HomeMy WebLinkAboutBld-23-004517 Fire Protection RECEIVED
FFEB 13 2023
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'`� BUILDING DEPARTMENT 2� c 1T
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1146 goide 28, & , OM 02664
APPLICATION FOR FIRE PROTECTION PERMIT
Date q7----C/2_ PERMIT NUMBER .b u -23-Ob 4+517
Projected Start Date: 2,/%3 Z`--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 cue- S!de__ Ro,_7Psi,LS �nC .
,� (Full name of person,Firm or 7oration)
Address f Z. 6 r /20 z.. J -`�.o 1-- 2c C'i /2(,/7
(Contact#) Mgr-"Oj 9 mail 620�1 (_Sc i�/cila-( `/l-(5 - D
Owner of property i o,•to,-/ du.-a7' o Y/car`/
Job Location 3Z? koc4- 6/1 7ti(ai►tip`- `f/r 1*, SAo/
(Street&City or Town)
For permission to (state c/i arly purpose for wd ( 4 )
'ch permit
requested) `__/ tA./ `Z Syvt o L �/S7 J/'l qL
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Name of competent operator(if applicable) A?? ,4 48$o 1."-e----h-e--/-
Cert. or Licens No. 2/ 7 C_ Estimated Cost of Construction: 2
,0: 7,
By
igna of Applic nt)
Buildin Official: Date: )-- I - '.3
FEE: $50.00
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.1st Cong Church 0
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NOTE-System is monitored and the —�
FACP is located next door in the -1A� v
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Church Utility room 1
—0 Photoelectric Smoke de ! ti{
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0 Fire Extinguisher
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H Fire Horn )4e...J eFiZA Ig h -,_
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P Fire Alarm Pull station [SG>EZ({ � SOtI'iv�4 I l }•
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AC K 02i25r022 CERTIFICATE OF LIABILITY INSURANCE DATEIMM/2022 YI
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 art endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s►.
PRODUCER NAM
CONTECT Emily Montgomery
Dowling&O'Neil Insurance Agency PHONE (800)640-1620 FAX
_LAIC,No,Eat). (AfC,Sal,
973 lyannough Road E AILss: emontgomery a'rdoins corn)
INSURER(S)AFFORDING COVERAGE NAILF
Hyannis MA 0260 INSURERA Crum&Forster Specialty Insurance Co _ 44520
INSURED INSURER B Safety Indemnity Insurance Company 33618
Seaside Alarms.Inc. INSURER c Hartford Fire Insurance Company 19682
1265 Route 28 INSURER D
INSURER E
South Yarmouth MA 02664 i INSURER F
COVERAGES CERTIFICATE NUMBER: 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. NOTIMTHSTANDING 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.S SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS ..__._
INSR ADDL SUBR I POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE !NWIVD POLICY NUMBER I(MMIDD/YYYYi IMMIDDIYYYY) _.
X COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 50.000
ICLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) S
MED EXP(Any one person) S 5.000
A GL0087043 03/25/2022 02/25/2023 PERSONALBADV INJURY s 1,000.000
GEN'L AGGREGATE t LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000.000
PRO- PRODUCTS-COMP/OPAGG $ 2.000,000
POLICY X JECT LOC PROFESSIONAL LIAB s 1,000 000
OTHER_ _ I COMBINED
SINGLE LIMIT S 1,000,000
AUTOMOBILE LIABILITY lEa ecfidanr)
ANY AUTO BODILY INJURY(Per person; S
B OWNED SCHEDULED 6222107 02/25/2022 02/25/2023 amity INJURY rPer acadanti S
AUTOS ONLY X AUTOS PROPERTY DAMAGE
XHIRED X AU S ONLY (Per accidenu 5
AUTOS ONLY
S
UMBRELLA LIAR OCCUR I EACH OCCURRENCE 5 1,UOO,000
A X EXCESS LIAB C IMS-MMADE SE0117502 02/25/2022 02/25/2023 AGGREGATE $ 1.000,000
DEG RETENTION S -.-- - S
WORKERS COMPENSATION -`X STA PERTUTE OTH-
AND EMPLOYERS'UABILITY YIN ER
1.000.000
ANY PROPRIETOR,PARTNERIEXECUTIVE N N I A OBVVE CAE7ZU7 02r25i2022 02'25i2023 E L EACH ACCIDENT $ _
C OFFICER/MEMBER EXCLUDED? 1.000,000
(Mandatory in NH) E L.DISEASE Fr EMPLOYEE S
if yes,deacnea under1 000.000 ....._..._..._
DESCRIPTION OF OPERATIONS below _ E L DISEASE POLICY LIMIT $ --
•
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached d more space is required)
Insurance coverage is limited to the terms conditions exclusions,otherlimrtalIons and endorsements. Nothing contained in the certificate ofinsurance shall
be deemed to have 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
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
1146 Route 28
AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 .4 fir/ _ �r�,,/
it(� '
0.
�° i9 1988-22r0e15 ACORD CORPORATION. All lights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
'°'is\ The Commonwealth of Massachusetts
Department of Industrial Accidents
121::
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1751)
wwwtnass.got/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businessiorganizationhlndividuah: Seaside Alarms Inc
Address: 1265 Route 28
City/State/Zip:South Yarmouth Phone#: 508-394-0599
Are you an employer?Check the appropriate box: Tope of project(required):
1.0 I am a employer with 19 4. 0 I am a general contractor and I 6. ❑New,construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
P ty 9. ❑Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. ❑ We area corporation and its 10.®Electrical repairs or additions
officers have exercised their 11.0 Plumbing repairs or additions
3.❑ I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] c. 152,§1(4),and we have no
employees. [No workers' 13.®Other SeCUrlty & fire alarl
comp. insurance required.]
*Any applicant that checks box*I 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.policy number.
I am an employer that i.e providing workers'compensation insurance for my employees. Below is the policy and job site
in formation.
Insurance Company Name: Hartford Fire Insurance Company
Policy#or Self-ins.Lic.#:08WECAE7ZU7 Expiration Date:2/25/23
Job Site Address: All sites in y A404 otglA _- 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 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. 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 unr correct.
Signature:> _'1 ./. _.__. Date: 2/25/22
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):
1 DBoard of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 51:1Plumbing
Inspector 6.❑Other
Contact Person: Phone#: