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APPLICATION FOR FIRE PROTECTION PERMIT
Date 9 — 3 0 ', , PERMIT NUMBER et(,6.,Z,3_,b)I-,y
Projected Start Date: S R P 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 eilre od ALAc�
0L l,(Full p ofpersonY1,�f FinC7 r��cr�ylJn orCorEporation) l
Address � W
(Contact#) 5O8 --5050 Email BAD S e Gfr c cod ALA rrn ,
Owner ofpropertyVrAilLmIc, yI,SiALr6}W rS OF (12)O5W/V
Job Location g8' Y6 RR L L Evv gdI
(Street&City or Town)
For permission to (state clearly purpose for which permit is
requested) rErLitae. Ill Pt L'eUtl/ e_Y iQW-1 V\Q E C6
NvvtroL fo viEL .
Name of competent operator(if applicable) �9" NE it rfil sac-
0
Cert. or License No. I bJ `C Estimated Cost of Construction: I(J U
By
(Signature of Applicant)
Building Official: Date: \O ..
FEE: $50.00
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The Commonwealth of Massachusetts
Department of Industrial Accidents F
Office of Investigations i
600 Washington Street
- ` - Boston,MA 02111
www.niass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organization/Individual): CAPE COD ALARM CO.,INC.
Y.
Address:204 OLD TOWNHOUSE ROAD
City/State/ZipWEST YARMOUTH,MA 02673 (508) 398-6316
Phone#: 1
Are you an employer?Check the appropriate box: 1 1
Type of project(required): 3
1.0 I am a employer with 30 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors
6. 0 New construction
II
2.El I am a sole proprietor or partner-
listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition I
working for me in any capacity. employees and have workers'
insurances 9. 0 Building addition
[No workers comp.comp.insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
i.
myself.[No workers' right of exemption per MGL
Ycomp. 12:0 Roof repairs l
insurance required.]t -c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other _ j
comp.insurance required.] _ G
*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 4
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.
Associated Employers Ins. Co.
Insurance Company Name: l
. i
Policy#or Self-ins,Lic.#: WCC-500-5006433-2022A Expiration Date: 9-1-2023
Jit
A
Job Site Address: �F ��'s� L. �Ps Z-L eV 4' Pdcity/State/Zip: LA)) Yfi r on OlATJ-P 1
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 o
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 4
Investigations of the DIA for insurance coverage verification. s
I do hereby certify under the pains and penalties of etjuty that the information provided above is true and correct.
Signature: 741. rt44w (4- 3 O°'r1 7 _ Date: 9 (3
Phone#: (508) 398-6316
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#:
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.::,,,,*•::4:COMMONIPitAtTt4 OF MASSACHU _ r.,...-.. •-,....,. _.. _ ,
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..':' DIVISION OF OCCUPATIONAL LICENSURE - • • .. ,
commonwealth of Massachusetts
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Division of Professional Licensure
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ELECTRICIANS . :.•;:•:,.0-,:>*4
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ISSUES THE OOLLOVNG,acENSE .,,.., , • ztamtAA-Licerisa I
.,REGISTERED SYSTEM TECHNICIAN :,:;vo,• TA t .
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; SSCO-000246 ";:;,' . . :,':,.%,:-.40.1 "Aspires:11107/2022 .
GENE A CORMIER',;],..:,,,f'"E,,,fi' ••" I .i
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CAPE COD ALARM
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LICENSE NUML ER PIRAT
I EXION DATE ER SIAk.NUMBER
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*IiI"JPCOMMON EALTH OF Itir SSACHUS. 2..8,- .
DIVISION OF OCCUPATIONAL LICENSURE
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ELECTRICIANS
,., ...,..FOLLOWING
ISSUES THE FO LICENSE
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REGISTERED SYSTEM CONTRACTOR
GENE A CORMIER 'A.: ''':.;.:-'•: '
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LICENSE NumnEn EXPIRATION DATE SERIAL NUMBER
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•?.• ELACTRICIANSmreliyi
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Yilt ISSUES PIE FOLLOWINit LICENSE f.t.:!6i ly ....e,
' fitoTERED ELEgrwpfoi.BUSINESS - I
CAPE COD ALARlikat INC
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40VOLD TOWN HOUSE RD
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•• ..'• WESTi.:Y*RmoUTH,MA0.. 6744f3.1
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LICENSE-c:NOMBER'. .EX PIR AT ION DATE ..S..-[y./N.I.:t.s.ilyniiBR
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