HomeMy WebLinkAboutBLDX-26-366 application of YAK RECEIVED HceUseOnlyhit
3. APR 2 3 2026 Amount
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'�CR'pPORlrEO��' BUILDING DEPARTMENT -
9y
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth,MA 02664
l (508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 15—() J ,S itong /J/'- ,S (.46/1'6-0c16-/
OWNER: The J/�`(Et1 frii-eui UkF I c).s 5hd e/0/', S.(1444e 't-, M/r(WC, cOi-S4il%74/C
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: g a.+��6i7,ie tk%-f IOC dri/ 41 5't 16rf-c�'"�l �Oo�06 L! CV? -- 0.-�1Q35
,�/� NAME / �/ / MAILING ADDRESS TEL.#
EMAIL: / 7G o1l 4c,7S% r pk4. CDo^
❑Residentialmmercial ❑Est.Cost of Construction$
Homeowner is Applicant? Yes No
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
,Fo -LlOC2 )
I-OpC3 D l sill WORK TO BE PERFORMED
Tent Duration 0,,(' Gh ) (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
i
*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 rev of my license and for prosecu i 1n.er M.G.L.Ch.268,Section 1.
Applicant's Signature: / !9t11/1
4 , Date: /)"1 /Owners Signature(or attachment) t�f/_9t(.74., G Date: 14/) 1/A (�
Approved By:
Dat
Building Official(or designee)
Rev 6/24
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r Certificate of Flame Resistance :„,:,
►- This is to certify that the materials described have been flame-retardant treated(or are inherently nonflammable) :Y
Issued By:
Celina Tent,Inc. ate;.
5373 State Route 29
C11114 tS ,
Celina,Ohio 45822-9210 ) ilif;;;,
www.CelinaTent.com lo.go
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.
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
Ow
Certification is hereby made that:The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the
t' application of said chemical was done in conformance with California Fire Marshal Code,and is equal to or exceeds Specification:NFPA-701 lgtt`.
Pos
>."i, Method of Application:IMPREGNATED Description of Item Certified:MASTER SERIES FRAME TENT OP,
t�` Mit
The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. W
This item is certified flame resistant or nonflammable,NOT FIRE PROOF.
4- 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.
Signed:.4 ,ey
'= C E L I N A TENT" Rev.20150709 llw'
404 5 t ' Ar�r ' r 16 @ 1 iW :. a R�W 5AAM i T "L' A '.7^Y J
The Commonwealth of Massachusetts
Department of Industrial Accidents
u ��// f
Office ofInvestigations
Jn .l f� g
1974 Lafayette City Center
/ 2 Avenue de Lafayette, Boston, MA 0 211 I-17 So
"' �=y�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print L.efiliiy
Business/Organization Name: Bayside Tent
Address: 40C Whites Path
City/State/Zip: S.Yarmouth, MA 02664 Phone #: 508-760-4025
Are you an employer? Check the appropriate box: Business Type (required):
1 . 0 I am a employer with 7 employees (full and/ 5. ❑ Retail
El or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
7 T ant q snip nrflllri�trlr t r n rtnprchin and have no r—, .
. '—' r• r• r•-• r I. U Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. El Non-profit
3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11 .E1
u Health fare
4. LJ We are a non-profit organization, staffed by volunteers, Tent Rental
with no employees. [No workers' comp. insurance req.] 12. 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 e that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Mcshea Insurance
Insurer's Address:
City/State/Zip:
Policy # or Self-ins. Lic. #WCC-500-5013321-2025A Expiration Date: 5/22/26
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.
1 do hereby certify, under the pains.4 4-and penalties of perjury that the information provided above is true and correct.
a� 9 • 4/16/26
Signature: • • Date:
Phone #: 6n8-24R-61 ?8
II I
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 2.0 Building Department 3.❑ City/Town Clerk 4.['Licensing Board
5.0 Selectmen's Office 6. [jOther
Contact Person: Phone #:
www.mass.gov/dia
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