ENC2001-00143CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
ENCROACHMENT PERMIT
(for working withi~ the
70 North First St. X-Ref. file
,,/~/Campbell, CA 95008 public right-of-way)
Permit expires in f2 mon~ Application Date
. Applica~o~ expires in 6 months
',, he ¥ for, bl,, ,4P/V
ae ~it ~ aot hsu~. Applicon F~ s ~m~n~le~r~ P~t b ~r~ ~ia
Wo~ ~s or ~ ~
p~it.
~1 wo~ ~I ~o~ tO ~e Ci~ of C~beH S~fl $~ifi~O~ ~ ~ for ~bl~
~ ~e Sp~ ~ovisiom for ~ pe~it, 1~ below. F~lure ~ ~ide by ~me ~fio~
P~o~ Sureti~ ~d ~h d~osi~. (S~ G~e~ Pe~t Co~ifio~ I ~ 25
L~T ~O DAYS ~EFO~ STATING WO~. NO~C~ MUST ~ O~N TO P~LIC WO~ AT L~T 2~ HO~ a~O~ ~~ ~ WO~.
Addr~s ~ ~ ~ ~ ~~ ~0 ~ 24 HO~ ~MERG~NCy ~LEPHO~ NO.
work ~ing done by ~e p~p~ owner a ~eir own ~id~? _ Y~ . ~, No
Appti~Uge~i~ her~y agr~ by fffaing ~e~ sig~re m a~ ~it to hold ~e Ci~ of C~be!l,
a~ or de~d for ~g~ r~ul~ng from ae work ~ver~ by ~ p~..
Appli~Pe~i~ her~y ~knowl~g~ ~ uhey Mve r~ ~d ~ea~d ~ ~e front
~o~ion.
: IZ Lrl-E ~
Work to be s~ by a li~ ~ S~or or C~il E~r ~ ~o'~ ~ of~ ~t s~ s~ m ~e ~br~ Wor~ ~ ~o~ s~ w~
Per S~n 4215 of ~ Gove~cm ~ ~ ~k ~ ~i ~d for ~ ~ U~ ~ Alcn ~) ~ ~ ~ ~ ~ ~
~tir~n n~mb~- h~ b~a e~r~ h~n. U~ ~ I-~7-2~. U~ ~C~ NO.
SEE PL"'BLIC WORKS FEE SCHEDL'LE FOR CURRE.X~i' FF'i::,¢ Ty_._.~
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
CONSTRUCTION CASH DEPOSIT
· .~c~r NO,
j:~torn~ ~pwl:
,GENERAL PERMIT CONDITIONS;
I. A CONSTRUCTION CASH DEPOSIT is required. Charges will be made agahtst this deposit if there/s an emergency call-out, overtime inspection
or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Pcnnkle¢.
2. A ONE-YEAR ,MAINTENANCE PERIOD AND SURETY are r~quired. Such period will begin on date of wfiwn acceptance by the City.
3. REFUND of the cash deposit balaace and refund or cancellation of the Faithful Performance Surety will be initiated by the writ~n acceptance of the
work by the City.
4. The Permit~e MUST REQUEST IN WRITING a final inspection and acceptance of the work upon completion. Acceptance by the City will be made
ia writing to the Permittee.
5. MAINTAIN ~afe pedestrian and vehicular crossings and free access to private driveways, bus s~ps, fire hydrants and water valves.
6, A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDLrLE is required for all lane closures, detours and street closures.
This plan must be REVIEWED and APPROVED prior to any lane closures.
7. The CONSTRUCTION TRAFFIC CONTROL PLAN shall conform with the Calwans Manual of TrafHc Controls for Construction and Maintenance
Work Zones, dated 1990, available at Caltrans. Tmf'Hc control equipment shall include Type E Hashing arrow signs if required.
8. REPLACE IN KIND any damaged or removed existing improvements, iacludiag planting.
9. Sawcut for all PCC or AC removals. Ail PCC removals ~hall be to nearest scoremark and shall be doweled to existing improvements.
10. OVERTLME INSPECTION PREMIUM will be charged against the cash deposit for inspe~on required outside the hours of 8:00 a.m. to 4:00 p.m.
at the current overm'ne rate. minimum one hour charge.
I i. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the current overtime rate with a three hour
minimum. Advance payment for the esnmated time is required.
12. Adequate signing and lighted BARRICADLNG is required on the job site. Failure to provide such signing and barricading may result in the City's
renting such signing and barricades and charging the cost (including all labor and materials) against the cash deposit.
13. Compaction testing of subgrade, base rock, and asphalt concrete by Permim~e is REQUIRED unless otherwise s~ated by the City Engineer.
I4. The Contractor or Perminee wLII have a SUPERVISORY REPRESENTATIVE available for contact on the project at all times during con.m'uction.
Contractor or Perminee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m.
15. No STOR,-~GE of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shouldeHine which would create
a hazardous condinon to the public.
I6. This permit shall not be construed as authorization for excavation and grading on private property ADJACENT to the work or any other work for
which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required'by law.
17. This pe,"mJt does NOT RELEASE the Perminee from any liabilities contained in other agreements or contracts with the Ci~/and any other public
agency.
18. This permit is NOT TRANSFERRABLE. Work must be performed by the Permiv, ee or his designated agent or conwactor as spec/fled thereon.
19. CALL BACK (caII out) due to emergencies regarding this permit, shall be at the curr~nt overtime rate with a thee (3) hour minimum charge per
20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm dram
system other than storm water. Applicant shall adhere to the BEST ,'vLM'~AGEMENT PRACTI.CES established by the Santa Clara Valley Nonpoim Source
Pollution Control Program.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and undergo, nd all of the above conditions.
Date
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To: Finance Director
Check Payable To:
Address- Line 1:
Line 2:
City:
Description:
Account Number:
Account Number:
Account Number:
(Finance Dept only)
Total Payable:
Purpose:
Refundable Deposit Check Request
Porte Vet Hospital
3265 Winchester
Campbell
Refund Deposit
101.2203
101.540.7448
Interest Earned
$740.00
Refund of Construction Cash Deposit
State: CA Zip: 95008
Amount: $740.00
Amount:
Amount:
(Finance Dept only)
(Exact Amount)
Voucher #:
Permit #: ENC2001-00143
Receipt #:
Requested by: ~
Approved b y~/~/~h ic~i''~L~
Michelle (~tinney
Finance Dept Only:
Verified by:
142765 Date: 09/18/2001
Title: PW Inspector Date:
Title: City Engineer Date:
Title:
06/12/2002
06112/20O2
Accounting Clerk II Date:
Approved by: Title: Accountant Date:
Special Instructions For H ndling Check
Mail As Is:
XX Mail in Attached Envelope: Interim Check:
Needed By:
Return To:
(Name)
(Department)
Other:
f/n: Forms/excel/chkreq Revised 05/00
PUBLIC WORKS DEPARTMENT RECEIPT
TO: Cit',' C',erk '
p ~as~ c,n¢c: & cept' ' g .
3,cC~ ..... rm~[ · '~:..~' ':'. ":".'.~::::( ::/'~Sf:~f:~?::::.:::.;...: : ~ . ::~
435535 I92~ Promct Revenue ~specffv pro~ecO
ENCROACItMENT PERMIT
17221 Apphcatton Fee
' Nun-Utthtv Encroachment Permit IS255.~
Minor Encroachment Permit < 55,~ (555
~ R-I First Permit (No Fee~ Subsequent PermwYr
: [ltlh[V Encroachment P~tmll
~ Arterml/Collectot Street ~S370.~)
Residential Street/Other Are~ --
2203J Plan ~ ~t- 2~ of ENGR. EST,
~ 100% ~
2233, L~dM ...... is Security - ,1~% of ENGR.EST~ '
~ 22031 Monumentauon Securer _ ~4% of ENGR.~mm,
2203 ~ Cash Deposit_
~ 2203~ t.abor and Material Securer_ v _
47221 En~r Est. < S250.~ (12% of ENGR. EST)
~-- 2293[ Enzr. Est.>5250.~ ~De~osit 8% of ENGR EST 530.~
4'22' Unhtv < $1~.;~)
Mlmmum Charge Per ~auon
~ Condu~ts/Pipelmes up to 5~ Feet
kbo~e 5~) Lmear Feet
Mannoles/Vaults/Etc.
Pine Set/Removal ($120.~;ea
~ StreetTree Plantain/Removal _ (Sl20'~/tree2
-- 2203' t;vi~tv > ~h~ ~ Actual Cost
47m)' Standard Seec:ficationq & Detads ~SI, P~15 [~/Bk)
47~3~ Comes ,~t ~Ma s & Plans_ ~S50.(X))
Aerial Print S ',2' x i I' ~520.~)
--
Maos ,md Wans 24' x 36'
4722t Penames. ~m unsate conditions_ $1~/C~endar
~ND DEVELOPMEN~
I a722 Lot Line qdmstment _ ($1.215 - 525/Lo.
1~22~ Parcel Ma~ a Lo~ess[ ~$1~570
~-22' Cernficat~
~ 4722~ Cer.t'ica~e of Correctmn (S345.~) _
[ 1722 Vacauon ot2%ohc Streeu & ~emenq
F 4v22~ Assessm:n Scarega.on or Reapoornonment
' - tS625.~)
~ E:,cD Xddinonal Lol _
[ 472: S[~: ~a Fee Per Acre (R-t 52.~) _
~A Other S2.5001 -
TRAFFIC
Traffic F~o~ Mao ~Dadv Traffic Volume~
4'2? Cun¢nefi Tra c Mode!_(Fuil Scooe xssessment~
-- 4'iS Camobei~ed Scooe AssessmcnO ___~
42' ', Truck Perm.~
"
"'_Actual C?: ?'us 2()'_: ()~¢rnexC
FOR
CITY CLERK RECEIV[
ONL'~
CHECK PAID: $5,483.00
CHECK NO: ~S/926/927
TE~SERED: $5~485,00
To: Finance Director
Check Payable To:
Address - Line 1:
Line 2:
City:
Description:
Account Number:
Account Number:
Account Number:
(Finance Dept only)
Total Payable:
Purpose:
Refundable Deposit Check Request
Karen F. Langemen
cio Porte Veterinary Hospital
3265 Winchester Blvd.
Campbell
Refund of Deposit
101.2203
101.540.7448
Interest Earned
$500.00
Refund of Plan Check Deposit
State: CA Zip: 95008
Amount: $500.00
Amount:
Amount:
(Finance Dept only)
(Exact Amount)
Voucher #:
Permit #: ENC2001-000143
Receipt #:
Requested by:
Approved by:
Finance Dept Only:
Verified by:
,,~./ ~---'~ ,, // Title:
Lynn Penoy~ ' ~ - ~
Title:
Date: 09/1412001
Land Dev. Engineer Date:
Land Dev. Manager Date:
Accounting Clerk II Date:
09/19/2001
09/19/2001
Approved by: Title: Accountant Date:
5peciol ;[nstructions For Hondling Check
Mail As Is:
XX Mail in Attached Envelope: Interim Check:
Needed By:
Return To:
Other:
(Name)
(Department)
f/n: Forms/excel/chkreq Revised 05/00
¥0: City Clerk
PU]~-.C WORKS DEPAWIWIENT RECEIPT Effective July 1. 2001
PUBLIC WORKS FILE NO.
PROPERTY ADDRESS
Please collect & receipt tbr the following monies:
435.535.4921 ] Pro}ect Revenue {specify proNct) ....................................... ' ......................
ENCROACHMENT PERMIT
4722 ApplicaPon Fee
2203
2203I
2203[
'~03I
22031
Non-Utdity Encroachment Permit ($255.00)
Minor Encroachment Permd < $5,000
R-I First Permit (No Fee) Subsequent Permit/Yr
Utility Encroachment Permit
4722
22031
{555.00)
(5115.00)
Arterial/Collector Street ($370.00)
Residential Street/Other Areas {$255.00)
Plan Check Deposit - 2% of ENGR. EST.
Faithful Pertbrmance Security (FPS)
Labor and Materials Security
Monulllentation Security
Cash Deposit
Labor and Material Security
($500 rain)
{100% of ENGR.EST.)
(100% of ENGR EST.)
000% of ENGR.EST.)
(4% of ENGR.EST.)($500 mtn/$10,OOO max)
{10t)% of ENGR. EST.)
Plan Check & Inspecuon Fee (Non-Uulity)
Engr,.Est. < $250,000 02% of ENGR. EST.)
Engr. Est. >$250.000 (Deposit 8% of ENGR. 1~ST./$30.000 min.)**
Utility < 5100.000
(5120.00/ca)
(5120.00/tree)
Actual Cost + 20%"
MinPnum Cbarge Per Location ($135.()O)
Conduits/Pipelines up to 500 Feet ($2. I0)
Above 500 Linear Feet {$1.30)
Manholes/Vaults/Etc. ($ t20.00/ea)
Pole SeffRemoval
Street Tree Planting/Removal ,
Utility > $100.000
Standard Specifications & Details
Project No.
($ l,'Pg 515.00/Bk)
i Aerial Plot 24" x 36' ($5000
I Aerial Print 8 1/2" x I I" ($20.00)
Maps and Plaos 24" x 36" (S7.50)
Penalties: Failure to restore public improvements {5100/Calendar Day)
Penallies: Failure to correct unsafe conditions
($100/Calendar Day)
47601
47221
LAND DEI'ELOPMENT
4722
4722
4722
4722[
47221
Lot Line Adiustment ($625.00)
Parcel Map (4 Lots or Less) ($I.215 + $25/Lot1
Final Tract Map /5 or More Lots) ($11570 + $25/Lot)
Certificate of Compliance t$565.00)
Certflicate of Correction {$345.00)
Notary Fee Iper signaturel ($10.00)
Vacation of Public Streets & Easements ($625.00)
Assessment Segregation or Reanportionment
First Spht
Each Additional Lot
($625.00)
(Rq. $2.000)
(Multi-Res. $2.250)
(All Other, 52.500)
Storm Dra,nage Area Fee Per Acre
Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy.
Postage
hltersection Turn Counts (Two-Hour Count) ($70.00)
($14000)
($30.00)
q$2.560.00)
4722
4721!
4920
4965I
TRAFFIC
4728
4z28
4728
4v28
Intersection Turn Counts (a.m. or p.m. peaks)
TraJfic FIo'a Map {Daily Traffic Volumes)
Campbell Traffic Model (Full Scope Assessment)
4728! Campbell Traffic Model (Reduced Scope Assessment) ($845.00)
4271 Truck Perm ns {$16.00/per trip)
4728 No Parking Signs (51/eacl or 525/
OTI-IER I '
' TOTAL
[~Actual Cust Plus _0% O~erhead ~Non-lnterest bearine deposal)
FOR
CITY CLERK
ONLY
j:~,t'orms',reccipOorm Ol 02xls rev 6-29-01
AMOiJ~T
CHECK PAiB:
~;'~ 919
CHANCE:
3755.00
TO CiT~ OF CAMPB~.T., 70 N. FIRST STREET
CAMPBFt~., CALIFORNIA 95008 I 108) 866-2150
'erm:.t No. c Z/3o;
TR or DEV
I am/We are the owner(s) of a savings account at
at its branch office at ~a~i I'~0~ ~.T~ ' , California, investmen~
certificate,, ~,,' NO. in ~h, names of ~V~.n ~ ~.~
-~uu~-~-7~5~'~' and having a present balance of $ (T, 500
balance {including interest, which accrues t. hereon} ~ and all other rights An connection
described as follows:
I have physically delivered verification of said investment certificate and duplicate of
this Assignment and Receipt to said assignee.
may act on the signature of the assignee without further inquiry.
Executed on , [ , }9
I understand that assignee can withdraw from said account any time on his signature alone
upon presentation of a written order to ~he issuer. I also understand that I may not
withdraw from said account unless I present a signed release from the assignee. The
issuer of the certificate assumes no responsibility for the conduct of the assignee and
at said office of the issuer.
sign. ~.0~ ~/~%~~ Assignor
print
ACKNOWLEDGEMENT BY ISSUER
Issuer affirms that there are no other holds on subject account, that subject monies are
available, and that the above described assignment has been noted on the Records of said
issuer. .-,
91/;'/o '
Date / By .' ../~ -.,W_--f/~...~ ,~--~ ATTACH
~ ' - Authorized Signature NOTARY
Title: /~'~ ~/~ ACKNOWLEDGEMENT
INSTRUCTIONS TO ASSIGNEE
.:lease sign below for signature identification and as acknowledgement of your notice of
Assignment. Return this Assignment and Receipt to the issuer at its address above.
Retain one copy of this Assignment and Receipt for your files.
/ / ' ' ks Director
RELEASE BY ASSIGNEE
~aid assignee hereby releases and relinquishes all his right, title and interest in and
:o said account, said investment certificate, said balance and all other rights in
connection therewith.
!
City of
BayView Bank
2121 South El Camino Real
San Mateo, CA 94403-1897
CERTIFICATE OF DEPOSIT RECEIPT
September 18, 2001
Account Title and Address:
KAREN F LANGEMAN
ASSIGNED TO THE
CITY OF CAMPBELL
3265 WINCHESTER BLVD
CAMPBELL CA 95008
Product Description:
Product I.D. Number:
CD/Jumbo CD
T406
Account Number:
4OO4224O374
Opening Deposit: $18,500.00
Date Opened: 09/18/2001
Maturity Date: 03/18/2002
Term: 6 months
Tiers - if balance is:
$2,000.00 or more but less than $10,000.00
$10,000.00 or more but less than $25,000.00
$25,000.00 or more but less than $50,000.00
$50,000.00 or more but less than $100,000.00
$100,000.00 or more
Interest Rate
Annual Percentage Yield
2.95% 3.00%
2.95% 3.00%
2.95% 3.00%
2.95% 3.00%
2.95% 3.00%
Thank you for choosing Bay View Bank. This receipt is an official record of your account with us.
We appreciate the opportunity to serve your banking needs. Should you have any questions, please contact
your Bay View Bank branch. Additional terms and conditions of your account are explained in our Deposit
Account Agreement.
Member FDIC By
BAY VIEW BANK
Authol nature
SA, 150 iT 97)
ALL-PURPOSE ACKNOW. I .~DGEMENT
State of Califomia
County of ~ ~ ~.l~'~ C~
On C~ ,- [ ~ ~ o~, ED.J j before me,
personally appeared
[] personally known to me OR -
SS.
NOUARYi
$1GNERIS~
,~srOVed to me on the basis of satisfactory
vidence to be the person(~T'whose namegs4
/i;l.r-e subscribed to the within instrument and
acknowledged to me that,hc--/she/~ executed
the same in l;fi-s-/her/~ir authorized
capacityLiz-'~, and that by ~i-s/her/t~
signatures(,W"On the instrument the person(q-h-.
or the entity upon behalf of which the
person(~W'-acted, executed the instrument.
WITNESS ~',ask,d and official seal.
OPTIONAL INFORMATION
The information below is not required by law. However. it could prevent fraudulent attachment of this acknowl-
edgement to an unauthorized document.
CAPACITY CLAIMED BY SIGNER (PRINCIPAL) DESCRIPTION OF ATTACItED DOCUMENT
['~ INDIVIDUAL
~ CORPORATE OFFICER
TITLE~S*
[] PARTNERI S)
[] ATTORNEY-IN-FACT
[] TRUSTEEt S'~
[] GUARD[AN/CONSERVATOR
[] OTHER:
TITLE OR TYPE OF DOCUMENT
NUMBER OF RAGES
DATE OF DOCUMENT
SIGNER IS REPRESENTING:
NAME OF PERSONtS} OR ENTITYIIESI
RIGHT THUMBPRINT
OF
SIGNER
OTHER
APA 5/99 VALLEY-SIERRA. 8¢X)-362-3369
BOND FOR FAITHFUL PERFORMANCE OF MAINTENANCE PERIOD
We, the undersigned KAREN LANGEMAN (hereinafter "Principal") and AMERICAN
CONTRACTORS INDEMNITY COMPANY , a corporation organized under the laws of the State of
CALIFORNIA , and authorized to transact business in the State of California, as Surety, are obligated to the
City of Campbell (hereinafter "City"), a municipal corporation under the laws of the State of California, in the
sum of FOUR THOUSAND SIX HUNDRED TWENTY- FIVE AND 00/100 dollars ($ 4~625.00 ) for
the payment of which sum we obligate ourselves and our successors and assigns, jointly and severally by the
following provisions:
The condition of this obligation is that the Principal entered, or is about to enter, into a certain written
Contract with the City dated MAY 31 ,20 02 . and entitled ENCROACHMENT PERMIT 2001-
00143 FOR STREET IMPROVEMENTS AT $265 WINCHESTER BLVD. a one year maintenance period
of the work described in said Contract, a true and correct copy of which is presently on file in the office of the
City Clerk of the City of Campbell, which said agreement is hereby referred to and made a part hereof. And, the
City requires a guarantee fi'om the Principal against defective materials and workmanship in connection with that
maintenance.
Now, therefore, the Principal agrees that it shall make all repairs or replacements necessary during the
period of one-year fi'om the date of acceptance of the contract work, by reason of defective materials or
workmanship in connection with the Contract. If those defective materials or workmanship occur within that
period, the City shall give the Principal and Surety written notice of that defect within 60 days after discovery.
When each replacement is made to the satisfaction of the City, the obligation of the Principal and Surety shall be
discharged as to that replacement, otherwise to remain in full force and effect, with surety obligated to secure
full and faithful performance of all Principal's obligations under the above-referenced contract.
Any repairs or replacements made under this bond shall in like manner be subject to the terms and
conditions of it.
No prepayment or delay in payment and no changes, extensions, addition or alteration of any provision
of said Contract or in any plans and specifications referred to herein, and no forbearance on the part of the City
shall operate to release the Surety fi'om liability on this bond, and consent to make such alterations without
further notice to or consent by the Surety is hereby given, and the Surety hereby waives the provisions of Section
2819 of the Civil Code of the State of California.
In witness, the parties have executed this agreement as of JUNE 18, 2002.
By(Principal)c~~ '.~~~
k~ Karen Langeman
(Attached Acknowledgement)
(Both Principal's and
Surety's Anorney in Fact)
0:\forms\fpmbond) (rev 8/00)
Title American Contractors Indemnity Company
Address of Surety 9841 Airport Blvd. 9t~ Floor
Los Angeles, CA 90045
Surety's Bond Number 150724
(Accompany this bond with Attorney-in-fact's
authority from Surety to execute the bond
certified to include the date of the bond.)
STATE OF CALIFORNIA
COUNTY OF SANTA CLARA
personally appeared
(Notary Public)
7.:~;,r, ally k,~,,i ~6 a~, (cc proved to me on tl~ b~s of satisf~o~ evidence) to be the person(s~ whose name(~0 is/am-'
subscn'bed to the within inslmmmm and acknowledged to me that-l~she/~ executed tl~ same in ~is/he~
autlmdzed capacit~i~), and that by l~m~ signature(~ on the insmm~nt, the person(~, or the entity' upon behalf
of which the person(~) acted, executed the insm~meut. '--
WITNESS my hand and official se. al.
(This area for notarial seal)
AmeriCan Contractors Indemnity C ,mpany
9841 Airport Blvd., 9th Floor Los Angeles, California 90045
POWER OF ATTORNEY
13-0677
KNOW ALL MEN BY THESE PRESENTS:
That American Contractors Indemnity Company of the State of California, a California corporation does hereby appoint.
Debbie Evans and Sophen La of San Jose, CA
Its true and lawful Attorney(s)-in-Fact, with full authority to execute on its behalf bonds, undertakings, recognizances and other contracts
of indemnity and writings obligatory in the nature thereof, issued in the course of its business and to bind the Company thereby, in an
Amount not to exceed $ ***l,500,000.00Dollars*** . This Power of Attorney shall expire without further action on
January 16, 2003.
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted
by the Board of Directors of AMERICAN CONTRACTORS INDEMNITY COMPANY at a meeting duly called and held on the 6th day
of December, 1990.
"RESOLVED that the Chief Executive Officer, President or any V~ce President, Executive ~ice President, Secretary or Assistant Secreta~; shall have
the power and authori~
To appoint Attorney(s)-in-Fact and to authorize them to execute on beha(f of the Compan. v, and attach the seal qf the Company thereto,
bonds and undertakings, contracts of indemniO, and other writings obligator3, in the nature thereof and,
2. To remove, at any time, any such Attorney-in-fact and revoke the authoriO' given.
RESOLVED FURTHER, that the signatures of such oJficers and the seal of the Company may be aJfixed to any such Power qf Attorney or certificate
relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or Jgcsimile seal shall be valid and
binding upon the Company and any such power so executed and certified by facsimile signatures and d&csimile seal shall be valid and binding upon the
Company in the future with respect to any bond or undertaking to which it is attached."
IN WITNESS WHEREOF, American Contractors Indemnity Company has caused its seal to be affixed hereto and executed by its
President on the 1 st day of September, 2000.
STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
AMERICA~N CONTRACTORS INDEMNITY COMPANY
Andy T. Faust. Jr., Corporate President
On this 1 st day of September, 2000 before me personally came Andy T. Faust, Jr., Corporate President of American Contractors Indemnity
Company, to me personally known to be the individual and officer described herein, and acknowledged that he executed the foregoing
instrument and affixed the seal of said corporation thereto by authority of his office.
WITNESS my hand and official seal
D~borah Reese. Notary
I, JAMES H. FERGUSON, Corporate Secretary of American Contractors Indemnity. Company, do hereby certify that the Power of
Attorney and the resolution adopted by the Board of Directors of said Company as set tbrth above, are true and correct transcripts thereof
and that neither the said Power of Attorney nor the resolution have been revoked and they are now in full force and effect.
IN WITNESS HEREOF, I have hereunto set my hand this 18TIt day of J1JIgg ,200 2
Bond No. 150726
Agency No. ~9013
V JAMLS ~. GU ON,~orporate Secretary
rev. POA04/20/01
CALIFORNIA
ALL-PURPOSE
ACKNOWLEDGEMENT
STATE OF CALIFORNIA
COUNTY OF SANTA CLARA
On Jura!: 18, 2002 before me,
DATE
DEBBIE EVANS
NAME, TITLE OFOFFICER-EG,"JANEDOE, NOTARYPUBLIC"
personally appeared, so~,m~ LA
personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s)
whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/
they executed the same in his/her/their authorized capacity(les), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted,
executed the instrument.
WITNESS my hand and official seal.
~..~A~ Y~P~ B L. iC *S'TGhXTU h ~
(SEAL)
OPTIONAL INFORMATION
:'::..!1 TITI E OR a'vpE OF r)O('l 'MENT ~:~
':".:,* v~
r ES ......
(~:?i DATE OF DOCUMEN', NL'MBER OF PAG
~:~i SIGNER(S) OTHER THAN NAMED ABOVE
State Farm
Insurance
Companies
I ~.,~1STATE FARM
December 24, 2002
North Coast Office
6400 State Farm Drive
Rohnert Park, California 94926-0001
City of Campbell
Development Agency
Attn: Dept of Public Works
70 N 1st St
Campbell CA 95008
NOU. Vm.e_mly~Otf
B~ltlOM OPlBnd
O3^J3O3B
RE: Willson, Stanley A
dba Willson's Concrete
854 S McGlincey Ln
Campbell CA 95008-5411
Policy Number:
Policy Type:
Location:
CANCELLATION DATE:
97-R9-9248-2
Contractors
Same As Above
January 28, 2003,
12:01 A.M.
To Whom It May Concern:
Coverage under this policy will cease as of the CANCELLATION DATE shown
above. We have notified our insured of our action.
Sincerely,
Jeanette Swenson
Commercial Account Underwriter
State Farm General Insurance Company
(707) 588-6083
JS:rp
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
WORKER'S COMPENSATION INSURANCE INFORMATION
The following worker's compensation insurance information is required for all Applicants and
Contractors. One of the following items for each Applicant and Contractor must be submitted
prior to working under a Public Works permit or contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant
A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No.
Expiration Date
~'--/- o 0-_ ; OR
A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ,any
person in a manner so as to become subject to the Workers' Compensation Laws of
California.
Title Ot3~)P~, C ~7._ -
NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of
Exemption, you should become subject to the Workers' Compensation provision of the
Labor Code, you must forthwith comply with such provisions or the Permit or Contract
will be cancelled or revoked.
j:\forms\workcomp(rev6/96)
Permit
INSURANCE REQUIREMENTS CHECKLIST
~00/- ~7g5/5/~ CIP Project #
The following insurance is required of all contractors working in the City of Campbell public
right-of-way. Insurance certificates must be accepted by City staff before work can begin.
These insurance requirements apply to work being performed under an Encroachment Permit
and work being performed under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
$1,000,000 per occurrence, and
[] $1,000,000 general aggregate limit applying separately to the project, and
$2,000,000 general aggregate limit.
[] Policy expiration date "~- ! tT/-tv '2~
Automotive Liability - "any auto"
~ $1,000,000 per accident for bodily injury and property damage
[] Policy expiration date
Worker's Compensation and Employer's Liability
$1,000,000 per accident,,t:?~r ' ' '
Policy expiration date ,~ b/~;~ry
or disease
Course of Construction (if required in Special Provisions)
[] Completed value of the project
[] Policy expiration date
Required Endorsement to General Liabili _ty and Automobile Liabili _ty Policies
Additional Insured Endorsement
[] 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.
Workers' Compensation Insurance Sheet Submitted
[] For General Contractor
[] Subrogation Clause
Insurance Certificate Reviewed
Initials
Date
Copy of Insurance Certificate placed in tickler file one month prior to expiration.
j:\forms\inscldst 4/96 (rev 6/96)
CERTIFICATE OF INSURANCE
This certifies that [] STATE FA[ FIRE AND CASUALTY COMPANY, Bloomin... 0, Illinois
STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois
STATE FARM FIRE AND CASUALTY COMPANY, Scarborough, Ontario
[] STATE FARM FLORIDA INSURANCE COMPANY, Winter Haven, Florida
[] STATE FARM LLOYDS, Dallas, Texas
insures the following policyholder for the coverages indicated below:
Name of policyholder Stanley' A. Willson
Address of policyholder
Location of operations 95~ S..~-'/-!'-'nccy T~.---~.C 3255 Wi~?~ctcr P.!vd.
Description of operations r~.~-.~ ~ ,-.~ (~nno r~-,,.~-,~-~ ~ ,-,~ o~nno
The policies listed below have been i-~-~-~J~'d~o~ p~'~'c'yhol~l~'~o~ the policy periods shown. The ~nsurance described i~ ~h~e~s~ policies is
subject to all the terms exclusions, and conditions of those policies. The limits of liability shown may have been reduced by any paid
claims.
POLICY PERIOD LIMITS OF LIABILITY
POLICY NUMBER TYPE OF INSURANCE Effective Date ~: Expiration Date (at beginning of policy period)
Comprehensive : BODILY INJURY AND
~-7- .- -9 -3-5 C:~-- ~- Business Liability 7 40~ i7 2- PROPERTY DAMAGE
This insurance includes: ~ Products - Completed Operations
Ixl Contractual Liability
[] Underground Hazard Coverage Each Occurrence $ 1~ 000,000
[] Personal Injury
[] Advertising Injury General Aggregate $ 2 ~ 000 ~ 000
[] Explosion Hazard Coverage
['-I Collapse Hazard Coverage Products - Completed $
[] Operations Aggregate
POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE
EXCESS LIABILITY Effective Date i Expiration Date (Combined Single Limit)
[] Umbrella : Each Occurrence $
[] Other I Aggregate $
: Part 1 STATUTORY
i Part 2 BODILY INJURY
Workers' Compensation
and Employers Liability ' Each Accident $
' Disease Each Employee $
', Disease - Policy Limit $
POLICY PERIOD LIMITS OF LIABILITY
POLICY NUMBER TYPE OF INSURANCE Effective Date i Expiration Date (at beginning of policy period)
.................... , ...... .000.000
THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY
AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN.
Name and Address of Certificate Holder
City Of Campbell
Attn: Dept. of Public Works
70 North First Street
Campbell, Ca. 95008
Permit# 2001-143
RECEIVED
HAY 1 7 200Z
PUBLIC WORK8
&DMINI~TFI&T!ON~
(also as additional Insured)
558-994 a.3 04-1999 Printed in U.S.A.
If any of the described policies are canceled before
its expiration date, State Farm will try to mail a
wdtten notice to the certificate holder days
before cancellation. If however, we fail to mail such
notice, no obligation or liability will be imposed on
State ~>~ representatives.
Signature of Auth0~ized Representative
..... 5115102
IAgent's Code Stamp
[..~ ~^~,.] ROD HILL, Agent
I ~ / Ucense #0424885
AFO Code j ~ ~ 1783 Curtner Ave
['"'u'*"c'~ San Jose, CA 95124
-- (40e) 445-0250
Fax: (408) 445-0252
STATE ".0: Box 420807, SAN FRANCISCO, CA 94142:0807
COMPENSATION :
INSURANCE
I= U N D
JANUARY 2, 2002
POLICY NUMBER:
CERTIFICATE EXPIRES:
F~
'crI'Y OF CAMPBELL
DEE OF PUBLIC WORKS '
70 N FIRST ST
CAMPBELL CA 95008 :
This is to certify that we have issued a valid Workers' Corn )ensation ~nsurance policy in a form approved by the California
Insurance Commissioner to the employer named below for',the pol~ period indicated.
This policy is not sub.j~t to cancellation by the Fund exce¢ upon~ days" advance written notice to the employer.
