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Home My WebLink AboutBLD-23-005815 Office Use Only y z Permit#COM 37 e.; Amount Permit expires 180 days from issue date 8LS-c23 -60 85 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 Lk_PR South Yarmouth, MA 02664 1 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 8 Anastatia Road West Yarmouth BUILDING DEPARTMENT By ASSESSOR'S INFORMATION: Map: Parcel: OWNER: William and Maureen Berardi 1433 Blue Hill Ave Milton,MA 617 719-6694 NAME PRESENT ADDRESS TEL. # CONTRACTOR: G&J Construction Co.,Inc. 1433 Blue Hill Ave Milton,MA 617 719-6694 NAME MAILING ADDRESS TEL.# RResidential ❑Commercial Est.Cost of Construction$ 70,200.00 Home Improvement Contractor Lie.# 107328 Construction Supervisor Lie.# CS-005235 Workman's Compensation Insurance: (check one) a I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove ri Siding: #of Squares 18 Replacement windows:# 17 Replacement doors: # 2 Roofing: #of Squares 22 (❑X )Remove existing*(max.2 layers) Insulation t 1 1 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I I *The debris will be disposed of at: Dumpster service to be hired 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 I. Applicant's Signature: Gox iGhs 6o4...a/U o Date: 3/22/2023 Owners Signature(or attachment)utellaiMLDate: 3/22/2023 Approved By: Date: Building Official(or d _nee EMAIL A ESS: wberardi1018@gmail.com Zoning District: Historical District: Yes No Flood Plain Lone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No __ The Commonwealth of Massachusetts ►"_' rl Department oflndustrialAccidents 1 Congress Street,Suite 100 _itir- ` Boston, MA 02114-2017 :� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): G&J Construction Co.,Inc. Address: 1433 Blue Hill Avenue City/State/Zip: Milton,MA 02186 Phone#: 617 719-6694 Are you an employer?Check the appropriate box: Type of project(required): I.0I am a employer with employees(full and/or part-time).* 7. D New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 9. [I Demolition 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 401 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.QPlumbing repairs or additions 5.®I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6_❑X We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 152,§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box#I 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 L4f LC(.LCun-A Signature: Date:3/22/2023 Phone#: 617 719-6694 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#: K,* 0 1 A- go 3 O 3maD Z m m DS7mp cn -�j = 9.c) IVrr-7) c 30c �0 •� rn<- 0 �^ 3 3 �wQ° m 3cz O c- O . CmD DmZ D xi :. om�s NI-C t1.-- .2 Z a'0 a 0 0 o -•1 pe1I rn<-I 0 {n s ot°'O 0)y mz � p� N NO xo 3N D O N` I is r W 03 O C Aa n M 0 0 6� O oo n v+ d fl -� c n 0 -1 �y Cm Oan @ du0rnCD I m Co < o I 0 m �� D m Q co �. 3 Ak ii o- 0 � � F'' "y wDp Ir • o f — cop3 >> �00so - _�.<. S (\) ✓ ^�"'••- G' 3 CD i - G CD , , 7dy etn a� x � ¢ 'm � � D co y � � w ' n.�.0 n N 2 a m �� > 4 �m- N C) a 0 occi a - .. 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