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HomeMy WebLinkAboutBCOI-23-1747- 7 O k 0 ci \ \ 2 \ m M a k ( LU ° 4, 0 a = . a; _ ± 6 m / Eo r- 3 m « / 2 / k0 0 / / ` . / � , o / 2 \ e at g \ \ \ C ¥ J 3g » f 22 0 0 § k & ( 5£% mE � t @ 0 = 0 2 = , = c > E § 7 ) \ S 2 \ 8 \ E \ / ) ® g $ f 2Sf CDC % t c & % 2 a % f £ ' .0 ° a e= se � a CO CO \ _ / &\7 \ \ \ 7 \ \ o c c o = a , L_ mo , o sot 10 E o o e2 , % � entaoa. 10 / � % �\� E \/ �k \7k ■ ■ y u « n70Er § EE e -c ® £ � 452 } 452 $ /$ 3 o CO � f / ■ r k \ ' 0 $ % / fk � / 22f m a 5 � < � £ z t 203 kk / k "' � •C— 0 2 # / 2 / � / \ ® = C 0 k % / ka) / E ^ $ / ( \ / k % � _r0) @ O CL U RI Q o m A e \ % \ E 2 o r0 , § ƒ U) i Zs k \ E § _ ± 2E 7 = 0 § \ \ k \ / /<_ n k a 3 I - E cc 3 7 ° L 5 » 2 / \ as� ) 0 � \ k \ / % k & CO 0 cf 2 : 2 \ ] / \ o ■ ƒ 5@ © � ¥ $ ; ) ■ = F- f 2 R m E E Z f § _ co 0 EECE o 0 = / ƒ zomo C >,/ 7 e .b = Ec 9 k k d $ .- _ a) o o = eL- » m —J y § Sf \ E / > / 0 co 02 S r ® f f 2 2 ± § >, c \ \ � o co � \ - / k e / / as " / \ k LE 2 0 Q 0 E _ \ % a) f 0 a 2 c ® g § c § 2 \ f \ \ \ o ■ @ DE IA S a) - 2 e 0 Q % « I- E k n % } co goc TOWN OF ,)M \ _ 0 _ /-3 . UTLDING I EPARTMENrf 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 APPLICATIO FOR CERTIFICATE OF INSPECTION August 1, 2023 PAYABLE UPON RECEIPT CO 1 ' 9 �r (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 329 /c,[ti St/ c V 4.0(k+et- rs ow;nee ail, \©r1 Name of Premises: C,km,r-GQ� � pAA, _Tel: SD&"'- 6'7 7 7 Y Purpose for which permit is used: (Al 0 f • fh License(s) or Permit(s) required for the premises by o er governmental agencies: License or Permit Agency ct.RQ. Certificate to be issued tc IAJA1C� V6jiK'0 Tel: ' ' 36 2- 6 57 7 Address: 32.4t /�,c�.i N S+, C4P 'tO aftt (\�1/� o Z.-6 7E Owner of Record of Building Address Present Holder of Certificate ignature of pers n to om Title Certificate is issued or his agent - -2.3 Date • Email Address: Al)M Fccl e/tiDcirri. OR 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# &,lam/Q3/may, 7 09/01/2023-09/01/2024 • Church Mutual Insurance Company, S.I. NCCI CARRIER CODE NO. 16853 WC 00 00 01A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE 1. The Insured: FIRST CONGREGATIONAL CHURCH Policy No. 0187606 07-473117 OF YARMOUTH Renewal of: 0187606 07-302281 Individual Partnership Mailing address:32 9 ROUTE 6A X YARMOUTH PORT, MA 0 2 6 7 5-1817 Corporation or Federal Employers I.D.# See Schedule Inter/Intrastate Risk I.D. # Other I.D. # Other workplaces not shown above: See Schedule Contact Phone Number 2. The policy period is from 12/23/2022 12:01 a.m. to 12/2 3/2 0 2 3 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 our 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: Part Three of the policy applies to the states, if any, listed here: All states except states designated in Item 3 .A. of the Information Page and ND, OH, WA, WY. 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. Premium Basis Rate Per Code Total Estimated $100 of Estimated Classification No. Annual Remuneration Remuneration Annual Premium See Item 4 . Extension WC 00 00 O1A Total Estimated Annual Premium$ 1, 8 95 Expense Constant$ 338 Taxes and Surcharges $ 70 Minimum Premium $ 292 (MA) 9101 Deposit Premium $ 1, 965 See Item 4 . Extension WC 00 00 O1A for the Taxes and Surcharges for: MA Premium Adjustment Period: Annual Countersigned by: Servicing Office: Church Mutual Insurance Company, S . I . Date: 03/18/2023 Producer: LAURA J. ROGGERO Church Mutuali\, Copyright 1987 National Council on Compensation Insurance. Original g INSURANCE yitt o - WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY POLICY NO. 0187606 0 7-4 7 3117 w EXTENSION OF INFORMATION PAGE c ITEM 4.CONTINUED PAGE NO. 1 0 0 Estimated Total Rates Per Estimated Annual Premiums CODE Annual $100 of Remun- Subject to CLASSIFICATION OF OPERATIONS NO. Remuneration 0 MA-2 0 eration Modification All Other 0 LOC. 1 SIC: 8661 NAICS : 813110 329 ROUTE 6A YARMOUTH PORT, (Barnstable) MA 02675-1817 001-001 FIRST CONGREGATIONAL CHURCH OF YARMOUTH FEIN: 04-6110040 From 12/23/2022 To 12/23/2023 RELIGIOUS ORGANIZATION: 8868 182, 16S 0 . 64 1, 166 PROFESSIONAL EMPLOYEES & CLERICAL (Amended) RELIGIOUS ORGANIZATION: ALL OTHER 9101 18, 293 3 . 24 593 EMPLOYEES (Amended) Deviation 9037 0 . 887 -199 Employer' s Liability (in 000 ' s) 9807 0 . 010 16 Limit: 500/500/500 TOTAL UNMODIFIED PREMIUM 1, 576 TOTAL MODIFIED PREMIUM 1, 576 Merit Rating 9885 0 . 950 -79 STANDARD PREMIUM 1, 497 All Risk Adjustment Program 0277 1 . 000 0 Expense Constant 0900 338 Terrorism 9740 0 . 0300 60 DIA Assessment 0 . 0418000 0935 70 . 00 TOTAL ESTIMATED PREMIUM 1, 895 WC 00 00 01A Church Mutual INSUR AN ( E