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APPLICATIO}I FOR PERMIT
s_:
U
Gity or Town:
Date:
Yarmouth
05/L4/2073
permit Number: '101293
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 36 Belle ofthe West Rd /South Yarmouth, MA 02664
For permassion to: lnstall Fire Alarm System (RESIDENTIAL)sz7CMR'|0:03
Name of Competent Operator ADT Security
Date lssued-Rejecled OS / L4/ 2OL3 By
Date of Expiration. O7 /14/20L3
Cert. No.
Fee: Sso.00 $ paid
115
368E01
(Signature of applicant)
Due
s\,€*V"*-r-"r*"*A{alLan*.^ra'9'qr,rarr*rrr/errr &er-alcat - 6fr.* ryA" 8t a &an q/,*n {o/3.'@.'%"* ne t, ga* gid, ;fu, a,y'ld o / z zS
FP5 (.6/. 3,OO,
City ot tL
Dare c r3
ln accordarce wi$ the provbbru ot IU.G.L Chapter 148, as pr€^ddBd in Socuon
by {a yn cls , f;2
4 c ,Be//c d{fi.e r,rttr't RJ
Rt* -/rr/;n/
<tlrrJ)Api 1e e 1sr17aer. t9: ielllo.7EoOO€eEa p =
+prcpt$*lGaoe
4l 0 UniversltY Avenue
6
@
saaE ol Ftdla\ F,|it e w"x}t,Address t0 /Jct t1 )tTfrt
For pennlssiBl to (state cleady prllposs ior which pemr.t b re4ussfsd)h5 7' //DT"S*rr,.(c/t tUt Te : St t o€ P/a^s,il 1", tr t) lg 7,c Lan
OIG SAFE NUMBER
Slarl Dal6:
U "* a,,7,ia. ,,t t;t L
Name ol competent operabr (lt Appficabla)
Dale lssue&rejected By
tyoafudaturt)
$ Paid_Due
€/.V",rrr-r..**h{%ft**r";t#* - @f,* dd*8atffi*","-""o ffi?.@.qj* /lzi,fihhq;al, &n,.q{donzs sVP:116 {.Ev. 3Do,
PERMIT
City
Date t{\udrr
ln accordance willr the pmvisions ol M,GL C-hapter l4E, as providad ln
t.
t:
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I
fib perhil is grE rt6d
ro ADT, LLC
DIG SAFE IilUi,lBEB
Start Dat6:
4I0dlrffi9!ffi8'rAq#fi€re1
for
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Fee FhH$ .
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This Psrmit wlx e)gire on
klq itub1d tFali,l)
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Signature ol OffEal Grading Permlt_ Tius
$ fnis permit must be consptcuously posled upon the premises t
-T
APPLICATION FOB PEBMIT
of qDiatton- -........'-_ Fes
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w
Permit Numner 0, apdidle) _
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Fl eshictions:
,A"J-11r,- den flJfi;f
Si n{ Plpnt i -y'c.J r,, J St^u,/4 /),V, tot.t
OsL on, eacA lcyc/.
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Tkc Common*vdlih of Massachusclts
Dqardaent of Indastial Accida*
Ofte e of lwestigations
6d) Washington Strcct
Boston, LtA 42171
ri.nnxmass.ga/dia
Xrorkers' Compensation hsurauce Afirhvit BuilderVContracbrs/Elcctrfuians/Phmbers
Apulicant I-uformatior Please hint l.e.siblv
Name (&,.;r-ss, 0rmiztioo/iutiviihrl): AsT LLo
Ad&ess: u{ lo r-- r-: i v r-RJ (1-l >.;A,.i |;6
9( r.,:.,os rh.A .+oQo Phooae# I S l- .3S S'S u tq
'Arl. "I'pli(.e 6rt de*s tG *l [[r dso 6U oEt rL !<!io[ b&r storiog ttlir rod!!E' (q,.!s{io policy ilerE i@-
T Eooeonoprs wb s tdit liir rfidreit ildistitrB fuy rE doi[g iII qrd tort ltELir! EBiie cel!(eE@.{ E&oil r ler r6dr9n iEdi<*iq firL
kocr<us trt cfrrl ti3 tox Eost rltr(led D ldklitirld Ser| sLfirilg rL !ft of fiE dc.@r&ri 6d El!r! shErk dnot lboEE .r0iries ]tce
eEployEer If th! Eub<nE rDrstuE! rry&tlen frly El5l lEsvid.lb.ir rELrtI'<ory. loliry trtlralr5.
Typc of project (rcquired):
6- [ New coo:twti:o
Z. ! feooaei;ng
8- D Dco@litioo
9. D Su diEg rdditi@
10. E Et€tai€al tEFirs q additi@s
ll-E Ptuorbing tE?drs or additina3
12. f'l ltoofr€Eairg
13F other A r,t'rRYw
iJ
)oi
/)
I an an emplolvr thdl is prurlfuIiat nv.r*cts' conqtcasaioa firs;.tnll.cz for ny cmylolwe* Bdot is the policX o joh sitc
inlornatioll,.
h:uraace Compul'Nmle:tMg L
Poliry # c,r Setf-irs- Uc. #: \N (,:& I S9 a-): os Eryiratioa D^E- t o
!es City,Shtt/Zb rfi(-Job Sie Address:
Attech e copy of thc rorkrr:' cmpeosrtior policr dctleretio! page (:bowirg the policy mrober rud eryiration d e).
Failure to secsrE cowrage as required uodcr Sectim 254 of MGL c 152 cu lead lo the iryocitim of crimioat pco.lties of a
firc up !o $ 1,500-00 aod/or oar-ytar ioprismed, as vell as civil peo*ies in 6c fum of a STOP WORE ORDER ead e finc
ofup to $250-00 a day agaiast thc riolatcr. Be ad!fued 6rt E cs,gy ofthis stat€,o€d EEy be &rwarded b 6e OfrcE of
Ir$Bstigatims oftte DIA ftr hsrraoce covcrage vtrificatico-
eryloyeea (ftll rd/or part-rirrE),*
2.E Ia:sa sote prcpde{o( orpgrto€r-
ahip aud hrvc no eoployeaa
wcdciag nor lrc ir aay capocity-
[No wortcrs' coop. iorumce
lqBirEdl
I a.m a boocormer doilg s[ trudr
u5,rlf [No vchrs' coorp.
iosurauce required-] I
I m a gtaeral cont'actc,r ud I
have hircd the $b-c@tractorB
listed oo lhe atladed gheet-
T!€se slb--cootr3ctors hre
eaqiloyees ud haw wodcers'
coop. iosuraoce.l
We are r corpot-atioo aad ie
officers havc exarcised tbeir
rigtt of eorptioo per MGL
c- 152, $1(4), aad we [ar"e ao
eoployees. [No worters'
coq- insorancc requircd.]
4.8
5.n
Are 5ou a.u alplo5ltr?Check the appropriatc bor;
p I an e coployer rrith )
1
3,n
I do hercfut landq ofperjury that the inlormation prwiibd abanc is tnu and co'Ircd-
i ol 1 | 'r-
Phoae #:
Oficial *se oa$. Do ^ot lartl8 in this arua,lo bc comlil2t{d by cily or town oficiel
Iruiug Authority (cirrJc onc):
1. Borrd of Eeelti 2. BdHing Irqrryhrnt 3. Cirt/Tora Clcrt 4. Elcctrical Il.qrcdor 5. Plumbiry lupcdor
6. O+Ier
PeruiUliccnsr f
Coltrct Persotr:Phonc d:
6
A,
Citv or Tosn:
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER RE\4SION NUMBER:3
10D1rm12
FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
THIS CERTIFICATE OF INSURANCE DOES i,IOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
SENTATIVE OR PRODUCER, AND THE CERT1FICATE HOLDER.
I'IPORTANT: lf tho certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. lf SUBROGATIOII lS WAIVED, subject to
the terms and conditlons of the poliry, certain policies may .equire an endoEemenl A statement on this certificate does not confer righls to the
certificate holder in lieu ofsuch endo
AFFORDING COVERAGE
Lbrsh USA, lnc.
1 166 Avenue ol lhe Americas
Ner, Yolx, NY 10036
furich ArEric,l luslr'lce Compery 16535
An€rbar fudch lnsurace Compary
ADT LtC
410 Univ€,sity Avenue
Westwood, i,/,A 02090
Ttlls lS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAi,!ED AEOVE FOR THE POLICY PERIOD
INOICATED. NOTWTHSTANDING ANY REOUIREMENT, TERM OR CONDI'ION OF ANY CONTRACT OR OTHER DOCUMENT W]TH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOW\I MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L]MITSPOLICY NUMBER
GLo 509589900
GENL AGGREOAIE LIM]TAPPLIES PER
X T--_'l DEtu T---'lPOIJCY iiii I LC]C
OCCUR
09t28rm12 100120r 3 EAC}I OCCURRENC'S
s
s
s
S
S
MED EXP
2 000 000
4 000,000
4,000 000
1i )"1:
2,000 c00
PRODUCTS . COMPIICP AGG
GENERAL AGGREGATE
PERSONAI & ADV INJURY
CO AINED SINGLE LIMIT I 00i ca{
BOOLY TNJURY (Pr r.q| t
EODILY IfUURY (Pr drj6l)5
I
AUTOT'OBILE UABIUTY
H]REDAL-TTOS
SCHEOULED
AU.TOSNONOVINEO
AUTOS
At-r o/vi{EoAUIOS
AL 5095900-00 2 10n12013
S
OCCUfi
ACESS UAB
S
s
EACN OCCURRENCE
46REGATE
I oTl+
E,L EACH ACC]OENT 2,0m,m0s
EL DISEASE. EA FMPIOYFF 2.0m,000s
WORKERS COMPEXSATOI{
ANO EI'PLOYERS LIABIUTY
ANY PROPRISOR/PARTNEfu EIECI]T]VE
OFFICER/MEMBER EXCLIJDED?
DESCRIPTToN oF oPFRATrotls b€re
WC 5m5897{0 (Deduclible)
WC s09s89&00 (Ret!)
@natm12
Nram12
10D12013
i0012013
E,L DISEASE - POL1CY UMIT 2,000 000s
DESCRPION OF OpEMiONS / locATloNs / IEHTCLES lAtrch ACORO 1ot. AddttioEr R.m.rks sa-h.dot.. d moE s;e is euEdr
CERTIFICATE HOLDER CANCELLATION
ADT UC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRAT1ON OATE THEREOF, NOTICE wlLL BE DELIVERED IN
ACCORDANCE wlTH THE POLICY PROVISIONS,
I
110 UNIVERSIII AVENUE
WESTWOOD. t{A 020$
AT,THORIZEO REPRESEI{TATIVE
C.r-*rd.-d) Vt-- Q;-Cynthia Y. Kjm
O 1988-2010 ACORD CORPORATION. All rights reserved.
TheACORD name and logo are registe,ed marks of ACORDACORD 2s (2010i0s)
6
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X X
TH OF
OD
c 07/3t,r73
Fold, Ti.n O.rrdr
3g
DflT$O OF PBOFESSIOTI'IL LIC€I{S{J8E; BOABD OF
SEBIAL No.ucElGEf,4 lEoBiroiiDArE
Commonviealth of Massachusetts
Depaimrent oi Public Safety
\rur[\ \r.trn,! ! l.i.E,{
L cense: SS-{}0'lr7 9
ThoBr! J Ire -'
dto t nirerrit-vive i?E Iwestwood M.+' {n090.i- ff .,.;
'i,/-- -z)at-" "Commrssroner
,=
Ex p:ratron
05/1 6i/20'l /t
/