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To d vm U - Cl) N J a m F 0 a 0 11) C c O {Q V 4- p C 0 N d U d .0 N N N w a) Q ~ a) E rn C coco 0 0 ° .YgRo TOWN OF YARMOUTH BUILDING DEPARTMENT " "`� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 RECFWE APPLICATION FOR CERTIFICATE OF INSPE TON JUN 15 2023 May 10, 2023 PAYABLE UPON CEIPT J (m'LPt ketititeddivu00. 0 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: Name of Premises: G o«is- Tel /drif �-- Purpose for which permit is used: r/4/) License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency c:J\ Certificate to be issued to 6 -11/er/t4s- 4 fi.-- / s� Tel: .,/7 9/a8-,� 1 Address: ' G �'r,�i�.� i lrm/ , /G�-�� �rai, .%// aQi/ Owner of Record of Building Address Present Holder of Certificate Signature of person to whom Title/ Certificate is issued or his agent //5 7/ Date Email Address: �, 4er,er�ert je, Gi/i o0c-7— 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 # /3(Ij/ ) /771,v 03/10/2023-03/10/2024 / '�----- CERTIFICATE OF LIABILITYDATE(MM/DD/YYYY) INSURANCE 02/06/2023 ' I 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 SUBROGATIONIS 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 CORCORAN&HAVLIN INSURANCE GROUP CONTACT NAME: 08086889 PHONE (800)304-8242 FAX PO BOX 9011 (A/C,No,Ext): (A/C,No): WELLESLEY MA 02482 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Hartford Fire Insurance Company 19682 INSURED INSURER B: CHARLES WHITE MANAGED PROPERTIES CORP INSURER C: 330 COMMONWEALTH AVE BOSTON MA 021 1 5-21 1 7 INSURER D: 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 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP INSR WVD (M /Y M/DDYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ICLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) — MED EXP(Any one person) PERSONAL&ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE POLICY PRo- LOC JECT PRODUCTS-COMP/OPAGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) — ANY AUTO BODILY INJURY(Per person) ALL OWNED —SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED AUTOS AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS' MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X PER OTH- ANY Y/N STATUTE ER A PROPRIETOR/PARTNER/EXECUTIVE — EL EACH ACCIDENT $500,000 W OFFICER/MEMBER EXCLUDED? A 08 WBC LD6253 02/02l2023 02102/2024 E.LDISEASE-EAEMPLOYEE $500,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below- E.L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION For Informational Purposes SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 330 COMMONWEALTH AVE BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED BOSTON MA 02115-2117 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD