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HomeMy WebLinkAboutBLDX-25-603 application og Y- RECEIVED _ Office use Only- 4t0` Permits 'A ,a 4i MAY 12 ij / Amount ''PO BUILDING BUILDING DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth. MA 02664 �(5508) 398-22311 Ext., 1261 CONSTRUCTION ADDRESS: /5 2_ (/C-.441 Sh ore `) ' ' "' OWNER: S/v/f/!PIfr - if L �'Sit1;-e /fir.5'.7e/ 14 fQ8,31'J �, 7(40 b NAME i'RE y! \I VI)I)kl SN TEL. a CONTRACTOR: a /* 4-- troc (...Ll., fi<--4 ..<?, t'I'1 r1 it f 8ij,4 dal bVf 5O L 4-O_�f d NAME �n `pry.I T t " MAILING ADDRESS TEL.a EMAIL: i� V J- li' e.,z__t Residential J Commercial Est.Cost of Construction S / / 0 LD U Homeowner is 1pplicantY 1 es No Dome Improsement Contractor I.ie.# Construction Supervisor Lic.# CZ ) )o 0-10 (1 vt 0,/qt IS/ik h verripa WORK TO BE PERFORMED Tent _ Duration t do7 (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 contai are true and correct to the best of my knowledge and belief. I understand that any false answerts) will be just cause for denial or rest on of my license nd fr' '��, under M.G.L.('h.26R.Section I. - / e Applicant's Signature: Date: J ( / )a3-- Owners Signature(or attachment) Date: 5 1 )a I J Approved By: _ Date: Building Official tor designee) Res 6 24 ry(1,r-1 b Cc Li .5 4- -i. e-vri 50(c— ,Ryb —(0,// F— ACO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `— 06/12/2024 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 CONTACT NAME: Michele McShea McShea Insurance Agency, Inc A/C.o (508)420�011 (A/C,No):(508)420-9010 1645 Falmouth Road, Rt 28 BLDG D E-MAIL ADDREss, michele2@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: PENN AMERICA INSURED INSURER B: Progressive Casualty 24260 Bayside Tent &Table, Inc. INSURERC: AIM Mutual 40c Whites Path _INSURER D: South Yarmouth, MA 02664 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00002179-449707 REVISION NUMBER: 2 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. INLTR TYPE OF INSURANCE pq L SUBR D MAID POLICY NUMBER POLICYMIDI EFF POLICY EXP LIMITS (AAMIDDIYYYY)-_(MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY PAV0504995 05/17/2024 05/17/2025 EACH OCCURRENCE $ _ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 50,000 MED EXP(My one person) $ 5,000 PERSONAL 8,ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ECT LOC PRODUCTS-COMP/OP AGG $ INC OTHER: _ $ INED B AUTOMOBILE LIABLm 02711576 10/26/2023 10/26/2024 (EaCO acddent81NGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ 100,000 AUTOS ONLY X AAUUTOSULED BODILY INJURY(Per accident) $ 300,000 HIRED AUTOS ONLY AUTOS ONLDY (Per accideMDAMAGE $ 1 OO,000 $ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ I $ `+ WORKERS COMPENSATION WCC-500-5013321-2024A 05/22/2024 05/22/2025 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY AFNYICERJMEMBER OPRIETOR PEARTNER/E ECUTIVE Y N/A E.L.EACH ACCIDENT $ 500,000 F(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 500,000 , DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Comp: Corporation owner Ryan Gillis is not included for coverage under the Workers Compensation policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED`` jj REPRESENTATIVE \Vl % �i"G_ - d (MFM) — ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by MFM on 06/12/2024 at 03:27PM The Commonwealth of Massachusetts Department of Industrial Accidents ti _;_t` 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 y� Please Print Legibly /� Name (Business/Organization/Individual): I J g 7 C � l t'�± Address: L4 Q C-- U'^'l,17J i),')7L• City/State/Zip: •ilk/"-r) j 0 &6 f Phone#: -'7 b 0, `1 O)j`-- Are pu an employer?Check the appropriate box: Type of project(required): 1.iJ I am a employer with —7 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 10.0Electrical repairs or additions required.] 5. ❑ We are a corporation and its eP 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.UPjther 7 ' 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: ni G S GL e 5 l/i St)(1""Er(? Policy#or Self-ins. Lic. #: W C L— 5-00 'Sd 1 3 °) I ' •-`44- Expiration Date: 3- [)--)-- Job Site Address: (Ss 5 •S 7,/() 19 City/State/Zip: ,14(//44141/-c O ((4 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 er the pains and en th the information provided above is true and correct Signature: ( f Date: f 1 )" ( �- Phone#: J U 1>i - ( k 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❑Board of Health 2❑Building Department 312City/Town Clerk 40 Electrical Inspector 50Plumbing Inspector 6.0Other Phone#: Contact Person: a as 4.i 4..4 d: ' f�.b",..a:. :: �. _r A�l C .I�4�1,�:..4_oiat6.1 '' '1 J...k _Cvi,%+1 t�i ALA 6w�d d is :d� _ w:u� � fi a i�l�l�l rMw 0 Certificate of Flame Resistance t, ,•. : This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) Issued By: Celina Tent, Inc. ,,,,,.., 444 5373 State Route 29 i Celina, Ohio 45822 9210 p www.CelinaTent.com MANUFACTURER OF FINISHED TENTf ;. PRODUCTS DESCRIBED HEREIN 0�e l Celina Tent, Inc.certifies that the fabrics used in its tent products are flame resistant.All tent, canopy, structure, and shelter products manufactured tit 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. '' ( -i=A lF i;-Y 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 ` 14 > Wit' Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the i 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 1.1 The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. ,�° This item is certified flame resistant or nonflammable, NOT FIRE PROOF. The fabric will burn if left in continuous contact with any flame source. Open flames should never be used under any tent, canopy, structure, or shelter. I` ii Tent Products Division—Celina Tent, Inc. E :., r cil60 Signed: _00,d‘ol, L:4,:',' F CELINA TENT`" i j Rev.20150709 P�• ' G - -r 7'•YT ,�T o'�•t�- 7,- . .-2� ,7 T"'�7. . fi +Ar 1`, ",,"'9'[�'"'�.7 i. 1711 7Ft. C�,77-, ", ..i 1- '•i�"'717 "" 1"�,.' •! r. -'7^ i 1, P lr," y, + f""` �'°f'7� ��'"S'` *`"r"'r's ,..�,. ,,,i .. �!� '�,;,� L "'�Y`t'�+"J r r '4::'.,'�r-.,,�.t. �n�-i-4'�+^�'ro i i� 7 .a,a:d .� .,:: �:.:.,.,e � ... .: a�..:p,.v.•: ..:.1:!• ♦ ., ...r.x ,.. ;p .,- _ +• .•.. r�r:!_r., ,. h,<A., ,.,A. S,';. �., n.A� r:a.�: ) ,.;. :., � � !�' ti�. }s.r,.;.r. � h. 7.4. ;,C;" a, S ,5,.,� t�..rat... s �•,.�!> A+, �!+. ,s. d, rb,.,a4 ,A A..A 4 � A A._A r,.h •� �:, ..+4 .,'�, {!..A h A,:.l, ^''• .•�a,>. e ,.� e .e„ �a A P,.:8. .3s .. .,,, �`k s ems. -. ;,.. ..>.. M .,r. :x� - a. .- -r... s>}h. J':, :ss.r�-a�r'�..,�"� . t ,. :'sp.t"x"=+r" 'Y.m ,..�.� ..'�"iz`3]t �.-:�:i� �,:. e r.:r+;.... r;'�„,-.'.w"�r...-..� .x �,�.s»�-_ �..+r....�3a�.':.tom ... t,.. k�t... '- ..?. ._ �t�s_;�(nt.?a.TE- �sz§'i.."'�o#, =.z€ ?`��v�.^rs`.%::a� t?.�._..., 1'�.1''�r :�ri� �♦ �f'. ;.9..'�'1 �S A 144,s1$ d. Y µ,S�. ��' rya, �A�, Sys,3 <� `�`�'' �y� @� 1 e�,St rY �' L+, �,kL ti) 1 1 L t ! ��� N ..,m�� �l �d- # �� YS` �ti,.idd, F�'. �"� .o F� '1F'7 1 �� •L ��I�� ¢ .�5 ! S �h Py.r d. G�..rz�'n ,�, �±� w'rr' .;� �" d,� 'a`�ri � ��`' "� �� Lt,4 a.,. �s t gilt:, '� �;. �x ,� � ( ' � �' , �, v, r> ' �, r �e �� '�' 'yy�1'�el�A"�'f�.A �.� � - x !t. �.. i�..a ��n�tW�day ir,wa�,���1 it, �i !FA � t�+1 d�Srl it. �„ '�r;a` t« � d ".. tOY k =. Certificate of Flame Resistance .4., „:„,,,,,, -- This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) 4 ' - Issued By: ;2 ' . ilirli 44-', Celina Tent, Inc. ' 5373 State Route 29 01 A., ; t_ Celina, Ohio 45822-9210 b adi www.CelinaTent.com " ,...... 4ii y'= MANUFACTURER OF FINISHED TENT . x; 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 byCelina Tent, Inc.will display a"Tent Identification and Warninglabel"certifying that it has been made of a flame resistant material. ` P Y Y g I � 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 ,E �' BS 5438 BS 7837(1996) DIN 4102-B1 r f _ Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the k zh, application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification: NFPA-701 t' to; 4., "47 Method of Application: IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT 1 .E 44, = The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. Mi This item is certified flame resistant or nonflammable, NOT FIRE PROOF. The fabric will burn if left in continuous contact with any flame source. 13 :--1 Open flames should never be used under any tent, canopy, structure, or shelter. Tent Products Division—Celina Tent, Inc. = 4 1.7: r � ! c114271 Signed: 440;i6010' r- ' C E L I N A TENT' Rev.20150709 . C« � d^" C. ° , .h. �. ,Y4, �, .,F x ,.a .ram, �, 2 a,.. qx ,u� �v; ,.,1, �.t'r �r. .:9 � r.. .t a t '� . t. At. �d. a; „k� rY 7�i t .r .< <:rn. Y .t. nra a �N� A _ram ems,, �..K� . �: �� r�,� .., �� � :. �Y; �-��+ � � ..-, . ir l u h u ' r $A nr ` p r i A v t g a $ f C �14 Certificate of Flame Resistance1-_-;,,, .4„, This is to certify that the materials described have been flame-retardant treated(or are inherently nonflammable) Issued By:' 1 Celina Tent, Inc. 5373 State Route 29 Celina, Ohio 45822-9210 /L. ' fir* www.CelinaTent.com . i MANUFACTURER OF FINISHED TENT ti; ., PRODUCTS DESCRIBED HEREIN �� per` 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. �§ -ai Imo. *- Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: i'''. ''-. NFPA-701 CPAI-84 ASTM D 6413 . • BS 5438 BS 7837(1996) DIN 4102-B1 1'1 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 t . Method of Application: IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT 1 y1, ,- ..0 The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. ;"'t F, " , This item is certified flame resistant or nonflammable, NOT FIRE PROOF. The fabric will burn if left in continuous contact with any flame source. Open flames should never be used under any tent,canopy,structure, or shelter. Tent Products Division—Celina Tent, Inc. ". IN .4/rara . Signed: -'440. CELINA TENT' Rev.20150709 - : ;; 4 iA'.. h. @� :C•�'{r 4 .1"..0 Nito.; 1. 'K. �. 2.44 1/4 ' i. t L�4. tl' 1`,l^ Ay�� 42 1 !