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Icncc d. . . � � kt �74 \ \ \ �~ / } \ °OUT r go .� TOWN OF YA ° ,�, , .., \ „a tt - ,C� j _ 1� .a ,u INC . . .. . .t _ M t"' NATFA $ , 'l f ; 1146 Route 28, South Yarmouth, MA 02664 0 -398-223 EDElVED APPLICATION FOR CERTIFICATE OF INSPECTION I IL OCT 05 2023 September 1, 2023 PAYABLE UPON RECE PET'UILDING DEPARTMENT (X) Fee Re u 4 - ---- ( ) 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: /76 9 ,£/ -�674/firit0iiiq m S Di '&2 C/ Name of Premises: f) ,LY -L v rd 4 0I 14, 11110. Tel: 54— /i 7-or/ Purpose for which permit ie d: p (U ‘� ( hU b t ` -o c a i h Ci License(s) or Permit(s) required for the premises by other governmental agencies: `\9 License or Permit Agency \ i L. l z ,/Le 4, ,1 ;_��. 1°41 OC" / /- O,fz c rf- 0 6-- k / 1/%L/) ✓`iv, Certificate to be issued to tU 1[ 1 k44 P c )J,4114141 `' Tel: Si-Xer 1 3 7— ) g/ Address: /74 j IV Le 5. (1 Phuvi'l W.4n55 626 Ll Owner of Record of Building / )h?0w.3 /L'96, Address ,1 U/ (f4 f (CgL LrtJ 8 9fe.ILI77/9Y9L6- /h N. Oz 630 -1 51Z Present Holder of Certificate 61(2Th0 0'pi L 04 6-6 # 2 27 b J on L- Ca'' 64 0(P6a-C 1 ' APM/4} Signature of p to whom TitleZ S Z3 Certificate is issued or his agent Date Email Addres:Rct, yo on,4 ro 7 o q i c cy / 10 or,L.• e014.4 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# (�J—J 3-- /7 12/31/2023-12/31/2024 Act CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDfYYYY) ‘...--- 10/09/2023 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 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). PRODUCER CONTACT Lockton Affinity, LLC PHONAME:_---- FA Lookton Affinity, LLC _LAICHoy I:866 836-3373 Li !c No1_913-652-7599 E-MAIL Y� B. O. Box 879610 ADDRESS: Kansas City, MO 64187-9610 INSURER(S)AFFORDING COVERAGE NAICa INSURER A:Nova Casualty Co 42552 INSURED INSURER B: Yarmouth Moose Lodge #2270 _ INSURER C: 769 Main Street, Route 28 INSURERD: South Yarmouth, MA 02664 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS;RI ADDLISUBR' POLICYEFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD_ POLICY NUMBER (MMIDEfYYYY) IMMIDD/YYYY)I LIMTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED I CLAIMS-MADE I 1 OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN°LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY jECj LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED I SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ — HIRED AUTOS AUTOS (Per acadentl $ LIAg t3GctR EACH OCCURRENGE §AtI i _ ACC?��_ITE $11)MBRIILA LIES[yld1= _ ti t: - „db i. 21.-04 iY&fiii:/ t'1'# I2ltiir7i�sin2 ii 1 ER 1F TH 4ANrt ,OYER3 l ATUTE ANY 'R,OPIV4 7 0Iti.cmj-rNhE t,CUTIVE Y3l r A E ::�;CPAtdoENT $1Cib:811f1CL ?v'ENI F CLUbEb? N i.K1` EL.DISEASE-E-REMP.O! $th0oilI rSckStary'<in I 1 IIONS itV lh " E.L. S-- 061�,. l.It'.�:*_ �`,-gdylL t�bw--- _-.�-�-�._ _. __�__.- __, _�_.-_-_ �..,__-_,..._..� II I bE'sdionioN Ort brie #TIcits t L( 1 tiaiis r .itL S(AbbRC(lei,Additional kemarks sike816,rh*i be afiachen if rx# Fe ipASR iy rEigii'l*, 9 CERTIFICATE HOLDER CANCELLATION 780345 Proof of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR/�I�"'I//' TAT� 1 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 46759533 780345