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HomeMy WebLinkAboutBLD-23-000501 pad// /za E &TWO FAMILY ONLY- BUILDING PERMIT JUL 29 Za Town of Yarmouth Building Department .r --� 1146 Route 28,South Yarmouth,MA 02664-4492 BUILDING DEPARTMENT 508-398-2231 ext. 1261 Fax 508-398-0836 By. { Massachusetts State Building Code,780 CMR o e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: g(.,15 2.3 S D i Date Applied: 7/26/22 Jlh•N CRTti " -- 7S-4` ,3, Building Official(Print Name) • Si ature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 21 Little Dipper Ln South Yarmouth 25 355 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-25 697() 100 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 G.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private© Zone:AE Outside Flood Zone? Municipal❑ On site disposal system `ii Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Barbara LeClair Life Est. Stephen LeClair Life Est. Plymouth, MA 02360 Name(Print) City,State,ZIP 77 Champlain Cir 508-932-2745 slec5@comcast.net No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 I Existing Building 11 Owner-Occupied 0 I Repairs(s) titT Alteration(s) 0 I Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Gut existing bathroom down to 2x4 walls, upgrade plumbing and electrical to code, insulate all walls. frame and finish new curb shower. SECTION 4:ESTIMATED CONSTRUCTION COSTS. Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ 1. Building Permit Fee:$150 Indicate how fee is determined; 2.ElectxicaI $ Ea Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash aunt: 6.Total Project Cost: $ 17,765 El Paid in Full ill Outstanding Balance ue: � (,\431- 2 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-091653 09/30/22 Walter R.Warren Jr. License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 259 Great Western Rd.Unit B No.and Street Type Description South Dennis,MA,02660 U j Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZIP R Restricted 1&2 Family Dwelling Ivl Ivlasonry RC j Roofing Covering • WS Window and Siding SF Solid Fuel Burning Appliances 508-694-5618 office@sanddollarcustoms.com I Insulation Telephone Email address D J Demolition 5.2 Registered Home Improvement Contractor CHIC) Sand Dollar Customs LLC 193567 10/29/22 HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date 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 Qf 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 see authorization attached to act on my behalf,in all matters relative to work authorized by this building permit application. Stephen LeClair 7126/22 Print Owner's Name(Electronic Signature) Date • SECTION 7b: OWNER1 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. Walter R.Warren Jr. 7/26/22 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 BIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/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 508-398-223t1 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 21 Little Dipper Ln South Yarmouth 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. u)a-e5A. 02a ee., July 26,2 022 pP Signature of Application& Date g Permit No. Sears, Tim From: Sears, Tim Sent: Thursday, August 4, Z02211:SSAK4 To: SanddnUar[ustoms Subject: 21 Little Dipper I have reviewed your application for bath renovations, and we are going to need a floor plan of the work area. Thank you Tirnntby Sears CBO Deputy Building Commissioner Town ofYarmouth 508'398-2231 Ext. 1259 mai|to:tseao@varmouth.ma.us l 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 I LI- /2 ' f p , r in accordance with signed estimate # 17 2 , dated _ / �/ (Sz Z Homeowner agrees to make payments to Sand Dollar Customs LLC in accordance with the payment schedule listed on the signed and agreed upon estimate. 2)24 ) 2_62? Homeowner Date 7ia(e/a2, Sand Dollar stoms Repres ve Date 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 Re 10 259 GREAT WESTERN RD.UNIT B Expiration.piExpiration.tlon: 10129/29lZ1122 SOUTH DENNIS,MA 02660 Update Address and Return Card. SCA 1 A 201.145,17 .Yf iarrr.FN rrvri�/f eV..7 i,+,ar rr,,1. Ounce of COrli10,116t Affairs 8.Bushes Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Carauralon before the expiration date. If found return to: aft0ISIES88131 EXpkdtloa Office of Consumer Affairs and Business Regulation 193667 106'2912022 1000 Washington Street-Suite 71D SAND DOLLAR CUSTOMS LLC Boston,MA 02118 WAITER R.WARREN 259 GREAT WESTERN RD.UNIT B SOUTH DENNIS.,MA 02660 UndersecretaryNot valid without signature Commonwealth of Massachusetts tif Division of Professional Licensure Board of Building Regulations and Standards Cortst i ka1'ip nrisor CS-091653 ires:09/30/2022 WAITER R WARREN J• 1 40 ALEXANDER DR YARMOUTH P9RT MA 02675 :+ �� Commissioner r, . . K. 't 641 AI- AC�® DATE(MM/DD/YYYY) ��. CERTIFICATE OF LIABILITY INSURANCE 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,Ext): (A/C,No): 973 lyannough Road E-MAIL treeves@doins.com ADDRESS: 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE /� OCCUR DAMAGE TO RENTED 500,000 PREMISES(Ea occurrence) $ 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 POLICY JECT PRO X LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED M1P9336Q 12/15/2021 12/15/2022 BODILYINJURY(Peraccident) $ _ AUTOS ONLY _ AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTION$ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B Y N ANY PROPRIETOR/PARTNER/EXECUTIVE I. N/A WCC50050197212021A 12/04/2021 12/04/2022 E.L.EACH ACCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 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 s 7 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD `\ The Commonwealth of Massachusetts _w= 1= /,1. r Department of Industrial Accidents s5/rantrsl 1 Congress Street,Suite 100 • - 1= Boston,MA 02114-2017 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. Ei New construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. D Remodeling any capacity.[No workers'comp.insurance required.) 9. D Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 1.0 Electrical repairs or additions proprietors with no employees. 12.D Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0ROOf repairs These sub-contractors have employees and have workers'comp.insurance.' 14.VOther Window&Door Replacement 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 4[J 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: 21 Little Dipper Ln City/State/Zip: South Yarmouth MA 02664 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: (1Oa , , a)a ay, 22, Date: 07/26/22 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(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • '..,4 w 01 , Z. '''-'"',-,'" / . 0 1. I m ,( J -I, f ,ti a