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HomeMy WebLinkAboutBLD-19-001751 • • RECEIVED • SEP 24, 2018 al "' ILDING D ' BU A T l'> o, ihi 4 V] e eOltdeg • D - o E 1146 geade 28, pawzeco%i, 'g&0266/ APPLICATION FOR FIRE PROTECTION PERMIT Dater/ya( PERMIT NUMBER 30 / 9 - cV /757 Projected Start Date: Date of issue In accordance with the provisions of 780 CMR and M.G.L. Chapter 148, as provided in Section 19 application is hereby made by Ake Ve.,1 .1 ?)a/vn `�i - (Full name of person,Firm or Corporatio ) Address `!/ �I/ /!Ji �+i tt4 OZ€I'YFos (Contact#) t-D S%PP () Job Location 3 Bit Rig-P. 5 l y Arncvt/gr/ri- . 1-,Sc$f -f (Street&City or Town) For permission to (state clearly purpose for which permit is requested) 9%T119l ex/ pc- Ja'u' /.4/Tin' cSin©�l� &2 Name of competent operator(if applicable) • Cert. or License No. Estimated Cost of Construction: Sid By (Signature of Applicant) PERMIT# - EE: $50.00 -yam-/ C \ , .. • \ . - . , -, , . \ , ;--\.“..._?,- --,-, k , • , - • • ...t. ,. •., •••• ,,(•,. ,• -, <, , ,. , •,, •• N ' . • • ,,,, , . e• V\!::: I: Vo.3.\„‘. . • ••• :'... \i- ..\ . . (-5‘4.(; .5 e5e \ le‘,... 11,)!.i I,:;-:2e:A - :),A k•-.T'7-'1/4 ...... , ,•^ . r, 1/4-".1/4 1 k.4 • ...)(2"41•-.111 •".. (.4.1.1/4•41/4.-\Ai: '1/4.0"!-.41,:_ig 4 ...,_ .4 ..p. _ . •p,4.4 _ ,.....x77 „ ..r7rT4-1/41 , _,.._ .. 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E; I 4 cil FOUNDA NON PLAN ° 4_r ¢sL k RmsE Know Noe . oMR 11.G Ow„'ICOMOR„no Nino n.° A3 - .n . • • • }iphalpgy E.g TH OF hang k lif33 MW S10417P$O#ESSIDNALitt- DBE I ". eoatitap . • • . ; G itclitNs,: a ' m . ISSUES..rHE: OLL'041iintatkicEMSE t ERED Mq�s7- lIECTRICt9cN�t ; . BRAN.REZENDES - ;..-...-�.s_ :-.\ i • LYS, Az:.,,ENGEAND LLC "' r}'-°, : `r.� 2 , 7 G0 -1pNG 4. I'!1 iC I 2 .. PLYMOUTH, MA 023Ga `b ;..- tr : v ' ,.' 131=19 # 211935 • • --1C.ENSEIUMSW—ExPIRn7iUN -"_ ERIMAUMBEA • • __ _— Com.,monwealth of frfec- • • . ^ husea Division or Prciessiora �c. w.. . • Scar_.or State Tr - = =; BRIAN L___ _. ----7.„-_—_,e- -•,__, i 7 GOEL .4 l'' � i .• I,_ , 11 PLYMOUi-r ,. il �. • i Master Eleca /4/ ' • 2221374 07/31/2019_ ,�v r License No. - 0010971 �rpi,-ahon Dam. Sada/No. • • ,In Commonwealth of Massachusetts. • iV. Department of Public Safety License; SSCC-007336 Security Systems-Certificate of =r`~ " • Clearance 'BRIAN L REZENDES , t _ =- . • ' ErnpIoyer. ' ,., •• • - ,.r.-i-- _ . . . . ALARM NEW ENGLAMD .. °' Commissioner Expiration: • — • - _ 08/25/20-18 • I v _A.4 • ,AC a CERTIFICATE OF LIABILITY INSURANCE DATE(MMmOYYY 7/25/2018 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(les) must 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 NAME: Michelle Hinckley May, Bones i Walsh, Inc, PHONE (860)372-4972 MgtExl1• (860)764-0555 NC•Not: DBA Insurance Provider Group 1DORIEBe,michelle@insuranceprovidergroup.coon 100 Great Meadow Rd Ste 705 INSURER(S)AFFORDING COVERAGE NAICII Wethersfield CT 06109 INSURER Arch Insurance Co. INSURED INSURER B:Phoenix Insurance Co. 25623 SSSH 3, Inc dba Alarm New England, Voice New England INSURERc:NorGDARD Insurance Company 31470 Sonitrol Security Systems of Hartford, Inc. dba maw/ER a:Travelers Prop. Cas. Co. of America 36161 • Sonitrol New England; 65 Inwood Road INSURER E: Rocky Hill CT 06067 INSURER F: COVERAGES CERTIFICATE NUMBER:18-19 Master 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.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR _ LTR TYPE OF INSURANCE INSO WYD POLICY NUMBER 42I(DDIYEY»7 DMMIIDDrrYXYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE A CLAIMS-MADE n OCCUR PREMISES(Es RENTED $ 100,000 X Errors i Omissions BAPX00019006 7/1/2018 7/1/2019 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE _ f 2,000,00F POLICI'O JECr0 LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: Employee Benefits Liability $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE OMIT $ 1,DOD,000 (Ee ecddent) _ B X ANY AUTO BODILY INJURY(Por person) S ALL OWNED SCHEDULED 810-7E696218 AUTOS AUTOS 7/1/2018 7/1/2019 BODILY INJURY(Per accident) I HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per eodden0 $ S X UMBRELLA LIAR X OCCUR EACH OCCURRENCE A EXCESS LIAB CLAIMS-MADE S 5,000,000 AGGREGATE $ 5,000,000 DEC X REM/MONS 10,000 BAPE00019106 7/1/2018 7/1/2019 S WORKERS COMPENSATION PER 0TH- AND EMPLOYERS LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNEREXECUTNE 500,000 OFFICER/MEMBER EXCLUDED? n EL EACH ACCIDENT $N/A C (Mandatary In NH) JLLWC923335 7/1/2018 7/1/2019 8 yes,desodbe undw E.L DISEASE•FA EMPLOYEES 500,000 • DESCRIPTION OF OPERATIONS below • EL DISFASF-POLICY LIMIT S 500,000 D Commercial Property 630-7E696218 7/1/2018 7/1/2019 Blanket Business Personal $5,418,058 Property DESCRIPTION OF OPERATIONS I LOCATIONS/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 SSSH 3, Inc dba Alarm New England, Voice THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sonitrol Security Systems of Hartford, In ACCORDANCE WITH THE POLICY PROVISIONS. Sonitrol New England 65 Inwood Rd AUTHORIZED REPRESENTATIVE Rocky Hill, CT 06067 q � Patrick Walsh*/IPGMH1 I7A /�/��2 _; ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014(01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts • T =_ Department of Industrial Accidents • {W Office of Investigations it i 600 Washington Street k;,.. 7.11,_ pi"~a Boston,MA 02111 13% www.mass.gov/din. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): SSSH3, Inc. dba Alarm New England Address: 22 Whites Path City/State/Zip: South Yarmouth, MA 02664 Phone#: 800-322-3500 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and I 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. 0 Remodeling ship and have no employees These sub-contractors have g• 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp. insurance comp. insurance.: 9. ❑Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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' 13.11Other Alarms 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. lithe 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: NorGuard Insurance Company Policy#or Self-ins.Lic.#: ALWC923335 a Expiration Date: 7/1/2019 Job Site Address: 3 '2o City/State/Zip: yc f✓4.49k,l Attach a copy of the workers'Soinpensation 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 pa' s and penalties of perjury that the information provided above is true and correct. t Signature: C --% Date: 7/1/2018 Phone#: Rnn-377-3c00 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#: I