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HomeMy WebLinkAboutBLDX-23-1034 application RE C I V E D Office Use Only r— �F_._._ Permit# —a 10 Z SEP 0 8 202o Amount ti EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth, MA 02664 (� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: IS 1 rOOkiitll In V`/LS} `iar Ago 41% MA O26'73 OWNER: Todd IUVOn �� � (VI4L1fl� L n Iiqu, *wo , MA- ( OZ- 105 Oolot NAME +r 2 /PRESENT ADDRESS 'I r� n p ,TEEL. # CONTRACTOR: FC(l.t4 Pt(loot )(l, 1(G , C t Colt, 1 T GIB t/cLe fjz Oz ' NAME ! MAILING ADDRESS TEL.# c q EMAIL: Mtr + f� I rO01-1 .c v� JdO�&Zs-D 00/ residential ❑Commercial IEst.Cost of Construction$ 1 20 0 Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# ( 1 35l,Sr Construction Supervisor Lic.# l 06 Z03 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofin #of Squares I Z 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:`ASZikt . 2 f &Ott 1—bli yI(IS+(ia/ e k(k oS)1t 1 P1 4- 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._ F G AadeOo/a U e6a2 Pne�is Date: O cj /O 3 I ZvZAPPlican Applicant's Signature: rQ Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 ACOR � CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) l 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 PHONE H Nro.Ext►: (508)752-9333 FAX ,No): ADMDARIESS: 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 INSURERC: INSURER D: 163 EXCHANGE ST STE 201 INSURERE: 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. LTREFF POUCY EXP TYPE OF INSURANCE INSD SWVD POLICY NUMBER (W DDY/YYYY) (MM DD//YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE $ CLAIMS-MADE OCCUR PREM SESO(EaENTED 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 AND EMPLOYERS'LIABILITY X ST TUTE OTH- ER A OFFICER/MEMBEREXC UDED''ECUTIVE E.L.EACH ACCIDENT $ 1,000,000 N/A N/A N/A 7PJUB1K76070825 12/22/2025 12/22/2026 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below i 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 Daniel(� M. CrcpArley,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 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration I rn ( Type: Supplement Card - Registration: 193875 GLOBAL HOME EXTERIORS INC ..' Expiration: 12/03/2026 D/B/A GLOBAL ROOFING i 60 DUVAL RD gla it SUTTON, MA 01590 M / 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 EXTERIORS INC ?IBA GLOBAL ROOFING =REDDY T.ARBOLEDA JARAMILLO i0 DUVAL RD ' F/E'e(/�� L /4/'�� ��K/� � G��/ 3UTTON, MA 01590 Undersecretary `� Not valid without signature Commonwealth of Massachusetts Construe Division of Occupational Licensure Board of Building Re ulations and Standards Restricted to: •Constructs sups II etpr Specialty CSSL.-RF - Roofing CSSL-106203 ' ,icpires: 03/18/2027 FREDY T AROLEDA JA► ALLOq 60 DUVAL RO SUTTON MA 11590 i. �- Failure to possess a turns Commissioner � Building ), ,,.., t1-.�' �,�,s.� Code is tau Contact OPSI: (617) 727-3