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HomeMy WebLinkAboutBLD-23-001477 RECEIVED p 16 2022� SE i aa.Y BUI *_ T NT ` " il gge 4 orea.d.,,,,tk,. -,,,,,z;-,,,,i," _.0, w_ D5atvihrkedvt f 'g ,vdS - C9 odve criltdany. anuniaivione4 114E (62 28, Doug PGAM13 4, ad)02664 APPLICATION FOR FIRE PROTECTION PERMIT Date ?60/Z-- 7 PERMIT NUMBER 5t±-2-3-a) I L4 77 Projected Start Date: 9 /9/Z 7 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 6 _ f j f)f ?oPu �itG s .�} ,�; (Full name ofperson,Firm or Cor oration) Address / Z., 6 c leaC Z 1 `moot LA4' L-v-77 /`iii7 (Contact#) :39 - O$9. mail cArt/1 � iJri- c .69 i/v1 Owner of property vA e-S l7 4-e.---ie-& Job Location /2.. £7 , r�%12�` LA) 7 (Street&City or Town) For permission to(state clearly purpose for which permit is requested) Gt rye. Are a 6_r Z e /474— 61,- ,ty , 6i 1 --- Name of competent operator(if applicable) /A2 4 _r 4 ,d:2,c__LA.,____K Cert. or Licens No. / / 7(-- Estimated Cost of Construction: 2 e By ig►?" of Aipplic nt) - Buildin Official: ' Date: c' ,kC= ,, , FEE: $50.00 ,.'..‘'7 s."' S. ,N. i.e..... WI i a Sy 7f./ tA..--c-. . L-00-y / i . 5G (t'LIA-700/"1 I I r- I _ r . 1 i 1 p°o i 1 , i21R LI virc( 14-00-1 ' kiki., I 1 1 1 i I GP t 1 i i 1 I 1 1 1 1 ,..._„.....I i . ot.toir _, - 1 , 1 op _ 1,,,e_ in_ 1 2 . 1 tIMUMMUMNUEL I *mica DET WE Op I eo OAS prracron 0 HEAT DET FT OP HEAT DET WE.FT 426 t t I I i J . I I -, , i i 1 OF ‘3011.. i A ftT c- i Attit I Op , i I I I I eP 1 i. ----- -'--'-"--"--1 / 77 i 4 i t ............ ............__..............___..._....._......;i „.....,....\I 4 4 . i 1,........... ....____ , --..---.. ....._.....-----...-..-.............--.---J . .. . . I I 1 i 1 ) 1 1 i i I i 1 GT. 46('fr-SeP 1 e.,1.)71— I i 5 i c.,.1z. I • ..., (Dp (....:...• i i CI, 0 ,; 11 I 1 . 1 i . i I. ! (DP 1 • -.17, , i , 1 c COMMONWEALTH OF MASSACHUSETTS DIVISION OF OCCUPATIONAL LICENSURE BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE REGISTERED SYSTEM CONTRACTOR a ROBERT K BOUCHER 1265 ROUTE 2801.1 S YARMOUTH,MA 02664-4455 S " 1317 C 07/31/2025 291777 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER Commonwealth of Massachusetts Division of Professional Licensure SecuritySysterr'§`- :License SSCO-000046 Expires:01/05/2023 �.a ROBERT K BOUCHER Employed SEASIDE ALARMS'INC Commissioner f ,-t AC R D CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02/25/2022 THITTT 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 FAX No: Dowling&O'Neil Insurance Agency (Arc,No,EA): ( ) 973 lyannough Road E-MAILSS: emontgomery@doins corn INSURER(S)AFFORDING COVERAGE NAIC 9 Hyannis MA 02601 INSURER A: Crum&Forster Specialty Insurance Co" 44520 INSURED Safety Indemnity Insurance Company 33618 INSURER B: Seaside Alarms,Inc. INSURER C: Hartford Fire Insurance Company 19682 1265 Route 28 INSURER D: INSURER E: South Yarmouth MA 02664 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. 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 ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD (MMIODtYYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I$ 1,000,000 �/ DAMAGEI O REN rED 50,000 CLAIMS-MADE I XI OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A I GL0087043 02/25/2022 02/25/2023 PERSONAL dADVINJURY $ 1,004.000 GENERAL AGGREGATE $ 2'000.000 GENII_AGGREGATE LIMIT APPLIES PER: POLICY I�/ PRODUCTS-COMP;OP AGG $ 2,000,000 XI AE T LOC 1 PROFESSIONAL LIAB. $ 1,000,000 OTHERS - COMBINED SINGLE LIMIT 1,000,000 AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO B OWNED SCHEDULED 6222107 02/25/2022 02/25/2023 BODILY INJURY(Per accident) S AUTOS ONLY X AUTOS HIRED NON-OWNED PROPERTY DAMAGE S X AUTOS ONLY X AUTOS ONLY (Per accident) IS UMBRELLA LIAR I EACH OCCURRENCE $ 1,000,000 _OCCUR A X EXCESS LIAB SE0117502 02/25/2022 02/25/2023 AGGREGATE $ 1,000,000 CLAIMS-MADE DED RETENTION$ $ PER OTH- WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS LIABILITY Y/N 1,000,000 ANY PROPRIETORJPARTNER/EXECUTIVE I N I NIA 08WECAE7ZU7 02t2512022 02/25/2023 E L EACH ACCIDENT $. C OFFICER/MEMBER EXCLUDED? EL.DISEASE-EAEMPLOYEE $ 1,000,000 (Mandatory in NH) -""— Ifyes.describe under EL DISEASE-POLICY LIMIT $ 1'000'000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Insurance coverage is limited to the terms,conditions,exclusions,otherlimitations 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 wAlliVi �"�� + nll�.a ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts _.__ Department of Industrial Accidents r�:! �' Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.got/dia 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibhy Name (Buss e-s'organi7ation/Individual): Seaside Alarms Inc _ Address:1265 Route 28 _ City/State/Zip: South Yarmouth Phone#:508-394-0599 Are you an employer? Check the appropriate box: I Type of project(required): .111 I am a employer with 19 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. El Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have S, ❑ Demolition working for me in any )-cap acit employees and have workers' 9. ❑ Building addition • [No workers' comp. insurance comp.insurance. ❑required.] 5. We are a corporation and its I O.1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2 ❑ Roof repairs insurance required.] + c. 152,§1(4),and we have no employees. [No workers' 13.111 Security ecurity &fire alarl 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 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 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 y ct."a z)G`l t k - — 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 S 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 5250.00 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. Signature:, ,,.�, k /�_.�f�-__-__ �.5 Date: 2/25/22 Phone 4: 508-394-0599 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector sDPlumbing Inspector 6.0Other Contact Person: Phone#: