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HomeMy WebLinkAboutGentileAPPLICATION FOR DRAINLAYER'S LICENSE" - MANSFIELD, MA DATE: Name and/or Corporation: & Address: -DFQtSY,rn Si�ert-' 1'l-�t�c Emergency 24 hour telephone n so' Please attach the following: YS. Valid Heavy Equipment operators License (copy); ✓2. Insurance Certificate (Town must be listed as additionally insured); 1v/A-3. Performance Bond; , 4. Three references who are familiar with your work with telephone numbers; ,, 5. Application fee of $250.00. The undersigned hereby acknowledges receipt, understanding of the Drainlayer's Re ation and at he/she has read the entire document. Signature: ' DPW APPROVED: -&t DATE: DEPT 50 HISC: $25i.i.0m T40002 TRAM 097008 06/21/95 RECEIPT 166955 C-12 $250.0u T1O002 TRO i197008 06/21/ 95 RECEIPT 166955 C4�2 $250.1- MIAMne CERTIFICATE OF INSURANCE °ATE(MM,°°'""' 06/20/95 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Donald F. Bradbury Iris. Agcy., Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 158 Main St., P.O. BOX 644 I HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR j ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I E Norfolk, MA 02056 COMPANIES AFFORDING COVERAGE COMPANY ` A Liberty Mutual [INSURED -__ ----. ---_ --.. ----. COMPANY L.J. Gentile & Sons, Inc./Gen Leasing, Inc. B Fidelity & Casualty Co. of NY P.O. Box 159 COMPANY Norfolk, MA 02056 C COMPANY D Jll !COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTP TYPE OF INSURANCE POLICY NUMBER POLICY DATE (MWDDVIY) VE PDATE(MM/DDY) OLICY EXPIRATION LIMITS € I ( GENERAL LIABILITY --- -- ---- ---- - GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGO $ ]CLAIMS MADE OCCUR PERSONAL & ADV INJURY.- $ OWNER'S &CONT PROT L EACH OCCURRENCE $ FIRE DAMAGE (Any one fire $ I MED EXP(Any one person)-- $ _. a AUTOMOBILE LIABILITY — COMBINED SINGLE LIMIT $ ANY AUTO ' ALL OWNED AUTOS [AM1-313-244605-014 06/28/94 06/28/95 ' € -- BODILY INJURY X SCHEDULED AUTOS AM1-313-244605-015 06/28/95 06/28/96 (Per person) $500,000. A HIREDAUTOS BODILY INJURY NON OWNED AUTOS (Per accident) $500,000. € I I i - -- -- PROPERTY DAMAGE $ 100,000. - GARAGE LIABILITY - - --- -- AUTO ONLY- EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY kk ( i EACH ACCIDENT $ 1 AGGREGATE i$ I EXCESS LIABILITY EACH OCCURRENCE $ i I (UMBRELLA FORM AGGREGATE I$ €s OTHER THAN UMBRELLA FORM $ j E€ WORKERS COMPENSATION AND -- ---- ---- -- STATUTORY LIMITS - s [ EMPLOYERS' LIABILITY B 128C 886 5499 95D I04/28/95 04/28/96 EACH ACCIDENT $100, 000. THC PROPRIETOR/ PARTNEBS/EXECUTIVE INCL DISEASE POLICY LIMIT $500,-000. OFFICERS ARE..... EXCL --. -.-.. - DISEASE EACH EMPLOYEE $ 100, 000. --� OTHER -- - I i t I DESCRIPTION OF 6PEggTION5ILOCATIONSNEHICLESISPECIAL ITEMS - --- t z I CERTIFICATE HOLDER CANCELLATION -I Town Of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1 Dept. Of PUb11C Works 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 50 W@S{' S{'. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Mansfield, MA 02048 TTTTTTOHHgHHqFANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUppppppB��B���IDREPgESENygTIV - -� i ACORD 25.3 (3/93) .. -. ©A RPORATION 1993 j ACORD� CERTIFICATE OF LIABILITY INSURANCE DATE(MnvDDnn I PRODUCER -- -- -- - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Commercial Iris. Exchange,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1 Thurber Blvd., Unit C HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Smithfield, R.I. 02917-1859 I _ _COMPANIES AFFORDING COVERAGE _ COMPANY A Assurance Company of America INSURED L. J. Gentile & Sons, Inc. COMPANY B P.O. Box 159 Norfolk, Ma. 02056-0159 COMPANY C COMPANY `COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION_ S OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICYNUMBER POLICY EFFECTIVE 1 POLICY EXPIRATIONLTR LIMITS I DATE(MM/DDM/) DATE(MWDD" A GENERAL LIABILITY -GENERAL AGGREGATE $ 2 000 000. X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [ X OCCUR I,, CFP 25606857 PRODUCTS-COMP/OPAGG $2 0.00 00.0_. 5-16-95 5-16-96 PERSONAL&. ADV INJURY ,$ 1,000,_OQO_ OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ D_OO , 000_ _ FIRE DAMAGE (Any one fire)_.. $ _50 pQjOLO. _�AUTOMOBILE __ _._....___._.........__-_._......__._..__.._.._ w.__..__._.__.._.__. MEDEXP(AnYoneperson) _$ _],-0_,_000 LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS N/A SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY (Pert ccid.n)RY $ J I ;PROPERTY DAMAGE '$ GARAGE LIABILITY 1 AUTO ONLY - EA ACCIDENT $ ANY AUTO N/A OTHER THAN AUTO ONLY. EACH ACCIDENT $ AGGREGATE $EACH EXCESS LIABILITY �UMBRELLA FORM NSA OCCURRENCE s$ ,AGGREGATE ;$ IIOTHERTHAN UMBRELLAFORM $ WORKERS COMPENSATION AND WC STATU OTH TORY LIMITS ER EMPLOYERS'LIABILITY N/A _ THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE I EL EACH ACCIDENT $ EL DISEASE POLICY LIMIT $ OFFICERS ARE: EXCL OTHER EL DISEASE - EA EMPLOYEE $ L_....._. ........._ I .__......_.._ .._..... ._..... DESCRIPTION OF OPERATIONSA-OCATIONSNENICLES/SPECOLL ITEMS ._..._ I, _._._ _.. _ Add additional insured- Town of Mansfield 'CERTIFICATE HOLDER CANCELLATION Town of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Dept. of Public Works iii EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 50 West Street 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Mansfield, Ma. 02048 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Attn: Rene OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES I AUTH RI ED REPRESENTATIVE ACORD12"(7/95) = Thomas T. Too ey/mp OACOR CORPORATION198B