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HomeMy WebLinkAboutBLD-19-000935 r' l Y I Office Use Only V �, g `�PeruSH �" 3r' ;t c h rod.°C)O Me* H a Amount., I ;'.Permit expires 180 days from ..?issue date.._.__..._.,. . ., BLN?-r O .RECEIVED EXPRESS BUILDING PERMIT APPLICATi N TOWN OF YARMOUTH AUG l e 2018 Yarmouth Building Department ------c _.. EUV )R ! : 1 MENT 1146 Route 28 t,Y ti __ South Yarmouth, MA 02664 �I Q (508)398-2231 Ext. 1261 /+ J, SOTS-737 34(13 CONSTRUCTION ADDRESS: 17 U 1`- llt-t .- 5��ct, Cod`s YwnY c;tC ((Q\ 0a 64 ASSESSOR'S INFORMATION: Map: 3 Z Parcel: 9 t4 OWNER: etreA-f is Cent A 1vaAwe 6d1{L '2f µ..,;, S}v,ect $.Yr...t,,.,,k.,M o1664• ps3 3 7y- 6-2-`D NAME PRESENT ADDRESS TEL. N CONTRACTOR Oat's:.(4T.en+.QiT'ab(e.ftn,c, 40 c. t..l...''c P.M., s- k4.n0,11,0 A oz.g tt `so .tu-9Ott NAME MAILING ADDRESS TEL.* ❑Residential /15/Commercial Est.Cost of Construction$ a Ott-- Home tt-- Home Improvement Contractor Lie.# Construction Supervisor Lia H Workman's Compensation Insurance: (check one) 0 I am the homeowner . ❑ I am the sole proprietor I-have Worker's Compensation Insurance ,t A to H. Insurance Company Name: AIM M viv Worker's Comp.Policy#W Ct �s 00,-So 1312 I—ZO 12•A andrs /DD X D CI J j L— G,/j rL WORK TO BE PERFORMED Tent -Duration det.' _3 (Fire Retardant Certificate attached7)ga 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 Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my lice for prosecution under M.G.L.Ch.268,Section 1. Q u /� Applicant's Signature: Date: Elf r 119 Owners Signature(or attachment) Date: (� ,f Iesi IOC{!j Approved By: mitiDate: b�'" 16� Building Official(or designee) EMAIL ADDRESS: Tom @ces.pe codclnallray r.4r3 Zoning District: t1 Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 R.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑ No 6,5p ,1tetiJ 4 _ . The Commonwealth of Massachusetts 1 =�—n—pet Department of Industrial Accidents �__:'l�li�_ . P • _tCongress Street,Suite=::! i 1 Boston, MA 02114-2017 100 f z/Lt.** www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): ,�(13244S It r-t9An- & -1— ToJ]'.P c Address: (IOC, whifess Pct-1-11 City/State/Zip: S . ya r-rnbi,L Phone#: Are you employer?Cheek the appropriate box: Type of project(required): I.[[ am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance, -1- d— 61 6.0 We area corporation and its officers have exercised their right of exemption per MOL e. 14�0` the[ 152,91(4),and we have no employees.No workers'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 contactors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contactors 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. Insurance Company Name: m,,"� 117----4-Pr C.C` S 12 ren re_ Policy#or Self-ins.Lie.#: U Ct'�lj W P—n 133I a n g-' Expiration Date: V5/04219 1 9 Job Site Address: qa 2 >i 17 e,j. S. City/State/Zip: - a 6- 73 Attach a copy of the workers'compensation policy decl ration page(showing the policy number nd 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cove ge verification. I hereby certify under th__LA( ,1 ' . es of perjury that the information provided above is true and correct. S'� afore: L ( -1 a:te• 67 /0 l$ Phone#: Official use only. Do not write in this area,to be completed by city or town offciaL 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#: k 4 • 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contact 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 • Accident 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 Industrial Accident. 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 r• ' 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 • ACOROe CERTIFICATE OF LIABILITY INSURANCE DATE(MNDDWYYY) `,/ 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: N the certificate holder Is an ADDITIONAL INSURED,the pollcy(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 lieu of such endorsement(s). PRODUCER NAMEACT : Elaine Donoghue MCShea Insurance Agency,Inc (A/CCNo Fell: (508)420.9011 ux,No): (508)420-9010 1645 Falmouth Road,Rt 28 BLDG D EADDRESS: elaine@mcsheainsurance.com Centerville, MA 02632 MSURER(S)AFFORDING COVERAGE NAICI INSURER A: Penn-America Insurance Company INSURED INSURER B: Prog e$SJYe Casualty 11770 Bayside Tent&Table,Inc. INSURER C: AIM Mutual 40c Whites Path INSURER D: South Yarmouth,MA 02664 INSURER E: 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 TYPE OF ADDL SUER POLICY EFF POLICY EXP LIMITS ran WVD POLICY NUMBER (MMIDD/YYYY1 (MMIDDIYYYbI A X COMMERCIAL GENERAL LIABILITY PAV0128463 05117(2018 05/17(2019 EACH OCCURRENCE I 1,000,000 Mt CLAIMSMADE n OCCUR PRREEMISES(ETO e�ocamence) I 50,000 MED EXP(My one person) I 5,000 PERSONAL a ADV INJURY I 1,000,000 GEENI AGGREGATE LIMIT IEAPPLIESPLPER: GENERAL AGGREGATE S 2,000,000 JL I POLICY !InI I LOC PRODUCTS•COMP/OP AGG S INC - I OTHER: S B AUTOMOBSEUABIUTY 02711576.2 1011212017 10/128018 COM(EsdeBlN SINGLE LIMIT I — ANY AUTO BODILY INJURY(Per parson) S 20,000 AUTOS DONLY X 77.SCHEDULED BODILY INJURY(Per accident) S 40.000 AUTOS HIRED AUTOS ONLY _ AUTOSONLY PPoO�e lD $ 5,000 I UMBRELLA LIAB _ OCCUR EACH OCCURRENCE I _ EXCESS LIAS CLAIMS-MADE AGGREGATE I DED RETENTION I S C WORKERS EMPLOYERS' WCC-500-5013321-2018 5/22/2018 05/22/2019 °STATUTE r MWPROPRETORE%RINERETXEDNT� ll MIA E.L.EACH ACCIDENT I 100,000 OFFICER/MEMBE(Mandatory In NH) E.L.DISEASE•EA EMPLOYEES 100,000 OyedRIPTIOe OFo DESCRIPTION OF OPERATIONS betow E.L.DISEASE•POLICY LIMIT S 500,000 DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES(ACORD 101,AddlHonal Ramada Schedule,may be attached N men apace Is.squired) 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 PRESENTATIVE I ,4‘� (ESD) 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name end logo are registered marks of ACORD Printed by ESD on May 29,2018 at 04:06PM a`t ;`tA ,'fit' s'Ati`g x'o l:+,v v-i `AY4A*V v`'A � `t tiv `. ° ,' A*Lou � v ;`� � G ciet W A VIA Certificate of Flame Resistance t This is to certify that the materials described have been flame-retardant treated(or are inherently nonflammable) < - Issued By: .- �` , Celina Tent,Inc. 5373 State Route 29 � > c IP ) Celina,Ohio 45822-9210C 9*•4 4www.CelinaTent.com MANUFACTURER OF FINISHED TENT N. PRODUCTS DESCRIBED HEREIN > Celina Tent,Inc.certifies that the fabrics used in its tent products are flame resistant.All tent,canopy,structure,and shelter products manufactured < and distributed by Celina Tent,Inc.will display a"Tent Identification and Warning label"certifying that it has been made of a flame resistant material. Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: it NFPA-701 CPAI-84 ASTM D 6413 BS 5438 BS 7837(1996) DIN 4102-B1 S. a Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the t?* application of said chemical was done in conformance with California Fire Marshal Code,and is equal to or exceeds Specification:NFPA-701 et ` Method of Application:IMPREGNATED - Description of Item Certified:MASTER SERIES FRAME TENTel The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. 4, 1*. This item is certified flame resistant or nonflammable,NOT FIRE PROOF.. The fabric will burn if left in continuous contact with any flame source. Open flames should never be used under any tent,canopy,structure,or shelter. Tent Products Division`� Tent,Inc. h �a Signed:_/��� , . ._, C E L I NA TENT' Rev.201507096, rs 4A z - t'A Dt s-2 A A 7 A 4 A 4- 4 V`4 4'• A 4.'rA 4 .b4 6A A 4 R 4*4 b A"ewe 8/14/2018 Pirate's Cove Adventure Golf-Google Maps Google Maps Pirate's Cove Adventure Golf ( � ". ! ,. k ;. K 4i' 1' t1 S ; y _ fit;"}y�`r l 21 xr 4.sY _ ' a.wFar °�'`'L�tr,C�•� i 'r+ a 14, } -�-'—,�-'-�a ri• 3° X /4'.44-44.,4 - s 'fY "Yl„a""''4�cj, ,�: x w s^ ,�. a r r_, ' ` • ,e ,c�. oaf -' w� ��a^.10.1 -a i 1y�'iS_ y JCIPCLLGod aisaM [:@j�a •.. r Y lej ,�s-, 't'' +mss. �r .. _ _ 4 . ,v . gC.,,..,.:twr.--."" ]/r`, �¢: • r y1 ! 'za' e X01 .:y �. - . g'''Pai3�lJ �'?. I - i^-{dt z " z--.}'-moi .F r �. _ !G r .aC' r '"f• `a! % ,�aya� r3. - \l stove . G I t ''S,34.-. . a . • tom' � -,4,,,..".. * Adventure Gott 1� w- e'; "C"'''' : �_t•` 1 •* vim Y ` ly .a+�' ,, -s 4.4e/-L" / �.n ">r ayc.Ate _ .' a'* F,.a 'iv : t_ 4 1x-e.+• :.r«G✓"ny tfu wa. '-% . "� +�� t..al- lL+ 't" '�bcearevhRean.. - i 14, „ ...' yf: y r -' 44 T� �. i y. ''?2 i.r 44.., ,-, y - Google :z15$4" n]3t 9• , .Seaatx is -�` .y, Imagery 02018 Google.Map data 02018 Google 50 ft [ - '- 4 'A. *�.�fir• `• fa s # -z3' aX - _ G if 1Y t.1 . _ a it1 https3/www.google.com/maps/plaee/Pirate's+Cove+Adventure+Golf/©41.6502999,70.2215052,171m/data=!3mt!183!4m5!3m4!1s0x0:Ox214051159748510a!am2!3d41.6500021!4d-70.2211712 1/3 GneOen er Cleo GOd Ga "Challenges are what make life interesting; overcoming them is what makes life meaningful' Tom Lavin - tom@capecodchallenger.org Telephone:508-420-6950 x1135 418 Bumps River Road Cell Phone:508-737-3443 Osterville,Massachusetts 02655 www.capecodchallenger.org