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HomeMy WebLinkAboutBLDG-22-006937 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vot CITY YARMOUTH MA DATE June 01,2022 PERMIT# BLDG-22-006937 JOBSITE ADDRESS 43 CIRCUIT RD NORTH OWNERS NAME KABURIS STEVE TRS G OWNER ADDRESS KABURIS MARIE TRS 43 CIRCUIT RD NORTH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. [8 REARDON CIR,8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL linspectionsefwinslow.com S310N M31/131:1 NYld #1IV 3d $:33d ❑ ❑ 11I4183d 3Hl St/S3A2i3S NOIlv3 lddv SIHl ON saA S31ON NO1133dSNI lYNId KINO 3Sfl H0103dSNI 2lOd 30Vd SIHI S310N NO1103dSNl SVD H0f10H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • �A1 1_ Z. CITY WEST YARMOUTH , MA DATE ' 5/23/22 PERMIT # JOBSITE ADDRESS 43 CIRCUIT ROAD NORTH OWNER'S NAME i STEVEN KABURIS GOWNER ADDRESS 11497 RUE JAMES MORRICE,MONTREAL QC/CANADA TEL 508-778-4121 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION REPLACEMENT: .fat, PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER . CONVERSION BURNER COOK STOVE .. DIRECT VENT HEATER DRYER _ 4_ h FIREPLACE E �pYOLaTOQ . , . FURNACE .- GENERATOR GRILLE INFRARED HEATER l . ...................: ..... LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER <n.... U: .�.u�,,...: ROOM / SPACE HEATER h. ,aa..,M r: _ ,,.�,,.,�, t.„,M~: a��, r,....,,art.,, , : . ..�,,,,...w ku..,,.,,,,a... ROOF TOP UNIT , TEST _.._. ..w,... ....... , UNIT HEATER UNVENTED ROOM HEATER WATER HEATER._.. _.._ _---- . . OTHER- TEST 1 • ,,.,,,s tiwuxo 04,. w\1.0.),.aa'awwrR...,, ;-:\.4.2,1Kai.o.,x., _ ,:._y ,,u... .x,... _ .. '_• _ _. _ _.. , INSURANCE COVERAGE I have a current liabilityinsurance policyor its substantial equivalent which meets the requirements of MGL. Ch. 142 YES L :� q q �.�� NO �M I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE PO ITV a,,.,,, OTHER TYPE lNDE i N T�i BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat to the b st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C\ 10 , ` J PLUMBER-GASFITTER NAME STEPHEN WINSLOW G LICENSE # 12298 ., SIGNATURE .w.nNrW nMXx,,,,cxec:ro.."r.' ... LPG! CORPORATION .# 3281C 1 PARTNERSHIP # LLC El# COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE . .... <aR.:<.: -•.wmumt.::i :::.::;,n.;i<<.., ...... :.... .::.:..,a,,,,.., ,,,(a.,,,,,..,,,,eMia.,uoar.,,,...¢ak roanto....1 v,:..WN::R�'amiaY.K'maU,4....,aW,*tA'A`S,Pt,' ,,,,,,lea:a U .ioYtidiR3iR.4222..**2WkYi \�1441 ,.::: CITY [SOUTH YARMOUTHe STATE MA JTELO8-394-7778;ZIP 02664 _._." .4.4.,,,, a,,,, FAX 508 394 8256 CELL NIA EMAIL, NSPECTIOIVS`(v EFWINSLOW.COM wcxcw..•�.a The Commonwealth of Massachusetts Department of Industrial Accidents i_"' Office of Investigations __ Lafayette City Center ' 2 Avenue de Lafayette, Boston,MA 02111-1750 ,' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: E.F. WINSLOW PLUMBING & HEATING CO, INC. Address:8 REARDON CIRCLE City/State/Zip:SOUTH YARMOUTH, MA 02664 Phone #:508-394-7778 Are you an employer? Check the appropriate box: Business Type(required): 1.111 I am a employer with 99 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole propriet twar partnership and have no 7. ❑ Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:ARROW MUTUAL INSURANCE COMPANY Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. #1964A Expiration Date:01/01/2023 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under §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 cen('���the pteins�Mnd-penalties of perjury that the information provided above is true and correct. Signature: Y Date: 12/01/2021 Phone#: 508-394-7778 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 2.0 Building Department 31:1 City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia