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HomeMy WebLinkAboutBLD-23-000616 RECEIVED ONE & TWO FAMILY ONLY- BUILDING PERMIT AU6 05 2021 Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 ,1411v, 508-398-2231 ext. 1261 Fax 508-398-0836 -. By: BUILDING DEPARTiT Massachusetts State Building Code,780 CMR Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 13 -? t{)b(pt fa Date Applied- 8/3/22 Building Official(Print Name) • ignature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 72 Route 6A Yarmouth Port MA 02675 121 33 1.1 a Is this an accepted street?yes y no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-40 119,354 4 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 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private Zone: _ Outside Flood Zone? Check if yes Municipal 0 On site disposal system SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Deborah L. Ream Yarmouth Port MA 02675 Name(Print) City,State,ZIP 72 Route 6A 508-221-5486 dlream©yahoo.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building®` Owner-Occupied CY I Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 I Accessory Bldg. 0 Number of Units Other ' Specify: interior work Brief Description of Proposed Work2: Master bathroom update/remodel with no change of configuration. SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ 1. Building Permit Fee:$15.0 Indicate how fee is determined: 2.Electrical $ b Standard City/Town Application Fee ❑Total Project Cost3(Items)x multi lier . x 3.Plumbing $ 2. Other Fees: $ 3S — G a L l 4.Mechanical (HVAC) $ List: b 5.Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $ Check No. Check Amount: Cash unt: , 4477.32 ❑Paid in Full II Outstanding Balance Du : { ' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-091653 9/30/22 Walter R. Warren Jr. 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 I Restricted 1(k2 Family Dwelling M Masonry • RC I Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 508-694-5618 office@sanddollarcustoms.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Sand Dollar Customs LLC 193567 10/29l22 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 259 Great Western Rd. Unit B office@sanddollarcustoms.com No.and Street @ South 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 0 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 LLC to act on my behalf,in all matters relative to work authorized by this building permit application. Deborah L. Ream (see attached authorization) 8/3/22 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 per jury 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. 8/3/22 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 nor 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.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" §TOWN OF YARMOUTH 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 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 72 Route 6A 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. a9 ,,, ,e 0)&44 44., 8/3/22 Pp g Si nature of Application I Date Permit No. LyP rG?�ilC!l�lh/1Cl�>''ll � i2�. 11GI f' Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type Corporation SAND DOLLAR CUSTOMS LLC Registration; 193567 259 GREAT WESTERN RD.UNIT B Expiration_ 10i29l2022 SOUTH DENNIS,MA 02660 xw405.7 Update Address and Return Card. Orrice of Grommet Affair S 6W ln.ee Re9uIN1on HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Corporation before the expiration date. If found return to: Regiatradog Exsltrafnn Office of Consumer Affairs and Business Regulation 193567 t0'29,2022 1000 Washington Street-Suite 710 SAND DOLLAR CUSTOMS LLC Boston,MA 02110 WALTER R.WARREN 259 GREAT WESTERN RD.UNIT 6 sswfc%f ',nr SOUTH DENNIS,MA o2660 Underset efary Not valid without signature Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConskrOtt}visor CS-091653 ices:09/3012022 WALTER R WAR-,;;, 40 ALEXANDER r441111111: YARMOUTH PORT s *,11. 3` 4444 It, ii Commissioner dr /. /;. 't 1L , _ The Commonwealth of Massachusetts 1 = - L Department of Industrial Accidents _s�► 1 Congress Street, Suite 100 *' � e�= Boston,MA 02114-2017 4.�. www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sand Dollar Customs LLC Address: 259 Great Western Rd 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. 1 am a employer with 9 employees(full and/or part-time).* 7. D New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on mYP property, I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.0 Roof repairs 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.VOther Window&Door Replacement 152,§1(4),and we have no 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. tContractors 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 Co. Policy#or Self-ins.Lic.#: WCC-500-5019721-2021A Expiration Date: 12/15/2022 Job Site Address: 73 Route 6A City/State/Zip: Yarmouth Port MA 02675 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.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: (t'2,, /e (,/,), / 24, Date: 8/3/22 Phone#: 508-894-5618 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4111 Sand Dollar Customs LLC 259 Great Western Rd. Unit B South Dennis MA 02660 508-694-5618 ''SiO � Sanddollarcustoms.com General Contractor and Owner Agreement Authorization To Proceed I hereby authorize Sand Dollar Customs LLC to proceed with construction at 72 Main Street, Yarmouthport in accordance with signed estimate # 1187 , dated 05 / 12 /2022 . Homeowner agrees to make payments to Sand Dollar Customs LLC in accordance with the payment schedule listed on the signed and agreed upon estimate. 05/15/2022 /94-a 1 4' P\12 Homeowner Date Sand Dollar Customs Representative Date ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 (A/C.No,Eat): (A/C,No): 973 lyannough Road E-MAIL ADDRESS: treeves@doins.com 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 'c- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) 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 12/15/2021 12/15/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN-'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X 0000POLICY ri JECT LOC PRODUCTS-COMP/OPAGG $ 2,0 , OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED M1P9336Q 12/15/2021 12/15/2022 BODILY INJURY Per accident $ AUTOS ONLY X AUTOS ( ) X HIRED X NAUTONOS ONL-OWNED PROPERTY DAMAGE AUTOS ONLY _ Y (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY Y/N X STATUTE EERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 B OFFICER/MEMBER EXCLUDED? n N/A WCC50050197212021A 12/04/2021 12/04/2022 (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/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 , R ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD -,L, •-•3 ---. —f- c_r\ Z.. eop --, q-',- --... ) _.) .. ..• —1-- c—,.. '.. .....( .' . ..t..- / D rs --- T..... CA...., / . -,,..,-, ....... 4,..r. r '' 0 *a• lil c; . ...„ ..., ... , •.„... t CNO— ------- - .• :....- ,c, z 'i I: - • . < Q, r1o.. _ (....— ( • s'2e:o. . •C t • -----r--) . . \(--- • I ....4._ D 1 -^"....,.., ," ........... 5 ... _ . .....- 1.-- •...) ti, . , ---- rt — (_)40 m ____