91-115
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.. 1
ern OF CAKPBELL
DEPT. OF PUBLIC WORXS
70 North First st.
ca.pbell. CA 95008
(408) 866-Z150
ENCROACHMENT PERMl:T
(for workinq in the
publ1c riCJbt-of-v.y)
I..ued 02/; L/ Jr-} I
Parait upiru in 12 110..
Permit Ho. 9/- / / :.':J'
X-Ref. fU. 9'0 -c:( ~3
,,) / - / .
Application Date~/ t/ 9/
Appl1cation upiru in 6 110..
APPLICATXDN - Application 18 hereby _de for a Public Workll Permit in .ccordance with CUapbell
Municipal COde, Section 11.04. (Appl1cation expiru in 6 IIOntha if perJIit not pulled)
A.
Work adc!rea. or tract, I b 50 .- 17 6 0 gAS C O,v\ A V c:
Utility trench location N.vJ. (.thJft..f-- ~ -Sn~ ~ '7,(...Wt1) ~~
.atura of work: vPr-/f'J6,,"'( vi v '7r1>iZ-V"'\ I.- C-P~ OJ?- f/J'I;'"5cc.- .,. ~\ L.-1l>10 .
(..j)N~ vi (r "i7~w~ (!.. f:.-o0vvf\t;'( pc:.JWv~. '
Attach five (5) doPi- of a drawinq .howinq the location, extent and diJaen.ione of the work
The drawinq ahall &how the relation of the proposed work to exi.tinq .urface and underqround
iapraveaenta. When .pproved by the city Enqineer, .aid dr.win; beCOllU . part of th1a permit.
~e General Conditione for .11 penaita are li.ted on the reverse .ide. Special Proviaione for
this penait are li.ted below. F.ilure to abide by the.e conditione .nd prov18ion. uy re.ult
in job &hut-down and/or forfeiture of F.ithful Performance Bonds and ca.h depo.ita. (See
General Cendi tiona 1 and 2).
B.
c.
D.
J:. An .pplication t_ IlU8t .cccmpany th18 .pplication. Th18 18
.... of Appl1cant W A I.-~ H- g 1-.1::>1,>-\. ~ I') N f12-A-L-- ~
Add.ru. 22 N AI.-MAht?J I't"'e. ~~ J"~~> C-A
non-refundable.
Telephone: qq f3 - 5 bO 0
~~I \0
Ia this work be1nCJ done by the property owner at their own reaidence? ~_ ~o
CCIIIlplete and .ttach Workara' COapen8.tion and COntractor Information fOJ:1l8.
The Appl1cant/Penait~ hereby .qre_ by affixinq their aiqn.ture to this-permit to hold the City
of
campbell. ita ofticers. .qenta and employee. tree, ..te and h.nale.. t~ any claim or d.-nd tor
~q_ reault1n; troll the work covered by this permit.
The Applicant/Permittee hereby acknovledqe. that they h.ve re.d and understand both the front and
back of thia permit. and that they will inform their contractor(.) ot the information.
ACCEPTED >\Dt:/ L.-kf~\D~ ~ (~ '1-'hl'1,
Applicant (Permitt_) pri I.iqn Date I ( .
NOTES: ALL MOB SIIALL CONFORM WI'l'B '1'BE A'1"1'ACHED, APPROVED PIAHS ABD ALL APPLICABLE CAllPBELL
STANDARD DRAWIHC:S ABD CONDrnDHS.
'1'BE CONTRAC'l'OR MUST HAVE TRIS PERMIT ABD APPROVED PLUS ABD MUST IIEET WI'l'B THE P.W. INSPECTOR ON
'1'BE SITE AT LEAST '1'IfO laYS BEFORE STARTINC: WOlUt. R E eEl V 15 D
NOTICE MUST D C:IVEN TO PUBLXC MORD AT LEAST 24 HOURS DFOU RESTARTINC: ANY WOIUt.
FE8 0 F; IJjJ
SPECIAL PRDVISl:DHS
_1. Street ahall not be open cut for underqround inatall.tion.. Minimwa cu&uWif "'om~noorin~
for connectiona or exploration hol_. Such cuta lIII1at be BaecHlcaHv armrcved bv the
In.".~ar.
_2. P.vement uy be cut for underqround inatall.tione and IlUBt be rutored in accordance with
the util1q. Trench Raatoration standard Drawing.
_3. Work to be ataked by . liceneed Land surveyor or Civil Enqineer and two (Z) copi_ of the
cut &heeta aent to the Public Work Deptartment before .tartinq work.
_4. ~e hours of work are lblited to wtaide the hours of 7-9 .... and 3-6 p... for any work
.ffectinq . traffic lane.
_5.
(.-1 ,
S'l'AHDARD
AMDtJRT
/~.":l. tJ /)
D~YP!' MO.
;?53i/"/
dS :.~t;. :.J- ,
. "f"lA>A'/;'
Ud1Jtr 1 __ ,:.' ,,- ; I L'
/-3/ L ;/:;,:,y / /
($!l0.00)
$100.00
$!l00.00
(lOOt OF ac:. EST.)
(4t OF BOND, $!SOO KIN)
PERMIT APPLICATION FEE
PLUI CHECK DEPOSIT
IlDHD FOR FAI'l'BFOL PERFORMANCE
CASH DEPOSIT ($ZOO.OO)
$ _-50 cJ ,o() () S~:5-t'-;
2-/1;//1"/
Date
PLUI CHECK , INSPECTION FEZ ($0 - $100,000 lOt'
$100,000 - $!Soo.ooo .t, $!l ,000 an aboVe ,t, $100 KIN)
APPROVED FOR ISSUANCE O-z:: I
tor City
(SEE amER SIIE)
E-i
H
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....:I
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ENCROACHMENT PERMIT ISSUANCE CHECK LIST
Ci ty of Campbell
Department of Public Works
~Applicant section complete
o
Encroachment Permit No.7/-/I~
X - .Atf-. ~tJ -c';i L/ <-~
~Applicant signature and date
~Permit Application fee $100.00 ($50.00 for R-1 Homeowner),
paid. Receipt number 0<~53 Ct, I
/,- //P1an check deposit, $50Q.O~ (waived for R-1 Homeowner),
/ paid. Receipt number JSd l. ."2-
~ ~Five sets of improvement plans submitted
--1------------------------------------------------------------------------
I
~-----Bond for faithful performance, 100% of City Engineer's
estimate, (waived for R-l.... Homepwner), SUPP1.ied, or p-=~ci:
Amount $ FormtfH/D-C( I.D..# hi; ,(.:).",,/'-/
,{,z <'(,.!Lc':;hL';J. Ci~
_____Cash Deposit: 4% of FP bond,! $500 min. ($200 for R-l
Homeowner), paid.
Amount $ Receipt No.
~Plan 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 $ ~,"C),;;--{). Receipt No. ,;)(.;5 9 I
~Worker's compensation information received for Applicant
(see Information Sheet for Encroachment Permits)
/
_____All 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
WHEN 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 (Misc forms) 7/90
TO:
City Clerk
1/- I/.J-
PUBLIC WORKS FILE NO.
35-3396
ACCT ITEM AMOUNT RECEIPT NO
Please collect & receipt
for the following monies:
. -.---.,
(3372.. )
i/3521)
3521
3521
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,000 9%; $500,000 and above 7%; $100 min.)
Project Plans & Specifications ($10)
General Conditions, Standard Provisions & Details ($10 or $1/page)
"No Parking" signs ($1/ea. 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 Drai rage Area Fee
Public Works Special Projects
Postage
$
/ (.If? (Ji) ,25.3~,/
..:5 (!i().. 00 ~.c:'::3 ;;..
R.1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min,)
v
Other Cash Deposit (specify)
($200)
3372
3373
3373
3373
3373
3373
3372
3372
3372
3372
3372
3395
3370
3380
3510
TOTAL
.fl z
'"", / '-. (L fZ!:- 'tee L
, '.1..
,
\ L
' ..,,..
.Lkl' IL-' A,/.
$ 0(!{l, (nO
c<55 - Y.-RE._ Ii;;;. il .. E. U
ZI P tf~~---z; ,/ <I .- ,-., . 'I . ,~ ^ .
I t.L l- !J,:il
NAME OF APPLICANT ~--l--1L.U'l-
ADDRESS ;J...{;. 7 ,:/.. 5' ~l/I{ll et L
FOR
CITY CLERK
ONLY
PHONE
/7/7" ~..
_'1- L. <: cL U/-lC
RECEIVED BY ,__, __ h~ C\Q L
DATE 2-1111 (11 ~k .t~. Z' ,>h~ I . Z~'.J3(J~l
CITY CLERK'S OFFICE
TO:
City Clerk
PUBLIC WORKS FILE NO.
q /~//s-
Please collect & receipt
for the following monies:
35-3396
ACCT ITEM AMOUNT RECEIPT NO
$
NAME OF APPLICANT
ADDRESS ." ;;2..-)7 .
FOR
CITY CLERK
ONLY
3372
3521
3521
3521
372'
3373
3373
3373
3373
3373
3372
3372
3372
3372
3372
3395
3370
3380
3510
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
R-1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4 % of FPB)
($500 min.)
Other Cash Deposit (specify)
($200)
Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,000 9%; $500,000 and above 7%; $100 min.)
Project Plans & Specifications ($10)
General Conditions, Standard Provisions & Details ($10 or $1/page)
"No Parking" signs ($1Iea. 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
7
TOTAL
~(. U ('d(l~ 1 (J ~ct
&t L( . ,.(/1'
$ ~~C', (", ()
eye; j/ - ~5"-? C ('
ZIP y.~//(
PHONE
~!-.-.
RECEIVED BY ~
DATE ~/15"/9/
.. :~.
