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HomeMy WebLinkAboutBLD-19-001519 O ceUseOnly r°� YqR� 1, -/q-CD �j �2 aq to ft es �y Amount . '�. 33ii Permit expires 180 days from r' -:::#1:j• • 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: VI Cokola4vs glot hv.C, ASSESSOR'S INFORMATION: 11 Map: Z2 Parcel: I OWNER: ;t.N E,UNi.tt otS /s1 41,,n, 4. S flit 714 Z 6 9 63 7S NAME 1 PRESENT ADDRESS A TEL. # CONTRACTOR: Undercover Tv, I- 411. ehr 31 Asteh c„ t„*1 V OromIS cog q��X NAME MAILINOADDRES T " rEL - iA r T%/` ICI f esidential 0 Commercial Est Cost of Construction S 1pUDe, Home Improvement Contractor Lie.# Construction Supervisor Lle.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor $I have Worker's Compensation Insurance Insurance Company Name: 6v44SfQ Its 5.,lr#1.1 C^C C 6 Worker's Comp.Policy# 1.4.4,11c- 33/11 7 Z 7 ' / LUE7�D/n/G W�ORK�(TO BE PERFORMED Tent C/ Duration II Ili —1/26 (Fire Retardant Ceerrt�cate attached?) Wood Stove Siding: #of Squares - Replacement windows:0 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. .a'sined 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 revoca+. _ ' and for prosecutio !d r r .L Ch.268,Section 1. X34;Applicant's Signature:! %-" �� Date: 945 f Owners Signature or attic• tiriMlir Date: 47/ a 9i 3/l D Approved By: f-a---4- 'iDate: '/IV ! . B 'ding Official(or d• ign ' EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: U Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No K ,.,41 ORDER CONFIRMATION: #15966-11 Page 1 of 2 - EVENT DAY: Saturday DATE: 09/22/2018 UNDERCOVER TENT EVENT TIME:DELIVERY: THU 09/20/2018 SUBJECT TO CHANGE `first Cass✓ants &Party Accessories PICKUP: MON 09242018 SUBJECT TO CHANGE SALES PERSON: BH PURCHASE ORDER#: 31 American Way South Dennis,MA 02660 ORDER DATE: 05/14/2018 TERMS: Phone:(508)398-9000 Fax:(508)398-9091 Website: www.undercovertentcom BILL TO: SHIP TO: TREATS CATERING (774)268-6376 GARY URGONSKI JUDY EDMUNDS HOUSE 19 COLUMBUS AVENUE 19 COLUMBUS AVENUE WEST YARMOUTH MA 02673 WEST YARMOUTH MA TEL: (774)268-6376 FAX: QTY ITEM DESCRIPTION PRICE TOTAL 1 30X40 FRAME TENT-WHITE 900.00 900.00 7 7X20 CLEAR SIDE WALL(OPTIONAL TO POINT OF DELIVERY) 25.50 178.50 6 60"ROUND TABLE 9.25 55.50 3 8'BANQUET TABLE(BAR/BUFFET) 9.50 28.50 1 6'BANQUET TABLE(BACK BAR) 9.50 9.50 1 36"ROUND TABLE 9.25 9.25 60 GARDEN CHAIR-WHITE-WITH WHITE PADDED SEAT 4.00 240.00 12 4X4 BIRCH-NEW ENGLAND PLANK DANCE FLOOR(12X16) 32.50 390.00 140 PERIMETER STRING LIGHTING 1.20 168.00 1 TENT PERMITTING FEE YARMOUTH 160.00 160.00 1 "DAMAGE/LOSS DEPOSIT" 125.00 125.00 60 10 1/4"WHITE DINNER PLATE-20 PER RACK 0.60 36.00 100 7 1/2"WHITE SALAD/DESSERT PLATE-20 PER RACK 0.55 55.00 40 WHITE CUP&SAUCER-20 PER RACK 0.95 38.00 72 6 OZ.WINE GLASS 0.48 34.56 72 6 OZ.CHAMPAGNE FLUTE-36 PER RACK 0.51 36.72 75 1012 OZ.WATER GOBLET-25 PER RACK 0.51 38.25 72 12 OZ.PILSNER BEER GLASS-36 PER RACK 0.51 36.72 SPECIAL INSTRUCTIONS: SUB TOTAL: 2,780.00 DISCOUNT: (278.00) SALES TAX: 0.00 DELIVERY: 40.00 / LABOR: 0.00 TOTAL: 2,542.00 & DEPOSIT PAID: 850.00 BALANCE DUE: 1,692.00 Cus •marSignatu Date *Customer is res•onsible for obtaining necessary permits and markings of any private underground utilities Including irrigation lines. *Undercover Tent and Party,Inc.will contact Dig Safe for your site in regards to the marking of public utilities. �? ,, ORDER CONFIRMATION: #15966-11 Page 2 of 2 • EVENT DAY: Saturday DATE: 09/22/2018 UNDERCOVER EVENT TIME: NT DELIVERY: THU 09/20/2018 SUBJECT TO CHANGE girt C21.4✓ants Er Party AcceMorie3 PICKUP: MON 09/24/2018 SUBJECT TO CHANGE SALES PERSON: BH PURCHASE ORDER#: 31 American Way South Dennis,MA 02660 ORDER DATE: 05/14/2018 TERMS: Phone:(508)398-9000 Fax(508)398-9091 Website: www.undercovertent.com BILL TO: SHIP TO: TREATS CATERING (774)268-6376 GARY URGONSKI JUDY EDMUNDS HOUSE 19 COLUMBUS AVENUE 19 COLUMBUS AVENUE WEST YARMOUTH MA 02673 WEST YARMOUTH MA TEL: (774)268-6376 FAX: QTY ITEM DESCRIPTION PRICE TOTAL 6 108'ROUND WHITE LINEN 16.00 96.00 1 90"X132"FULL LENGTH WHITE BANQUET LINEN-FOR 6'TABLE 21.50 21.50 3 901%156"FULL LENGTH WHITE BANQUET LINEN-FOR 8'TABLE 22.00 66.00 60 20"X20"NAPKIN-(PERIWINKLE) 0.95 57.00 SUB TOTAL: 2,780.00 SPECIAL INSTRUCTIONS: DISCOUNT: (278.00) SALES TAX: 0.00 DELIVERY: 40.00 LABOR: 0.00 TOTAL 2,542.00 DEPOSIT PAID: 850.00 BALANCE DUE: 1,692.00 Customer Signature Date *Customer is responsible for obtaining necessary permits and markings of any private underground utilities including irrigation lines. `Undercover Tent and Party,Inc.will contact Dig Safe for your site in regards to the marking of public utilities. UNDER-1 OP ID: MIKE ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNY) AE08/28/18 (MWDDN PRODUCER Phone:617-479-5500 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DPS Insurance Group,Inc. Fax:617.479-8761 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Granite Ave.,Suite 2 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 500 500on,MA ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 02e6 Daniel P Sullivan COMPANIES AFFORDING COVERAGE COMPANY a Arch Insurance Company INSURED Undercover Tent&Party COMPANY Tony Priai b Quincy Mutual 31 American Way South Dennis,MA 02660 COMPPPANY Wesco Insurance Co COMPANY D COVERAGES 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. CO TYPE OF INSURANCE POUCY NUMBER POUCY EFFECTIVE POLICY EXPIRATION UNITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERALLIABILITY BODILY INJURY OCC f A COMPREHENSIVE FORM PRPKG0008601 11/21/17 11/21/18 BODILY INJURY AGG ^ f PREMISES/OPERATIONS PROPERTY DAMAGE OCC f UNDERGROUND PROPERTY DAMAGE AGG f EXPLOSION&COLLAPSE HAZARD PRODUCTS/COMPLETED OPER 81&PD COMBINED OCC S CONTRACTUAL BI&PD COMBINED AGG f INDEPENDENT CONTRACTORS PERSONAL INJURY AGG f BROAD FORM PROPERTY DAMAGE PERSONAL INJURY AUTOMOBILE LIABILITY BODILY INJURY B ANY AUTO AFV206208 11/21/17 11/21/18 (PER PERSON) _S ALL OWNED AUTOS(Private Pass) BODILY INJURY X ALLOWNEDAUTOS (PER ACCIDENT) S (Omer Than Pnvate Passenger) X HIRED AUTOS PROPERTY DAMAGE f X NON.OWNED AUTOS GARAGE LIABILITY BODILY INJURY& PROPERTY DAMAGE f 1,000,000 COMBINED EXCESS LIABILITY EACH OCCURRENCE f _ UMBRELLA FORM AGGREGATE f _ OTHER THAN UMBRELLAFORM f WC STATU- OTH- WORKERS COMPENSATION AND X TORY I IMITS FR EMPLOYERS'LIABILITY EL EACH ACCIDENT f 1,000,000 C THE PROPRIETOR/ INCL WWC3314727 11/21/17 11/21/18 EL DISEASE•POLICY LIMIT f 1,000,000 PARTNERS/EXECUTIVE — OFFICERS ARE EXCL EL DISEASE-EA EMPLOYEE f 1,000,000 OTHER A Equipment Floater PRPKG0008601 11/21/17 11/21118 Equipment 600,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Party Goods Rentals CERTIFICATE HOLDER CANCELLATION GARYURG Should any of the above described policies be cancelled before the EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Gary Urgonskl 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 19 Columbus Avenue but failure to mail such notice shall Impose no obligation or liability West Yarmouth,MA 02673 of any Mind upon the company,Its agents or representatives. AUTHORIZED REPRESENTATIVE // /�i�L ACORD 25-N(1/95) ©ACORD CORPORATION 1988 Judy Edmunds UNDERCOVER TENT 9/22/18 .---- y3y ' ' 60 Guests — I 4111111,1111* 1101 :4 'AS 100111SI -----4j-1111111111:...„.41,:* , ,,,,,,p. :,. 4:1‘. ..' . - ' .. - 7801ibralli":„„te„,111 �' it f -!',six p rt,, .�-I ■ Eiti 04 -.Sala 1010 rig el lig. -- \, . sio BAR BUFFET _ 0 41 BVI L' lip+ u : NNW :t?t, ! '4041. .. L^3rsg�L'L•., A f j..,F' qr1 is x S ,ih 1 _' �I � , t i fyY' :.� IL in MI mop.. ....: ..:•(fes I ..;A.:,.ii. NI . 1 _ _ ma IN II /lil • t I■ ■I II II IN III i The Commonwealth of Massachusetts ...t..=-,__i Department oflndastrialAceldents • —t 1- n— :: 1 Congress Street,Supe 100 'c_`l = zr Boston,MA 02114-2017 ltrww mass govJdia Workers'Compensation Insurance Affidavit Bu Uders/Contractors/Electr}dam/Phrmbers. TO BE FILED WIT HTTtE PERMITTING AUTHORITY. Aooliant Intormatlon Pian Print Leatbh Name magnestiorgmbasontbdividuair Undercover Tent& Party Inc. ' Address: 31 American Way City/State/Zip: South Dennis MA 02660 Phone#: 508-398-9000 An roe as employer?Oak the appropriate ben Type of project(required): LEI sat a employer with 20 employees Van endrorpar4time),e 7. ❑New cons:notion . 2Qlcssole propriamrapermaddpand have noemployees witting ttaeeb S. ❑Remodeling anryapsehy.(Nowaken'weep.buena required] Demolition 9. ❑ 3.Q 1 em a haawmerdoine ae wet myself No workers' ke s'comp.tmaana»gpted.]t 10❑Building addition 4.0 t ee a baeeowc sed wits be brine contractors to conduct MI work on my propaq.I will ensure that all&sanes either have walkers'compensatko ismnoea ce are We 11.0 Electrical repairs or additions prapttatwtth no employees. 12.❑Plumbing repairs or add 8ohs , 5.01111111110;MI emanctor and 1 ham hired the stbeorthatices listed as te steiehed sheet 13. Roof repairs have sn employeand have comp.Sane ❑ repdri m . 6.0 We ars a=poretlaend teofficers havemcadaedsdrdelaofcampdonmrSMe. 141210tha Tent Install 152.11(41 ad we hat no employees[No waters'cooR instates ] •Any apyicomthat Meeks box St must also All ootshe section below showing their workers.oempwtlon polity k ..aeon. • t Haneowmers'Am submit fait affidavit indicating they me doing all work and than bin ounida aooaolasnaut submit a new admit indicating ads. :Contractors tot cheek this box must amrcbed as additional aha thawing the mane of the ab oaennaa and nate whether or not dame e a ben employees. Mho aboomtarmw have employees.they mat provide their wallas camp.policy number. , gi lam an employer that ltproviding workers'compensators Statue employers. Below U thepollcy andjob site , t tfannattom. Insurance Company Name Wesco Insurance Co. • • PolicykorSelf-Ms.M.1: WWC3314727 Etl$ratlonDate; 11/21/18 • Job Site Address: Icy .$ f�l/ Co 1 u 14-15xt- City/ Zip: L'5" A tined.. , i Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tntderMGL e. 152,125A h acriminal violation punishable by afne up to 51,500.00 . and/or one-year Imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator.A copy of this statement may be Converged to the Office of Investigations of the DIA for Insurance coverage vellication. ' 1daherebycertifyunderthepainsandpelattiesofpcJwythattheinfant:eonprovidedaboveIs!sereandcort Simon: Petenitib teDate: 9/13/8 mono g: 508-398-9000 OfJictol use onJ}t Do not write in this area,to be completed by city ortoan ofclat ' f City or Town: Pennk/Llcense0 Issuing Authority(drele one): I.Board of Health 2.Building Department 3.CltytFown Clerk 4.EletMad Inspector 5.Plumbing Inspector 6.Other Contact Perron: Phone Mr , . •,