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HomeMy WebLinkAboutBLD-23-002012 P t i i - -7//- ONE OCT —lvv FAMILY ONLY- B CTILDING PERMI�' r 141-' Town of Yarmouth Building Department ,-oF".".r T 2 2022 1 46 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext, 1261 Fax 508-398-0836 i 1 "'; Eri B U I L D I N G U E PA R T 1v1 E= � '�' \ T Massachusetts State Building Code,780 CMR -, bP-er zit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: f')(..0— 23—L)L 2Df-2 Date Applied: Building Official(Print Name) • ;nature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 123 Wianno Rd Yarmouth Port MA 02675 135 - 201 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-40 Residential Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided no ch nge to setbacks no change to setbacks no change,to setbacks 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Richard Ventrone Yarmouth Port MA 02675 Name(Print) City,State,ZIP 123 Wianno Rd 401-465-3896 rav9463@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building t ' Owner-Occupied RI( I Repairs(s) I7 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg.0 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: Repair water damage to HVAC ducts and re-hang board and reinsulate openings. SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: Official-Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:S L Indicate how fee is determined: 2.Electrical $ t1 Standard City/Town Application Fee 0 TotaI Project Costa Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $C P� gu}31 4 (\-1 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash mint) 6.Total Project Cost: $ 12,474 ❑Paid in Full CO Outstanding Balance D e: 1 h \ \ 3- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Walter R. Warren, Jr. CS-091653 9/30/23 License Number Expiration Date Name of CSL Holder 259 Great Western Rd. Unit B List CSL Type(see below) U No.and Street Type Description South Dennis MA 02660 U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted Ic&2 Family Dwelling M Masonry CS-091653 RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-694-5618 office@sandddollarcustoms.com Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Sand Dollar Customs LLC 193567 10/29/24 HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date 259 Great Western Rd. Unit B office sanddollarcustoms.com No.and Street @sanddollarcustoms.com Dennis MA 02660 508-694-5618 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 of the building permit. Signed Affidavit Attached? Yes Gil No .0 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 Walter R. Warren, Jr. to act on my behalf,in all matters relative to work authorized by this building permit application. Richard Ventrone 10/10/22 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 peijury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. ahA /e l.(/) 4., 10/10/22 Print Owner's or Authorized Agent's Name(Elec nic Signature) Date NOTES: 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.cov/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" §TOWN OF YARMOU H 1146 Route 28, South Yarmouth, MA 02664 508-398-22311 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at 123 Wianno Rd Yarmouth Port MA 02675 Work Address Is to be disposed of oat the following location: Town of Yarmouth Disposal Area Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Lt/Q�'aiL WG4 AZ • 10/10/22 Signature of Application Date Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents wireOffice of Investigations tom(, 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): Sand Dollar Customs LLC Address:259 Great Western Rd Suite B City/State/Zip: South Dennis MA 02660 Phone#:508-694-5618 Are you an employer?Check the appropriate box: Type of project(required): 1.E I am a employer with 9 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. 0 Remodeling shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.: 9. El Building addition comp.[No workers' 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 13.0 Other HVAC repair 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 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: Associated Employers Insurance Company Policy#or Self-ins. Lic. #:WCC50050197212021A Expiration Date: 12/4/22 Job Site Address: 123 Wianno Rd City/State/Zip:Yarmouth Port MA 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: a)alt&L / a2 Ki Date: 10/11/22 Phone#: 508-694-5618 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 3fCity/Town Clerk 4.❑Electrical Inspector 5E:Plumbing Inspector 6.0Other Contact Person: Phone#: .------" ® I ACO/RO /Y CERTIFICATE OF LIABILITY INSURANCE DATE v 12/14/2021 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 Tina Reeves NAME: Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX IA/C,No,Ezt): (A/C,No): 973 lyannough Road E-MAIL s: treeves©doins.com ADDRE INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: NGM Insurance Company 14788 INSURED INSURER B: Associated Employers Ins Co 11104 Sand Dollar Customs,LLC INSURER C 259 Great Western Rd. INSURER D: Unit B INSURER E: South Dennis MA 02660 INSURER F: COVERAGES CERTIFICATE NUMBER: CL21121493449 REVISION NUMBER: 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. INSR ADDL SUBR LTR TYPE OF INSURANCE INS() POLICY NUMBER MM ODYY POLICY EXP W X COMMERCIAL GENERAL LIABILITY ( ) (MM/DD YYYY) LIMITS 1 000,000 — EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) S 10,000 A MPP9284Q 12/15/2021 12/15/2022 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 PRO X 00000POLICY JECT LOC PRODUCTS-COMP/OPAGG S2,0 , OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED M1 P9336Q 12/15/2021 12/15/2022 BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ —^WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE �. N/A WCC50050197212021A 12/04/2021 12/04/2022 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (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/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements.Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended thecoverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Sand Dollar Customs ACCORDANCE WITH THE POLICY PROVISIONS. 259 Great Western Road,Unit B AUTHORIZED REPRESENTATIVE South Dennis MA 02660 s(„ram 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD c%/Lf' iwbezzewl!�{�a (.t �.:/"�%/lrf(7C It flfl' Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 -tome Improvement Contractor Registration Typo: Corporation SAND DOLLAR CUSTOMS LLC lie,istmtion: 193567 259 GREAT WESTERN RD.UNIT B Expiration: 10129l2022 SOUTH DENNIS,MA 02660 Update Address and Return Card. SCA I 0 aon145.17 Meant'Consum.r Affairs a Business RaguIeaen HOME IMPROVEMENT CONTRACTOR Regtstratlon valid for Individual ueo only TYPE:Comoration ocforc the expiration date. If found return to: allyiatratlnn Fxnfrafgp ,3t'fice of Consumer Affairs and Business Regulation 193567 '0,20.2022 1000 Washington Street-Suite 710 SAND L•L'LLAN CUSTOMS at; Boston.MA 02116 WALI ER R.WARREN 259 GREAT WESTERN RD.UNIT 13 yf(.nnf.!, SOUTH DENNIS MA 07560 Undcxsecrelary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure • Board of Building Regulations and Standards Const qtt tS Y1S ,visor CS-091653 w iy5pires: 09130/2022 WALTER R WARREN JR f, 40 ALEXANDER DR YARMOUTH P9RT M 02675 § i ti Commissioner o1 !,'. blektat .. • Paid To Name: Massachusetts Division of Professional Licensure-Office of Public Safety and Inspections Address 1: 1000 Washington Street Address 2: Suite 710 City: Boston State: Massachusetts Zip: 02118 Payment On Behalf Of First Name: WALTER R Last WARREN JR Name: Address 1: 40 ALEXANDER DR Address 2: City: YARNIOUTH PORT State: MA Zip: 02675 Phone: (508)694-5618 Description ID Amount Renewal Fee $100.00 Receipt Date:9.14 2022 9 58:15 AM EDT Convenience Fee:$0.35 Invoice Number:0a78tgd1-d71C-4da7-dd1C-Ia2tt;Cc76585 Total Amount Paid:fi100.35 Billing Information Credit/Debit Card Information Name Walter Warren Gard Type Checking Email RANDICSANDDOLLARCUSTOMS.COM Card Number ******0961 Street 259 Great Western Rd.,Unit B City South Dennis State/Territory MA Zip 02660 Important Information Please verify the information shown above. Your payment has been submitted to the Office of Public Safety and Inspections. • This payment will appear on your statement as"NCOURT*MA OPSIONLINE-PAY". • For license renewals: your renewal request is now complete.Your renewal will be processed in the order it was received. If OPSI needs additional documentation, a notice will be sent to your e-mail or mailing address on file. Otherwise,you can expect to receive a new license within 3-5 weeks. You can also check the status of your license at htlps://l;nadpi.ml6cer.•se.com,Verificationl. • If you have a question regarding your license,please contact the agency at 617-727-3200. • Please note that although the system may show that your payment transaction was successful upon submission, your payment will be considered a pending transaction until proof of available funds in your account has been confirmed. Payments that are denied by EPA'?will incur an additional 523 fee to process. • For refund policies,contact the Division of Professional Licensure at D-_-EL- Accountinqamassn;aii_state ma.us. Please include your invoice number and license number in your email. r: 1; n r IE. ) \ I. . • :11 I . . • t•A..... .. 0) II —} .. _ Tt 9'-10° O y _.] 0 c ii 70 1, /\ e I N i{ ,fir•ill \\.:;11111111--"1111111:-:%HI.' (::• : --- i el'''''/// \\'‘u..**AA : : : : L I F., ' • '- 1 li r t w Li I Ale , • • 1