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HomeMy WebLinkAboutbld-20-414 Office Use Only 4_ 0 _ �� Amount 1740 0?) NA11 P Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 �} (508) 398-2231 Ext. 1261 �'1�5 IgTIO Y 4' CONSTRUCTION ADDRESS: tit "V kAll 1(6‘r 01CA.f % 191/4=Yt ASSESSOR'S INFORMATION: M Map: Parcel: OWNER: 1 / S1.\ Mph 11 1..v1'C... 'S t7l 53$ `VI33 NAME PRESENT ADDRESS TEL. # CONTRACTOR: \poke(WV{,( VYl\4 3\ huvveV!(q., L" .5 Demiiif 50% 3 w 1090 NAME MAILING ADDRESS TEL.# O Residential 0 Commercial Est.Cost of Construction$ 'j'7S Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner Cs I am the sole proprietor Si;I have Worker's Compensation Insurance Insurance Company Name: A,/e5 C )a 5 v rA ti t-e. (o Worker's Comp.Policy# tv t✓e 3 3 4 .3'8 l WORK TO BE PERFORMED Tent Duration 7/I S -7 /q(Fire Retardant Certificate attached?) 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 30)4 3o — rtAw1;I� (vci tivertkn *The debris will be disposed of at: Location of Facility 1 declare under penalties of perjury the . • .tem ,0 ei' n 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 r . of oIIPZnce and for prosecution under M.G.L.Ch.268,Section l .— / c� ��j Applicant's Signature: . Date: ✓� / [ Owners Signature(or attachment) Date: C [ Z t ( Approved By: Date: Building ral si ee) EMAIL RESS: Zoning District: Historical District: .. Yes No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: Yes C No C Yes _ No ORDER CONFIRMATION: #17011-5 Page 1 of 1 doo./ .....,,. EVENT DAY: Friday DATE: 07/26/2019 EVENT TIME: I.�NDERCOVER TENT DELIVERY: WED 07/24/2019 SUBJECT TO CHANGE Arty 2 is>;t&`�tcz' .s,� €s/;S €�';�' r°d�r�_.�`te�9hcra•z�'a PICKUP: MON 07/29/2019 SUBJECT TO CHANGE .. ' SALES PERSON: GST PURCHASE ORDER#: 31American Way South Dennis, MA 02660 ORDER DATE: 07/02/2019 TERMS: Phone: (508)398-9000 Fax: (508)398-9091 Website: www.undercovertent.com BILL TO: SHIP TO: (832) 588-4933 MIKE SHERMAN EMILY SHERMAN 111 WHARF LANE 111 WHARF LANE YARMOUTHPORT MA YARMOUTH PORT MA TEL: (832) 588-4933 FAX: QTY ITEM DESCRIPTION PRICE TOTAL 1 30X30 JUMBO TRAC LITE FRAME TENT-WHITE 875.00 875.00 6 8X20 CLEAR SIDE WALL(OPTIONAL TO TIME OF DELIVERY) 32.00 192.00 5 60" ROUND TABLE 9.25 46.25 3 8' BANQUET TABLE 9.50 28.50 50 GARDEN CHAIR-WHITE-WITH WHITE PADDED SEAT 4.30 215.00 120 PERIMETER STRING LIGHTING 1.25 150.00 1 SAFETY PACKAGE- EXIT SIGNS, FIRE EXTINGUISHERS, NON SMOKING 85.00 85.00 1 TENT PERMITTING FEE YARMOUTH 160.00 160.00 1 **DAMAGE/LOSS DEPOSIT** 125.00 125.00 5 108' ROUND LINEN-WHITE 16.00 80.00 3 90"X156" FULL LENGTH WHITE BANQUET LINEN- FOR 8'TABLE 22.00 66.00 SPECIAL INSTRUCTIONS: SUB TOTAL: 2,022.75 SALES TAX: 108.61 DELIVERY: 60.00 LABOR: 0.00 TOTAL: 2,191.36 DEPOSIT PAID: 2,191.36 BALANCE DUE: 0.00 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. *Undercover Tent and Party, Inc. is not responsible for irrigation line damage as a result of staking. *Customer has read and agreed to the terms and conditions as specified in attached documents. .�•°"1 UNDER-1 OP ID: MIKE AcoRr>, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/23/2019 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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 617-479-5500 CONTACT Michael Fithian DPS Insurance Group,Inc. PHONE FAX 500 Granite Ave.,Su 2 (NC,No,Eat):617-479-5500 (A/C,No):617-479-8761 Milton,MA 02186 E-MAILDSS:MFithian@dpsinsurancegroup.com Daniel P Sullivan INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arch Insurance Company 11150 ilSURED INSURER B:We5c0 Insurance Co ndercover Tent&Party Safe Insurance on Prizzi INSURER C 31 American Wa South Dennis,MA 02660 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYYI IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X OCCUR PRPKG00086 02 11/21/2018 11/21/2019 PREM SES(a occu ence) $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ X AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO 2709556 11/21/2018 11/21/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-AWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X PER ATUTE EOTH AND EMPLOYERS'LIABILITY C3382389 11/21/2018 11/21/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE R Y/N W WE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Floater PRPKG00086 02 11/21/2018 11/21/2019 Equipment 600,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Party Goods Rentals CERTIFICATE HOLDER CANCELLATION MIKESHE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Mike Sherman THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 111 Wharf Lane Yarmouthport,MA 02675 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD x The Commonwealth of Massachusetts Department of Industrial Accidents �` '/ Office of Investigations .S =A arwr 600 Washington Street I Boston,MA 02111 :,. i WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Undercover Tent& Party Inc. Address: 31 American Way City/State/Zip: South Dennis, MA 02660 Phone #: 508-398-9000 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 18 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in anycapacity. employees and have workers' P n 9. Building addition [No workers' comp. insurance comp.insurance. required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. ✓ Other TENT INSTALL 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 contractors must submit a new affidavit indicating such. tContractors 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: Wesco Insurance Company Policy#or Self-ins.Lic.#: WWC3382389 Expiration Date: 11/21/19 Job Site Address: "\ t`A"i{ h“f- City/State/Zip: WI etenodth fb 0 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 petjury that the information provided above is true and correct. Signature: P t4A- Cyr2.0t. Date: 7/24/`/1 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 Contact Person: Phone#: ,:. ______ ._.. ._- ------ --. --1- - - \ -1\-/ -\-- 11,ifh1eA1l1itl4il.1,1 11,,,:r,1:m1':::4!a:,,,!1l-h''N,i';'''o'l'lo-',i 1::-.:'l i ®R 'III ,, k li,i .a r-:, p-1 i ..,.p,4,'---,'z. ee4I1h: ,.,.:1.4.,„.„.:l:,:". t 1 Ih4i,iiL ikW,;,,-I,-i-:.i,p,c,±-i-,,,,...„,,-,,-,,-,K, -,-,4.,.W w P111111111111111111111111111111111 u J 6 , _. 4 .'' / VVI '''''', ' '' * I.''''''' ' ''''''''S ''''''' 11114-,::: :,-m''''::::-,,:,'-':#:'/111 4 Li'''''''''''''' #/ . Ill �.y. II * 1 4