97-155
CITY OF CA.\1PBELL
PUBLIC WORKS DEPT.
70 N. First St.
Campbell, CA 95008
(408)866-2150
FAX (408)376-0958
i
OWNER OCCUPIED R-I
NO FEE ENCROACHMENT PERMIT
(for working within the
public right-of-way)
($5,000 maximum value of work)
ISSUED !5/2j91__g-m7:J
I Permit No. ;;'7 -/85
X-Ref. File' ,/.
Application Date .5/2/9 'I
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 , 110 B~N Ai~ C--6...)iL~_
B. Nature ofWor~o~ c.~. _ i'<1....!~ ST/<-<p
C. Attach three (3) copies of a drawing showing 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
M GuN T At N BAt C~N $'~-Uc..N TELEPHONE (415 ) 3Cj4-- 755 1-
(Print Name)
~ A....J ~O ~/\E ~ h2-Ar-Jc-t S LV CA Cfi-t ( I
) ,
ADDRESS 7S 5
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)1 the information.
ACCEPTED ~ ~
Applica erminee (Sign)
~dq
5.d--97
Date
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
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RECEIPT NO.
IJ
.JJ /A
( 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 wrinen acceptance by the City.
2. A ONE-YEAR MAINTENANCE PERIOD for all work is required. Such period will begin on the date of wrinen
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 wrinen acceptance of the work by
the City.
4. The Perminee 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 Perminee.
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 sawcuning or washing, the Contractor shall place filter fabric
material in the flow line of the guner 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 guner 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 perminee.
9. The Contractor or Perminee will have a SUPERVISORY REPRESENT A TIVE 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 shoulder line 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 Perminee 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 Perminee.
14. This permit does NOT RELEASE the Perminee 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" Perminee 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.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all
of the abov onditions.
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mSURANCEREQumffiMENTSCHECKL~T
Permit # 7'7 ~ I % R~) ClP Project #
/Yl d7A./I ~:tu,t~
The following insurance is require 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:
o $1,000,000 per occurrence, and
o $1,000,000 general aggregate limit applying separately to the project, and
~ $2,000,000 general aggre/;3lJ> limit.
o Policy expiration date 2 2- 5}4 "6
Automotive Liability - "any auto" ~ rnl?~-n1
~ $1,000,000 per accident for bodily injury and property damage
~ Policy expiration date 2-/2-5) C1 -0
Worker's Compensation and Employer's Liability
'tt $1,000,000 per accident fl bodily injury or disease
';gL Policy expiration date / I q tJ
- / I
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
~ The City, the City of Campbell Redevelo~~ent ~gency, its offic~;;(-,n-_ L (_
employees and volunteers are named as additional msured. (n0~ (1 Lc/bLt.~)
o The insurance coverage ,afforded to the Additional Insured is primary
insurance. ~ OVL/.:>-<.J ~
Workers' Compensation Insurance Sheet Submitted
o For General Contractor
zs:. Subrogation Clause " oj ~
5) ~JC1l Ole 10 ~cc.e--pt- \\ CJb\..)tL. r u:vUf?J1LQ
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Insurance Certificate Reviewed ~~V-
1niti4l1s
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per ~2fLLl~V .
5)6/ c; ")
Date
o Copy of Insurance Certificate placed in tickler file mie month prior to expiration.
j:\forms\inscklst 4/96 (rev 6/96)
....................................................... ................................................................................................ ...........................................................
