa. ~ EACH OCCURRENCE $ COUUERC~. GENER~ UAmUT~ RRE C~U,U~GE (.~ oM ~} $ GENERAL AGGREGATE $ GEN'L. AGGREGATE UMIT APPUES PER: ~ PRO- ['~ PROOUCTS. COMP/Dp AGG $ POUCY I I JFCT LOC AUTO~O~LE UA~UTY COMBINED SINGLE UMIT ANY AUTO (Ea acOeem) , $ BODILY INJURY SCHEOU[EO AUTOS (Per p~n) $ ~RED AUTOS i BO~LY INJURY GARAGE UAaiLrW AUTO ONLY. EA ACCIDENT $ OTHER TI-L4N EA ACC $ AUTO ONLY: AGO S RETENllON $ $ WORKER~ COMPENSATION AND X l wc STATU- TORY UMITS I EUP~Y~WU~a.n~ 13182204 04/01/2000 04/01/2001 E.LEACHACClOENT $ l~000t000 ! E.L DISEASE - EA EMPLOYEE $ 1#000~000 E.UC~SEASE-~UCYUU~T $ 1,000,000 OTHER ~JPTtON OF OPEJ~I~ON~/LOCATIONSNEHICLE~F.~CLU~ON$ ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ~erations of the Named In,~,ed wiffi re~lX~t to work pedcxmed for the Certificate Holder. ~a¥ no~e ~ nonpayment of Ix~nium. ,TIFICATE HOLDER I ADOJTIONAL INSURED; INSURER LETrER: City of Campbell Business License 70 North First S~reet Campbell CA 95008- )RD 25-S (7/97) CANCELLATION Should any of the above deSCribed policies be cancelled before the exp~tJon date thereof, the issuing company will endeavor to mail 30 days written notice to the ce~f~,at~ holder named to the tetL But failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives. c ACORD CORPORATION 1988 WORKER'S COMPENSATION INSURANCE INFORMATION The following worker's compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit or contract. WORKERS' COMPENSATION INFORMATION: Name of ContractorZ~; [] A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR [] A Certificate of Workers' Compensation Insurance' Insurance Co. Policy No. Expiration Date ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION Title ~X/' I certify that in the performance of the work for this contract, I shall not employ.any person in a manner so as to become subject to the Workers' Compensation Laws of S ig nec~ ~--e'-~/..- ~-~~z''~ Date/( f-- ~2_ --O/' NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the Permit or Contract will be cancelled or revoked. j:\ forms\workcomp(rev6/96) CITY OF CAMPBELL Public ~(/orks Department CAMPBELL July 15, 2003 Jeffrey Wyatt Wyatt Enterprises, Inc. 14630 Horseshoe Drive Saratoga, CA 95070 SUBJECT: PERMIT NO. ENC2000-00020 LOCATION: 368 E. Campbell Avenue MAINTENANCE INSPECTION - ACCEPTANCE Dear Mr. Wyatt: The City of .Campbell has made the final maintenance inspection of subject Public Works improvements and find that no remedial work is required. Your construction cash deposit of $960.00, plus any interest due, is now being processed and wili be sent to you under separate cover. Please find attached your original Faithful Performance and Labor and Material bonds which we are returning to you. Sincerely, Syed~ahidi Public Works Inspector MQ ~ CC: Permit 2000-00020 Public Works/Maintenance Division Old Republic Surety Company, c/o 300 N. Sepulveda Blvd., Ste. 1070, E1 Segundo 90245 H:\permitsL2000-00020 maint accept(mp) 70 North First Street · Campbell, California 95008-1436 - TEL 408.866.2150 · F^X 408.376.0958 - TDD 408.866.2790 Old Republic Surety Company Old Republic Insurance Company International Business & Mercantile REassurance Company 300 N. Sepulveda Blvd., Suite 1070 El Segundo, CA 90245-4469 Phone: (310) 322-9693 / (800) 438-7475 Fax: (310) 322-8583 /www.orsurety.com June 13, 2003 CITY OF CAMPBELL CITY CLERK 70 N. FIRST STREET CAMPBELL, CA 95008 CI IAI3031:I 2nd REQUEST Our Bond No. WCN1208858 Contract #: 7499999 Contractor: WYATT, JEFFREY L. AND GAYLENE A. 14630 HORSESHOE DR. SARATOGA, CA 95070 Description of Contract: BOND FOR LABOR & MATERIALS BOND FOR FAITHFUL PERFORMANCE Contract Price $ 24,000 Bond $ 24,000 Effective Date: 12/19/2002 Without prejudicing your rights or affecting our liability under our bond(s) described above, we would appreciate as much of the following information as ~ is now available. 1. IF CONTRACT COMPLETED, PLEASE STATE: ' ~= of completion of work ~i ~eli~'ery) Approxlmate .... Approximate acceptance date Final Contract Price 2. IF CONTRACT UNCOMPLETED, PLEASE STATE: Approximate percentage or dollar amount of contract completed or delivered 3. Do you know of any unpaid bills for labor or matezial __ Yes __ No 4. How much has contractor been paid to date? $ 5. Please describe any change orders which have been approved Remarks: Date ~!~'~ !0~ '~ L ~ Signature -=c~ Address 70 N I~ Attention CITY OF CAMPBELL Public k¥'orks Department June 13, 2002 Jeff and Gaylene Wyatt 14630 Horseshoe Drive Saratoga, CA 95070 Re: PLN 2000-170 - 368 E. Campbell Avenue Dear Mr. and Mrs. Wyatt: This letter is in response to a question from your contractor, Tom Kane of Tom Dodge Builders, concerning the periodic discharge of contaminated domestic water pumped from the on-site elevator shaft pit, as a result of using the emergency fire protection system. The City of Campbell has no objection to accepting the water providing it is first pumped onto the surface of the parking lot where the water will be filtered at the drainage inlets in accordance with the approved grading and drainage plan. Please give me a call if you should have any questions. Since, rely,/. Land Development Engineer Cc: Lynn Penoyer, Land Development Manager Bill Bruckart, Building Official Tom Kane, Tom Dodge Builders, 851 McGlincy Ln, Campbell 95008 Encroachment Permit 2000-20 H:\landdevk't68ecampbell wu' discharge ltr(mp) 70 North First Street · Campbell, California 95008-1436 · TEL 408.866.2150 · FAX 408.376.0958 . TDD 408.866.2790 City of Campbell Department of Public Works ~ROACHMENT PERMIT ISSUANCE CI Encroachment Permit No. ra No. Address: _ _ L2'. LIST ITEMS REQUIRED FOR PERMIT APPLICATION: Applicant section complete Applicant signature and date (front and back) Permit Application Fee $245.00 paid - Receipt Number Engineer's Estimate Submitted tg/a_ Plan Check Deposit Paid (2% of Engineer's Estimate, $500 min) Receipt Number Five .Sefs of Improvement Plans Submitted ITEMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS Plan Check & Inspection Fee: If Engineer's Estimate < $250,000, then 12% of Engineer's Estimate. If Engineer's Estimate > $250,000, then Actual Cost + 20%. (Deposit of 8% of Engineer's Estimate required; $30,000 minimum deposit). Amount $ Receipt No. '~ Security for Monumentation Amount $ Receipt No. __ Security for Faithful Performance and Labor and Materials, 100% each of Engineer's Estimate, supplied or paid. Amount $ Form I.D. # LO/(._ Construction Emergency Cash Deposit: 4% of Engineer's Estimate. ($500 minimum, $10,000 maximum) Amount $. Receipt No. ~/C_. Storm Drainage Area Fee Amount $ Receipt No. :orker's Compensation Insurance Information Sheet Received for Applicant. 11 other Public_ W~ks requirements listec~ in .the Conditions of A. pproval of the development. ~ Other Fees,, Payments, Deposits Amount $. Receipt No. ~TEMS REQUIRE~OR TO ISSUANCE OF ENCROACHME~ PERMIT: ~) ~ Contractor's signature added to the permit application (front and back) '~~'s Compensation Irk~uran~e Information Sheet received from Contractor. ~ ~ertificate of Insurance with Additional Insured's Endorsement received from Applicant or Contractor. 0 ~-~ One mylar set and four blueline sets of off-site plans signed by licensed engineer, stamped APPROVED FOR CONSTRUCTION. C ~{.~ Permit signed by City Engineer. WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED, Issuer: Initial and date and f'fie with permit. ~.~~PON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND j:\forms\pmtcklst rev. 8/00 0~ · C,44~$~ CITY OF CAMPBELL Public kY/orks Department Date: June 14. 2OQ]. TRANSMI'I-I'AL FROM THE PUBLIC WORKS DEPARTMENT Jeffrey and Gayleen Wyatt 14630 Horseshoe Drive r Saratoga, CA 95070 I. Harold Housley, Land Development Engineer 368 E. Campbell Avenue TO: FROM: SUBJECT: We are forwarding the following: 1. CoDv_ of recorded Street Tmnrn~r~m~ne_ . Agreement fnr ynnr records. 2. Copy of Grant Deed for Public Street Purposes for your records. 3. Original Bond for Faithful Performance and Bond for Labor and Material. The signatures of Jeffrey Wyatt and Gayleen Wyatt need to be notarized on both bond forms. Once notarized, they should be returned to this office. Remarks: If you have any questions, please call me or Marlene Pomeroy, Department Secretary at 866-2150. J:\FORMS\CETRANS(EXCEL) / I. Harold Housley, P.E. ~ Land Development Engineer 70 North First Street · Campbell CaliFornia 95008- 1423 . TEL 408.866.'2 150 F&X 405 376.0958 · TDD 408.866.2790 MEMO FOR RECORD CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT FROM: Bo Chen DATE: 3/4/02 10:30AM SUBJECT: 368 E Campbell I contacted Mark Hilton fi:om Giuliani & Kull, Inc today at 10:25 to explain the comments we had on his Street Improvement plans. I told him (the exact locations of comments) the dash line at the southwest comer should be deleted and the southeast comer note for SSCO should be stated as "Ex. SSCO. to remove or relocate (to be determined by the city public work inspector)" Bo CALIFORNIAWENTY DAY PRELIML NOTICE II PREPARED FOR THE C~ B Y: ASSET RESEARCH SERVICES, INC. * P O Box 50057 Phoenix, Arizona 85076 480-940-4290 Toll free 1-800-783-9636 Fax 888.-496-5736 IN ACCORDANCE WITH SECTION 3097 AND 3098, CALIFORNIA CIVIL CODE **" THIS IS NOT A LIEN. *** THIS IS NOT A REFLECTION ON THE INTEGRITY OF ANY CONTRACTOR OR SUBCONTRACTOR NOTICE IS HEREBY GIVEN that: CAMERON ASHLEY BUILDING PRODUCTS #67 SAN JOSE BRANCH 380 LINCOLN AVENUE SAN 20SE CA 95126 626 357-7405 H~orwillFumishlabo~servic~,equipment, ormatedal~ ffenerallydeseribed ROOFING AND ALL RELATED BUILDING MATERIALS To be furnished or furnished for the building, structure or the work of improvement described as follows: 368 E. CAMPBELL AVENUE CAMPBELL. CA 95008 SANTA CLARA COUNTY. CALIFORNIA APN 412-07-035 Name ofPersonorFirmwhocon~actedforpurchaseofthelabor, servic~, equipmen~ orm~erialsis: ABOVE ALL ROOFING 700 NORTHRUP STREET SAN JOSE CA 95126-3715 408 292-4188 An estima~ of thc to~! price of said labo~ service, equipment or materials is: $2900.00 *** NOTICE TO PROPERTY OWNER *** IF BILLS ARE NOT PAID IN FULL FOR THE LABOR, SERVICES, EQUIPMENT OR MATERIALS, FURNISHED OR TO BE FURNISHED, A MECHANIC'S LIEN LEADING TO TH~ LOSS, THROUGH COI3'RY~ORECLOSURE PROCEEDINGS, OF ALL OR PART OF YOUR PROPERTY BEING SO IMPROVED MAY BE PLACED AGAINST THE PROPERTY EVEN THOUGH YOU HAVE PAID YOUR CONTRACTOR IN FULI~ YOU MAY WISH TO PROTECT YOURSELF AGAINST THIS CONSEQUENCE BY: (1) REQUIRING YOUR CONTRACTOR TO FURNISH A SIGNED RELEASE BY THE PERSON OR FIRM GIVING YOU THIS NOTICE BEFORE MAKING PAYMENT TO YOUR CONTRACTOR (2) ANY OTHER METHOD OR DEVICE THAT IS APPROPRIATE UNDER THE CIRCUMSTANCES. OWNER OR REPUTED OWNER OR PUBLIC AGENCY JEFFREY L WYATT AND GAYLENE A WYATT 1798 TECHNOLOGY DRIVE #200 SAN JOSE CA 95110-1323 CERTIFIED MAIL # 7119 6571 7070 0072 0242 LENDER OR REPUTED LENDER *** OWNER FINANCED *** CERTIFIED MAIL # ORIGINAL OR REPUTED ORIGINAL CONTRACTOR TOM DODGE BUILDERS 851 MCGLINCEY LANE CAMPBELL CA 95008 408 559-0200 CERTIFIED MAIL # 7119 657i 7070 0072 0259 SUBCONTRACTOR with whom claimam has con~a~ed ABOVE ALL ROOFING 700 NORTHRUP STREET SAN 30SE CA 95126-3715 408 292-4188 ALSO NOTIFIED CITY OF CAMPBELL 70 N 1ST STREET CAMPBELL CA 95008-!436 7119 6571 7070 0072 0266 Inv/Job~ or Amends: Contract/Project #: DATED 10/03/2001 ASS ET,RE'RW, a~CH~ER · BY FOR: CAMERON ASHLEY BUILDING PRODUCTS #67 SAN JOSE BRANCH Doc#678261 CPRLM Rws#6797 Batch#4629\l\15:18\A A2 COPY IF THIS NOTICE IS GIVEN BY A SUBCONTRACTOR WHO HAS FAILED TO PAY ALI. COMPENSATION DUE TO HIS OR HER LABORERS ON THE JOB, THIS NOTICE SHALL ALSO CONTAIN THE IDENTITY AND ADDRESS OF ANY LABORER AND ANY EXPRESS TRUST FUND TO WHOM EMPLOYER PAYMENTS ARE DUE AS FOLLOWS TRUST FUNDS TO WHICH SUPPLEMENTAL FRINGE BENEFITS ARE PAYABLE I*ASSET RESEARCH SERVICES, INC. IS ACTING ONLY AS LIMITED AGENT FOR THE CLAiMANT AND HAS NO AUTHORITY BEYOND THE PREPARATION OF DOCUMENTS NECESSARY TO IMPOSE A CLAIM OF LIEN. THE ABOVE INFORMATION NEEDS VERIFICATION PPdOR TO FILING A LIEN © 1995 ASSET RESEARCH SERVICES, INC. Harold Housle]/ From: Sent: To: Cc: Subject: Harold Housley Monday, March 26, 2001 9:46 AM Bill Bruckart Alan Hom 368 Campbell Ave. For your information, in c, ase your are not already aware, the project engineer/contractor had to raise the FF of the building to comply with ADA. Also the proposed on-site storm drain on the east side of Central is being "squeezed" between the proposed building and the R/W. I will hand you a revised plan that the contractor gave me last Friday. The contractor said he will proceed and install the storm drain but the building may have to be changed. Alan Hom is going to look at the situation for the PWD. L 9(arof~tt['ouxfey, cp. Telephone: 408-866-2158 F.:dension: 2158 Fax: 408-378-0958 Email: public works@ci.campbell.ca.us Chuck Gomez From: Sent: To: CC: Subject: Chuck Gomez Wednesday, March 28, 2001 1:40 PM Lynn Penoyer Chuck Gomez; Harold Housley 368 E. Campbell Avenue, ENC2000-00020 Street Improvement Plans Lynn, I need for you and I to field mark limits of removal and reconstruction at this site first thing tomorrow morning or as soon as you can make it. The contractor and his sub were here this afternoon and were telling me that you and or Harold had given Giulinani and Kull offsite plan check offsite comments and that they were ready to start the work. Did you give the engineer some offsite comments that you have not shared with me? After you and I do the field marking I will meet with their engineer in the field and get this thing out of our hair. Thnaks, Chuckg Chuck Gomez From: Sent: To: Cc: Subject: Chuck Gomez Friday, March 02, 2001 10:17 AM Lynn Penoyer; Harold Housley Chuck Gomez; Bill Bruckart; Tim Haley RE: 368 E. Campbell Avenue, Agreement, bond, fees,ENC 2000-00020 Well, here we go again, with this on again off gain development. Wyat's contractor was in this Friday to get the building permits and Ithought that by now VVyat would have had enough time into this project to have complied with all the requirements. Not so, apparently. In reviewing the files, I do not find the grant deed for the street right of way on Centra! Avenue, and the grant deeds that he had were the originals that were wet stamped, wet signed, and dated by the engineer/surveyor, so that those originals may have to be recreated. I also do not find any record that Harold has approved the grading and drainage plans. Aisc, apparently, there is a question concerning the creation of an ~ngress and egress easement through the Wyat property to the benefit of the property to the east. Apparently that has not occured left Harold a telephone message at his house today. ..... Original Message ..... From: Chuck Gomez Sent: Tuesday, October 31, 2000 2:41 PM To: Bill Helms; Harold Housley CC: Chuck 6omez Subject-' RE: 368 E. Campbell Avenue, Agreement, bond, fees, ENC 2000-00020 We really need to have a field meeting at the site to see what it is that we are up against w~th this development t~9h[ now we have the two backs of sidewalk intersecting at the corner at right angles more or less. On the (Jentral Aver~ue side, the back of sidewalk at the south property line is 10.25' from the face of curb; the back of sidewalk at the exisiting BCR at 30' south from the Campbell Avenue centerline is 8.45' from the face of curb. The new back of sidewalk will be at ten feet from the face of curb of Central Avenue which will then curve with a 20' radius and then go tangent to the back of sidewalk of Campbell Avenue. This will create three longitudinal scorelines for the sidewalk, and create one sidewalk sliver from 0.00' at the south end to 1.55' at the future BCR at approx 44' south from the Campbell Avenue centerline, which has no other relationship to the existing BCR other than that they on the sma side of the street. One is the FC BCR,the other is the back of sidewalk BCR. If that were not enough, then we have another issue to deal with. the building line which is a totally separate line which does two 45 degree angles to turn the corner onto Campbell Avenue. The width of this concrete expanse from faces of curbs to the building lines of the building at 2% crossslope is something that architect needs to take carefully into consideration. I am concerned that the engineer may not have given these items due consideration. Jeff Wyatt had said that he was willing to bring his engineer in to discuss our comments. Chuckg ..... Original Message ..... From: Chuck Gomez Sent: Monday, October 23, 2000 9:24 AM To: Harold Housley Cc: Chuck Gomez; Bill Helms Subject: 368 E. Campbell Avenue, Agreement, bond, fees, ENC 2000-00020 On Friday, October 20, Jeff Wyatt, 832-6598, called me out of the blue to say that he he was going to get his building permit in about a month and that he wanted to know what were the outstading issues. On May 31, I gave him an agreement, bonds and fees, and I aslo left him a grant deed in the will call box that he never picked up even after some repeated calls. Anyhow, what is really outstanding are those issues which I have mentioned above and a storm drainage area fee of $495. One other major item which is outstanding which we all discussed was the grading and drainage which is shown on public property and otherwise has an impact on the building itsself since the storm drain system needs to be under the building itsself. We need to discuss this site today, and we should plan to get together tomorrow to go over the rest of the other develooooopments. Chuckg Harold Housley From: Sent: To: Cc: Subject: Harold Housley Friday, January 12, 2001 10:38 AM Tim Haley; Geoff Bradley Frank Mills; Chuck Gomez; Lynn Penoyer RE: Jeff Wyatt's Building From a Public Works perspective, we do not have any information from the applicant re the access agreement, but the issue needs to be resolved prior to issuance of building permits. In addition, the applicant still has some minor things to do on the G and D plan, and he must pay fees, provide faithful performance security, and execute a street improvement agreement prior to clearance of building permits. The access issue can be incorporated into the standard street improvement agreement. Furthermore, the off-site improvement plans must be substantially complete prior to clearance of the building permits. I. Harold Housley, P.E. Telephone: 408-866-2158 Extension: 2158 Fax: 408-376-0958 Email: public works@ci.campbell.ca.us ..... Original Message ..... From: Tim Haley Sent: Thursday, January 11, 2001 11:53 AM To: Geoff Bradley Cc: Frank Mills; Harold Housley Subject: Jeff Wyatt's Building Geoff: I received a call from Richard Haro today regarding a clearance for the building at the corner of 368 E. Campbell Avenue(Central and Campbell). The only thing I see outstanding from a Planning perspective is the agreement regarding future access to the alleyway. Have you seen any new information from Jeff Wyatt? I'm not sure how close the other departments are to providing a clearance to building. Tim J. Haley Associate Planner 408.866.2144 timh@ci.campbell.ca.us Recording Requested by: City of Campbell When recorded mail to: City Clerk City of Campbell 70 North First Street Campbell, CA 95008 ) ..) ) ) ) ) ) ) ) (Space above this line for Recorder's use only.) STREET IMPROVEN NT AGREEMENT THIS AGREEMENT (identified as File No. S 98-17, UP 98-11) made and entered into this __ day of ,2000, by and between JEFFREY L. WYATT AND GAYLENE A. WYATT, HUSBAND AND WIFE AS COMMUNITY PROPERTY, hereunder referred to as "Owner," and the CITY OF CAMPBELL, a municipal corporation of the County of Santa Clara, State of California, hereinafter referred to as "City." WHEREAS, on November 24 , 1998 the Planning Commission granted conditional approval of S 98-17, UP 98-11 for that certain real property, described in Exhibit A attached and incorporated as though fully set forth herein, and commonly known as 368 EAST CAMPBELL AVENUE , which property is hereinafter referred to as "said real property "; WHEREAS, compliance with the terms and conditions of this Agreement are conditions to the approval of the above described Site and Architectural and Use Permit applications; NOW, THEREFORE, IN CONSIDERATION OF THE ABOVE-MENTIONED APPROVAL, and satisfaction of the conditions to that approval, (1) Owner shall provide, construct and/or install at his own proper cost and expense, street improvements as described in Section 11.24.040 of the City Code within 12 months from the date f'n'st mentioned hereinabove; provided, however, that in the computation of said 12 month period, delays due to, or caused by acts of God, viz., unusually inclement weather, major strikes, and other delays beyond the control of Owner or his successors shall be excluded. (2) It is expressly understood and agreed to that if Owner shall fail to complete the work required by this Agreement within the said 12 month period, the City, after giving ten (10) days written notice thereof to Owner, or his successors, may construct and/or install said improvements and recover the full cost and expense thereof from owner, or his successors. (3) Owner, or his successors, shall cause to be prepared at his cost and expense improvement plans for the construction and/or installation of said improvements prior to such construction or installation. Said plans shall be prepared by a civil engineer registered by the State of California and submitted to the City Engineer for examination and approval. All of said improvements shall be constructed and/or installed in accordance with those plans approved by the City Engineer and shall be made under the supervision and inspection and to the satisfaction of the City Engineer. Said construction and/or installation shall be in accordance with the existing ordinances and resolutions of the City of Campbell and to all plans, specifications, standards, sizes, lines and grades approved by the City Engineer, and all State and County statutes applicable thereto. Upon completion and acceptance of the improvements by City, Owner, or his successors, shall provide reproducible as-built plans to the City Engineer. (4) The construction work of the improvements embraced by this Agreement shall be done in accordance with the specifications of the City of Campbell and West Valley Sanitation District of Santa Clara County, where indicated. (5) Prior to approval of the plans by the City Engineer pursuant to Section (3) of this Agreement, Owner, or his successors, shall pay to the City for examination of improvement plans, field inspection of construction of improvements and all necessary expenses incurred by City in connection with said improvements, a sum calculated in accordance with Resolution No. 9539 as adopted by the City Council on June 1, 1999, or as may subsequently be adopted by the City Council. (6) Owner, or his successors, shall file with City, prior to beginning construction, surety acceptable to the City in amount equal to the City Engineer's estimated cost of the street improvements to ensure full and faithful performance of the construction of all the aforementioned improvement work, excluding sanitary sewers and water distribution system. Said surety shall guarantee that Owner, and his successors, will correct any defects which may appear in said improvement work within one (1) year from the date of acceptance of the work by City and pay for any damage to other work resulting from the construction thereof, as well as pay the cost of all labor and materials involved. This surety shall remain in effect until one (1) year after date of f'mal acceptance of said improvements by City. Said surety amount may be reduced by the City Engineer after the date of f'mal acceptance to not less than twenty-five (25) percent of its full value. (7) Upon final release of said surety by City, the obligations of Owner, and his successors, contained in this Agreement shall be considered null and void. (8) When called upon by City to do so, Owner, or his successors, will execute a petition for the formation of any special assessment district created pursuant .to any special assessment act as provided in the Streets and Highways Code of the State of California created for the purpose of constructing and/or installing any or all of said improvements. (9) Owner, or his successors, shall participate in and become a part of any special assessment district as described in paragraph (8) of this Agreement. It is expressly understood that any obligations of Owner, or his successors, contained in this Agreement that are accomplished to the satisfaction of said City Engineer by said special assessment district shall be considered null and void. (10) Owner, or his successors, shall make such deposits or file such bonds and enter into such agreement as required by West Valley Sanitation District of Santa Clara County to ensure the installation of a sanitary sewage system to serve said real property, and Owner, or his successors, shall file with City, upon execution of this Agreement, a letter from said Sanitation District stating that Owner, or his successors, have made such deposits or filed such bonds and entered into such agreements. (11) Owner, or his successors, shall pay to Pacific Gas and Electric Company any and all fees required for installation of underground wiring circuit to all electroliers within said real property when Owner, or his successors, is notified by either the City Engineer or the Pacific Gas and Electric Company that said fees are due and payable. Owner's, and his successors', obligations under this section shall not be relieved by delay or the passage of time, but shall remain binding indefinitely and forever. (12) Owner, or his successors, shall make such deposits or file such bonds and enter into such agreement as required by San Jose Water Company when called upon to do so to ensure the installation of a water distribution system to serve said real property, including fire hydrant. Owner's, and his successors', obligations under this section shall not be relieved by delay or the passage of time, but shall bind Owner and successors indefinitely and forever. (13) Any easement and right of way within or without said real property necessary for the completion of the improvements shown upon aforesaid improvement plans shall be acquired by Owner, or his successors, at his own cost and expense. It is provided, however, that in the event eminent domain proceedings are required for the purpose of securing said easement and right of way, Owner, or his successors, shall deposit or cause to be deposited with City a sum covering the reasonable market value of the land proposed to be taken and to be included in said sum shall be a reasonable allowance for severance damages, if any. It is further provided that in addition thereto such sums as may be required for legal fees and costs, engineering and other incidental costs shall be deposited with the City. (14) Owner, or his successors, shall carry out any and all negotiations with all interested parties and shall perform or cause to be performed at his own cost and expense and to the satisfaction of the City Engineer any and all work required to abandon, remove, raise, lower, relocate and otherwise modify irrigation line or lines within the boundary of said real property. (15) To the fullest extent permitted by law, Owner, and his successors, shall indemnify, defend and hold the City of Campbell, and its agents, employees, attorneys, officers, officials and assignees harmless from any and all claims, damages, losses and expenses, including, but not limited to, attorneys' fees, arising out of, or resulting from any negligent or intentional act or omission (including misconduct) of said Owner, or his successors, or any subcontractor, or anyone directly or indirectly employed by him, or anyone for whose acts any of them may be liable in the course of performance of the Agreement. The Owner, and his successors, shall also indemnify, defend and hold the City of Campbell, and its agents, attorneys, employees, officers, officials, and assignees harmless against and from any and all claims, demands, liabilities, losses, lawsuits, judgments, damages, costs and expenses (including, but not limited to, attorneys' fees and court costs, whether incurred at trial, appellate or administrative levels) which the City of Campbell may incur or suffer, or to which the City of Campbell may be subjected resulting from the failure of Owner, or his successors, or his agents, employees, subcontractors, or anyone performing services under him, to fulfill any of the obligations imposed under this Agreement. (16) It is acknowledged that the provisions of this Agreement constitute covenants for the improvement of the subject real property for the mutual benefit of Owner's property, commonly known as 368 E. CAMPBELL AVENUE , and the City's property, commonly described as CAMPBELL AVENUE AND CENTRAL AVENUE where it adjoins Owner's property. These covenants shall be considered to affect rights in the above-described real properties, and shall be binding on the heirs, assigns, successors, and grantees of Owner to said real property. (17) Nothing contained herein shall be construed to transfer any unvested interests in real or personal property for purposes of the rule against perpetuities. (18) In the event that Owner, or his successors, should breach any of the terms, conditions, or covenants of this Agreement, the City shall be entitled to recover, in addition to any other relief available in law or equity, all costs incurred in attempting to obtain enforcement of the Agreement, or compensation for such breach. These costs shall include reasonable attorneys' fees and court costs. (19) This is the entire Agreement between the parties, and there are no representations, agreements, arrangements or understandings that are not fully expressed herein. (20) This Agreement can be executed in counterparts by the parties hereto, and as so executed shall consist of one agreement, binding on all parties. (21) Owner shall proVide and construct public street improvements per preliminary plans titled "Street Improvement Plan.q for 368 E. Campbell Avenue. Encroachment Permit ENC 2000-00020 ," which are subject to approval by the City Engineer, prepared by Giuliani & Kull, Inc. 4880 Stevens Creek Blvd., Suite 205, San Jose, CA 95129 IN WITNESS WHEREOF, said City has caused its name to be affixed by its Public Works Director and City Clerk, who are duly authorized by Ordinance 1951 adopted September 2, 1997, and said Owner has caused his name to be affixed the day and year first above written. JEFFREY L. WYATT AND GAYLENE A. WYATT, HUSBAND AND WIFE AS COMMUNITY PROPERTY Jeffrey L. Wyatt Gaylene A. Wyatt (Notary Acknowledgment for above siguator(ies) MUST be attached.) CITY OF CAMPBELL Robert Kass, Public Works Director Attest: Anne Bybee, City Clerk H:\agr\368ecampbellagr(mp) STATE OF CALIFORNIA COUNTY OF SANTA CLAi~ On before me, personally appeared (Notary Public) personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument, the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. (Signature of Notary Public) (This area for notarial seal) EXHIBIT A All that certain real property in the City of Campbell, County of Santa Clara, State of California, described as follows: That certain parcel of land described as "PARCEL FIVE" in that certain grant deed to Jeffrey L. Wyatt and Gaylene A. Wyatt, which was recorded at Instrument No. 99-1433909 on May 27, 1999, in Santa Clara County Official Records. End of Description. CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEER'S ESTIMATE Address: 368 E. CAMPBELL AVENUE Date: 05/1612000 ENCROACHMENT PERMIT NO. ENC 2000-00020 APPLICATI( ~, i ~.~, s,~'~ ~'~u. ~ '~5-1/, Ut' ~)~$-[ 1 ITEM UNIT PRICES FOR PROJECT AMO~T NO. DESCRI~ON UNIT Q~ < $30 K $30 K to $150 K > $150 K $ AMOUNT I. ~ACE CON~-I'RU~ON MOBILI~ON I ~ $ 2,~.~ $ 7~.~ S 2,~.~ CONS~U~ON ~C CON~OLCO~O~P~S~G ~ $ 1,~.~ $ 7~.~ S 1,~.~. CONS~U~ON ST~NG I ~ $ 5~.~ $ 175.~ S 5~.~ CONS~U~ON ~G I ~ $ I,~.~ $ 262.50 $ I,~.~ II. DEMOL~ON/CL~G 1. C~ARING & GRUBBING ~ $2,~.~ 5 2,~.~ 2. ~SAWCUT P.C.C.IA.C.(UP TO 6') 126 LF ~.50 $3.~ S2.~ $ 567.~ 3. P.C.C. REMOVAL 76 SY 530.~ $~.~ $10.~ S 2,280.~ 4. CUrB ~D GU~R ~MOV~ 72 LF $6.~ $3.~ $2.~ 5 432.~ 5. MEDIAN ~MOVAL SF ~.50 $2.~ S1.~ 6. DEMOLISH ~IS~G INLET~LUG RCP'S EA $3~.~ [II. ~O~ D~AGE 1. 12' R.C.P. (C~S ~ 12 LF $~-~ ~.~ S20.~ S 720.~ 2. 15' R.C.P. (C~S lib LF 5~.~ ~8.~ $38.~ 3. 18' R.C.P. (C~ lid LF ~0.~ $~-~ $52.~ 4. 24' R.C.P. (C~ lid LF ~0.~ ' $68.~ $59.~ 5. 30' R.C.p. (C~S$ I~ LF $~.~ $75.~ ~.~ 6. T.V. INSPE~ON (12') LF $1.20 ~.75 ~.~ 7. S~. D~INAGE INLET EA $I,~.~ Sl,3~.~ $1,~.~ C.C. DETAIL 9) 8. F~T G~ ~T I EA $1,~.~ ' $1,I~.~ $~.~ S 1,~.~ '(C.C. DETAIL ~ 9. ST~D~ M~OLE EA $2,~.~ $1 ,~.~ $1,3~.~ (C.S.J. DETAIL D-ti) INCLUDES ~E & LID) 10. BRE~ ~ E~R M.H./D.I. I EA ~.~ $550.~ '~50.~ $ 7~.~ Page 1 ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT [v. CONCRETE I~MPROVEMENT$ 1. SIDEWALK 371 SF $6.50 ' $4..50 $2.75 $ 2,411.50 2. DRIVEWAY APPROACH 314 SF $7.50 $5.50 $3.75 5 2355.00 3. CURB AND GUTTER 72 LF $22.00 $18.00. $15.00 $ 1,58~.00 4. VALLEY GUTTER SF $12.50 $10.00 $8.25 5. HtMNDICAP RAMP EA $1,200.00 $800.00 $700.00 6. I'YPE B-I CURB LF $12.00 ' $9.50 $7.50 7. TYPE Al-B3 CURB LF $15.00 $12.00 $10.00 8. COBBLESTONE MEDIAN SURFACE SF $12.00 $8.00 $5.00 9. P.C.C. DRIVEWAY CONFORM SF $7.00 $5.50 $4,.50 I0. A.C. DRIVEWAY CONFORM SF $4.50 $3.75 $3.00 V. PAVEMENT 1. ASPHALT DIGOUT AND REPLACE 72 CF $5.00 $3.50 52.50 i $ 360.00 2. PAVEMENT WEDGE CUT (6') LF $5.00 $2.50 SI.50 3. PAVEMENT GRINDING 72 SF $0.80 $0.50 $0.35 S 57.60 4.. PAVEMENT FABRIC (PETRO-MAT) 8 SY $2.00 $1.85 $1.50 5 16.00 5. ASPHALT CONCRETE (TYPE A) T $80.00 I $50.00 $35.00 6. ,AGGREGATE BASE (CLASS 2) T $40.00 $20.00 $12.00 7. SLURRY SEAL (TYPE II) SF $0.07 $0.06 80.05 8. SLURRY SEAL (TYPE III) SF $0.11 $0.09 $0.07 VI. TR.A.FFIC SIGNAL,S/LIGHTS 1. DETECTOR LOOP (6' ROUND) EA $450.00 $300.00 $250.00 2. DETECTOR LOOP (6' x 30') EA $650.00 $5,$0.00 $4~0.00 3. DETECTOR LOOP (6' x 50') EA $900.00 $750.00 $640.00 4. ELECTROLIER EA $2,600.00 $2,200.00 $1,800.00 4.5 RELOCATE EA $2,000.00 $ 2,000.00 5. I I/2' RIGID CONDUIT 12 LF $9.00 $7.00 $5.00 $ 108.00 6. 2' RIGID CONDUIT LF $17.00 $13.00 $I0.00 7 CONDUCTOR 36 LF $0.70 $0.55 $0.45 $ 25.20 Page 2 ITEM UNIT PRICES FOR PRO.IECT AMOUNT NO. DESCRIPTION UNIT QTY < 530 K $30 K to 5150 bt > $I$0 K $ AMOUNT - 8 PULL BOX (NO. 3 1/2) EA 5300.00 5240.00 $185.00 S 300.00 9 PULL BOX (NO. 5) EA $400.00 $350.00 $300.00 VII. STRIPING AND SIGNS 1. REMOVE PVMT. MARIGNG$ (PAINT) SF $2.50 $1.50 $1.00 2. REMOVE PVMT. MARKINGS (THERMO) SF $3.00 $2.00 $1.40 3. REMOVE PVMT STRIPING LF $1.40 $0.80 $0.40 4. STRIPING DETAIL 9 LF $I .35 $0.85 $0.35 4.5 STR/PING DETAIL 22 LF $2.25 $1.65 5. STRIPING DETAIL 29 LF $2.25 $1.65 $1.20 6. STRIPING DETAIL 32 LF $2.40 ~ $1.75 $1.25 7. STRIPING DETAIL 37 (THERMO) LF $1.85 $1.50 $I.00 8. STRIPING DETAIL 38 (THERMO) LF $2.50 $1.85 $I. 15 9. STRIPING DETAIL 39 LF $1.50 $0.85 $0.45 10. STRIPING DETAIL 40 LF $2.20 $1.70 $I.00 1 I. LIMIT LINE LF $1.35 $1.05 $0.90 12. CROSSWALK LF $1.35 $1.05 $0.90 13. PAVEMENT MARKINGS (PAINT) SF $2.50 $1.90 $1.60 14. PAVEMENT MARKINGS (THERMO) SF $5.50 $3.80 $2.60 15. PAVEMENT MARKER (NON-REFL.) EA $4.50 $3.00 $2.20 16. PAVEMENT MARKER (REFLECTIVE) EA $6.00 $4.15 $3.15 17. TYPE K MARKER EA $95.00 $80.00 ' $70.00 18. TYPE N MARKER EA $95.00 $80.00 $70.00 19. SALVAGE ROAD SIGN EA $85.00 $75.00 $65.00 20. RELOCATE ROAD SIGN EA $I00.00 $85.00 $75.00 ~ 21. INST. RD. SIGN ON EXIST. POLE EA $200.00 $145.00 $I 10.00 22. ROAD SIGN WITH POST EA $300.00 $240.00 $195.00 23 STANDARD BARRICADE LF $15.00 Page 3 ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT VIII. LANDSCAPING 1. IRRIGATION, PLANTING WORK SF $8.00 $8.00 2 PRUNE TREE ROOTS EA $125.00 $100.00 $85.00 3. tREE REMOVAL EA $650.00 $500.00 $400.00 4. ROOT BARRIER (12') LIe $20.00 SI0.00 $6.00 5. ROOT BARRIER (18") LF $25.00 $15.00 $I0.00 6. STREET TREE (24' BOX) EA 5450.00 $325.00 $250.00 7. STREET TREE (36' BOX) EA $700.00 $550.00 SaO0.O0 8. TOP SOIL BACKFILL CY $20,00 $20.00 9 NEENAH R-8814-A TREE GRATE EA 5150.00 48' x 36" WI16" ID OPENING IX. MISCELLANEOUS 1. PEDESTRIAN BARRIER LF $75.00 $60.00 $50.00 2. CHAIN LINK FENCE (6') LF $15.00 $11.50 $9.25 3. RAISE MISC. BOX TO GRADE EA $300.00 $200.00 5175.00 4. RAISE MANHOLE TO GRADE EA $~O0.00 $275.00 $200.00 5. INSTALL MONUMENT BOX EA $450.00 $350.00 $300.00 6. MEDIAN BACKFILL CY $19.00 $17.00 $15.50 SUBTOTAL $21,816.30 PREPARED BY: 10% SECURITY ENFORCEMENT FEE $ 2,181.63 REVIEWED BY: TOTAL ESTIMATE FOR FAITHFUL $23,997.93 APPROVED BY: PERFORMANCE SECURITY $24,000.00 *See Section 66499.4 of ~e Map Act. H:\excel\368ecampbellengestS_00.xls(mp) Page 4 ENGINEER'S COST ESTirvlATE 368 E. Campbell Avenue February 25, 2000 Job #99201 SURFACE CONSTRUCTION 1 LS MOBILIZATION $ 2 LS CONSTRUCTION TRAFFIC CONTROL/PHA,~ $ 3 LS CONSTRUCTION STAKING 4 LS CONSTRUCTION TESTING DEMOLITION / CLEARING 5 LS 6 120 LF 7 24 SY 8 40 LF STORM DRAINAGE 9 8' LF 10 CLEARING AND GRUBBING SAWCUT P.C.C./A.C. (UP TO 6") P.C.C. REMOVAL CURB AND GUTTER REMOVAL 8" P.V.C. BREAK AND ENTER M.HJD.I. CONCRETE IMPROVEMENTS 11 208 SF SIDEWALK 12 320 SF DRIVEWAY APPROACH 13 58 LF CURBAND GUTTER PAVEMENT 14 15 12 CF ASPHALT DIGOUT AND REPLACE 1.5 T ASPHALT CONCRETE ('TYPE A) TRAFFIC SIGNALS / LIGHTS 16 I F_A ELECTROLJER (RELOCATE) 17 10 LF 1 1/2" RIGID CONDUIT 19 10 LF CONDUCTOR 20 1 EA PULL BOX (NO. 3 1/2) UNIT COST 2,000.00 1,000.00 $ 2,500.00 $ 1,000.00 $ $ $ $ $ $ $ $ $ $ $ $ $ 2,000.00 4.50 30.00 6.00 20.00 700.00 6.50 7.50 22.00 5.00 80.00 1,000.00 9.00 1.00 300.00 TOTAL PLUS 10% TOTAL AMOUNT $ 2,000.00 $ 1,000.00 $ 2,500.00 $ 1,000.00 $ 2,000.00 $ 540.00 $ 720.00 $ 240.00 $ 160.00 $ ': 700.00 1,352.00 2,400.00 1,276.00 60.00 120.00 $ 1,00~00 $ 90.00 $ 10.00 $ 300.00 $ 17,468.00 $ 1,746.80 $ 19,214.80 "T.K." TOm Kane ~// Pr~o_ject M~na~ 851 McGIi~cey Lane Campbell, ~ ~008 408/559-~00 FAX: 408/371-5373 Li~nse No. 308413 (408) 374-7440 (408) 374-4597 FAX WEST VALLEY PLUMBING & HEATING, INC. INDUSTRIAL, COMMERCIAL & RESIDENTIAL CONTRACTORS LIC #249656 TODD SLATTERY 1260 DELL AVENUE slatsdome@io125.com CAMPBELL, CA 95008