REFUNDABLE DEPOSIT
CHECK REQUEST
t-' ,
, ..' " ~- j
...L"
"~~~
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
t',
'II
~
,~ ;
Please issue check payable to:
Hunter Properties
\.':
.'~
Address:
Line 1: 20725 Valley Green Drive
Line 2:
City: Cupertino
. State: CA Zip: 95014
Description: Ref Deposit/Permit No:
Exact Amount Payable: $500.0'0
Account Number: 001.00.905.4662
91-115
INTEREST EARNED
001.05.540.4448
LOCATION:
1650/1780 Bascom Avenue
DATE AND NO. OF RECEIPT: 2-11-91 / 25362
PURPOSE:
Plan Check Deposit
Requested by:
Approved by:
Verified by:
~
M1ke Fuller
Michelle QUin~
Titl.: Asst.Engr. Date; ~.
Ti tl e: Acting City Engr. Date:
Title:
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Ma i1 as i s
Return to:
~tI~tIG wau/C<:>
Department)
Mail in attached envelope
'uIU rVC, L~f2..
(Name)
Other:
Rev 11/21/91
LuIIp S_ t.tiaaU - $
/'1 LF@ $ 4.00 - $
?.;-- SF @ 3.00 - ,
LF@ 5.00 - ,
EA@ 600.00 $
LF@ 14.00 - $
,;LS-- SF@ 4.00 - $
SF @ 5.50 - $
IAt 400 . 00 - $
LF@ '.50 - ,
LF@ 50.00 - $
SF)x($0.10)x,-.) - $
SF)x($0.30)xc--'-.) - $
CITY OF CAMPBELL, CITY ENCINEER'S CONSTRUCTION COST ESTlKATE
,'/I-I~/LTZ/~/
Addre.. ,::.~>! ::. .
Surf.e. Con.~ru~~ion
Claar1na & Crubb1na
Savcut Cone rate
Concrete ae.oval
Curb & Cutter ae.oval
Inlot Draln v1th '1pe
Curb & Cutter
S1devalJr.
Dr1veway Approach
Hand1cap "-p
btruded Curb
larrlcacla
Str.et bcavat10n
AC Pava.ant
Adjust Kanhola to Cracla
IA@ 375.00
IA@ 275.00
IA@ 600.00
lA' 300.00
LF@ 0.65
IA@ 40.00
IA@ 120.00
IA@ 15.00
LF@ 10.00
Adjust IIandhola to Crade
Mon_nt lox "/Kon-.nt
Straet Tr.e (15-..110n)
Pev_nt Strip11l1 ($100 ain)
'eva..nt Lalrnda ($100 aln)
Stop, Street Wase or Other SlID
'ave.ent Karkar.
'ava.ent Kay Cut
Surfaca Subtotal
.5.
Adjuat for 81sa: .5"<$30,000 a44 20\. .5.>$100,000 aubtract 10' (+ or -) $
6C)( ::-'0
Str..r: U.ht.in.
&lectrol1ar
lA' 2.000.00
1.1' t 10.00
Ccn*l t
Conductor. palr
1.1"
I.a@
2.00
200.00
Pull lox
1~l!Irw bratty..
...,
.10 LF@ 60.00
1.1" 70.00
lA' 1.600.00
IA@ 2,400.00
/ IA@ 650.00
12- or 15. ac.
U. or 21. at.
Streat Inlat
llaahola
.raak . Inter Manhola
7' - I'l ,1,-" -) .'
,L_AC- ('_' .-:?... c. ~ C'C'
..--;-. S/J /'C> C-7)
/"'" ,..e--c. _J C./ . v
'enit .0.9/-I/J-
byU *'- clate~I/~/? I
-Z c'c:t.\ on
.5b,(j()
It? S; c7'b
It/v
- $
- $
- ,
- $
- $
- $
- $
- $
- $
- $
- $
- $
~3c) I, 00
- $
- ,
- $
- $
- $
_ .. / %60oD
. ,I
,
- .
- .
. ;;.,. ~().. ,-yO
- $
'I'OTAL IS1'lMTE
US! POI. IOlI1l
$ ~3/ 0 /I. 7-- ()
.
. ~3 oDe, .00
rrria.d 6/IB
f/coll-co.t-e.t
UNITED PACIFIC INSUR.ANCE COMPANY
HOME OFFICE, TACOMA, WASHINGTON
SUBDIVISION BOND
Bond No. B 1685514
Walsh Building Contractors
KNOW ALL MEN BY THESE PRESENTS, that we
as Principal, and UNITED PACIFIC INSURANCE COMPANY of Tacoma, Washington, a Washington Corporation,
authorized to do business in the State of Washington_
, as Surety, are held and firmly bound unto
City of Campbe 11
One Hundred Forty Five Thousand Eight Hundred and 00/00
as Obligee, in the penal sum of
($ 145,800
DOLLARS, lawful money of the United States of America, for the payment of which well and truly to be made, we
bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by
these presents.
WHEREAS,
WALSH BUILDING CONTRACTORS
NO. 204
ATTORNEY-IN-FACT ACKNOWLEDGMENT~_ M ---
_ _ _'..~ .~.~_ _~._ - ,~~~: ':,-.:.=2-=:",~'::,':~~~:,~,~,:'?'~?2-?~~~~~??':;<?22~~.a~.:2:'-~..: ~=
State>of CALIFORNIA 1 Onthisthe 1st day of October
before me, the undersigned Notary Public, personally appeared
(;nllnt/nf Santa Clara 55. II~"~__ 1 n____.L'__
CORPOF,lATE ACKNOWLEDGMENT ~_- :.:;;;c,-~.; :-; C;-;;;-.
