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HomeMy WebLinkAboutBCOI-23-1710- -o e d ° U O co \ ,•o �i ElN e � � N Z .ak o w` E 7 a s ,I w 7 W N E OD N N 4. N ai 0 ° c c 0. `V .. c o a CA d O k.. 4O p C�1 N N 1 c..) co C t O c E 'n -c7 A as u- rnch ct co •— V ` E E O N 7 3 °o E ° E a) OM(AM We' N co n. as N N co h co ,,nm o :Q Z. .c .0 0 N V 0 p t •5. ai V C C T fQ C G U) ti N N�p O V V co E N C G G d N a3 :s O O e w w 15 ++ .0 CD ID coN 1111i; O 1E E E Oycc Z 0 a)as O o Y :: m a c 0 U CO .'�' m I 2 I p cc V u) O 0 w 7 V 7 .ci a) ,O e t Q. C .0 a) Or3 MfiNd' NON N! ‘\ `� ,�E c E e 0 CV 2 E 42 c �R CA y c6 cfs i Q N m as Q. U c .Q re •a a) 1- c M I— o y m � ° _ Ec ° 1 O _ v W I- 0 II-D �' as h RI ii. 3HQ ctoz y ° cco> cn N L V C 0 '. 0 cI- C MD a v C 'o m E _ 0 ti C O c3i v s m' _a E 0 0 m 00 •.. (n O N O N o i h M M N •"'' O a C O '0 c Z 0 vv y ' L V co O a0 cEQ oc � c = 3 a) i E w'• O , V) a a1 I— Z a) t -a .0 4- N E E c __ �_ E E c E 0 4 3t0a7 zc� �nc� U o c 0 . c 4 Y c v ca c m aa)i cm o m -C y �, 13 L `O c N U O co O0 O N a) c co t 0 O in C N ~ t_ 0 II O O m t y >, 7 N A �o+ co C co R 0 w co I; C 0.412 0 co .c .2 += 0. r... 0 N 5-- '0 N 7 O c y d w A V a? — 0 c. 3 y v c 9 C.) 0 8 To O.4* Uas0ococH J Q d2 0 o CQ !_UN � I— cai co ppz E c m rnUZ o cY -1, . 'l HAT SCE ° _ 1146 Route 28, South Yarmouth, MAENT . a� 02664 5(13-315-2231 ext. 1260 R RieaCiAVI R CERTIFICATE OF INSPECTION May 1, 2023 , MAY 17 2023 , PAYABLE UPON RECEIPT ----- - (X) Fee Required $304.00 Qutt01, 1C C� NARTMENT ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate ofInspection for-the-below-namedpremises located at the following address. p --- Street and Number: 32 ? M' Sii6 trc_ 1>t L/—e..—,.. Name of Premises: I 2 0 CE?may'\ CU Tel: co a 39 & ci c S Purpose for which permit is used: License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to C�1L ©C.eav) C�I�,I� Tel: td� q �( Address: . .d`'Ci t 5Viore__ ‘).lic Ve S ' o VV\&O A k Owner of Record of Building Address L. N E�YICL.0 ( r- - WQ - CLNp� Present Holder of Certificate 4_0((in e---e-neircil 1/1441116K- ignature of person to whom Title Certificate is issued or his agent /1470�� Date rilifootillalc4 .vdib s,��5 s ' , col 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# 1 COI 23—/ 7/D 06/07/2023-06/07/2024 Firefox about:blank • i WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue,Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 40959 POLICY NO. [WCC-500-5021374-2022A PRIOR NO. WCC-500-5021374-2021 A ITEM 1. The Insured: Ocean Club Home Owners Association DBA: Mailing address: 329 South Shore Drive FEIN:*`—***5454 S Yarmouth,MA 02664 Legal Entity Type: Assoc,Labor Union,Relig.Org Other workplaces not shown above: 2. The policy period is from 01/01/2022 to 01/01/2023 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 001190676 INTER SEEI CLASS CODE SCHEDU_E Minimum Premium $276 Total Estimated Annual Premium $7,830 GOV Deposit Premium $2,034 STATE`CLASS State Assessments/Surcharges harges L ..MA.... 9052� $7,234.00 x 4.1800%/ $302 This policy,including all endorsements,is hereby countersigned by 12/16/2021 Authorized Signature �e Service Office: HUB International New England LLC 54 Third Avenue PO Box 696 Burlington MA 01803 Wilmington,MA 01887 WC000001 A(7-11) includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. 5/11/2023, 11:20 AM 1 of 1