HomeMy WebLinkAbout2014 May 06 - Sign Off Transmittal, InfoTOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location:
Proposed Improvement:
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Applicant: �At t kc, 2 t C' c-✓ I C'_. 'y Tel. No.: -) W
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Address: 1 p b 6 0� 4o S /1 E. </ y ( U (� L 1 Date Filed:
**Ifyou would like e-mail notification ofsign off, please provide e-mail address: Mj V_{°S r h0 { b-ee
A ' 5 yj/(Gc I I .«
Owner Name: M j" I✓�L t-e 0Gj i&4A_ )
Owner Address: .� Alrh_C_
Owner Tel. No.: S6A4'( --
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
Site Plan showing existing buildings, water line location,
and septic system location;
Floor plan labeling ALL rooms within building
(all existing and proposed)`�I On 11-1* 1t
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee. f; l-e w�v U �l
....................................................................................................................................................................................................................................................................................................................................................................
VIEWED BY: t DATE:
V` PLEASE NOTE
OMMENTS/CONDITIONS:
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ALL JOIN I J OL I VIL-�
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1/2" = 1' - ()"
17
8'(TIP)
RESERVE AREA 33
BETwEEN TRENCHES U?
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SEPTIC 'SYSTEM PLAN
20'
t5ins - 11110
r(Ue 5 officivi Inspacbm Form: SubWrfa0s Sewage DiSPOW System - Page 18 of 'a
NOTICE OF ASSIGNMENT - PENDING PAYMENT
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EMPLOYER:
CAPE COD FOOD GROUP INC
PO BOX 659
ESSEX, MA 01929
The Waiver of Our Right to
Recover from Others Endorsement
is available on Pool policies.
Contact your agent for details.
COMBO I.D.
000148100
COVERAGE GROUP
1057783
STATUS OF EMPLOYER
Corporation
Coverage under this assignment
annl iPa +n MAPaAnhiiaaa++c
operations only. For coverage
outside of ;Massachusetts, contact
the appropriate Pool or Plan for
that state.
AGENT STERLING IN917PANOP Ar-PMVV TNV 1R1E@Fq10 v 1E1D
OR M ELIZABETH CAHILL
PRODUCER: 306 CABOT STREET P O BOX 493 h� JJ. (;( U 14
BEVERLY, MA 01915
HEALTH DEPT
AGENCY FEIN:042195633
cxA"axrxcATIOIQ or OlSr-wrio 4
CIAM 55
ESTIMATED ANTE
ES'1:1MA'17El)
CODE
TOTAL ANNUAL
PREMIUM
--------------------------------------------
-----
REMUNERATION
-------------- ----------
----------
RESTAURANT NOC
9079
$182,000
1.07
$1,947
CLERICAL OFFICE EMPLOYEES NOC
8810
$10,400
0.09
$9
EMPLOYERS LIABILITY 10011001500
9845
Mon FAr-TO72
49$5
_ OS
4;_9fl
STANDARD PREMIUM
$1,858
EXPENSE CONSTANT
0900
$338
TERRORISM CHARGE
9740
$58
TOTAL POLICY MINIMUM PREMIUM
$216
TOTAL ESTIMATED PREMIUM
$2,254
DIA ASSESS. 3.4%
$63
TOTAL EST. PREMIUM PLUS ASSESSMENT
$2,317
INSTALLMENT BASIS: Annual
DEPOSIT PREMIUM:
$2, 317
THIS IS NOT A BILL
COMMENTS
Subject to 08/07 Anniversary Rate Date.
Coverage under this Notice of Assignment applies to the captioned entity only. If
coverage is required for an additional entity, the employer must submit an application,
check, and an ERM to the Pool for the additional entity.
)ATE OF NOTICE: 05 / 14 / 14 PREPARED BY: Joanne Shea
EXT 530
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 - FAX (617)439-6055 - www.wcribme.org