: .,:c-::: / -=.;:: .-=.:: 2:::::'=-:"~ ::= --;;;.;C:::=::222<<??:?~'-=-~~~~~~'N~-V';'-C' - ,.. -
On this the --lst- day of October 1990, before me,
State of
(AI TFnRNT A
}ss
County of
Santa Clara
~~
.N;{9G'(9CGCGCGCGCGCGCGCGCG~ i;
;,\ ..4" " OFFICIAL SEAL ~
~ /;:~ ANNA MAR1E SWEETEN ~
2 J,;,V:;-P?L NOTARY PUllLlC. CI\,-ifC;RNIA ~
2 '.<;.'~~ SANT A CLi\RA COUNTY 2
2 My Commission Expiros Aug., 9,.19~3, '"
" " "'<lG}:l(,).:iu);:l(,Nu>:i(,,.;j~,,)o:/~(''Xi(i);:l,,~
"'~~"""
19
90
NO. 202
Anna Marie Sweeten
the undersigned Notary Public, personally appeared
Michael M. Walsh
IXI personally known to me
o proved to me on the basis of satisfactory evidence
to be the person(s) who executed the within instrument as
Vice President or on behalf of the corporation therein
named, and acknowledged to me that the corporation executed it.
r;:::an)k::~~
Notary's Signature
ATTENTION NOTARY: Although the information requested below is OPTIONAL. it could prevent fraudulent attachment of this certificate to another document.
Title or Type of Document
THIS CERTlRCATE
MUST BE ATIACHED
TO THE DOCUMENT
DESCRIBED AT RIGHT:
Date of Document
Number of Pages
Signer(s) Other Than Named Above
-~._~~ .- --- ---.--_.--.-_.-- - --,--
_ :Y .'~ _~ _.: _:~ "'~ "~_ "".: - T :".:. . - ~~ "
@ NATIONAL NOTARY ASSOCIATlON.8236 Remmel Ave,. PO. Box 7184. Canoga f'at1<, CA 91304.7184
UNITED PACIFIC INSURANCE COMPANY
HUD O"IC!. FEDEAA!. WAY. WAlHINGTON
POWER OF ATTORNEY
KNCW A&..L MEN IV n.UI ~UENTS. "., lhe UNITED 'ACIFIC 'H'U"ANCI COM,ANV, . CIOtJlOl'ttlaa duly orll"l_ ..-, ,,. ..... Of the
ltat. 0' W....."itOfl. do. hereO., INIM. oon<<m..tt MClIllOOI'"
WILLIAM J. PRENiICE of SANTA CLARA. CALIFORNIA ----.-.
ItIlNlt Ind I.~ul AttotNy-jn.Ftc1.10 rrIIk., .utu"...1 2/loi "tiiv., fOlIl't on iU blnaf,...... itllllt -..
ANY AND ALL BONDS AND UN~ERTAKINGS OF SURETYSHIP --------
end 10 bend IN UNITED 'ACIFIC INSUAANC! COMPANY Itle~., II ~,,"y Iftd to 1M .mI .~lf'It .. If audl bol'ldllnd undIrtllcl"9Ulld Olhe, MI,,1I9'
Clbli~,ory .ft Ih. /laIY,. I'-rtol wert Illned by'" htQ,llllle Ofh,*, 0' 1M UNITEO PACIFiC INSUll'ANCE COMPANY ,nd Maltd .nd ..unled ts" one
other ollYetl othC8rI. Ind "'r~y reti'itt Ind COl'llirnu ,II '11I1111 MId Attornevhi-i,,-FtcIINV dO in "",sloIAn~ herlof.
nlla Po_I ~, Auorne" ia erlnled ul'der .nd ITf 'uthorll" of Atticle VII o. 1M 8y,uWI of UNITED 'ACIF Ie INSUAANCc COMPANY whICh
DIca/N .ffecll", St:)t,tl"iwr 7, t978, wnlcnprOV.tlOnl In no"" ,ft lull 'orCII .nd .If"" rl8d"~ II 10110.....
AATICL! VII - '!'I(ECUTIOH OF aCNOS ANO UNDEATAICINGS
:...'3--
t. T~ 100IO of Olrmon. the PfnlcM"l. 1119 Chalf";;" of the Board, .ftV Seftlor ViOl Ilr"idlnt. Iny ",ce 'res;dtnl 01 A"ill'"' ""Cl Prllldel'lt
0/1 ~thff olhcer dfllin".o 1)'11 IN Iotro 01 CirfCtort 1....11 hlv. power ..,d luthorlty to 111._inl Atlorneys,"\.Ftet Ind to III,IloriZllllem 10 ..lCutt
on tleNlIf 01 Ih. C.::lm.-"y, bo"cn .nd undert,ki"i" rtCOQ"lunCft. COn"lC'tI 01 InClmnity .no otl'ltr _lIlftg. OI;Iliplor"( ift thl I\Itlolr' lherlOf, Iftd lbl
10 '''''0''' Iny 'ueft AttorneY'ln-F.ct .t .ny IUN .rtd 'wok, III. ~r .n~ lW:hot!tV V1v.t to hiM.
2, Anornev..;n.;rlct .nail N'4 POlNt!' Irtd luthorltY. wblK'! 10 the terrN IftCIllmitltlon' of 1M IlIOwe, gf IttorlWy itAUlId 10 fNrft, 10 UHUI.
and d.llvlr 0" beh,lf of tl1. c"l'I'lC)Iny, bondt .nd Undtrt.kll\9l, r~I'lIU"I;ft, ="IrN!I.)f Indemnlly Ind ot"", writl",1 ~Iilllto'y In th. nillur. th.r.ol.
Th. eorlllOral. IUI " /l01 MCnlat'f lor 1111 Vlht:ltly of a"" boftdllfld ~na.rtlki"",. rKCi"ll4InClll, cafttr.c:u of indemnity Inca otnet wt,tin,1 oO/;91tor'll
I" Ih, n.IUr. lher.of.
~. AlI"r r'l.y,.,n.FJet ,,..11 II.Iw ~_r .I'd tut"Oflty :0 ..ICut, .ffldlviU rtcl~,'td 10 be .ltaCfled to P)Ol'l(ll. t~"lzanctl, contt.c:t1 of ,naem.
nllY or 01"", ~l'IdIIlO,,-1 0' c01iiltorv ulld,rtlili"il ."d tll.., INII ,110 ;Witt ;la_t WId '~noti'v to C111"t"y !~ fio"ltllciAl Itlltf'/\tr'll 01 tl'll Compenv .nd
Ie caDI" of 1M ."UM 011119 e""......t1V Of ,,,y Irtlell or )fCt.on 11\1I1Of.
TIllS gowlr 01 'ttorney 11 liVntd .nd IIIled by lacslmlll ul'ldtr 'l'Id b" autll",.ly of I'" lollowln; Rllolutlon Idoptltd b., t!'lie loard .,1 O""to..l of
UNITED 'ACI"C :~SUrlANCE COMPANY .t. tnIItl~ II.ld Qft 1M 3tl'l ~V of Jul'll, 197~. .tl'ofticll' ~l.lOfu," WlI Ql'lSiH'lt, Inca wid R'lQh,ilI0ft II" not
o..n .amended 01 r.",_IId:
"Reaolved, that tl'll si;natur'" of $ud\ dirlCtcrs Ind otficl" end It'I. ...1 of Itll ~m~n., "..., be lI'ind 10 Iny luch ~Mr of
IItOrn.., or a"., CIIrtaflot. r''-\ln; th."to by l,cslm,le. .nd ,ny IU~ llO....' 01 ,tlO'"'Y or eertlfiColle be' II I'll Iyel\ ,aQII"II'"
S.~n4I\o1"I or ,.01.....11. ..., I~ll ;. v,lId ,nd l:lltld'"'I UllO'" Ine c.,m101l"Y '"d '"'1' Iwen pC......, 10 ,nC::..I.d and ClIIII,1fd by
I.cs,mll. IIINt...... .nd f.C1lrnll. 11I1 shall 0. ....lie: a"d br"~I~ \oIl:On Ill, ~fT'\9IlIIlY I" Ihe ,...Iur, ,I/.th ,~ct 10 Iny bond 0'
\n~trtllu~ to """'ICl'Ilt .1 In.ctttd."
IN WITNESS NHe~gOF.lll. UNITEp I'ACIFIC lN$UfU.NC; COMPANY "-a CII",M(j III!M p""""U 10 be :1;Nd llV its "iet Plald,nl..nd its carport"
..,, 10 tlIlv!relo ,ff,ua. tlli. 2", t h ~"of 1'\ U g U s t , t l:S 7
~:;Z;Z""'
Viol ,....idto'lt
ST A Ti 0' Was h i n 9 ton
COUNTY 0' K 1 n g
0" mlt 2 4 t h day of
}-.
August
, 158 7 , i'll'Ionllly IClPl,rtd
Lawrence W. Carlstrom
to I"I'\e kf'lO"'''' to \)I I"" VI~~,..id.t1t ~f tll. I.INITiC "ACIPIC I....SUlllANCi COMPANV. Ind xkno",,:tdged ~hlt h. .uc:~tJd ,nd IUtatld lh, lor..
~I", l"struIMI'If .nd .'fi..1d t1\1 ..I of .id corl)onUon V"fltO, 'M t1'l1t Artlell VII, s.c:IlOn '.2. _ 3 0/ In. ""~JWa of Slid Comoany, and Ill.
'blOtlltlon, ., fOrlh tM,in, It, "11111'1 lull foret, .,' ~~ 7f
...---,.... & 6t
My Cotl'.,"..on Expa,..: '(/IIl:AI~ . ~"- " -
.... I
May 15 . HI 9 0 \~:!:~ Notary ''''11; il'lltld lor Ita.. 0 Was h ~ ton
A...a,"9 .t T a com a
I, J 0 h n E. Van eel "'111mi'll SoIctr.ar" of llW UNITE;:) PACIFIC INSUAANce eOMP"NY, 00 "'1'"''' CIIr,lf" thlt U\II
.oolle and 'o,~,~ II . trlHllnd CCl'rlCt =~ 01 . Jlo-, ot At~Cl("-'i U1C\lttd by .id UNITED !lACI' I': INSURANC! ~CMP "NY. oMIl.:t1IIIlI11,1'I 'ylI
fort:e 'nd ,fitct.
IN WI1N!$$ W~!REOF. ll'lalw"re\,lnto Mt my hind and ./fixlld tM _I 0' uid CorniM"y~.. 1 st 0.'1' 01 October' 11 90
.- ()
.D.. '''''d. .'SO .............."'" ~ t.. th ~lj
ohn E. V4nce
SEP-27-90 T~U 16:52 WALS~ BUILDING
-[]
JARDINE INSURANCE 8ROKERS
1ez N. 3RD ST. SUITE 800
SAN JOSE, CA. 15"2
1l14/iO
I A IS' UE AS A MA T R 0 INfORMATION OMY'
AND CONFERS NO RIQHTS UPON THE CERTIFICATE HOlOER, THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVEIUO!
AFFORDED IV THI! POLICIES BEl.OW.
.., ---- -..........
aMtANIES AFFORDING COVERAGES
..~.08"UJ~'9qq,
tH5UR!O
'...~ ...., .'.' '" ~.--_... ....-- -,.-------
COMPANY A ..._~_._._..._._., - ....'
~ETT~~__, I REM~$ fU~D INS 1... ~~.__. ~.. .._...._. .
COMPANY 8 .
~ETTER.~iPU8L.1 C_J ~SURANC~~.C911.~.AN.'i _., ".-.. -. .. ..
COMPANY C
LUTU
COMPAM' 0
lETTER
tOMPAM' E
LUTER
---- --,_... ..""
WALSH CONSTRUCTION INe
22. N. ALMADEN AVE
SAN JOSE
CA 81"0
o I A L W VEl I ED 0 H INSURE NAM AlOVi FOR TIoIi
POLICY PfRIOD INDICA TED, NOTWlTHSTANOINC3 ANV REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER
DOcUM[NT WITH RUPECT TO WJo4ICH THIS CERTIFICA TE Mol V 8E ISSUED OR MA Y PERTAIN. THE INSURANCE AF'ORCED Ill' THE
...PO.l!.CJ~~ ,!-lE~~F!1..8!Q.B!~.!lli.J~SU8JECT. TO ALL IH' TERMS, E)(~!:.U.SION$ ~ND CONOI!19.~S OF SUCH !o.~.I.9J!!.._.. .' .
'OI.ICY lflECllV( 'OllCY l)('I~ TIOt!
IlA IE MlVOflM1 DA 11 ~OlllYVl
All liMITS IN THOUSANDS
~T~ TVP~ 01 INSUAAt\CE POLICV Nl;MSER
. effNERAi." i.1A8lllfy"'--' ... ..... ...-._-_.~._,_.~.,
A . 'lco.M~Cl~L OftiEML U.elLllV
..... .]el~Ih1S wOf [~oetU~INC( MXX80431517
~ (;lIlktA'S" COHlMcrcu '~OIlCIIVf
.... .. .....<11... ro. "... .-.-.--.
. . AU10'MOiILtu'Aiit"fv"'-~" -..-...-.-'"-
-- Am AUTO
AU. OWNED AUTOS
. SCHfOOlED AUTOS
HlllfO AUTOS
'. NON.OWNED AUTOS
OARAG€ lIABILITV
.,.......~_...
4130/10
4/30111
, ...._..~"~...,...,,._..:.:,_.~...L ...__".J.".__.
Excns LIUILlTY
'~10!~~A_.:H.~~ _U~~.L~~ .~ORM
WORKER"
COMP~NSA TION
AND
EMPLOVERS' lIA8Il.ITY
.8.. ttiEi\"'-' ~-"-"p_-''''''''
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.........---..
_"'4 ._...--.""
...~...-....
44i'
~Q.5/90
~/051'.L
bEseiiiHION 'o(o'fERA'fibfi'-, L'OCAYiONS'j VEHICLES (RESTRICTIONS' SI>ECIAL rUMS . w._....
E: HAMILTON PLAZA, OFF-SITES lOCATED AT 1810-1780 BASCOM AVE.
~"'-'----'"'' -- .....
CI TV OF CAMP6!L!.
70 N, ,ST ST.
CAMP8ELL. CA. I~OO.
SEP-27-90 THU
l6:52 WALSH BUILDING
-:-
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-'.. .,;., ....:_..!:~=:
i.tXXS0431517 ~.
::~.~~.~~::::.:. ~~~.~:=,:.~ ..:,:.=:~.-:-.,
_. . I <: ." I ~ C ~ c: - . . .. " I.... C' ' · "I G ,. - -...... ? C I t C'I ? I .. . S - :;::' . 0 r'" c · ~ .. - U L' '(
, :~ ... :..,:..; K .. :. . , , :. :, I l~ ,.. I , r.:1 1M::' .. I " .. :. ," ::.' . -,.., · ,... . . :. r _.
ADDITIONAL INSURED - O'NNERS, LESSEES OR
CONTRACTORS (FORiv' B) .'
T~IS ~,"'C':l"s.~e~: ~cClfjes :M..:,;'l"':':f ::':"'"::~-: \Jnce~ :l"Il! toilCWIf",G:
-:: .',1 ~.l:: ?C;;' i. ~ ~ ~~ c:::: ;.:_ r~!.:.;; IL 17Y CO V :;~;.a ~ ~;.~,..
SCHEOULE
Name o~ p!rson or OrJlni:lcion:
THE CITY OF CAMPBELL & ITS RESPECiIVE OFFICERS
AGENTS AND EMPLOYEES
70 N. 1st. St.
Campbell. CA. 95008
RE: HAMILTON PLAZA, OFF-SIrES
LOCATED AT 1650-1780 Basc::r~
Ave.
(It no ~,,::'/ ;J;::-=J~~ .'::C:'/t. iC"l!::~c1\lcn re~~::'e.; to c:n'uit>~~ :l"Il.. ~'\~('l(somCnl will C~ shown in the Dt.:c!.:r~~ ::".:
:'! ~:::lIc::~Il!t ~o t~IS .;:~cJCflar.-:en:.)
\'::_;:' 1$ ,;..'~ 1~~SIJ!=l:.':J (St'=::CI". ill is ame~cec :0 ::",:~:I,,:ce as In insu~ec tr\e ;:ic:~son 0" crial"\iz~tICr', Sl'Icwn ':". :,-.",
5C~,~-:,:'..I'l!. :;:.:t :)nly wltn res;:i':: :0 !iaoillty ..rlslng out at "'feur ""'0(\4," ior t.h3r inSurQt"\ by or for 'leu.
Slch insurance as is afforded by the General Liabiiity policy ;s primary insuranc!
ind no other ;nsuranci of the additional insured will be called upon to contribute
;0 a 1ess.
.... . - ..
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SEP-27-912l THU
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16:5~ WALSH BUILDINC
P.12l4
CalifornIa Steste Automobile . .~soclati()1\
l!'ller-Insurance Bureau
Automobile Policy Declarations
PLEASE KEEP WITH YOUR POLICY.
SEE IMPORTANr NonCE ON REVERSE.
1S0 Vln NUl Avltnue
P.O, BOx le~O
S.n Frllf'lcisl;O, CA 94101-,egO
~ O~:~~~~l~.~~~.~;"~'" o,.J" i I P"i.
~: ~~':;i~~;,c.r.~'~'!~~J..~J..d.Oi~~'!" . ,.. '. .
c: Member '2.-18-89 -..,..-
~ ~.o~;y Nvme.; ---... ... ... . - -"- -- --- ..-.. -. ..' ,-
~ M2-S3-14-3
__...0.._ a__~......., .,,___.........a_.......a ...--..-"
> '(OUR IFICl::'i l To
3 ~~~lg6 L~1..-:-.~.~.~gQ_. ._!.1.:~~_~_~.1...._ .......
o \2:01 A.M. Sur,dll(l Tir.'.. II trl. .<ldrtU
c.. of l~. N',lI,(l ItlS\JIU It 'T.t.~ ....r.:n.
....,., "'~. .. "~' \....--,. .', .~-'..'-''''"" ,....,--,. ,-~_.".. ..., ,. ..-.~_.,.....""'''' .... _....~.._...II._-_.'.......-- ,..._ ....... ".,.....-...
AlUln.Jl. ,Mer,,, I oe~'''l:itlc'' I AI( .rnal. JII'lmol: l hl'~~,OI1' lI:..,mOI(
WALSH CONSTRUCTION CIV lNG/OFFIC 998-5000 984-25$7
,,'., .-, . ... " ,',."~ '.,.-..... ..........". .....' ..",.._-".~,. ,'..-'" ....".---'^. .,...~~......._.""'-~" ........- ..._""-"-"""~'-. ,...--.......--...,...... .... .
lOll,"" ft.OtR4~OI ~B~<l8,~I' Il,O/C:: TT'i:: I V,l'\ie!. Ic:!~,tJr;c.l;gn t~lJmc,r V; CI\~;EN Ori~~ 7L~C:;;S; ;'10'
89 ..,. 1FTCR10TOJUA45727 ffi El.IZA!n N90071S~
02 fORO 1T 2'0'./0 1FOKf37G7KKA2H47 > lEW N8U3Sl63
0: DOU.GLAS N5533202
C Drivers ~= not nl~uurlly carrupel'ld
.' . ...... .. ......_ _.. ....__..... ._..... ''1'0 ..'_'. .____.. ,.- .w.... _". w._I.~,~~rnCijl~~'(OIl.r.t.!~y."i.~!.!~~.._ ~.,. .........
tC"'!R~t:: L. .. ..w~!~'.!L!.T:~..~!~.!.i.~_ .~..._I..._._'~.!r'.O.~__..__J....__tl~!~.03.-:.........__.U..~-_.~:,._.. ... !..!~rl\. ....
r E~c!'l Po'san I I!J~" eCC"I~e~.cl C'~'w'!,! p:,,,,ium I Oe:::uct. I Pr,muJm O':::u~(. I Pr,Il1""m Otd\JC~. I P'''I\',"''
8~4iiy- 'l" ..' . .' ._._..~,..... m... '0 .,.-. ':'~'::~kd-"i 0 . ....- -.- ~'i~#n~~:l-'-"" . .-..' .~1~;~r.fiJ( -. .' -.. .~..:,r.;i::~t:i .. ..
I J 500 000 1 000 000 '.. ...~>...,~~~ 511'7S :...,,,:;:.........1 547S . .." ..::~::"I;':,.~.,~,.'.:i
. n.u~y,.. .~. ..... ~. ...~. " _ _'Y"~" ~.~_~.:...<"'_.._ .:~;~iq~~';!::! " ... . ::1':f::;~~~t~T;.:)
ModIca' I '\'~Ji:~' r' '~'!r'~:~':':!:;:.:i"~'e~~ ':rit:;,::'~l.^l I
I 5 000 .,~.f;i,~:... ~.' ~!\'!Wol'~:'~I~ ...,....~<.()O"..1 S S 6 B '
P I Vn\ . n Is , ".r;;~:,. 'I~; : ,:~~~~,'!:>";'~.':\'; ,: ~~It::", ~~;:=l 6 a !
. . . . . \ .. . ...._... ~ . ~ ~ . _ _: ~~',~,::::.':~~ ;:~~~ .:~,~ ~~. .:;:::;~it:f::t~;~:.,~ J
Uninsured \ 50 I ,;~~.i:~~;! $ .. ':1
MotorIsts 0.000 1.000 .000 ':~;~fri;~~~:'I' 5194 19., !
~\'("'<!~""": ..
. . ,... ..... . .~ ,_ .....',_'" . _..,' . .. -C:"lo'.. '~>>.""oI...1 .> "',I'
Pro"crt'l ::;:~ ;;i..~ .;~..... ;.;..~;~~.i ,>..,.: .:.
o~~a,c .:;1: .~;~ 100 000 ;:qi~~:i 5'34 $134 ..1
, A' . .~. ,.. .~~~~.. .. ..... .~._ _. '... .,~:.;;.t::',;-,'i:;: :;:
Compr.honshl.
AelYll Cash Value lns OedlJ(li/,lla
. -. .. .... ~ -.-..' ..' ~,~~., -- ... .. .-... .. .
Calli,lon
Actual Cnh ValvII LISS Oeduclibl.
'," .. . .__......~ -"....~".....-.-._~.,..._~
All RI"ks
AClual cash Value \'.55 Ot~vctibl. Nc Core r Ige
..~~ ~... ,.. ~_.. ...,',..'. .-"'''' -.... . - ..-..-. -. -,.. ., --_.~ . .-,......
" l\Io!f\~a ar.:j Adcr. n of 1(\5lJred
WALSH MICHAEL M OR BARARA
~jALSH CONTRUCr ION
2'. N ALAMADEN AVE
SAN JOSE CA 95110-2425
DB),
100
$84
S 1 19
500
Sl9!
52.87
10rAL P~EMILM PER VeHIC~E )II-
$1150
51277
Aulomobllo ~Q'a. -lk."-h~e. ';I~~'I'I:~'~.~:J.O.'~~:~:'.~~~'~'~~~~~~... ,.- -.-... ...~..~~.5~~a~ ::~"-::il.iO'41 :::~:..~.. . .......C~:i'nc:~i ,'. - ,.. _.....Pl~m\~.."
. .... __.' .. .... ..!..!.!S;~~~~~rl.t..'~~..i..I.!~L~...~.I~'!'~.....!::!!~J~~ ,,"~~I)~I!~I.!?~~. ._.~ -~'._- ...... -- _........
Pr.rnlIlT1l $url1ll'\ar)' CA Surcharge: 524.2.7
~r:T h'i~'" ;~'''ilot' , :~7iI. ..~:
Savings Cividend: 5146.00 Annual Prtmium: $2,451,27
'$C'II."lJl, o"'C'\an~;'" ___..... . --...---.---,.....-..........-.....-.--..-.....-- __...-_0""""'- ,----" ...-_.... ..., .....--
. ..,. .__.'~-"'_. .._..~_. "'_.~- .......--,--.,...-...-- .--..,',.......-,...-- ..-,.....~_..
Saf.ty Oisc;ountJ: Collisilln Avoid~nct! light, none. M~turo Driv4lf. none.
Ii.",
... . --.. j'i;;-'. ..--.....-.. "-_... .._......n.... ...--. ., .. - '''~\9.UB+~g.~:~~'~'r,iy .
io.1t1S 56"':~:' 51 .' 0 C ~I
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