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Home My WebLink AboutBLDX-25-1255 0 Office Use Only RECEIVED ' Permit# X5-1 a-'5 3 4; 2 2 2025 — No SEP Amount� ��'�.,onAisy,,," BUILDING DEPARTMENT By ____ --__------- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7 ' OWNER: /g, % ,f A/c wen 34 dove//e&/// ire NAME PRESENT ADDRESS TEL. # A' CONTRACTOR: 'Li/ del S /We--7 el7 79/1.54'c 4i,' -5' .6`' ei'!/7/5 ( 7& f'�///i X' NAMEG �71,7 7/-gar//7i?,1 MAILING ADDRESS / TE EMAIL: T/iG?'/7/I GO/'Ill/C'� L' ,-7,S//1 7 OJ J �g G// ' G 72.71 E'Residential ❑Commercial Est.Cost of Construction$ / 9O e, Homeowner is Applicant? Yes No �y Home Improvement Contractor Lic.# / 43 0 Construction Supervisor Lic.# e 5 -�5/ g 3 /e 7/-3 e WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# /6 Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review *The debris will be disposed of at: aihelirii (/C.S/,e_ mama /7co /,? a//'/ Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev ation of been and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �7 Date: /a 0.5- Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 AcoRO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMDMYYY) 06262025 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(les)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 art endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT David Attridge NAME: DELAND GIBSON INSURANCE ASSOCIATES INC Ltd PHONNo Bey (781)239-7660 No)_ iteptiLiee. dattrldgeOdelandgibsan.com 36 WASHINGTON ST INSURERISI AFFORDING COVERAGE NAILS WELLESLEY HILLS MA 02481 IN5LRERA:AIM MUTUAL INS CO 33758 INSURED INSURER B FRANK CORMIER INSURER C INSURER D: 79 ASACK DR INSURERE S DENNIS MA 02660 INSURERF: COVERAGES CERTIFICATE NUMBER:1130596 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. i TTR TYPE OF INSURANCE Arum won POLICY NUMBER (MMI OI'I YICY�V17 IMMID PCYYTT LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MAZE❑OCCUR DAMAGE 10 RENTEDPRFMIRFR(Ea pcoaraRrel $ MED EXP(Any one person) $ N/A PERSONAL 3,AOV INJURY $ GEN-L AGGREGATE LIMpIT.APPUES PER 1 GENERAL AGGREGATE S POUCY O tT LOC I PRODUCTS-COMP/OP AGG $ $ OTHER COMBINED SINGLEUMIT $ INrTOMDSIJ!LSISLLfrY (Ea Eddied) ANY AUTO BODILY INJURY(Per person) E OWNED SCHEDULED N/A GODLY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE— s AUTOS ONLY __AUTOS ONLY (PR accident) UMSRaLLALIAB OCCUR EACHOCCURRENCE S EXCESS LIA6 CLAIMS-MADE N/A AGGREGATE S DED I I RETENTIONS ppEERR pp S WORKERS COMPENSATION XI STATUTE I ERA AID EMPLOYERS'LIABILITY A FICERMHIIETMBOEwRO(CRT ERIEYEC-.I.v_ wA N/A MA VWC10060033542025A 01/142025 01/142026 EL EAa+ACOEDCT $ 100,000 54endebry IA NH) E.L DISEASE-EA EMPLOYEES 100,000 I describe under DESCRIPTION OF OPERyTIONS baton, E L DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATORS I LOCATIONS/VEIICLES(ACORD 101,Addabnel Remelts Schedule,my be Mlach.d If moto Spay.b regMd) Workers'Compensator benefits WA be pad to Massachusetts employees onN Pursuant to Endorsement WC 20 03 05 B.no au0000dion Isgreet to pay clams for boner to employees in sides other then Massachusetts I the Insured hires.or has hired those employees outsde of HMSO uSerts. This CYGICCe of Insurance shows the policy in force on the date that Ills CanEEC ate was issued(unless the arp;r8bon date on the above policy precedes the issue date of this cenelcale of In surarre) Toe status of this coverage can be monitored daily by accessing Ire Prod of Coverage-Coverage Venliceton Search tool e craw mess gwtMNWorkers-compensatbn/mvesegdronb Sole propndo has not MecCad c ware ga. Continuation of above Named In•.used.F C CONSTRUCTION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town of YarmouthACCORDANCE WITH THE POUCY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Cowley,CPCU,Vice Resident—Residual Market—WCRIBMA O 198B-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD FCCONST-01 DATTRIf1AF ACOROI CERTIFICATE OF LIABILITY INSURANCE DATE 6l2612025 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 pollcy(tes)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 sucChpendorsement(s). NA PRODUCER MEACT Deland,Gibson Insurance Associates,Inc. PHONE , .(781)237-1515 N'I'(FAX 78 } 1 237.1803 36 Washington Street Est). wC' Suite 40 ol'ss.ilffoadelandgibson.com Wellesley Hills,MA 02481 INSURERISI AFFORDING COVERAGE NAICI INSLRER A:Naln Street America Assurance Company INSURED INSURER/ Commerce(Citation Insurance Co. 40274 Frank C:ormler DBA F.C.Construction INSURERO: 79 Asack Drive INSURER D. South Dennis,MA 02660 INSURERS; 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 CONTRACTOR 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 uPO�L`ICIIIEpS.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID TYPE OF INSURANCE �AyDR POLICY NUMBER (MyehON , (MMIDOM'YYl LIMB A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 500,000 I CLAIMS-Mr DEEl OCCUR CP00149020 7/112025 7/1/2026 p°p^'^ '(p;o^ rat S 500,000 MED EXP(Ars we Parson) S 1S,ODS '— PFRSONAL&ADVIN.AIRY $ 500,000 _Ca-'LAGGR^ LIMIT APv S PER GENERAL AGGREGATE $ 1,000,000 PBp. Li X FOLIC', LOC PRODUCTS-COMP/DP AGO e 1,000,000 Gin=R Llabllily General A9 egate s B AUTOMOBILE LIABYJTY /FCO NSD9NGLELIMN ANY AUTO BJGJLL 4/21/2025 4/212028 BODILY IN URY IPer IAIVUT S 250,000 _AUTOSS ONLY NED X AUNOSVJ�� BODILY IN CRY(Pm prudent: S AUTOS '00O ONLY —AUTOS IXJLY Per PERiEY DAMAGE S 100,000 UMBRELLA 1.11B OCCUR ,FACHOCCC IRRFNu S EXCESS UAB CLAIMSMADE AGORFOATE S _ DED I I RETENTION$ MUTE $ WORKERS COMPENSATION I STATUTE I I ER AND EMPLOYERS.LIABILITY ,I ', ANY'IPROPRIETONEARR-NDRRECJTIVE IJ NIA E.L EACH ACCIDENT S OF C2nAEMEEH DD77 u E L.DISEASE.EA EMPLOYEE$ Iffiyes describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATORS 1 LOCATIONS(VEHICLES IACORS 101,Additional Remarks Schedule,may be attached If more space la regziree) C RT1FlC T H L ER CANCELLATION SNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1148 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE /J ACORD 25(2016/03) a 1988-2015 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts =,_= Department of Industrial Accidents ': =' Office of Investigations 'e""�t1_�' Lafayette City Center c"1 - 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual):A?,61IJ 7 S7 1 L� ./#97 _ Address: 79'rf sac- 4f r/vse- 55v/A je/I,,i/S%i4t City/State/Zip: i /•/// O'26¢O Phone#: 7 7 ') ?yy/2 o?C) Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 4. ❑t am a general contractor and 1 loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling 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.intiurance.t required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 1 I.❑Plumbing repairs or additions 3.El I am a homeowner doing all work myself.[No workers'comp. right of exemption per MGL YP 12.❑Roof repairs insurance required.]t c.152,§1(4),and we have no 13.❑Other �/ employees.[No workers' comp.insurance required.] t°/Q/eikLt1 ir- *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 subcontractors 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. / y� y A, Insurance Company Name:de%19�G/f7 )?.. .,. S , `-/17c'f/l2rs'/'niveQri(�'X S- A/n7/Ifrtfva/J.1. ', ee. Policy#or Self-ins.Lic.#: /73 O,y pG Expiration Date: /� Job Site Address:.3� C' " 1//e1e�O/f y� City/State/Zip.$,j'q'/+/j70[J /114 41 f 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 hereby certify under the ins and penalties of perjury that the information provided above is true and correct Signature: T4/ 25)7' ZC/� �/'/7jJ7G{h Date: /32Jr Phone#: (/ 9j �o2a0 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❑City/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts Construction Supervisor �� Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building Req ilations and Standards 36,000 cubic feet(991 cubic meters)of enclosed space. Constil>kion gIt'yrvisor CS-045788 4p1res: 02/21/2027 cr FRANK N CQRMIER 79 ASACK DFEIVE SOUTH DENFA,MA 02660 >' 0 rf'tib fJV`i'1 1, Failure to possess a current edition of the Massachusetts State Building Code Is cause for revocation of this license. Commissioner 2Ws..— Contact OPSI:(617)7273200 or visit www.mass.govldpl/opsi THE COMMONWEALTH OF MASSACHUSETT o Office of Consumer Affairs & Business Regulation Registration valid for individual use onlybefore the expiration date. if found return to: HOME iMPROVEM CONTRACTOR Office of Consumer Affairs and Business Regulation TYPE: Individual low)Washington Street - Suite 710 R�cl�trat� �107138 09f29/2026 Boston, MA 42118 FRANK CORMIER D/B/A F. C, CONSTRUCTION FRANK N, CORMIER 4q �� " 79 ASACK DR Not valid Without signature SOUTH DENNIS, MA 02660 Undersecretary