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HomeMy WebLinkAboutBLDP&G-22-001093 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rya CITY YARMOUTH MA DATE 8/26/21 PERMIT# BLDP-22-001093 t f . JOBSITE ADDRESS 35 BELLE OF THE WEST RD OWNER'S NAME TARDIF MARTHA P P OWNER ADDRESS TARDIF PAUL R 35 BELLE OF THE WEST RD YARMOUTH PORT,MA 02675-1205 TEL ] TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURFS FLOORS-. BSM, 1 2 , 3 , 4 5 6 , 7 1 8 , 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND 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 _ WATER HEATER 1 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❑ 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. 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 16856 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# ] 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 ❑ FEES$ PERMIT# PLAN REVIEW NOTES I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 ., _ CITY 1.,. -,,. ,. �...�€ MA DATE / —( PERMIT# ' :OBSITE ADDRESS Iw..�.. . 3 S 6-C/(t. c1 T WI S f ' OWNER'S NAME. l't/ 1 - 174 rcI .(-f-- POWNER ADDRESS s _ Y_ _I TEL FAX r..�'.v ' TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ' RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ,/ PLANS SUBMITTED: YES NO FIXTURES - FLOOR-i 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/OIL/SAND 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 STALL111 _ SERVICE / MOP SINK TOILET ._ �_ URINAL 7-. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING A.. - _..�._ _,t , OTHER — INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES / NO 17.1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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 c liance with all P rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,4 ` j--- PLUMBER'S NAME Mark Couto RI , ;LICENSE # 15856 I SIGNATURE . MP i JP ' CORPORATION i # 3408 PARTNERSHIPE1#E— !LC: # COMPANY NAME. Mark Couto Plb & Htg Inc. ADDRESS ; 103 Lake Shore Dr _ �' CITY Brewster STATE MA ZIP 02631 TEL r: •-_ ., ' ' FAX 508-896-2577 CELL I t 1EMAIL i Markjcouto@yahoo.com .� _ 6,24.2021 .� BUILDING By. U�p - ___. �_'— r�ENT The Commonwealth of Massachusetts Department of Industrial Accidents 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):Mark Couto Plumbing& Heating Inc. Address:103 Lake Shore Dr. City/State/Zip:Brewster, MA. 02631 Phone#:508-965-2145 Are you an employer?Check the appropriate box: Type of project(required): LID I am a employer with 0 employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor or partnership and have no employees working for me in'�❑ 8. ❑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.❑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.❑Plumbing repairs or additions 5.0 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.❑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 Insurance Co. Policy#or Self-ins.Lic.#: Expiration Date:10/20 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 perjury 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vit'l CITY YARMOUTH MA DATE August 26,2021 PERMIT# BLDP-22-001093 'i JOBSITE ADDRESS 35 BELLE OF THE WEST RD OWNER'S NAME TARDIF MARTHA P G OWNER ADDRESS TARDIF PAUL R 35 BELLE OF THE WEST RD YARMOUTH PORT MA 02675-1205 TEL _ TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY I NEW: ❑ RENOVATION:❑ REPLACEMENT:El 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 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 1 _ 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 Mark Couto LICENSE# 15856 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# ] COMPANY NAME: MARK J COUTO ADDRESS. 103 LAKE SHORE DR, CITY BREWSTER STATE MA ZIP 026312429 TEL FAX CELL EMAIL marklcoutona,yahoo.com S310N M3IA321 NVId #1IIN2f3d $:33d ❑ ❑ 11111213d 3H1 SV S2A 9S NOI1NOIlddV SIHI ON SSA S31ON NO1133dSNI IVNId AINO 3Sl 210133dSNI 210d 30Vd SIH1 S310N NO1103dSNI SV9 HJl021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ?"-IV-1CITY MA DATE tO/„:.6fr l ; PERMIT# JOBSITE ADDRESS OWNER'S NAME / 04- lc1tTT- C. = O NER ADDRRESS T Ei FAQ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL- PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: . PLANS SUBMITTED: YES: NO APPLIANCES 7 FLOORS--► BSM I 1 2 1 3 4 5 t 6 i 7 8 1 9 10 11 12 13 14 — _ BOILER , BOOSTER i l i I i I i - -I i i CONVERSION BURNER COOK STOVE DIRECT VENT HEATER .1 -DRYER FIREPLACE _ FRYOLATOR - 1-�t h —t— - -- - - -- __ __ _____ LRNACE i i I -i t GENERATOR L i GRILLE - .- ---- - INFRARED HEATER , _ t _ , - - -, LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER l ROOM / SPACE NEATER -- t ; — - ;-- --1- - ROOF TOP UNIT TEST _ _ - - - UNIT HEATER _ UNVENTED ROOM HEATER r WATER HEATER 1 _ OTHER ' I l I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 YES f NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 4 LIABILITY INSURANCE POLICY = OTHER TYPE INDEMNITY BOND 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 in co - rice with all Pertinent provision of th^ Massachusetts State Plumbing Code and Chapter 142 of the General Laws_ GL �" 1' 1,,_. o PLUMBER-GASFITTER NAME Mark Couto LICENSE# 15856 SIGNATURE MP 1 MGF JP JGF LPGI CORPORATION i # 3408 PARTNERSHIP # LLC # COMPANY NAME: Mark Couto Pib & Htg Inc_ ADDRESS 103 Lake Shore Dr C'TY Brewster STATE MA ZIP 02631 TEL 508-955.2145 FAX 508-896-2577 CELL EMAIL Markjcouto@yahoo.com R E C E.1...V__.Frol AUG 25 2021 BUILDING DEPARTMENT By. ----------__ MDead=tlQf rnTesssn.T,,$g.aIaais - - vtice[rvr�ze �: - a@ FF En w 3t3S@R- $rii_--.----& __ - Illi a- 'e- a sa w: •,.t_ naeYBAC atii)TSIMeriAr easE S _ 0.1�,.z€ n ay 3 ei`n.t.3.P�3 7 aDeiB 44fit./Le--,-& Ba e Ch- c- oisieidup_ lv--ews A.4A ci -- i phlmea 5- t&. tyS - :you enosagtopecs l'aYl. 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