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Bld-20-001329 y Office Use Only -70' Permit l 1- Amount (C/ 40 V LIJ'2 0 -13Z Q 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) 398-2231Ext. 1261 CONSTRUCTION ADDRESS: 7 9 tJji rook_ l ASSESSOR'S INFORMATION: Map: Parcel: OWNER: NAME � PRESENT ADDRESS TEL. # CONTRACTOR: �hc�Ff' ( 1 +,4 /0 AvkSo4S4iccv r, S sot4JAN vtiv\© v 63 NAME MAILING ADDRESS TEL.17,1.yt y 3 „ 7 icp ❑Residential 1)9:Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# (/ Construction Supervisor Lic.# Al Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# no side — 9I 23 a?bX(� WORK TO BE PERFORMED Tent/ ' Duration 0)1A t-i'O'1Fire 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 *The debris will be disposed of at: t' v ocati4- on of Facility I declare under penalties of perjury that the statements herein contained are true and ct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or io of my license and for prosecut dCf1 .G.L.Ch.268,Section 1. Applicant's Signature: Date: o ! �O — to(5 Owners Signature(or attachment) Date: Approved By: Date: / —�� / Building Offi ' or gnee E ADDRESS:go k 4"cfr e 4044 `c,�a4tk /Ia-�- S rCoH.ti Zoning District: Historical District: Li Yes No Flood Plain Zone: L' Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: Li Yes U No ❑ Yes No The Commonwealth of Massachusetts 1,! lt Department of Industrial Accidents , 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia -44.01 Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual):Bnkes Etc. Inc Address:10 Jan Sebastian Drive Unit 3 City/State/Zip:Sandwich, MA 02563 Phone#:774-413-9191 Are you an employer?Check the appropriate box: Type of project(required): II:I am a employer with 30 employees(full and/or part-time)." 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required:] 9. C Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]'' 10 Q Building addition 4.0I 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 MO.O 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, 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL e. 14.p OtherTent 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 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:MA Retail Merchants WC Group Inc. -Deland,Gibson Insurance Associates Inc. Policy#or Self-ins, Lic.#:014005034175119 Expiration Date:01/01/2020 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjuty that the information provided above is e and correct Signature. ,.-' Date: 7 / V e I Phone#:774 191 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Tertificate of Niamt 11 esistance ;,„..,,,0,,,.., .., REGISTERED JAN, , A USEMENT 1 Date tregted or i I 1 7 i' 4** '' ...* .°' APPLICATION NcANVAS$ TFITTERs #37827 ) manufactured CONCERN No. efsvANN` i , . lr -... •11,• ... Z F-419.01 Tent Renters Supply November 2015 , 5008 E Hanna Ave.Tampa,FL 33610 -,_ _....3 . ... :40365-5064 Fax 813/740-8370 This is to certify that the materials described on this certificate have been flame retardant treated or are inherently nonflammable and were supplied to: NAME. _Canal Fish & Lobster AT 2952 Falmouth Rd CITY Osterville STATE MA, 02655_ _ _ Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with Federal Specification NFPA 701/ CSFM/ASTM E84-81A/ CAN/ULC-S109/ CPAI 84/ MVSS302 Method of application: INHERENTLY FLAMERES.I.SIANI_ . Trade name of flame-resistant fabric or material used ___HLGLOSS. Chem. Reg, No.__E-419.01 .___,.. _,..... ,. _ The Flame Retardant Process Used WILL NOT Be Removed By Washing (will or wilt not) and is good for the life of the fabric. Renewal Certification unnecessary. Color and weight of fabric: _Sunblockwhite.16..oz_pay_ Description of item certified: (1) 2(rx 60'...8-..cs Hip Roof Frame Tent Top Jeff Sucher By PRODUCTION SUPERVISOR ...5 Name of Apptecatot or Production Superintendent Idle W. hereby certify this to bsv a true copy of the original "CERTIFICATE OF FLAME RESISTANCE" Issued to us, "original copy" of which has boon Mad with Ma California State Fir. Marshal. Signed by Waleska Rodriguez • R. h 44 f • .tie . _ t ,. d ` • • y ,, c you • S 8 % ice • • a ,y. C • .11 a` SIN y�G.. ,�"a ,�+ ,i � ` 4iiiit a v s t r 14-7606 `* '" x ► • 4V tom' .4 elk & ,� S - M1 "9Lii .v J