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HomeMy WebLinkAboutBuilding Permit #659-15 - 11 SAUNDERS STREET 5/1/2018 ttORTM BUILDING PERMIT o�,,eo gtio TOWN OF NORTH ANDOVER 02a?�w ° ` APPLICATION FOR PLAN EXAMINATION '' 2 M _ :h Oc Permit No#: Date Received " 4 ��SSACHUS���� Date Issued: IMPORTANT:Applicant must complete all items on this page l LOCATION /J 5d -2hcueE" �)r^-yee't A)bCA � ,�-,vc, Print PROPERTY OWNER Sr►4 u� 1nc�e�s �f- F e- ') f l=L Print 100 Year Structure yes no MAP ? PARCEL: C_-ZONING DISTRICT: -Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: XCommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: , 11 .[� (-Aal �/ � i6tion - Please Type or Piit AClearly OWNER: Name: Phone: q $ 7 0 Address: Contractor Name:Cz,L,. , -qs Phone:9 �y I-ry Address: ,._��}�r d t)r,N rt Supervisor's Construction License: S ,� / 3 Exp. Date: Home Improvement License: . Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 6 a D o� FEE: $ J, 60 Check No.: Receipt No.: � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owne j,',�f .. Signature of contracto cy Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TypF OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Sw"mning Pools 0 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 Signature_ COMMENTS `> �� `}ley1,� .` V` �,. ��. Lei �y���' .Jk, a CONSERVATION Reviewed on Signature n COMMENTS i HEALTH Reviewed on Signature COMMENTS + / Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street o ,y�5'tm'k o+gfgj` �;. t^•t 'zt F.pR 'X%+ IREDE ATMENTTernp ®umpster onsiter yes1zh � noi� 7 R U-•+ Rs v.�P��.?•n" .Z�$�f,�yb L .A' �� -9�y�"�` "ni ��Y'L �� �� � 1 �'+'4E4.-"t # iz ° � .i yar. 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 i 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 u Building Permit Application o Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application o Certified Surveyed Plot Plan Li Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) u Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) a Copy of Contract o Mass check Energy Compliance Report u 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 2014 Location No. Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ �G Building/Frame Permit Fee $ -- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r s Check# 2 !,. ,j Building Inspector p� r ��YJ �� �� v � x� `��� � � � � � ��� �' ,� �� � �� � �� March 9, 2015 Mr.Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, MA 01845 Re: 11 Saunders Street, North Andover, MA 01845 Dear Inspector Brown: Please accept this letter and accompanying affidavit as a request for temporary occupancy permit for 11 Saunders Street, North Andover, MA. To date, in our efforts to make the bathroom and office handicap accessible, licensed contractors have completed the plumbing and electrical work associated with the moving of the sink and toilet and we have enlarged the doorway, cut back the countertop and re-tiled. To complete the project,we need to install the handicap ramp and to enlarge the outside door once the ramp is installed. We are respectfully requesting that we be allowed to delay completion of the project until the late Spring when the weather and ground conditions are more appropriate. As such,we are asking that you grant us a temporary occupancy permit to allow us to relocate our business to the above address and begin our business operations on the condition that we pledge to complete the project timely and properly. We thank you for the direction and assistance you have shown us with regard to this project. We are available4Jnkowsk er any questio s or concerns that you may have. Sincerely Michael Durso and Jankowski Insurance Agency i Get behind the shield ` Gs`'p"es Posk Durso & � PITNEY BOWES Jankowski 198 MASSACHUSETTS AVENUE EST 1930 I N S U R A N C E NORTH ANDOVER,MA 01845 02 1P $ ®00■480 0001734706 MAR 12 2015 MAILED FROM ZIP CODE 01 845 f NORTH 1 neo X67 ti0 I Town of North Andover Community Development and Services Division ea 1600 Osgood Street,Suite 2035 09q LO[wLww.LOM1. ,E7_ OR'7E0�pP c5 North Andover, Massachusetts 01845 �SSgcHus�� TRC Meeting Minutes October 8,2014 1600 Osgood Street 11:00 AM Staff Present: H. Gaffney, S.Sawyer, M. Egge, F. McCarthy,J. Brown,J. Enright Applicant: Durso&Jankowski Insurance, LLC(Brian & Darlene Randone, Mike Jankowski, Brian Cronin, Chris Shark) CC: T.Willet, G. Willis, M. Grant,J. Bradshaw, K. Fitzgibbons,J. Hughes, EJ Foulds,A. Melnikas,C. Bellavance,A. Maylor Subiect: Durso&Jankowski Insurance, LLC—11 Saunders Street The applicants are proposing to purchase a single family residence located at 11 Saunders Street to operate their insurance business from. Durso&Jankowski Insurance was founded in 1930 and is currently located at 198 Massachusetts Avenue, North Andover. Eleven Saunders Street is 4 approximately 1,700 sq.ft.and has recently been renovated. The property is in the General Business zoning district and within the Downtown Overlay District. The applicants would like to construct a handicap ramp and a handicap accessible bathroom. H. Gaffney: There are not any wetlands within jurisdiction of this parcel. J. Brown: This is an allowed Use; however, it is a change of Use. Sketches of Intent(conceptual plans) will be required to determine parking requirements. Building permits will require architectural plans. A handicap parking space will be required. A single handicap bathroom will require a variance from the State Plumbing Board. S.Sawyer: If you do request the variance the Health Department will be required to sign to indicate they received the application. M. Eege: The change of Use will require a Site Plan Review special permit from the Planning Board. If necessary, a reduction in parking requirements can be requested. F. McCarthy: Since the building was recently renovated the fire alarm system and CO2 detectors should be hard wired. An architect will look at the regulations and determine if this is acceptable. Fire extinguishers will be required. r _ _ V NORTy •� , W' 0 . _ _ ve" _'o O No. 145 h ver, Mass, /s COCNtCH(WICK �r-J P � S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System C _ THIS CERTIFIES THAT ,�l fit,v .�:' ...:Sf ......., l c� ... �' (,; ��C BUILDING INSPECTOR ........... ....... .. ...... .. ......................... ��C/��C��j S Foundation has permission to erect .......................... buildings on ./1.......... .. .�..................................... Rough to be occupied as ........... ... .....(7 .. ..4. �.. .................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT STARTS Rough Service .............. ..................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. �i CABINETS O CABINETSJANUARY 13, 2015 iimvo FI21DGE a I DATE DESCRIPTION CABINETS COUNTER REVISION REMOVE WALL TO .�2. or OWNER: ACCOMMODATE NEW _3„ 70 DOOR LOCATION(TYP.) _ 41 -1 O--- 11 SAUNDERS STREET FILL EXISTING WALL a ^ v REALTY TRUST 7 11 SAUNDERS STREET NOTES: NORTH ANDDOVER, MA 1. PROVIDE RAMP TO BSMT 01845 ENTRY DOOR IN DOOR CLOSET COMPLIANCE WITH ;I MASSACHUSETTS AA8 i.i _ .............. . REQUIREMENTS 2. 