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Home My WebLink AboutBld-20-000433 to; ` Re I' Ls t c ✓ C/e�a rrcert 512,14f. C�J�n7icee - @ ,ice Gfre 03. �mtnia rQiz 1146 gLide 28, 5, 0E1'02564 APPLICATION FOR FIRE PROTECTION PERMIT Date //�1/� 1719 PERMIT NUMBER BLl)`a a - CO6 Cf Projected Start Date: psfi P Date of issue In accordance with the provisions of 780 CMR and M.G.L. Chapter 148, as provided in Section b This application is hereby made fi- 1 e rn �� l (Full name ofperso, yFirm or orporation) Address 020� oLd ( o w h a-WL4SE Pool �� Yoor OC J-( (Contact#) 5O '-39F-63i Email 5(t ,ES () ( r,...Co d(2 La r rY1 6 COM Owner of property j J esi- Youranousr-A Se r e5 Job Location /5'�{ (�j e r cv 1 j'e Y)lA E Street&City or Town) For permission to(state clearly purpose for which permit is requested) rzet_the THE exLsTi n Ada 1Lv�LFuVi on;v� 1Fi fe a La r r� co hI--co L ow g L , Name of competent operator(if applicable) G P In a CO r 1%,e C • ( r ri Cert. or License No. J.J 92 - C Estimated Cost of Construction: 150 0 ° By (Signature of Applicant) Building Official: � Date: ) -3 o /y FEE: $50.00 -, The Commonwealth of Massachusetts __.� I= t Department of Industrial Accidents t =EFIdI= 1 1 Congress Street,Suite 100 e,=li�l_ Boston,MA 02114-2017 ,. E 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):CAPE COD ALARM COMPANY, 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): l.0 I am a employer with -7 a employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doingall work myself[No workers'comp.insurance t 9. ❑Demolition Y p required.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m Y property.ro i will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs ?7 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.(✓ Other f e�o _.eE 'Ct J c 152,§1(4),and we have no employees.[No workers'comp.insurance required.) e(v 4Q-t ire ate rm *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. COI i I.'rp t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a vit indicating sum. • cA n E L :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 Insurance Company Policy#or Self-ins.Lic.#:WCC-500-5006433-2018A Expiration Date:September 1,2019 Job Site Address: 15-V 6e rIN t?VE'r)tit E City/State/Zip: eSc Vot, o10'1, n-( Attach a copy of the workers'compensa on 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 unde he nd pen ies of perjury that the information provided above is true and correct Signature: � L' r //1 Date: V—�r� -" pains 19 Phone#:50858-2624 fA, 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#: •••.. 4tOMMONWEALTH OF MASSACHUSETTS, C 01111,.11.0 YIL'i ea 0 f assach,,setts DIVISION OF PROFESSIONAL LICENSURE DBOARD 0 ivision Profess-1(3mi: Licensnrc:: • ELECTRICIANS I ISSUES THE FOLLOWING LICENSE • F. REGISTERED SYSTEM TECHNICIAN ss CO-000248 .-z? li07/9020 GENE A o CORNIER 41" 0 Eiltp_Qyed CAPE .• ' 4(1) SOUTH DENNIS, MA 02660-2667COD Al.• 6 212805 ,•-•< Commissioner C/1-- LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER ..g.'.0aiibOMMONWELALTH OF 1Wil.SSACHUSETTS ,.W1 DIVISION OF PROFESSIONAL LICENSURE BOARD OF • EtEctRiCIAN$4 ,:, ••••:-: ISSUES THE FOLLOWiNG'(itEriSE REGISTERED SYSTEM CONTRACTOR ( CORNIER CAPE COD ALARM CO INC 204 OLD TOWN HOUSE RD •.WEStYARMOUTH,MA 02673-1531 1592 C 07/11/202g,.:•,*::•,,,::&0 655106 • LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • • ••