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Home My WebLink AboutBLDG-22-007178 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 13,2022 PERMIT# BLDG-22-007178 u JOBSITE ADDRESS 3 BUTTERCUP LN OWNER'S NAME KURTOWICZ PETER L G OWNER ADDRESS KURTOWICZ MAUREEN T 3 BUTTERCUP LN SOUTH YARMOUTH MA 02664-1105 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT❑ PLANS SUBMITTED:YES 0 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/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 LABILITY 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 he in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'Stephen Winslow I LICENSE# 12298 SIGNATURE MP El MGF 0 JP 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: 'STEPHEN A WINSLOW I ADDRESS, 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH ISTATE MA ZIP 026641207 TEL I FAX I I CELL I I EMAIL linsoectionsRefwinslaw.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,:,. is CITY YARMOUTH j MA DATE[5126122 j PERMIT # _-_ JOBSITE ADDRESS[3 BUTTERCUP LN S YARMOUTH 02664 OWNER'S NAME [PETER KURTOWICZ _ J GOWNER ADDRESS [SAME rt _ J TEL 5083944415 44 IFAXL I TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: D PLANS SUBMITTED: YESP NO APPLIANCES Z FLOORS—► BSM 1 2 III 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER <._ CONVERSION BURNER 1� . _ Adir.ii..- =_ COOK STOVE --- (_ _ -. _. DIRECT VENT HEATER —I DRYER FIREPLACE - _ FRYOLATOR �' ,� FURNACE -_„_ ... GENERATOR GRILLE m , . ,-- - _ INFRARED HEATER - (�~., -In r LABORATORY COCKS MIME u _ MAKEUP AIR UNIT '' OVEN -.. .H.------ ....... ,--- POOL HEATER _________ wie_i_lli --- .... ROOM / SPACE HEATER .. . j ROOF TOP UNIT -ice TEST 1 ; r UNIT HEATER Mir UNVENTED ROOM HEATER IM 3 WATER HEATER _...1 OTHER n.= rMI 1 1 r---. . 1111111.1011111 11110111 1 IIIIII . MI;PIM MINI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES r NO El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY BOND ri 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 a SIGNATURE OF OWNER OR AGENT cJ\ 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 Azief and that all plumbing work and installations performed under the permit issued for this application will be in complianc 1 a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. °-- l's PLUMBER-GASFITTER NAME STEPHEN WINSLOW I LICENSE # 12298 SIGNATURE (-- - a— MP v MGF JP JGF El LPG!® CORPORATION #[3281 C PARTNERSHIP(J# .., .. LLC LJ#I — COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 1 8 REARDON CIRCLE CITY i SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 ig— FAX 508-394-8256 CELL N/A 1EMAIL I NSPECTIONS@EFWINSLOW.COM l The Commonwealth of Massachusetts Department of Industrial Accidents 1�=1 Office of Investigations " IMMOma— 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.® I am a employer with 90 employees (full and/ 5. ❑ Retail — or part-time).*.* t,. ) -- -�. ❑ Rc�taucant/Ba�/Eating Establishment---- - 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real a :te, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] ❑ 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, 11.0Health Care with no employees. [No workers' comp. insurance req.] 12.0 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:01/01/2022 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 thie unposition 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 ce the ins and penalties of perjury that the information provided above is true and correct. Signature: Y Date: 01/02/2021 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): 1fBoard of Health 2.0 Building Department 3.1=1 City/Town Clerk 4.❑Licensing Board 50 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia