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HomeMy WebLinkAboutBLDP-23-005110 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kk 7, ; CITY YARMOUTH MA DATE 3/16/23 PERMIT# BLDP-23-005110 „., JOBSITE ADDRESS 9 CAPT NOYES RD OWNERS NAME LEBLANC CRAIG D OWNER ADDRESS 9 CAPT NOYES RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES NO m FIXTURES .1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 1 LAVATORY_ 2 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 1 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 m NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m OTHER TYPE OF INDEMNITY 0 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 aN Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Mark Couto LICENS415856 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 I R E.C -E I V E D /3d- 6D MASSACH SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 0:4,,,,..,==t MAR 16 2021 — CITY° MA DATE 3 f/mil a 3 PERMIT#73LL°''Z3—O S/'U q 7I - UIL DING u�NARTMENT Kay r� L�A3{R=SS (. Gir�f� a ye S OWNER'S NAME; 1 11) OWNER ADDRESS TEL -FAX TYPE OR OCCUPANCY TYPE COMMERCIAL` EDUCATIONAL 1 RESIDENTIAL. '.------ PRINT _ CLEARLY I NEW: RENOVATION: REPLACEMENT: PLANS SUBMI I !ED_ YES NO: FIXTURES 1 FLOOR—, BSM I 1 2 3 4 I 5 I 6 i 7 8 1 9 10 11 12 13 14 BATHTUB I { CROSS CONNECTION DEVICE � i i i ' — _A. '— —I - —I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I 1 I I I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ _ _ . DEDICATED WATER RECYCLE SYSTEM I DISHWASHER I DRINKING FOUNTAIN I ( I I FOOD DISPOSER I FLOOR I AREA DRAIN I INTERCEPTOR(INTERIOR) I KITCHEN SINK I LAVATORY 12- 12. ROOF DRAIN I I I I I [ SHOWER STALL i ( . i i I I I I SERVICE I MOP SINK I I I ' t I I TOILET I I 1 I URINAL I I WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES I I I WATER PIPING I OTHER_ — -- — I t I i l I I I I t i . I 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 BOLD 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 an 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 perfoared under the permit issued for this application will be' .lance with all rtin?r*provisi n of the Massachusetts State PL..:n-is:y Cars end Chapter 142 athe General Laws. PW.VC PLUMBER'S NAME.Mark Couto LICENSE# 15856 SIGNATURE MP ' JP CORPORATION � # 3408 PARTNERSHIP # LLC It COMPANY NAME: Mark Couto PIb&Htg Inc_ ADDRESS 103 Lake Shore Dr _ CITY Brewster STATE I:aA ZIP 02631 TEL:508 965 2145 - FAX :508-896-2577 CELL •EMAIL Markjcouto@yahoo_com a - J. • The Commonwealth of llassachusetts Department of InriatAccr: 1 Congress Stree Snit Z00 Boston,MA 02114-2017 w-Rag ra s.gore c'£ '�3--ei;ate..;_`° Ksu:. A a TO BE FLED WITH THE PERMITTING AUTBOR-rrl. Anaemia irtionnation PIease Print Lesibr Name(Sus ness/O tionftndivio„,r:Nitrk Cat_ &Heating in Address'103 Lake Shore L_ C itv/Sb /Z`p:Bremt- 114i1 02631 Atl�ir:- .u_5f&-965.2145 F� ')Are you an employer?Check the appropnatebox Type of project(required): t_l✓ I am a employer with 0 employees(full and/orpart-time)_ 7- 0 New construction 2.0 I am a sole p.upiietnrorparnoership and have no employee:working ftr-me in s. El Remodeling any capacity_[Noworlms comp_insurance required.] in�-7 9_ El Demolition I am a bunteoamereomg all woremyselr`(,No will-I.- ' I Lv Yji•• � s c1]T r 4_f7 a aims o andw lb ••umn or Wconk,ctal work.en nynrop�_€wli . l0 $T�Itlit►�i di€iOn ensure that all contractors either bavc workers compensation insurance oraresole 11.O Electrical repairs or additions proprietors with no employees. l 120 Plumbing ielraiwa or additions 5.0 I am a genial contract rand I have hired the sub-contractors listed on the attached sheet_ 13 EI 0 f repairs These sulrcontractorslrave employees and have workers'comp.insurance: 6.0 We area corporation and its of-itcersbavc exercised theireglrt o€exemption perMMMGL c. 14_0Other 152,61(4),mad we have noe oyt D'wmters'amp_ *Any applicantthatchecks box p1 must also fill ant the section below showingtndraorkers compensation policyinfbmmtiori t Homeowners who submit this affidavitiodicalbg they are dminoall work and Mel hire outside cofactors must submit a new art:davit indicating suck Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and statewhether or not those entities have employees. If the sorb-canitactms have employees,they mastprrovide their worktw'comp.policy number_ I am an employer that is providing worlarrs'compensation insurance for my employee& Below is the policy and job site information ., �e Hartford Insurance Co. insurance€..tsmpany]�a�: -. Policy#or Self- Lie_ Expiration Date:10/2 j Job Site Address: City/State/Zip: -- Attack a copy of the workers'comp on policy des 1nrat1on page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation puni liable by a iinc.up to$1,500 00 and/or one-year imprisonment,as welt as civil penalties in the form of a STOP WORK ORDER and afineofup to S250.00 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 ofperjury thatLs brf ormafian provided above is true and correct Signature: (1 Dot? / d a - 77 Phone#: ��� iiOfficial use only. Do not write in this area,to be completed by city or town official ICity or Town: Pernti Licease II Issuing Authority(ciele one): li 1_--.roan i o_Re &, _Fill.csli. i-T t i u rt �=i itv will clerk 4_"Kledriell Luspetior S tium is s ie`or 'I 6.Other III Contact Person: PnoDe#: