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HomeMy WebLinkAboutSign application expired 11822 °5. TOWN OF YARMOUTH BUILDING DEPARTMENT O` /47 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 fir` r;.�� ts�=, SIGN PERMIT APPLICATION Date t tl e/20 2 2... Application Accepted Permit No. Applicant Instructions 1) Applicant shall complete both sides of application. 2) One application form is required for each sign. Each sign will be assigned its own permit number. 3) Applicant shall attach separate 8 %z"x 11"sheets including the following diagrams: A) Design,dimensions and colors of the proposed sign B) Freestanding Signs:provide certified plan by a professional land surveyor that describes how the proposed sign meets the zoning requirements included in Zoning Bylaw 303.5.6 or 303.5.4.2 (as applicable). A stamped and sealed"as-built"will be required before the permit will be issued. C) Attached Signs: show length of portion of building frontage that is occupied by applicant. D) Temporary Signs: show location for sign 4) Sign permits are$40.00.' each,payable at the time of application. 'j Address of proposed sign `(a0 °uTe-= 6 Historic District Name of Business for proposed sign C4 2 + 15t t DS ilk Name of Business owner r"`SH (s (Ce 4' I S(AlNLYS iC-.0-.). Mailing Address of Business owner l T O Lb Ley J SET W- bC-N Nl$ 1" 4. 01,10 Business Owner Phone:Business 11q- 2 `q -I. `^ 4 31. Home Name of BuildingOwner C4PL-i-- 151A s �: Phone Sign Builder Nc`1CNA. 57(oN CCIZPOAATI OW Sign Materials A k 't IN CA" (,4 (tc clo Ai( , Sign Builder Address OK f ND /ILLTI L �, {OL 3t- ' M X-14 44 Phone DUg`(o)Z.(oft S dtwi Singly Occupied Building Business Center Internal Light External Light'' 0 �' e G7 ((AL dSfluio se Freestanding Sign Size���i�k �i ��© L7 �©r� ��u f�1(o�T-: Attached Sign Size: flA — 3d" y to' 7 ''e a to k c4, e '4.- (s(Ar' o -94' x d a ' Temporary Sign Size: e `'l`t k, Dates: RECEIVED Please complete other side of Sign Permit Application NOV 14 2022 BUILDING DEPARTMENT By 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 (w re applicable). Freesta ing sign permits are not valid until the "as-built" from a professional land survey h be n recei e Date �"' c Signature of Applicano DP i us e Property Owner Authorization: I hereby authorizeSOkYeCt the applicant to act on my y behalf in all matters related to this application. (Signature) D Y .D • ` ` Date 51 1 ( X& sign ( t ,4-t-4 N, l /Date Approved by: With the following conditions: I have read and understood the conditions of this Sign Permit listed above: Pattison Sign Group Powering Your Brand LETTER OF AUTHORIZATION Note:All items in bold to be filled in. Property Owner/Agent Address Information Site Address Information Company Name: Company Name: MASH Realty LLC CIK Auto Group,Inc dba Cape&Islands Kia Mailing Address: Mailing Address: 17 Old Main Street 760 Route 28 West Dennis,MA 02670 South Yarmouth,MA 02664 Contact: Contact: Steven Sewell Steven Sewell Telephone: Telephone: 774-244-2537 774-244-2537 Fax: Fax: Email: Email: steve@kiacape.com steve@kiacape.com I, Steven Sewell PROPERTY OWNER/AGENT-PLEASE PRINT NAME am the owner/agent of the property,give Pattison Sign Group,Inc and its sub-contractors authorization to install signage at the above-mentioned property.This letter shall also serve to authorize Pattison Sign Group, Inc.and its sub-contractors to act as our agent when applying for the necessary municipal approvals and permits. Date: S( 19 2, Owner/Agent Signature: Legal Description of Property 520 West Summit Hill Drive, Suite 702 Knoxville, TN 37902 Phone: (865)693-1105 --_ • The Cm Commonwealth of Massachusetts . - ' Department of Industrial Accidents -, i __:'" Office of Investigations _ . I , t Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 =' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationllndividual): NATIONAL SIGN CORPORATION _ Address: 780 FOUR ROD ROAD City/State/Zip: BERLIN CT 06037 Phone #: 860-829-9060 Are you an employer? Check the appropriate box: Type of project(required): 1.El I am a employer with 1 00 4. n I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance.- required.] 5. n We are a corporation and its 10.n Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.(l Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] f c. 152, §1(4), and we have no employees. [No workers' 13.0 Other install SIgTI comp. insurance required.] *Any applicant that checks box#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. :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: NATIONAL FIRE ISURANCE CO OF HARTFORD Policy#or Self-ins. Lic. #:5095051305 Expiration D‘te: .1/19/2023 (6k, (-1 Job Site Address: 1(oO 41 V City/State/Zip: IA.- A44 Attach a copy of the workers' compensation policy declaration page(showing the policy mber 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 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 Investigatio s ,f the DIA for insu anc coverage verification. I do hereby certify and `i ai s id penalties ofpefjury that the information provided above ' true and correct. Si ture: AM2, __ Date: Phone#: 860-829-9060 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): 10Board of Health 20 Building Department 31:City/Town Clerk 4.3 Electrical Inspector 5Eilumbing Inspector 6.0Other Contact Person: Phone#: A �� CERTIFICATE OF LIABILITY INSURANCE - DATE,MMJD — THIS CERTIFICATE IS ISSUED1/6/2022 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 1 corsIEACT Corrine S.Sternberg Smith Brothers Insurance,LLC. I PHONE 68 National Drive i MC.No.Ezty(860)430-3234 I Fax (A/C.No): Glastonbury,CT 06033 1 brass,csternberg@smithbrothersusa.com I INSURERS)AFFORDING COVERAGE I NAIC S INSURED I INSURER A:Continental Casualty Company 120443 I INSURER B:All America 120222 National Sign Corporation I INSURER C:The Continental Insurance Company 135289 780 Four Rod Road I INSURER D:National Fire Ins Co of I lttti 120478 Berlin,CT 06037 I I INSURER E: r I 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. 1NSR; SUBR t.TR TYPE OF INSURANCE IADDL INSD I W VD POLICY NUMBER I oruS/YYVY)I tMMIDDMVYY1 I LIMITS A X I COMMERCIALLl GENERAL LBi1JTY I EACH OCCURRENCE S 1,000,000 I I CLAIMS-MADE X I OCCUR I x 5095051353 1/19/2022 1/19/2023 DAMAGE To RENTED 300,000 I PREMISES fEa ocamer,ce) S NED EXP(Any one person) S 15,000 lI PERSONAL&ADV INJURY IS 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: ; GENERAL AGGREGATE S 2,000,000 I POLICY i j� i X 1 Loc. I PRODUCTS-COMP/OPAGG S 2,000,000 I OTHER: t S B I AUTOMOBILE LIABILITY I I COMBINED OMBa (SINGLE LIMIT S 1,000,000 I X ANY AUTO BAP 9788685 1/1912022 1/19/2023 I BODILY INJURY(Per person S OWNED ri SCHEDULED I ) i 1 AUTOS ONLY AUTOS I BODILY INJURY(Per accident) S I X 'HIRED 1 NON-OWNED f PROP iDAMAGE S AUTOS ONLY i AUTOS ONLY t[ II II I s C I X 'UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 5,000,000 EXCESS LIAR CLAIMS-MADE; 7012209937 1/19/2022 1/19/2023 5,000,000 I I DED I X I RETENTION S 10,000. AGGREGATE S I (S D I WORKERS COMPENSATION * , t AND EMPLOYERS'LIABILITY Y/N I X I PER- -rE i 1 OTRH- I 1 F,NYPROPRIETOR/PARTNER/EXECUTIVE •• : SD9SO51305 1/1912022 1/19/2023 500,000 (OFFICER/MEMBER EXCLUDED? N/A EL EACH ACCIDENT 15 :Mandatory in ) EL DISEASE-EA EMPLOYE S 500,000 f yes,desrn unde r er i 1 nFSCRIPTION OF OPERATIONR ryelm. — __ I A _____..r EL DSEASE-POLICYLIMrr I S 500ppt] I I I I • i 1 I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Adcrgional Rernmb Schedule,may be attached if more space is required) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS_ AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) i ©198$2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _ 0 g ,O 3 ■ a 0 T O ' O W 30" ,l‘ 0 < ug p 1 I! O F Z A C 3 p a �_ o n 1 1, -F, 3 z x N 3. _i vya) = < 3 J a. , n v•= .< o s u CL CI oao ; ^ 3a - 0 ,- $ G 0 3 $ w n 3 C m f n n c R 3 a = P. 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