96-125
ADMINISTRA TIOI\:
APPUCAnON - AppIicatioa illIenby IUdc for a Public Worb Pamit iD IlClXlI'daDce widI r....,,-. Nuai&:ipaI Code, SecIiaD 11.0.. (ApplDtinB.....
iD 6 .-tIII if the permit iI DOt iIIued).
A. Wmaddnaortnct# ffO-ct Fl-1h / (5~/httlerR'e/J V~e) / Me ~~v ffue/Ju€/ (~tpt;,1
Utilitytnadllocatioa See Pkn5 a~r,-)ve.J 6\/ 1v-{/5j) (;r //,c~( -f fJ7b/ I
, / I
B. Natureofwork /."'st. ) fJ./..e I(I/t'J. >e,..,N'7 /,,;1/.:,\ /J1cL, Ave. 5e.....,..r Gfr.;>., ::h -for !.d\c...+ ~
C
c. AttKb four (4) copicI of aD ~ dnwiq Ibowia& the Iacatioa, ClltCDt aDd IIim I . - of tile wart. Tbe dnnriD& IlIaD .... tile NIatioD of tile g
propoICd work to CliltiJllIUlfIliCC aDd UDdcrpouDd dDpIo.cmcIllL WbCD ~~ .". tile Cty E8aiJIocr, said dmriDC beclc-. a put 01 tbiI permiL r-
D. AD work IbaII coafonD to tile Cty'1 GeDenI CaadidaaI, StaDcIard CclaItnIcIiml ~ aDd 5mBdud CoaIInctioa DetdI ... '-bIic WOIb Ce
CoaItructioa; the GeDeral Permit CaoditioGlliIted OIl the ~ 8de; aDd the Spedal ~ lor ... penIIit, lilted below. p.-.. to Ibide by
tbcIe CODditioGl _ prcMIioaI may rau1t ill job aut.... _/or foJfeiture 01 PaitbfuI PafonDaDce SuretieI aDd mill clcpalilL (See Geaera1 e:
PermitCoaditioGll~~) lI'tcf.. 0s'lJl/.~)Jt<f-&20t ,cli/I /r'JC-e. ~
E. A DClDICfwldablc applic:abOD fee allllt.. fet{ J' '6-Ijl(, '/ I- o/tf.)tD 36 . ~
Name of Applicant TeIepboae f(YB - 3'; g - ~ tk..r; ~
~ oofl. e
aI'Y OP o.LLCE .IV E b
DEPT. OP PUBUC WORKS
~=t.~ :cJEB 151996
(a) 1166-2150
PU"...il. -~,. ~;i'~'"
lZl
III .
:.J =
Q
:. III
- 100
~ III
I:f.l.c:
~~
= III
= 100
Q III
100 4J
llDCl
.. III
III
~ =
c: III
::l III
,Q
.....
... In
4J ~
=.c:
::I
-
= .
Q 0
.....z
4J
~4J
> III
~.w
u u
.c.....
1IlE-4
-
...
:: 100
- III
~1
..... c:
~
> c:
Q
.........
Q 4J
c: C'd
(,I
tIl.....
..... 100I
.....
........
..... c:
e~
Ill.....
Q.
lZl t
..........
.c: ='
.... c:r
c:
Ill.....
~
Q III
'-'.c:
4J
....
C:~
III c:
~ ~
IooOC
III III
>.....
8~
4J
III Q
.c: =
....
c:
100I III
Q III
,Q
It'\
- lZl
N ~
~.c:
c:_
Q<
.....I:f.l
....::l
u-
III
al 4J
100
.. III
Ill.....
Q.<
Add!aI
'OU
II thiI WOIt beiDa doae by the property 0WDeI' at their 0WII1'IIideDce? Yea
ENCllOACfNENI' PEJWrr
(for wortiq witbill the
pubIC j-ol4rf) ~
.....2 ~~
Pamit .... ill U IDOL
,
....:..... tlc :~"r~-:" -
X-Ref. file Cf5- i MAi" !J~lIeLoPM'fftT'.
Apptic:atioa Date ,;) /; t; / Ii (, ·
AppIi-tinII ..... .. 6 ...
No
..
t
~
~
..
Campiete _ anacb Workers' Compelllltioa _ Coatnctor laformatioa fanIIL
The AppIicaDt/permittcc hereby apeeI by affixiq their lipature to tbiI permit to bald tile Cty 01 ~ ill ofticerI, ..... ..... ~JUI frae, afe
aDd banDJeII hom allY claim or dclDllld for damapI Ja1I1tiq hom the work covered by tbiI permiL
The ApplicaDt/permittcc hereby ackDowledpl dlat they bIve rad _ UDdcIItaDd botIl the float _ bKk of tbiI permit, _ tbcy wiD iIlfonD their
ccatrlCtor(s) of the iDformatioD. @
_ -z::k"/A G~w,^~ p~ b-- _~ 1;/76
(ApplicaDt (permittee)/' priat/lip .
~
NOTES: ALL WORK. SHAll.. CONFORM WI'IH 1HE ATIAOIFD, APPROVED PlANS AND ALL APPUCABLE CAMPBELL STANDARD
DRAWINGS AND CONDmONS.
1HE CONrRACfOR MUST HA VB nus PERMIT AND APPROVED PLANS AT 1HE srI'E AND MUST NOTIPY 1HE PUBUC WORKS
DEPARTMENT AT LEAST lWO DAYS BEFORE STAR11NG WORK..
SPECIAL PROVISIONS
NonCE MUST BE GIVEN TO PUBUC WORKS AT LEAST 24 HOURS BEFORE RPSI'AR11NG ANY WORK..
,.
_2-
i:
Street Iba1I DOt be opeD cut for 1I8dergrouDd iDItaIIatioaL NiJlimlllll aatI may be allowed for ~ or apIcntioa IIoIeL SudI aatI.IU!!t
be mecificaIJv atJDJ'OIYed bv the lDsDector mor to cuttin2.
hvemeDt may be cut for UDdcqrouDd iIlstalIatioGl aDd mUlt be ratored iIlllCCllll'daDce widI tile Utility TI'CIICb R....1I:watliae 5aDdud Dmwia&-
Work to be Itated by alic:caled LaDd Surwyor or CMl EqiDecr _ two (2) copieI 01 tile cut UeetlleIlt to tile Public Worb DepuuDeDt
before It.IrtiD& work.
P~M rr PiAN S M..fJ ""'jJ()j6 f4R... JE.i!M JJ tl9t;~:J.) t
~
C
t
t
_1.
PERMIT APPUC'AnON PEE
PlAN OIECX DEPOSIT
SUJUrrY FOR PAl'IHP'UL PERFORMANCE
CASH DEPOSIT
PlAN OIECX a. INSPECIlON PEE
Next $30,000-$80,000 100j AmouDt
APPROVED FOR ISSUANCE
b:PW PERMITfRev.4/94
USA phone (800) 642-2444
7< 7<
STANDARD
AMOUNT
S .;lJ.5J 00
S
S
S
s.Jt.ol... ~o
RErFIJPT NO.
9!Orr
mo.oo
SSOO.oo
(1m9' OP ENO. ESI'.)
(4~ OP SUJUrrY, SSOO MIN)
SG-S3O,ooo 14~j
miD)
qloP~
(lee other lick)
TICKET NO.
PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1, 1995
TO: City Clerk PUBLIC WORKS FILE NO. '!to J J;). 5
PROPERTY ADDRESS McCoy ~~~,.ofkPJt:LJ) ~
Please collect & receipt for the monies: .....
ACCT... ..'........
A"" '"'' AM,I ProiectRevenlJe (snA"if\l nroiect)
ENCROACHMENT PERMIT
472;< Application Fee
Non-Utility Encroachment Permit ($225)
R-1 First Permit (No Fee) Subseauent Permit/Vr ($100)
Utilitv Encroachment Permit
Arterial/Collector Street ($325)
Residential Street/Other Areas ($225) .:!.:l.... () 0
220 Plan Check DeDosit ($500)
2203 Faithful Performance Surety (FPS) (100% of ENGR.EST.)
2203 Monumentation Surety (100% of ENGR.EST.)
2203 Cash DeDosit (4% of FPS)($500 min.)
2203 Labor and Material Surety (100% of ENGR. EST.)
472.~ Plan Check & Inspection Fee (Non-Utility)
Engr.Est. < $250,000 (12% of ENGR. EST.)
.. 2203 Enar.Est. > $250,000 (DeDosit 15% of ENGR. EST.)"
47221 Utilitv < $100000 "00 ,/ 7,0
Conduits/Pinelines UD to 500 Feet ($1.60/ft.) 1>"
Above 500 Feet ($1.10/ft.) bw,4" .,9"
Manholes/Vaults/Etc. ($105/ea) q
Pole Set/Removal ($105/eal
Minimum Charge Per Location ($120)
Street Tree P1antina/Removal ($105/tree)
.. 220 Utilitv > $100000 (DeDDsit 15% of ENGR. EST.)"
4760 Proiect Plans & Snecifications Proiect No.
476C Standard SDecifications & Details ($lIPa $12/Book)
476C Conies of Ennlneerinn Mans & Plans ($.50/sa.ft.)
472 Penalties: Failure to restore Dublic imDrovements ($1oo/Calendar Dav)
(Muni Code Section 11.34.010)
47221 Penalties: Failure to correct unsafe conditions ($100/Calendar Davl
LAND DEVELOPMENT
4722 Lot Line Adiustment ($500)
47221 Parcel MaD (4 Lots or Lessl ($1 060 + $25/Lotl
472 Final Tract MaD (5 or More Lotsl ($1.380 + $25/Lotl
472 Certificate of ComDliance ($400)
472 Certificate of Correction ($300)
472 Vacation of Public Streets & Easements ($550)
472 Assessment Segregation or RelDDortionment
First SDlit ($550)
Elch Additional Lot ($170)
472 Storm Drainage Area Fee Per Acre (R-1. $2.0001
(Multi-Res. $2.250)
(All Other $2 5001
492C Parkland Dedication Fee (75%/25% Due UDon Cert. of OccuDlncV)
4965 Postaae
TRAFFIC
472 Intersection Turn Counts (Two-Hour Count) ($60)
472 Intersection Turn Counts (a.m. or D.m. Deaks) ($125)
472 Traffic Flow Man (DailY Traffic Volumes) ($27)
472 CamDbell Traffic Model (Full ScoDe Assessmentll$2 250)
472 CamDbell Traffic Model (Reduced ScoDe Assessrn$740)
427 Truck Permits ($35/triD)
4728 No Parkin a Sians ($lIeach or $25/100)
OTHER
TOTAL $ J. F ~/. "1f::>
NAME OF APPLICANT IA/ I/SLl ~. v1'11.Ai. ./ / ~~~J..~f..~/z4'X...J
NAME OF PAVOR . ~J11 /}t....L.rt..l./, Y/; i/ a 9./; (Id~ PHONE
ADDRESS /aift I "lili.i0/I'Jv;udJi./ ,;;14,/1 )kAl.... / ZIP '7.5/ ,,/ {I
I l/
.. Actual Cost Plus 20% Overhead (Non-Interest bearina deDosit)
~.
00.
CITY C1.EH
ONLY
I~
~1IY..... ..................................... .<
_ c c. ttfo0B
I
RECEIVED
fEB 2 21996
CITY CLERK'S OFfiCE
..F()rPlanC~eckandCash Deposits, send yellow CQPV.to
DateJlnitiels
h:\recfrm3.wk3(mp)rev.1/9/96
-.......-
CITY OF CAMPBELL
FIELD ENGINEER' S DAILY REPORT
'T"t-..--r-:- c.....-, ~I 4.c. \
\. S ~ -z.. v---\ c:.. c.. 0''''-(
PROJECT NO.q~._ l'L.~
REPORT NO:
~~U \...r:::.\~ I
CONTRACTOR: 'J<...L '-..f<::;'" t':::::. \
h ~~,...,... ~ Uf-.)
DATE .
~'-\~-9f.o
WEATHER: <:...L..~t2.\ V-..f.r:::..n.;,'-I.. I
",,-c. ..4..
INSPECTOR:
c... . ~ \.'-r\.&-z..
ITEM
DESCRIPTION
N::>\t.. :
#.1 jAf~K.uQ a--a ,~C/~{HJ ltJ~fL
-'
cc:
PAGE:
OF
CITY OF CAMPBELL
FIELD ENGINEER I S DAILY REPORT
PNY( ~71P (
Meeo ~/)u-.~.(;dJ ~r.
CONTRACTOR: AMl/~ Prht\1!7
2~1 !IIQ .
ITEM
DESCRIPl'ION
. a cce..J5
c.
cc:
PROJECT NO. 9t:. -p.1)
REPORT NO: I
DATE: ; -//-1&,
WEATHER:~~y --LlGJ/1 !HfiTy tltl,.)
INSPECTOR: K. kJ~.STrALL
PAGE: I
OF I
l_ffi//r -fP 9t -- /) '5
VJV~{j - lY<-ACT 87 ~ (
i4d
J/I(?l~b
~ J(,Vlt~
~ 0..'0\ ,-af)
I
~ Mf4 tt r~ tti~ -1t- L
- .-
I 2- t) 4-. s /
2 5 14f,l:)' I
~ 4- 10\ s
~ l !>S. ~ /
'l & 104.5'/
& 1 J+l.lJ' )
7 ~ 4~,S /
D
~ 9 91.~
01/ %WSrCc 16-0tl_ 7gS.o '
~
SJo1 ~ J.ldJ -:: ~ 6() . () 0
4y5 '~/.1~ ~ 533, 50
~.. 4 I- Lde/oJ5
3)(2):=. 01
7x \ 2-.!- ~4-
I y J 4- ~ It+-
3 x 2.,L ~ b0
1)((.,7:=; GS
2CJt I
d7'?>( /. 10 ~ 317, g ()
· ~1VW-N6lE-=>
9 x /05 ~ 19'5; (J ()
'PLi\1\l eMU t t- 1~JS/'E,-T/'-.ltJ Fcc- fr lfpQG" ~o
liE
LIFE & CASUALTY
THE I 'NTERPRISE 2000
PROPERTY/LIABILITY POLICY
CHANGE ENDORSEMENT
FA' 'NGTON CASUALTY COMPANY
HAk I FORD, CONNECTICUT 06156
A Stock Insurance Company
AGENT
This endorsement amends your policy as of the date shown 4900 BARLOCKER-LORENZI-MASASSO
in the" Effective Date of Change" block.
NAMED INSURED AND ADDRESS (If Applicable) CHANGE NUMBER 002
POLICY NUMBER
INCE CONSTRUCTION CO. 063 MP 0024902386 TWF
DOUG INCE, DBA:
2573 ALUM ROCK AVENUE EFFECTIVE DATE OF CHANGE
SAN JOSE, CA 95116
02/16/96
12:01 am STANDARD TIME at the
Insured's Address Stated Herein.
PER ATTACHED FORM SP-PL01 (GN079) WAIVER OF TRANSFER RIGHTS OF RECOVERY
HAS BEEN ADDED TO THE POLICY:
CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES & VOLUNTEERS
70 N. FIRST ST.
CAMPBELL, CA 95008
REVISED TOTAL POLICY PREMIUM
3 2 1.09
This change endorsement is not valid unless countersigned by a duly authorized Agent of the Company.
(~u!fi.) /-/~
Authorized Agent Countersignature Date
AE023 (ED. 09.90)
MEMORANDUM COPY
PRINTED IN U.S.A.
Elm
LIFE & CASUALTY
THE I 'NTERPRISE 2000
PROPERTY/LIABILITY POLICY
CHANGE ENDORSEMENT
.....................'...-...--..................................................................,',.....................,.........'............'......,",....................................................................-...-."............................
... .........................................................................p....O....R....M.....S.../A.....TT.. ..A.... .0.8.15.. .D..A......S..'J'H.....e...R..E....S.U.U...]'...Q.. .P...T..H..I..S..C....HA,...N.....O.E.................
....".................... "'''_''_d__ _.............. __,.... ......... ..... _.. .. ............
.....'.....-.-.......-....-.............................--.................-..-...-....... ... . . ". . ..., . ..... .... ..... ... .. ... ...., ...... .. .", . ... . ..............
",. ..... ......--..."..................-.-.. ....._-............. ,. ......., .,... ..... .. . ... " , ....... '.. ,. . .............
.. ..-.-.-..-.,..-.,......,',........ ...-.-.--. -.' -.- .......,.... ,. .. ... .. . -.. .... ,... ... ... ... -.... . -. . .... . . ...........
::::::::.::::--:-::::::-:-:-:::::::-:-:-:::::::::::;:;:;:-:::-:-::::::::::::-:-:-:::-:-:::-:::::::-:':::::-/::::::-:::::-:-;-:::-:- ::::.' ....-:.. ..../ ",:: :::.,:' ......,::. ... .-:::,. .:;:::: ::.:;, "::::.:-. ". .. '.: ".::,'/:-. .'.:::::-::::.:-.:: :_:. ::::.' ,'..:: .'. :.... . ".:::::-:-:............
MP009
SP-PL02
0288 .4:2000 POLICY SURCHARGE / TAX INFORMATION ENDORSEMENT
0988 COMMERCIAL PROPERTY/GENERAL LIABILITY
AE023 (ED. 09-90)
MEMORANDUM COPY
PRINTED IN U.S.A.
:.t....... ....... . .,.......~... "
~\ AGeIID.)W . '"
~~~",~~.ut"~~:;:S''IS_ __.:~ ,..~. t~t~
f'ROOUCIft
8ARLOCICfIl-UlRDIZl MA$ASSD 111$. SERVICES
1901 G SlIm
MERCED CA 95340
209-383-0220
'-'-DAft(ii~' T
~i~t~t' ';"'vw . OZ 16 96 ;;
THIS CERTIFICATE IS ISSUED AS A MATTEA OF INFORMAnON
ONLY AND CONFERS NO RIGHTS UPON THE eER'l'lFlCATE
HOWER. THIS CERTIfICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POlICIES BElOW.
CONP/lNIES AFFORDING COVERAGE
aJlAPN<<
A AETIIA CASUALTY - IMLIIIT came:
lICECOIIS1IIJCTIOI
~J Ar ROCK AVE. CA '5116
COMPN<<
B
INSURED
COMPANY
C
a:MPN<<
D
,-. li~.~~:""i;lii~>>:l<'rl""''ti'" ""~olf'h......",."t'.;!i :l...v'r"'-'.'" ~ jloj;~Mi'~),l.""aJl.."".......t",WN'.~~'.~"."'II.""" . ;;zf~"''''''''''''',~~;'Ii'i.<'li1'i$H;!<lj;,*~}l,~'''''mI'~m.''a~.'''''' . ....,
.*_~ .-k. ....'JA.~.AA~~~I~t~:81~~~1,~~l};t:t:t~J;i~~~~fi~!l~5l'~~;~~~~~~~~~.!~~ieg~t:~~;;.;~~~~~~tt:t:~ih~~ii~t~!t~1d;1.~~~~~;:n~tiXtm.'U;~e!iti(~~"i~!~~~~~~~,~~i
THIS IS TO camFV THAT THE pOUClIiS OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A8O\IE FOR THE POUCY PeRfOO
INDICATED. N01WITHSTANDlNG AHV REQUIREMENT. TERM OR CONomON OF ANY CONTRACT OR OtHER OOCUMENTWITH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY tHE POUClES DlSCAlBED tiERElN IS SU8JECT TO ALL lHE TERMS.
EXCLUalONS AND CONDITIONS OF SUCH POUCIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
co 'IYl'E Of IIIIUMIICI ..oucY IMIRR t'OIJCV EFFECnVE POUC'f' ElCI'IttA11ON UIIlft
LTIl OA'M (IIMIDD/W) OATEIII~
GlNE1W. UAIIU1Y QENERAL~'TE . 2 000 Oot
I CCIoM!JlCW.OENSW- UAIIlIJlY PIlODUCl9. OOMPlCP N;tG S 2,000 000
A CLAIMS UADE [I] 0lXlJA 0024902316 05/21/95 OS/21/16 PeRSONAL & M:N NJUR\' $ 1 Oot 000
ONNER!l&~PROT I:ACH OCCURRINCE s 1 000 000
F1RE~ Uvt'I-1ll'I) , 50000
MIlt) ilCP ~- . 5000
,wroIIOIIllf UA8lUYY OOMBINEO 8lNOIJ! L.UT $
X At<< AUTO 1 000 000
ALL OWNEO AUTOS BODLV INJUAV
(P<<~ s
SCHEDULSl AlJ1C9
A tWDAUTOS 0024902386 115/21195 05/21/16 llOOIl. Y INJURV
(Per~ t
~DAUlOS
~OAMAOE s
DARAQE UMIU1V AUTO ONI.Y. eA ACOt!EHT .
/Hi AUTO O'TH!A lHAN AUlO~Y:
eACH ACClOeHT .
AGGABIA'TE .
DCDlI LIAIIutV fAOiOOCU~ S
uu8RB-1A FOAM AGOflEBA'IE .
Oll'lER lHAN UMllREIJA FORIool .
WDRIC!M COIIlPEllSA11OlI AND STAlUTORYUM11'$
EIm.OYIM'LWIlUlY eACH ACCIDENT S
ll'lE HlOPAlElORl INCL ~ -POUC'IL.UT .
p~
0FFICER9 ARE: r:xa. 0l9EASE.l!ACH~ s
OlHfll
DESCIlll'!lON 01 OPIRATIOIIll/lOCA11ON&NEHIClD1SHCIAL ITPIS
T1II CITY. ITS OFFICERS, EMPLOYEES .. VOLUITf(l$ AI[ IW4ED
ADDITIOIAl IIISIIIIED PEl FORM f(:G2010 AlII) T1IlS POUCY SHALl
If PIIMAIY PER FOIIM 1GII079. ..fIOTIC[ OF CAllCfUATICIIt SHALL
.. '. ..~~t~."n;~'x~"'~~a~~*~~'ii :etz~~#::-ij~]~~]~.i'~:~~"~1~' ~;.it~;':;~w' .
.........,.....~.. ... ~.... ,,;_"'_y_ " ...._._._~;_"'v:....\.t.~Jt'l':.~_.,_~)Il_~_}".I<1;c1Jl"';.:J(~.,'~_A1.....A.a.J.s__)Il..~1it~.~~...:i~_'_~~, ,-',.
IEMAII 10 DAY FOR _-'AYMENT OF PRlMIIIt"
CITY OF C>>RELL
70 I. nRST STREET
CAMPBELL CA '5001
. .,u ....' W.~~~'~AWA~x'""'~'li~::' ''"a'.8.,..'' ~::~~~t:'~ ~. 'l:l'.lI'~~oi"l Iii,;'
. .~..~'-~~ AJ'lI~W~~'~i\;9~~........."U...ltlt!l~~Wi'.f. ...",A~~.",,,,,t'/l:l626~~
SMOULD AllY Of ntlE A8t1/IIE __ POUC:IEI IE CAIII>f' .- -.aM 'hIE
ElCI'IM1lON DA'ft nttMOF. 111I IMUING ~AIfY WIU....MX. MAIL
..a.. l)A\'& WIlITI'O 1I011C! TO THE canlFD15 IIOI.DER IIAIIEO TO THE LDT.
IUt)tXllUtdC~...tIB
<<IK>iIH< X1flMX~
TATlVE
OSS~S~W-IZN3~Ol 8~:60 96. 22 83~
POLlCY NUMBER 0024902386
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 20 10 11 85
AODfTIONALINSURED-OWNERS, LESSEES OR CONTRACTORS (FORM B)
Cl246
(t 1-85)
This endorsement modifies insurance provided under th~ following
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or OrganizatiDn:
City of Campbell, its Officers,
70 N. First Street
Campbell, CA 95008
Employees & Volunteers
.
(If no entry appears above. information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to Include as an insured the person or organization shown In the
Schedule. but only with respect to liability arising out of "your work" for that Insured by or for you,
Ince Construction
5/21/95 to 5/21/96
~
,-\:;
.....--......-
~.!lg)
'-- ._,
(', :., .I' :,1, ~ ; r I" - If:"" ,. . ,f'.')I' t , . ;1,1' "
.'--,1.
2"d
OSS~S~W-IZN3~Ol 6~:60 96. 22 83~
COVERAGE PARt' NtJM~R! COMMeRCIAL GENERAL WASIUTY
THIS ENDORSEMENT CHANGES THe POLICY, PL~E READ IT CAREFULLY.
PRIMARY INSURANCE
WAIVER OF TRANSFER RIGHTS OF RECOVERY AGAINST OTHERS
AMENDMENT · SEPARATION OF INSUREDS
This endorlle"",nt Rlodllles inaunwJoe provided unde, t~ IoIIUWing:
COMMERCIAL GENiRAL UA81UTV C;:OVEMCE PART
1. T1'IO following Rmend SECTION IV - COMMERCIAL GeNeFW.IJABIU1Y CONDlTION8:
e. Thlc inN.no. it primary wi1h t8ll*=t to 1he 8ddItIooaI irllMed. MY DflW ItlSUfatlCe tvtilMble to that person
Of oroAl\ization i.s ...-.. -net non-&antributing.
b. We WGiIlO any,,,,", of 'oeov.,y .... may he.... "9.I"Il1 lI\o J3C1'llU" Of' organlutlon Shown in the Schedule
becauoo of pQynter\t8 we mak. for ;"jwy \)r U;,/IIlll1t1 ulllinQ Out 01 "your WOtIC~ Gone urad., . ~ 'VitI't
tlud per.on Of org:ani%ation. 'th6 wClYeI' applie. only tu tits person or OfOMution shown III !he Schedule.
c. Scdion lV, COMME~CIAt. GF.NEAAl.. LJAelLllY CONDITIONS. Port T, &lp!ntlon of In'u'$(js is ~ to
include paragraph c;
leI rr.. Inclusion of ony DeP.tOII or organlJ:atltl/'l .:1 an jlllMtId will not ,'I4IC:( Afly rights (hat person or
GrOMiration lIVnul<l 'reve a5 a clalmanl il 1101 includeclllS an InSured.
,....
SCHEDULIE
~Me OF penSON ()Iq (lR(\ANllAnON;
City of Campbell~ Its Officers, Employees & Volunteers
70 N. First Street
Campbell. CA 9500B
,-.
.GNQ7i (eO. 01-901
CAT. NIlUIO
PAIN1'En .. U.8,,",.
E'd
OS~t;t?I;::lW- 12N3~Ol os: 60 96, ?2 83.:l"'h _
FEB 13 '96 06:00
--- .
STA~E
CCM~.NaA"O'"
'NSU"ANC.
FUND
CIU~' "'lie
ISSUE DAre:oa-01-M',
INC6:f'OOUGLA!, "
r Nt'l,' CONS TRill! t I 0
2573: ALU" ROt! iii A
SA. JOSE CA !5' 1
ThIS is to. cernfY thlIt WI'. I' WI' I
C.alifor,:," ,~~, ,~.~I"I' ~/1f
This POliCY is not subjtJct ~,~
We will also ~ y~ 1IJ ~;l'
, 1!'
, . II.'.'
This c:ertiflclt~ 'Of . ,,"-ura'IC, I ,i~1 I
,b, the polic:ilis:~cI hefpll, 1~~1o
wllh ~C1 ~,~h tt4J ..'tl
polteittl dnCl'~ h..in' .h,.~
'"
"
"
).1,'
~i "
I I..' I '
.~ytaA.,~IL!Tt' r~'*
IT.... ,'~...:. II,iCIt
FOtt'_'~;;S::~;"L.t"rl
, I f ~ ' .
I
.1
, "
",,1
,.,4
(;!,
Ht~\f
"I'
il I'
:1 :"
,,;;:1 I
',1 :,
I:
"
"1'1
.OVeR
f. i
"
, . I': .:\
'tc$!\...,....= _aN
1.7:1:"'" Ie ,',MW
~.... 'ea .:H.
I, r.. ,I,
, " .1 I
i',
'C.
"I'
I ~ : , I
,
,('
"
'I
f,
'. "
f:
"
II
II I' . ,I
TO: 408 3760958
P01
HI
"l '.~ ,,) " ' : 1
. I . , . f . . ", ~
[fOller. MId do.- not .....nd. .)l,t.lId or .Mn,ttY_ 1:O,\Ief_ .~.. " ""I
,i,t"~t. ,terl1\, gf' COf'dltlon, ot ,1i1y C;.,ntrEt Dr .\t1eIr. ~ "
't.ri~tS:;~ C~~~f ':c~;:~:...t,for~ ev r~': .. " 'I, ',;
.,' '. ~'.'. · ....,. 'A;';",L~~'( ::,:::,
.,: './ c;.rr~~'~~..>' '.
, ......,~~ ,,~'~l" ,.. ~ I
, . . <",', ':\ ;,;<>:, ,:: ..
;~...cttsTS. '1.000~OOO~OOPltt<0CCPIIt".." , ".' ,41,'
I' ' , ", "'..,'" . h,
11is:_:-~ AND wtPEBPa.ovI.. tm' .u..~r:>! ;:i!;"
I ~1F1.' .., ' '", . ,.1,' :'. '~.
h ,I' '., I .'," ' .' ,~~~II.. r,lr
\1 ':1: '
':" \:
... ~
"'
, .
N FRANCISCO.CA 9410' -0807
! ~
f' ,
. MQ!RS' ..COMPENSATlON INSURANCE
POllCYNU~ 1124111 ~ ~:
C~IFlC"'~."Ii:X\Jl'RES; ~-o1-'1. "
~: 'IIOOF Of' JtISfal..'
Cllnl ; rc:a,. , . .
allCl Orkef.~ Compensati01'l ihsur.,ce polley in . form l!)I:)foved by'~
.1!!'1!f.~"'~~ .for tI!- ~oltcy_~~ i~ed. '~,. ,~_~.,
ty
:~~ except upon tOd.ys' .ctv.~e INrln_n notICe to ~ ,employ.,.
C,t41
hoUlCl tt1h1 policy be clncelled pr~ to its "ormIIl expltltion.
ura
~,,'
"_I
It>
({iii
....
~
I' ~ I
I: '
i ~
I)
,
,,,.._. t"'_'"~"~'.'"
, .
.Il'
. ~ \
\
, , '
~ II, >, ;f;;: :.~;t
ll.' .~_II_ It.._.
.. '1 1.11
,
~~;.k _"_'_'
i:
,
\:
""',
1'\,
\l~. 'I
'I
,:\1 t,
L.UL.,..
~' ..
':,
'.
INCl. ....AI '
. J , j': ~',
"
"
" .
'Il
"
I ,t, "",'
. ,
"lit
,
- . ~,~, ';
.11
. ',,, ~
"'",
'""
., ~,
,
.,.
r: ~,
" :
...' I..", . ,4 ~ .
~ . ~" > ,": I
.' ~, ''':''~'J : ;; ~ f '. 'j.
L .,.....1. II
" .;,.'. ...., 1 "0
. .' 1 ,I , , " ~
:1; 1I. .. '~:; " ,~ " '/
~I . , '$ ': ~ , I..~ j f
1,;~:~~!:L._". :~U~."_'_
..,
".' '!",
, .
:~! ;..
',' "
. I. ~" :,1.
, ~ v ;.....-
, ; :' ~
"' ,.rt
. "/;'1'
I ): .~1: '~I .
. ..
1'\1
'I'
, I'
. , \,
"
. " ~ ,
" 'I
. h ~ 'I
d" ...11',.
':' 1"
'" "
1 11'
. ,
. "'f ,">1
" "
llq:'r'
",.
, "
" ,
, r
'k
,,' I,
,;r'; ,
.,';;1,'r
I
,t