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Building Permit # 1/17/2017
Permit NO: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATI Date Receive Date Issued:0i I IMPORTANT: Applicant must complete all items on this page TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building Cis Addition [?Alteration 7 One family ❑ Two or more family No. of units: D Industrial C.[ Commercial ❑ Repair, replacement ❑ Demolition Di Assessory Bldg ❑ Others: ❑ Other .,..,:.r.l e c.:w� . ,.:, Y...........:..,.,,.:.. .......E , .,, ,.. F . w.....�.,:.,,�.... � �......,,�:..: ..:,... „�:..u...... oo a n. 1:; ":et r...�. . , ,''w� �� �: `:try i�- "ti'l�. Cal S Identification Please Type or Print Clearly) OWNER: Name: � CA. A-(, CA-. LL C.. Address: Phone: 4 ` s Ccrq 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: $ i q FEE: $ / G jO,0 f l oo,,�car (_c � r Check No.: 4 Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to Jhe guaranty fund S� nature;of A entlOwrier -Si nature of c•aritracto i 9 g g . ; Conservation Decision: Plans Submitted Plans Waived Certified Plot Plan _ Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Welt 1 Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Duampster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT OMENTS \)11\011.1 11 kn \\kft,i) elmcif wd\c, UAIEkLJEUIEL) UAIEAP KOVED CONSERVATION COMMENTS DATE REJECTED DA APP3VD vir CQoQr 6tct5 HEALTH COMMENTS C DATE REJECTED DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Comments Water & Sewer Connection/Signature & Date Located at 384 Osgood Street ill 41p: a (*! 4siaOa Driveway Permit ;.0 114 raw z r— BOARD OF HEALTH Food/Kitchen Septic System BUILDING INSPECTOR Foundation Rough Chimney Final PLUMBING INSPECTOR Rough Final • ig. o U pl. In U G w cc 0 a 0 F- Z w 2 I- a o re U. W 4 u t GO - - Q7 E N O 0 N Y a)0 0A o cc (n C II 0 CC C a: 7 CO y E N V1 hi O at co V O 0- 0 U 0f < - C 0 co E Y o E C) C ca 0 • L .+ N " 3 a> m 03 a'c a co o ▪ c0 a c ..cc ▪ .C-C �az :o C.11 O H 0.cb �4-ctl C 0) •o C C AL 03 0 '5 +n 0po -0 - 0 0 ' 4- 4 o cvi '0 0w - — 2 o -a a� 2o 4. o 2 ,_CO VIOLATION of the Zoning or Building Regulations Voids this Permit. Li! >14 LU od EL! 0 CO CO z 4L 0 uired to Occu 0 V a) N C Y N O • • 1-1 • •� E m m ca 2 t7 O as sr, DIa c--a O c Enter construction cost for fee cal - Construction Cost North Andover Fee Calculation 140,000 00 m 1,680.00 Plumbing Fee Gas Fee 100 comm. Electrical Fee 210.00 100.00 210.00 Total fees collected Foundation 2,200.00 100 27 Charles Street 719-2017 on 1/17/17 Interior Reno for Great Clips THE AMERICAN AGREEMENT made as of the INSTITUTE OF ARCHITECTS STANDARD FORM OF AGREEMENT BETWEEN CONTRACTOR AND SUBCONTRACTOR 1987 EDITION THIS DOCUMENT HAS IMPORTANT LEGAL CONSEQUENCES; CONSULTATION WITH AN ATTORNEY IS ENCOURAGED WI TH RESPECT TO ITS COMPLETION OR MODIFICATION This document has been approved and endorsed by The Americas Subcontractors Association and the Associated Specialty Contractors, inc. day of in the year of BETWEEN the Contractor: and the Subcontractor: The Owner: For the following Project: (Name and Location) 27 Charles Street LLC 200 Sutton Street North Andover, MA Charles Construction Co. Inc. 200 Sutton Street North Andover, MA 27 Charles Street LLC Great Clips which Contract is hereinafter referred to as the Prime Contractor and which provides for the furnishing of labor, materials, equipment and services in connection with the construction of the Project. A copy of the Prime Contract, consisting of the Agreement Between Owner and Contractor (from which compensation amounts may be deleted) and the other Contract Documents enumerated therein has been made available to the Subcontractor. The Architect for the Project is: ARTICLE I THE SUBCONTRACT DOCUMENTS 1.1. The Subcontract Documents consist of (I) this Agreement; (2) the Prime Contract, consisting of the Agreement between the Owner and Contractor and the other Contract Documents enumerated therein, including Conditions of the Contract (General, Supplementary and other Conditions), Drawings, Specifications, Addenda issued prior to execution of the Agreement between the Owner and Contractor and Modifications issued subsequent to the execution of the Agreement between the Owner and Contractor, whether before or after the execution of this Agreement, and other Contract Documents, if any, listed in the Owner -Contractor Agreement; (3) other documents listed in Article 16 of this Agreement; and (4) Modifications to this Subcontract issued after execution of this Agreement. These form the Subcontract, and are as fully a part of the Subcontract as if attached to this Agreement or repeated herein. The Subcontract represents the entire and integrated agreement between the parties hereto and supersedes prior negotiations, representations or agreements, either written or oral. An enumeration of the Subcontract Documents, other than Modifications issued subsequent to the execution of this Agreement, appears in Article 16. 1.2 The Subcontractor shall be furnished copies of the Subcontract Documents upon request, but the Contractor may charge the Subcontractor for the cost of reproduction. ARTICLE 2 MUTUAL RIGHTS AND RESPONSIBILITIES 2.1 The Contractor and Subcontractor shall be mutually bound by the terms of this Agreement and, to the extent that provisions of the Prime Contract apply to the Work of the Subcontractor, the Contractor shall assume toward the Subcontractor all obligations and responsibilities that the Owner, under the Prime Contract, assumes toward the Contractor, and the Subcontractor shall assume toward the Contractor all obligations and responsibilities which the Contractor, under the Prime Contract, assumes toward the Owner and the Architect. The Contractor shall have the benefit of all rights, remedies and redress against the Subcontractor which the Owner, under the Prime Contract, has against the Contractor, and the Subcontractor shall have the benefit of all rights, remedies and redress against the Contractor which the Contractor, under the Prime Contract, has against the Owner, insofar as applicable to this Subcontract. Where a provision of the Prime Contract is inconsistent with a provision of this Agreement, this Agreement shall govern. 2.2 The Contractor may require the Subcontractor to enter into agreements with subcontractors performing portions of the Work of this Subcontract by which the Subcontractor and the Sub -subcontractor are mutually bound, to the extent of the Work to be performed by the Sub - subcontractor, assuming toward each other all obligations and responsibilities which the Contractor and Subcontractor assume toward each other and having the benefit of all rights, remedies and redress each against the other which the Contractor and Subcontractor have by virtue of the provisions of this Agreement. ARTICLE 3 TERMS AND CONDITIONS OF AGREEMENT BETWEEN CONTRACTOR AND SUBCONTRACTOR 3.1 SERVICES PROVIDED BY THE CONTRACTOR 3.1.1 The Contractor shall cooperate with the Subcontractor in scheduling and performing the Contractor's Work to avoid conflicts or interference in the Subcontractor's Work and shall expedite written responses to submittals made by the Subcontractor in accordance with Paragraph 4.1 and Article 5 . As soon as practicable after execution of this Agreement, the Contractor shall provide the Subcontractor copies of the Contractor's construction schedule and schedule of submittals, together with such additional scheduling details as will enable the Subcontractor to plan and perform the Subcontractor's Work properly. The Subcontractor shall be notified promptly of subsequent changes in the construction and submittal schedules and additional scheduling details. 3.1.2 The Contractor shall provide suitable areas for storage of the Subcontractors materials and equipment during the course of the Work. Additional costs to the Subcontractor resulting from relocation of such facilities at the direction of the Contractor, except as previously agreed upon, shall not be reimbursed by the Contractor. 3.1.3 Except as provided in Article 14, the Contractor's equipment will be available to the Subcontractor only at the Contractor's discretion and on mutually satisfactory terms. 3.2 COMMUNICATIONS 3.2.1 The Contractor shall promptly make available to the Subcontractor information which affects this Subcontract and which becomes available to the Contractor subsequent to execution of this Subcontract. 3.2.2 The Contractor shall not give instructions or orders directly to employees or workmen of the Subcontractor, except to persons designated as authorized representatives of the Subcontractor. 3.2.3 The Contractor shall permit the Subcontractor to request directly from the Architect information regarding the percent ages of completion and the amount certified on account of Work done by the Subcontractor. 3.2.4 If hazardous substances of a type of which an employer is required by law to notify its employees are being used on the site by the Contractor, a subcontractor or anyone directly or indirectly employed by them (other than the Subcontractor) the Contractor shall, prior to harmful exposure of the Subcontractor's employees to such substance, give written notice of the chemical composition thereof to the Subcontractor in sufficient detail and time to permit the Subcontractor's compliance with such laws. 3.3 CLAIMS BY THE CONTRACTOR 3.3.1 Liquidated damages for delay, if provided for in Paragraph 9.3 of this Agreement, shall be assessed against the Subcontractor only to the extent caused by the Subcontractor, the Subcontractor's employees and agents Sub -subcontractors, suppliers or any person or entity for whose acts the Subcontractor may be liable, and in no case for delays or causes arising outside the scope of this Subcontract. 3.3.2 Except as may be indicated in this Agreement, the Contractor agrees that no claim for payment for services rendered or materials anc equipment furnished by the Contractor to the Subcontractor shall be valid without prior notice to the Subcontractor and unless written notic thereof is given by the Contractor to the Subcontractor not later than the tenth day of the calendar month following that in which the claim originated. 3.4 CONTRACTOR'S REMEDIES 3.4.1 If the Subcontractor defaults or neglects to carry out the Work in accordance with this Agreement and fails within three working days after receipt of written notice from the Contractor to commence and continue correction of such default or neglect with diligence and promptness, the Contractor may after three days following receipt by the Subcontractor of an additional written notice, and without prejudice to any other remedy the Contractor may have, make good such deficiencies and may deduct the cost thereof from the payments then or thereafter due the Subcontractor, provided, however, that if such action is based upon faulty workmanship or materials and equipment, the Architect shall first have determined that the workmanship or materials and equipment are not in accordance with requirements of the Prime Contract. ARTICLE 4 SUBCONTRACTOR 4.1 EXECUTION AND PROGRESS OF THE WORK 4.1.1 The Subcontractor shall cooperate with the Contractor in scheduling and performing the Subcontractor's Work to avoid conflict, delay in or interference with the Work of the Contractor, other subcontractors or Owner's own forces. 4.1.2 The Subcontractor shall promptly submit Shop Drawings, Product Data, Samples and similar submittals required by the Subcontract Documents with reasonable promptness and in such sequence as to cause no delay in the Work or in the activities of the Contractor or other subcontractors. 4.1.3 The Subcontractor shall submit to the Contractor a schedule of values allocated to the various parts of the Work of this Subcontract, aggregating the Subcontract Sum, made a tin on oru such s detail asd the by the Contractor and Subcontractor may agree P Owner, and supported by such evidence as the Contractor may direct. In applying for payment, the Subcontractor shall submit statements based upon this schedule. 4.1.4 The Subcontractor shall furnish to the Contractor periodic progress reports on the Work of this Subcontract as mutually agreed, including information on the status of materials and equipment which may be in the course of preparation or manufacture. 4.1.5 The Subcontractor agrees that the Architect will have the authority to reject Work which does not conform to the Prime Contract. The Architect's decisions on matters relating to aesthetic effect shall be final if consistent with the intent expressed in the Prime Contract 4.1.6 The Subcontractor shalt pay for materials, equipment and labor used in connection with the performance of this Subcontract through the period covered by previous payments received from the Contractor, and shall furnish satisfactory evidence, when requested by the Contractor, to verify compliance with the above requirements. 4.1.7 The Subcontractor shall take necessary precautions to protect properly the Work of other subcontractors from damage caused by operations under this Subcontract. 4.1.81'he Subcontractor shall cooperate with the Contractor other subcontractors and the Owner's own forces whose Work might interfere with the Subcontractor's Work. The Subcontractor shall participate in the preparation of coordinated drawings in areas of congestion, if required by the Prime Contract, specifically noting and advising the Contractor of potential conflicts between the Work of the Subcontractor and that of the Contractor, other subcontractors or the Owner's own forces. 4.2 LAWS, PERMITS, FEES AND NOTICES 4.2.1 The Subcontractor shall give notices and comply with laws, ordinances, rules, regulations and orders of public authorities bearing on performance of the Work of this Subcontract. The Subcontractor shall secure and pay for permits and governmental fees, licenses and inspections necessary for proper execution and completion of the Subcontractor's Work, the furnishing of which is required of the Contractor by the Prime Contract . 4.2.2 The Subcontractor shall comply with Federal, state and local tax laws, social security acts, unemployment compensation acts and workers' or workmen's compensation acts insofar as applicable to the performance of this Subcontract. 4.3 SAFETY PRECAUTIONS AND PROCEDURES 4.3.1 The Subcontractor shall take reasonable safety precautions with respect to performance of this Subcontract, shall comply with safety measures initiated by the Contractor and with applicable laws, ordinances, rules, regulations and orders of public authorities for the safety of persons or property in accordance with the requirements of the Prime Contract. The Subcontractor shall report to the Contractor within three days an injury to an employee or agent of the Subcontractor which occurred at the site. 4.3.2 If hazardous substances of a type of which an employer is required by law to notify its employees are being used on the site by the subcontractor, the subcontractor's subcontractors or anyone directly or indirectly employed by them, the subcontractor shall, prior to harmful exposure of any employees on the site to such substance, give written notice of the chemical composition thereof with the Contractor in sufficient detail and time to permit compliance with such laws by the Contractor, other subcontractors and other employers on the site. 4.3.3 In the event the Subcontractor encounters on the site material reasonably believed to be asbestos or polychlorinated biphenyl (PCB) which has not been rendered harmless, the Subcontractor shall immediately stop Work in the area affected and report the condition to the Contractor in writing. The Work in the affected area shall resume in the absence of asbestos or polychlorinated biphenyl (PCB), or when it has been rendered harmless, by written agreement of the Contractor and Subcontractor, or in accordance with final determination by the Architect on which arbitration has not been demanded, or by arbitration as provided in this Agreement The Subcontractor shall not be required pursuant to Article 5 to perform without consent any Work relating to asbestos or polychlorinated biphenyl (PCB). 4.3.4 To the fullest extent permitted by law, the Contractor shall indemnify and hold harmless the Subcontractor, the Subcontractor's Sub -subcontractors, and agents and employees of any of them from and against claims, damages, losses and expenses, including but not limited to attorneys' fees, arising out of or resuming from performance of the Work in the affected area if in fact the material is asbestos or polychlorinated biphenyl (PCB) and has not been rendered harmless, provided that such claim, damage, loss or expense is attributable to bodily injury, sickness, disease or death, or to injury to or destruction of tangible property (other than the Work itself including loss of use resulting therefrom, but only to the extent caused in whole or in part b3 negligent acts or omissions of the Contractor, Architect, Owner, anyon directly or indirectly employed by any of them, or anyone for whose acts any of them may be liable, regardless of whether or not such clain damage, loss or expense is caused in part by a party indemnified hereunder. Such obligation shall not be construed to negate, abridge, e y which would exist reduce other or obligations ode described in histSubparagraph 4.3.4. otherwise exist as to a party person 4.4 CLEANING UP 4.4.1 The Subcontractor shall keep the premises and surrounding area free from accumulation of waste materials or rubbish caused by operations performed under this Subcontract. The Subcontractor shall not be held responsible for unclean conditions caused by other contractors or subcontractors. 4.5 WARRANTY 4.5.1 The Subcontractor warrants to the Owner, Architect and Contractor that materials and equipment furnished under this Subcontract will be of good quality and new unless otherwise required or permitted by the Subcontract Documents, that the Work of this Subcontract will be free from defects not inherent in the quality required or permitted, and that the Work will conform with the requirements of the Subcontract Documents. Work not conformingoand to these requirements, including substitutions not properly approved authorized, may be considered defective. The Subcontractor's warranty excludes remedy for damage or defect caused by abuse, modifications not executed by the Subcontractor, improper or insufficient maintenance, improper operation, or normal wear and tear under normal usage. This warranty shall be an addition to and not in limitation of any other warranty or remedy required by law or by the Subcontract Documents. 4.6 INDEMNIFICATION 4.6.1 To the fullest extent permitted by law, the Subcontractor shall indemnify and hold harmless the Owner, Contractor, Architect, Architect's consultants, and agents and employees of any of them from and against claims, damages, losses and expenses, including but not limited to attorney's fees, arising out of or resulting from performance of the Subcontractor's Work under thus Subcontract, provided that such claim, damage, loss or expense is attributable to bodily injury, sickness, disease or death, or to injury to or destruction of tangible property (other than the Work itself including loss of use resulting therefrom, but only to the extent caused in whole or in part by negligent acts or omissions of the Subcontractor, the Subcontractor's Sub -subcontractors, anyone directly or indirectly employed by them or anyone for whose acts they may be liable, regardless of whether or not such claim, damage, loss or expense is caused in part by a party indemnified hereunder. Such obligation shall not be construed to negate, abridge, or otherwise reduce other rights or obligations of indemnity which would otherwise exist as to a party or person described in this Paragraph 4.6. 4.6.2 In claims against any person or entity indemnified under this Paragraph 4.6 by an employee of the Subcontractor, the Subcontractor's Sub -subcontractors, anyone directly or indirectly employed by them or anyone for whose acts they may be liable, the indemnification obligation under this Paragraph 4.6 shall not be limited by a limitation on amount or type of damages, compensation or benefits payable by or for the Subcontractor or the Subcontractor's Sub -subcontractors under workers' or workmen's compensation acts, disability benefit acts or other employee benefit acts. 4.6.3 The obligations of the Subcontractor under this Paragraph 4.6 shall not extend to the liability of the Architect, the Architect's consultants, and agents and employees of any of them arising out of (1) the preparation or approval of maps, drawings, opinions, reports, surveys, Change Orders, designs or specifications, or (2) the giving of or the failure to give directions or instructions by the Architect, the Architect's consultants, and agents and employees of any of them, provided such giving or failure to give is the primary cause of the injury or damage. 