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ENC1999-00194
?ITY OF CAMPBELL ~i ENCROACHMENT PERMIT ;' Permit No. DEPT. OF PUBLIC WORKS (for working within the X-Reft file 70 North First St. publ/c righ¢of-way) (408) 866-2150 Issued O2'~p ..... months - L/CATION A - pplicafion is hereby made for a Public Works Permit in accordance with Campbell Municipal COde, it the permit is not issued. Application Fe~ is non-refundable.) Sec~aon 11.04. (Apphcanoo expires in 6 morah~ A. · ? ,'c,,, -o7/ or u'act # ' ~ Utility ~nch loc~ion ~2Q '7 q - B. Namr~ of work C. AR,ach four (4) copies of an engineered plans showing the location and extem of the work, and four (4) copies of the preliminary Engineer's Esmna~ of work. The plans slmll show the relation of the propos~i work to existing surfac~ and underground improvements. Wben approved by the City Engine-r, said plan Ix~om~ a part of ~ permit. D. All work shall conform to thc City of Campbell Standard Specificadons and De~Jls for Public Works Cons~rua/on; the Genera/ Permit Conditions l/smd on ~e rever~e side; and thc SpeciaJ Provisions for this permit, [ist-'d below. Failure to abide by these conditions and provisiom may re,tult in job shut-down and/or forfeiture of FaithfiJl Performance Sureties and cash deposits. ($~ General Permit Conditions i and 2.) E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVVmD PLANS AT THE SITE AND MU~T NOTIFY TI-~ PUBLIC WORK~ DEPARTMENT AT LEA~T TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GWEN TO PUBLIC WORJ~ AT LEAST 24 HOUR~ BEFORE REXTARTING ANY WORK. .tr. ,.¢ r ,,. Address ~gg ~[, j~'~l~.,f~,r' ...... ~'~ ~"'~J 24HOUR EMERGENCY TELEPHONENo.f~ Is this work being done by file property owner at their own residence? _ Yes A No The Applicam/Permitu~ hereby agre~ by aft-~xing their signature to this permit to hold the City of Campbell, its officers, agents and enkuloyees fre~. safe and harmless from any claim or dermmd for damages resulting from the work Covered by this permit. The ApplicanffPermim,-~ hereby acknowledges tha~ they ~ and understand both the front and ba~k of this permit, and th,y will inform their corer(s) of the im'orma~ion. M ] rmlv.~e) (sign) ~ ~ Dat~ Strut shall not be op~n cut for urmerground hmallatiom. Minimum mrs may 1~ allowed for contax=ions or exploration holes. S0ch c~s~ _a~roved by ,,he Inspector prior to eu~inr,. Pavement may be cut for underground iasta]latiom and must be' restored in accordance with the Utility Trench Restoration Standard Details, M~od 'A' Backfill. unless otherwise ~pproved by Impecmr. Work to be stoked by a lic~.ms:d Land Surveyor or Civil Engineer and two (2) cx~pi~ of the mt shez'ts sm m thc P'abl~ Worlt~ D~artn~m b~for: smiling work Per Section 4215 of ~ Government Co~e m/s permk is ~ valid for :xcavmon~ umil Underground Sers4c: Alert (Lr~A) lms ~ notified and th~ inClUU7 id~adt-za~ion number has be~n en~:red h~:oo. USA Phon,. 1-800-227~2600. USA. TICY~-T NO. SEE PUBLIC WORKS FEE $CHEDLrLE FOR CURRENT ImE~_~ PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIAI~ CONSTRUCTION CASH DEPOSIT PLAN CHECK 8: INSPECTION FEE APPROVED FOR I~SUANCE TYPE ' AMOUNT RECEIPT NO. '"' GENERAL PERMIT CONDITION I, A CONSTRUCTION CASH DEPOSIT is required, Cl:~rges will be made against this depo~ i~ there is an emergency call-out, overtime inspection or when Cil7 ordered barricading is required. Any such costs in excess of thc deposit will be billed to the Pemfiv~e. 2. A ONE-YEAR MAINTEN,MqCE PERIOD AND SU'RETY are required. Such period will begin on date of writmn accep~anc~ by the City. 3. REFUND of the c~sh deposit balance and refund or cancellation of thc Faithful Performance Surety will be initiated by the wrimm accep~c~ of the worse by the Cily. 4. The Permdt~e MUST REQUEST IN WRITING a f'm~l inspection ;md accep~nce of the work upon completion. Acceptance by the City will be made in writing to the Permit',ce. 5. MAINTAIN sate pedestrian and vehicular crossings and free access to private driveways, bus stops, tim hydrants and water valves. street closures. / ~orkThCzCoOr~Ns~TR~CiT~oN. ,vT~a~a~t~=~~_~_~o~o~ w,th ,th,e..Cai,wa,ns, _,Manual of Traffic Con=Is for Consm~cfion ~ud Maintenance ....... ~,uI~; ~;omroi cqmpmen[ snail mcluue lype ri' flashing arrow signs if required. g, REPLACE IN KIND any damaged or removed existing improvements, including planting, 9. Sawcut for all PCC or AC removals, All PCC rernbvals shaft be to nearest scoremark and shall be doweled ~o existing improvements, 10. OVERTIME INSPECTION PREMITJ'M will be charged against the cash deposit for inspection required outside the hours of 8:00 a.m. to 4:00 p,m. at the current overtime rate, minimum one hour charge, 11. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection lime is charged at the current overtime rate with a are.- hour minimum. Advance payment for the estanated lirae is required. I2. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and barricading may result in the City's reining such signing and bamcades and charging the cost (including all labor and materials) against the cash deposit. I.~. Compaction testing of subgrade, base rock, and asphalt cohere-- by Permi~,-~e is REQUIRED u~gess otherwise s~a~.~d by the City E~gineer. I4. Tile Conwactor or Perrninee will have a SUPERVISORY REPRESENTATIVE available for con~act on thc project at all times during construction. Conw~ctor or PermiRee 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 STORAGE of materials or equipment will be allowed near the edge of pavement, the waveled way, or within the ~oulderline which would creato a ~;'nrdous condition m thc public. I6. This permit shall not be conswued as authorization for excavation and grading on priva~ property ADJACENT to thc wo~ or any other wortc for which a separate permit may be required, nor does it relieve the Permi~e of any obligation ~o obtain any other permit required'by law. 17. This permit does NOT RELE. ASE the Permit~ee from any liabilities contained in other agreements or contracts with thc City and any other public agency. 18. This permit is NOT TR2uN'SFERRABLE. Work must be performed by the Permit~e or his designated agent or conwactor ~s specified thereon. 19. CALL BACK (call out) due to emergencies regarding this permit, shall be at thc current overtime ~acc with a three (3) hour mi.lmum charge per 20. P~rsuant to Chapter l-t.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal s~orm drain system other than storm water. Applicant shall adhere ~o the BEST M~N'AGEMENT PRACTICES established by the San~a Clara Valley Nonpoint Source Pollution Control Program. - Appiican~ shall be responsible for er Applic~'0( j:\forr~\pwperm2 6/96 _g'~that all those providing services under the applicant are aware of and understand all of the above conditions. Dam 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: Voucher #: Receipt #: Requested by: Approved by: Finance Dept Only: Verified by: Approved by: Refundable Deposit Check Request SILICON VALLEY HABITAT FOR HU~I~/'~ 888 N. FIRST ST., SUITE 215 SAN JOSE Refund Maintenance Security 101.540.7448 Interest Earned State: CA Zip: 95112 Amount: $350.00 Amount: Amount: (Finance Dept only) (Exact Amount) One year maintenance period expired 5/3/01. Maintenance Security was never refunded. Permit #: 130335 ~n~ J?t~v~ ~ 'Jh~ui Date: Marlene Pomeroy ~ll~¢/U"~' Tftle: IJL~'chelle Ouinney Title: 99-194 5/3/00 Executive Assistant Date: City Engineer Date: Title: Accounting Clerk II Date: Title: Accountant Date: 9/24/03 9/24/O3 Special ]:nstructions For Handling Check Mail As Is: Return To: Mall in Attached Envelope: Marlene Pomero¥ (Name) Interim Check: Needed By: Public Works (Department) Other: h:\permits 99-194 refundable ckreq(mp) t .C WORKS DEPARTMENT RECEIPT Effective August 1, 1999 TO: City Clerk PUBLIC WORKS PILE NO. P~eas. ~o~ ~t.~ ~ P~. ~.~ .{e~fi~ mfi~ ................................................................................................................................ ENCROAC~ENT PE~ a~2 Appli~ion F~ Non-Utili~ E~r~chment Permit ($236.25) Minor Encroachment Permit ~ $5~ ($50.~) R-I Fi~t Permit (No F~) Subgquent PermiCYr ($105) Utility Encr~chmem Permit A~rial/Coll~tor S~t ($341 Resident~l S~¢~er Ar~ ($236.~) 2203 Plan Ch~k De. it - 2% of ENGR. ~. f ($5~ rain) 2203 Faithful Performa~ Securi~ (FPS)~~ ~ (I~5 of ENGR.EST.) * 2203 ~r and Materials S~urity (1~% of ENGR. ~T.) 2203 Monumenmtion S~urity (1~% of ENGR.EST.) 2203 C~h Deposit (4% of ENGR.~.)(~ min/$10~ 2203 ~bor and Materi~ S~urity (1~% of ENGR. EST.) Plan Ch~k & lns~tion F~ (Non-Utili~) ~722 Engr.~t. < $250,~ (12% of ENGR. ~T.) · * 2203 Engr. Est. >$250~ (~sit 8% of ENGR. ~T./$30~ min.)** 4722 Utility < $1~,~ Minimum Ch~ge Per ~tion ($126) Co~uim/Pi~li~s up to 5~ F~t ($1.75/fQ Above 5~ Lin~ F~t ($1. Manholes/Vaul~/Eg. ($1 lO.25/ea) Pole SeCRemoval ($1 lO.25/ea) S~t Tree Planting/Remov~ ($110.25/~) · * 2203 Utility > $1~ Actual C~t + 20% ** 4~2 Street Tr~ Planting/Removal Permit ($110.25) ~7~ Pro}ect Pla~ & S~ifications Proj~t No. g7~ SmM~d S~ifications & Derails ($1/Pg $12.50~k) 47~ Copies of Engi~ring Maps & Pla~ Aerial Plot 24' x 36' Aerial Print 8 I/2' x I1' Maps and Plato 24" x 36' ~722 Penalties: Failu~ to restore public improvemenm ($1~/Calend~ Day) ~ c~e S~.l 1.34.01o) ~722 Penalties: Failure to co~t unsafe conditio~ ($1~/Calen~ Day) ~ DE~LOPMENT g722 ~t Line Adjustment ($5~.50) 4~2 P~cel M~ (4 ~m or ~ss) ($1,125 + $25/~t) 4722 Fi~l T~t M~ (5 or M~e ~m) ($1,450 + $25/~t) 4~2 Certificam of Complia~ ($525) 4722 CeniHcate of Correction ($315) 4~2 No~y Fee (~r signature) ($10) ~2 V~c~fion of Public S~ & ~emenm 4~2 Assessment Segregation or R~p~Hionment Fi~t Split ($5~.50) ~ch Additio~l ~ ($178.50) 4~1 Storm Drainage Ar~ Fee Per Acre (R-I~ (Multi-Res, $2,~0) (All Other, ~01 Parkland Dedication F~ (75%~% Due U~n Cert. of ~upancy) ~5 ] Postage ~A~C 4~8: lmer~tion Turn Counm ~w~Hour Count) 4~8 Imers~tion Turn Counm (a.m. or p.m. ~) ($131.25) 4728 Traffic Flow M~ (Daily Traffic Volum~) ($28.35) 4728 Campbell Traffic M~el (Full Sco~ As~sment) ($2,362.50) 4~8 Camp~ll T~ffic M~el (Redu~ S~ ~ment) ($~ ~271 Truck Permim ($36.75/trip) ~8 No Parking Sigm ($1/~h or $25/1~) ~R TO n= · *Actual Cost Plus 20% Overbid (Non-lnmrest ~ing de.sit) Fog .............. . ............................................. ~. ~ ......................... h:\forms\ecfrm4.xls rev. 7113199 (rap) To: City of Cempbell - Refundeble beposit Check Request. Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Total Payable: Account Number:. Account Number:. Account Number: (Finance Dept only) Purpose: Silicon Valley Habitat for Humanity 888 North 1st Street, Suite 215 San Jose Refund Deposit $750.00 101.2203 101.540.7448 Interest Earned Refund Monumentation Security Voucher #: Rec~ ~ //_ ~3:~0 Req~~ L~Bill ~ Approved by: ~ ~,l ,~- Finance Dept Only: ~ Vedfied by: Title: Title: Title: State: CA 95112 (Exact Amount) Amount: $750.00 Amount: Amount: (Finance Dept only) Date: Permit #: 99-194 Date: 08124/1999 Land Dev. Engineer Land Dev. Manager Date: Accounting Clerk II Date: 0910512000 0910512000 Approved by: Title: Accountant Date: Special ]:nstructions For Handling Check Mail As Is: Mail in Attached Envelope: __ Interim Check: Joanne D'Ambrosia (Name) Needed By: Public Works/City Hall (Department) Other: Return To: f/n: Fom~s/excel/chkmq -. Revised 02/00 City of ¢-_mpbell - Refundable Deposit Check To: Finance Director Check Payable To: Line 2: City: State: Zip: Description: Total Payable: Account Number. Account Number:. Account Number. (Finance Dept only) Refund Deposit 101.540.7448 Interest Earned (Exact Amount) Amount: ~---~O. ~C::~ Amount: Amount: (Finance Dept only) Purpose: Permit #: ~- 1C~4 Date: Voucher #: Receipt #: ~'Z~"~-7 '~ ~' Requested by: ~~----.--- Approved by: Nichelle Quinney Verified by: ~ Title: PW Inspector Title: City Engineer Date: Title: Accounting Clerk II Date: 5/3/00 5/3/00 ,' Speci(d Instructions For Handling Check Mail As Is: Mail in Attached Envelope: Interim Check: Needed By: Return To: (Name) (Department) Other: In: Fmms/excel/chkmq TO: City Clerk PU WORKS DEPARTMENT RECEIPT .tfective August I. 1999 P e~e co ect & rece pt for the b ow ng mon es ...... . ~ ' : ..... :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ¢:: :~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:~:~:~:~:~: ~: ~ ~: : :l~ ........... '"'"'"'""'"'"' '"'"'" ~NCROAC~IENT PERMIT Application F~ Non-Utdity Encr~hment Permit Minor Encroachment Permit < S5.000 R-I First Permit (No Fee) Subsequent PermittYr Iltllity Encroachment Permit ~$50.00) &rterlal/Collector Street /$341 ?25) ResMenual Street/Other Areas 1S236.25) 22031 Plan Check Deposn - 2% of ENGR. EST. ~$500 mm) i 22031 Fmthful Pertormance Security iFPS) f100% of ENGR.EST.) [22031 ~0dMisSty .... ...... .... /IOO%ofENGR.EST., {' ~_~-~ i 2203t Monumenlatmn Security ([00% of ENGR.EST.) ! 22031 Cash Deposit (4% or ENGR.EST0($500 mm/$10,O00 max) 2203t Labor and Malerial Security (100% of ENGR. EST./ ~ Plan Check & inspection Fe~ INon-Utility) · on i I-- 2203i Engr. Esl. >$250,000 (Deposit 8% bi' ENGR. EST..$30.O00 rain. i"' 22031 4.722[ Minimum Charge Per Location ($126) Conduits/Pipelines up to 500 Feet (Sl 75/fi) Above 500 Linear Feet ~$1.15/fi) Manholes/Vaults/Etc. ($1 IO.25/ea) Pole Set/Removal I$1 VD.25/ea) Street Free Planting/Removal (5,110.25/tree) Util~tv > Sl00.000 Actual Cost + 20%" 47._, Street Tree Ptanung/Removal Perma i$110,25) 4760[ Pro)cci P)ans & Spectficauons Prolect No. 17601 Standard Specifications & Details r$1/Pg $12.50/Bk) I 17601 Comes bt' Enemeermg Maps & Plans Aerial Plot 24" ~ 36" %rial ?rlnl ~ i 2" x [ i Maos and Plans 21' ,( 36' ,$42) ~$15) ~ .t.722! ?enaities: Fadure to restore public improvements~5,100/Calendar Day) 4,7221 Penalties: Failure to correct unsa/~ condinons ($1001Calendar Day) I LAND DEVELOPMENT 4,722 Lot Line Adjustment ~$577.50) ¢722[ Parcel Map ~4 Lots or Less) ($1,125 + 5,25/LoQ 17221 Fiual Tract Map 15 or More LotsI !$1,450 + 525tkot) 4,7221 Ceruficate of Compliance 15525) 4,~21 Certificate or' Correction (5,315) 4~21 Notary Fee ,per slgnarur~) ($10) 4,722tr Vacauon of PubLic Streets & Easements ~5577 50) ..17221 Assessment Segregation or Reapportionment ! First Split I Each Additional Lot ~$577.50) ~$178.50) 4721; Slrm Drainage \rea Fee Per Acre , R- } (Mulls-Res, S2,250) (All Other. $2.500) 4,g20~ ?art:land Dedicauon Fee ~75%/25% Due Upon Cert. ffOccupancyl ?ostage 4,965[ '/r.amc 4,7251 ',nlersecuon Turn Counts ITwo-Hour Count) I,$63) -~7281 [atersecuon Turn Counts/a.m. or p.m. pea~s? ~$131.25) 17281 Traffic Flow Map (Daily Traffic Volumes} ~$28.35) 1728 Camp~etl Traffic M~el {Full Sco~ Assessment) ,'$2.362.50) 1~8 t~a~np0ell Traffic M~el (Reduced Sc~ Assessment?t5777~ 1271~ Truck fferm~ts ,$3h.75/trtp? 15,1teach or $251100) ]OTiiFarR)728! No Parking Signs //~ // // ~NAME OF PAYOR ..................................... ................ .......................................................... ........ :' xiI '~ . I _ ,/. , z ..... '. . :: m ~.:~ :l::~::z:~i~i~i~ii:~:~: ii:i:s '::s:::::: :::::::i:Z:/;~:~t~ ~~ iisi :~:~ ::::: :5 :: ::::::: : : :::::::::::::::::::::::::::: .............. ..................... ......... ..... ' Oll . - h:~f~ms~fm4.xls rev 7113/99 (rap) CHE~ NO: 0i~ ~" ~ City of Campbell To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Total Payable: Account Number: Account Number: Account Number: (Finance Dept only) Purpose: - Refundable beposit Check Request Habitat for Humanity 888 N. First Street, Suite 215 San Jose Refund Deposit $500.00 101.2203 101.540.7448 Interest Earned Refund Plan Check Deposit State: CA Zip: 95112 (Exact Amount) Amount: $500.00 Amount: Amount: (Finance Dept only) Voucher #: Receipt #: 120981 Cruz.,S.,(3c~&i~' - Approved by: /{~_~../_ _ Title: Bili.~'eh;hs Finance Dept Only: Verified by: Title: Approved by: Title: Permit #: 99-194 Date: 05/12/1999 Assistant Engineer Land Dev. Mgr. Accounting Clerk II Accountant Date: Date: Date: Date: Special ]:nstructions For Handling Check XX Mail in Attached Envelope: Interim Check: Needed By: Mail As Is: Return To: (Name) Other: (Department) 07/2612000 07/26/2000 f/n: Forms/excel/chkreq - Revised 02/00 UBLIC WORKS DEPARTMENT RECEIPT EE~cdvc July 1, 1996 ACCT~ ITEM 435.5354921 ] Pro ect Revenue (speedy p~'t) ENCROACHMENT PERMIT 4722 Application Fee Non-Utility ~ea, Pe~nit (,22,) R-I F~m Pennis (No Fee), Subsoil Permit/Yr Utili~ Enc~-oaeJunat Permit Ane~al/Collectm. Su~et Residential S~ Areas (S225) 2203 Ptan C~eck Deposil. 2% o1' ENGR. EST, 2203 Faith£ui PorCormance Secuti~- eFTS) (100% of ENGR. EST.} 22[U Labor and Matenak Sectary (~00% of ENGR. EST.) 2203 Monumcntatio~ Securi~ ( ] O(P/e of ENGR. EST,) 22113 Cash Deposit (4% of ENGR. E~'T.X$5OO min/$10,000 max) Plan C~cck .e. lnspe~Uon Fee (Non-Utility) 4722 Engt..~t. <$250,000 (12% ot'l~qGR. EST.) *- 2203 En~-.E~t.>S25O.000 4722 Ut~li~ < Minimum C~'~'~o P~ location ('$120) Conduiu/Pipellnes up ~o $00 Feet ($1.60/fl) Above $00 Feet ($1.10/1t.) Manholes/Vaults/Etc. (Sl05/ea) Polo Set/R~-moval SUeet Tree Ptantin~,/IC-mova! 4722 Sm:et Tn~c Plnntin~cmoval Pe~nit ($105) 476(] P~iect P~ans & Speci~ca6ons Prelect No. 47~1 Standard Speci~¢a6ons & Detoi~ ($ I,~'~ $12.~ook) 476(I Copics et' ~n~ineenng Maps & ~ans ($.§O/~q.l~) 4722 (Muni Code Section 11.34.O10) Penalties: ~ailure to co,oct uns~o conditions (Sl00/C. ak~dar Day) LAND DEVELOPMENT 4722 Lot Line Adjusm~ent 4722 lqnal Tract Map (5 or Mom Lou) ($1.380 + $25/Lm) 4722 Certificate of Compliance 4722 Certificate of Correction (~300) 4722 Vacation et' Publi~ Strata & Ense~ems (S551)) 4722 Assessment Segregation or Reappo~ionment Fire Split Each Additional Lo~ ($170) 4721 Storm DrninaSo A~a Fee ~ Acre (R-I, ('Multi-Re~. S2.250) (All Other. S2~00) 49211 Parkland Dedication Fee 4728 [nter,.ectiofl Turn Counu (a,m, or p,m. ~.~) (Sl 25) 472S Tra~¢ Flow ,'dap (D~ily TraQ'tc Volumes) ('S27~ 4271 Track Permiu NAME R£CEIVE. D HAY 1 2 1999 CIT CLERE'S. 0EFICE AS~£GNMENT AND RECEIPT OF IN~. f~LENT CERTIFICATE TO CItY OF CAMPB~.r., 70 N. FIRST STREET CAMPB~.L, CALIFORNIA 95008 (408) 866-2150 · I hereby gr~t, transfer and assi~ said accost, sa~d ~ves~t ce~ f~cate, sa~d balance (including interest which acc~es ~ereon), ~d all o~er rights ~ co~ection therewith to ~e CI~ OF ~B~L, assi~ee, for a g~d ~d val~le consideration, recei~ of which is hereby ac~owledged, for ~e p~se of ~ns~g cons~ction descried as follows: !..have h sicall delivered verification of said ~nment and Rece/pt ~o ~ ~ -------- investment certificate and ~ o sa~d assignee. T understand that assignee can withdraw from said account any t/me on his signature alone upon presentation of a written order to the issuer. I also understand withdraw from said account unl ............ that I may not ~o ~ m=~sen= a s~gnea re,ease from ~he assignee. The issuer of the certificate assumes no responsibility for the conduct of th may act on the si ture of .... ~ ............ e assignee and gna th~ -~.ee w~=nou~ ~urther ~nqu~_-'y. AC~O~LE~F_~L~F~ BY Issuer aff£~ms that there are no other holds on subject account, that subject ~onies are available, and that the above described assignment has been noted on the Records of said issuer. Au=hot, zed Signature NOTARY Title: ,~ n a.~ e ,~ / c, ACK~OWLEDGEKENT ~RSTRUCTZONS TO Please 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. o .pbel RELEAS~ BY ASSIGN~ Said assignee hereby releases and relinquishes all his right, title and interest in and to said account, said investment certificate, said balance and all other rights ~n connection therewi~h. Date.--~'/~/00 City 9f ,Cal~pbe~l CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California County of ,..~/YT,~ SS. Date personally appeared , before me, Name and Title of Officer ~'e.g., "Jane Doe, Notary Public") ~ffpersonally known to me _ proved to me on the basis of satisfactory evidence \',~**,~2~v/ santa Ck~ ~ ~ My Corru"n. Expire. Mar 12, :~001 Place Notary Seal Above 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(ies), 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. Signature of Notary Public OPTIONAL Though the information below is not required by/aw, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached .Document Title or Type of Document: ,~.5.~1¢/I/l~//'/' ,~ ~.C.E./F)' 41,c/#t~..57/¢~¢T ~W/'/¢,07'£ -/~C.J~//C~IJ~..Z~£/V/EiY? 8Y Document Date: ~'/9' 9? Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer, Signer's Name: l~l~.l;l~ ~ Individual Corporate Officer-- Tit e(s): _% Partner--C Limited -- General ~ Attorney in Fact C Trustee ~ Guardian or Conservator Signer Is Representing: Top of [humb here © 1997 National Notary Association · 9350 De Soto Ave., P.O. Box 2402 · Chatsworth, CA 91313-2402 Prod. No. 5907 Reorder: Call Toll-Free 1-800-876-6827 BANK O EWEST TIME DEPOSIT RECEIPT Branch Name: CIVIC CENTER Today's Date: 8/23/99 Account Number: 010-006-854768 Tax ID Number:93-0926083 Branch Approval: ~ ~ SILICON VALLEY HABITAT FOR HUMANITY INC ITF CITY OF CAMPBELL 888 N FIRST STREET STE 215 SAN JOSE, CA 95112 Deposit receipt not needed for redemption. Date of Deposit: 8/23/99 Amount of Deposit: **'14,000.00'** Maturity Date: 02/21/00 Initial Interest Rate: 4.60% Initial Annual Percentage Yield:4 · 70% Interest Payment Method: CAPITALIZED Pay Interest to Account #: First Date Interest Paid: 9 / 23 / 9 9 Term: 182 DAYS Auto Renew: YES Thank you tbr opening a Certificate of Deposit with Bank of the West. Your account has been opened for the amount and terms shown above. Any questions regarding your certificate of deposit can be answered by your branch or by calling the Bank's Telephone Banking center (800-488-BANK or 408-94:7-5030). INFORMATION REGARDING CERTIFICATE OF DEPOSIT A CCO UNTS ADDITION-AL DEPOSITS - If you wish to add funds to your Certificate of Deposit. you may do so during the 10 calendar day grace period following the account's maturity date. For 7-31 days certificates, you may add funds during the I calendar day grace period [ollowing the maturity date. Interest on thc additional funds both cash and noncash begins to accrue interest on the business day you deposit it and at the same rate in effect for the renewed certificate. The additional funds will mature at the same time as the renewed certificate. The minimum amount for an additional deposit is $100.00. WITHDRAWALS - Interest which has been reinvested may be withdrawn at any time. if the account term and interest rate have not changed since thc reinvestment. Additional withdrawals without penalty are permitted, during the 10 calendar day grace period following maturity (1 calendar day grace perio,: for 7-31 days certificates) for automatically renewable certificates, or upon the death or mental incapacity of the depositor. Accounts closed during the grace period will forfeit any interest accrued during the grace period. Withdrawals at any other time may be permitted at the bank's discretion and are subject to interest penalties. INTEREST - Interest is accrued on the daily balance. The annual percentage yield assumes that interest earned is reinvested in the account monthly and all funds remain on deposit for one year from the date of deposit, and the interest rate does not change. Interest withdrawn during the term of the account will reduce the annual percentage yield earned. TERMS OF 32 DAYS OR LONGER - You may choose the frequency of interest payments. Interest can be paid as frequently as monthly but must be paid at least once a year. Interest may be reinvested into the account, credited to another checking or savings account, or paid by check. TERMS OF 7-31 DAYS - You will receive interest at maturity only. Interest may be reinvested into the certificate, or as a deposit to a Bank of thc West checking or savings account. , / MATURITY - Multiple Maturity certificates of deposit renew automatically at the rate in effect on the maturity date and for the same term and conditions Ia~t disclosed unless we tell you otherwise (Auto Renew = YES). A single maturity certificate of deposit (Auto'Renew = NO) will not ehrn interest from thc maturity date. Maturity notices are mailed to you approximately [5 days before the maturity date to your last known address (except for 7-14 days terms). It therefore important that you keep the Bank informed of your ct~rrent address. The maturity notice will include a number you can call on or alter the maturit~ date to find out the interest rate and annual percentage yield on your renewed certificate of deposit. EARLY WITHDRAWAL PENALTIES - All penalties are calculated on a simple interest basis. The penalty assessed may reduce the balance remaining ~m your account after the withdrawal. For variable rate accounts, the penalty is calculated at the interest rate in effect at the time of the withdrawal. The bank usc~ the last in-first out {LIFO) method on calculating this penalty. For fixed rate accounts, the penalty is calculated at the interest rate in effect at the time thc certificate was opened or last renewed. The penalties on the amount withdrawn are: 7 -31 DAYS TERM - 7 days simple interest lost, 32 DAYS - I YEAR TERM - 30 days simple interest lost or OVER 1 YEAR TERM - 90 days simple interest lost. CHANGES IN TERMS & CONDITIONS - When you open a deposit account with us, you agree to abide by the terms & conditions detailed on this pag,: and in the Account Agreement you sign. We can change these terms & conditions at any time. We'll notify you in advance of any changes that affect rights and obligations to the extent required by law'. You indicate that you accept a change we make by continuing your account relationship with us or, ii' tl~c change affects your certificate of deposit, by allowing the certificate to renew after the change becomes effective. DISCLOSURE OF YOUR ACCOUNT - Account intbrmation may be disclosed to third parties when it is required for governmental reporting for legai processes, or to persons or companies who the Bank believes would legitimately use such information. Certain transactions are also automatically reportable the government. OTHER INFORMATION REGARDING DEPOSIT ACCOUNTS - Additional information pertaining to the rules & regulations governing deposit accounts can be provided if you request a current copy of the Bank of the West Deposit Account Disclosure which is available by phone or in person at any the Bank's branch offices. You may also call our Telephone Banking Center and request that we send you a Deposit Account Disclosure. NOT PAYABLE BEFORE MATURITY 120-01820 IRev. 5/98) NON-NEGOTIABLE NOT TRANSFERABLE MEMBER FDIC CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California Coun o, G _nc¢ ss. On .... I::~T '~-7. !~'~ ,before me, ]~ Date m ' O 'cer (e.g.. "Jane Doe. N~taW Public") personally appeared Ck~, ~ ~, ,.'~ ~ Name(s) of Signer(s) _~ personally known to me ~ 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 off. j~al seal. Place Notary Seal Above {/"" . J ' Sig f ry Public OPTIONAL Though the information be/ow is not required by/aw, it may prove va/uab/e ~o persons re/ying on the document and could prevent fraudulent removal and reattachment of this form to another document, Description of Attached,Document _--- ,_ ~ : ~ Title or Type of Document: ~" i~-~,~ ~ ct t '~/~_{2 (~6'~ ~-~' ~ _~ ['~ k_~(;- ~-~-'r'~o/~. ( CCJ L T Document Date,.'lU. Cv- .~g ~O~c'3q Nurr~er ' ~ " ~ ' 'i tt ! of~'ages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer Signer's Name: _~ Individual _-- Corporate Officer-- Title(s): F- Partner--- Limited~_~- General ~ Attorney in Fact [-- Trustee ~_ Guardian or Conservator ~¢" Other: ' :! ~ [ ~t6~..¢.~ .~:>¢_~.~, CC ~ Signer Is Representing;'~,4.~ lC Top of thumb here © 1997 National Notary Association · 9'350 De Soto Ave., P.O. Box 2402 · Chatsworth, CA 91313-2402 Prod. No. 5907 Reorder: Call Toll-Free 1-800-876-6827 INS URANCE REQUIREMENTS CHECKLIST Permit # C,/~ _/9 t_~ ~ cie Project # The following insurance is required of ali 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 pertbrmed 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, or '~. $2.000,000 general aggrezate limit. -x.g, policy expiration date R-[, I O I Automotive Liability,: ~ "Any Auto" checked on certificate "~ $1,000,000 per accident for boflilv injury and property damage X, Policy expiration date 9../', [°i Workers' Compensation and Employer's Liability ~ Waiver of Subrogation clause ~ $1,000,000 per accident for,bo¢ly inju,ry o/disease ~ Policy expiration date 'i~ ! / ! Course of Construction (if required in Special Provisions) ~ Completed value of the project -n Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional insured Endorsement x~' 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. ~ 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 ~ For General Contractor ~ For Developer or Owner Acceptability of Insurer(s) Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the~/'State of California. , Insurance Certificate Reviewed~~© '"-~nnitials ' D~te Copy of Insurance Certificate placed in tickler file for month of expiration. j:\fonns\inscklst (rev 11/99) C/ient~: 12707 CERTIFICI 'E OF LIABILITY INSU[ RHWEH I DATE (MM/DD/YY) kNCE O3/lO/OO PRODUCER Dorsey, Hazeltine & Wynne P.O. Box 50307 (CA License #: 0281413) Palo Alto, CA 94303 INSURED R.H. Wehner Concrete Construction 2025 Stone Avenue .... ~.~l\[~ San Jose, CA 95125 ~ THIS CERTIFICATE IS ISSUED AS A MAl-rER 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 ,NSURERA:Caliber One Indemnity Co./PMA-RE ~Insurance Company of the West ~RERc:General Security Insurance Co. INSURERD~Republic Indemnity Co. of America COVERAGES THE OLICIES OF INSURANCE LISTED BELOW HAVE BEEN i~S~U~O~[iO '~'.~'~'..~D NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CON~,,~ ~'CUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICrE~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 LIMITS ' LTR ~ ~PE OF INSURANCE I POLICY NUMBER ~ DATE (MM/DD~Y) r DATE (MM/DD~Y) A [Ge. ERALL,AmU~ CGO000Z3450Z ]02/0~/00 02/0~/0~ [EACHOC~URRENCE .... ~$~, 00..0 L000 ~ ~ COM M ERCIAL GENERAL L IABILI~ ~ ~ FIRE DAMAGE (Any one fire) J $ 5 0, 0 0 0 [ MED EXP (A.y O.e De.on) [ sExcluded L~i/pD Ded:2,SQp~ ' I ' J - I I ~[PERSONAL&ADVINJURY $1 ~ 0001000 GEN'L AGGREGATE LIB IT APPLIES PER: ~ J PRODUCTS-COMP/OPAGG $~] 000 000 9 ,~u.o~o.,.~.,..,u~ CSA~ S S ? 2 ~ ~ 0 ~ 0 2 / 0 ~ / 0 0 0 2 / 0 ~ / 0 ~ ~co~.,.~o s,.~.~ _~ ANY AUTO /(EM accident) $1, 0 0 0 , 0 0 0 ~ ~ ALL OWNED AUTOS ~ I ~ BODILY INJURY ~ SCHEDULED AUTOS (Per pemon) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS ] ~ (Per accident) $ PROPER~ DAMAGE I (Per accident) ! ~ GARAGE LIABIM~ ~ ~ AUTO ONLY - EA ACCIDENT $ /I ~200 i ~ ' c ~xc~u~.,u~ ::~ ro~/oz/oo o~/o~/oz~o. occ~..~.o~ ~:,ooo.,o~o CL , SM D f,I 000, 00 _ XI RETENTION $1 0 0 0 0 mm ~ J WC STATU- m mOTH- ) $ D wo..~.s ~o~.~.~.~,o.... 0 0 ~ Z 0 7; Z 0 Z / 0 Z / 0 0 m o z / o ~ / o z ~q;o" ~co,~;,~ ~, o5-6; o o o ) EMPLOYERS' LIABILIW ) ~RY LIMITS m m ER ) i m ~~~;~O~LZ 0 0 ,'5 0 0 m [ ~ ~E.L. DISEASE- POLICY LIMIT ~ $~ 0 0 0 t 0 0 0 i m ~ OTHER m sc.,.Tio. o. .ov,s o.s Re: 2?3 & 275 G=a~b Sb., Campbell, CA - All ~o=~ i~ ~ubllc =ighb-o~-~ay. Wo%k Com~ ~o[ic~ co~bal~s wal~e~ ce sub%o9ablo~ 1~ Ea~o% ce: (See Abbacbed Desc=iDbio~s) CERTIFICATE HOLDER I X I ADDmONALINSURED;INSURERLE'I-rER: A CANCFLLATION City of Campbell Dept. of Public Works 70 North First Street Campbell, CA 95008 ACORD25'S(7/97)l of 3 #20371 SHOULD ANYOF TH E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WlLL]i~I~.]/~I~..~[.~AIL 3 0 DAYSWRITTEN NOTICETOTHE CERTIFICATE HOLDERNAMED TOTHE I ~o'q'flG~IZF..,D REPRESENTATIVE ~ DJH ~J ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD25-S(7/97)2 O'F 3 #2037:]_ DE~~r RIPTIONS (Continued from Ir 1) officers, officials, employees and volunteers Re: 273 & 275 Grant St., Campbell, CA - Ail work in public right-of-way. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided for under the following: COMMERCIAL GENEP~AL LIABILITY COVERAGE PART WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s) shown in the Schedule as an insured but only with respect to liability arising out of "your work" for that insured by or for you. SCHEDULE Name of Person or Organization: As required by written contract The City of Campbell, the City of Campbell Redevelopment Agency, its officers, officials, employees and volunteers If you are required, by written contract, prior to an occurrence or offense, to provide primary insurance, then this policy shall be primary and Condition 4. Other Insurance does not apply, but only with respect to coverages provided by this policy. COI .E107A (10-98) AMS 25.3 (07~97) 3 O f 3 #2 0 3 7 1 P1¢~F~-ll-2000 15;~5 DOF~SEY, HF4ZELTINE & HYNNE 650 85~ 102~ P.01/04 DORSEY, HAZELTINE & WYNNE FAX NUMBER: (650) 856-1023 Fax No: ~.)r( ,~ ~ G (~.)c~ ~ From: Deborah J. Hannagan ~ ~ ~. \ Total Number of Pages Including oover sheet: q certilicate of Insurance follows. Original will follow by mail. If you have any questions, plea;e give me a call. * NOTE: IF ANY OF THI~-SE FAX COPIES ~ IT~[.~J;IBLI~, OR YO0 DO NOT SAI~ Ng~BEE OF PAGES AS STATED, PLFJ~E CONTACT US i~[KEDZATELY AT; (650) 858--2375. 560 SAN ANTONIO ROAD, SUITE 102 - PALO ALTO, CA 94306 - P.O. BOX 50307 · PALO ALTO, CA 94303 PH: 650-858-2375 · FAX: 650-856-1OIL:r3 CALIFORNIA DEPARTMENT OF INSURANCE LICENSE NUMBER: 0281413 M~R-11-2000 15:~5 DORSEY, HRZELTINE & WYNNE ACORD CERTIFICA": OF LIABILITY INSUR/ Dorsey, ~azeltine & Wynne P.O. Box 50307 (CA License #: 0281413) Palo Alto, CJ~ 9&303 R.~. Wehne~ ~o~cre~e Co~s~r~c~o~ San ~ose, CA ~51~5 650 856 1023 P.02/04 ] 03/].0/oo THIS CERTIFICATE I$ I,~$1JEl~ A~ A MATTER OF INFORMATION ONLY AND CONFERS NO RI;HTS UPON THE CER11FICATE HOLDER. THIS CERTIRCATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED B.Y THE POLICIES BELOW. INSURER~ AFFORDING COVERAGE Insurance Comp&ny of Che West Geheral Security Insurance co. ' Re-~£c' ~A-demEft'~ ~. b-f America THE POUCIES OF INSURANCE USTED BELOW NAVE BEEN ISSUED TO THE II~SUREO NAMED AI~:)VE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PF. RTAIN. THE INSUFIAN~"E AFFORDED BY THE POUCIE$ DE~CRIEED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGRECtATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAJD CLAIMS, LTR l~P[ OI~ INSUR~',N(~G POUCY NUMBER ! 0ATE {I~IM.,O~,'Y¥1 DA'n= ~l,~[l:)~rY[~ UMITS A l~,z~u.m,~ CGO000134501 02/01/00 02/01/01 [__A.C.H_OCC. URRENCE .... Si, 000, 000 'XL~_J~T/PD Ded: 2, s[, 009~ .000 'L AGG~EGATE Lla IT A~.l~$ P~R; I PR(~T$ · COMP/O~ ~G $1~ 000 000 ; ~ OWNED AUTOS ~ BODILY INJURY ~ sC. EOUU;0 ~UTOS [ [l'er ;er~) $ X.~ H,IREO AUTOS { ' BOOILY INJURY PROPERTY DAMAGE $ l -~ ~ {Pe~ I OTHER TH^N ' i AUTOQNL¥: AC:,6 I $ C i'=xcmssuam'u~ UM2007249 102/01'/00 t02/0[/01 e~CHOCCu..ENC[ S2,_0_0-0-, 000 J X[.~ al0000 ; . E.L. EACH~CClOE,? sl, 000 ~ 000 I DE~K~RIFTION OF O~F.R~13ON~I.OC, ATIQNS~EHICLES/EXCLUSIONS ADDLED BY ~NDO~¥~C-CL4d. P'ROVI~0NS '" THIS C~.RTIFICATE REVISES AND REPLACES ALL PRIOR C~RTIFICATES. Re: 273 & 275 Grant St., Campbell, CA - All work in public right-of-way. Work Comp policy contains waiver of subrogation in favor of: The City of Campbell, the City of Campbell Redevelopment Agency, its (See Attached Descriptions) CERTIFICATE HOLDER ! X t AODmONALINIUI:IID:IN$'URJIRLII'r~Iq; A CANCEM~TION City of Campbell Dept. of Public works 70 North First Street Campbell, CA 95008 ACORO 25-,8 ('T/97) 1. O.F 3 #20371 ~RR-~-2000 15:36 DORSEY, HRZELTINE & MYNNE 658 856 ~023 P.03/04 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les} must be endorsed. A statement on this certificate does not confer righzs Zo lhe certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. nCO~D~"~{7;~92 of 3 #20371 MRR-11-2000 15=36 DORSEY, HRZELTINE & DYNNE 658 856 ~023 P.04/04 DES-' IPTIONS (Continued from Pal 1) officers, officials, employees and volunteers Re: 273 & 275 Grant St., Campbell, CA - Ail work in public right-of-way. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSUReD-OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided for under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s) shown in the Schedule as an insured but only with respect to liability arising out of "your work" for that insured by or for you. SCHEDULE Name of Person or Organization: As required by written contract - The City of Campbell, the City of Campbell Redevelopment Agency, its officers, officials, employees and volunteers If you are required, by written contract, prior to an occurrence or offense, to provide primary insurance, then this policy shall be primary and Condition 4. Other Insurance does not apply, but only with respect to coYera~es provided by this policy. COI . E107A (10-98) AMS 25.3 of 3 #20371 TOTAL P. 04 C/ient~: 12707 RHWEH CERTIFICA F-- OF LIABILITY INSUI NCE DATE (MIVVDD/YY) 03/10/00 PRODUCER Dorsey, Hazeltine & Wynne P.O. Box 50307 (CA License #: 0281413) Palo Alto, CA 94303 INSURED R.H. Wehner Concrete Construction 2025 Stone Avenue San Jose, CA 95125 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 ,NSURER~; Caliber One Indemnity Co./PMA-RE f'NSURERS: ~urance CO~- ~f the West INSURER~: ~-~h~ral Se~c~--~"~,~e Col I i 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 ~ i POLICY EFFECTIVE~P~'I.~CY EXPIRATION LTR ! TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY~ DATE (MM/DD/YY) LIMITS A !GENERA'"AS'"W CGO000134501 02/01/00102/01/01 E^CHOCCURRENCE M ERCIAL GENERAL LIABILITY RECEIVED , FIRE DAMAGE (Any one fire) '50 000 CLAIMSMADE [;~(~ OCCUR .~E_D?XP(Anyonoperson) sExclude_~_ ~BI/PD Deal: 2,500 ~AR I 3 ZO0O [PERSONAL&ADVINJURY ~__lj__0_0~0 ! 000 , [ GENERAL AGGREGATE [$2,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PUBLIC WORK~ ~PRODUCTS -COMP/OP AGG $1 ~ 000 L 000 , iPOLICY ~ JEQTPRO' ~ LOC ~M'N'~,R*T,O,~ B ' AUTOMOBILE LIABILITY CSA155726601 02/01/00 02/01/01 COMBINED SINGLE LIMIT $1~.000 000 /~ANY AUTO i (Ea accident) , i iALL OWNED AUTOS-- BODILY INJURY ; (Per person) $ : _ SCHEDULED AUTOS X ! HIRED AUTOS, I BODILY INJURY F x ! NON-OWNED AUTOS i I i (Peraccident) ......... PROPERTY DAMAGE [ $ ! I ' (Per accident) , __ I GARAGE LIABILITY i AUTO ONLY - EA ACCIDENT $ I i ANY AUTO I J [ OTHER THAN EAACC~$ ' : , IAuT° °NLY: c i EXCESS L,AB,L,~ IU~2 0 0 7 2 ~ ~0 2 / 0 1 / 0 0 0 2 / 0 I / 0 Z EAC, OCCURRENCE 000~000 , X! OCCUR ~J CLAIMS MADE i, AGGREGATE ~ _S_2. 000 LC) C) 0 , i ~ l DEDUCTIBLE I " I ! ! Xi RETENTION $10000 i $ D WORXERSCOMPE.SAT, ONAND 00310711 ;01/01/00 01/01/01__~mRyX IWCSTATU-....TS II IOETRH- ! EMPLOYERS' LIABILITY ', E.L EACH ACCIDENT i$l-; ~'6 ~70 0 d : ! ' ~ DIS~E_A_SE_ :_EA EMPLOYEE sl, 0 0 0, 0 0 0 r i ].. °,SE^SE-,O.,OY,,M,T, OTHER I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: 273 & 275 Grant St., Campbell, CA - All work in public right-of-way. (See Attached Descriptions) CERTIFICATE HOLDER I X [ ADDITIONALINSURED;INSURERLE3-DER: A CANCELLATION City of Campbell Dept. of Public Works 70 North First Street Campbell, CA 95008 ACORD 25-S (7/97) 1 0 f 3 #20345 SHOULD ANYOFTH E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WlLL..I~~AIL~_ DAYSWRI~EN NOTICE TOTHE CERTIFICATE HOLDERNAMED TOTHE LEFT,~];I~.~[~C~x DJH ® '~,4~ORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(les)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD25-S(7/97)2 O:~ 3 #203,~5 DES': tlPTIONS (Continued from Fje 1) Re: 273 & 275 Grant St., Campbell, CA - Ail work in public right-of-way. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided for under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s) shown in the Schedule as an insured but only with respect to liability arising out of "your work" for that insured by or for you. SCHEDULE Name of Person or Organization: As required by written contract - The City of Campbell, the City of Campbell Redevelopment Agency, its officers, employees and volunteers If you are required, by written contract, prior to an occurrence or offense, to provide primary insurance, then this policy shall be primary and Condition 4. Other Insurance does not apply, but only with respect to coverages provided by this policy. COI. E107A (10-98) AMS25.3(07/97) 3 of 3 #20345 FAX TO: Phone Fax Phone Deborah J. Hannagan Dorsey, Hazeltine & Wynne PO Box 50307 Palo Alto, CA 94303 (650) 858-23 75 (650) 856-1023 CC: Date 3/10/00 I Number ofpages including cover sheet FR OM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2150 (408)3?6-0958 REMARKS: [] Urgent [] For your review Re: Insured: RH Wehner Concrete Construction Permit No. 99-194/271-275 Grant Street [] Reply ASAP [] Please Comment We have reviewed the certificate of insurance that has been submitted in connection with the above referenced permit and find that the following item needs to be added to meet our minimum insurance requirements: We require a subrogation clause in connection with the workers' compensation coverage stating that the insurer agrees to waive all rights of subrogation agains the City, the City of Campbell Redevelopment Agency, its officers, officials, employees and volunteers for losses arising from work performed by the Contractor for the City. Copies of the applicable section of our insurance requirements follow for your reference as well as a copy of the original certificate that was submitted. Please call me if you have any questions. Thanks for your help in this matter. C_OEJ CERTIFICATE OF LIABILITY INSURANCE Dorsey, Hazeltine & Wynne P.O. Box 50307 (CA License #: 0281413) Palo Alto. CA 94303 I~UR~D R.M. Wehner Concrete Construction 2025 Stone Avenue San Jose, CA 95125 , 03/10/00 ONLY AND ~NF~ NO R~ UPON ~E ~ER. TWS C~R~ ~ ~ ~D, ~E~ OR AL~ ~ ~RAGE A~R~ BY ~E ~ B~OW. INSURERS AFFORDING COVERAC.-~ ,~suR~R,~ Caliber One Indemnity Co./PMA-R-~ ,.su.~,~ I~surance Company of the West INSUR~ D: COVERAGES THE POUCIES OF INSUP, ANCE USTED BELOW HAVE ~F..~I 'ISSUED TO THE INSURED N)UvlED ABOVE FOR THE FK)IJCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CON01TION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 1'0 WHICH THIS CEI::~IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUFIANCt= Ar'FORDED BY THE POUClES DESCRIBED HEREIN IS SUBJECT TO Al.[. THE TERMS, EXCLUSIONS ~JflO CON01TION,S OF SUCH POLJCI~ES AGGREGATE LIMITS SHOWN MAY HAV~ B~N REOUC~ 8Y PgdD CLAIMS. LT~ TYPE O~U~UP~NCE ;POUCY'rdw~c'nvE- ,'~,,]~'r--'E~mRa~ ~ A ",~E,~,..,.~mUT', CGO000134501 02/01/00 02/01/01 i~.c. occun,~NcE $1,000,000 XiBI/PD Ded:2,5001 ~P~.Sow_&~v,,uu,,, ,~., 0O0,000 000 B ,,.ua.u. CSA155726601 i02/01/00 02/01/01 i B(~DILY IN,fURY C !~ssu~u~ UM2067'249 102/01/00 ;02/01/01 ~c. occu~.~ ,2,000,000 ~ o~u, L__] r.~,~,,~ ' I ~ .......... . ,2,0 0 0 .~ 0 0 EMRL~E~' U~ I~ E.~ ~H ~T $ l t 0 0 0 t 0 0 0 Re: 273 & 275 Granz St., Campbell, CA - All work in p~lic right-of-way. (See Attached Descriptions) CERTIFICATE HOLDER I X ] ~u~ornoq~EOiaq~u~q~m.arr~ A.. CANCEI. L~TION City of Campbell Dept. of Public Works 70 North Firsc Street Campbell, CA ~5008 ACORO2S-S(7~)~. of 3 #20345 ~RR-ZO-2000 t4:00 DORSEY, HRZELT~NE & MYNNE 650 856 ~02~ P.OL¢04 DORSEY, HAZELTINE & WYNNE FAX NUMBER: (650) 856-1023 From: Deborah J. Hannagan Fax No: Total Number of Pages including cover sheet: Certificate of Insurance fOllows. Original w~ll follow by mail. If you have any questions, please give m~ a call. IF ANY OF THESE FAX COPIES ARE II.T.F~ZBLE, OR YOU DO NOT lt~CI~ZV~ THE S~ ~~ OF PAGES ~ STATED, P~ CO~A~ US I~D~LY AT: (650) 858-2375. 5~ ~ ~NIO RO~, SUITE 102 - PALO ALTO, CA ~06 - RO. BOX 50307 · P~O ~, CA ~303 PH: ~~75 - F~: ~0-~10~ ~LIFORNIA DE~MENT OF INSU~CE LICENSE NUMBER: 0281413 MRF:;~,-10-20E~ 14:~ DORSEY, HAZELTINE & WYNNE 6'50 8'56 102'3 P.02/04 ACQED. CERTIFICA';. OF LIABILI INSURt 'ICE p~n ~S CE~fl~ IS I~UED AS A ~ OF INFOR~ON DOTSe7, Hazeltine & W7nne ONLY AND ~NF~ NO RIG.S UPON ~E GE~TE HOLDER. THIS C~TIR~ ~ES N~ A~D, ~END OR ~ .O. BOX 50307 ~L~ ~E ~RAGE A~RDED BY ~E ~LIClES BELOW. (~ License ~: 0281413) P~o ~Zto, c~ 9~303 INSURERSAFFOR~NGCO~GE ~U=~ ..................................... ,.SU.E.A: C~[ibec One Zn~e~it~ Co. R.~. Wehne: Concrete ConstcucCion ,.su.~.;: Insurance Company o~ t~~ .... 2025 Stone Avenue ;,.su.~.c.~&*i San Jose. CA 95125 ~.su.~.~: Republic Inde~i~_~... J COVERAGES THE POUCIES OF INSURANCE USTED BELOW HAVE ~E'~ ISSUED TO THE INSURED NAMED ABOVE FOR THE POliCY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 0THOR 00CUM~NT WITH RESPECT TO WHICH THIS CER~FICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AF;ORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SuCH POUClES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAJD CLAIMS. A ;GE~ERAL~.mmUTY CGO000134501 02/01/00 02/01/01 ; EACH OCCURRENCE ,~BI_[/PD Ded:2. 500[ .~s~&~v,~u.~ s%. 000,000 GENI. AGGREGATELIMF~A~S~R~ PRODUCTS -COMP/OPAGG 151 ,, 000 z 000 I B ~~uA~u~ CSAZ55726601 i02/01/00 02/01/01 co.~.;os..G~Eu.~ $1 000 000 __j N.L OWNEO.N./'ro$ 8OOILY INJURY ~i S I raGHEDULED AUTOS ,! e'er Oee~on) ........ ~ ~" HIREOAUTC~ i B~D~LV I~URV ANY AUTO [ 01'HER 'D'~AN EA ACC t AUTO ONLY' AGG ! · DEDUCTIBLE I ' , $ .__ D {WORd.SCOa.ERSt. ON""" !003~'0711 01/01/00 01/01/01 t~ wCST^TU. FMJLOYER~' M&I~LI~ ! ~.[. F. ACM ACCIDENT $ ~ ! 000 t 000 Re: 273 & 275 Grant St.. Campbell, CA - All work in public right-of-way. (See Attached Descriptions) CERTIFICATE HOLDER I X [ ~orn0~$U;E0i~SU~R~E~E~ A CANCELLATION City of Campbell Dept. of Public Works 70 North First Street Campbell. CA 95008 ACOnD2S-S(Tm?)Z of 3 ~20345 MAR-10-~000 14~01 DORSEY~ WAZE-LTINE & WYNNE ~50 05~ 102~ P.0~/0~ IMPORTANT the certificate holder is an ADDITIONAL INSURED. the policy(les)must be endorsed, A statement on this certificate does not confer rights to the certifioate holder in lieu of such endorsement(s). If SUEiROGATION I$ WAIVED, subject to the terms and conditions of tiqe policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this lorm does not constitute a contract between the issuing insurer(s), authorized r~presentatJve or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD2S'SUmT)2 of 3 #20345 MAR-10-2000 1~:01 DORSEY, HAZELTINE & ~YNNE 650 856 1025 P.04/04 DEScrIPTIONS { on inu d ffom 1) Re: 273 & 275 Grant St., Campbell, CA - Ail work in public right-of-way. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSUK~D-OWN~RS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided for under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s) shown in the Schedule as an insured but only with respect to liability arising out of "your work" for that insured by or for you. SCHEDULE Name of Person or Organization: As required by written contract - The City of Campbell, the City of Campbell Redevelopment Agency, its officers, employees and volunteers If you are required, by written contract, prior to an occurrence or offense, to provide primary insurance, then this policy shall be primary and Condition 4. Other Insurance does not apply, but only with respect to coverages provided by this policy. COI.E107A (10-98) AMSZS.3(O?/9'r) 3 of 3 #20345 TOTAL P. 04 INSURANCE REQUIREMI*~S CI-~CKLIST fol~1_ _ / ~ C~ Proj~t ~ ~e o mg ~ur~ce is requirea o~ all co~cto~ wor~g ~ ~e Ci~ of C~pbell Public right-of-way. Imurance cenifi~tes m~t ~ accepted by Ci~ stuff before work ~ begin.. ~ese ~ur~ce requiremen~ apply to work ~g peffo~ed ~der ~ EncroaC~em Pe~it ~d work being peffo~ed under con.ct for Capitol ~provemem Project. Limits : Commercial General Liability for bodily, personal injury and property damage: )81 $1,000,000 per occurrence, and ~ $1 '000'000 general aggregate l~n~t.~plying separately t° $2,000,000 general aggre~at~ limit the project, and Policy expiration date 4-']1 . ~ Automotive Liability - 'any auto' "~ $1,000,000 per accident ~pr b~dily inj~--y and property damage ~ Policy expiration date 7/~]qq (_ /'LL5/Sg~ /LC F).4 (~,.f~ ]) Worker's Compensation and Employer's Liability [] $1,000,000 per accident for bodily injury or disease [] .Policy expiration date Course of Construction (if required in Special Provisions) [] Completed value of the proj<t [] Policy expiration date Required Endorsement to General Liability and Automobile Liability Policies Cdditional In.tared 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 Additio..nal Insured is primary insurance. Workers' Compensation Insurance Sheet Submitted [] For General Contractor Subrogation Clause ~' ( r(_ [F~ Insurance Certificate Reviewed Date Copy'of Insurance Certificate placed in tickler file ',~e month prior to expiration. j:\forms\inscldst 4/96 (rev 6/96) WORKF~R'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: 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 ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIYICATE 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 Californi~ ///~0 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) 05/19/99 17:12 FA~ 973 425 9605__ ~001/005 1300 Mt- Kcmbl~ Ave. P.O. Box 191¢ Mocri~,low~, Ncw Jcr~y 07962-1919 (')73) 4,25-(~W~) · Fax ~97~) FACSIMILE COVER SHEET DATE: TO; FAX: FROM: RE: NUMBER OP PAGES: May 19, 1999 Bill Arnopp silicon Valley 408-294-6462 Alexis Kuhn City of Campbell 3 + COVER SHEET Dear Bill: Please see attached certificate and endorsements for the City of C ampbe 11 I will forward the originals to you as soon as I receive the endorsement from the insurance carrier. Should you need anything further, please do not hesitate to call me. Best rega. rds, Alexis Kuhn Account Manager www.nco~a.com 05/19/99 17:12 FA~ 973 425 9605 ~002/005 .... . ................. .. ,, ,, , CO~ ~O~G P.O. ~ 1919 ~rti~own, ~ 07962-1919 ~uman~ C 888 N. ;i~t Stre~ San Jo~, C~ 95112 ~v_ w~_.. ~ ~ ~ .... ~ ~]~_ r .~ A X C~. ~ ~ 50~051964 4101 ~9 4/01 lOC ~ ~- 2000000 ~ ~ x~ ~ 33655~ ?/23/98 7/23/99 ~ ~ ~0000 officers. ~p~y~. ~ ~u~m ~e ~i~i ~ur~s ATIMA respe~s ~nbil~ ~r CG 20 09. ~ ~o~ in ~ rlg~f-wey re: Pmiect~r~ Numb~ a~ L~ of work. A~: De~ of Pu~ Works 70 ~ ~t Street 05/19/99 17:13 FA~ 973 425 9605 ~003/005 COI~ERCIAL GENERAL LIABILITY OLICY NU~IBER: 5060051964 THIS ENDORSEHENT CHANGES THE POLICY. PLEASE RF~D IT CAREFULLY. ADDITIONAL INSURED--OWNERS, LESSEES or CONTRACTORS (Form A) 'his endorsement modifies insurance provided under the following: COHHERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE 4a~e of Pers~rn or Organization (Additional Insured): Location of ~L'~/CI~ ~ Covered Ol~rations ~'t~: ~, ~c~ ~flj~ (Per ~roperLy Oa~e Li~i I~ty Cost $1~ of cosC) $ Total Advance Premium $ (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 1. WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization (called "additional insured") shown in the Schedule but only with respect to liability arising out of: A. "Your work" for the additional insured(s) at the location designated above, or B. Acts or omissions of the additional insured(s) in connection with their general supervision of "yOUr vOFk" at the location shown in the Schedule, 2. With respect to the insurance afforded these additional insureds, the following additional provisions apply: A. None of the exclusions under Coverage A, except exclusions ia), id), (e), if), ih2), ii), and (m), apply to this insurance. B. Additional Exclusions. This insurance does not apply to: (1) "Bodily injury" or "property damage" for ~hich the additional insured(s) are obligaLed to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liabi{ity for damages that the additional insured(s) would have in the absence of the contract or agreement. 05/19/99 17:14 FAX 973 425 9605 ~004/005 (2) "Bodi I¥ injury" or -property damage" occurring after: All work on the project (other than service, maintenance, or repairs) to be performed by or on behalf of the ~ditional insured(s) at the site of the covered operations has been completed; or (b) That portion of "your work" out of ~hich the injury or damage arises has been put to its inLended use by any person or organization other than anoLher contractor or subcontractor engaged in performing operations for a principal as a part of the same project. (3) "Bodily injury" or "property damage" arising out of any act or omission of the additional insured(s) or any of their employees, other than the general supervision of work performed for the additional insured(s) by you. (4) ~Property damage" to: (a) Property owned, used or occupied by or rented Lo the additional insured(s); (b) Property in the care, custody, or control of the additional insured(s) or over which the additional insured(s) are for any purpose exercising physical control; or (c) "Your work" for Lhe additional insured(s)- CG 20 09 11 85 Copyright. Insurance Services Office, Inc., 1984 ~004/005 "Bodily injury" or "property damage" occurring after: (a) All work on the project (other than service, maintenance, or repairs) to be perfor~d by or on behalf of the additional insured(s) at the site of the covered operations has been co. meted; or (b) That portion of "your work" o~ of which the injury or da~e arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the ~ project. (3) "Bodily injury" or "property damage" arising out of any act or omission of the additional insured(s) or any of their employees, other than the general supervision of work perfor~d for the additional insured(s) by you. (4) "Property damage" to: (a) Property owned, used or occupied by or rented Co the additional insured(s); (b) Property in the care, custody, or control of the additional insured(s) or over which the additional insured(s) are for any purpose exercising physicai control; or (c) "Your work" for the additional insured(s). CG 20 09 11 85 Copyright, Insurance Services Office, inc., 1984 05/19/99 17:14 FAX 973 4Z5 9605 11;1~ ~005/005 P.~ ~ ~ Sili~o~ Valley Habitat for Humanity 5006051964 CITY OF CAMPBELL Public ~/orks Department CAMPBELL Date: October 6, 2003 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: Silicon Valley Habitat for Humanity 888 N. First Street, Suite 215 San Jose, CA 95112 FROM: Joanne M. D'Ambrosia, Senior Office Assistant SUBJECT: 271-275 Grant Avenue Encroachment Permit No. 99-194 Enclosed is a check in the amount of $373.29 representing a refund of your maintenance security, plus accrued interest, in connection with the above property. Enclosure 70 North First Street . Campbell, California 95008-1436 · 'rEt 408.866.2150 · F^x 408.376.0958 - TDI) 408.866.2790 CITY OF CAMPBELL Public '~7orks Department September 20, 2000 Silicon Valley Habitat for Humanity 888 North First ,Street San Jose, CA 95112 Subject: PERMIT NO. 99-194 LOCATION: 271 and 275 Grant Street MONUMENTATION CASH SECURITY REFUND Gentlemen: Enclosed is a check in the amount of $789.54 representing your refund of the Monumentation Cash Security, plus interest, on the above-referenced development. If you have any questions, please call me at (408) 866-2168. Sincerely, L anff Devel6pmenT'Er gl~neer/ Enclosure cc: LD File/271 and 275 Grant Avenue EP File/99-194 Lester Ikegami, Allied Engineering Company, 3170 Williams Road, San Jose, CA 95117 H:\WORD\LANDDEV'~271GRANT(JD) 70 North First Street · Campbell, California 95008-1423 · TEL 408.866.2150 · F^X 408.376.0958 · TDD 408.866.2790 ALLIED ENGINEERING COMPANY R CE)VED August 28, 2000 File No. 9903 Mr. Harold Housley city of Campbell Public Works Dept. 70 N. First St. Campbell, CA 90558-1423 RE: Parcel Map No. 719h 271 and 275 Grant Avenue Campbell, CA Dear Mr. Housley: This letter serves to inform you that the property corners for the above-referenced project were set September 1, 1999. Yours very truly LI:dg ALLIED ENGINEERING COMPANY Lester I kegami cc: J. Dawson, Habitat For Humanity Lester Ikegami Kenneth G. Masunaga Dianne Growitz aengco@gte.net Allied Engineering Company A Division of IK-GM Consulting Civil Engineers 3170 Williams Road (408) 241-1960 Consulting Engineering, Inc. Surveyors & Land Planners San Jose, CA 96117-2658 (408) 241-3047 FAX August 21, 2000 CITY OF CAMPBELL Public Works Department Silicon Valley Habitat for Humanity 888 North First Street San Jose, CA 95112 Re: Project Address: 271 and 275 Grant Avenue EP 99-194, Parcel Map No. 719 1/2 Monumentation Cash Security Dear Developer: According to the City's records, a $750.00 cash security bond is still being retained for setting the survey monuments for the above-referenced Parcel Map No. 719 1/2. Please provide us with a letter from your civil engineer/land surveyor that all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the recorded Parcel Map No. 719 1/2, and that he/she has been paid for his/her services. Upon written request for refund of the security by the party who posted it, the staff will check the site to verify that the monuments have been set. When the monumentation has been completed, the staff will an'ange to have your security released by the City Council. According to recorded Parcel Map No. 719 1/2, monuments should have been set on or before September 10, 1999. Please respond within two (2) weeks of receiving this letter. (408) 866-2158 if you have any questions. Sincerely,///~ I. Harold Housley, P.E Land Development Engineer Contact David Corona or me at CC: LD File/271 and 275 Grant Avenue EP File/99-194 Alan Hom, Public Works Inspector Michelle Quinney, City Engineer Lester Ikegami, Allied Engineering Company, 3170 Williams Road, San Jose, CA 95117 j:\ldXmonuments due 70 North First Street · Campbell, California 95008-1423 - TEL 408.866.2150 · FAX 408.376.0958 · TDD 408.866.2790 May 3, 2000 CITY OF CAMPBELL Public Works Department Silicon Valley Habitat for Humanity, Inc. 888 North First Street, Suite 215 San Jose, CA 95112 SUBJECT: PERMIT NO. 99-194 LOCATION: 271 and 275 Grant Street FINAL INSPECTION AND ACCEPTANCE Gentlemen: 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 $560.00, plus any interest due, is now being processed and will be sent to you under separate cover. Your Maintenance Surety in the amount of $350 has been received, therefore, we are returning the attached Faithful Performance Certificate of Deposit. If you have any questions, please call me at (408) 866-2168. Sincerelyy~),,. (,. Alan HoUri-c~-~c~- Public Works Inspector cc: Suspense - t 1 months Permit g99-194 Inspector File H:\permits\99-194finalltr(mp) 70 North First Street . Campbell, California 95008-1423 · TEL 408.866.2150 · VaX 408.376.0958 · TDD 408.866.2790 City of Campbell Department of Public Works IOACI-IMENT PERMIT ISSUANCE CL ,: LIST Encroachment Permit No. Tract No. Address: .~.-~__,./~ ..~:v.~--- ~T.,,~_..~: _..~.,~_ .,~,~., ITEMS REQUIRED FOR PERMIT APPLICATION: pr~li~pplicant section complete En=ineer s Estimate Submitted Y Plan...Check Deposit Paid (2 % of Engineer's Estimate, $500 rain) Receipt Number ~Five Sets of Improvement Plans Submitted ri'EMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS /"'/Plan Check & Inspection Fee: If Engineer's Estimate < $250,000, then 12% of Engineer's Estimate. If Engineer'S Estimate > $250,000, then Actual Cost + 20%. (Deposit of 8% of Engineer's Estimate required; $30,000 minimum dep_gsit). ~ Amount $ ////'z~ Receipt No. . //AmountSecurity sf°r/,¢Faithful~Perf°rmance andFormLabor and~7 ~terials, 100%i.D. #each~/°f~Engineer's-~'~ -,~',~"~d',7~/,~Estimate' supplied or paid. ~ecarity for Monumentation Amount $ ~7,~'-g:9 Receipt No. .___~ C~ o_~__t_~m~c~on E y Cash Deposit: 4% of Engineer's Estimate. ($500 minimum, $10,000 maximum)' m~'~5~ Receipt No. ~ ~Storm Drainage Area Fee Amount $ ~,~.2e~ Receipt No. /.~,~7.~ z_-'7_.%- 02.Worker,s Compensation Insurance Information Sheet Received for Applicant. All other Public Works requirements listed in the Conditions of Approval of the development. Other Fees, Payments, Deposits Amount $ Receipt No. ITEMS REQUIRED PRIOR TO ISSUANCE OF ENCROACHMENT PE1LMIT: Contractor's signature added to the permit application (front and back) Worker's Compensation Insurance Information Sheet received from Contractor. Or-- r Certificate of Insurance with Additional Insured's Endorsement received from Applicant or Contractor. ~~r~.~D. One mylar set and four blueline sets of off-site plans signed by licensed engineer, stamped APPROVED FOR CONSTRUCTION. Permit signed by City Engineer. WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED. Issuer: Initial and date and file with permit. -7/~ UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND j:\w~rd\forms\pmtcklst rev. 4/97 WORKER'S COMPENSATION INSURANCE INFORMATIOn5 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 r~ 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 ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIHCATE 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. Signed Y:: ~,,,-d [')~'~:~" Date ~.~ 2%, 2000 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) R. H. WEHNER CONCRETE CONSTRUCTION CO. Curbs - Gutters - Sidewalks 2025 Slone Avenue San Jose, CA 95125 (408) 288-6607 Fax (408) 288-8139 Fax ANDREW J. BARDAKOS ENGINEER'S CONSTRUCT]ON STAKING CONSTRUCTION TF..STING CLEARING & GRUBBING SAWCUT P.C.C./A.C.(UP TO 6') 3. P.C.C. REMOVAL &. ,C'JRI~ AND Gb~-'TE-R REMOVAL MEDIAN REMOVAL DEMOLI~H EXLe~NG 5NL~'T/PLUG RC?*~ I5' R.C.P. (~ IID ir ~C.P. (C~ lid IV. 4. 24' ?..CP. (CLASS III) $. ~0' R.C.P. (CLASS III) 6. ~.V. INSPECTION (I'~') !c.c. DE'r^m 9) FLAT GRATE INL.?r {C.C. DETAIL 6) 9. STANDARD MANHOLE !C..IJ. DETAIL D-II) ~INCLUDES FRAME & LID) BRF~AK AND ENTER M.H.~D.I. SIDEWALl( L DRD,'EWAy APPROACH SF LF LF LF LF LF ~o s~i UNIT PRICE~ FOR PROJECT AA4OUNT <130K { ~30Kto$150K >$1~0K I l $71.0 :,$0.7t Sl..~0.~0 Sl.I~O.{X) $10.GOi $2.~0 $1.25 $1 $450.~0' AMOUNT ~ ~999 27-Jim-96 Page 1 of 4 PAVEMENT FAiJRIC (PETRO-MAT) ASPHALT CONCRETE (TYPE A) 7. SLURRY SEAL {TYPE II) SLURRY SEAL Ci'Y'PE lid : D~E~ORL~P(6'x~') 3. ,~ETECTOR LOOP (6' x $0') 4. ELEC'T~OLIER $. I 1~' RIGID CONDUIT 6. :' RIGID CONDUIT SF /. SF LF~ '~"' fl0t $1&m $1~.00 $11~0 $I0.00 $~0.0 $I~0{ $10.~ ~l.001 ~.00~ $~-~ .~_~ ~$0.~01 $I.~0; $I~00j $1.~0.fl0 $I0.001 27-3'un-96 Page 2 of 4 NO. I DESCRIPTIOn, 7. CONDUCT,Ok L PULL BOX (NO. 3 ,P~LL SOX (NO. ~ 1. ILk'MOVE PVMT. MAIUClNGS REMOVE PVMT. MARKINGS {THI~.MO) 3. REMOVE PVMT STRJPING 4. ~'RIP~NG DETAIL 9 $. ~T'RIPING DETAIL 29 STRIPING D~TAZL 32 7. STRIPING DETAIL 37 (THERMO) 8. STRIHNG DETA/L .38 (THERMO) 9. 5T'RIPING DETAIL 39 10. STRIPING DETAIL ~O II. LIMIT LINE 12. CROS~vVALK 13. ?AVEME.N~T MARKINGS (PAINT) M. PAVEMENT MARKINGS CTI-IERMO) :.1-. 'PAVEMENT MARKER (NON-REFL.) PAVEME~rr MARKER (REFLECTIVE) 17. ~PE K MARKER 18. TYPE N MARKER I9. SALVAGE ROAD SIGN '~0. RELOCATE ROAD SIGN 21. INST. RD. SIGN ON E3CXST. POLE ~. ROAD SIGN W~ ~ QUANTrrlES LF SF SF $1.40! ~O. aO ~ r J · =c-r .uaotm'r > SI.SO K Sl~.OO SI.m $1.ao S0.451 SI.00 $I.~0 ~.00i SIIO. COI · 27-Jun-96 Page 3 of 4 NO. I DESCRIPrlt,. ]IRRIGATION. PLANTING WORI~ ~EE REMOVAL 4.R~ ~A~ER R~T ~ARR~R 6.~E~ ~4' ~O~ 7. ~EE ~' ~O~ 8. ~OP SOIL M~t 1 ~O~S I. ,PED~I~ B~RIER C~AIN ~ FENC~ (6') ~ISE MISC. gOX TO GRADE 4. RAL~E MANHOLE TO GRADE $. IN~'ALL, MONUMEN'T BOX 6. MEDIAN RACKFILL $I00.~0 $I0.0 $Z$.~0 $10./X $ AMOUNT PREPARED BY: ~..~'- R EVI~'I,rE.D BY: APPROVED BY: 10% SECL/RIrY' ENFORCEJvIENT FEE TOTAL ESTlaATE FOR FAITH"FUL PERFORMA.qC~ SECURrTY ~ ..~ction 66499.4, ofc~e M~p AC:. H:'.CEC OST:--~T. WK3I M p) REV6~/96 27-.Tun-96 Page 4 of 4 City of Campbell Department of Public Works Tract No. Address: I'J~ REQUIRED FOR PERMIT APPLICATION: Applicant section complete /~,, Applicant signature ~,~ont and back) ..... -~, Permit Application F~.2~5..~.: paid- Receipt Number '(~-'vlan Paid (2% of Engineers Estima~in) Receipt Number _./Five Sets of Improvement P1ans Submitted ]_ , ~ .-' Plan Check & InspecUon Fee: If Engineer's Estimate < $250,000, ~_ 1~__~. f_' .~e?s Es~Ltim~& If Engineer's Estimate > $250,000, then Actual Cost + 20%. (Deposit of 8% of Engmeer's_Estimate required; $30,000 minimum. ~ i~:'2 Receipt No. deposit). Amount $ ~" "--~"~ Security for Faithful Performance and Labor and Materials, 100% each of Engineer's Estimate, supplied or paid. , .... ~.Am°unt $ //)~,~ 4~':t/, Form _,,~__,~/' I.D. # '--__ :.. Security for Monumentation Amount $ ,,..~A/,~ Receipt No. . ,, Construction Emergency Cash Deposit:,-~4% qf Engineer's Estimate. (S500 minimum, $10,000 maximum) ........... Amount $ ReC~iPfN°. .x.~-,,A' Storm Drainage Area Fee Amount $ ~-5: ~'> Receipt No. Worker's compensation Insurance Information Sheet Received for APplicant. ,,. Ail other Public Works requirements listed in the Conditions of Approval of the development. Other Fees, Payments, Deposits Amount $ Receipt No. ITEMS REQUIRED PRIOR TO ISSUANC .O~i7 ENCROACI-IMENT PERaMIT:', ." ~-' Contractor's signature added to the permit application (front and back) Worker's Compensation Insurance Information Sheet received from Contractor. Certificate of Insurance with Additional hnsured's Endorsement received from Applicant or Contractor. One mylar set and four blueline sets of off-site plans signed by licensed engineer, stamped APPROVED FOR CONSTRUCTION. ,,t Permit signed by City Engineer. WI-IEN ALL OF THE A. BOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED. /Bsuer: Initial and date and f'fle with permit. CITY OF CA~4~BEI.L I~'BLIC WORKS DEY'ARTME~T E~GINEER'S F..STI~TE Er~'rmct~n~nt I~,,,;~ No. L DESCRIPTION MOBILIZATION ,CONm'RUC--flON TR.~FF~C ~Oh'rROLCOm'ROL/?tL~ZNG ~ONSTRUCTION ~ING CO~U~ON ~NG CLEARING .e. GRUBBING -" SAWCUT P.C.C..tA.C.(LTP TO ,3. ?.C.C. R I:',MOYAL .t. CUR8 AND GLrl'F~R REMOVAL $. MEDIAN R!:MOYAL DEMOLISH EXISTING INLET/PLUG RC?'$ , OuA~rrrms. 4. 24' R.C.P. (C'.,.AS5 III) ~0' R.C.?. {CI.A.~ 6. ~.V. INSP£C'rlON (12') 7. STD. DRAINAGE INLET [C.C. DETAIL 9) 8. FLAT GRATE INLET (C.C. DETAIL 6) 9. STANDARD MANHOLE {C.S.J. DETAIL D-I 1) [INCLUDES FRAME & LID) lO. BRF~UC AND ENTER M.H./D.I. I. SIDEWALK DRIVEWAY APPROACH SF LF LF LF t/hTr PRIC~ FOR PROJEC"r AMOUI~rr {30 K to S150 K S1,100.00 SI.(~XLO0 · $1:50 K ~'.00! $10.001 SI.2~ $1,OCO.0 $1300.00 .. SAMOUN"r 27-Jun-96 Page 1 of 4 L Z. 3'. 4.. .~. 6, 7. Vl. 3. PAVEMENT GRINDING AVEMENT FABRIC (PETRO-MAT) ASPHALT CONCRETE (TYPE A) ~AGGREGATE BASE (CLASS 2) SLURRY SEAL ~'Y'PE II) SLURRY SEAL ~I"YPE lid DETECTOR LOOP (6' x 30') DETECTOR LOOP (5' x $09 ELECTROLIER ,~ I~' RIGID CONDUrr ~' RIGID CONDUrr SI-200.00i LFI S12.00 SF{ $12.~0 SF ! ~'.00 SF; 13.801 SY ! {ZOO I i. I EA ', LF ~ S17.C0~ UNIT PRIC~.. .OJECT ~OUNT > $I~0 K S1~.00 $'~0.00 $7.~0 SI0.00 I3.00 $1.~0; $0.35 $I.~0 ~.~; $10.00l $ AlVlOUNT 27Jun-96 Page 2 of 4 '7. CONDUCTOR I. pULL BOX (NO. 3 I~) ~uu. aox 0~o. g 1. R[MOVE ~MT. MA~IN~ ~AI~ REMOVE ~. MA~GS ~ERMO) REMO~ ~PING ~IPING D~AIL 9 ~IPING D~AIL29 7. ~RIPING D~AIL 37 ~HE~O) ~RIPING b~A~ 38 ~ERMO) 9. ~IPING D~AIL 39 10. STRIPING DETAIL 40 II. LLMIT LINE 12. CROS,SWAL.X I'~. PAVEMENT MAR~ZNGS (PAIN'T) 14. PAVEMENT MARKINGS (T'rlERMO) 15. PAVEMENT MARKER (NON-REFL.) 16. PAVEMENrT MARKER (REFLECTIVE) 17. ~TYPE K MARKER 18. TYPE N MARKER 19. SALVAGE ROAD SIGN 20. ~ELOCATE ROAD SIGN 21. INST. RD. SIGN ON EXIST. POLE ROAD SIGN WITH POST 27-Jun-96 Page 3 of 4 2. 4. $. 6. 7. 8. .IX. I. 2. NO. ! DF-~R~Cm ~RUNE TREE ROOTS ~REE REMOVAL R~ ~A~IER T ~ARRIER (Ig") 7OP SOIL .PED~IAN B~RIER ~HAIN M~ ~NCE (~') ~ISE MISC. ~OX TO GRADE 4. RAISE MANHOLE TO GRADE $- INSTALL MONUMENT 6. 1MEDIAN BACKFILL $I0.00 S15.0 $11~01 $10.~ $9.?7. S17.00i $15.501 $ AMOOI~rr PREP ARED BY: L~" REVIEWED BY: APPROVED ny: 105 SECURITY ENFORCEMENT FEE TOTAL, EST~4ATE FOR FAITHFUL PERFORMAN(~ SECURITY ~ ..%etlon 66499.4 of~ Ma0 Act. H:\CECOSTEST.WT:3(Mp)REV6/3/96 27-Iun-96 Page 4 of 4