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HomeMy WebLinkAboutBCOI-23-1706 2024 2 o a Z E k Z a a O ° � § . c % A § N N - NI ° c 0 D3 . k cn z kk a) 2 k � 2 § J \ © k lb' co a axi - ckk ti k e g « § .0 Q � c § o GCS / k 2 ® . ■ c0 % % a ' a e e » c22 O vi © , 2 co m � � 22 £ 02 © q ° $ § 02 % 10 o . . -1 _ L. 03 o k a g2a) = 7 § 22 / ® IV s ■ - � $ ' ate © 2 © tee § © Vic ° �\ ` ® .c � = q 62 � 0 0 akqt,-; w « - ■ . k a E z k J § X o 0 CO $ / I" k % '` o ■ � ° � 0 ° 0 W 2 co - @ O � > ® �k • . / m c C 2 ❑ cq ■ t 0) P- C § t $ § k $ k o \ 0 E - k k § o k k \ : Ere , % © ® - �- - � ° CL § 2 § V _ r, 7 k 0 032ti t § k k § \ k . GS o 2. I- 0 ® � � � pb 0f )k Z 2 R. § k zO Q 0 .Cu) c >a 2 g co § =/ e ■ 2 ° 2 k '- j �f } _ L. a) � � ° ° � 0 , \ / as c as� —i k� § c as e ® -0 ® 0 � c k \ 2 ■ @ 0a -0 o a % 0 0 U o § 2 E k 4* E f 2 F co k § § @ CSC I % P o - $ ) % % ® § E k¥ F z JG \\., - ., „ti 1146 Route 28, South Yarmouth, M „6 " z � ;:+.,,„ 02664 1 - 9 r' 1 _ } - APPLICATION FOR CERTIFICATE OF INSPECTION MY 1 2023 DEPARTMENT May 1, 2023 PAYABLE UPON RECEIPT By ---- (X) Fee Required $50.00 ( ) No Fee RequiBUILDINGred 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 m A located at the following address: Q�(�J 5- Street and Number: V Id c, , �T, c, \" C��/ U��.l4 ►'� 1 �,"I 026(P Name of Premises: Sk- j� 6,g i Sl t.-Y C fiu Tel: 6-(A - 3q`1 _,, ..„ Purpose for which permit is used: (f 1L),ULC,1A, 7 Mil- am i L3a.h at g License(s) or Permit(s)required for the premises by other govetnmefltal a enci J N N1 License or Permit Agency `j .. kA Certificate IR be issued o J\ •� A S ISC l ,�j Tel: (_j2 - S IC(-C'�4�"�'Z Address: a U 5 C.9�4 �1 ,Sk, 1 5. u► k vn tM .1 VVl . (f 2�0 Co`C Owner of Record of Building 4 . /i 4' Address AO c 0 tcl VUAez....,..,. SA-, S' tsU- ``( ,i yh,,t- - Present Holder of Certificate Sa.�l1 + '0 A-d 'S Cp1 Sr efec„..c CIR-A-Lvirc 1. ._ FU1/1-tg Avunk&a.- rAM (I%---1L-11-e-A-pe Signature of person to whom Title Certificate is issued or his agent 6f 1 �-I a ?j Date Email Address: 1 a.an C e ThTdCr`kJl CIA S . CU()L'�i I t"cJ i 3 • (14- 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 C NOT ISSUE YOUR CERTIFICATE OF INSPECTION. Certificate of Inspection# e)/c 3.. /7Q 4 06/18/2023-06/18/2024 h. c xx •1 ® /DD/YYYY) A(CORD 2022 CERTIFICATE OF LIABILITY INSURANCE August DATE(MM 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 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). CONTACT PRODUCER NAME: Tracey Parent The Church Insurance Agency Corp PHONE FAX 210 South St,Suite 2 (A/C,No,Ext):(800)293-3525 (A/C,No):(800)557-1395 Bennington,VT 05201 E-MAIL ADDRESS: PRODUCER CUSTOMER ID#: INSURERISI AFFORDING COVERAGE NAIC# INSURED INSURER A: Liberty Insurance Corp Diocese Of Massachusetts INSURER B: INSURER C: 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 I 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, NNEXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I R TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER i (MM/DDT) (MM/DD/YYYY} LIMITS GENE �IBILITY EACH OCCURRENCE ,DAMAGE TO RENTED COMMERCIAL GENERAL PREMISES(Ea occurrence) $ CLAIMS-MADE I OCCUR I ED EXP(An one erson PERSONAL&ADV INJURY I I ENERAL AGGREGATE r (PRODUCTS-COMP/OP AGG GEN'L AGGREGATE LIMIT APPLIES PER' I POLICY PRO-CT LOC I I ABILITY OMBINED SINGLE LIMIT I IS I(Ea accident) I _ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS kPer accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB _OCCUR • EACH OCCURRENCE $ EXCESS LIABAGGREGATE $ CLAIMS-MADE I EDUCTIBLE $ RETENTION $ I $ ORKERS COMPENSATION WC STATU- OTH- A ND EMPLOYERS'LIABILITY YIN Y X WC7625900009022110 9/30/2022 9/30/2023 TORY LIMITS ER NY RO E.L.EACH ACCIDENT $1,000,000 P PRIETOR/PARTNER/EXE UTIVE FFId /r AA atyFNFR FXr`I I Ir1Fr1'� _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 1,000,000 If vice rlce�ril.e mrlor DESCRIPTION OF OPERATIONS below F.L.DISEASE-POLICY LIMIT 1,000,000 I (DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION St Davids Episcopal Church SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 205 Old Main St THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN South Yarmouth,MA 02664-4529 ACCORDANCE WITH THE POLICY PROVISIONS. 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