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Home My WebLink AboutBLDX-25-433 applicaiton Office Use Only Permit#_ //�� Amount 60/OD a COY—a 67--l33 EXPRESS BUILDING PERMIT APPLICATI iT E -. ', l V 0 I TOWN OF YARMOUTH , - - - Yarmouth Building Department APR 09 2025 1 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BB, C -1 L `r CONSTRUCTION ADDRESS:CAMP WINGATE KIRLKLAND 79 WHITE ROCK ROADH YARMOUTH PORT MA 02675 OWNER: SANDY RUBENSTEIN 20 LINNELL LANE YARMOUTH PORT 508-362-3798 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# EMAIL: HEYSANDY@CAMPWK.COM ❑Residential X Commercial ❑Est.Cost of Construction$ I,S UU 10 Homeowner is Applicant? Yes No Home Improvement Contractor Lie.# Construction Supervisor Lie.# K.36 v WORK TO BE PERFORMED Tent X Duration 4/1 - 11/1 (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review '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 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachmen _ - :::.: Approved By: ��/ '"'`^"�' 4,C l � l W Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents =J Office of Investigations 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/Organization/Individual): CAMP WINGATE KIRKLAND Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH PORT, MA 02675 Phone#: 508-362-3798 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' p 9. ❑Building addition [No workers' comp.insurance comp.insurance.: required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13..iOther TENT 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: PMA COMPANIES Policy#or Self-ins.Lic.#: 2025010291401Y Expiration Date: 2/1/2026 Job Site Address: 79 WHITE ROCK ROAD City/State/Zip: YARMOUTH PORT, MA 02675 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 civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 11=1Board of Health 20 Building Department 3LJCity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: 4k,. { s 1,-. V-2 *.* '' -. �� x. t ',} •� e s ' . :i�{ ' S :+„$i` ,t z . '. ate. r , , i Oil - . , ti 1 , . , , . „.. . . __ i , ....,._ . ..ram ...._,.s tw r t. _.. „,.....,.:4,,,,,,‘„:„.,..,. ..:.;.,.....,.....„ -xs „ j s, z,1< _ ,�. :..„-ate e ;`ms � , � .# Y' "`x . ,-i�11„ DINING HALL TENT 20X30 - r�i .'�+!G'�F.,-�.y;� �...�a ,g s^:...s .a� .�:° �� ... s Wig. �x✓i%:, o._ �'"3Kt. �.4,°>'�'.'::aaks�� .��ra��.,� a ; .S,-�w'>~R• EIV t � �'x" 4 �w 1»"f�•• '`p .i •L' ''`"',r,4irikig��y, ' Ni / / \•. V ° ,t {y7�r ¢{y '��j` pi( 'k"V''r �•�yA&.,Y.�,{ ( `yp��:y'v •�'• "�' .'F;.•Nq • (, F ` e f'�;Y�C�1 11 UfYW A'+�. ��11i�11°�lu�L_L�mJ 6u��bJ tldf ..�6�1 ��n r:�•t�9• y�t�i�� VAWJt � � . 'A7,' Xi 6�."Jt�k l"�'IIl l��ni '�1 l'»t'AL N�AI l�N4Atl!tldGIN l"�'1��1 t�1.Y Cw".'��l 15�.4 L"�1L lt'�i 'L 7�h � u�,� 4a3 x -- ,.. , ;s.,,,.,_, 4.:_r: Certificate of Flame Resistance • ,,k This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) A >. Al Issued By: Celina Tent, Inc. 4 5373 State Route 29 Celina,Ohio 45822-9210 , 4 www.CelinaTent.com >"' MANUFACTURER OF FINISHED TENT > PRODUCTS DESCRIBED HEREIN Celina Tent,Inc.certifies that the fabrics used in its tent products are flame resistant.All tent,canopy, structure, and shelter products manufactured . and distributed by Celina Tent, Inc.will display a"Tent Identification and Warning label"certifying that it has been made of a flame resistant material. 4 Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: NFPA-701 CPAI-84 ASTM D 6413 "' BS 5438 BS 7837(1996) DIN 4102-B1 'IV Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification:NFPA-701 > Method of Application:IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT ".":4, �> at The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. 4 4, This item is certified flame resistant or nonflammable, NOT FIRE PROOF. LS*4 The fabric will burn if left in continuous contact with any flame source. 4,:, Open flames should never be used under any tent, canopy, structure, or shelter. �_ Tent Products Division—Celina Tent, Inc r- >" ti4dig Signed:_//1:4‘.410t7 -4 `> CELINA TENT" Rev.20150709 00 40 . - ...•. .». •. •: .�• •»•. �»t •. � •X •. ••.•• «!! A.,. ».•. ,�» .«. ••» •» ..1. •« •.•. � •t ».• .L !d t to rn }�: fr. c } u,;. ., +,� �, ;»l. a . a.; ., .h. k•. ,rr a. :tat r u•; •.t., y Cy i• a r n }c• ,y AAA f.s 4 .: 'f 4, . ki A- ,F 4 `+ .' :x . .>, 4ca ,d w w Q :n ,o . s \h �\ M , � ,�.�; �A irk - �..� ,� .� ... �,. :� � � � �.A, � � � �` �.•�. �s �A �`;� r� '�` ic�^E��^�'"4�: ,( �u�"'a�d'�aa��a.A'+u.�a�«Y'3V..�a`� ,., . :p�.l ..: _... ..,,.� s° .., �:..