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Home My WebLink AboutBLDG-21-003028 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH L11 MA DATE November 27,202(PERMIT# BLDG-21-003028 JOBSITE ADDRESS 48 PEREGRINE LN OWNERS NAME SULLIVAN JEANNINE G G OWNER ADDRESS 28 APRICOT HILL LN WEST SPRINGFIELD MA 01089-4460 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 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 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY BOND 0 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 0 MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: MARK J COUTO ADDRESS. 103 LAKE SHORE DR, CITY BREWSTER STATE MA ZIP 026312429 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 1:1 El FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE / 3 l� PERMIT# 15Li2/-OQ3OL1 / / JOBSITE ADDRESS V OWNER'S NAME B✓`" $Ad rjef 44-e if OWNER ADDRESS TEL FAX _._ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL --- PRINT CLEARLY I NEW: RENOVATION: REPLACEMENT: � PLANS SUBMITTED: YES NO APPLIANCES Z 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 1 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 OTHER INSURANCE COVERAGE I have a current liabili insurance policy or its 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 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 cowitance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws_ 4-1 PLUMBER-GASFITTER NAME Mark Couto LICENSE # 15856 SIGNATURE MP MGF JP JGF LPGI CORPORATION ' # 3408 PARTNERSHIP # LLC # COMPANY NAME: Mark Couto Pib & Htg Inc. ADDRESS 103 Lake Shore Dr CITY Brewster STATE MA ZIP 02631 TEL 508-965T2145........,__ 6 ;+ - 41 FAX 508-896-2577 CELL EMAIL Markjcouto@yahoo_com - O V 4 2020 It I I t�� rc ��1? N LBy .&.' The fu uw neu tk elatssizekasetts _ t=,.. ..._. the!o_frect rimatAride�wiic - - - Office rT ves7i as ,- - 6007rs la:3,7eet - _ t J. Bosto M Gil_I - -- - - - wana—wr¢¢a°ov/,�e_'¢ - - . 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I atn a sole nrinii cor&oi er Imo = �d sheet_ `r_0 Remodeling shin and have no x.�-PID. -�'�'1i"c� -e -o.0 Doi1RE0.R warTu-g Hn-me tapecay_ ice isr+a mimed [No wotsrs' t in r re cn�n tomce,= 9❑3ID�I�o easier-ion requirsal 5-Q tWeama®eaion end.its 10_0Fleraicalzvaic-m-addidos 1-1_am ahomeowner dni.c art math_ a ce ec esed i> 1.0 Pluibingaepwa oraddi:innc_ myself_[No wadmm'gyp_ -a, os4 '^'n� + insurance mluired_7 t c_tom= i CAL ter,=ba no ❑Roof c�,as, t -L•vo emir ' 1-3_0 al/ cmpo_Z—��.r-,nu ..4] yaonlicent[etcnedN—bag. mostalsoBf m¢mesecooa bdowsao iaS i.ei.:u eaoue,veea ppyy emeown r-ianosuirmit e LermiinrcT.=aryey a�rrdoing all - µ m6id_=tr_m=ra3a:ntnian_4sra iiimiSr ri+Fme i.nuxctoril detcueet tid;a s zudmor]aaLi'.usw:_ _ esai-call 4rsznd aoEmtiterorntoilE.,m5ioys_Mhesib—amemsneiesi T.wiaeair`-...1.`cowgpadq.-auem¢ r.an employer tht iaroP rwa«a mamee.&'war_=_sumr1e;orRDelmioyae.Below W die popcp mad job ide ariratior uranceCom, a Bras- 1 t't-C 1 Maiejr-iC5 vS. - icy-or Self Lic. . m.:a nm.Da¢_ LD hit -- u Site Addlaau C.y/Stalefrir_ _- bath a copy of-ate-workers'cnapensaBaa policy declaran psan(showing,the policy mmnberand empiradon date). Aura to seam cave-age asz erred underSec ion k osM-GL c iZ m learitoma impwsiuna ofrrimiaral paaldes of a - e UP to SI5011-00 aud/&ane-ycse-imnisnnmeik Bell a cna nil.es bttheimth urn STOP WORK ORDER and awe up to S2SO.00 a day sgamst Me-Violainc Be advised-ftwt a cnay ;aia s maotmay ha fora arderi to Ins Office of eestigadons at-the DTA for kouraoco coverage v 7o o hereby ceiir1"g bider illegifims mre'DaNptnac o1Dajny that the bzoraatimprav r cmu and comrc !nature_/ irz�/ etL--c- a_c"I t fP D �//✓7 jl tne- t S .,3%I7 S - ., • Official rue an1y.Ea notwilEem ads'ineq is he coaoleted by-city ors J. .1. amity or Town_ P.et,a WAcense= Issuing Authority(circle one)_ t_Board of-Health 3Bnr gD -i CByTown Clerk t Mect ical lnsLecdar> �o.Pl �rrsp®r , i.Oder Contact Person: - _ Phone