HomeMy WebLinkAboutBLDG-19-005868 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
auk CITY y141&WV MA DATE 4 (� (l_4 PERMIT#/ �6/�Gd — O
JOBSITE ADDRESS / 7 4,41414V t it r i`c.. OWNER'S NAME Mi a I{A t I IIC l(�_
OWNER ADDRESS :TB FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL` EDUCATIONAL, :' RESIDENTIAL '
PRINT
CLEARLY NEW:: RENOVATION: — REPLACEMENT: PLANS SUBMITTED: YES- JT NO'
APPLIANCES 1 FLOORS—, • BM 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 .1 1. ZU
TEST _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or as substantial equivalent which meets the requirements of MGL.Ch.142 YES +^NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY :+ _ OTHER TYPE INDEMNITY BOND I
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 i 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 compliance with all Pertinent provision of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. w i /t. (iv t L t-z
_
PLUMBER-GASFITTER NAME Mark Couto LICENSE#�15856 SIGNATURE I
MP MGF JP JGF LPG' CORPORATION'• #-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!Matkjcouto@yahoo.00m
The Commonwealth of ss ehr setts .
_Eft Department of ndrertria1Accidel�fs - -
,=��i—= Office o f.�cvest�gaiions
• _ 1 - 600 Washington�"'tteez
-�• , Boston,MA02111
. - www rnasss.gov/dia •
Workers' Compensa.-tiou insurance A_davit:Builders/C s acttt lecfririansfPli bees
Applicant Information Please p=iitt LeP..ibiv
Name s/o antis; ndvidual): t'"t 4i _ CO u.TO p L'b e E "lr .pU L .
Address_ (03 LA tt.t 5 e v- 6 4 -
CityIS i At I : 8 V'-e-'5 MA V :/ phone#: 5U*"9f&5'a- /Y -
a re you an employer?Check the appropriate bow Type of project(required):
i.[' I m a employerwith ( '-am a general contractor and I 6. [l New constntetiom
employees(cull and/or par iiw.e)-T Ye d e -contractors
.❑ I am a sole proprietor or punier-
These one attached sweet i_ ❑Remodeling
ship and have no employees Th=ae sib-c° zct°rs have -8. 0 Demolition
working for me in any capacity_ employeesa worlmrs' g- Q Building addition -
[No workers'comp.insurance cmp-insurwee
squired] 5_ 0 We are a corpo_adon and its 10.0 Elecuical repairs or additions
r:.❑ 1 am a homeowner doing all work oZcetS have exercised their i 11.0 Plumbing repairs or additions .
myself.[No workers'camp. rn ht of ex mptton per MGL n
insurance,rc-Quired1 t C. i j r ?i('�),rid vie have no �'❑Roof repairs
in
- employee_ Io .orers' t3-C Other
comp_ins ce rrquffrd.]
'Any applicant that checks bDg1 must alsozr1I out the section be{owsbowinsthe anryrs'compensationpolicyiafnmation
i Homeowners who submit this affidavit indiczring they are doing all work end en bin outside en=tractors mvstsubmitanew amdzvk indicaringsw.h.
=Contractom that check this box must aaacbed an additimmi sheetshoa as the name of the sub-ccntmctos and state whether or not those asides have
employees. If the sub-contzccos have eapioye they roust provide their waske;'COW?.policy number.
1 am an employer that is➢roviding workers'compertsa ion.?LSw an.cljor my employees. Below is the policy and job site
information_
insurance Company Name: TILL 1 'ceP .GAS s C-U
Policy_or Self-inns.Lice Expiration Date: C 0 f I -
Iob Site:.ddrass: City/State/Zip:
Attach a copy of the workers compensation policy declaration page(rho-wing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGT..c_152 can lead to the imposition of criminal penalties of a •
one tin to 51,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
F do hereby certify under the pones mid penalties of perjury that the infonnatiots_provided above is true and correct
Signature: "--------)riPet'ei't_ Date:
?hone-: g'T(t6?I V'S"--
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 i BuiidingDepartment 3_C.ityiTown Clerk 4_Electrical Inspector Plum bang lx:speccor
6.Other _
Contact Person: - - . Phone