The URL can be used to link to this page

Home My WebLink AboutBld-20-001037 ,Y *Bice Use Only NAmount i , grA «wrF n a • Permit expires 180 days from .:= issue date r 1 R E C E I Y E L EXPRESS BUILDING PERMIT APPLICATION- ] TOWN OF YARMOUTH ' AUG 23 2019 Yarmouth Building Department 1146 Route 28 u , r _ f I South Yarmouth,MA 02664 L1.�(�-_ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: log sav r/2ie to ftmeg# yflit mourl'/04e r ASSESSOR'S INFORMATION: D Z 6-45 Map: 15 t Parcel: Z. , vot/ Mrs rZ 6-/4 & %?f_ /o fox 3t 7 ►,i24, 616' 6 s 7 39 39 OWNER: PmE t/AA �, �-�OC• p(i/'W p PRESENT ADDRESS ✓17/9 0216 3D TEL. # CONTRACTOR:4 (G-/J�?iJW7 7 t / ,$O)( f34�� f 1r4Yl)4f/L r goo -c7Z q.S.�S NAME MAILING ADDRESS Amt p Z to 4 g TEL.# ❑Residential 0 Commercial Est.Cost of Construction$ /u�G Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# a o X y D WORK TO BE PERFORMED Tent t/ Duration /D 9 (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings HighwayfHistoric 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 or revocationon of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signaturo j�eG��(/t w Q if y/ ri / ff Cap,Deptd Owners Signature(or attachment) Or 40 ' Date: Approved By: ... Date: ' a.% '1 i Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No LL Yes ❑ No dow ( d. coktolcco @ ,9 (ffia ( . 00 (31 The Commonweaith of Massachusetts ► — !/ Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 , www. s.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): American Tent&Table,Inc Address: PO Box 1348/381 Old Falmouth Rd City/State/Zip: Marstons Mills,MA 02648 Phone#: 508-420-2215 Are you an employer'Cheek the appropriate box; Type of project(required): 1.[ I am a employer with 20 employees(full and/or part-time).' 7. ❑New construction 201 am a solo proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on nnr propetty I will ]0 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.0 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'camp insurance 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 14. Other TENT(s) 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box if 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. =Contracbrs 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. lithe 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 Co. _ Policy#or Self-ins.Lic.#: WWC3329399 Expiration Date: 01/21/2020 Job Site Address: 108 Bray Farm Rd N. City/State/Zip: Yarmouthport,MA 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 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$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 certib under the pains and penalties of perjury that the information provided above is true and correct. Signature: Trill Wham Date: 02-12-19 Phone#: 508-420-2215 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permlt/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 AMERI-2 OP ID:MIKE '4 �" CERTIFICATE OF LIABILITY INSURANCE °A01/18/2(MWDDPIWY)019 LZHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS .ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES JELOW. 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 Neu of such endorsement(s). PRODUCER 617.470-5500 MOCT Michael Fithian DPS Insurance Group,Inc. PHONE 617-479-5500 FAX 617.479-8761 500 Granite Ave.,Suite 2 (A/C,No,Ext): I(MC,No): Milton,MA 02186 Mass:mfithian@dpsinsurancegroup.com Daniel P Sullivan INSURERS)AFFORDING COVERAGE NAIC s INSURER A:Arch Insurance Company 11150 INSURED American Tent&Table,Inc. INSURER B:Wesco Insurance Co Allen Sylvester P.O.Box 1348 INSURER C: _ Marston Mills,MA 026481 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. MR ADDL LTR TYPE OF INSURANCE D Bw1 VAR POLICY NUMBER 1 FYI UNITS A X COLIIIIERCIAL GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 BADE X OCCUR PRPKG00139 02 01/21/2019 01/21/2020 DAMAGE TOmaRENTEDa ) $ 300,000 HEED EXP(My one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENE AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 1 POLICY I I COMP/OP PRODUCTS-COPAGG $ 2, ,000 ---\ OTHER: _ $ AUTOMOBILE LIABILITY (GONsINEG Ea SINGLE UNAIT $ 1,000,000 X ANY AUTO PRAUT00006 02 01/21/2019 01/21/2020 BODILY INJURY(Perperson) $ OWNED —SCHEDULED AUTOSAHURR�Epp ONLY NAUUTTOSSW�U��p pBRODILY*WRY(Per accident) $ AUTOS ONLY _AUTOS ONLY (PerOI:E= GE S _ $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 1,000,000 EXCE38 LIAR CLAMS-MADE PRFXS00069 02 01/21/2019 01/21/2020 AGGREGATE $ 1,000,000 BED X RETENTION 10,000 S_ $ B A WORKERS CONPENSATION Z Er EMPLOYERS'LIMN X TY Y/N WWC3329399 01/21/2019 01/21/2020 500,000 ia ANY PR TORIPA CUT VE N N i A EL EACH ACCIDENT S=hiltieg EXCLUDED? EL DISEASE-EA EMPLOYEE $ 500,000 k yse,describe uDESCRIPTION nder 500,000 A Equipment Floater PRPKG0013902 01/21/2019 01/21/2020 EquiEL pment-POLICY UNIT $ 450,000 DESCRPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addkianal Remarks Schedule,may be attached I more space Is required) Rental Stores CERTIFICATE HOLDER CANCELLATION AMERICA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE American Tent&Table Inc THE EXPIRATION DATE THEREOF, NOTICE WILL. DELIVERED BE IN ACCORDANCE WITH THE POLICY PROVISIONS. `--. Evidence of Coverage AUTHORED REPRESENTATIVE I ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD , , ,. Qtertifturteof jfiamc % eitante 1%5r. ..3 REGISTERED ISSUED SY: ow aeeau ar %, a APPLICATION AZTEC TENTS CONCERN NO "r" ` i+; �4`" � 490 ALASKA AVENUE 006 .. - i- /'. M i! TORRANCE.CA 90503 �• - ', ,.... cu cow r 41am 310 2 �'. { )9 8-b060 1i1., This is to certify that the materials described below hereof have been flame retardant treated(or are Miter- 4' wrtfy nonflammable). ,_ FOR AMERICAN TENT&TA NA IMIC. ADDRESS NHOLD PALNOUTH ROAD _' CITY AfAR.STONS'HILL4 STATE NA. 02548 ' Certification is hereby made that:(check "a"or"b") (a) The articles described below this certificate have been treated with a flame retardant chemical approved end registered by the State Fire flarehAl and that the application of said chemical was done in confer: trance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Name of chemical used -...-...... .Chem.Reg.No...—..-.....-........ Seethed 0f application_... _~_. _.. .................. .. (b) The articles described below hereof are made from a flame-resistant fabric or material registered and . approved by the Stets Fire Marshal for such use;Fabric has been tested and passes NFPAT01-96 Trade name of flame-resistant fabric or material used. .Reg.Mo.......t ? .... , ry The Flame Retardant Process Used WILL NOT Be Removed by Washing ;< a pee awe nu0 David Bradley Chuck Miller-President wn..rAonso.mrarn csarr+ond.a rr. r 1 � ' 1‘ r 1 r ,_ J ' r . , rt f CUSTOMER ORDER NO. R160230 ITEMS MANUFACTURED: 2-30'x30'(2 PC)STANDARD TOP ONLY--ULTRA WHITE "';; < i ,T/-r, , h,' rt ... •1 ' i i..;