Loading...
HomeMy WebLinkAboutBCOI-23-1805 2025 611 •YA TOWN OF YARMOUTH -N o Office of the Building Commissioner t t 44 :} 1146 Route 28, South Yarmouth, MA 02664 y 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE ck ,` O'PORATEv, . APPLICATION FOR CERTIFICATE OF INSPECTION September 23,2024 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: go'.a 1ClUA a. 'S Le&AM y r \ Name of Premises: W i Se., L-u Ks c,\ C AYY1a1P Tel: 1 — (DC)—t-t,, Purpose for which permit is used: CD vl VI- MICA-S 1 VtZ 3 KOLA- UtALU d_ License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Li c,2u.e.,yi_LA L.e",)—e Certificate to be issued to Tel: Address: T,,' -, eciu.j 25 �je (�u_. ry„..„,. .-i„--. Owner of Record of Building L Address , Present Holder of Certificate \S UU v-6- . rm-erk. Signa i re of person to whom Title j Certificate is issued or his agent tom/ a7 Date Email Address: 5 Gundb,-ti..s 'ec.se - v ►Cc,►,--, 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# 12/31/2024-12/31/2025 ACCPRO IY CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYY) 06/15/2023 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 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 Anna Seymour NAME: C&S Insurance Agency,Inc. PAHONE Ext): (508)339-2951 FAX No): (508)339-4811 190 Chauncy St E-MAIL anna@candsins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC C Mansfield MA 02048 INSURER A: Associated Employers Insurance Company INSURED INSURER B: Wise Living Management LLC(see overflow for additional names) INSURER C: PO Box 785 INSURER D: 935 Main Street INSURER E: Chatham MA 02633 INSURER F: COVERAGES CERTIFICATE NUMBER: 23-24 Workers Comp 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 ADOL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ,INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE OCCUR PREMISES(Ea E occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: _ $ AUTOMOBILE LIABILITYCOMBINED 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 LIAR _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X [MUTE EMPLOYERS'LIABILITY STATUTE ER Y/N 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A WCC-500-5015767-2023A 04/05/2023 04/05/2024 E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED. $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 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 Rte 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD