HomeMy WebLinkAboutBLDP-19-005308 e,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 13 71p E3 .CI—, OWNER'S NAME 1Z4//ltcfi 5 be✓Ai
I OWNER ADDRESS ah.G" /I ( pfra Ss atVZr TEL FAX-
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ' RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR—' BS14 11 2 3 4 1 5 6 7 8 I 9 10 11 12 13 14
BATHTUB •I I _ • "
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM I _ _
DEDICATED GREASE SYSTEM
_
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER LI
DRINKING FOUNTAIN I
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK I
LAVATORY t- • -
ROOF DRAIN I I 1 tr
L-
SHOWER STALL -9t4i
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SERVICE/MOP SINK I `•kI\ rI' ; ; ' _ v
TOILET
URINAL .__
WASHING MACHINE CONNECTION r {
WATER HEATER ALL TYPES _ I
WATER PIPING
OTHER - - I
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES f 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 I
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. f, `4/1.-k=— 6, v
PLUMBER'S NAME Mark Couto LICENSE# 15856 SIGNATURE
MP , JP 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 Markjcouto@yahoo.com
/4-._/7
The Commonwealth ofMVfassachusetts _
4 fleparrcent of Industrial Accidents
Office of Investig rations
• - 600 Washington Street
_, Boston,MA. 02111 _ .
•
-. zvww mass_gov/dia -
Worke_-s' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information 'lease Pint Lesibiv
Name(Business/Organization/Individual): •
Address: -
Ciy/State/Zip: Phone ': .
Are you an employer?Check the appropriate box:
Type of project(required):
1.El I am a employer with "-- ❑ I am a general contractor and I
employees(full and/or par arne).- have hired the sub-contractors employees
❑New construction
2.❑ I am a sole proprietor or parmer-
listed on the attached sheet. 7_ ❑Remodeling
ship and have no employees These sub-contractors have '8. ❑Demolition
working for rue in any capacity. employees anti nave workers' -
comp_insurance? 9_ ❑Building addition1No workers' comp-insurance P
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.Li I am a homeowner doing all work officers have exercised their - 11.0 Plumbing repairs or additions .
myself[No workers' right of exemption per ivMGL
Y comp. 12.0 Roofrepairs
insurance required.1 t c. 152_ 61(4),and we have no
- employees_[No workers' 13.❑ Other
comp-insurance required] I
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this a=idavit indicating they are doing all work_.c thea hire outside contractors must submit a new affidavit indicating such_
=Contractors that check this box must arached 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 wo:kcs'corm.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job side
information.
Insurance Company Name:
Policy_or Self-ins.Lic.=: Expiration Date:
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 Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a •
fine up to S1,500.00 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.
I do hereby cer4151 under the pains and penalties of perjury that the rzformation 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 �_Plumbing Inspec-ior
6.Other _
Contact Person: - - Phone#: