Loading...
HomeMy WebLinkAboutBLD-19-1085 RECEIVED • :�-- a AUG 22 M8 F !, �: BUILDING DEPARTMENT }e. 2 �O V�� : Cj"o By: C �e ircer�st9 inationaQ�¢�viceo - o ice ` ' t ✓J,apting. Comm aaiane„ 1146 govie 28, eLouti Jaw occg, ore 02664 APPLICATION FOR FIRE PROTECTION PERMIT Date '10-020/g PERMIT NUMBER 80 —(1 oO /073-- Projected Start Date: A5P 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 Codr 6}Zarrn Address �� Old ©� / (Full name ofperson,Firm or Corporatio h3fou.sc Road 1 Wesv- arrnourI4 (Contact#1) 5O8"�`tj$-2`g,?/ Job Location 100 IduarF L.arjE , YarTnotJzn porn � -A (Street&City or Town) t3/cc Z 'icfnit) For permission to (state cltiarly purpose for which permit is requested) insccaL2 LAY;ceLess rice alarm sysTem, 51-nvKE1 3-Z e OP& ay1cd Careoh rrycynok;OE ,veerors. Q-t-'S.Dci irMc 4 -ne10,Z _ W►/C &ie luau.) S ysrs t TAT' 1-1 -7y ADM Cast Name of competent operator(if applicable) Gene rrn-ier Cate Gd flZar • Cert. or License No. 159A-C Estimated Cost of Construction: 7 0. p0 By WaSP 1 (Signature of Applicant) 0 �a� �� p - 1'# Thal p , FEE: $50.00 l' F�' ' 1:-" "` a The Commonwealth of Massachusetts t ';n Department of Industrial Accidents et• -i ,.fi A; Office of Investigations a - n : _rvirg4 600 Washington Street in = t • f Boston, MA 02111 • • -?, www.massgov/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. ❑ 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 8. 0 Demolition working for me in any capacity. employees and have workers' insurance.' 9. ❑ Building addition comp.[No workers' comp. insurance 10.0 Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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' 13.0 Other i'y)Sy'(i1L2 iA/i relE5S comp. insurance required.] rice (A2.arm Foree'ie *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 lob Site Address: 100 tth-tqfp LOLYIE City/State/Zip: Yq,rMOVIT1-( Orf 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under:thelepaiinn...a,gd penalties of perjury that the information provided above is true and correct 17 Signature: ✓ "- Date: 0^it0�O Phone#: 5 08'2_58-26214 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other 4 I 0 • 7f GOMMONWEA1TH SiA OF MASC�•IUSETTS i �� ,. Commonwealth of Massachusettsr 'x I a" f911iiSION,OF.PROFES$IONAL LIOENS FLE^�?_y i� Department of Public Safety 2,w0 iw 4::t�BOARD'0 . E[ TftICIAS " > License: SSCO-000248 ( :,., ` SSUES TIE,�F,�OLLOWING LI 1:N S Security Systems -S-Llcense • 4 , RE'GISTEREO SYSTEM CONTRAC1OR; • 4:SP;' a 3`' :15.)••••,, ^^ tg {.ip'�°;g GENE C012MIER'� _ GENE A CORMIER`SF'"'' .. Employer: `•••� " "'� _GENE CAPE COD.AtfAR CO INC111 M CAPE COD ALAR 204 OLiDdlicklN HQUSE RDA.r4 •-.:4••. - WESTYARMOUTH,N L).'.02tt3-1531, •• '' ' :fib f,; k `� "` M,iz C../LL Expiration: -"41592 nr ''� 07/31!201,9 tis 123442 ' Commissioner 11/07/2018 iot.ENSENU BEB Y01.0EXEIBATIOP,DATEW2a?SIBERIA. NUMBER # GOMMONWE h OF MASSAC IfSifr " 1 =',x".:DIVISION OP.PROFESSI,ONALI � a, LIGENSURE ELEcutiCIAMS ' » $3yd• �4 ISSUE$THE FOLLOWING LSCENSE ,@�.:s.wig #P`' F& :2Y ^. .map•• 6 cREG1S `ERED SYSTEI >TECHNICIANt;F4. .‘g....z. ^$.(95.'',x' "ii '7 ii. - GNE A CORMIER = 'q+' " ' ; lb ‘l.; MARGAT5LN . t :,ii; /, • SOUTF ptNI iS MA 02668:266c -111. 1C.\'6 S)-ra 1507 07131!20,1 9 :�, 212805 `^ Axa.. aaxs », • • I r r • _ ____::: .-4& . J.N3na g s rl W o o� Z g i oznag -a Q R s U j EH 70 I ® m ,-r va II nt)..® b it 14,109.Arog : 30011 (roof ------T- © bv!v d a s / }l yg I • �. chi 1r------" H.Aca \\.:1 :z • I E ! ' ' 7' �� 1 Vl401 i, Usyv-N7 Q i O G u aya{ ! boort b,,_,‘i, I ® od 'gi 1iai hV./i '2;i 1 ThUM •001