We will also give you]C~l[N days' advance notice should this policy be cancelled prior to its normal exPiration.
This certificate of insurance is not an insuranCe policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. NotWithstanding any requirement,i term, or condition of any contract or other document with
respect to:which this certificate of insurance may be i~sued or may pertain, the insurance afforded by the policies
described herein is subject to all the terms, exclusions and ',conditions of such policies.
AUTHORIZED REPRESENTATIVE ~ PRESIDENT
EI"IPI~YER"S LIABILITY LIMIT INCLUDING DEFENSE COSTS: ,I,000'000 PER OCC~CE.
ENDORSEMENT #2065 ENTITLED CERTIFICATE!HoLDERS'NOTICE EFFEO"rIVE
01/01/02 IS ATTAUrlED TO AND FOP, MS A PART OF THIg POLICY.
RECEIVED
JAN 0:~ ~00~
PUBLI
EMPLOYER
C WORKS
ADM!NISTRATION
STANLEY A WlLLSON
DBA WILLSON CONSTRUCTION
R54___ MCGLINCEY LN :
CAMPBELL CA 95008
046-02 UNIT 0004498
1-1-03
CITY OF CAMPBELL
Public Works Department
70 North First Street
Campbell, CA 95008
Date:
TO:
FACSIMILE COVER SHEET
Fax Telephone No.
FROM:
Number of Pages Transmitted (including this page)
MESSAGE:
Transmitted from Fax Phone ,~ (408) 376-0958
If there are any problems with this transmission, please call
Dept. Phone No.
J:\FORMS\FAX FORM(WORD)
[783 cu~T~k~ AVE, ':
SAN'jOsE,cA 95124
WILL$ON,S'I'ANLEY A.
DBA WILLSON"$ CONCRETE
854 S. MCCLINCEY LN
CAMPBELL,CA 95008
COMPANIES AFFORDING COVEIqAG[
STATE FARM INSURANCE
97-0M-9356-9G
CONTRACTORS POLI~
.PlO-O436-a 22-05a
:MILL, TON LIAR1LI
AUT8
7/14/01
7/22/01
[y LIMTT5
Potd~t'
7/27/02
ON ALL
~,0~0.000
;e$¢a,pncsuF'OP~j:iATiONS.L~i?iOI,iruVKi, iCLF.~,d~P[Ctik~$ LOC~TION 3245 S, WI~CHESI[ ~ CA. PDELb,L.A
c~pbell, City of C~pbcll Redevelopmem~ Agen~ officers, ~ployeem ~d volunteers are
.....LL r-J ~pI~CN QA~ ~ECF. ~E iSSUING CCMPA~ '~ ~~ '
CIIY 0 ......... W ..... [;] M~,L 30 OAYS wm~ ~C~cE m mE c~c~ ~ ,~ ~ ~
c.~,,r~ ~L, c., ~ , ko.=° .,~~~~ ~~_
t
WI[,LSON,STANLEY
DBA WILLSON"S CONC~ET~
54 NCGLINCEY LN CAmPBELL,CA 95008
policy~97-OM--9356-gG
CONTRACTORS ROLICY
; ,,,jJ~ ' T 1"O ALL C2T1't~.~ i~--.., r~ ,.~ ~ ' UT ONLY WITH
Ull, . , = OE~-q¥1ED PRIMARY, B
RSEMENT SHALL B CC ,-~' N wr'ru
, BY ThIS ENCO NNE,,.,,IC ,.
~tG W~I~V. ~_.,.~¢-O~M ED ,gV OR ~(]R T'~E NAMED INSUFtED IN
ADDIT O['/'L%INSURED- OWNERs, LESSEEs or
uUN.TRACTORS [Form A]
This endorsement modifies insurance provided under the roll,wing:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization (Adc~iIicnal Insured):
L~.at./cn of
CITY OF C.~paE~. Covered Opera,ohs
A3'TN:D£PT. OF PUB~C WORK$ RE: ~1! ~'o,t-k iu Dubl~,c r:[ght:-o
?0 NORTH RRST STREET ·
CAMPBELJ. CAg5008 C~.t? DE Campbell
XasUXeds as respects liabil;t;''~u as additional
per CG 2009.
Bc0iiy Injury and Premium Basis Rates Advance Premium
(Per
Property Damage LJability Cos! $1000 of co~t)
TotAIAdvance Premium $
(Il' no entry appeam above, informa~Jcn required to complete ~his endorsement will De Shown in
aS applicable to this endorsement.)
I. WHO I$ AN INSURED (Sec:fcn Ii) ~s amended to
Include as an insured the
(c. al!ed. 'additional insurs~e.~_cn ~r. organization (a) All w~rk on ~he Project (other than
,n~wn ~n [he School- service, maintenance,
um ~u[ only w/t.h res,coot to lia. l:ili -,
or repairs) to
A. Your WOrk n ,, ..... ~ ansin ou~ of. be cerformed by or on behalf ot the
f_r ,,,,~ ,, .. . g .
the fccation designated~m~na~ ~nsured(s) at a¢~it~onaj Jnsurecl(s) at The site
8..Acts or emissions O! ~,,,a~.~v_,.e.: or covereo ,-, ....... . of ~e
In, .Connec!/on with t ' .__ nsured(s D/erect; or'~=''~uuns nas Peen com.
of - our - heJr ge,,~rm . · ) (b) That ~ort/on of 'Your work' out of
~,j'Y_ , work at the icc-.:-- .sul3e~smn which injury or damage arises h
,.,., o~,, or organJza~ion other th~n-a~-
. With respect to the insurance afforded these
adc~itionaJ insurers, the i'el~a ·
pro.v/s/cns al:ely- wtng ac~c~iflonai Other contractor Or Su~:c0nlrac:or
A. Ncne of th~'exc:usions uno, er Coverage A engaged in perfom3/ng operat/ons for
excep~ exclusions ('aL (c~ (e a Pnncipal a3 a part of the
anc~ m a , ' . )' ), (0, (h2 "
O* )..,~ PDly ,,o, thts msura ), (0, ~m~ect. same
B. AdcLtla,,~I Exclusions ].~,~n..c_e: ($) 'BoCi/y In/u,.,,- or '
no~ a~pl to' ' -'"~ insurance does ansin o Drcpe ~a ·
· :~ . .
(1) Boafly /nju~' adchhona/ insu~,i/,.[ u_r omlss, jo.n ot the
or * r~
for which t~ .. P ~erty c/ama e' ~,,~ ~r any or their em-
ack~t~ona/ msureols)
pJoy~es ozher t,han [he eno
s/on of wcm ~erf .... ~ . r'aJ Supervi-
obligate0 to pay damn es insured(s) by'~o~'me~ mr the additional
.-..- .... ont. rh,s ~,.,., ..... "- '= ~untract or ~_P,r?.?ert7 c~am'~g;~, to:
insured(%) would n; .... '_'~L'ne .~a~,':;cna/ or rentec~ to the =-,-: ...... upled by
~,,,u-tonal insured(s);
· ..-~ n] [ne a~sence of (b) Prcpe~/in the care. Custody Or con-
the contracl or agreement
(2) 'Bodily Injur/" or ._ . trot et, [he aclditionaj insure (S) or
'' occur~ng aden ~ro~er~y damage' ~Vr:~cWr~c,,~e._acJdit,onal.insdured(s)
.... ~' ~u~Pose excensing phys.
~cal con~rOl/or
(c) 'Your work' tot the adc~itional in.
Sure¢(s).
CG 20 09 ~ ~ 85
Copyright, insurance Service Office, Inc.. 1984
AUG-14-01 09:55 AM ROD HILL 408 4450252
~IS ENDORSEMENT CHANGE~ ~E POUCY, PL~SE READ IT CARE~y.
FAX
Date 4/22/2002
I Number of pages includ~n$ cover sheet
TO:
Phone
Fax Phone
CC:
Carbajal Insurance Agency
1280 Boulevard Way, Suite 204
Walnut Creek, CA 94595
(925) 935-4400
(925) 933-3008
FROM:
Phone
Fax Phone
Joanne D'Ambrosia
City of Campbell
70 North First Street
Campbell, CA 95008
(408)866-2701
(408)376-0958
REMARKS: [] Urgent
[] For your review [] Reply ASAP [] Please Comment
Re: Insured: Alaniz Construction, Inc.
Work Site: 3265 Winchester Blvd., Campbell
Permit No: ENC2001-00143
We recently received the insurance certificate from you in connection with the above permit. After
reviewing the certificate, we find that we must ask you to provide the following additional items or make
the following changes to meet our minimum iasurance requirements:
1. The insurers must have a current A.M. Best Rating of A:VII and be authorized to transact business in
the State of California. We find that National American Insurance Company only has an AM Best
Rating of B++:VII and that General Security Indemnity Insurance Company is not authorized to
transact business in California according to the Department of Insurance.
2. We require that the "ANY AUTO" box be checked in the Automobile Liability section of the
certificate of insurance.'
o
The cancellation area of the certificate needs to be edited to deleter "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".
A copy of the certificate as well applicable sections of our insurance requirements follow for your
reference. 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.
INSURANCE REQUIREMENTS CHECKLIST
CIP Project #
The following insurance is required of all contractors working in the City of Campbell public
right-or:way. Insurance certificates must be accepted by City staff bet'ore 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:
';8- $1.000.000 per occurrence, and
-n $1.000.000 general aggregate limit applying separately to the project, or
"~ $2,000,000 aeneral aagreaate limit.
'5~ Policy expiration dat~ W' JtT2--
Automotive Liability:
"Any Auto" checked on certificate
S 1.000.000 per accident for bodily injury and propertT' damage
PolicF'expiration date ~/, [07z_. '
Workers' Compensation and Employer's Liability
,,~ Waiver of Subrogation clause
X $1.000.000 per accident for bodily injury or disease
a Policy' expiration date i'2,/~1 lb 1...
Course of Construction/.if required in Special Provisions)
a Completed value of the project
-n Policy' expiration date
Required Endorsements to General Liability and Automobile Liability Policies
Additional insured Endorsement
',,d:- The City. the City of Campbell Redevelopment Agency. its officers, employees and
volunteers are named as additional insured.
'¢. The insurance coverage aftbrded to the Additional Insured is primary insurance.
a 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".
a Workers' Compensation Insurance Sheet Submitted
a For General Contractor
a For Deveioper or Owner (..90~.'~('oJ c.,~-C4,'r"t~--1 ~qc, lemnd~l
Acceptability or'Insurer(sttc~ > IxJ~oT I [~r~.~t~ ~"t,.S,,r-~c-~ ~
Insurer(s) has current A.M. Best Rating of A:VH and is authorized to transact
business in the State of Cali~'ornia.
Insurance Certificate Reviewed
Initials Date
Copy of Insurance Certificate placed in tickler file for month of expiration.
jg, forms'dnscklst (rev l l'90)
CERTIFICATEI F LIABILITY INSURANCE
DATE (MM/DD/YY)
04/22/2002
PRODUCER
Carbajal Insurance Agency
12~ Boulevard Way Suite 204
Wa t t Creek, CA-~945~5~
1-9z5-935-4400 q3~ -30(~(~'
INSURED ALANIZ CONSTRUCTION, INC.
JESSE ALANIZ
519 HAMILTON AVENUE
MENLO PARK, CA 94025
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
INSURERA: GENERAL SECURITY INDEMNITY
~NSURERB: NATIONAL AMERICAN INSURANCE CO.
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFFECTIVEPOLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE ~MMIDD/YYt DATI= {MM/DD/YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000 , 000
X COMMERCIAL GENERAL LIABILI3~' FIRE DAMAGE (Any one fire) $ 10 0, 0 0 0
I CLAIMS MADE [--~ OCCUR MED EXP (Any one person)$ 5, 000
A 21-L22000090-01 07/01/01 07/01/02 PERSONAL&ADVINJURY $1, 000, 000
GENERAL AGGREGATE $ 2,0 0 0, 0 0 0
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/DP AGG $1, 0 0 0, 0 0 0
~ PRO-
~"~ POLICY I I ,IF~T
LOC
AUTOMOBILE LIABILITY
-- COMBINED SINGLE LIMIT $ 1
ANY AUTO (Ea accident) , 000 , 000
__ ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) $
B X HIRED AUTOS NAC-3012636 07/01/01 07/01/02
-- BODILY INJURY
X NON-OWNED AUTOS (Per accident) $
-- PROPERTY DAMAGE
(Per accident) $
~ ,GE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG
EXCESS LIABILITY EACH OCCURRENCE $
I OCCUR F--IcL*'MSMADE AGGREGATE s
BI4klOM O1' ~lld $
DEDUCTIBLE $
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $
EL DISEASE- EA EMPLOYEE $
E.L DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ALL WORK PERFORMED BY THE INSURED IN PUBLIC EIGHT-OF-WAY, CITY OF CAMPBELL,
CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES, AND VOLUNTEERS
ARE NAMED AS ADDITIONAL INSUREDS ON THE POLICY. PER CG 20 10 03/99A
WAIVER OF SUBROGATION AND PRIMARY WORDING APPLIES.
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER: --, CANCELLATION
CITY OF CAMPBELL
ATTN: DEPARTMENT OF PUBLIC WORKS
70 NORTH 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 ENDEAVOR TO MAIL 3 0 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
,;,;,o.S;s ;,,o.,.;,;vTs?..o, o. ,.,..,.,,¥ o,=
AUTHORIZED REPRESENTATIVE
~)ACORD CORP(~TION 1988
~-JLk No. t¢4U (34..]!4 '02~ ')"'%"
PAGE
POLfCY NUMt~ER': COMMERCIAL GENERAL LIABILITY
THfS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY-
ADDITIONAL INSURED -OWNERS, LESSEES OR
CONTRACTORS- SCHEDULED PERSON OR
ORGANIZATION
-fhis endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIAB~LfT¥ COVERAGE PART
SCHEDULE
Name ~t' Person or Organization:
ALL WORK PERFORMED BY THE INSURED IN PUBLIC
RIGHT-OF-WAY, CITY OF CAMPBELL, CITY OF CAMPBELL
REDEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES, AND
VOLUNTEERS
{'t! no entry appears above, information required to complete this endorsement will be shown in the Declarations as
~p~c~b~e. ~.,3 this e.ndc~rGement ~
Who Is An insured (Section Il) is amended to i~clude as an insured the person or organization shown In the
Schedule, but only with respect to liability arising out et your ongoing ~or~t[o~% pedormed lot that insured
pnmaw insurance. Any other insurance maintained by the additional Insureds or its officer~ and employees shall be
excess onW and not contributing with the insurance afforded by this endorsement, except In (he event of sola or
contributory negligence on the part of the additional insurers" _
IncJudes Copyrighted information insurance Services Office, loc,,
~9e6
Page I of 1
11/21/01
· ' I
STATE
COMPENSAT.ION
INSURANCE
I=UND
APRIL 16, 2002
P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
POLICY NUMBER:
CERTIFICATE EXPIRES:
CITY OF CAMPBELL
PUBLIC WORKS
70 N FIRST ST
CAMPBELL CA 95008
1&19051
12-31-02
- O]
This ~s to certify that we have ~ssueo a valid Workers Compensation ~nsurance policy ~n a form approved by the California
Insurance Commissioner to the employer named below fOr the policy period indicated.
This policy ~s not subject to cancellation Dy the Fund except uponX~(~ days advance written notice to the employer.
30
We wdl also give you)~N days advance notice should th~s policy be cancelled prior to its normal expiration.
This certificate of insurance ~s not an insurance policy ar~d does not amend, extend or alter the coverage afforded by the
pohoes listed herein. Notwithstanding any requirement, term. or condition of any contract or other document with
respect to which th~s certificate'of insurance may De issued or may pertain, the insurance afforded by the poli'~ies'
described herein is subject to all the terms, exclusions an~l conditions of such policies.
AUTHORIZED REPRESENTATIVE
EMPLOYER'S LIABILITY LIMIT INCLUDING
DEFENSE COSTS:
PRESIDENT
$1,000,000 PER OCCURRENCE~
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS'NOTICE EFFECTIVE
12/31/01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT fl2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE
04/16/02 IS ATTACHED TO AND FORMS A PART OF THIS POLICY.
THIRD PARTY NAME: CITY OF CAMPBELL
EMPLOYER
ALANIZ CONSTRUCTION INC
519 HAMILTON AVE
MENLO PARK CA 94025
II
o~'
CITY OF CAMPBELL
Public ~"orks Department
June 3, 2003
Karen Langeman
3265 Winchester Blvd.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC2001-00143
LOCATION: 3265 Winchester Blvd.
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Ms. Langeman:
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.
Please find attached your original Maintenance Bond which we are returning to you.
