HomeMy WebLinkAboutBuilding Permit #605 - 98 LYMAN ROAD 4/15/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: 'y�
IMPORTANT: Applicant must complete all items on this page
LOCATION Ly/it
PROPERTY OWNER � A Pint f y)4&0&r911// y
Print,
MAP NO: PARCEL: ZONING DISTRICT: Historic District
�� �Machine Shop
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yes no
ves no
TYPE OF IMPROVEMENT
PROPOSED USE
C CS 106
Exp.
Residential
Non- Residential
New Building
One family
Exp.
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PRE
U ri, �'c�.cc (�x�� V, w,l S)dit4
OWNER: Name
Address:
CONTRACTOR Name:
Address:
fPlow,- f�,TN2100-10
I 1le"'i
Identification Please T
�10ti4 M#ll�
VIUw��"6 9-- �a I
or Print Clearly)
Phone:
9/rakes �CA(,-e
64 Aon
Vn-
tndl Phone:
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $8-361��-00 FEE:
Check No.: O Receipt No.: �' d
NOTE: Persons contracting with unregistered contractors do not have access to t#e paran fund
Supervisor's Construction License:
C CS 106
Exp.
Date: 5//O//o t
Home Improvement License:
6c y3�
Exp.
Cate; 7/7
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $8-361��-00 FEE:
Check No.: O Receipt No.: �' d
NOTE: Persons contracting with unregistered contractors do not have access to t#e paran fund
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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTN ENTMFORM07
Revised 2.2008
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
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
`f
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Conservation Decision:
Water & Sewer Con
Comments
Com
DPW Town Engineer: Signgture:
FIRE DEPARTMENT - Temp Dumpster on
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Zoning Decision/receipt submitted yes
Located 384 Osgood Street
no
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
Locationif-
No. Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #/P-0-3-
21 084 Building Inspector
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MELILLO CONSTRUCTION INC
179A LAKESHORE ROAD
BOXFORD, MA 01921
office 978-3524917
fax 978-3524918
cell 781-760-1313
FQEPR:0P0S-:
Proposal No.: m7 8 6
Date: March 21, 2008
C
MRS MARQ-1,*— /% Q/Jq f' Job Name: 4ffiRem
/li(
StartDate: 3-21-08
I
99 LYMAN ROAD Job Location: SAME
e
NORTH ANDOVER,MA 01845
n
t
Job Phone: 978-682-0972
DESCRIPTION OF WORK TO BE PERFORMED
INSTALL
NEW 200&M ELECTRICAL PANEL LM 60 P PANEL AN GARAGE,
REPLACE OLD PLUGS
WITH
NEW CHILD PROOF PLUGS, HARD WIRE SMOKES ER
PLUGS,NEW
BATHROOM AND KITCHENS CIRCUITS,PLUGS OUTLETS
UNDER
AND
NEW LIGHT IN GARAGE, ALSO NEW LIGHT IN BASEMENT.-
NEW 70 GALLON GAS
PLUMBINGHOT WATER HEAZER.NEW ROUGH R H
D BATHROOM, 2 OUTSIDE
= W L
O BOILER LESS BURNER
3 30NES 1ST FL, IST
FL.AND
2ND EL RENDVE D RADIATOR AND INSTALL NEW BASEBOARD
HOT ffLZER RADIATORS,
SPECIFICATIONS AND ESTIMATES OF PROPOSAL
UNIT PARTS/DESCRIPTION/WORK TO BE PERFORMED
UNIT COST
AMOUNT
,�.
BATHROOM= NEW WALK IN TUB, TOILET AND SINK NEW
1
PASTERD WALLS AND CEILINGS AND FLOORING
$78,275.00
$78,275.00
2.
BASEMENT= NEW BULK HEAD DOOR, SUMP PUMP (1),NEW
LIGHTING AND FRAME OFF AREA FOR WASHER/DRYER
3'
KITCHEN= NEW CABINETS,FORMICA COUNTERTOP
,LIGHTING,GARBAGE DISP INCLUDED.AND FLOORING
4'
EXTERIOR= NEW 6X6 WHITE VINYL FENCE,REMOVE (2)
TREES IN FRONT OF HOUSE, VINYL SIDING, SHUTTERS
5.
6.
7.
8.
Additional information pertaining to this Proposal
Total Job
Cost for
$78, 275.00
Proposal
Job Cost does not include tax, or applicable surcharges
Authon
Signature
kaze-111
DUPLICATE
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The Commonwealth of Massachusetts
Department of Industrial Accidents
„. Office of Investigations
' d 600 Washington Street
Boston, MA 02111
7 OW
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): i%leA Al 0
6`N
Address:_ A (-
City/State/Zip: (r* CN I Phone.
#:
Are you an employer? Check the appropriate box:
1. II am a employer with a'1 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comp. insurance - comp. insurance.$
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
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..0 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.
I 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. o
Insurance Company Name: �t \
Policy # or Self -ins. Lic. #: SC)) .C) Expiration
Job Site Address: °u �/ (h gl`' City/State/Zip: L��Ik\h ✓4q- (3t 8�6
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 c i der the ain and penalties of perjury that the information provided above is true and correct
Si atur : Date: I ��
Phone #: ,')&)\ - -� W' 131I
not write in this area, to
City or Town:
or town officiaL
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
61., Other
Contact .Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written." '
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to,operate>a business or to construct buildings in the commonwealth for any ,
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(') states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax # 617-727-7749
www.mass.gov/dia
DATE I _
CERTIFIC TE OF LIABILITY' INSURANCE 07/2 R00
781-233-8119 THis CERTIFICATE 16 ISSUED AS A MATTER OF INFORMATION
ooucal ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DONOVAN INSURANCE AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
17 ESSEX STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SAUGUS, , MA 01906NAIC f_
1 INSURER6 AFFORDING COVERAGE
�R� — meuaERA: WORKERS COMP BUREAU _
MELILLO CONSTRUCTION C. INSURERS. _
179A LAKEVIEW DR w6uaERc:
SOXFORD MA
THE POLICIES OF INSURANCE LISTED BEL
ANY REQUIREMENT, TERM OR CONDITION
MAY PERTAIN, THE INSURANCE AFFOROE
POLICIES. AGGREGATE LIMITS SHOWN MA
eN
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMSMADE n OCCUR
i
OEwkAGGREGATE LIMIT APPLIES PER:
POucrr D
PROI LOC 4
AYTOMOBILE LABILITY
ANVAUTO
ALL OWNED AUT08
5CHtl0uLEDAUT08 ;
,
HtREO AUTO$
NON/OWNEO AUTOS
i
GARAGE LIABILITY
~ ANYAUTO
AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER 100 INDICATED. NOTWITHSTANDING
ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
fHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
'E BEEN REDUCED BY PAID CLAIMS.
OCCUR U CLAIM8 MADE
_ DEDUCTIBLE
RETENTION T
WORKERS COMPENSATION AND
A EMPLOYERS'LIABI.ITY x=355012007
ANY PROPMETORIPARTHERIEXECUTIVE
OFFICERIMEMBEREXCLUDED?
SPEGIIAL W046 bobw
OTHER
DESCRIPTION
25
NTIONS I VEHICUIN IOICLUSIONSADM
04/13/07 1 04/13/08
BY ENDOR SEMENT I SPECIAL PROVISIONS
s
PERSONAL AADVINJVRV f
GENERAL AGOREGATE S
PROOUCTSICOMPIOPAGG S
ICOMBINED SINGLELIMIT =
BODILYINJURY f
(Pa penon)
BODILY INJURY S
(PRiocwent)
PROPERTYDAMAGE
(Peroeckent)
AUTO ONLY I EA ACCIDENT t
OTHER THAN EAACC t
AUTOONI,Y: Add
EACH OCCURRENCE T
AOOREOATE t
EACH ACCIDENT Is
DISEASE I EA EMPLOYEE S
DISEASR . Pot.,,,.T f
SHOULD ANY OF THE ABOVE DESCRIBED POUrM8 BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER MALL ENDEAVOR TO MAIL 1S DAYS WRITTEN
NOTICE TO THE CERTIRCATE "OLDER NAMED TO THE LEFT, BUT FAILURE To 00 SO SHALL
IMPOSE NO OSUGATION OR LABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
e
J6Z� �-' avi"o1c,EfGP(Lyj, I \.
BOARD OF BUILDING REGULATIONS
J%e
License: CONSTRUCTION SUPERVISOR
Number: CS 068105
Birthdate: 05/19/1969
Expires: 05/19/2008 Tr. no: 26902
Restricted: 00
CHRISTOPHER J MELILLO
179 A LAKESHORE RD
,-1 BOXFORD, MA 01921 C
Commissioner
Board of Building R gulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 124536
Exp►rafion:` 7/15/2009
Tr# 131893
Type: Individual
Christopher J. Melillo
Christopher Melipo `
179A Lakeshore Rd.
Boxford, MA 01931•..
Administrator
qy Av
Location
No.
9016 Date
Check # 4-f5��
TOWN OF NORTH ANDOVER.
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL 41;�
X�Au ildi ng, inspector