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HomeMy WebLinkAboutBCOI-24-1 2027 • , - g 'YA.4 , TOWN OF YARMOUTH . o e' Office of the Building Commissioner �; 1146 Route 28, South Yarmouth, MA 02664 'o Yam.y 508-398-2231 ext. 1260 Fax 508-398-0836 \ICACHEESE RAtE ,s' _: — APPLICATION FOR CERTIFICATE OF INSPECTION December 01, 2026 PAYABLE UPON RECEIPT (X) Fee Required$100.00 ( ) No Fee Required In accordance with the provisions of the Massachusetts State Building Code, Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: f LD 42 at Name of Premises: K�kikL K( Q\tO Tel: 5 cb"T7 I—4 b3L) Purpose for which permit is used: Res. O k License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to kebl i L t( plU\m 6IJ Tel: 501�� 77/_1�� Address: Li i c g-- d$ w i'' oUTW{-- Owner of Record of Building 1`1(� Ej Address j (6 Itl)1�N4 1/ S t'(t" ' ent Ho de Certificate '3 ) Nt9 ( 456 witeic- Signaturee of person to Title — RECEIVED Certificate is issued or • nt I c l o-- )3 .u- — ^^ hh// Date Email Address: riL I L k i1t ter3.Q ()ICIVE0 DEC 16 2025 i BOIL I,- f� NT Brc 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-24-1^ 01/01/2026-01/01/2027 v ' -- �; -) :. . ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/12/2025 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 CONTACT NAME: Paychex Insurance Agency,Inc. PAYCHEX INSURANCE AGENCY, INC. co877-266-6850 FAX (A/C. Ext): C,No): 225 KENNETH DRIVE E-MAIL FlexCerts@ a Chex.com ROCHESTER,NY 14623 ADDRESS: P Y INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Security National Insurance Company 19879 INSURED INSURER B: Keltic Korporation Inc INSURER C: 415 Route 28 West Yarmouth,MA 02673 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 ADDLSUER POLICPOLICY NUMBER (M/DDY EFF/YYYY) (MM/DDY EXP /Y LTRINSD TYPE OF INSURANCE WVD YYY) LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE [_ OCCUR PREMISES(Ea occurrence) $ MED EXP(My one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: CMBINED AUTOMOBILELIABIUTY Ea accident) SINGLE LIMIT $ 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 LIAR OCCUR EACH OCCURRENCE _ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICEANYPR /MEMB REXC EXCLUDED? (Mandatory in NH) LY NA N SWC1576190 07/17/2025 07/17/2026 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION keltic korporation LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 415 rt 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN west yarmouth,MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -1 - ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD