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97-143 CITY OF CAMPBELL ~.-- DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 Fax (408) 376-0958 .....! r.. ENCROACHMENT PERMIT (for working within the public right-of-way) Permit No. 97-/ It S X-Ref. file Issued , 1 Permit expires in 12 mon Application Date l(- / - 9'7 Application expires in 6 months APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months if the permit is not issued. Application Fee is non-refundable.) R"'l.Ii'" 0 8f.t....~ fer .. Pr'fr;"{l t>vstU't2.Y" A. Worle address or tract # /3 DO Dell ~ve..' Ct\1\A t b.J.1 0"1 sJ 3$/ - 6(. -<-<. Utility trench location B. Nature of work jJPIJ l:>\.prrM\~"~ (.~~) c~.lt t G:.~-< i qrtL..'IoJ~ (../-.:... jAi t..~>k C;tr 5h.r~ C. Aaach four (4) copies of an engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer. said plan becomes a pan of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shut-down and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions I and 2.) E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK. N_ "Appl",", lac-',fT <. .:>.:...\; ~' I'J.s f ~Jf J :t:N L . Td""'" t~/~ ~O - 'N 'f Y Address ~O(,.(",. WA-r-. -S;,..-;;.J..W;intC/) li-e-fVl.C>tII-i 24 HOUR EMERGENCY TELEPHONENO.J)~ IQ) fc.'S- "'fg!! V I r ~ Is this work being done by the property owner at their own residence? Yes /' No The ApplicanllPermittee 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/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. /JIidorJ /I~,~--4t_~IfW 4-/- ? 7 Date Accepted SPECIAL PROVISIONS _1. Street shall not be open cut for underground installations. Minimum cuts~beallowedfor connections or exploration holes. Such cuts may be soecitieally approved by the Inspector prior to cuttinl!. . .. .. .... ... .. . .... ..... ... ......... .. ... ... . ... .... ... .. . ... . . ..... . ... .. Pavement may be cut for underground installations and must be restored in accordance with theytilityTrench RestorationSla/Idardpetails. Method . A'Backtm~ unless otherwise approved by Inspector. . . Worle to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public WorlcsDepanment before starting work. Per Section 4215 of the Government Code this pcrmit is not valid for excavations until Underground Service Alert (USA) bas been notified and the inquiry identifICation number has been enrered hereon. USAPhone 1-800.2~H600. ..< SA TICKET NO. UjE 'I c: ..... ..oJ .O/WCG AI. 1'- _2. _3. _4. _So SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES !Y.ffi . · AMOUNT PERMIT APPLICATION FEE AAg..i-CT,t.... PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS /tJ,,2,1.. B/.(tt/t. ~>7. ~~~~~~~~~E~_ $ ~J.')' -" s .--- $~ ~:~~ RECEIPT NO. NJ O~? 10/02..1 101 CJ 1. 7- Ihl 0 23 !f-/-,97 Date City of Campbell - Refundable Deposit Check Request Interim Check Required: To: Finance Director Return Check to: Please Issue Check Payable to: Department: Pacific Sealing & Asphalt, Inc. Address - Line I: Line 2: 2066 Warm Springs Court City: Fremont State: CA Zip: 94539 Description: Refundable Deposit Finance Use Only Amount Payable: $1,250.00 (Exact Amount) Interest Earned Account Number: 101.2203 101.540.7448 Purpose: Refund faithful performance surety Voucher #: Permit #: 97-143 Date: 4/1/97 Title: PW Inspector Date: 09/22/98 Title: City Engineer Date: 09/22/98 Title: Account Clerk II Date: Title: Date: Requested by: Michelle Quinney Approved by: Verified by: Approved by: Special Instructions For Handling Check Mail As Is: x Mail in Attached Envelope: Other: fin: S;/exceVchkreq - Revised 1/98 Requested by: ,~_ .--' -, Robert Phillips Approved by: ~ Michelle Quinney FINANCE ONLY: Verified by: To: Accounts Receivable Please Issue Check Payable to: Address - Line I: Line 2: City: Description: Amount Payable: Account Number: ate and Receipt No: Permit No: Purpose: Approved by: Mail As Is: Return To: (NAME) Other: rev: 3/25/95 CitJ Jf Campbell- Chel.A Re.q.uest Pacific Sealing & Asphalt, Inc. 2066 Warm Springs Court Fremont State: CA Zip: 94539 REFUNDABLE DEPOSIT Finance Only: INTEREST EARNED $4,250.00 101.2203 101.540.7448 4/1/97 #101021 & 101022 97-143 nd of 75% Of Faithful Performance Surety $3,750.00) and 100% of Cash Deposit ($500.00) TItle: Project Inspector Date: 4/25/97 Date: 4 .'Zj /c;V Title: City Engineer Title: Date: TItle: Date: Special Instructions For Handling Check xx Mail in Attached Envelope: (Department) PUBUC WORKS DEPARTMENT RECEIPT Effective JuJy I, 1996 TO: CilyClerIi PUBLIC WORKS FILE NO. 97 -J'f ~ PROPERTY ADDRESS l:1do {)o../I A~. Please collect & receipt for the folJowinl monies: ACCT. ITEM ...................... ........................ ........ 4JS.l3H92I I Project Revenue (specify project) S ENCROACHIlilL"IT PERMIT ~ ) Application Fee ..1...1 5 -- Non-Utility Encroachment Permit (S22S) R-I Fint Permit (No Fcc), Subsequent PennitfYr (SIOII) Utiliry Encroachment Permit ArteriaVCollcctor Street (S32S) RcsidcntiaJ Street/Other Area! (S22S) 220J Plan Check Deposit - 2% of ENGR. EST. (SSUU min) . ( 220J Faithful Performance Security (FPS) (I"I%ofENGREST.) . - 220J Labor and Motcrials Securitv (llJll"1o ofENGR EST.) 220J Monumenl4ltion Security (I")%ofENGREST.) . (220J~ Cash Deposit (41'. ofENGREST.)(SSOO minl1lO.000 maxI . "Jt'l("} - - Plan Ched. & Inspection fee (Non.Utility) ~t}O ~ ) Engr.Esl. < S250."lO (121'. of ENGR EST.) .. 2203 Engr.Esl>$250.()()l) (Deposit 8e;. ofENGR. EST./SJO.OOO min.)" . 4722 Utility < SIlHI.OlKJ Minimum C'hargc Per Location (SI20) ConduitslPipe:lines up to 500 fcct (SI.60/11) Above 500 Feet (SUO/fl.) ManholesNaultsIErc:. (SIOS/ea) Pole SetlRemoval (S IOS/ea) Streee Tree Planeing/Removal (S 1051....) .. 2203 Utility:> SIOll.()(IU Actual Cose + 2()1'/. .. . 4722 StreCC Tree PlantinlJl'Removal Pennie (SillS) 4761l Project Plans & Specifications Project No. 47(1) Standard Specifications & Details (Slll'g S12lBook) 4160 Copies of Enginccring Maps & Plans (S.Sll/sq.ll.) 4722 Penalties: Failure to restore public improvements (SI()(I/C.1lendar Day) (Muni Code Section 11.34.0(0) 4722 Penalties: F3ilure to correct unsafe conditions ($ lOll/Calendar Day) LAND DEVELOPMENT 4722 Lot Line Adjustment (S5(lO) 4722 Parcel Map (4 LolS or Less) (SI.06ll + S2SILoI) 4722 Final Trace Map (5 or More Lots) (SI,J81l + S2SILoI) 4722 Certificate of Compliance (S5IMI) 4722 Certificate of Correc:tion (SliM)) 4722 Vacatian of Public SlrCClS & Easements (SSSIl) 4722 Assessment Segregation ar Reapportionmenc Firse Splie (SS511) Each Additional Lot (SI711) 4721 Slonn Drainage Area Fee Per Acre (R-I. S2.II'MI) (Molo.Res. S2,250) (All Other. S2.5"1) 4921l Pa.rkl;:md Dedication Fee: 496S Post.1ge TRAFFIC 472'1 Interscction Turn Counts ITwo.Hour Coune} (S6II) 4728 Intersection Turn Counts (a.m. or p.m. peaks) (SI2S) 4728 Tranic flow Map (Daily Traffic Volumes) (S271 472'1 Campbell Traffic Model (Full Scope Assessment) (S2.2S0) 4728 Campbell Traffic Model (Reduced Scope Assessment) (S740) 4271 Truck Penn its (SJS/lrip) 472' No P:uking Signs (SI/each or S251IUU) OTHER s~3;l<; - TOTAL NAME OF APPLICANT ~Gjr;t:J C. .1,',.,.. ~ ~lflh~2;t /"e-. NAME OF PA YOR ;OCif;CI ~,,~ ~ AC,Ahrlf IJrtc-. PHONE 5)(j - 1f4~ ... 9'9 ~ ADDRESS .laVe., IAJI1f~ ~"""\"J bJ. "/Q.,wt..,~ (';1/ ZIP 94,)JC? I J .. Actual Cost Plus 21W.. Ovcmclld (Non.lnlcrest bearing deposit) 10 1\,)23 /010'2./ /0/022- JIJ lOll Jt ~7:J-2 (!. S/.J 5' - /d/Ol] 5 t:' ,.o(._~ d'l"'J\t Z2.. .:JJ 2.203 (!., J o.a.~EI ,,~. r"i,O'~ ;\l'l C~S OffiCE FOR CITY CLERK ONLY RECEIVED BY '\ D.te .For Pt.m Chct:l and Dsh,DeposiLS, send yellow cop)' tarmancc. h:\recCnn4(exc)mp(rcv 1/2191) Permit # INSURANCE REQUIREMENTS CHECKLIST q 7 ~ I Lj3 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 Pennit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: ~ $1,000,000 per occurrence, and ~ $1,000,000 general aggregate limit applying separately to the project, and ~ $2,000,000 general aggregate limit. 'I::::J Policy expiration date 4 J I ) Cj S Automotive Liability - "any~o" if $1,000,000 per accident 11' r ~odily injury and property damage . if Policy expiration date Lt _ J I q 6 W,9fker's Compensation and Employer' ~ Liability C) .\ q V,h) ~....I\/ 'd $1,000,000 per accidem for bodily UUnry or disease ~ \ I ,I / I ~ ^ lOll} ~ ,Policy expiration date -4) J 1'19-. u I r ~ oJ!) Course of Constroction (if required in Special Provisions) ,KIP. ~ I V. rvbL"Y o Completed value of the project \./, v . {1l/V' () Ofll' o Policy expiration date Ii' \ ,.YJ JV~ Reauired Endorsement to General Liability and Automobile Liability Policies ~ Additional Insured Endorsement > 0 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. ~ .; {~\' I \ :): .'/ '\ Workers' Compensation Insurance Sheet Submitted o For General Contractor o Subrogation Clause o ~ Insuran<:e Certificate ReVi~ ~ ~t3.A......' _ Initi~ls 4 );;L3 )77 Date ){. Copy of Insurance Certificate placed in tickler file OIie month prior to expiration. j: \fOrm. s\inscklst 4/96 (rev 6/96) .'./_ /I,~ '. ,p /! ~ ~ / A . _ ly\'i7 k- 1D (/Cc.epr-- We/r; W U"c/1UJ2:> ~-~~O . ifl 0,) -, ~- / h rv I" CtflrpLc2cQ- CJ::Y kAT/.-/(..--/ t.o U t^-JdG r . AkORDN eER'-U=,C.l\'--OFI..I.l\B1l1l"a'INStJR," . "e~~gI~~4 DA;: 7~;;r;~ 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 COMPANY i A - fl-E C E , " f5"" APR 181997: COM~ANY PUBLIC WORK ADMIN S Pacific Insurance Company LTD PRODUCER All West Insurance Brokers P.O. Box 1737 Campbell CA 95009-1737 Janice Berthold CLU,ChFC,CPCU Phone No. 4 0 8 - 3 7 9 - 3 4 0 0 Fax No. INSURED Kemper National Insurance Corp Pacific Sealing & Asphalt 2066 Warm Springs Ct Fremont CA 94539 General Security Insurance COVERAGES COMPANY D State Compensation Ins. Fund THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I , i POLICY EFFECTIVE I POLICY EXPIRATION i DATE (MM/DDIYY) DATE (MM/DDIYY) CO LTR TYPE OF INSURANCE POLICY NUMBER LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY i Z I 0 0 05392 CLAIMS MADE i_:lCJ OCCUR i OWNER'S & CONTRACTOR'S PROT 04/01/97 GENERAL AGGREGATE 04/0 1/98 i PRODUCTS - COMP/OP AGG PERSONAL & ADV INJURY , EACH OCCURRENCE i FIRE DAMAGE (Anyone fire) MED EXP (Anyone person) AUTOMOBILE LIABILITY C X ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS X HIRED AUTOS X NON-OWNED AUTOS CA4010253 04/01/97 04/01/98 COMBINED SINGLE LIMIT $ 2,000,000 $ 2,000,000 $ 1,000,000 $ 1, 000 , O~O $ 50,000 $ 5,000 $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY ANY AUTO EXCESS LIABILITY A X UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TJ0002431 , AUTO ONLY - EA ACCIDENT $ , OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ I EACH OCCURRENCE $ 3, 000 , 000 04/01/97 i 04/01/98 iAGGREGATE $ 3,000,000 $ D THE PROPRIETOR! PARTNERS/EXECUTIVE OFFICERS ARE' OTHER INCL i 71345096 EXCL, 04/01/97 04/01/98 'WC STATU- OTH- TORY LIMITS ER EL EACH ACCIDENT EL DISEASE - POLICY LIMIT EL DISEASE. EA EMPLOYEE $~OJl~ 000 $ 1,000,000 $ 1,000,000 B A 04/01/97 04/01/97 04/01/98 04/01/98 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Certificate Holder is listed as additional insured per CG2010 attached. Thisinsurance is primary per endorsement attached. CERTIFICATE HOLDER CITYCAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 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 REPRESENTA TIVES. AUTHORIZED REPRESENTATIVE City of Campbell Dept of Public Works 70 North First Street Campbell CA 95008 ACORD 25-S (1/95) Janice Berthold CLU,ChFC,CPCU @ACORDCORPORATION 1988 pOl.!CYNUMBER: Zl 000 '2 Pacific Sealing & Aspha~C~~ :R~!AL (.~'=,. .':", LIABILITY --- THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - O'VNERS LESSEES OR , CONTRACTORS (FOffi\iI B) Tnis endorsement modifies insurance provided under the following: COM:MERCIAL GENERAL LIABILITY COVERA.GE PART SCHEDULE Name of Person or Organiz3tioa: City of Campbell (If DO e::try app~ above, information required to complete this c:ldorsement will be shown in the Declarations as ~-plicable to this endorsement) WHO IS AN ]},"SURED (Section II) is amended to include as arl. insured the person or organization sho\1ffi i:1 the Sc;:~cle, but only with respect to liability ar.sing out of your ongoing operations performed for that rnsured. CG 20 10 1093 Copyright, Insurance Servic~ omc:, rnc., 1992 ACORD,. GER....IF1GA....-\C)F ..I..IABII..IN1NSl.JR. 'JG t IDBM DATE (MMIDDIYY) ....... ...> . ..ACIF14 04/08/97 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE All West Insurance Brokers HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 1737 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Campbell CA 95009-1737 It?.\,,tO COMPANIES AFFORDING COVERAGE .--- Janice Berthold CLU,ChFC,CPCU COMPANY i A Pacific Insurance Company LTD Phone No. 408-379-.3400 Fax No. I ---- INSURED ') t ~ W\" COMPANY .~ ~~~ . B Kemper National Insurance Corp \\V~ _...:> COMPANY Pacific Sealing & Asphalt . yi""" \O~ C General Security Insurance 2066 Warm Springs Ct .\ \..... ~9-p..\ ! COMPANY . .~\S Fremont CA 94539 ...~\ D State Compensation Ins. Fund ),v . COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ---.-.---. I I POLICY EFFECTIVE POLICY EXPIRATION CO TYPE OF INSURANCE POLICY NUMBER LIMITS LTR , DATE (MM/DDIYY) DATE (MM/DDIYY) GENERAL LIABILITY , GENERAL AGGREGATE $ 2,000,000 I I A X COMMERCIAL GENERAL LIABILITY ZIOO05392 04/01/97 04/01/98 PRODUCTS - COMP/OP AGG $ 2,000,000 CLAIMS MADE X OCCUR I ! PERSONAL & ADV INJURY $ 1,000,000 OWNER'S & CONTRACTOR'S PROT . , , EACH OCCURRENCE $ 1,000,000 I , , FIRE DAMAGE (Anyone fire) $ 50,000 ---- I , MED EXP (Anyone person) $ 5,000 AUTOMOBILE LIABILITY ! 04/01/97 , 04/01/98 COMBINED SINGLE LIMIT $ C X ANY AUTO CA4010253 I , --._- ALL OWNED AUTOS I BODILY INJURY $ SCHEDULED AUTOS (Per person) --. X HIRED AUTOS ! BODILY INJURY $ 1,000, X NON-OWNED AUTOS (Per accident) I -----~ I I PROPERTY DAMAGE $ I , - GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ -~---_.~.- ANY AUTO OTHER THAN AUTO ONLY ~----._--- -- I EACH ACCIDENT $ ---.---- --. ! AGGREGATE $ EXCESS LIABILITY 1 EACH OCCURRENCE $ 3,000,000 I A X UMBRELLA FORM TJOO02431 I 04/01/97 04/01/98 AGGREGATE $ 3,000,000 ---- OTHER THAN UMBRELLA FORM ! $ , WC STATU- 'OTH. WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY I EL EACH ACCIDENT $ 1,000,000 D THE PROPRIETOR/ INCL 71345096 I 04/01/97 04/01/98 EL DISEASE - POLICY LIMIT $ 1,000,000 PARTNERS/EXECUTIVE - I OFFICERS ARE: I EXCL , EL DISEASE - EA EMPLOYEE $ 1,000,000 OTHER I T ! ! B ! 04/01/97 04/01/98 A I 04/01/97 04/01/98 , DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Certificate Holder is listed as additional insured per CG2010 attached. Thisinsurance is primary per endorsement attached. CERTIFICATEHOtDER .,' IATIOt./ CITYCAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL City of Campbell ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Dept of Public Works BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 70 North First Street Campbell CA 95008 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Janice Berthold CLU,ChFC CPCU ACORD 25-S (1195) @ACORDCORPORATION 1988 FOLICYNUMBER: 21 0005.):12 Pacific Sealing & Asphal('~M._~..:.RC:!Ar.~8"~""':~IABILITY TffiS ENDORSElMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - O'VNERS LESSEES OR , CONTRACTORS (FOR1\'I B) This endorsement modifies insurance provided under the folIowing: 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 Dedarations as applicable to this endorsement.) WHO IS AN msURED (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 insured. CG20 10 1093 Copyright, lnsw'ance Services Otlice, Inc., 1992 /' /~ POUCY NUMEER: :-'7--"::"; cf INS'URA..'iCE COMP~'l't rsstIED TO: THIS ENDOR$L'\1EI'i'I' CllA.."\GES nIE l'OLICY. PLEASE RE.....D IT CAREFUlLY. ~O~~i# ADDIrIONAL IN5UUD-OWl'l'XRS. ussllS OR CO:\JRAcr(l~ (FORM B) This endotse1Tlem modifies insurance providtd ~ the folll1"'ina: COMM:fltCIAL ~UABn.m" COVERAGE PART In oonsicle:ration of an Idd.ititllltl ptemium or S ". it is hereby ~ tlJat; WHO IS ~ DlSlJ'"RED (SeaioA II) is Imecded to indw!e i5 art insurod U\c :)C."'$OIl or organization shO'AlI. in th: Sclu:du1e. but 0111)' with r::spea to tiability ariSit.g out of "ya'Jt WQtk" tar ~ iNut:d by or for you.. h is further agr.ed that The foUowml pangraJ.'h i$ aMccllo SCO:llJ94, Specbl Broad. Form Comme:n:W Celu~r.1lllibi1ity ::tado~ement. 1.. Addidonal Insureds. By CoaU'act. A:ntmot12C or Permit: c. CO\'aage prtMcX4 by this poll'1' lO t..'!t: Mdiucnal InsurM(s) li~ed. t::e1ew sh&ll l)e pci:nat}' inslolranc;e b'oIJ. C)~y il$ rc:spects the projl:Ct listed below and any othcr in:ur"al"ll;1;. n:aitlwir.t:d by the Addilicnal blnre:1(s) shall be c;a;~ ud :.on~cntr.~U1ory. SCHEDULE Name orPersol1 Ot Org;LDiutioll: Project: 'I1d.I i.nsunnce d~ ~ ap,ly to '"bcdiI'y ~a.rt". "pJ~ Wnige-. 'lemma! UUUIy" ~. "advertising l.I1jury"" uifu, cn.rt of lbt r=4erilOg 01' .rai1urc tg tende: a.~ p1of'cs:sioual snvit;es by ClI' for you, mcludlua: L The preparing. a}1Ptc"#i.:tj. or !ailing ~ prepare or :.pprnve maps. dr3.v.i~. op'nicns, fCjlCrts, :turvey5, d'.an;c o.rdUS, designs or spcCficatiC1'ls: aM 2, Supe~. inspe::tion or c&~ee1'inc SErvices. COYCo"a;= prQ'lidcd \UI.licr this endor&emc.t is specifiea1ly limi:d to projcclS 10Ci:.ted in th~ sta~ cr Califomi~. ~: 1lUI cndorzelnwt does ~t clul1~e the puUc., ~(lt as shown. Of'C."tit 4,.' ,o~ f.. t't' ... r" U !"" " -So .. ... ., ,,' f)/fCHA\1.\'l CITY OF CAMPBELL Public Works Department September 22, 1998 Pacific Sealing & Asphalt, Inc. 2066 Warm Springs Court Fremont, CA 94539 SUBJECT: PERMIT NO. 97-143 LOCATION: 1300 Dell Avenue ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE Dear Mr. Walitsch: 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 and any surety, therefore, are hereby released. Your warranty deposit of $1,250, plus any interest due, will be sent directly to you from our Finance Department. sm21~ Alan Horn Public Works Inspector MQMA.- cc: Permit 97-143 Public Works/Maintenance Division H:\ WORD\PERMITS\97143ACC(JD) 70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOD 408.866.2790 .Of'CA.4t-o 4. ~ f.. ~ ... l'" U r" ~ . . '" 0$- ~ ~ORCHAV.\) CITY OF CAMPBELL Public Works Department April 24, 1997 Pacific Sealing & Asphalt, Inc. 2066 Warm Springs Court Fremont, CA 94539 SUBJECT: PERMIT NO. 97-143 LOOCATION: 1300 Dell Avenue FINAL INSPECTION AND ACCEPTANCE Dear Mr. Walitsch: 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. The City will continue to hold $1,250.00 of your $5,000.00 Faithful Performance Surety cash deposit, receipt #101021, as your Maintenance Surety. Additionally, your cash deposit of $500.00, plus any interest due, is now being processed and will be sent to you under separate cover. If you have any questions, please call me at (408) 866-2165. Sincerely, .......-7 ____ y// -- ~---'- Robert Phillips Project Inspector MQ lit & cc: Suspense - 11 months Permit #97-143 H:\ WORD\PERMITS\97143FINGd) 70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOO 408.866.2790 CITY OF CAMPBELL FIELD ENGINEER'S DAILY REPORT PROJECT HO. REPORT HO: "2 /3 0<5 Drc. l l DATE : Cf_ / f - '17 WEATHER: C C E"c:tt'l CONTRACTOR: INSPECTOR: /;J Il/rCl./Q~ ITEM DESCRIPTION l) Crl/~ (It /7:" :::- ,vr<.<.} I ~ C-- F L, i3/e/,,"!fr" /Clr Sit: <_ C>"I'J L.., /1/. --co DZ:, C <-' _R IS r-/l c Ith d ( or.:- ,'c< Cd,,! / .c. C~ u o^-I Cr- I 9 n-" ::.-----~~ cc: PAGE: I OF I CITY OF CAMPBELL FIELD ENGINEER' S DAILY REPORT PROJECT NO. REPORT NO: I .'~ (l (1 7/ ~ -#--r: T) I;, ( C DATE: L(_ J/- q 7 WEATHER: e { fZ 1M: CONTRACTOR: INSPECTOR: ./-::::> j-/-!l{( :J (" --:> ITEM DESCRIPTION " ] l .'; 'IlL (f; 'c: /l( -/e, 1 { /C,-,Z /7/" ~ )3/;< ( S I~ (;) C'; /" C' c/? P 2' I rYe ///( (, I' n./ Tit 1) h ;/( ,J( T&(( : ,'1/ C /( If T/i -' K Ct.. ~ L-<./ i T 1'1' -2 /l-:c L {'./e If -0- ...J- . <l/ 7#/[ /'/2/" /;;;/:: /V, J S r () "'/ c.. ~V{Jy i6 /(/([ /i','IC TCt'2 -- -' cc: /~~- PAGE: I OF I . . - March 13, 1997 Mr. Roland Buehler 2806 Bay View Drive Alameda, California 94501 Page 1 of 2 Subject: 1300 Dell Avenue Parking Lot Paving Dear Roland, The following is our updated cost for the work you requested on the parking lot. Please note that we have included the cost for the 1320 Dell Ave., site. SCOPE OF WORK ITEM I - NORTH DRIVEWAY & REAR OF BUILDING A. Approximately 6,800 square feet of 4" paving. B. 8' x 28' of PCC approach. C. 6" of class II baserock under approach. D. New storm drain & line. E. Existing sidewalk removal. F. Curb & gutter and transition, G, Encroachment permit. H. 155' x 2' concrete swale. COST: $24,290.00 ITEM II - SOUTH DRIVEWAY A. 15' x 8' concrete approach with 6" of new baserock, B. New drain inlet & line, C, 205' x 3' wide concrete swale, D. Approximately 8,200 square feet of new pavement. E, 12' x 30' concrete pad for garbage bin. F. 39' of headerboards, G. Curb & gutter with transition. H. Re-stripe parking lot per new plan. COST: $31,578.00 March 13, 1997 Mr, Roland Buehler Page 2 of 2 ITEM II/ - 1320 DELL AVENUE SIDE A. 1/2 of the valley gutter & 820 square feet of pavement repair should be paid by the owner of 1320 Dell Ave., since this is figured on his property. This cost is $4,180.00 and would reduce the cost of Item 1/ ($31,278.00) by $4,180.00. B. Place concrete approach and curb & gutter with transitions. COST: $2,815,00 C. Additional pavement that should be repaired at 4" thick. (Approx. 3,800 square feet) COST: $7,410.00 If you have any questions, please feel free to call me. Sincerely, PACIFIC SEALING & ASPHALT INC. Michael Walitsch Vice President Pr~;f 9/J jtf's C1\1( w tE;sf'. (:::'a U C 5 (lI~ ().O ~)l4- ~ ~i)-f- 5'f ~ 5.5 co :; I ~ 9 2- . 1Wv.icJ;J !bf/ e.- ) ~ L/C3 Lor _ . (t1I<J c:. \.:? --- (}~/J(1 ~ /2l 71~ C~G lf~ I :>I I r ~ H ~,~~ ~ ~j' ... ~)~ O/vJ AG~ rG, s,: ~ )IJ ')' 3~1 -- . M 6* ~) (D 5 /~) ::; 112,c~ ::: /U~<:. ~2\ :: :L6G - 4i~c:. ra-W\D-'~ t;J? - ~ 5'(j~Q -- ~ <.1 () x' Ib ~ ~ 6d G -- CITY OF CAMPBELL PVBUC WORKS DEPARTMENT ENGINEER'S ESTIMATE Address Encroachment Permit No. ITEM i NO. i 'I. DESCRIPTION ~ACE CONSTRUCTION MOBILIZATION i FONSTRUCfION TRAFFIC r:;ONTROLCONTROLIPHASING .tONSTRUCfION STAKING CONSTRUCfION TESTING I i II, DEMOLITION/CLEARING I. bLEARING'" GRUBBING I 0~AWCUT P.C.C.lA.C.CUP TO 6') ~.C.C. REMOVAL i 0FURB AND GU1TER REMOVAL ! 5. ~fEDlAN REMOVAL I 6. DEMOLISH EXISTING INLETIPLUG RCP'S I ; III~ ~TORM DRAINAGE ~2' R.C.P. (CLASS V) ; 2. 15" R.C.P. (CLASS 110 ! 3. ~8" R.C.P. (CLASS III) 4. 24" R.C.P. (CLASS 110 I 5. ~" R.C.P. (CLASS 110 ! 6. rV. INSPECfION (12") I 7. STD. DRAINAGE INLET I rC.C. DETAIL 9) 8. FLAT GRATE INLET fC.C. DETAIL 6) 9. STANDARD MANHOLE fC.S.!. DETAIL 0-11) tlNCLUDES FRAME'" LID) I ;fo:\~REAK AND ENTER M.H./D.l. i~ i IV. fONCRETE IMPROVEMENTS t. SIDEWALK I I 0RIVEWA Y APPROACH 27-Jun-96 QUAl'ITITlES J Da.. Application No. UNIT PRICES FOR PROJECf AMOUNT <S3OK 1 S30KtoSISOK I >SISOK LS LS LS LS LS LF $4.501 SY , i S3O.oo 1 I ; LF $6.001 SF $4.SO: i EA LF $60.00 . LF 565.00 ' IF ! S70.oo I LF S80.oo LF S90.oo LF S1.20 t ! S1.6OO.oo ! EA EA. S1.4OO.oo : EA S2.000.oo ! EA S700.oo ' SF $6.SO, SF S7.SO SI,300.oo SI,loo.oo SI.6OO.oo $5SO.oo Page 1 of 4 $3.00 $23.001 $3.001 I $2.251 I 1 $40.00 $48.001 $60.001 $68.001 $75.00 ' $0.75 $4.SO I $2.001 SIO.ool I $2.001 I SI.251 I $20.00 I ::1 $59.00 I 565.001 $0.60 SI.OOO.oo S9OO.oo SI.300.oo S450.oo $2.751 I S3.75 1 S AMOUNT ITEM I DESCRIPTION 3. FURB AND GlJITER 1 I 4. IV ALLEY GlJITER S. HANDICAP RAMP 6. TYPE B-1 CURB 7. TYPE AI-B3 CURB 1 I 8. FOBBLESTONE MEDIAN SURFACE 9. P.C.C. DRIVEWAY CONFORM I @ ,A.C. DRIVEWAY CONFORM I I V. PAVEMENT I. ~SPHAL T DIGOUT AND REPLACE I 2. PA VEMEI'<f WEDGE CUT (6') I 3. "A VEMEI'<f GRINDING 4. rAVEMEI'<f FABRIC (PETRO-MAn , S. i^SPHALT CONCRETE (TYPE A) ! G AGGREGATE BASE (CLASS 2) 7. SLURRY SEAL (TYPE n) 8. SLURR Y SEAL (TYPE nn VI. ~mc SIGNALSILIGHTS t. pETEerOR LOOP (6' ROUND) i 2. DETEerOR LOOP (6' x 30') , 3. DETEerOR LOOP (6' x SO') 4. ELEerROLfER S. 11/2" RIGID CONDUIT I 6. 2" RIGID CONDUIT 27 -Jun-96 U AI'<fIT/ES LF I SFI I SF! i SF! I ! I CFI ! LFI I I SFI ! , I SYI I Ti i TI I SFI I i SF I I EAI , i EAi I I EAI I EAI I LFI I 1 LFi S AMOU/IIT <S3OK $22.001 I UNIT PRICES FOR. ,Eer AMOU/IIT , SF S12.S0! , , EA SI,200.001 LFI S12.001 I I SIS.OOI , i , SI2.00! LF $7.001 ! ~'SOI ! SS.OOI I SS.OOi i so.801 I I $2.00! I S80.001 , , ~,ool so.071 I SO. 11 1 I I I S450.00 i ! S6.50.00 i 1 I S900.00 I $2,600.00 I I S9,001 SI7.001 S30 K to SISO K SI8.00 SIO.OO SSOO.OO SI2.00 $8.00 SS.SO S3.SO $2.S0 SO.SO SI.~I sso.oo/ , $20.00 SO.06 SO.09 SJOO.OO SS40.00 I S7SO.00 $2,200.00 $7.00 SI3.00 Page 2 of 4 S9.SO > SISO K SIS.OO! S8.2.S I , I S7lXl.00 I I I S7.SOI I SIO.OO SS.OO ~.SO $3.00 $2.SO SI.SOI 1 ~~I St.SOI m.ool I S:.:I I SO.071 I I S2S0.00/ S440.00 ' S640.00 Sf ,800.00 I SS'OOi SIO.OO UNIT PRICES FOR Pk~,eCT AMOUr-rr DESCRIPTION UAJlITITIES < SJOK . SJOKTO SISOK > SISO K S AMOUJIIT LFI SO.701 SO.55 SO'45/ i I I S. ~ULL BOX (NO.3 1/2) EAI S300.oo ' ~~'ool SIBS.oo[ 1 I ! i 9. PULL BOX (NO.5) EAI S4OO.oo : S350.ool S3OO.oo i I I VII. ~ING AND SIGNS I I. . EMOVE PVMT. MARKINGS (PAlm) SFj $2.50: SI.SO Sl.oo I I I Z. R.EMOVE PVMT. MARKINGS (THERMO) SF! 53.00 ~.OO SI.~ I I I I 3. REMOVE PVMT STRIPING LFI SI.~ SO.lkIl SO.~ I ~ I 4. fI'RIPING DETAIL 9 LFi SI.35 SO.BS' SO.35 1 i i LFI 5. FRIPING DETAIL 29 $2.25 SI.6S S1.20 6. rRIPING DETAIL 32 LFI ~.~, SI.751 SI.25 I 1 7. fRIPING DETAIL 37 (THERMO) LFi SI.BS SI.SO Sl.oo I I i I S. ~RIPING DETAIL 38 (THERMO) LFi ~.50, SI.BS SI.15 9. LRIPING DETAIL 39 LFI SI.SO SO.BS SOA5 I I i I 10. ISTRIPING DET AIL ~ LFI $2.20i SI.70 Sl.oo I I LFI 11. 1.IMIT LINE SI.35 SI.05 so.~1 I I SI.05I I 12. ~'=WAU LFI S1.J5 SO.~ I I 13. AVEMEr-rr MARKINGS (PAIJIIT) SFI S2.50 SI.~I SI.60 I I I 14. rAVEMEr-rr MARKINGS (THERMO) SFI 55.50' 53.lkIl ~.60 EJ 15. rAVEMEr-rr MARKER (NON.REFL.) $4.50 53.00 ~.20 I I 16. ~A VEMEr-rr MARKER (REFLECTIVE) EAi $6.00: $4.15 53.15 i I I i I 17. rPE K MARKER EA S95.OO $80.00 $70.00 18. hPE N MARKER EA S95.oo i $80.00 $70.00 I EAI t9. ~ALVAGE ROAD SIGN $85.00 : $75.00 565.00 I 20. rELOCATE ROAD SIGN EA Sloo.oo I $85.00 S75 .00 i 'S110.oo 21. rNST. RD. SIGN ON EXIST. POLE EA $200.00 I S145.oo I I 22. rOAD SIGN WITH POST EA S300.oo I S240.oo SI95.oo 27-Jun-96 Page 3 of 4 ITEM I UNIT PRICES FOR PRuJECT AMOUNT , NO. DESCRIPTION <S3OK 30 K TO SISO K SI50K S AMOUNT VIII. ~SCAPING t. IRRIGATION, PLANTING WORK LS; , I ! 2. ~RUNE TREE ROOTS EAi SI25.oo I Sloo.oo sas.oo i I 3. TREE REMOVAL EAI S6S0.00 SSOO.OO S4OO.oo i I I , i 4. ROOT BARRIER (12") LF' $20.00 I SIO.oo $6.00 I 5. ROOT BARRIER (IS") LF $25.00 I S15.OO SIO.oo I I i 6. ~REETTREE (24' BOX) EA, $4SO.OO I $325.00 S2S0.00 I i I 7. ~REET TREE (36' BOX) EA S1OO.oo I $5SO.oo S4OO.oo , 8. ~OP SOIL BACKFILL CYI i , i IX. ~ISCELLANEOUS t. PEDESTRIAN BARRIER LF S75.OO $60.00 $50.00 , I 2. CHAIN LINK FENCE (6') LF' SI5.oo/ SI1.SO S9.25 I I I I , 3. rAISE MISe. BOX TO GRADE EAI S3OO.oo I S2OO.oo S175.oo I 4. RAISE MANHOLE TO GRADE HI S4OO.oo I S275.oo S2OO.oo ! i 5. ~NSTALL MONUMENT BOX E.... $4SO.OO S3S0.00 S3OO.oo S19.00I i 6. ~EDlAN BACKFILL CY S17.OO SI5.SO SUBTOTAL PREPARED BY: IO~ SECURITY ENFORCEMENT FEE REVIEWED BY: TOTAL ESTIMATE FOR FAITHFUL APPROVED BY: PERFORMANCE SECURITY "See Section 66499.4 of the Map Act. H:\CECOSTEST. 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