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HomeMy WebLinkAboutBLDCI-17-000194-06 The Common \'. a h of Massachusetts Ci ) \ \own of } v, OUT!!n .+ / `�:► ! New and Renewal Certificate of Inspection In accordance with the Massachusetts State Building Code, Section 110.7 Certificate No. Identify Name of Establishment gLDCl-17-000194-06 Issued to Business Name:ECONO LODGE MOTEL Trade Name: ECONO LODGE MOTEL ficate Expiration Identify property address including street number, name,city or town and county Certi i c to Exp3 iration 0 Located at 59 ROUTE 28 WEST YARMOUTH,MA 02673 Other Occupancy Use Group Use Group Floor ---__ 24 units-Note: Classlficat101'ts(s) 01st Floor 24 R-1 Hotel/Motel/Boarding House/Transient rooms 101 o 102 may not be rented to quest R-1 with children Swimming pool,game • cupant L r. room,laundry Occupant Load room,vending room 24 units 02nd Floor 25 R-1 Hotel/Motel/Boarding House/Transient 4M units Apartment issued been for bythe undersigned to certify that the premise,structure or portionin a roof ac herein ows placespeciwithinfied has space inspectedas directed generalTh certificate i fire and of inspection sp safety f is hereby life safety features. This certificate ned. aae urshall bpeoe r tampering with the and/or conntentsted of they erposted tificate is strictly prohibited. by the undersigned. Failure top111111 Date of /g . Name of MunicipalMEM Inspection �o Name of Municipal Building Commissioner .11111 Date of Signature of Municipal Issuance Signature of Municipal Building CommissionerW D���� / /112 4110111. Fee: $220.00 BLD Certoflnspection.rpt :4� . _� : TOWN OF YARMOUTH It , ' H BUILDING DEPARTMENT �cs),<. ;,, ,''''q 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 6°/ APPLICATION FOR CERTIFICATE OF INSPECTION \`\ d' May 1, 2022 PAYABLE UPON RECEIPT (X) Fee Requi d $220.00 ( ) No Fee Re .red In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: S 9 1-2...p k& oc S \h(,ey t. Xcutrwt3&_, Name of Premises: F c ovlo\o(1.1 1L Tel: 5 14,E - 1,1,© `,c\ Purpose for which permit is used: &.e,"(\1 14-Q, `j,vkApikkics� License(s) or Permit(s)required for the emises y other g ernmen 1 agencies: License or Permit Agency RECEIVED MAY 051012 I BOIL Certificate to be issued to O�no\c Tel: rjp�.q 1-j,c� (n - _ ___ NT Address: 53 fp .,L .,2� I\„,i C8\--- ray ,\,L[ (col I . - c'�,f rr,,}_ Owner of Record of Building y 4,� P� ,, Tt) Address — Sam .- Present Holder of Certificate )._.\u,l41 0 EllAcg v' w TAC6, Signature of person to whom Titlel Certificate is issued or his agent C) 5/0,2/2:O,t 2-- Date Email Address: e( \i‘s,oAyLc-L ,F cc cAc�1 c l,n2cu, ,co,vvt- Instructions: Make check payable to: Town of Yarmouth 1146 Route 28, South Yarmouth, MA 02664 Return this application to: Building Inspector's Office Please note: Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified. Application must be received before the certificate will be issued. The building official shall be notified within ten(10) days of any change in the above information. PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH THIS APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# 06/29/2022-06/29/2023 Worker's Cc.r u es " v M� erKsh re HaGLJARDthaway 01 ;• Insurance Peoria a; spa iL�,S`v b�t a iaee ►PA Companies i CC! N :, . 44] Policy Informatics. Jage [1]Named Insured and Mailing Address Agency Dipti, LLC DOWLING & O'NEiL INSURANCE AGENCY DBA/ A Econolodge 973 Iyannough Road 59 Route 28 P.G. Box 1.990 West Yarmouth, MA 02673 Hyannis, MA 02601 Agency Code. MADOWLIO Federal Employer's ID XX-XXX2078 Insured is Limited Liability Co. (LLC) Additional Names of Insured (tit) Econo'ndge — • [2] Policy Period From November 24, 2021 to November 24, 2022, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium • The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required infcrrnation is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ Tota "surcharges/Assessments $ $42 Oc- Total Estimated Cost $1,446 0C �.: INTERNAL USE XX Page - 1 - Informat'on Page MGA : DIWC295676 WC 00000IA Date : 10/20/2021 MANOTE Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-6arre, PA 18703-0020 www.g-aave.cor F,°