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Home My WebLink AboutBLDX-26-968 application RECEIVED Office Use Only AUG 2 4 2026 i 1 Permit#X`tJ140 -'c't Amount BUl/ lf P WIT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �Ir -,� (508) 398-2231 Ext. 1261 $ CONSTRUCTION ADDRESS: (II T sums L41 y00,610001 F00- ,PIA MC 15 OWNER:Sk)OVI 5d'iId/e SI Pe5e4 Surds Ln Yioliouth , MA- 5©d - 3(7 - c13°13 NAME PRESENT ADDRESS OZ 6,'I S II !. # ^ 1,, I/W1�1� ` II CONTRACTOR: FNAMtd4 Artlol ecL IGE j ,3 ACING ADDRESS� b g pt R TEL. - LS — 0001 EMAIL: rou s-j • Low, Residential 0 Commercial Est.Cost of Construction$ `Y 2 7, '1 V Homeowner is Applicant? Yes No home Improvement Contractor Lic.# h 3 0 1 S Construction Supervisor Lic.# IQ 203 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 3- 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:(WC IL W WIG S%skv l5 ' &kir Hill .YhaII, 'f1 41 Park (30*Lm1 t MA- vZ)2 r 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. PIA* -ffgr6ai,P.e or;' /107- Applicant's Signature: Date: Owners Signature (or attachment) lawn Schild a Date: 08/19/2026 Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents �� Office of Investigations == = _� , Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 ~ — !� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): Ft-atrlrbotedee_- &iok l RctF•ncj Address: l(3 Lxciquvi f G 261 PG Guei-, RI- Q 2 8 0 City/State/Zip: pc,(,j},04 , JZ L I3 L O Phone #: SOS" (026- - 600a Are you an employer? Check the appropriate box: Type of project(required): 1.` W I am a employer with 3 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. [' New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p y 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ILO Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152. §1(4), and we have no employees. [No workers' 13.V1 Other rOoF (Id 4 PJ 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. :Contractors 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: Uiv'exfAI 7-h,),/f Q,Vtt Policy# or Self-ins. Lic. #: 1 r 7 U Q 1 K 7(907 Og2S Expiration Date: 12/ 2 Z / 2076' Job Site Address:$1 peceA4SrAh013h Yrv%'wo4i Parr ,i44 City/State/Zip: Ytitr MOali palm-, Mf} O ' 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 pains and penalties of perjury that the information provided above is true and correct. Signa> 4'269t.4Z Z G- — 16,6ai - Date: 08/19/2026 Phone#: 2S 000c1 (UJ 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 4.11 Electrical Inspector 5EIPlumbing Inspector 6.0Other Contact Person: Phone#: ACCPRO CERTIFICATE OF LIABILITY INSURANCE DATEWMMDDIYYYYI 12/22/2025 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 Jackie Medeiros NAME: Universal Insurance Agency,Inc. PHONE A/C No,Ext): (508)752-9333 W I FAXC,No (508)752-9303 374 Belmont Street E-MAIL ackie universali ADDRESS: ) nsa enc.corn g y INSURER(S)AFFORDING COVERAGE NAIC s Worcester MA 01604 INSURERS: NAUTILUS INSURANCE CO 17370 INSURED INSURER B: ARWC Travelers Indemnity Company 25658 Global Home Exteriors Inc' INSURER C: 769 Washington Street INSURER D: INSURER E: Auburn MA 01501 INSURER F: COVERAGES CERTIFICATE NUMBER: TEMP 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENT EU 100,000 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) 8 _ MED EXP(Any one person) $5,000 A NN1917634 12/22/2025 12/22/2026 PERSONAL BADVINJURY S 1,000,000 GEN'L AGGREGATE OMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY❑P ❑ JECROT LOC PRODUCTS-COMPIOP AGG $2,000,000 OTHER. $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ -OVTNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $2,000,000 A EXCESS LIAR CLAIMS-MADE AN1371058 12/22/2025 12/22/2026 AGGREGATE $ DED I I RETENTION$ �I $ WORKERS COMPENSATION STATUTE I I KH- AN!)EMPLOYERS'LIABILITY YIN 1,000,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE NIA TBA 12/22/2025 12/22/2026 E.L.EACH ACCIDENT $_ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C..-111y 1.— ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD C ® DATE(MMIDD/YYYY) A CC CERTIFICATE OF LIABILITY INSURANCE 12/24/2025 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 JACKIE MEDEIROS NAME: UNIVERSAL INSURANCE AGENCY (AIC o, Ext):ONE (508) 752-9333 (A/C, No): ADDRIESS: JACKIE@UNIVERSALINSAGENCY.COM 374 BELMONT ST INSURER(S)AFFORDING COVERAGE NAIC# WORCESTER MA 01604 INSURER A : TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B : GLOBAL HOME EXTERIORS INC INSURER C : INSURER D : 163 EXCHANGE ST STE: 201 INSURER E: PAWTUCKET RI 02860 INSURER F : COVERAGES CERTIFICATE NUMBER: 1182648 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 TYPE OF INSURANCE ADDL SUBRI • POLICY EFF ' POLICY EXP LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP (Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY __ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION XOTH STATUTE ER AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?� ECUTIVE N/A N/A N/A 7PJUB1K76070825 12/22/2025 12/22/2026 E.L. EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ 1 ,000,000 If yes, describe under 1 000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers' Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE t L I. Daniel M. Crow!, CPCU, Vice President — Residual Market — WCRIBMA © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD t. Commonwealth of Massachusetts Construe If Division of Occupational Licensure Board of Building Regulations and Standards Restricted to: Constructs '' upe r Specialty CSSL-RF - Roofing CSSL-106203 ," spires 03/18/2027 FREDY T AR$O f LO" 60 DUVAL RO10 ; SUTTON MA' J15 I r O 4 Vb 1*1 , co, r- Failure to possess a curre Commissioner Building g Code Is eau Contact OPSI: (617) 727-3 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affal and Business Regulation 1000 Washingtc rest-Suite 710 Boston, Massachusetts 02118 Home ImprovementCOntractor Registration B __ t Type: Supplement Card M 7 Registration: 193875 GLOBAL HOME EXTERIORS INC a _ Expiration: 12/03/2026 D/B/A GLOBAL ROOFING 60 DUVAL RD SUTTON,MA 01590 • sNS Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Supplement Card Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street-Suite 710 193875 12/03/2026 Boston,MA 02118 3LOBAL HOME EXTERIORSINp d _ D/B/A GLOBAL ROOFING " 1 'REDDY T.ARBOLEDA JARAMILLO ! 1d �.0 � 7/-1X-/�A/L,7/� ��7X��/I�//�A 30 DUVAL RD ` / ([ (r ((( /` LC 3UTTON,MA 01590 .Y P i`%' Undersecretary Not valid without signature