HomeMy WebLinkAboutBLDP-19-003606 f
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g;J, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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!- -- — --+ i,� w MADATE -71.7/1.--1/-rPERMirs ii�-/iA/�l 9601r'
JOBSITE ADDRESS 3 0 7 N+7 A. 6 4,v k. a.d, ,OWNER'S NAME • 1 -�geii
OWNER ADDRESS- 113 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL"•: RESIDENTIAL
PRINT
CLEARLY NEW , RENOVATION: REPLACEMENT - PLANSSUBNfTTED: YES , : NO `
_:.
FIXTURES I • FLOOR-0 BSM 1 2 3 4 5 8 7 8 a 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE - .. _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM- ,
DEDICATED GREASE SYSTEM .
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN •• -
FOOD DISPOSER
- - - - - `
FLOOR/AREA DRAIN -•
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN , .. _ __. - - - - - -
SHOWER STALL
SERVICE/MOP SINK - - - .
TOILET - .._
URINAL - -
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES
WATER PIPING -..
OTHER
INSURANCE COVERAGE
I have a current liability Insurance poky or its substantial equivalent which meets the requirements of MGL Ch.142 YES i N0'
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECIONG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY, BOND
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage .. •
• 1
Massachusetts General Laws,and that signature9 by Chapter 142 of the
my on this PermR application waives this requirement. _ _.
SIGNATURE OF OWNER OR AGENT _ .
CHECK ONE ONLY: OWNER AGENT 1 - '?
I hereby certify that all of the details and Information I have submitted or entered regarding this application are hue and accurate to the best of my Imowledge - r'
and that all planting work and installations performed under the permit issued for this application will be in compares with all Perdnmd provision of the
Massadesets Stats Plmnbing Code and Chapter 142 of Its General Laws. -' ., AA,`c. /'
PLUMBER'S NAME•Mark.Couto UCENSE# 15858 SIGNATURE .." p_
MP.r JP > CORPORATION'+ # 3408 - PARTNERSHIP S LLC, #
COMPANY NAME Mark Couto Fib&Htg Inc. ADDRESS; 103 Lake Shore Dr
.
CITY Brewster - ___ ._._._ _STATE` MA ZIP 02631 TEL 508-965-2145 .
FAX 508.898.2577 CELL.`` - � :EMAIL:MlarkjcdltoQyahoo.com: .. i i s �,: �. i r'
- j _ i DEC 3 2018
S:t2q4_. cif
s"` 27ic Comnmmvealth a}
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_ _.__ ... ._ Dep¢rtinentgflnd¢ttrialArdde s •
• cs Ofcc oflnveatfgatiorrs
zy - 600 Wushitrgton*Street
Boston;MA 02111 •
'� • www.mmzgon/dda. •
Workers' CompensafiolsInsarance Affidavit:Bofldera/Camiractprs/Elec ridans/Pinmbers _
Applicant Information - •Please Pkint Lely
. - ,14ttE CoWta Ptb UI7- ;Avc _._.. _
_
Ntlme _ _
Marne (03 LL(Le _5 letcvt r-
City/State/Zsp: L Q rtor5(t t. .--M.& o i Phone t- SUS 90S—;at
Are you anemployer?Cie*the appropriate hoe TI
pQ of Project
( rcd)•
1.[TI am aemployee with ( 4.)]I am ageneral eot>fracborand/
employees(fall and/or parte).! .. .- have hired the mob-coatrooms . 6 D blew t�sCmctiool
lined on the cracked sheet.._ 7.
2.0 I am asole ptoptiet�tttpathtrr 0 Remodeling
._ Thin -._ 0
ship and have no employees� --- � 8.' D®oIIHon. ._
wonting forme inany capacity. _ employees end have makers'. .. 9 D Sad as
o workers' insurance)
IN cep ins . . 5.D We a commotion and Its . . ..10.0 Electrical repairs oradditions
3.0 Iamit homeowner doing all work-. .officers have exercised flick .-. 11.0Plumbingrepairsoradditions . -
myself[No workers'comp. . . riot of exemption Per Mar-
insurance required.] . c152,§1(4),and wehave no .--01 0IT
employees.[No workers' _ 13.D Other
comp.tura=realised.]
:Any applicant diet ehedabox ail mesa=fie eaiheseedonbdafloww**- a'diameter . aoapoIIg• =
tHomeowneraMID aohmfthis etvltsl rlos ritzy ors doing elen&zed*any=side cometmmnRmlmdtaraw affidav$l as ,
familia=that ask this bmcmint=dad so=Moral sbeetshowbgdumaa:efau mdstemetehear=dossenddsffiae - ..
employees.Iftheseb ureewe herenmlaynq,they must provide their=rhea'amp.pray=mat_ _. .- ..
I am nen employer that Is providing workers'compensation insuraneejormy amproyeesr Below is t epon y and job site
Insurance Company llama - / ►i c ({vtheritA%> SNS. Cp
Policy:or Self-ins.Lifrt Expiration Date: 10 fes,/9,.
Job Site Address C1ty/State/Zlp
Attach a copy of the workers'compensation policy declaration page(showing the policy number and agitation date).
Failure m secure eoverade=required imder Section 25A ofMOL c152 am lead to the
fine up to 51,500.00 and/or one-year immiso imcit as well as civil Imposition ofcrimiand
a
penalties ofaSl'OP WORK ORDER andafine
of up to 5250.00 a day agdaathe violator. Be advised that a copy of this statement may be forwarded to the Office of
Inveslig o:ions ofthe DIA forinsurance coverage verifuxtton _..
I do hereby remit router ikepabrs dttdp cipWjmy thoithe btfarrectiongrapfded above Istrue and imrect
,Signature: .Ctt--k- C044--
Fit...,
ewphoneR:
Official use only. Domrtwrt<ehethIrrant mbacompldedblrcity ortown crew .
City or Town: Permitil icensef
Issuing Authority(circle one):
1.Board orHealth 2.Building Deparbneot 3.CtyfTown Oak 4.ISIeeaiea]Iacpeetor iptembmglaspector
6.Ott
Contact Person:
• Phone Or
• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
cnyL AA V't 1-17-71 DATE t 2-1/2-1/-fr pcmarr#/3ADP:/9-Co 9e,
joasiTEADDREssr-3 0 k as 7 h b/tfut R4 ;OWNER'S NAME ./.1•3-, g do Cares ir-e.
G OWNER ADDRESS I TEIT— -1FA)C1
TYPE OR OCCUPANCY TypE
COMMERCIAL 1 EDUCATIONAL p RESIDENTIALFr_
PIIINT
CLEARLY NEW:n RENOVATION:n REPLACEMENT:I PLANS SUBMITTED: YES/r2/ NOn
APPLIANCES 1 FLOORS— BSM 1 2 3 4 6 8 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
- -
COOK STOVE
DIRECT VENT HEATER
DRYER
FREPLACE
FRYOLATOR
FURNACE
•
GENERATOR
GRILLE
INFRARED HEATER - •
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER -
ROOF TOP UNIT
TEST _ _
UNIT HEATER
UNVENTED ROOM HEATER
QTHERI
INSURANCE COVERAGE
I have a current Jiability insurance policy ors substantial equivalent which meets the requirements of MGL Ch.142 YES /f'NO s '
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
LIABILITY INSURANCE POLICY e.„ OTHER TYPE INDO/iNiTY BOND fl
OWNER'S INSURANCE WAIVER I am aware that the licensee es not have,the Instance 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 Cl AGENT IC
I hereby certify that all of the details end Intonnalice I have submitted or entered regarding this appacation are titre end scants to the beet et my knowledge
and that ail plumbing wort and Installations pertained under the permit Issued kr this application will be In swillset all Pertinent proviska of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI17ER NAME Mark Couto
MP T MGF• JP 7. JGF LPGi— CORPORATION T# 3408 PARTNERSHIP LW
••
COMPANYNAME: Mark Couto Rib&Htig Inc. ADDRESS 103 Lake Shore Dr
CITY ;Brewster STATE MA ZIP 02631 'TEL I 50846S-2145 •-' •
• , —_—
FAX'008-1396-2577 •CELLI :EMAIL'Mallgcoutceyahoo
.com
' DEC 1 3 2016 ' I
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