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HomeMy WebLinkAboutBLDCI-16-007004-07 0 o E 0 , p 2W N Gfl b O LO 0. A c V _i m m N W 2 P' c� r m V Z m Z Q .3) O o m o 0 g V .0 N 0J N g Q .0 E 0 L'I a coO O c 0 as •� CA = C4 .0 cti 2 •t' I; Nilik --.'-) WI 0 CI $ I c R C� Cti 0 I— W = 0 ill q '. `p...4 g Cu 32 ce 00wce .0 pp co g 2 °0 0 0 w V/ rOS W x- CO D °' > > 0 a; ��• N c O c Ep Z as E c a Q o 6 on oq E cu ai ai N co } C9 s 2 o p "p e c u W ;� c o c p A � � ` c Ev cv' V Ca m 0 ° 2 , (55 I. 0 o o zm (nm t as -0 = o cu S cn 2 w a) 13 0. -cs :41 I w U 0 .0 W cm c O N N 'd + ��f, cob N .S as O 8 .CJ co c:. LL •- acu 8 c o w N {L O NO 4"N eH 2 w a as a (a +ti w a6 a 0 0 J _ c_.$ CA e� c0 U I�4 la• Ilii=ell I IIH amO i= x7 co U o aD45 o R C Z U) TOWN OF YARMOUTH 'GptiV /it•. t�kBUILDING DEPARTMENT eN, .._v, 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 RECEIVED APPLICATION FOR CERTIFICATE OF INSPECTION `y HAY 03 2023 April 1, 2023 PAYABLE UPON RECEIP ( �--- (X) F:egequireGdDS19t �1ENT ( ) No Fee Required V 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: 41 12-f 2 e' i 42 \f` 1 tiVIskc 6'26c)'z Name of Premises: P L g Tel: I c`r)a 7 7 c o'7 6'2__ Purpose for which permit is used: CC�k z3 I b ti qui n 2 q 1411 , � 1(.A License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Pc i PR--KAA 1 ©A-x, 1Tvt4 ( M T OW GG` yt Certificate to be issued to S L-1? - 2 Tel: cot -7`Y1 O 6 Z Address: j) I etc 2- MO- 1 MQ.'(r*4 0„1 r 02 U 1 Owner of Record of Building 4:=-<, 1 5.+1s:rc Address 3 A-C-6 U 1v.- '1)32--1 it (2,L 2-ti/A1 Or'faw7 O'Jk J d lgtZ Present Holder of Certificate lvrks P r Signature of person to whom Title Certificate is issued or his agent tA3v1/1 � 3 Date Email Address: 14 iv11N1 4< ' G `I ,6tjOn 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# '- 05/15/2023-05/15/2024 R AC../- CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDD/YYW) 105/03/2023 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: DOWLING &O'NEIL INSURANCE AGENCY PHONE FAX 973 Iyannough Road (A/C.No.Ext): (A/C,No): E- L P.O. Box 1990 ADDRESS: Hyannis, MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NorGUARD Insurance Company 31470 INSURED Super 8 Motel INSURERB: DBA/TA Super 8 Motel INSURER C: 3 Algonquin Dr INSURERD: Burlington, MA 01803-3601 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. 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/DDIWYY) (MM/DDIWYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 0 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 0 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 0 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- GENERAL AGGREGATE $ JECT LOC PRODUCTS-COMP/OP AGG $ 0 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ OWNED BODILY INJURY(Per person) $ SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS LIABILITY Y/N X I STATUTE I I ERH ANYPROPRI ETOR/PARTNER/EXECUTIVE A OFFICER/MEMBEREXCLUDED? N NIA AUWC352531 10/21/2022 10/21/2023 E.L.EACH ACCIDENT $SQQ,00O (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Employees: Full Time: 1; Part Time: 1 Governing Class Description: HOTEL-ALL OTHER EMPLOYEES CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Rt 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE: .77 . . . . . ACORD©1988-2015 CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD