The URL can be used to link to this page

Home My WebLink AboutD&J Excavating-0 /0&3 APPLICATION FOR DRAINLAYER'S LICENSE MANSFIELD, MA DATE: 1 11- / S Name and/or Corporation: f & Address: 992- OCl K ST' Emergency 24 hour telephone tt, Please attach the following: iG o H A N LLD 95 AUG -2 PM 7: 25 MANSHELD 0�3391:-k?S- 1. Valid Heavy Equipment operators License (copy); 2. Insurance Certificate (Town must be listed as additionally insured); 3. Performance Bond; our work with 4. Three references who are familiar with y telephone numbers; 5. Application fee of $250.00. The undersigned hereby acknowledges receipt, understanding of the Drainlayer's Regulations, and that he/she has read the entire document. ^ ^ ^ '4 Signature: DPW Approved: ` Date: �� /� ...,:"i:':.:4(�:�.r.r•,�:.,.....�:�:;`i;::`"::"':ji��:�.:`9..(µ::y.::<::(`:ii[":�:"$I:.:t:::::c::is��f',::f''`:""":,,..:...�::i)l:'::::::�:::5::::::::::`:'<::_:'j�j::::`:%EL'::::::::::'::<:::';:::�::<': DATE :.M M/o....:.......:.:: 07/14/95 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION commsxclAL INSURANCE PROVIDERS, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 577 KBLLBY BLVD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE COMPANY NORTH ATTLEBORO, MA 02760- (508) 695-2090 A Employers Mutual Co. INSURED COMPANY D & J Excavating B COMPANY James & David Garner DBA 792 Oak St. C Brockton MA 02401- COMPANY 584 9059 D A(K508) 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. LI R TYPE OF INSURANCE POLICY NUMBER FOUCYEFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY GENERAL AGGREGATE $1,000,000 X PRODUCTS-COMP/OP AGO $1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS MADE X�OCCUR IDo-39-83-95 12/06/9S 12/06/96 PERSONAL &ADV INJURY $1,000,000 EACH OCCURRENCE $1,000.000 OWNER'S&CONTRACTOR'S PROT FIRE DAMAGE (Any one fire) $So,000 MED EXP (Any one person) $ 5, o00 A AUTOMOBILE LIABILITY ANYAUTO TBD 05/23/95 05/23/96 COMBINED SINGLE LIMIT $ % % BODILY INJURY (Per person) $ 500,000 ALLOWNEDAUTOS SCHEDULED AUTOS % X BODILY INJURY (Peraccident) $ 1,000, 000 HIREDAUTOS NON -OWNED AUTOS % PROPERTY DAMAGE $ 100,000 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 WORKERS COMPENSATION AND STATUTORY LIMITS ... i..... EMPLOYERS' LIABILITY EACH ACCIDENT $ THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE DISEASE - POLICY LIMIT $ DISEASE - EACH EMPLOYEE $ OFFICERS ARE: EXCL OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Additional Insured: 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of Mansfield BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 50 West St. OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. Mansfield MA 02048 AUTHORIZED REP L :: CERTIFICATE OF INSURANCE ISSUE DATE PRODUCER 06/05/95 THIS CERTIFICATE ISSUED AS MATTER OF INFOR- LONG INSURANCE AGENCY, INC MATION ONLY AND CONFERS NO RIGHTS UPON THE 211 NORTH STREET CERTIFICATE HOLDER; IT DOES NOT AMEND, EX- FOXBORO, MA 02035 TEND OR ALTER COVERAGE AFFORDED BY THE POL- COMMERCIAL INSURANCE PROVIDERS, ICIES BELOW. COMPANIES AFFORDING COVERAGE: INC. COMPANY 577 KELLEY BLVD,N. ATTLEBORO MA LETTER A EMPLOYERS MUTUAL INSURANCE 508-543-1515 COMPANY INSURED LETTER B EMPLOYERS MUTUAL INSURANCE JAMES GARNER, DAVID GARNER DBA COMPANY D&J EXCAVATING LETTER C 792 OAK STREET COMPANY BROCKTON, MA 02401 LETTER D COMPANY LETTER E COVERAGES: THIS CERTIFIES THAT INSURANCE POLICIES BELOW HAVE BEEN ISSUED TO THE ABOVE INSURED FOR POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR DOCUMENT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE HEREIN IS SUBJECT TO ALL TERMS OF SUCH POLICIES. CO TYPE OF POLICY POLICY POLICY ALL LIMITS IN LTR INSURANCE NUMBER EFF DATE EXP DATE THOUSANDS A GENERAL LIABILITY 1D03983-85 12/06/94 12/06/95 GEN AGGREGATE $1,000 X COMMERCIAL GENERAL LIABILITY PR-CMP/OPS AG $1,000 CL MADE XOCCURRENCE PERS&ADV INJUR $1,000 OWNER'S & CONTRACTORS PROTECTIVE EACH OCCURANCE $1,000 FIRE DAMAGE $50,00 X AUTOMOBILE LIAB NEW 05/23/95 05/23/96 MEDICAL EXPENS $5,000 X ANY AUTO CSL $ X ALL OWNED AUTOS BODILY INJURY (/PERS) X SCHEDULED AUTOS $500,0 X HIRED AUTOS BODILY INJURY (/ACCID) X NON -OWNED AUTOS $1,000 GARAGE LIABILITY PROPERTY DAMAGE $100,0 EXCESS LIABILITY EACH AGGREGATE OTHER THAN UMBRELLA FORM $ $ WORKERS' COMPEN- STATUTORY SATION AND $ (EACH ACCID) EMPLOYERS' LIABILITY $ (DIS-POL LIM) OTHER $ (DIS EA EMPL) DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS SEWER & PIPE WORK CERTIFICATE HOLDER TOWN OF MANSFIELD 50 WEST STREET MANSFIELD, MA 02048 CANCELLATION SHOULD ABOVE POLICIES BE CANCELLED BEFORE E RATION DATE, COMPANY WILL ENDEAVOR TO I 21 DAYS WRITTEN NOTICE TO CERTIFICATE HO ER (AT EFT ; FAILURE TO IL NOTICE S LL IMPO OBLIGATION LIABILITY OF A YKI,NN TI THEAU�ANZEDITS AGENTS OR REPRESENTATIVE: FORM 25-S (11/85)