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HomeMy WebLinkAboutBld-20-002134 , 1 • ~Y` .yam, j;431:IY � s ft "IN 2.1 h +`� c T4 � fZQfiLf LQ i7r(�Z ,,/Q /Vj/y{yam. JE� .':,,. : -,...: 0 n, 'g�> S - 0✓% eI die Oudelfuj eanunidaone4 1146 gi0444 28, e5oufg pa,renoat4 gig 02664 APPLICATION FOR FIRE PROTECTION PERMIT Date l°//f7/7 PERMIT NUMBER J L� - 0,A - .2/3 y Projected Start Date: /J O /, Date of issue In accordance with the provisions of 780 CMR and M.G.L. Chapter 148,as provided in Section This application is hereby made by ,-�e t..7 ids ecty/v/ S /n C.— (Full name of person,Firm or Corporation) Address /ZCvS kot -1LZ- 2E() --5 Y4-y nk 0,("7' ) /14, 0 Z/0 6 `t (Contact#) S g-,39 v -°. 9'7 Email 1�t- -7&." , .a..1 c-r $ . !�el Owner of property 4J�0rA ✓ sikdt6� Job Location 170 0,0e'[.',_Sc44 / S/- 6'i,,,e_s",/- /J/0G (Street&City or Town) For permission to(state clearly purpose for which permit is requested) ._.. --A,S1/2--1/ ---- /14 0/6".-- 14 _...c.-afir'.404 fr(04 OX/e-k_ e. 672'_c L4-/: _/ ' "We" r(0471 /". . jil .e-e-7---Z-,,e-/e.4/— ,Ce,,,AAA6e1 - Name of competent operator(if applicable) Cert.or License No. ' l 7 L !� Estimated Cost of Construction: 2 By (Si fApplica )1.3 Buildin Official: Date: (U -16-1`i FEE: $50.00 \--..... . . 7: ... \ la ...--. ..",-•:'.: ': _, , . \ . , \ , ---- \ ,\ _ ..., ..." „„e•of;\,' __ ' ' ' ,' ' '.\, \ \ :-:' \'' \ \\ ,-- \ '. / ,, , 2 2' \(\eit) '' ti, ' ) 4° .."- .7777,-- ,,\O 01,614,5_,, ,,v .," / ..--- ' V-' ''' '' <•!--'-\ 0)/7' CD ..-'''‘' ' 'N \ - \\\ ef ' •' / N . ,."\i'•'-.-\\\';','•••s\`',\s"- ,...2\ \'\\."\s-,'N,.\,,,\ ''' _. • 'TA 4 i 'P, ,. V. Tr-,-,., \''<.'\' '\‘' \ ' \''''''' ' "1.• 13 ./.--: ‘to \''''‘‘‘;'.'', , '''''W`, „'..\\ s• T-- 1 - \''''''' ''^*\‘-e/'\\''t CN •'''• VI-- . , • -'' . 't• , •., . \ '',‘‘‘,\ • ' \\''r\'‘ : , (''''• `'' \,,,,-- , 0 ' , , Ir:ir \ -\ \ , '\('''\ .\•‘.. \\'' ' '''' . ‘ -----..., \ 13 \ ,.\\'>,\ .', . s''''R\: - •—• \ \ , , .: '''''— -,.`\,s- % . " 4‘ 1\-- \'11\\:: 0 : r' 110, \ ' \ \f ,.. .. • eN1 46 (r) \ \ \ \ 5.,.. , \ • 7---, ,/ \ \ \ -A • , (9 ‹C\ 6 \ ,,,,,, ,--'"• ).> ,.... \ '\•.•••\:,','„ it\ .....1....„ rr:C.' „/ X' N. \ 8 ,.- \\. .•7'''..---y/..---- \ / '2\ •-•..A ti . ..-- -7/ ' /\\ \ \ „„..--- \V7 .. . (1),\ ..-- \. - ‘.'• -- i ------"\ ...- ..---77- m ; • s, ,..--- \ ___---------\ -- \.<____ \ ...-- g 0 g \ \ _A \ _______\___----- . N F \\ \ o e N„ ... . . \,, • Commonwealth of Massachusetts Division of ProfessionalC � Licensure Y\tti i Secur`, s i/-S-License r SSCO-000046 "txpires: 01/05/2021 ROBERK i'1 E m9YeB � SEASIDEiLARM ` Commissioner a... OOMMONIK . . OF.� q,. -SUS DIVISION OF PROFESSIONAL LICENSURE • g m�Tp x' ELECTRICIANS ISSUESHE FOLLOWING LICEE• _ REGISTERED SYSTEM ONTRAC'TOR i PERT K 80UCHER� � �, SEASIt S1NC 'f j r 12 1265 RU .26 S YARMOUTH,MA 02664-14455 • 1317` r 071311 ! 6942 C46 • LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER COMMONWEALTH OR:MA NUS 5 S DIVISION OF PROFESSIONAL LICENSURE RDA ELECTRICIANS ISSUES FOLLOWING LICENSE REGISTERED SYSTEM§XSTERFIVICHRICIAN I� II BERT K BOUCHER :.. 1265 ROU' S YARIVMOUTH,MA 026� io' iJ • 463,D 0713. 112022 694240 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Client#:21641 2SEASIDEAL YY ACORDTM DATE(MM/DD/vvYY) CERTIFICATE OF LIABILITY INSURANCE 07J20/2019 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(ies)must have ADDITIONAL INSURED provisions or 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CQNTACT NwwME: The Hilb Group of N.E.dba PHONE 508 775-1620 FAX (AI ,No,Ext): (A/C,No): SO87781218 Dowling&O'Neil Insurance Agy E-MAIL P.O.Box 1990 ADDRESS: Hyannis,MA 02601 m INSURER(S)AFFORDING COVERAGE NAIC It INSURER A:Cru &Forster Specialty Insurance CO. 44520 INSURED Seaside Alarms,Inc. INSURER B:Associated Employers Insurance Company 11104 1265 Route 28 INSURER C:Safety Indemnity Insurance Company 33618 South Yarmouth,MA 02664 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LR TYPE OF INSURANCE ADDSUBR NSRL WVD POLICY NUMBER EX (MMILDICYD/YYYF POLIY) (,ACD/YYYYY) LIMITS A X COMMERCIAL GENERAL UABILITY GL0582133 02125/2019 02/25/2020 EACH � O OCCURRENCEE $1,000,000 E CLAIMS-MADE X OCCUR PREMISE (EaE�ence) $50,000 X BI/PD Ded:1,000 MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ C AUTOMOBILE LIABIUTY 6222107COM06 02I25/2019 02/25/2020 (E°a deD SINGLE LIMIT $1,000,000 _ ANY AUTO BODILY INJURY(Per person) $ OUTNEOWSDONLY SCHOEDSULED BODILY INJURY(Per accident) $ A X AUT HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR SE0103960 02/25/2019 02/25/2020 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION WCC50050128332019A 02/25/2019 02/25/2020 X STATUTE FORH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Professional Liab GL0582133 02/25/2019 02125/2020 $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE r ` ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #5230264/M230244 LS1 . The Commonwealth of Massachusetts 1!?; Department of Industrial Accidents iE11il_ 1 Congress Street,Suite 100 - _ C;i= Boston,MA 02114-2017 www mass.gov/dia .. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aualicant Information Please Print Leeibly Name(Business/OrganizationMdividual): Seaside Alarms Inc. Address: 1265 Route 28 City/State/Zip: South Yarmouth, MA Phone#: 508-394-0599 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 19 employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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 13.0Roof 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 Other security alarms 152,§1(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 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 Policy#or Self-ins.Lic.#: 1NCC50050128332019A Expiration Date: 2/25/20 Job Site Address: All sites in City/State/Zip: Attach a copy of the workers'compensation 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 tip 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 u e pains and penalties of perjury that the information provided above is true and correct. Signature: r Date: LS % Phone#: 508-394-0599 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 Contact Person: Phone#: