Loading...
HomeMy WebLinkAboutBLDR-23-10011 RECEIVED ONE & TWO FAMILY ONLY- BUILDING PERMIT _ Town of Yarmouth Building Department MAY (1 ��� ,. 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext, 1261 Fax 508-398-0836 �':Al Massachusetts State Building Code,780 CMR BU I ''' r ` r '` Building Permit Application To Construct, Repair, Renovate Oisli r.k a One-or Two-Family Dwelling 13c-bg-23—(p0I I This Section For Official Use Only Building Permit Number: Ij tb 73--DL& ) Date Applied: r Sees ------_ r— /C-0 3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property ddre • 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Z nine Information: 1.4 Property Dime s: ,,------- V="40 MI6/AM 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 P.equirec3 provided 1.6 Water Supply: ( . .L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: Outside Flood one?T Municipal❑ On site disposal system e Check if ye SECTION 2: PROPERTY WNERSBIP1 2 nert of Reco rd: � , ,e„ ��\l 1 s VAA 02c61 Name(Print) City, tate,ZIP , % *9 ir\A Pa .uo a— 3,)- 35m-C;nn e n l . ( No.and Street elephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) / New Construction 0 Existing Building 131- Owner-Occupied q/Repairs(s) 0 Alteration(s) (L Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: �� Y-rw✓Y12, ry or1 P SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: 1 r--o Official Use Only (Labor and Materials) 1. Building Permit Fee:$ Indicate how feei's titt is d:g 1 V E 1.Building $ --- ix Standard City/Town Application Fee F • 2.Electrical $ 0 Total Project Cost3 t m 6)x multiplier x ja Y 1 6 2023 3.Plumbing $ 2. Other Fees: $ % , 4.Mechanical (EVAC) $ List BUILDING D t P T E N T By 5.Mechanical (Fire $ t, Suppression) Total All Fees:$ Check No. Check Amount: Cash t: 6.Total Project Cost: $ J O. 0.217 0 Paid in Full MI Outstanding Balance D : 1 � , 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Constr ction Su ervissor r License(CSL) /► S-c5 ' �JGL\ �'� W A,YY7 _ License Number Expiration Dat Name of CSL Holder c:Rn i /_ 1/1 , -Ve m 0/ l List CSL Type(see below) U No,and Street /� T e Description ‘500`✓ �.Df 1 n is NIA k D(p(j C ) O. Unrestricted(Buildings up to 35,000 cu.ft.) _ Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering • ] ' WS Window and Siding (5c!& (St (,}i j_5Ld rA 'C SF Solid Fuel Burning Appliances l�t`( �✓� I Insulation elee Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC)Con l ��- far-- L te) I J�—3—. I� HIC i Registration Number Ex ratio Date HIC Corn any Name or HIC Registrant Name L/ �J,��� ]� M r No. Oa I L(.£S,-1�fr (I . VA,1-6. 0\A i ctde �� cue l� s e call 5i rI) Oil 14 G (P 0 M-(,qi-i 1 V Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE A!+'r'IDAVIT(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 'C No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WREN 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. Ste_ A 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. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 IIIC Program can be found at www.mass.sovioca Information on the Construction Supervisor License can be found at www.mass.zov/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 9 ! ►_ ',_ Office of Investigations =v�,l_ Lafayette City Center innontmaw 2Avenue de Lafayette, Boston,MA 02111-1750 ti,„ r.5,` 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 Road, Unit 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. El New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7emodeling 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. El 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.❑ 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. #:WCC50050197212022A Expiration Date: 12/04/2023 v(11-1-� tgil Job Site Address: 3� ad616 I c-A . t , yea- City/State/Zi 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: Date: 4/c2�`a. 3 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 31:City/Town Clerk 4.0 Electrical Inspector 51klumbing Inspector 6.0Other Contact Person: Phone#: §TOWN OF YAR.MOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext.•.•1.261 Fox 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 30 0 ialuc.tt 1 Ls Can 4 62-d on di- /S/9 yct rro Work Address Is to be disposed of oat the following location: (Ara) Di6 f6 SaA Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. L/A-V(223 Signature of p c tion Date Permit No. • AC ORE,® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) \rr..►'� 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,LLCI PHONNryE (800)640-1620 FAX dba Dowling&O'Neil E-MAIL ADDRESS: )treeves hilbg p'rou com (A/C,No): 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 - MED EXP(Any one person) $ 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 n JEC IT LOC PRODUCTS•COMP/OP AGG $ 2,000,000 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 BODILYINJURY(Per $ AUTOS ONLY /� AUTOSaccident) X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE N/A WCC50050197212022A 12/04/2022 12/04/2023 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ` I 0,000 (Mandatory In NH) 50 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/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 Division of Occupational Licensure ./ Board of Building Regulations and Standards Constt n rvisor 4 CS-091653 ` E'14pires: 09/30/2024 WALTER R*AR . 259 GREAT WES ;21, NIT UNIT B SOUTH DENN* MA ��l,lE•3:1�� Commissioner c. 9creG • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer AffI Business Regulation 1000 Washing rti Suite 710 Bosto - 1 118 Home !mp�ro 1;1RR =-a istration 11") F J i 9 i a {-" =.... 4 „,,Type: LLC SAND DOLLAR CUSTOMS LLC ^ e ' ation: 193567 _ -- E 6i ation: 10/29/2024 1851 FALMOUTH RD. 7 CENTERVILLE,MA 02632 .. Ao r E. / ij r v Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaftls&Business Regulation Registration valid for individual use only before the HOME IMPROVE f ONTRACTOR expiration date. If found return to: Office of Consumer Affairs and Business Regulation ,1 1000 Washington Street -Suite 710 b. t Boston,MA 02118 SAND DOLLAR CUST a c- 4= r� WALTER R.WARREN 41k` £ ' 259 GREAT WESTERN a.,��,4- SOUTH DENNIS,MA 0268R , �` Undersecretary Not valid without signature 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 00 Est),A r 51ay-, 0 0-- i'/} in accordance with signed estimate # ! Zi7 C) , dated / / / Z 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. IV/ /23 Homeowner Date Sand Dollar Customs Representative Date YARMOUTH WATER DIVISION 99 BUCK ISLAND ROAD WEST YARMOUTH,MA 02673 PH.:508.771.7921 FAX:508-771-7998 BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET Bldg.Site Location 3 6vc t_%stQ d Q 1.Ur1 r map#: t-1 Lot#: 94- Lvh.L-t corm Proposed Improvement: ej - _Nr Zi d a 4 ( 'kJ 000 2) Applicant: Sand.Tao 14.E CUS4i5r11S Address ZSq 6rca.A-(ili.itern EA Tel.#: 5b' (o941-57.1t Date Filed: 4-03/o23 vrrm 4-6. 5•acnru 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 and Town Regulations,i.e.,Requirements for Septage Disposal and other Public Health Activities Fire Department: Determines Compliance to State and Town Requirements for Personal, Safety,Property Protection;,I.e.Smoke Detectors,Sprinkler Systems,Etc... �! a)/a Signature of applicant Date PLEASE NOTE: COMMENTS: S2,1�Z3 ReviewWater Division Date