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HomeMy WebLinkAboutBCOI-23-1724 2026 g YA�� TOWN OF YARMOUTH t0 = (c r _ Office of the Building Commissioner ' : . 1146 Route 28, South Yarmouth, MA 02664 N ;" • ,rt 508-398-2231 ext. 1260 Fax 508-398-0836 MAT[ACHEESE- ' APPLICATION FOR CERTIFICATE OF INSPECTION February 03, 2025 PAYABLE UPON RECEIPT (X) Fee Required$100.00 ( ) 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: V /t% S7— I Name of Premises: a L/e'4s t 0001 Tel: 6)1 S. / 'j`6----- Purpose for which permit is used: /2� 7/9 License(s)or Permit(s)required for the remises by other governmental agencies: License or Permit Agency Certificate to be issued to _ ,? I C "/I+ Telo/1 a faff) Address: 3 v .` oh I/ do.. // Owner of Recor of Building 10)11 Address ep/yLoi Present Holder of Certificate 54)4A—v--- Alif Signature of pers n to whom Certificate is issued or his agent /itle/ /Taate EmaiLAddress;- G ��^d/G��L/ toCO1t 1T.� am,ram % -1CJ)/'s Glom ® eo' 's ter' 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# ,)0/,R 3—/7„),V 03/10/2025-03/10/2026 1 CHARWHI-03 JLOOMIS ACORC,' CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) 5/13/213/2025 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 rCi2MEAcr Hillary Desir Corcoran&Havlin Insurance Group PHONE 287 Linden Street (ac,No,Exl):(781)235-3100 241 I Fax (A/C,No): Wellesley,MA 02482 ADDRESS:Hillary.Desir@chinsurance.com INSURER(S)AFFORDING COVERAGE NAIC II INSURER A:Hartford Accident&Indemnity 22357 INSURED INSURER B: Charles White Managed Properties Corp INSURER C: 330 Commonwealth Avenue INSURERD: Boston,MA 02115 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 INSD SUERW POLICY NUMBER POLICY EFF POLICY EXP LIMITS (dIMIDD/YYYY1 (MMIDD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ • CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED UTTO BODILY INJURY(Per accident), $ HIREDTO ONLY AUTOS ONLYY (PerR PROPERTY ) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N X PERERH STATUTE ER 08WBCLD6253 2/2/2025 2/2/2026 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVERR�/ gg E.L.EACH ACCIDENT AoMandaR/ _ ( MEn NFIR EXCLUDED? N I A 500,000 E.L DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS I 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 George Deraleau THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. 345 Camp Street West Yarmouth,MA 02673 AUTHORIZED414- REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD