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Home My WebLink AboutBLDP-23-000895 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 8/18/22 PERMIT# BLDP-23-000895 JOBSITE ADDRESS 26 ST ANDREWS WAY OWNER'S NAME GARBUTT EDWIN B P OWNER ADDRESS GARBUTT SONJA 126 ST ANDREWS WAY SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Cl RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES • FLOORS—, BSM 1 2 3 4 5 6 7 _ 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND Cl 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 1 856 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME MARK J COUTO ADDRESS 103 LAKE SHORE DR CITY BREWSTER STATE MA ZIP 026312429 TEL FAX CELL EMAIL markjcouto@yahoo.com ROUGII PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r _ ...):7: PERMIT# Z"S_ D "`x ; ,� CITY MA DATE /7:-it(p ( if ' '5L---_,,, ftt-4.---TLC——.... JOBSITE ADDRESS ' a & J R'S NAME1-.~Rt4 I e/. OWNER ADDRESS _-._ _-. TEL FAX , TYPE OR OCCUPANCY TYPE COMMEI CIA r AUG 17 Zan NA RESIDENTIAL a.--"-- PRINT CLEARLY I NEW: / RENOVATION: EF kCUE i L EPARTMEN7 PLANS SUBMITTED: YES NO FIXTURES 1 FLOOR—i BSM 1 r R 5 6 7 8 9 10 11 12 13 14 1.3BUI:.BATHTUB CROSS CONNECTION DEVICE 1 ( - DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER I - r DRINKING FOUNTAIN I ____ FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) _ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES WATER PIPING OTHER -1- I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i NO 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 -. co- liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws_ AA (L Of PLUMBER'S NAME : Mark Couto LICENSE # 15856 SIGNATURE MP / JP CORPORATION i # 3408 PARTNERSHIP # LLC # COMPANY NAME' Mark Couto PIb & Htg Inc. ADDRESS 103 Lake Shore Dr CITY Brewster STATE MA ZIP 02631 TEL 508-965-2145 FAX 508-896-2577 CELL EMAIL Markjcouto@yahoo.com ".!7te Commonwealth ofMassachusetts fi, iQ1 Department of Industrial Accidents G�1 1 Congress Street,Suite 100 =�� f Boston,MA 02114-2017 'y www nass.govittia --:„ricers'Compensation Insurance Affidavit:Burtdens/Con:ractors/E3ectricisens;'Plembers. TO BE FILED WITH THE PERMITTING AUTHORI'=_. Applicant Information PIease Print Leeib' Name(SusinesslOtgattization/lndividuan.Mark Couto Plumbing&Heating t„� Addres,-103 Lake Shore Er: City/State/Zip:Brewster,MA.02631 Phone#:508-965-2145 Are you an employer?Check the appropriate box. I I Type of project(required): 1.0 I am a employer with 0 employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in ( 8. Remodeling any capacity.[No workers'comp_insurance required] ?.t-i f am a homeowner doing all work myself.(No workers'comp_insruanc required:I t 9_ El Demolition 10 0 Building addition 4.1 I am a homeowner and will be hiring contactors 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. I2.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 130Roof repairs These sub-contractors have employees and have workers'comp.insuance.: 6.0 We arc a corporation and its officers have exercised theirright of exemption per MGL c_ 14_❑Other 152,§1(4),and we have no employees_[No workers'camp_insurance required] *Any applicant that checks box#i 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 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 Companyivarr}te:The Hartford in-ruin---f n, Policy#or Self-ins.Lie.#: 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): II 1_Board of Health 2.Building Deoar heat 3.CityiTown Clerk 4.Electrical inspector S.Plumbing Inspector 1i '' 6.Other Contact Person: Phone#: .