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A CORDTMllllmIIII11l1j'IIII'IBIIlliIIlIRIIIII ...JIU< ;:T/E~~M//~~~
PRODUCER ........................................~~k~skhis.....b~;~~kcA~;"...~lli;~.....,4'I'~'4'1................~~;~....~.~;I';:~~;~~IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
MBO INSURANCE BROKERS, INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
LICENSE NO. 0621959 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
855 OAK GROVE AVENUE, STE. 100 COMPANIES AFFORDING COVERAGE
MENLO PARK, CA 94025-5544 COMPANY
A
ZENITH INS CO
MOUNTAIN BAY CONSTRUCTION, INC
755 SANSOME STREET
SAN FRANCISCO, CA 94111
COMPANY
B
R E C E , \LE-o-~
INSURED
COMPANY
C
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/DDIYY) DATE (MM/DDIYY)
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE D OCCUR
OWNER'S & CONTRACTOR.S PROT
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
PERSONAL & ADV INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED EXP (Anyone person) $
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NCN-OWNED AUTOS
COMBINED SINGLE LIMIT $
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE $
GARAGE LIABILITY
ANY AUTO
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
EXCESS LIABILITY
UMBRELLA FORM
07HER THAN UMBRELLA FORM
A WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AGGREGATE
$
$
Z041257002
01/01/1997 01/01/1998
$
EL DISEASE - POLICY LIMIT $
EL DISEASE - EA EMPLOYEE $
1000000
1000000
1000000
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
INCL
X EXCL
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
RE: ALL CALIFORNIA OPERATIONS- WAIVER OF SUBROGATION APPLIES: THE INSURER SHALL AGREE TO WAIVE
ALL RIGHTS OF SUBROGATION AGAINST THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS
OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS FOR LOSSES ARISING FROM WORK PERFORMED BY THE
o
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RANDY WEST
CITY OF CAMPBELL
DEPARTMENT OF PUBLIC WORKS
70 N. FIRST STREET
CAMPBELL, CA 95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~AIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
AUTHORIZED REPRESENTATIVE
APR 25 '97 04:03PM MBO INSURANCE 415 853 3881
f~~~~~_ti:"
DO I.BU~ JUlOJtDS, IlfC.
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.55 OU CMon Av&'M1., sr.. laa
_~o PARK, CA '4025-5$44
P.2
IIOUlf'l'AIN .BAY CONS'l'ltrICTIOB, IIIC
155 BAJfSOlIa SDB,no
SAN I'UlfCIBCO, CA 'fl11
COMPANY
A S.NIrH INS co
THIS IS TO Cf:ATlp:)' THAT TI'II; POLICII;I3 OF INSURANC! lilTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AiJ01IE FOR THE POLICY PEAIOO
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM oR COIIIDITION OF AIIIY CONTAACT O~ OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFleATE MAY BE IHUED OR MAY PER'I'AIN, THE IN8UFlANC! AFFORDED ~ THE POUCIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS.
EXCI,USIONS AND CONDITIONS OF SUCH POLICIES. UMITS sHOWN MAY HAVE BEEN REDUCED BY PAlO ClAIMS.
_OUBO 0
CCMPNlY
D
ED
AAfB5197
4D';/~~ VVV'~K~
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COMPANY
B
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C
co ,.,..E OF IIISUMNC:' POUC'f Iluullllll POLICY EFFECTlV! I'OLJC;Y UJtllUll101f UMITI
LM DATlIMMIDIli'tYI DATE (MII/DDM)
apllUlL ua.IUTY GENEIW. AGGREaA TE I
COMMERCIAl OENEAAl. UAIIIUlY PII;lOUC'TS - COMPIO" AGB S
CI..AlMS w.De D OCOJR PERSONAL.. ADV INJIJF!'f S
OWNER'S & CONTRACTOR'S PIlOT EACH OCCUMiNCE S
F1!\E OAMAGE (AnJ one fl .
MiD ElCP (Anyon. IlIlISll"l s
AI/1OIIIIO.ILf LIAIILI1Y COMBINED !INGLE LIMIT
S
ANY AUTO
ALL OWI\IEO AUTOS BOOJI. Y INJURY
.
SCHI:CULEO AUTOS IPtr corson)
HIREO AUTOS !!COlLY INJURY
(lie' aeeld!nI) .
NOIll.owNEO AUTOS
PROPERTY CNMGe S
GAlWJE LlAJILITf AUTO ONLY. Ell ACCIDENT I
Atlf AU1'O OTHI:'" TI'W\II'IUTO ONLY:
EACM~DENT S
AGGFEGATE I
DCEI& LlMlLlTV EACH OCCURRI:NCE S
UMBRELLA FOAM ~"'mA'rE .
OTHeM'THAN UMIl"EllA FORM
A waMSRI COMPIiNSATlOIl MID lIGfUJ7GDlI 01/01/1"7 U/01/UII
IMPLO'tIM' UAIIIUlY , 1000000
1MI: PfIOI'fIIETOPI INCL I 1000000
PAATNEIlSIEXECUTlVi
O"lce~ ARe: 1C EXCL S 1000000
OTNER
D='~O~T;:::~~c;.r;u':r"i~~~WIrvn 01' SOBJOGA'IIOB APPLIIS: TIlE "D1SURD S1JALL AGREE TO VAIVE
ALL RlGllTS 01' SlDIOGA.'lIOW AGAIlIST ~ . Cl'l!~. . ~.J;IT.J..gp CAIIrBELL DDEV'KLOPMIIIT AGDct. ITS
~~omC:w.SL !MPL011ms AID VOLUil'tms lOa LOSSBS AtISI1IG PIOH WOK PEUOUKD BY TBI
--nm IU' "I'IT 0' l;AIU"~.
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IMOULD IM'I OF THE AIIO'IE IlISCN8ED ~LICtn II CAllCIEUID IEFOIlIE THI
DfIlIlATIOfII DATE THEREOf', THE "GUilla COM"IM'I WIlt ~"".AIL
H- DAft _TTUI IIOTICl TO THE CERTIFICATE ItOlbI" IlAMID TO TNI LErr.
.lANDr an
eI'r1" 01' CAIIP.~u.
DJrPunr.arr 0" PUaLIC WOJlU
70 N. 'I&Br sr"~
CUl'B.U., C.I J$ODS
AUTHORIZED REJlRBIIlTATIVI
C,~OJO
A COR'DTM .1.WtBij;;I:?I<:I1.W::*=iji&i!i.:..iA:ti:I.:YI:~'I::i.~:.:::.:Wj:i&\,~t;:
mr~!~[)/tt...L..tt...~_'ff:': . .;~r~S4~Eti~_~_..i_...\.~ril~)u..1'~~Qi_1m8 - :~~_t?)/~~~){;:;:::::::::::-..:-.......
PRODUCER
3
...... DATE (MM/DD/YV)
04/24/1997
THIS CERTIFICATl 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
MBO INSURANCE BROKERS, INC.
LICENSE NO. 0621959
855 OAK GROVE A VENUE, STE.
MENLO PARK, CA 94025-5544
100
COMPANY
A
ZENITH INS CO
~D
f991
INSURED
MOUNTAIN BAY CONSTRUCTION, INC
755 SANSOME STREET
SAN FRANCISCO, CA 94111
COMPANY
B
COMPANY
C
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.
POLICY EFFECTIVE POLICY EXPIRATION I
DATE (MM/DDiYY) DATE (MM/DD/YV)
CO
LTR
TYPE OF INSURANCE
POLley NUMBER
UI\UrS
GENERAL LIABILITY
COMMERCIAL GENERAL UABIUTY
CLAIMS MADE D OCCUR
OWNER'S & CONTRACTOR'S PROT
GENERAL AGGREGATE $
PRODUCTS. COMP/OP AGG $
PERSONAL & ADV INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED EXP (Anyone person) $
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
i COMBINED SINGLE LIMIT $
I
BODILY INJURY !
(Per person) $
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY
ANY AUTO
AUTO ONLY. EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
hCESS LIABILITY
UMBRELLA FORM
. OTHER THAN UMBRELLA FORM
A ,WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AGGREGATE
$
$
Z041257002
01/01/1997 01/01/1998
$
EL DISEASE. POLICY LIMIT $
EL DISEASE - EA EMPLOYEE $
1000000
1000000
1000000
THE PROPRIETOR!
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
INCL
X EXCL
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
RE: ALL CALIFORNIA OPERATIONS - WAIVER OF SUBROGATION APPLIES: THE INSURER SHALL AGREE TO WAIVE
ALL RIGHTS OF SUBROGATION AGAINST THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS
OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS FOR LOSSES ARISING FROM WORK PERFORMED BY THE
&f~d4~~;gl.:::@#*~::~~:::::~NP~t:!9N.<>>>>
RANDY WEST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
CITY OF CAMPBELL EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
DEPARTMENT OF PUBLIC WORKS 111.- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
70 N. FIRST STREET BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
CAMPBELL, CA 95008 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
A&QRP~$.::d~).....}
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. ..............................................................
.......................................................
.......................................................
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......................................................
A CORDmiIBSmIEIIII.
................................................................................................. .......................................................
................................................................................................ .....................................................
............................................................................................... ..................-...............................
.............................................................................................. ...............................................
J?1f11:IW..:i;lI'.'I' . ~':.'.I'k'~"t:lAJ 1.....13:................................. <.. DATE (MM/DD/YY)
......-:::::~:rt:::~...,,:~:....:~:-..?,?::!>::::....:':l:S1:S!:g~~:::-.. .."I:;i 04/22/1997
3 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
MBO INSURANCE BROKERS, INC.
LICENSE NO. 0621959
855 OAK GROVE AVENUE, STE.
MENLO PARK, CA 94025-5544
100
ZENITH INS CO
INSURED
MOUNTAIN BAY CONSTRUCTION, INC
755 SANSOME STREET
SAN FRANCISCO, CA 94111
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 I TYPE OF INSURANCE I POLICY NUMBER I POLICY EFFECTIVE I POLICY EXPIRATION I
LTR DATE (MM/DD/YY) DATE (MM/DD/YY)
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE D OCCUR
OWNER'S & CONTRACTOR'S PROT
A WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
Z041257002
IlECj GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
. I VE D PERSONAL & ADV INJURY $
APR >> 8_ EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
rJ MED EXP (Anyone person) $
.'4DMIN ',~. COMBINED SINGLE LIMIT $
1ST .4 Tl6fu
BODILY INJURY $
(Per person)
BODILY INJURY I
(Per accident) 1$
PROPERTY DAMAGE $
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
$
01/01/1997 01/01/1998
EL EACH ACCIDENT $ 1000000
EL DISEASE. POLICY LIMIT $ 1000000
EL DISEASE - EA EMPLOYEE $ 1000000
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCESS LIABILITY
UMBRELLA FORM
OTf-'ER THA~I UMBR"LLA. FORM
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
INCL
X EXCL
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
RE: ALL CALIFORNIA OPERATIONS
RANDY WEST
CITY OF CAMPBELL
DEPARTMENT OF PUBLIC WORKS
70 N. FIRST STREET
CAMPBELL, CA 95008
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 REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
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O~CH"\lO'
CITY OF CAMPBELL
Public Works Department
July 17, 1997
Perry Eguerola
Mountain Bay Construction
755 Sansome
San Francisco, CA 94111
RE: PERMIT NO. 97-155 (R-l)
LOCATION: 1170 Bucknam Court
FINAL INSPECTION AND ACCEPTANCE
Dear Mr. Eguerola:
The City of Campbell has made a fmal 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.
If you have any questions, please call me at (408) 866-2168.
Sincerely,
v------~
v
Robert Phillips
Project Inspector
-,
MQ~
cc: Permit #97-155
H: \ WORD\PERMITS\97155FIIN (JD)
70 North First Street. Campbell, California 95008,1423 . TEL 408,866.2150 . FAX 408.376,0958 . TOD 408,866.2790
CITY OF CAMPBELL
ITEM
CONTRACTOR: P~1'1
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DESCRIPTION
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CGlI'!ffr.
PROJECT NO. 91- / 5' Y-"
REPORT NO: (
DATE: 5 ,,/;]
WEATHER: r:AI R,
INSPECTOR: K. ~~51fALL
FIELD ENGINEER'S DAILY REPORT
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