96-180
I
rV1 J \ CITY OF CAMPBELL
1~~'fPEPT. OF PUBLIC WORKS
i...) ~ 70 North First 51.
(j1 ~~ Campbell, CA 95008
~. (408) 866-2150
~ ,~ Fax (408) 376-0958
,
ENCROACHMENT PERMIT
(for working within the
public right-of-way) r
Issued /d- 6 - j?~
Permit expires in 12 months
I. F.:~ No. ql::..=-~~'(~
. X-Ref. file
Application Date d1- 9&
Application expires in 6 months
APPLiCATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code. Section 11.04. (Application expires in 6 months
if the permit is not issued. Application Fee is non-refundable.)
A. Work address or uact # 4- C--.J l\';<J. \..~ t-""'1 \.U\C-> ~
Utility trench location t--.t/ Jb-
B. Nature of work CO::;::;~tc:.~T \ \i---\ P k?-C->\.1t:S ~-1 \S4---3T~
C. Auach four (4) copies of an 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 plan becomes a pan of
this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse
side; and the Special Provisions for this permit, 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 Permit Conditions I and 2.)
E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE ST ARTINO WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE REST ARTINO ANY WORK.
Name of Applicant G~ - r~N I IN'e"'..., Telephone~9-l~SC
(Print r:une)
Address ~ C2..\.S'Tt CA:-\ L.AN \=::::.. 24 HOUR EMERGENCY TELEPHONE NO.~
Is this work being done by the property owner at their own residence?
Yes
/NO
The ApplicantlPermiuee hereby agrees by affixing their signature to this permit 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 permit.
The ApplicantlPermiuee hereby acknowledges that they have read and understand both the front and back of this permit. and they will inform their contractor(s) of the
information.
Accepted
....--s.
SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. Minimum cuts !!!!Y be allowed for connections or exploration holes. Such cuts may be soccificaJlv
approved bv the Inspector prior to cuttine.
Pavement may be cut for underground installations and must be restored in accordance with the Utility Trench Restoration Standard Details. Method 'A. Badefin.
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the CUl sheets senlto the Public WorksDepartmcnl before starting work..
Per Section 4215 of the Oovernment Code this permit is'not valid for excaVations until Underground Service Alen (USA) has been notified and the inquiry
identification number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
0.
0.
_5.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
TYPE
~T~~
AMOUNT
RECEIPT NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCElLABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT, ... /,
PLAN CHECK & INSPECTION FEE /,
~ .
s v.Jh- \...;. ~:~l-~
S v-...t~ , \.lEi">
154,0<<::> .00 O~O'Z'7"b:T<C:.
S\...~ .00 \ C:34"-
$409-:0.(.')0 lO+~
Refundable Deposit Check Request
To: Finance Director
Check Payable To: GEN CON, INC.
Address - Line 1:
Line 2: 800 CRISTICH LANE
City: CAMPBELL State: CA Zip: 95008
Description: Refund Deposit
Account Number: 101.2203 Amount: $1,157.73
Account Number: Amount:
Account Number: 101.540.7448 Amount:
(Finance Dept only) Interest Earned (Finance Dept only)
Total Payable: 1157,73 (Exact Amount)
Purpose: Project complete. Refund labor/material security less back charges
for inspector overtime.
Voucher #: Permit #: 99-201
Receipt #: 1042 (paper) Date: 12/03/1996
Requested by: Alan Horn ~ Title: Sr, PW Inspector Date: 08/24/2001
Approved by: Michelle Quinney ~ Title: City Engineer Date: 08/24/2001
Finance Dept Only:
Verified by: Title: Accounting Clerk II Date:
Approved by: Title: Accountant Date:
~ecial Instructions For Handling Check
Mail As Is: X Mail in Attached Envelope: Interim Check:
-
Needed By:
Return To:
(Name) (Department)
Other: $202.27 for Inspector overtime charges should be moved to account
4722 Inspection fees.
.
h:\permits\96-180refund 401 hamilton.xls(mp)
UBLIC WORKS DEPARTMENT RECEIPT
Effective July I, 1996
TO: City Clerk PUBLIC WORKS FILE NO. t- t>c(~-\c;L/-,.
4.e:~' \ ~, \-\r.::.\:.--\\ L- ,C.:. H
PROPERTY ADDRESS
Please collect & monies:
..rM ..... ..................... .......
435.535.4921 I Proiect Revenue (s_ifv nro'ectl S
ENCROACHMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit (S225)
R-I First Permit (No F~ Subseauent PermitlYr ISIOO\
Utilitv Encroachment Permit
Arterial/Collector Street S325\
Residential Street/Other Areas S22S)
2203 Plan Check Deoosit - 20/. ofENGR. EST. SSOO minI .
2203 Faithful Performance Security (FPS\ 100'10 ofENGR.EST.\ .
2203 Labor and Materials Security 100'/. of ENGR. EST)
2203 Monumentation Securitv 100% ofENGR.EST. .
2203 Cash Deposit 4% ofENGR.EST.\lSSOO min/SIO.ooo maxI .
2203 Labor and Material Security 100'10 ofENGR. EST.\ . . ~...)
Plan Check & Inspection Fee (Non-Utility) ... -.ro..r.
4722 Engr.Est. < S2S0,ooo (12% ofENGR. EST.)
.. 2203 ERI....Est.>S250.ooo (Deposit 8% of ENGR. EST./S30,ooo min. \.. .
4722 Utilitv < SI00.ooo (8%\
Minimum Charge Per Location (SI20)
ConduitslPipelines up to SOO Feel (SI.6O/ft)
Above 500 Feet (SLlO/ft.)
ManholesIV aultsIEtc. (SI05/08)
Pole SetlRemoval (S I 05/08)
Street Tree PlantinalRemoval (SI05/tree)
.. 2203 Utilitv > 5 I 00.000 Actual Cost + 20% .. .
4760 Proiect Plans & Soec:ifications Proiect No.
4760 Standard Soec:ifications & Details (SlIP. SI2/Book\
4760 Cooies of En.ineenn. Maos & Plans (S.50/5O.ft.\
4722 Penalties: Failure to restore Dublic imnrovements (SIOO/Calendar D~
IMuni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions IS I OO/Calendar Dav\
LAND DEVELOPMENT
4722 Lot Line Adiustment S500\
4722 Parcel Man 14 Lots or Less\ SI.06O + S25/Lot\
4722 Final Tract Mao (5 or More Lots\ SI.380 + S25/Lot\
4722 Certificate of Comoliance SSOO)
4722 Certificate of Correction S300\
4722 Vacation of Public Streets & Easements S550\
4722 Assessment Segregation or Reapportionment
First Split (S550)
Each Additional Lot (SI70)
4721 Storm Drainage Area Fee Per Acre (R-I. S2.ooo)
(Multi-Res, S2,2S0)
(All Other. S2,5(0)
4920 Parkland Dedication Fee
4965 Postage
TRAFFIC
4728 Intersection Turn Counts wo-Hour Count (S6O)
4728 Intersection Turn Counts (a.m. or n.m. oeaks) (SI25\
4728 Traffic Flow Man (Dailv Traffic Volumes\ S27)
4728 Camobell Traffic ModellFull Scone Assessment) S2,250)
4728 Camobell Traffic Model (Reduced Scone Assessment) S74O)
4271 Truck Permits S35/trio\
4728 No Parkin. SilUls SlIeach or 525/100\
OTHER
TOTAL S~.ae
NAME OF APPLICANT
NAME OF PAYOR GEu- ~H \Wc PHONE ~1 ("1' - \.- {;.~~~.
....",. -, _ erz\~$\C\+ ~t ,,"'=.. ZIP q:-=-~ ('~
ADDRESS
CT-.......-'\\~e"t-,L. . ~
.. Actual Cost Plus 20% Overhead (Non-Interest bearin. deoositl
"For Plan Check and Cash DepositS,sendyeUowcopytl>Finance.
Re.Ce.,,,~D
DEt 6 3 \996
C\1~ CLER\<.'S Off\CE
FOR
CITY CLERK
ONLY
RECEIVED BY
Recelpt#~~l'1
Date
h:lrecfrm4. wk3(mp )rev7/1/96
e
lXl
o
lXl
(D
or
;:!;
ex:
o
II.
DATE~19~ ,0. 1042
AECEIVEDF~DM~~UV - ~,,<.'
AOORESSj;,o5~~~~~ ef "'\\0 -\~O
~()\ W ~ ~~ ~ . DOLLARS $ I 3~ 0 ~\6
FOR ~ {1'" ft\~-el ~ ~ 'l_'d 0\\0\4..1- ~ 0 i j'
i
CHECK
MONEY
ORDER
BY
CJt
C!l
lXl
o
lXl
(D
or
;:!;
ex:
o
II.
DATE 'L\ S\ 19 4..\0 NO. 1043
AECEIVEDFADM--?\~ - (~ ~~V
ADDRESS R.uS~G\~(~ / 4o\..W~"VJ'- E ~ G\\o--\rt:>
DOLLARS $ ~O go 0 ~J(
FOR ~~......DO~~ PI~ a....Jc. +- ~'V)I.Lj'~j'
i
ACCOUNT
. -..
AMT. OF
ACCOUNT
AMI. PAID
BALANCE
DUE
CASH
CHECK , it 31.
MONEY
ORDER
BY
G
G
is:
iSJ
(,'.1
......
.....j
...
o
....
[f'l
U-J
[f'l
OJ
...
00-1 "tJ
"11:110 )>
~~ -<
:1Im
C -,J c:
D tS: f-i
..:::~
.... Z .-<
i}.1
in 'I C:
l~ ......~ i
-,"I
.A.,;
,,.,
U)
-1
cn
-1
..
.... .-,
, .'
ru D
.... ...[i
0 (Jl
0 G
0 G
CD
ru
~ r
OJ
-
..
0
0
[f'l
U-J
0 0
0
-.]
..D
r
ru
...
09101317.95
o
..,...
..1."
3
T1
i}.:l
iTl
r-.
......
......
,
m
.....0
,>
...o-f
O"m
*
*
*
*
*
4:-
&
~
.0
~
&:l
*
;~:
,.
1-'
......'
i.__
-...j
C1
L._
rn
J)
o IX> C)
>om
~~Oz
omO .
.!!!m;!!o
~F~o
'PooZ
o;>:I:~
IX>U)s:-
OOlZZ
8mO
IX> .
o
i1~
H
C.I
I
--1
-<
~
'..-'
o
D
...,..,
...._1
iJ)
D
Z
1::1
z
o
D
m
z
-j
(.i1
=e
m
r-
:=1;
..,.
1\))>
~::u
~r;)
~o
Om
)>
z
,..
Ell SKurlty le8Iures Included. Details on back.
ISi
.....
0"
("j
0"
(D
f-"
.......t::l
fl) J)
JS:J-'1
'-iT!
oJ)
!}'1
~:. !--~
f!~! <:~:
iSlC:
J...CI;. ~
!J""lri
iTl
C)
)Jl)
(=1[)
UJ ::{
ff13
3 iT!
DZ
::0 -oj
-:-~
'__~.r
~'i
'-....
L.i
,-n
Il!
r-
T1
C)
:.1::
"TJ
''>'>
[1'1
I'
-0
rn
::0
..:>.
H
-1
"
fn
4:-
-.II ,"
~l,':
N-::,
(DCI
iSle:
. -0"
rSi-j
ISi
n
I
,
-j
o
-j
J)
..i>
z
~
i'i
..;.,-~.j
~
G
CD
is!
,
~
en
w
en
co
is!
is}
C)
m
Z
.
o
o
Z
Z
o
C}
1'0, " ~',' - . ,.'.
,~~~lji-{~';1~
;.-.,
....~.:
rh-;
r)i
, .
L.;
c:
TSJ~
:;;~
IS'1)
CLS
GC::
JI rN~
~~
,
~i
en
w
en
co
. -~
OO-i "tI
..,,:110 ).
li::i! -<
:11m
CJ 0
H Z
~ t:J:j
>-< t-:3
0 ::r::
"7j 0
c::
CJ C/)
.. ~ ;t:-
Z
0 'I:l d
.... to ~
t:J:j
IP r ::r::
r r ~
t:J:j
Ul t:J:j
0 ::r::
... c::
z
- d
.. ~
.... t:J:j
d
ru
C/)
.... H
0 ><
0 t-:3
~
0
ru d
0
r r
OJ r
;t:-
.. :::d
0 C/)
0 ;t:-
IP Z
d
U-J Z
0
0 (/ "-
0 I-'
0
-.J 0
..[] *
*
r *
I-' *
ru N *
.. ,,-0 *
N~ *
~m *
*
0'\ *
*
*
*
*
*
*
*
*
*
*
*
*
.fh
I-'
)>
WS:
0'\0
Oc
. Z
0-1
0
....,..f".,.
EI s.curtly l8aJ_ _. DtImltII on _.
o CD G')
>om
~~oz
01110.
$m:!:!o
~F~o
'Pooz
;>>>:I:_
CD(Or-
o",:J>Z
g~o
CD .
=e
m
r-
r-
=CIl
'T1
1\)>
~:u
~Ii)
~O
olll
>
Z
~
......
0>
~
C11
o
~ CJ G')
t:J:j OJ m
d [j)
::r' Z
Z .
d d 0
;t:- (1) 0
to "0 Z
r 0
t:J:j [j)
f-J. Z
t:l rt P
t:J:j
'I:l H>
0 0
C/) '1
H
~ ~
0
I [j)
(1)
.fh a
I-' OJ
~ '1
W '<
0'\
0 t:J:j
. I-'
0 (1)
0 a
(1)
::l
rt
OJ
'1
'<
(f)
n
::r'
0
0
I-'
t:J:j
:::l
n
'1
0
OJ
n
::r'
a
(1)
:::l
rt
'ij
(1)
'1
a
f-J.
rt
"
;-
~.~~,~~~
......
0>
~
C11
o
. ...
Permit #
INSURANCE REQUIREMENTS CHECKLIST
9rp - /6(.)
CIP Project #
The following insurance is required of all contractors working in the City of Campbell public
right-of-way. Insurance certificates must be accepted by City staff before work can begin.
These insurance requirements apply to work being performed under an Encroachment Permit
and work being perfonned under contract for Capital Improvement Projects.
~*
Limits
Commercial General Liability for bodily, personal injury and property damage:
i:f $1,000,000 per occurrence, and
e $1,000,000 general aggregate limit applying separately to the project, and
o.-B $2,000,000 general aggr~1e ~~. -...L. I ~ on"--.L 1 . Ire \ I I
M Policy expiration date :J:2I!:t!l;i.. 't)~ ~1 I DO
Automotive Liability - "any auto" ~
J2J $1,000,000 per accident for bodily i11iu~perty llama. ge I
~ Policy expiration date ~ U I I '" TO ~ \. I I cj:)
Worker's Compensation and Employer's Liability ~9.--
er $1,000,000 per accide!'l fo! lx)<Ii1y. in~'Ury or disease Or. D\C"-U J
0' Policy expiration date /;J;fJ.~70 ~uv~---^" cvt \. ('7 .
.-. \)'I C/' J\)
Course of Construction (if required in Special prov~Ir~ I ~ ~ ~/l31 '1lo
D Completed value of the project \2.j\ \ 00 'I \ 2\ 1-11,,-1
o Policy expiration date
Required Endorsement to General Liability and Automobile Liability Policies
Additional Insured Endorsement
EI The City, the City of Campbell Redevelopment Agency, its officers,
employees and volunteers are named as additional insured.
0' The insurance coverage afforded to the Additional Insured is primary
insurance.
Workers' Compensation Insurance Sheet Submitted
.ef For General Contractor
0' Subrogation Clause
'\~ ~
Sf1I1~~
Insurance Certificate ReviewedL
I /
L.../ lnitiais
g
L!~ Ii 0
Date
)( Copy of Insurance Certificate placed in tickler file one month prior to expiration.
j:\forms\inscklst 4/96 (rev 6/96)
ACORD~ CERTIFICA"'~ OF LIABILITY INSUP 'NC~~~C%<:5 DATE (MM/DDIYY)
12/09/99
PRODUCER THIS CERTIFICATE IS ISSUED AS A MAHER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
R. G. Speno, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
18900 Stevens Creek Blvd. #200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cupertino, CA 95014-3674 COMPANIES AFFORDING COVERAGE
Francis E. Cook, C.P.C.U. COMPANY
A St Paul Fire & Marine Ins
Phone No. 408-973-9500 Fax No.
INSURED COMPANY
B REPUBLIC IND CO OF AMERICA
Gen-Con, Inc. COMPANY
Ms. Paula Mohr C nr:' (-Ci\/Cn
800 Cristich Lane COMPANY 1'1.---....--
Campbell CA 95008 D ... po ^ . .n'",,,
COVERAGES U t. \.. , '1 I oJ oJ oJ
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIPUfi.qlt WORKS
INDICA TED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO Wml'" S T 'N
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TH , RAT 0 -
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE (MM/DDIYY) DATE (MM/DDIYY)
GENERAL LIABILITY GENERAL AGGREGATE $2,000,000.
-
A X COMMERCIAL GENERAL LIABILITY KK08300574 01/01/99 01/01/00 PRODUCTS. COMP/OP AGG $2,000,000.
I CLAIMS MADE ~ OCCUR PERSONAL & ADV INJURY $ 1,000,000,
~ OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000.
X Per Project Agg, FIRE DAMAGE (Anyone fire) $ 50,000.
MED EXP (Anyone person) $ 5,000,
AUTOMOBILE LIABILITY
- COMBINED SINGLE LIMIT $1,000,000.
A X ANY AUTO KK08300574 01/01/99 01/01/00
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
f--
X HIRED AUTOS BODILY INJURY
f-- $
X NON-OWNED AUTOS (Per accident)
f--
f-- PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
f--
ANY AUTO OTHER THAN AUTO ONLY:
f--
EACH ACCIDENT $
-
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $ 1,000,000
A ~ UMBRELLA FORM KK08300574 01/01/99 01/01/00 AGGREGATE $1,000,000
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND !WCSTATU. I IOTH-
X TORY LIMITS ER
EMPLOYERS' LIABILITY 1000000
EL EACH ACCIDENT $
B THE PROPRIETOR! RINCL 02564608 12/11/99 12/11/00 EL DISEASE - POLICY LIMIT $ 1000000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE EA EMPLOYEE $ 1000000
OTHER
A Leased/Rntd Equip KK08300574 01/01/99 01/01/00 $20,000
DESCRIPTION OF OPERA TlONS/LOCA TlONSNEHICLESlSPECIAL ITEMS
* 10 day notice of cancellation for non-~a~ent of ~remium.
Re: Rosema~ Elementarr School Permit # 6-180 - 40 W. Hamilton Ave.
Additional Insured per orm CG 2010 attached,
Workers' Compensation Waiver of Subrogation included.
EP
CERTIFICA TE HOLDER CANCELLATION
C-CAM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WIL' MAIL
City of Campbell 30 * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Department of Public Works -
70 North 1st Street
Campbell CA 95008 AUTHORIZED REPRESENTATIVE .~.~
C.P. /(
Francis E, Cook, -V CORPO~
ACORD 25-S (1/95)
/
tD R. G. SPENO, INC. /
Insurance Brokerage
TRANSNUTTALSHEET
DATE: December 13, 1999
TO: David Day
COMPANY: Republic Indemnity
FAX#: 415-954-3406
FROM: Desiree Santa for Caroline Harton
***TBIS DOCUMENT CONSISTS OF 4 PAGE(S) INCLUDING COVER PAGE***
IF YOU DO NOT RECEIVE THE ENTIRE DOCUMENT OR IF IT IS ILLEGmLE,
PLEASE CALL THE TELEPHONE NUMBER SHOWN BELOW
******************************************************************************
RE: Gen-Con Inc.
WC Policy # 02564608
Dear David,
Please issue a Workers Compensation waiver of subrogation to the following holders:
1. City of Campbell Department of Public Works
RE: Rosemary Elementary School Permit #96-180 - 401 W. Hamilton Ave.
2. San Jose Unified School District
RE: Grant & Washington Elementary Schools Project Bid Package #4 - Doors/ Frames/
Hardware, Windows & Louvers
3. San Lorenzo Valley Unified School District
RE: San Lorenzo Valley High School Community Swimming Pool
Certificates of Insurance Additional Insured Endorsement are attached for your records.
Should you have any questions, please feel free to give us a call.
Sincerely,
L~~
Caroline Harton
Account Manager L'
Chi ds
DOCUMENT FAXED:_DATE:~ TIME:~ITIALS:~ .
CORPORATE OFFICE. 18900 STEVENS CREEK BLVD.. SUITE 200. CUPERTINO, CALIFORNIA 95014. (408) 973-9500. FAX (408) 257-2985
.----- ------.-....,............"""'.,.........".""""'......"."""."....-...""..,-------......-.......".'"".,..........
,ACORDTM vER.....IFIC~_r-Ofl..l~BII.I....'IIINISI.JII.t"'~tEcsRCH DATE (MM/DDIYYI
",.".""""",.",..,."""""",'"J~aNGQ...5.. 12/10/98 .',
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
R. G. Speno, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
18900 Stevens Creek Blvd. #200 AL TER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cupertino, CA 95014-3674 E'Veo COMPANIES AFFORDING COVERAGE
Francis E. Cook, C.P.C.~~~ COMPANY
A St. Paul Fire & Marine Ins.
Phone No. 408-973-9500 Fax No. .-...""
INSURED JAN , 3 ":I:t COMPANY
PUBl.IC 'MORK~ B Republic Indemnity Company
Gen-Con Inc. I.OtA\N\S,.Rf\,.,O - COMPANY
Attn: Ms. Paula Mohr C
800 Cristich Lane COMPANY
Campbell CA 95008 D
'/ 2d i) "'.'."".".'" i
".,. ,......,.,..., ,., ,.,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REOUIREMENT, 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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE (MM/DD/YYI DATE (MM/DDIYY)
GENERAL LIABILITY GENERAL AGGREGATE $2,000,000
-
A X COMMERCIAL GENERAL LIABILITY KK08300574 01/01/99 01/01/00 PRODUCTS - COMP/OP AGG $2,000,000
i I CLAIMS MADE [!] OCCUR PERSONAL & ADV INJURY $1,000,000
~ OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000
X Per proj. Aggreg FIRE DAMAGE (Anyone fire) $ 50,000
-
MED EXP (Anyone person) $ 5,000
AUTOMOBILE LIABILITY
f-- COMBINED SINGLE LIMIT $1,000,000
A X ANY AUTO KK08300574 01/01/99 01/01/00
f--
ALL OWNED AUTOS BODILY INJURY
f-- $
SCHEDULED AUTOS (Per person)
I--
~ HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
I-- PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
I-- - '.'.'.'........',.,
ANY AUTO OTHER THAN AUTO ONLY:
I--
EACH ACCIDENT $
I--
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $1,000,000
A ~ UMBRELLA FORM KK08300574 01/01/99 01/01/00 AGGREGATE $1,000,000
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND I WC STATU- I IOTH- .,.,.,..",.............
TORY LIMITS ER
EMPLOYERS' LIABILITY $1,000,000
EL EACH ACCIDENT
B THE PROPRIETOR/ RINCL 2564606 12/11/98 12/11/99 EL DISEASE - POLICY LIMIT $1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE - EA EMPLOYEE $1,000,000
OTHER
A Leased/Rented KK08300574 01/01/99 01/01/00 $20,000
Equipment
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
* 10 day notice of cancellation for non-~a~ent of ~remium.
Re: Rosema~ Elementart School Permit # 6-180 - 40 W. Hamilton Ave.
Additional Insured per orm CG 2010 attached.
Workers' Compensation Waiver of Subrogation included.
EP --------
.,.....,......,.,.,.,..... '.'.......,. ....,......
...,.,.,.,.,.,.. "..........
C-CAM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL
City of Campbell 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
--. . - un n_ ___ -.;';;: -- -
Department of Public Works ./7
70 North 1st Street
Campbell CA 95008 AUTHORIZED REPRESEN~~ /: C,<'{./ f~
........., .,."............,.,.,.... ,.,..,..',',',.,.,',. Francis E. Co....""poo o.;-.:l."~ u
,."""""""...,,' < <.".",
AI NUMBER: YR98-003
DATE ISSUED: January 12, 1999
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: KK08300574
INSURED: GEN-CON, INC.
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
Name of Person or Organization:
The City, The City of Campbell Redevelopment Agency, its officers, employees and volunteers
With respects to: Rosemary Elementary School- Permit # 96-180 - 401 W. Hamilton Ave.
(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.
PRIMARY INSURANCE
It is further agreed that such insurance as is afforded by this policy for the benefit of the above additional insured(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 non-contributory with the insurance provided
hereunder.
CG 20 10 II 85
Copyright, Insurance Service Office, Inc. 1984
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY
WC040306
(Ed. 4/84)
Waiver of Our Right to Recover From Others Endorsement - California
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the persons or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 5.00 % of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization
Job Description
The City, the City of Campbell
Redevelopment Agency, its officers
employees and volunteers
401 W. Hamilton Ave.
Rosemary Elementary School
Permit #96-180
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Republic Indemnity Company of America@
Company No. 19739
Insured: Gen Con, Inc.
Policy Number: 03526285
Endorsement Number: 003
Endorsement Effective: January 01, 1999
Printed on: January 12, 1999
Form No. WC306 10/93
--,- --
_A CORDTM CER"FIFICA"'~OF.1IABILI"FY INSURf \JCE8~c~~5
R. G, Speno, Inc.
18900 Stevens Creek Blvd. #200
Cupertino, CA 95014-3674
Francis E. Cook, C.P.C,U,
Phone No. 4 0 8 - 97 3 - 9500 Fax No.
INSURED
i
aECE'V~~.:Y
fEB , 2 19~OM;ANY
~OMPANY
PU61.IC WOR ~ C
AOMINISTRAT'
, COMPANY
I D
DATE IMM/DD/YY)
02/11/98
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
St. Paul Fire & Marine Ins.
Republic Indemnity Company
Gen-Con Inc.
Attn: Ms. Paula Mohr
800 Cristich Lane
Campbell CA 95008
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HA VE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICA TE MAYBE 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.
--r i ~ I
co i TYPE OF INSURANCE I ! POLlCV EFFECTIVE POLlCV EXPIRATION I
LTR : POLICY NUMBER i DATE (MM/DDIVYI DATE (MM/DDIYY) i
LIMITS
I GENERAL LIABILITY
>----,
A ~MMERCIAL GENERAL LIABILITY
8--J CLAIMS MADE ~ OCCUR
~ OWNER'S & CONTRACTOR'S PROT
~per Proj. Aggreg
~~OMOBILE LIABILITY
A ~ ANY AUTO
L-J ALL OWNED AUTOS
L ! SCHEDULED AUTOS
~ HIRED AUTOS
H "'~w"'o '"00"
BARA. GE LIABILITY
ANY AUTO
I
-~------~
KK08300574
01/01/98
GENERAL AGGREGATE $ 2, 000, 000
01/01/99 PRODUCTS - COMP/OP AGG $ 2,000,000
PERSONAL & ADV INJURY $ 1, 000 , 0 0 0
EACH OCCURRENCE $ 1, 000 , 000
FIRE DAMAGE (Anyone fire) I $ 50 , 000
MED EXP (Anyone person) $ 5 , 000
KK08300574
01/01/98
I COMBINED SINGLE LIMIT
01/01/99 i
I BODILY INJURY
i (Per person)
I
$1,000,000
i
I BODILY INJURY
i (Per accident)
I $
PROPERTY DAMAGE
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
; EXCESS LIABILITY i I EACH OCCURRENCE _+~1, OO~QP.Q__
I I
~ UMBRELLA FORM I I
A I KK08300574 01/01/98 01/01/99 AGGREGATE $1,000,000
_._u.. ....
I OTHER THAN UMBRELLA FORM I I $
WORKERS COMPENSATION AND I 1 I wc STATU- ! 10TH-
TORY LIMITS I ER I
EMPLOYERS' LIABILITY : f:L EACH ACCIDENT -~---
RINCL I i $ 1,000,000
B THE PROPRIETOR/ 03526285 I 12/11/97 12/11/98 EL DISEASE - POLICY L1M IT $ 1,000,000
PARTNERS/EXECUTIVE I
OFFICERS ARE: EXCL' EL DISEASE - EA EM PLOYEE $ 1,000,000
OTHER I
A Leased/Rented KK08300574 01/01/98 01/01/99 $20,000
Equipment I
I
I
I
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
*10 day notice of cancellation for non-p.ayment of premium.
Re: Rosemary Elementary School Permit ~96-180 - 401 W. Hamilton Ave.
Additional Insured per rorm CG 2010 attached.
Workers Compensation Waiver of Subrogation included,
EP
CERTIFICATE HOLDER CANCELLATION
C-CAM-3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL
30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
City of Campbell
Department of Public Works
70 North 1st Street
Campbell CA 95008
AUTHORIZED REPRESENTATIVE. ~r / _ /f /~
Francis E. Cook, .C~~ _~ l
"" /' -<DACORDCORPORATJ 1988
;/
ACORD 25-S (1/95)
AI NUMBER: YR98-028
DATE ISSUED: February 11,1998
POLICY NUMBER: KK08300574
INSURED: GEN-CON, INC.,
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (Fonn B)
This endorsement modifies insurance provided under the following:
COl\1MERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
The City, The City of Campbell Redevelopment Agency, its officers, employees and
volunteers
With respects to: 401 W. Hamilton Ave., Rosemary Elementary School - Permit # 96-180
(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 witll respect to liability arising out of "your work" for that insured by 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 insured(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 non-contributory with the insurance provided
hereunder.
CG 20 10 11 85
Copyright, Insurance Service Office, Inc. 1984
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY
WC040306
(Ed. 4/84)
Waiver of Our Right to Recover From Others Endorsement - California
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the persons or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 5,00 % of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization
Job Description
The City, the City of
Campbell Redevelopment Agency,
its officers, employees and
volunteers
401 W. Hamilton Ave.
Rosemary Elementary School
Pennit #96-180
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Republic Indemnity Company of America@
Company No, 19739
Insured: Gen Con, Inc.
Policy Number: 03526285
Endorsement Number: 001
Endorsement Effective: February 11, 1998
Printed on: February 11, 1998
Form No. WC306 10/93
INSURANCE
COMPANY
NAME AND
ADDRESS
OF INSURED/
APPLICANT
Ulico Casualty Company
14726 Ramona Avenue
Chino, CA 91710-5747
Gen-Con, Inc.
Ms. Paula Mohr
800 Cristich Lane
Campbell, CA 95008
LI~\~p
~ ~/
Nf'TICE OF CANCELLATION,. NONRENEWAL,
RL ..NAL OR DECLINATION OF INSURANCE
(California)
KIND OF POLICY:
Packa e
POLICY NO.:
CANCELLATION OR EXPIRATION WILL TAKE EFFECT AT:
1-01-98 ~e 12:01 a.m.
DATE OF MAILING: Janua 30 1998
ISSUED THROUGH AGENCY OR OFFICE AT:
Chino, California 91710
IHOUR.swtDARD TIMe
RECC!\'r-o
FEB D ~ '998
PUa~/c
AOMINI8TWOfH~{;
RATION
(Specific Information concerning the cancellation
or nonrenewal has been given to the Insured,)
INSURANCE
COMPANY
NAME AND
ADDRESS
OF LIEN-
HOLDER
TO LIENHOLDER:
You are hereby notified that the agreement under the Loss Payable Clause payable to you as Lienholder, which is a part of the above policy, issued to the
above insured, is hereby cancelled or nonrenewed in accordance with the conditions of the policy, said cancellation or nonrenewal to be effective on and
after the hour and date mentioned above.
. Ulico Casualty Company
14726 Ramona Avenue
Chino, CA 91710-5747
City of Campbell
Department of Public Works
70 North 1st Street
Campbell, CA 95008
GU 8111F (Ed. 2-97) UNIFORM PRINTING & SUPPLY, INC.. = 1996
~
AUTHORIZED REPRESEtmTlYE
LIENHOLDER'S COPY
1D
R. G. SPENO, INC.
/
Insurance Brokerage
December 15, 1997
Re: Certificate of Insurance
Gen-Con, Inc.
Dear Sir/Madam:
We have updated the Workers' Compensation policy term to 12/11/97 -
12/11/98. Attached is the certificate which replaces previously
issued.
Should you have any questions, please feel free to glve us a call.
Thanks & Regards,
C~--e.t./
Carole G. Ubaldo
. enclosure
CORPORATE OFFICE. 18900 STEVENS CREEK BLVD.. SUITE 200. CUPERTINO, CALIFORNIA 95014. (408) 973-9500. FAX (408) 257-2985
BRANCH OFFICE. 894 MEINECKE AVE., SUITE C . SAN LUIS OBISPO, CA 93401 . (805) 784-0104 . FAX (805) 784-0105
ACORQM
CERT1FICAT- OF LIABILITY INSURJ' "ICE 8~~C~~5
DATE (MM/DD/YYI
R. G. Speno, Inc,
18900 Stevens Creek Blvd. #200
Cupertino, CA 95014-3674
Francis E. Cook, C.P.C.U.
Phone No. 408 - 973 - 9500 Fax No.
INSURED
~,"';: ,I,; ~t
12/15/97
THIS CERTIFICATE IS ISSUED AS A MAHER 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
('0
I
I
l COM;ANY
I COMPANY
I B
~
i COMPANY
! C
~ COM;ANY
i D
Fireman's Fund Insurance Co.
-1 ,.", ~\(\OJ-1
-, , :~ r~1
Ulico Casualty Company
Gen-Con Inc.
Attn: Ms. Paula Mohr
800 Cristich Lane
Campbell CA 95008
Republic Indemnity Company
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I POLICY EFFEC~ POLICY EXPIRATION 'I'
TYPE OF INSURANCE POLICY NUMBER I DATE IMM/D~/~~1 I DATE (MMIDDNY) ,
CO
LTR,
L1M ITS
GENERAL LIABILITY
B Xl COMMERCIAL GENERAL LIABILITY CLU0001248
kJ-J CLAIMS MADE i X i OCCUR
f-XJ OWNER'S & CONTRACTOR'S PROT
I I .
:--x_1 Per ProJ, Aggreg
08/01/97
GENERAL AGGREGATE
08/01/98 I PRODUCTS - CDMP/DP AGG
I
, PERSONAL & ADV INJURY
, EACH OCCURRENCE
$2,000,000
$2,000,000
$1,000,000
'H-
1$1,000,000
i FIRE DAMAGE (Anyone tire) i $ 50 , 000
f----. ---T--------
i MED EXP (Anyone person) I $ 5 , 000
! AUTOMOBILE LIABILITY
B r-X-1 ANY AUTO
l j ALL OWNED AUTOS
~___~ SCHEDULED AUTOS
~ HIRED AUTOS
r-X NON-OWNED AUTOS
~~
I GARAGE LIABILITY
[1 ANY AUTO
I ,
EXCESS LIABILITY
A [--
IX UMBRELLA FORM
r-
OTHER THAN UMBRELLA FORM
i WORKERS COMPENSATION AND
! fiViPLU1c(\S' liABiLITY
C I THE PROPRIETOR/ INCL
I PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
OTHER
B Leased/Rented
Equipment
CLU0001248
08/01/97
COMBINED SINGLE LIMIT
08/01/98 '
!$l,OOO,OOO
BODILY INJURY
(Per person)
BODILY INJURY
(Per accidenll
PROPERTY DAMAGE
AUTO ONLY. EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE
XEK00083119156
08/01/97
EACH OCCURRENCE
08/01/98 AGGREGATE
$1,000,000
$1,000,000
L__ ~._-_.._- --
12/11/971 i $ 1,000,000
03526285 12/11/98 ~ DISEASE - POLICY LIMIT 1,000,000
EL DISEASE. EA EMPLOYEE I $ 1,000,000
CLUOOO1248 08/01/97 08/01/98 $20,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
*Ten (10) day notice of cancellation for non payment of premium.
RE: 401 W. Hamilton Ave., Rosemary Elementary School - Permit #96-180
See Additional Insured Form CG2010 attached
Workers Compensation Waiver of Subrogation included
EP
CERTIFICATE HOLDER CANCELLATION
C-CAM-3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL I MAIL
30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
City of Campbell
Department of Public Works
70 North 1st Street
Campbell CA 95008
Francis E. Cook,
AUTHORIZED REPRESENTATIVE
ACORD 25-S (1/95)
A~~~.I!lt..
CERTIFICA T OFINSURANCE
CSR CE
GENCQ-5 08/05/97
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.
I COMPANIES AFFORDING COVERAGE
,--------- ----.----.---.------- .----
~\ ! C_O_.MAP_ANY
Fireman's Fund Insurance Co.
-~ f C. ,~ . ! COMPANY
& jftft'J! B
lUG ." tt3. I COMPANY
. I C
'Iv ~..ii(I";) ~--_.
. . .'~~STRATLON I COMPANY
~~l~\~' D
DATE IMM/DD/YYI
PRODUCER
R. G. Speno, Inc.
18900 Stevens Creek Blvd. #200
Cupertino, CA 95014-3674
Francis E. Cook, C.P.C.U.
~No. 408- 9}3 -9500 Fax No.
INSURED
Ulico Casualty Company
Gen-Con Inc,
Ms. Paula Mohr
800 Cristich Lane
Campbell CA 95008
COVERAGES
Republic Indemnity Company
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HA VE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REOUIREMENT, 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.
~ I I' POLICY EFFECTIVE POLICY EXPIRATION I
l~~ I TYPE OF INSURANCE ! POLICY NUMBER DATE (MM/DD/VV) DATE (MM/DDIYYI I LIMITS
~NERAl LIABILITY I r! I GENERAL AGGREGATE : $ 2, 000, 000
B ~"O,MMERCIALGENERALLlABILlTY I CLU0001248 I' 08/01/971 08/01/98 1-;~ODUCTS-COMP/OPA<3.~h~.'-()OO,Jl-~-
L-.l-.J CLAIMS MADE ~l OCCUR I! PERSONAL & ADV INJUR':.._....s...! ' 000-'.000 __
~ X ! -~VIfNER'S & CONTRACT;R'S PROT I EACH OCCURRENCE $ 1, 000 , 000
f xjper Proj. Aggreg ! II! FIRE DAMAGE (Anyone fire) $ 50, 000
I !! MED EXP (Anyone person) $ 5 , 000
L.AlJ!OMOBllE LIABILITY 11 ~
' , COMBINED SINGLE LIMIT $ 1, ' 000 , 000
B I X I ANY AUTO CLU0001248 08/01/97 08/01/98
~I--.j ALL OWNED AUTOS BODILY I!::-~~.-~--T$-------n----
SCHEDULED AUTOS (Per person)
. -~--_.-
X HIRED AUTOS BODILY INJURY $
~. NON-OWNED AUTOS I IPer accident)
- .'1 .------ -.,----.-- I PROPERTY DAMAGE $
--
ANY AUTO
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
-----
GARAGE LIABILITY
'..n_
--
.-._,~-
EXCESS LIABILITY
A -Xl UMBRELLA FORM
I OTHER THAN UMBRELLA FORM
XEK00083119156
08/01/97
EACH OCCURRENCE
08/01/98 AGGREGATE
$1,000,000
$1,000,000
._m___
$
C WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
I THE PROPRIETOR/ R--1 INCL I 03526285
I PARTNERS/EXECUTIVE I
OFFICERS ARE: EXCL !
IMHffi I
B Leased/Rented CLU0001248
I Equipment I
I !
i
DESCRIPTION OF OPERATIONS/lOCATIONSIVEHIClES/SPECIAllTEMS
*Ten (10) day notice of cancellation for non payment of
RE: 401 W. Hamilton Ave., Rosemary Elementary School -
See Additional Insured Form CG20l0 attached
Workers Compensation Waiver of Subrogation included
EP
CERTIFICATEHOLDER
i
I
I
I
12/11/97
I STATUTORY LIMITS
~ACH ACCIDENT ----r!---:I:L()Q.().'-<>.()-Q.-
DISEASE. POLICY LIMIT $ 1, 000 , 0 Sl...Cl.....
DISEASE - EACH EMPLOYEE $ 1, 000, 000
I
I
08/01/98
$20,000
premium.
Permit #96-180
CANCELLATION
C-CAM-3
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEllED BEFORE THE
City of Campbell
Department of Public Works
70 North 1st Street
Campbell CA 95008
EXPIRATION DATE THEREOF, THE ISSUING COMPANY Will T MAil
30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE lEFT.
J! __ _ I
r I I~ .-.. ~'7f:""
C.P.~LD~~
AUTHORIZED REPRESENTATIVE
Francis E. Cook,
ACORD 25-S (3/93)
AI NUMBER: YR97-28
DATE ISSUED: August 5, 1997
POLICY NUMBER: CLU0001248
INSURED: GEN-CON, INC.
COMMERCIAL GENERAL LIABILITY
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 CENERAL LIABILITY COVERACE PART
SCHEDULE
Name of Person or Organization:
The city, The City of Campbell Redevelopment Agency, its officers, employees and
volunteers
With respects to: 401 W. Hamilton Ave., Rosemary Elementary School
Permit # 96-180
(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.
PRIMARY INSURANCE
It is further agreed that such insurance as is afforded by this policy for the benefit of the above
additional insured(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 non-contributory with the insurance provided
hereunder.
CG20101185
Copyright, Insurance Service Office, Inc. 1984
WC040306
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY (Ed. 4/84)
Waiver of Our Right to Recover From Others Endorsement - California
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the persons or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 5.00 % of the California workers' compensation premium
otherwise due on such remuneration.
Schedule
Person or Organization
Job Description
The City, the City of
Campbell Redevelopment Agency,
its officers, employees and
volunteers
401 W. Hamilton Ave.
Rosemary Elementary School
Permit #96-180
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Republic Indemnity Company of America@
Company No. 19739
Insured: Gen Con, Inc.
Policy Number: 03515720
Endorsement Number:
Endorsement Effective: 12/19/96
Printed on: 12/19/96
Form No. WC306
10/93
Insured Copy
..-......-..---.-..."'."""""""""'.".,...-.-.--.--.--..-----..-....
A~~~.ltl... ~eFf..II:::I;A1'FOFINSI..IRANeEd CSR<CE DATE IMM/DDIVYj
..
.>GENCQ...5 12/19/96 ......
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
R. G. Speno, Inc. ,,,I ~HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
18900 Stevens Creek Blvd. #200a t C i ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cupertino, CA 95014-3674 COMPANIES AFFORDING COVERAGE
Francis E. Cook, C.P.C.U. nl=C2S_ COMPANY
A Ulico Casualty Company
Phone No. 408-973-9500 Fax No.
INSURED -
. \(. VIJ Vl"""'~t COMPANY
:~~~N\SlRAi\O B Republic Indemnity Company
Gen-Con Inc. COMPANY
Ms. Paula Mohr C of America
800 Cristich Lane COMPANY
Campbell CA 95008 D Fireman's Fund Insurance Co.
....... ...................... ................ > ............ .................... >
I.. ............. ...... ........................... ..........................
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE I POLICY EXPIRATION LIMITS
lTR DATE IMM/DDIVY) DATE IMM/DDIVYI
. ,
GENERAL LIABILITY GENERAL AGGREGATE $2,000,000
-
A X COMMERCIAL GENERAL LIABILITY CLUOOO1248 08/01/96 08/01/97 PRODUCTS - COMP/OP AGG $2,000,000
> I CLAIMS MADE ~ OCCUR PERSONAL & ADV INJURY $1,000,000
~ OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000
~ Per Job Site Agg FIRE DAMAGE (Anyone firel $ 50,000
MED EXP (Anyone person) $ 5,000
AUTOMOBILE LIABILITY
- COMBINED SINGLE LIMIT $ 1,000,000
A ~ ANY AUTO CLUOOO1248 08/01/96 08/01/97
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
~ HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accidentl
- PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $
- >
ANY AUTO OTHER THAN AUTO ONLY: ...............
-
EACH ACCIDENT $
-
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $1,000,000
D ~ UMBRELLA FORM XEK67910687 09/18/96 08/01/97 AGGREGATE $1,000,000
OTHER THAN UMBRELLA FORM $
B WORKERS COMPENSATlml AND I I STATUTORY LIMITS ........>uuS.. <.
EMPLOYERS' LIABILITY 1,000,000
EACH ACCIDENT $
THE PROPRIETOR/ MINCL 03526285 12/11/96 12/11/97 DISEASE - POLICY LIMIT $ 1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE - EACH EMPLOYEE $ 1,000,000
OTHER
A Leased/Rented CLUOOO1248 08/01/96 08/01/97 SpecForm $40,000
Equipment inc Theft $1000 ded.
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
*Ten 410) da~ notice of cancellation for non pa~ent of ~remium.
RE: 01 W. amilton Ave., Rosema~ Elementary chool - ermit #96-180
See Additional Insured Form CG2010 attached
Workers Compensation Waiver of Subrogation included
EP
........ --------------- ....... .....
...........
C-CAM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL - MAIL
City of Campbell 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Department of Public Works -
70 North 1st Street
Campbell CA 95008 AufkoRIZED REPRESENTATIVE C~~ fd/~
................... .... Francis E. Cook,
............. ........ ................ ....... < ........ / .~
..;
AI NUMBER: YR96-28
DATE ISSUED: December 19,1996
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: CLU0001248
INSURED: GEN-CON, INC.
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 CENERAL LIABILITY COVERACE PART
SCHEDULE
Name of Person or Organization:
The City, The City of Campbell Redevelopment Agency, its officers, employees and
volunteers
With respects to: 401 W. Hamilton Ave., Rosemary Elementary school
Permit # 96-180
(If no entry appears above, information required to complete this endorsement will be
shown in the Declarations as applicable to this endorsementJ
WHO IS AN INSURED csection 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.
PRIMARY INSURANCE
It is further agreed that such insurance as is afforded by this policy for the benefit of the
above additional insuredCs) 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 insuredCs) shall be excess and non-contributory with the insurance provided
hereunder.
CG 20 10 11 85
copyright, Insurance Service Office, Inc. 1984
WC040306
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY (Ed. 4/84)
Waiver of Our Right to Recover From Others Endorsement - California
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the persons or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 5.00 % of the California workers' compensation premium
otherwise due on such remuneration,
Schedule
Person or Organization
Job Description
The City, the City of
Campbell Redevelopment Agency,
its officers, employees and
volunteers
401 W. Hamilton Ave.
Rosemary Elementary School
Permit #96-180
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Republic Indemnity Company of America@
Company No. 19739
Insured: Gen Con, Inc.
Policy Number: 03515720
Endorsement Number:
Endorsement Effective: 12/19/96
Printed on: 12/19/96
Form No, WC306 10/93
Insured Copy
. A.~..III".
12/19/96
THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND CONVEYS ALL THE
RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY.
EVltl.EH.eE....t'.. ...~.......ft80F>EFitY......IHSl..lRAH
'I:
C:;~RCE
DATE (MM/DDIYYI
PRODUCER
~g~~:'~t,:4 08 - 97 3 - 9500/
COMPANY
R. G. Speno, Inc.
18900 Stevens Creek Blvd. #200
Cupertino, CA 95014-3674
Francis E. Cook C.P.C.U.
CODE: 04-126-602 SUB CODE:
~3~~g~ER ID #: GENCO - 5
INSURED
Fireman's Fund Insurance Co.
P.O. Box 5984
San Jose CA 95150
Gen-Con Inc.
800 Cristich Lane
Campbell CA 95008
EFFECTIVE DATE
MXI80332590
LOAN NUMBER
POLICY NUMBER
05/07/96 05/07/97
THIS REPLACES PRIOR EVIDENCE DATED:
CONTINUED UNTIL
TERMINATED IF CHECKED
11/25/96
LOCATION/DESCRIPTION
001
401 W. Hamilton Ave.
Campbell CA 95008
Improvements at Rosemary Elementary
school-per.mit #96-180
COVERAGE/PERILS/FORMS
AMOUNT OF INSURANCE
DEDUCTIBLE
Special Causes of Loss - Replacement Cost
34,000
1000
THE POLICY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE
POLICY BE TERMINATED, THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 3 0 DAYS
WRITTEN NOTICE, AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT
INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW,
City of Campbell
Public Works Department
70 No. First St.
Campbell CA 95008
MORTGAGEE
NAME AND ADDRESS
AUTHORIZED REPRESENTATIVE
I
ACORD 27 (3/93)
Francis E. Cook,
0i~~~~~
DEC-19-96 THU 15:25
RG SPENO INC
FAX NO, 4082572985
p, 02
r
At~C.ltI.A
CERTIFICATE ""fINSURANCE
CSiR CE
. QZNCO~5 12/19/96
THIS CERTIr:ICA TE IS ISSUED AS A MAHER 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
DATE 1IV11'/1/t1PIYYI
PIIUDUCER
R. G. Speno, Ine,
18900 Stevens Creek Blvd. .200
CUpertino, CA 95014-3674
Francis E. Cook, C.P.C.U.
PhontND. 408-973-9500 fuND.
INSVIIW
.--
COMPANY
A
Ulico Casualty Company
...--
COMPANV
B
~epublic Indgmn1ty Company
Gan-Con Inc.
Ms. Paula l5ob:t'
800 Cr18t1ch Lane
Campbell CA 95008
COVERAGES ... .
THIS IS TO CERTIFY '1'I-lAT THE POLICIES OF INSURANCE LISTED DElOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVe FOR TIojE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUlfiEMENT. TEAM OR CONDITION OF ANY CONTR.ACT OR OTHER DOCUMENT WITH flESI'ECT TO W1lICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE ,.OllCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICies. LIMITS SHOWN MAY HAV~ BEEN nEDUCED BY PAID CLAIMS
. -- - - ..-
~
COMPANY
C
of America
COMPANY
D
Fireman'S Fund Insurance Co.
CO
~TIl
TYPE Of INSVIIAI\ICE
POlICY NV1VI8EIl
PUlley EffECTiVe POLICY EXPIRATION LIMITS
DATE l~"'/DDIYYI DATE IMM/PPIYYJ
-.-
G'NElIAl AGGIl~C;;A TE '2,000,_OuOO
08/01/96 08/01/97 PIIOOUCTS . COMP/OP AGel $2,000.000
--.-.
PERSONAl a. ADV INJURY .1,000,000
. .
EACH OCCURRCNCE '1,000,000
~IRE DAMAGE IAny Qn, fl,.l . SO,OOO
MED EXP !Any on" perso"l . 5,000
08/01/95 08/01/97 COMBII'I"O SINGL~ LIMIT .1,000,000
.. ..
800llY INJUIIY r
(P" P"10I11
.. ---
BODilY INJURV S
<<P... ."Gtacnl)
PIIOPEIITY DAMAGE .
AUTO ONLY. EA ACCIO'NT .
OTHEII THAN AUTO ONLY.
EACH ACCIDENT .
AGGROGATE $
EACH OCCURRENCE '1,000,000
-.
09/18/96 08/01/97 "'<lGRE<lATE '1,0.9.0,000
---.
.
!STATUTOIlY LIM!.:~_.. M"'_"~_
E"'CH ACCIDENT . 1,000,000
-----.. .....-----.
12/11/96' 12/11/97 DISE"SE . POLICY LIMIT . 1,000,000
..:.. -..----.--....-.- . ..-.._----_.--
DISEASE. EACH EMI'LOYEE . 1,000,000
08/01/96 08/01/97 SpecForm '40.000
inc Theft $1000 ded.
~E"Al L1ADILITY
l\ X COMMEIIClAlllENEMlllADlllTY CLU0001248
:=:tJ CLAIMS MADE [!J OCCUR
~ OWNER'S & CONTRACTOR'S PAOT
~.!. Per Job Site Agg
AUTOMOBILE lIAIllITY
f--
" X ANY AUTO
AU. OWNEb AUTOli
f--
SCHEDULED AUTOS
t--
X Hlfl~O AUTOS
-
...!. NON-OWNED "UTOS
-
CLUOOOI248
GARAGE l.....IUTy
--
-
A.NY"UTO
lXCEflS U.BIUTY
D Xl UMBREllA ~ORM
--, O'HCI< THAN 11MBR!u.A FOkM
B WORltlill5 COlllPUl5ATlON AND
EMPLOYERS' LIABIlITY
XEK671110687
TH~ J'llIO ~kIEtORJ
PARTNrRsn:XEC;UTIV~
OFFICEI\S NlE:
OTHEII
A Leased/Rented
Equipment
rillNCL
nEltCL
03526385
CLU0001248
PfSC""'TION 0' OP5AATIONll/lOCATIDNSMHICU;IlISP(CIAlITEMS
*Tsft (10) day no~ie. of eancella~ion for non pa~nt of
RIl:: 401 W. Hamilton Ave., Rosemau EleJllentary School -
See Additional In8ure4 ro~ OG2010 attached
Worker. compensation waiver of Subrogation ineluded
EP
CERTIFICATE HOLDER
premium .
Permit 196-180
CANCELLATION
C-CAM-3
SHOULD ANY Of THE ADOVE DESCNDEP POLICIES liE CI\NCEllEP IIEfQl\E THE
~xPlIlA'r10N DATE THEREOF, THE ISSUING COMPANY Will MAIL
30. DAYS WRITTiN NOTICE TO THE CERTifiCATE HOLDER NAMEI) TO THE LEfT.
City of Campbe~~
Department of Public works
10 North 1st Street
Campbell CA 95008
.OIllZED II_SENTATlVE
I'rancis E. Cook,
c~Ld/~
...,.. -.;- ""ORD.COR;O~~.93
./
ACOIn' 25.513/93]
DEC-19-96 THU 15:26
RG SPENO INC
FAX NO, 4082572985
P. 03
Al NUMBER: YR96.28
DATE ISSUED: December 19, 1996
POLICY NUMBER: CLU0001248
INSURED: CEN-CON, INC.
COMMERCIAL GENERAL LIABILITY
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 COVERACE PART
SCHEDULE
Name of Person or Organization:
The City. The City of campbell Redevelopment Agency. its officers, employees and
volunteers
With respects to: 401 W. Hamilton Ave., Rosemary Elementary School
Permit, 96-180
(If no entry appears above, informatIon reQuired to complete this endorsement will be
shown In the Declarations as appllcable 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.
PRIMARY INSURANCE
It Is further agreed that such Insurance 3S Is afforded by this policy for the benefit of the
above additionallnsured(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
addltlonallnsured(S) shall be excess and non-contributory with the insurance provided
hereunder,
CC 20 10 11 85
copyright, Insurance service Office, Inc. 1984
DEC-19-96 THU 15:26
RG SPENO INC
FAX NO, 4082572985
P. 04
WC040306
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY (Ed. 4/84)
Waiver of Our Right to Recover From Others Endorsement - California
We have the right to recover our payments from anyone liable tor an injury Cl}vered by this policy. We will nOl enforce
our right ai;lIUm the l)ersODs or organi/..ation named in the Schedul\;. Thi.~ agreement iill1plies only to the extenr thllt you
perfurm work unul!r a written cuotract thai require... you to obtain this agreement from u.~.
You must maintain payroll records accurately ~gregatmg the remuneration of your tmployees while engaged in the
work de~cl'ibe(l in the Scbedule.
The additional premium fur this endorsement shel\l be 5,00 % of the California workers' compensation premium
otherwise due on such remuneration,
Schedule
PUSQD or Orlan~.twD
Job Description
The City. the City of
Campbell Redevelopment Agency,
iL~ otrlcers, enlployees an\!
volunteers
401 w. HamiltQn Ave.
Rosemary Elementary School
Permit #96-180
This endorsement changes the policy to which it is atr..ached and is effective on the date issued unless otherwise stated.
Republic Indemnity Company of America@
Company No. 19739
Insured: Gen Con. Inc.
Policy Number: 03515720
Endorsement Number:
Endorsement Effective: 12/19/96
Printed on: 12/19/96
Form No. WC306 10193
Insured Copy
DEC-19-96 THU 15:27
RG SPENO INC
FAX NO. 4082572985
p, 05
r--
AC..III.. EVIDENCEOFr'ROPERTY'INS'ORANCE CSR Cs DATEIMMiDDIYVl
THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED. IS IN FORCE. AND CONVEYS ALLT~t/;9t~!i
RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY.
PRODUCER INC.... ~\l408-973-950Ot COMPMY
R. G. Speno, XnC.
18900 Stevens C~.ek Blvd. #JOO
Cupertino, CA 95014-3674
~ aneis E. Cook C.P.C.U.
CODE: 04-126-602 SUB CODE:
CI.I$TOMEflID .: GENCO - 5
INaURED
Fireman'lI Fund Insurance Co.
P.O. Box 5984
San Jose CA 95150
lOAN NUMBEII
POLICY NUMI'R
Gen-Con Inc.
800 Cristich Lane
Campbell CA 95008
Uf~OATE
MXI80332S90
EXPIRATION DATE
05/07/96 ....05/07/97
THI6 ..mACES ""101\ lVIDE~cr'DAT'D' . - -.-
PRIJ~1.;RiXJN'P~.ATlO~
lOCAYtONiDESCIlIl'TlO'"
001
401 W. H~lton Ave.
Campbell CA 95008
Improvements at Rosemary IUem~n~Ary
School-Pe~t "6-180
. COVf;RAGEINFORlI/tATION
CONTINVED UNTIL
TERMINATED IF C~'CI(ED
COVEIlAGElPEllII.SIFORMI
AMou",r OF INSURANCE
1000
cANe~l..LA1'lON
THE POLICY IS SUBJECT TO THE PREMIUMS. FORMS, AND RULES IN EFFECT FOR EACH POLlCY PERIOD, SHOULD THE
POLICY BE TERMINATED. THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 30 DAYS
WRITTEN NOTICE. AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT
INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW.
AOI)l'rlC2~ 1P41~p.eST
NAME AND ADORE"
Special Caus.. of LOIIII - Replacement CO;EJt
REMARKS 11"~di~1r S~.cT" CoJ1d"",~ri.l
~.J ADDITIO~ INSIJ_RiD
City of Campbell
Puhl~c Work. D.par~ent
70 Jlo. ri:r:st St:.
Campbell CA 95008
I
. ACORD 27 {;.l/93)
AUTtiDIUZED Ri:PRESENr,ArwE
DfDUCTIBlE
34,000
~~M'
1"b- /gv
fD
R. G. SPENO, INC.
/
Insurance Brokerage
18900 STEVENS CREEK BLVD.. SUITE 200 . CUPERTINO, CALIFORNIA 95014 . (408) 973-9500 . FAX (408) 257-2985
December 16, 1996
() / .
~ ' ,
It.. , y .' t
/ ',i, ',.'tl~,\' "~",J", . :"', ' "..
j . d,. ,'V}
. .
_ :, l
:('.\ '
''I' ,
\J ~_
City of Campbell
70 No, First St,
Campbell, Ca 95008
RE: Gen Con, Inc.
Your Project - Rosemary Elementary School
401 W. Hamilton Ave,
Gentlemen:
Enclosed is the waiver of subrogation endorsement for Gen Con's
workers' compensation policy.
If you have any questions, please let me know,
Sin<;:erely,
// ~ ~-_.
( /\'_,~.,I I. .J-~~.---c...:....
, ,
Car 1 yn Ea t'on
S:c, Account. ivianager
enclosure
cc: Gen Con, Inc,
WC040306
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY (Ed,4-84)
Waiver of Our Right to Recover From Others Endorsement - California
We have the right to recover our payments from anyone liable for an injwy covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us.
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsementshall be
othelWise due on such remuneration.
5.00 % of the California workers' compensation premium
Schedule
Person or Organization
THE CITY, THE CITY OF CAMPBELL
REDEVELOPMENT AGENCY, ITS
OFFICERS, EMPLOYEES AND VOLUNTEERS
70 NORTH 1ST STREET
CAMPBELL, CA 95008
Job Description
ROSEMARY ELEMENTARY SCHOOL 401 w.
HAHILTON AVE.
This endorsement changes the policy to which it is attached and is effective on the date issued unless othelWise stated.
Republic Indemnity Company of America@
Company No. 19739
Insured; GEN-CON, INC.
Policy Nwnber: 03515720
Endorsement Nwnber: 0008
Endorsement Effective: November 25,1996 Printed on: December 10,1996
Form No. WC306 10/93
111111I1111111111111111111I11111111111111111111111
Insured Copy
11111111111111111111111111111111111111111111111111
/ GEN-CON /
INC.
BUILDING CONTRACTORS
RECEIVED
DEe 20..1996
FAX TRANSMITTAL COVER LETTER
PEf?~~\;""\ q,~-'l~
hJi.H.I( WUi<.i(S
ADMINISTRATION
DATE: 12/19/96
TIME: R .1n
A.M. !IR)MX
TO: Carlyn
COMPANY & FAX: R.G. Speno
FROM: Paula
RE: Revised Certificate of Insurance
City of Campbell
New Workers Compensation Expiration Date
Re: Rosemary Elementary School - 401 W. Hamilton Avenue, Campbell CA
TOTAL NUMBER OF PAGES INCLUDING THIS PAGE IS: 5
ORIGINAL TO FOLLOW BY MAIL:
)fEa: ! NO
COMMENTS:
PLEASE FAX 376-0958 AND MAIL TO THE CITY OF CAMPBELL A r:OMPUTF NEW
CERTIFICATE OF INSURANCE WITH A CURRENT EXPIRATION DATE (12/11/97) FOR
THE WORKERS COMPo AND ALL OF THE SAME EXACT ENDORSEMENTS PREVIOUSLY
ISSUED ON 12/3/96 (SEE ATTACHED).
IF YOU HAVE ANY QUESTIONS, PLEASE CALL.
cc: City of Campbell Public Works (Chuck/JoAnne) - 376-0958
IF YOU DO NOT RECEIVE THE PAGE(S) OR ARE DISCONNECTED, PLEASE CALL
BACK AS SOON AS POSSIBLE AT (408)879-1680.
CONFIDENTIALITY NOTICE
THE DOCUMENT(S) ACCOMPANYING THIS TElECOPY TRANSMISSION CONTAIN INFORMATION BELONGING TO THE SENDER
WHICH IS lEGALLY PRIVILEGED. THE INFORMATION IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED
ABOVE IN DIRECT BUSINESS DEALINGS WITH GEN-CON, INC. IF YOU ARE NOT THE INTENDED RECIPIENT, YOU ARE HEREBY
NOTIFIED THAT ANY DISCLOSURE. COPYING. DISTRIBUTION OR THE TAKING or: ANY ACTION IN RELIANCE ON THE CONTENTS
OF THIS TElECOPIED INFORMATION IS STRICTLY PROHIBITED. DISTRIBUTION OF THIS TELECOPIED INFORMATION BY THE
RECIPIENT TO ANY OTHER PARTY IS ALSO EXPRESSLY FORBIDDEN EXCEPT WITH WRITTEN AUTHORIZATION FROM
GEN-CON. INC
800 Cristich Lane. Campbell, CA 95008 · (408) 879-1680 · FAX (408) 879-1686
LiCt:'n~l' # 53370H
..... A.~.'lal~" ~ERtlfIC~r" . <OfINSI.JIANIE CSR<CE DATE (MM/DDIYY)
GENC();,.5 12/03/96 i
PRODUCER Rt=f"'r "TeT') THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
R. G. Speno, Inc. DEe - 41996 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
18900 Stevens Creek Blvd. #200 AL TER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cupertino, CA 95014-3674 COMPANIES AFFORDING COVERAGE
Francis E. Cook, C.P.C.U. GEN-CON, INC , COMPANY
A Ulico Casualty Company
Phone No. 408-973-9500 Fax No.
INSUREO COMPANY
B Republic Indemnity Company
Gen-Con Inc. COMPANY
Ms. Paula Mohr C of America
800 Cristich Lane COMPANY
Campbell CA 95008 D Fireman's Fund Insurance Co.
................. > ........................ ................... .................. < ....................................... ................... ........... ................. ...................
.......... ............. ............... .................
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, 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 PO!ICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
lTR DATE (MM/DDIYYI DATE (MM/DDIYY)
GENERAL LIABILITY GENERAL AGGREGATE $2,000,000
-
A X COMMERCIAL GENERAL LIABILITY CLUOOO1248 08/01/96 08/01/97 PRODUCTS - COMP/OP AGG $2,000,000
> I CLAIMS MADE [!] OCCUR PERSONAL & ADV INJURY $1,000,000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $1,000,000
-
X Per Job Site Agg FIRE DAMAGE (Anyone fire) $ 50,000
-
MED EXP (Anyone personl $ 5,000
AUTOMOBILE LIABILITY
- COMBINED SINGLE LIMIT $1,000,000
A X ANY AUTO CLUOOO1248 08/01/96 08/01/97
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
X HIRED AUTOS BODILY INJURY
- $
~ NON-OWNED AUTOS (Per accident)
.
r-- PROPERTY DAMAGE $
GARAGE liABILITY AUTO ONLY - EA ACCIDENT $
r--
ANY AUTO OTHER THAN AUTO ONLY: I i>
f---
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $1,000,000
D M UMBRELLA FORM XEK67910687 09/18/96 08/01/97 AGGREGATE $1,000,000
OTHER THAN UMBRELLA FORM $
B I WORKERS COMPENSATION AND I I I STATUTORY LIMITS < >
EMPLOYERS' LIABILITY 1,000,000
EACH ACCIDENT $
THi: PROPRIETOR/ M INCL ' 03515720 12/11/95 I 12/11/96 DISEASE - POLICY LIMIT $ 1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE - EACH EMPLOYEE $ 1,000,000
OTHER
A Leased/Rented CLUOOO1248 08/01/96 08/01/97 SpecForm $40,000
Equipment inc Theft $1000 ded.
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
*Ten d10) day notice of cancellation for non pa~ent of premium.
RE: 4 1 W. Hamilton Ave., - Rosemary Elementary School - Permit #96-180
See Additional Insured Form CG2010 attached.
Workers comEensation Waiver oj Sjbrogation included.
~VISING CE TIFICATE DATED 11 25 96 E P
......><...> ..................... ....... ............. ................ < > > <
....... ./ ......
C-CAM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL_ 'AIL
City of Campbell 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Department of Public Works n r . - ~
70 North 1st Street
Campbell CA 95008 ~rno"'~"'_~mN' _ _ ~ *~
.............. ...............> ...........................< i Franc1s E. Cook,c-~. _. U
i . ......... ........< . .....<><...... .......... .... 1993
/
AI NUMBER: YR96-28
DATE ISSUED: December 3, 1996
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: CLU0001248
INSURED: GEN-CON, INC.
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
Name of Person or organization:
The City, The City of Campbell Redevelopment Agency, its officers, employees and
volunteers
With respects to: 401 W. Hamilton Ave., Rosemary Elementary School
permit # 96.180
(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 inciude 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.
PRIMARY INSURANCE
It is further agreed that such insurance as is afforded by this policy for the benefit of the
above additional insured(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 non-contributory with the insurance provided
hereunder.
CG 20 10 11 85
Copyright, Insurance Service Office, Inc. 1984
WORKERS' COMPENSATION ANI> EMPI,OYERS' LIABILITY POLICY
Waiver of Our Right to Recover I-rom Other. Endorsement - Culiforuia
W( '0403()(i
(Ed. 4.8.1)
We .114 ve the right to JeCOverour payments from anyone liable for an injwy covered by Ihis policy. We wi! I nol enforce
our right again.. the penon or organization named in the Schedule. This agreement applies only to the extcntthat you
perfoffil work unde,. written contract that require. you to obtainlhi. agreement from liS.
You must mamt.in payroll recorda accurately segregating the rennmerationof your employees while engaged in the
work described in the Schedule.
The additionalpmnium forthi. endorsement shall be
otllerwlsedue onlUChremWleration.
5. 00% of the California workers' compensation premium
Scheel.1e
PersoD or OrpabaUoa
The City. the City of
Campbell Redevelopment Agency,
its officers, employees and
volunteers
Job DeKrlptfo.
401 W. Hamilton Ave.
Rosemary Elementary School
Permit #96-180
This endorsement changes the policy to which it is attached and is effective on the date issued unlcss otherwise stated.
Republic Indemnity Company of America@
COl1IpllOy No, 19739
Insu.red: ~n Con, I nc .
Policy Nwnber: 035 2~Z8.s-
Endonemam Number:
~..Eff~:
FODD No. WC306
11/25/96
1M3
Printed on:
12/03/96
,..........
Inaared Copy
I..........
I
I
I
I
I
I
I
I
I
I
I
I
I
J
A.~t.III.B
12/03/96
THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND CONVEYS ALL THE
RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY.
EVIDENCE C
IRc)f>ER"I"~IIStJR~1
"=
C$FiCE
DATE (MM/DDIYY)
PRODUCER
:1\g~~:.~t):4 0 8 - 973 - 950 0/
COMPANY
R. G. Speno, Inc.
18900 Stevens Creek Blvd. #200
Cupertino, CA 95014-3674
Francis E. Cook C.P.C.U.
CODE: 04-126-602 SUB CODE:
~3~~gr..ER ID #: GENCO - 5
INSURED
Fireman's Fund Insurance CO.
P.O. Box 5984
San Jose CA 95150
Gen-Con Inc.
800 Cristich Lane
Campbell CA 95008
EFFECTIVE DATE
MXI80332590
LOAN NUMBER
POLICY NUMBER
05/07/96 05/07/97
THIS REPLACES PRIOR EVIDENCE DATED:
CONTINUED UNTIL
TERMINATED IF CHECKED
11/25/96
LOCATION/DESCRIPTION
001
401 W. Hamilton Ave.
Campbell CA 95008
Improvements at Rosemary Elementary
School-Permit #96-180
COVERAGE/PERILS/FORMS
AMOUNT OF INSURANCE
DEDUCTIBLE
Special Causes of Loss - Replacement Cost
34,000
1000
City of Campbell
Public Works Department
70 No. First St.
Campbell CA 95008
MORTGAGEE
X LOSS PAYEE
LOAN #
THE POLICY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD, SHOULD THE
POLICY BE TERMINATED, THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 30 DAYS
WRITTEN NOTICE, AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT
INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW.
NAME AND ADDRESS
ADDITIONAL INSURED
Francis E.
AUTHORIZED REPRESENTATIVE
PREMIUM INCLUDED IN PERFORMANCE BONI
~~ lOR LABOR AND MATD ~;' \(1 .6tf' ... { l." LBv.JJ-,
. i FIDELITY & DEPOSIT
'We, the IIDdcr:tipcd G EN - CON, IN C . , ~ '.PriIIcipalj IDil G: 0 M PAN y 0 F MARY LAN D
_' a corponticm orlaaizcd ....,. dID laft of _ Stall of MA R Y LAN D:: : i , -.I ~
10 traDSaCl busineas in me Slat cICaIIfDaU.. II Jucty. .0 oblip1ecllO * ~ ;r~U ~t -car" .
lllUDiQpal corporaQoD uadBr It. .WI of.. SraIc of cmtomia. in dlUIIII~ of'T HII R l' Y F 0 tlr R THO USA N D
00Uus ($ 3 4 , 0 0 0 . 0 0 * 1<) for dID ~~ 01 wbiICh SIIIIl we ob1ipeD _..... aDd our "C'U1aU aDd auips,
joimly aDCl .-veraJly by die fDJIowiDI........: .;' .
The co11dhioa of1llis ob1fpdoa Is ... _lEiIIdpIl cmered. or is ... to .~ iaro a ~iu.iq wri1Ia ~
1ri1b.dJeCilydued NOVEMBER 25 ,19 96 _lIIlh~ROSEiMARY ELEMENTARY SCROOi
· trUe and comet copy of wbIcb is ~ 011 ale ill tbe oftlc:c of me C1ly acn f,t1fl!e ~ cit ~ wbicJa IUd JOB fl9 6 -
Comraet is betcby referred 1D IDd .. & pill bereof. ..:;. i 1 9
. ,: : I
, Because Princ:ipaJ is teqIlired fO tbmisIl a bond in coaaeaion widl;tat .~ provicImi lbat If ~. or
allY of its subcontrac1Ors, sbaIl fail 10 pay _ aIlfllllMials. or od!Ier supplies. odor ~:tPark ol! *' oalbc CCIIIIIIClIec1
wort ol aD]' kind. or for ,... .IW em. -*t.. ~ iDsudaee Kt .. ~ 10 ady ~ or Iabot OIl dlis .
project, ch. Surety OD dais boacl will pay lor 1be debc, in 20 amouar DOt exr~. die ~ ~ iD tills bcmd, and
also, ia case suit is broqIat upoa dIt boad. a rtaClIIIble aaomey's fee to be fiad ~ die comt. : .
l FIDEL1TY & DEPOSIT COMPANY
Now, ther.An,.., GEN-CON. INC. .8SPriac~.~ O.F MARYLAND
_'.- Sunty, art ftblipMd to die City 0( ea.p.n. bulle SlIIIl oiS T H I R t y1 F 0 U R T Ji[ 0 USA N D DOL L A R S
Ja'W1bJ moacy of tho UaitIcl S-. for .. ,.,... cl wbicb SGmS wiD _ i:nIJj to:tle~, 1ll!' .. said PriDc:ipal2IId
Surety bind ouae.lYe$, ~tIIOIS Ulcllllips, joiady lad scveraJly, by rhese pmtaoas. ';
!be C08lIldaIl of 6is ollIIpdoo . *" ;t Pria<ipoI. ;" .....-. ~ <!oiP. L -. ..
subcolUUCtOtS, sbaJl f&l1O pa.y tw ., 1Ibln. ---. or odIcr sappUcs.: aald ~ die of dMt work
comractcd (0 be dooc. or for' s~ dlcllDllcr 1bo lIDCIDpJoymcm lI-.A.~e 1lCt.....:~ 10 dais ..me 01' labor. r:bet1
Ibe SUtety on dIis boad 1dD plY k tIIIaL ill .. UJOUIU JIOt ~ecdiDc dIo ~ ~ ill dIiS~, IIId ill CUI .wI
is ~Iht upon rbis boIId wiD abo pay a ~. lIIDl"IE)"s -. to be a.d'bJ ~ ~ ; .
No prepaymllll or dell71a ~...A"" cUIIes. emoskus. ~ dr-aIi.:ratioapt:aay ~ of Aid
CoDU'ld or in aD)' plaDs ad .-cia. tIliHI rd:md m bercJD. IDlIIIO foJtac-ao .. die paR qf iac'CiIy IUD opaaIID
tIO re1eaR the Sum)' from...... ml1bls bcmd. ... coueat to IIJIb md2 allDI.-;.... ~ DDdcc 10 or ~
by tbe Surety is boreby Jifta. ad die SDr.,-lIrnby waives Iba prOYisioDs or ~ 2119 ofdMt GYil Code oldie s.:
of CaJiforDia. :
. .
Ia ~. 1be pardo$ J&a-wo ~ tis ap;c.mc1It as of NO V E MER R. ? ') :
.19~.
Trde .Al J\ri,zoat
I
(SlIRC,y) .
FIDEL
~
FR ~ . COOK , ATTORNEY -IN -FACT
/ .
A~~~~: roo FIRST SL, 111700
1 I,":
SAN FR~NCI8.CO, CA 94105
, . .
-
(AUICh Ac1:Dow1edpmems)
(Bod! Principal's met
Surety's Aaomey in Fact)
(h:\torms\bonds.trm)(mp)
~'I:~NwDbcr 08023676
~~~ boDd With Aaumey-bl-faQc'.
~dty . :ft~ .d ~ dlc boDd,
cet1i1ied to!" : JbC ~ of dla bood.)
I.' I
,
'.
I
: I
i
State of California
County of Santa Clara
On 11/25/96
DATE
before me, Paula Mohr , Notarv Public
NAME, TITLE OF OFFICER - E.G" "JANE DOE, NOTARY PUBLIC'
personally appeared Al Anzoategui
NAME(S) OF SIGNER(S)
rXJ personally known to me - OR - D proved to me on the basis of satisfactory evidence
to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged
to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/
her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the
person(s) acted, executed the instrument.
(~ L
\ c' " '- x , "-,, .', "-\,\\
Signature of Notary
. .....
-..,... ---
LA MOHR ~
Camm,I1080726 1"\
MYPUaIC.CAL'FOR;~:AUI
....A CLARA COUNTY 0
Comm. Exp, MInltt 24, 2000 ~
WITNESS my hand and official seal.
(Seal)
OPTIONAL
Though the data below is not required by law, it may prove valuable to persons relying on the document and
could prevent fraudulent reattachment of this form.
CAPACITY CLAIMED BY SIGNER
DESCRIPTION OF ATTACHED DOCUMENT
o INDIVIDUAL
o CORPORATE OFFICER
TITLE(S)
TITLE OR TYPE OF DOCUMENT
o PARTNER(S)
o LIMITED
o GENERAL
o ATTORNEY-IN-FACT
o TRUSTEE(S)
o GUARDIAN/CONSERVATOR
o OTHER:
NUMBER OF PAGES
DATE OF DOCUMENT
SIGNER IS REPRESENTING:
NAME OF PERSON(S) OR ENTITY(IES)
SIGNER(S) OTHER THAN NAMED ABOVE
ALL-PURPOSE ACKNOWLEDGMENT
r.~.~.~.~.~.~.~.~.~.~.~.~.~.~.~.~.~.,
. State of California } .
t County of Santa Clara SS. t
i On NOVEMBER 25, 1996 before me, Danijela L. Mosunic i
(DATE) (NOTARY)
,. personally appeared F ran cis ~\. Coo k ,.
SIGNER(S)
i IX] personally known to me - OR- 0 proved to me on the basis of satisfactory i
. evidence to be the person(.x) whose name~) .
t ishmI subscribed to the within instrument and t
t. acknowledged to me that helxl:le{m)C executed t.
the same in hislire.xht>>lf.M- authorized
. capacity(~, and that by hisltrexntlu{M- .
t _"'_'_~"""""""'''''''''''''''''''''''''~~"" signature~) on the instrument the person(~, t
· DAf\l!JELA L. ~iOSU:'.JC ". or the entity upon behalf of which the ·
, Camm, 11077354 (;~ person~) acted, executed the instrument. t
. \W"A;;: FJ3L:C. C~LiFORtJlA 1,Ii .
t ~"'1 ,':ar' C""nt'j .... t
'-"".1',. "', '" Jt.. :.' ~.',
j,' '"';","",~'''''Y ~,~~.~;.l?<::~,~
i WITNESS my hand and official seal. i
i ~~e~' i
i NOTARY'S SIGNATURE i
· OPTIONAL INFORMATION ·
t The information below is not required by law. However. it could prevent fraudulent attachment of this acknowl- t
t. edgment to an unauthorized document. t.
CAPACITY CLAIMED BY SIGNER (PRINCIPAL) DESCRIPTION OF ATTACHED DOCUMENT
. .
, 0 INDIVIDUAL ,
o CORPORATE OFFlCER
· FINAL BOND ·
t m~~~~~~ t
TITLE(S)
. .
t D PAR1NER(S) ,
[Xl ATTORNEY-IN-FACT
i D TRUSTEE(S) NUMBER;F PAGES i
· 0 GUARDIAN/CONSERVATOR ·
, D OTHER: ,
i NOVEMBER 25, 1996 t.
, DATE OF DOCUMENT
. .
t SIGNER IS REPRESENTING: ,
t. NAME OF PERSON(S) OR El'o'TITY(lES) t.
FIDELITY & DEPOSIT COMPANY GEN-CON, INC.
. OF MARYLAND OlliER.
L._.~._._.~.~._.~._._._. _._.~.~.~._.~
APA 1194
VALLEY-SIERRA,800-362-3369
BOND NO. 08023676
Power of AHorney
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
HOME OFFICE, BALTIMORE, MO.
KNOW ALL MEN BY THESE PRESENTS: That ~he FIDELITY AND DEPOSIT COMPANY OF MARYLAND, a corporation of the
State of Maryland, by C. M. PEcor, JR. , Vice-President, and C. W. ROBBINS ,
Assistant Secretary, in pursuance of authority granted by Article VI, Section 2, of the By-Laws of said Company, which
reads as follows:
"The Chairman of the Board. or the President. or ~y Executive Vice. President. or any of the Senior Vice.Presidents or Vice-Presidents
specially authoriz:ld so to do by the Board of Directors or by the Executive Committee, shall have power. by and with the concurrence of the Secretary
or any Qne of the Assistant Secretaries, to appoint Resident Vice-Presidents. Assistant .Vice.Presidents and Attorneys.in.Fact as the business of the
Company may require. or to authorize any person or persons to execute on behalf of the Company any bonds. undertakings, recognizances,
stipulations, policies, contracts. agreements. deeds. and releases and assignments of judgements, decrees, mortgages and instruments in the nature of
mortgages. . ,. and to affix the seal of the Company thereto," .
does hereby nominate constitute and appoint Francis E. Cook of Cupertino, California...
. its true and lawful agent and Attorney.in-Fact, to make, execute, seal and deliver, for, and on its behalf as surety, and as
its act and deed: any and all bonds and undertakings................................
And the execution of such bonds or undertakings in pursuance of these presents, shall be as binding upon said
Company, as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged by the
regularly elected officers of the Company at its office in Baltimore, Md" in their own proper persons.
This power of attorney revokes that issued on behalf of Francis E. Cook, dated,
October 25, 1984.
A ITEST:
e
.......;o!
STATE or MARYLAND ~
CITY OF BALTIMORE f 55:
Onlhis 18th day of March .A,D,19 85 ,beforethesubscriber.aNotaryPublicoftheStateofMaryland.in
and for the City of Baltimore. duly commissioned and qualified. came the above. named Vice-President and Assistant Secretary of the FIDEUTY .~
DEPOSIT COMPANY OF MARYLAND. to me personall y known to be the individuals and officers described in and who executed the preceding instrument,
and they each acknowledged the execution of the same, and being by me duly sworn, severally and each for himself depoaeth and saith. that they are
the said officers of the Company aforesaid, and that the seal affixed to the preceding instrument is the Corporate Seal of said Company. and that the
said Corporate Seal and their signatures as such officers were duly affixed and subscribed to the said instrument by the authority and direction of the
said Corporation.
1'r=.O>YW.....'.lha..ha~."~'mi ~jdE.Nb,~fi~~.~;AF2~9'.:~=1"=~;i:~;
'~.~. c'1'\ N o';;.~.1 ~i~~' Expires ........Y.....,...............
CERTIFICATE
The said Assistant Secretary does hereby certify that the aforegoing is a true copy of Article VI, Section 2, of the By.Laws of said Company. and is
now in force.
IN WITNESS WHEREOF, the said Vice.President and Assistant Secretary have hereunto subscribed their names and
affixed the Corporate Seal of the said FIDEUTY AND DEPOSIT COMPANY OF MARYLAND, this ..........L?~h.........m....day
of ........m....M~u:.c;:.Q............................. , A,D, 19...~.~...
............c..~~;::~:IT::::..~~_..
A uistant Secretary Vice- .
I, the undersigned. Assistant Secretary of the FIDEUTY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that the original Power of
Attorney of which the foregoing is a full. true and correct copy, is in full force and effect on the date of this certificate; and I do further certify that the
Vice. President who executed the said Power of Attorney was one of the additional Vice. Presidents specially authorized by the Board of Directors to
appoint any Attorney.in.Fact as provided in Article VI. Section 2 of the By.Laws of the FIDEUTY AND DEPOSIT COMPANY OF MARYLAND,
This Certificate may be signed by facsimile under and by authority of the following resolution of the Board of Directors of the FIDEUTY AND
DEPOSIT COMPANY OF MARYUND at a meeting duly called and held on the 16th day of July. 1969.
REsOLVED: "That the facsimile or mechanically reproduced signature of any Assistant Secretary of the Company. whether made heretofore or
hereafter, wherever appearing upon a certified copy of any ~ower of attorney issued by the Company, shall be valid and binding upon the Company
with the same force and effect as though manually affixed. .
IN TEsTIMONY WHEREOF, I have hereunto subscribed my name and affixed the corporate seal of the said Company. this...m~.~JIL... day
NOVEMBER 96
of .................................................. , 19..........
LI428a-C,f. -016-2359
A uistant Secretary
WORKER'S COMPENSATION INSURANCE INFORMATION
The following worker's compensation insurance information is required for all Applicants and
Contractors. One of the following items for each Applicant and Contractor must be submitted
prior to working under a Public Works permit or contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant Gen-Con , Inc.
o A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
::ec A Certificate of Workers' Compensation Insurance
Insurance Co, Republic Indemnity Company of America
Policy No, 03515720
Expiration Date 12/11/96
; OR
o A signed Certificate of Exemption from the Workers' Compensation laws as printed
below,
CERTIFICA TE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ any
person in a manner so as to become subject to the Workers' Compensation Laws of
California,
Signed
Date
Title
NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of
Exemption, you should become subject to the Workers' Compensation provision of the
Labor Code, you must forthwith comply with such provisions or the Permit or Contract
will be cancelled-or revoked,
j: \forms \ wor kcomp (rev6/96)
. .
- I \~
CA'1j. V"'-~ ( Lf\ v GU....L( /1-
BOND FOR: _THFULPERFORMANCE .D' NO. '08023676
PREMIUM: $340.00
We.the~ GEN-CON, INC. . '.' : ,~'.:
.CoDU'actDr-) aDd !W-xirt Y Q ~ m V t 1~ 11 ' a CQl~ ~ .....- me laws of dae Sf.- of
MA R Y L AN D . 8lIlI1I1IxlriDd to In:IIKt ~~.... of CaMcnia. . SunIr. are
obUpted ~ m. Cay of C-~ll, (blniadIr "City, . ~t c-puaa..:' .... Jaws of.. S. ofCaUlbmia.
IDlbcsumoCTHIRTY FOUR THOUSAND DOLLARS AND O' ($iL.. nnn no***')
for d)e pa,mCDt of wbidl SlIm we oWJpm CIZDCIvcs mcl oar - ~..on: aI!d . joiadf. lad IIft:rIJIy IIY Ib
roUowiD& provisions: '
11le coDdidoJl of 1bIJ abUpdoIl Is:
B-""- me obliptDd C"...,...- -. .. N 0 V E MB E R 2 5 I : "" 19 9 6 . ; . emInld imo WI'ial:n
Contract with me CIly for die PIojea edidDd R 0 S E MA RYE L EM E N T.t K t . i ~ r. BOO Ti . a apy of wIiidl is
IIW:bed aDd made a part of dsi$ boalI. for comcnC1ioD of Project. JOB t1' 9 6 +- U9 :
. . 1;::1 .
- : 1'..1 .
Now, d=efore. if_ ~ abaJl faiddI1Iy pedoaD die wact:ia'~ 'llI'i!b" pJaaI. ".-eifi~tV.DS-
aacl co=let ~ darizIa die oriPllIrm. ... ar ~~ oldie ~~~:. ..,tl. ~ by da8 Cny.
with or wWlOUl nocice to die 1lIlCIJ. ad if. sbIII sadafr all daiaIs 11I4 dI"..ua.. . . I:: lIIIIIer ~ ~ .. -.n
fiilly iDdcumify aDd save JaamsJe. ... Ck.r frcm aD c:aItS mil damqa ~it ., . by ieaO!l of faiJdre co do
to, m:l sbaU reimbunc at alp&! die Cq all GIlday aDd apaIIC wa.Il .. ~ r+J ~, ill JUtiq ., cIdaaIt. 1bcn
tis obllgadon sbaD be void; ~ TD r1IIIIIiD ill mn fom: mil e&ct. ~ . i ;
If any lep.I ac:tioa be med 1IpOIl mil bead, Il sbaD be flied widziD ~~l+ 1iaal piJmem JIIs been made
_ ... 0laIract =""""c1llo __ paiod. if..,. __- i111Il!i C'V-":_lIola 1lIo c;...sy
of Santa ClaIa. Swe of CIJiDDia. aad tUl DeIY, for fth1e receiftd .1~ : 1Ui II) ~. -K-...td)o1
of 1ime. alteration or acldi1iol11O die 1ImDS of 1:be CoDIrxt 01' to dlB 1IlOrt ro; bel' .,: ~ ~ or 1Ile specifiWions
accoa1P2D)'mS it shall ill any ~ atrect ill oNipjoo 00 dIis boDd. aDd it ~ lit ~ I. WliYe DOCice ~ my cbaap.
ar=sioll of time... al___ or Mdift_ ID die aImS of the COIIInCE Of 10" ...atiqW '.' ~ specffica.... aDS daenby
waives me provisions at Secdoa 2819 of \tat a.tl Codt of tbt .. at 0IIiIlIaia!- :! '1 :
: i. I .
In wItnesa. comraaof ad .., 11Ift .:ac.. 1IIiI ~ u ~. N biv i MB E R 2 5 . , 19.2,.L.
Jl:fonns\bouds.frm(mp)
MARYLAND
(Auach Ada1owlcdgemcua)
, . :,:G::GOKt ATTORNEY J~IN FACT
~.ll.pH) F R$T S'T., m1 700 :
. , II: . . : I
I It. .
. f.j : .'
SAN FRAliCIS 'G, CAi 94105 '
; .' !!: J
. 1:.:1
Sureq's~: ! j':' 08023676
: : 'i! ;
: ~. ~ wida j,....L-..iIH#t.$
(~~.. I" ~-r
auJhoricJ ftQf,a~~: aecql1bc boDd.
ccrtificd to ~ . ., d&= PI. boD!l)
:. i ,: I
1 . i :1
! '1 . :
i:f .1 ~8.:
I
I
I
I
,...
I
!
I
I
i I
i
I
i
i
I
(Both PriDcipaI's m1
SUrety's At1I:JnJey in Faa)
State of California
County of Santa Clara
On
11/25/96
DATE
before me, Paula Mohr , Notary Public
NAME. TITLE OF OFFICER - E.G., "JANE DOE, NOTARY PUBLIC.
personally appeared Al Anzoategui
NAME(S) OF SIGNER(S)
~ personally known to me - OR - D proved to me on the basis of satisfactory evidence
to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged
to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/
her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the
person(s) acted, executed the instrument.
WITNESS my hand and official seal.
~(-, ~ ,Q 0 "'---\ ,,,- A X,\
Signature of Notary
\""'-".... -
PAULA MOHR
Comm. .1 090726 ~
MY PU8UC . CAlIFORNIAoJU
SANTA ClARA COUNTY
Comm. Exp. MItch 24, 2000 ~
(Seal)
OPTIONAL
Though the data below is not required by law, it may prove valuable to persons relying on the document and
could prevent fraudulent reattachment of this form.
CAPACITY CLAIMED BY SIGNER
DESCRIPTION OF ATTACHED DOCUMENT
o INDIVIDUAL
o CORPORATE OFFICER
TITLE(S)
TITLE OR TYPE OF DOCUMENT
o LIMITED
o GENERAL
o ATTORNEY-IN-FACT
o TRUSTEE(S)
o GUARDIAN/CONSERVATOR
D OTHER:
D PARTNER(S)
NUMBER OF PAGES
DATE OF DOCUMENT
SIGNER IS REPRESENTING:
NAME OF PERSON(S) OR ENTITY(IES)
SIGNER(S) OTHER THAN NAMED ABOVE
ALL-PURPOSE ACKNOWLEDGMENT
r--------------------------------- --,
i State of California } ss, t-
, County of San ta C lar a
i On NOVEMBER 25. 1996 before me, Danij ela L. Mosunic i
(DATE) (NOTARY)
,- personally appeared Francis ~\. Cook ,-
SIGNER(S)
i [X] personally known to me - OR- D proved to me on the basis of satisfactory i
- evidence to be the person(x) whose name~) _
t ishmr subscribed to the within instrument and t
,- acknowledged to me that helxbeltlb1eJ executed ,-
the same in his!irem>>lfM- authorized
- capacity(~, and that by his!irexMlu~k -
t signature(t) on the instrument the person(~, t
or the entity upon behalf of which the
i person~) acted, executed the instrument. i
- -
t t
i WITNESS my hand and official seal. i
i ~LlAA i
i NOTARY'S StGNATURE i
OPTIONAL INFORMATION
i The information below is not required by law. However. it could prevent fraudulent attachment of this acknowl- i
i ~~;:~; ~=:;~~ :I~:;n~PRINCIPAL) DESCRIPTION OF ATTACHED DOCUMENT i
- -
, D INDIVIDUAL ,
D CORPORATE OFFICER ,
- FINAL BOND -
t TITI..E OR 1YPE OF DOCUMENT t
TITLE(S)
, D PARrnER(S) ,
· [X] A TIORNEY -IN-FACT ·
i D TRUSTEE(S) NUMBER ~F PAGES i
- D GUARDIAN/CONSERVATOR -
t D OTHER: t
t- NOVEMBER 25. 1996 t-
DATE OF DOCUMENT
i SIGNER IS REPRESENTING: i
t- NAME OF PERSON(S) OR E/lITITY(lES) t-
FIDELITY & DEPOSIT COMPANY GEN-CON. INC.
_ OF MARYLAND OiliER_
L______._._._____._._.___._____.___..-1
APA 1194
VALLEY-SIERRA, 800-362-3369
CSR eE DATE IMMIDMYJ
.. G&HCO~S 12/03/95
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS U,"ON TH! CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Al TER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
(;en-Con :Inc.
Ms. Paula Mohr
800 Cristich Lane
Campbell CA 95008
COVERAGES
'l'HIS IS TO CERTIFY THAT TliE POLICIES OF INSURANCE LISTED 5flOW HAVf "fEN ISSU/;D TO THI; INSURED NAMED AIlOVE FOR TliE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY t:ONTRACT OR OTHER DOCUMENT WITti RESPECT 10 WHICH THIS
CERTIFICAT& I\IlAY 8E ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIOED MEREIN IS SUBJECT '1'0 All THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
DEC- 3-96 rUE 10:30
RG SPENO INC
FAX NO. 4082572985
A4~..ItI'.
. .. .:;.;.:;.; '0:.
CERTIFICATt;;OF INSURANCE
PROOUCEII
R. G. Speno, Inc.
18900 Stevena creek Blvd. .200
Cupertino, CA 95014-3674
rranci. a. Cook, C.P.C.U.
Plla"" No. 408-973-9500 '""No.
IN5URED
eOMPAN~
A U11co Casualty Company
'1 \~t\\.
COMPANY
a Republic Indemnity Company
COMPA,.,V
C
of America
--
~OMPANY
D
Fireman's Fund :InBurance Co.
co
lTll
POLICY NVNl8Ef1
,"OllCY UFIC'I'IVl POLICY tl(PlIlATlON
DATI (MMIDDIYYI DATE (MMIDDIYYI
TYPE OF INIURAl'iCE
lJENEII.I\L LIAIIIUTY
-
A X COMMEtlCIAL GENERAL LIABILITY
:tJ CLAIMS MADE ~ OCCUR
~ OWNE"'6' CONTRACTOR" PROT
r-!- PAr JOo~ Sit..~
CLU0001248
08/01/.97
~~NE~ALAGGAEGATE
PRODuCr6. COM~/OP AGG
I'fRSONAl & MY INJURY
EACH OCCURRENCE
08/01/96
FlRE DAMAGE (Anyon, Ii..,
MtD EXP lAny Qno pt'~onl
A
AUTQM081U LIABILITY
t--
X NjY AUTO
t--
All OWN~O AUTOS
t--
'CIlEDULfD AUTOS
t--
~ IlIRfD AUT05
...!. NON,OWNED AUTOS
t--
PROPERTY DAMAGE
CLU0001248
08/01/97
COM8INEt> SINGle liMIT
08/01/96
8DDIl Y INJURY
(P.,- pOr"$-QnJ
BODilY INJURY
(r.r aGc;ichnt)
GAllAGE llAllUTY
I--
AUTO ONLY, EA ACCIDENT .
ANY AUTO
OTH[R TH^N AUTO ONLY:
I-- --
EACIoI ACCIDENT ,
ElICHS lIABILITY
D txl UMBRELlA!'ORM
n OTIliR TIlAN UMllREllA roPIM
B WORKEIIS COMPENSATION A1'iD
fMPI.OYllII' LIABilITY
AGGREGATE
EACH OCCVRIlENC E
08/01/97 AG~~EGATE
XEKfi7910687
09/18196
03515720
12/11/95
I STATUTORY LIMITS
E4CIoI 4CCIDENT
1-----.. .....-.
12/11/96 DISEASE, POLlCYlIMlT
WIKCl
1'1 EXCL
THi PROPRIETOR/
P4IlTN[ASlEXfCUTIVE
OF~ICERS ARE:
OTIlER
A Le~sed/Rented
Equipment
OISEASE ' EACH EMP'l.OVE!
CLU0001248
08/01/96
08/01/97
Spec Form
inc Theft
DESCRIPTION 0' OPIMTIQNS/lOCATIONSIVEHIClE5I5PECIAI. InM$
*Ten (10) dakiotice of cancellation for non pa~nt pf prem1ym.
RE: 401 Wi B lton Aye., - R"~ry a1ementary School - ~er~t .96-180
S.. Addit on. In.urea Form C lDl0 attaQhed!
worker. Compensation Waiver 0 subrogat10n ncluded.
REVISING CERTIFICATE DATED 11 25/95
CERTtfICA'f.E:HQLDIiR. cANtEL1.ATION
II: ~
p, 02
LIMITS
.2,000,000
'2,000,000
tl.OOO.OOO
'1,000,000
· 50,000
s 5,000
'1.000.000
.
.
.
11,000,000
· 1, 0,0.9.. Cl~
.
, 1,000,000
'0 · 1,_000d~..Q.Q......
. 1,000,000
$40,000
$1000 ded.
SHOUlll ANY OF THE AlIOVE DESCRIII!Il POLICIES IE CANCElLEP IPOM YI4;
EXPIIlATION I:II'TI TH'~OF, THE ISSUINQ COMPANY WILL 1- m 1AlL
.l.9~ OATS W/UTTEN NOTICE TO THE CERTIFICATE 1l0lDER NI\MEO TO THE LEFT.
J J.__
C-CAK~3
City of Campbell
Depar~ent of Public Works
70 North 1st Str.et
Campbell CA 'S008
ACORP 25-$ (!/93)
AUTHOAlZm REPlIUEflTATIYE L. _ .///2
Franci. 1:.. Cook, 4.. e . u. ..~J1;~~...
... .~"""...~ACORbcOtlfORl'rq 1993
./
.
DEC- 3-96 TUE 10:30
RG SPENO INC
FAX NO, 4082572985
P. 03
AI NUMBER: YR96-28
DATE ISSUED: December 3, 1996
POLICY NUMBER: CLU0001248
INSURED: CEN-CON, INC.
COMMERCIAL GENERAL LIABILITY
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 COVERAOE PART
SCHEDULE
Name of Person or organization:
The city, The city of campbell Redevelopment Agem;y. its oUicers, employees and
volunteers
With respects to: 401 W. Hamilton Ave.. Rosemary Elementary School
Permit,96-180
(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) 15 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.
PRIMARY INSURANCE
It Is further agreed that such Insurance as is affOrded by this policy for the benefit of the
above additional insured(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 non-contributory with the insurance provided
hereunder.
CO 20 10 11 85
copyright, Insurance service Office, Inc. 1984
DEC- 3-96 rUE 10:31
RG SPENO INC
FAX NO, 4082572985
p, 04
WORKERS' COMPENSA'J'IO!\t AN)) EMPLOV..:RS' UAJULlT\' poUt '\'
w{ '()~()if)(,
f1~. 4.8.tl
W"ver of Our Right to Recover .'rom Olhen Endot'!ll'lueul - Calliforuia
We hav~ the riaNlonc:ovetoW')l&yment.from InyonclilbJe for an injwycot'cmthy Ihi, policy. We will nol enforce
our rig.hllglUl'I Ole penon or o'llDizalion named in UIe Schedule, "fhi. llpmrn' applies only to the exlCllllhat yOll
pel1umlwOrkunde,. wrilten conlnldthal reqlliR. )'01110 ohlainthiuSlumenl fiomu~.
Yau musl m..... pI)'tOlI <<coni. accunalely Jc~glli.n& Ihe remum:ralionof your employees while engllged in Ihe
work described m the Sl:hedule.
l1u: addilionalpnmium forthi, endonemenlihalI be
otllelWlsedue ODlUdll~JnUneRtion.
5.00 % ofthc California worlcers' compensation premnllll
Selled.1e
Penoa 01' Orp".
The City. tbe City of
Campbell Redevelopment Agency.
its officers. e~ployees and
volunteers
Job ~tnfp...
401 W. B~milton Ave.
Rosemary Elementary School
Permit #96-180
This ~ndorxm~nt chilllges the policy to which it is 3ttllched and is effective on the dale iSl;ued unless olhcfWise slated.
Republic Indemnity Company of America@
Conapuy No. 19739
InIured: C"Irn-C on. lne.
Policy Nwnber: 0352~28r
Eado~ Number:
~Eft...:
fan. No. WC306
11/25/96
1M3
PrirMd 011:
12/03/96
,.........
tn.u.d Cop)'
,..........
DEC- 3-96 TUE 10:32
RG SPENO INC
FAX NO, 4082572985
p, 05
AtDttll".
EVI DENCE.'O..PROPER-rYINSURAN C L.
CSR CE
DATE lMMJDDIYYI
12/03/96
THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED. IS IN FORCE, AND CONVEYS All THE
RIGHTS AND PRIVilEGES AFFORDED UNDER THE POLICY,
PIlODUC~R I="~:'''t.:~~~ ~ - 9 1. 3 - 9 5 0 01
CQ""PANY
R. G. Speno, Inc.
18900 Stevens cr..k B~vd. #~OO
Cup.~tino, CA 95014-3674
'Gr cis E. _cook C.P.C.U.
CODE: 04-12Ei-60~ SU8COD~
CU~~E/lID #, <:ENCO - 5
IN$VIlED
Fireman'. ~und Insurance Co.
1'.0. Box 5984
SlID Jose CA 95150
,.ftqP~It1''l''.l/'ifPR~t'ON
lOC"T10~"CAlPTION
001
MXIB0332S90
EXPIRATION DATE
CONTINUED UNTIL
TfI\MINATIKII~ CHIiCKED
LO"'" NUMIIER
POLICY HUM.ER
Gen-Con J:ne.
800 Crt.tich Lane
Campbell CA 95008
401 H. Hamilton ~ye.
C~bell CA 95008
Improvements at Rosemary Elementary
School-Permit #96-180
CQ"ERA~~ lNFORMA lION
CovEllAGElPERIL$IFOAMI
AIIlIOUHT !;If fN$\lAANCE
D[OUCTlBlf
Special Cause. of ~o.. - Replacement Cost
34,000
1000
RE,N1A1JKS(IIu:fudin~9[J1icl~ po~dit!~,"l
CA,Ne~(LATIUN
THE POLICY IS SUBJECT TO THE PREMIUMS, FOAMS. AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE
POLICY BE TERMINATED. THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 30 DAYS
WRITTEN NOTICE. AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLlCY THAT WOULD AFFECT THAT
INTERl!ST.IN ACCORDANCE WITH THt POLICY PROVISIONS OR AS REQUIRED BY LAW
ADVIT'QNAL.iNTEtlEST
IlIAME MD ADDIIEllS
City of Campbell
PUblie Work. Department
70 No. J'irllt St.
Campbell CA 95008
H .ODITIONA~'NS~~O
I
ACOBD n f!I9~1
Pr.ncis B. Cook,
AuTHOAfzrD m:'IIRENTAT1VE
;,lIfk'~~' -
J.f';cJ;'~',
ot . CAI/1
. ~O>
f: ("
- (""'
u ,-
~ .>..
~ '-
C' G'
aRc H 1',,1l
CITY OF CAMPBELL
Public Works Department
August 24, 2001
Gen-Con, Inc,
800 Cristich Lane
Campbell, CA 95008
SUBJECT: PERMIT NO. 96-180
LOCATION: 401 W, Hamilton Avenue
MAINTENANCE INSPECTION - ACCEPTANCE
Gentlemen:
The City of Campbell has made the final maintenance inspection of subject Public Works
improvements and find that no remedial work is required.
Your warranty requirements and any surety, therefore, are hereby released, Your Labor and
Material Security deposit, plus any interest due, minus a back charge for after hours inspection
of $202.27, will be sent directly to you from our Finance Department.
Attached is your original Bond for Faithful Performance and Bond for Labor and Material
which we are returning to you.
Sincerely ~c ~
Alan Q.
Senior Public Works Inspector
MQ ,A,~
cc: Permit 96-180
Public Works/Maintenance Division
Fidelity & Deposit Company of Maryland, 100 First St., # 1700, San Francisco 94105
J: \FORMS\MTCEACC(WORD)
70 North First Street Campbell, California 95008-1423 . ~EL 408.866.2 t 50 FAX 408.376.0958 . TDD .W8.866.2790
Actual Plan Check and Inspection Charges Summary
For the pay period ending August 20, 2000
Regular Overtime Total Total
Hours Hours Hours Costs
PERMIT 96-180
401 W. Hamilton Ave. 3.50 2.00 5.50 202.27
2 PERMIT 98-202
Abbas, E. Campbell 1.00 1.00 47.17
3 PERMIT 98-219
Campbell Tech. Pk. 1,231.30 74.50 1,305.80 74,471.14
4 Permit 98-247
Abbas, East Campbell 2.00 2.00 133.58
5 Permit 98-276
Hamilton @ Esther, SJWD 4.00 40.00 44.00 2,249.84
6 Permit 98-277
W. Hamilton Campbell Park 1.00 1.00 47.17
7 Permit 99-123
166 W. Campbell 3.00 3.00 200.38
8 Permit 99-176
Hamilton Water 11.00 4.50 15.50 824.12
9 Permit 99-215
Pulte Home 6.00 6.00 308.16
10 Permit 99-282
BIC Furia 1.00 1.00 51.36
11 Permit OO..Q012 1.00 1.00 2.00 132.98
Summerhill
Grand Total 1,259.80 127.00 1,386.80 78,668.17
Subdiv
8/28/00 10:14 AM
Actual Plan Check and Inspection Charges
Name
Invoice/or
PPE
Date
Invoice/or
Hourly
Rate
OT
Hourly
Rate
Regular
Hours
Overtime
Hours
Staff/
Invoices
Incl 20% OH
Date
Received
401 W Hamilton 196-180)
Gade, Derek R.
01/12/97
26.48
37.94
3.50
2.00
202.27
01/15/97
3.50
2.00
202.27
E, Campbell (98-202)
Hom, Alan
05/02/99
39.31
55.66
1.00
47.17
05/05/99
1.00 47.17
EP (98-219\
Gomez, Cruz S. 09/06/98 44.34 62.92 44.00 2,341.15 09/09/98
Housley I. Harold 09/06/98 49.56 70.20 2.50 148.68 09/06/98
Jue, Matthew J. 09/06/98 40.56 57.47 7.00 340.70 09/06/98
Gomez, Cruz S. 09/20/98 44.34 62.92 38.00 2,021.90 09/22/98
Housley I. Harold 09/20/98 49.56 70.20 1.00 59.47 09/22/98
Jue, Matthew J. 09/20/98 40.56 57.47 9.00 438.05 09/22/98
Gomez, Cruz S. 1 0/04/98 44.34 62.92 54.50 2,899.84 10/07/98
Housley I. Harold 1 0/04/98 49.56 70.20 15.80 939.66 10/07/98
Gomez. Cruz S. 10/18/98 44.34 62.92 44.50 2,367.76 10/21/98
Housl~y I. Harold 10/18/98 49.56 70.20 7.50 446.04 10/21/98
Gomez, Cruz S. 11/01/98 44.34 62.92 12.00 638.50 11/04/98
Housley I. Harold 11/01/98 49.56 70.20 6.00 356.83 11/04/98
Gomez, Cruz S. 11/15/98 44.34 62.92 11.50 611.89 11/18/98
Housley I. Harold 11/15/98 49.56 70.20 1.50 89.21 11/18/98
Housley I. H3rold 11/29/98 49.56 70.20 8.00 475.78 12/02/98
Gomez, Cruz S. 12/13/98 44.34 62.92 42.00 2.234.74 12/16/98
Housley I. Harold 12/13/98 49.56 70.20 7.00 416.30 12/16/98
Gomez, Cruz S. 12/27/98 44.34 62.92 12.50 665.10 12/31/98
Housley I. Harold 12/27/98 49.56 70.20 3.00 178.42 12/31/98
Gomez, Cruz S. 01/10/99 44.34 62.92 2.50 133.02 01/14/99
Housley I. Harold 01/10/99 49.56 70.20 4.00 237.89 01/14/99
Jue, Matthew J. 01/10/99 40.56 57.47 6.00 292.03 01/14/99
Gomez, Cruz S. 01/24/99 44.34 62.92 3.50 186.23 01/27/99
Housley I. Harold 01/24/99 49.56 70.20 1.00 59.47 01/27/99
Gomez, Cruz S. 02/07/99 44.34 62.92 5.50 292.64 02/09/99
Housley I. Harold 02/07/99 49.56 70.20 2.00 118.94 02/09/99
Gomez, Cruz S. 02/07/99 44.34 62.92 4.00 212.83 02/21/99
Housley I. Harold 02/21/99 49.56 70.20 1.00 59.47 02124/99
Gomez, Cruz S. 03/07/99 44.34 62.92 3.00 159.62 03/07/99
Housley I. Harold 03/07/99 49.56 70.20 1.00 59.47 03/09/99
Gomez, Cruz S. 03/21/99 44.34 62.92 0.50 26.60 03/09/99
Gomez. Cruz S. 04/04/99 44.34 62.92 13.00 691.70 04/07/99
Housley I. Harold 04/04/99 49.56 70.20 4.00 237.89 04/04/99
Gomez, Cruz S. 03/07/99 44.34 62.92 16.00 851.33
Gomez, Cruz S. 04/11/99 44.34 62.92 16.50 877.93 04/21/99
Gomez, Cruz S. 04/18/99 44.34 62.92 9.00 478.87 04/21/99
Gomez. Cruz S. 04/25/99 44.34 62.92 3.50 186.23 05/05/99
Gomez. Cruz S. 05/09/99 44.34 62.92 1.00 53.21 05/19/99
Gomez. Cruz S. 05/16/99 44.34 62.92 6.00 319.25 05/19/99
Housley I. Harold 05/16/99 49.56 70.20 3.00 178.42 05/19/99
Gomez, Cruz S. OS/23/99 44.34 62.92 1.50 79.81 06/02199
Gomez, Cruz S. OS/23/99 44.34 62.92 3.50 186.23 06/02199
Housley I. H:]rold OS/23/00 49.56 70.20 7.50 446.04 05/19/99
Gomez, Cruz S. 06/06/99 44.34 62.92 6.50 345.8~/28/00 ~J~1~
~~~a~ Cruz S. 06/13/99 44.34 ~2.92 3.50 186.2 0 ,
Of'C4A(
..,: .0 ~
~~c;:L.'~ ~
..... :,~~:~!1;.~~'-'. r-
U -5("ii;'" r-
) '{i~\:
""0$- '_t ;,,"
~ c.'
'OIiCHA\l.Q
CITY OF CAMPBELL
Public Works Department
September 23, 1998
Mr. Frank Borunda
Gen-Con, Inc.
800 Cristich Lane
Campbell, CA 95008
SUBJECT:
PERMIT NO, 96-180
LOCATION: 401 W. Hamilton Avenue, Rosemary Elementary School
FINAL INSPECTION AND ACCEPTANCE
Dear Frank:
The City of Campbell has made a final inspection of subject Public Works improvements and finds the
work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts
the improvements.
The one year maintenance period stated in the permit begins as of the date of this acceptance letter.
The permittee is responsible for the repair and/or replacement of any defective work or failures that
occur within one year, The City will inspect the improvements within one year and notify you, in
writing, whether or not any repairs are required.
Your Faithful Performance Bond will be kept in force for the duration of the one year maintenance
period or until a Maintenance Surety equal to 25 % of the Faithful Performance Bond is received,
If you have any questions, please call me at (408) 866-2168,
SinceaL
Alan Horn
Public Works Inspector
MQ fLlL
cc: Suspense - 11 months
Permit #96-180
Inspector File
Fidelity & Deposit Co. of Maryland. c/o Francis Cook, 100 First St., #1700, San Francisco, CA 94105
H: \ WORD\PERMITS\96180FIN(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TDD 408.866.2790
Of'C.4'4
. .a
t~~. ~~
u . t""'
... ..
" "-
1- <.
f!'. 0 ,,'
.qCHA'ilO
CITY OF CAMPBELL
Public Works Department
January 21, 1998
Mr, Frank Borunda
Gen-Con, Inc.
800 Cristich Lane
Campbell, CA 95008
Subject:
Permit No. 96-180
Location: 401 W. Hamilton Avenue - Rosemary Elementary School
Correction to Work
Dear Frank:
I have visited the site mentioned above and the new squares of sidewalk that were vandalized
with graffiti have not been addressed since my conversation with you on December 31, 1997,
Please call me at 866-2168 and let me know the status of your project. Thank you.
Alan Horn
Public Works Inspector
cc: Randy Westfall, Public Works Inspector
Permit 96-180
h: \permits\96180(mp)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOD 408.866.2790
Of' Cot A~
~4.~' '''lj.)~~
... ~
U 1""
. .
... ...
-s. '"
~. G....
o<tCH' Ill)'
CITY OF CAMPBELL
Public Works Department
Mr. Frank Borunda
GEN-CON Inc.
800 Cristich Lane
Campbell, CA 95008
9-05-97
RE: Rosemary Elementary School
Subject: "Punch List"
Dear Frank
As per our discussion yesterday, I have painted "remove" at all driveway and
sidewalk areas that do not meet City of Campbell standards, In addition, please re-
position the utility boxes so that they are at grade and set at right angles within the
landscape area of the sidewalk. As a reminder, the A.C. section at the lip of curb has not
been completed to date. It is my understanding that you will contact Public Works to
coordinate inspection of this work when it occurs.
As always, I appreciate your continued support and cooperation.
Sincerely,
,
~
"
Robert Phillips
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOD 408.866.2790
Actual Plan Check and Inspect/on Charges
Invoice/or Invoice/or OT Staff/
PPE Hourly Hourly Regular Overt/me Invoices Date
Name Date Rate Rate Hours Hours Incl 20% OH Received
Littleton Place (96.151)
Westfall, Randy 06/16/96 39.22 55.20 1.00 66.24 10/09/96
Westfall. Randy 11/03/96 39.22 55.20 7.00 463.68 11/06/96
8.00 529.92
401 W. Hamilton (96-1801
Gade, Derek R. 01/12/97 26.48 37.94 3.50 2.00 202.27 01/15/97
3.50
2.00
202.27
Grand Total
1,915.30
91.00
111.518.02
8/26/97 10:07 AM
Subdiv98
10
Actual Plan Check and Inspection Charges Summary
For the pay period ending June 1, 1997
Regular Overtime Total Total
Hours Hours Hours Costs
PERMIT 94-222
2 Way Railway 1,001.00 175.50 1,176.50 70,620.89
II PERMIT 94-203
A. 500 Railway Offsites (Msc.) 48.50 48.50 5,198.33
B. KennedylWinchester Signals 77.00 3.50 80.50 3,871.03
Permit 94-203 Total 129.00 9,069.36
III PERMIT 95-145
Pollard Road / New City Dev 710.50 25.00 735.50 35,460.92
IV Permit 95-201
Emily Chen 4.50 4.50 279.55
V PERMIT 95-215
San Jose Water Co. 20.00 2.00 22.00 1,008.88
VI PERMIT 95-218
1522 McCoy 505.50 32.00 537.50 39,042.59
VII PERMIT 95-223
18755 Bascom 672.80 13.50 686.30 34,588.84
IX PERMIT 95-264
Hatcher Court 1.00 1.00 66.24
X PERMIT 96-138
Gold's Gym 1.50 1.50 93.19
XI PERMIT 96-151
Littleton Place 8.00 8.00 529.92
XII PERMIT 96-180
401 W. Hamilton Ave. 3.50 2.00 5.50 202.27
Grand Total 3,038.80 268.50 3,307.30 190,962.65
(0.00)
6/11/97 3:11 AM
Subdiv
Actual Plan Check and Inspection Charges
Invoice/or Invoice/or OT Staff/
PPE Hourly Hourly Regular Overtime Invoices Date
Name Date Rate Rate Hours Hours Incl 20% OH Received
r Littleton Place /96.151)
\;~Jk' andy 06/16/96 ../~.._,./16io~~--'.
Wall, Randy 11/ 7.00 . 11/06/96
8.00 529.92
401 W. Hamilton /96-180)
Gade, Derek R. 01/12/97 26.48 37.94 3.50 2.00 202.27 01/15/97
3.50
2.00
202.27
Grand Total
3,038.80
268.50
190,962.65
0.00
6/11/97 3:12 AM
Subdiv
15
Actual Plan Check and Inspection Charges
Invoice/or Invoice/or OT Staff/
PPE Hourly Hourly Regular Overtime Invoices Date
Name Date Rate Rate Hours Hours Incl 20"10 OH Received
Littleton Place (96-151)
Westfall, Randy 06/16/96 39.22 55.20 1.00 66.24 1 0/09/96
Westfall, Randy 11/03/96 39.22 55.20 7.00 463.68 11/06/96
8.00 529.92
401 W. Hamill
Gade, Derek R. 01/12/97 26.48 37.94 3.50 2.00 202.27 01/15/97
3.50 2.00 202.27
Grand Total 3,017.80 266.00 189,807.19
0.00
5/14/97 3:32 AM
Subdiv
15
Actual Plan Check and Inspection Charges
Involce/or Involce/or OT Staffl
PPE Hourly Hourly Regular Overtime Invoices Date
Name Date Rate Rate Hours Hours incl 20% OH Received
Littleton Place /96.151)
Westfall, Randy 06/16/96 39.22 55.20 1.00 66.24 1 0/09/96
Westfall, Randy 11/03/96 39.22 55.20 7.00 463.68 11/06/96
8.00 529.92
401 W, Hamilton /96-180)
Gade, Derek R. 01/12/97 26.48 37.94 3.50 2.00 202.27 01/15/97
3.50 2.00 202.27
Grand Total 2,971.80 266.00 187,636.70
0.00
4/8/97 10:20 PM
Subdiv
16
Of' C.4 A.
....~., ''1A~
" . ~
U r;.
. .
,;.. ...
1- '"
<!'. ,,'
O.qCH,\RO'
CITY OF CAMPBELL
Public Works Department
December 12, 1996
Mr. Kevin Smith
Public Works Department
City of San Jose
801 North First Street
San Jose, CA 95110
SUBJECT: 401 W. Hamilton Avenue, Rosemary Elementary School
Encroachment Permit 96-180
Dear Mr. Smith;
We are enclosing two sets of the off-site improvement plans for work on Eden A venue for your
use, Please let us know if you need additional copies.
The work will be performed by Gen-Con, Inc" 800 Cristich Lane, Campbell, CA 95008,
telephone number (408) 879-1680,
Please contact Randy Westfall, Public Works Inspector for the City of Campbell at (408) 866-
2165 or me at (408) 866-2163 if you have any questions or comments.
Very truly yours,
Cruz S omez
Assistant Engineer
Enclosures
cc: Ben Ortiz, Gen-Con, Inc.
Michelle Quinney, City Engineer
Randy Westfall, Public Works Inspector
H:\401WHA2,LTR(WP)(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.379.2572 . TDD 408.866.2790
NEW PW FAX #
408-376-0958
ENe >ACHMENT PERMIT ISSUANCE CI ~K LIST
City of Campbell
Department of Public Works
Encroachment Permit No9.&-..::.'- \~n~
4c) \. v..J.. \..~v---\\. ,--"~~_')
ITEMS REQUIRED FOR PERMIT APPLICATION:
\""2 -" - 9 <- Applicant section complete
""1- -'1.. -q:c Applicant signature and date (front and back)
'\&J.~".ir ~l.;::,. Permit Application Fee $225,00 paid - Receipt Number
'O-Ci'1-9 \,.. Engineer's Estimate submitted
~.~ lo..~IE'-.-... Plan Check Deposit paid (2 % of Engineer's Estimate, $500 min)
Receipt Number
""-':?,.- \.~-~v-, Five sets of improvement plans submitted
ITEMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS
,<-,- "2.~<1...:...._ Plan Check & Inspection Fee: If Engineer's Estimate < $250,000, then 12 % of Engineer's
Estimate. If Engineer's Estimate> $250,000, then Actual Cost + 20%, (Deposit of 8% of
Engineer's Estimate reguired; $30,000 minimum deposit)~4f:~ .e.c:-
'~G~l;>T"' 't--ic,. \ C-., ..ct,~
\.~ --z ~..t<- Security for Faithful Performance and Labor and Materials, 100% ~ach of Engineer's Estimate,
supplied or paid. Ft'" ~~ L..::f\-1 f;=~\-"... VC'e-"4.A~-,-
Amount ~. (!X:::.e>-~ ~~ Form I.D. # O~.":>-z...~t.,..;lC-
~, \'.~lEL.\~ 'sf- \) ~;:'t.:_"~-..\,\ e.a-"'A.v"V'_JL~' r o\~ V.~I }\...(C. V-I--.J ':::-"
\,,--'2- ""-ie:.. Construction Emergency Cash Deposit: 4% of Engineer's Estimate. ($500 minimum, $10,000
maximum)
Amount $ ~~rCJ-O Receipt No. \bL\'-L
"'-..f 1>-1. '-i E:~ Worker's Compensation Insurance Information Sheet received for Applicant.
~;&.. All other Public Works requirements listed in the Conditions of Approval of the development.
'f-..l:o c.c:)t.-)\.., t'110 1--J"'_ C>t'=-)I-"...~ pt"<-D~,-
ITEMS REQUIRED PRIOR TQ ISSUANCE OF ENCROACHMENT PERMIT:
'.'''2. -~ -'4.. L... Contractor's signature added to the permit application (front and back)
\<-.--2. - q '- Worker's Compensation Insurance Information Sheet received from Contractor.
\'2-~-""ik- Certificate of Insurance with Additional Insured's Endorsement received from Applicant or
Contractor,
l""t.---s _ Gt~
\4-~'.q,-
One mylar set and four blueline sets of off-site plans signed by licensed engineer, stamped
APPROVED FOR CONSTRUCTION,
\.. ""Z.- - c- --9<.c.
Permit signed by City Engineer.
WIlEN ALL OF ~ ITEMS ARE COMPLETE, PERMIT MAYBE ISSUED.
Issuer: ~ L6' and date /0/ d and file with permit.
L UPON ISSUA~. WITIAT)', glEgc R!i9UEST.FQR PLAN CHECK DllPOSWREFUND
t:/ ~~ ~~R'~Z.4"~.d-"<__.a~/A"~-,.
j:\mq\ld\pmtcklst rev. 6/96 /
o".c.""'t
f....:...~A<$lt<'
~'. . ~
~ ..
1- "-
'" .'
'O~CHA\l\J"
CITY OF CAMPBELL
Public Works Department
December 3, 1996
Mr. Ben Ortiz
Gen-Con, Inc.
800 Cristich Lane
Campbell, CA 95008
SUBJECT: 401 West Hamilton Avenue, Rosemary School, Permit 96-180
Dear Mr. Ortiz:
We are returning the Special Purpose Certificate of Deposit dated November 23, 1996, in the
amount of $1,360.00, issued by the Wells Fargo Bank which you brought to the City of
Campbell December 2, 1996. The $1,360 construction cash deposit amount on the permit has
been paid by Gen-Con, Inc. check number 16450 dated December 2, 1996.
Please call me at (408) 866-2163 if you have any questions or comments.
Very truly yours,
ik~A-~x~.
Cruz S~fJb;;'ez ( /'
Assistant Engineer- ./
Enclosures
cc: EP 96-180 File
401 West Hamilton File
H: \401 WHAM. L TR(WP)(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.379.2572 . TDD 408.866.2790
NEW PW FAX #
40R.H7 h.OO"'R
FT :D :D " @
oO"-lQ a CD Ol 15'
CD '<
:r CD :r CD => " Ol CD
~ ~~. D~ CD CD 0'
~ <. en
co ('0'0- CD ~
0. 0
~m~ ~ ~ co a I-'
::J __. _ 3 ~
'<" 0' 0' 3
~~~ ~ CD ()
" ~~ ~ @ ~
3 aCii- ~ 0
a"'::l 0 3
cWo;;t:;' '0
~.~ 7 . e
co ~~ ~
-<-:::r 0.
g-CD~ 0 ~~~.
_CD(/) =>
~ i> ~ Ol ~
"-Ol W (j - ~
~~~ O'J
0 ~ S;~ ~
(/) -. 0.
CDe"
.., am Ol
'<
~:.< ~ C5 ~1
~:T3.
o(i)'~ ~
-a.cS" 0'
::TCD=> Ol ~.
CD '00 (/)
00_ w s:
--00 _ 3' Ol
"';:::+::r <:
g.~. ~ ro- ~
C/J =.., Cil .:;z
~ ~~: ~ 0.
~ Ol ~
cno~ co ~
g~2
ctl :::!:..., ~ ~
OJ ~2~
Ol t'"l
=> 3.~~
" t'"l
:D -~CD
o CD_
CD ~ => (/) 00
'0 ~ ~ eg"
Cil ~
(/) c.. CD
CD ;:::+:-la.
=> g-~~
g
<' ~CD:y 0 ~
CD 3.3 CD Ol ~
(/)- 0(/)'0 co
(J) 3o~ 0
.0' ~;~
=> I-' ~
Ol g CD""oo- S
<:
Cil Ol " ~
O'CDCD
o ~.c Z
c ~~. 3' W
-n"co co ~ ~
~~a. Ol Cil
eCD_ => ~ ""
~ - 0
Ol or:E m
(") (")_.
8~:T " CD
5 :5"@ Cil f Zl>
"'~:E 9,
ro- on
::T_ .~
CD c: 0.
a~ 0 ~
CD. Ol (II
~::;; n
S' n W
0
~ CD e W
a~ 3- .,<;2
CD '0 => 0 C
e 0\
0 3 )> )>
a.~ 0' => 00
~ => 3
~ (ji" e 0 I-'
e!. e
E ~. ~ 3- \C
Ol- iI> W
-::T
'O~ Cl
CD I
CD Ol => <Jl. C
~ :E or
2=> co I-' C
::Jo- CD
S"~ '< W C
COo (5'
~ro ""
c: 0
![~ f .
0._ 0
- e
w:::::!. 0
ro~
(/)-
C:::T
s: .2:~
CD CD
CD ~3
3 .,<;2
-Ol 0
0- 0,<
~
."
0 it:
0
.O\"C'"'-it,o
""...~<1'~
... ~
U r-
. .
-' "-
-So ...
.<> ,
.." 1/ C ff A V. \l Co
CITY OF CAMPBELL
Public Works Department
November 4, 1996
Marcia Plumleigh, Superintendent
Campbell Union School District
155 N. Third Street
Campbell, CA 95008
Re: 401 W. Hamilton Avenue - Rosemary Elementary School
Dear Dr. Plumleigh:
We have reviewed the plans prepared by Giuliani and Kull for offsite work on Eden and
Hamilton A venues. These plans will be a part of an Encroachment Permit to be issued by the
City of Campbell Department of Public Works.
The permit will be issued to your General Contractor. Weare enclosing an Encroachment
Permit packet for your contractor's use. Please have your contractor fIle the applications for
the permit, post the required Labor and Materials and Faithful Performance Bonds in the amount
of $34,000 each, submit the certificates of insurance, post the construction cash deposit in the
amount of $1,360.00, and pay the plan check and inspection fee in the amount of $4,080,00.
Upon receipt of the above, this Department will approve the plans and issue the encroachment
permit. The construction cash deposit is a refundable amount if it is not necessary for the City
to use any part of it,
Please have your contractor call our office at (408)866-2163 if he has any questions or
comments.
Yery truly yours,
Cruz S. ez
Assistant Engineer
Enclosures
cc:
Giuliani & Kull
Michelle Quinney
File: 401 W. Hamilton
Permit 96-180
,
h:\401 whamilton.ltr(mp)wp
70 North First Street. Campbell, California 95008.14:23 . TEL 408.866.2150 . FAX 408.379.:2572 . TOO 408.866.2790
N~:! ~W FAX"
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
ENGINEER'S ESTIMATE
Address: 401 W. HAMILTON AVENUE. CAMPBELL ELEMENTARY SCHOOL D1STR1Cf
Date:
Application No.
11/4/96
Encroachment Permit No. 96-180
ITEM UNIT PRICES FOR PROJECf AMOUNT
NO. DESCRIPTION UNIT QTY < S30 K S30 K to S150 K > SI50 K S AMOUNT
I. SURFACE CONSTRUCTION
MOBILIZA nON 1 LS S 1,500.00 S 1,500.00
CONSTRUCTION TRAFFIC
CONTROLCONTROUPHASING I LS S 750.00 S 750.00
CONSTRUCTION STAKING 1 LS S 250.00 S 250.00
CONSTRUCTION TESTING 1 LS S 150.00 S 150.00
n. DEMOLmON/CLEARING
1. CLEARING & GRUBBING LS
2. SAWClIT P.C.C.lA.C.(UP TO 6') 292 LF $4.50 S3.00 S2.00 S 1,314.00
3. P.C.C. REMOVAL 86 SY S30.00 S23.00 SIO.OO S 2,580.00
4. CURB AND GUTTER REMOVAL 115 LF $6.00 S3.00 S2.00 S 690.00
5. MEDIAN REMOVAL SF $4.50 S2.25 S1.25
6. DEMOLISH EXISTING INLET/PLUG RCP'S EA
III. STORM DRAINAGE
1. 12" R.C.P. (CLASS V) 98 LF S60.00 $40.00 S20.00 S 5,880.00
2. 15" R.C.P. (CLASS nD LF S65.00 $48.00 S38.00
3. 18" R.C.P. (CLASS nD LF S70.00 S60.00 S52.00
4. 24" R.C.P. (CLASS nD LF S8O.00 S68.00 $59.00
5. 30" R.C.P. (CLASS nD LF S90.00 $75.00 $65.00
6. T.V. INSPECTION (12") 98 LF S 1.20 SO.75 SO. 60 S 117.60
7. STD. DRAINAGE INLET EA SI,600.00 S 1,300.00 SI,OOO.OO
(C.C. DETAIL 9)
8. FLAT GRATE INLET 2 EA . SI,400.00 SI,I00.00 S900.00 S 2,800.00
(C.C. DETAIL 6)
9. STANDARD MANHOLE 1 EA S2,OOO.00 SI,600.00 SI,300.00 S 2,000.00
(C.S.J. DETAIL D.ll)
(INCLUDES FRAME & LID)
10. BREAK AND ENTER M.H.lD.1. EA S700.00 S550.00 $450.00
Page 1
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DESCRIPTION UNIT QTY < S30K S30 K to SI50 K > SI50 K S AMOUNT
IV. CONCRETE IMPROVEMENTS
1. SIDEWALK 90 SF $6.50 $4.50 S2.75 S58S .00
2. DRIVEWAY APPROACH 1093 SF $7.50 SS.50 $3.75 S 8,197.50
3. CURB AND GUTTER 115 LF S22.00 SI8.00 SI5.00 S 2,530.00
4. V ALLEY GUTTER SF S12.50 SIO.OO SS.25
5. HANDICAP RAMP EA SI,200.00 S8OO.00 $700.00
6. TYPE B-1 CURB LF SI2.00 S9.50 $7.50
7. TYPE AI-B3 CURB LF SI5.00 SI2.00 SIO.OO
8. COBBLESTONE MEDIAN SURFACE SF SI2.00 S8.00 SS.OO
9. P.C.C. DRNEWAY CONFORM SF S7.00 S5.50 $4.50
10. A.C. DRIVEWAY CONFORM SF $4.50 S3.75 S3.00
V.
PAVEMENT
1. ASPHALT DIGOUT AND REPLACE 96 CF S2.00 S3.50 S2.50 S 192.00
(I0'XI2"X115' PCC SLURRY)
2. PAVEMENT WEDGE CUT (6') LF SS.OO S2.50 S 1.50
3. PAVEMENT GRINDING 115 SF SO. 80 SO.50 SO.35 S 92.00
4. PAVEMENT FABRIC (PETRO-MAT) 13 SY S2.00 S1.85 S1.50 S 26.00
5. ASPHALT CONCRETE (TYPE A) 3 T S80.00 SSO.OO S35.00 S 240.00
6. AGGREGATE BASE (CLASS 2) T $40.00 S20.00 SI2.00
7. SLURRY SEAL (TYPE II) SF SO.07 SO.06 SO.05
8. SLURRY SEAL (TYPE III) SF SO. II SO.09 SO.07
VI. TRAFFIC SIGNALS/LIGHTS
1. DETECTOR LOOP (6' ROUND) EA $450.00 S300.00 S250.00
2. DETECTOR LOOP (6' x 30') EA S650.00 SS40.00 S440.00
3. DETECTOR LOOP (6' x 50') EA S900.00 S750.00 S64O.00
4. ELECTROLIER EA S2,600.00 S2,200.00 SI,8OO.00 S -
5. I 1/2" RIGID CONDUIT 90 LF S9.00 S7.00 SS.OO S 810.00
6. 2" RIGID CONDUIT LF S17.00 SI3.00 SIO.OO
7 CONDUCTOR 90 LF SO.70 SO.55 SO.45 $63.00
Page 2
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DESCRIPTION UNIT QTY < S30 K S30 K to S150 K > S150 K S AMOUNT
8 PULL BOX (NO.3 1/2) EA S300.00 S24O.00 SI8.5.00
9 PULL BOX (NO.5) EA S4OO.00 S350.00 S300.00
VI/. STRIPING AND SIGNS
1. REMOVE PVMT. MARKINGS (PAIN1) SF S2.50 SUO SI.OO
2. REMOVE PVMT. MARKINGS (THERMO) SF S3.00 S2.00 SI.4O
3. REMOVE PVMT STRIPING LF SI.4O SO.80 SO.4O
4. STRIPING DETAIL 9 LF S1.35 SO. 8.5 SO.35
5. STRIPING DETAIL 29 LF S2.25 SI.6S S 1.20
6. STRIPING DETAIL 32 LF S2.4O SI. 75 SI.25
7. STRIPING DETAIL 37 (THERMO) LF SI.8.5 SUO SI.OO
8. STRIPING DETAIL 38 (THERMO) LF S2.50 S 1.85 SI.l5
9. STRIPING DETAIL 39 LF SUO SO. 85 SO.45
10. STRIPING DETAIL 40 LF S2.20 S1.70 SI.OO
11. LIMIT LINE LF S1.35 SI.05 SO,90
12. CROSSW ALl( LF S1.35 SI.05 SO.90
13. PAVEMENT MARKINGS (PAINT) SF S2.50 SI. 90 SI.6O
14. PAVEMENT MARKINGS (THERMO) SF S5.50 S3.8O S2.6O
15. PAVEMENT MARKER (NON-REFL.) EA $4.50 S3.00 S2.2O
16. PAVEMENT MARKER (REFLECTIVE) EA $6.00 $4.15 S3.15
17. TYPE K MARKER EA S95.00 S8O.00 S70.00
18. TYPE N MARKER EA S95.00 S8O.00 S70.00
19. SALVAGE ROAD SIGN EA S85.00 S75.00 S6S.00
20. RELOCATE ROAD SIGN EA SI00.00 S85.00 S75.00
21. INST. RD. SIGN ON EXIST. POLE EA S200.00 SI45.00 SIIO.00
22. ROAD SIGN WITH POST EA S300.00 S24O.00 SI95.00
VlII. LANDSCAPING
1. IRRIGATION, PLANTING WORK LS S6.00
(62)(5)= 310 SF
2. PRUNE TREE ROOTS EA S12S.00 SI00.00 S85.00
Page 3
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DESCRIPTION UNIT QTY <S30K $30 K to $150 K > SI50 K S AMOUNT
3. TREE REMOVAL EA $650.00 S500.00 $400.00
4. ROOT BARRIER (12") LF S20.00 SIO.OO $6.00
5. ROOT BARRIER (18") LF S25.00 $15.00 SIO.OO
6. STREET TREE (24" BOX) EA $450.00 S325.00 $250.00
7. STREET TREE (36" BOX) EA S700.00 $550.00 $400.00
8. TOP SOIL BACKFILL CY $15.00
(119)(7)(12")/27 =
IX. MISCELLANEOUS
1. PEDESTRIAN BARRIER LF $15.00 $60.00 $50.00
2. CHAIN LINK FENCE (6') LF $15.00 $11.50 $9.25
3. RAISE MISC. BOX TO GRADE EA S300.00 S200.00 SI75.00
4. RAISE MANHOLE TO GRADE EA $400.00 $275.00 S200.00
5. INSTALL MONUMENT BOX EA $450.00 $350.00 $300.00
6. MEDIAN BACKFILL CY SI9.00 SI7.00 S15.50
SUBTOTAL S30. 767.10
PREPARED'Y, C:;t:: ll- <"=.-~Cc:.
/~-t -f~ 10% SECURITY ENFORCEMENT FEE S 3,076.71
REVIEWED BY:
TOTAL ESTIMATE FOR FAITHFUL $33,843.81
APPROVED BY: PERFORMANCE SECURITY S34,OOO.00
.See Section 66499.4 of the Map Act.
h:\40 1 hamil(mp)exc.
Page 4
OCT-29-1996 09:28 FROM Giuliani & KuII, Inc
TO
3792572
P.01
Cupertino - Oakdale - Aubum
FACSIMILE TRANSMITTAL FORM
~\. ~,\Jh...~lL~~
Date:
\'0 ~cJfI-q~ .
~. .5"141-
E.tuA- ax, ..~.p~~'
~ ~-Aye,;
Project No.
Subject:
From:
Our Fax No. is (408) .25 7 -64'S'~
To:
Organization:
-6),1 '1.. .~
~~,
~11 - ;(Sl;;J.. ()
Attention:
Your Fax No.
This Message is:
Routine ( )
Comments: ~~ (Q~1;~
~.
Urgent ( )
~~
Total Number of pages transmitted including this sheet:
. Original document to be mail~d:
Yes ( )
No ( )
If you do not receive a1.1oft.hepag~s, or have any questio.ns,
please call us at (408) 257~64464
20431 Stevens Creek Blvd. · Suite 230 · Cupel11no, California 95014 . (408) 257-6446
.
OCT-29-1996 09:29 FROM Giuliani & Kull, Inc
TO
Kult, Inc.
Cupertino - Ookdole - Aubum
ED~r$l~ate
Eden Ave.l8tprovemeats
10/29/96
InstaJI12" R..C.P,
Install 10" ~,P.
. Unit
Cost
1000.00. $
5,00 $
;12.00 $
:425:00 S
630.00 $
1500.00 $
,2500.00 $
30.00 $
A5.00 $
3792572
P.02
Job.#. 5144, .
TGtaI
.Ceil
1000.00
1050.00
384.00'
.425.00:
1 60.00
3 000.00
.00
300.00
3 960.00
SubTotal = $ 13,879.00
]OOAa'~ $
0' " ".. c'
,. . ....... .".,. " .... . .'. I:,:
20431 Stevens Creek Blvd, · Suite 230.CupeftJhO~ CalifornIa ~ :9501,4:'
, . - .
.... . ,'; ':...0',
. ~.l~' ,\,:::>}'.~'::~~:.-
(408)'2S7~'F7' .
-' i-'-'
Of,c.4'4
$~'~. ,o~~
. . .
.. ..
1- "-
~ (,'
f) R (' H ~ \l \).
CITY OF CAMPBELL
Public Works Department
November 4, 1996
Marcia Plumleigh, Superintendent
Campbell Union School District
155 N. Third Street
Campbell, CA 95008
Re: 401 W. Hamilton Avenue - Rosemary Elementary School
Dear Dr. Plumleigh:
We have reviewed the plans prepared by Giuliani and Kull for offsite work on Eden and
Hamilton Avenues. These plans will be a part of an Encroachment Permit to be issued by the
City of Campbell Department of Public Works.
The permit will be issued to your General Contractor. Weare enclosing an Encroachment
Permit packet for your contractor's use. Please have your contractor file the applications for
the permit, post the required Labor and Materials and Faithful Performance Bonds in the amount
of $34,000 each, submit the certificates of insurance, post the construction cash deposit in the
amount of $1,360.00, and pay the plan check and inspection fee in the amount of $4,080.00.
Upon receipt of the above, this Department will approve the plans and issue the encroachment
permit. The construction cash deposit is a refundable amount if it is not necessary for the City
to use any part of it,
Please have your contractor call our office at (408)866-2163 if he has any questions or
comments.
Yery truly yours,
Cruz S. ez
Assistant Engineer
Enclosures
cc:
Giuliani & Kull
Michelle Quinney
File: 401 W. Hamilton
Permit 96-180
I
h:\401 whamilton.ltr(mp)wp
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.379.2572 . TOO 408.866.2790
NEW PW FAX '#
4.0R.'l'7.t:: .........'"
.!. .:l
Af] N.'v\'v'HO
- --".-.- --
NMOHS S'rJ
3lV;)S
SNOISII\3H
3l'v'O
(1./
I', }II
r-:-p,l
~,/
'" ,~
".,.". /"
--;--: -::- -:- -::' ~ ~:y
.. , ,~~Y
-;-. -====- ::::--:- /""
-----.::......=....:.- ~
.~oI'IInJI ~ 10811nln
<;:..
-~~~~
~~~
-:.~~~
~,,<>~
.,,~~
~@
3nN3^V
s 9/, I? / Xi!?'--'
GG
N3Q3
*-
"1...
"
~~
~~
1~
"~~ ..)
'\I~ ~
~~ ~~
l~~
~~~
III
III
~
2
y
f
~
JS\
~ ~
I.LI · \Ii
:;)Jl
~1
-
J t: ~
d ~.~)
1 3
1i ~~ ~J
z
~ ~
~ ~
~ ~l~ -
~ ~:2
~~ ~ C
~I.~~~ 3:
~~~~~
~ ~~~~
\it
~~~\1
~
~
.
U)
~
'\
~
~
~
l
,
~
,:\.
. . .. .
, .:' .'.
. .
":. ;, ,;.;:~ :~. .~::.~ ;',: .:.'
gO
\I)
\I)
~
~
1
J
r
fu
@II:.II,.,II
.11"
\,11' 'I
.11" I
1:1\ 'I
I: II' '
I, II, ~.I
I'll . I
I'll " I
1'1' I
, I,
1'\1 " I
r \I'- '.1
I'll, : :
1'1\', I
1'111,1
I 'I\' .\
1\',1
1'1: .\
Ir'l
H.'"
\11)
II' .1
1'1 . I
II. ,1
;11': \
\,t;~
\~~~\
\\.;' "
~. '-
~ ". "
.' ~~.">-
.IOp ,~~~ "-:--::-
~ ...~.....::~~
-- -....=-.
~
3nN3^V
. ~
~
~ ~ NO.1 1 IW
~ ~~==
./ . --;;;.---:-;-
\0 /. - """~'. .
to.. /,~, ,.'-
'OJ /"~, ,,...,..-
;:#,."/
//1';/
.j; .,;1
. " '/
1,1 :.1
\'\ . I
'I" .1
I J ' '1
SlN3\
(/)
1-'
Z.
. "
:)
z
w
~
z
o
I-
..J
-
:E
<
:I:
o
...
2
-~
..
~
LtJ
...J
c(
(.)
o (/)
o
N