HomeMy WebLinkAboutBLD-19-000836 of•Y•94 TOWN OF YARMOUTH Building Department BUILDING
4. (508) 398-2231 ext.1261
y PERMIT NO :BLD-19-000836 LAV3`1C4 PERMIT
ka 'vac 4.
�;5' ISSUE DATE ;08113/2018 JOB WEATHER CARD
APPLICANT ;Sperry Tents PERMIT TO : New
AT(LOCATION) 118 STRAWBERRY LN,YARMOUTH PORT,MA 026 I ZONING DISTRICT I I Bldg.Type: Residential
SUBDIVISION MAP BLOCK LOT 122.83.1 BUILDING IS TO BE: CONST TYPE V B USE GROUP IR-3
REMARKS Tent:32 x 50ft Sperry Tent 8/17 to 8/20 Inspection Is needed on 8/17/18 by CONTRACTOR
1:00 PM by Building And Fire Department LICENSE
AREA(SQ FT) 2,352,849,84! EST COST($) 1600.00 PERMIT FEE($) 149.00
OWNER WILLIAMS BENJAMIN J JR TRS
BUILDING DEPT BY
ADDRESS C/O PERERA JOAN, 13 BIRCHWOOD LN /)
LINCOLN (MA 01773 /- / PHONE
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET ,• ' •- SIDEWALK 0 ANY PART THEREOF, EITHER TEMPORARILY OR
PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NO SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE
APPROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE
OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM
MINIMUM INSPECTIONS REQUIRED FOR ALL APPROVED PLANS MUST BE RETAINED ON WHERE APPLICABLE SEPARATE
CONSTRUCTION WORK: 1)FOUNDATIONS OR JOB AND THIS CARD KEPT POSTED UNTIL PERMITS ARE REQUIRED FOR
FOOTINGS.2)PRIOR TO COVERING STRUCTURAL FINAL INSPECTION HAS BEEN MADE.WHERE ELECTRICAL PLUMBING/GAS
MEMBERS(READY FOR LATH OR FINISH COVERING) A CERTIFICATE OF OCCUPANCY IS AND MECHANICAL
3)FINAL INSPECTION BEFORE OCCUPANCY 4) REQUIRED,SUCH BUILDING SHALL NOT BE INSTALLATIONS.
REFER TO DETAILED INSPECTION SCHEDULE OCCUPIED UNTIL FINAL INSPECTION HAS
BEEN MADE.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTIONS APPROVALS
OTHER:
WORK SHALL NOT PROCEED PERMIT WILL BECOME NULL AND VOID IF INPSECTIONS INDICATED ON THIS CARD
UNTIL THE INSPECTOR HAS CONSTRUCTION WORK IS NOT STARTED WITHIN SIX CAN BE ARRANGED FOR BY TELEPHONE
APPROVED THE VARIOUS MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED OR WRITTEN NOTIFICATION.
STAGES OF CONSTRUCTION ARfI\/F
"° v Uitma usa UM')
R L
2 'ti-o PrnNta
pr , t y y Fees D�
Permit expires 6 monde from
ka :....;e't - 1 Issue date,
, b-N-OGS ,6
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 13, S)-(04 dC eay Ln
ASSESSOR'S INFORMATION: /
(�, Map: Parcel:
OWNER: WeAC 1 tet" eco. A (yt 3 tI 44aa
NAME PRESENT ADDRESSTEL a
CONTRACTOR: S{h°C{y re 2�?Gt-1�t(SoV-• C rni‘C Qr] 50?7a%
14917C
NAME / MAILING ADDRESS TEL x
Commercial 0 Est.Cost of Constmction S )1,00.0 a
Home Improvement Contractor Lfe.I Construction Supervisor Lie.I
Workman's Compensation Insurance: (check one)
I am the homeowner `` II-am the sole proprietor I have Worker's Compensation Insurance ,( 1-f (1 ('/
Insurance Company Name: SAGA .r JJOJri l.r a Worker's Comp.Policy# M c-A 0%to " / b R6
2140-111 / 8j!7 tleiI� WORK TO BE PERFORMED
Cot (Fire Retardant Cenifi ate attached) 0 wood Stove Shed
C Siding: *of Squares C Replacement windows:a
0 Replacement doors: it
❑Re-mot *of Squares C Insulation
()Stripping old shingles* ()going over layers of existing roof ❑ Old Kings HighwayMlstoric District
Roofing/Siding(Like for Like)
*The debris will be disposed of at:
N
Location of Facility
I declare under penalties of perjury that the statements herein contained are rote and correct to the best of my knowledge and belief. I understand that any false answer(s)
will bejust cause for denial or tevRcaloe of my license and/fpEosecudMAILon under ML Cit.268.Section I.
Applicant's Signature: � a* A .��(.f/f'l/�- Date: 9/4-1 hr
Owners Signature(or attach ))) A Dom: 8/1/2018 )2
Approved By: �/ rte— - Dem:
W ' / /8
g s tial(or designer)
gioS/ / Zoning District:
/�/F� 2/^Tpa Historical District Yes Na Flood Plain Zone: Yes No
4 %S�age I Water Resource Protection District: Within 100 R.of Wetlands:
Y �ij P �Dn ( Yes No Yes No
11.�'L r O 6 3,01
• -2...---- , SPERTEN-05 AMIDDLETOAI
•A���� CERTIFICATE OF LIABILITY INSURANCE D08%012018
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(les)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 Ileu of such eeNTndorsement(s).
PRODUCER NRMEpa
Foundation Insurance Group PHO
(NC,NNE
Err):(703)527-8780I ac,No):(703)5324300
9190
ls Church,VA 22042airview Park o 104
FalMist•Info @figva.com
M '
INSURER(S)AFFORDING COVERAGE NAIC S
INSURER A:Axis Insurance Company 37273
INSURED INSURER B:State National Insurance 12831
Sperry Tents Inc.,Sperry Tents Marlon Inc. INSURER C:
28 Patterson Brook Road Unit 2 INSURER D:
West Wareham,MA 02576
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 ADDLSUBR POLICY (PAM/OD/TM)
POLICY EFF POLICY EXP LIMITS
LTRINSD WVO (MYYY
MIDDIY ) IMMIDDFYYYYI
A X COMMERCIAL GENERAL LIABILRY EACH OCCURRENCE 3 1,000,000^
CLAIMS-MADE I I OCCUR A1SPMA002-017772.01 09/01/2017 09/01/2018 DAMAGE OEoNcaTEnDencel $ 100,000
—
MED EXP(Any one person) $ 5'000
—
PERSONAL&ADV INJURY I 1,000,000
GEN'L AGGREGATE❑JELpGTIMo-IT APPLIES PER: GENERAL AGGREGATE 3 2'000'000
POLICY LOC PRODUCTS-COMP/OP AGO j 1,000,000
OTHER $
A AUTOMOBILE UABIUTY (Ea BINEDaccidenSINGLE LIMIT 1 1,000,000
X ANY AUTO A7SPMA002-017773-01 09/01/2017 09/01/2018 BODILYINJURY(Perpmaon) S
OWNED SCHEDULED
AUTOSg�� ONLY AUTOSUpNN�pyyyyryryEEpp BODILY INJURY(Per ecddenl) $
X AUTOS ONLY X OWE Pore odl)AMAGE E
5
A UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1.000,000
X EXCESS UAB CLAIMS-MADE ASSPMA002-017774-01 09/01/2017 09101/2018 AGGREGATE $ 1,000,000
DED X RETENTIONS 0 $
B WORKERS COMPENSATION X STATURE FOR-
AND EMPLOYERS'IJABIIJry NFA0867886 09/01/2017 0910112018 1,000,000
ANYQ� PROPRIETOR/PARTNER/EXECUTIVE YI I EL EACH ACCIDENT $
(alFiWrtory In NH)EXCLUDED'? I NIA E L DISEASE-EA EMPLOYEE $
lM 1,000,000
If yes,desaibe under 1,000,000•
DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT S
•
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N mon space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Helen Perera ACCORDANCE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
• 18 Strawberry Lane
Yarmouth Port,MA 02675
AUTHORIZED REPRESENTATIVE
I e
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
The Commonwealth ofMassachusetts
1 w__ Department of Industrial Accidents
ttr
w1=0t Office of Investigations
1 = r 600 Washington Street
v — Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): e ,c c 7 }S
r \
Address: a-CC 7cx\\c t SONn S6 n I PRA _ V n i 4 a--
City/State/Zip: \,j Wa,reVo ,., AM-- 001-1.5t Phone#: eo 7L1St179a-
Are you an employer?Check the appropriate box: Type of project(required):
I. 1ST:
I am a employer with 00 4. 0 I am a general contractor and I 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ We area corporation and its
required] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.[No workers'] Otherrev� ]
comp. insurance required
*Any applicant that checks box#1 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �� "
Insurance Company Name: 5k3-5rC NO 14 o.\ jyt s,,t QMcCr
Policy#or Self-ins.Lic.#: NFA O 'G 7 gL R („ Expiration Date: 9// // P
Job Site Address: 61 I$ L L City/State/Zip: /avj•h ,4,4
�i�CntJ�oef'C / N Ci /StatelZi
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
•
I do hereby certfy under the pains and penalties of perjury that the information provided above is true and correct
Signature: /a/L_'tt l�� Date: l/l3/it
Phone#: 4 O g "Pit / 7 c /
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Certificate of Flame Resistance
n rry Sails Date of Manufacture
r e
30.Nov-06
pimufaetorerlumber S
417
11 Marconi Lane
Marion,MA 02738
(508)748-2581
This is to certify that the materials described have been
flame-retardant treated or are inherentlynnon-flammatkle
and were supplied
{
neramithi .
Certification is herby
made that:
The articles described on this certificate have been treated t on with osaid
a
flame-retardant approved chemical and that the app y
chemical was in conformance with
or exceeding 701.`rnia Fire innbal Code
CPAI 84
al
• . • ' • (t. Pole Tent
Description of Item Certified:
24x44
Flame,Retardant Process Used Will Not Be Removed By
Washing And is Effective For The Life Of The fabric
Name of Applicator of FR Finish % ,J
Kolon f Ill/
..ala ain n itrance�t . �` -'. " , -- � " "
...t ;�,'a `_ Mount Auburn Cemetery
h > 3,°�i , ;>hs,. �t,t ''` ,$ � Garden Road Site
R g }'4wisgy .---a- -,,,, I: - �.rhe . -, t v., t a tt 4 s�
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` cak .t- "°'x xsa''' k -naCar "" 1 w . .,T • t y ;'; +.
a. .#.,,tc;y„ 4:n‘, t. .' , '� ' a 32 x 50 R.9SperryTent(White)
kis " r x r r X., "'- .c i' e. " +', �, ..°ta a .. a�i Ir.k. _ , `,r w Eight60" able
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rL.;h*�x#�_ (Seating for 64-80 Guests)
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4:0;:'±1:1 "a ,.,.' v.. fi t i t': r t f sSl�'y' act r "' b t -%`'-‘4414.7.41
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', , rtr '!J 1995 + - ^;:'�" "a. -• • J s . r t . `•Imagery Date:4/14/2017 42°22'29.85"N .71°0838.85'W�elev•'25 R'' eye alb '.374 ft 0