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, 111"/Li,'„. .{),,--,.•A::',...-::;i";.7'' t'e- ••,,-;'• "pp:".- ..-APPILIDAtieNi TO CONSTRUCT,REPAIR, CHANGETHE USE,OCCUPANCY,OF,
- it:'•,..::''.1;',7'''"•••• •''''':'''';'' ia.,.... Tk.: .. - , OR DEMOLISH ANY BUILDING OTHERTHAN NONE OR TWO FAMILY DWELLING "-r:. „. :•-":±-r ,,,
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• • 3.2 Registered Home Improvement Contractor.
Company Name Not Anatebbbe •••
D4A1 I• EPs4if& tiJ Reg/Gf�oS�
Address
75 SPSirr 97y-8c3c•. <43rs9 Expiration Os
er
Signature Telephone
Section 4•Workers'Compensation Insurance Affidavit(M.aL a 152 S 250(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of a issuance of the building permit.
Signed Affidavit Attached Yes ..Z No
Section 5•Professional Design and Construction 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
Not Applicable U
•
Name(Registrant):
RegistatlOn Number
Address
Expiration Date
Signature Telephone
Section 5.2 Registered Professional Engineer(s)1
Name Area al Responsibility
Address Regtstratbn Number
Signature Telephone- Expiator Date
Name Area of Responsibility
•
Address Registration Number
• Signature Telephone Expiration Date
Name Area of Responsibility
•
Address Registration Number
Signature
Telephone Expiation Dan
Hams Area of Responsibuiry
Address Registration Number
Signature Telephone Expiration Date
•
Section 5.3 General Contractor
`
4. cspai l t �w1 Ccz.3 C74 Not Applicable Q
C7psny\••Nam^ . spesfintvi 1 - .. t�
Pe • Res— ConstructionnO. f`JV GcJC2 e
•
111
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a Telephone
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• r'"r{CMcra .7.'♦fsl",2‘,72, Z, .T�7-TC171,nmwY'117e.",".'?*",:I,w k ,
'r.4;2'7)` .. Section 6 •‘'Description of Proposed Work(check a8 applicable) " � := . e.'1- ;.
'••••"'`-; ' '`f New-ConstrucIon: ❑. ;(kir multiple limit only) 'No,of Bedrooms';"'-I-- -(tot multiple family only) No.of BatlirpomS;•' ,,.;‘,; '
. sy'r‘' y; Existing Bfdg,,,Q'„t Repalr(s).Cr:': .TAtteratiorit Q:,. Addition,❑' '' ' ”' ,-'." . ..,'Ar.-Ti,',.."':',' :
..e.,../i,." Accessory Bldg CI ' ' • IDemolition T}Other, Specify- ":
\
.i Brief Description of Proposed Work:.' -:,;',';.-% - `'" '';i
r"•4.37'.'''.;'''''-'; -. 1&fc 9-c5 'e-nsry.1) G ..n 94,ee(i -'6-o"x2:67'D& '
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+'• '/T C!"i� 4'«..''�' *7 ft . :Sa, f ,e.. ,,�,. r "xn t•,,c', '.1.,
. Section 7'4 UseGroupand Construction Type t.' . . `
•a " ...:; ' :: 'i, • ' , :..,{:,,- Building Use Group(Check as applcapable) „`°,':,. -,t L',-,! , . c....., . :,Constitution Type . .
t- ,:j A� ASSEM9LY,' as .'A A.2` 'A.3.'❑. >`lA'.;❑:.�� .
I^ ,` i Al ❑',.,..L.- ' t. 'A-5 {] ,, j:`79,',Q ' .
` ,,. E,(EOUCATIONAL'
eF,`11'• ' ,..:'+ FFACTORY'. ' „4, ❑ _,"rr,;''„ ., P-T.❑ --,.,••-:'..,2::.. .-', F-2. - ,
0'' . , ,. , . .42C'+'- .T .. ,:>; 7''.:..' ,
-YJ„t. , _ H .HIGH)4424S13-.” ❑ . . -, .i , e . ,
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""''•II•'r' - i. ;INSTTUTiONAL ❑. : a❑... . 1•r: ,62''❑. �t -.F3' ❑; „ , .'�';❑"•:"� '"'',�;` :i ,`;,
4.J' "4:*
,f M MERCHANTILE ❑: , • ''
, ' + .4 -❑ - r- .
1.
L }` " R REsioEwnAI:, ❑ R-1 ❑ R.2 ❑ ' R 3 ❑ . M _
'+ S`STORAGE �. ' , -s-T ❑ S'2 59.. ❑
y.i AN: - >.� U-.U7/UTY.' ❑, 1C .. ,> , SPECIFY:', , , ' + . . .., . . _ \ -
><t
r M.'MIZEO USE', ❑ q SPECIFY '` s ' ' „ ' '' '
e ' n S:SPECUL USE« ❑ r' . ' '�'5ECI ' r' . :±. +. , ,. . r.,:.,4,.....,;!......,,,,::,. ;.............,... ' `
.f,, .fr , N
' '`' (Complete this section If existing building undergoing.renovations;additions and/or change In use. "'-`:',.;4)`I ,
T 1.
sF , ; Existed Use Group d '•w,'.b• ' - < ' Proposed Use Group' E.` ' ��
.-,;1,1,,,,,,__, .` , Existing Hazard Index 780 CMR3d ' r•t:;,
{ "-•• s ' 'I .Proposed Hnaid tndeiT80 CMR 34.. '
tr;
p= "' Section 8 Building Height and Area , - :i`.,. .. '.: .
I � �,- . . '� Exdslin (f a ikabie Proposed .,
p ,,r NurrmMdfbOre metwiee'• - + A; e'
":r .', include tiasemehi leveli . . r'•- ' • w ,
.7,-.1';''.::::.` i.. Flat Area Per Floor(st) .,,. . ,
, . . , : t�<���0 r fe . . - '. .
ce Total Area Afnodes(sf)''' Tt7.7cip'.`' -'\, ' . w' '
h >
. Teta:Heigh((n) 't.:r;.7', :.1/4::::.:H
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I ,1.+ • <;• ;6 Section 9 STRUCTURAL PEER REVIEW-{780CMA 110`11) ,
t " " ','i Independent Stit)chrial Engineering 6Wd .
ural Peer Review Required .- „�
i '',Yes „:. . '
, ,. , , _
,No,. .. , + J:
('" ' '
i.
(._:,i,, , is ,, r., SECTION 1o OWNER AUT{IORIZATION .,TO BE COMPLETED WHEN;'• ;',..:,..‘-c",..:,`1,..•:; ,' ; -
-} -:.1. ? OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,". , ' t ,
!''i.,;%;,`! 1.-::'0,-2.,', ... "'k"r ;.{ . .i`;:: . a,":r. . ,a'..;,- cy\„ .:1.,-,. ',asowner'ofthesubjECtpropeny `f.':'
,+.
r \, i� 4 t t ! • r J• i .▪ b r p ..
, hereby.authonie ' to act on
), �''= my,•-hale n all matters'rele'ye-to.'Work authortzed by this building permit appdcatlon.'
is;
+\ 4rM ' Y "-cl -` y/ - 4. t f y. t - , - y. .r....{ t
t, -
r + wrr PTrknt r, V'. ' 3011 jtzloy ▪ : t
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11.7 .4",r11::11.1,17.,:..771. .
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SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION I •
1, t)v ` A . 32PaPKn.n4) .asOwner/Allyl .� • •-pt
hereby declare that the statements and information on the forgoing application are true a • acurate,to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
• 0J A_ • /r 1-.J
PSC
pal-aSi Own-„„,S a - Date Date
Section 11 -ESTIMATED CONSTRUCTION COSTS
nem ' Estimated Cost(Dollars)to be
completed by permit applicant
t.oolong
l2
2 Sectriol
7.Plumbing f Gas
4.MMetartat(HVAC)
5.Fire Protection
e.Total.(1.2.744,5)
7.'fatal Soon Ft.Orme nuns Ileacs gC000
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical
Commission approval
(If applicable)
•
4ofa
The Commonwealth of Massachusetts Print Form
I
@= Department of Industrial Accidents
Office of Investigations
t VI
-..r.:04.1.=, 1 Congress Street, Suite 100
%`lam°. Boston,MA 02114-2017
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A i licant Information
Please Print Le.ibl
Name(Business/Organization/Individual): al 4t, • it . . moi,
• t/ . • !rte S' mIJC /p,
Address: / •
City/State/Zip: a, ' ?wGC_
Are you an employer?Check the a Phone#: ���
ppropriate boX, __.
1.Q I am a employer with 4. Dram a general contractor and I Type of project(required):
2.0 employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have
working for me in any capacity, employees and have workers' s' 0 Demolition
[No workers'comp, insurance comp. insurance.= 9. 1]i3uilding addition
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their
myself.[No workers'comp. right of exemption per MGL 11.0 Plumbing repairs or additions
insurance required.]t e. 152, §1(4),and we have no 12.0 Roof repairs
employees. [No workers' 13.0 Other
comp. insurance required.]
t Homeowners plicant I o submit that checksthis affidavit x NI must also
they aret
tdoing all work and then hire outside contractors must submit aa
ubmias new affidavit indicating such,
tContmctos 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 pmvide their workers'comp.pulley number.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 4 _ p C,..
Policy#or Self-ins.Lic.# j)C C-60603..tr, Expiration.. Date:_/‘ c4z._-
Job Site Address:... i i , 0 - At Ar
Attach a copy of the workers' compensation policy declaration page(showingthe policy number pi iosn date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties
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 • } r the tains d e ties o •er u that the information provided above is true and correct.
Si•nature:ff_
— Date: a
Phone#: !�
G . C85 "
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#:
. ' 1
- TOWN OF YARMOUTH
z 4. 4, TOWN
BUILDING DEPARTMENT
o -1 "_ $ 1146 Route 28,South Yarmouth,MA 02664
63 �. 508-398-2231 ext.1261 Fax 508-398-0836
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR,Chapter 1, Section 111 S,
[hereby certify that the debris resulting from the proposed work/demolition to be
conducted at Sc-ac., #3 2/o S7 nzlJAcEJ SO. Wife _
Work Address
Is to be disposed of at the following location: 5 r 5i=XGo C.
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
eAfft
Signature of Application Date
Permit No.
•
Commonwealth of Massachusetts
Division of Professional Licensure Femmenavagifel 1rKiaJJachle4e/4
Board of Building Regulations and Standards Office of Consumer Affairs&Business Regulation
Constructttn`StIpervisor HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
CS-037636 Expires; 04/22/2020 Reaistratioq Exolration
,. c q;,,120040 /41oro6/2d19
DAN A SPEAKMAN ` + DAN A SPEAKMAN•—t I�! •
15 SPEAK WAY DAN SPEAKMAN '
HARWICH MA 02645 `
r
15 SPEAK WAY, ,
trlt��`�'tt�j1 "' NO HARWICH,MA�,02645 ! •
Undersecretary
Commissioner
• WORKERS COMPENSATION A FORMATIONPLOY RS LIABILITY INSURANCE POLICY
PAE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5009565-2017A
PRIOR NO. WCC-500-5009565-2016A
ITEM
1. The Insured: Dan Speakman
DBA: Dan A Seakman Construction
Mailing address: 15 Speak Way FEIN:•'--""4938
Harwich, MA 02645-0000
Legal Entity Type: Sole Proprietor
Other workplaces not shown above:
2. The policy period is from 11/10/2017 to 11/10/2018 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance:Part Two of the policy applies to work In each state listed in Item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
All Information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated - Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 137314 •
INTER SEE CLASS CODE SCHEDU_E
Minimum Premium $550 Total Estimated Annual Premium
GOV GOV Deposit Premium
STATE CLASS State Assessments/Surcharges
MA 5645 $6,923.00 x 4.5600%
This policy,including all endorsements,is hereby countersigned by 10/13/2017
Authorized Signature Date
Service Office: HUB International New England LLC
54 Third Avenue 299 Ballardvaie Street
Burlington MA 01803 Wilmington, MA 01887
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with Its permission.
Occupancy 1 Building Photo
Exterior Wall 1 ' Pre-finsh Metl
Exterior Wall 2 - -
Roof Structure Gable/Hip
Roof Cover Metal/Tin r +
Interior Wall 1 Minim/Masonry MillirI �r1 i•
Interior Wall 2 Drywall/Sheet t t (
1 i � pitio
Interior Floor 1 Concr-Finished
r � R
Interior Floor 2 "'Af,R 'tits f.
Heating Fuel Gas � ''` y**,te r/
Heating Type Hot Air-no Duc
AC Type None (http://Images.vgsl.com/photos2/yarmouthMAPhotos//\00\02\87
Bldg Use MUNICPAL M96 Building Layout
Total Rooms
Total Bedrms "^*��
Total Baths
1st Floor Use:
Heat/AC NONE
Frame Type LT STEEL 'RAS If
Baths/Plumbing AVERAGE
Ceiling/Wall NONE
Rooms/Prtns AVERAGE
Wall Height 30 " K'
0/0 Comn Wall Building Sub-Areas (sq ft) Lggg d
Code Description Gross Living
Area Area
BAS First Floor 3,600 3,600
3,600 3,600
Building 7 : Section 1
Year Built: 2007
Living Area: 864
Replacement Cost: $52,970
Building Percent 93
Good:
Replacement Cost
Less Depreciation: $49,300
Building Attributes : Bldg 7 of 8
Field Description
STYLE Sm Commercial
MODEL Comm/Ind
Grade Excellent
Stories: 2
Occupancy 1 Building Photo
Exterior Wall 1 • Pre-finsh Metl
Exterior Wall 2
Roof Structure Gable/Hip p.
Roof Cover Metal/Tin
Interior Wall 1 Minim/Masonry "���'t �t t1' 1,11,x, MM
Interior Wall 2 Drywall/Sheet h ,
Interior Floor 1 Concr-Finishedi
Interior Floor 2
Heating Fuel Gas ¢ g
Heating Type Hot Air-no Duc
AC Type None (http://Images.vgsi.com/photos2/yarmouthMAPhotos//\00\02\87
Bldg Use MUNICPAL M96 Building Layout
Total Rooms
Total Bedrms .
Total Baths
1st Floor Use:
Heat/AC NONE
Frame Type LT STEEL i SAS ti
Baths/Plumbing AVERAGE
Ceiling/Wall NONE
Rooms/Prtns AVERAGE
Wall Height 30 t' '
%Comn Wall Building Sub-Areas (sq ft) l„ggend
Code Description Gross Living
Area Area
MS First Floor 3,600 3,600
3,600 3,600
Building 7 : Section 1
Year Built: 2007
Living Area: 864
Replacement Cost: $52,970
Building Percent 93
Good:
Replacement Cost
Less Depreciation: $49,300
Building Attributes : Bldg 7 of 8
Field Description
STYLE Sm Commercial
MODEL Comm/Ind
Grade Excellent
Stories: 2
DAN A. SPEAKMAN CONSTRUCTION
GENERAL CONTRACTOR
Construction Supervisor License#37636 Home Improvement Contractor#120040
15 SPEAK WAY
NORTH HARWICH, MASSACHUSETTS 02645
Phone: (508)432-5565/Fax: (508)432-5099
Email address: danaspeakman&.'dhntmail.com
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REVIEWED FOR BUILDING AND ZONING CODE COMPLI.
A CE. ERRORS OR OMMISSIONS DO NOT RELIEVE 111Ei
A•PLICANTFROM THE RESPONSIBILITY OF'AS BUILT' 1
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