HomeMy WebLinkAboutBLD-23-001186 RECEIVED
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APPLICATION FOR FIRE PROTECTION PERMIT
Date q t Jam_ PERMIT NUMBER LD 2.2rb0(I
Projected Start Date: 9/VZ C 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 .-Se side. .09/cr't4 S /4G
(Full name of person,Firm or Corporation)
Address /ZC_5---,Woc,Z 2.87, ---5 y4_7,r't0c. , 714 g O L/cCo Y
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Owner of property ja^ I/O try
Job Location 9:c RA C- (o tie; ('`10� (A) Y .
(Street&City or Town
For permission to(state clearly purpose for which permit is
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Cert.or License No. 0 ) 7 C- Estimated Cost of Construction: 2 /c.
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(Si fippliea t)
Buildin Official: Date: C1
FEE: $50.00
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N " s 11,4 HAYES RESIDENCE GARY A.ELLIS
2 - s Of►NKOWi CN,WRIT WMaOYY/r.IAA 141 Main Street
u Yarmoutfipor4Massactrusetts
ELEVATION/FOUNDATION PLAN/SECTION 774-487-0355
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Commonwealth of Massachusetts
Division of Professional Licensure
.i lit=
Securi,# 'rsiern License
SSCO-000046 xp►res.0110512023
ROGER K c
SEASIDE
ofssa
Commissioner d,,,,fl„ �mca
t• I
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette city Center
2 Avenue de Lafayette, Boston,MA 02111-1750
wwn:mass.gov/diu
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name tBusiness/Organizationitad vidual):Seaside Alarms Inc
Address:1265 Route 28
City/State/Zip:South Yarmouth Phone#:508-394-0599
Are you an employer?Check the appropriate box: Type of project(required):
I.El I am a employer with 19
4. haveI am a general contractor and I 6 hired the sub contractors ❑New construction
❑
employees(full and/or part-time).* 7. Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 0 g
ship and have no employees These sub-contractors have g. Demolition
employees and have workers'
working for. me many capacity. � 9. ❑Building addition
[No workers' comp.insurance comp.insurance.:
required.]
5. 0 We are a corporation and its I0.®Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
right of exemption per MGL Roof repairs
myself. [No workers'comp.. 12.0 p
insurance required.] c. 152,§1(4),and we have no
] employees. [No workers' 13.111 Other Security&fire alan
comp. insurance required.]
*Any applicant that checks box l must also fill out the section below showing their workers'compensation policy information.
+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.pokey 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: Hartford Fire Insurance Company
Policy or Self-ins. Lie.#:08WECAE7ZU7 Expiration Date:2/25/23
Job Site Address: All sites in ytt+Ai �z .e.- 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 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 pains and penalties of perjury that the information provided above is true and correct.
i f
� ,_. s°• ,.^- �- Date: 2/25/22
Signature
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(check one):
I❑Board of Health, 20 Building Department 31:City/Town Clerk 413 Electrical Inspector 5lumbing
Inspector 6.0Other
Contact Person:_ Phone#:
DATE IMMtooIYYYY)
ACa of CERTIFICATE OF LIABILITY INSURANCE E(MMI2022
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 rights to the certificate holder in lieu of such endorsement(s).
CONTACT Emily Montgomery
PRODUCER .NAME:
PHONE (800)640-1620 I t FAX Not:
Dowling&O'Neil Insurance Agency PHONE
No.Exd:
E-MAIL emontgomery@dOifS,com
973 lyannough Road ADDRESS:
INSURERS)AFFORDING COVERAGE NAIC S
MA 02601Crum&Forster Specialty Insurance Co. 44520
Hyannis INSURER A: 33618
INSURED INSURER5 Safety Indemnity Insurance Company
Seaside Alarms Inc, INSURER c.
Hartford Fire Insurance Company 19682
1265 Route 28 INSURER D:
INSURER E:
South Yarmouth MA 02664 INSURER F
COVERAGES CERTIFICATENUMBER: CL2222501858 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,
INSR POLICY EFFICro ) LIMITS
LTR AUULSUt POLICY NUMBER. (MMIDDIYYYY)
Irrt OF INSURANCE INSD wVD 100D000
X COMMERCIAL.GENERALUABIUTY EACH OCCURRENCE $ , ,
RENTED
DAMAGE TO 50;000
I CLAIMS-MADE I X OCCUR PREMISES(Ea occurrence) $
MED EXP(Any one person) $ 5,000
GL0087043 02/25/2022 02/25/2023 PERSONALSADVINJURY $ 1,000,000
A 2,000,000
--
GEN'L AGGREGATE LIMIT GENERAL AGGREGATE
PER. 2,000,000
$
PRODUCTS-COMP/OP AGG $
_ T OHEL POLICY X JEo- (LOC PROFESSIONAL LIAB. $ 1,000,000
: COMBINED SINGLE LIMIT $ 1,000,000
AUTOMOBILE UABIUTY (Ea accident)
BODILY INJURY(Pet person) $
ANY AUTO
02/25/2022 02/25/2023 BODILY INJURY(Per accident) $
B OWNED SCHEDULED 6222107 AUTOS ONLY AUTOS (Per accident)
HIRED NON-OWNED PROPERTY DAMAGE $
X AUTOS. ONLY. AUTOS ONLY $
_ 1,000,000
UMBRELLA UAB OCCUR _EACH OCCURRENCE
$
A X EXCESS UAB CLAIMS-MADE
SE0117502 02/25(2022 02/2512023 AGGREGATE $ 1,000•
000
$
DED I I RETENTION$
WORKERS COMPENSATION XI.u 4m 1 I ET
AND EMPLOYERS'UABIUTY Y IN E.L.EACH ACCIDENT g 1,000;000
ANY PROPRIETOR/PARTNER/FYFCUTIVE N w rA Og)A/ECAE7ZU7 02/25/2022 D2/25/2023 1,000;000
C (Mandatory H}EXCLUDED? E.LDISEASE-EAEMPLOYEE $
If yes,desalt*under E.L DISEASE•.PDUCY LIMIT. $ 1:000,ODD
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD'101,Additional Remarks Schedule,may be attached it more space is required)
Insurance coverage is limited to the terms,conditions,exclusions,otherfmitations and endorsements. Nothing contained in the certificate ofinsurance shall
be deemed to nave altered,waived,or extended thecoverage provided by the policy provisions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Yarmouth
1146 Route 28 AUTHORIZED REPRESENTATIVE
South Yarmouth MA 02664
rc ram'
I CI,1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD
•
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JAI
Inc.
1265 Route 28 • South Yarmouth, MA 02664 • 508-394-0599 • MA LIC. #1317C
24 HOUR PROTECTION RECEIVED
DEC 12 2022
BUILDING DEPARTMENT
By
December 6, 2022
Yarmouth Building and Fire Department
1146 Route 28
South Yarmouth MA 02664
Re: Fire Alarm installation @ 95 Pine Cove Drive, West Yarmouth, MA
Permit# BLD-23-001186
Dear Inspectors,
Seaside Alarms has installed and tested a low voltage fire alarm at the above address.
The new detector locations and operation were reviewed and tested with the Yarmouth fire
department as part of the building permit sign off on 12/6/2022. This system meets MA state
building and fire code requirements and was left fully operational.
Seaside Alarms will provide routine and emergency service as required.
Sincerely,
Paul Haygood
Seaside Alarms Inc.