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HomeMy WebLinkAboutBLD-23-005794 Office Use Only Cif•YitittA `7 'Permit# COP1635 �t 01 0 .0 k" Iri. mount Permit expires 180 days from ;, k4 issue date LD -013 - 005-76/y EXPRESS BUILDING PERMIT APPLICATI? 1 F C F I V D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 APR 18 2023 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: 2 1 (Xkl n ik t Cfcx*bcdt d ASSESSOR'S INFORMATION: ►y���,_Mjyap:y� Mom Parcel: Ave- n �Q OWNER: Them) 'ktrr� eygn U 'q SMVU) �LD i�-+j7n. , t�d yar abl NAME l PRESENT,, � ADDRESS TEL. # j K CONTRACTOR: C . Cod pNAME ( UmacArik u 1�1Va �� 1.i MV 02q 55 ADDRESS TEL# 5os `5(0-1" tv 90 0 0 Residential Commercial Est.Cost of Construction$ 2,000 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor XI have Worker's Compensation Insurance' Insurance Company Name: EPIC Worker's Comp.Policy# W W C 3Crisi 311 g so(Lio Lik) LibLi 123 WORK TO BE PERFORMED Tent J Duration dcki S (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares )'`'I 0 FT Replacement windows:# Replacement doors: # Rooting: #of Squares (El)Remove existing*(max.2 layers) Insulation In n Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n *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 revocation of my licen and for prosecution under M.G.L.Ch.268,Section 1 Applicant's Signature: Leid Wie7- ' Owners Signature(or attachment) Approved By: Date: Building Offici r de ' ee) EMAIL__ RESS: Zoning District: Historical District: Yes No FIood Plain Zone: "' Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No _ Yes No ®C� p /(t ' cod , G�� ACCORD D CERTIFICATE OF LIABILITY INSURANCE 04/10/20223"�'' 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 CA LIC OB29370 1-925-798-3334 CONTACT Samantha Stuart Edgewood Partners Insurance Center (EPIC) PHONE FAX 925.609.5531 [Concord Programs Group - Branch 15558] E-MAIL No.Ext): (AIC.No): P.O. Box 5668 ADDRESS: certificatesprorental@epicbrokers.com INSURER(S)AFFORDING COVERAGE HAWS Concord, CA 94524 INSURER A:ARCH INS CO 11150 INSURED INSURER B: WESCO INS CO 25011 True North Event Rentals INSURER C: 25 Nest View Lane INSURER D: INSURER E: Centerville, MA 02632 INSURER F: COVERAGES CERTIFICATE NUMBER:68416119 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 INSD WVp POUCY NUMBER POUCY EFF POLICY EXP (MMIpP/YYYY) (MM/DDryYYY) LIMITS A X COMMERCIAL GENERAL LIABIUTY X PRPXG0082505 04/10/23 04/10/24 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY EI° LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY PRAUT0003605 04/10/23 04/10/24 COMaaccBidewEnt)t INGLEUMIT $ 1+000,000 (E X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILYINJURY(Per $ AUTOS ONLY AUTOSaccident) 8 HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) X COLL 1,000 X OTC 1,000 $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION YIN WWC3643778 03/10/23 03/10/24 X STATUTE ERH AND EMPLOYERS'UABIUTY ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? piN/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Equipment Floater PRPKG0082505 04/10/23 04/10/24 Special Form 1,450,000 Replacement Cost 10,000Ded DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) The Certificate Bolder as per written contract are Additional Insured with respect to General Liability as per the attached endorsement. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Toms THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 334 Hokum Rock Rd S. AUTHORIZED REPRESENTATIVE Dennis, MA 02660 P� I USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SamStuart 68416119 IMPORTANT DOCUMENT Certificate of Flame Wrsistance Date of Shipment ISSUED BY 06/04/10 Registration Number 4 INDSRIEIIPNC.8 Tent Identification -12110 14870560 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable)and were supplied to: PARTY CAPE COD 660 MACARTHUR BLVD POCASSET, MA 025592230 A,_.---.:, • 0 10 .. Alit_A 1,•:. .ta, t",-471.4 4,ifft • ...i.a, ' AS:,k 1 " r 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 California Fire Marshall Code. AD fabric has been tested and passes NFPA 701, CPA1 84. Serial# 8106200(8) Description of item certified: 30x40 Frame Tent , Flame Retardant Process Used Will Not Be Removed By Washing And is Effective For The Life Of The Fabric TRIVANTAGE STATESVILLE NC Name of Applicator of Flame Resistant Finish Signed: 71------7,1 AL ANc HOR INDUSTRIES INC el ...ore • •- r •, Party Cape Cod s,.: ,,t, `sue'+,'. .' 660 MacArthur Boulevard RESERVATION . 11* �`:•. ' 41;74; Pocasset, MA 02559 Contract No. 0039673 •4! ` + .: Phone: (508)-564-6900 • a v ;• Contract Date 04/22/23 • Fax: (508)-564-6904 Customer No. DENNI01 vim._1y A �8 4 Email: PCC c@r partycapecod.com Invoice No. 1 P www.PartyCapeCod.com Bill To DENNI01 Ship To DENNIS YARMOUTH HIGH SCHOOL 296 STATION AVE. -FOOTBALL FIELD 296 STATION AVE. DLV REQ FRI 4/22 DY GRADUATION FUNDS PCC PICK-UP TBD YARMOUTH, MA 02664 YARMOUTH, MA 02664 Ph: (508)398-7656 Jane Coelho Ph: (508)889-8721 Steve Pro# sls I _ i_ _ __ Job Reference Status 1 Tag# i Terms 1 User I Pg# OW Bereavement Open MIN Net 30 Days Min 1 Trnsi Item# 1 Description 1 Rental 1 Due/Return ! Qty 1 Unit Price Total Rent'000WHW-000 WHITE GARDEN PADDED 04/22/23@13:24 04/23/23@13:24 20.00 0.0000 0.00 * FOLDING CHAIR Sale DLV DELIVERY/PICKUP/LABOR/FUEL 1.00 0.0000 0.00 Sale MISC please bring extra sidewall incase * they decide to enclose more of the 1.00 0.0000' 0.00 tent Rent OOSTAN-000 CHROME STANCHIONS 04/22/23@13:24 04/23/23@13:24 18.00 0.0000' 0.00 * Rent OBROPE-000 6'BLACK VELVET STANCHION 04/22/23@13:24 04/23/23@13:24 17.00 0.0000' 0.00 * ROPE Rent'30X40E-000 30X40 WHITE FRAME TENT 04/22/23@13:24 04/23/23@13:24 1.00 0.0000 0.00 * Rent PERMIT-001 TENT PERMIT REQUIRED(PCC 04/22/23(§13:24 04/23/23@13:24 1.00' 0.0000' 0.00 * FEE+TOWN FEE) Rent SAFETY-000 TENT INSPECTION SAFETY KIT(2 '04/22/23@13:24 04/23/23@13:24 1.00 0.0000 0.00 * EXIT SIGNS,2 FIRE EXTINGUISHERS, 1 NO SMOKING SIGN) Rent'SD7CLE-000 7'CLEAR SIDEWALUFT.(20 FT. 04/22/23@13:24 04/23/23@13:24 80.00 0.0000 0.00 * SECTIONS) Cash: 0.00 Check: 0.00Crdt C: 0.00 Billed: 0.00 Rental Charges 2,350.50 Job Ref: Bereavement Sale/Used Amount 0.00 Instructions: Delivery:04/22/23 Saturday @ 13:24 Pickup: 04/23/23 Sunday @ 13:24 Discount -2,350.50 Delivery/Misc Dy High School-Football Field 0.00 Please Call The Facilities Manager, Steve, On Your Way. 508-889-8721 Damage Waiver/Ern 0.00 Use/Sales Tax 0.00 Non-Refundable Reservation Deposit of 50%or$ Current Total 0.00 Signed Rental Contract Agreement Due by: Due by: Contract Total 0.00 y Non-Refundable Final Payment or$ Due b : Valid credit card on file for security:Yes No Paid-To-Date 0.00 Rental teens and conditions outlined in Rental Contract Agreement. BALANCE DUE I 0.00 - urren ransa ions •n y 04/17/23 01:42:12