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HomeMy WebLinkAboutBLD-23-004140 /2/ //23 RFDEiVED & TWO FAMILY ONLY- BUILDING PERMIT` ' JAN 24 2023Town of Yarmouth Building Department :'oF... , 1146 Route 28,South Yarmouth,MA 02664-4492 :``f _ 4N\ 't 508-398-2231 ext. 1261 Fax 508-398-0836 I BUIL_DING DEPARTMENT Massachusetts State Building Code,780 CMR &e By _ Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: (33U)— o 14b Date Applied: \\ram I'N(5 V--).- Building Official(Print Name) Sign re Date SECTION 1:SITE INFORMATION • L1 Property Address: 1.2 Assessors Map&Parcel Numbers 73 Hazelmoor Rd South Yarmouth, MA 02664 78 249 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-40 No change 16117 120 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) no change to setbacks Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (Ivi.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public E l Private❑ —Zone: Outside Flood Zone? Municipal 0 On site disposal system El Check if yesEif SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: James E Benoit Marlborough, MA 01752 Name(Print) City,State,ZIP 14 Long Dr 603-315-3620 james.f.benoit@fmr.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 1 Existing Building hi Owner-Occupied [3/ i Repairs(s) 0 Alteration(s) Cf Addition 0 Demolition 0 I Accessory Bldg. 0 Number of Units 1 Other 0 Specify; Brief Description of Proposed Work2: Remove existing bathroom cabinet, vanity, toilet, and 3 pc tub& shower unit. Install new subfloor, tub, control valve, go board, tile walls, finish flooring, vanity, cabinet, cabinet and toilet as well as any other fixtures. Insulate as needed. SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) • 1.Building $ 1. Building Permit Fee:$ \5 U .Indicate how fee is determined: 2.Electrical $ lEkStandard City/Town Application Fee 0 Total Project Cost Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ C 13 3S 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount . �< ,\ 6.Total Project Cost: $ 7,143 0 Paid in Full l i Outstanding Balance Due: \\ ' 7. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cs-058987 2/4/24 Stephen E. Bobola, Sr. License Number Expiration Date Name of CSL Holder 259 Great Western Rd Suite B List CSL Type(see below) U No.and Street Type Description U I Unrestricted(Buildings up to 35,000 cu.ft.) South Dennis MA 02660 R Restricted 1&2 Family Dwelling City/Town,State,ZIP NI Masonry RC I Roofing Covering • WS Window and Siding SF Solid Fuel Burning Appliances 508-694-5618 steve@sanddollarcustoms.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 193567 10/29/24 Sand Dollar Customs LLC HIC Registration Number Expiration Date HIC Company Name or HIC Re istrant Name 259 Great Western Rd Suite B office@sandddollarcustoms.com No.and Street Email address South Dennis, MA 02660 508-694-5618 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 Eir No ❑ 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 Sand Dollar Customs to act on my behalf,in all matters relative to work authorized by this building permit application. James E Benoit (see attached authorization) 1/13/23 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 peijuty that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Walter R. Warren, Jr. 1/13/23 Print Owner's or Authorized Agent's Name(Electronic 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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" The Commonwealth of Massachusetts Department of Industrial Accidents _;+ ►—_ Office of Investigations w= ; Lafayette City Center 2Avenue 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): LEI 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. ❑■ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P h 9. ❑ Building addition [No workers' comp. insurance 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.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My 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. #:WCC50050197212021 A Expiration Date: 12/4/23 Job Site Address: 73 Hazelmoor Rd City/State/Zip:South Yarmouth, 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 wider the pains and penalties of perjury that the information provided above is true and correct. Signature: j.(/alez /r; (.2.2Z424.4.- Date: 1/13/23 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): 10Board of Health 20 Building Department 3.DCity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: Sand Dollar Customs LLC 259 Great Western Rd. Unit B South Dennis MA 02660 508-694-5618 ') Sanddollarcustoms.com General Contractor and Owner Agreement Authorization To Proceed I hereby authorize Sand Dollar Customs LLC to proceed with construction at r '3 k A-7__ La'Yno() `i 4 i 'J ARdvt 414. in accordance with signed estimate # ( 3 , dated )o / 2$7 2 2 • Homeowner agrees to make payments to Sand Dollar Customs LLC in accordance with the payment schedule listed on the signed and agreed upon estimate. K/e 45/2-2- Homeowner Date li) Wad 4-, 11/15/22 Sand Dollar Customs Representat' a Date AccPREP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/06/2023 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: The Hilb Group New England,LLC PHONE (800)640-1620 FAX IA/C,No,Extl: (A/C,No): dba Dowling&O'Neil E-MAIL treeves@hilbgroup.com ADDRESS: 973 lyannough Road INSURER(S)AFFORDING COVERAGE NAIC# Hyannis MA 02601 INSURER A: Main Street America Assurance Co 29939 INSURED INSURER B: NGM Insurance Company 14788 Sand Dollar Customs,LLC INSURER C: Associated Employers Insurance Co 11104 259 Great Western Rd.Unit B INSURER D: INSURER E: South Dennis MA 02660 INSURER F: 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 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD, (MMIDD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,00Q,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPP9284Q 12/15/2022 12/15/2023 PERSONAL&ADVINJURY $ 1'000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PRO X LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B - OWNED X SCHEDULED M1P9336Q 12/15/2022 12/15/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS _ HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS LIABILITY STATUTE ER YIN 500 000 C OFFICER/MEMBER EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A WCC50050197212022A 12/04/2022 12/04/2023 E.L.EACH ACCIDENT $ , (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: Rob Warren and Steve Bobola,Members 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 the coverage 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts • i Division of Occupational Licensure lilf Board of Building Re ulations and Standards I TLt :„., Constctivedh siti),rvisor 46..;.- il-'!":. .k. .... 4.. - - . _ r•O., CS-058987 1 ,,,..;- 44.47 _ 151‘pires: 02/04/2024 dr, STEPHEN E 00BOLA, -4i , .. .._.. .:..... . 24 ST FRANCAS CAR i 1 r i HYANNIS WI 4A---":fi 2601 . : . , . ICLVtla j .. Commissioner argie(2 K Filo/nut/I& . . ,:. . ,..- . ........ .... THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Pi Y Type: LLC v r,,,— ...ii `egistration: 193567 SAND DOLLAR CUSTOMS LLC M,i Expiration: 10/29/2024 1851 FALMOUTH RD. 1 ...... " ' CENTERVILLE, MA 02632 G R i 1 M Sv @ Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 193567 10/29/2024 Boston,MA 02118 SAND DOLLAR CUSTOMS LLC - WALTER R.WARREN JR ' 259 GREAT WESTERN RD. UNIT B> ` ''-!' SOUTH DENNIS. MA 02660 v Undersecretary Not valid without signature §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-223*1 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 73 Hazelmoor Rd South Yarmouth, MA 02664 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. 0.1 (,{J�,�iuj , 1/13/23 G Signature of Application Date Permit No. • 36.00' 8.00' lel 1000~t1 . ' _.T Bedroom Bedroom ; Bedroom ! c1 cl I �' ,eA61 S-1 YI j n--- / iippr - _ Bat �J Sun Room L 4-- ,s-ea_ i , r-E \c\i - Porch — Living Room 10.00' ; ' kitchen t' 2�LWLot�r 8.00' i--_,,,,,, 36.00' l J. i :L T' -3- a.3 a L_ L.� YJ 1� A f Y