HomeMy WebLinkAboutBuilding Permit #620 - 436 OSGOOD STREET 4/14/2010BUILDING PERMIT
TOW"F4-NORTH ANDOVER
APPLICATION FOR PLA XAMINATION
Permit NO: D ®,,—,
Date Reserve"d Id
Date Issued:
IMPORTANT: Applicant must complete albs on this page
LOCATION c,3G JS• �+ Gccl S':71' ,,..,-..
Print'
PROPERTY OWNE
Print
MAP 210" PARCEL: ZONING DISTRICT: Historic District
A ? Machine Shop'
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Of
.a
yes no
yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
UtSGKIPTION OF WORK TO BE -PREFORMED:
ZdYle- oet De C /C O/ 13%0 c if o I4 04A � .e C/l —
Identification Please Type or Print Clearly)
OWNER: Name:
Address:
hone:
CONTRACTOR Name:_ %�'r L4C 0114 t, Phone: $%J 67f.2 a
Address: oV
Supervisor's Construction License: Exp. Date: � 1Lr4 a -1-z z
Home Improvement License: Y7 7 YI Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $1200 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $�' LTS dZ'- a-` FEE: $ �
Check No.: 7-9 S2' Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
signature of Agent/Owner Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body 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 Reviewed o
COMMENTS_
HEALTH
COMMENTS
nature
'S' "'A\' n 1 OD
Reviewed on Signature
Zaning 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:
Locatea 664 vsgooa Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 2010
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
Li 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: Building Permit Revised 2008
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of frcvestigations
Uf 600 Washington Street
Boston, ALL 02111
i+ ww.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nniirronf Tnf-.,f:,...
Name (Business/Orgmization/Individual): c C.
Address: � �Gsyt% S �cG
City/State/Zip: Phone#: Q%7 F �t� %�
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
e ployees (full and/or part-time).*
have hired the sub -contractors
2. am a sole proprietor or partner-
listed on the attached sheet t
ship and have no employees
These sub=contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. L?J�ew construction
7. [] Remodeling
8. 0 Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
tut vat Luc Semon ne w sh-l"..^._-2 the,'- workers' comp=s--,; ....,,i:...,
t inform ti --
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submitt 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 job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Sob Site Address: 73 6 /�'S 601 c( City/State/Zip: elf
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 ce�� der t e pains and penaltr� f perjury that the information provided above is true and correct
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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
/o
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(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
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 be 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 peruit or License is being requested, net 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 bum 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
Fax # 617-727-7749
Revised 5-26-05
wvvw.mass.gov/dia
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Massachusetts - Department of Puhiic Satict�
Board of Buildinl- Regulations and Standards
Construction Supervisor License
License: CS 52307
Restricted to: 1 G
MICHAEL P DIODATI "
22 THOMAS RD
LAWRENCE, MA 01843 "
Expiration: 7/15/2011
( nnnnissiuncr Tr#: 565
Office /`icons me Wa rrs usit st COL
HOME'IMPROVEMENT CONTRACTO 2
Registrationv,11 ,147741
Expiration -81412011 Tri# 287418
Type ;individuaF_ ...„
MIKE DIODATI
MIKE ,PIODATI
2210.MAS�--
LAWRENCE, MA 0J843 �l LlnsferseretarY
0
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@comcast.net
VISA AND MASTERCARD ACCEPTED
4/13/2010
Ms. Inga Gamble
436 Osgood st.
North Andover, Ma .01845
At the predetermined location at the rear of the dwelling a 12x16 deck is to be constructed. The deck
frame will be constructed using pressure treated 2x8 placed 16 inches on center and supported by a double
2x10 pressure treated carrying beam. The carrying beam will be secured to (3) 10 inch cement tubes placed
upon Bigfoot which have been dug to a depth of 48 inches below grade. The railings will be a grey vinyl
prefabricated railings system. Decking will be standard grey trex decking. A set of stairs will also be
constructed of the same materials leading to grade in a location from the deck to be detertmined.
The deck will be attaches to the dwelling using 3/8 lag bolts secured to the existing house sill. New flashing
to protect from water infiltration will be installed along the entire interior edge of the deck.
Upon completion the area will be broom swept clean and free of any debris
Construction costs $ 5,500.00
Terms of payment 1/3 due start
1/3 due upon completion of framing
1/3 Payment due upon completion of decking and railing installation
Construction start date 5/3/2010
Construction completion date 5/9/2010
This contract can be voided with no penalties with in 3 days from the above date
Homeownerj4v'm"/I— Date �/13/�
Contractor 4r4 ,00- Date �,;�� C//G
SEC'EION 4 -WORKERS COMPENSATION(KG.L C 152 § 25c(6) `
Workers Compensation Insurance affidavit must be'compl'eted•and'submitted•with this. application.. Failure to provide this affidavit
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... &I No.
SECTION 5 Description of Proposed Work(check all a lfcable
New Construction Existing Building ❑ Repair(s) ❑Alterations(s)".0 Addition ❑ .,
Accessory Bldg. ❑
Demolition- ❑
Other ❑ Specify
Brief Description of Proposed Work:-,;
a
Q l._) e 1 tr\ f� t A.)i -+-In r.X- Q C, a r c- cx. t -t -ca C- k e A
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
GAT"USE
aj
ONLY '
Completed by permit applicant
1. Building
(a) Building Permit Fee
Io�S X' /q(D Y SS"
9 13
1 40 000
Multiplier
,�K
2 Electrical
0
(b) Estimated Total Cost of
�,DO
Construction
3 Plumbing
0 n
Building Permit fee (a) X (b)
d
4 Mechanical (HVAC)`
101
5 Fire. Protection
W A
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION T BE COMPLETED WHEN
OWNERS AGENT AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
01-J (S
P_-' CL ry\ as Owner/Authorized Agent of subject property.
Hereby authorize L�L) '1 \ 1 CA m � a. cc C, "{-�" to act on
My be If, i all matter lative to work authorized by this building permit application.
`�
ar s 5!4k/k, Ll- lr _711c2
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
�
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Si attue of Owner/Anent Date
11111111 HIS
NO. OF STORIES SIZE --
BASEMENT OR SLAB t—
SIZE OF FLOOR TIMBERS lbi Xlb 2 ND 9L JY 1 3 ,� 1(�
SPAN 1 y r
DEVIENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS 14— e
HEIGHT OF FOUNDATION THICKNESS %0"
SIZE OF FOOTING X
MATERIAL OF CHIMNEY jpar
IS BUILDING ON SOLID OR FILLED LAND „
IS BUILDING CONNECTED TO NATURAL GAS LINE N
INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or lagdov rier from compliance with any applicable requirements.
■rrrrrrrrrrrrrrrrrr�.■rrrrrrrr■■rrOman rrrrrr■ gnomon rrrrrrrrrrrrrrmeans rwoman
APPLICANT �,� 1 u m e� rte ' PHONE b a: —;a,3 GL Q
ASSESSORS MAP NUMBER 10 LOTNUMBER n
SUBDIVISION LOT NUMBER
STREET d S 9 Q C�. C� UC �'. STREET NUMBER
OFFICIAL USE ONLY
Bosoms mmumnsm
REC NS OF TOWN AGENTS
,r■ ■ ■■ ■rrrr■■rrr�r■rrrrrrrrr■rrirrrr■rrrrrrrrrr■rrrrrrrr-■rrrrrrrrrrr
DATE APPROVED /% Z
ERVATIOWADKIR&TRATOR
DATE REJECTED
FC INSPECTOR -'HEALTH
�/ r y �'
SE C INSPECTOR - HEAL
DATE APPROVED�-
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
COMMENTS "7 P
17
PUBLIC WORKS - SEWER I WATER CONNECTIONS
DRIVEWAY /PERMIT le -9 ,
r � vl �°� G c� ATE APPROVED
IRE . EPARTMENT C ,fi-F D
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR
North Andover MIMAP
436 Osgood Street
April 5, 2010
-._:7 -.--Ion:
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102.0-0002
094.0-0003AI&-
102.0-0001
094.0-0004
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095.0-00.56
::: :- -: - 095.A-0012
09.5.0-00.5
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0070 /
09 .4- 09
Rall Line
Interstates
Interstate
Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83,
— Major Roads
NORTIq
Meters Data Sources: The data for this map was produced by Merrimack
Valley Planning Commission (MVPC) using data provided by the Town of
Roads
Ci Easements
Of tie a q�
?bet ' °t° OO
North Andover. Additional data provided by the Executive Office of
Environmental Affairs/MassGIS. The information depicted on this map Is
- Tralls3'
0 MVPC Boundary
L
f +–• -• o
`
for planning purposes only. It may not be adequate for legal boundary
definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
THE ACCURACY, COMPLETENESS, RELIABILITY,
O Municipal Boundarys
EI Parcels
*
.^,
! o
OR SUITABILITY
OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
Hydrographic Features
Streams
�� !
q�'+o -' -"`•
,SSACHUs�t
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
Wetlands
0 Exempt Lands 1" = 149 ft �°
Location
No. e"--2
Date
TOWN OF NORTH ANDOVER
Certificate Occupancy $
of
HU
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
22963
Building Inspector