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MA 026� 5 8-398-223 ext. 1260 REcEIv rY APPLICATION FOR CERTIFICATE OF INSPECTION JUL 17 20 July 1, 2023 PAYABLE UPON RECEIPT - _�%_z'"� (X) Fee e fired luu.uu MENT ( ) 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: (74,01NI"l, �/. Q. Name of Premises: o rs Tel s-3) 9 7- 303 Purpose for which permit is used: Co m,N,u r o-\ cO c r,'u • License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency 1� • Certificate to be issued to CC. .4 SS UG, 6l: ° I(4.a\-- aTel: (W-) 9,'7 L/,3 00 Address: LL N .A, eC � -'vC j (.), er w.nv tk,NQ (`Ja(e7J Owner of Record of Building o(' c- Address �� �� \2 r ��•rev-�- ) arw..o ,. NN4s, bc:q(4-7*._1 1' Present Holder of Certificate ZLI ce:,[4:es Signature of person to whom Title Certificate is issued or his agent Date Email Address: `ir'a 1� ,I' U CC 1.04 r Guru 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# 0/—d3--/N6 08/18/2023-08/18/2024 ~s t CIT.00A DATE(MM/DD/YYYY) - CERTIFICATE OF LIABILITY INSURANCE 07/11/2023 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 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 CONTACT DOWLING&O'NEIL INS AGENCY/PHS NAME: 08088233 PHONE (866)467-8730 FAX The Hartford Business Service Center (NC,No,Ext): (NC,No): 3600 Wiseman Blvd E-MAIL San Antonio,TX 78251 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Twin City Fire Insurance Company 29459 CAPE COD ISLAND ASSOCIATION INSURER B 22 MID TECH DR WEST YARMOUTH MA 02673-2560 INSURER C 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/Y YYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-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/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) _ BODILY INJURY(Per person) ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS AUTOS (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS- MADE AGGREGATE DED RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X (STATUTE ER ANY Y/N $500,000 A PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A 08 WEC NJ2677 11/30/2022 11/30/2023 E.L.DISEASE-EA EMPLOYEE $500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS below 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 22 MID TECH DR BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED WEST YARMOUTH MA 02673-2560 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVEVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD t