96-142
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
"""" 3Jdl j~* ~'i
Pennit exp(res in 12. ..../
.....--- ----
APPIlCATION - Application is hereby made for a Public Works Pennit in ICCOrdance with Campbell Municipal Code, Section 11.04.
expires in 6 months if the pennit is not issued Application Fee is non-refundable).
A. Work address or tract # <<~r 4&, ,gz~ r2~ ~~.:? 4#d ~A!f;
Utility trench location
B Nmmeofwork .UY/<;M'~//z ~~/Plf'/l;r; /~/J{/~
CITY OF CAMPBELL
DEPT. OF PUBIlC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 37~58
~nnit No.
{-Ref. File
~fjil/
Application Date 3--.1.,.., 910
Application expires in 6 mos.
(Application
~
C. Attach four (4) copies of 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 wort to existing surface and wxlerground improvements. When approved by
the City Engineer, said plans become a part of this pennit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Pennit Conditions
listed on the reverse side; and the Special Provisions for this pennit, 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 Genera1 Pennit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE TInS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBIlC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBIlC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK. .
Name of ApplicantlPermittee /CJ1/ #d;/ /fPkt!/ Telephone)( '?7;l~/.tJ!:?
Address e;, e
Is this work being done by the pro~ No
The Applicant/Permittee hereby agrees by affixing their signature to this pennit to hold the City of Campbell, its officers, agents and employees free,
safe and harmless from any claim or demand for damages resulting from the work covered by this pennit.
The ApplicantIPermittee hereby acknowledges that they have read and understand both the front and bact of this pennit, and they will inform their
contractor(s) of the information:
/<
'.:J 6E (
I(Q
o V~T"'
..
.. SET TAB STOPS AT A.RROWS . .
Certificate of Insurant
.
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 LISTED BELOW.
COMPANIES AFFORDING COVERAGES
L
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY 0
LETTER
COMPANY E
LETTER
TRAVELERS INDEMNITY
,.AME AND ADDRESS OF AGENCY
MOORE & MIllER INS. AGCY
3333 SOQUEl DR./SOQUEl
F'. 0.. DO::"; ?!:.i7
CAPITOlA) CALIFORNIA 95010
(.4()B) 46;:.... {.(,i00
NAME AND ADDRESS OF INSURED
i'i E:: L I... D P I F' E l.. I N E S
260 MCG~INCEY LANE
CAMPBEll) CALIFORNIA
TRAVELERS INDEMNITY
lRHVLLERS INDEMNITY
TRAVELERS INDEMNI1Y
C/~50()B
This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. 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.
COMPANY
LETTER
TYPE OF INSURANCE
,"1
GENERAL LIABILITY
ITCOMPREHENSIVE FORM
O~PREMIS ES-OPERA T IONS
O:'EXPLOSION AND COLLAPSE
..' HAZARD
c:r~UNDERGROUND HAZARD
a"PRODUCTS/COMPLETED
;' OPERATIONS HAZARD
Q:CONTRACTUAL INSURANCE
O":BROAD FORM PROPERTY
0.. DAMAGE
~INDEPENDENT CONTRACTORS
O....PERSONAL INJURY
Limits of Liability in Thousan s
EACH
OCCURRENCE
AGGREGATE
POLICY NUMBER
POLICY
EXPIRATION DATE
Y',
.'.:-<
A,YTOMOBILE LIABILITY
[1COMPREHENSIVE FORM
O';OWNED
O::HIRED
O\NON.OWNED
(2'ICr~'i26:i. 03E;4:'?';
o E: ....0" () 1 .,/ (.1 t;j
BODILY INJURY $
EXCESS LIABILITY
C::l'UMBRELLA FORM
D OTHER THAN UMBRELLA
FORM
.U
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
PROPERTY DAMAGE
$
BODIL Y INJURY AND
PROPERTY DAMAGE
COMBINED
~.:.i (:1 () ... 1 ... (} () ()
$
PERSONAL INJURY
$
F J:~.:~i:.') 1 ():?)82t)
Crf5./0:i. ../<?b
BODILY INJURY
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
$
PROPERTY DAMAGE
BODIL Y INJURY AND
PROPERTY DAMAGE
COMBINED
)::: ~) ::~ 6 :I. 0 ~'5 t$ ,{.l. ::.:~
() B ,/' 0 :i. ./" (? E:
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
C:::~::6 J. O:~;d 1. '/
() ~:) ../ () .i. ,,/ .:.:.;. b
(EACH ACC1DENTI
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES
/11. L Ci~'Ii... I F'ORN I (I UF'EF;:i:~ T I DNS
Cancellation: Should any of the above describ..e.d policies be cancelled before the expiration date thereof. the issuing com-
,"il}
pany will endeavor to mail ---=-::. days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company.
OtJ/:I.? /'?7
NAME AND ADDRESS OF CERTIFICATE HOLDER:
DATE ISSUED:
r;)~:5 0 (jf3
CITY OF CAMF'BELL
75 N. CENTRAL AVENUE
Ctlr1F'BEL.L. / C~l
F:C.If:;EF-:T r.'iY 1::-1 TT
M~R-21-1996 08:25
(A..ID, :>>;H&I:R"'~l~ 'II!. U" I N~UI1AN\';J:
;~;.oDUCI'"'' ,. ...",......... . "",:",:;;:,.,:,~,::\,:,~.<;,...:<,.....;:;.. .....:.....
MOORE & MILLER INS. AGENCY
PO BOX 757 CAPI~OLA, CA 95010
3333 SOgUEL DRIVE
SOQUEL, CA 95073
P.Ol
HI CER IFICATE 151S5U A A L g
CONFERS NO RIGHTS UPON THE CERTIFII..ATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND. EXTI!ND OR ALTER THE COV1:RAGE AFFORDED BY THE
POlICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY A AETlfA C , S
LETTER
COMPANY 8 REel:,
l..kTml AETNA C , S
COMPANY C .,~{ If ~ ..~
LEmA AE~NA C & S . ...::
COMPANY 0 MAR 2 i 1996
!ETTER ASTRA C & S
~~YE
(408)'62-6900
INSUM>>
TORY MELLO PIPELINES
260 MCGLIHCEY LANE
CAMPBELL, CA 95008
377-tf/tf3
(., .<~ .~
THIS IS TO CERTIFY THAT THE POliCIES Of' INSlJRANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POlIcY PERIOD
INDICATED. N01WlTl1STANOING",.Y REQUIAEMENl. TERM OR CONDITION OF""Y CONTRACT 0J4 OTHER OOCVMENT WITH RESPECT TO WHICH THlS
ceRTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POlICIES OESC~BED HEREIN IS SlJ6JECT TO ALL THE TERMS.
EXClU&lONS N4D CONomONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE 6E€N REDUCED BY PAID ClAlUS.
co
lTll
POUCT EFFEC'TlV1i POLICT EXPIRATION
DATE \MMIODIYYl ~T' (MM/DDI'/Yl
UIIII1T5
'""IE OF INlIUIINICE
POLlCT IiIUMIIER
. GENERAl UMlUTY
X COMUEI\CIAL OENERo\l,. UAIIIUTT
A .~MI\O!! : XOCClRI
i'~S&CO~'SPAOT
ACM24997329
08/01/5608/01/96
GENERAlAOOREGATE S
. . ..,
PACJDUCTS.COMPIOI' /lOG. ,
PERSONI\L 6 NJV I"JUIlY S
~ OCCURRENCE S
FIRE DAMAGE 1M, _ ",e' . S
. .... .-.........-..---.-.--.. - .,"".".
MfD. EXI'IiNSE lAnT - ~l S
B ~MOBllll UMlLlTY
X . AN'( AUTO
AU. OWNIEO Al1T06
6Q4e)UlED AUro6
...J HrflS)AV!"OS
X . HOM<OWl'lED ALITOS
GAlWJI! UA8lUTY
FJZ4991384
08/10/95 08/01/96
COMIlNED SlNOlE
UMIr
BODIlY INJUfIY
(Pwr~1
800ILY INJURY
~~
PROPERTY D.tMAOE S
C DCB5 UAIIIUTY
X .. UNlllRliLl.A1'OAM
. cm1EA TI-I>>I \JMlIRtiUA f'QI'IM
024997400
08/01/95 08/01/96 EACMOCCUfll'lEJG . S
AOGRmI\11: .. S
D
CZ4997317
08{01/95 08 01/96 ~AwroIlYUM~
~w ACCIDENT S
OlSEASE-POUCY lR/Ii'T S
0lSQ5E . ElICH EWIPloYEE .. ,
WORKER'S coJl'IM'ATlON
AND
fMPLOYER'lj uA81UTV
OTHBl
,
100000
100000
50090
50000
.3.0.090.
