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HomeMy WebLinkAboutBCOI-26-5 2027 /4 Y-_ TOWN OF YARMOUTH ,;; 3 AP> Office of the Building Commissioner �' 1146 Route 28, South Yarmouth, MA 02664 se. _ �; 508-398-2231 ext. 1260 Fax 508-398-0836 [ACHEESE cf. PORATE% �`` APPLICATION FOR CERTIFICATE OF INSPECTION March 16, 2025 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: ! 3`W 7,--\- aq Name of Premises: i-wN't l I 0\We Cot ""bD(AA-4� Tel: ;r:f$41444=1-.1 Purpose for which permit is used: License(s) or Permit(s) required for the premises by other governmental agencies: License or Permit Agency Certificate to be issued to i O i i 1't k e,b�e LU'tAso(' Tel: Address: L Owner of Record of Building y�. ' i►'Vl© AJ�AU '`Z L- Address I 3 31 R V ai ,SotA kr ewe © �. ( Co Present Holder of Certificate fAvrtiI'( -re, to Co( e.60re-k-i it.. 6k9 Sig re of son to whom Tit1 Certificate is issued or his agent 'Y�]ti 2C4 Da e Email Address: J@:4 r e &it y ta. C ot(&►roll ve. , U ram' RECEIVED I APR 2 7 2026 B L I -P, 7 975 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# 5/16/26-5-16/2026 - ° X 0 5 7 Cs' S p ^1 /v d (7 m I [1---(1:5" r V 1 49=71 o7 -P V m Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD/YYYY) 04/28/2026 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 Lisa Dowd NAME: The Hilb Group New England,LLC PHONE (800)640-1620 FAX (A/C,No,Ext): (A/C,No): E-MAIL lisa.dowd@hilbgroup.com ADDRESS: 973 lyannough Road INSURER(s)AFFORDING COVERAGE NAIC Hyannis MA 02601 _INSURER A: Philadelphia Indemnity Insurance Co 18058 INSURED INSURER B: Safety Indemnity Insurance Co 33618 Family Table Collaborative Inc. INSURER C: Associated Employers Insurance Co 11104 c/o Glivinski&Associates INSURER D: 261 Whites Path Suite 5 INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: 26/27 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMiDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 [IMATO RET'ED CLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) $ 100'000 MED EXP(Any one person) $ 5'000 A PHPK2679974-00E 05/05/2026 05/05/2027 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n JECT PRO- LOC PRODUCTS-COMP/'OPAGG $ 2,000,QOO OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED v SCHEDULED 5924173 03/11/2026 03/11/2027 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) Medical payments $ 10,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION$ $ WORKERS COMPENSATION X PER OTH STATUTE ER AND EMPLOYERS'LIABILITY Y•N C ANY PROPRIETOR'PARTNER'EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED N 1,000,OOO N!A WCC50050322382025A 08/26/2025 08/26/2026 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 It yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations,and endorsements.Nothing contained in the Certificate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions 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 MA-28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 I � ©1988-2015 ACORD CORPORATION. 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