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HomeMy WebLinkAboutBLD-19-855 1 o� RECEIVESUse ��► ' 52:,kr) AUG 142018 IAm,no� BUI • '_ �q E T Permit expires 180 days from p ey _ �i i 'issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH ( � Yarmouth Building Department C 1146 Route 28 Gin � & lD 9 £ i � U South Yarmouth,MA 02664 0? 2.- Old , fO(508)n.4eAi?398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Old kfn_vyl`' len 1 � ;' ('// 1 /ft ?-k INFORMATION: Map: Parcel: OWNER: NAME PRESENT ADDRESS TEL # Email Address: CONTRACTOR: ( ayside it-s+ 'Inc wishi',#1 ecierw-ovll., & tc Sok-760.440as" NAME MAILING ADDRESS TEL# II,, II Addddrress* Residential Commercial Est Cost of Construction$ /1 VV�VOL, s� cow} Home Improvement Contractor Lic.# _ Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance v Insurance Company Name: Mc"fAt r t f✓`f y✓4tCt' Worker's Comp.Policy# WCC. Soo- D,U,2 1-clot-,. ltoXecn IOn o WORK TO BE PERFORMED Tent Duration /J-g/a0 (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like *The debris will be disposed of at Location of Facility I declare under penalties of perjury that the statements herein contain' a true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be Just cause for denial orrevy on of my license and f =tion under M.G.L Ch.268,Section 1. Applicant's Signature: tie 1 Date: Owners Signature(ort t) Date: Approved By: ✓..r_ Date: S''', Buil g0 tct (ordeals get Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District Within 100 ft.of Wetlands: Yes No Yes No • • The Commonwealth of Massachusetts /, I�Ira 11$ Department of Industrial Accidents lm= 1 Congress Street, Suite 100 • -f j Boston, MA 02114-2017 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information J Please Print Legibly Name (Business/Organization/Individual): 6Gtr.{'%de 7pjl.'T Address: /10 C bik t e )9441-- City/State/Zip: a .City/State/Zip: ,'tf uir -ovek 1444- O?&"1' Phone #: se-og - 760 - es— Are you an employer?Check the appropriate box: G Type of project(required): I.�a employer with i employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in S. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m Y property.PtY• I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E-Cther �('/v71— 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box Ni must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �n -t • Insurance Company Name: `v( C s/j Ph YM SV�r�Ccs Policy#or Self-ins.Lic. #: Lu C'C Coo - 50( 3$) ( -'?o(f,4 Expiration Date: Sl ZZ//Ii Job Site Address: 61761 Ale a1/4. City/State/Zip: Jti� �A Da1,6q Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u the pains and penalti s of er'ury that the information provided above is true and correct. Signature: rn,! Date: 50Phone#: --r W Oa C Official use only. Do not write in this area, to be completed by city or town official • City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • Information and Instructions • Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MOL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of f Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia • AC o® CERTIFICATE OF LIABILITY INSURANCE DATE ILIMIDDM'YY) 4.....--- 05/29/2018 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 CONTNAME:ACT Elaine Donoghue McShea Insurance Agency,Inc PHONE s yaw (508)420.9011 ime,No):(508)420.9010 1645 Falmouth Road,Rt 28 BLDG D ADDREss: elaineemcsheainsurance.com Centerville,MA 02632 INSLJRERIS)AFFORDING COVERAGE NAIC• INSURER A: Penn-America Insurance Company INSURED INSURERS: Progressive Casualty 11770 Bayside Tent 8 Table,Inc. INSURER C: AIM Mutual , , 40c Whites Path INSURER 0: South Yarmouth,MA 02664 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-132030 REVISION NUMBER: 11 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 ADOL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER IMM/DDNYVVI (MMIDDNYYY) LIMITS A x1 COMMERCIAL GENERAL LIABILITY CLAIMS-MADE X OCCUR PAV0128463 05/17/2018 05/17/2019 EACH OCCURRENCE TED $ 1,000,000_ �_ DAMAGE TO RENTED PREMISES IEE cel $ 50,000 H MED EXP(Any one person) f 5,000 , PERSONAL SADV INJURY S 1000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY Tei n LOC PRODUCTS•COMP/OPAGG $ INC _ OTHER' $ B AUTOMOBILEUABILRY 02711576-2 10/12/2017 10/12/2018 IEei6`NdNISINGLE LIMIT f ANY AUTO BODILY INJURY(Per person) $ 20,000 OWNEDSCHEDULED BODILY INJURY(Per ecddenl)If AUTOS ONLY X AUTOS 4O OOO AUTOS ONLY _ AUTOS ONLHIRED NON-OWNECV ler acc4den PROPERTYDAMAGE f 5,000 f UMBRELLA LIAB _ OCCUR EACH OCCURRENCE I$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ OED RETENTIONS S C WORKERS xo erEivior°COMPENSATION WCC-500-5013321.2018A05/22/2018 05/22/2019 I PER I ER ANY PROPRIETOR/PARTNERIEXECUTIVE 'INEL EACH ACCIDENT $ 100,000_ OFFICERIMEMBER EXCLUDED? n NIA - - (Mandatory In NH) E L.DISEASE•EA EMPLOYEE$ 100,000 DESCRIPTION uOF eOPERATIONS below E L.DISEASE•POLICY LIMIT E 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N mon space M required) CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED FOR THE DURATION OF THE CONTRACT. 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 aEPRESENTATIVE I ^ /�� (ESD) CI 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by ESD on May 29,2018 at 04:O6PM • • • Certificate of Flame Resistance REGISTERED FABRIC ISSUED BY hate of Nanu.".telure NUM3ER JOHNSON OUTDOORS INC. BINGHAMTON,NEW YORK 73902 JANUARY 1948 F•140.01 nem easere of me 17nesf Tent Pet tis Dessnhwf Herrn • This to to certify that the products herein have been manufactured fmm material Inherently Damn retardant as here after sport Red by the material suppPer. NAME: BAYSIAE ENT CITY: SANDWICH,MA) rasittication is hereby made that Thn ntic`a5 danctlted cn alis mraticafc have Leen manu'anetnd WI an approved fame tenant glemtral In complance with Canfomia State fire matcher Code,14FPA.7C1•.Undonnnes Laboratory of Canada,and have bean Wotad In armrndanen with Ihn rata?Taal M tc 1 Spa&miens arvi mean&evened tin bmtlary Sane Spetlrr'alions cf Mi.-Cr-0:S1n6G, Type,entre and weight of malot"ai 14 01 MITE EILOCKDUT Drccnofon at item trailed: GENESIS 20'hfiD 40 SECTION Flame Retardant Process Used Will Not Be Removed By Washing And • Is Effective For The Life Ot.The Fabric . Snyder Manufacturing,Inc. � i f : Inamfswnr&Flema PetrdaNUbna trninl,D+e T.NTOFPAI%A74T.JO"DI$CN C •'ORSIN . .. .. .: .;,. ' ser E;ele • • • l • Certificate of Flame Resistance REGIS Itto-D ISSUCO BY ftata ce Minutemen FABRIC HUMBER OUTDOORS NC. NEW YCRK 134C2 1 F-140.01 Maen3ctafe s of ere Finast SAT.U.41CY 14a.$ Tern Prtnkttls Cneanead I femtn This is to certify that the products herein have been manufactured from material inhorer.tyflame retardant as here after specified by the material supplier. NAME, BAYSIDETENT CRY: SANDWICH.,AU! Certlnceeen is hereby made/tint Tho crticYc de:t.t* l en ibis cerancate IvtW bass mars/acted wit,ctrl eppravdt flans remnant Avelino IA canpntnee nth • C,ffvnta Stets fire r.trshal Cc**FA-101'. Unenv rnee Ubonecry ct para and Wit barn Wand M setnrdanua vdth the Federal Test Method Spedteatotts and meet or moved ilio 41Litary Nona$peaficzncns et M'L-C•4900$G- • Tyre.column sett cf melon! 140L Vain StOCKOUr Dadladon of heat'wiled: GENETS 40X40 2PC MN7T • 1 Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric • Snyder Manufacturing,Inc. Mn is:two et name'Want got v'.M Lame.tts 'rEtIT L1F.7AFT>AFNi',JONtA0t10 e0f25 d1 :i � 's; 'toss Bram j' G.44*trn: # ...ardOHVyVa r A `°al,.$Y'aV 7' v'S v..rw. 4rWV#iIr;lvg)V. 4V..AV Wet/. . :Y mer m N tt, PC.' r' &nl/heft& �J��C.Gnz& eW .�% kt/tee' o`.. ISSUED BUY _CESS NEN7a' ( CCONCERN MBER ,�'� CELINA TENT INC. ii oSTE e t7ate of Manufacture / `r i .� CELINA,OHIO 4" • , x ' I F-72235 r1iell r�' 5373 State Route 29 €P 4.110.-• 3 5/12/2017 I k.,.' — I CELINA TENT" Celina,Ohio 45822 r;A'r �! z:e — MANUFACTURER OF FINISHED 74rF"/Rt m .9 Wig°, TENT PRODUCTS DESCRIBED HEREIN ;%REVS-/ 4.:r This is to certify that the materials described have been flame-retardant treated(or are inherently nonflammable)and were supplied to: QR < NAME: Bayside Tent "5CITY: South Yarmouth STATE MA _ y I. Certification is hereby made that: The articles described on this Certificate have been treated with flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshal Code,and is equal to or exceeds Specification NEPA-701 —_ 2..r., Method of application:, IMPREGNATCD - ...__--_... ^-- –„_—_,----_-_- } Type,color and weight of material: White 16oz Vinyl . AM Description of Item certified: 10x20 Classic Frame Tent 1 PC , ' Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric. tort • 5:`' Tent Products Division-Celina Tent,Inc. ._ ik : •' CELINA? 0 ry h _ :'i ire a .'i`d '4 -¢G6$l:Jd;4Td�3�'a,3}.7 '".4, -VAVAt1F ;'T'd,od i .t, �t+vlf`� idhtie J'vF.#"'.r {'Y�iiVioa,44.% '?d;,b 4yI, • It g"),"*., ,v 7tj4'4. %yeAO Sb' .,' • • ..fY Ari' u .,'?.�,,, .,m�«, M9rab,03.1 .: , ;Y9W-..R:,, a),-. 'i.`- ''�xi°``Y.„4,4,z4.444, 41.!...t' $'JR . . 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QC 0 No Amount(s):$4%sVrfryc ` —I r gore flj°d Will an auction or raffle be held?0 Yes Er< Will signs/banners be posted? [J t Will Ly Traffic Control be needed? 1'es � EI No ❑No Wi 1 muslc/amusement devices be at event?9C 0 No WM tents be erected?[ es []No Will sanitary facilities be provided?[gores ❑No Will food be served or sold? PCs.'" 0 No If Yes to food,please describe where food is being prepared and what is being served -4- LOCA L = ter: .:,_ — t►u: -e. C . _,, C'hoat ***IMPORTANT*** Certificate of liability Insurance must be submitted to cover the event prior to granting permission for use of Town properly, Action by Adminlstretor. Approved essubmitted Approved with the foAbwin9=Moly Disapproved for the following reasons: "SF 0 02, ..20d Ame Town . - ,. : Strata : .,to