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APPLICATION FOR DRAIN'LAYER'S 'LICENSZJ,''
// MANSFIELD, MA
DATE:
Name and/or Corpporat' on:���JL�� (J y lvz L"Z'��
& Address: 5./�G L`2 ST !2 Jai /✓S /fL
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. /J
Signature: �� ? eld�
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DPW APPROVAL:
DATE: �ZrO195
DEFT 50_ 412C:
T4T1111 TRANl,137234 06/20/95
RECEIPT 145612 C31
t25[(.0
E250.0
. -_iii TRRId 2�;'_'S�'r Liti%2l{/nr
ACHIRIPe CERTIFICATE OF INSURANCE ISSUE DATE (MM/DD/YY)
X 06/07/95
PflooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
NEW ENGLAND SECURITY INSURANCE AGENCY INC! CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
I DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
200 CHAUNGY STREET — SUITE 100 POLICIES BELOW.
MANSFIELD, MA 02048 COMPANIES AFFORDING COVERAGE
COMPANY
LETTER A TRAVELERS INSURANCE COMPANY
COMPANY
INSURED LETTER B PHOENIX INSURANCE COMPANY
ROBERT J. BRUNELLE
DBA BRUNELLE CONTRACTING LETTERNv C
52 GILBERT STREET
MANSFIELD, MA 02048 LETTERNY D
COMPANY E
LETTER
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.
"0 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE ;POLICY EXPIRATION
TR. DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS
GENERAL LIABILITY m�� ®� w�. .,._ _»ten GENERAL AGGREGATE �$1,000,000
A X COMMERCIAL GENERAL LIABILITY 660-617E151A—COF-94 07/27/94 07/27/95 PRODUCTS-COMP/OP AGG. $1,000,000
!CLAIMS MADE X !OCCUR. PERSONAL &ADV. INJURY $ 500,000
OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $ 500,000
FIRE DAMAGE (Any one Ilre) $ 50,000
. „ Aw...�.._,..,.. .�»�,..,..�.... ..m., �»�,.. �..,,......
MED. EXPENSE (Any one person) $ 5,000
AUTOMOBILEE LIABILITY
Y
COMBINED SINGLE $
ANY AUTO LIMIT
ALL OWNED AUTOS BODILY INJURY
A X SCHEDULED AUTOS AO—BAP258K421—A-95 01/01/95 01/01/96 (Per person) $ 500,000
X HIRED AUTOS
BODILY INJURY $ X NON -OWNED AUTOS (Per eccldent) 500,000
GARAGE LIABILITY
PROPERTY DAMAGE $ 100,000
EACH OCCURRENCE $1,000,000
UMBRELLAFORM �..,...._....,, PSMCDP _...... _..„ �. _..�. .............._ ,.,,._.. _,_. .. ...._.. ,..,..,,... ,..w..».. ,._,-,.,,,.�__._....._....
Y
A g 526K559-0-94 07/27/94 07/27/95 AGGREGATE $1,000,000
OTHER THAN UMBRELLA FORM
COMPENSATION X STATUTORY LIMITS
B; AND 6N—UB-731KO31-5-95 03/31/95 03/19/96 EACHACCIDENT $ 100,000
EMPLOYERS' LIABILITY DISEASE —POLICY LIMIT $ 500.,000
DISEASE EACH EMPLOYEE $ 100,,000OTH
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
EXCAVATION & DRAINAGE SYSTEM CONSTRUCTII
TOWN OF MANSIELD IS AN ADDITIONAL ATIMA
TOWN OF MANSFIELD
DEPARTMENT OF PUBLIC WORKS
C/O BOB SWANSON
50 WEST STREET
MANSFIELD, MA 02048
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURk TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LI QTTY 9F ANY II O UP*T.09 QOMPAt�}�'„ ITS AGENTS OR REPRESENTATIVES,
, INC.