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Home My WebLink AboutBLDR-23-10012 (2) pato15/Z5 RECE. 11ED ONE & TWO FAMILY ONLY- BUILDING ERMIT Town of Yarmouth Building Department MAY 0 3 20 ./- 1146 Route 28,South Yarmouth,MA 02664-44,92 ,� 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPAf� ' l..• '� Massachusetts State Building Code,780 CME By ----- Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-FamilyDwelling I?,t�Q-2 3- 1DD1 -, . This Section,¢_ For Official Use Only Building Permit Number: L�0(.U/ ate Applied: i --7/A 3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1_prfper A m j��_ Qn 1.2 tyi e;sors Map&Parcel Num ier2/ l aitIod/)(D4 I l(�n 1.1 a Is this an accepted street?yes no Map Nu ber Parcel Nu ber 1.3 Zoformation: 1.4 Property ' lions: Zoning District Proposed Use Lot Arealsq ft) Frontaga ) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required - Provided Required Provid Required Provided 1.6 Water Supply: (ivf.G.L c.40,§54) 1. Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public _Private 0 Check if yell J Municipal 0 On site disposal system ?h SECTION 2: PROPERTY OWNERSFIIP' 2 wner'of R_eco : _ Nf" Y 1 ) r�� n� C. i to Z\ ._i I l�1 — NV't Ci 7�- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 I Repairs(s) j Alteration(s) 0 I Addition Cl Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: ijV 4-�r Cl(� �uvz�J �. 1.3C tyl,Sl.tt&A tI ` SECTION 4: ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) ��.� 1.Building $ 1. Building Permit Fee:S Indicate how fee is determined: 2.Electrical $ tr Standard City/Town Application Fee 0 Total Project Costl.(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ . \� 4.Mechanical (HVAC) $ List: (1 ��V� 5.Mechanical (Fire $ J Suppression) Total All Fees:$ Check No. Check Amount: Cash ounce �� ' 6.Total Project Cost: $ f,Ii�DO 0 Paid in Full 12 Outstanding Balance ue:1\'- n �� U` rvi • ecuc (•, YAM }. • • • • • • • SECTION 5: CONSTRUCTION SERVICES 5.rr1�� Construction Supervisor License(CSL) C c _ D�I to V`Ji1, � GL� � _ �il rlr�-� ,� I`p J License Number Expir tion ate Name of CSL Holder CCI / , - eS4—aY) Q(Ai j �j List CSL Type(see below) No,and Street( I` T�_ Description , t4 41 'L/wj. .e) { U_) Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP Restricted 1&2 Family Dwelling Ivl Masonry RC I Roofing Covering • WS Window and Siding (c1i' /� �SF" Solid Fuel Burning Appliances ) L9 -s61g o Ic M&f) I ;�ll.1K3) insulation Telephone Email address Cai/r' D Demolition 5.2 Registered Home Improvement Contractor(HIC) a 7 ID eta a� k akaffa.r" LusTms t LC- HIC Registration Number Expiration Date HIC y vame or C ggistr t Name N� j(au-e tug 'n Lip - ► o� ccu.C� i Ct ,^_tl Mai` l;'�-1 111 S Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT 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 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 to act on my behalf,in all matters relative to work authorized by this building permit application. S Q- mac-\ec 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: 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.sov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/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 1 "Total Project Square Footage"may be substituted for"Total Project Cost" THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Jqh"st L Type: LLC Registration: 193567 SAND DOLLAR CUSTOMS LLC Expiration: 10/29/2024 1851 FALMOUTH RD. CENTERVILLE,MA 02632 =�- - C� v b1M Sve 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 fourd 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 /2 259 GREAT WESTERN RD.UNIT B SOUTH DENNIS,MA 02660 Undersecretary Not valid without signature 1® Commonwealth of Massachusetts i Division of Occupational Licensure Board of Building Regulations and Standards Constoitilkon IS rvisor CS-091653 z f;zyires: 09/30/2024 WALTER R WARREN JR 259 GREAT WESTERN RD.,UNIT EL- UNIT B SOUTH DENNIS MA 02667,5 • la,. "tier-.'Toilva . Commissioner da fi'. tiic:ha, ''r I '� I:,./ Sand Dollar Customs LLC 259 Great Western Rd. Unit B South Dennis MA 02660 508-694-5618 e TOE Sanddollarcustoms.com General Contractor and Owner Agreement Authorization To Proceed I hereby authorize Sand Dollar Customs LLC to proceed with construction at 41 J 1''C� J Po-o Cl GV Pv i �Gyt�Y�G��Gc l'Dr" in accordance with signed estimate # 2,j/3 , dated / / a 3 . Homeowner agrees to make payments to Sand Dollar Customs LLC in accordance with the payment schedule listed on the signed and agreed upon estimate. HomeownerA f4aie.oev Z 02,3 / D e Sand Dollar Customs Representative Date The Commonwealth of Massachusetts _i J Department of Industrial Accidents ç Office of Investigations s' '�' l� ^ta, . _ or Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ")14, — 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 employees (full and/or part-time).* have hired the sub-contractors 6. ['yew construction 2.El I am a sole ro rietor or artner- listed on the attached sheet. 7. Remodeling P P P ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty. 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.1: Electrical repairs or additions officers have exercised their 11.❑ Plumbing repairs or additions 3.El I am a homeowner doing all work 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. Licit. #:WCC50050197212022A Expiration Date: 12/04/2023 Job Site Address: 4 P/ /-0 W_ City/State/Zip: yO 1-- /"i.T L2& Attach a copy of the workers' compensation olicy 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 perlurl'that the information provided above is true and correct. Signature: Date: j---z- 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 3.11City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: � 1 ®AC o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDM'YY) 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 (A/C,No,Ext): (A/C,No): dba Dowling&O'Neil E-MAIL ADDRESS: 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 ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LTR INSD WVD (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 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 !ET OTHER $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY $ 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 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 Y I N STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y NIA WCC50050197212022A 12/04/2022 12/04/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 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 s ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD §TOWN OF YARMOUTH 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 P-� ) ('c v Wc� c Wo rk Address Is to be disposed of oat the following location: prmQ-u` A N i O:l`ec Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Ch. 111, §150A. Signature of ication Date Permit No. 4 Perch Pond Sears, Tim <tsears@yarmouth.ma.us> Tue 5/16/2023 9:25 AM To:Sanddollar Customs <office@sanddollarcustoms.com> I have reviewed your application and you need to submit a floor plan of the work area. Thank you This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application for a permit for any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100, within 45 days of this notice. Timothy Sears CBO Deputy Building Commissioner Town of Yarmouth 508-398-2231 Ext. 1259 mailto:tsears@yarmouth.ma.us