96-241
CITY OF CAMPBELL
PUBLIC WC'RKS DEPT.
70 N. First St.
Campbell, CA 95008
(408)866-2150
FAX (408)376-0958
..
.
OWNER OCCUPIED R.l
NO FEE ENCROACHMENT PERMIT
(for working within the
public right-of-way)
($5,000 maximum value of work)
ISSUED lO/3 { /9 ~
. Permit No. 10./ J..Lf I
4 X-Ref. File .
Application Date CJ/Lt,/?ft
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.)
A. Work Address
B. Nature of Work I
C. Attach three (3) copies of a d in howing the location, extent and dimensions of the work. The drawing shall show
the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing becomes
a part 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
securities.
NAME OF APPLICANT rJ'AtWv:^ 6cw: ~ Co tl<-f-l. .C,. ):c. TELEPHONE trof--11/- /4 tJ 6
(Print Name) y1:;[ I a (
ADDRESS It4U /.Z~1I C;rd.u) ~o.- J~~ cA 9S J/1-
J
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant 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 Applicant hereby acknowledges that they have read and understand both the front and back of this permit, and that they will
inform their contractor(s) of the information.
ACCEPTED
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL ST ANDARD DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH
THE PUBLIC WORKS INSPECTOR AT THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
PER SECTION 4215 OF THE GOVERNMENT CODE THIS PERMIT IS NOT VALID FOR EXCAVATIONS UNTIL
UNDERGROUND SERVICE ALERT (USA) HAS BEEN NOTIFIED AND THE INQUIRY IDENTIFICATION NUMBER
(TICKET NO.) HAS BEEN ENTERED HEREON. USA PHONE: 1-800-227-2600. TICKET NO.
M:1J
STANDARD
% OF ENG. EST.)
AMOUNT
$/05'0 -
RECEIPT NO.
or City Engineer
6 Months After the Date of Issuance
APPROVED FOR ISSUANCE
( SEE OTHER SIDE)
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STAR ~.JSURANCE COIV~ 'ANY
9790 Gateway Drive Suite #200 Reno, NV 89511
(702) 850-5100 (800) 262-5252 FAX (702) 850-5120
NOTICE OF CANCELLATION
Obligee:
9/30/97
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
70 N. FIRST ST.
CAMPBELL CA 95008
Re: BOND NUMBER: SA1316740
TYPE OF BOND: HIGHWAY/STREET ENCROACHMENT PER
HIGHWAY/STREET ENCROACHMENT PERMIT
Principal:
MARVIN DAVIS CONSTRUCTION, INC.
1440 KOLL CIRCLE, SUITE 104
iECE'VED
0..,..,. ~)
.L j ~ 1997
SAN JOSE
CA 95112
:';\J...jt,~( \;',,/ '~./,,( ','\
qDMIN'STRAT'-O~
GENTLEMEN:
The above bonding Company hereby notifies you that it has elected to cancel
said bond in its entirety. This Notice is given to you in accordance with
the cancellation provision in above mentioned bond and applicable state
insurance statutes.
.
\~ \ I
\' \~~(~ i-.
By:
STAR INSURANCE COMPANY
,J .. \
'1, 1 \. l'l
- \~l\~ J.o.).tL
Attorney-in-fact
(A)
*** OBLIGEE COPY ***
BOND NO. SA1316740 .
EMIUM: $100.00
,(le./,n,... ,
.oND mll~AJTHFUL PRltJ'ORMANCE- p l~~} ct. n
V(U ( I'
I .:. ) 31 /1...,[.
W..lbeuadcfsiped MARVIN. DAVIS CQNSTRUCTTON T}j'C'; I (~
"eo.aclDJ'") dd S TAR IN S URAN C E C OMP A NY & corporadoa crpaizcd lIIldcr * IaWl of me Sa. of
M I C H T G AN. aDd IIIIborizcd 10 trIIIACl blItiDesI q Ibc S. of Callfonia, 1$ Sumy. are
oblipDld 10 dae Chy of Campbell. 0IIniIaftIr -CllJ-) a ~ CQlPUIADoa UDder die laws of.. SlMD of CaBnia.
._I\I1II01 ONE TH'DuSAND FIFTY' DOLLARS & NO/IOQ)ollm($l,OSO.OO***)
for' me paymem of WlUdI _ .. cbIipIe oandvcs aDd oar IIJIXCS.JOn aai uRps. Joi8d7 ud ~Iy by 1M
toUowiaI provisiou:
1be ~ of ads obIipIiaa II:
Because lhc oblipllcl CoIIIrx1Dr JIJs. on I IP ~ .-red imo wriaea
CoDlrlCt wkIl tZIc C1q for die ProjecuMbSad PER M T T N n 9 6 - 2 4 1 . a copy of wtUch is
IDCbfd aDd made a pan ot ~ boIId. tw coasuucdoD of Proj~
Now. Ibclefim, if_ Co.racw sba11 &idafa1J,. perform" wort ill accordace wish me plaDs, SS*i1leacio~
_ COIIItact ~"'QU cIIariq tbc orjpIIlCrIII. aID'! mnSoI1S of. comnct wIdcb may be JrlDIed by die City,
widl or widKM DOtic:c 10 _ RmJ. -.I if it sWl saIisfy all cJaiats aDd deaIInds iJarrecl.... 11>> C01l1I'ICt. - sba1l
CIaIly iDdamdfy &ad AYe b......tr.,' _ Citr from all COStS IIIl! damapc whic:.b it may SIIffu by l'eucm of faihn 1IO do
10, aad IbaJI RimINnc &lid ICp&y 1bI at, all oUay &lid IOlI** w!Iic:b die City IDlY iucnr in makiIIc Jtrf default. dlen
dais obliplioD sba.U be voicl; odIIrwiIe 1:) JeIIJIisl ill i1I1 ton>> aDd elfec&.
If 1A'11e3al1C1:iclla .,. aw .. dIis boK, 11 sIIaIl be tuecl widIiD OllIe year dI:r laa19lJlDeDI hu bcea made
IDler die CouInct txcJudiII.... ..,.., period. If'." provided fer ill dae ~ aad Wdltlball Ue III lilt Coway
of Sam Clua, SI:Ia ot CaIi6lni.. ad _ ~. for value .tceiwd ..;p.1_~ IDlI qrees dial II) dIaDp. maas.ion
oftiale. &IIInl:ioa ot MdiDoa eo cia .... 01 die Coanct 01' to die work to be ~1la.....4 \IIIder iI or die ~..
ICrooOi .4J~ it sba.lI m.,. ..,. a1fecE its ohHpioD 0Il11Jis boDd. m:I it does by dill DICIDS waM DOdee of allY ~c,
~ of bme, dma1ioa OIl6!:tioa II) 1be -.s ofdle Comna Of to 1be work Qr' to dIe~. .s dIacby
"'VW tM proviajcmI of Sec:doa 21i9 01.... cml QxIt of die SIIIe of CaIiIxIia.
"
III ..mz-. comK1Dr _..., baft ..DIal. 1his ."..... as of 0 C T 0 B E R 2 5
. 1922....
1l:fDnBI\bo8ds.1rm(mp)
COMPANY
, ATTORNEY-IN-FACT
. SUITE 302
(.AJ:w:!I N.:bIow~)
Samy'. Bood N1bDbcc c; A 1 i 1 h 7 t. 0
(Boa PriDcipal's aDd
Sm'ec1's Aatctwr in FIiCT.)
(/tQoompaay dID bcaI wkb ~iD-fact's
~ flom SlImy to exeaue cbe boall.
c;e:Ufieci to iDeble the date of dae boIId.)
ALL-PURPOSE ACKNOWLEDGMENT
r._._._._._._._._._._.~._.~.~.~._.~.,
t. State of California } s's. t.
County of Santa Clara
i On OCTOBER 25,1996 before me, Danijela L. Mosunic i
(DATE) (NOTARY)
t. personally appeared Francis ~\. Cook t.
SIGNER(S)
i [] personally known to me - OR- D proved to me on the basis of satisfactory i
. evidence to be the person(x.) whose name~) .
t ishul[ subscribed to the within instrument and t
. acknowledged to me that he/xbclmJ executed ·
t the same in his!ireU>>JfIt authorized t
. capacity(~, and that by his/ireu>><<k ·
t signature~) on the instrument the person(i), t
t . ~---O"\.J\\;t'\ or the entity upon behalf of which the t
:--~;~~i'I'~l~~il'l~ m person~) acted, executed the instrument. :
t _1 ::~{ .-'"'~~..57-'. >J '\ u\J3IJC' ~,~Urv '. -' t
. "c~'. "'~'{i'~1 fll)H<H { '" ,rount'l dI
~". "'.'''....3-.. -."..A'.' .,,:) c'e.'~c... ,)..IJ vJ ,_oM'
i '<~g~:\.;:.;:.:;c:;:.;.;:;;'" WITNESS my hand and official seal. i
i ~/ - i
i N",ARY':'~ i
· OPTIONAL INFORMATION ·
t The information below is not required by law. However, it could prevent fraudulent attachment of this acknowl- t
i ~~;:~; ;=:;ri~~d :I:=n~PRINCIPAL) DESCRIPTION OF ATTACHED DOCUMENT i
. .
to INDIVIDUAL t
o CORPORATE OFFICER
t. PERMIT BOND t.
TITI..E OR lYPE OF DOCUMENT
TITLE(S)
. .
to PARTNER(S) t
. [i] ATTORNEY-IN-FACT .
t 0 TRUSTEE(S) NUMBiR OF PAGES t
· 0 GUARDIAN/CONSERVATOR ·
t 0 OTHER: t
t. OCTOBER 25, 1996 t.
DATE OF DOCUMENT
. .
t SIGNER IS REPRESENTING: t
i NAME OFPERSON(Sl OR EmITY(lES) MARVIN DAVIS CONSTRUCTION - INC. i
, STAR INSURANCE COMPANY I ,
. OlliER.
L.~.~._._.~.~.~.~.~.~._. _._._._.~._.~
APA 1194
VALLEY.SIERRA.800-362.3369
ST. ~ INSURANCE COMP p .....TY
GENERAL POWER OF ATTORNEY
NO.: SA 1316740
(Void unless numbered in red.)
KNOW ALL MEN BY THESE PRESENTS, that Star Insurance Company has made, constituted and appointed, and by these presents does
make, constitute and appoint.'
FRANCIS E. COOK OF CUPERTINO, CALIFORNIA
its true and lawful attorney-in-fact, for it and in its name. place, and stead to execute on behalf of the said Company, as surety, bonds,
undertakings and contracts or suretyship to be given to
Applicable to All Obligees
provided that no bond or undertaking or contract of suretyship executed under this authroity shall exceed in amount the sum of
one million ($1,000,000.00) dollars.
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution
adopted by the Board of Directors of the Company on the 7th day of January, 1993.
"RESOL VED, that the Chairman of the Board, the Vice Chairman of the Board, the President, an Executive Vice President or a Senior
Vice President or a Vice President of the Company be, and that each or any of them is, authorized to execute Powers of Attorney qualifying the
attorney-in-fact named in the given Power of Attorney to execute in behalf of the Company bonds, undertakings and all contracts of suretyship;
and that an Assistant Vice President, a Secretary or an Assistant Secretary be, and that each or any of them hereby is, authorized to attest the
execution of any such Power of Attorney, and to attach thereto the seal of the Company.
FURTHER RESOLVED, that the signatures of such officers and the seal of the Company may be affixed to any such Power of
Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or
facsimile seal shall be valid and binding upon the Company when so affixed and in the future with respect to any bond, undertaking or contract of
suretyship to which it is attached."
IN WITNESS WHEREOF, STAR INSURANCE COMPANY has caused its official seal to be hereunto affixed, and these presents to
be signed by one of its Senior Vice Presidents and attested by one of its Assistant Vice Presidents this 13th day of March, 1995.
Attest:
STAR INSURANCE COMPANY
STATE OF MICHIGAN
ss.:
~_-,~r: .)?J.
~~~AsSistant Vice President
COUNTY OF OAKLAND
On this 13th day of March, 1995, before me personally came Marc S. Willner, to me known, who being by me duly sworn. did depose
and say that he is a Senior Vice President of STAR INSURANCE COMPANY, the corporation described in and which executed the above
instrument; that he knows the seal of the said corporation; that the seal affixed to the said instrument is such corporate seal; that it was so affixed
by order of the Board of Directors of said corporation and that he signed his name thereto by like order.
COllEEN KElTZ
Notary Public, 0aIdand CoIfty, MI
My Commis8ion ExpiAlS 1>;1. 30,1999
I. the undersigned. of STAR INSURANCE COMPANY, a Michigan corporation, DO HEREBY CERTIFY that the foregoing and
attached Power of Attorney remains in full force and has not been revoked; and furthermore that the Resolution of the Board of Directors, set
forth in the said Power of Attorney, is now in force.
CERTIFICA TE
Signed and sealed at the city of Southfield in the State of Michigan. Dated the 2 5 T Iday of 0 C TO BE R , 19--.26
~~~.~
6033-Mar.95
Page 1 of 1
CALIFORNIA ALL.PURPOS~ ACKNOWLEDGMENT
No. 5907
State of (1.li .fa;" I ()...
County of -SO/\ hA. Q;[a.ro...
On {OI~{2{" before me, 1Jn ne"~~:'~c,~~~!f,,.~,~l:"~
personally appeared J roC' ' (hor r ,'~h
~ NAME(S) OF SIGNER(S)
o personally known to me - OR - ~ proved to me on the basis of satisfactory evidence
to be the personE-s1 whose namete7 is/a.F&
subscribed to the within instrument and ac-
knowledged to me that he/.ih9.zthoy executed
the same in his/R-or/thci-r authorized
capacity(j.e.s.), and that by his/h.er/thei,r
signature(sr on the instrument the person(~,
or the entity upon behalf of which the
person (-at acted, executed the instrument.
- .& - - ... ... :N;~- - ~ 1
1 a. Commission 11086504 l;
~ -,,; Notrny PubDc - Callfomla ~
~ .. Santa Clara COUTIV 1
1_ ~ _ _My~:m~Ex~res~: 5~~
WITN~nd and official ~eaL
~
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
D INDIVIDUAL
D CORPORATE OFFICER
DESCRIPTION OF ATTACHED DOCUMENT
TITlE(S)
TiTLE OR TYPE OF DOCUMENT
o PARTNER(S)
o LIMITED
D GENERAL
o ATTORNEY-iN-FACT
D TRUSTEE(S)
D GUARDIAN/CONSERVATOR
D OTHER:
NUMBER OF PAGES
DATE OF DOCUMENT
SIGNER IS REPRESENTING:
NAME OF PERSON(S) OR ENTITY(IES)
SIGNER(S) OTHER THAN NAMED ABOVE
@1993 NATIONAL NOTARY ASSOCIATION. 8236 Remmel Ave., P.O. Box 7184. Canoga Park, CA 91309-7184
INSURANCE REQUIREMENTS CHECKLIST
Permit # I b -~ 4- J 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 performed under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
ET $1,000,000 per occurrence, and
IT $1,000,000 general aggregate limit applying separately to the project, and
8' $2,000,000 general ag~ate linjit. !Ill
er Policy expiration date /, ZB/9~ ~1
Automotive Liabili - "any auto" ~ ~
er $1,000, cCloent for bodily injury and property damage
0" Policy expiration date if 2. 'f3 /7"X </
.
Worker's Compensation and Employer's Liability
E( $1,000,000 per accident f~ bodily injury or disease
6 ~olicy expiration date J I J q"{ <J
Course of Construction (if required in Special Provisions)
o Completed value of the project
o Policy expiration date
, I
,I" ;
(r I
Required Endorsement to General Liabilitv and Automobile Liability Policies
AdJlitional Insured Endorsement
e:r The City, the City of Campbell Redevelopment Agency, its officers,
employees and volunteers are named as additional insured.
The insurance coverage afforded to the Additional Insured is primary
insurance.
/~
0/
eJ
Wprkers' Compensation Insurance Sheet Submitted
o For General Contractor
o Subrogation Clause
w
Insurance Certificate Reviewed ~ ~ ~
lniti::ls
7/
Date
o
Copy of Insurance Certificate placed in tickler file one nonth prior to expiration.
t<-'_,jl C) D ( j .. /. ,(:, '';1
/'./ I l /<.li
/ / F ~, ,
j:\forms\inscklst 4/96 (rev 6/96)
q0-~\
PRODUCER SCHAAPHOK INSURANCE AGENCY THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1799 E. HAMILTON AVE., STE 103 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.o. BOX 1244 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
CAMPBELL CA 95009 COMPANIES AFFORDING COVERAGE
COMPANY
A
FARMERS TRUCK INSURANCE EXCHANGE
INSURED
MARVIN DAVIS CONSTRUCTION, INC.
1370 TULLY ROAD #508
SAN JOSE CA 95122
COMPANY
B
TRUCK INSURANCE EXCHANGE
COMPANY
C
COMPANY
D
::~.tt:I::\:::::::I::::I::III:::t::@:t::t:\t:\::::t::::::nmttt:I:::::::::@:t:II:t::::t:::m:\:m:mtt:\:\t::=::::m:::::tt:::t::::t:::::m::@t:t:t:::::t:::::::ttt:ttt:t::\:\:\:\t::::::@::::tt::::::t::::\:\::::::t:::t:::t::t:\:\:I::tt:: ::. " .......Jtttt::n:tt:t::::t
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED VE FOR THE POLICY PERIOD
INDICATED, NOlWlTHSTANDING 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 lVPE OF INSURANCE POUCYNUMBER POUCY EFFECTIVE POUCY EXPIRAnON UMITS
LTR DATE (MMJDDIYV) DATE (MMIDDIYV)
A GENERAL UABIUTY GENERAL AGGREGATE $ 2,000 000
COMMERCIAL GENERAL UABIUTY PRODUCTS - COMPIOP AGG $ 2,000 000
CLAIMS MADE W OCCUR 60121 95 58 1128/98 1128/99 PERSONAL & ADV INJURY $ 2,000 000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000 000
FIRE DAMAGE (Anyone fire) $ 50,000
MED EXP (Anyone person) $ 5 000
A AUTOMOBILE UABIUTY
COMBINED SINGLE UMIT $
ANY AUTO 1 000,000
ALL OWNED AUTOS BODILY INJURY
X 60121 95 58 1/28/98 1/28/99 (per person) $
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY
(Per accident) $
X NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS UABIUTY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
B WORKERS COMPENSATION AND X STATUTORY UMITS
EMPLOYERS' UABIUTY A1911 44 33 1/01/98 1/01/99 EACH ACCIDENT $ 1,000,000
THE PROPRIETOR! INCL DISEASE - POUCY UMIT $ 1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: X EXCl DISEASE - EACH EMPLOYEE $ 1 000 000
A OntER ONTENTS 5500 OED 5 30,000
BUSINESS PERSONAL PROPERTY 60121 95 58 1/28/98 1/28/99 OMPUTER 5500 OED 5 14,000
1 EQUIPMENT FLOATER QUIP FLTR 5500 OED 5 14,000
DESCRIPTION OF OPERATIONS/LOCAnONSNEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER REMAINS NAMED AS ADDITIONAL INSURED
ENDORSEMENT CG 20 10 10 93 APPLIES
RENINSTATEMENT CERTIFICATE
J;~lI.::~:::::::!:!:t!1:\=:=::::::::::::::::::::::::::\=:::::::::::::::::::::::=::!:!:!:!:!:t!:tt:::::::::::::::::::::::::1::=:1:!:!:!:!:!:!:!:::::!::::=:'::!:!:!:!:::::::::\:!:!1::r:!P.i__U9.tl'!:!:!:!:::t\:\::::::::::::::::::::::::1:!:::\:t:::::::::::::::::'::::::!:\:!::::::::::::=:::=:::,!::::::::::::::::::::::::::::=:=::::::::::::::!:::::\'\'::\::::::::1:::::::::::::\:\::1:::::::::::::::::::::::::
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE ntE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAil
CITY OF CAMPBELL ~ DAYS WRlneN NOnCE TO THE CERTIFICATE HOLDER NAMED TO ntE LEFT,
A TTN: DEPT OF PUBLI C WORKS BUT FAILURE TO MAil SUCH NOTICE SHALL IMPOSE NO OBUGATlON OR UABIUTY
70 NORTH FIRST STREET OF ANY KIND UPON TH MPANY, I AGENTS OR REPRESENTATIVES.
CAMPBELL CA 95008 AU ~., ~ESENTATI' i.l'7./1I.
::lo.R:Br::,:,:".:.:::.:..\tttt:r:t::ttmrrr:::t:rrrr:tt:::::rrrrrrtttttttt:::r:ttt:rr:::::::tttt:rrrr:::ili::~:~;;~i~it*}iimtt:~r::~i:i::i:::I~:i.:le.b.$.tu.t"'MM.Nd_m
POliCY NUMBER:
6012 I ::6 58
_OMMERCIAL 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 L1ABIt.ITY COVERAGE PART
Name of Person or Organization:
SCHEDULE
CITY OF CAMPBELL
ATTN: DEFT OF PUBLIC WORKS
(If no entry appears above, information required to complete this endorsement will be shown in the Declara-
tions 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 ongoing operations performed for that in-
sured.
CG 20 10 10 93 ' -
Copyright, Insurance Services Office, Inc., 1992
o
NOTICE OF CANCELLATION
OF MORTGAGEE AND/OR
CERTIFICATE HOLDER
-'" -.'
"1'.-- . jLj)
v/ .
D TRUCK INSURANCE EXCHANGE
D FARMERS INSURANCE EXCHANGE
~ MID-CENTURY INSURANCE COMPANY
D
INSURED:
HARVIN DAVIS CONSTRUCTION INC
PROPERTY
ADDRESS:
1370 TUllY RD STe 508
POLICY OR
CERTIFICATE NUMBER(S) AGENT'S NUMBER CANCELLATION DATE
60121-95-58 96-90-39 R 11/13/98
[]I You are hereby notified, that all coverage extended to you under the above listed
policy is cancelled effective at 12:00 Noon (12:01 A.M. in California, Oregon,
Texas, Oklahoma and Washington) on the Cancellation Date shown above, unless
you have been notified of a more recent cancellation under other provisions of the
policy,
D You are hereby notified that all coverage extended to you under the above policy(ies)
or certificate(s) on:
is cancelled effective at 12:00 Noon (12:01 A.M. in California, Oregon, Texas,
Oklahoma and Washington) on the Cancellation Date shown above, unless you
have been notified of a more recent cancellation under other provisions of the policy.
Loan #
. CITY OF CAMPBELL
. ATTN: OEPT OF PUBLIC WORKS
. 70 NORTH FIRST STREET
.
CAMPBELL
CA 95008
NOTE TO MORTGAGEE: Your loan with this policyholder may have expired;
however, this notice complies with the provision of our policy.
25-0489 10/97 1521
."@
..
'0 '
~
Cj~ ~.2'f(
..................................................... ........",....................................................................................,
................................................... ........,.....................................................................................
At~t.III.~i:~ERmllll~~\~JI&IR5mmIRIEF>
INSURED
INC.
RECE,\V
fE9 27
PU6\..IC WO~
AOMINI81""1\
DATE (MM/DDIYV)
2/26/98
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
SCHAAPHOK INSURANCE AGENCY
1262 E. HAMILTON AVE., STE
P.O. BOX 1244
CAMPBELL CA 95009
1-C
FARMERS TRUCK INSURANCE EXCHANGE
MARVIN DAVIS CONSTRUCTION,
1370 TULLY ROAD #508
SAN JOSE CA 95122
TRUCK INSURANCE EXCHANGE
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOlWlTHSTANDING 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 (MM/DDIYV) DATE (MM/DDIYV)
A GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000
X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $ 2,000,000
CLAIMS MADE Q OCCUR 60121 95 58 1/28/98 1/28/99 PERSONAL & ADV INJURY $ 2,000,000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE (Anyone fire) $ 50,000
~--~~----_.~-~
MED EXP (Anyone person) $ 5 000
A AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO f--- 1,000,000
ALL OWNED AUTOS BODILY INJURY
(Per person) $
X SCHEDULED AUTOS 60121 95 58 1/28/98 1/28/99
X HIRED AUTOS BODILY INJURY
- (Per accident) $
X NON-OWNED AUTOS
-..-- PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
---~----
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
B WORKERS COMPENSATION AND X STATUTORY LIMITS
EMPLOYERS' lIABIUTY A1911 44 33 1/01/98 1/01/99 EACH ACCIDENT $ 1,000,000
THE PROPRIETORl INCL DISEASE - POLICY LIMIT $ 1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: X EXCL DISEASE - EACH EMPLOYEE $ 1 000 000
A OTHER ONTENTS $500 OED $ 30,000
BUSINESS PERSONAL PROPERTY 60121 95 58 1/28/98 1/28/99 OMPUTER $500 OED $ 14,000
/ EQUIPMENT FLOATER QUIP FLTR $500 OED $ 14,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
CITY OF CAMPBELL
ATTN: DEPT OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL CA 95008
A<<QflP~$S$(~~<<<>
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
---1Q... DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE CO ANY, ITS AGENTS OR REPRESENTATIVES.
AUTHO.l!fZ9.9~P~ENTATIVY- po } L
.... .. ...~~:;;.i;~~-.i;..~~~~~~f1PCRRPQflAngNj~~
CERTIFICATE AS TO EVIDENCE OF INSURANCE
fV1 (PRIMARY )
LAI INSURANCE The E
mge or Company shown on the reverse side, ,umber
(} {, / c;J <-1 I
2
D ( ~~~S~E) Excess over Primary with Company shown on reverse side as number
IN N This certificate supersedes any previouslv issued certificate, .
THIS IS NC' AN INSURANCE POLICY THIS IS ONLY A VERIFICATION OF INSURANCE. IT DOES NOT IN ANY WAY AMEND. EXTEND OR
AL TER THE COVERAGE PROVIDED BY THE POLICIES LISTED BELOW.
Named MARVIN DAVIS CONSTRUCTION !NC
Insured . 1440 KOLL CIRCLE STE 104
Address . SAN JOSE CA 95112
Excess Policy or Certificate Number
96 90 39R 60121 95 58
Agent Policy Number
WORKERS' COMPENSATION
COVERED NOT COVERED
[] 0 ST A TUTORY
COMBINED PRIMARY & EXCESS LIMITS OF INSURANCE
GENERAL AGGREGATE LIMIT (Other
Than Products-Completed Operations)
PRODUCTS-COMPLETED OPERATIONS
AGGREGATE LIMIT $
PERSONAL & ADVERTISING INJURY LIMIT $
EACH OCCURRENCE LIMIT $
FIRE DAMAGE LIMIT $
MEDICAL EXPENSE LIMIT $
EMPLOYER'S LIABILITY INSURANCE LIMITS
BODILY INJURY BY ACCIDENT $ each Accident
BODILY INJURY BY ACCIDENT $ each Employee
BODILY INJURY BY ACCIDENT $ Policv Limit
AUTO and/or GARAGE LIABILITY COVERA E COMBINED LIMITS OF PRIMARY & EXCESS INSURANCE
o DEALERS (Plan I) 0 NON-DEALERS (Plan II)
COVERED NOT COVERED
~ 0 Owned
[] 0 Hired
[] 0 Non-Owned
We certify that pOlicies for the above Named Insured are in force as follows:
Effective from: 1-28-97
to:
cancelled. (Box "X'd" applies),
COMMERCIAL GENERAL LIABILITY COVERAGE
COVERED NOT COVERED
~ 0 PREMISES/OPERATIONS
~ 0 PRODUCTS-COMPLETED
OPERATIONS
at which time this certificate becomes 0 VOID or
IKJ continuous until
$ 2,000,000
2,000,000
1,000,000
1,000,000
100,000
5,000
ANY ONE FIRE
ANY ONE PERSON
Bodily Injury
$
$
$
$
,000 each person
,000 each Accident
,000 each Accident
,000
Single Limit Liability for Coverages checked 00 above.
Property Damage
Aggregate Limit
(Garage Plan Only)
COVERED
o
NOT COVERED
.f] Cargo
$
$
$
1 , ()()() ,000 each Accident
,000 each Vehicle
,000 each occurrence
OWNED
AUTOS
IF
COVERED
O Described Vl Description
below ~ waived
YEAR, MAKE, TYPE OF BODY, LOAD CAPACITY
'VE-I)
;;:4~.
!ClJT'
IDENTlFICA TlON NUMBER
UMBRELLA LIABILITY
'0. ~~ e
,,(S
~ T.toN
$
$
$
,000 retained limit
,000 each occurrence
,000 aggregate
POLICY NUMBER
Umbrella Liability
Upon cancellation or termination of this policy or policies from any cause we will mail 3() days written notice to the
other interest shown below, Notice of cancellation of the primary coverage automatically terminates excess coverage.
Certificate Issued To:
Name CITY OF CAMPBELL
and ATTN: DEFT OF PUBLIC WORKS
Address 70 NORTH FIRST STREET
CAMPBELL CA 95008 Countersigned by Authorized Representative
OHIO Only: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty O(ofiv~eSUr)rance fraud. H-96 1451./ .~.. @
565287 1ST EDITION 4 86 ~
~~~
.,
-
-
I
POLC'( ;\lUMBER:
60121 /; 58
,-OMMERC:AL GENERAL UABILiT'f
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
Name of Person or Organization:
SCHEDULE
CITY OF CAMPBELL
ATTN: DEPT OF PUBLIC WORKS
(If no entry appears above, information required to complete this endorsement will be shown in the Declara-
tions 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 ongoing operations performed for that in-
sured.
CG 20 10 10 93 . -
Copyright. Insurance Services Office, Inc., 1992
o
S 2l 96 02-40P SCHAAPHOK INS AGENCY 408 377 1223
ep - -; -. . 'I'1l1r'"'' 'C"~ I U CYIUC"\,l: Ut' IN:-- ~ANCf
I:XI (~) The Exchange or Company shown on the reverse side as number
P.02
2
o (Ju~) Excess over Primary with Company shown on reverse side as number
This certificate supersedes an)l previousl~ issued certificate. '
THIS IS NOT AN INSURANCE POLICY. THIS IS ONLY A VERIFICATION OF INSURANCE. IT DOES NOT IN ANY WAY AMEND. EXTEND OR
AL TER THE COVERAGE PROVIDED BY THE POLICIES LISTED BELOW.
Named . MARVIN DAVIS CONSTRUCTION INC
Insured . 1440 KOLL CIRCLe STe 104
Addre.. . SAN JOSE CA 95112
01' Certificate Number
60121 95 58
Policy Number
We certify that policies for the above Named Insured are in force as follows:
Effective from: 9-19-96
to:
cancelled. (Box "X'd" applies).
COMMERCIAL GENERAL LIABILITY COVERAGE COMBINED PRIMARY & EXCESS LIMITS OF INSURANCE
COVERED NOT COVERED GENERAL AGGREGATE LIMIT (Other
IX! 0 PREMISEs/OPERATIONS Than Products-Completed Operations)
!Xl 0 PRODUCTS-COMPLETED PRODUCTS-COMPLETED OPERATIONS
OPERATIONS AGGREGATE LIMIT $
PERSONAL & ADVERTISING INJURY LIMIT $
EACH OCCURRENCE LIMIT $
FIRE DAMAGE LIMIT $
MEDICAL EXPENSE LIMIT $
EMPLOYER'S LIABILITY INSURANCE LIMITS
BODILY INJURY BY ACCIDENT $ each Accident
BOOlL Y INJURY BY ACCIDENT $ each Employee
BODILY INJURY BY ACCIDENT $ Policy Limit
AUTO and/or GARAGE LIABILITY COVERA E COMBINED LIMITS OF PRIMARY & EXCESS INSURANCE
o DEALERS (Plan I) 00 NON-DEALERS (Plan II)
COVERED NOT COVERED
~ 0 Owned
~ 0 Hired
~ 0 Non-Owned
at which time this certificate becomes 0 VOID or
!xl continuous until
$ 2.000.000
2.000.000
1. 000,000
1. 000 . 000
50.000
5,000
ANY ONE FIRE
ANY ONE PERSON
WORKERS' COMPENSATION
COVERED NOT COVERED
o [Xl STATUTORY
Bodily Injury
$
$
$
$
,000 each person
,000 each Accident
,000 each Accident
,000
Property Oamage
Aggregate Limit
(Garage Plan Only)
Single limit Liability for Coverages checked [Xl above.
$ l~OOO
,000 each Accident
OWNED
AUTOS
IF
COVERED
NOT COVERED
D!I Cargo
O Described rY'I Description
below ~ waived
YEAR, MAKE, TYPE OF BODY, LOAD CAPACITY
$
$
,000 each Vehicle
,000 each occurrence
COVERED
o
IDENTIFICA liON NUMBER
UMBRELLA LIABILITY
Umbrella liability
$
$
$
,000 retained limit
,000 each occurrence
,000 aggregate
POLICY NUMBER
"-.-
Upon cancellation or termination of this policy or pOlicies from any cause we will mail 30 days written notice to the
other interest shown below. Notice of cancellation of the primary coverage automatically terminates excess coverage.
Certificate Issued To: SEE CG20101093
Name CITY OF CAMPBELL
and . A TTN: DEPT OF PUBLI C WORKS
Address. 70 NORTH FIRST STREET ~ ...L'~0~_
CAMPBELL CA 95008 Co ersign~ Representative
OHIO Only: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
tiles a claim containing a false or deceptive statement is guilty of iQsurance fraud. ~
56-5287 1ST EDITION 4-86 (Over) (1.96 1401 _
At~~tllltlD ~ER"FIt=ICI 'eOFINSIJAANeE CSRCE DATE (MMJDDNYI
MARVJ:...5 01/17/97
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 Calif. Compensation & Fire
Phone No. 408-973-9500 Fax No.
INSURED COMPANY
B Insurance Company
Marvin Davis Construction, Inc. COMPANY
Marian Francisco C
1440 Koll Circle Suite 104 COMPANY
San Jose CA 95112 D
ii 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 ~J'JMI!E!l ! POLICY EFFECTIVE ! POLICY EXPIRATlQ;. LIMITS
LTR DATE (MMJDDNYI DATE...!!.MJDDNYI
GENERAL LIABILITY e. e ~ \~ t.lJ' GENERAL AGGREGATE $
f-----
COMMERCIAL GENERAL LIABILITY PRODUCTS - COMPJOP AGG $
[I =:J CLAIMS MADE D OCCUR tl ~1 PERSONAL & ADV INJURY $
OWNER'S & CONTRACTOR'S PROT j\\~ t,\ 1 EACH OCCURRENCE $
I----
FIRE DAMAGE (Anyone fire) $
f----- " -J "'........
.t,.,r- '..''1'\0'" MED EXP (Anyone person) $
AUTOMOBILE LIABILITY lI..O!>l\\N\';) \.
f----- COMBINED SINGLE LIMIT $
ANY AUTO
I----
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
~ ............... ..... <<<i
ANY AUTO OTHER THAN AUTO ONLY:
-
EACH ACCIDENT $
-
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
~ UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
A WORKERS COMPENSATION AND I STATUTORY LIMITS ii .'. .... .... ....
EMPLOYERS' LIABILITY $1,000,000
EACH ACCIDENT
THE PROPRIETOR/ RINCL W971131600 01/01/97 01/01/98 DISEASE - POLICY LIMIT $1,000,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE - EACH EMPLOYEE $1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
*10 day notice of cancellation for non payment of premium
All Ca ifornia operations PU.niJ ~/V
E 9fo --clLf/ /Lfi7
~ i ........ ~'''',.. < <<. <
......... ........
C-CAM-3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL EN8~.un ,0 MAIL
City of Campbell 30* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
Dept. of Public Works DU Y ~E""S nR TY
./1
70 North 1st Street ~p .,.",
Campbell CA 95008 AUTHORIZED REPRESENTAT:~__;: ~ ~
cc ...... ............ Francis E. Cook, rzTf.
'''''0'>' ......... ........... ....... ........ ..",ti", ..
------'.--.--..---.~-...-........, ..,_.,....... '... .... -. ""-'--'.~-.., - -~.~--__~'_._'___M_' .~_'~'''__n'_
At..lllt.
CERTIFICI
.. OF INSURANCE
ISSUE DATE (MM/DD/YY)
PRODUCER
&arlocker Insurance Services
San Jose Branch Office
P.O. 80x 63uU
San Jose. CA 95150
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
LETTER
n:r>r..
." "", r:i \,..,. .....
.~~
INSURED
COMPANY B
LETTER
~arvin Uavis Construction Inc
1440 lOll Circle. Ste 104
San Jose. Calif 9~112
~~T~~~NY C
SEP 2 (} 1996
~~T~~NY D
"o~~.....".. ;0",,;' In' "
C a I Com pIn sur a nee L 0 . ., , ..
COMPANY E
LETTER
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 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
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YY) DATE (MMIDD/YY)
LIMITS
_.._--_.._---~--,~-,.__.~..._,_..._--_.__.,-"._, ---.--.-----------.-...-.---
G~N~RAL LIABILITY
COMMERCIAL GENERAL LIABILITY
_...._---._'.._.._--_._._--~.~'-------._._.
CLAIMS MADE
OCCUR.
GENERAL AGGREGATE S
PRODUCTS-COMP/OP AGG. S
PERSONAL & ADV. INJURY S
OWNER'S & CONTRACTOR'S PROTo
EACH OCCURRENCE
s
FIRE DAMAGE (Anyone fire) $
-.-. _~""__.a"_---"",~_, ..,.---- ..._._....._. . _. -_.__._.__._______h.....__..._.,_.,'___.__._...._.._..._._.__ _...." ...~._.,_.__~__.,~....._'_.___h...
MED. EXPENSE (Anyone person) S
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
COMBINED SINGLE S
LIMIT
BODILY INJURY $
(Per person)
BODILV INJURY S
(Per accident)
PROPERTy DAMAGE S
_..._.a'____~_____._.________,______.....____________......,._~_. _______.______...__._._____._. ...',.,__.___.__.__~__~______._.._
EXC~SS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
AGGREGATE
S
...-...........__.._~_.__...~_._....-........._._~-~..., ~.. --.- -"-'-.--'''''-'''-'- --...--... -..-'-- - '..' -'- '-.-.-p'-P--.----....-..-------.-.-....----. .. ~..___..__.______.._
AND
1t1961131600 1/01/96 1/01/97 J( STATUTORYLIMITS
EACH ACCIDENT $ 1 U U U {J U U
DISEASE-POLICY LIMIT S 1 U(/(JUUU
-_.._ ___.,,"_.__ .... _ ._".. _._ .. _______.__, ....____._.. ._ DIS~S:.=-~~.:~~LOY-=-=--~_JJI (I U U U 0
D
WORKER'S COMPENSATION
EMPLOYERS' LIABILITY
OTHER
.-._-_.~--_._--_.__._--
DESCRIPTION OF OPERATlONS/LOCATIONSIVEHICLESISPECIAL ITEMS
l
: CERTIFICATE HOLDER
CANCEllA TION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL --.1tiJAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
. ~~O_~~.25-S (7/90)
AUTHORIZED 9,.,ESENTA:V:
!
"
*-ORO CORPORATION ,.",.
'[OOd
S66,[-,[t;.t;. BOt;.
-::>UI
....._ '.,'.J<
-+SUO::>
s~^ea U~^.Aew
t;.'[:'['[
96-T7--6nw
-
A.~.tltl."
CERTIReAl.... OF INSURANCE
ISSUE DATE (MMIDD/VY)
.' ~1 0
PRODUCER
d a r [) .:1 l; e r
i.. n...;; Li.: ran -': e ,) 6" f~ V l t' 2 .,::
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
~~ /i:~ Ij {I .~' t:'
~. o. /l c n ;j t . \. ..:' e
.~ Ij t: (j ,~
o.)U(..1
..' a ,'-t (j:) .';' f? .
1--1 ,':I ,) .1~: U
C~T~~~NY A
~ p~
:;-
.,\1"-
'It_, ~
'~', .;~
INSURED
~~T~~~NY B
':-t~'f;, 1 n
\.i ,/-"t <'J '99[,'
l,,_< .
t'i a r~, I /l i) a. t/ l:.r C 0 /1.s ~' r u. t.: t I. 0 0. .i. n c
~~T~~~NY C
1. I~ 4 il 1'~ () {{ I..: I r (' i e
.!te LU4
.J d lr I) () S E' .
c a { l 7 :::'.~).i 1. .:;,:
~~T~~NY D
(. a , ,~, I) m 0 i I( S U .' a II c e C 0
~~T~~~NY E
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.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/VY) DATE (MMIDD/YY)
LIMITS
CLAIMS MADE
OCCUR.
GENERAL AGGREGATE $
PRODUCTS-COMP/OP AGG. $
PERSONAL & ADV. INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED. EXPENSE (Anyone person) $
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
OWNER'S & CONTRACTOR'S PROTo
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
COMBINED SINGLE $
LIMIT
BODIL Y INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIABILITY
L.J
iIIJtJL:~fJbUU
1 /U .i / :,1 t)
.i/iJJ/!:..~
X STATUTORY LIMITS
EACH ACCIDENT
DISEASE-POLICY LIMIT
$ iU')U//~ii':
WORKER'S COMPENSATION
AND
$ .i ;j ,~_: U (f ,j U
EMPLOYERS' LIABILITY
DISEASE-EACH EMPLOYEE $ _l U U U U ':-' Ii
OTHER
DESCRIPTION OF OPERA TIONS/LOCA T10NS/VEHICLES/SPECIAL ITEMS
J., it '- a l t. f 0;-. /1 (.7t. :j[)e( Ei.l Z UT;:':;'
CERTIFICATE HOLDER
CANCELLATION
/ ~I iV
.t.:..t J_r.eet
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRA1;ION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
'"'"0'"'' '1;'r~~ ! :Itff:::- COllPORATION ,."
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c a (t( D () t;- { i.," A I-l .~I ij Ii 8
ACORD 25-S (7/90)
WORKER'S COMPENSATION INSURANCE INFORMATION
The following worker's compensation insurance information is required for all Applicants and
C~ntractors. .One of the follo~ing items for ~ach Applicant and Contra<l>renft ~ submitted
pnor to workmg under a PublIc Works permit or contract. . .....
Sfp 2
;. 6 1996
WORKERS' COMPENSATION INFORMATION:
41);\11'. ",.
"II'S)I\ ",
Name of Contractor/Applicant
jV\ O-~ \\(\ Y ~\) b
o A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
~ A Certificate of Workers' Compensation Insurance
Insurance Co. go.-c--\0d.L.e f'
~' ,
1- C^...<; ~. S e Q \! '
Policy No.
uJctb\l ~ l.(pCO
Expiration Date
D I /6 \ / C{ 7
, ,
; OR
o A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICATE 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\ workcomp(rev6/96)
............................................................................. .....................................................................................................
..................................................
...... A.t~t.I!I.,,::::~~~~I.a;I.:~^.
...................................:.:.;.;.;.;.;.;.;.;.;.;.;.;.;.;.;.; ;:::::::~:~:.:::;..rJt..::m:..:~~:::..
PRODUCER
SCHAAPHOK INSURANCE AGENCY
1262 E. HAMILTON AVE., SUITE
P.O. BOX 1588
CAMPBELL CA 95009
..........................................................................................
.........................................................................................
:.::::::::::::::e;~~!~rs~~m~~~~::!:!:i::::::i:i:::i:i:::::::;:::::::::::::::;:::;:;.:;::;;;:;:::::.:.:::,::::::: DA;;~;;~:DIYV)
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
FARMERS TRUCK INSURANCE EXCHANGE
COMPANY
A
INSURED
MARVIN DAVIS CONSTRUCTION, INC.
1440 KOLL CIRCLE, SUITE 104
SAN JOSE CA 95112
COMPANY
8
COMPANY
C
S E P 2 G 19 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 (MM/DDIYV) DATE (MM/DDIYV)
A GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000
X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $ 2,000,000
CLAIMS MADE [i] OCCUR 60120 95 58 1/28/96 1/28/97 PERSONAL & ADV INJURY $ 2,000,000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE (Anyone fire) $ 50,000
MED EXP (Anyone person) $ 5 000
A AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO 1,000,000
ALL OWNED AUTOS BODILY iNJURY
60121 95 58 1/28/96 (Per person) $
X SCHEDULED AUTOS 1/28/97
X HIRED AUTOS BODILY INJURY
(Per accident) $
X NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
WCRKEnz COMPEtlSATION AND STATUTORY LIMITS
EMPLOYERS' LIABILITY
EACH ACCIDENT $
THE PROPRIETOR/ INCL DISEASE - POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE - EACH EMPLOYEE $
A OTHER ONTENTS $500 OED $ 30,000
BUSINESS PERSONAL PROPERTY 60120 95 58 1/28/96 1/28/97 OMPUTER $500 OED $ 14,000
/ EQUIPMENT FLOATER QUIP FLTR $500 OED $ 14,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
Peters/1447 Patio Dr: ALL WORK IN PUBLIC RIGHT-OF-WAY. CITY OF CAMPBELL, CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS
OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPECTS LIABILITY PER CG2010, TO BE ISSUED BY
CARRIER
CITY OF CAMPBELL
ATTN: DEPT OF PUBLIC WORKS
70 NORTH FIRST STREET
CAMPBELL CA 95008
.......................L...........................................
A~9I=lP~?8$(~J~j>".. .
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL - , MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
- -..... "1?~r-..- --. .~.~.~.. ~~ .. '-,
AUTHORIZEI?~~~TATIVE
_'er-':;;r ";/'
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.................................................A....C.....O...R...D.......C...O....R...P...O...R...A...T...I.O....N...........g...g.........
.................... ." . .' - ,. .. .
..................... . ,.. ...... ,... ."..
:.:.:.:::::.:::.:::::.:::::.:.:.:.:.:.:)~'::..:.......:.......:........::.:...:::/..:, ..::::./:... ... .:. .:. ....... ,. .::1.:..:. ..:3>
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'O~CHA\l\J
CITY OF CAMPBELL
Public Works Department
September 22, 1998
Mr. Marvin Davis
Marvin Davis Construction Company
1379 Tully Road, Suite 508
San Jose, CA 95122
SUBJECT: PERMIT NO. 96-241
LOCATION: 1447 Patio Drive
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Mr. Davis:
The City of Campbell has made the final one year maintenance inspection of subject Public
Works improvements and find that no remedial work is required.
Your warranty requirements are hereby released.
S~{;iL
Alan Horn
Public Works Inspector
MQ/JL
cc: Permit 96-241
Public Works/Maintenance Division
H:\ WORD\PERMITS\96241ACC(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TDD 408.866.2790
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CITY OF CAMPBELL
Public Works Department
t
R-I PERMIT
April 11, 1997
Marvin Davis Construction Company
1440 Koll Circle, Suite 104
San Jose, CA 95112
Attn: Tracy Morrish:
RE: PERMIT NO. 96-241
LOCATION: 1447 Patio Drive, Campbell
FINAL INSPECTION AND ACCEPTANCE
Dear Tracy Morrish:
The City of Campbell has made a final inspection of subject Public Works improvements and fmds 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 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.
We are returning the attached Faithful Performance Bond.
If you have any questions, please call at (408) 866-2168.
Sincerely,
-;/ .
;/~
:/
Robert Phillips
Project Inspector
M Qittl
cc: Suspense - 11 months
Permit # q(.. -:2.:.;/
J:\ WORD\FORMS\FINRIL TR
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376,0958 . TOD 408.866.2790
Commercial [,.,. Residential Building Solutions
~/.jl
.If vI W
M~~ vin Davis Construction, ~c.
To: City of Campbell - Public Works Dept.
70 North 1 st Street
Campbell, CA 95008-7423
Attention: Randy Westfall
Sept. 26,1996
Re: Peters Residence
1447 Patio Drive
Campbell, CA 95008
~E
,,, '. elf:" .,.
. '~.. ~ ~
'.'.'. /
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\.\tP 27
19.96
Sbj: New Drive Way Costs
Dear Mr. Westfall,
The following list is a line item cost associated with the removal and replacement
of the concrete driveway approach at the above referenced address.
1.) Concrete demolition and disposal.
2.) Form and install new concrete driveway approach.
$450.00
$600.00
Total cost to remove and replace driveway approach.
$1050,00
If you have any questions or need further information, please call me at my
office.
Anthony We b 1ffr-
1440 KolI Circle, Suite 104 · San Jose, California 95112-4(i09 · 408/441-1400 · fax 408/441-1995
fj,.. No. 4/3420 · Sincl' I WI!
Sep-26-96 09:40 Marvin Davis Canst. Inc. 408 441-1995
Marvin Davis Construction, Inc.
Commercial & Residential Building Solutions
To: City of Campbell - Public Works Dept.
70 North 1 st Street
Campbell, CA 95008-7423
Attention: Randy Westfall
Sept. 26,1996
Re: Peters Residence
1447 Patio Drive
Campbell, CA 95008
Sbj: New Drive Way Costs
Dear Mr. Westfall,
The following list is a line item cost associated with the removal and replacement
of the concrete driveway approach at the above referenced address.
1.) Concrete demolition and disposal.
2.) Form and install new concrete driveway approach.
$450.00
$600,00
$1050.00
Total cost to remove and replace driveway approach.
If you have any questions or need further information, please call me at my
office,
Anthony We b 1ffr-
1440 KolI Circle, Suite 104 · San Jose, Califomia 951l2-4(i09 · 40R/441-1400 · fax 40H/441-19<)5
I.... No. 413420 · Si/~.(' /'N/l
P.02