HomeMy WebLinkAboutBCOI-23-1703- g - TOWN OF YARMOUTH
,� Office of the Building Commissioner
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+ ' 1146 Route 28 South Yarmouth MA 02664
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508-398-2231 ext. 1260 Fax 508-398-0836
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'�"' APPLICATION FOR CERTIFICATE OF INSPECTION
June 1, 2026 PAYABLE UPON RECEIPT
(X) Fee Required$214.00
( ) 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: 55 ( ThAit 02 C
Name of Premises: 1! i V1 Lt.0 )dA S coN4 Tel: GO ,14-1 -0693
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 o Tel: Soi ,A 1 -0 6 9 5
Address: Sg p p ut .?g \14 ej t- yrAtwic,ALL N►A 0,2443
Owner of Record of Building l7 Qvnr►-y pcsitgl
Address S 9 �� , d18 v.l,y 04 lau'tin..
Present Holder of Certificate H 1y r (21(Act c— — M
Signature f per on to whom Title
Certificate is issued or his agent (35/,,4,/-u�26 — D
Dae RECEIV lI
Email Address: P(OM�O\o C� C A\ C.(\M \ -C6YDa 1
MAY 0 4 2025 j,
BUILDING DEPARTIENT
By
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 USA COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH Ti
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# BCOI-23-1703
06/29/2026-06/29/2027
WORKERS'COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company(500)
54 Third Avenue,Burlington,MA 01803.0970
(800)876-2765
NCCI NO: 40959
Policy No. WCC-500-5030196-2025A
Prior Policy No.
ITEM
1. The Insured: DIPTI LLC
DBA: Econo Lodge
Mailing Address: 59 E Main Street FEIN: *****2078
West Yarmouth,MA 02673
Legal Entity Type: Limited Liability Company(LLC)
Other workplaces not shown above: See Location
2, The policy period is from:11/24/2025 To 11/24/2026 12:01 a.m.at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here:
MA
B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3.A.The limits of our
liability under Part Two are: Bodily Injury by Accident $500,000 each accident
Bodily Injury by Disease $500,000 policy limit
Bodily Injury by Disease $500.000 each employee
C. Other States Insurance:Part Three of the policy applies to the states,if any,listed here:
Coverage Replaced by Endorsement WC 20 03 06 B
D. This policy Includes these endorsements and schedules:SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All information
required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Total Estimated Per Estimated
No Annual $100 of Annual
Remuneration Remuneration Premium
INTRA:000048617
SEE CLASS CODE SCHEDULE
INTER:
Minimum Premium:$267 Total Estimated Annual Premium: $631
GOV GOV Deposit Premium: $646
STATE CLASS
MA 9052 State Assessments/Surcharge: $15
This policy,including all endorsements,is hereby countersigned by / 10/20/2025
Authorized Signature Date
Service Office: P.O.Box 4070 Agency: HUB International New England LLC-
Budington,MA 01803-0970 600 LONGWATER DRIVE
NORWELL.MA 02061
WC 00 00 01 A(Ed.7.41)
Includes copyrighted material of the National Council on Compensation Insurance,Inc.,used with Its permission.
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