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APPLICATION FOR FIRE PROTECTION PERMIT
Date / /o76o4?019 PERMIT NUMBER ,Z3LL)
Projected Start Date: ci95/1P Date of issue
In accordance with the provisions of 780 CMR and M.G.L. Chapter 148, as provided in
Section
byThis (C applicatign is hereby(Cd de
Low rn
q (Full name of person,Fir n or Corpo ation
Address °X V 0/4 T/ OW)(11f 01iL 3 E. K.,0aa 70vm o t. a-e
(Contact#) 5O —3 98-(.3I C Email S (' E
Owner of property ,V o r V'i ew R e. o r 7-
Job Location 3 y /U e a-1nne Lane
(Street&City or Town) 7[711 Fa A. 1'IG1F t
For permission to(state clearly purpose for which permit is
requested) r e/0661,TE 'CM E ex i ST1 n- n`, 5 ou4 v 4 e r F c o m
nS;OE `a-te CLOSET"TO OluMS1 oe clE CLOSET Y)
seLeex nUrnber o coo msSo rl -r r11- scw4o 5 MdT Bff/1 I ID
Ohc6C t3Ei,Uo- iN rffarcA ,
Name of competent operator(if applicable) G e Y1 E o r r2nw.>C' Cry e C.l
/ f O Z '�"11
Cert. or License No. /5�'2 - C Estimated Cost of Construction: / 0 •
By (L)211J�o
(Signature ofApplican)
Building Official: Date: 3- ct ` Id
FEE: $50.00 lL 'z f( 9-€ o c-F I iV{ c_ - / - q - Z O
The Commonwealth ofMassachusetts
► -='-: h�l Department of Industrial Accidents
=Met S 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.nuns.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):
1.0 I am a employer with YA, employees(full and/or part-time).• 7. ❑New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.(No workers'comp.insurance required)
3.0I am a homeowner doing all work myself(No workers'comp.insurance required.]a 9. ❑Demolition
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all worik on my property. 1 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 1 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 �e�� Ff'OY have exercised their right of exemption per MGL c. 14. Qther( r c b(? f61+n i
152,*1(4),and we have no employees.(No workers'comp.insurance required.] e. U t Y1S i Q E Q3i�
rO eta O tAx5 pE
'Any applicant that checks box HI 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 Insurance Company
Policy#or Self-ins.Lie.#: �W/CC-500-5006433-2019A Expiration Date:SEPTEMBER 1,2020
Job Site Artiness: (/►�i4' �i U y)e. Lane. City/State/Zip:5014 el Marl X)WAgle
Attach a copy of the workers' pensation 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 S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 undo epains p of perjury that the information provided above is true and correct.
f
Signature: /Y _ 1 Date: 10h Oi 19
ly
Phone#:508 58-2624
Official use only. Do not write in this area,to be completed by city or town ofciat
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#:
•
•
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COMMONWEALTH OF MA..SSACHUSETTS
Commonwealth of Massachusetts
Division ot Professional Licensure
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
••••••• ..,„:..„
Sec u nseli
LLOWING:446ENSE
ELECTRICIANS
ISSUES Fo •• •• -• •'••• •
. SS C 0-000248 , Expires: 11/07/20?0
REGISTERED SYSTEM TECHNICIANA
GENEitCOR
GENE A CORMIER :lz EmPT:9Yed 9 • ,
MARGATE LN CAPE COD AL.
SOUTH DENNIS, • itwo
.• . .
. .
683°°1 •
Commissioner CI-
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
CitOMMONWEALTH OF IVIA.StACHUSETTSftN
DIVISION OF PROFESSIONAL LICENSURE
.......BOARD OF
•
ELECTRICIANS I .
ISSUES..THE FOLLOWING LICENSE
REGISTERED SYSTEM CONTRACTOR .'••
....G.ENg A CORMIER
CAPE cOrt•Ak-4A00 CO INC g:
204 OLD TOWN HOUSE RD . • sr• 6
• • • WEST
• .
1592 C 0713112022 655106
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER