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HomeMy WebLinkAboutBLD-19-7257 Office Use Only 41 Pennit# 4,0�� r y d Amount I ':t nwrrwln cac•�' _ `�*°°.�° P End' Permit expires 180 days from II: "c= ; / b_t9 745 °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: tAie,64- ±L4-r)t7Jt& J_.I b( zA-'(./\ ,,r79( D( 28 J ASSESSOR'S INFORMATION: Map: Parcel: / ' / ` OWNER: l OZ y. O4 N(a k / f�,rY�(.�3Lc„ -1\ I kai e ,! NAME PRESEE��TT ADDRESS TEL. # r __ c) G�6 - "]to �r(CONTRACTOR: 3 Sl(.fie (IQ/tile-5MAILING ADDRESS SS ki .5 k'T r) `5 og-#=/�el y a�ZS NAMETEL. I -� ❑Residential Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner &I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: \ Worker's Comp.Policy# WORK TO BE PERFORMED ° �� /� Ir j S vrnrne2 �Qtv��] 67 Tent Duration ,/7'S 11(j (Fire Retardant Certificate attached?) 1 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 o vocation of my license d for prosecution under M.G.L.Ch.268,Section 1. 1 Applicant's Signature: � � � Date: � � y I ( 7 Hers Signature(or attachment) Date: Approved By: ✓ ,...L. • Date: V -a -I ct • Building Official(or designee) - EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No • . The Commonwealth of Massachusetts ;;;~= !k." Department of Industrial Accidents i? 1 Congress Street,Suite 100 V r °' Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER%IITTING AUTHORITY. Applicant information Please Print Legibly Name(Business Organization/individual):Bayside Tent Address:40C Whites Path City/State/Zip:S.Yarmouth,MA 02664 Phone#:508.760.4025 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 7 employees(full and%or part-time).• 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in N. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 0 Building addition 4.01 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 arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5 0 i am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3-❑Roof repairs These sub-contractors have employees and have workers'comp.Insurance.• 6.0 We are a corporation and its officers have exercised their right of exemption per MGL r 14.0OtherTent 152.*I(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that cheeks box qI must also till out the section below showing their workers'compensation policy information. +Homeowners who submit this affidavit indicating they arc 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'compensationdncurance for my employees. Below is the policy and job cite information. • Insurance Company Name:Mcshea Insurance Policy#or Self-ins.Lic.#: LJ ' 50O '.S G 1 3 3 d I-'"1''1X/-,< Expiration Date: 5/74 0 Job Site Address ft l4fIr? q 2/k_r+.s"t' City/State/Zip: (,A/. '/I/ ti rL �'4-1 6 ?C 7 3 Attach a copy of the workers'compensation policy declaration page(showing the policy number and cspiratioridate). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and-or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. 1 do hereby certify der the pains and pena ' ' f perjury that the information provided above is true and correct. Signature: aL�� Date: 61/t)y//� Phone#:508.760.4 5 !ll 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#: s ACCORD CERTIFICATE OF LIABILITY INSURANCE I °A'E`M"'°°""""' 05/21/2019 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: H 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 lieu of such endorsement(s). PRODUCER McShea Insurance Agency,Inc ACT Sharon Covino FAx 1645 Falmouth Road,Rt 28 BLDG D Nn Elm (508)420-9011 I m Nea(508)a20-9o10 Centerville,MA 02632 • sharon@mesheainsunnee.com INSURER(S)AFFORDING COVERAGE 1 NAIL A . _.._ INURERAI P. :AMERICA:.INSURED ... .,.. Bayside Tent&Table,inc. INSURERS: Progressive Casualty 11177..L 40c Whites Path INSURERC: AIM Mutual f South Yarmouth,MA 02664 INFO` NSURERE.._.. _. 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. LTTRR TYPE OF INSURANCE I T POLICxNUMBER -714=I.1 Uy� A X I COMMERCIAL GENERAL LIABILITY , I PAV0128463 05/17/20191 !05/1T/2020 EACH OCCURRENCE I s 1.000,000 I CLAIMS MADE { {OCCUR _Eakaarro- gEM (j ED rs 50.000 —I t p EO EXP(Am one person) s 5,000 ...I { I {PERSONAL a ADV INJURY f 1,000,000 GEML AGGREGATE UMptt.T.APPLIES PER: jI ' �IPOUCYj�JECT I11 LOC ! GENERAL AGGREGATE S __2.000,000 !OTHER- I I I I PRODUCTS-COMP/OP AGO s INC $ B AUTOMOBILE LIABILITY + I BINED SINGLE UM17 02711576-3 10/12/2018 10/12/2019 I,EaCOMr;, s ANY AUTO i J BODILY INJURY{Per persanj S nn �;HIRED. ONLY AUTOS SCHEDULED NON-0VrIJED ( BODILY INJURY(Per accident) S 300,000 AUTOS_ AUTOS ONLY AUTOS ONLYJEN accident) GE I� 109,000 f UMBRELLA LIAO 'EXCEBSLIAB OCCUR I { I I I 1.EACH000URRENCE 5,..,__ . GLAIMS•MADE I I AGGREGATE S .OEO I RETENTION$ I S C YAORIOiRSCWdPENSAl10N TH- AND EMPLOYERS'LIABILITY WCC-S00-501 3 321-201$ 2/2019 08/22f2112D,�.I_ AE, {gR YIN ANYPROPRIETORIPARTNECUTtVE { i ._ . . (MandatoryY „aOR/PARTNER/EXCLUDED? ri 4L EACH ACCIDENT f 100,000 yyasaa I I E.L.DISEASE.EA EMPLOYE f 100,000 (DESCRIPTION OF°Peas:nous baiow ) E.L DISEASE•POLICY LIMIT S 500,000 1 a OF OPERATIONS/LOCATIONS I { 1ossca attachedbe CERT FICATE HOLDER IS LISTEDDAAS ADDDITICORD IONA IL NSURED FFORR THE DURATION O V mote F THE la required) • 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. AUTHf>Fa2EDpEPRESENTATIVE /�(�,/,/ (SSC) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25,(2018/03) The ACORD name and logo are registered marks of ACORD Printed by SSC on May 21,2019 at 10:57AM ,. � � -7 'fin T. 44 Certificate of Flame Resistance AI tThis is to certify that the materials described have been flame-retardant treated(or are inherently non flammable) Issued By: to 64 Celina Tent, Inc. 5373 State Route 29 4 sl Celina, Ohio 45822-9210 , , 0 www.CelinaTent.com r MANUFACTURER OF FINISHED TENT PRODUCTS DESCRIBED HEREIN A t A Celina Tent,Inc. certifies that the fabrics used in its tent products are flame resistant.All tent,canopy, structure, and shelter products manufactured l ice 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. Iv , -41 t4 AA Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: NFPA-701 CPAI-84 ASTM D 6413 El BS 5438 BS 7837(1996) DIN 4102-B1 r£,' r-- 41 sy: 41 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 k. Pw Method of Application:IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT Wg*', 4111 The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. ; ,461 This item is certified flame resistant or nonflammable,NOT FIRE PROOF. tisk 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—Celina Tent, Inc. lEiip Signed: ,AsiLe--,02 Pfi i A W ZN' 'P , II CELINA TENT' Rev.20150709 osii