Loading...
HomeMy WebLinkAboutBCOI-25-4 (2) 0� YAK.., ` TOWN OF YARMOUTH r 0 Office of the Building Commissioner = 1146 Route 28, South Yarmouth, • , _ �., ' V E D 508-398-2231 ext. 1260 Fax 508-3 • ; • 1 r MATTACHEESE �, '"�o ��q.✓'� MAY 2 7 2025 gPORATEO :") ``' APPLICATION FOR CERTIFICATE OF INSPECTIO BUILDING DEPARTMENT May 15, 2025 PAYA:' �' '4 (X) Fee Required$50.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: Qoi-/ R-e. 2 S, W e .3+ IOrvflt1?uIh Ma 0,2673 Name of Premises: CAN AA N c)b A Cif\u Cr/ 1 Tel: 6;) - 266 / 139 Purpose for which permit is used: Yea I�f _70 6 °��4 �7 07 License(s)or Permit(s)required for the premises by other‘68,6-h overnmental agencies: License or Permit Agency Certificate to be issued to G Jc b Tel: / {.• — /6/J9 Address: 070G( Rte` 01,$ ad vu ma 0-173 Owner of Record of Building 111 th S�n Al.ft t' r ddress 1/!�'-5 MO O(c K 1-�1f lY y i 43L t Holder C_, ertif cate L,..AIW 9� at - ��I� � sc � �� a ofper'.on to whom Tit icate is issued or his agent 075- Date Email Address:V yob U f fe r J a AD D "637Y) 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# 04/01/2025-04/01/2026LU/-- 5—� 1 GENCSN 159 Bank Street,Fourth Floor Burlington,Vermont 05401 COMMERCIAL PROPERTY EXTENSION OF DECLARATIONS - STATEMENT OF VALUES Name Insured: Northeastern Conference Corporation of Seventh-day Adventists Policy Number: 64821 Policy Term: 08/01/2024 -08/01/2025 Policy Level Information See Deductible Limitation Equipment Breakdown Blanket Limit: $100,000,000 Organizational Level Information Organization Name: HYANNIS MA CANAAN SDA CHURCH Organization Code: 667399 307 FALMOUTH RD HYANNIS, Massachusetts, 02601 Business Income Extra Expense: $78,000 Excess Business Income Extra Expense: $0 Location Information Loc/Bldg: 038-002 Description: WEST YARMOUTH MA CANAAN PC: 3 CHURCH Risk ID: Address: 204 RTE 28 County: Barnstable WEST YARMOUTH, Massachusetts, 02673 Property No: 202743 Sq Feet: 4,950 Construction: Frame Coverage Description ConditionNaluation Limit Building Replacement Cost $600,000 Equipment Breakdown Included Personal Property of Insured Replacement Cost $180,000 Building Ordinance or Law $60,000 Sub Coverages Description Class Code Description Limit Organization Summary Building Values: $600,000 Business Personal Property Values: $180,000 Scheduled Property Values: $0 Total Additional Limits and Scheduled Property Values $780,000 GICV 122 09 23 ©Gencon Insurance Company of Vermont Page 1 AC DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 8/1/2024 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 NAME: Adventist Risk Management,Inc. (A/C.N ,Exit: FAX No): 12501 Old Columbia Pike Silver E-MAIL Spring,MD 20904-6000 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Gencon Insurance Company of Vermont 10594 INSURED General Conference Corporation of Seventh-day Adventist,et al INSURER B: Northeastern Conference Corporation of Seventh-day Adventists 11550 Merrick Boulevard Jamaica,NY 11434 INSURER C:_ HYANNIS MA CANAAN SDA CHURCH INSURER D: _ 667399,307 FALMOUTH RD INSURER E: HYANNIS,MA 02601 INSURERE: 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. IN SR R ADDL TYPE OF INSURANCE N {MM/DDIYYT /Y SD SWVD POLICY NUMBER UBR POLICY POLICY EXP LIMITS Y) (MM/DDYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1.000.000 DAMAGE RENTED CLAIMS-MADE x OCCUR PREMISESO(Ea occurrence) $1,000,000 MED EXP(Any one person) $10,000 8/1/2024 8/1/2025 A PERSONAL 8,ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ N/A POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGO $ N/A 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 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ AUTO PHYSICAL DAMAGE COMPREHENSIVE COLLISION $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of coverage as respects to property: 202743: WEST YARMOUTH MA CANAAN CHURCH 204 RTE 28 WEST YARMOUTH, MA 02673 Who is An Insured is amended to include lessors or property managers as an additional insured for details see CG 20 11 12 19 attached. CERTIFICATE HOLDER CANCELLATION To Whom It May Concern SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ✓ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD