97-126
CITY OF CAMPBELL
PUBLIC WORKS 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 -2/;:27), 7 ?frnC)
7~ih 07 - / I I'
. 'rermit No. I ~
X-Ref. File
Application Date ::2/ .2'7/ q 7
, ~
RECEIVE"
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell ~If.c~....Section
11.04. (Application expires in 6 months if the permit is not issued.) ('~1
II. r:.. u IH. H... \Iv Uk 1\5
A. Work Address ""u
B. Nature of Work
C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall s ow
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 FaithfiJI PerfoII!1anc~
securities. .. % .LS/ e~cV7
NAME OF APPLICANT .~ d /Y7 /?,D soBc!J UT/ TELEPHON~* 70 -/97D
(Print Name)
ADDRESS ;<5&) 5r J/ rB J J E, 1.!..4/h /C-TorV AtI~ ~..BelL) eA I
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 acknowledge
inform their contractor(s) nfo
ACCEPTED
tand both the front and back of this permit, and that they will
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED. APPROVED PLANS AND ALL APPLICABLE
CAMPBELL STANDARD 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.
SPECIAL PROVISIONS
-rff<< !6ICM. IT /$ ~/( It 'f6M;1~~ .4. c. t1Rh/6~A-1. WU-t.
STANDARD
% OF ENG. EST.)
AMOUNT
$ IJ/>>
RECEIPT NO.
APPROVED FOR ISSUANCE
Date
( SEE OTHER SIDE)
GENERAL PERMIT CONDITIONS
1. A SECURITY to insure FAITHFUL PERFORMANCE and completion of the work is required. This SECURITY
is refundable upon completion of the work and written acceptance by the City.
2. A ONE-YEAR MAINTENANCE PERIOD for all work is required. Such period will begin on the date of written
acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the
one-year maintenance period.
3. REFUND or cancellation of the Faithful Performance security will be initiated by the written acceptance of the work by
the City.
4. The Permittee MUST REQUEST IN WRITING a final inspection and acceptance of the work upon completion.
Acceptance by the City will be made in writing to the Permittee.
5. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
6. REPLACE IN KIND any damaged or removed existing improvements, including planting.
7. SA WCUT for all PCC or AC removals. Prior to concrete sawcutting or washing, the Contractor shall place filter fabric
material in the flow line of the gutter to retain all construction debris. All construction debris shall be wet vacuumed,
broom swept, picked up and disposed of by the Contractor. Concrete sawcut debris shall not be swept or water hosed
into the gutter and into the storm drain system.
8. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and
barricading as specified by the City Engineer may result in the City's renting such signing and barricades and charging
the cost to the permittee.
9. The Contractor or Permittee will have a SUPERVISORY REPRESENTATIVE available for contact on the project at
all times during construction.
10. This permit shall be kept at the site of work and must be shown to any authorized representative of the City of Campbell
or any law enforcement officer upon demand.
11. No STORAGE of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within
the shoulderline which would create a hazardous condition to the public.
12. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work
or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to
obtain any other permit required by law.
13. All necessary ROAD REPAIRS resulting from the permit work shall be made in accordance with City Standards and
Specifications at the sole expense of the Permittee.
14. This permit does NOT RELEASE the Permittee from any liabilities contained in other agreements or contracts with the
City and any other public agency.
15. This permit is NOT TRANSFERRABLE. Work must be performed by the Permittee or his designated agent or
contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may
require reimbursement of inspection costs at the current overtime rate.
17. Call back (call out) due to emergencies regarding this permit, shall be at the current overtime rate with a three (3) hour
minimum charge per occurrence.
n g that all those providing services under the applicant are aware of and understand all
d-/J-7/97
Date
u
~ ~~
ti ~>-
~ g!::
u
.oz ,Cf4' <7~ ~~ ~ - ---------
!
a~ ReCE,veD
~s ,~
~.. fEB 27199T.
-<t: '.Ei
~ll tJ V'I urtl<'S
2
:t~ :i \lVIII-II.. ~I
" ~OM\N\SlRA1\ON
Q ~t ~
~~
r:L ....1
":%t:l ~ - "1-
3\U -
I c..~ n.. 4 8
.-' "'It
:l:! - ~.
<:l'l -\) -
~.~ -
..3 .J .
~ I() ~~ ~ ~& .J ~o
0 ~
0 wll ~:z:
lQ ~~ --
~ c...a~ <( -t
i. c:i
(~ - y ~~
t-
\ ~
0
UJ
1& ~
Cl 0 0 4.ct
c-t -- >.---: a,O
:z.:
~ ~ -.3 ~~
~1 C! I'C'\
. ~ ~...
- - nJ~
:J ~~
. ..~~_____--J .~
:z ..J' \-
~l: ,
al "
1 '17. M\~.
'-
~t
~ p' F) j!"(: '.;' :""
t ,.'.;
r~~' (-1 f)
..~. i r 1 :'
Public., .
.:;.-,':' h:':I2 rhcsy! plans
en ti:2 icb site during construction.
(
Permit #
INSURANCE REQUIREMENTS CHECKLIST
9'7-/26
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 perfonned under an Encroachment Pennit
and work being perfonned under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
g , $1,000,000 per occurrence, and
Er . $1,000,000 general aggregate limit applying separately to the project, and
~ $2,000,000 general aggregate limit.
go'''- Policy expiration date I -0// ..;)...../ C; 7
A1J!Omotive Liability - It any auto". '
EJ. $1,000,000 per accident for bodily injury and property damage
e:r Policy expiration date /0), 2-/9 7
Worker's Compensation and Employer's Liability
ICY' $1,000,000 per accident for bodily injury or disease
a---- Policy expiration date 9// I q 7
~ , !
Course of Construction (if required in Special Provisions)
o Completed value of the project
o Policy expiration date
Required Endorsement to General Liability and Automobile Liability Policies
Additional Insured Endorsement
1Id/ The City, the City of Campbell Redevelopment Agency, its officers,
employees and volunteers are named as additional insured.
if' The insurance coverage afforded to the Additional Insured is primary
insurance.
Workers' Compensation Insurance Sheet Submitted
o ~r General Contractor
kJ Subrogation Clause
!
. R' ~Sf{~_hl~UU__j
Insurance CertIficate eVlewed ( / . .
, - Initials
if
~
"1" Copy of Insurance Certificate placed in tickler file one month prior to expiration.
~/~'/ /1 7
Date
j:\forms\inscklst 4/96 (rev 6/96)
Dempsey Insurance Servo
(408) 985-0930
POBox 6210
San Jose, CA 95150
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
PRODUCER
E~~~~NY A
Transcontinental Ins.Co.
DN
INSURED
E~~~NY B
Valley Forge Ins. Co.
Amedcan Cas Co of Reading'IB 28 1991
L.S.I. Construction, Inc.
256 East Hamilton Ave., #J
Campbell, CA 95008
E~~~NY C
E~~NY D
Superior National Ins.
PiJJLlC Vol '.....,...,,~
E~~~NY E
::CQw~:m!.$.:::l::::::::mK;m:::::::rtW;l:mrw:mm:r:mf:::m::r:::f:::::tr:rtt:::::tmn:m:miit:fii:fii:::::ffff:t:::::::WmfW:::mt:t:::::::::::ffmm:t:::::m:m:::::i:mt::t:m::t:ttifW:tt:::::t:tt:t::tm:::w::mt::t::tt:::mi::mm:t:::::::m:::m:m:m::::::r:::tt::mmt:mm:::m:ta
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 CONDIllON 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 CONDIllONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFEC11VE POLICY EXPIRA 110N
DATE (MMIDDIYY) DATE (MMIDDIYY)
LIMITS
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
A CLAIMS MADE W OCCUR.
OWNER'S & CONTRACTOR'S PROT
B122637744
10/12/96
10/12/97
GENERAL AGGREGATE $ 2,000,000
PRODUCTS-COMP,QP AGG, $ 2,000,000
PERSO~Al & ADV INJURY __~OOO!~~~__
EACH OCCURRENCE$---.!!~~~!~~~_ _. _
FIRE DAMAGE (Anyone fire) !__~_~~!f!~~
MED. EXPENSE (Anyone person) $ 5,000
B
AUTOMOBILE LIABILITY
ANY AUTO
AlL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
GARAGE LIABILITY
COMBINED SINGLE
LIMIT
$
1,000,000
B1226377758
10/12/96
10/12/97
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE $
EXCESS LIABILITY
C X
B129797712
10/12/96
10/12/97
EACH OCCURRENCE
AGGREGATE
$ 1,000,000
$ -!!??!~~~~,,:c,';
OTHER THAN UMBRELLA FORM
........... .....
....................
...,...............
....................
.. ::::;:;:::;:::::::::;:::::::::::::;:;:: .....
09/01/97
STATUTORY LIMITS
EACH ACCIDENT $
DISEASE-POLICY LIMIT $
DISEASE-EACH EMPLOYEE $
D
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
WCD27901 E
09/01/96
1,000,O~!___
1,OOO,OOf!_
1,000,000
OTHER
DESCRIP110N OF OPERATlONS/LOCATlONSNEHICLES/SPECIAL ITEMS
RE: 1260 Burrows, Campbell, CA All work in public right-of-way, City of
Campbell, City of Campbell Redevelopment Agency, its officers, employees &
volunteers are named as ad ' . n '
i;~"a;tl~lt.~"':;~"'~i:!:!:@!:m:::!mt~!m!:i::tW:@:t!i.:t:@:::::::m:mi::M:::mmmi::mii::t:::i!::::mmt:m:i:i:mii:::!!i!!*g~~ijl;;illQfi:::m::imii/mmimi@Iill//ii\i@miW:i/iiiiim!:////:ii::Wi:::/ifmimii:!im:mit/{/::gfi:;;@i:/:imimi/i::?:mim/::i:::?m@@)@);
::;::: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
:::;:; EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL liWWU~eil\;xle
Works "",. MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
" LEFT, smxf'lQL~Jq(;lIX~~"X~IiX5~KX/MllfQJ5IixmJ(JOOUI5MlGNXUl
.., ~D.'lI1ll"~'lCllKlflli)( lOOMUhllQ:J1:1iS: SlGNXI;UIIl~~,
City of Campbell
Attn: Dept. of Public
70 North First street
Campbell, CA 95008
.. ..
...... .. ......
::;:::::;:;:;:;:::::::;:::;:;:;:;:::::::;:;=::::;:;
'ACiQijtt~$/ti~lmimimi!/imi:ifHJm/::im:ffm::/Jl//fIrr:Ng:IWHml:[riImrr:ii7{]@IJ7iJ777::::::I1i:{i7
, I
I v '.....~ . 1';.....,', : I
I I " ._" I i: "., ~"i ,'. I '," '., \... ,j, 1,,,,, ,j
I . I~"
Insured Name
L.S.I. Construction, Inc.
PoDey #
B122637744
PRIMARY WORDING.:
SUBJECT TO AU. OTHER TEAMS AND PROVISIONS OF THii POUCY. SUCH INSURANCe AS
PROVIDeD BY nns ENDORSEMeNT'SHALL BE DEEMeD PRIMARY, 'BUT ONl.Y WITH
RESPECT TO WORK P~FORMED BY OR FOR THE NAMED ~NSUReo IN CONNECTION WITH
THE ABOVE DesCRIBED CONTRACT.
l'OLley N111'v18Ff?
10226.3 77 4Ll
L.S.!. Construction, Inc.
COMMUWIAl CCNERAl L1ABILI fY
THIS ENDORSEM~NT CHANGES THE POLICY. PLEASE READ IT CAREFULL Y.
ADOfTIONAllNSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
T Ill"; end~rSerlle/lt modifies insurance provided under the following:
COMMERCIAL GENEr,AL LIABILITY COVERAGE PART
Name of PersOIl or Organization:
SCHEDULE
City of Campbell, City of Campbell Redevelopment
Agency, its officers, employees & volunteers
(If no entry appe::lrs above, information required to complete this endorsement will be shown in the Declarations
iJS ;'lpplicable to this endorsemenl.)
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
CG 20 10 11 85
Copyright. Insurance Services Office. Inc,. 1984
u
Superior National
Ins. Co.
WOJ1/{ERS COMPENSATION
and
FORM NUMBER
EMPLOYERS LIABILITY INSURANCE POLICY
California
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
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 person(s) or organization(s) 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% of the California Workers'
Compensation premium otherwise due on such remuneration.
Minimum Premium:
Schedule:
Person or Organization:
Job Description:
City of Casmpell
1260 Burrows, CAmpbell
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise staled,
(The information below is required only when this endorsement is issued subsequent to preparation of the policy,)
Endorsement Effective 2 - 2 7 - 97
Policy No, WCD27901 E
Endorsement No, 8
Insured L. S. I. Construction
~ . k/-j~"
--eOUnie;:Signedb7JUi#lii~tI.e --- ~
Date Printed: 06/22/94
President
FEE 27 '97 l0:00~M DEMPSEY INS. 408 247 9699
P.l
4.
PIWOUCIII
Delllpley Insurance Serv.
(408) 985.0930
POBox 6210 COMPANIES AFFORDING COVERAGE
San Jose, CA 95150
~"MH A TransconUnentallns.Co.
l,E1jEA .
ON
~~ B Valley Fora' Ins. Co.
IlIU11ED
~D
American Cu Co of Readlol PA
Superior National Ins.
L.8.I. ConItrudion, Inc.
25' East Uamllton Ave., III
Campbell, CA 9S001
COMPANY C
~A
11iI61$ TO CEATlFV 1HAT 1l1E POUOES OF IHSURAHCE U8TEO BELOW HAVE BEeN ISSUED TO 'THE IN8URi:D NAMED ABOve FOA Tl-fE POlICY PEAIOD
INDICA'T!;D. NOlWllM8TANDING ANY IEQUlREMENT, TEI"M OR CONDITION or: MY CONTRACT OA On4EA coc;UMENT WITH ASPECT TO WHICH 'THIS
CERTIf1CATE MAY BE ISSIRD 0fII MAY ~TAlN. lHE IMSUAANcE ","","DED BY THE POLICIES DESCRIBeD HEfII&IN 18 SUIJECT TO ~ ltlE TEAMS.
EXClUSIONS AND CONDITIONS OF SUCH POUOIES. UMllli sHOWN MAY tfAVl; BEEN RCDUCED IY PAID CLAIMS,
co '"" OF INllUIlMCE POUCY NU...." POLJCl' I!FFUmVE POLICY ElCPII/l1lOll UIolllS '
111 ~TE (MMo'DD/'1'V) DATE (MMIODrN')
GDlEIlM.I.NIUl'f GENEIW. AGGIlEGAn , 000 000
X ClOtMfIClAL GENERAL l~BlllT'l' PI'ODUCI'IoCOMI",ol" AGG. . 2000,000
A ClAIM8MADi[l] QCCUI\ BIZZ'37144 10/11.'" 10l1Z19"1 PEAIONAL 1m#.INMY I I,MO 000
OWNEII" . CDIl1WlC'I'OI\'S PlIO EACI-I QCCUMENCE . 1,110,110
FlFII DAMAOE 1-.-tIe) . '0 100
MEI:l ElCI'eN5! (A"f-,.,..1Ij I 5000
AU'la1lO1lLE UUUl'I' CClll/IlIlNED SINGLE
, 1,000,000
Rtf AlJTO UIMT
/ILL OWNIID AUTOS IIODlL Y INJURY
.
B ICHfOULlD AUTOe BIZ2f3777S1 10/1Zl96 100U}" l"erpeon'1
HIllED NT'O& BODILY I~UR'I'
.
NON-OWNI!D AUTO'!I (POI ~enl)
CWW3i UAIILlTY
PAOPEIITY ~E I
EXCES5 UUlLl'IV I!ACI-I OOCUR/lENCE $ 1 000,000
C X B12979771Z 10/12/96 10/lU97 AGGRiIiiA~ I 1,000,000
0TtC1I ~ ur.tMl!!u.A PONtl
WGlldll.. COIlllEMA'nO- sTAM'ClA'f U"'"
D WCD27901E 0'181'" 09/01197 EACP1 ~DINf I
AltD
DlGEME-POUCV LIM1' .
EIIPl-OYEM' LIlIlIlL/lY D1Sl!!.&-liICH EMPI.O'lEl .
01MEft
DUC"IPllON of OI'ERA11ON8ILOCA11CI~MICLES"1IECW. mM5
RE: 1260 B~rrows, Campbell, CA All work in public right-of-way, City of
campbell, C1ty of Campbell Redevelopment Aqency, its offioers, employees &
volunteers are . '
City of Campbell
Attn: Oept. of Public Works
70 North First street
Campbell, CA 95008
SHOULD ""Y OF 'THE ABOVE DESCRIBED POLIOIES Be CANCEllED BEFOFIE THE
t;)(f>IFlATlON DATE ltlEREOF. THE ISSUING COMPANV WIll ~x.
MAIL ..3.Q..... DAYS WRltrEN NOTICE TO TliE CERTlFlCA1E HOLDER NAMED TO THE
LEFT, ......".~__...__PI~QMIJM1lIIIX8l
_mnellllMOl "'I..-~
~~B 27 '~7 09:48AM DEMPSEY INS. 408 247 9699
t' 1 1'-'__' J.~._~ll" ~ l\\,p!, 101' "lll ...,_\..l.. I ."IL..~"'" 1("".-1' {'U'_..
'. I. .~ 10>.,1_
P,.~....
, Inwred Hlme
L.S.I. construction, Inc.
Poley #
B122637744
""'MARY WORDI~
IUlJICT TO ALJ..C71'HIR TIJW8 AND PRCMIIONI OPTHIIIOUCY. IUCH INSURANCE AS
pAOYlDiO 8V THIS INOOMI!MI!NT'IIHALL. DIEIMID MIMNIY,.8lJT ON'-V WITN
..a'earTOWORl<~&g lVOf' PQRTHlHAMED INSURED INOONNI!CT1OHwrTH
r.- ABOVE DIDICAIIID CON1'IW:T.
FEB 27 '97 09:48AM DEMPSEY INS. 408 247 9699
P.3
POLlCV NUMBEFtl0226.377lii,
L.~.!. Construction, Inc.
COMMERCIAL (iCNCRAl. LIABlLrrV
THIS ENDORSEM~NT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, L'ESSEES OR
CONTRACTORS (FORM B)
Thi:5 endr:rsen1'!n! modifies in')ural1ce provided un~1t't th~ following
COMMERCIAL GENERAL LIABILITY COVERAGE PART,
Name of Person or Organization:
SCHEDULE
City of Campbell, City of campbell Redevelopment
Agency, its officers, employees & volunteers
(If no entry <lppe,m; abo...~. information required to complet'l! this endorsement will be Shown in the D$claratiO"5
as 1!lppllcHble to thi, endor:;emel'\t.)
WHO IS AN INSURED (Section II) is amended to inClude as an insured the person or ol's"n1zatlon shown In the
Sch(!ciul~. bul only with I'c!lpeet to liability arising out of "your work" for that Insured by or for you,
CG 20 10 II 85
Copyright. Insurance ~entlces Office. Inc.. 1984
o
',',
FEB 27 '97 09:48AM DEMPSEY INS. 408 247 9699
P.4
superior National
Ins. co.
NOFlKERS COMPENSATION
and
EMPLOYERS LIABILITY INSURANCE POLICY
California
FORM NUMBER
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
We have the right to recover our payments from anyone liable for an injury covered by
this polley. We will not enforce our right against the person(s) or organizatlon(s) named
in the Schedule. (This agreement applies only to the extent thal 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% of the California Workers'
Compensation premium otherwise due on such remuneration. .
Minimum Premium:
Schedule:
Person or Organization:
City of casmpell
Job Description:
1260 Burrows, CAmpbell
This l!T1dorsemenl changes thl! poficy 10 which it is .tlached and I:; eHectivl! on the date ISllUed unless olherNisl!! st.ted.
(Tnll InlolT1'lallon below ill required only when thill endorsement IS issued SUbseQuenllo pr'llparation olll1e policy,)
.'
Endorsernl!l1t Ellec\ive 2:; 2 7..; 9 7
Policy No. WCD27901E .
Elldoreement No, 8
L.S.I. Construct1op,
..____ . h ~'_~/L~
..u..S."'9"M": ~~~
o.t. Print.d' 08/22/94
pl'1!sld.nl
Page 1
Burrows
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
ENGINEER'S ESTIMATE
Address: 1260, 1270 BURROWS.. SOBOUTI
Encroachment Permit No, 96-167
Date:
Application No,
10/26/96
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO, DESCRIPTION UNIT QTY < $30K $30 K to $150 K > $150 K $ AMOUNT
L SURFACE CONSTRUCTION
MOBILIZATION 1 LS $ 250,00 $ 250,00
CONSTRUCTION TRAFFIC
CONTROLCONTROLlPHASING 1 LS $ 250,00 $ 250,00
CONSTRUCTION STAKING I LS $ 150,00 $ 150,00
CONSTRUCTION TESTING I LS $ 150,00 $ 150,00
11. DEMOLITION/CLEARING
1. CLEARING & GRUBBING LS
2. SAWCUT P,C,CJA,C,(UP TO 6') LF $4.50 $3,00 $2,00 $ ..
3, P,C,C, REMOVAL SY $30,00 $23,00 $10,00
4, CURB AND GUTTER REMOVAL LF $6,00 $3,00 $2,00 $ ..
5, MEDIAN REMOVAL SF $4,50 $2,25 $1.25
6, DEMOLISH EXISTING INLET/PLUG RCP'S EA
III, STORM DRAINAGE
1. 12' R,C,P, (CLASS V) 9 LF $60,00 $40,00 $20,00 $ 540,00
2, 15' R,C,P, (CLASS III) LF $65,00 $48,00 $38,00
3, 18' R,C,P, (CLASS III) LF $70,00 $60,00 $52,00
4, 24' R,C,P, (CLASS III) LF $80,00 $68,00 $59,00
5. 30' R,C,P, (CLASS III) LF $90,00 $75,00 $65,00
6, T,V, INSPECTION (12") LF $1.20 $0,75 $0,60 $ ,
7, STD, DRAINAGE INLET EA $1,600,00 $1.300,00 $1,000,00
(C,C, DETAIL 9)
8, FLAT GRATE INLET EA $1,400,00 $1.100,00 $900,00 $ ..
(C,C, DETAIL 6)
9, STANDARD MANHOLE 1 EA $2,000,00 $1,600,00 $1.300,00 $ 2,000,00
(C,SJ, DETAIL D-11)
(INCLUDES FRAME & LID)
10, BREAK AND ENTER M,HJD,L EA $700,00 $550,00 $450,00
Page 1
Page 2
Burrows
[TEM UN[T PR[CES FOR PROJECT AMOUNT
NO, DESCR[PTlON UNIT QTY < $30K $30 K to $[50 K > $[50 K $ AMOUNT
[V, CONCRETE IMPROVEMENTS
I. SIDEWALK SF $6,50 $4,50 $2,75
2, DR[VEW A Y APPROACH SF $7,50 $5,50 $3,75 $ -
3, CURB AND GUITER LF $22,00 $[8,00 $15,00 $ -
4, V ALLEY GUITER SF $12.50 $10,00 $8,25
5, HANDICAP RAMP EA $1,200,00 $800,00 $700,00
6, TYPE B-1 CURB LF $12,00 $9.50 $7,50
7, TYPE AI-B3 CURB LF $15,00 $12,00 $10,00
8, COBBLESTONE MEDIAN SURFACE SF $12,00 $8,00 $5,00
9, P,C,C, DRIVEWAY CONFORM SF $7,00 $5,50 $4,50
10, A,C, DR[VEWAY CONFORM SF $4.50 $3,75 $3,00
V,
PAVEMENT
I. ASPHALT DlGOUT AND REPLACE CF $5,00 $3.50 $2,50 $ -
2, PAVEMENT WEDGE CUT (6') LF $5,00 $2.50 $1.50
3, PAVEMENT GR[NDlNG SF $0,80 $0.50 $0,35 $ -
4, PAVEMENT FABR[C (PETRO-MAT) SY $2,00 $1.85 $ 1.50
5, ASPHALT CONCRETE (TYPE A) T $80,00 $50,00 $35,00 $ -
(1235')( 13 ')( 1.5")(0,0775')
6, AGGREGATE BASE (CLASS 2) T $40,00 $20,00 $12,00
7, SLURRY SEAL (TYPE II) SF $0,07 $0,06 $0,05
8, SLURRY SEAL (TYPE III) SF $0,11 $0,09 $0,07
VI. TRAFFIC S[GNALS/L1GHTS
I. DETECTOR LOOP (6' ROUND) EA $450,00 $300,00 $250,00
2, DETECTOR LOOP (6' x 30') EA $650,00 $540,00 $440,00
3, DETECTOR LOOP (6' x 50') EA $900,00 $750,00 $640,00
4, ELECTROLlER EA $2,600,00 $2,200,00 $1,800,00 $ -
5, 1 1/2" R[GID CONDUIT LF $9,00 $7,00 $5,00 $ -
6, 2" RIGID CONDUIT LF $17,00 $13,00 $10,00
7 CONDUCTOR LF $0,70 $0,55 $0.45
Page 2
Page 3
Burrows
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO, DESCRIPTION UNIT QTY < $30K $30 K 10 $150 K > $150 K $ AMOUNT
8 PULL BOX (NO, 3 1/2) EA $300.00 $240,00 $185,00
9 PULL BOX (NO, 5) EA $400,00 $350,00 $300,00
VII, STRIPING AND SIGNS
I. REMOVE PVMT, MARKINGS (PAINl) SF $2.50 $1.50 $1.00
2, REMOVE PVMT, MARKINGS (THERMO) SF $3,00 $2,00 $1.40
3, REMOVE PVMT STRIPING LF $1.40 $0,80 $0,40
4, STRIPING DETAIL 9 LF $1.35 $0,85 $0,35
5, STRIPING DETAIL 29 LF $2,25 $1.65 $1.20
6, STRIPING DETAIL 32 LF $2.40 $1.75 $1.25
7, STRIPING DETAIL 37 (THERMO) LF $1.85 $1.50 $1.00
8, STRIPING DETAIL 38 (THERMO) LF $2.50 $1.85 $1.15
9, STRIPING DETAIL 39 LF $1.50 $0,85 $0.45
10, STRIPING DETAIL 40 LF $2,20 $1.70 $1.00
II. LIMIT LINE LF $1.35 $1.05 $0,90
12, CROSSWALK LF $1.35 $1.05 $0,90
13, PAVEMENT MARKINGS (P AINl) SF $2,50 $1.90 $1.60
14, PAVEMENT MARKINGS (THERMO) SF $5.50 $3,80 $2,60
15, PAVEMENT MARKER (NON-REFL.) EA $4.50 $3,00 $2.20
16, PAVEMENT MARKER (REFLECTIVE) EA $6,00 $4,15 $3,15
17, TYPE K MARKER EA $95,00 $80,00 $70,00
18, TYPE N MARKER EA $95,00 $80,00 $70,00
19, SALVAGE ROAD SIGN EA $85,00 $75,00 $65,00
20, RELOCATE ROAD SIGN EA $100,00 $85,00 $75,00
21. INST, RD, SIGN ON EXIST. POLE EA $200,00 $145,00 $110,00
22, ROAD SIGN WITH POST EA $300,00 $240,00 $195,00
VIII, LANDSCAPING
I. IRRIGATION. PLANTING WORK LS $4,996,00 $0,00
(119)(7)($6,00)
2, PRUNE TREE ROOTS EA $125,00 $100,00 $85,00
Page 3
Page 4
Burrows
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO, DESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT
3, TREE REMOVAL EA $650,00 $500,00 $400,00
4, ROOT BARRIER (12") LF $20,00 $10,00 $6,00
5, ROOT BARRIER (18") LF $25,00 $15,00 $10,00 $0,00
6, STREET TREE (24" BOX) EA $450,00 $325,00 $250,00 $0,00
7, STREET TREE (36" BOX) EA $700,00 $550,00 $400,00
8, TOP SOIL BACKFILL CY $15,00 $0,00
(119)(7)(12")/27 =
IX, MISCELLANEOUS
I. PEDESTRIAN BARRIER LF $75,00 $60,00 $50,00
2, CHAIN LINK FENCE (6') LF $15,00 $11.50 $9,25
3, RAISE MISC, BOX TO GRADE EA $300,00 $200,00 $175,00
4, RAISE MANHOLE TO GRADE EA $400,00 $275,00 $200,00
5, INSTALL MONUMENT BOX EA $450,00 $350,00 $300,00
6, MEDIAN BACKFILL CY $19,00 $17,00 $15,50
\ e ( L.. t.::. \. ct.Go SUBTOTAL $3,340,00
PREPARED BY: c= ,~~
)U{) 10% SECURITY ENFORCEMENT FEE $ 334,00
REVIEWED BY:
TOTAL ESTIMATE FOR FAITHFUL $3,674,00
/.,if -
APPROVED BY: PERFORMANCE SECURITY $3,700,00
~
*See Section 66499.4 of the Map Act,
H:\BURROWS(MP)EXC
Page 4
R-l ENCRI_ ~CHMENT PERMIT ISSUANC CHECK LIST
City of Campbell
Department of Public Works
Encroachment Permit No.
ITEMS REOUIRED FOR PERMIT APPLICATION:
../ Applicant section complete
V Applicant signature and date (front and back) 1\ d
3 .-f'ivc Sets of improvement plans submitted g Yz 'I l \
~o Engineer's Estimate submitted
ITEMS REOUIRED PRIOR TO ISSUANCE OF ENGINEERING CLEARANCE FOR BUILDING PERMIT:
, to Security for Faithful Performance and Labor and Materials, 100% each of Engineer's Estimate, supplied
f' or paid.
Amount $ Form I.D. #
ITEMS REOUIRED PRIOR TO ISSUANCE OF ENCROACHMENT PERMIT:
V/ Worker's Compensation Insurance Information Sheet received from Applicant and/or Contractor..:..... &6
V Certificate of Insurance with Additional Insured's Endorsement received from Contractor. S~
· ! 5t)''B.eo6\r\if~ ~g'/ ~~
~ne mylar set and three blueline sets of off-s te plans SIgned by lIcensed engmeer, stamped APPROVED
Y FOR CONSTRUCTION.
V Permit signed by City Engineer.
WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED.
Issuer: Initial
and date
and file with permit.
j:\forms\Rlcklst rev. 6/96