HomeMy WebLinkAboutBLD-23-001743 RECEIVED
OCT 03 2022
BUILDING DEPARTMENT
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1146 Rospto 28, Sowa pwrmwa,a, OM)02664
APPLICATION FOR FIRE PROTECTION PERMIT
Date 9 -30 PERMIT NUMBER 13 Lb--23-Doi-7(4
Projected Start Date: A sia 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 e 2,prnn
(Full name of person,FA-m or Corporation) \
Address j0 Li 0 Lid r---)1 0 w n e act Ki y1:4 c tenOvq.\-t
(Contact#)50E-30?-5050 Email 51:11-e...S eAre. ct Lifl-r oi ... o ry)
Owner of property(Arc. eod oe.., in cat Lo
/30 ,
Job Location i,.)71i Y\S L. PR L-LP_T ROA d_
(Street&City or Town)
For permission to (state clearly purpose for which permit is
requested) rEr 2-A Of fit 111..-f\Ain ex-%OKA vAg F /42_14 fik
edom-cot_ /061.1.6z,.
Name of competent operator(if applicable)
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Cert. or License No. )53,02 C Estimated Cost of Construction: 3 000,
By
(Signature of Applicant)
Building Official: •• Date: K.)-1-k-44,
FEE: $50.00
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
w; v mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): CAPE COD ALARM CO.,INC.
Address:204 OLD TOWNHOUSE ROAD
City/State/Zip:WEST YARMOUTH, MA 02673 Phone#: (508) 398-6316
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 30 4. ❑ I am a general contractor and I
employees(full and/or part-time). 6. ❑New construction.
* have hired the sub contractors
2..0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling r
These sub-contractors have
ship and have no employees 8. ❑Demolition
working for me in any capacity. employees and have workers'
insurance.$ 9. ❑Building addition
[No workers'comp,insurance comp.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a'homeowner doing all work officers have exercised their MC Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL_
r 412.❑Roof repairs
insurance required.] c. 152'§1 O,and we have no 13.0 Other
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.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tC:ontractois that check this box must attached an additional sheet showing the name of the sub-contractors and slate 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 Ins., Co.
Policy#or Self-ins.Lie.#: WCC-500-5006433-2022A Expiration Date: 9-1-2023
Job Site Address: j A W5 L {/ l L1A 'RC 1CL City/State/Zip: j /j�Y �\o l J t /4
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 etyuty that the information provided above is true and correct.
9 q �,
Signature: lOr,�.s e" �V Date: (? 1
1
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.Pltunbing Inspector
6.Other
.•
Contact Person: • Phone#:
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COMMONWEALTH OF 1A.,sisACHU ,,,S,,,-,, • •
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DIVISION OF OCCUPATIONAL LICENSURE : c
BOARD ommonwealth of Peassachusetts
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, ,,,, Division of Professional Licensure
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— ELECTRICIANS,.,: v.a.:0,1 .
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ISSUES THE POLLOVIANGitPEP1SE
SeelLiGiVAStOrffiwIl.ta-LICCOnes
•.'''..' ' REGISTERED SYSTEM TECHNICIAN
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GENE A CORMIER ';.:,...,.:. --..--',. - ' IS .• .-fi ::A'neg:,"•...-: ..,..:Fk -i-,'.i.if.:EAtii ,
.a,z:5:87MARGATE A: .; . •:.:::.......:. 1. 7-N§ • GEN*0-1 Co$0b 8=7g.8'-k4
SOUTH NA 02660-2667, En504
CAPE COD ALARM
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Commissioner dtte2, K. 5316,,,latik,' :
LICENSE NUMBEil EXPIRAJ1•TON DATE SE RIAL Ni.INI. BER
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COMMONWEALTH t bF MAS§Ati4USE f.,S.W."
1 DIVISION OF OCCUPATIONAL LICENSURE . 1
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,... ELECTRICIANS,::.„,:ov,K...:.;:i,,,,,f • :
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;':iiii:YVIIY ISSUES THE FOLLOWING LICENSE
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REGISTERED SYSTEM CONTRACTOR "..,N•'• I . ,.
GE.NE A CORMIER -,:•;,:* - '1• : •
9MARGATE 414,:,,,:,..R
SOUTH OONtiltS MA 02660-467#
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1.-,•,f0' 1692 0,.:e.,.i.t.',::;i:.:$6r01131/2025 ,.. -i., 290760
LICENE N SUMBER EXPIRATION DATE SERIAL NUMBER
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131\1SiION.OF PROFESSIONAL LICENSURE
t§: .„,;...;,,.•,'',, - BOARD OF
ELECTRICIANS • -
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ISSUES THE FOLLOWING ttaigtE
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::: ' OBGIBITERED ELECTRICAL BUSINESS •,, • ,
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.,,...CAPE COD ALARaCOINC
204 OLD TOWN HOUSE RD
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• LICENSE NUMITR.. EXPIHATI;1` DATE -_'''' ..:9_!EJ1.11t4..li..M,.R.ER
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