96-187
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X-Ref. file
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
(for working within the
public right-of-way)
Issued {'''1I- q~
Permit expires in 12 mos.
Application Date (,..It -1 (p
Application expires in 6 mos.
APPLICATION. Applicalion is berdly IIIIlIe for. Pllblic worts Pamit in ar:conIaDce with CaIqIbeII MuIIicipaI Code, SecIioD 1l.1M. (ApplicldoD aplns Ia 6111l1111bs
If the permit Is DOt issued. App1iclDoa Fee is IIOII-reluDdable.)
A. Workaddras orlrllCt' C\C\ Q u\\\ \) \C'l'\ \ h'; 0vU
\ \
Ulility lrend1IOC11ion
Q \ ~\ ^ ~ <C\f \k j(\ \,y._ ,~ \ ~C rF
\
C. AaadI four (4) copies of III qineercd plllls lbowiDa the IoCIIioIl and ateIII of lbe wort. and four (4) copies of lbe pI'IIimIMry EDaiDeer'a IiIcimIre of work. The
plllls abIIllbow !be reIalion of !be proposed work to aistina I1IrUce and lIIIIIerpouDd improvemeall. WbeD Ipproved by lbe City EDaiDea'. aaid plan becoaIa . pert of
Ibis permit.
B. NIIIIre of work
\(12-\)\O.c-P
-~
S<::.~ Q. -\\ ~)"\ y-~ c)"~.
D. All work sball confonn to !be City of Campbell Srandard SpecificaIious aad DelaiIs for Pllblic: Works COIIIInICIion; lbe Geacn1 Pamit ,.ftIUI;,w. IiIIed OIIlbe _
aide; and lhc Special Provisions for Ibis permit, lisled below. Failure to abide by Ibeae COIIdi&icIIlI and pmvisioDs may reauIl in job abut-dowD fIJIJIor forfeilure of FaiIhfuI
Jl.-fonnance Sureties aDd casb deposits. (See General Pamit CoodiIicms 1 aad 2.)
E. THE CONTRACTOR MUST HAVE TIDS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBUC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST 2<6 HOURS BEFORE RESTARTING ANY WORK.
Hale of Applicant
'\\ '(\ ~ \V\ D \\ \~ 'E.. - c-::)O \\ -= ( /~L
(print name)
01.- \('\\\C \. ^\\ \-\\)f' \\ \)f' / , c:; .l. ,
.
C t'\\\ ~ -A-nx -\1 t\\ Telcphone
24 H>UR EMfMiEl<<:Y
Is this work bein& done by the property owner at their own residence? Yes
CAcsocsr:, TELEPHONE NO.
t/ No
Address \0..\0
The ApplicantlPenniaee hereby 8Iree5 by aff'Wna their lipature to Ibis permit to hold lbe City of CampbeU, ill oft"xcn, ... and ~Ioyees free, safe and bIrmIeu from
any daim or demand for dama&es resultin& from !be work covered by this permit.
The ApplicantlPennittee berdly acknowlcdaes that they bave raid and IIIIIIcmIIId both lbe froG aDd back of Ibis permit, and they willlnform their CIlIIIrIClOI'(s) of lbe
Iaformation.
Accepted
--Y\\\Y\
\\\Jc---v...E ~\ \h~{~~~\\\~ rt:lL
(ApplicantlPennittee) (sip) \
~. \ \. CHp
Date
CITY OF CAMPBELL
Public Works Department
September 17, 1998
. Ms. Tina Moore
San Jose Construction
1210 Coleman Avenue
Santa Clara, CA 95050
SUBJECT: PERMIT NO. 96-187
LOCATION: 901 Campisi Way
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Ms. Moore:
The City of Campbell has made the final one year maintenance inspection of subject Public
Works improvements and fmd that no remedial work is required.
smcer~~
Alan Horn
Public Works Inspector
MQf"l;\.
cc: Permit 96-187
Public Works/Maintenance Division
H:\ WORD\PERMITS\96187 ACC(JD)
70 North First Street. Campbell, California 95008.1423 ' TEL 408.866,2150 . FAX 408.376,0958 . TDD 408.866.2790
o,,'C4<1t
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O~CHA\lQ-
CITY OF CAMPBELL
Public Works Department
July 10, 1997
Ms. Tina Moore
San Jose Construction
1210 Coleman Avenue
Santa Clara, CA 95050
SUBJECT: PERMIT NO. 96-187
LOOCA TION: 901 Campisi Way
FINAL INSPECTION AND ACCEPTANCE
Dear Ms. Moore:
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.
If you have any questions, please call me at (408) 866-2168.
Sincerely,
.-r-7 ~. _
~ ----- - -
Robert Phillips
Project Inspector
MQ~
cc: Suspense - 11 months
Permit #/6-187
J. L....J / ~~Co"A'l <--L.>
H:\ WORD\PERMITS\96187FIN(JD)
70 North First Street. Campbell, California 95008.1423 ' TEL 408.866.2150 . FAX 408.376.0958 . TDD 408.866.2790
i
I
i
ITo: City Clerk
I
PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1. 1995
PUBLIC WORKS FILE NO. 9b. .... ) r-;
7() / C ' M
PROPERTY ADDRESS a..rJ fJ /';
Please collect & receipt for the following monies:
Accr_ mM AMOUNT
435.535.4921: Proiect Revenue (specifv project) $ i
ENCROACHMENT PERMIT I
4722 Application Fee I ~~ '5.06 :
i Non-Utility Encroachment Permit ($225)
, R-l First Permit (No Fee). Subsequent Permit/Vr ($100) I !
I Utility Encroachment Permit
i Arterial/Collector Street ($325)
Residential Street/Other Areas ($225) I I
I
2203 Plan Check Deposit ($500) ~ I
2203 Faithful Performance Surety (FPS) (100% of ENGR.EST.) r I
--j
2203 Monumentation Surety (100% of ENGR.EST.) .. I
2203 Cash Deoosit (4% of FPS)($5oo min.) ~ I
2203 Labor and Material Suretv (100% of ENGR. EST.) r I
I Plan Check & Inspection Fee (Non-Utility) I
I I~CJ,(JO
4722 Engr.Est. < $250,000 (12% of ENGR. EST.)
.. 2203 Engr.Est. > $250,000 (Deoosit 15% of ENGR. EST,)" i
4722 Utilitv < $100.000 i
Conduits/Pipelines up to 500 Feet ($1.60/ft.) (MIN. $105)
Above 500 Feet ($1.10/ft.) i I
I I
Manholes/Vaults/Etc. ($105/ea) L
Pole Set/Removal ($105/ea)
Minimum Charge Per Location ($120)
Street Tree Planting/Removal ($105/tree)
.. 2203 Utilitv > $100,000 (Deoosit 15% of ENGR. EST.)"
4760 Pro' ect Plans & Specifications Proiect No.
4760 Standard Soecifications & Details ($1/Po $12/Book) I
4760 Copies of Enoineerino MaDs & Plans ($.50/so.ft.) i I
4722 Penalties: Failure to restore public imorovements ($1 OO/Calendar Dav) I
I I
I (Muni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions ($loo/Calendar Dav) ,
LAND DEVELOPMENT
4722 Lot Line Adiustment ($500) I
4722 Parcel Map (4 Lots or Less) ($1 060 + $25/Lot) I
4722 Final Tract Map (5 or More Lots) ($1,380 + $25/Lot) I
4722 Certificate of Compliance ($400)
4722 Certificate of Correction ($300)
4722 Vacation of Public Streets & Easements ($550) g
4722 Assessment Segregation or Reapportionment
i First Split ($550)
Each Additional Lot ($170)
4721 Storm Drainage Area Fee Per Acre (R-l, $2.000)
I (Multi:Res. $2.250) I
(All Other, $2.500) ,
4920 Parkland Dedication Fee (75%/25% Due Uoon Cert. of Occupancv) I
4965 Postaoe i
TRAFFIC I l
4728 Intersection Turn Counts (Two-Hour Count) ($60) I
4728 Intersection Turn Counts (a.m. or o.m. oeaks) ($125)
4728 Traffic Flow Map (Dailv Traffic Volumes) ($27)
4728 Camobell Traffic Model (Full Scooe Assessment) ($2 250)
4728 Campbell Traffic Model (Reduced Scone Assessni$740)
4271 Truck Permits ($35/trio)
4728 No Parking Signs ($lIeach or $25/100)
OTHER I
34-5'. /)0 ,
I
TOTAL $
NAME OF APPLICANT 5a- 1~ Co.., 1-f-t''^ c"ti u -r- G. / ftc.~ .
.- !
NAME OF PAVOR 5a.... )()~ C~I\ sfr. ('4. II! C . PHONE 9?6- 97/1 I
ADDRESS /;),0 C'~~~) r;: ;~ C/o-rA ZIP 950 '5 () I
I
"Actual Cost Plus 20% Overhead (Non-Interest bearinn denosit)
roR
CITY CLEIlX
ONLY
I::-~ ~q~
<For Plan Check and Cash Deposits, send yellow copy to Finance.
Date/Initials
RECEIVED
JUN 1 11996
CITY CLERK'S OFFICE
h:\recfrm3. wk3(mp)rev. 1 /9/96
Att...tlt@
CERTIFICA~
--
-
-
OF INSURANCE
-I~I
PRonUCER
Commercial Lines Unit
ALBURGER BASSO de GROSZ INS.
301 Island Parkway, Suite 300
Belmont, CA 94002-4110
DATE (MM/DD/YY)
03/27/97
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.
COMPANIES AFFORDING COVERAGE
___n_..'__'_ ..____._.__...__~.,___._____.._ _ ____
COMPANY
ASt.Pau1 Fire & Marine
INSURED
San Jose Construction Co.,
1210 Coleman Avenue
Santa Clara, CA 95050
Inc.
COMPANY
BCIGNA
--1t- -e--cl-lV-~ 0
Indemnity ~1_
- -Ant)- -
Mf" ')'\ ... . ------
COMPANY
CRe_puplic_
CO
LTR
COMPANY
D WvrU'..::'
CO~~~sA~:o CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOV~~~~~~~~Y 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.
_--r---- -- ------u1------- - n--r--
1 POLICY EFFECTIVE rOLlCY EXPIRATIONi
I DATE (MM/DD/YY) - DATE (MM/DD/YY) I
11/30/96 11/30/9 7 l~_NE:R.AL AGG_R.EGAT.E=... $~1 G9_Q ,Q.Q_9
IPRODUC-rS-COMP/OP AGG $~~.Q_Q_LQQ 0._
PER_S()_N.AL &~()v INJU~': _ $~L 0 GOL 090__
EACH_OCCURRE_NC~ , .!hQ 09.,0 QQ_
FIRE DAMAGE (An~,olle fire) (L.o o._L 00.9.
ME D EXP (Anyone person) $5 0 0 0.
11/30/96 11/30/971
! COMBINED SINGLE LIMIT $1, 000 , 000
I ~ODIL Y INJU-RY - --, $
(Per person)
-- ----
~ODIL Y INJURY
(Per accident)
--'-'_."_._._~---
I
I PROPERTY DAMAGE
TYPE OF INSURANCE
POLICY NUMBER
LIMITS
A GENERAL LIABILITY i
XF_ OMMERCIAL GENERilL L1ABILlT:
- ! _] CLAIMS MADE ~XJ OCCUR
PWNER'S & CONTRACTOR'S PRO.
I i
i
KKo.8300369
A AUTOMOBILE LIABILITY KK08300369
X ANY AUTO
ALL OWNED AUTOS
: SCHEDULED AUTOS
X I HIRE D AUTOS
X NON-OWNED AUTOS
1 GARAGE LIABILITY
r-- -\
i ANY AUTO
1
i---- I
B i EXCESS LIABILITY XLXG18856360
I ] UMBRELLA FORM I
i X I OTHER THAN UMBRELLA FORM
C WORKERS COMPENSATION AND 320090.3
EMPLOYERS' LIABILITY
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
$
$
AUTO ONL Y -EA A~CIDENT L.....__,_~_~_,_
OTHER THAN AUTO ONL Y:
-~_._--
11/30/96111/30/97
1
_ ---.E_ACH ACCIDEtliT $
AGGREGATE $
EACHO~Uf'lI'lE.NCE _ _ !5-L.OQQLQ.Q0
I AGGREGATE $
$
04/01/97 04/01/98
I I
X STATUTORY LIMITS
E~C H ACCII)E:'!I_ ____ $J...1.Q.o. _~_O QQ__
~:::::~~~~C;~~~~YEE l:i1 ~ 66 L6~6
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS
RE: ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL, ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS
LIABILITY PER ENDORSEMENT ATTACHED.
CERTIFICATE HOlDER
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
CANCEUATION'I'eIlDayNobiCef6::tNon-.payrnen.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANYWILlHllNBEJ....9F1 T9 U~IL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
IiIIJTr~.I~IIRIi TQ ~4AIb.. C'!II","&-I t.lnTI~~ C......41 I lupn~~ Nn nRIIA.4TlnN nR I IAAIIITY
A~IVE
ACORD 25-$ (3193)1 of 1
RAT ~ ACORD CORPORATION 1993
POLICY NUMBER: KK08300369
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLlCY:-PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEESS or
CONTRACTORS [FORMB]
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
{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.
RE: ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL, ITS
OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL
INSUREDS AS RESPECTS LIABILITY PER ENDORSEMENT ATTACHED.
CG 20 10 11 85
"/ -17'
PRODUCER
Alburger Basso de Grosz
301 Island Parkway
P.O. Box 2017
Belmont, CA 94002-1169
DATE (MM/DDNY)
11/27/96
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
COMPANY
A St. Paul Fire & Marine
INSURED
San Jose Construction Co., Inc
Etal
1210 Coleman Ave
Santa Clara, CA 95050
COMPANY
B Cigna
COMPANY
C Republic Indemnity
"'~' f
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 POLICY EXPIRATION LIMITS
LTR DATE (MMlDDNY) DATE (MMlDDNY)
A GENERAL LIABILITY KK08300369 11/30/96 11/30/97 GENERAL AGGREGATE $ 2 000 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $ 2 000 000
CLAIMS MADE [i] OCCUR PERSONAL & ADV INJURY $ 2 000 000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1 000 000
FIRE DAMAGE (Anyone fire) $ 100 000
MED EXP (Anyone person) $ 5000
A AUTOMOBILE LIABILITY 1,000,000
X KK08300369 11/30/96 11/30/97 COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
(Per person) $
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY
X (Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY, EA ACCIDENT
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
B EXCESS LIABILITY XLX G 18856360 11/30/96 11/30/97 EACH OCCURRENCE $ 5 000 000
UMBRELLA FORM AGGREGATE $ 5 000 000
X OTHER THAN UMBRELLA FORM
C WORKERS COMPENSATION AND NC3522754 04/01/96 04/01/97
EMPLOYERS' LIABILITY
$ 2 000 000
THE PROPRIETOR! INCL EL DISEASE, POLICY LIMIT $ 2 000 000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE, EA EMPLOYEE $ 2 000 000
OTHER
DESCRIPTION OF OPERATIONSJLOCATIONSNEHICLESlSPECIAL ITEMS
RE: ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL, ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS
LIABILITY PER ENDORSEMENT ATTACHED.
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL IIIIJ8III<<]Rl(JII) MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
.~IMlIXDEX:lll1l:XllllJllSIDKIII:lIIIIIIIIl19B:DXllllmlII~XllIBIIlII1I:
POLICY NUMBER: KK08300369
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 COVERAGE PART
SCHEDULE
Name of Person or Organization:
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
(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.
RE: ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL, ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS
LIABILITY PER ENDORSEMENT ATTACHED.
CG 20 1 0 11 85
Copyright, Insurance Service Office, Inc., 1984
PRODUCER
Alburger Basso de Grosz
301 Island Parkway
P.O. Box 2017
Belmont, CA 94002-1169
DATE (MMlDD/YY)
04/01196
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
COMPANY
A St. Paul Fire & Marine
; \10 ~ ,... ,..
:.- .;;... t~ .q ~
~ ,....
INSURED
San Jose Construction Co., Inc
1210 Coleman Ave
Santa Clara, CA 95050
COMPANY
B
Cigna
:q P L;
" ,
COMPANY
C
Republic Indemnity
tf..J" C
,- ...;'.... c
, to.. ~
"1I1v IS -/',
II'( "" ~/
.10.
THIS !S 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 POLICY EXPIRATION LIMITS
LTR DATE (MMlDDIYY) DATE (MMlDD/YY)
A GENERAL LIABILITY KK08300236 11/01/95 11/30/96 GENERAL AGGREGATE $ 2 000 000
COMMERCIAL GENERAL LIABILITY PRODUCTS. COMP/OP AGG $ 2 000 000
CLAIMS MADE [Xl OCCUR PERSONAL & ADV INJURY $ 2 000 000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1 000 000
FIRE DAMAGE (Any one fire) $ 100 000
MED EXP (Any one person) $ 5000
A AUTOMOBILE LIABILITY 1,000,000
KK08300236 11/01/95 11130/96 COMBINEO SINGLE LIMIT $
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY
(Per person) $
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY
X (Per accident) $
NON.OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
B EXCESS LIABILITY XUXG18441081 11/01/95 11/30/96 EACH OCCURRENCE 5 000 000
X UMBRELLA FORM AGGREGATE 5 000 000
OTHER THAN UMBRELLA FORM
C WORKERS COMPENSATION AND NC3519844 04/01/96 04/01/97
EMPLOYERS' LIABILITY EL EACH ACCIDENT $ 1 000 000
THE PROPRIETOR! INCL EL DISEASE. POLICY LIMIT $ 1 000 000
PARTNERs/EXECUTIVE 1 000 000
OFFICERS ARE: EXCL EL DISEASE - EA EMPLOYEE S
OTHER
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLESlSPECIAL ITEMS
RE: ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL, ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS
LIABILITY PER CG 2009.
lifiEiliilll:il,lgiC'C' "-,
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL -lDIKlIII MAIL
.JL DAYS WRITTEN NOTICE TO THE CERTIRCATE HOLDER NAMED TO THE LEFT,
.IIXD1IX8XIUIMlIXSIII:N..-.--nr~.XlIIIIIIliIIIIa
POLICY NUMBER: KK08300..._J
....JMMERCIAL 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 COVERAGE PART
SCHEDULE
Name of Person or Organization:
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
(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.
RE: ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL,ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS
LIABILITY PER CG 2009.
CG 20 10 11 85
Copyright, Insurance Service Office, Inc., 1984
Insured Name
San Jose Construction Co. Inc.
1210 Coleman Ave.
Santa Clara, CA 95050
Policy #
KK08300236
PRIMARY WORDING:
SUBJECT TO ALL OTHER TERMS AND PROVISIONS OF THE POLICY, SUCH INSURANCE AS
PROVIDED BY THIS ENDORSEMENT SHALL BE DEEMED PRIMARY, BUT ONLY WITH
RESPECT TO WORK PERFORMED BY OR FOR THE NAMED INSURED IN CONNECTION WITH
THE ABOVE DESCRIBED CONTRACT.
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