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HomeMy WebLinkAboutCI-19-005389-04 COMM o dai G M o Z M 7 f .rhn vs ..+tso •` `a p d'I NI O0 co v d Fi r M � co d U F NI- ge GEp a � y c CO •C V` `O r W a a • U N ` 11) a E E ? M }4 0 p„ U m o 0 0 f° .c C I o 8 m O a 0 o f o �' d _ w ,S as co) •- o _= o ro) .0 0- z§:0) Z'C g P 1 \, cu CA a � I D A GA 0 C Z 3 E E ,0 V �j c . .2 af , C 0 g c r � Coo v JhIH aa cb c a�c °��' osmisil lue 22 •�_ L tg 4 V/ ^yac W 9 F c 1- x U •^I C W Q m a 0 c c hi dii o° ai °' d N . ra ornF = } ¢ ¢ -eO -oz - a,: E RI c.) D o orn c E :° c vu = w y v v Z m if) mcD c; • E 43 ■+r M 4C m Z alc1) o n o a> •t' CI, y = O coI— O C S .y as. o ,�al 3 4i c 'a a L y O m 3 p b O co m E O .c a m U cs a� a0 R w N ��ilgll�b i��i�� c- .§ H f� a 7.3 1 •'� A T " III4 c N c 03 c6 rn Z BUILDING RT ENT 421 .' 1146 Route 28, South Yarmouth, MA 02664 508-39 -2231 et. 1260 APPLICATION FOR CERTIFICATE OF INSPECTION March 1, 2023 PAYABLE UPON RECEIPT (X) Fee Required$100.00 ( ) No Fee Required 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: /11z11� �j 4 0.,.t c"N AN Name of Premises: F'd-�?r' ''/vc,c c` K Tel: SG F 3 6 ;1_ C/CSC P Purpose for which permit is used: 5' ,4 c, �,: /�( a— f�, �> �> �7 �i ny- License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency RECEIVED MAR 2 0 2023 Certificate to be issued to f BUI DING DEPARTMENT i � E'-Z arc' c Tel: � � j�� *_ — Address: f( /1/Fra-, ;-!AA,I,k Owner of Record of Building if g4., ,2 ,,;:.,,k Address //)t) /71 ',-/ p,�- Present Holder of CertificateSigna e of person to whom Title Certificate is issued or his agent _721-' Date Email Address: 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# 04/06/2023-04/06/2024 A OR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/27/2022 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(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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Kathryn Kock BALDWIN KRYSTYN SHERMAN PARTNERS LLC (A/C.No. (508)760-4604 FAX (A/C, ADDRESS: Kathryn.Kock@rogersgray.com 4211 West Boy Scout Blvd Suite 800 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURERA: ATLANTIC CHARTER INS CO 44326 INSURED INSURER B: HEATHERWOOD AT KINGS WAY CONDO TRUST INSURERC: INSURER D: 100 HEATHERWOOD INSURERE: YARMOUTH PORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 847144 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILYINJURY(Per ONLY AUTOSaccident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER STATUTE EH R AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED7 N/A N/A N/A WCV01253207 10/26/2022 10/26/2023 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance for Heatherwood at Kings Way Condominium Trust ACCORDANCE WITH THE POLICY PROVISIONS. 100Heatherwood-Drive — - --- AUTHORIZEDREPRESENTATIVE ---- - - -" "-- Yarmouth Port MA 02675 Daniel M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD