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Home My WebLink AboutRicciofr/(9"'� �L APPLICATION FOR`DRASNLAYER'S LICEENS ' MANSFIELD, MA DATE: Name and/or Co�geen: & Address L i �l rt vc�0 kSS z Emergency 24 hour telephone "n css - • ��i —35z S Please attach the following: 1. Valid Heavy Equipment operators License (copy); 2. Insurance Certificate (Town must be listed as insured); 3. Performance Bond; 4. Three references who are familiar with your telephone numbers; 5. Application fee of $250.00. additionally work with The undersigned hereby acknowledges receipt, understanding of the Drainlayer's Regulations, and that het —she —has read the entire document. 1 Signature: DPW Approval: Date: ,. :�� ISSUE GATE (MM/DDNY) 05 30 95 .:.IS ,._.. ,...TIFICATEIS PRODUCER:::.::............................:.............:......................:...................:............... THIS CERTIFICATE ISSUED AS A,MATTER OFINFORMATION ONLY AND Iris Advantage Agency g g Y 61 East Main Street CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. COMPANIES AFFORDING COVERAGE Orton, Ma 02766 COMPANY A LETTER Generali (508) 285-4848 COMPANY B LETTER Arbella INSURED 1CC10 Builders & Developers P. 0. BOX 807 COMPANY `. LETTER COMPANY D LETTER ansfield MA 02048 COMPANY E LETTER (508) 339-3925 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE (MM/DDIYY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $1 OOO OOO COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OPAGG. $1 000,000 CLAIMS MADE X�OCCUR. NGL706956 01/13/95 01/13/96 PERSONAL&ADV. INJURY $1 OOO OOO OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $1 0 0 O , O O 0 FIRE DAMAGE (Anyone fire) $ MED,E(PENSE(Anyonepemon) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $1,000,000 BODILY INJURY (Per pereon) $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 4QF519061 10/26/94 10/26/95 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ UMBRELLA FORM / / / / OTHER THAN UMBRELLA FORM STATUTORY LIMITS WORKER'S COMPENSATION EACH ACCIDENT $ AND DISEASE --POLICY LIMIT $ EMPLOYERS' LIABILITY DISEASE -EACH EMPLOYEE IS OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Town of Mansfield "Additional Insured" own Of Mansfield ::: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 50 West Street > EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Kansfield, MA 02048 MAIL 2 O DAYSWRITTEN NOTICETO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTH 2ED REPRESENTATIVE J$�?I�I7 i"1!N CICQ t&1L:: ISSUE DATE (MM/DD/YY) r on :.. 05 30 95 `THIS PROD ICER . CERTIFICATEISISSUEDASAMATTEROFINFORMATION ONLY AND Iris Advantage Agency 61 East Main Street CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE Orton, Ma 02766 (508) 285-4848 COMPANY A LETTER Generali COMPANY B LETTER Arbella INSURED 1Ccio Builders & Developers P. 0. BOX 807 COMPANY `. LETTER COMPANY D LETTER ansfield MA 02048 (508) 339-3925 COMPANY E LETTER 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 CONTRACI' OR OTHER DOCUMENT WITH. RESPECT TO WHICH PHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE DATE (MWDD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $1 000OOO PRODUCTS-COMP/OPAGG. $1 00O 000 COMMERCIAL GENERAL LIABILITY CLAIMSMADEI OCCUR. NGL706956 01/13/95 01/13/96 PERSONAL&ADV. INJURY $1 000 000 EACH OCCURRENCE $1 0 0 0 , 000 OWNER'S & CONTRACTOR'S PROT. FIRE DAMAGE (Any one fire) $ MED.EXPENSE(Anyoneperson) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $1 000,000 BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 4QF519061 10/26/94 10/26/95 BODILY INJURY (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM / / / / AGGREGATE $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY STATUTORY LIMITS .!: EACH ACCIDENT $ DISEASE --POLICY LIMIT $ DISEASE --EACH EMPLOYEE Is OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS own of Mansfield "Additional Insured" <a<<<s(z''`5;>;€'''"::.::<::>r''::<.>:<:a;>:a::'a<::»».;a:<:>.>::I<>::>::::e:: OWn Of Mansfield SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE O West Street EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO Mansfield, MA 02048 MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR (ABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. 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