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HomeMy WebLinkAboutBCOI-23-1702 2024 ,�°• Y:4 TOWN OF YARMOUTH pq'. r, e O �"� MAp.I419 14 � .BUILDING DEPARTMENT �`J�^*•�.:t 1146 Route 28, South Yarmouth, MA 02664 508-399 E D APPLICATION FOR CERTIFICATE OF INSPECTION NOV 07 2022 May 1, 2022 PAYABLE UPON RECEIPTBYUILDING DEPARTMENT (X) Fee Required $.1U.Uu ( ) 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: 1-1\1 • Name of Premises: < h\J r'`, Tel: Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency ClCertificate to be issu d to ��' ^ `�� Tel: Svc y` 4� - Address: 1 �� Owner of Record of Building Address Present Holder of .ficate Signature of person to whom Tit e Certificate is issued or his agent D k Date Email Address: ` ��2 C_L) \ 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# L /)/-Q3_,OO y) 06/30/2022-06/30/2023 �/o SO 77s-Dt,3J " / AcORco CERTIFICATE OF LIABILITY INSURANCE DA11/022022 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 have ADDITIONAL INSURED provisions or 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 Erica H.O'Connor HART INSURANCE AGENCY,INC. NAME: 243 MAIN STREET (NC No.Ext): FAX No): PO BOX 700 E-MAIL ADDRESS: eoconnor//l1L% enc g yhartinsurancea .tom BUZZARDS BAY,MA 025320700 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: SCOTTSDALE INSURANCE CO 41297 INSURED Pier 7 Condominium Trust INSURERS: Associated Employers Ins Co. 11104 711 Route 28 South Yarmouth,MA 02664 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A V COMMERCIAL GENERAL LIABILITY CPS7500553 01/01/2022 01/01/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE RENTE CLAIMS-MADE IV OCCUR PREMISESO(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 VI POLICY JECT PRO- LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050114672022A 11/06/2022 11/06/2023 VI PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY OFFICER/EIMBEER EXCLUDEDETOR/PARTNER/EX?ECUTIVE N N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION Fax#:(508)398-0836 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN STREET South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE // 7.4440: 4. • ©1988-2015 ACORD CORPORATION. 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