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Home My WebLink AboutMiscellaneous - 27 COCHICHEWICK DRIVE 4/30/2018 (3),S -s 7 1 1,11 0 �- 5 Date... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........ f,24 . e, ..-C/ ...... .. .................................... has permission to perform ...... ....... . ......................... plumbing in the buildings of ...... .......................................... a -:4.1 ...... (-- C �-%- f r— t... .............................................................................. , North Andover, Mass. Fee,.-3.� .............. Lic. No. f .... ................................................................................. PLUMBING INSPECTOR Check #40 42,3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING CITY MA DATE -n,--. —PERMIT# JOBSITE ADDRESS 7-1 OWNER'S NAME OWNER ADDRESS TELI JIFAX TYPE OR OCCUPAICYTYPE COMMERCIAL ED EDUCATIONAL EQ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Of FIXTURES -1 FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER OTHER RESIDENTIAL [I PLANS SUBMITTED: YES 01 NO 9 1 10 1 11 1 12 1 131 INSURANCE COVERAGE: I have a c I urrent liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CO V-ERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY [:]I BOND 0 an: OWNER'S INSURANCENVYVER: I am aware that the licensee does not have the insurance cove . rage required by Chapter 142 of the Massachusetts ri!�Kaws,an��- y signature on this permit application waives this requirement. CHECKONEONLY: OWNER 01 AGENT SIGNATURE OF OWNER OR AGENT i I hereby certify that all of the details and information I have submitted or entered regarding this application are truearTO accuratee to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application Will be in compli- ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !�It� I PLUMBER' 'eu LICENSE # SIGNATURE MID CORPORATION RJ PARTNERSHIPD# LLC E COMPANY NAME CITY ISTATE ZIP TEL FAX CELL EMAIL Th.e Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 wwwmass.gov1dia Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. NaMe (Business/Organization/Individud): Phone #: Are =youa mployer? Ch , e�k t 'e apli�opriaie 'box: �e �_! employees (full and/or part-time).* 2.FJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole prop'riet;rs with no employees. 5.FJI am a general contractor and I have hired the sub -contractors listed on the attached sheet. I . 11 1 . . Th , es'6 si�b-contrictoris haie employees and have wo I rkers' comp. insurance.t 6. We are a corporation and ' its . officers have exercised their right of 'exemption per MGL c. l52,§l(4),an4wehavpnoe loyees. [No workers' cpmp. insurance required.] Type of project (Tequired): 7. F1 New construction 8. Remodeling 9. Demolition 10 E] Building addition I i. Electrical repairs or additions 1�. FJ Plumbing repairs or additions 13. F1 Roof repairs 14. E] Other *Any applicant that checks box #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 indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If - the sub-cbi16c6S fi�a,ve, , e'n plo�ye'es,, ifiey must provide their workers' comp. policy number. i a m an �mployer th at is pro viding w orkers' comp ensation insu ran cefor my employees.' Below is th e p oficy an djob site information. Insurance Company Name: h� cn, Policy # or Self -ins.. Lie. Expiration Date: JobSiteAddress: 21 C_0CkJCKQW;cfe 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 of up 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. I do h ereby certify u#der tLiofains an dpenalties ofperjury th at th e information provided above is true gn d correct. Phone #: !I 3A I - as 2 7 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 5. Plumbing Inspector 6. Other Contact Person: Phone#: Division of Professional Licensure: License Search A The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home ) Division of Professional Licensure > .......... I ........... I .............................................. ............ ............................................ .... . .................................. ......................... .................. Clieck A Professional License By the Division of Professional Licensure LICENSEE Name: KEVIN P. RAYMOND LAWRENCE, MA NEW SEARCH "This Licensee has additional Licenses, ctick here to view them.** Licensing Board: PLUMBERS F1 GASFITTERS License Type: MASTER PLUMBER License Number: 15321 Status: CURRENT Expiration Date: 5/11/20116 Issue Date: 10/13/2007 Exam Date: 10/13/2007 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the DiAision of professional. Licensure web server on Thursday, April 09y 2015 at 4:22:52 IRM. 0 2007-2011 Commonwealth of Massachusetts Page I of I Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES& RELATEDINFO Disdaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board—code=PL&type—class=—M&Iic... 4/9/2015 -.,*ldNw- EAEtH. SM. "TAWAII-17h Klo,;A�1019902m� PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: I.,KEVIN P RAYMOND 2 PILGRIM RD LAWRENCE M -A 15,321 05/01/14 17636571 0 k WILLIAM BALKUS ASSOSCIATES I )WCTHIYJM TEL. 978 887 3351 WBAARCHITECTS.COM TEN SOUIH MAIN SMEFTOPSFUID MA 01983 WNBALKUSASSQQ@MEQQM MEMORANDUM TO: MR. GERALD BROWN FROM: WILLIAM BALKUS DATE: MAY 24,2012 SUBJECT: CAMPION HALL CONDOMINUMS, SUMMER HOUSE UNITS 11, 15, 17, AND 19. CENTENIAL HOUSE UNITS 21,23,25, AND 27. BUILDING TYPE: V13 USE GROUP: R-3 I have reviewed the completed work done on the above listed units, and to the best of my ability, I would say that the work meets the original design concept and the requirements of the Massachusetts State Building Code. William Balkus 114 Date I UNIT# I ROUGH I PASS�j FAIL INSP I FINAL I PASS I FAIL PERM T # IT # 10294 I ROUGH I PASS I FAIL FINAL