HomeMy WebLinkAboutMiscellaneous - Suite 300��
l-
Location <i/4✓/.r .C4 Jy,�2 — WA "
No Date 22 — le)
NORT►, TOWN OF NORTH ANDOVER
• H _ 9
Certificate of Occupancy $ �0y
�'� s"•••° • Eta'
NUS Building/Frame Permit Fee $
AC
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
2Z G
Building Inspector
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 160 Date: January 22, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 451 Andover St '- .Y& 2f":
MAY BE OCCUPIED AS Tenant Fit up — Dr Wachtel Office IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: NAOP LLC
451 Andover ST
North Andover MA 01845
Building Inspector
o
a�
CQ
O
w
&O
Cl)
Pd
00
w
or.
c
w
to
O
A
c
U
G
w
w
PO
a
O
w
G
d.
a
of
aR.
U
w
W
O
y
v6
Cd
C
w
O
O
C4
CO
G
ii
W
A
a
w
I
� N
o
z
cn
0
cn
a�
O
C L
O
V
Z co
CL
O y
CD C C
O•—
y
CD
O •O
m m
CD CD
� t
CL
= O �
•r 3
O
� � L
CL
0
CL CMa
C.0 C
O C
3
•C ' CD
V0 CL
` CO)
ctsC
cc
d
is
� N
VCj
1
CL
Q A A
O
A�- E a
p•�
o
m
.dvo=
0
C3 $
�:
u a
me
.,
im
d
N
N
cm
N
_:CMD.,3
N
O
_m
SZH
C
c
O
:
A
CLU
m
_
7
CD o
S
i ;mom
m
V N O
Z
O
c Ca
.0
Q
y m O
O
=
m
CL — C2
:a
N
ao
`r
cc
R O r O
Z
LJJ
.CA
oc
�E
aro5
C=J CUD N
Z
O
C-3
a
m�C2
s
F.
t
$ aim
i
a�
O
C L
O
V
Z co
CL
O y
CD C C
O•—
y
CD
O •O
m m
CD CD
� t
CL
= O �
•r 3
O
� � L
CL
0
CL CMa
C.0 C
O C
3
•C ' CD
V0 CL
` CO)
ctsC
W
W
ix
W
cc
d
is
W
W
ix
W
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, AMASSACHUSETTS D
Building Location /WOW P2 / Owners Name 1 0 1 Date0A
Permit #
Amount
/' Type of Occupancy
New E Renovation Replacement 0 Plans Submitted Yes No
(Print or type)Check one: Certificate
Installing Company
lT
Naame e e',j-
` jU �� +� �
Address / Q2 G�� Partner.
Ie l
Business Telephone ? �%_ t- _ n Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate e type of ins -coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature i
Owner ❑ Agent 11
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and insta ons performed d Permit ssued for this application will be in
compliance with all pertinent provisions of the Massachus to PI n ad d pter 1 2 of the General Laws.
By:
Signature 01 LJOC-n-Su(ju r
Title
Type of Plumbing Lice
se
City/Town icense um er Master
APPROVED (OFFICE USE ONLY El
ourneyman
.r
r
•
r
.M
.J
:: `fir o►17����������������MM
���������
MMM
IM
----
,,1=4.'
1M11MM
---
-E-���-���
(Print or type)Check one: Certificate
Installing Company
lT
Naame e e',j-
` jU �� +� �
Address / Q2 G�� Partner.
Ie l
Business Telephone ? �%_ t- _ n Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate e type of ins -coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature i
Owner ❑ Agent 11
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and insta ons performed d Permit ssued for this application will be in
compliance with all pertinent provisions of the Massachus to PI n ad d pter 1 2 of the General Laws.
By:
Signature 01 LJOC-n-Su(ju r
Title
Type of Plumbing Lice
se
City/Town icense um er Master
APPROVED (OFFICE USE ONLY El
ourneyman
f
tf
I
Jo� Noq
r� Date .�
This k'ly � •!�� -
has certcPe pF/Q F N'
Pic, Per�1ssc s°n that ",—,9
M�r�o y4
ar �bcng iq tO Per/,, • ./.� p� UM ���FR
F ri e�hC
Cheek Of
��c N'4
.819 •.
9
Pc�,yej�c / DdO`er � •dam
ISPF' ass
G °T
w
r; 1�0.3MIS
r�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesiig ationc
600 FMashington Street
Boston, MA 02111
Workers' Cwww-nzarsgov/dia .
ompensation iasiu-anee Af£davit: Builders/Contractors/Eiectricians/Piambers
3-Plitr Mt Information .
Name (Business organiraiiorL4ndividual):--ClLtz.(Z-�
Address: --I
City/State/Zip:_L�� �7zi RA
2.D
Effull
Phone #.. 9 2�F
Yo employer? Cheok.the appropriate box:
am a employer with 3
4. ❑ 1 am a general contractor
employees (fun and/or part-time).*
and I
have Dred the mb-contractors
I am .a.sole proprietor or pm i ner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity,
[No workers.' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required_]
I ain a homeowner doing all work
officers have exercised their
right of exemption per MOL
myself [No•workin' comp.
C. iS2, § 1(4),'and we have no
insurance required.] .t
.employees. [No workers'
COMM insurance uired.I
Type of projeet (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demoiition
9. ❑ Building addition
10. ❑ Electrical repairs or additions,
11.❑ Plumbing repairs or additions
12.[] Roof repairs
I3.7.0ther
`Any 9PPlicsm that checks bcrl I mutt aFso ffil outthe section below sbowing their woricen ' oompensetiooI poiuy mformahon I
1 Homeowners who submit this tttrldavit indic sting they am doing all work end then his outside conttactom must'suhmit anew affidavit indicW* such.
?Contra-tttw that check this box mustatreohed an additiaual sheer show'
mg• lite name of the sttb.contractocs and their work=, coM• In ic.• infarn Won.
1 ant an erdploj,er 1*at &Pronrdirg:work= competrsarron insurance or
information. -f JW "Floyem Below is &e pa&,7' and job site .
Insurance Company Name: N
Policy # or Self -ins. Lie. 9:
Expiration Daze:
Job Site Address:--Z--r/ �.tJhu-eA J-/-Ae G7
Attsch a copy of the workers' com Crty/Stata/ZIp' �vAukvf2
peasation policy declaration page (showing the policy number and expiration date].
Failure to secure coverage as required. under Section 25A of MOL c. 152 can lead to the imposition of criminal
fine up to $1,500a and/or on�year imprisonment, as well ss civil penalties m the form of a STOP WORK ORDER anfl a fine
Of up to 5250.00 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 c 'und a
41 PerjwY Mat the information Provided obove ' true ron�ecx
Si
Date:
Phone #• 7t�" �� -- �'7
Official ase only. Do not write in this area
to be completed or town o
by COY ficial
City or Town:
Permit/L.icense #
Issuing AathoritY (circle one):
1. Board of Health L Building Department 3. City/Town •Clerk 4. Electri
6. Other cal Inspector 5. Plumbing Inspector
Contact Person:
Phone #: