HomeMy WebLinkAboutBCOI-23-1706 YAK. RECEIVED
�g ,� ,, TOWN OF YARMOUTH.
MAY 07 202C1 fi e of the Building Commissioner
P 1146 o to 28, South Yarmouth, MA 02664
�, =;�yr BUILDING DEPSW _By ; -2231 ext. 1260 Fax 508-398-0836
/�CZPPORATE2,
" "" APPLICATION FOR CERTIFICATE OF INSPECTION
June 1, 2026 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 U 5-- Vt a U V l CIUA - S = CA) ;(,{ '1/1M a,1 1 14/1 D(-
Name of Premises: S - -(N�S P1SL cJ CkLt Lock o: 5U 39 q—y� -,.)___
Purpose for which permit is used: CLA.AC
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
-----41 -44
Certificate to be issued to S C.. . e y —( -�
Address: a 0Gj 0 1 �� -1-L_ y a„vvt CIA.11-.. ( 1/1'l Pi"
Owner of Record of Building _ v.j's
Address Saw.--LA- —
Present Holder of Certificate Sc,�.A.A.— —'
g:U/ (f,LA.AA4314-- , _ ,
Signature of person to whom Title
Certificate is issued or his agent 51 3/2 ZQ •
[/] Date
Email Address: _ it 11 CLiI L2 4(1/x4m S 1 0`�� , 0-4 6I ; IV 71--
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_
06/18/2026-06/18/2027
® DATE(MM/DDIYYYY)
AC to CERTIFICATE OF LIABILITY INSURANCE 025
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/C,N Ext). (800)293-3525 (A/c,No): (800)557-1395
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.
ADIL R TYPE OF INSURANCE INSD SUBRD POLICY NUMBER POLICY EFF POLICY EXP LIMITS
(MM/DD/YYYY) (MM/DD/YYYI)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE
AMA PREMISES RENTED
Dnce) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $
POLICY JECT LOC PRODUCTS-COMP/OP AGG $
OTHER:
AUTOMOBILECOMBINED SINGLE LIMIT
LIABILITY $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY
DAMAGE $
AUTOS ONLY AUTOS ONLY
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITYANYPROPRIETO l STATUTE I I EH
-
AND OF ICER/MEMBER $ 1,000,000
XCLU ED?ECUTIVE Y X WC7625900009025110 9/30/2025 9/30/2026 E.L.EACH ACCIDENT -
(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
David Episcopal Church THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
St Dav
lid Old Main St ACCORDANCE WITH THE POLICY PROVISIONS.
South Yarmouth MA 02664-4529
AUTHORIZED REPRESENTATIVE (�{�!�/}
. /1? �\