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Scott Masdon T H E • C t T Y � O F C(�PPELL .;�t�1L;�� t,?. :`�:a .r1 G r-.'.�, ."f' �'1''Z�-+��—, i1' Lsrl:�-�--..':-� �+ l�'�� .�,,i-x.a' <-��'O �� ,:i�.�''`:: '�- Q � A 6 , t D City of Coppell Public Works Dept. 816 S. Coppell Road Coppell, TX 75019 972-462-5150 www.coppelltx.gov BACKFLOW REGISTRATION FORM Registration is for one year from the date of registration or re-registration. � / /J � Date of Registration � � / � � Name: � C � ''7�" � G S �� C7 .'\ Name of Company: �U �-� \ �r"' ��-t 1� -� . �'�'� � � �c= �l��j �(��1 .�� Mailing Address: � C�� (r � t �, �'' ��'`(' <<;�v� -� �� 7 ��! �� (Street&Number/PO Box, City, State and Zip) Physical Address: (Street&Number, City, State and Zip) Office Phone Number: �� — �� Mobile Phone Number: E-mail Address: ��J � e.� /� �' ( v C.J ,� ij C < <:C..�Q „ l' U �� / , � DATE(MMIDDIVYYY) ACORL7 CERTIFICATE OF LIABILITY INSURANCE ��. oan i�2o�s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS Nd RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certiflcate does not confer rights to the certificate holder in Iieu of such endorsement(s). PRODUCER CONTACT �enn'rfer Lancaster NAME: Patterson&Associates Insurance Agency,Inc. �c No �ce: (972)669-243� ac No: (972)783-0831 P.O.Box 852037 E•MAIL jenn'rfer@piainsure.com ADORESS: INSURER(5)AFFORDING COVERAOE NAIC F Richardson TX 75085-2037 iNsua�tn: Scottsdale Insurance Co, 41297 INSURED INSURER B: Masdon Professional Services Inc IN9URER C: DBA:001 Professional Backkfiow Tesling IN3URER D: 5068 Avery Lane INSURER E: The Colony TX 75056 INSURER F: COVERAGES CERTIFICATE NUMBER: 18��9 REVISION NUMBER: 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. 'LTR T'PE OF INSURANCE gp POLACY NUMBER MMIDDY MM DDY�P LIMR3 COMMERCNLGENERALLIABILfTY EACHOCCURRENCE $ 1,000,000 � 100,000 CLAIMS-MADE �OCCUR PR M SES Ea occu n S MED EXP(Any orre person) g S,OOO A CPS3103471 09/2712018 09/27/2019 pERSONALBADVINJURY g 1,0�0,00� GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE g 2,�00,000 POLICY�ECT �LOC PRODUCTS-COMPlOPAGG S 2�000,000 OTHER' S AUTOMOBILE IIABILtTY COMBINED SINGLE L1MIT S Ea xcideM ANYAUTO 60DILYINJURY(Perpersml S OWNED SCHEDULED BODILYINJURY(Peraaident) $ AUTOS ONLY AUTQS HIRED NON-0WNED PROPERTYDAMAGE g AUTOS ONLY AUTOS ONLY Per atcide�t S UMBRELLALIAB OCCUR EACHOCCURRENCE $ F�CCESS LIAB CLAIMS-MADE AGGRECaATE S � DED RETENTION S 5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY V�N STATUTE ER ANYPROPRIETOWPARTNER/EXECUTIVE ❑ N�A E.LEACHACGDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.OISEASE-EA EMPLOYEE S 1(ye5,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICV LIMIT S DESCRIPTION OP OPERATIONS/LOCATION5/VEMICLES(ACORD 707,Adtlltional RemaAcs Sehedule,may be attaehed N more space b requirad) installation of fire sprinkler systems underground fire mains CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE IXPIRATION DATE THEREOF,NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. � AUTHORtZED REPRESENTATNE � �� OO 1988-2015 ACORD CORPORATION. Ali righffi reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD aa �� ".ah ,A- rx.«..! �rK �.. b� . .3�3. .d.,= � � � � ' • a9 �' � S � � � ■ w�. _�.�� ,�y �;�"�`g�� e�..:�� BILLING CONTACT � Scott Masdon � ' .001 Professional Backflow Testing �• • 5068 Avery Ln • The Colony, Tx 75056 • INVOICE NUMBER INVOICE DATE INVOICE DUE DATE INVOICE STATUS INVOICE DESCRIPTION INV-19-00015785 03/15/2019 03/15/2019 Due NONE REFERENCE NUMBER FEE NAME TOTAL Misc Fee Backflow Contractor Registration $75.00 SUB TOTAL $75.00 REMITTANCE INFORMATION TOTAL $75.00 City Of Coppell P.O. Box 9478 Coppell, TX 75019 March 15, 2019 255 Parkway Boulevard, Coppell Texas 75019 Page 1 of 1 City of Coppell, TX Engineering 255 Parkway Blvd, Coppell, TX 75019 Coppell, TX 75019 972-304-3500 Welcome 002627-0001 Priscilla 03/15/2019 02 : 42PM ENERGOV INVOICE Masdon, Scott ( . 001 Professional Backflow Testing) 2019 Item: INV-19-00015785 Balance due: 0. 00 Balance unpaid: 0 . 00 Backflow Contractor Registration 75 . 00 Payment Id: 13563 75.00 Subtotal 75. 00 Total 75. 00 CHECK 75. 00 Check Number 6363 Change due 0.00 Paid by: Scott Masdon Thank you for your payment CUSTOMER COPY _