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Home My WebLink AboutBLDG-23-006018 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =I' r: CITY YARMOUTH MA DATE May 01,2023 PERMIT# BLDG 23 006018 1i=j JOBSITE ADDRESS 15 ROBIN RD OWNER'S NAME ULLRAM FRANCESCA LAMBERT G OWNER ADDRESS 15 ROBIN RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 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 Brian Kalinowski LICENSE# 15755 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Brian K Kalinowski ADDRESS. 25 VICTORIA RD, CITY HARWICH STATE MA ZIP 026451510 TEL FAX CELL EMAIL S310N M3IA3a NVId #111A1213d $ 33d ❑ ❑ 11M3d 3H1 SV S3AN3S NOIJVOIIddV SIHL ON seA S31ON NO1103dSNI 1VNld ,LINO 3Sf1 a0103dSNI HOd 3OVd SIHl S3lON NOIl03dSNI SVO H0l0a :. \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rir.-:-_, - Wkr. CITY Yarmouth MA DATE 4/27/2023 PERMIT # t3 - C 'C _ 23 6b 1S s JOBSITE ADDRESS 15 Robin Road OWNER'S NAME Ullram GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS BSM L 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 1 GRILLE _ - _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM / SPACE HEATER — _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE 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. ________ 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 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 Brian Kalinowski LICENSE # 157551--66.4i*/64;tt-U---11C(2\--- MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: Kalinowski Mechanical Ltd ADDRESS PO Box 1562 CITY Harwich STATE IMA IZIP102645 TEL 508-, 303E C F FAX CELL 508-237-8161 EMAIL kmechanical@yahoo.com I K 2 1023 ' B ± tff ± jLJ By. - The Commonwealth of Massachusetts Department of Industrial Accidents _1301- 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Kalinowski Mechanical LTD Address: PO Box 1562 City/State/Zip: Harwich, MA 02645 Phone#: 508-430-4374 Are you an employer?Check the appropriate box: Type of project(required): 1.p✓ I am a employer with 4 employees(full andor part-time).* 7. ❑ New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10 Building addition 4.1:1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5E1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOf repairs These sub-contractors have employees and have workers'comp.insurance? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4).and we have no 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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:The Hartford Fire Insurance Policy#or Self-ins.Lic. #:08 WEC AB2G83 Expiration Date:4/13/2024 Job Site Address:15 Robin Road City/State/Zip:Yarmouth, MA 02673 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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: .i%I;l.�11/� -- Date: J27)7g Phone#:508-4 -4374 Official use only. Do not trite 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#: