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HomeMy WebLinkAboutBLDG-23-002075 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 18,2022 PERMIT# BLDG-23-002075 JOBSITE ADDRESS 108 BEACON ST OWNER'S NAME MELCHIONO FRANCES E G OWNER ADDRESS 108 BEACON ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES ❑ NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 ! 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 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 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND ❑ OWNERS 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© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MARK J COUTO ADDRESS. 103 LAKE SHORE DR, CITY BREWSTER STATE MA ZIP 026312429 TEL FAX CELL EMAIL marklcouto(rD.vahoo.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES —= APPLICATION FOR A Per To PERFORM GAS FITHNS rPC YAW'' CM(- -•- MA >�TE. .1 0 . _ . _..., .PERIWTit 2 3_ .JOBSITEADDRESS OWNER'S NAME._ -'Fr -N A _ e L:c W kko / ram' -- • - .- x O gRA.I ESS 6 d S_!J21kC.d jZ C _ - - $ FAXTY 3- PPRIE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL . RESIDENTIAL'.✓- "a CLEARLY NEW.:f RE OVATIatt : REPLACEMENT; _ - PLANS SLEINITECt YES; ; NO: APPLIANCES Z FLOORS-.- 13Sr 1 2 3 4 5 6 7- 8 9 19 11 12 ' 13 ' 14 iBOILER - -- - --BOOS I ER } _�_ - CONVERSION BURNER COOK STOVE ( - - -- DIRECT VENT HEATER - DRYER " .;:. : ,. . . _ .. ____ FIREPLACE FRYOLATOR FURNACE _ - - GENERATOR - GRILLE - - - -- ,_. INFRARED HEATER _ - LABORATORY COCKS - MAKEUP AIR UNIT - - - OVEN POOL HEATER - ROOM I SPACE HEATER i g ROOF TOP UNIT - - - " TEST - UNIT HEA T ER UNVENTED ROOM HEATER —_ INA I t_R HEATER = - - - - - _ OTHER _ . - -- - •- • INSURANCE COVERAGE _ I have a liabilitycurrent policy orbs substantial equivalent vAich meets the regr requirements of FAQ_Ch.142 YES :+:NO I IF YOU CHECKED YES,PLEASE Lf BCATETHETYPE OF COVERAGE BY CHECKAIG THE APPROPRIATE BOX BELOW LIP.SILIIYINSLIRANCEPOUCY--f OTHEt TYPE t fY - B J --- OWNER'S INSLWANCEWABIM I an aware that the licensee does not he the insurance coverage regiked byCbailter 742 ante Massachusetts Germs Laws,aid itaW my signature on this pernitappicaion Waives tits requirement CHECK MIL T:LY:-=.OIN&E12- MEW- -- SIGNATURE OF OWNER OR AGM* -I hereby certify that ail("the details and-aeon I have subnulted or ended regarding this and accurate to the bed.of myknowledge and that all plumbing wait and irstallaiionsperformed under the penny issued for this appr tvrel in all - of the Massachusetts Slate Plumbing Code and 15856 Chapter I42 of Uwe General Laws_ - - F(TTER NAME Mark Couto -U- • V PLUMBER-GAS S GNATURE MP / MGF JP JGF LPGI CORPORATION f.II: 3408 PARTS # -LLC- # COMPANY NAME Mark Canto Fib&HIg Inc_ ADDRESS 103 Lake Slue Dr Y �-- an' Srewster STATE MA ZIP.OZn3 i 1EL 51 -2145 FAX 508-8 7 f:Hi- _tom.-Madciceuto@yaboaccan - RFCEIVED 1 OCT 17 2022 L. j aU!LDNe, )L r'ARTMENT- Hy -0-- a a Commonwealth ofMassachnsefts �.. (, Deparmtentof.badusb1B1Accidents 1 Congress Stree4 Suite 100 !i•-� " Boston,MA 92114-2017 - a q ! .$ - wwpanums.govitha - ..miens'Compensation Insurance Attidavl ,•. ... _ . .,. • TO BE FILED WITH THE PERMITTING minima Aaalicant lnformtation Please Print Lesii ' Name (Business/Organization/Individual):Mark Couto Plumbing&Heating W . AddresE.103 Lake Shore f . City/State/Zip:Brewster,MA 02631 Phone#: 5-2145 Are you an employer?Cheek the appropriate box: I Type of Project(required): 1 i.0 I am a employer with 0 employees(fall and/arpart-time).* 7. New construction 20 I am a sale proprietor or partnership and have no employees working forme in 8. 1:1 Remodeling any capacity.[No workers'tom.insurance required.] 3.01 am a homeowner doing all work myself.[No corners'comp.insurance required]t 9. Demolition lop Building addition 4.01 am a homeowner and will be biting contractors to conduct all work our my property.I win ensure that all contractors either have workrs compensation insurance or are sods 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.ire.: 13-❑RDof repairs 6.[J We area corporation and its officers have aracised their right of exemption per hiGL c. 14.IJOdier 152,§1(4),and we have no employees.(No workers'comp_insurance required.) *Any applicant that checks burr#1 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 inking such. =Contractors that check this box nest attached an additional sheet showing the name of the sub-contracto rs and state whether or not those entities have employees. If the have employees,they most provide their workers'comp.policy number. I am an employer thattis provtialnrg workers'compensation insurance for my entployees. Below is the policy and job site information. Insurance Company Name:The Hartford Insurance Co. Policy#or Self-ins.Lie.#: Expiration Date:10 '2 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-9Lnp 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. 1 do hereby certify err the pains andpenalties of perjury that die information provided above is true and correca Signature: l - Cd4 -/ ' " Date: /1/1-i/i- 7i Phone#: area, completedby� Official 8se only. Do not write in thism beor fawn o City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - f