96-150
CITY OF CAMPBELL
DEPT. OF PUBUC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
::'k ':[e:/q (p
Pennit expires in 12 mos.
q 0 - J~
"'enni! No.
..Ref. File qtf. .LJ~
.....- - ti J s! CI ~
Application expires' 6 Mos.
APPUCATION - Application is hereby made for a Public Works Pennit in accordance with Campbell Municipal Code, Section 11.04. (Application
expires in 6 months if the pennit is not issued Application Fee is non-refundable).
\! ~'5 :t15 oS,w 'k/JJf!S Jp"");J /k
.-lI1J.1Jii1- ( J 0 I IV( rlLr;NCN)
A. Work address or tract # 9;' I L-/ ~
Utility trench location
B. N""" of..... J Ii2 WiU ~ot#.T Ii Oli.rjA.
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 work to existing surface and underground improvements. When approved by
the City Engineer, said plans become a pan of this pennit.
D. All work shaH conform to the City of CampbeH 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 General Pennit Conditions 1 and 2.)
E. TIlE CONTRACTOR MUST HAVE TIllS PERMIT AND APPROVED PLANS AT TIlE 3ITE AND MUST NOTIFY TIlE PUBUC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK. fk
=AW1;;:;;~~;;;~fJJ;,:1t:~ it~'(:1;~ ~c;-IJh1
Is Ibis work being done by the property owner at their own residence? .:/ Yes 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.
PUBLIC WORKS DEPARTMENT RECEIPT I
Effective July 1, 1995
TO: CitY Clerk PUBLIC WORKS FILE NO. 9b-/5'0 I
I
PROPERTY ADDRESS Fifo) - fp,> :)(1.,. fc;......, ~
Please collect & receipt for the .." monies:
ACCT;::::.:::...::::::::::::.:::::::::::::::.: J'II!W AMOIIIIT
435.535.49211 Proiect Revenue (snecif 1
$ I
ENCROACHMENT PERMIT I I
4722 Application Fee ,
Non-Utility Encroachment Permit ($225) ,
R-l First Permit (No Fee) Subseouent Permit/Yr ($100) I
Utilitv Encroachment Permit I I
Arterial/Collector Street ($325) I ~~,oo
Residential Street/Other Areas ($225) I I
220 Plan Check Deoosit ($500) " I
220 Faithful Performance Surety (FPS) (100% of ENGR.EST.) ~
220 Monumentation Surety (100% of ENGR.EST.) I
220 Cash Deoosit (4% of FPS)($500 min.) ..
220 Labor and Material Surety 1100% of ENGR. EST.) \ I
472. Plan Check & Inspection Fee (Non-Utility)
Engr.Est. < $250.000 (12% of ENGR. EST.) I
*. 2203 Enor.Est. > $250,000 (Deoosit 15% of ENGR. EST.)" r
4722 Utilitv < $100 000 1(,~,)~0l}
Conduits/Pipelines UP to 500 Feet ($1.60/ft.) (MIN. $105) I
Above 500 Feet ($1.10/ft.) I ,
Manholes/Vaults/Etc. ($105/ea) l
Pole Set/Removal ($105/ea) i
Minimum Charge Per Location 1$120) I
Street Tree Plantinn/Removal ($105/treel i
.. 220 Utilitv > $100,000 (DeDosit 15% of ENGR. EST.)" I
476 Proiect Plans & Soecifications Proiect No. I
476 Standard Soecifications & Details ($l/Po $12/Book) I
476 CODies of Enoineerina MaDs & Plans ($.50/s-c.ft.) I
472 Penalties: Failure to restore nublic imnrovements ($l00/Calendar Dav) ,
,
(Muni Code Section 11.34.010) I
472 Penalties: Failure to correct unsafe conditions ($l00/Calendar Dav) I
LAND DEVELOPMENT ,
4722 Lot Line Adiustment ($500) I
472 Parcel Man (4 Lots or Less) ($1.060 + $25/Lot) :
472 Final Tract MaD (5 or More Lots) ($1 380 + $25/Lot) \
472 Certificate of Comnliance ($400) I
472 Certificate of Correction ($300) I
472 Vacation of Public Streets & Easements ($550) ,
,
472 Assessment Segregation or Reapportionment I I
First Split ($550) I I
I
Each Additional Lot ($170) I !
472 Storm Drainage Area Fee Per Acre (R-l, $2,0001 I I
(Multi-Res. $2,250) I I
(All Other, $2.500) ,
,
492 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy)
496 Postaoe
TRAFFIC I
472 Intersection Turn Counts (Two-Hour Count) ($60) I I
472 Intersection Turn Counts (a.m. or n.m. neaks) ($125) 1
472 Traffic Flow MaD (Dailv Traffic Volumes) ($27) I I
472 Camobell Traffic Model (Full ScoDe Assessment) ($2250) I i
472 CamDbell Traffic Model (Reduced Scooe Assessm$740) 1 I
427 Truck Permits ( $35/trio) I I
472 No Parkino Sinns ($l/each or $25/100) I I
OTHER I
I
TOTAL $ /99CJ.oO I
~~nlc. I
C-,,~./?:J ~A/-e CoPyyt(J () t- I
NAME OF APPLICANT i
,
Cobb G2~ iDne~ umLh:-d Dev. I
PHONE fir;. sCJ,>-. J7(P7 I
NAME OF PAYOR I
ADDRESS /C}1f -rAJ.. 410.. wvie..- 5'",,- ju r, rA ZIP 9'5 IJ 0, I
" I
I
* * Actual Cost Plus 20% Overhead (Non-Interest bearino de DOS it) I
oJ (2J.
":FOr..Pllln.ChllCk..and.:CllSh.'Deposits, send .yellow..coPV.toFinance;
Date/ll1itials
-RECEIVED
APR 0 8 1996
CITV CLERK'S OFFICE
lOR
CITY CLEIlX
ONLY
I:-F~qt28S1
h:\recfrm3. wk3(mp)rev. 1/9/96
A~~~tRlt~ .:I:Ii::d~I'III:i:tf..:.:: :::::..:iSl::~::::I.:i::tilj'~::I..~.iSi.d]r.::':..."~.ts..E\.j ... ....... DAlE (MMIDDNY)
.. .:V.....:D?:':.J: ."#i!J:::~Or::::Ji:"Q' .lii:li"'J".JJOUOt' .\ilK),< 01/30/98
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
PRODUCER
Schaefer-Smith-Ankeney
2002 E. Osborn Road
P. O. Box 10067
Phoenix
AZ 85064-7291 _
\J
~(jI ~ "
i ~;
" )1"
COMPANY
A
Evanston c/o Crump Group
Sun Lakes Marketing
9532 E. Riggs Road
K\
COMPANY
B
TIG c/o Crump Group
INSURED
Sun Lakes
AZ 85224
S'
COMPANY
C
CNA
CEIV
FE8 05 19
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR
INDICATED. NOlWlTHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH
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.
i
CO I
LTR I
A
TYPE OF INSURANCE
POUCY NUMBER
POUCY EFFECTlVE
DATE (MMIDD/YY)
POUCY EXPlRA nON
DATE (MM/DDtYY)
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE [I] OCCUR
OWNER'S & CONTRACTOR'S PROT
BINDER20342
01/01/98
01/01/99
UMITS
GENERAL AGGREGAlE $ 2,000,000
PRODUCTS - COM PlOP AGG $ 1,000,000
PERSONAL & ADV INJURY $ 1,000,000
EACH OCCURRENCE S 1,000,000
FIRE DAMAGE (Anyone fire) $ 50,000
MED EXP (Anyone person) $ 5,000
COMBINED SINGLE LIMIT $ 1,000,000
C AUTOMOBILE LIABILITY BUA1004982693
X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
01/01/98
01/01/99
A EXCESS LIABILITY
rxl UMBR8J.A FORM
n OTHER THAN UMBRELLA FORM
BINDER20342
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGAlE $
01/01/98 01/01/99 EACH OCCURRENCE $ 25,000,000
AGGREGAlE $ 25,000.000
$
EL EACH ACCIDENT $
EL DISEASE - POLICY LIMIT S
EL DISEASE - EA EMPLOYEE $
GARAGE LIABILITY
ANY AUTO
I VVCiRKEi15 COMFENSAiiON Ai-"'O
EMPLOYERS' LIABILITY
THE PROPRIETOR!
PARTNERSiEXECUTIVE
OFFICERS ARE:
OTHER
INCL
EXCL
DESCRIPTION OF OPERATIONSA.OCATIONSNEHICLESiSPECiAL IlEMS
The City, its officers, employees and volunteers are to be named as
Additional Insureds as respects: liability arising out of activities
performed by or on behalp fo the Contractor, products and completed ops.
the contractor, premises owned, occupied or used by the Contractor, or
This coverage shall be primary and any coverage
carried by additional insured shall be excess only
of 845-885 S. San Tomas Aquino Rd, Tract 8748
permit #95-213
CA
95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPiRATION DAlE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
----.l!!.... DAYS WRITTEN NOTICE TO THE CERTIFICAlE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAiL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE CO AN.Y, ITS AGEN OR REPRESENTATIVES.
AUTHORIZED REPRESENT
Cindy Greer, CIC
City of Campbell
Public Works Dept.
70N.lstSt.
Campbell
010596
:Ad6~b~jtmA1iONail....i/..i.
3
...............................................................................
....................................................................
.. ......................................................... .................
.......... .............. . .................. ... ........
.....I$:fi~I.....I!;I..:A;... .-;:':j'"I$:,'\'t:.,J$.I....:)!jiA::i:.IS':I$);:; .....:....<:::.:: ISSUE DATE (MMIODNY)
!?:Ef1..!:::.~,..Y~. .e::)Sl:!I:;))::.:!JQ,::..::::p:""~:.t::::\:::::: ........ "",':::::):::::.:.::.:.:.:.::.:.:.::.::::::::.:;: I
::::::::;:;:;:::::::::::::::;:::;:;:::::::;:::;:::::::;:;:::;:;:;:::::::::;:;:::::;:;:;:;:::::::;:;:::::;:;:::::;:;:;:::::::::::::::;:::::;:;:;: .. ...........w.. .... '.' ....................:..::::.:.:.:::::::::::.:.:::::::::::::::::::::::::::::::::::::::::\\;::::}:::: :: 01 20/97
.. p~rbO~33"'~Jf:~d gg~~~~~:f::~~~~;~!~~D ~~ A~i~$~:i;~~~~i~11rii~~~~lJE
~:J t7 ~JOT' POLICIES BELOW.
....,'---.....""...,............-.
, ..."".................-..
. .
.', '
. .
> .".....1'1. ::.
..d. n.... . .~::
PRODUCER
Schaeler.Smith.Ankeney
2002 E. Osborn Road
P.O. BOJ( 10067
PhoeniJ(
AZ 85064.7291
COMPANIES AFFORDING COVERAGE
T.G 'nsurance ,*,Crump Grp
CHA . 'Re~~~~~~
J~~~~
INSURED
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY D
LETTER
E
United Capital ,*,Crump Grp
Sun Lalres Construction of California
Santa Clara Development
1978 The Alameda ":2 ./Ie:.. \ -, \ &7
San Jose CA 95126 ~-....r I'll
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, N01WITHSTANDING 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.
CO
LTR
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIDDNY) DATE (MMIDDNY)
TYPE OF INSURANCE
POLICY NUMBER
A GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X OCCUR.
OWNER'S & CONTRACTOR'S PROT.
01/01/97
01/01/98
GENERAL AGGREGATE
PRODUCTS-COMPIOP AGG.
PERSONAL & ADV. INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone fire)
MED. EXPENSE (Anyone
COMBINED SINGLE
LIMIT
BINDER20342
C AUTOMOBILE LIABILITY
X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
GARAGE LIABILITY
01/01/97
01/01/98
BUA1004982693
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
B EXCESS LIABILITY
X UMBRELLA FORM
OTHER THAN UMBRELLA FORM
BINDER20342
01/01/97
01/01/98
EACH OCCURRENCE
AGGREGATE
WORKER'S COMPENSATION
STATUTORY LIMITS
EACH ACCIDENT
DISEASE - POLICY LIMIT
DISEASE - EACH EMPLOYEE
AND
EMPLOYERS' LIABILITY
OTHER
Ci'S-21'B\V)5--213 1'1/0- 15a
lS'Z-Z- MLC~
DESCRIPTION OF OPERATIONSA.OCATIONSNEHICLESlSPECIAL ITEMS
The City, its officers, employees and volunteers are to be named as
Additional Insureds as respects: liability arising out of activities
performed by or on behalp fo the Contractor, products and completed ops. of
the contractor, premises owned. occupied or used by the Contractor, or
automobiles owned, leased, hired or borrowed by the Contractor.
LIMITS
2,000,000
1 000 000
1,000,000
1,000,000
50,000
5,000
1,000,000
5,000,000
5 000,000
This coverage shall be primary and any coverage
carried by additional insured shall be excess only
McCoy Avenue, Tract #8761 Landscape Mangement
agreement, Summerfield Village L.P.
Special Cancellation Claus.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~XXX
MAIL 30 * DAYS WRITIEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT. B)g)[)eQlX)BEXJO:JUAmCS}gE>EXJ)(omgJ!:)OO~;oO(MR~~lOltXXXXXXXXX
}(OOI){}(OO(~~~~D.~~XXXXXX
City 01 Campbell
Public Works Dept.
70 H. 1st St.
Campbell
032996
CA
95008
064
A.!",R- 4-'96 THU 14: 1 7 TEMP~I; .__~_ 1EMPLE
408 424 1277
P.01
ACORQ~
I PRODUCER
i
!
l
I
I
!
I
; lNSURtlD
Underground Utility Construction Company
701 - 12C Kings Row
Sdn Jose. California 95112
Superior National Ins. Company
i
I
I
: ~v~~~ci~s' : ,I; ::"T~:q-~;q:::r;;~!F::7;~t.:"'(T":"~'~ '-''-
i THIS IS TO CERTIFY THAT THE POUCIES 01=' INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A60VE FOR THE POLICY PERIOD
I INDICATED, NOTWITHSTANDING ANY l'IEO\JIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHE~ DOCUMENT WITH J:lESPECT TO WHICH THiS
, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE pOLICIES DESCRIBED HEREIN IS SV6JECT TO Al L THE TE:RMS.
1.- EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOwN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
l~ ._..._~,-~~~~~6URAN~ . POlICYNUMBER n_.._.--']~;~~~~':~~~;(~:~~n;;N
1 liENERAL lIAlIlUTY
1 '
1 A~XC~ME"CIALGEN~LlIAIlILITY i PAC6012737
!, ,.1 : CLAIMS MIlDE LX; occu'" i
l XX~ OWNEIIS & CONTRACTORS PAOT :
i I
I '1 .. ..
j- "B":-;~:=~~~;;;L~--
, ,
I : ALL OWNeD A.lJT03
: XX SCHEDULED AUTOS
I XX HIReo AU'fOS
! X~ NON.OWNED AUTOS
I'"!
1-" .........."" '-"---1--'-'-"'-
1 ,.. '! ANY AUTO I
1;~:=,"-~-----~'
1 '1 I
, o-rHER THAN UMMELLA FORM
I'" _,._. -'-_._......."....--"...--.... ,---'-'....,-'--" _.n.
WORKEAS COMPENSATION AND I I:
, t:MI'I.O'nRC' LIAIMLITY
THe~OPRIET~ '.I'NCl I' 1450180-961 II 1/4/96 : 1/4/97
c p ARThlERSlEX~CUT1V~ I .
1_-- s>~~~~~.._._._- 1 I E)(CL1 ..______.1[1 --------- '".
: OTtlEIl
I II!
, I
\ 1 --L'
1- __... _'_'''''''"~''''''_ __ __ ....."..,....., .. -- .------ _______..,J....."' ~.
lDESCRIPTION OF OPERAnoHSILOCATlONSlVEHICLESIS...,;:elAL ~""s
Sun lakes Construction of California. Elam Avenue, Tract 8748, Campbell, California
Please See Additional Insured Endorsement Attached.
'.'c'.\.~."Ififi:i,....'.~.,-~'~"'.'."':re~-.-.'.','ij.-..'~-<..L..-.i......~,.-".'.."'..'..<... ... ...... ~'-=l'----..~..........,.,..~..-. ..,,,"" .. - ..
~ .~_ ""0;;"" . . ',".> ';'<':'}!:(~l ';'<;<-:!";~'J101lt. 10 Day N01"l-Payment ',',
Ci ty of Campbell 9{' _ /5' (j SIlOULD ANY OF THE "eOVE DESCRIIIlED POLICIE5 BE CANCElLED BEFORE THE
U""TS
31364084
2/20/96
2/20/97
GENERAL AGG"!:G'" TE , S 2, 000 , 000
PRODUCTS - COM~IOP 1'.00 : '. 1,000,000
~PEF\SONAL & A.OV INJURY : $ 1.000,000
, EAel< OCCiJRRENCE . S 1 J 000 I 000
: !'IRE DAMAGE (Any on, I,..) $ 50.000 i
. MED E~PI""'Y o~n'''''n) Is.. 5"OOQ :
COMBINED SINGLE LIMIT ! $ 1.000.000 I
: i10DIL Y INJUI>\Y , $ 1
: (P9r p,,.,l:m)
1
1117195
1117196
I
..,-....,+-..---.-----,.
, 90DIL Y INJURY
I (Por ~l:;Qiden()
I
is
PROPERTY DAMAGIi
, S
AUTO ONLY. E'" ACCIDENT : $
OTHER TI<AN AUTO ONLY' :
I'
EACH ACClC'I."NT ; $
AGGREGA TE~ S
i EACH OCCUl'RENCf: '1 S
,AGt;;REGATE : $
I
"
We:: STATU- p,TH. !.
. 'TORY LIMITS ,EfI I
. El EACI< ACCIDENT is 1 000 000
, , J I
EL DISE,",SE - POLlCv L1MIY .$ 1 J 000.000
EL DISE~SE EAEM~LO.YE~J S ---1-,.000., 000
Attention:
Randy Wes tfa 11
EXPIRATIO~ DATE ntEAEOF, TtlI! ISSUING COMPANY WILL )(1')(l)(*~9( TO MAIL
-3Q-.. CAYS WRrnEN NOTICE TO THE CERTIFICATE HOLDER NANlEO TO TltE Ln,.,
~J~Jt*Ml)(~I)(~~'X~)f~K~~~M~OK~K<<iX'X
IB~. XmX~XK9t!dx.xlX... ~>>llX~K*M~~ - :
AUTHOfllZEO R~PflESENTAT1VE
~#,~.__...../- ....' ' ~'
I' -'<;"< 'V,I','",," ".."",,<.,..".' "~"'ACO"DCO.'Pll\b.lTI"""1' ".
~ ~',_ :__~:.~.( ':..,__ :.,_.~;~(: ~~~__ ':, . ';:' , ,.. ~", ","" "'" a
. . , \
" -: '.,
I
I
Fax #376-0958
(ACORD250~' (1195)" .'
1'- ,," '" '",,"
APR- 4-96 THU 14:18 TEMPLE & TEMPLE
4138 424 1277
P.132
POLICY NUMBER PAC6012137
COMMEHCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED-DESIGNATED PERSON OR
ORGANIZATION
ThIS endorsement modifies insurance provided under the followIng'
COMMERCIAL Gt:NER,~L LIABILITY COVERAGE PART.
SCHEDULE
Name of PersOn or Organization:
City of Campbell. its officers, employees and volunteers are to be covered as
insureds as respects: liability arising out of activities performed by or on
behalf of the Contractor, products and completed operations of the Contractor,
premises owned, occupied or uged by the Contractor, or automobiles owned,
leased, hired or borrowed by the Contractor. This coverage shall be primary
and any coverage carried by additional insured shall be exceSS insurance
only.
(If no entry appears above, information reqUIred to complete thiS endorsement will be shown In the .)ec:1aratlons
as applicable to this endorsement.)
WHO IS AN INSURED (SectIOn 11) IS amended to include as an Insured the person or organization ~,hown In the
Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or
rented to you.
CG 20 26 11 85
COPYright. Insurance ~ervlces Office. Ir'lC, 1984
j
CITY OF CAMPBELL
CONTRACTOR: tAl, U/lCfr-lAt6; '-.J
PROJECT NO. 9t-/ ()
REPORT NO:
DATE: q. -'I cJ ~
WEATHER: I::vy
INSPECTOR: K. .v~.STfALL
FIELD ENGINEER'S DAILY REPORT
rMcl 7?Cf g'
{j tw'-- ~)-/
ITEM
DESCRIPTION
I~ CMt fc,f
cc:
PAGE: I
OF I