The URL can be used to link to this page

Home My WebLink AboutBCOI-23-1706 2026 (---g YA TOWN OF YARMOUTH 0 Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 MATTACHEESE �` ""'` APPLICATION FOR CERTIFICATE OF INSPECTION May 6, 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: a&DId YllG.t 4t 3S6-ii l/K,it/1m10id4, rn Il. 02.6 4, y Name of Premises: &- (IM c1 15 % ' tcee C l, ilieL Tel: 6'b i- /0 e-'/ -3-D- Purpose for which permit is used: n6r-pit g211 i S (:�.t-xi I k. rLicense(s) or Permit(s) required for the preniisesk-e y other governmental agencies: License or Permit Agency Certificate to be issued to �' t tJWL(S f 514)ci I C�1u i 1el: 6b s -.34, 1/-4�. -.1' Address: &Q5' 0. (.d�, - 1t .d'� \` t , wig- 0-24 to f Owner of Record of Building , ��w Address t` L L ` ` Present Holder of Certificate 4" end S EkteS,91-6044- A- c.:LP imt),. • Signature of person to whom f Title Certificate is issued or his agent 5736102C --.5-- Date Email Address: V(12, eec 54'david S 10-4-,)- L CmCLL_S-1- vs _r)c-t- • 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-23-1706 06/18/2025-06/18/2026 ACCoR�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)9/19/2024 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: The Church Insurance Agency Corp (A/cc,No,Ext): (800)293-3525 (A/CC,No): (800)557-1395 E-MAIL 210 South St,Suite 2 ADDRESS: Bennington,VT 05201 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Liberty Insurance Corp INSURED INSURER B: INSURER C: Diocese Of Massachusetts INSURER D: 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 AODL SUBR POE ' POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS 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 JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY C�OMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS DAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STE ATUTE RH ANYPROPRIETORIPARTNER/EXECUTIVE Y E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? X WC7625900009024110 9/30/2024 9/30/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 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 St Davids Church THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN lid Old EpiscopalMaia St ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth MA 02664-4529 AUTHORIZED REPRESENTATIVE & 36',4&