HomeMy WebLinkAboutGrant Bros.APPLICATION FOR DRAINLAYER'S LICENSE U
_ MANSFIELD, MA
/ . 9 -) , q S 95 JUL -6 Pi i 12* 32
Name and/or Corporation: G na4-i 6rc5s
& Address:—(.4 �7, e rh /m ,,
Emergency 24 hour telephone # 5$T
Please attach the following:
61
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 f $250.00.
The undersigned hereby acknowledges receipt, understanding of the
Drainlayer's Regulations, and that he/she has read the entire
document. A .
Signature:
DPW Approved:
Date:
5Ci
J5i'��
ACORD .. 1 T CATE (IF
( YY
0 6
..... ..........................'....'... / 2 9/ 9 5
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
The Hills Insurance Agency
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 157
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
38 Colchester Rd.
COMPANY
Plympton MA 02367-0157
(617) 585-4410
A Essex Insurance Company
INSURED
COMPANY
Grant Brother Associates
B ITT Hartford
COMPANY
P.O. Box 11
C Pilgrim Insurance Co.
COMPANY
Manfield MA 02048-
(508) 339 7777
D
.... . :.:...
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.
LT
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICYEFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DDPM
LIMITS
A
GENERAL
LIABILITY
GENERAL AGGREGATE
$1000000
PR
PRODUCTS-COMP/OP AGG
$1000000
)MOMMERCIAL GENERAL LIABILITY
3 AS 8628
03/04/95
03/04/96
CLAIMS MADE 0 OCCUR
PERSONAL&ADV INJURY
$
EACH OCCURRENCE
$1000000
OWNER'S&CONTRACTOR'S PROT
FIRE DAMAGE (Any one fire)
$
MED EXP (Any -no person)
$
C
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$
ANYAUTO
AMCB040620
01/05/95
01/OS/96
BODILY INJURY
(Per person)
$
1000000
ALL OWNED AUTOS
SCHEOULEDAUTOS
Y
BODILY INJURY
(Per accident)
$
1000000
HIRED AUTOS
NON -OWNED AUTOS
Y
PROPERTY DAMAGE
$
1000000
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT
$
OTHER THAN AUTO ONLY:
........................................
ANY AUTO
/ /
/ /
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
UMBRELLA FORM
/ /
/ /
$
OTHER THAN UMBRELLA FORM
B
WORKERS COMPENSATION AND
TIH—
WC SLIMIT ER
EL EACH ACCIDENT
$100000
EMPLOYERS' LIABILITY
77 WE CR 9490
11/19/94
11/19/95
EL DISEASE -POLICY LIMIT
$500000
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
EL DISEASE - EA EMPLOYEE
1 $100000
OFFICERSARE: EXCL
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
Town of Mansfield is Additional Insured
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Town Of Mansfield, Town Hall
SO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Engineering
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
50 West St.
OF ANY KIND UPON THE COMPANY, TS AGENTS OR REPRESENTATIVES.
Mansfield MA 02049
f2ED RESENTATI E
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