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Home My WebLink AboutBLDP-22-000942 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,ty CITY YARMOUTH MA DATE 8/18/21 PERMIT# BLDP-22-000942 ist wy JOBSITE ADDRESS 39 BOB-0-LINK LN OWNER'S NAME HIRD GRAHAM C JR P OWNER ADDRESS HIRD NICKI L 29 MONROE RD ENFIELD,CT 06082 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS FLOORS--* BSM 1 2 3 4 5 6 7 8 9 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 SYSTE 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 1 WATER HEATER WATER PIPING 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 0 OTHER TYPE OF INDEMNITY❑ BOND 0 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'S NAME Mark Couto LICENSE 1856 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC El# COMPANY NAME MARK J COUTO ADDRESS 103 LAKE SHORE DR CITY BREWSTER STATE MA ZIP 026312429 TEL FAX CELL EMAIL markjcouto@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El ❑ FEES$ PERMIT# PLAN REVIEW NOTES -.,ACa , i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ill ` tt CITY I _..- �. .. _.: MA DATE ,e?-Iw 'PERMIT# Z Z 9(-11__ ,x, JOBSITE ADDRESS I 3 U 6-0-U f%)lL OWNER'S NAME C-✓'4�tRr^1 1+l rd: OWNER ADDRESS ; TEL _IFAX I 1 LLQ ' }C YPCOR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL lRESIDENTIAL. P Y 1 1 CLE Y NEW*`M. ,: RENOVATION:L 2 REPLACEMENT:ri PLANS SUBMITTED: YES n NOLI FIXTURES 1 FLOOR-I I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 IBATHTUB ' ON CROSS CONNECTION DEVICE t MIN lilt DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM pw MIN DEDICATED GRAY WATER SYSTEM Imo " __ DEDICATED WATER RECYCLE SYSTEM d111111111111111 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) A KITCHEN SINK ._ .. -` ~' ., - . -_.�. __.._- w: . LAVATORY — ROOF DRAIN SHOWER STALL /11111 SERVICE/MOP SINK _ TOILET N IIIIIIIIIII . URINAL III a WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ OTHER i { 1111111111M1111r.On- --- MIIIIIIIOIIIMIIIIIII 11111111111111 1101111111/M1111 7- M1 US min g s T INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES r+ NO ri IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY I+I OTHER TYPE OF INDEMNITY i BOND r 1 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 ip earn fiancewith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws_ PLUMBER'S NAME!Mark Couto 1 - ;LICENSE#;15856 SIGNATURE MPS^%; JP CORPORATION{+ #13408 (PARTNERSHIP),,i#{ ?LLC #i �F COMPANY NAME 1 Mark Couto PIb&Htg Inc ADDRESS 103 Lake Shore Dr CITY f.Brewster STATE' MMMA ZIP 102631 TEL 1508-2145 FAX 508-896-2577 =CELL s `,EMAIL `Markjcouto@yahoo.com �,� The Commonwealth of Massachusetts !1, Department of Industrial Accidents ii--1.-r„...-- ,_- 1 Congress Street,Suite 100 ` Boston,MA 02114-2017 _7, .�—t www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElecMeians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/organization/individual):Mark Couto Plumbing&Heating inc. Address:103 Lake Shore Dr. City/State/Zip:Brewster,MA.02631 Phone#:5°8-965'2145 Are you au employer?Check the appropriate box: Type of project(required): 1.Q✓ I am a employer with 0 employees(fill and/or part-time).* 7. 0 New construction •• 2.0 I am a sole proprietor or partnership and have no employees working forme in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required]t 10 0 Building addition 4.01 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13.0Roof repairs 6.❑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. :Contractors 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. lithe 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 Insurance Co. Policy#or Self-ins.Lic.#: Expiration Date:10/26 Job Site Address: City/State/Zip: . 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 pedury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: