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HomeMy WebLinkAboutBLD-23-003873 ....-----"" ,---icut , • ,.01-.-49R BUILDING PERMIT APPLICATION 'r• APPLICATION TO CONSTRUCT, REPAIR, RENOVATE , CHANGE TH:i.S e•' ;,- (-Q. eF 7 0 OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMIL •,A,, ■. I...*. ' �: Town of-Yarmouth Building Department 1�TTa.0 A CCl �.'„•f.`Ca Tel: 11-16 Route _ail • Yarmouth. MA 0966 i—i499 JAN 22023 ! 508-398-2231 ext. 1261 Fax 508-398-003. __..._. _ _ J F;;it+;,INC; PARrPis n! Office Use Only Planning Board Information Assessors Department Informs io`tfY Permit No.aQ�-23- a e Plan Type_ Map Lot Permit Fee $ Endorsement Date 87 / 204 Recording Date New Deposit Rec'd. $ Date Plan No._ 1.4 Property Dimensions Net Due $ jother 7 acres 480 r?ia Lot Area(sf) Frontage(tt) Lot Coverage This Section for Office Use Onty Building Permit Number fjate Issued: Signature: f — Certificate of Occupancy Building O dalDate is is not /� required 'Section 1 - Site Information 1 1.1 Property Address; 1.2 Zoning Information: 528 Forest Rd South Yarmouth MA 0664 R-40 no change Zoning District Proposed Use 1.3 Building Setbacks (ft) no change to setbacks Front Yard Side Yards Rear Yard Required Provided _ Requi-ed I Provided Required I Provided 110 I 1.4 Water Supply(r.t.Q.1..,c.40.S 54) 1.5 Rood Zona information: f r a Comments l Public ✓ Private Zone: _ BFE Section 2 - Property Ownership/Authorized Agent I • 2.1 Owner of Record: Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 Name(print) Mailing Address: see signed contract attached 508-398-2231 lhayden@yarmouth.ma.us Signature Telephone Telephone Email Address: I 2.2 Authorized Agent: Walter R. Warren, Jr. 259 Great Western Rd Unit#B S. Dennis,MA 02660 Name(print) Mailing Address: /,t1a1bit, 0.)c -, 508-694-5618 office@sandddollarcustoms.com Signature Telephone Fax Email Address . Section 3 - Construction Services • 3.1 Licensed Construction Supervisor: Not Applicable Stephen E. Bobola, Sr. 259 Great Western Rd Unit#B S. Dennis, MA 02660 License Number Address cs-058987 3 �1B6B6i 5z- • 508-694-5618 steve@sanddollarcustoms.com Expiration Date Sign Lure Telephone Email Address: 1 3.2 Registered Home Improvement Contractor. • Company Name Not Applicable ❑ Sand Dollar Customs LLC 259 Great Western Rd Unit#B S.Dennis.MA 02660 • Address Registration Number 1 �z¢rt L�rz. 5(18-694-5618 Expiration rt Date Date Signature Telephone 10/29/24 Section 4-Workers' Compensation Insurance Affidavit(M,G.L c. 152 S 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 ...V No Section 5 - Professional Design and Constructon Services-for Buildings and Structures Subject to Construction Control Pursuant to 780 CMR 116(containing more Than 35,000 c.f. of enclosed space) Section 5.1 Registered Architect: N-A Not Applicable Name (Registrant): Registration Number Address Expiration Date Signature Telephone Section 5.2 Registered Professional Engineer N/A Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Hama Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Section 5.3 General Contractor Sand Dollar Customs LLC Not Applicable ❑ Company Hama Stephen E. Bobola, Sr. Person Responsible for Construction 259 Great Western Rd Unit#B S. Dennis, MA 02660 Address 508-694-5618 Signature Telephone Section 6 - Description of Proposed Work(heck all applicable) • ' New Construction i] (tor multiple family only) Nc.of Bedrooms (for multiple family only) No.of Bathrooms Existing Bldg. ❑ , Repair(s) ❑ Alterations ❑ Addition ❑ Accessory Bldg. ❑ Type I Demolition Other Specify: P fY- Brief Description of Proposed Work: Remove 9 existing skylights and replace with 5 new units, deleting 4. Reframing, reinsulating, and reroofing disturbed areas. Section 7- Use Group and Construction Type] Building Use Group (Check as applicapable) Construction Type A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA D A-4 ❑ A-5 ❑ 18 ❑ B BUSINESS ❑ ❑ E EDUCATIONAL I`] ❑ F FACTORY ❑ F-1 ❑ F-2 ❑ 2C ❑ H HIGH HAZARD ❑ 3A ❑ I INSTITUTIONAL ❑ 1-1 ❑ I-2 ❑ 1.3 ❑ 38 ❑ M MERCHANTILE ❑ 4 ❑ R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R 3 ❑ sA ❑ S STORAGE ❑ S-1 Q S-2 SB D U UTILITY 1 ❑ SPECIFY M MIXED USE ❑ SPECIFY S SPECIAL USE ❑ SPECIFY • Complete this section if existing building undergoing renovations,additions and/or change iri use.1 Existing Use Group: Proposed Use Group: no change Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34 Section 8 Building Height and Area Building Area Existing(f applicable) Proposed Number of floors or stories include basement levels 1 1 Floor Area per Floor(sf) 12,176 no change Total Area All Floors (sf) 12,176 no change Total Height (ft) Section 9 - STRUCTURAL PEER REVIEW (730CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Town of Yarmouth Authorized Agent as Owner of the subject property, hereby authorize SAND DOLLAR CUSTOMS LLC to act on my behalf, in all matters relative to work authorized by this building permit application. see attached signed contract 1/16/23 Signature of Owner Data • SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION Walter R. Warren, Jr. , as Owner/Authorized Agent hereby declare that the statements and information on the forgoing application are true and acurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Walter R. Warren, Jr. • Print Name u/ - «�, �- 01/16/23 Signature of Owner/Agent Date Section 11 - ESTIMATED CONSTRUCTION COSTS Item ' I Estimated Cost(Dollars)to be completed by permit applicant 1.Building 2.Electrical 3.Plumbing/Gas 4.Mechanical(HVAC) 5.Fire Protection 5.Total=(1+2+3+4+5) 7.Total Square Ft Oar now smcnnes S ad44,0n1 31,300.00 Check Below ❑ Conservation-Commission Filing (if applicable) ❑ Old Kings Highway& Historical Commission approval (if applicable) not applicable §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 528 Forest 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. (,{J (i)a- g-, 1/16/23 Pp Signature of Application ' Date g Permit No. The Commonwealth of Massachusetts Department of Industrial Accidents c;" ►- G Office of Investigations =v= 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.❑■ I am a employer with 9 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑■ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 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.] *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.#:WCC50050197212021 A Expiration Date: 12/4/24 Job Site Address: 528 Forest 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: l f}a,e A / 6t"a ti Date: 01/13/22 - 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): 10Board of Health 2❑Building Department 30City/Town Clerk 4.0 Electrical Inspector 5LPlumbing Inspector 6.0Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration It^' r 4 w Type: Supplement Card SAND DOLLAR CUSTOMS LLC ro 42 �z,� Registration: 193567 r, ��:_ .�.r...I.' Expiration: 10/29/2024 1851 FALMOUTH RD. CENTERVILLE. MA 02632 =' 43 it y� Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HO..IVIIL ratio„cloth. If found return IMPROVEMENT LIVILIV I CONTRACTOR RAI,T VR �I"'' ' TYPE:Supplement Card Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 193567 #,10/29/2024 Boston,MA 02118 SAND DOLLAR CUSTOMS LLO I ? k STEVEN G.BOBOLA ) • 259 GREAT WESTERN RD.UNIT B i;r4,,,,K1.?. ,G/,-(' SOUTH DENNIS, MA 02660 Undersecretary Not valid without signature It., Commonwealth of Massachusetts Division of Occupational Licensure Board of Building fie ulations and Standards Cons ton rvisor ?� r�Y CS-058987 Spires : 02/04/2024 STEPHEN E 90BOLA i 5.1 24 ST FRANC1S CIR ' e HYANNIS MKfi2601 -. } ..*?' 11 * : Commissioner dad& K covitA., , A DATE(MMIDD/YYVV) CERTIFICATE OF LIABILITY INSURANCE 12/30/2022 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 (A/C,No,Ext): (A/C,No): dba Dowling&O'Neil ADDRIESS: treeves@hilbgroup.com 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 iADDL�'SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MMIDD/YYYY) (MM/DDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADEDAMAGE TO RENTED 500,000 X OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) S 10,000 A MPP9284Q 12/15/2022 12/15/2023 PERSONAL&ADV INJURY $ 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 TNT _ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED >/ SCHEDULED M1P9336Q 12/15/2022 12/15/2023 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS XHIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) - UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION $ $ WORKERS COMPENSATION X ;MUTE EMPLOYERS'LIABILITY STATUTE ER YIN 500,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A WCC50050197212022A 12/04/2022 12/04/2023 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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/LOCATIONS I 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 Job:Yarmouth Senior Center,528 Forest Road,South Yarmouth,MA 02664 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 Town of Yarmouth,Department of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 74 Town Brook Road AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Rev.11/10 Form ST-5C Massacltus.tts pl P ` ` Contractor's Sales Tax Exempt Department of Purchase Certificate Revenue Part A. To be completed by governmental body, agency or IRC Section 501(c)(3) certified exempt organization Exempt number Contract number E 046 — 001 — 377 #981 Name of exempt organization Town of Yarmouth Authonnng agnatl7re --� iihDste I r !1�t i / 12/21/22 Part B. To be completed b purchasing contractor or subco tractor claiming exemption under MGL.Ch. 64H, sec. 6(d), (e), (f) or(tt) t afArz r c V s cv Purcmaser(®contractor C.subcontractors 259 Great Western Rd. Unit B South Dennis MA 02660 Address 12/21/22 Date Vendor registration number;rr applicable) Contract/s9poortract number Contracttsubcontract date Estimated date of completion Part C. To be completed by purchasing contractor or subcontractor claiming exemption. See instructions. I claim the exemption corresponding to the box checked below,and certify as follows(check appropriate box below) 1. V Exemption under MGL Ch. 64H, sec. 6(d)or(e): Contractor as Agent of Exempt Entity. I certify that the purchaser is a contractor or subcontractor engaged in the performance of the above described contract and that the purchaser is acting as an agent of one the entities described below(check appropriate box) in purchasing tangible personal property(other than building materials and supplies de- scribed in MGL Ch.64H. sec. 6(f)). itti Governmental body or agency described in MGL Ch.64H,sec. 6(d)(local public school,city/town government,state agency,etc) Attach Form ST-2,Certificate of Exemption. If Form ST-2 is not available, enter agency's exemption number. Tax exempt organization (under IRC Section 501(c)(3)) as described in MGL Ch. 64H, sec. 6(e) (parochial school, Scout troop. PTO,etc.).Attach Form ST-2,Certificate of Exemption. To the best of my knowledge and belief, the quantities of tangible personal properly noted on the reverse side are exempt from the sales/use tax under the provisions of MGL Ch.64 H,sec.6(d)or(e)as they are purchased by a purchaser acting as an agent for either a Massachusetts governmental body or for a tax-exempt organization under IRC section 501(c)(3). 2. V Exemption under MGL Ch. 64H, sec. 6(1): Building Materials and Supplies. I certify that the purchaser is a contractor or subcon- tractor engaged in the performance of a contract for the construction, reconstruction, alteration, remodeling or repair of a building or structure for a govemmental body or agency or for a certified IRC Section 501(c)(3)exempt organization or other protect described in MGL Ch. 64H, sec 6(f). To the best of my knowledge and belief, the described quantities of building materials and supplies noted on the reverse side are exempt from sales/use tax under the provisions of MGL Ch. 64H, sec. 6(f), and the described quantities of these materials and supplies are being purchased for use exclusively in the above contract. 3. L._'Exemption under MGL Ch. 64H, sec. 6(tt):Consulting/Operating Contractor as Agent of Governmental Entity. I certify that the pur- chaser is a consulting or operating contractor or subcontractor as defined in MGL Ch.64H,sec.6(tt)and that the purchaser is authorized and acting as an agent of, and providing"qualified services,"as defined in MGL Ch. 64H, sec. 6(tt),to a governmental body or agency described in MGL Ch.64H, sec.6(d).Attach Form ST-2. If Form ST-2 is not available,enter agency's exemption number.To the best of my knowledge and belief,the quantities of tangible personal property noted on the reverse side are exempt from the sales/use tax under the provisions of MGL Ch 64 H. sec.6(tt).The purchaser has been authorized under the above contract by a govemmental body. Regardless of the exemption claimed,I will maintain adequate records to show the disposition of all property purchased under this certifi- cate. I understand that I am fully liable for the payment of any sales/use tax due in the event that the property purchased under this cer- tificate is used in a non-exempt manner. Signed under the penalties of perjury. Walter R. Warren, Jr. , Owner Sand Dollar Customs LLC Signature ,� l/ Title WQ fit- , (.1 apt.¢ t- 12/21/22 revised 12/27/22 Location and description of project and de ription of kind aid quantity of property or receipts/invoices must be attached or noted on the back of this form.This form Is approved by the Commissioner of Revenue and may be reproduced. Part D. Location and description of project Remove 9 old inefficient skylights and delete 4 to be replaced by 5 new units with flashing kits. Roof, framing and insulation to be installed as needed. Part E. Description of kind and quantity of property purchased Date Description Quantity Cost 12/21/22 Velux a21 Special Fixed Curb Mount Skylight 5 $5123.95 12/21/22 LP Curb Flashing Kit w/ Unerlayment for Velux Skylights 5 $1005.00 12/27/22 Roofing Shingles(unknown square)of Patch Material to match existing $ 12/27/22 Tongue&Groove(unknown linear footage)boards to match existing ceiling $ $ $ $ $ $ $ $ $ $ Total cost $6128.95 Additional information about the use of this form may be obtained by calling the Customer Service Bureau at(617)887-MDOR or toll-free,in Massachusetts, 1-800-392-6089. ®ported on recycled paper