0 BEBATHROOM 11 SAUNDERS STREET COMPLIANCE WITH MASSACHUSETTS AAB /CC (TAX MAP 29 / LOT 22) REQUIREMENTS NORTH ANDOVER, MA 01845 OUTLINED IN SECTION 3-6� 521 CMR 30: PUBLIC TOILET ROOMS -7" TO 2ND sj FLOOR PROJECT : 8. PREPARED BY: BENJAMIN C. OSGOOD, JR. P.E. PREPARED BY: TTI ENVIRONMENTAL 13 BRANCH STREET METHUEN, MA. 01844 �D Ona-pcxx O-casn,ucnoi 110YMS11U1xW Td: 978 749-9929 Fax: 978 749-9920 DRAWING TITLE: HORIZONTAL SCALE FIRST FLOOR PLAN 4 0 2 4 DRAWING : FIRST FLOOR PLAN C - 2 ( IN FEET ) 11 SAUNDERS STREET 1"=4' (1/4"=1') ACVRO� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/11/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C NTA T Victoria Lowes CISR NA E: + MTM Insurance Associates PHONE . (978)681-5700 1 ac o:(978)681-5777 1320 Osgood Street EMAILAppgESS.vickiel@mtminsure.cotn INSURER(S) AFFORDING COVERAGE NAIC# North Andover MA 01845 INSURERA:State Auto Insurance INSURED INSURERB:Commerce & Industry Insurance Cote & Foster Contracting, Inc INSURER C: 20 Aegean Drive INSURER D: Unit 15INSURER E: Methuen MA 01844 INSURER F: COVERAGES CERTIFICATE NUMBER:13-14 Master List REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INTR TYPE OF INSURANCE L U POLICY EFF POLICY EXP POLICY NUM ER (MMIDDAYM IMMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO FGqTET- X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 300,000 A CLAIMS-MADEOCCUR BOP2722545 2/31/2013 2/31/2014 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 HXGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY (Ea dED SING LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED 2370166 2/31/2013 2/31/2014 AUTOS X AUTOS BODILY INJURY(Per accident) $ X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Medical payments $ $ 000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION R WC STATU- DTH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVEFRI NIA E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? 0004962937 6/20/2014 6/20/2015 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 A Property Coverage BOP2722545 2/31/2013 2/31/2014 Business Personal Property $39,367 A Scheduled Equipment BOP2722545 12/31/201312/31/2014 Contractors Equipment $169,928 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) Certificate holder as listed below CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 384 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 P MacDonald CPCU, CIC ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS026(2o1om).ot The ACORD name and logo are registered marks of ACORD COTE FOSTER CUSTOM BUILDING + REMODELING 20 Aegean Drive,Unit 151 Tel:978-682-6518 Methuen,.MA 01844 Fax:978-682-1221 www.coteandfoster.com I to Massachusetts _ Board of Suiidin Department otpubiic Safe g Regulations and Stan/ Constrr;r-6a Sz;pet�isor dards I y License: CS-085173 el II.LIAM T FOS�R , 65 COACH DR DRACUT MA 01$26 6-13 v Comm,lssioner Expiration - - _ - 11h0/2016 •f frice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistratior 107602 Type:i Supplement C t Expiration 8/5/2016:;, 4 COTE&FOSTER COSI - " WILLIAM FOSTER g 20 Aegean Dr Unit 15 ,Methuen,MA 01844 Undersecretary i e S A V i( i�i p�rc BENJAMIN G. !' 09000D,JR. NO. CIV ���` JANUARY 5, 2015 O _ ........._,_..._.....,.. . ,._ ...... ... � � 7 EXISTINGDATE " ESCRIPTI N CONCRETE 65't '�--��� REVISION WALKWAYr---- ^"'�.. ..,.-.._,._._._......_......_......