500
50000
s
s
100000
100000
100000
100000
100000
DE&CRIPTlON Of OPERATIONS/LOCATIONSI\'P4ICW/SPfClAl, ITlMS
RE:ALL WORK IR PUBLIC RIGHT OF MAY,CITY OF CAMPBELL, ITS OFFICERSrZMPLOYBES AND
VOL~BERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS LIABILI~Y PER CG2009
SHOULD N4Y OF THE ABOVE OeSCRIBED POLICIES BE CANCEUED BEFORE THl!
EXPIRATION DATETt1EAEOF. THE ISSUING COMPANYWlUI~XXX
MAIL 30 DAYS 'ffflJTTEN NOTICE TO THE CEmlFlCATE HOLDER NAMeD TO THE
LEFT.U__~~~~~XXX
lW8XOMtKJItK)tJHOC\X>K'Hli~.j6dUt~tilW4~~KXXXX
" ' >__'.~'q!" . "', ~_:;:;~_;~.t:::--:r;:~,:~,.. A:::>>.:'~--;::~-';' ,
CITY OF CAMPBELL
ATT1f: PUBLIC WORKSr
lUUfDY lfZS~FALL
70 RORTH l"IaS~ ST.
CAMPBELL, CA 95008
'.'~j.f"Y?~i.;'.7',~iC,'~.'!.t>.)L,:?!;;..'.' .'.
.; ...~..::.....<0At.0iiD~1iOIt1 .
TOT~L P.01
MRR-21-1996 07:53
P.02
POLICY NUMBER: ACM24997329 COMMERCIAL GENERAL UABILITY
THIS ENDORSEMENT CHANGES THE POLICY
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following;
COMMERCIAL GENERAL LIABILITY PART
SCHEDULE
Name of Person Or Organization:CITY OF CAMPBELL, ATTN: PUBLIC WORKS
70 NORTH FIRST ST., CAMPBELL, CA 95008, RE: ALL WORK IN PUBLIC
RIGHT OF WAY, CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND
VOLUNTEERS ARE NAMES AS ADDITIONAL INSUREDS AS RESPECTS
LIABll..1TY PER CG2008
(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 11) is amended to include as an insured the person or
organization shoWTI in the Schedule, but only with respect to liability arising out of your
work for that insured or for you.
PRIMARY iNSURANCE It is further agreed that such insurance as is afforded by this
policy for the benefit of the above additional illsured(s) shall be primary insurance as
respects any claim. loss or liability arising out of the named insured's operations. and any
other insurance maintained by the additional insured(s) shall be excess and
noncontributory with the insurance provided hereunder.
CANCELLATION CLAUSE It is understood and agreed that this policy will not be
canceled. limited, or allowed to expire without renewal until after (30) days written notice
has been given to:
CG2010 11 85
TOTRL P.02
CITY OF CAMPBELL
FIELD ENGINEER' S DAILY REPORT
7/ttcf, ~73 r
erts ~,
CONTRACTOR: ~d Pfr II.. s '
PROJECT NO. q" L
REPORT NO:
DATE: 3--J-/--D;0 - 32r; '9b
WEATHER: fa; ('
INSPECTOR: K. ~51fALL
ITEM
DESCRIPTION
r'Nk
;,Jjj- tJ.
u/'
/wu l't
c.-~ ,;tc-,
PAGE: I OF I
CITY OF CAMPBELL
FIELD ENGINEER' S DAILY REPORT
7f~c;t r 7? r)
16 Wh~ cJc t '
CONTRACTOR: fl1df. Ar(/~'.
PROJECT NO. Cj'f:y-//f L
REPORT NO::J
DATE: 3~d1oJ9(P
WEATHER:
If
INSPECTOR: K. .v~51fALL
ITEM
DESCRIPl'ION
PAGE: I OF I
CITY OF CAMPBELL
;(a..d ~73 ~
'9/0 Wh,tw Ot t5
CONTRACTOR: 4M r.f rfN-/ '
PROJECT NO. 1(, - ~
REPORT NO: (
DATE: '!rd C;Jjv
WEATHER: ~ ,'(
INSPECTOR: K. .v~51fALL
FIELD ENGINEER' S DAILY REPORT
ITEM
DESCRIPTION
wAj j>5~
k
cc:
PAGE: I
OF I