Sincerely,
Public Works Inspector
MQ
cc: Permit #ENC2002-00143
Public Works/Maintenance Division
Sophen La, Attorney-in-Fact, Amer. Contractors Indemnity Co., 9841 Airport Blvd, 9th Flr, Los Angeles, CA 90045
H:\word\permitsL2001_143acc(id)
70 North First Street . Campbell, California 95008-1436 · TEL 408.866.2150 . F^X 408.376.0958 · TDD 408.866.2790
h
American Contractors Indemnity Company'
12 S ISI STREET, STI~, 611, SAN JOSE, CA 95113
PAX: 408 292-1306 PllOl~z &08 292-139!
Contract Status Letter
Date: ~ 17, 2003
Obligce: CITY OF CAI~BELL
PUBLIC 14ORKS DEXSARTMEHT
ATTN: SXllJ) ldlllIDI
70 HORTit I~II~T gTR.~ET
c,3a~BELL, CA 95008-1436
Contract Description: PgllltI'r BO. KlqC2001-0Olt~3
V~A YA~ 408 376-0958
Contractor: ~ LANG~
Contract Price: $4,625.00 Bond Amount: $/~,625.00 Branch: g-~ JOSE
Bond No.: 150726 Effective Date: 05/31/02 Agent; ~ INS. SVCS.
Please provide thc following information and return this form in the enclosed postage-paid return envelope, or by fax. It
is understood lhat the information contained herein is furnished as a matter of courtesy for the confidential use of Surety
and is merely an expression of opinion. It is aisc agreed that in furnishing this information, no warranty of accuracy of
information is made and no responsibility is assume ts a result of reliance by thc Surety whether such information is
furnished by owner or by an architect or engineer as agent of the owner.
If the contract is completed: _ t · _
A. Date of completion: ~[19.4 0'[ ~
B. No,ice of Completion ,ed (o ' se 0frete ,i .
C. Final contract price: $ --
2. if contract is not completed:
A. Pementagc or dollar amount of contract complete
as of_
B. Are there any unpaid bills for Labor material?
If so, please explain
C. How much of the contract has been paid to date?
D. Please describe any changes of the contract which have been approved and make comments on the work
performed by the contractor to date:
E. Anticipated Date of Compleli_o~i~
Information provided by
(Signature)
Phone Number
(Printed Name & Title)
Address (if different from above):_
TOTRL P.Ol
CIVIL ENGINEERS - LAND SURVEYORS
PLANNERS - CONSTRUCTION MANAGERS
7651 Eigleberry Street 408-842-2173
Gilroy, CA 95020-5122 Fax 842-3662
E-Mail: hanna@ garlic.com
CHECKED BY DATE
.e3/ 7
CIVIL ENGINEERS - LAND SURVEYORS
PLANNERS - CONSTRUCTION MANAGERS
7651 Eigleberry Street 408-842-2173
Gilroy, CA 95020-5122 Fax 842-3662
E-Mail: hanna @ garlic.corn
SHEET NO. 2 OF
CALCULATED BY ///~: ~,:~ DATE
CHECKED BY DATE
CITY OF CAMPBELL
Public Works Department
70 North First Street
Campbell, CA 95008
Date:
TO:
FACSIMILE COVER SHEET
FROM:
Fax Telephone No.
Number of Pages Transmitted (including this page)
Transmitted from Fax Phone # (408) 376-0958
If there are any problems with this transmission, please call 4l~9~- c~[a (,, - $Z77¢
Dept. Phone No.
J:\FORMS\FAXFORM(WORD)
CITY OF CAMPBELL
Public XYdorks Department
June 12,2002
Karen Langeman
3265 Winchester
'S4m4o~, CA 95008
SUBJECT: PERMIT NO. ENC2001-00143
LOCATION: 3265 Winchester Boulevard
FINAL INSPECTION AND ACCEPTANCE
Dear Ms. Langeman:
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.
Your Construction Cash Deposit of $740.00, plus any interest due, is now being processed and will be sent
to you under separate cover.
Your Maintenance Bond has been received, therefore, we are returning the attached Faithful Performance
Bond.
If you have any questions, please call me at (408:) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
MQ~,~k.
cc:
Suspense- 11 months
Permit #ENC2001-00143
Inspector File
Bay View Bank. 2121 South El Camino Real. San Mateo, CA 94403-1897s
h :\word\permitsL2001_00143 fin (j d)
70 North First Street · Campbell, California 95008-1436 · TEL 408.866.2150 . F.aX 408.376.0958 . rOD 408.866.2790
E~CROACHM~-~T PERMIT ISSUANCE CHECK LIST
City of Campbell Encroachment Permit No.._>.~/.~/k
Department of Public Worl~ Tract No.
ITEMS REQUIRED FOR PERMIT .APPLICATION:
panplicant section complete '
pplicam signatm'e and date (front and back)
rmit Application Fee $~5.00 paid - Receipt Number
gineer's Estimate Submitted ,
Check Deposit Paid (2 % of Engineer s Estimate, $500 rain) Receipt Number
Five Sets of Improvement Plans Submitted
ri'EMS
REQLrlIZED PRIOR TO PUBLIC WORK CLEARA/~CE FOR BLrII.DING PERMITS
Plan Check & Inspection Fee: If Engineer's Estimate < $250,000, then 12% of Engineer's Estimate, If EngLneer's
Estimate > $250,000, then Actual Cost + 20%. (Deposit of 8% of Engineer,'s Estimate. requiz, ed; 530,000 minimum
deposit). Amount $ ~,~.,~.~ Receipt No. r9./ozr~ /,qZZ~ 7~,~~-~
Security for Faithful Performance and Labor and Mater,Ms, 100% each of Engineer's Estimate, supplied or paid.
Amount $/'~:~, ~cr~ Form I.D. #
Security for Monumentation Amount S Receipt No.
~mount 5 R~ceipt No, 0 {~O /~~
Sto~ Drainage .&'ca Fee Amo=t S .V~ Receipt No. ~ I DoC I ~Z ~
__ Worker's Compe=ation L':surance Information Sheet Received for Applicant.
__ A:I e~er ~ablic Worlcs requirements listed in the Condi:icrrs of Approval of the development.
'O&er Fees, Payments, Deposits Amovmt S Receipt No.
ITEMS ,~OL-tRED PR.IOR TO ISSU.&NCE OF ENCROACH2v[ENT PEKS, HT:
cO {~- Ccnzactor's si~amre added to the permit application (front and back)
61 {~- Worker's Compensation Insurance Information Sheet received from Contractor.
__ Cezificare of L'-.sur=ce with Additional Insured's Endorsemem received ;"rem ApFIica.nt or Cot'.:rac:er.
One my:.zr set md ."our ivluelne sets of
o::-,,..~ ,lans signed by licensed engineer, stzmoed A?PRD'.,'ED FOR
CONSTRUCTION.
0"~ Re,.--'.,it signed by City Eng;meer.
W'I--E~N AI.L OF TI--EE .-LBOVE I i-FEMS .aRE CObL-~LETE, PER.,%rlT MAY BE ISSUED.
/ssxer: i.-.:::ai -and date and file ;vi:,5 perm/:.
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
i. ,orms pm,c:cst rev. ~,'00
O~ ·
CITY OF CAMPBELL
Public ~'orks Department
September 20, 2001
Karen F. Langemen
Porte Veterinary Hospital
3265 Winchester Boulevard
Campbell, CA 95008
Re:
3265 Winchester Boulevard
Encroachment Permit #ENC2001-00143
Dear Ms. Langeman:
Enclosed is your receipt for the miscellaneous fees and securities you paid to the City of
Campbell on 9/18/01 in connection with your planned improvements at the above
property. For your information, now that we are in receipt of your Plan Check and
Inspection Fee, we are processing a refund of your previously paid Plan Check Deposit.
Our Finance Department will mail out a refund check to you on Monday, 10/1/2001, the
next scheduled date for check disbursement.
Please contact the undersigned at (408) 866-2158 if you have any questions concerning
this matter.
Sincerely/
I. Harold Housley, P.E.
Land Development Engineer
Enclosure
H:\word\permits~20011431tr(jd)
70 North First Street . Campbell, California 95008-1423 · TEL 408.866.2150 · FAX 408.376.0958 - TDD 408.866.2790
CITY OF CAMPBELL
PUBLIC WORldS DEPARTMENT
ENGINEERING DIVISION
Site Address: .~ ENC. No. r.._~.. , ' ~ ',, ' - '. /? ~
NO. DESCRIPTION UNIT QTY < $30 K $30 K to $150 K> $150 K $ AMOUNT
L DEMOLITION/CLEARING
1. CLEARING & GRUBBING LS $1.052.50
2. SAWCUT P.C.C./A.C.(UP TO 6') LF $6.10 $4.10 $2.?5
3. P.C.C. REMOVAL SY $34.75 $26.30 $12.65
4. CURB AND GUTTER REMOVAL LF $?.05 $3.45 $2.65
5. MEDIAN REMOVAL SF $5.25 $2.65 $1.60
6. )EMOLISH EXISTING INLET/PLUG RCP'S EA
II.STORM DRAINAGE
1. 12' R.C.P. (CLASS V) LF $69.50 $47.35 $23.15
2. 15' R.C.P. (CLASS HI) LF $75.80 $55.80 $44.20
3. 18' R.C.P. (CLASS Ill) LF $81.05 $69.45 $60.00
4. 24' R.C.P. (CLASS 111) LF $92.60 $78.95 $68.40
5. 30' R.C.P. (CLASS Ill) LF $104.20 $87.35 $75.80
6, T.V. INSPECTION (12') LF $1.25 $0.80 $0.65
?. STD. DRAINAGE INLET (C.C. DETAIL 9) EA $1,852.00 $1,505.00 $1.157.00
$. FLAT GRATE INLET (C.C. DETAIL 6) EA $1,620.00 $1,275.00 $1~042.00
9. STD MANHOLE (C.S.J. DETAIL D-I 1) EA $2,315.00 $1,850.00 ! $1.505.00
10. BREAK AND ENTER M.H./D.I. EA $810.00 $635.00 $520,00
i11. cONCRETE IMpRoVEMENTS -'
1. SIDEWALK SF $?.90 $6.75 $6.00
2, DRIVEWAY APPROACH SF $9.05 $7.80 $6.85
3. CURB AND GUTTER LF $36.85 $29.50 $24.20
4. VALLEY GUTTER SF $14.50 $11.60 $9.50
5. CURB RAMP EA $1,440.00 $1,052.50 $947.25
6. TYPE B-I CURB LF $13.90 $11.05 $8.?0
7. ITYPE Al-B3 CURB LF $17.35 $13.90 $11.60
8. COBBLESTONE MEDIAN SURFACE SF $15.15 $11.05 $?. 10
9. P.C.C. DRIVEWAY CONFORM SF $8.20 $6.30 $5.25
Page 1 of 4
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
ENGINEERING DIVISION
Dam: For File No(s):
Sim Address: ENC. No.
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT
I0. A.C. DRIVEWAY CONFORM SF $5.25 $4.40 $3.70
IV, PAVEMENT
1. ASPHALT DIGOUT AND REPLACE CF $5.80 $4.10 $2.95
2. PAVEMENT WEDGE CUT (6') LF $$.00 $2.6~ $1.60
3. PAVEMENT GRINDING SF $0.95 $0.63 $0.42
4. PAVEMENT FABRIC (PETROTECH) SY $2.30 $2.10 $1.75
5. ASPHALT CONCRETE (TYPE A) T $92.50 $5?.90 $42.10
6. AGGREGATE BASE (CLASS 2) T $47.35 $23.15 $13.90
7. SLURRY SEAL (TYPE Il) SF $0.09 $0.08 $0.07
8 AC OVERLAY $52.00
9 SLURRY SEAL (TYPE Ill) SF $0.13 $0.11 $0.90
V.TRAFF1C SIGNALS/LIGHTS
1. DETECTOR LOOP (6' ROUND) EA $520.00 $347.00 $289.00
2. DETECTOR LOOP (6' x 30') EA $752.50 $626.25 $510.45
3. DETECTOR LOOP (6' x 50') EA $1,042.00 $868.30 $741.00
4. ELECTROLIER EA $2,947.00 $2,526.00 $2,084.00
5. I I/2' RIGID CONDUIT LF $10.40 $8.20 $5.80
6 2' RIGID TRAFFIC SIGNAL CONDUIT LF $ 19.70$ 15.05 $ 11.60 i
7 CONDUCTOR LF $ 0.85 $ 0.65 $ 0.55
g PULL BOX (NO. 3 1/2) EA $347.00 $278.00 $214.75
9 TRAFFIC SIGNAL PULL BOX (NO. 5) EA $463.00 $405.25 $347.30
10 DULL ROPE LF $0.57
VI. 5TRIP1NG AND SIGNS
1. REMOVE PVMT. MARKINGS (PAINT) SF $2.65 $1.60 $1.05
2. REMOVE PVMT. MARKINGS (THERMO) SF $3.70 $3.40 $1.75
3. REMOVE PVMT STRIPING LF $1.50 $0.85 $0.45
4. STRIPING DETAIL 9 LF $1.30 $0.75 $0.32
5 STRIPING DETAIL 22 LF $1.30 $0.75 $0.32
6 ;TRIPING DETAIL 29 LF $2.35 $1.75 $1.25
Page 2 of 4
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
ENGINEERING DtVI~ION
Date: For File No(s):
Si~e Address: ENC. No.
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DE. SCRIPTION UNIT QTY < $30 K $30 K to $150 K> $150 K S AMOUNT
7 STRIPING DETAIL 32 LF $2.50 $1.85 $1.30
8 STRIPING DETAIL 37 (THERMO) SF $2.10 $1.75 $1.15
9 STRIPING DETAIL 38 (THERMO) SF $2.90 $2.10 $1.30
10 STRIPING DETAIL 39 LF $1.60 $0.90 $0.47
11. LIMIT LINE LF $1.70 $1.30 $1.15
12. CROSSWALK. 12' WHITE LF $1.40 $1.10 $0.90
13. PAVEMENT MARKINGS (PAINT) SF $3.25 $2.50 $2.10
14. PAVEMENT MARKINGS (THERMO) SF $6.60 $5.05 $3.40
15. PAVEMENT MARKER (NON-REFL.) EA $5.;20 $3.50 $2.50
16. PAVEMENT MARKER (REFLECTIVE) EA $6.95 $4.?5 $3.65
17. TYPE K MARKER EA $109.50 $92.50
18. TYPE N MARKER EA $109.50 $92.50 $81.00
19. SALVAGE ROAD SIGN EA $99.00 $87.35 $75.75
20. RELOCATE ROAD SIGN (WSI ON NEW POST) EA $115.75 $99.00 $87.35
21. INST. RD. SIGN ON EXIST. POLE EA $231.55 $168.50 $126.30
22. ROAD SIGN WITH POST EA $347.30 $277.85 $226.30
23 INSTALL 1226S SIGN WITH POST EA $252.60
24 STANDARD BARRICADE LF $15.75
VIi. LANDSCAPING
I. IRRIGATION, PLANTING WORK SF $7.35
2 PRUNE TREE ROOTS EA $147.35 $115.75 $100.00
3 TREE REMOVAL EA $684.10 $526.25 $421.00
4. ROOT BARRIER (12') L~ $21.05 $10.50 $6.30
5. ROOT BARRIER (18") LF $26.30 $15.80 $10.50
6. STREET TREE (24" BOX) EA $447.30 $342.05 S315.75
7. STREET TREE (36' BOX) EA $710.40 $589.40 $421.00
8. TOP SOIL BACKFILL CY $26.30 $22.60 $19.05
Page 3 of 4
CiTY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
ENGINEERING DIVISION
Date: For File No(s):
Site Addre~: ENC. No.
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DESCRIPTION UNIT Q'rY < $30 K $30 K to $150 K> $150 K $ AMOUNT
9 IRRIGATION LS $1.368.25 $710.40
Vlll. MISCELLANEOUS
1. PEDESTRIAN BARRIER LF $86.85 $69.45 $57.90
2. :HAIN LINK FENCE (6') LF $17.35 $13.70 $10.50
3. RAISE MISC. BOX TO GRADE EA $315.75 $210.50 $184.20
,4. RAISE MANHOLE TO GRADE EA $421.00 $364.45 $315.75
5. INSTALL MONUMENT BOX EA $473.60 $364.45 $315.75
6. MEDIAN BACKFILL CY $22.10 $19.70 $16.85
PREPARED BY: 10% MOBILIZATION, CONSTRUCTION
TRAFFIC CONTROL/PHASING,
REVIEWED BY: r CONSTRUCTION STAKING
~ :/ CONSTRUCTION TESTING / ~ ,.,.
,:7 - ,~>, ,/ -
APPROVED BY: ' *
10% CONTINGENCY
105 SECURITY ENFORCEMENT ~/ ~ ~ ~.~
TOTAL FAITHFUL PERFORMANCE SECURITY
use T.,s AMO.NT FOR SECUR,TY
'See Section 66499.4 of the Map Act.
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Page 4 of ~