HomeMy WebLinkAboutBuilding Permit #699-2017 - 436 OSGOOD STREET 1/6/2017III, wj�Lt,
Permit No#: bq�
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION'-*
Date Received
TYPE OF IMPROVEMENT
USE
-PROPOSED
Residential
Non- Residential
0 New Building
WoCfne family
0 Addition
0 Two or more family
0 Industrial
0 Alteration
No. of units:
11 Commercial
WoRepair, replacement
0 Assessory Bldg
El Others:
0 Demolition0
Other
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-.Water /Sewer.
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Identification - Please Type or Print Clearly
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OWNER: Name: Phone:
Address: OC _9fy 12 5 etL Y--� A t/
4* Lh
Contractor Name L71 .
_ &AP biig, V2f_.w' P',O 7Z'
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SupervisorC-bilstrui2- IM x P_
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VKOM-0
ARCHITECT/ENGINEER
Address:
Phone:
Reg. No.. "'
FEE SCHEDULE. BULDING PERMIT: $Izoo PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
._,rotal Project Cost: $ 31, DT -0 FEE: $
Check No.: Receipt No,,: Li I �
NOTE: Persons contracting with unregistered contractors Ahave�.-accs �to the gu�rantyfund
'c or
�inra
C�
0�jii� t��
nff�4btor`
f6l Aci (an t Te Of co
Plans Subtinitted ❑
Plans WaivedEl Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
TanningWassageBody Art ❑
Swimming pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Pennanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On
COMMENTS
Signature
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
TA,.Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
u
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town. Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signatureldate
COMMENTS
iimension
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 Ido
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
Doc.Building Permit Revised 2014
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
r
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/Cross Section/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
UOTE: 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
DOTE: 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 t
Doc: Building Permit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 319500.00
m
$ -
$
378.00
Plumbing Fee
$
47.25
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
47.25
Total fees collected
$
572.50
436 Osgood Street
699-2017 on 1/6/2017
bathroom remodel
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Diodati Construction
22 Thomas Road
Lawrence, Mass. 01843-3227
Fully Insured and Licensed
General Contractor
Design and Build Foundation to Finish
Phone 978 682-7628
Fax 978 685-6997
E-mail mikediodati(&diodaticonstruction.com
VISA AND MASTERCARD ACCEPTED
1/4/2017
Mr. and Mrs. Art Larson
436 Osgood st
North Andover, Ma 01845
Diodati Construction (Mike Diodati) agrees to perform the following work. All existing bathroom
fixtures will be removed and delivered to Habitate for Humanity store. All plaster wall will be
removed and new'/: inch cement board will be placed wherever new tile is to be applied. The floor
will have '/z cement glued and screwed and made ready to accept new tile. Once new fixtures have
been installed new predetermined wall and floor tile supplied by Diodati Construction will be
installed . New the will be grouted and sealed to manufactures specification. Upon completion the
area will be left broom swept clean and free of any debris. An on site dump trailer will be used to
remove all debris and dispose of debris at LLS recycling center in Salem N.H.
Start Date 1/9/2017 (app).
Completion date 2/1/2017 (app.)
Term of payment
Payment 1 $ 12,500.00 upon delivery of bathroom fixtures
Payment 2 $ 12,500.00 upon completion of all rough in
Payment 3 $ 10,000.00 upon satisfactory completion of work.
Contractor Date -` / T 02 U/
do
Home owner Date � �,?0 7
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3268
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The commonwealth of Massachusetts
Department of-ndusipialAccideaats
- e 100
ry �.�- � � �ong�ess 5`i.�ee% Shit
M. d Boston, MA o2114-2017
qc www.mass.govldiu
VQOM S'yy
W4kers' Cox�apensationXnsuranceAdavii:BaiJders/CGAUTHOsl�i7''.cians/lmmbers.
TO BE FREDi�STHT�P�NQT� vToacP Print I
A ' licant a][uornraw��,a
C,
Na7zte(Busanessl6igariizaizovllndividua�:
Address: .2 2
City/SiaielZip: L fid• ry
i� �ti e ,�lll� hone
Are you an employer? 6eclt tiie appropriate box:
l.[� I am aemployer with employees (fuII and/or palt th=).'`
2. asoleproprietororpartamshiPandhavenoemployeesvraorkingfor
mem
any capacity. [Nogtorkers' comp. insruanee required.]
3.p I am a homeowner doing allworkmyself [go Workers' comp. insirrancerequired ] i
4.❑lam a homeowner andwilt be hiring contractors to conduct all work onnry properly. 'win
msurethat all coniractbts c#erhave workers' compensation insurance or are sole
'-`" l
proprietors withno emg oyres.
5.❑I am a general contractor 4a4 Ihave, hired the sub -contactors EsEed on the attached sheet.
These sub -contractors have employees andhavewoIers' comp. insurance.
6•Fj vie are a corporatiov.and i;S officers we exereisedtbeirrigbt of exemptio. PerMGL c.
4 and'we kava no employees. [No workrrs' comp. insurance required ]
'Type ofproject (required);
7. ElNdWd6nstri d-Rou
8. (Remodeling
9. [] Demolition
10 [:]Building addition
11.❑ Elecix%cal repairs or additions
12_�]:pj. mb ug repairs or additions
13,.0Roofrepairs
14.n Other
152, §1( ),
*Any appHe,aut that checks boxfl mast also fill o.,Me section below showing then workers' compens,t ),, must submit
atiom
t Homeowners who submittbis affidavit indicaiingthey am doing all viorkandthenhire outside contractors must sabm i a new affidavit indicafing Bach
tContractors that checkthis Box must attached an additional sheet showing thr name of the sub -contractors and statewhether or notihose entities have
run.PP� ifthesub-coufractorshaveemployees,ilrrymtistprovidethei� workers'comp.policynnrnber. _
t
X am an employer that is providing-woTken'
information.
Insurance Company
compensation inszzxancefor my employees. Below zs t/iepolzcy �zdj'ob sz e
ExpirationDate,
policy # or Serif—RLS—UGI 4"..
rob Site Address:C
S 4 d City/State/Zip: /t/, �n c� a✓ �.L r// 9i� —
Attach a copy of the �oxkexs' c p ensatzon policy declaration page (shownag the policy number and expirationdate).
to X00.00
pailuxe to secure coverage as required undexM mall les ins the form of art ST�p w0 O�Mviolation land a ane oe by a fulb f up to $250.00 a
and/or one-yeax imprisonment, as well as czvil p
day against the violator. A copy of this statement may be forwarded to the Oiftce of Investigations of the DIA. for insurance
coverage verification.
X do hereby certify under tlzepains andpenaldes cfpeIjuyy fzat the information provided move s fru_e anJ correct
Phone #:
Official use only.
Do not write in this area, ja be corzpleted by city or town official.
Peranii/License #
City or Town`
XssuiugAnthorIty (circle one): ' ector rte. Pl b ghspectox
I. Board of ff ealth. 2. JBuild Rg D epartMent 3. Ciiylx ovan Clerk 4. I+ lectxical Insp
6. Other
phone #:
Contact
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their e, np dyees.
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 "au individual; partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint euterprise, and including the legal representatives of a deceased employer, or the
receivei'oz trastde pf an individual, partnership, association or other legal entity, employing employees.. However flue
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of fh.e
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 b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing ageney shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildrags in the commonwealth for any
applicantwlio has notproduced acceptable evidence of compliance with the insurance coverage xequYred."
Additionally, MGL chapter 152, §25C(7) 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
necessaxy, supply sub=contractor(s)name(s), address(es) and phone number(s) along with their cerdficate(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 be submitted to the Department of Industrial
Accidents for confa m.ation 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
Iudustaial 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 fdl out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to JM in the permit/license number which will be used as a reference number. In addition, an applicant
thaf must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary) and under "Job Site Address" the applicant should write •"alt locations in (city or
town)." A copy of the affidavit that has b een officially stamp ed or marked by the city or tovm may b e provided to the
applicant as proof that a valid affidavit is on fife for future permits or licenses. Anew affidavit must be flied 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 buua leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial. Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617.727-4900 ext. 7406 or 1-877 MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
CERTIFICATE OF LIABILITY INSURANCE
'rH3 CERTIFICATE 18 WAND AS A mATTER OF INFORMATION ONLY MD CONFERS NO RIGMiTS t�ON 11dE C&iflFiC OY THEfOHOLD. TMS
CEIRMFICATE DOW NOT AFFIIIMAMLY OR NEGAMMY AAAA, EXTEND OR ALTER THE COVERAGE AFFORi7ED 6ti' THE HOWE.5
SEL OW. TMS ceRnFICATE OF WSURANCE DOES NOT CON WnnE A CONTRACT BErN EN THE WANG MURER(S), AUCMO�0
REMMENTAIWE OR PRODUCT, AND IM CERMICATR. MOLDM
ffAPMANT-ae r is an 1 , the polkyAaai ttlwst etd N s BROGA t
ally ton" wad mcudom of the poky, Cwtswt pulicks rmy a+ Wim an andommmiL A datsmeet on WS cermlaw does not eontir rights to The
cerdBcate h*Wr in Ueu of such sWormion�*.
KIP. Roberts Insurance Agency
1.060 Osgood Street
plorth Andover, M& 01845
44 -IMM
DIODA.TI CONSTRUCTION
NICP.= DI04OA.4'I DBA
22 THOMS V=
x,A4f Wes, Mx 01843
A)ICATEA. NOi MTfdSTAid NG ANY RBQUIREMEMT, TMM OR C(NN011M OP AMY CE>WRACT OR MMER ly
;EpTtFICRTE MAY 6E ISSUSO OR MAY PERTAIN, THE INT MWA AFF'OPIDED BY THE POLICW GIBED
MuLUSON6 AND CONDITIONS OF WCH POUC,tES. LIMtf S 940M MAY HAVE BEEN REDIA BY PAID CLAWS.
A j j ,0 MALLVOW
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DBSC'MPMU OP OPERA4" / UXAMN6 I VI MOLES tA1uSA ACDRD l(K. AtN§Nd RtVM Im Sd+1x1uM. H11aor6 epuw to eagdtefll
-3T WIT)i FmPlaCT TO Wmal Troy
N IS SUBJECT TO AU THE TERMS,
"CURRENCE 0 �, 4A!A.
iOpA.
one 000
I4LrIADVINJUAY S ..N., ..
LAGORWATE S
xs-CDWWAWIS 2.000,060.
8
9ODILYIRJURY{Parl*f6M} IS
aODA.YHUM (Pet mcidenq S
a� S
S
i 8MWL V ANY OF TW ABOVE WSCROU POLICE$ 6E CANCULLED BEFORE
1 THE EAPIRATM DATE TWROOP, N M06 WILL IM DELIVERED IN
ART 1"SON ACCORDANCE WMW THE POLICY PROVISIONS.
436 OSGOOD ETRE T
NORTH ANDOMR, MA 01045 AURIORIM NellaM@,TATPIE
I MICML P ROBERTS
0 IM4010 ACORD CORPOMTM. All rghls roxam
ACORD 26 (2(K 0=1 TM ACMD aanw aetd 16" aro meadlti &S of ACORD
wle: tet: C� �V. Ertl;
.n
ca.
aam", Office of Consumer Affairs & Business Regulation
s ;,NOME IMPROVEMENT CONTRACTOR
Registration: 177783 Type:.
R AV
� I Expiration ; -4/28/2018 Individual
MICHAEL DIODATI ="
MICHAEL DIODATI
22 THOMAS RD
LA!NRENCE, MA 01843 Undersecretary
Massachusetts Department of Public Safety
l`. Board of Building Regulations and Standards
License: CSFA-052307
Construction Supervisor 1 & 2s°
Family
m„
L
MICHAEL P DIODATI
22 THOMAS RD
LAWRENCE MA01843 +
Expiration:
Commissioner 07/15/2047
Location
1-1
Check #1ii''
`C ,)
Date 1 !a
}
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ _`�7yo V,_
Foundation Permit Fee $
Other Permit Fee $ .�
TOTAL
I
Building Inspector