HomeMy WebLinkAboutBLD-23-006139 ;,A, a ; /r Office Use Only
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Permit# 0. 5Q)2
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;.,.•: issue date
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EXPRESS BUILDING PERMIT APPLICATION oozp/L5q
TOWN OF YARMOUTH RECEIVFD
Yarmouth Building Department ----
1146 Route 28 MAY 05 2023
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
BUILDING DEPARTMENT
By:
CONSTRtiCTION ADDRESS: I CA j cal l<\ VG,(rev e.ct Nn( , \(ai ry L{,h Oac,`-IS
ASSESSOR'S INFORMATION: J
Map: IS- i Parcel:
OWNER: h(h LJ f 1 0-C 110,Y f )i ti'1 Ili-(C; Izt P-is (• tl c-4 mot. •n S G s'- A l,S_2 2 3 i
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Uf 1tP4(Oti(! Te:rt 3 P 41tt 11 2- Ur1it .1 (,re�+.1 tJeNtern Jar( S06" 3 tla-,1 GbO
NAME l MAILING ADDRESS S.De net,1 TEL.#
0 Residential 0 Commercial Est.Cost of Constniction$ (10 O G
Home Improvement Contractor Lic.#N/A Construction Supervisor Lic.#N/A
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Wesco Insurance Company Worker's Comp.Policy#WWC3614658
L/L f y 3 f //- /01-/a3 WORK TO BE PERFORMED
Tent Z Duration 4-1 el(13S (Fire Retardant Certificate attached?) Wood Stove El
Siding: #of Squares Replacement windows: # Replacement doors: #
Roofing: #of Squares (n)Remove existing*(max.2 layers) Insulation 1 1
I I Old Kings Highway/Historic Dist. (f Replacing like for like Pool fencing I I
*The debris will be disposed of at: N/A
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 license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: .a.7/�4_ cam. ---% __Date: L) 1 2 1 Z. 3
Owners Signature(or attachment) Date: 0 --/7
2-3
Approved By: `/ '` Date; —2
Building Official(or si EMAIL ADDRES
Zoning District:
Historical District: '- Yes No Flood Plain Zone: : Yes F. No
Water Resource Protection District: Within 100 ft.of Wetlands:
i i Yes J No iX Yes No
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Project Description
Tent Installation, 44x63 Tidewater Sailcloth Tent for a 110 guest
Wedding on Saturday June 10th, with the planned tent installation on
Thursday June 8th and tent removal on Monday June 12th. Sides are
provided if the weather is bad, otherwise the tent will be open.
Please reach out to our office at 508-398-9000 or email at
info@uctent.com if any further information / documentation is needed.
Kaylee Bergstrom
Office Manager
The Commonwealth of Massachusetts
---=— Department of Industrial Accidents
Office of Investigations
1=_
}1
Lafayette City Center
zrat.; = / 2 Avenue de Lafayette,Boston,MA 02111-1750
' www.mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:UnderCover Tent and Party, Inc.
Address:112 Great Western, Unit 1
City/State/Zip:South Dennis, MA 02660 Phone#:508-398-9000
Are you an employer?Check the appropriate box: Business Type(required):
1.0 I am a employer with 13 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp, insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:Wesco Insurance Company
Insurer's Address:420 Maple Ave
City/State/Zip: Yukon,OK 73099
Policy#or Self-ins. Lic. #WWC3614658 Expiration Date:11/21/23
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§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 perjury that the information provided above is true and correct.
Signature: 5 .e.e.e -- Date: ""] ! ,2 0 2 3
Phone#: 508-398-9000
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):
1.0Board of Health 2.❑Building Department 3.0 City/Town Clerk 4.0Licensing Board
50 Selectmen's Office 6.[]Other
Contact Person: Phone#:
www.mass.gov/dia
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. / UNDERCOVER TENT
EXIT ------ First Class Tents&Party Accessories