�......................................................... OWNER: 11 SAUNDERS STREET • EXISTING PORCH REALTY TRUST O 11 USTREET NORTHANODOVER, MA ...............018_.1..8 45.......... ... .... .,..... P ,! '�.991'�' I RECONSTRUCTSTAIRS AS '- MAIYT H' l 21) LOT _ - REQUIRED t (TAX MAP 29 / SAUNDERS STREE (TAX MAP 29 / LOT 22) O EXISTING COVERED ' ? NORTH ANDOVER, MA 01845 (, ENTRYWAY WITH ' !RAISE EXISTING LANDING TO BE .,r \:J TO BE FLUSH WITH CONSTRUCTED INERIOR FLOOR OF WOOD .............................................................._.._..._.................._........... ..........._.. EZ—ACCESS +I HANDICAPPED EXISTING LANDING RAMP ENTRANCE { EX-ACCESSPROJECT LANDING •.s '� 6' i O PREPARED BY: 1 AM . OOR, O HANDICAPPED BENJ ... ....... .......IN C........ .._SGOD,.:....,"...,......_.J.. P.E.__.....,. RAMP 5' PREPARED BY: &; `r 12 CDU TTI ENVIRONMENTAL (TYP) ,�- (TAX MAP 29/LOT 20) 13 BRANCH STREET i METHUEN, MA. 01844 INFILL WITH 795" Uwa KMMNG-aE9M-WPmmrTwa-comwuCTON ASPHALT �/ NOTES: AGMIM18WAlxx1 PAVEMENT ,/ Tel: (976) 749-9929 $ 24 1. EXISTING CONDITIONS INFORMATION OBTAINED FROM RECORD INFORMATION Fax: (978) 749-9920 ' FROM MASS GIS, NORTH ANDOVER GIS THE NORTH ESSEX REGISTRY AND """'""'"""".....—""•""""•"'"""""""•""" ON SITE MEASURFMFNTS PERFORMED BY CIVIL DESING INC. CONSULTANT'S, DRAWING TITLE: HORIZONTAL SCALE 5' SITE PLAN \, 2. THIS PLAN HAS BEEN PREPARED TO ILLUSTRATE PROPOSED ENTRANCE 10 0 5 10 — IMPROVEMENTS AND IS W1 TO BE USED TO ESTABLISH PROPERTY LINES � — EZ—ACCESS OR BUILDING SETBACKS. PROPERTY LINES AND BUILDING LOCATIONS LANDING ARE GRAPHIC ONLY. NO REPRESENTATION OR CERTIFICATION AS TO THE DRAWING ACCURACY OF THOSE SHOWN IS IMPLIED OR INTENDED. j ( IN FEET ) 3. RAMPS SHALL BE CONSTRUCTED OF EZ—ACCESS ALUMINUM SECTIONS i 1"=10' UNLESS OTHERWISE NOTED. 4. TOTAL RISE OF RAMP IS 36" — RAMP SLOPE 1 12 January 13,2015 Gerald Brown,Inspector of Buildings 1600 Osgood Street Building 20,Suite 2035 North Andover,MA 01845 Re:Proposed renovations to 1 i Saunders Street Dear Mr.Brown: JONN PEANSON I have been engaged by the Engineer,TTI Environmental,for the owner of the above project to advise on compliance with the Massachusetts Architectural Access Board relating to the proposed accessible unisex restroom on the ground floor. The revised drawing C-2 dated January 13,2015 (Copy attached) shows a layout that conforms to the MAAB architectural guidelines as follows: The room has a clear width of 5' and length of 9' which allows for a 60"wheelchair turning diameter. There is a clear floor area that includes the water closet that is 5'wide and 6' deep with water closet located 18"off the wall and with grab rails provided. There is a 30"X 48"clear floor space at the lavatory that is not intruded on by door swing. The 36"door swings out from the space and has the required maneuvering space at pull side and at push side. Please feel free to call me if you have questions about these points or if you require additional information, st regards, P �� o a 41 z 3 ro (:Joh Pearson,AIA, LEED AP Principal f www.johnpearsonarchitect.com // john@johnpearsonarchitect.com 140 Raven Road,Lowell,NIA 01852 // 617.905.8546 CABINETS ¢3 (D CABINETS FRIDGE JANUARY 13, 2015 ... _............. 1 DATE DESC IPTION CABINETS COUNTER REVISIONSI REMOVE WALL TO ._Z. OWNER: ACCOMMODATE NEW ._3„ DOOR LOCATION(TYP.) '� ^ it SAUNDERS STREET FILL EXISTING WALL a i7I Z3 REALTY TRUST NOTES. 11 SAUNDERS STREET NORTH ANDDOVER, MA 1. PROVIDE RAMP TO BSM'T ENTRY DOOR IN DOOR CLOSET 01845 COMPLIANCE WITH MASSACHUSETTS AAB REQUIREMENTS 2. BATHROOM FrATURESTO BE IN O COMPLIANCE WITH � 11 SAUNDERS STREET MASSACHUSETTS AAB (TAX MAP 29 / LOT 22) REQUIREMENTS OUTLINED IN SECTION NORTH ANDOVER, MA 01845 13^-6" 521 CMR 30: PUBLIC + TOILET ROOMS ,0n n -7" TO 2ND F FLOOR PROJECT jC 7'--6PREPARED BY: BENJAMIN C. OSGOOD, JR. P.E. PREPARED BY: _ TTI ENVIRONMENTAL 13 BRANCH STREET METHUEN, MA. 01844 uxo w4W.10-0=-WAV MnW-eaemucna 11T01 Tei: 978)749-9929 Fox: 978)749-9920 DRAWING TITLE: HORIZONTAL SCALE FIRST FLOOR PLAN 4 0 2 4 FIRST FLOOR PLAN DRAWING IN FEET > 11 SAUNDERS STREET C - 2 The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations Y 600 Washington,Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: q City/State/Z / Phone #: ?'tal �� - �✓�/� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4.A I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have $ employees and have workers' ❑Demolition working for me in any capacity: 9. Buildingaddition [No workers' comp. insurance comp.insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL c. 152, 1(4), and we have no 12.F-1 Roof repairs t insurance required.] § employees. [No workers' 13.❑Other comp. insurance required.) *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: y n 1 m E iL c f %L D U,57`IZ y Policy#or Self-ins.Lic.#: Li.1 L o O y'9� a g 3? Expiration Date: Job Site Address: City/State/Zip: 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 andNa 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 cer fy under the pains andpenalties ofperjury that the information provided above is true and correct. Simature: r Date: _ la? ` J� Phone#: 19 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): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: COTE fill FOSTER-z• (: 1j5 •I () M BUILDING + RENiODEi. IN6 This agreement made this 3011 day of January,year Two thousand and Fifteen by and between Cote and Foster Contracting,Inc.hereinafter called the Contractor and Durso& Jankowski for Saunders St.Reality Trust,hereinafter called the Owners,witnesses that the Owners intend to include work at a new location which will include ADA conforming bathroom at the address of 1 l Saunders St.,North Andover. Now,therefore,the Contractor and the Owner,for consideration hereinafter named,agree as follows: ARTICLE 1 The Contractor agrees to provide all the labor and materials to do all things necessary for the proper construction and completion of the work shown and described on drawings. The drawings and specifications are the basis of the contract. ARTICLE 2 In consideration of the performance of the contract,the Owner agrees to pay the Contractor,in current funds as compensation for his services hereunder$5,563.00 to be paid as follows: Payment 1 -$2,500.00 at signing of contract Payment 2-$1,5W.00 at completion of framing Payment 3-$1,563.00 at completion of project ARTICLE 3 Final payment on contract amount as agreed above to be paid within ten(10)days of project completion or occupancy. If final payment has not been made within this time a 10%charge per month on the balance due will be charged All minor punchlist items will be complete as part of the one year warranty on the finish product. Failure to pay balance within ninety(90)da s may uh in 1 on. Initials: 20 Aegean Drive - Unit 15 - Methuen,MA 01844 Tel:978-682-6518 - Fax:978-682-1221 www.coteandfoster.com ARTICLE 4 Additional work above and beyond the contract agreement.- All greement:All additional work done to be quoted at the time the client requests the work. The work will be done and billable at its completion. The client has ten(10)days to pay the additional cost after he or she has been billed for it. Initials: written.In witness whereof they have executed this agreement the day and year first above Mr.Durso,0caner r. an s ner Steven M.Cote DBA Cote&Foster