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HomeMy WebLinkAboutBuilding Permit #440-11 - 75 ROSEMONT DRIVE 11/23/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �—o -ELDate Received Date Issued: ( ~4'3 IMPORTANT:Applicant must com lete all items on this page LOCATION 9 S t2OS-�`r"io"�� OL�-'`e Print PROPERTY OWNER 1531 K gy� a c, Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑A ition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other F --p= ,,. - `0Watershe`dIDistrict? t Septic Dwell aY ©DFloodplaintAWetlands� r i � - x h DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: K S r4 'nal Phone: Address: -I s7 CLo&.two�n�- n�(•�P :-- CONTRACTOR Name: ©/ 1rQA.s� SinS �d�S Phone: Address: 3"5-k Supervisor's Construction License: C G (68' 10 S )3xp. Date: Home Improvement License: —1b-7 52 Exp. Date: �3 Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINcG[ERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. t: �f 5 0 FEE: $ C �, Tota( Project Cos $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th uaranty fund Signature;of_AgentOwner ----' -- - :Signature:of::cont'racto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Pools;.. , ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ 1 THE FOLLOWING SECTIONS FOR,OFFICE USE ONLI(- INTERDEPARTMENTAL SIGN OFF = U FORM '. ' DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS' HEALTH Reviewed on Signature e COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: t , C ` •� Located 384 Osgpod Street FIRE DEPA.RTAMT T -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMAMNTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use U Notified for pickup - Date Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit n all cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals 'gat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording [a st be submitted with the building application Doc: Doc.Building Permit Revised 2008mi LocationT � � No. d — f Date NORTN TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ s' °�cMus9 Buildin /Frame Permit Fee $ Ewa s, e Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # T- 237 %1.,03 ��a - 2 3 7 `,0 S Building Inspector ORTM T0VM of dover No. 0 = - -a y � over, 1Vlass.,i - Z� � � a O COCHIC EWICK V 7�ADRATED PPat'\C� SS BOARD OF HEALTH Food/Kitchen PERM IT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........<�.r �.tl.!........D-A..L� .. .................................................................................. Foundation has permission to erect........................................ buildings on .._7.. .�........... ...... 0. Rough TG / '� - `..............5 }�(y4G. �tC.GMt�"� 1 .. Chimney to be occupied as.............t.. ............... ... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final � Z. PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU O S TS ELECTRICAL INSPECTOR Rough ....................................... ....:.......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the- Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I Office`dt�o�s����tBiC�iire5'it�t(1�ttt�"' 19HOME IMPROVEMENT CONTRACTOR Registration:- 167452 Type: Expiration: _ %23 /2012 Individual T MELILLO ==a tom:-: __✓�.. LOUIS MELILLO 128 ESSEX ST SAUGUS,MA 01906<=;; Undersecretary Massachusetts - Department of Public Safct.N Board of Buildm,_, Re,_,ulations and Standards License: CS 68105 u CHRISTOPHER J MELILLO 5; 179 A LAKESHORE RD BOXFORD, MA 01921 �--G- ---' Expiration: 5/19/2012 ('unuu issi„ner Tr#: 2965 ,per �1� -�omvno�eurealCli o�,�//laaaaclivaetla -\ Office of Consumer Affairs&Bu Regulation HOME IMPROVEMENT CONTRACTOR Registration: 124536 tt Expiration: 7/15/2011 Tr# 287041 Type: Individual Christopher J. Melillo 9 Christopher Melillo c 179A Lakeshore Rd. � � -- Boxford, MA 01931 Undersecretary The Commonwealth of Massachusetts Department of Industrial,4celdents Office of Investigations 600 Washington Street t Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plulmbers Applicant Information Please Print Legib1Y Name(Business/Organization/Individual): �A� 4S . y 44l I,c._A_)06-S Address: --xs 1 So q Y�14�y1 S 7 City/State/Zip: YN d�1, 9 s Phone#: Z*i'may+-03 Are you an employer?Check the appropriate box: Type of project(required): 1.IRII am a employer with _c� 4. ❑ I am a general contractor and I 6. Xemodeling construction. employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.? . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. 0 Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance -required.] employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box BI must also ffll 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. 1 Insurance Company Name: L\ 6,e-4r—M 0 7� Policy#or Self-ins.Lic.#: WL 131 % -6-79 q-t 9 O Expiration Date: t 6-L- 1-0 1 Job Site Address: -7 5 2094 vrovki City/State/Zip:. o-Aln 19.4c),40- My 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. f do hereby certify n the pains andpenalties of rjury that the information provided above is true and correct. Si afore: Date: Phone +4 Official use only. Do not write in this area,to he 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 C ontact Person: Phone#: A� CERTIFICATE OF LIABILITY INSURANCE _DATE 11/22/2010010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT sTEVE GILL NAME, EA Stevens Company, Inc. PHONE Ext); (781)3222324 FAX (781)397-7672 AIC No 389 Main St. ADDR1ESS:sgill@eastevensins.com P. O. Box 188 CRODUCER USTGMERID#00006972 Malden MA 02148 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Travelers Indemity CO of 25666 INSURER B.Liberty Mutual NORTHEAST INSTALLATIONS INSURERC: 251 S MAIN STREET INSURERD: INSURER E: MIDDLETON MA 01949 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TYPE OF INSURANCE ADDL B POLICY EFF POLICY EXP LTR INR WVD POLICY NUMBER IMM1DDIYYYYI IMMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE ❑X OCCUR 6800244TO19 9/22/2010 9/22/2011 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED AUTOS 68002447019 9/22/2010 9/22/2011 BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION INC131S3799790 0/6/2010 10/6/2011WCSTATULIM - OTH- AND EMPLOYERS'LIABILITY TFR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ -900,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Town of North Andover is an additional insured on the General Liability policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE Francis M Clifford Jr, CPCU, CIC ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2009M) The ACORD name and logo are registered marks of ACORD