HomeMy WebLinkAboutBLD-23-005302 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department of r -.
1146 Route 28,South Yarmouth,MA 02664-4492 .
508-398-2231 ext. 1261 Fax 508-398-0836 ! ..._!� ■ ';
I;
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling
, R E C O
This Section For Official Use y . .___----•
Building Permit Number: —Z 1 ✓UZDate Appli : APR 03 2023
'I\ Sep ------7.-- '1,3 _
Building Official(Print ame) ignature BlD ty)1N ``i PA f kit Bkt
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
7 Po2TS/lDc)7-// 7c7tJcE Jo to 3/
1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
VO geS //`/o'1 S ,-'. /oo 0V
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
30 3 3.5 2v /fig 6P ZO' `/G • t
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public L1 Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system r;
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
THOMA A n. neAsceK REV./2. VA R AT Oe 73
Name(Print) City,State,ZIP SC OVA c_ri‘cEt/4%EF4
7 fo•'ZrS fl))J nt-1 TE/c,e". a'03- .5(. ZY0 :0 oA), o
No.and Street Telephone Email Address I V D
SECTION 3:DESCRTI N OF PROPOSED WORK"(check all that apply)
New Construction 0 Existing Building Owner-Occupied UVRepairs(s) 0 Alteration(s) 0 A..itiMAY 1
201��
JP
Demolition ❑ Accessory Bldg. 0 Number of Units 1 Other ❑ Specify:
Brief Description of ProposedWork2: BUILDING 'EPARTt,�FNT
avT As. r4S
#.0f/I
SECTION 4:ESTIMATED CONSTRUCTION COSTS. �'
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.BuiIding $ 1. Building Permit Fee:$__Indicate how fee is determined:
2.Electrical $ IN Standard City/Town Application Fee
0 Total Project Cost3(Item 6/) ulti lier x
3.Plumbing $ 2. Other Fees: $ l/1) C- 3Z bw
4.Mechanical (HVAC) $ List: G
5.Mechanical (Fire $ I\t$S
Suppression) Total All Fees:$
Check No. Check Amount: Cash ount:
6.Total Project Cost: L.. .f-
$
3 0 0Paid in Full 18 Outstanding Balance ue:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /
y GSo3,G L
36. < /224
Di &� A. spek /Ll4]J License Number Expiration Date
Name of CSL Holder
3E4 &,o' List CSL Type(see below) 0
No.and Street Type Description
��/�l�l LcJ I C/1' �� (� G Ll j U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted lcfc2 Family Dwelling
Iv1 Masonry
RC Roofing Covering
t��AAS106f1�Kt'Y1i9� WS Window and Siding
�/ �� Cii� C e/oT M,9/C.GO✓''l SF Solid Fuel Burning Appliances
l I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) .. �� I
t7,9AJ A. Sr°E 11 /►'1,'/ /2ao yo
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street 1 ,/ �A�
5 f&4A- (.( y/-l/9/?eC//C//22T P_360 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>ance of the building permit.
Signed Affidavit Attached? Yes ..❑ No U
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_ Ol) 4. c`^7 () /9/tit.44,j(J
to act on my behalf,in all matters relative to work authorized by this building permit application.
WZI
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.
Dq i1. S PEAt ivl N 3 kY/23
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.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"
!,„..3/ & S°E19lc- 3 0 (-�Oi /L . U ,,..r
-!' .YA TOWN OF S',ARki0i 11 I
�'� WATER DEPARTMENT
a1 ;.4 99 Burk Island Road
t naa4I ,A( ' YArtt•rrsth.MA tl2f>"
' ». li,li,ption - 1-7)21 • Fay ;08 ,_1-"99ts
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATION:• `��43ZrS/''�CJs>r %c T't2./�C
PROPOSED WORK: &J1G3 Dc 7 t' — r4-04 5274 aa.5
APPLICANT: _Pil'9 .,..,?1 _.,,.c 6 _.._.._.,. . _.
ADDRESS: /5 s pe-.9/c 4 r, H9�?e-'Cry' '4c' _. .._
.I ELPHONE: 72 7 . 03 6". - &05`
RFSII.)I N`I IAL AND :OR C'OMMFRCIAL BUILDING
1.ater I)eparttnent: Determines Compliance of Water Availahiltt) and or existing location
I:ngiaeering Department: I)eterniincs Compliance for Parking and Drainage
C'onscm anon Commission; Determines Compliance to Wetlands Act: i e 11'lot(s)border any type of
wciIantis.streams.ponds.ricers.ocean.bogs.boys.marshland, ETC .:
I lealtk Department: Determines Compliance to State and l'ou n Regulations,i.e.
requirements for Septage Disposal and other Public I learnt Aetiw itcs
Fire Department: Determines Compliance to State and Town Requirements for Personal
Safety.Property Protections,i.e.Smorce Detectors,Sprinkler Systems.etc
t 1
i LICANT SIGNA URE DATE
OFFICE USE:COMMENTS ON PERMIT APPROVAL OR DENIAL
44L_ ri.--/e- 23
RI':VIF. ID BY \V TER DIVISION(SIGNATURE) DATE
Mk
\ o Conservation Office
c
Town of Yarmouth
p( - �,_-�;�'��_ y bdirienzoAyarmouth.ma.us
Conservation Commission
Building Permit Sign-off Application
TO BE FILLED OUT BY BUILDING PERMIT APPLICANT:
Building Site Location: 7
Map # / Lot(s) # 3/
Property Owner: i f�l, S. ZE.4- C7" Date filed: 3/ 7 /2-3
*Applicant: !Y
Applicant Address: /5 p&- C I C(--Li(r
Email: Ap4A.)0//oi/7/C-,.(0'.`7 Telephone: 7)`-/-vSC .6 8i
Please note:by submitting this application,the applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed).
Proposed Project Description:
/ZE,c3v k-Q , 4-04 7-4/
Site Plan Title/Date: Si,4 d P\cA Jl 1 ?or 1-Srh0 r ct (� �j 23 ) t o 7-3
TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR:
Does the proposed project require a permit? Adri\`�. �vuew
Refer to: SE83- or DOA permit
Comments from Conservation Commission: Approved 'tonally Approved edvo ed Rejected
V)00• Lt,MO- t,.rCk1n-f1US1dn Colni ` stilt • fnc.(
a S ,rav\r w -HI Of S'vh,\cr) ."G\1 15 tr 3)-GI !-tC1 Abel XI✓`'tcel-tly
1b`1S RdM 9fc1P0S.(C1 s ors
Conservation Commission Sign-off Signature: / Date: 7I , 0 z L 3
*TO APPLICANT:
All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each
day, the area shall be clean and no debris shall be in the Resource Area.
If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the
Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed,
along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site
during construction. Please refer to the Order of Conditions for further details.
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-223*1 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 ? POTci SMour,-( ) '1'41PC,AT
Work Address
Is to be disposed of oat the following location: . T
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
.(rC (2t(
Signature of Application Date
Permit No.
The Commonwealth of Massachusetts v Print Form
�
Department of Industrial Accidents
Ii:
Office of Investigations
.a
' -1.315 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizati on/Ind ividual):DAM A„ S{ E+`/14.4� G'a gri?vc.Ti0
Address: /s sSPE 4,4 ,"
City/State/Zip: / '4, wGC/-/ Phone#: C045"9
Are you an employer?Check the appropriate bOXS Type of project(required):
1.❑ I am a employer with 4• [ 4am a general contractor and [
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
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'
comp insurance.* 9. (7'3uilding addition
[No workers' comp. insurance P
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t c. 152, §l(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.
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: A- C-t. e-,1104,0�2 5 /14S c
Policy#or Self-ins. Lic.#0. CC—S00 --$Cjp 95C,5 0/9 Expiration Date: `C• 0/ZO Z 3 _
Job Site Address:_ ) Pb '7 S/'') D 0 77-e 7erfAC Ej )/,Ff j? City/State/Zip:.
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 herebyttrnifran r the pains td pe ties of perjury that the information provided above is true and correct.
Signature:I �i
Dater 8 72Y/03
Phone#: 7 7y .. (53G • C.85 9
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#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5009565-2021A
PRIOR NO. WCC-500-5009565-2020A
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: Individual
Other workplaces not shown above: See Location
2. The policy period is from 11/10/2021 to 11/10/2022 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 000137314
INTER SEE CLASS CODE SCHEDU_E
Minimum Premium $550
GOV GOV
STATE CLASS
MA 5645
This policy,including all endorsements,is hereby countersigned by 10/28/2021
Authorized Signature Date
Service Office: HUB International New England LLC
54 Third Avenue PO Box 696
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.
Commonwealth of Massachusetts 1
S Division of Occupational Licensure-
Board of Building Re ulations and Standards
Cons r
Icon*rvisor
CS-037636
* Splres:04/221202n
DAN A SPEAgM. k1 4 l
15 SPEAK WAY t
i1/4
HARWICH M4j 0 „S
""OIJ,w111:3• J
Commissioner daia ;;• `Pif;;4,
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
120040 10/08/2023
DAN A SPEAKMAN
DAN A.SPEAKMAN ,.,
15 SPEAK WAY re%_ d((� z"r�
v
NO HARW ICH,MA 02645
Undersecretary
(l s-iAjL . 6,u
of:X-gR,L TOWN OF YARMOUTH
e. HEALTH DEPARTMENT
•
4
''4��• PERMIT APPLICATION SIGN OFF TRANSMITTAL itarzivED
To be completed by Applicant: ANK Ii 7 2023
Building Site Location: 7 0 2 C S -i 00 P4 j • f? c HEALTH DEPT.
Proposed Improvement: 1\C An,43 E i/j i 2Z
Applicant: D4;') /4 . 3 PL4 cIt- , j Tel. No.: .7)'i u3C✓. 6.0ci)
Address: 1 S.%4i (- /> / 114()2&.11 CJT Date Filed: `1( )/2-3
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: TH G^--/A-/ 4S L6' (-'/O o of 2-)0
Owner Address: ,7 ,l�c��'T S/L7 O J; j 2 i Z Owner Tel. No.: 56-t
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: (c�`c _ DATE: Li--al
PLEASE NOTE
COMMENTS/CONDITIONS:
PZ- -Z71 pS2A-41--)t.
111 ECE V_
APR 212023
BUILDING DEPARTMENT
By _ --
4/5/23, 1:49 PM Mail-Sears,Tim-Outlook
7 Portsmouth Terr
Sears, Tim <tsears@yarmouth.ma.us>
Wed 4/5/2023 1:48 PM
To: Dan Speakman <danaspeakman@hotmail.com>
Dan,
I have reviewed your application and there are some items needed.
Health Department sign off
yVvater Department sign off
Thank you
Timothy Sears CBO
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsearsf yarmouth.ma.us
https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQADZUygUyHL5MoGfJxz9... 1/1