HomeMy WebLinkAboutBLD-19-896 RECEIVED
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APPLICATION FOR FIRE PROTECTION PERMIT
Date &—9- O(S PERMIT NUMBER St.. O—/Q_0u7 cy 9
Projected Start Date: AS/3 P Date of issue
In accordance with the provisions of 780 CMR and M.G.L. Chapter 148, as provided in
Section
application is hereby made by Cape Cod A tarrn
a i�/ (Full name ojpersoq Firm or Corporation) v
Address lnl nia-toUce 12 Yairrnousta(
Job Location S�- c ^ ,(Contact#) 9 oe-g58-RCR,1�
(Street&City or Town) a
For permission to (state clearl purpose for which permit is
requested) /. LZ ' SA On ito h a tC I
! • e or 1$o; er
Poem cMaa eoinneex v-o etc?stiNg rnov>,;wrored e;re
atarmiane, .
Name of competent operator (if applicable) 17e rrnr1"%er- /zre cod �2a rm
Cert. or icense No. / 9 -C Estimated Cost of Construction: "3"00. 0 O
By i , 4 ,
(Signature of Applicant)
PERM-17# FEE: $50.00
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, The Commonwealth of Massachusetts
° " ' r&; Department of Industrial Accidents
lr t . k, Office of Investigations
._, 1S rr' , ': 600 Washington Street
fit'` "" -.4 Boston, MA 02111
sit, r f3 4
.;;,-41/4,-;.-v---:,,./1,44 it +r, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): CAPE COD ALARM CO., INC.
Address: 204 OLD TOWNHOUSE ROAD
City/State/Zip:WEST YARMOUTH, MA 02673 Phone #: (508) 398-6316
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 30 4. 0 I am a general contractor and I
employees(full and/or part-time).
• have hired the sub-contractors 6. 0 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.) 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t c. 152, §I(4),and we have no
employees. [No workers' 13.0 Other i%lG'ttt22 eatfla r
comp. insurance required.] cooro OeTe(yCOf 'ine&Ler^
"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: Associated Employers Ins., Co.
Policy# or Self-ins. Lic. #: WCC-500-5006433-2017A Expiration Date: September 1, 2018
Job Site Address: 9 V So wort Swore K\r\vp City/State/Zip: >Ovc fltLcCI-t
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der th pain yd penalties of perjury that the information provided above is true and correct
Sitmature: `/:/�??!1-7 �,pj> Date: • 8) 9)KO/8
Phone#: 5 0 8-2_58-262 z{
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
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s?!•'d:COMMONWEAUTH OF MIASiACHSETTS m'I il Commonwealth of Massachusetts♦—�
' EjPJUISION OF.PROFESSIONALrLICENSUREt; kV) Department of Public Safety
t(*ar,y;: sIffaii RD'OFµ ,
ELEC RICIANS License: SSCO-000248 .,,.,
Y.1=r,s , 5?{;3 "...:;1;r:;" Security Systems -�S.Licensg
i ISSUES TIiF,FOLLOWING LICENSEXS A
59.3 F6.e. Y
' ,yVVry
FTGI$TRRD SYS EM.CONTRAC_;.OR h;
g , y. , GENE C012MIER,;
GENE A CORMIER �' Em to er: 'i•c ?eTht -�
'CAPE COD.ALAI 'CO INC =w CAPE COD ALARM'
204 OLD t6wN HOUSE,Ruszn '
WESTTYARMOUTH,MAg'O2G73-1531 .••
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.., .€ :a A � Expiration:
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1592 '),4=.3;y 07/31/2019, 123442 ;, Commissioner 1110712018
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8 4E SEMI 8E8ia "PEXE RATIDNiDATEUt*,&'SEMIA NUMX •
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f dOMMONWEALTH OF MASSACHUSETTS IAA
I`=N YDIViSION oPITROFESSICHAVLICENSUREsa
Oair
Eth6fmciA.Nf sp.nr -4 ,
tom etat-,71 ISSUES� THE FOLLOWING LICENSE
jRE '2sTERtDSYST TECHNIC,VCf';s'\
GE,fEACORMIER co '21 , x>
': yea,9mARGA'TEl-f�,^. it; •• ,wv,%i
• $ SOUTI14NP AS,IIIA 02660;266f`'� 1 •••,\ "i;'
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