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HomeMy WebLinkAboutBLD-23-001026 Ind ie/t e/dq/H— n,---, Office Use Only c ,6©l'•YgR A /� �j��II d'. Permit# C- f'��O, �J {C4t. E +� T'c Amount TQ,eh ``1UTT- M st..'�� < �,.+ a c Permit expires 180 days from `issue date &I)—023 -ad/4 Z, EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department By 1146 Route 28 RECEIVED South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 AUG 25 2012 { CONSTRUCTION ADDRESS: 17 Aunt Edith Rd RTMENT e — -. ASSESSOR'S INFORMATION: ______________ Map: Parcel: OWNER: Roy Wilschut 17 Aunt Edith Rd South Yli 917 584 2929 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Party Cape Corj 660 MacArthur Blvd Pocaqii 508 564 6900 NAME MAILING ADDRESS TEL.# 0 Residential ❑Commercial Est.Cost of Construction$4000 Home Improvement Contractor Lic.#Al PAMA002-031743-08 Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Id I have Worker's Compensation Insurance Insurance Company Name: AmeriTrust Insurance Worker's Comp.Policy#WC0870132 04 x140 9/� Z n WORK TO BE PERFORMED Tent LI Duration 5 days (Fire Retardant Certificate attached?) Wood Stove eveil4- °Il"'lZ2 Siding: #of Squares Replacement windows:# Replacement doors: #�_ Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation Fl n _ i l Old Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing 1 (_,_ *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 1 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: Date: Owners Signature(or attachment) Date: Approved By: Date: gJ -‘ ---p,,Q_ Building Official(o igne EMAIL.ADDRES Zoning District: Historical District: Yes No Flood Plain Zone: -'- Yes ..] No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No IMPORTANT DOCUMENT Certificate of Ekime lOsistance Date of Shipment ISSUED BY 06/04/10 Registration Number A HR INDUSCT9 RIE,. INC. Tent Identification F-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 ‘5 E te/ OAS r -‘9.9 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. All 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: 4 • ANCHOR INDUSTRIES INC - . The Commonwealth of Massachusetts .A.:,..,.... Department of Industrial Accidents Office of Investigations Lafayette City Center '."';'. 1.5;7---• ':'' 2 Avenue de Lafayette, Boston,MA 02111-1750 „_... ---t.:--...---.. www.mass.gov/dia Workers Compensation Insurance Affidavit: ituilders/Contractorsitiectriciansifiumbert; Applicant Information Please Print Legibly Name (Business/Organizatioalindividual): Patty ideptl i.:t.),..i, int:. — Address:660 MacArthur Blvd City/State/Zip:Pocasset,_MA 02559 Phone#: 508-564-6900 ___ _ Are you an employer? Check the appropriate box: Type of project(required): 1 full&part time 15 4, El Lam a general contractor and 1.E] I am a employer with 6. El New construction employees (full and/or part-time).* have hired the sub-contractors 2.El I am a sole proprietor or partner- listed on These sub-contractors have the attached sheet. 7. El Remodeling ship and have no employees 8. 0 Demolition m employees and have workers' working for e in any capacity. 9. El Building addition [No workers' comp. insurance comp. insurance.: 5. 0 We are a corporation and its 10.0 Electrical repairs or additionsrequired.] 3.Cil I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions right of exemption per MGL myself. [No workers' comp. 12.0 Roof repairs insurance required.] c. 152, §I(4),and we have no '` II ] employees. [No workers' I 3. Other Tents comp. insurance required.] -Amy appocian dial Ci.W1.1,::::UUX di IIII.I.S1 also till cue tile SCCIWEI beiow SilOWLItt,'Lnclr workers comrrfism,(,,,pui,cy,itioi„,d,,,,,,, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. T-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 is site information, Insurance Company Name: Afl I rust insurwice Corp Policy#or Self-ins. Lic. #:WC0870132 04 Expiration Date:02/09/2023 job Site Aiitlt. kss, CiiyiLiidiciLip: Aittscit a easy oi"the workers' compensation policy declaration page(showing the policy number anti 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.1.4. o.uo a°ay against the violator. i3e advised that a 1.:upy of this StaLCIlleilt may be iortvardeu to the Oitice ot Investigations of the DIA for insurance coverage verification. 7.— ...._ I do hereby certift under the pains and penalties of perjury that the information provided above is true and correct. Signature: fA) CLK.,.2"..t...._ /".'...eU„..t....,.._ Date: ( — t Phone#: (--) - 0 • _ () ___ 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 4.0 Electrical Inspector 50Plumbing Inspector 6.00ther Contact Person: Phone#: "CS us a) a_ CD a) I- 0 v;. CD .s_1.4 tx0 t..) c c X to X w W E c LL w CD C"C.:7\CP 000 I ta.o x tx) ,t14) ;i1 C c 41; ij X ti3 LLJ C C W CD 0 „„, • Linen Procedures:Linen must be shaken out and returned in the provided Party Cape Cod linen bags. Linen returned with bums,tears,or irremovable stains from misuse(chewing gum,footprints,ink)will be billed to the customer at current retail price. Please help us eliminate mold,do not store used linen in plastic bags. Cooking Equipment Procedures:All grills and ovens must be returned in the condition that they are rented in. Failure to do so will result in an automatic cleaning fee. Self-Installer Tents:it is the customers responsibility to set up and take down any self-installer tent.If the self-installer tent is not taken down,packed up, and ready for pick up and PCC must break down the tent,an additional$200 charge may apply.All containers and bags in which the tent was delivered in must also be returned or an additional charge will apply. Damage Wavier All reservations include a 7.5%damage waiver fee of the gross rental charge. All rental items will be subject to the waiver with the exception of tents,tent accessories and tent flooring.This wavier covers normal wear and tear of rental items. This damage waiver is NOT insurance.It does not cover loss. missing or damage due to neglect of rental items. Circumstances not covered by the waiver will be charged a replacement fee. These items are billable to the customer at current retail prices. We strongly recommend that you provide security and supervision of all rental items from the time of delivery to the time of pickup. Rental Contract Agreement The following may result in additional charges: • Deliveries resulting in delays over one hour(ex.long distance carry,flights of stairs,use of elevators,landscaping delays) • Technical installations(decks,pools,etc.) • Beach deliveries a Man on site • Holiday delivery and/or pickup-Weekday deliveries with specific time restrictions • Obtaining a tent permit • • Last minute order additions or emergency deliveries • Sub-rented items(Chiavari chairs) • Returning customer pick-ups later than agreed upon time/keeping items for an additional day if you have read and understand the fofowing_agreement,sign below and return with the required deposit. Customer's Signature ';_, Date 08/09/22 Printed Name Roy WllSchut Contract# 50%Deposit Amount$ Event Date Pick Up Drop Off Page 2 of 2