HomeMy WebLinkAboutBLD-23-001742 RECEIVED
[0.5_,T 03 2422
EPARTMENT
{JJ�JOECLO, Cat •�y-'f
D,� e5 - fbe a ;i„y
1146 J 28, S pa,urwag, J O2664
APPLICATION FOR FIRE PROTECTION PERMIT
Date 9 -30 o2,2 PERMIT NUMBER B LD--23 -DoriLl2
Projected Start Date: Asp- 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 Cod g 2- fttrrai
` �,,/ (Full name ofperson,Finn or Corpora/ion)
Address c 0 2 o z- l 0 wri a-f o l.tS'E ROA Of
(Contact#).5OY 3 93-`&) 0 Email 3i9 L�S� �',R¢��Ct�Gt��1 � 1 C a 'l Coal
Owner of property ' a r pP COIL Pe 66&CI (7,5
Job Location /7 9 6o\AI1& G
(Street&City or Town)
For peituission to (state clearly purpose for which permit is
requested) r F_r 2J�C'� �a QE i S rr\h( (Fir E -2A r CD a'r02_
jOflL And ; 4'1S-reLL W; rEL ss rctho Fo mov ror;v1 .
Name of competent operator(if applicable)
Cert. or License No. 15 g Estimated � 2(O0 o
Cost of Construction:
By
(Signature of Applicant)
Building Official: J— Date: to- - -�)
FEE: $50.00 JUL n L. re I T T OZ/ QZd (Po(.01/mous e R d
vp ; YArrmc A 0,- C73
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Wivwumass.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:
1.0 I am a employer with 30 4. [] I am a general contractor and I Type of project(required):
employees(frill and/or part-time).* have hired the sub-contractors 6 ❑New construction
2..0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, employees and have workers'
[No workers' comp.insurance comp.insurance.I 9• El Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doingall work officers have exercised their
11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL. y
insurance required.]t c. 152, §1(4),and we have no 12.0 Roof repairs
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 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 shorting 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 Ins., Co.
•
Policy#or Self-ins.Lie.#: WCC-500-5006433-2022A Expiration Date: 9-1-2023
Job Site Address:
- City/State/Zip f A6-11:101.,( ,3-� ��OCcJ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratkin 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pairs and penalties of'eryury that the information provided above is true and correct.
Si nature: f-c
�`� Date: 9 -30
Phone#: (508) 398-6316
Official.use •
only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department.3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
•
•
Contact Person: • Phone#: •
• ---
•."- -- --.
- •
•
•
. .
• :
. .
•
---- .
COMMONWEALTH OF ' ASSACHU ,,.$.9,,::,..
.... ss
...',' DIVISION OF OCCUPATIONAL LICENSURE . -...
conanonweeith Or Massachusetts
_.,,,..EIDMiP-'0- ,,,...
:„ Division of Professional Licensure
ELECTRICIANS ,..n..gt.,'W •.
•
ISSUES THE*OLLOWINGViCENSE ,,,,;,‘,.k.-•;.41.'.k.A' • "
.. g..scuritMeganisti!,,B-Licens9
REGISTERED SYSTEM TECHNICIAN 4,..., . ,
i7
,:•::::,,;',*,,•; •,:: ......,:s.,„,4i.'::':•.,•.,;:' '4,,. SSCO-000246 iziY .. .. Wires:11/0712022
,.,.:,,,,k,,,,,i -.
• GENE A CORMIER'.0„ .'••,1.' ' ' ,,':
. , ,.„....,.,„..„.
9--MARGATE LN .. .:,,.; ,, .. „Aft
N ,11'! . GENOORMJE7RA,
•• :•,...,. ...,, , , ,:-, ,,,,,7,...,,0-_-„,--- „,,:,,,,,,,::,,:-.,
SOUTRDEiliki8;MA 02660-20.674 v, , EmigPied-by1WW
CAPE cop ALARM
,c...- .',:-';11 •: =-,-- -.-',Y-',`,„ .
..., .. .-....,, .., .
-:':::' • 't,,,,, • . '‘ , ,',',..!,'4.,- -.. , .r.,-k.. -
.. •„.; _-_ .‘,...„ ,,:,, .„.„.„...,-_„ . „...„..„.„
.........,..... ..:::: .,:.,:
1607 D.:,•::. .,.,.•:-..:],. ..,.:0713112025 .,„ 290762 -::•,.,4••••••- Commissioner vi...4tuepl K. BlEmilia,..,. .
LICENSE NUMBER . ,EXPIRATION.DATE SERIAL NUMBER
..... .. .- . - •- -
•. .
.- ....,„,..,,
*SFCOMMON EALTH OF bit.''.SSACHUSE 1.:Si,
.w
DIVISION OF OCCUPATIONAL LICENSURE
_,,,..,119.?4,.flPY
IX • ,.. .
,.., EOTRICIANS
....,:- p...,...:•,:!4:,-,f," ,..ii
''qd:P. ElY ISSUES THE FOLLOWING LICENSE
..,.,;:,:'-,', ' -,P.:::--,-,-..,•;,k..
REGISTERED SYSTEM CONTRACTOR '•'•,- ". ,,0 : ..r.
GENE ‘?., A CORMIER :i;:.'.: :,-• ' . \ N'.2• : -
• tilrillIARGATE LN.„ i, • •::
• - SOUTI-t;.:DENINIC MA 0266040074 , , , •
,..:....,..,„, .,
, .••:, - „.\.. : .
• .,. ,:.,„.,..,....„. ,.. .i,:-\:i
1592 C.::•]. ::::'.kNi:!::07:/31/2025 - 290760 Y:.- :',";""':'•
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
--i ....,
• ,
---...q.li,-:!1:I'• 0 Li 1_1 0 l ,i .; ., 0 . ,... - E,2.....
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
A ' Kg6TiliciANS::::::, ,','.'.ii.A]*.lt
, .4.4 1,;.,
ISSUES THE FOLLOWINGIACENSE pi,,,,.. '....-10, ........,
REGISTERED ELEcTRICAL BUSINESS
CAPE COD COD ALAROGCY1NO . \\::
if laiiiii.OLD TOWN HOUSE RD
-:•].„.,-
;.-.:,•,..,.,,c:.- .,.:,- . ..,',
WESIglit*OuTti,mf%„:919,71-4031
'';;F:';'•::t.,,,I
1395 Al ei,f,i;]:•.'' 07/31120,22,,.. ." .q., 936314 '.:-•:,.tr'''''
'' '' :•,:-._. ('':,?•-'.;•::KS'''.4g •i-,.-: • '
LicEN$ENOMBER' ,-.-,_EXPIRATION DATE - ' .SERIALNyMBEr!
- ''-
' .
-N.