HomeMy WebLinkAboutMiscellaneous - 71 CORTLAND DRIVE 4/30/2018Date .!,^. f..r....::..�.I.�......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .A....I.... .....................J..,.. �..1 c�•, JA,, �.... �...................
has permission to perform .... t,..�.,;. ��. c.�...fA ?.............................................
plumbing in the buildings of.....,.'�r�.s?.•..............................................................
at ...... ....i .....................2.4...). . ..... ......... . ...., North Andover, Mass.
:.,
Fee'1':.... :7..... Lic. No. 9...`... ....
PLUMBING INSPECTOR
Check # � � 1 �
.PE2EVi'�tA.+TB2d.Q$ET
on 1
Feb 201310:20a p,1
The Commonwealth of Massachusetts Print Forrn
Department of Indus'trialAct Idents
I�Office of Investigations
I Congress Street, Suite 100
ti Boston, MA 02119-2017
.r,,✓ www.mas&govldia
Workers' Compensation Insurance Affidavit: Builders/ContractorslMIectricians!Plumbers
APPUcant Information. Please Print L2&Lbly
Name (Business/OrganizatiordlndividuO): L
Address:_ 5D113110V 1,, !% ��ST,
,
City/StatelZip V, MA 01�((/ -/ Phone #: % 7� "5-D0 -06-7
Are you an employer? Check title appropriate boa:
Type of project (required):
I am a employer with.
4. I am a general contractor and 1
� g
6. ❑ New contraction
employees (full and/or part-time).
have hired the sub -contractors
I am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g. Demolition
working for me in any capacity.
'LNo
employees and have workers'
comp. insurance.
9. ❑ Building addition
workers' comp. insurance
required.]
5. E] We are a corporation and its
10. Electrical repairs or additions
I am a homeowner doing all work
officers have exercised their
11. Plumbing repairs or additions
myself. (No workers' comp.
right of exemption per MGL
12. ❑ Roof repairs
insurance required.] t
c. 152, §1(4), and we have no
13.0 Other
employees. (No workers'
come. insurance required./
*Any applicant that checks box #1 =st also fill out the section Mow showing their workers' compensation policy information.
f Homeowners vto submit this affidavit indicating thea are doirt all work and then hue outside conru.:ctora must subudt a am affidavit indicauag such.
IContracsots that checkthis box must attached an adcEitional sheet showing the name ofthe sub -contractors and state whether or not those entities have
employees. If the sub-coatmetors bavc employees, they toast provide their workers' comp. policy number,
I am an employer that is providing workers' compensation insurance for my employees. Below is tate policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: 7I Unt " DW Ye City/StateiZip-VU-0 IJsWK01 /M 0 /sLV
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 $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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do provided above is true w d eon a
Phone #:.
Official use only. Do not write in this area, to be completed by city or town offIciaL
City or Toren: PermitlLicense ##
Issuing Authority (circle one):
2. Board of Health 2. Building IIepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing .inspector
6. Other
Contact Person: Phone;
Division of Professional' Licensure: License Search
Page 1 of 1
Division of Professional Licensure
Mass.Gov
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ONLINE SERVICES
.......... I .......................... ..................................................................................................................................................................................... _...............
..................
Check A Pmfessdcnal, License
LoczteaLim
P
By the D:irs of P gfesstar LiEensq-e
Od s C7=,�X
Ca�s1 t'�r.��asg
LICENSEE
Name:MICHAEL J. CLARK
REFERENCES &
ROWLEY, MA
RELATED INFO
1a t iv :kt t;
Disda±ner Regard4-V
"Ttas L-xeresee has anal Licenses, dick hese to view them"
Wtbs�e License Seardies
- --- ----- -- -_ _ — - - -- — -- - -- - -
- - amsary of Lcc einse Stas
Codes
Licensing Board: PLLW-1M RS ft GASFITTERS
License Type: JOURNEYMAN PLUMBER
License Number: 32199
Status: CLPJZDfi
Expiration Date: 5/1/2016
Issue Date: 10/12/2010
Exam Date: 10/12/2010
5
This web site displays disciplinary actions dating back to 1993.
This license has had no disciplinary actions taken during this time.
s�acC x,11 -=23,=-4z"_ A:
2=--7— * i Cir; ' e - d. s*-_ PC:=ias C&�'u
http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_code=PL&type_class=_J&Iic... 6/23/2014
Date ........... .. ... 7—
.................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Ab (CrV -&,2722-C-i-
Thiscertifies that ........................%r..........................................✓C) ... .....................................
r-%,
has permission to perform .......... ..........
.... ......
wiring in the building of ......................... tHkt).O.S .............................................................
.at ................................ -/ C-E)t -Fl, Z �I ............ t)R -n North Andover, Mass.
..................... ...
Fee...�� I ic. No.
......... .... .............
Ci LECTRICA e!i4ECTOR
Check #
BOARD OF FIRE PREVENTION REGULATIONS
official urs�e Only
Permit No. `7 41 —
Occupancy and Fee Checked
ev. 1/07j save blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC),2L7L''CMR 12.00
(PLEASE PRINT INRVK OR TYPEALL B&ORMATIOA9 Date: f ZDI/ T
City or Town Ok Q0a4k-, dovCA _. To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work descn'bed below.
Location (Street & Number) 1'%%
t� o��l,a t.,c� Utz• v e
Owner or Tenant PaAm-k PgN)Ckg Telephone No.911%-4th4 .61q
Owner's Address Same as above
Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Bos)
Purpose of Building Dwelling Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Vohs. Overhead ❑ Undgrd ❑ No of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Rip c� d �o�.w �6� rz vt.i-�l*.�•.i
Completion ofdw followint,table may be waived by the Inspector of Wires.
No of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fanso.
of To tal
Transformers KVA
No. of Luminaire Outlets
No of Hot Tabs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool emd, ❑ d. 13
Ba ° UnitsEmecY LAgilting
No. of Receptacle Outlets
No of Oil Burners
FIRE ALARMEEO-
:Of Zones
No. of Switches
No. of Gas Burners
o. 0 on and
Initiating Devices
No of Ranges _
No. of Air Cond. Tons
No of Alerting Devices
No. of Waste Disposers
�
Beatp
Totals•
amber Tons KW
o. of Self -Contained
Detect 9n/Ale Devices
No. of Dishwashers 1 ►
SpacelArea Heating KW
Municipal
Local ❑ Connection ❑ Other
No. of Dryers
Heating Appliances KW
SecNo of 'ces or Equivalent
No. of ater,
Heaters:
o. of o. of
S' Ballasts
Data RrI
No. of Devices or fanivalent
Hydromassage Bathtubs
�o. Hent
y
No of Motors Total HP
etommurcatrons
No. of Devices or E �
N
OTHER .
Analis a=wnat aerau tJ aestreq or as regatrea oy Lm Lmlm&awr vt rr ircJ.
Estimated Value of Elec" al �Jork: $650.00 (When required by municipal policy.)
Work to Start: (�J f `� Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE. INSURANCE 0 BOND[] OTHER [I (Specify:)
I �er*, underthepains and penalties ofpm*-uy, that the infornradm on this application is true and complete-
FIRM
ompleteFIRM NAME: Northeast Electrical Services INC. LIC. NO.: 20782A
Licensee: Daniel B. Kobus . Signature C. NO.:
(If applicable, emvr "exempt» in the license mm�ber line.) Bus. TeL No.� x-966-7467
Address: 40 N. Main Street, P.O Box 361, Bellinqham. MA 02019 Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No
OW XER'S-INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law.. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agenL
Owner/Agent
Telephone No. PERMIT FEE: S. 5 �'
Signature .
l
`a The Commonwealth of Massachusetts
Print 1�6 IMT
Department of Industrial Accidents
Office of Investigations
" I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov; ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Northeast Electrical Services_
Address:40 N. Main Street, P.O Box 361
City/State/Zip: Bellingham, MA 02019
Phone #:508-966-7467 x307
Are you an employer? Check the appropriate bog:
1. ❑✓ I am a employer with 24
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. [_1 I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.1
required.]
5. ❑✓ We are a corporation and its
3. ❑ I am a homeowner doing all work officers have exercised their
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑✓ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.21 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ 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.
#Contractors 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 -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Automatic Data Processing Insurance Agency, Inc.
Policy # or Self -ins. Lic. #:NOW428117 Expiration Date:7/29/14
Job Site Address: / II L1V I,LI A ud _(A(A`'JZJA1 V -Q City/State/Zip-71f (/ /(,�(,('Z K! J 4VM
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 $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. 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 certify under the pains and penalties ofperLury that the information provided above is true and correct
.508-966-7467 x 307
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 #:
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 169 (9/1/06) Date: Janupa 25. 2008
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 71 Cortland Drive
MAY BE OCCUPIED AS Single Family Dwelline IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Meeting House Commons LLC
115 Carterfeld
North Andover MA
Building Inspector
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APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
ADDRESS/LOCATION OF PROPERTY
Building- Permit # 6�
Co C+ I Ct Vj
Map /0 K C Parcel 3 1 Lot Number i� I
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION /2 /Za)
CLOSING DATE ON PROPERTY: 1/1 w l08
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
NOT MEET ALL
Permit Issued to:
Address
SIGNED
CONSERVATION
PLANNING
DPW - WATER METER
SEWER/WATER CONNECTION
NOTE
R TING
Ivo0-aOR 1SbVCTI03an}L
0 Nlh-cl -4oB
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW
Signature
File: Application for OC form revised Jan 2007
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Date.. .. ....... C......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation ................
in the buildings of .......
at ....
(/North Andover, Mass.
, L'�
. .
. . . . ... . . . . . .
Feee ........ Lic. No./ ........
............
GAS INS.�A R
Check #,,,.:
J0/`
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) / Date
NORTH ANDOVER, MASSACHUSETTS J
Building Locations % �_ �s i�/'7/�-n in Permit #
Owner's Name �'Amount $
New Renovation ❑ Replacement ❑ Plans Submitted ❑
(Print or type)
Name
Address
usiness
e Name of Licensed Plumber or Gas Fitter
Che k one: Certificate Installing Company
Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I herehv certifv that all of the —4 ;-,r-.
- - - - »•� �vl ranricu) in aoove application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat Code
nd Cher 1Jthefd9eral Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber j L/57 7
Wmaster s Fitter icense um er
❑Journeyman
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SU B-BASEM ENT
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BASEM ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
STH. FLOOR
6TH. FLOOR
7 T H. F L O O R
8TH. FLOOR
(Print or type)
Name
Address
usiness
e Name of Licensed Plumber or Gas Fitter
Che k one: Certificate Installing Company
Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ❑ 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I herehv certifv that all of the —4 ;-,r-.
- - - - »•� �vl ranricu) in aoove application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat Code
nd Cher 1Jthefd9eral Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber j L/57 7
Wmaster s Fitter icense um er
❑Journeyman
4
1%
Date...... � - �?.3..-...U..7
.......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................. /.. R. Y. l'- -. r.-%�........ ..................
has permission to perform ....... U. �... .................................
wiring in the building of ..... ..........................................
at .......
.... .................... . North Andover, Mass.
Fee .......... Lic. No. ..........
ELECTRICAL INSPECTOR G—
Check #
d Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
N
Official Use Only
Permit No. L
Occupancy and Fee Checked ' ( e
[Rev. 9/051 leave blank
APPLICATION FOR PERMIT TO ,PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code MEC) 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: t 1 Z 3'1 O -j
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street J
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes L!!J No U (Check Appropriate Box)
Purpose of Building 4&.5 6,v1 Wim— Utility Authorization No. I"1 1 667 2___ -
Existing Service Amps / Volts
New Service? Amps j / 2K(�Volts
Number of Feeders and Ampacity
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd EQ"-' No. of Meters
Location and Nature of Proposed Electrical Work: U -It w6 (1.DUSE
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: �4cop,
No. of Ceil.-Susp. (Paddle) Fans
No. of— Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- r-1
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number
Tons
KW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Co n ecti El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or E uivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications irmg:
No. of Devices or Equivalent
OTHER:
CA) Attach
required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VERAGE. Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: �jil-�- vim LIC. NO.: $1
Licensee: ,/AkCA4,A&L- AA-r-D0,v„4-� Signature LIC. NO.: &7-'7 lbs
(If applicable, enter -exempt in the license number line.' Bus. Tel. No. . `3BZ l
Address: � PV 41LA �d4jj W't /L% l'�t�bS%bUt'w1 Q3�1� Alt. Tel. No.: 1-* 31S 0�6
*Security System Contractor Vicense required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent 7ERMITFEE.
$ 34v0
Signature Telephone No.
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