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HomeMy WebLinkAboutBLD-19-1886 'r0 RECEIVED '----- SEP 27 2018 BUILD iithr 6i � _ rti f� ger �' o 9_ erg .`.� :F .. ..., .J Det tt rnet s i . leer�� - 0b. st9tite gating 6onu uaa.is 1146 geoute 28, 5044.tg cizrnawtg, EWQ 02664 APPLICATION FOR FIRE PROTECTION PERMIT Date 7 (K PERMIT NUMBER Projected Start Date: Date of issue In accordance with the provisions of 780 CMR and M.G.L. Chapter 148, as provided in Section WC. �/ � application is hereby made by i n 5/ C. "AY'rt 4 —��G (Full name ajperson,Firm or Corp r on) Address /7.61S— R f z�J S ya )44-0 t-A-rin I P1/9 (Contact#) 3Fj •T)4/ on/ Job Location 3 A�e(n,5 1'A/ / (Street&City or To ) cS. - '/Gtr/yv cj �� For permission to (state clearly purpose for w i h permit is requested) r - -"LSIlicci/ Oa 'Lec r 7 at Erie_ Q-l te) 114�r- Z.1,---fire net Cote /gs p A . 4o Ido/tic Sy.cftrg'l Name of competent operator(if applicable) M lAtr -- de Y Cert. or License No. , 7G Estimated Cost of Construction: /4/00 By .411111., ea (Si:na yeo!Applicant) PERMIT# 8LOAC - &"8-(40 FEE: $50.00 ./--4:mo i JO-- 1 - 1l' • ,dam The Commonwealth of Massachusetts • Department oflndustrialAccidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 a �,� www.mass.gov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TAE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Seaside Alarms Inc Address: 1265 Route 28 City/State/Zip: South Yarmouth, MA 02664 Phone T4: 508494-0599 Areyoa an employer?Check the appropriate box: Type of project(required): I.01 am a employer with 19 employees(full and/orpartfime).• 7. Q New construction 2.01 em a sole proprietor or partnership and have no employees working for me in 8. ElRemodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all wart myselt[No workers'comp.insurance required]r 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 lip Electrical repairs or additions proprietors with no employees 12.C7 Plumbing repairs or additions SC I am a general contractor and t have hired the sub-contractors listed on the attached sheet 13.QRoof repairs These sub-contractors have employees and have workers'comp.insurance 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.1:1Otheralarms 152,§I(4),and we have no employees.[No workers'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 ofthe 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 ant an employer that it providingworkers'compensation insarancefor my employees. Below Is the policy and job site information. Insurance Company Name:Associated Employers Policy if or Self-ins.Lia#: WCC50050128332018A Expiration Date: 225/19 Job Site Address: All sites in p a w City/State�p: Attach a copy of the workers'comps tion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e.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$250.00 a day against the violator.A copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ceeitrtt �underthepains and penalties of perjury that the Information provided above Is true and correct. Sierlature: +`i/✓�.n ./rt‹ 1 i'3 f Ci c ...err— Date•, a'/a3 I$ Phone#: 50&394-0599 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 L Contact Person: Phone#: VIV414a2. 5 Tab 1r/°a dO O 4M-sit ! Ir-312 I Iry dO dO 71/� o- 1 -vet - +oo tom MelId•UN 130 1Y314 3777 1 I Wag/171 \AV ® 1`110.1.03120 CYO 07 ' d© LA ita■Yore cadina I kd1.AY G1J� Avcr c-peri&' s z void ���� vu