TOWN OF ADDISON Required Documentation: 16801 WESTGROVE DR. 1. Copy of HVAC license. P.O. Box 9010 ADDISON, TX 75001 2. Copy of drivers license. Phone: 972/450-2880 Fax: 972/450-2820 3. Certificate of insurance. U APPLICATION FOR REGISTRATION MECHANICAL CONTRACTOR COMPANY NAME Air Patrol Air Conditioning $75.00 REGISTRATION FEE DATE 09-12-2019 COMPANY ADDRESS 13644 Neutron Rd Suite 100 PHONE 214-261-0034 NUMBER STREET Dallas TX 75244 CELL 214-261-0035 CITY STATE ZIP EMAIL sgazor@airpatrolac.com OWNER OF COMPANY: NAME Afshin Shawn Gazer HOME ADDRESS 609 Forest Meadow Dr.. NUMBER STREET Colleyville TX 76034 CITY STATE ZIP HOME PHONE 214-317-6540 THOSE IN THE BUSINESS WHO ARE AUTHORIZED TO SIGN FOR PERMITS: PURSUANT TO THE REQUIREMENT OF THE TOWN OF ADDISON THAT ANY INDIVIDUAL, PERSON, FIRM OR CORPORATION, ENGAGING IN THE HEATING, VENTILATING AND AIR CONDITIONING BUSINESS EITHER SHALL BE A LICENSED AIR CONDITIONING CONTRACTOR OR HAVE IN CONTINUOUS EMPLOY A LICENSED AIR CONDITIONING CONTRACTOR, THE FOLLOWING PERSON SHALL SERVE AS AIR CONDITIONING CONTRACTOR AND SHALL BE DELEGATED FULL RESPONSIBILITY FOR THE SAFETY OF ALL WORK THAT MAY BE DONE ACCORDING TO THE INTERNATIONAL MECHANICAL CODE. LICENSED AIR CONDITIONING CONTRACTOR Afshin Shawn Gazer HOME ADDRESS 609 Forest Meadow Dr, NUMBER STREET Colleyville T'X 76034 CITY STATE ZIP HOME PHONE 214-317-6540 LICENSE NO. TACLB23526E SIGNED AUTHORIZED SIGNATURE GATE PAID __, CHECK# RECEIPT #____ REGISTRATION# A�/ , ® CERTIFICATE ®F LIABILITY INSURANCE DATE15/2 19 07/15/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO 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(les) must 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 281-852-3333 866-821-6134 TWFG Insurance 18477 W. Lake Houston Pkwy, Ste 30 Humble TX 77346 CONTACT NAME: Brian Johnson _ NE:t) 281-852-3333 a/c No:866-821-6134 PHONo nl oaess, brian tWf .corn INSURERS AFFORDING COVERAGE NAIC9 INSURER A: Republic Franklin Insurance Co. 12475 INSURED 214-261-0034 214-261-0035 Air Patrol Air Conditioning and Heating of Texas Inc. 13644 Neutron Rd. Suite 100 Dallas TX 75244 INSURER B: Utica National insurance of Texas 43478 INSURER c: Graphic Arts Mutual Insurance Co. 25984 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. NOTWTHSTANDING 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. INSR R TYPE OF INSURANCE MenADDL SUBRIQ NUMBER POLPOLICY MMIID� MMI��IYYYY LIMITS p`DAMAGE GENERALLIABILITY V( COMMERCIAL GENERAL LIABILITY CLAIMS-MADEOCCUR CPP4548654 05/04/2019 05/04/2020 EACH OCCURRENCE $1,000,000 10 RENTED PREMSESEaoecunence $100000 MED EXP (Any one person) &5000 PERSONAL& ADV INJURY $ 1 MUM GENERAL AGGREGATE -$2000000 G 1 AGGREGATELIMIT APPLIES PER: POLICY PRO- LOC PRODUCTS-COMPIOPAGG $2000000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON,OWNED HIREDAUTOS AUTOS COMBINED SINGLE LIMIT Ea accident) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ Per deedent B ✓ UMBRELLA LIAR EXCESS LIAB n OCCUR CLAIMS -MADE CULP4541394 05/04/2019 05/04/2020 EACH OCCURRENCE $ 1,000,000 AGGREGATE $1,000,000 DED V( RETENTION $ 1 O OOO $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY OPFICERIMEMBEER EXCLUDED (Mandatory in NH) ESCRIPTION OF OPERATIONS below desailhe under NIA NIA 4544978 08/02/2019 06/02/2020 / WCSTATT- OTH- Y FIR E.L. EACH ACCIDENT $1 OOO OOO E.L. DISEASE - EA EMPLOYEd $1 000000 E.L. DISEASE -POLICY LIMIT I $1.000.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required) AM Best Ratings for Insurer A, B and C: A-, XI CERTIFICATE HOLDER CANCELLATION For Bid Purposes Unly SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 6 V � e © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD