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ENC2001-00028
CITY OF CAMPBELL PUBLIC WORKS DEPT. 70 N. Ftrst St. Campbell. CA 95008 (408)866-2150 FAX (408)376-0958 OWNER OC~ R-I FEE ENCROACHMENT PERMIT (for working within the public right-of-way) ($5,000 max~m value of work) APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell 11.04. (Application expires in 6 month-~ if the l~rmk is not issued.) Secdon Work Address Nature of Work Attach three (3) copies of a drawing showing the location, extent and the relation of thc proposed work to existing imp~'ovements. City a part of this permit. All work shall conform to the City of Campbell ~tandard Specifications and Details for General Permit Conditions listed on the reverse side; and the Special Provisions for to abide by these conditions and provisions may result in job shut-down and/or securities. work. shall show said drawing becomes Works Consu'uction; the listed below. Failure of Faithful Performance NAME OF APPLICANT (Print Name) The Applicant hereby confirms that this work is being done by the Micant at their own residence. The Applicant hereby agrees by affixing their signature to this permit employees free, safe and harmless from any claim or demand for the City of Campbell, its officers, agents and resulting from the work covered by this permit. The Applicant hereby acknowledges inform their contractor(s) of the ACCEPTED itme (Sign) and both the front and back of this permit, and that they will NOTES: ALL WORK CAMPBELL STANDARD AND ATTACHED, APPROVED PLANS AND ALL APPLICABLE ~IS. THE CONTRACTOR MUST HAVE THIS THE PUBLIC WORKS INSPECTOR AT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH SITE AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLII AT LEAST 24 HOURS BEFORE KESTARTING ANY WORK. PER SECTION 4215 OF THE UNDERGROUND SERVICE AL (TICKET NO.) HAS BEEN CODE THIS PEP, MIT IS NOT VALID FOR EXCAVATIONS UNTIL (USA) HAS BEEN NOTIFIED AND THE INQUIRY IDENTIFICATION NUMBER' HEREON. USA PHONE: 1-800-227-2600. TICKET NO. ~PI~CIAL PROVISIONS SECURITY PERFORMANCE ~/,ND~aU) AMOUNT (lOO% OF ENG. EST.) S~ ISSUANCE for City Engineer Permit Expires 6 Months After the Date of Issuance Date GENERAL PERMIT CONDITIONS SECUR/TY to insure FAITHFUL PERFORMANC~ ~d compl~on of the work is r~ T~h SECI3Rn'Y refundable upon completion of the work ~-d writ~n acceptance by the City. o 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. REFUND or cancellation of the Faithful Performance security will be initiated by the wri~en acceptance of the work by the City. The Perminee MUST REQUEST 1N WRITING a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. .. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, fire hydrams and wate'r valves. REPLACE IN KIND any damaged or removed existing improvements, including planting. SAWCUT 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 consmiction debris. All consmiction 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. 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. The Contractor or Perminee will have a SUPERVISORY REPR.F~ENTATIVE available for contact on the project at all times during construction. I0. 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. I1. 12. 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. 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 Perrninee of any obligation to obtain any other permit required by law. 13. Ail necessary ROAD REPAIR~ 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. minimum charge per occurrence. Applicant shall be re~uring that~.tl~ those Call back (call out) due to emergencies regarding this permit, shall be at the current overtime rate with a three (3) hour providing services under the applicant are aware of and understand all CITY OF CAMPBELL Public ~Y/orks Department TRANSMITTAL CAMPBELL August5,2003 To: Michael Bloomquist 1350 Oakhurst Avenue Los Altos, CA 94024 From The Desk Of: Marlene Pomeroy Executive Assistant (408) 866-2776 e-mail: marlenep @ci.campbell.ca.us Enclosed please find City of Campbeli Check #102789 which represents a refund, plus interest earned, for the remainder of the faithful performance surety deposited with the City in 2001 with regard to Encroachment Permit 2001-00028. If you have any questions, please contadt me at the above number. Marlene Pomeroy~ Executive Assistant Enclosure 70 North First Street · Campbell, California 95OO8-1436 . 'I'EL 408.866.2150 - FAX 408.376.0958 · TDI) 408.866.2790 CITY OF CAMPBELL CAMPBELL, CA. WARRANT NO. 1O2789 1 (.') .~ ?. ?. (-)~ 101 . 540 744B CR071 CR07142003 625.00 REFUND DEPOSIT 35.74 INTEREST EARNED (.')(.')(.')(])4371 I'! I CHAEL BI_OOMQU I ST REMITTANCE ADVICE-PLEASE DETACH BEFORE BANKING CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 VOID AFTER 90 DAYS 11-35 "1210 BANK OF AMERICA wARRANT NO. CAMPBELL OFFICE 125 E. CAMPBELL AVE, 102789 CAMPBELL, CA. 95008 DATE 08/04/03 102789 AMOUNT PAY SIX HUNDRED SIXTY DOLLARS & 74 CENTS TO SIGNATURE .'-, '::1' ~ 0 0 0 Refundable DePosit Check Request To: Finance Director Check Payable To: Address - Line 1' Line 2: City: MICHAEL BLOOMQUIST 1350 OAKHURST AVENUE LOS ALTOS Refundable Deposit State: CA Zip: 94024 Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Voucher #: 101.2203 Amount: $625.00 (Finance Dept only) 101.540.7448i Interest Earned Amount: Amount: (Exact Amount) Maintenance period expired. Refund balance of maintenance surety. Permit #: 2001-00028 Receipt #: Requested by: Approved by: Finance Dept Only: Verified by: 137865 Date: 3/1/01 Alan Hem . Title: Sr. PW Inspector Date: Michelle Quinney ~ Title: City Engineer Date: Title: Accounting Clerk II Date: 7/14/03 7/14/03 Approved by: , Title: Accountant Date: Special ]:nstructions For Handling Check Mail As Is: Mail in Attached EnvelOpe: __ Interim Check: Needed By: Return To: Other: MARLENE POMEROY ! PUBLIC WORKS (Name) (Department) Please return check to Publiq Works for transmittal to permit holder. H:~permits~001-00028 maint accept 166nfirst(mp) CITY OF CAMPBELL Public IWorks Department December 31, 2002 Michael Blomquist 1350 Oakhurst Avenue Los Altos, CA 94024 SUBJECT: PERMIT NO. ENC 2001-00163 LOCATION: 166 N. First Street FINAL INSPECTION ANDi ACCEPTANCE CAMPBELL Dear Mr. Blomquist: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in corlformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated ia the permit begins as of the date of this acceptance letter. The permittee is responsible for th~ 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 25% ($62~.00) of your $2,500.00 Faithful Performance Surety cash deposit, receipt #01000137866, as your Maintenance Surety. If you have any questions, please call me ati(408) 866-2165. Syed Wahidi Public Works Inspector, MQ t'4 CC: Suspense - 11 months Permit #2001-00163 Inspector File H:\permits\2001-163final(mp) 70 North First Street . Campbell, California 95008-1436 . TEL. 408.866.2150 - FAX 408.376.0958 . 'rDD 408.866.2790 Refundoble Deposit Check Request To: Finance Director Check Payable To: Address - Line 1: Line 2: MICHAEL BLOMQUIST 1350 OAKHURST AVENUE LOS ALTOS REFUND DEPOSIT City: Description: Account Number: State: CA Zip: 94024 101.2203i Amount: $1,875.00 Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: 101.540.74 8 Interest Earne~~ Refund Partial FaithfuI Amount: Amount: (Finance Dept only) Voucher #: Receipt #: 1000137865 Requested by: S Approved by: ~ ~ I~lichel're Quinn~Y Finance Dept Only: Verified by: (Exact Amount) Security Cash Deposit Permit #: ENC 2001-00163 Date: 3/1/01 Title: PW Inspector Date: Title: City Engineer Date: 12/31/02 12/31/02 Title: Accounting Clerk II Date: Approved by: , Title: Accountant Date: Special Instr'ucti0ns Fo ' Handlin Check Mail As Is: X Mail in Attached Envelope:__ Interim Check: Needed By: Return To: (Name) (Department) Other: h:r~permits~001-00163refund P~LJ ,ORIr,.S DEPARTMENT RECEIPT Effective August 1, 3000 TO: City Clerk PUBLIC WORKS FILE NO. PROPERTY ADDRESS 435.535.4921 ! Pro{ecl Revenue (specify proiect) ENCROACI'UHENT PEILMIT 47221 Application Fee Non-Utility Encroachment Permit Minor Encroachment Permit < $5,000 ~$2~5.00) fsso.oo) R-I First Permit (No Fee) Subsequent Permit/Yr Utility Encroachment Permit /$11o) i Arterial/Collector Street ($355.00} , Residential S~em/Other Areas { (5245.00) 22031 Plan Check Deposit - 2 % of ENGR. EST. I (S5OO mtnt 2203l Faithful Performance Security (FPS) i 000% of ENGR.EST.) 2203l Labor and Materials Security { (100% of ENGR. EST.) 2203{ Monumentation Security I (100% of ENGR.EST.) 2203 } Cash Deposit 22031 Labor and Material Security I Plan Check & Inspection Fee (Non-Utility) 4.722! Engr. Est.< 5250.0~O ( 2% of ENGR EST ) 2203{ Engr. Est.> $250,000 fDeposit 8% of ENGR. EST.,530.000 mtn.)" 4.722[ Utility < Slob.boO Minimum Charge Per Location I {5130) Conduits/Pipelines up to 500 Feet { /$2.OO) { Above 500 Linear Feet I ($1.25) [ Manholes/Vaults/Etc. I t5115.ob/ed} { Pole Set'Removal I (SI 15.oo/ea} ! Street Tree Planting/Removal { f$115.00/tree1 22031 Utility > Sloo,O00 Actual Cost 4- 20% ** (1.% of ENGR. ESW.)($500 mir~$10.000 max) (100% of ENGR. EST.) .v,, (5115.Ob) 4.7~_; Street Tree Planting/Removal Permit 4.76Oi Prmect Plans & Specifications Proiect No. 4.76OI Standard Spectfication~ & Details {$1/Pg SI2.50/Bk) J. 76OI Cob~eS of Engineering Maps & Plans ; Aerial Plot 24' x 36' ($45) Aenai Print 8 1/2' x 11' {515) 1722! Maps and Plans24' x 36' ($5) Penalties: Failure to restore public improvements ' IS 100/Calendar Day) Penalties: Failure to correct unsafe conditions ] {$100/Calendar Day} ~MuTM Code S~. 1 t .34.0 IO) LAND DEVELOPMENT 4-722 Lot Line Ad{ustment (56OO.00) 4-722[ Parcel Map (4 Lots or Less) i ($1,170 + S25/LoQ 17221 Final Tract Map (5 or More Lots) ~i {Sl.510 + S.25/Lot) 4722{ Certificate of Compliance { ($545.OO) 4.722l Certificate of Correction i !5330.00) 4.722} Notary Fee tper signature) I !$10.OO) 4.7221 Vacation bt Public Streets & Ea~ement~ (5600.OO) 47221 Assessment Segregation or Reapportionment I First Split l Each Additional Lot i ($185.00) a7211 Storm Drainage Area Fee Per Acre ; (R-I. S2,000) i i (Multi-Res, S2,250) i (All Other, $2,500) 4-9201 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupant:y) 49651 Postage TRAFFIC 4.72_81 Intersecuon Turn Counts (Two-Hour Count) I f$65.50) 4.7281 [ntersection Turn Counts (a.m. or p.m. peals) (5136.50) 4.728[ Traffic Flo~v Map (Daily Traffic Volumes) I (529.50) 47281 Camp0ell Traffic Model (Full Scope Assessment) (S2,4.60.00) 4.728{ Campbell Traffic Model (Reduced Scope Assessment) (S810.00) 42711 Truck Permits ($32.00/rnd trip) 4.7281 No Parking Signs (SI/each or S25/100) )THER I TOTAL h:\forms\receiplformOO-01.xls rev 7-17-00 (rap) CiTY OF CAMPBELL, ~6 ~n~i'~ BY: JA~H niF~OiiQ~&~ PAYOR: HiC~EL S BLDH~UiST Tn~^v,e bATE: ~/~t/n~ REGISTER DA~= 0)/0!/0! TIE: 11:~37 REF [~POSiTS -i0i.2203 12,500.00 CHEC~ PA!~: TE~ERE~: CHAN~: $2,500,00 i2,500.00 $,00 Owner :Blomquist Michael Campbell 95008 Mail :1350 Oakhurst Ave Los Altos Ca 94024 Use :01 Res,Single Family Residence Bedrm :2 Bath :l.00rotRm :3 YB1900 Pool :No Parc~z Xfered :279 40 003 :10/05/2000 Price :$325,000 Full Phone :650-938-9147 BldgSF:557 Ac:.10 Owner :De~ickso~rt L &~ra S Site :2~0 N C~traffave c~P~ll 95008 Mail :~50~entr~ A~Camp~ell Ca 95~08 Use ~01 ~es,Sing/le~Family R%sidence Sedr~:4 Bath :~fotRm-:8 YB1989i Ba' I ~..~_. Pool :No : MetroS~kn / Santa Clara (CA) Parcel Xfered :279 40 030 :08/08/1989 Price :$341,500 Full Phone : BldgSF:l,873 Ac :.14 CITY OF CAMPBELL PU~MC WOItl~ DEPAR~ ENGI?CEER'S ESTIMATE .. AY./ Enc~unclu~.~ Perm~ No DESCRIFTION 2. 3. 4. 5. 6. IlL 1. 2. 3. 4. 5. 6. 7. 10. ~ONSTRUCTION TRAFPIC ?ONTROLCONTROL./PHASING COIx~TRUCTION STAKING CONSTRUCTION TF.h'T~NG CLEARING & GRUBBING SAWCUT P,C.C./A.C.(UP TO 6') P.C.C, REMOVAL ~URB AI~ GU"F~R I~MOVAL MEDIAN REMOVAL DEMOLISH EXISTING INLET/PLUG RCP'S i .' ~,~ D~*'~ ":i.;i :~'1 12' R,C.P. (CLASS V) 15' R,C.P. (CLASS lid ]8' R.C.P. (CLASS 111) 24.' R.C.P. (CLASS lid 30' R.C.P. (CLASS lid ,T.V. INSPECT'ION (12') STD. DRAINAGE INLET !C.C. DETAIL 9) FLAT GRATE INLET [C.C. DETAIL 6) STANDARD MANHOLE I{INCLUDES FRAME & LID) BREAK AND ENTER M.H./D.L SIDEWALX $1,(~0.001 $1.~00.00I $1.(~0.00 ~9.00 ! SI.2GO. O0 27-Jun-96 Page 1 of 4 NO. DL-'~'ZJ- n~iON ,V. i vx. 4. IALLEY GUTTER 5. I.IANDICAP RAMP 7. ~ Al-B3 Ct. JI~ & COBBLESTONE MEDIAN SURFACE 9. P.C.C. DRIVEWAY CONFORM 10. 'A.C. DRIVEWAY CONFORM ~'ASPHALT DIGOUT AND REP{ACE pAVEMENT WEDGE cur (6') PAVEMENT GRINDING PAVEMENT FABRIC (PETRO-MAT) ASPHALT CONCRETE (TYPE A) 6. AGGREGATE BASE (CLASS 2) 7. SLURRY SEAL (TYPE 11) {. SLURRY SEAL (TYPE Ill) ,~UtFFIC SIG~A~,T. IGh"TS Dk-TECTOR LOOP (6' ROUND) 2. DETECTOR LOOP (6' x 309 ]. D~rEC'TOR LOOF (6' x ~') ELEC'TROLI£R $. I 1/2' RIGID CONDUIT 6. ~' RIGID CONDUIT UNIT NucF~ For ~ECT AMOUNT SF SF $I~.00 $15.00 $1~001 $17.001 $1UO S10.00] S800.00 S12.00 $3.7~ $1.85 S13.001 $1~.00 $I.$0 S1.50[ $3~.00 $I,~0.00 $10.001 27-Jua-96 Page 2 of 4 REMOVE FVMT STR~NG ~TRIPING DETAIL 9 STRIPING DETAIL 29 STRIPING DETAIL 32 ?. b'rRIPING DETAIL 3'/O'HERMO) STRIPING DETAIL 38 (THERMO) 9. STRIPING DETAIL 39 I0. STRIPING DETAIL aO IL LIMIT LINE 12,. CROSSWAL~ 13. PAVEMENT MARKINGS (PAINT) I4. PAVEMENT MARKINGS (T~IERMO) IS. PAVEMENT MARKER (NON-REFL.) 16. PAVEMENT MARKER (REFLECTIVE) t7. ~TYPE K MARKER 18. ~ N MARKER 19. SALVAGE ROAD SIGN 20. RELOCATE ROAD SIGN 21. INST. RD. SIGN ON EXIST. POLE 22. ROAD SIGN WITH POST LF LF~ SF EA{ Sl.~! SI.35 ~ $1.50: ~.00~ $91.00[ S IO0.O01 Sl.05 $1.~0 $1.60 $4.15[ ~3.1SI I $ AMOUNT 27-Jun-96 Page 3 of 4 DESCrIPTiON ~ REMOVAL ROOT BAI~RIER (12') ROOT BARRIER (lIP) TOP SOIL BA~L ~D~ g~RRI~R CHAIN LINK FENCE (6') PAISE MISC. BOX TO GRADE RAISE MANHOLE TO GRADE IN~'I'AI t MONUMENT BOX MEDIAN BACKFU.L PREPARED BY: REVIEWED BY: APPROVED BY: ~e~ Secllon 66490.4 of the Map Act. H:\CECOSTEST.WK3(M P) REV6/3/96 { ~UAmTr~s LF{ > SLqOK S125.00{ $20.00t $10.00 ~2~.00! S15.00 $75.001 $60.00 $19.001 $17.00I 10% SECURITY ENFORCEMENT FEE PERFORMANCE SECURrI'Y $10.00 $,lO0.O0 $ AMOUNT $17~.001 27-Jua-96 Page 4 of 4 INSURANCE REQUIREMENTS CHECKLIST Permit # z~/~': 2 col - CX.X)2- ~ The following insurance is required of a right-of-way. Insurance certificates mu: These insurance requirements apply to wo work being pertbrmed under contract for / CIP Project # contractors workin= in the City of Campbell public be accepted by City. staff before work can begin. rk being performed under an Encroachment Permit and :apital Improvement Projects. Limits I Commercial General Liability for~odily, personal injury, and property damage: ~ $1,000.000 per occurrence, anc~ ~ $1,000,000 general aggregate llmit applying separately to the project, or ~ $2,000,000 general aggregate limit. Policv expiration date Automotive Liability.: ~ ~ "Any Auto" checked on certifiqate $ 1,000.000 per accident for bodily injury and property damage Policy expiration date Workers' Compensation and Empl,>yer's Liability :~ Waiver of Subrogation clause ,~ $1,000,000 per accident for~bo([i!y, injury or disease ~ Policy expiration date Course of Construction (if required in Special Provisions) ~n Completed value of the project! -~ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement ! ~;~ The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. ~i~ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail ~ such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". Workers' Compensation Insurance Sheet Submitted . o For General Contractor , = For Developer or Owner . N~.4"l^tt~:~'~)' · · ~lei ~' Or ! ~&~ 'WO'~' Acceptabd,tv o f Insurer(s) ~(~ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact -- business in the State__of Califo~ia. i2j5[o Initials Date Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst (rev 11/99) ACORD. TIBR Q~'~O00-01 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 3.2/3/2003. PRODUCER ($30)668-2777 George Petersen Insurance Agency, Inc. !Richard Norlie , II !Agency License # 0B50501 P.O. Box 1270 Woodland CA 95776 INSURED 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 Legion A COMPANY B Insurance Company DEC 07 :uu, COMPANY P.O. BOX 33162 COMPANY Ai)MINISTRAT_IO~. I Los Gatos CA 95031-3162 D 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 AI~FORDED 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. TYPE OF INSURANCE GENERAL LIABILITY COMPREHENSIVE FORM PREMISES/OPERATIONS UNDERGROUND EXPLOSION & COLLAPSE HAZARD PRODUCTS/COMPLETED OPER CONTRACTUAL INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE PERSONAL INJURY AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS (Private Pass) ALL OWNED AUTOS (Other than Private Passenger) H~RED AUTOS NON-OWNED AUTOS GARAGE LIABILITY EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ ~] INCL PARTNERS/EXECUTIVE OFFICERS ARE: EXCL OTHER WC11653134 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS .c_ C 2001 --0Q928, s POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) 5/24/2001 POLICY EXPIRATION DATE (MMIDD/YY) 5/24/2002 LIMITS BODILY INJURY OtC $ BODILY INJURY AGG $ PROPERTY DAMAGE OCC $ PROPERTY DAMAGE AGG $ BI & PD COMBINED OCC $ BI & PD COMBINED AGG $ PERSONAL INJURY AGG $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ $ BODILY INJURY & PROPERTY DAMAGE COMBINED EACH OCCURRENCE $ AGGREGATE $ X l WC STATU- I I OTH- I TORY LIMITS I I ER EL EACH ACCIDENT $ $ 1000000 EL DISEASE - EA EMPLOYEE EL DISEASE - POLICY LIMIT $ 1000000 1000000 CERTIFICATE HOLDER CANCELLATION City of Campbell 70 North 1st Street Attn: Joanne in Public Works Campbell CA 95008-1423 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRrrrEN 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 ACORD 25-N (1/95) 1988 Dec 05 01 03:29p p, 1 sent By: OEO~(3E PETERSEN [NSUR&NCE %lCY;530 §§6 t431; Dec-4-01 7.'19' Page 414 ~ B~ o~oooo-ox ~ CORD_ ICATE OF UA INSU~~ ACORC_ CERTIF ._ , ~.~ ~ A ~e. o~ =~. ~ ~LY ~O C~S NO ~8 U~ ~ I~i~TEO. ~H~t A~ ~OUt~e~. ~ ~ GV ~E ~ICIE6 ~R~EO ~R~ I~ ~CT TO ~ THE ~MS. L~LITV I0~.¥ lld3~JRV & Nc11653134 5/24/2001 5124/2002 ACORD.'. ,CERTIFICAT,· OF LIABILITY INSUR; J DATE,MM,DDt, 12/05/01 PRODUCER INB I~surance Services Corp. License #0680989 P.O. Box 699 Los Gatos CA 95031 Phone: 408-395-7900 Fax: 408-395-3711 INSURED 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. INSURERS AFFORDING COVERAGE (7/97) " ACOR4 RPORATION 1988 INSURERA: Everest National ~ INSURER B: arrell Quails INSURER C: P.O. Box 33162 INSURERD: LOS Gatos CA 95031 I INSURER E: COVERAGES &DMINIST~ ...... THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED qAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ..... ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN F 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY I EACH OCCURRENCE $ i ~ 000,000 A X COMMERCIAL GENERAL LIABILITY 3700000163001 i 12/22/00 12/22/01 FIRE DAMAGE (Any one fire) $ 100,000 I CLAIMS MADE J~ OCCUR MED EXP (Any one person) $ 5 ~ 000 X XUC COY INCLUDED ; PERSONAL&ADVlNJURY $1,000,000 X LIMITED POLLUTION GENERAL AGGREGATE $ 2, 000,000 GEN'LAGGREGATE LIMIT APPLIES PER i PRODUCTS-COMP/OPAGG $ 2,000,000 ~ PRO- J DED 1 ~ 000 I POLICY I I JECT ~ LOC AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT A X ANYAUTO 3700000162001 , 12/22/00 12/22/01 (Eaaccident) $ 1,000,000 I ALL OWNED AUTOS X SCHEDULED AUTOS il (PerBODILYperson)lNJURY $ X HIRED AUTOS BODILY INJURY X NON~)WNED AUTOS I (Per accident) $ I I PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ ANYAUTO I OTHER THAN EA ACC $ i, AUTO ONLY: AGG $ I EXCESS LIABILITY I EACH OCCURRENCE $ I OCCUR ~-] CLAIMS MADE I AGGREGATE $ DEDUCTIBLE $ RETENTION $ ' $ WORKERS COMPENSATION AND I WC STATU- OTH- TORY L M TS ER EMPLOYERS' LIABILITY ~ E.L- EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEI i $ E.L. DISEASE · POLICY LIMIT $ OTHER A UNSCHEDULED EQUIP. 3700000163001 12/22/00 12/22/01 ALL RISK 25,000 DED. 250 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDOR.~ EMENT/SPECIAL PROVISIONS 30 Day Notice of Cancellation except 10 day notice for Non-Payment of Premium. Re: Permit No. ENC2001-00028/166 N. First Street. Certificate holder is named additional insured per atta.=hed endorsement. FAX: Joanne - 376-0958 I Y I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION CERTIFICATE HOLDER CAMP 302 SHOULD ANY OF THE ~BOVE DESCRmED POUCHES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL MAIL City of Campbell 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Attn: Dept. of Public Works 70 N. First Street LEFT, B~=AILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF Campbell CA 95008 AN~I~I~D~JPON TJ~SURER, ITS AGEN~TS OR RE~i~SENTAT~jES. POLICY NUMBER: 3700000163001- COMMERCIAL GENERAL LIABi[.J'i'Y' THIS ENDORSEMENT CHANGES THE P ADDITIONAL INSURED- CONTRACTO :DLJCY. P =LEASE READ IT CAREFULLY. OWNERS, LESSEES OR :S - (FORM B) This endorsement modifies insurance provided under the 'Otlowin[;: COMMERCIAL GENERAL LJABIU ~'FY' COVERAGE P~ 'ET. " SCHE]:: ULE Name of Person or Organization: " City of Campbell All ~'ork Attn: Dept. of Public Campkell, Works Agenc 70 N. First Street volun in Public Right of Way. City of City of Campbell Redevelopment y, its officers, employees and teers are named additional insureds Campbell, CA 95008 (If no entry aDDeam adore, info.on required D comoiet this endomement wilt be shown in the Dectamtions as aD~iicabte t~ this endorsement) ' ' , WHO IS AN INSURED (Se~on II} is amen0ed to in~0e ~s an insured the pemon or organ~afion shown in the Schedule, but only with resDe~ to lia~il~ arising out ~ ~oulwo~" for that insured by or for you. Subject to all other terms and provisions of the policy, Such insurance as provided by this endorsement shall be deemed primary, ~ut only w~th respect to work performed by or for the name~ insure · n connection with the above descriled contract, d Waiver of subrogation applies. ECG ZO 501 ~2 99 CoD.Vngnt, =veres~ Reinsurance Comoany, 1998 lnciuOes copyngmed rna[anal of insurance Services Office, inc. used with its permission. Copyright, Insurance Services Office, Inc., 1984 Page 1 of ACOaO. CERTIFICAT=. OF LIABILITY INSURA PRODUCER IN~ Insurance Services Co~. P.0. Box 699 Los GarDe ~ 9~031 ~ mhoae: 408-395-7900 Fax: 408-395-3711 ~arrell Quells P.O. Box 33162 Los Gatos CA 95031 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE ~--==;~'.b ISSUED TO THE INSURED DATE IMM/DO/YY) 12/o5/oz THIS CERTIFICATE IS ISS~ 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, IINSURER A; INSURER D: INSURER C: INSURER D: INSURER E: INSURERS AFFORDING COVERAGE ~vereet National T~uranOe Co. lAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES D~CRIDED HEREIN IS POLICIES, AGGREGATE LIMIT; 0HOWN MAy HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER TYPEOFINSUEANCE GENERAL LIABILITY COMMERCIAL GEN~ALLIABILITY __ CLAIMS MAD~[~OCCUR XUC cov INCLUDED LIMITED POLLUTION GBN'I. A~OREGATE LIMIT APPLIES PER AUTOMOBILE LIABILITY 3700000263001 ANY AUTO ALL OWNED AUTO~ SCHEDULED AUTOS RIBED AUTOS NON.OWNED AUTO~ 3700000162001 :AR, AGE LIABILI1~ ANY AUTO ExCE~s LIABILITY OCCUR [__J CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OTHER UN$CHE:Dr..TLED EQUIP. 3700000163001 DESCRIPTION OF O~RA~glL~ATION~VEMCLE$~XCLU~IONS ADDED BY EN~E 30 Day Notice of Cancellation except 10 day IPremium. Re: P~rmit No. ENC2001-00028/166 Iholder i$ named additional insured ~er at,ac FAX: Joanne - ~76-0958 CERTIFICATE HOLDER r W~TH RESPECT TO WHICH THIS CEf~TtFICATE MAY BE I.~SUEO OR ~UBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICY EPPJ"[; ;iv~ / POLICY ~XPIRAT~ON DATE IMM/D. DP(Y) J DA~.(MM~D~] EAC~ OCCURRE~E 12/22/00 ~2/22/01 ADDITIONAL INSURED; INSURER LEI?ER: __ . C. AH~E 02 City of Campbell Attn: Dept. of Public Works 70 N. First Street Campbell CA 95008 ~2/22/00 12/22/00 ~2/22/0~ 12/22/01 PUBLIG WOAKS]' ADMINtaTR&It_O!~ LIMIT(, FIRE DAMAGE ~An¥ one fire) RED EXP (Anv one pomon) PERSONAL & ADV INJURY GENERAL AGGREGATE PROO~TS - COMP~P AGO COMBINED ~INOLE LIMIT (Es accl;lont) $1~000,000 $ 100tO00 $ 5~000 ~1~000,000 ~2,000,000 2,000,000 1~000 si,000,000 DODILY INJURY (Per pemon) BODILY INJURY (Po~ occident) PROPf~RTY DAMAGE (Per occlOoflt) AUTO ONLY - EA OTHE~ ~HAN EA ACC AUTO ONLY: AGO EACH OCCURRENCE AOGREOATE E.L, EACH ACCIDENT E.L, DISEASE - EA EMPLOYE E.L. DISEASE - POLICY LIMIT ACORD 25-S (7/97) ALL RIS~ DED. 250 MENT~PECIALPRO~ONS utica fo: Non-Payment First Street. Certificate hsd endorsement. CANCELLATION 25,000 SHOULD ANY OF THE ABO~ ~SCR~ED POI. ICIES BE CAN~:~'LL;D BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INOURER WILL MAIL 3 0 DAyS WRITTEN HOTIC; TO THE CERTIFICATE HOLDLeR NAMED TO TN;; LEFT, BhI~AILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LN~JlLIT~ OF ^qiqllo~PONJJ TJ~SUReR. frs An..qEr$ OR REJIIqSENTAT, ilIE$.., "ACO~0 C~POEA~ION ~9~8 POUCY NUMB=-"~: 3'7000001 $30~ COMMERCIAL -.~IERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. P =L~ASE READ IT CAREFULLY. ADDFi'IONAL INSURED OWNERS, LESSEES OR CONTRACTORS -(FORM B) ThIs enc~orsement modifies insuranc~ providecl unaer tho ~lloW~n~: COMMERCIAL GENERAL LIABIUTY COVERAGE PA~T. " Name of Pemon or-Organization: SCHED LILE All w Campb Agenc volun~ City of Campbell Attn: Dept. of Public Works 70 N. First Street Campbell, CA 95008 ~rk in Public Right of way. City of ~ll, City of Campbell Redevelopment !, its officers, employees and :eers are named additional insureds (If no ent~ aooeam aDove, info.on ~ired ~ ~mole~ this enOomement will aDplica~le to this enoorsemen~) ' ~WcH©I$ ~N INSURED (Se~on I]} is amended to incluoe Is an insured [he person or organt=~on shown in th~ neou~e, gut only w~ rsspe~ to lia~il~ a:sing out ~ "~u~wo~' for t~at tnsum~ by or Subject to all other terms and provisions of the 01lc insurance as provided by this .~._k ......... P ~ y,.such uu~ onzy wlcn respect tn ~,~ ------~----~ ....... primary, in connection w~ ~ i~L~_?=~¥f~~ oy or zor ~ne named insured ~ ..... ~ ~uuv~ QescrlDtQ contract Waiver of subrogation applies. icg ZO ~;01 12 99 Con.va_oat --verast teinsurance Company, 1998 ~ncluctes coo.vfi_ontecl mat~rtal of msuran!ca serwcss Oh~c.~. Inc. useO witl~ its t:ermlsmon. CopynDrlt. Insurance} Services Office, Inc., 1984 Page 1 of 1 ACORD. CERTIFICAT; OF LIABILITY INSURe NC:. ,D DJ DATE,M DD ') , -- "~r~MQUAL 12/04/01 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, PRODUCER '' INB Insurance Services Corp. License #0680989 P.0. Box 699 Los Gatos CA 95031 Phone: 408-395-7900 Fax:408-395-3711 INSURED ~arrell Qualls P.O. Box 33162 Los Gatos CA 95031 INSURERS AFFORDING COVERAGE INSURER A: INSURER B: INSURER C: Everest National Insurance Co. INSURER D: INSURER E: COVERAGES THE POLiCiES OF iNSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED AMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWlTHSTANDIN~'%lWIIIII~II~ I wl~% I l~w '~' ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN'I WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS ;UBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE IMM/DD/YYI DATE (MMIDD/YY) LIMITS GENERAL LIABILITY , EACH OCCURRENCE $ 1 ~ 000 ~ 000 A X COMMERCIAL GENERAL LIABILITY 3700000163001 12/22/00 12/22/01 FIRE DAMAGE (Any one fire} $ 100 , 000 I CLAIMS MADE I'--X-'-J OCCUR i MED EXP (Any one person) $ 5, 000 X XUC COV INCLUDED PERSONAL&ADVINJURY $11000,000 X LIMITED POLLUTION ! GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE MMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2 , 000, 000 [--]PRO'F----]JECT I POLICY LOC DED 1 000 AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT A ANY AUTO 3700000162001 i 12/22/00 12/22/01 (Ea accident) $ I , 000, 000 i ALL OWNED AUTOS i BODILY INJURY (Per person) X SCHEDULED AUTOSIi X HIRED AUTOS ! BODILY INJURY X i NON-OWNED AUTOS i (Per accident) I I PROPERTY DAMAGE $ i (Per accident) GARAGE LIABILITY AUTO ONLY- EAACCIDENT $ ANY AUTO OTHER THAN EAACC $ . AUTO ONLY: AGG $ I EXCESS LIABILITY EACH OCCURRENCE $ I OCCUR J--] CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ i $ WC STATU- OTH- WORKERS COMPENSATION AND TORY L M TS ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ I E.L. DISEASE - EA EMPLOYEE} $ E.L. DISEASE - POLICY LIMITI $ OTHER A UNSCHEDULED EQUIP. 3700000163001 12/22/00 12/22/01 ALL RISK 25,000 DED. 250 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDOR: EMENT/SPEClAL PROVISIONS 30 DAY NOTICE OF CANCELLATION EXCEPT 10 DAY NOTICE FOR NON-PAYMENT OF PREMIUM. RE: PERMIT NO. 99-123/166 W. ~4PBELL AVE. ALL WORK IN PUBLIC RIGHT OF WAY. CITY OF CAMPBELL, CITY OF C~BELL REDEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAME]) AS ADDITIONAL INSUREDS AS RESPECTS LIABILITY. FAX: 376-0958 Attn: Joanne CITY OF CAMPBELL ATTN: DEPT. OF PUBLIC WORKS 70 N. FIRST STREET CAMPBELL CA 95008 ACORD 25-S (7~97) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE INB Insurance~~C~.. ~_ 0 ~ "ACO~~ POLICY ~IUMBER: 3700000163001- ,' COMMERCIA,. GENERAL LIABIUTY THIS ENDORSEMENT CHANGES THE ADDfTIONAL INSURED CONTP, ACTOR :)L]CY. P =LEASE R=.AD IT CAREFULLY. OWNERS, LESSEES OR S -(FORM B) This en:~orsemen~ modifies insurance provided under t~e ftllowing: COMMERCIAL GENEF, AL LLABILJTY COVERAGE PA~T. " Name of Person or Organization: SCHEDULE City of Campbell All Work in public right of way. Attn: Dept. of Public Works i City of Campbell, City of Campbell 70 North First Street Redevelopment Agency, its officers, Campbell, CA 95008 employees and volunteers are named additional insureds. (Ifnoent~ aDDea~ anove, in~on ~uimdtocomDje thisendomementwillbeshownlnt~eDecta~tionsas a.D~ticabtetothisendorsement) I WHO IS AN INSURED (Section II} is amended to include Scneciuie, hut only with res.Dec: [o liat~ility arising ou[ of '~our Subject to all other terms and p~ as oprovided by this endorsement with respect to work performed b~ with the above described contrac~ Waiver of subrogation applies is an insured the person or o~anization shown in the worK" for that insured by or for you. ovisions of the policy, such shall be deemed primary, but or for the named insured in insurance only connection -- ~ 99 CG 20 501 12 coDyngm, Overeat Reinsurance Comuany, 1998 lnc:udes coDyrignied mamnai of insurance Services Office, inc. used with its permission Copyright. Insurance Services Offic.% inc., 1984 Page 1 of 1 ACORD. PRODUCER IN~ Ineu~no~ S~=v~cea Co~p. License %0680989 P.O. Box 699 Los GarDe CA 95031 Phone:408-395-7900 Fax:408-395-3711 INSURED CERTIFICAT= OF LIABILITY INSURANC % j THIS CERTIFICATE IS ISSU, S 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, INSURERS AFFORDING COVERAGE INSURER. A: ~-v~r~sl~ National Insurance Co. INSURER B: LM arrell Quall$ I~Su. ER c: P.O. Box 33162 ,.SURE,O. Los Gato~ CA 95031 J IN~UR~R E: COVERAGES ~ TH~ POUCI~ OF INSURAHCE LISTED BEL~ HAV~ BEEN ISSUED T0 THE INSURED N~;~ ~BO~ POR ~HE POLICY PERIOD INDICATED. NO~IT~TAN~NG ANY REQUIREMENT. ~RM OR CON,ON OF ANY CONTACT OR O~ER DOCUMENT~H RESPECT TO WHICH THIS CER~FICATE MAY BE ISSUED OR MAY PERTAIN. THE IN~U~NCE A~OROED BY THE ~OMCIES DESCRIBED HEREIN 15 5~BJECT TO ALL THE TERMS. EXCLU~ONS AND CONOI~ONS OF SUCH POLICI~. AGGREGATE LI~TS S~WN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ~ .......'"l P0 ICYEFFE TIVE PO Y PIRATIOt COMMe~C~e~U~mU~ 370000016~00[ [2/22/00 [2/22/0[ FmE~mnyone~) ~ CLAI~MAOE rxj oCCUR MEO ~P(A~yo~ pe~eofl) LIMITED POLLUTION r G~t~L AGGR;GAT~ 3700000162001 GEN'L AGGREGATE UM~T APPLIES PER AUTOMOBII.E LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTO~ NON.OWNED AUTOS GARAGE LIABILITY ANY AUto EXCEgg LIABILITY OCCUR g.--J CLAIMS MADE DEDUCTIBLE RETENTION PRODUCTS - COMPlOP AGG COMBINED SINGLE LIMIT lea mccid~t) BOOTY INJURY IPer perBOn) BODILY INJURY (Per accident) PROPER~ DAMAOE AUTO ONLY · EA ACCIDENT EA ACC OT~R THAN AUTO ONLY: ABC EACH OCCURR~GE AGGREGATE ~ TORY U~IT~I EACH ACCIDENT DISEASE - EA EMPLOYE! E.L. OlgEA~E . POLICY LIMIT %%/ORKERS COMPENSATION AND EMPLOYERS' LIABILI'rY i OTHER A i UNSCH£DUL~D ~QUIP. 3700000163001 ~SCmP~ONOFOPE~7~ON~LOCA~IONSNE,ICLES~XCLUS~ONSADDESSYEHDO~E~ 30 DAY NOTIC~ OF CANCELLATION EXCEPT 10 DAY pReMIUM. RE: PE~IT NO. 99-123/166 W. CAJ RIGHT OF WAY. CITY OF C~ELL, CITY OF ~ OFFICERS, E~LOYEES ~ ~L~TEERS ~ N~D ~SPECTS LI~ILITY. F~: 376-0958 - CERTIFICATE HOLDER ]N [ AOOITIONAL 'NS~; INSURER L~ ~0 ~, ~[~S~ S~ C~BE~ CA 95008 ACORD 25-S 12/22/00 i2/22/0i [2/22/00 12/22/01 lr000?000 100~000 _ 5,O00 , 1~0007000 2,000,000 27000?000 ltO00 1,000,000 ALL RISK DED, 250 25,000 ~E~PECIAL PROVISIONS lO~IC~ FOR NON-PA!~ENT OF ~BELL AV~. ALL WOR~ IN PUBLIC ~BELL REDEVELOEb~NT AGENCY, ITS AS ~DITION~ INS~DS AS A~n: Jo~e CANCELLATION SH~UL~ ANY OF TH~ ABOVI~ DrSCRmEO POLICIES BE CANCF. LL~I3 ll¢l~On~ TWG EXPI~0N DATE THEREOF. THE ISSUING INSURER WILL MAIL 3 0 OATS WRI~N HOTIC~ TO TNB CERTIFICATE HOL~R NAM~ TO ~E mouc¥ NUMBER: 3700000163001 COMMERCIAL 4ERAL LIABIUTY THIS ENDORSEMENT CHANGE~ THE P~LJCY. PLEASE R=_AD IT CAREFULLY. ADDITIONAL INSURED-OWNERS, LESSEES OR CON Ac O _ / COMMERCIAL GENEFLAL LJABIIJ ,-V COVERAG= PAR~. " Name of Person or Organi.-'~tton: SCHEDL City of Campbell Attn: Dept. of Public Works 70 North First Street Campbell, CA 95008 (Jfnoent~ ~m~ea~ above, in~n ~ui~dtoc~mDle~ ap~licaDletotnisen~o~em~) WHO IS AN INSURED (Section II} is arnende~ to inctude a: Scnemule, but onl.v with respect to liability arising out of, '~our Subject to all other terms and pr~ as oprovided by this endorsement : with respect to work performed by with the above described contract Waiver of subrogation applies --'CG 2D SO'l ~2 99 LE Ail Work in public right of way. City of Campbell, City of Campbell Redevelopment Agency, its officers, employees and volunteers are named additional insured.s. .his eR~o~ement wil b~ shown ~n {Se Dec~a~tion$ as an insum~ [he ~on or organtT.~on shown in t~ ~o~" ~r that insu~0 by or for you. >~isions o~ the policy, such i~surance ~hall be deeme~ primary~ but only o~ fo= the named insure8 in co~ection Coo.vngnt =_,/ere~ {einsurance Cammany' 1998 lncluoes cOD.vn_ohted material of insurance Servi:9s Of~t~a, inc. useO with its D_ormi_~sion. Coovngn;. )nsuranc~ Sel-ViC~S Office. inc., 19Bz~ Page 1 of 1 of.-- FAX TO: NIB Insurance Services Corp. PO Box 699 Los Gatos, CA 95031 Phone Fax Phone (408) 395- 7900 (408) 395-3711 CC: REMARKS: [] Urgent [] Foryo: Re~ Insured: QLM/Darrell Qualls Permit No. 2001-00028 Work Address: 166 North First Street I Date 12/4/2001 I Number of pages including cover sheet FROM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 tr review [] Reply ASAP [] Please Comment We recently received your insurance certificate in connection with the above insured. After review, we find that we must ask you to provide the following additional items to meet our minimum insurance requirements: ' 1. We also require that the "Any Auto" box be checked on the certificate in the Automobile Liability section. ~ 2. Please change the reference to the work a~ldress and permit number to match what is shown on this fax. Certificate should read: "Re'. Permit 1~o. ENC2001-00028/166 N. First Street". A copy of the certificate follows for your refe :ence. You may forward the requested items to us by fax for approval. Please call me if you have any questions. Thanks for your help in this matter. INSUR.atNCE REQqlREMENTS CHECKLIST Permit # CIP Project # The following insurance is required of right-of-way. Insurance certificates mm These insurance requirements apply to wo work being pertbrmed under contract for Limits ~. --~ommerci~General Liability for ~ $1,000.0¢13 per occurrence, anc ~a $1,000,000.~eneral aggregate ,n $2,000,000 gk,neral aggregate ~'~ Policy expirati6q, date IO~2>1 I Aut,o, motive Li.a, bility."'N a 'Anv Auto' checked'on certifi(;ate :n $1,0'00,000 per accideP~X -n Policv expiration date Workers' Compensation and a Waiver of Subrogation clause a $1,000,000 per accident for bo, ca Policy expiration date~ Course of Construction a Completed value of ~ Policy expiration contractors working in the City of Campbell public be accepted by City. staff before work can begin. ? being performed under an Encroac_hrnent Permit and ,apital Improvement Projects. / ~o&ly, personal ~njurv and pr/opertv dama,oe: mit applying separately }6 the project, or // injury property, damage ,iability injury or disease cial Provisions) Required Endorsements Additional General dlitv and omobile Liabilitv Policies of Campbe] Redevelo' Agency, its officers, employees and is primary insurance. to" and "but failure to mail kind upon the company,,j.ts~. The City, volunteers na~ed as insured. The ' coverage to the Additional Cancella~on area of certificate edited to delete such notice shall impose no ligation or liability of agents or representatives". 1 Workers' Compensation Insurance Sheet Submitted rq For General Contractor ! ~ For Developer or Owner Rating of A:VII and Acceptability of Insurer(s) [ Insut~er(s) has current A.M. Best business in the State of California. is authorized to transact Insurance Certificate Reviewed Initials Date Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forrns',inscklst (rev 11/99) FAX TO: Skyles Insurance Agencyl 9840 Business Park Drive Sacramento, CA 95827 Phone Fax Phone (888) 900-9989 (916) 361-9821 CC: Date 11/01/2 001 I Number ofpases includin$ cover sheet FROM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 1 REMARKS: [] Urgent [] For yotr review I Re: City of Campbell Encroachment Permit / Insured: Sierra Interior Trim We recently received your insurance certificate find that we must ask you to provide the follow requirements: 1. On General Liability and Auto Liability coy, the following provisions: [] Reply ASAP [] Please Comment in connection with the above Permit. After review, we ng additional items to meet our minimum insurance ~rages, we require they contain or be endorsed to contain a. The City, the City of Campbell Redevelo ?ment Agency, its officer, employees and volunteers are to be named as additional insureds. The underlined entities need to be added to the list of the additional insured. ! b. For any claims related to the permit, the Contractor's insurance coverage shall be primary insurance as respects the City. ! c. We require a 30 day notice of cancellatio/~ and 10 day notice of cancellation due to non-payment of premium. ! We require Auto Liability coverage in the m Auto" box be checked on the certificate in 3. We require Workers' Compensation cover~ "Waiver of Subrogation" clause in connect/ 4. Insurance must be used by an issuer with a Environmental & Casualty on the A.M. Best Ri A copy of the certificate as well as our insu nount of $1,000,000. Also, we require that the "Any ~e Automobile Liability section. ~e in the amount of $1,000,000. We also require a >n with the Workers' Compensation insurance. :urrent A.M. Best Rating of at least A:VII. We do not find .ting list. forward the requested items to us by fax for al:proval. for your help in this matter. :ance requirements follow for your reference. You may Please call me if you have any questions. Thanks FROM : S~YI_ES INS AGENCY FAX NO. i 916 361 9821 Oct. 31 28~1 10:17AM Pi __AC_O_R_D. CERTIFICATE OF LIA .-- ......... I__ , 00.9989 ~ : 888-9 ' HIS C 10/$1/~001 SKYLES INSURAN "~ ~_NLY AND CONI:ER$ N ~A[,'r-M--A-TI'-ER OF INFORMATION _9840 BUSINESS PARK DRIVE ~~O~'I~I~.~E A ........ MEND. EX.ND OR ..... "'"; ~v=KAGE AFFORDED BY ~HE POLl SACR~ENTO, CA 95827 ClES BELOw. ~ ~D INSURERS AFFORDING COVERAGE SIEE~ INTERIOR TRIM ~10 DORCHESTER WAY . ~.u.. a: C~M~NY- .................. . . ~KURER O: , ~ ~URER COVE~GES . ~E P~C~ OF ~U~NC~ U~T~D ~LOW HA~ BE~N ISSUED TO ~E INSURED NAMED ABOV~ FOR ANY RE~UIREM~T, ~RM OR CONOfflO~ OF A MAY-~RT-~IH THfflN~u ~ . NY CONTRACT ~R ~HER OOCu OUCY P~RIOD - __ MT~v-~,-.~YHAVE~ ~ · ~JECT O'~ .... ~ M~ , I OOR w~ ~ ~ ~ .... IN R~D .......... ~O. US.O~ AND ~T ON~,~suc~ i, --- '. .... : ~ ~ : ........ ~ ...... ~'~ g AUTO ONLY- ~ ~lOel(T ~ S -- '. ~JTO ONLY: 90 DAY NOTICE OF CANCELLATION FOR NON-PAYMENT OR I FOR INSURANCE PURPOSES ACORD 2S-S (TFJ?) ~ON-REPORT OF PAYROLL CANCEU~T1ON IMPOSII NO DIIUGATIOM ON UA~LI'r'¢ OF ANY KIND U,iGN THE IISU~ER, II~ AM'I4f& OK ~ .... ~* ~ OACORD CORPORATION 1081 FEM3M,:,SKYLES INS AGENCY FAX NO. ~ 916 361 9~1 [ ~1 ~1 18:17AM P1 ..... A_CO . CERTIFICATE OF LIABILITY INSURANCE SKYLES INSURANCE AGENCY J HOLBEE. TH~ CERTIFICATE nn=~ .~.~_ CERTIFICATE 984D BUSINESS PARK DRIVE ALTER THE COVEEAGE ~ .u~ ~NU. EXTEND OR SACR~ENT0, CA 95827 AFFORDED BY THE POLICIES BELOW, SIERRA INTERIOR TRIM 7710 DORCHESTER WAY STOCKTON. CA 95207 C..~_OVERA OES THE POLICIEs OF INSUt~ANCE LISTED BELOW HAVE BEEN fSSUED TO 1 ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 0 MAY ~RT-AIN, THE'INSURA,~iCE AFFORDED _-y TH[ POLICIES DESCRI! POLICIEs. AGGREGATE UMITS ~HOWN MAY HAVE BE~.N REDUCED BY ANY ~O AUTOs ~. J DEDUC~BL, HE INSUREO NAMED ABOVE FOR THE POLICY PERIOD INDICATED THEE DOCUMENT WIT ~ ~T Tn uu~', ..... . NOTWITHSTANOING H RE_P .......... vH im15 CERTIFICATE MAY BE ISSUED OR ,~D HERE!N ~S SUBJECT~C ''! ~Hc PAID CLAIMS. ' .......... ' ..... EXGLt~S!ONS AND 10-31.01 10-31-02 AUTO ONLY - EA ACCIDENT OT.~ THA~ _~A ^c._~_c., AUTO ONLY: EACH OCCURRENCE A GGRk=<]~ITE $ ~ G,L. EACft ACCIDENT I $ ,L. msaA~, ax .uP~ov~j' 8 '10 DAY NOTICE OF CANCELLATION FOR NON.PAYMI=I~? C11~ M~kl DCDf'~DT /'~E' r~ir, Vl'l/N, , State of Californic CONTRACTORS STATE LICEI~ '" -~" . ACTIVE LICENSE Busir~essNam~']'ERl:~J~ INTERIOR TRI CJassificMion(B HIC ~ hpiralion Dar0 2 / 2 8 / 2 0 0 3 E BOARD Entily INDIV CITY OF CAMPBELL 70 NO. FIRST STI CAMPBELL, CA c. (408) 866-21~ PERMIT OR PROJECT NO. ADDRESS/LOCATION TO: ~ RE: ~EET ~5008 ~0 DATE FIELD MEMO INSPECTOR/ENGINEER RECEIVED BY FILE