HomeMy WebLinkAboutBCOI-24-55 2026 �f Y'A*,,, TOWN OF YARMOUTH
, ' . . 0. Office of the Building Commissioner
.,' 1146 Route 28, South Yarmouth, MA 02664
le _�` 508-398-2231 ext. 1260 Fax 508-398-0836
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MATTAGHEESE �`
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'` ----' APPLICATION FOR CERTIFICATE OF INSPECTION
April 01, 2025 PAYABLE UPON RECEIPT
(X) Fee Required$50.00
( ) 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: if l / H cli IV C✓swe11 ROoi ot,
Name of Premises: /\1 Y l eJT4m&"°t r14 G4°/1.6It- Tel: SW-77/ " J?6,276
Purpose for which permit is used: t-✓O(5-4,o JYw1ref
License(s) or Permit(s)required for the premises by other governmental agencies: 1 E C E iED
V
License or Permit Agency APR 14 2025
BUILDING DEPARTMENT
Certificate to be issued to /Voir-r-PSrG0,-AT /3410 la C4 nip Tel: SD<57, 711 - L?,2-7( By —
Address: ` 7) /1-t1S"'s GJo[ArA Ro-rJ-
Owner of Record of Building i
Address
Present Holder of Certificate
%, Mil— dea,otp- i
Signature o erson to whom Title
Certificate is issued or his agent Wk9/02j
Date
Email Address: S j 4ati 777 6 0 ��,1, Gaor
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omit, G462, 1/ me pn mj c,e11p'° G 77 it--- ir`'r7- 0300
1 0 ,ereneC, Tine-.
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-24-55
05/01/2025-05/01/2026
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ILBROTHERHOOD k, DATE 20W
POLICY NUMBER 20WSA049A0494716
l i MUTUAL. AGENCY 2800-
NEW ENGLANDLIGHTWELL LLC INSURANCE ADVISORS
OFAUDIT PERIOD 12/31/2023 12:01 a.m.-12/31/2024 12:01 a.m.
standard time at Insured's location
Audit Worksheet: Workers' Compensation Policy
Audit Period: 12/31/2023 - 12/31/2024
NEW TESTAMENT BAPTIST CHURCH
491 Higgins Crowell Rd
West Yarmouth MA 02673-2506
AUDIT AUDIT ORIGINAL ORIGINAL
CLASSIFICATION CODE BASIS RATE EXPOSURE PREMIUM EXPOSURE PREMIUM
CHURCH 8868 Payroll 0.6000 34,575 $207 33,900 $203
DEVIATION 9037 (0.1000) 207 ($21) 203 ($20)
LOSS CONSTANT 0032 0.0000 0 $20 0 $20
EXPENSE CONSTANT 0900 0.0000 0 $159 0 $159
TERRORISM 9740 Payroll 0.0300 34,575 $10 33,900 $10
Audit Premium Total: $375
Minimum Premium: $200 Less Original Premium Paid: $372
(excludes terrorism&assessment charges) Due Company: $3
Remarks:All Additional or Refund Premiums of$5 or less are waived.
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WKSHT_AUDT(03/19) Page 1 of 1
6400 Brotherhood Way,P.O.Box 2227,Fort Wayne,IN 46801-2227 I p.260.482.8668 I f.260.483.7525 I brotherhoodmutual.com
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