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•
. SECTION 5:.CONSTRUCTION SERVICES •. .
5.1.1Construction Supervisor License(CSL)
Ala/kr R, t t rrwn/ —v'? (' S e O S(t c te v
License Number Exp tion ate
Name of CSL Holder
90 4/1 J /�� List CSL Type(see below)
No.and Street /``4�/�L /�/ '. Type . ..: > Description
ya �� . ,/_ f` ) /_ / 9ei. 01((7 Unrestricted(Buildings up to 35,000 cu.ft)
City/Town,
/ d Restricted l&2 Family Dwelling
rty/fown,State,ZIP M Masonry
RC Roofing Covering
•
/PoSSo(e��ar WS Window and Siding
SF Solid Fuel Burning Appliances
So&-- 671/-3-6/e cus 4n% • (din I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/ 9' S;6 7 SaNSPdo//arcvs!oa LLQ /��S-4 7 ' 9 ata
HIC Company N or, C Re •strant m4 HI Registration Number Expiration Date
jec SPI yFet lss AW, /cc�tY (rli at54,,a,Ate .sfc025. <n1
ryo•( ��74/n7/*' p Q. Ov67'� Sall- lirch.5 /8 Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance f the building permit.
Signed Affidavit Attached? Yes !J' No C
• SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ..
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
•
Print Owner's Name(Electronic Signature) Date
• . . SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
.
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
1.(AUl // /7
Print Owner's or Authoriz is Name(Electronic Signature) Date
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will rLar have access to the arbitration
program or guaranty fimd under M.G.L.c. 142A.Other important information on the TUC Program can be found at
www.mass.gov/ocq Information on the Construction Supervisor License can be found at www,mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
o0'''AR4 TOWN OF YARMOUTH
*.r
,, r C BUILDING DEPARTMENT
N -pa ° i 1146 Route 28,South Yarmouth,MA 02664
/ 508-398-2231 ext. 1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed� work/demolition to be
conducted at a Co Sc �- wjU/e /2oa d0 61_ ya ymw-/"t
Work Address
Is to be disposed of at the following location:7A/4J 3 \/c,fdylawi LG (�'/I
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
S. //3// 5
Signature i • lication Date
Permit No.
The Commonwealth of Massachusetts
e *rev Department oflndustrialAccldents
=i'int= 1 Congress Street,Suite 100
_ _= Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information a Please Print Legibl'
Name(Business/Organization/Individual): SO nal eti7/air- fey Shaun# I I C.
Address:, ) 1vh,4S /a,MM)
City/State/Zip: So. yrs f#*4o'#i g/4. 0266 S' Phone#: Svcg - 6 9 y fide
Are you an employer?Cheek the appropriate box: Type of project(required):
1.13Cm a employer with / employees(full and/or part-time).* 7. 0 New construction
2.01 am a sole proprietor or partnership and have no employees working for me in 8. remodeling
any capacity.[No workers'comp.insurance required.)
3. I am a homeowner doingall work 9. ❑Demolition
❑ myself(No workers'comp.insurance required]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or aro�s . I will
proprietors with no employees. sole 11.0 Electrical repairs or additions
12.❑Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a coiporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,$1(4),and we have no employees.[No workers'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 suck
: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: 41556 C $vyf1 /o/e/S t'tr$
Polity#or Self-ins.Lie.#:i!✓C t^.c aJ S0 /q 74) /? tri R Expiration Date: >s/y// 7
Job Site Address:_3 to 3 °' °mots/t Rd City/State/Zip: Wo. & 73
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisotmtent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c under the pains and penalties of perjury that the information provided above is true and correct
Sienature: \J�/ Date: ( 3(
Phone#: - (f get — S"ee t'
Official use only. Do not write in this area,to be completed by city or town offidaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
•
•
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, M , chusetts 02118
Home Improve tractor Registration
r
Type: Corporation
SAND DOLLAR CUSTOMS LLC _it Registration: 193587
1851 FALMOUTH ROAD ==.v' Expiration: 1029/2020
CENTERVILLE,MA 02632 = �[a}`�'
Ir
e
7M INEV
Update Address and Return Card.
SCA 1 O 201405/17
Office of Consumer Again&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE'`. . . before the expiration date. If found return to:
• oiraf
• -v..i,.-. Exon Office of Consumer Affairs and Business Regulation
9350 10/29/2020 1000 Washington Street-Suite 710
SAND DO " 1$ • S '• Boston,MA 02118
WALTER R.WA-- Q--- x.coef— �, �
1851 FALMOUTH Ra •.a U
CENTERVILLE,MA 0 2 Undersecretary Not v..• • Ig. nature
• C. Commonwealth of Massachusetts
®� Division of Professional Licensure
Board of Building Regulations and Standards
Con strgEttdri%Itpervi so r
•Ir.
CS-091653 j' • ' E',o1res:09/302020
i t 5 r l
WALTER R WARREN J!4{) „i
40ALEXAN DR ly x 41
YARMOUTH MA 02678,lO Y '
r1n/tSL1
Commissioner J
•
/""i SANDD-2 OP ID:DS
•
.Ami�� CERTIFICATE OF LIABILITY INSURANCE DATE
s
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 Ian ADDITIONAL INSURED,the polcyfes)must have ADDITIONAL INSURED provisions or be endorsed.
N SUBROGATION IS WAIVED,sublect 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 508-7754060H ,ACT Bryden&Sullivan Insurance
Bryden&Sullivan Ins Agency rat.
88 Falmouth Road E 508.775$060 A,�c NM:508-790-1414
Hyannis.MA 02601 Mks&
Bryden S Sullivan Insurance
INSURER(S)AFFORDING COVERAGE NAW I
INSURER A:Mapfre Insurance 34754
iliiEPoll arCums LLC MEURER1;Assoclated EEmployersIrInsurancence
r
o armo 02681 msuRERc,
MSURERD;
INSURER E:
INSURER FI _
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 AU.THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EPS POLICY EXP
salt TYPE OF INSURANCE Mao MD POLICY NUMBER DIPMFYYYTY1 imhymyymi LENTS
COMMERCIAL GENERALUABI.fIY
EACH OCCURRENCE $
CLAIMS-MADE ❑ PRFMI.SF
OCCUR S(�Q PIMca) $ _
MED EXP(Any oode.m) $ _
PERSONAL 4 ADV INJURY $ —
GEINL AGGREGATE MET APPLIES PER: GENERAL AGGREGATE $
HH POLICY L JECT 0 LOC PRODUCTS-COMP/OP AGO $
MEP' e
A AUTOMOBILE LIABILITY ICA
COMBINED LIMB
I
— ANY AUTO _ BHMWLT 02/0212018 02/02/2019 BODILY ITUURY RXIcMIT0) i 100,000
_
AUTOS X AUTOS BODILYMir,Ime6 e„ $ 300,000
X 1.Y&ONLY X ANUUfO /7en.wRdTMwd4AMAGE $ 250,006
s
•
— UMBRELLA UAa _ OCCUR EACH OCCURRENCE $ I.
EXCESS LV18 CLAIMS-MADE AGGREGATE $
DED I RETENTIONS s
B WORKERS COMPENSATION I PER W-
AND EMPLOYERS'Maur( WCC60050197212018 12/04/201812AM/2019 sTAnrtE ER 500,000
ANY PR IETORIPARTNERIEXECUINE E.L EACH ACCIDENT $
gig MEW EXCLUDED Y a(A
�'ry:NW
EL DISEASE-EA EMPLOYEE 5 600,000
I eA debit.Under
DESCRIPTION OF OPERATIONS Wow EL OGEASE-POLICY LIMIT $ 600,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLES(ACORD101,nation/Retorts Schad^may W.eaeled'more space le resulted)
Certificate Issued for Insurance verification.
CERTIFICATE HOLDER _CANCELLATION
HECH000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HECH ACCORDANCE WITH THE POLICY PROVISIONS.
120 Main St
PO Box 638 AUTHORDED REPRESENTATIVE
West Harwich,MA 02671 Bryden&Sullivan Insurance
(
ACORD 25(2016/03) 1 1 01988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD .
•
Sand Dollar Customs LLC Estimate
23 Whites Path
Suite G2 Date Estimate#
South Yarmouth MA. 8 1 2018 206
02664
Name lAddress
Mark Sheytanian
26 Sagamore Road
West Yarmouth Ma.02673
Project
•
Description Qty Cost Total
lre .aLY9
Door Landings:
Remove existing landings,install 12'sono tubes with concrete and
install new 4x4 PT decks.
0 each.
Exterior Doors(2):
Eng each
Permits,Disposal,Insurance • 00 CPO'
X03,
Wt: AaeCast NE, it la so You CPN ST19!r-r 114& watt 'me
l./4764 of iita IF `�o0 WOtuL> Lila; . tEr ftp %row . WE
WILL t eini J otd "lie ft- cn► I I I q IC You LUANr TO
MEC-r- ‘110 To Go ea Att_ TIC j ut s d-r-T4e (-&usc.
CAS �„{G 14-11nbc- UDC+) s*- 3411
NYS
Notal�.
Total ' �/�
Customer Signature
Page 4 •
t Y^
TOWN OF YARMOUTH
• mAli
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicantt:: , /�
Building Site Location: a SC? bxnr
we /cir
Proposed Improveme99t: / ri/OV-e off- — 7 < 3 /a tt OS �rr/✓l/t
is fAt4 u.•vc/ /f.Q/tla6 n ' at ij ',�3 ' // T F'nsited'
Applicant: Ala ' P ii at/entrg Tel. No.9 Yt 7-3-6 ?Co
Address: 70 teltale/ #7.; Yo//9?0V/4/ ?'77,0G Date Filed: 74/27
* /fyou would like e-mail notificationofsign off please provide e-mail address:
Owner Name: Site= .i/4 he '/l 4 4-7Owner Address 6 .Sa £4fiferee A7amm-714 Owner Tel.No.:fit 17-11Y6 307/
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed)—
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWEDBY:4POCY M DATE: 4-1el?
PLEASE NOTE
COMMENTS/CONDITIONS:
•
3,‘1
YARMOUTH WATER DIVISION
99 BUCK ISLAND ROAD
WEST YARMOUTH, MA 02673
PH.: 508.771.7921
FAX: 508-771-7998
BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFFDTRANSMITTAL SHEET
Bldg. Site Location c).. Co S 6-q ww /`tet i Q Map #: 4C/ Lot #: 1 1 3 c'
Proposed Improvement: pq f�ev.p f- fl via(.e ,_ i 24 �6 j Cy Po C/$
Applicant: a_)0. (1-4 r ,C. ((1Q in/0—re c
Address 70 �1. On,,,. Tel. #L9c36) S?73Date Filed: // 47
`fa-747 47./ /7*
RESIDENTIAL AND / OR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Availability and or Existing Location
Engineering Department: Determines Compliance for Parking and Drainage
Conservation Commission: Determines Compliance to Wetlands Acts; I.e. If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Ocean, Bogs, Bays, Marshland, Etc...
. Health Department: Determines Compliance to State anJnwn Regulations, i.e., Requirements
for Septage Disposal and otherPtblic Health Activities
Fire Department: Determines Complianceto State and Town Requirements for Personal,
Safety, Property Protection;, I.e. Smoke Detectors, Sprinkler Systems, Etc...
(A) i
l /3//i
Signature of applican Date
40
PLEASE NOTE:
COMMENTS:
/2i02 Kim sifiverivA/ liw AM2L' A v,
S-2-21 z4 " / f26o& n15 n .Vo 3v zciik1 //-i/5x/ ' i' it)Pet.9
747" z47.?/? G/ it KS . C/21—<:1 I
Rev b ater Divi ' n !D ill
.miry ,Thrm 'a ?Lor/3y
LOT N0. :0- / I ADDRESS: ,Q Co Ser PnOD( nc(
w
oY
OWNERS NAME: i.03-tf -t C,0%4rl%4 Cronin—O
SEWAGE PERMIT NO. : 9.1-attd.NEW: REPAIR: X
DATE ISSUED: C/3/55 DATE INSTALLED: /O--S^99
.INSTALLERS NAME: r(Ii'3 6 rc1 .pd Cont/...C1
CO,
. INSTALLATION OF: /90 , ria-
.05
WATER TABLE:13i. FINAL INSPECTION BY: 8.6-01
DRAWING OF '•INSTALLATION ON REVERSE SIDE:
laA
T5ACA. r
Cos
1 01
IS' 12 . 113
t •
Yarmouth Health Department
lame Date
epa� ka rciie/ ii: - I 1 .relefl 10;1/4111A6
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— REVIEWED FOR BUILDING AND ZCKCiO CODEDH" tI j
a �i Ste_ a✓Yla/� fiOG
C/� 7CO�APLI•
,, ` Y° I/l9 044' IA 1-� .) 4 34 1 - -—APPLICANT
PP IC CE.OMTHERESPONSIBILANCE. ERRORS OR OMMISSIONS OITYOFi ASBUILNOT RELIEVE T'E
I I H 1 I'- I I L I ! 1_ -I -I __1_DATE: jI - 11 /9 I I I I _i I L.
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