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Home My WebLink AboutP&G- 23-11616 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/TOWN MA DATE '871 °1' PERMIT# ,84_,D/2- C' //; /6 JOBSITE ADDRESS 2%, Iti• g74//U 5/ OWNERS NAME L' IN ( 6c d POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�-- PRINT • CLEARLY NEW:❑ RENOVATION:❑ .REPLACEMENT:[/ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR 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 SYSTEM _ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR i AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ' LAVATORY Alf: i J ROOF DRAIN __ ___—_.1'I111111Witt*,IY t■'_ SHOWER STALL I I SERVICE/MOP SINK I .Vic; 11 -PA TMET TOILET 1 gv URINAL —" WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I _ WATER PIPING OTHER y ; C ESTIMATED VALUE OF WORK: I I. I I I 1 I I 1 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 TYPE 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. • 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 lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t G,. PLUMBERS NAME ‘114412kt. Coug.4v LICENSE# /-5 d S SIGNATURE MP(V JP❑ ^.CORPORATION 0# 3 4/0 fi PARTNERSHIP❑# J LLC❑# COMPANY NAME /'A,- 2 1L Cv),1r PL b $ re, ADDRESS / °-3 It 4e Skc'62 b✓ cm aW' STATE AM' ZIP 0 .63 1 TEL 5 y%‹ ILA FAX CELL EMAIL 04,41.e,. j C c - Q `f 4 4 0-0 CC'Wl j^T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y, CITY MA DATE:. ?/a 3 PERMIT# 'Z ,6 23 //6/6 JOBSITE ADDRESS 43 n/. ,N 44.4 T OWNERS NAME- Ili w /1":c _ it-iJ - . . 0 VI!Nr-R ADDRESS rE;- FAX - - TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL- 4---- PRINT PKINT CLEARLY NEW_- RENOVATION:: - REPLACEMENT__- PLANS SUBMITTED: YES i . NO APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 i 6 7 8 9 10 11 12 ' 13 14 BOILER Ei00SIER -, —__ I I CONVERSION BURNER _ COOK STOVE ' I DIRECT VENT HEATER DRYER FIREPLACE _ FRYOLATOR I_-_� FURNACE , E _ I 1 I GENERATOR - GRILLE _- INFRARED HEATER - ` LABORATORY COCKS -MAKEUP AIR UNIT - OVEN POOL HEATER I C- CrrF u ROOM I SPACE HEATER ` ; i "'7 ROOF TOP UNIT 1 _ _ 2 i MQ( TEST ll .11 71173 UNIT HEATER '° UNVENTED ROOM HEAIEH - � - - _t. _ _ . _ . t RUIi UINU DEPARTMENT WATER HEATER I By,— --- OTHER . i I I I E — INSURANCE COVERAGE _ f have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES I NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILR T l'sl'-SIIRA ICE POUCY , OTHER TYPE INDE NFI t BumD 1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 oldie 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 walk and installations performed under the permit issued for this application will he inyorrgiancewtlit all Pertinent provision of the iviassachusetts Slate P)tsmbinn Code and Chapter 14-2 of the General Laws_ /,/�`u �� 1� r j7v l PLUMBER-GASFI I I ER NAME Mark Couto LICENSE# 15856 SIGNATURE MP / MGF JP JGF LPGI CORPORATION f # 3408 PARTNERSHIP # LLC= # _ COMPANY NAME: Mark Couto Plb&Htg Inc. ADDRESS 103 Lake Shore Dr C;-1" Brewster STATE ATE MA ZIP 02631 f EL 5508-965_14.5 FAX 508-896-25T7 CELL- EMAIL Markjcouto@yahoo.com ` '-'71e Commonwealth of Massachusetts _Th-, iI Department of Industrial Accidents I Congress Streei Suite 100 ip- Boston,MA 02114-2017 .3% www.mass.govidia - - ,ricers'Comnensauon Insurance Affidavit:Buuders/Contractors/Eiectricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORS:_ Applicant Information Please Print Leeitr Name(Business/Organaation/IndividuaD:Msrk Couto Plumbing&Heating it: Address.'103 Lake Shore City/State/zit,:Bremer, MA.02631 Phone#:508-965-2145 Are you an employer?Check the appropriate box: f1 Type of project(required): 1.E I am a employer with 0 employees(full and/or part-time)_* 7. 0 New construction 2_0 I am a sole proprietor or partnership and have no employees working for me in 8. t—t any capacity.[No workers'comp_insurance required.] 9. El Remodeling Dliti s.[ 11 am a homeowner doing all work myself[No workers'comp.insurance required.]i g` �`�e�O �Q� 4_I-1 I am a homeOwner and wi!!be hiring contractors to conduct all work on property_ 10 Li Building addition 4 my P PertY- l 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 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14_❑Qll±er 152,§1(4),and we have no employees.[No workers'comp.insurance re:coked_] *Any applicant that checks box#1 most 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_ 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 CompanyName:The Hartford Insurance Co, Policy#or Self-ins.Lie.#: Expiration 1 p/2, 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 DfA 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: vie6.4 (/Ult 7 i' Date: V7/9 3 Phone#: 1 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): 1 1.Board of Health 2.Building Department 3.City/'Town Clerk 4.Electrical Inspector 5_Plumbing Inspector !I 6.Other Contact Person: Phone#: 1 The Commonwealth of Massachusetts a =_ _fl Department of Industrial Accidents _:�81= 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 nit PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): I i I(. t'c 4 t z L,-i 47 7/rJ 1;(/'c Address: / 3 L a iU 5/6-e re < I City/State/Zip: He.,✓ c Phone#: S c A • 7-G'.5-- , /47_3 Are you an employer?Check the appropriate box: Type of project(required): 1.12riam a employer with 0 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• El Remodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑ my property.I am a homeowner and will be hiring contractors to conduct all work on I will10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof 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. If the sub-contractors have employees,they roust 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: Tie>a f"Jhne-el Policy#or Self-ins.Lie.#: Expiration Date: / ,' .3 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 r the pains and penalties of perjury that the information provided above is true and correct: Signature: C . >f 4 'C ) / Date: �7/ r�3 Phone#: . Official use only. Do not write in this area,to be completed by city or town offieiaL 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#: