91-100
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crTY OF CAMPBELL
DEPT. OF PUBLIC WORltS
70 North First St.
ca.pbell, CA '5008
(408) '66-2150
~CROACHMENT PERMIT
(for working in the
public rivbt-of_ay)
1.8Ued //7/ f;
I'U1Iit upiru in 12 110..
Permit No.
9/ -/t:U.)
X-Ref. file
Application Date //3/9/
Appl1cation expiru in 6 110..
APPLICATION - Application 18 hereby _de for a Plmlie Worb Per1ait in accordance with ca.pltell
llunicipal COde, Section 11.04. (Appl1cation expiru in 6 IIOntha if per1ait not pIllled)
A. Worlt addru. or tract . -t) AJ. rM,(l..() C A.MP~': I L
lb
VWiqr trench location 'sA""-6:. A~ Aa.. " L.
.ature of worltl 11UE.'t"&..L. .' () 1"0 C, i",/ S II\)U..'i
B. f!> fL.. .
C. Attach five (!l) copi_ of a drawinq aboving the location, extent and diaenaiona of tbe worlt
':be draw1nq aball 8bov tbe nlation of tbe propo.ed work 1:0 ex1.tinq .urface and underqround
illpl"DV-.nta. tfben appl"DVed by tbe C1qr Engineer, aaid drawinCJ be=-- . part of tbia penit.
D. ':be General Conditione for all per1aita an liated on tbe reverea aide. .peeial PraY18iona for
tbi. per1ait an l1atect belovo ..allun to abide by tbe.e conditiona and pl"DV18iona .Y ruult
in job abut-down and/or forfeiture of Faithful Perforaance Banda and c:aab depoaita. (S..
General COnd1 tiona 1 ud 2).
z. An application f.. .u8t ~ till. application.
.... of Applicant 0A"'O E:;.7"i!...v...~t2.:r'
Addru. r~~ c.. i..t:JQ ( AIlL... ~ 0() I CA ·
'rbi. 18 DOn-nflmdable.
'l'alepba...: ~oq- ~$Lf. Cof-'2.G..
q~240
~
la tbi. worlt beincJ do... by tbe property awn8r at tbeir own naideDca7 --.:r-
Complete and attach Workers' CGIIpeIUIation and contractor Infomation fOI:ll&.
'file Appl1cant/Per1a1ttee hereby avre- by affixing their .i9ftatun to tb18-per1ait to boleS tbe City
of
CaIlpbell, ita officers, aventa and aploy... free, .ate ane! baral_. f~ any claia or e!aand for
daaagu n.ultin; fnm tbe worlt cavered by tbi. per1ait.
':be Applicant/Permittee bereby aeltnovledve. that they bave read and understand both tb. front and
back of tbi~t, ~ that ~ 7i11 inform their cantrllctorc.) of the infomation.
A~E1) ~~,. _ ~~ --.T;;"--/q\
Applicant (Peraitt..) print/.1vn Date ~
NO'1'ZS: ALL IIORIt SIIALL CDNlORII 1fI'1'Il '1'BE AT'fACBED, APPROVED PLAlIS AIm ALL APPLICABLE CAllPBZLL
STANlWtD DltA1fINGS AIm CONDI'l'IOIII.
'1'BE CONTRAC'l"OR MUST BAft 'ftID PZRIIIT AIm APPRuVZD PLAlIS AIm II'DS'l' IID'1' Wl'l'Il '1'BE 1'... lIISPEC'l"OR ON
'1'BE Sm: Nt LEUT 'ftIO laYS UI'OU I'.rAElDIG ~.
IIO'l'ICZ MUST D GIVDf '1'0 POJILtC WORD Ilt LZA8'1' 24 BODItS Ul"OB IlZITARTlIIG AllY 'IIOU.
SPECIAL PROVISYONS
_1.
Street aball not be open cat for underground inatallationa. 1lin1aua cuta .y be alloved
for cannectiona or exploration bol_. Such cute W1Ust be .Decific.llv .DEIroveli bY the
In.Dee1:ar.
pav_ant .Y be cat for underground iutallationa and .un: be natoncS in accordance with
tbe vt1l1qr 'french Ilaatoration standard DnwincJ.
Worlt to be .taIted by a l1een.ecS 1.ancS suneyor or CivU Bnqineer and two (2) copi_ of tb.
cut abeeta aent to tbe Plmlic Work Daptart:allllt befon atartincJ work.
':be boun of worlt an l1a1~ed 1:0 outaicle the boun of 7-' a.a. and 3-. p.a. for any worlt
affect1n; a traffic laDe.
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_3.
_4.
_5.
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S'l'AJIDARD
AMOmft'
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ut!!:YPr MD.
PZRKI'1' APPLICATION n:z ('!lO.OO) $100.00
PLAN CBECJt DZJlOS1'1' $!l00. 00
BOND lOR FAI'l'BI'UL PDPORKAIICZ (lOOt OF IIIG. ZS'1' . )
CASH DEI'OS1'1' (1200.00) (4t OF BOND, $!l00 KIN)
($0 - $100,000 lOt,
. ", $lQO KIN)
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REFUNDABLE DEPOSIT
CHECK REOUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to:
MEEHLEIS MODULAR BUILDINGS, INC.
Address:
Line 1:
ATTN: DAVID STEWART
Line 2:
1303 E. LODI AVE.
City :
LODI
State: ~ Zip: 95240
Description:
Refundable Deoosit
Exact Amount Payable:
$125.00
Account Number:
905.4662
PERMIT NO:
91-100
LOCATION:
155 N. THIRD ST.
DATE AND NO. OF RECEIPT:
1/7/91
2-864-687
PljRPOSE:
RETURNING FAITHFUL PERFORMANCE BOND. ONE YEAR MAINTENANCE
tiUNV - ~3J:).uO. J:{.t;l"UNV VU.t; U1" :;;.L~::>.UU
Requested by:
TED THOENY
Title: SR. CIVIL ENGRDate:
Approved by:
BILL HELMS
Ti tle : ENGR. MGR.
Date:
Verified by:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
04/18/91
TO:
City Clerk
PUBLIC WORKS FILE NO.
V"/-/CJtJ
Please collect & receipt
for the following monies:
35.3396
ACtT . ITEM AMOUNT RECEIPT NO
3521
Other Cash Deposit (specify)
$
/OCJ,tJO ~4-o1 \
..::Joo. t'J tJ .;l~o13
/1JtJ.OO ~ *ol.7-
TOTAL
NAME OF APPLlCANT~~~)-n J-~/3L~ PHONE
ADDRESS /3tJ 3 ~ _ .' _~ 96 -.:< ~O
FOR I RECEIVED BY~' *~\\(;"1
CITY CLERK -,
ONLY DATE \ - Ik.... ~ \
~
3373
3373
3373
3373
3373
3372
3372
3372
3372
3372
3395
3370
3380
3510
($200)
Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
Project Plans & Specifications ($10)
General Conditions, Standard Provisions & Details ($10 or $1/page)
"No Parking" signs ($lIea. or $25/100)
Work Area Traffic Control Handbook ($5)
Copies of Engineering Maps & Plans ($.50/sq.ft.)
Final Parcel Map Filing Fee ($450 + $20 per lot)
Final Tract Map Filing Fee ($500 + $20 per lot)
Lot Line Adjustment Fee/Certificate of Compliance ($400)
Vacation of Public Streets and Easements ($500)
Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
Park Dedication In-lieu Fee per Unit ($4,548)
Storm Drainage Area Fee
Public Works Special Projects
Postage
7ot!),OO
$ t ~- -,
I~) 33</-~?37
ZIP 76 :2..~
CITY OF CAMPBEll
70 NORTH FIRST STREET
C AMP BEL L. C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
May 20, 1991
Mr. David stewart
1303 E. Lodi Ave.
Lodi, CA 95240
SUBJECT: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO.: 91-100
LOCATION: 155 N. THIRD ST.
Dear Mr. stewart
We have made a final inspection of subject Public Works
construction and find it acceptable and in conformance with
City standards. Accordingly, the work is hereby accepted
subject to the one year maintenance requirement indicated
below.
You are responsible for the maintenance, repair and/or
replacement of all work done should any failures occur
within one (1) year of this date.
We will inspect the work in one (1) year and advise you
whether or not maintenance is needed.
We will retain $375.00 as your maintenance bond and refund
the remaining $125.00 under separate cover. Enclosed is
your Faithful Performance Bond.
Please feel free to call me if you have any questions.
Sincerely,
Ted Thoeny
Sr. Civil Engineer
TT/CC
Encl.
cc: suspense - 1 year
f:91-100 (Permits)
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ENCROACHMENT PERKIT ISSUANCE CHECK LIST
City of Campbell
Department of Public Works
~App1icant section complete
Encroachment Permit No.9/-/[J(l
~App1icant signature and date
~Permit Application fee $100.00 ($50.00 for R-1 Homeowner),
paid. Receipt number ,;<'/()/I
~P1an check deposit, $500.00 (waived for R-1 Homeowner),
paid. Receipt number ~~QZ3
~/Five sets of improvement plans submitted
~Bond for faithful performance, 100% of City Engineer's
estimate, (waived for R-1 Homeowner), supplied or paid,_
Amount $ /..!)C'C? C? () Form 1. D. # -.2-Y 0'-1 - 6:. 8 7
_Cash Deposit: 4% of FP bond, $500 min. ($200 for R-1
Homeowner), paid.
Amount $ Receipt No.
~P1an Check & Inspection fee of 10% of F.P. Bond for
amounts of $0 - $100,000; 9% for $100,000 - $500,000;
7% for $500,000 and above; $100 min.
(waived for R-1 Homeowner) paid.
Amount $ /I)(J.CO Receipt No. ';<'-I(]~/
~ Worker's compensation information received for Applicant
(see Information Sheet for Encroachment Permits)
~A11 other Public Works requirements listed in the
Conditions of Approval of the development.
~Worker's comp and Contractor's Information received for
.. Contractor (see Information Sheet for Encroachment Permits)
~Certificate of Insurance with Additional Insured's
Endorsement received from Contractor (see General Summary of
Insurance Requirements for Encroachment Permits)
~Three sets of off-site plans, stamped APPROVED (Tract or
Development and Public Works Permit number and property
address on plans)
_Permit signed for City Engineer
\ffiEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED
Issuer: Initial and date and file with permit
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
f:pmtcklst (Mise forms) 7/90
1.......':--. . .____-__..___...____
l. - -.. - - -- ;;1~~: "9i- - - i4~ 54P -- - tMOO- ;79uis7;'u. - u. ..,u CAMPBELL-G391
____P___.___~___.r--..---.P---~-
il0L2
BOND '0Il1AIT11J'DL. .EUOlUiA:NCE
Bond No. 2-864-687
Premium: $50.00
!'ltOJlct., ~l I
~k\-r '-10.
C\\-\OD
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~~ 1..IJ.. ...:m BY "!'USE PRESENT:
.!
nJAt ....
PriJ1C1.pal. and
i-r.tCol1.orat.cl under thll laQ of the ltat. of
.'old aut:horized to axacute ~cSa and unde~t:a1dn&s as .ole Sure~1. are held
and firmly bound unto the City of C..p~.ll, a municipal corporA~1on of the
Scat& of Califorrd.a, in 1:h. .um
oi ONE THOUSAND FIVE HUNDRED AND NO/100---------------------------------
------------------------------------------Dollars ($1,500.00 )
J
fl;)l: the puyment t:hereof. veil and. ~ly'to be ..de t ..1d Pdnc:1pal and
Surety bind thlD8elve., chet~ administrators. successor. and a..1IUS.
j",intly and severally. f1rmly by chile pr...nt.
DURAN & VENABLES, INC.
THE OHIO CASUALTY INSURANCE COMPANY
.
OHIO
..,
I
:\
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'the conditiDn of dae foreloing oblig,atLon 1.8 such that: \lhare.. the
fahove 'bounden Principal ba8 entered, or i. a~t to onter. into a oart.ln
cuut'ta.ct \lich th. C1ty of CAIIlPbell ~ 8n1:11:1_4
hLCUECT_ ~\~~. (;t l- lOC) \ \~ \-l.
Tl+JJ2-V"~ ~-T: \ l'~ M-P R~ t (!..~.
k truu and correct copY of whi.ch agr.e1lent ill presently on file in tbt
oificu of the City Clerk of the Ci~ pf Campb.ll, which said &I~eement 1j
h~~eby referred to and ..de . part tha~.of.
~ I
JlOV'. 'l.'HEaEFOJX. if tba above 'bounden Principal .han well .anti truly
p....1:'fora the work cont}':'acC:,cl to 1)e pertoraed u.a.d.ar said contract. then thi.s
oullJntion shall b. volcl, otherw18e to reaa11l in full force and .ffect,
No prepaYIHnt or d.ta,. In payment and no chani8., extenS1ou, addition
O~ .lteration af any provision of sald ~ontract or 1n any plana ~
.paelf1caticma referred 1:0 "ra1n, and DO forebearance on the pare ot th~
City Uhall operata to releal' the aurecy froa liability on thi. Bond, anJ
con.aenC: to -.ake such alterad.ona v1thout: f\lrcher notice to or con.eot lIy
the Surety 1.J hereby Jiven. anel the Surety hereby va:l.veli the provid,Qu Ilf
S.:c:t:lon 2819 of the Civil Code of tb, State of California,
i
I
_L_
~ted thll ..z.t.1l- day of JANUARY
. 1991
. -.
DURAN & VENABLES. INC.
. ~
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(~t:tac.h .k:knuw1adS"'uu )
(Uot:b Prb..clpal.'. &lad )
(~ur.~yt. ~ttorn.1 In Fact: )
(PlIlfCIPAL)
17-
."
TFE Q~bO CASUALTY INSURANCE COMPANY
.
(SUUTY)
('
CERTIFIED COpy OF POWER OF ATIORNEY
THE OIDO CASUALTY INSURANCE COMPANY
No. 25-933
~nofu ~ll '(!INen b~ 'mqese 'resents: That THE OHIO CASUALTY INSURANCE COMPANY, in pursuance
of authority granted by Article VI, Se:ction 7 of the By-Laws of said Company, does hereby nominate, constitute and appoint:
HOME OFFICE, HAMILTON, OHIO
Frank E. Weingart or David McGarry or Fran Pitagara - _of San 'Jose. California
its true: and lawful agent and attorney -in-fact, to make, e:xecute, seal and deliver for and on its behalf as surety, and as
its act :md deed my md all BONDS, UNDERTAKINGS, md RECOGNIZANCES, not exceeding in any single instance
THREE MILLION _ _ _ _ _ _ _ - .. - - - - - - - - - - - - - - ($ 3 000 000.00 - J Dollars,
e:XCluamg. nowe:ver, any bond(s) or unde:rtaking{s) guaranteeing the payment of notes and interest thereon · ·
And the e:xecution ~f such bonds or undertakings in pursuance of these presents, shall be as binding upon said Company,
as fully and amply, to all intents md purposes, as if they had been duly executed and acknowle:dged by the regularly
de:cted officers of the: Company at its office in Hamilton, Ohio, in the:ir own prope:r persons.
Th.: authority granted hereunde:r supe:rsedes any previous authority heretofore granted the above named attorney(s)-in-fact.
In WITNESS WHEREOF, the undersigned officer of the said The Ohio Casualty
Insurance Company has hereunto subscribed his name and affIXed the Corporate Seal of th'e
said The Ohio Casualty Insurance Company this 26th day of September 19 89.
~ ~..:P
......-.-...----...-.----..--....--..........
Assistant Secretary
STATE OF OHIO,
COUNTY OF BUTLER
] 5S.
On this 26th day of September A. D. 19 89 before
the subscriber, a Notary Public of the State of Ohio, in and for the County ,of Buder, duly commissioned md qualified, came
John B. Vail, Assistant Secretary of THE OHIO CASUALTY INSURANCE COMPANY, to me personally known to be the
individual and officer described in, and who .:xecuted the preceding instrument, and he acknowledged the exe:cution
of the same, and being by me duly sworn deposeth md saith, that he is the officer of the Compmy aforesaid. .md
that the seal affixed to the preceding instrument is the Corporate Seal of said Company, :md' the said Corporate Seal and his
signature as officer were duly affixe:d and subscribed to the said instrument by the authority and direction of the said
Corporation.
~"'"''''
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\$.~~i.~'!.~~1
711" f'",~",,>>JI'
IIIUI..........
IN TESTIMONY WHEREOF, I have hereunto set my hand :md affixed my Official
Seal at the City ot Hamilton, State of Ohio, t . and year first above written.
.....~
,~ nt of Buder, State ot Ohio
My Commission expires __'" .c.e.rn.b.e.f__Z.5...._1.9..9.L..
This power of attorney is granted under and by authority of Article VI, Section 7 of the By-Laws of the Company, adopted by
its directors on April 2, 1954, extracts from which read:
"ARTICLE VI"
"Section 7. Appointment of Attornev-in-Fact, etc. The chairman of the board. the president, any vice-president, the
secretary or any assistant secretary shall be :md is hereby vested with full power :md authority to appoint attorneys-in-fact
for the purpose of signing the name of the Company as surety to, and to exec1,1te, attach the corporate seal, acknowle:dge
and deliver 1ny and 111 bonds, recognizances, stipulations, undertakings or other instruments of suretyship and policies of
insurance to be given in favor of any individual, firm, corporation, or the official representative thereot, or to any county
or sute, or any otficial board or boards ot county or state, or the United States of America, or to any other political sub-
di vision. "
This instrument is signed and sealed by facsimile as authorized by the following Resolution adopted by the directors of the
Company on May 27, 1970:
"RESOLVED that the signature of any officer of the Company authorized by Article VI Section 7 of the by-laws to appoint
attorneys in fact, the signature of the Secretary or any Assistant Secretary certifying to the correctness of any copy of a
power of attorney and the seal of the Company may be affixed by facsimile to any power of attorney or copy thereot issued
on behalf of the Company. Such signatures and. seal are hereby adopted by the Company as original signatures and seal,
to be valid and binding upon the Company with the same force and effect as though manually affixed."
CERTIFlCA TE
I, the undersigned Assistant Secretary of The Ohio Casualty Insurance Company, do hereby certify that the foregoing power
of 1tCOrney, Article VI Se:ction 7 of the by-laws of the: Company and the above Resolution of its Board of Directors .lre: true:
1nd correct copies and are in full force and dfe:ct on this date. ~ A.D
IN WITNESS WHEREOF, I have hereunto set my hand and the seal of the Company this ,n cia. ~., 199.0
~4?~~~
~-~
CITY OF CAMPBELL
PUBLIC WORKS INSPECTION REPORT
DATE: 5 IdOl c:; I PERMIT/PROJECT NO. :q J-I Do
TRACT NO.
ADDRESS: I~ n, '-rtw1A- 5f.
TYPE OF WORK: STREET:
STORM: ,X
SANITARY:
ELEC:
P.C.C. :
PARKWAY:
OTHER:
o
o FINAL INSPECTION WITH DEFICIENCY LIST
~ FINAL INSPECTION ACCEPTANCE
SIGNED PLANS ? YES
PRELIMINARY INSPECTION WITH DEFICIENCY LIST
NoL
NoL
,
COUNCIL ACTION ?
YES
CHARGES AGAINST DEPOSIT? YES
NO
OVERTIME :
HRS. @ $
PER HOUR = S
EQUIPMENT RENTAL: TYPE:
AMOUNT: $
DATE:
I
I
REASON:
TOTAL CHARGES:$
o ONE YEAR MAINTENANCE WITH DEFICIENCY LIST
o ONE YEAR MAINTENANCE ACCEPTANCE
r
CITY OF CAMPBELL
70 NORTH FIRST STREET
C AMP 8 ELL. C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
May 6, 1992
Meehleis Modular Buildings, Inc.
Attn: David stewart
1303 E. Lodi Avenue
Lodi, CA 95240
SUBJECT: ONE YEAR MAINTENANCE INSPECTION
PROJECT NO.: 91-100 155 N. THIRD STREET
Dear Mr. Stewart:
We have made a one (1) year maintenance inspection of subject
public works improvements and find that no maintenance is required.
Your maintenance requirements and cash deposit of $375.00 &
interest therefore, are hereby released.
~~~
Sal Duckworth-Lanzo
Senior civil Engineer
SDL/bg (wp)
f:91-100
CITY OF CAMPBEll
PUBLIC YORKS ENCROACHMENT PERMIT/PROJECT
INSPECTION REPORT
DATE: 5-5-92
PERMIT/PROJECT NO.: 91-100
TRACT NO.
ADDRESS: 155 N. Third Street
TYPE OF YORK: STREET:
STORM: X SANITARY:
SIGNALS
LIGHTING:
SIGNING:
STRIPING:
IRRIGATION:
PLANTING:
P.C.C.:_____PARKWAY:
OTHER:
PRELIMINARY INSPECTION YITH DEFICIENCY LIST:
(Date)
FINAL INSPECTION AND ACCEPTANCE:
(Date)
SIGNED PLANS?
COUNCIL ACTION?
C E ACTION?
FILE NOC?
YES_____
YES_____
YES_____
YES_____
NO X
NO~
NO ...A.....-
NO X
CHARGES AGAINST DEPOSIT? YES_____
NO_____
OVERTIME:
HRS. @ $
PER HOUR - $
EQUIPMENT RENTAL: TYPE:-
AMOUNT: $
DATE:
REASON:
TOTAL CHARGES:$
ONE YEAR MAINTENANCE YITH DEFICIENCY LIST
---1L- ONE YEAR MAINTENANCE ACCEPTANCE
~lt U~L~.-
INSPECTOR
!)'... '7'- 92
DATE
f:pw insp
9/91
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to:
Meehleis Modular Buildings, Inc.
Address:
Line 1:
Attn: David Stewart
Line 2:
1303 E. Lodi Avenue
City :
Lodi
State: CA Zip: 95240
Description: Ref Deposit/Permit No: 91 -\00 INTEREST EARNED
Exact Amount Payable:
$375.00
Account Number: 001.00.905.4662
001.05.540.4448
LOCATION: 155 N. Third Street
DATE AND NO. OF RECEIPT: 1-4-9
#24073
PURPOSE:
Release of 1 year Maintenance Bond
Requested by:
Approved by:
Verified by:
H. Imokawa 1J.Jt Title: P.W. Inspector
S.Dllckworth-Lan~itle:sr. Enqineer
Date: 5-5-92
Date: 5,1-'11-
Title:
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Ma il as i s
Mail in attached envelope
Return to: Public Works Enqineerinq
(Department)
Sal Duckworth-Lanzo
(Name)
Other:
Rev 11/21/91
-
TEL NO:415-853-7564
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J~N-04- , 91 FR I 16: 02 ID: CRSEY RND COI'1FRN'r'
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ISSUE DAlE MMIDOIYV)
1-4-~1
THIS CERTIFICATE IS ISSUED AS A MATTEA OF INFORMATlm, ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH:S~ERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFohDED BV THE
P BE
CERTIFICATE OF INSURANCE
f'''OI)UCIR
ClaY . cu.1Mr D1I ..~
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INSUIIID
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IOU. C'A t5UI
COMPANIES AFFORDING COVERAGE
RICIIVID
Jr-\N 04 1991
COMPANY A
LETTER I't.f UJ '. ....,
COMF>~NV 8
LETTllFl ~ IMOD
Public W orbl EngineerinG
COMPANY C
LETTER a..1).~ ~ I .01. "_1_
COMPANY 0
LeTTI!R __UO ".be>> n. Q)
COMPANY E
LETTER
: COV.RAGES
THIS IS "TO CERTIFY "THA"T THe POLICIES OF INSURANCE 1..1STeO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P'> CY PERIOD
INDICATED, NOIWITH8TANDING ANY REQUIREMENT. TERM OR CONDITION OF' ANY CONTRACT OR OTHER DOCUMENT WITH FlESPECT r 'JHICH nus
C~~TIFICATI; MAY BE JSSIJJiiD OR MAY PI!:~TAIN, THE INSURANCE AFFOFlDEO BY THI; POLICIES DESCRIBeD HEREIN IS SUBJECT "TO AL_ n1e TERMS,
EKCLUSfONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAve BEEN REDUCEO BY PAID CLAIMS,
co
LTA
POUOY NUMBIFl
TY". OF INSURANCI
A oa""AL L.IA.,LITV
.a. COMMERCI....L GIiNEI'I....L LIABILITY
CLAIMS MAD!! .x OCCUI't
OWNER'S I CONTRAOTOR'S PROT,
IIIZ 104SIIIO
POLICV EFFICTIVi: ~OLICV IXPIAATION
gAU (MM/OOIYY) DAn (MM/OO/YY)
LIMITS
GENERAL AGGI'\IiGATE , 2",.,.
PRODuctS-COMPIOP AGG. ,2:,,*._
PEI'lSONAL 5. ADV, INJURY $ 1 ~OOO,_
EACH OCCI,IRRIiNCE .. 1,,000,100
FIRS DAMAGE (AnV 011& Ii...) $
MID. ExPENSE (kr( - ponon) ..
10-1-10
.1...,1
. 1tIia ~ ilZr f"''lClt T -X,C,U .-''1.- ...4IU_.
AUTotI08ILI LIABILITY COMBINED SINGLE
. X. ANV AUTO 1M IOONW 10-1-10 1O--1-tl LIMit .. 500,000
ALl. OWNEtI AUTOs . BODILY INJURV
.
SOHtlDULED AUTOS (per pef8Ol'l)
HIRED AUTOS BOOIl Y IlllJUAY
,
NON.OWNED AUTOS (P'r .~nl)
GMAOE UAalLlrY
PROPERTY DAMAOE $
bcue &,IAlILITY EACH OCCURI'lENCE ... 000-
:D ... .....-.03 10-1.... 1O--1-t1 ..>lif ,
UMBRELl.A FOAM AGGREGATE , lot_-
. OTHEfI THAN UMIReLLA FORM -.\,..
WORk'I'" COM'INtUION STATUTORY LIMITS
EACH AOOIClENT $ l...ooo,DOO
C AND 11: II07Nt
10-1.... 10-1-91 DISEASE-POLICY LIMIT · 1..*,000
IM"1.0YIA,' LIA"LITY
OISEASE-EACH EMPLOYEE I ~ ?
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OTHER
DEJI~'TION 01' OPERATIONIILOCATIONaNIHICl.IIISPECIAL ITEIIS
... ~l1zwIti~ MI~~ta,. tw..ter, r~~l' tad.CIl .....01 Di-tle'fot
CANCELlA TION
SHOULD ANY OF THE ABOVe DESCRIBED POl..ICIES BE CANCELLEt "iFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL E'CEAVOR TO
MAIL>>- DAYS WRITTEN NOTICE TO THE eE~TIFICATE HOLDEFlI\AHED TO THE
LEFT, BUT FAILURE TO MAIl. eM NOTICE SHAI.L IMPOSE NO OtlU 3ATION OR
LIABILITY OF ANY KIND UPON T COMPANY, ITS AGENTS OR RcPFI':S,NTATIVES.
1. AUTHOAIZED AEf'RE8t:NTATIVI!.....
~ -1 .. YOr- ~ J , - ~ ,-.., l:- ~ ;' ()\.,__~ /
ACORD 25.8 (7/10) c; ~,Atf'~ .~ ._~_" /". ..- ~ ~ CACORD CORPORATION 1110.
CERTIFICATE HOLblR
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JRN-04-' '31 FR I 15: 03 ID: CRSEY RND COr1PRN"
TEL NO:415-853-7554
1:;573 pr1~
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POLICY NUMBER: MZX 80458280
COMMERCIAL GENERAL ll/,8'L1TY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Nlme of Person or Orlanlz.tlon~
The City of Canpbell arXl its respect.ive officers, agents and enployees are
named as add! tional insured, solely as respects operations of the Narred Insure'",
for or on behalf of the CaIrptell Union School District on the installation prc: "'ect
of an Inst.n1Ctional Materials center for the Districg.
(If no entry appears above, information required to complete this endorsement will be shown in the DeclarE ions
liS applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown the
Schedule, but only with r.spect to liability arising out of "your work" for that Insured by or for you.
It is further agreed that such insurance as is afforded by this poltey fo"
the benefit of the above additional lnsured(s) shall be primary insurance cS
.. respects any claim. loss or liabi Ii ty arising out of the named insured
operations. and any other insurance maintained by the additional insured(s
shall be excess and non-contributory with the insurance provided hereunder.
CG 20 10 11 85
Copyright. lns.urilnce ~ervices Office, Inc.. 1984
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