HomeMy WebLinkAboutBCOI-24-34- - rt40 M TOWN OF YAROUTH
. y BUILDING DEPARTMENT
� qr...,,.,�.•�'.a� 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
March 1, 2024 PAYABLE UPON RECEIPT
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1i �� j S Jj& (X) Fee Required $172.00
) ( ) 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 premiseslAocaated at the following address:
Street and Number: 77 <7 G e Gt/ —
Name of Premises: vVaereri4allekeiTel:. $llO-'127&
Purpose for which permit is used: 'L Le4i7 ail/ Pe-die -L2gtl7
License(s) or Permit(s) required for the premises by other governmental agencies:
RECEIVED
License or Permit Agency
MAR 112024
BUILDING DEPARTMENT
Certificate to be issued to 4)4171ifii619444N ,P Tel: 4Z7Z
Address: / �
Owner of Record of Building V'11 .Q - �C-
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Address 777 10 tuft
Present Holder of Certificate
frelSignature of person to whom itle
Certificate is issued or his agent P
// Date
Email Address: h4�c[ viiikirCea�.-e� rt.“1Q: co!')
Instructions: Make check payable to: Town of Yarmouth
1 146 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 CANN,O I UE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection # cj f..a .
04/29/2024-04/29/2025
Latc'yrity ATEGRITY SPECIALTY INSURANCE COMPANY
14000 N.Pima Road,Suite 200,Scottsdale,AZ 85260
FORMS SCHEDULE
QUOTE NO:01-C-PK-Q240122869161-02
ACCOUNT NUMBER: AGENCY NUMBER:0000002068
NAMED INSURED AND MAILING ADDRESS AGENCY AND MAILING ADDRESS
The Village Center Group LLP XS Brokers Insurance Agency,Inc.
77 Route 28 13 Temple St
West Yarmouth MA 02673 Quincy Massachusetts 02169
POLICY PERIOD:FROM 03/08/2024 TO 03/08/2025 AT 12:01 AM STANDARD TIME AT YOUR MAILING ADDRESS
SHOWN ABOVE.
ASIC-NOT-0004 12 20 Policyholder Disclosure-Notice Of Terrorism Insurance Coverage
CG 00 01 04 13 Commercial General Liability Coverage Form
CG 20 08 04 13 Additional-insured-users-of-golfmobiles
CG 21 04 11 85 Exclusion Prod/comp Ops Hazard
CG 21 07 05 14 Exclusion-Access Or Disclosure Of Confidential Or Personal Information And Data-
related Liability-Limited Bodily Injury
CG 21 39 10 93 Limitation Contractual Liability
CG 21 44 04 17 Limitation Of Coverage To Designated Premises,Project Or Operation
CG 21 47 12 07 Exclusion Employment-related Practices
CG 21 67 12 04 Exclusion Fungi Or Bacteria
CG 21 73 01 15 Exclusion Of Certified Acts Of Terrorism
CG 21 86 12 04 Exclusion Exterior Insulation Finishing Systems
CG 22 45 04 13 Exclusion-Specified Therapeutic Or Cosmetic Services
CG 24 16 12 07 Canoes Or Rowboats
IL 00 17 11 85 Common Policy Conditions
IL 00 21 09 08 Nuclear Energy Liability Exclusion
02/23/2024 FORMS-SCHEDULE-Page 2