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HomeMy WebLinkAboutBCOI-24-26 2026 og' TOWN OF YARMOUTH �,� �. Office of the Building Commissioner tor f 1146 Route 28, South Yarmouth, MA 02664 iii 508-398-2231 ext. 1260 Fax 508-398-0836 `• macro {Rts[/ti .. O b ORPORA-11.j `'' APPLICATION FOR CERTIFICATE OF INSPECTION January 23, 2026 PAYABLE UPON RECEIPT (X) Fee Required$150.00 ( ) 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: ` 1 2. --\-2-<- ' Z 2. .q Al d A, i✓1'.1 n"ih he .v/- / —Z- /"1`a -- Name of Premises— ic.,L =el: cJ --7 b / 3 7 ,) - -) t 2 Purpose for which permit is used: S t,,, a.,.,,,,,,l 1-.4 u cif' ct-.,.1 ; r License(s)or Permit(s)required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to �/'V,' S t r k&ir S Tel: ci -1 8 " s / c s y�L Address: it 4 z.,e w-s 1 '/nf.,,.., A , Al A L L. c. -7 3 Owner of Record of Building S•l-u,-,)5,v' -"44'"'►,rA-+- /, ''' Address D/ L .�..� ;h c,.%,-s/ )/4/"0 /I' . ,v?/► `' .c 7 3 Present lderof e ' i ate Si-Js4v M4ii4r.---1, .-,o c 0/3/� ,s44,k1 /J Signature of person to whom Title/ Certificate is issued or his agent 3 / 3 Z L. Date Email Address: v''•1 I-PYI,Iic,v 1 f G e ,:"44•l-C-''' MAR 03 2026 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 an chair jn the above information. 41. t' ' Certificate of Inspection#_BCOI-24-26_ 04/01/2026-11/30/2026 l C DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 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: Choice Insurance Agency PHONE.Ext). 978-343-4853 FAX No): 978-345-1007 376 Summer Street E-MAIL Fitchburg,MA 01420 ADDRESS. INSURER(S)AFFORDING COVERAGE NAIC# _INSURER A: PinnaclePoint Insurance Company INSURED INSURER B: XSB-Trisura Specialty Insurance Company Sandbar Management Inc INSURER C: 100 Wood Ave S,Suite 209 INSURER D: Iselin,NJ 08830 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 ADDLBUHR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 B CPS7362638 06/26/25 06/26/26 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 - POLICY n 1,1V-1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — OWNED x 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 LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER A OFFICER/MEMBER EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 WCP7010234 10/01/25 10/01/26 (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 Occurrence 1,000,000 B Liquor Liability CPS7362638 06/26/25 06/26/26 Gen Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Issued as evidence of coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD