HomeMy WebLinkAboutBuilding Permit #764 - 166 SUTTON STREET 5/27/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: --,&q. Date Received
�Date Issued: �/274'` 10
IMPORTANT:
r <�
UI�AP 210 r SPA
p�
TYPE OF IMPROVEMENT"
New Building
Addition
Repair, replacement
Demolition
PROPOSED USE
Residential
One family
Two or more family
No. of units:
Assessory Bldg
Other
Non- Residential
Industrial
Commercial
Others:
if
Identification Please Type or Print Clearly)
OWNER: Name: j Phone: 8.36^S low
Address:
ARCHITECT/ENGINEER 024\l k(�,yp G W � SO- Phone: 7v . 03 'X37 2
..G M lccS r7s GooDhtve ea,
Address: _– /Afm—N Reg. No. 4647 V617�3
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $_ -�a�D FEE: $
Check No.: 1. U 1 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guar nty. fund
r g
Signature,of.A ent/Ow
g Si .nature 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/Sap's';
"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 6t;Ver �'5PeJs�yt�eo� lle fes{ ,�
CONSERV ION Reviewed on Signature
NTS
.9
/ ` HEALTH
.L
COMMENTS
Reviewed on Z'/z Vty Signature
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:
gnatureldate;
rVeJAI A
wreei
z
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
o Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits,for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Pian
❑ 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
Location
No. 7 y
Date 4�1a -7/0
°
Na�Th TOWN OF NORTH ANDOVER
� _ L
9
Certificate of Occupancy $
�� s'•^° •; Building/Frame Permit Fee $ 3
QC Mus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # /dl<-
23214
Building Inspector
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 764-2011 Date: September 7, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 166 Sutton Street, North Andover, MA 01845
Sultan Mediterranean Cafe.
MAY BE OCCUPIED AS a restaurant (12 seats) IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to:
Fee: 100.00
Receipt: 23214
Sutton Square Realty
Building Inspe for
The Commonwealth of Massachusetts
Department o f industrial Accidents
Office of Lnvestigations
IV 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
mlicant Informnfinn
Name (Business/orgmiza6on/Individual):
Address:
City/State/Zip:_ �� J-e,r L.,. %-I _
L4
Phone #: d �'("� 1 2Z 16
A
VIeu an employer? Check the appropriate a:
am a employer with 4. [ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
?. ❑ I am a sole proprietor or partner- listed on the attached sheet I
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 '
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
rte
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance regn%red.]
t'pti,.anr that cher
-n ..s boy.�t mast s?so fir'. o:tt firs „er-tio_� ceiow slier.^.
Type of project (required):
6. ❑ New construction
7. YRemodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
I30meowners who submit this affidavit indicatingth. , aro doing , ••. a `"'" °� � comp=
e aL work and Than hire outside contracto s mus .submit 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' co oii information.
comp. P c1
I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:
Policy # or Self -ins. Li c. #. W CZ02,o002214 2n rl
Expiration Date: U p
Zi -0
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 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.
Ido hereby �,erafy under sins penalties of perjury that the information. provided above is true and correct
Si�aturc. A.t.�-�
Phone #:
Official use only. Do not write in this area, to be completed by city or town officiaL
Cita, or Town: Permit/License #
issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Information am d 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 ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than'#hiee apartmLent 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 cnonstru. 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 uu-til acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please HE out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), addresses) 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' comp enation 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 store to site n and date the affidavit The affidavit should
.i the t at � li • r-- the pe � �C"n.°e i being ."eq:leS+wd,�nat ..�'�..
be ivt'e'uue� to vit�' or uJwTi that the auveiCauflii tui rl$11t or li $ t e DepE.*1.^:e.^t of
Industrial Accidents. Should you have any questions regardirn g the law or if` you are r e l i it ed to obtain a workers'
compensation policy, please call the Department at the numbe=r 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 affidavit5,for you to fill out in the event the Office of In4estigations'has to contact you regarding the applicant
Please be sift 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 application 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 location 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 perxnits 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 Ifice to than you in advance for your cooperation and should you have any question,
please do not hesitate to give us a call
The Deparunent's address; telephone and:faxnumber.._
The Conmonwmltl2 of Massachusetts
Department of industrial Accidents
Office of Investibatious
600 Washington Street
Boston, MA 0.2111.
Tel. 617-72.7-4900 ea. -t 406 or 1-9 77-MASSAFE
Revised 5-26-05
Fax '# 617-72.7-7749
v''vrw Mass.., -ov/din.
ACORD CERTIFICATE OF LIABILITY INSURANCE
MM1DDfYYYY
4/30/2010 )
PRODUCER (617) 354-4640 FAB: (617) 354-5828
T. Edmund Garrity & Co., Inc.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
545 Concord Ave.
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Cambridge LSA 02138
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURERA:EsseX IIIc Co
INSURERaAcadla IIIS
Fortis Builders LLC & Citation Realty LLC
INSURER C:
127 Winter St #19
INSURER D:
INSURER
Haverhill MA 01830
COVERAGES
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.
kTE LIMITS SH MAY HAVE BEE 4 REDUCED BY PAID CLAIMS.
INSR
DD'L
TYPE OF INSURANCE
POLICY NUMBER
POLICYEFFECTNE
DATE MMIDD
POLICY EXPIRATION
DATE MMIOD
LIMITS
GENE RAL LIABILITY
EACH NC 500 000
DPREMISES AMAGE I E.REoccurrencel NTED $ 50,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE Q OCCUR
3M1376
1/30/2010
1/30/2011
MED EP person) exclude
PERSONAL & ADV INJURY S 500,000
1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - QOMPIQP A G $ 1,000,000
PRO-
X POLICY JECT LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
(Ee accident)
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
BODILYINJURY $
(Per accident)
PROPERTYDAMAGE $
(Per accidert)
GARAGELIABILITY
AUTO ONLY-EA ACCIDENT $
OTHERTHAN EAACQ
ANY AUTO
AUTO ONLY: AGG $
EXCESSIUM13RELLA LIABILITY
EACH OCCI IRRFNCE
AGGREGATE $
OCCUR FICLAIMS MADE
$
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
WC202000229300
10/02/2009
10/02/2010
g Two CSTATU- OTH-
E.L. EACH ACCIDENT $ 100,000
B
EMPLOYERS' LIABILITY
ANY PROP RIETORIPARTNERfEXECUTIVE
OFFICERIMEMBEREXCLUDED?
E.L DISEASE -EA EMPLOYE 100,000
E.L. DISEASE -POLICY LIMIT $ 500,000
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
(978)688-9542
Town of North Andover
Building Dept
N. Andover, HA
ACORD 25 (2001/08)
I WSI194 r na, ns.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO $0 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
AUTHORIZED REPRESENTATIVE
Killiam Garrity/ANNIE
O ACORD CORPORATION 1988
Para i W?
Massachusetts - Department of Public Safet.%
Board of Buildi.no Re-,ulations and StandardsConstruction Supervisor License
License: CS 91645
Restricted to: 00'
FRANCIS J BEVILACQUA III
32 BOXFORD RD
BRADFORD, MA 01835
Expiration: 7/19/2010
('ununissiuner Tr#: 442
OFFICE OF BUILDING INSPECTOR
TOWN OF NORTH ANDOVER
'•*tiJ CONSTRUCTION CONTROL
PROJECT NUMBER:
PROJECT TITLE: .5UV- PJ MEDiMgEL&AI e!fAFE
PROJECT LOCATION: /46 SU-1TTO tJ 571LM7-
NAME OF BUILDING: St/MAJ '1 4t APZ
NATURE OF PROJECT:_ 10t R41OX 7EN*N7' F17 •11f r-04
ID
P-65*rA0PLA NT
tDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE,
AO OEAJA4 ALDER'r REGISTRATION NO. 4627
BEING A REGISTERED PROFESSIONALRCHITECH HEREBY CERTIFY THAT I
HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT 0 ARCHITECTURAL I STRUCTURAL 0 MECHANICAL 0
FIRE PROTECTION 0 ELECTRICAL 0 OTHER (SPECIFY)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS,
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B
EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. Review, for conformance to the design concept, shop drawings, samples and other submittals
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approval of the quality control procedures for all code -required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become, generally familiar
with6the progress and quality of the work and to determine, in general, if the work is being
performed in a manner consistent with the construction documents.
PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMITSEEKLY , A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY.
SIGNATURE
SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF 19
NOTARY PUBLIC
MY COMMISSION EXPIRES
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Construction Contract
This agreement is made on the date written above our signatures between
Contractor Name: Fortis Builders, LLC (Contractor)
Contractor Contact Info: _127 Winter St Unit 19 Haverhill, MA 01830 and
Owner Name: Issam Ramey (Owner)
Owner Contact Info:
The Construction Site
Address: 166 Sutton St
City: North Andover State: MA Zip: 01845
I. Description of the Project and Description of the Significant Materials to be
Used and Equipment to be Installed
A. For a price identified below, Contractor agrees to complete home improvements
(identified as the Project in this agreement) for Owner.
B. Description of the work, materials and equipment to be installed:
• Misc Rough Framing
• Sheetrock
• Plumbing, Electrical, HVAC as per plans
• Painting
• Flooring
II. Contract Price
A. In addition to any other charges specified in this agreement, Owner agrees to pay
Contractor $ 29650.00 for completing the Work described as the Project.
III. Approximate Start Date
A. Work under this agreement will begin any time after the building permit is issued.
B. The Project will be considered substantially commenced when tools and materials
arrive at the Job Site.
IV. Approximate Completion Date
A. Work under this agreement will be Substantially Complete after 6/18/2010.
V. List of Documents Incorporated into this Contract
A. The Glossary of Terms which follows our signatures is incorporated into this
contract as though included in full as part of this agreement.
B. This agreement incorporates by reference certain disclosures and notices required
by federal and state law. The following documents are incorporated as though included in
full as part of this agreement.
Plans by architect Ron Albert, AIA and Mechanical Engineer McCabe Associates.
VI. Scope of Work
A. Contractor shall supervise and direct the Work and accepts responsibility for
construction means, methods, techniques, sequences and procedures required to complete
the Project in compliance with the Contract Documents.
VII. Compliance with Law
A. Contractor and Owner mutually commit to use reasonable care to meet the
Requirements of state, federal and local Law when discharging their responsibilities
under this agreement.
VIII. Owner's Responsibilities
A. Owner shall have sole responsibility to secure financing for the Project and shall
pay all fees, charges, or other costs of such financing, including Inspection fees charged
by any lender. The nonperformance of any lender shall not affect the obligation of Owner
to Contractor. Owner hereby authorizes and directs any lender on the Project to furnish
Contractor with full information on undisbursed loan proceeds when requested by
Contractor.
B. Owner will not interfere with or permit others to interfere with, stop, hinder, or
delay completion of the Work by Contractor or Subcontractors except as provided under
this agreement.
X. Representations by Contractor
A. Owner has reported to Contractor all conditions known to Owner which may not be
apparent to Contractor and which might significantly increase cost of the Work or delay
completion. These concealed conditions include, but are not limited to, hazards on the
Job Site, unsuitable soil conditions, prior Defective Work of others, latent Defects in the
Plans or Specifications, earlier attempts to do Similar or related Work, and obligations
imposed by government.
XI. Disclaimer by Owner, Reliance by Contractor
A. Owner has provided Contractor with information on subsurface or concealed
conditions at the Job Site. Except to the extent that Contractor knows this information to
be false, Contractor is entitled to rely on the accuracy of this information.
XII. Payment Plan
A. Owner will pay to Contractor the Contract Price in 2 installments, final payment
once work is complete.
XIII. Downpayment
A. The downpayment is $ 500
B. Upon execution of this agreement, Owner shall pay to Contractor
$ 500 as an advance on the Contract Price.
C. Except as otherwise provided in this agreement, Contractor may retain
$ from the initial payment as a non-refundable deposit if this
contract is terminated for any reason other than default by Contractor.
XVI. Final Payment
A. Contractor will submit an application for final payment to Owner when the Work
has been completed in compliance with the Contract Documents. If Owner agrees that
Work has been completed, payment is due Contractor for the entire unpaid balance of the
contract amount (including any Retainage).
B. Making of final payment constitutes waiver of all Claims by Owner against
Contractor except those Claims previously made in writing and delivered to Contractor
and those obligations otherwise provided by this agreement or by operation of Law.
C. If completion of the Work is delayed unreasonably at no fault of Contractor,
Contractor shall be entitled to final payment for all Work completed (including
Retainage) without prejudice to the right of Contractor to complete the Project at a later
date and without prejudice to the right of Owner to make Claims against Contractor for
Defects in Work completed.
XVII. Changes in the Work
A. Contractor is authorized to make minor changes in the Work which are in the
interest of Owner, do not materially alter the quality or performance of the Work, and do
not affect the cost or time of performance, and comply with applicable Laws, codes,
ordinances and regulations. Contractor will inform Owner of each minor change made in
the Work.
Note About Extra Work and Change Orders
Extra Work and Change Orders become part of the contract once the order is prepared in
writing and signed by the Parties prior to commencement of any Work covered by the
new Change Order. The order must describe the scope of the Extra Work or change, the
cost to be added or subtracted from the contract, and the effect the order will have on the
schedule of progress payments.
Signatures
This agreement is entered into as of the date written below.
Owner Name: ,
Owner
(Signature)
(Date)
(Printed Name)
Contractor Name: s 1
Cont�acto
(Signa e)% (Date)
I-V C k
(Printed Name and titlej
Electrical — BRIMAC Electric
Plumbing/HVAC — Tim Coyle Plumbing and Heating
Carpentry/ Painting -Fortis