4.7 REMEDIES FOR NONPAYMENT 4.7.1 If the Contractor does not pay the Subcontractor through no fault of the Subcontractor, within seven days from the time payment should be made as provided in this Agreement, the Subcontractor may, without prejudice to other available remedies, upon seven additional days' written notice to the Contractor, stop the Work of this Subcontract until payment of the amount owing has been received. The Subcontract Sum shall, by apropriate adjustment, be increased by the amount of the Subcontrac orr'ss reasonable costs of shutdown, delay and start-up. ARTICLE 5 CHANGES IN THE WORK 5.1 The Owner may make changes in the Work by issuing Modifications to the Prime Contract. Upon receipt of such a Modification issued subsequent to the execution of the Subcon tract Agreement, the Contractor shall promptly notify the Sub contractor of the Modification. Unless otherwise directed by the Contractor, the Subcontractor shall not thereafter order materials or perform Work which would be inconsistent with changes made by the Modifications to the Prime Contract. 5.2 The Subcontractor may he ordered in writing by the Contractor, without invalidating this Subcontract, to make changes in the Work within the general scope of this Subcontract consisting of additions, deletions or other revisions, including those required by cations to the Prime Contract issued subsequent to the execution of this Agreement, the Subcontract Sum and the Subcontract Time being adjusted accordingly. The Subcontractor, prior to the commencement of such changed or revised Work, shall submit promptly to the Contractor written copies of a claim for adjustment to the Subcontract Sum and Subcontract Time for such revised Work in a manner consistent with requirements of the Subcontract Documents. 5.3 The Subcontractor shall make claims promptly to the Contractor for additional cost, extensions of time and damages for delays or other causes in accordance with the Subcontract Documents. A claim which will affect or become part of a claim which the Contractor is required to make under the Prime Contract within a specified time period or in a specified manner shall be made in sufficient time to permit the Contractor to satisfy the requirements of the Prime Contract. Such claims shall be received by the Contractor not less than two working days preceding the time by which the Contractors claim must be made. Failure of the Subcontractor to make such a timely claim shall bind the Subcontractor to the same consequences as those to which the Contractor is bound. ARTICLE 6 ARBITRATION 6.1 Any controversy or claim between the Contractor and the Subcontractor arising out of or related to this Subcontract, or the breac thereof, shall be settled by arbitration, which shall be conducted in the same manner and under the same procedure as provided in the Prime Contract with respect to claims between the Owner and the Contracto except that a decision by the Architect shall not be a condition precedent to arbitration. If the Prime Contract does not provide for arbitration or fails to specify the manner and procedure for arbitration it shall be conducted in accordance with the Construction industry Arbitration Rules of the American Arbitration Association currently i effect unless the parties mutually agree otherwise. 6.2 Except by written consent of the person or entity sought to be joined, no arbitration arising out of or relating to the Subcontract shall include, by consolidation or joinder or in any other manner, any person or entity not a party to the Agreement under which such arbitration arises, unless it is shown at the time the demand for arbitration is filed that (I) such person or entity is substantially involved in a common question of fact or law, (2) the presence of such person or entity is required if complete relief is to be accorded in the arbitration, (3) the interest or responsibility of such person or entity in the matter is not insubstantial, and (4) such person or entity is not the Architect, the Architect's employee, the Architect's consultant, or an employee or agent of any of them. This agreement to arbitrate and any other written agreement to arbitrate with an additional person or persons referred to herein shall be specifically enforceable under applicable law in any court having jurisdiction thereof . 6.3 The Contractor shall give the Subcontractor prompt written notice of any demand received or made by the Contractor for arbitration if the dispute involves or relates to the Work materials, equipment, rights or responsibilities of the Subcontractor. The Contractor shall consent to inclusion of the Subcontractor in the arbitration proceeding whether by joinder consolidation or otherwise, if the Subcontractor requests in writing to be included within ten days after receipt of the Contractor's notice. 6.4 The award rendered by the arbitrator or arbitrators shall be final, and judgment may he entered upon it in accordance with applicable law in any court having jurisdiction thereof. 6.5 This Article 6 shall not be deemed a limitation of rights or remedies which the Subcontractor may have under Federal law, under state mechanics' lien laws, or under applicable labor or material payment bonds unless such rights or remedies are expressly waived by the Subcontractor. ARTICLE 7 TERMINATION, SUSPENSION OR ASSIGNMENT OF THE SUBCONTRACT 7.1 TERMINATION BY THE SUBCONTRACTOR 7.1.1 The Subcontractor may terminate the Subcontract for the same reasons and under the same circumstances and procedures with respect to the Contractor as the Contractor may terminate with respect to the Owner under the Prime Contract, or for nonpayment of amounts due under this Subcontract for 60 days or longer. In the event of such termination by the Subcontractor for any reason which is not the fault of the Subcontractor, Sub -subcontractors or their agents or employees or other persons performing portions of the Work under contract with the Subcontractor, the Subcontractor shall be entitled to recover from the Contractor payment for Work executed and for proven loss with respect to materials, equipment tools, and construction equipment and machinery, including reasonable overhead, profit and damages. 7.2 TERMINATION BY THE CONTRACTOR 7.2.1 If the Subcontractor persistently or repeatedly fails or neglects to carry out the Work in accordance with the Subcontract Documents or otherwise to perform in accordance with this Agreement and fails within three days after receipt of written notice to commence and continue correction of such default or neglect with diligence and promptness, the Contractor may, after three days following receipt by the Subcontractor of an additional written notice and without prejudice to any other remedy the Contractor may have, terminate the Subcontract and finish the Subcontractor's Work by whatever method the Contractor may deem expedient, If the unpaid balance of the Subcontract Sum exceeds the expense of finishing the Sub, contractor's Work, such excess shall be paid to the Subcontractor, but if such expense exceeds such unpaid balance, the Subcontractor shall pay the difference to the Contractor. 7.3 ASSIGNMENT OF THE SUBCONTRACT 7.3.1 In the event of termination of the Prime Contract by the Owner the Contractor may assign this Subcontract to the Owner with the Owner's agreement, subject to the provisions of the Prime Contract and to the prior rights of the surety, if any, obligated under bonds relating to the Prime Contract if the Work of the Prime Contract has been suspended for more than 30 days, the Subcontractor's compensation shall be equitably adjusted. 7.3.2 The Subcontractor shall not assign the Work of this Subcontract without the written consent of the Contractor nor subcontract the whole of this Subcontract without the written consent of the Contractor, nor further subcontract portions of this Subcontract without written notification to the Contractor when such notification is requested by the Contractor. ARTICLE 8 THE WORK OF THIS SUBCONTRACT 8i The Subcontractor shall execute the following portion of the Work: Complete suite fit up per the drawings. Allowances are as per drawings. ARTICLE 9 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION e of Paragraph 9,3 is measured; it shall be the 9.1 The Subcontractors fist written above, unless different date is stated below orprovision ins made for the date to be fixed in notice to date proceed issued by the Agreement, Contractor. 9.2 Unless the date of commencement is established by a notice to proceed issued by the Contractor, or the Contractor has commenced visible Work at the site under the Prime Contract, the Subcontractor shall notify the Contractor in writing not less than five days when he will mobilize on the project. 9 3 The Work of this Subcontract shall be substantially completed not later than: March 21, 2017 (Insert the calendar date or number of calendar days after the Subcontractor's date of commencement. Also insert any requirements for earlier Substantial Completion of certain portions of the Subcontractor's Work, if not stated elsewhere in the Subcontract Documents.) subject to adjustments of this Subcontract Time as provided an the Subcontract Documents. (Insert provisions, if any„ for liquidated damages relating to failure to complete on time) 9.4 Time is of the essence of this Subcontract, 9.5 No extension of time will be valid without the Contractors written consent after claim made by the Subcontractor in accordance with Paragraph 5.2. ARTICLE 10 SUBCONTRACT SUM 10.1 The Contractor shall pay the Subcontractor in current funds for performance of the Subcontract the Subcontract Sum of Dollars ($ 140,000.00 ) subject to additions and deductions as provided in the Subcontract Documents. 10.2 The Subcontract Sum is based upon the following alternates, if any, which are described in the Subcontract Documents and have been accepted by the Owner and the Contractor: (Insert the numbers or other identification of accepted alternates) There will be no Change Orders for extra Work/Monies on this Project unless authorized in writing by the Owner. Contract Breakdown: Contractor reserves the right to terminate for any reason at any time. 10.3 Unit prices, if any, are as follows: ARTICLE 11 PROGRESS PAYMENTS 11.1 Based upon applications for payment submitted to the Contractor by the Subcontractor, corresponding to Applications for Payment submitted by the Contractor to the Architect, and Certificates for Payment issued by the Architect, the Contractor shall make progress payments on account of the Subcontract Sum to the Subcontractor as provided below and elsewhere in the Subcontract Documents. 11.2 The period covered by each application for payment shall be one calendar month ending on the last day of the month, or as follows: The retainage is per the contract: 5% 11.3 Provided an application for payment is received by the Contractor not later than the (25 th) day of a month the Contractor shall include the Subcontractors Work covered by that application in the next Application for Payment which the Contractor is entitled to submit to the Architect. The Contractor shall pay the Subcontractor each progress payment THIS IS NOT A PREVAILING WAGE RATED PROJECT. The Sub contractor will be paid within 5 days after the General Contractor is paid by the Owner within three working days after the Contractor receives payment from the Owner if the Architect does not issue a Certificate for Payment or the Contractor does not receive payment for any cause which is not the fault of the Subcontractor, the Contractor shall pay the Subcontractor, on demand, a progress payment computed as provided in Paragraphs 11.7 and 11.8. 11.4 If an application for payment is received by the Contractor after the application date fixed above, the Subcontractor's Work covered by it shall be included by the Contractor in the next Application for Payment submitted to the Architect. 11.5 Each application for payment shall be based upon the most recent schedule of values submitted by the Subcontractor in accordance with the Subcontract Documents. The schedule of values shall allocate the entire Subcontract Sum among the various portions of the Subcontractor's Work and be prepared in such form and supported by such data to substantiate its accuracy as the Contractor may require. This schedule, unless objected to by the Contractor, shall be used as a basis for reviewing the Subcontractor's applications for payment. 11.6 Applications for payment submitted by the Subcontractor shall indicate the percentage of completion of each portion of the Subcontractor's Work as of the end of the period covered by me application for payment. 11.7 Subject to the provisions of the Subcontract Documents, The amount of each progress payment shall be computed as follows: 11.7.1 Take that portion of the Subcontract Sum properly allocable to completed Work as determined by multiplying the percentage Completion of each portion of the Subcontractor's Work by the share of the total Subcontractor's Sum allocated to that portion of the Subcontractor's Work in the schedule of values, less that percentage actually retained, if any, from payments to the Contractor on account of the Work of the Subcontractor. Pending final determination of cost to the Contractor of changes in the Work which have been properly authorized by Construction Change Directive, amounts not in dispute may be included to the same extent provided in the Prime Contract, even though the Subcontract Sum has not yet been adjusted; 11.7.2 Add that portion of the Subcontract Sum properly allocable to materials and equipment delivered and suitably stored at the site by the Subcontractor for subsequent incorporation in the Subcontractor's Work or, if approved in advance by the Owner suitably stored off the site at a location agreed upon in writing, less the same percentage retainage required by the Prime Contract to be applied to such materials and equipment in the Contractor's Application for Payment; 11.7.3 Subtract the aggregate of previous payments made by the Contractor; and 11.7.4 Subtract amounts, if any, calculated under Subparagraph 11.7 1 or 11.7.2 which are related to Work of the Subcontractor for which the Architect has withheld or nullified, in whole or in part, a Certificate of Payment for a cause which is the fault of the Subcontractor. 11.8 SUBSTANTIAL COMPLETION 11.8.1 When the Subcontractor's Work or a designated portion thereof is substantially complete and in accordance with the requirements of the Prime Contract, the Contractor shall, upon application by the Subcontractor, make prompt application for payment for such Work. Within 30 days following issuance by the Architect of the Certificate for Payment covering such substantially completed Work, the Contractor shall to the full extent allowed in the Prime Contract, make payment to the Subcontractor deducting any portion of the funds for the Subcontractor's Work withheld in accordance with the Certificate to cover costs of items to be completed or corrected by the Subcontractor. Such payment to the Subcontractor shall be the entire unpaid balance of the Subcontract Sum if a full release of retainage is allowed under the Prime Contract for the Subcontractor's Work prior to the completion of the entire Project. If the Prime Contract does not allow for a full release of retainage, Then such payment shall be an amount which, when added to previous payments to She Subcontractor, will reduce the retainage on the Subcontractor's substantially completed Work to the same percentage of retainage as that on the Contractor's Work covered by the Certificate. ARTICLE 12 FINAL PAYMENT 12.1 Final payment, constituting the entire unpaid balance of the subcontract sum, shall be made by the Contractor to the Subcontractor when the subcontractors Work is fully performed in accordance with the requirements of the Contract Documents, the Architect has issued a Certificate for Payment covering the Subcontractor's completed Work and the Contractor has received payment from the Owner. 45 Days after Substantial Completion 12.2 Before issuance of the final payment the Subcontractor if required shall submit evidence satisfactory to the contractor that all payrolls, bills for materials and equipment, and all known indebtedness connected with the Subcontractor's Work have been satisfied . ARTICLE 13 INSURANCE AND BONDS 13.1 The Subcontractor shall purchase and maintain insurance of the following types of coverage and limits of liability Per the Contract Documents No payments will be made to the Sub contractors unless the Sub contractor had the proper Insurance coverages satisfactory to the General Contractor. All subcontract ors are to maintain $ Workers OCompens Coempensation nh Insoccurance, Employee Liability Insurance and General Liability Insurance in the amounts of at least S2,000,000.00, General Aggregate 13.2 Coverage's, whether written on an occurrence or claims made basis, shall be maintained without interruption from date of commencement of the Subcontractor's Work until date of final payment and termination of any coverage required to be maintained after final payment. 13.3 Certificates of insurance acceptable to the Contractor shall be filed with the Contractor prior to commencement of the Subcontractor's Work. These certificates and the insurance policies required by this Article 13 shall contain a provision that coverage's afforded under the policies will not be conceded or allowed to expire until at least 50 days' prior written notice has been given to the Contractor. If any of the foregoing insurance coverage's are required to remain in force after final payment and are reasonably available, an additional certificate evidencing continuation of such coverage shad be submitted with the final application for payment as required in Article 12. If any Information concerning reduction of coverage is not furnished by the insurer, it shall be furnished by the Subcontractor with reasonable promptness according to the Subcontractor's information and belief 13.4 The Contractor shall furnish to the Subcontractor satisfactory evidence of insurance required of the Contractor under the Prime Contract. 13.5 Waivers of Subrogation. The Contractor and Subcontractor waive all rights against (I) each other and any of their Subcontractor's, Sub - subcontractors, agents and employees, each of the other, and (2) the Owner, the Architect, the Architect's consultants, separate contractors, and any of their subcontractors, sub subcontractor's, agents and employees for damages caused by fire or other perils to the extent covered by property insurance provided under the Prime Contract or other property insurance applicable to the Work, except such rights as they may have to proceeds ofouch r insurance held by the Owner as fiduciary. The Subcontractor shall require of the Subcontractor's Sub -subcontractors, agents and employees, by app pate agreements, written where legally required for validity, similar waivers in favor of other parties enumerated herein. The policies shall provide such waivers of subrogation by endorsement or otherwise. A waiver of subrogation shad be effective as to a person or entity even though that person or entity would otherwise have a duty of indemnification, contractual or otherwise, did not pay the insurance premium directly or indirectly, and whether or not the person or entity had an insurable interest in the property damaged. 13.6 The Contractor shall promptly, upon request of the Subcontractor, furnish a copy or permit a copy to be made of any bond covering payment of obligations arising under the Subcontract. 13.7 Performance Bond and Payment Bond: ARTICLE 14 TEMPORARY FACILITIES AND WORKING CONDITIONS 14.1 The Contractor shall furnish and make available to the Subcontractor the following temporary facilities, equipment and services; these shall be furnished at no cost to the Subcontractor unless otherwise indicated below: each Sub contractor is responsible for his own temp. Facilities, services 14.2 Specific working conditions: All/each subcontractor is work on this project in complete harmony with all other subcontractors/trades. Each subcontractor is responsible for his own debris removal offsite. If this is not done per Charles Construction Co. Inc. satisfaction, then the subcontractor will be backcharged accordingly. ARTICLE 15 MISCELLANEOUS PROVISIONS 15.1 Where reference is made in this Agreement to a provision of the General Conditions or another Subcontract Document, reference refers to that provision as amended or supplemented by other provisions of the Subcontract Documents. 15.2 Payments due and unpaid under this Subcontract shall bear interest from the date payment is due at such rate as the parties may agree upon in writing or, in the absence thereof, at the legal rate prevailing from time to time at the place where the Project is located. Any legal cost/OSHA penalties incurred by the Owner and/or contractor directly resulting from work from this subcontractor shall be paid by the subcontractor. ARTICLE 16 ENUMERATION OF SUBCONTRACT DOCUMENTS 16.1 The Subcontract Documents, except for Modificauons issued after execution of this Agreement, are enumerated as follows: 16.1.1 This executed Standard Form of Agreement Between Contractor and Subcontractor, AIA Document A401, 1987 Edition; 16.1.2 The Prime Contract consisting of the Agreement between the Owner and Contractor dated as first entered above and the other Contract Documents enumerated in the Owner Contractor Agreement; Conditions of the Contract (General, Supplementary and other Conditions), Drawings, Specifications, Addenda and other documents enumerated therein: 16.1.3 The following Modifications to the Prime Contract, if any, issued subsequent to the execution of the Owner -Contractor Agreement but prior to the execution of this Agreement: Modifications Date 16.1.4 Other Documents, if any, forming part of the Subcontract Documents are as follows: This Agreement entered into as of the day and year first written above. CONTRACTOR: 27 Charles Street LLC SUBCONTRACTOR: Charles Construction Co. (Signature) (Signature) (Print name and title) (Print name and title) "' 111ruir CONSTRUCTION COMPANY, INC. Line Item Breakout Great Clips at 27 Charles Street Demolition $7/000.00 Concrete $2,000-00 Rough Carpentry 56,000-00 Finish Carpentry $2,500.00 Glass and Glazing $4,000.00 Drywall $20,000.00 insulation $3,000.00 Acoustical Ceiling $5,000.00 Floor Covering $8,000.00 Painting $9,000.00 Sprinkler $4,500.00 Plumbing $8,000.00 Electrical $30,000.00 HVAC $2,000.00 Permit $2/000l0 General Requirements $13,000.00 O+p $14'000.00 Total $140,000.00* *Price does not include engineered drawings. Tenant is to Supply Charles Construction with Stamped Drawings for Town of North Andover Building Permits. 20UsuTTowSTREET, NORTH xwoovsR.MxeoAcHuaerra TELEPHONE 0nma86-9u26-TEusrAx(97mo88-4\m 27 CHAR LES STRE December 21, 2016 Town of North Andover Donald Belanger Building Department 120 Main Street North Andover, MA 01845 RE: 27 Charles Street Parking: Great Clips, Inc. Dear Mr. Belanger: Please be advised that 27 Charles Street, LLC, is the owner of the building and property, located at 27 Charles Street. 27 Charles Street, LLC is the Landlord and Great Clips, Inc. is a new tenant. I am the owner and manager of 27 Charles Street, LLC. 27 Charles Street, LLC has contracted with a company, in which I am principal, Charles Construction Co., Inc. to build out the Suite for a new tenant, Great Clips, Inc. Please be advised that the Great Clips, Inc. facility is to be utilized as an employment training office and not open to the public. We hope to start construction as soon as possible. For your records, I have enclosed a facility plan, showing the building and all parking as signed by the Town of North Andover. Although eighty (80) parking spaces are required, we maintain approximately 100 spaces, within the site. Parking is also permitted on Charles Street, which I own. If you should have any other questions, do not hesitate to contact me at my office: 978-686-9526. Very Truly Yours, er Charles T. Matses CTM/ebb Hand -delivered: December 21, 2016 P.O, BOX 847, NORTI1 ANDOVER, MASSACHUSETPS 01845TELEPHONE 978-688-2263 ex R. Gary Glueck Architecture Planning Licensed in 50 States DC Guam 3797 Loop Road PO Box 939 Nashville, NC 27856 Phone: 252-459-5900 Fax: 252-459-8900 E-mail: GlueeltArch@netzero.com December 21, 2016 To: City of Andover Attn: Inspections Reference: Great Clips Training Center at 27 Charles Street in Andover, MA 1.The use of this space is for training purposes only for Great Clips employees. There shall be no public access to this space. 2. See sheet Al code analysis already shown 3. Scope of work has been added to sheet Al 4. There are no additional roof penetrations for this space 5. The existing common restroom facilities provided by the landlord shall be adequate for our use and comply with MA code. This is not in our scope of work. Project Title: Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107 l'7 ft-CAT C t j ._ 0 Date: Property Address: 9-1 1Q S s+-reQ-t ,P1-1„,c)over'r -!yi l� Project: Check one or both as applicable: i.: New construction :1 Existing Construction Project description: i i —i r. \A 0' I C rz C, i i n c.cdkd-. MA Registration Number: Q1-l? Expiration date: ', ` l 7c I , am a registered design'professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Architectural [ I Structural [ ] Mechanical [ j Fire Protection [ I Electrical itie, Other Cam, r-ro for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that 1 (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR When required by the building official, 1 shall submit field/progress reports (see item 3.) together wttl?G comments, in a form acceptable to the building official. '` .9''op, Upon completion of the work, I shall submit to the building official a 'Final Construction Contr Enter in the space to the right a "wet" o Q, •' ; �c,�` electronic signature and seal: ,� ,,. Matte .�c ca ray MOUNT. E Phone number: S z .,L-. 000 Email: (Gt h.r5 ' I LA Z el yahoo, C.CJ Building Official Name: Building Official Use Only Permit No.: J Date: Version O6_11_2013 Project Title: Property Address: Final Construction Control Document To be submitted at completion of construction by a Registered Design Professional for work per the 8`h edition of the Massachusetts State Building Code, 780 CMR, Section 107 die., Date: /-1. -'Zi"/ (.0 Permit No. 777- Crb IL Ck4k,-k SI-rej I A Ax)Ok .k.141 Project: Check one or both as applicable: Project description: c4. Li New construction L.1 Existing Construction 1 Eg-( (.., 6,:A1(.76.,- (--,(-- MA. Registration Number: qS7e-i0 Expiration date: 6-3o-zot8 , am a regisiered design prgfessional, and 1 have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: [ ] Architectural [ 1 Structural 14.0,. V Mechanical [ I Fire Protection Electrical [] Other: for the above named project. 1, or my designee, have performed the necessary professional services and was present at the construction site on a regular and periodic basis. To the best of my knowledge, information, and belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building permit and that 1 or my designee: 1. Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding thi R 107. Enter in the space to the right a "wet" or electronic signature and seal: Phone number: Email: 16 OF as- 844 ERIC ENGE tr. MECHANICAL No.45140 "..sstcognt. Building Official Use Only Building Official Name; Permit No,: Date: Version 06_11_2013 CERTIFICATE OF LIABILITY INSURANCE PAYE RAMrt)OW YY► 12/08P O16 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 INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL. INSURED, the pollcy(ies) must be endorsed, If SUBROGATION IS WAIVED, subject to the terrors 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 endnrsement(s}, PRODUCER E A Kelley 4E0Veterans Memorial Parkway Building 5 East Providence RI 02914 tNSUREP Charles Construction Co. inc. 200 Sutton Street North Andover MA 01845 c2NNTTAAJ:T Nicholas San Martino No, (4011709 60337 800470.2924 _ . Piet• Via.,, nichola$seeaketle +.cam Ris14 10, 21)4327... INSUAEt11SIAFFQRDING COVERAGE INSURER A: Nautilus Ins. CO. INEURER6: 173i0 INSURER Et INSURER Q; . INSURER E: INSURER F: COVERAGES rcoralrbT t I lu s:o, THIS INDICATED. CERTIFICATE IS TO CERTIFY THAT THE POLICIES OF INSURANCE NOTWTHSTANO N0 ANY REQUIREMENT, NAY BE ISSUED OR MAY PERTAIN. THE CJ.USIONS.AND CONDITIQNS OF SUCH POLJCI TERM INSURANCEAFFORDED = +. WITS LISTED .BELOWHAVE BEEN ISSUED TO THE OR CONDITION OF ANY CONTRACT OR OTHER BY THE POLICIES DESCRIBED SI'(QW1N MAY HAVE REEtt_RIAUUQQ'�Q flY P INSURED NAMED ABOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT MALL THE TERMS, O Q Ar µ�qE 1i�' TYPE.0FINBURAHCB 1!'i't . ;e P•OucvNusEER , i1INfiO EFF P@ an N HMV _ . LOWS A GENER X M. LIABILrre c.:4 mmeoe.ia4e. ekpi L.IAStU Yg' Cl A7Aa-41At: DoC,c P NNE61921 05/16,2015 05/16/2017 r:-.a�ttn,70.,PPEUCr F 1,000.000 ,{;st,..Vit �>z Ft,�,141�,:k?rid (�6+33Rta7<41 , i 1(it�.Ql�� mED> aJ(mvune.Cers,-4-,1 I 5,000 `FER7,3oHALi Aov irJ.i.Ilz'r T 1,000,000 GENEPALACA'IIFGAT;` T 2,000,000 gE,Nta,POITO,)ATELIMIT NPOT PEP37 PROLLrr:r .1.Y.4, r>,zs• F, s Included AIrtOMOBILE .�,,. LIABILITY ALL M'sgdlEt.sAU1't.IS ji„ t3trpote hums HIRED AUTOS ti :1414ANTILLIAJ'UE - 7.0MBIK , (=t P E.L AI t's:'i(41' IN.,5P cTIop;rrgeV I r.,,i,1-Iti.L ' ,'Pk"'n7asdt 3 PPLI,E,ITY EI.AMAGE (Pr,r rlrxa4nll $ • A .EMM9YE A LFAPPLFULALim rx sxcERsuAO r,"filth Q,AmifiALCQE - AN028218 05/16/2016 05/16/2017 Eiv:N+1 uNPF /A $ _...- 1.000.000 A :.I G are $ 1,000,000 REETK 1.411ir�,}N $ S • -.. - • . 4 - - y� Tye S'LiA19U[1Y NANO V/N ANY PF. fiR i? l..1k3I] ? XF.r;IJ71 gtrttrs&7Eary n� "Ct t '?;(a. h1 'S yp5 4sg5tge+ice+r NIA I fn'qvluck t.I. CIsC;HAf;s IC JY L1: I -AU- ST•EA €t,11:W( F EL C41c`ca:E- POLICY LIMIT A . Business Personal Property NN881921 05118/201El 05/16+2017 Limit: $30,000 Oedurtlhla: $1,000 Special - Incl. Theft. 60% Coins, RCV . _ __ _ DEECHIPTi0Pi. DE OPERATIONS /LOCATIONS I VEHICLES {AK.ChACORi-1S1.AddhinnIl Hinuerks SChiquI , Ne aor Spires is rrqulndl Carpentry at Contractors, Town of North Andover 120 Main Street North Andover ACORD 25 (z00e/00} SHOULD MY OP THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICEWILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED rt RSBENTAYIVE MA 01Ak$ s 1199E4009 ACORD CORPORATION. All tights reserved, The ACORD name and logo are registered marks of ACORD kt,. '1\ &Lc, J ci7v,,ic d'shOno : Expiration Date,. - �a°'✓ �ak (yt City/State/Zip: olicy number and expiration. on. date) - A SiteAdcpy o compensation policy declaration pages awe up to $�.>500.te of the -�©r7�.exs ca-mp hale by Fa Attach a copy o.152, §25Aisa erimin' alviolation.p ER and a1 e ofup $ ,500.00 a and/or to - secure coverage as requited as met e11 as civil penalties in the faro, of a STOW WORK O�ati ones of the DIA fax iv saaranee dnylagonstthe iolal cop asbe forwarded to the Ofdeeoflrkvestig the viola of -this statement may day against coverage verification. ado hereby cert. Si_, atgre: Phone ci or'toWn official. Official use only. Do not -write in this area, to be completed by t3' �'erzai-i:ILice7ase # City or Town: Inspector 5. l'1nmToing Inspector foilingnd o tkleaty' (circle one):nz o Clerk. 4_ Electrical ,l_.ara;�,crTlenart[nEns 3. CitylT vvn 1.Boaxrl 6. Other maw 0. �_c n �. The Commonwealth of Massachusetts Department' of IfcUxttl.cezdents 1 Congress SirState 100 0 Boston, AM 02ZZ i ww.mass.goviella ambers, ensation surance A fdaavitr 13n9i ciexslContrractorsiMetricxanzs/ „ Wa hers Comp G AY3leC0i�7C7ySr TOPEFxL��':Cl'TATHETE 1?leasekx'int 'bl A :licant lrriorrnation Name (Business/Org ationfindivid Address: Zc-D° ./�" re you an employer? Cheelcthe appropriate7ocx: employees (full andlor part -lime).'' X.❑ I atn aempinyer with �— ees working for me in any rigor or partnership avdhaven° employ I y capacity. [No workers' comp. a sole prep insurance required-1 self, [go -workers' comp. anstuancerequired.] 3.Q I am ahomeovrricr doing allwezkmY roe I vrili contractors toconductall work army p p rt'3` h-� I era ahomell con andcontractors will be hiring compensation insurance or are sole ensure that all coutrd�'�� either have workers' proprietors with na eu�ployees. am a general contactor andVaav elan hasub-contractors rs comp. lile d onthe attached skeet. 5 "'� These sub -contractors have employ oratig?i and its,ofdcershave exeroisedtheir right of exemption per Mal., c. fi. 15e are a corp ees o,xorkers' comp. insurance required.1 olic ikon uatior� ' 152, §1(4'). andtivebavenu env**. their workers' compensationp y affidaviturdicatizig such the are doing all work andthenlure outside contractors must submit a new Auyapplicantthat��°��hX�l'�rsalsdiillnuttheseciionbelovrslro owing � �ameo�thesuh-conizactozsandsiateTNh�rerorpoithoseentiiieshave i I�orneawners vrlaa submihth;ss siatt attached ling Y policy number. th%s box fnust aitac]ied an additional pi v ids their workers' corny. p Y al'i �zts employees. that check , they �plcyees. Iithe sub -contractors have employees,erz2 to ees. •.�• siow is the pot' --icy arzdjr I am an eynployer that iS,pr'oyidir2g'�Yvo1'kePs' compensation insura�ee for my p y �Nc rC.----- information. iosi cane Company Name: Tolley #orSewins.Lie. #: Type of project ((e od) 7. 0 N `d8nstri ciion S. [modal3ug 9. ❑ Demolition 100 Building addition 11,.[] E1eoixical xep�irs or addzti.ops 124P1 rn ing repairs or additioz9 13,QRoofropans 14.L Other (Showing tb.e p tor. A copy erf u' that the information provided move is true and cor�r'ect, the pains aced penarfies ofp ] I _ 1 i - (e Date: F'hole#: Contact Verson: „ 1:)))))„,,," l)V1i)10,),),)),),11))))))))))))11, ,))),) iri)))))).1))))))),),)11111)))))