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HomeMy WebLinkAboutBld-20-001041 Office Use Only o:'•YRR` • I ' ' ' y �� _W1es- 3a Permit*: A1,4 •Ol. .�H' ;Amount . .1 �_ ,w"T* n9ET' Permit expires 180 days from *.:•-'' l issue date 1RECEIVEDi EXPRESS BUILDING PERMIT APPLICATION-- 7 TOWN OF YARMOUTH ' AUG 22 201`.j Yarmouth Building Department 1146 Route 28 3u11 oirT, [)EPAR TM NT South Yarmouth, MA 02664 __.° (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: i2JpCNT j 1,�E j MAi j 5 j 6atri4 YYAlzpilaim3 AA t2421-14' ASSESSOR'S INFORMATION: Map: Parcel:,O ER: � i 6 l i Ll bAt. -1 bi tA lApAottrif . AAA �, T TEL. # CONTRACTOR: OP 61 b y 4t, v4 r10 170 , (AtI t't 14ttt V, -4)IA TbE2 fT 5 OES- 4 204.001CO NAME MAIL G ADDRESS ►156 ❑Residential 0 Commercial Est.Cost of Construction$ - 5 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insuranceoov_o3 Company Name: IFOT . A11 Worker's Comp.Policy# w�� t r2. 6 1 bai:Ali6YORK TO BE PERFORMED Tent 4 Duratio4--2 6 (Fire Retardant Certificate attached?)yjj 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 penaltie of perj that a tatem 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 de o voca. my lie and for prosecution under M.G.L.Ch.268,Section 1. i Applicant's Signature: ► uk:ty ,gate: qul Owners Signature(or chmen C3$ateQ /;- //11 Approved By: ✓,.1�. Date: s Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts Department oflndustrialAccidents =nel= I Congress Street, Suite 100 •_ �- Boston, MA 02114-2017 5'•"''� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): (i1 cvd .�D ��1iQ� Address: ' iQ ga44 _eivb F�`- � City/State/Zip: T i1 ) j4 02435 Phone #: :� Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]` _ 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will — ensure that all contractors either have workers'compensation insurance or are sole 11.❑ 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 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone#: Contact Person: ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD'""YY) L.� 05/29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(km)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNAME: Elaine Elaine Donoghue McShea Insurance Agency,Inc (A/C."n o.Ext): (508)420.9011 FAX No):(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D E-MAIL -M IIE$S: elaine@mcsheainsurance.com Centerville,MA 02632 INSURER(S)AFFORDING COVERAGE NAIC INSURER A: Penn-America Insurance Company INSURED INSURER B: Progressive 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 VNTH 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 ADOL SUBR POUCY EFF POUCY EXP UNITS LTR INSD WVD POUCY NUMBER (MMIDO/YYYY) (MM/DD/YYYYI A X COMMERCIAL GENERAL UABIUTY PAV0128463 05/17/2018 05/17/2019 EACH OCCURRENCE $ 1,000,000 O RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JEC LOC PRODUCTS-COMP/OPAGG $ INC OTHER: $ B AUTOMOBILE UABIUTY 02711576-2 10/12/2017 10/12/2018 (EaM&SINGLE UMIT $ ANY AUTO BODILY INJURY(Per person) $ 20.000 —_ OO OS ONLY NED X SCHEDULED BODILY INJURY(Per accident) $ 40,000 AU HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY AUTOS ONLY (Per accident) S,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION C OTH- AND EMPLOYERS'LIABILITY WCC'500-5013321.2018A05/22/2018 05/22/2019 STATUTE ER ANY AFYIPRONIEMB�EXRTNER E ECUTIVE NIA Li E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under E.L.DISEASE-POUCY UNIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is 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 PRESENTATIVE (ESD) 01988-2015 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 04:06PM ."-�?:+.�`�wrt�s«.;�,c."�a+; .. '.'x,$.3.��q' ls"5-sat" '. r',att�,ss9"'�..''a -.'ha°. �:. r.... �< �. ,�'.ae*` ". '."'�,� r.. -... ;3w' :.: as', „'aar. .a\r.�_ :fit ."- �,: ,,..".F_., .:; .. .,. ..�.>,. ,..u.t . . .�'�...: . "`ern.::�... .�+s.,., 19 e'�'�/, "?va�'.''�, ..:s.9` �'..."��.;-?..r''a,e";az�',a�'�✓`'�,:<-'�?¢,a'>.yrt`.�t.*.�',"':sA"'?ar"r.. �, ,,s� ,�,....�y�" .....„S,:�C. .•. .�. rr �,,p, .r�..f�,.�.. ..., � .�i; Y.:a� ,.�..�r.V�s,�+:Y. .q S. ,#�y'.E .Y ':W '4441 ��r:.•�; •'�' . 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L ik i.„a k h}a ut'a'm .a tY Lko Lit s'ax'4 i, LS a '4 A 1 at`'as u u' ! r ', 4 .v gi rN. ill em Certificate of Flame Resistance iiti Ire »>=4 This is to certify that the materials described have been flame-retardant treated(or are inherently nonflammable) �� ; w a €F,X Y -=�= Issued By: `��` Celina Tent, Inc. a 5373 State Route 29 : AO Celina, Ohio 45822-9210 ; A:A z www.CelinaTent.com Fx . ,.„ MANUFACTURER OF FINISHED TENT 17 -Al,PRODUCTS DESCRIBED HEREIN r, (; =� Celina Tent, Inc. certifies that the fabrics used in its tent products are flame resistant.All tent,canopy, structure, and shelterproducts manufactured `a :k= and distributed byCelina Tent,Inc.will display a"Tent Identification and Warninglabel"certifying that it has been made of flame resistant material. R ":10 P Y g Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: t 4k 4, .0 NFPA-701 CPAI-84 ASTM D 6413 )44 Bip S 5438 BS 7837(1996) DIN 4102-B1 will i': ,ti Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the •' application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification:NFPA-701 -4 ,�-�� PP q p =4,; Method of Application:IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. 41 This item is certified flame resistant or nonflammable, NOT FIRE PROOF. The fabric will burn if left in continuous contact with any flame source. Divl ekit Open flames should never be used under anytent, canopy, structure, or shelter. P Tent Products Division—Celina Tent, Inc. _11_444.0, -> Signed: 0:-1 cd4471; INC E L I N A TENT"' Rev.20150709 ``s 1147 r'a ,�4 n�4�W'^I raetr r„^,n T, R';,n-ti��tp"l� 1"'y n Pt»1 r� 1TA� t1�;;a r,7'1 r s7 n':^�r rt.7h7 r7dfl 1'57�49 r"NJ n »� r� •�n 7 :'a ::t' t 4 N k,' Y' :r .J �yh!�, !1{'y". 't"tip h}f'y .�t ',V'�' N ..L f: 'N'" lt'. 't�� 1 yp G�' 'A"' 1 ,r. '4n .Yf' •i:v' v1'U :v. .1 1,u, A;.:t�.. ...5 •.� 't t r, q1'"4 i ,y. : ,. . ... . ,§� -_ �- �t . �? �:. :...I �• ,... .,., �. � �,c'�:,.���!; e.�y.:a,< ..'. .�.,¢��Jbs a� , Rr���' yy �r.yy•?��ti �S. J�r'.,. �'�at''`� Y � +.a ...'t_,bY-v._.�'n, +,.. '�..�».-,sue_->'~:._ cr_�"`��oJk.'>;,-.�-4..�k-..�,r+s� -�;^+t..s�._:ae--a+.-,:..�r�,_.1\_1�,,..rl"w...\.-Y�F` CF_.��:Nk�R°4...1\'.::.�'W.`i,:-- h�!"��:9)•ri-....\ M�.:Y"�Y..N1x:`Osz:�F�-./'[c_�°kc�'�"�.. �c:_.iF Yxi�e:.=F'4i1.6°....J'�tt.�1� /. '�...;.. A�RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMD0fYY(Y} THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS19 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((es)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 CONTACT _r AMEE Sharon Covino McShea Insurance Agency, Inc PHONEjAtc — — -- ----- 1645 Falmouth Road, Rt 28 BLDG D i - �Y—sharp 20-9011 FAX Nob:,(508)420-9010 Centerville,MA 02632 _ADDR5ss: aharon@mcsheainsurance.com _- INSURER(;)AFFORDING COVERAGE I #NAIC it INSURERA: PENtjAMERICA _INSURED _ Bayside Tent&Table, Inc. INSURER B:__Progressive Ca.sujt_ 11 J'O INSURER C: AtM_Mutuai 1 40c Whites Path South Yarmouth, MA 02664 INSURERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 19 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. LTR! TYPE OF INSURANCE ;w�sum!j POLICY NUMBER ' MO/EFF I POLICY EXP -- -- - fMM1DD/YYYYI;fMhVDD(YYYYI I LIMITS A 1 X I COMMERCIAL GENERAL UABIUTY , PAV0128463 1 05/17/2019 1 05/17/2020 1 EACH OCCURRENCE $ 1,000,000 I CLAIMS-MADE iJ OCCUR ` t 1 DAMA E Tp RENTED "-- PREMISES(Ea9ccwrrence) $ ---- 50,000 --- - 1 MED EXP(Any one person) $ 5 OOO -- ! PERSONAL d ADV INJURY �; 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. I GENERAL AGGREGATE I$ 2,000,000 1 POLICY PRO I 1 LOG I I-PRODUCTS-COMP/OP AGG4$ INC ,OTHER $ B !AUTOMOBILE UABIUTY 02711576-3 10/12/2018 10/12/2019 COMBINED SINGLE LIMIT g i1 ANY AUTO BODILY INJURY(Per person) I$ 10 OVVNED ,000 1 AUTOS ONLY X I AUTO SCHEDULED ' I I BODILY INJURY(Per accident)1$ 3n0�oAQ-. HIRED .NON-OWNEDSONLY F PROPERTY DAMAGE "` 1 Y (Pa accident) ; 10,000 UMBRELLA UAB I I ` '. I_��OCCUR EACH OCCURRENCE L EXCESS LIAR CLAIMS-MADE� I I � AGGREGATE DED I RETENTION; - - - -I>S_ `+ I !WORKERS COMPENSATION t ` I I$ AND EMPLOYERS'UABIUTY WCC-500-5013321-2018/o5n2/2019 06/22/2020 I I PER I I OTH Y/N I �..I_STATUS;_..._._I ER - _.�.___._..ANY PROPRIETOR/PARTNER/EXECUTIVE ---..-... IOFFICER/MEMBER EXCLUDED? y i N/A I ' L.EACH ACCIDENT g. 100,000 pry In NH) I. I E L DISEASE_EA EMPLOYES$ 1 OO,000 Jt yes,describe under 'DESCRIPTION OF OPERATIONS below — -.-- } I E.L.DISEASE-POLICY LIMIT I$ 500,000 1 1 I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is 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. AUTHORIZED EPRESENTATIVEg /.tom/// (SSC) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD Printed by SSC on May 21,2019 at 10:57AM