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HomeMy WebLinkAboutREGISTRY OF MOTOE VECHICLES o - R • TOWN OF YARMOUTHR ECEIVED a(*I. _;y BUILDING DEPARTMENT DEC 09 2022 ,,,\.,T...�.;,, 11 1146 Route 28, South Yarmouth, MA 02664 508-39 -2E3l_ext. 1261 `' BUILDING DEPARTMENT By SIGN PERMIT APPLICATION CK' S 5 3 Date I g- a-0,,I, Permit No. • Applicant Instructions 1) Applicant shall complete both sides of application. 2) One application form is required for each type of sign. Each sign will be assigned its own permit number. 3) Applicant shall attach a separate 8 '/2"x 1 l"sheet including two diagrams: A) Design, dimension and colors of the proposed sign(s) B) Freestanding Signs: Indicate location of the proposed sign(s) with setbacks from property lines that are at least 6 feet.Attached signs:must show running footage of portion of building frontage occupied by business. Location/Address for proposed sign(s) /0 b Li (lo 8-Q) g,,,vi-e__, a Ec Assessor's Map 50 Lot 1a.3Zoning District: B1 B2 , B3 Res Hist.Dist Name of Business for proposed sign(s) e ' S 0 0 Veitvile_ Name(s)of Business owner(s) S---& -e en c tY) iq SS Mailing Address of Business owner(s) /0 a (O-w4,e D S- Business Owner(s)Phone: Business 5 7- 3(p 8' - 8''!c3 I Home Name of Building Owner(s) laki n i- r-R€a —1--'n,Z-1- Phone ,50% • 07`7 y - . 9W Sign Builder 3I Q h --be s i S r.) Inc C , Sign Materials di'Icy-A Sign Builder Address 1 OO LI b' 61-. ,' rO iC i ►'16 Phone 1/4.57) 8 - a 5. 7 7$'( C e-l( 601.301 67)(3 560 9 y Internal Light External Light Freestanding Sign(s) Size of proposed Freestanding Sign: Attached Sign(s) Size of proposed Attached Sign: I(9 0 I Temporary Sign(s) Size of proposed Temporary Sign Dates of proposed Temporary Sign: Please complete other side of Sign Permit Application All Permits are subject to the approval of the Sign Inspector I hereby agree to conform to the provisions of Town of Yarmouth Zoning By-law Section 303 governing sign construction and installation. I further agree that this sign will not be altered,added to or changed in any way unless a new permit has been issued. Sign Permits are not valid until the Building Commissioner issues Use and Occupancy Permits(where applicable). Signature of Applicant: 1A4 &tM1ck d j4Y) / Proper Owner Authorization: I hereby authorize the applicant to act on my behalf in all matters related to this ign application. (signature) Date This Permit Replaces# Approved by: Date With the following conditions: I have read and understood the conditions of this Sign Permit listed above: December 2,2022 Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 To Whom It May Concern: I authorize Sign Design,Inc. to act as our agentn� for the enclosed sign permit application. Business Name: �ve�p°-- O-ea,[ /y sfr V 3 t Property Location: l6 fi Pt Building Owner: 1)e,1;f t 6"Lvrhl° Building Owner Address: c) O A/• �t u t S 5 / a —'we Q a 6 y Phone: _roe' a?`( --$'t 4 ( Sincerely, '‘'‘4.,4 Z.& "'coif/c /44^ spr f / /01- _ Signature Title Date .. .1.u.1".(9 3 Print Name Address if different from above 158198 ___--- .................. -._. ...__..__.._ -._.....--- Version 03 Sign Panel 11-21-22 Quantity: 1 Single-Sided Department of Motor Size: 120"W x 18"H A Vehicles Material: 1/4 Dibond Panel 1084 MA-28 Graphics: Digitally Printed(Latex)on IJ180 Vinyl 4 S.Yarmouth.MA 02664 Lamination: 3M Matte Lam Installation: Fastened to Building Facsia Registry of Motor Vehicles South Yarmouth .a�+ Signage 1 R I — • i/4„ gNi Registry of Motor Vehicles siGNOEseet gy 170 Liberty Street Brockton,MA 02301 1 508-580-0094 120" Scott Clement TJI MR • Cindy Dunham �emv. re.at,2 ;,.r:rio NK scale SI MI G01.00 ,`\. The Commonwealth of Massachusetts Department of Industrial 9. " r, Office of Investigations I •i7 Lafayette City Center j=' 2Avenue de Lafayette, Boston,MA 02111-1750 � `'� www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sign Design Inc. Address' 170 Liberty St. City/State/Zip:Brockton MA 02301 _ Phone#:508-580094 Are you an employer?Check the appropriate box: 1. ■0 I am a employer with 68 4. 0 I am a general contractor and I Type of project(required): 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. 0 Remodeling ship and have no employees These sub-contractors have ,working for me in any capacity. employees and have workers' 8. El Demolition [No workers' comp. insurance comp. insurance.: 9• ❑Building addition 3.❑ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL 11 0 Plumbing repairs or additions insurance required.] t c. 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.E Other Signs comp. insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. f 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: Selective Insurance Company of the Southeast Policy#or Self-ins. Lic.#:WC9080309 Expiration Date: 1/21/2023 Job Site Addres6/2 7) 10X0 row ,IL, - City/State/Zip: 5. 90„,rniovi-P\ �"/�- D L a� l 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 c'!vil 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 perjury that face information provided above is true and correct. Signature•�� -17-C1\ /1(7 ell-P h3,l(9 � t Date: I2� E oZ 508-580-0094 x202 Phone#: `'r ��ni / • Official use only. Do not write In this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): IDBoard of Health 20 Building Department 30City/T'own Clerk 4.0 Electrical Inspector 50'lumbing Inspector 6.0Other Contact Person: Phone#: . 1 CO A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM(DD/riYY) 01/18/2022 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 HOLDEF;. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,thin 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 CONTACT Shannon Gallagher Roger Keith&Sons Insurance Agency PHONE (508)583-1106 FAX 50 1575 Main Street (A/C,No,Eat): (A/C,Nal: ( B)583-8478 E-MAIL sgallagher@rogerkeith.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC II Brockton MA 02301 Selective Insurance Comp any of America 12572 INSURED Selective Ins Co of South Carolina INSURER a: 19259 Sign Design Inc Selective Insurance Company of the Southeast 170 Liberty St INSURERC: P Y 39926 INSURER D: INSURER E: Brockton MA 02301 INSURER F: COVERAGES CERTIFICATE NUMBER: 2022-2023 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 0: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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMSESO(Ea otccuDnce) S 500,000 X CONTRACTUAL MED EXP(Any one person) $ 15,000 A X NO RESIDENTIAL EXCLUSIONS S 2379251 01/21/2022 01/21/2023 1,000,000 PERSONAL&ADV INJURY $ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY n PRO ri- JECT LOC PRODUCTS-COMP/OP AGG 5 2,000,000 OTHER: 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 1,000,000 X ANY AUTO (Ea acddenp BODILY INJURY(Per person) 5 B OWNED SCHEDULED A 9107007 AUTOS ONLY AUTOS 01/21/2022 01/2112023 BODILY INJURY(Per acddenl) S HIRED NON-OV,NED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE S (Peerracrid odden:I 5 X UMBRELLA LIAB X OCCUR 5,000,000 EACH OCCURRENCE f A EXCESS LIAB CLAIMS-MADE S 2379251 01/21/2022 01/21/2023 5,000,0000 AGGREGATE $ DEO RETENTION S WORKERS COMPENSATION v f • AND EMPLOYERS'LIABILITY Y/N • X STATUTE OTH- ER C ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA WC 9080309 E.L.EACH ACCIDENT S 1,000,000 • OFFICER/MEMBER EXCLUDED? 01/21/2022 01/21/2023 (Mandatory In NH) 1,000,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE 5 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 CONTRACTORS EQUIPMENT UNSCHEDULED EQUIP 353,000 A LEASED/RENTED EQUIPMENT S 2379251 01/21/2022 01/21/2023 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Policy limits in effect at policy inception. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SIGN DESIGN INC ACCORDANCE WITH THE POLICY PROVISIONS. - 170 LIBERTY STREET AUTHORIZED REPRESENTATIVE BROCKTON MA 02301 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD a" Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regqulations and Standards I Const 1`Z ofT SSrvisor CS-068112 - 6cpires : 08/ 21 , 2024 1. - RALPH R FERIGNO, JR . 81 JOHNSON/FARM ROAD NEWBURY NH 03255 --... -, rill). ..... ,..... r .. . , �': _ v a . As /� n n ,� t- /1- ..�i f.I,.I� .-\/.I ,�. . I /., I Y--f / . . . V V 1 1 1 1 1 1 1.7 J 1 V 1 1.. 1 ;✓I LL64.4 / 1 ✓ '♦ 1, �-`-,.✓�_