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HomeMy WebLinkAboutBCOI-24-30 2026 /6.1* 'YA TOWN OF YARMOUTH Office of the BuildingCommissioner �; 1146 Route 28, South Yarmouth, MA 02664 - = 508-398-2231 ext. 1260 Fax 508-3 ' ;. i �• MATTACHEESE- / E I \I E D yCORP O R AT E°,b3'''`` APPLICATION FOR CERTIFICATE OF INSPECTIO MAR 17 2025 March 04, 2025 PAY• NT (X) e �. ... .:. , .�� 01 ( ) 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: , 6 '`C1Ii 1eL to Name of Premises: Ti4C Ae r qa 1/ Tel: 5C11,- —14,E:Lk Purpose for which permit is used: Pt /1 L 0-Le' h i h✓►- i I License(s) or Permit(s)required for the premises by other governmental agencies: License or Permit / Agency K__i_ - l( ✓1�'Yuwv ''l 5rtn�' J 6(JrtvD� I�0`/ SC!�.eu4-inCYl // k Pi Certificate to be isN ed/t-o /!�A4L( a Tel: �0 g _ G2 -it too (,(, I' Address: .2 emte Gfm c j'� or 4 Q2-41 Owner of Record of Building yG r nt,tj' , tux, Wire f.Jerd,A 1-; Ar l'r)) e.. Address SA.ie Present Holder of Certjficate - %),L it l �eaS1+rer at Signure of person to whohi . Titl Certificate is issued or his agent g/j3 /g6 / Die ) Email Address: 1,v zet e gm�1�I . Ct)rr) 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#BCOI-24-30 04/10/2025-04/10/2026 �"� ^w �(u� � / ��� ' - _-�__ _____-_^ - � `-' __� _ _ - �� -_- �_- _ -_ - -_ -- � --- - -�� �� - -- - --- -�� --- -| ' | . . | / ! i / | . -AC L CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/12/2025 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 NAME:CONTACT Mary Murphy Roger Keith&Sons Insurance Agency PHONE (508)583-1106 FAX (508)583-8478 (A/C,No,Ext): (A/C,No): 1575 Main Street E-MAIL mmurphy@rogerkeith.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Brockton MA 02301 INSURER A: Associated Employers Insurance 11104 INSURED INSURER B Yarmouth New Church Preservation Foundation Inc INSURER C: PO Box 237 INSURER D: INSURER E: Yarmouthport MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2531214039 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD 1/1/VD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL BADV INJURY $ GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PET n LOC PRODUCTS-COMP/OP AGG $ 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$ $ WORKERS COMPENSATION X PER N/ OTH- AND EMPLOYERS'LIABILITY STATUTE /� ER YIN 500000 A OFFICER/MEMBER EXCLUDED? ANY PROPRIETOR/PARTNER/EXECUTIVE N IA WCC-500-5030614-2025A 04/01/2025 04/01/2026 E.L.EACH ACCIDENT $ , (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 50Q000 If yes,describe under 500,000 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) POLICY LIMITS IN EFFECT AT POLICY INCEPTION. 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 Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 [// ✓'9. / J ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD .e. ti E i 1 1 