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APPLICATION FOR DRAINLAYER'S LSCENSE-.,r
MANSFIELD, MA
DATE: l
Name and/or Corporation: Tt
& Address• / )✓n+ ^(
Emergency 24 hour telephone
Please attach the following:
1. Valid Heavy Equipment Operators License (copy);
2. Insurance Certificate (Town must be listed as additionally
insured);
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 Regulations, and that he/she has read the entire
document.
Signature: --7=f —�`—
DPW Approval:
Date:
l
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`CERTIFICATE OF INSURANCE DATE MINGO
6/1( 2/95 NY)
/1
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Robert W. Eames Ins. Agency, Inc.
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
! 126 North Main Street
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
P. 0. Box 289
Mansfield, MA 02048
COMPANIES AFFORDING COVERAGE
COMPANY HANOVER INSURANCE COMPANY j
INSURED
COMPANY
Christian & Feck Development Corp.
B MASSACHUSETTS BAY INSURANCE COMPANY
j 2 Elmwood Court
COMPANY
E Mansfield, MA 02048
C WORKERS COMP. INS. PLAN OF MA
COMPANY
D
COVERAGES
I 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 I
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, k,
EXCLUSIONS AND CONDITIONS OF SUCH. POLICIES LIMITS SHOWN. MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO ! TYPE OF INSURANCE POLICY NUMBER
LTR
POLICVEFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YV) DATE (MMIDD/YV) LIMITS
GENERAL LIABILITY
GENERAL AGGREGATE $2,000,000
A IX J COMMERCIAL GENERAL LIABILITY
PRODUCTS-COMP/OP AGO $Not Covered
') __.ICLAIMS MADE I X OCCUR ZHN3213135
9/15/94 9/15/95 PERSONAL & ADV INJURY $1,000.,000
s OWNEWSB CONT PROT -
EACH OCCURRENCE _ 1 $ 1,000.,000
FIRE DAMAGE (Any one fire) .. i$ 50,000
MED E%P (Any one person) $ 5,000
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
ALL OWNED AUTOS
B X...., SCHEDULED AUTOS ADN4246880
�
BODILY INJURY
12/15/94 12/15/95 (Per person) $ 250, 000
MIRED AUTOS
I I
BODILYINJU
Br 00 000 `
i$ 5
NON -OWNED AUTOS
i
(Peer accident) Y{
PROPERTY DAMAGE $ 100,000
GARAGE LIABILITY
AUTO ONLY EA ACCIDENT. $ l
_ ANY AUTO
OTHER THAN AUTO ONLY:
_
EACHACCIDENT Is 1
AGGREGATE $
EXCESS LIABILITY
l
EACH OCCURRENCE $
UMBRELLA FORM
AGGREGATE $
' OTHER THAN UMBRELLA FORM
$
WORKERS COMPENSATION AND
( I STATUTORY LIMITS
EMPLOYERS LIABILITY
EACH ACCIDENT $ 100' 000
C THE PROPRIETOR/ IINCL NEW POLICY
PARTNERS/EXECUTIVE
6/7/95 6/7/96 DISEASE POLICY LIMIT $ 500., 000
[ OFFICERS ARE: EXCL
DISEASE EACH EMPLOYEE I $ 100., 000
OTHER _.. _...
...
(DESCRIPTION OF OPERATIONS/LOCA710NSNE ICLES/SPECIALITEMB
Town of Mansfield is listed as Additional
i
Insured - State or Political Subdivisions.
I
CERTIFICATE HOLDER
r4
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Town of Mansfield
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
50 West Street
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
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
(
AUTHORIZED REPRESENTATIVE I
I
ACORD 25.5
(3/93)
ORD.CORPORATION 1993,