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HomeMy WebLinkAboutBLDX-26-733 application -�3 o ,tlM"R E C' F 3 `a E D Office Use Only o� YA�� rTii1 _ g O -�, y Amount le %" BUILDING DEPARTMENT — ;4, RPORl7E��: B EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 / / 1. CONSTRUCTION ADDRESS: S l " ‘111`S 1—ir ��Di c , -[ Grr,Jt`___ OWNER: y G/ ~�L l�a/i/7 3i old t-Q. c`1,,,,W7 z 114/'/0,,,k l / od ,.--Ivo. ci t D-D NAME y PRESENT ADDRESS y/ �1TEL. # CONTRACTOR: &IS( ui o< C J�44'1- s`�6/iYJ�1 —jIt/ + 02,4G 1 14,6- NAME � MAILING ADDRESS TEL.# (4aa� EMAIL: K 7'54 0 `//JG`7S (�/, - C2v" ❑Residential iZmmercial 0 Est.Cost of Construction$ Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# Construction Supervisor Lie.# ii(i)doXtnv 4.40) to At° / WORK TO BE PERFORMED Tent Duration i( rill? (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 . statements herein contained are truy_''correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revo : ..of my license and pro �,A er. .G_L.Ch.268,Section 1. Applicant's Signature: / > 1 " /� Date: `7/3/a .�7 Owners Signature(or attachment) WP(� I Date: ( :/ -6 Date: Approved By: Building Official(or designee) Rev 6/24 :_ .�. .r - .. .. .., .. . ,r. c.'. - `M _K :a - F1... 'T. t :"a '?r hf e'!fYM'fre..' 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B Rom_' � � ��a� Certificate of Flame Resistance o __ This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) }r I1 Issued By: fi,,;i.,::-...:,..,,.., I tit Celina Tent, Inc. 4 ; 5373 State Route 29 y a Celina, Ohio 45822-9210 -, www.CelinaTent.com �lRI 40'.' 1' ,�� MANUFACTURER OF FINISHED TENT ; 4 PRODUCTS DESCRIBED HEREIN I • Celina Tent, Inc.certifies that the fabrics used in its tent products are flame resistant.All tent, canopy, structure, and shelter products manufactured Dog 074,e, 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: I al NFPA-701 CPAI-84 ASTM D 6413 t - BS 5438 BS 7837(1996) DIN 4102-B1 :>. - 0 Vi l 'z' 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 1, i pp _ The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. r ', : This item is certified flame resistant or nonflammable, NOT FIRE PROOF. { 31 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. -4"' Y,4 Tent Products Division—Celina Tent, Inc. I f ' 1/L17V Signed: �_�,: a CELINA TENT'" Rev.20150709 IV ,.- 9771„�...^P^„,77.,C1"-'77!P,,Y' ',7!'L- ""w.',l-T77:',"rL"p�r:^n,` T7' 1` Gt"'.1 rally P",R,7'P*�";ff •'",TY,^"fP" 1 T1^"e`T,`"„7;41�,.,.r}rw1"'7 ',^^� ' P�� 4 „ ," .Y� '1 At•„ 'y rj, rY �r, t'_ •,: 4 w,y S,✓ CO as : , M Ai _ 1 e. :t, r w r _r -r. ! t. r c :t. t r r, r . r +�, ��.!?� /.r1r T tir. .r--:. i ?al• .,. r .... ,...:. �''��hl, ?.f-�.:� ,. �'-�:. lsl r'^.' Wit. "'arr`�1 .ti✓"'�3.rY-Z./�:�r. �.��'�..��1. ���az:�?f,r,-.`�1r.r d .n i�ck���C.%"�.''+,,i. 't! ?rr:�1•.e!'?�ilr''Ari)�N hV! a.. '!�f;T'1�-.�!f1.^mac% '+fir-.� e.}e:?�cr-7•a�t:: 'eft -i.- �'" f .n.. s. >, +�` ,. � � .s-. ,> z . � <n > yry ./•. { .� a. �. ,ir.Sp�iJ�C. 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This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) 1' Issued By: ; �` zt,- Celina Tent, Inc. - ii-`! , =', 5373 State Route 29 �' Celina, Ohio 45822-9210 A _, www.CelinaTent.com t 1= 'ix,, MANUFACTURER OF FINISHED TENT E y,S 1 -=Ytlii; PRODUCTS DESCRIBED HEREIN . .r: t Io i Celina Tent, Inc. certifies that the fabrics used in its tent products are flame resistant. All tent, canopy, structure, and shelter products manufactured Air, 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" ,1g1 Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: 0--.: NFPA-701 CPAI-84 ASTM D 6413 _ 4,0 - '.l . BS 5438 BS 7837 (1996) DIN 4102—B1 E x " Certification is herebymade that: The articles described on this Certificate have been treated with flame-retardant approved chemicals and that theiVg ktti- y application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification: NFPA-701 i= 1 : is 1ii'f'4 °' Method of Application: IMPREGNATED Description of Item Certified: MASTER SERIES FRAME TENT Lt 4.41 The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. _`,' 44 - . This item is certified flame resistant or nonflammable, NOT FIRE PROOF. It0 41 ' `_ y -.:- The fabric will burn if left in continuous contact with an flame source. g :::i.:__ � li I R wr. _ ;' Open flames should never be used under any tent, canopy, structure, or shelter. ,, 4•• Tent Products Division — Celina Tent, Inc.ifitior;ii"e, . . . i b- c/A4riro Signed: CELINA TENT" Rev. 20150709 ° % • � •'qql%k.» c+t+�•.:� ` F t« r7 ' { ' 1 ""g 7 .. 1MTI �W ) ib S S1 1 I *w4tdd A �SA <7w.-0 v ‘ YrY>Wt ; t :N* 7 + .N1*4i4� s 0 M� e� � $ K iLwS � r , .�' -.r :s 's r �r '[ ,5+ iT- - -'k, -'R .:TI.iwa•,t r,''f /' "a,r�'�7itr.--�¢, .oEi��'vhle;Y�ai;;.- :Y'�...>F<.::, ,.• E. :r w:�.. ,c.- 3 d Tr^y, �s; 3 '�aN'+r•?leri fir' -°�' rse�' .. r�,�l>�-� a '�>r' r >e?'L.?t r' 'k � .r r •'�4 r. .��''`-�✓�= ,:a "'R14.. .A.F' .Y`.r��'.. M.' .:r�l�•"a !`fit✓.=`•'�a0 *`��� '"Icri k.+.'�-.•dlc':'-`"isa,'•' .t .+l" Pf;'.�E-`'.td%• -.'fir .a.. �!,.a. 2.•k. ,; a.. t •.'"fit �.�,•!-�'�i!`-,` f_,J�. z'�-. ��Ph i"�. 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INI 11'lll lltl 15.�1�1111 n1.' 11 1 6�J1 LMi.' f��itll ��11� AI'$1� dill1"1 11 '11�11 11 p� �II�NI� Ay: 115f11� �ININIF IILq'll ��111 IN 1 ��� �Il�l� NIIH ,�,j/t•.'1q 111/ !, .LLt"d 1..,,,.h IB _.�WII�.�1Y4+1�-.�11�u1�.��Jyy�-,�. _ JIN�E!e�- '�k � � .��J�IIEI���Jtl��1Y�ib6o9H�flhcfltllam.,....• ®�-�'3"—� �IrYMLLlI.+ Will� '' •� "K i t 1e1,::_ .4.N tti-411... Certificate of Flame Resistance cl,,,„, 'it ZA ' = This is to certify that the materials described have been flame-retardant treated (or are inherently nonflammable) I PiiIssued By Celina Tent, Inc. T ? ',~ 5373 State Route 29 `` Celina, Ohio 45822-9210 4-1- e,:qi-- www.CelinaTent.com _ t .; l _ MANUFACTURER OF FINISHED TENT 44 PRODUCTS DESCRIBED HEREIN _ =� Celina Tent4=4 , Inc. certifies that the fabrics used in its tent products are flame resistant. All tent, canopy, structure, and shelter products manufactured tand distributed by Celina Tent, Inc. will display a "Tent Identification and Warning label" certifying that it has been made of a flame resistant material. _ nil FY4 A I Tent fabrics have been independently tested to meet or exceed one or more of the following flammability specifications: , A! ill go.' ite4 NFPA-701. CPAI-84 ASTM D 6413 = BS 5438 BS 7837 (1996) DIN 4102—B1 -{ . ' Certification is hereby made that: The articles described on this Certificate have been treated with flame-retardant approved chemicals and that the -.Ilig • F:o 1 i ; ry. application of said chemical was done in conformance with California Fire Marshal Code, and is equal to or exceeds Specification: NFPA-701 gat, 4S }III =_1, Method of Application: IMPREGNATED Description of Item Certified: MASTER SERIES FRAME TENT Ar -1:44'-i ft ,.- r The Application Of Any Foreign Subsantance To The Tent Fabric May Render The Flame Resistant Properties Innefective. = i This item is certified flame resistant or nonflammable, NOT FIRE PROOF. q 44 0: 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. it-;:v4,11 ;, c144141 Signed: 1,40iii ________________ ,,.. ,,, � = 1 CELINA TENT ;y 17 11 111 INM ! 111 II 1111 Ilr� i 11 1 II iN }N x n N 1 u1I nN{ 1 1 1/1 NIN 11 N N p 11/I 1 Inn P 1 III I111U 11 1(1 Ipl 1 ul I N 11 1 1 1 / NNN Illy 1 II fl !N1 111 .it i ii i'I iilli In 1 r u� 1 I HN 1 1 NI N I 11� *s;, 11w 111 n• 11 N 111 N f: #::,:. 11 11 INI Inl« INI• .0 11 .14 II 1 11 11+.:4 1 111 :: Il,�� M 1 ,1 r..��.1 r11 w us, �1 ., '1 �. t Mt, S4 1 t' 7 r. a" `5 Y S.1 r S 11 r�ll h i� I j�l 111 1 � .n1� i« ,�a 5C'r .5?5Y � •5 �1,1.5 .� �N.�1.' d r. •J.' IY� 11 "t' �.I11 S'1�' '�111r 'N�5' + N .J "rtr: ��• 1jn 1 11 n7 Iti1 �1 1 1�1 n �w 1� tut 1•. •1��;}� 1�' .� 1. �J, 1, 5�55+; I f' '�/'. '!.S' Y.. QVr r5 'r7 5'• 1��( ,r! t ' �'N' .';1,� .r ':7' �r. 7�{. �':'�7. h'• r:�' ''f�� \�i r;¢•r t` '•aSgV <• �h' 45 44 Y. F .1 •v •Y r' t(l' x r: ir. �}' S ' f 'Q, i J" ` <2' A 1 .2T'' S.. '` ,1g, ':J; �i' {�, ?7; .r• t � E•r.. r.. ..p '�+{' :e�s 3, 1 +F� „-�'t? .�+>.(v 'iv AY*, v C` ry ..r. � 'H" �'!' �:v '�?''� ?{s'' .:. i �'• � •mob « ` ..L.11 •�, ,,5�.1 s lye �p`y� i � '•�4' 'r�• '•k' •i .F �.� '•'.i. .�i •'•y.. U' 1'#: `•�•'-!�i....�w'.�{l•:°�'•k� �•� �.., �. •:31"i •t �� rp �[If�� �{ yg�... �y��yy�(.�gyy��!�/y� ��{�- +���zo' y[r .ef y .J�` y� y Yam �/y�� �( ° A.443.� ,x } �_.�.. �,y...� }�:.��tv - a -Y+.-'�•, -K '-�- r�� �st,:. < �C�'�' ��•'.• ��'gift'R�,vY•ll •}::�ARi� ����•f('""1Y1"i>P 46•'•G�QT'1C �1.'X�%0 ltf:.��h����•7—�1W' Y�/��i^ 4�:�r��l 'i4f:�Ft5� � 5{O'=!�\A��Kii.����'lY��"1A.. �fil"t-t. ��'�n 1 '?•1C-} '4� w^ AC DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/26/2026 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: Sean McGrath _ McShea Insurance Agency, Inc PHONE Extj: (508)420-9011 is No): (508)420-9010 1645 Falmouth Road, Rt 28 BLDG D EL ADDRESS: Sean@mcsheainsurance.com Centerville, MA 02632 INSURER(S)AFFORDING COVERAGE NAICN INSURERA: PENN AMERICA INSURED INSURERB: Pilgrim Insurance Company 21750 Bayside Tent&Table, Inc. INSURER C: AIM Mutual 40c Whites Path INSURER D: South Yarmouth, MA 02664-1212 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00002179-0 REVISION NUMBER: 4 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.LIMITS SHOWN ARE INCLUSIVE OF AMOUNTS REQUESTED BY THE CERTIFICATE HOLDER AND MAY NOT REFLECT POLICY LIMIT AMOUNTS IN EXCESS OF THOSE REQUESTED. Not Applicable in WY INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MMIDDIYYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 1 PAV0634965 05/17/2026 05/17/2027 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PROJECT- LOC PRODUCTS-COMP/OPAGG $ INC OTHER: B AUTOMOBILE LIABILITY CSC00001015534 10/26/2025 10/26/2026 Ea accideDDSINGLE LIMIT $ 1,000,000 ANY AUTO li BODILY INJURY(Per person) $ 20,000 AUTOOWNED ONLY X SCHEDULED BODILY INJURY(Per accident) $ 50,000 HIRED NON-OWNED I PROPERTY DAMAGE AUTOS ONLY L AUTOS ONLY der accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ I $ PER C WORKERS COMPENSATION WCC-500-5013321-2026A 05/22/2026 05/22/2027 X STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORJPARTNERIEXECUTIVE Y N/A E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/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 REPRESENTATIVE (SPM) ACORD 25(2025/12) ©1988-2025 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by SPM on 05/26/2026 at 10:20AM The Commonwealth of Massachusetts Department of Industrial Accidents �cl-ul Office of Investigations Lafayette City Center 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses Applicant Information Please Print Legibly 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.® I am a employer with 9 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑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]** 4.ElWe are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees.[No workers'comp.insurance req.] 12.E Other Tent Rental *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 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 2026A Expiration Date:5/22/27 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. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. 7/03/26 Signature: Date: Phone#: 508-246-6128 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): lflnoard of Health 2.0 Building Department 30 City/Town Clerk 4.❑Licensing Board 5rJ Selectmen's Office 6.❑Other Contact Person: Phone#: www.mass.gov/dia 2Ox4C tent Pxit ' I (r) x Cll x L ► I x I t 2OxLO tent Exit CD cn U) x (n x C I CD LT_ Exit C) Make Google Earth yours Complete your profile to help improve your experience File EdIt Vief,,,.. Add Tools Help laity., , ....... r Yk."4" ' 044- • a_r.4 e -l .' Yamou th F own Halr7C) ' ' ;•,,ti,-,--*44.rarti ,.". - : ., „.0..-. ..0.•• _. ., --:.....: '.,.' • ...,.. .0*.:- ,s, -0,. -- • .-, , , -. . 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