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HomeMy WebLinkAboutBuilding Permit #520-13 - 58 PETERS STREET 1/17/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: 5 Z—o � Date Received Date Issued: [I IMPORTANT• Applicant must complete all items on this page ,�. .y n 7 T 1+ C 77 -7iw IRANI ,.:PY, OWNER a'! t ; 'f �.� � Ur S �,�„ A �c X100 Year • f Pi �f .. 4 W-� wires ' Ino kyes =no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ ddition ❑ Two or more family El Industrial S Alteration No. of units: Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑5 pis Welf _ ❑ Other ®Flo dpjan aWet-lands .SWa;District $* DESCRIPTION OF VVU K I u 0t r Kr KMr-U. cv , Gh 19L W(4 �9Yee 010))P IY�d P� 4C,7ne m. O�oCGTjlov, dT e f Id of cation Ple se Ty p r Pri Cl "/Vor OWNER: Name: 6 Nr d hone: ?9`/ ARCHITECT/ENGINEER v�,e Phone: Address: S—���� ���, %�� U��f Reg. No. �S'3 C� FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 9 Q� �' "FEE: $�• t Check No.: �' Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the uaran fund �# �'d'`„Y. r'Y. Y''�"r.';r�' ��'-#�:s..r�.t 1es78z t"s'ti-.Lair.'.'.` �. a � .,s :Cinn�+i irc.nf.nnntrantnr Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans f Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans TYPE OF SEWERAGE DISPOS Public Sewer Tannin � g e/Bod assa Art ❑ Y Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ , - - THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNINX&VELOPMENT ❑ ❑ COM TS ' I CON SERV ION Reviewed on Signature i • 1 OMMENTS COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments It Conservation Decision: Comments Water & Seger Connection/Signature & Date Driveway Permit Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast 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 D 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. Ing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit -}- YS- jkLd e -z— Photo Copy Of . And/Or C.S.L. Licenses --a- Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products DOTE: 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 _ o 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 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One -To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products gOTE: 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 submtted with the building application Doc: Doc.Building permit Revised 2012 evWILR Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 50-W \ (-� 26098 Building Inspector Enter construction cost for fee cal - North Andover Fee 'Cakulation Construction Cost $ 901650.00 m $ - $ 1,087.80 Plumbing Fee $ 135.98 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 135.98 Total fees collected $ 1,459.75 58 Peters Street 520-13 on 1/17/2013 Panera Interior remodel • O 'a > C a) o =C,o �n - -0 0 O t E c tt� 0 cn Q ,a = t � = .Q 4- O t 0 Oz ' �.�� N C w• 3 � o~ L Q. 0.4) w C ea w .y w O 0) v O = C Q L L :O = as Q m '0 F• O to 0 y LV O 0 — O O LL '� C N 0 Mnuj •V :5 V w E c���0 V Q 0-0 O w CO) m O � w `c. o 0 O W :a z z co 0 m 2 r OCl) CDL N Z f 1 .0 co m U) W DC 0 x Z V W c W —1 CL Z O C •0 N O t O z O Q J4,06 > a dEnIft `Iv .N ti = r. O O Rf CC � as x FAQ 0 O L � Zi C O b L cn • V 3 CD VU Q' J co OC Z LLI W W x LA vA u LL z Z Z W O Z p Z Z u W OLU C7 � E m J 1J. O. W u Y > NN O N " v Z O 41 O O L O O c O y O O v O LL {^ LL Q' U LL K LL C' N 11 d' I.J• O] l% N • O 'a > C a) o =C,o �n - -0 0 O t E c tt� 0 cn Q ,a = t � = .Q 4- O t 0 Oz ' �.�� N C w• 3 � o~ L Q. 0.4) w C ea w .y w O 0) v O = C Q L L :O = as Q m '0 F• O to 0 y LV O 0 — O O LL '� C N 0 Mnuj •V :5 V w E c���0 V Q 0-0 O w CO) m O � w `c. o 0 O W :a z z co 0 m 2 r OCl) CDL N Z f 1 .0 co m U) W DC 0 x Z V W c W —1 CL Z O C •0 N O t O z O Q J4,06 > a dEnIft `Iv .N ti = r. O O Rf Q. � as FAQ L � Zi C L cn • V 3 CD Q' J co • O 'a > C a) o =C,o �n - -0 0 O t E c tt� 0 cn Q ,a = t � = .Q 4- O t 0 Oz ' �.�� N C w• 3 � o~ L Q. 0.4) w C ea w .y w O 0) v O = C Q L L :O = as Q m '0 F• O to 0 y LV O 0 — O O LL '� C N 0 Mnuj •V :5 V w E c���0 V Q 0-0 O w CO) m O � w `c. o 0 O W :a z z co 0 m 2 r OCl) CDL N Z f 1 .0 co m U) W DC 0 x Z V W c W —1 CL Z O C •0 N O t O z O Q J4,06 > a dEnIft `Iv .N ti Post- I urnover Carpentry 40 HOURS 58.00 2L320.00 - 2,320 00 j PLUMENG �I Heater 163 Grand Arany Highway - Swansea, NIA 02777 508-679-2500 Phone 508-679-2600 Fax www.comerstonedesignbuild.com Page: 1 of: 2 F i111E1 CORNERSTONE DESIGN/BUILD SERVICES, INC. Date: 12/6/12 Project: Panera Bread Remodel - North Andover, MA Architect: N/A Plan Dated: 10/17112 Description Qty I unit Cost_ Sub-Total Tax Sub-Total GENERAL REQUIREMENTS Job Superintendent 80 HOURS 60.00 4,800.00 - 4,800.00 Dumpsters 3 EA 550.00 1,650.00 - 1,650.00 Cleaning 1 ALLOW 1,250.00 1,250.00 - 1,250.00 Stora e Trailers 1 LS 600.00 600.00 - 600.00 DEMOLITION. Remove All Carpet 20 HOURS 58.00 1,160.00 - 1,160.00 Carpet Stripper Rental 1 LS 300.00 300.00 18.75 318.75 Remove Wallcovering,Graphics, & Artwork 10 HOURS 58.00 580.00 - 580.00 CONCRETE Concrete Removal, Excavation, & Patching 50 HOURS 58.00 2,900.00 - 2,900.00 Equipment Rental 1 LS 425.00 425.00 26.56 451.56 Materials 1 LS 250.00 250.00 15.63 265.63 CARPENTRY Metal Stud Framing, Durock, & Plywood 1 LS 4,900.00 4,900.00 - 4,900.00 Drywall &Taping 1 LS 1,150.00 1,150.00 - 1,150.00 FRP 1 LS 1,300.00 1,300.00 - 1,300.00 Patch & Repair Existing Drywall/Wall Prep 10 HOURS 58.00 580.00 - 580.00 Materials 1 LS 100.00 100.00 6,25 106.25 Patch Wall (s) In BOH (To Accommodate Vent Piping) 10 HOURS 58.00 580.00 - 580.00 Materials 1 LS 250.00 250.00 15.63 265.63 Misc. Carpentry Items 20 HOURS 58.00 1,160.00 - 1,160.00 DaiIX Jobsite Labor 40 HOURS 30.00 1,200.00 - 1,200,00 FINISHES Carpet, Walk-Off Mat, & Vinyl Base 1 LS 6,905.00 6,905.00 - 6,905,00 Floor Prep 1 ALLOW 1,500.00 1,500.00 - 1,500.00 Ceramic & Quarry Tile - Labor 1 LS 3,500.00 3,500.00 - 3,500.00 Tile Materials 1 LS 2,875.00 2,875.00 179.69 3,054.69 Grout/Tile Repairs In BOH 40 HOURS 58.00 2,320.00 - 2,320.00 Patch Acoustical Ceiling 20 HOURS 58.00 1,160.00 - 1,160.00 Materials 1 ALLOW 300.00 300.00 18.75 318.75 Clean Existing Fireplace - Stone & Hearth 1 LS 500.00 500.00 - 500.00 Clean Ceiling Tiles In Service & BOH 1 ALLOW 1,000.00 1,000.00 - 1,000.00 Wallcovering Materials i LS 275.00 275.00 17.19 292.19 Painting, Wallcovering Removal & Wall Prep 1 LS 12 770.00 1277000 - 12 770.00 SPECIALTIES Impact Base & Comers 1 LS 800.00 800.00 50.00 850.00 Decorative FRP 1 LS 500.00 500.00 31.25 531.25 Insulated Curb Cover For Panini Fan Removal 1 LS 125.00 125.00 7.81 132.81 Stainless Wall Panels For Coffee Station 1 LS 600.00 600.00 37.50 637.50 Misc. Stainless Steel 1 LS 400.00 400.00 25.00 425.00 Post- I urnover Carpentry 40 HOURS 58.00 2L320.00 - 2,320 00 j PLUMENG �I Heater 163 Grand Arany Highway - Swansea, NIA 02777 508-679-2500 Phone 508-679-2600 Fax www.comerstonedesignbuild.com Page: 1 of: 2 Relocate/Add Sprinkler Heads As Required 1 ALLOW 39000.00 3,000.00 - 3,000.00 HVAC Replace Existing Diffusers & Return Grills In FOH 1 ALLOW 31500.00 3500.00 - 3,500.00 ELECTRICAL Electrical Wiring & Lighting Installation 1 LS 6,500.00 64500.00 - 6,500.00 Subtotal: Overhead & Profit: REMODEL BUDGET TOTAL: 83,935.00 6,714.80 90 649.80 WORK TO BE COMPLETED BY PANEFtA VENDORS Pepsi Disconnect/Re-Connect ITEMS SUPPLIED BY PANERA VENDORS AND INSTALLED BY GC Furniture, Wood Trim, Steel Accessories, Millwork, Artwork, Food Service Equipment, Lochinvar Shield Water Heater BUDGET NOTES Increased insurance limits will be subject to additional costs (We carry $3M). Existing furniture, millwork, & designated food service equipment shall be disposed of on site unless otherwise directed by owner. It is assumed that the existing power supply will accommodate the new lighting plan and equipment. It is assumed that the LL will allow storage container & dumpster on site. In order to relocate the espresso station without shutting down the cafe, the cafe will need to operate without an operational espresso station for 1 - 2 days. Existing dining room ceiling was ProCoated during previous remodel. There may be some variation with any new replacement tiles. Construction schedule based on a 4 week schedule all night work). APPROVALS_ _ General Contractor Owner Cornerstone Design Build Services PR Restaurants - Panera Bread Robert Sanford - Cornerstone Mitch Roberts /"Z -J" Si nature Date I� Signature Date 163 Grand Army Highway - Swansea, MA 02777 508-679-2500 Phone 508-679-2600 Fax www.cornerstonedesignbuild.com Page: 2 of: 2 NORTH ANDOVER VENTURES LIMITED PARTNERSHIP 990 Washington Street — Suite 212 Dedham, MA 02026 781 407 7799 Fax 781 407 7733 January 9, 2013 Building Department Town of North Andover 1600 Osgood Street North Andover, MA 01845 Gentlemen: As Owner of 58 Peters Street in North Andover, please consider this letter as our authorization for Panera Bread to apply for a permit for interior alterations of their space at our center. If there is any question, please feel free to contact me at your convenience. Sincerely, NORTH ANDOVER VENTURES LTD PTNRSHP By NORTH ANDOVER VENTURES, INC. Ann M. Moreno Director of Real Estate • ���u rte: • North Andover Health Departmot Community Development Division January 11, 2013 Panera Bread 58 Peters Street North Andover, MA D1845 Re Plan review Panes Bread remodel, North Andover Dear hood Establishment Operator, T1re Health Departrnenthas received your application for a remodel of multiple service. and display areas within Panera Bread. This plan has been approved. This establ slu ent will continue to serve the public through various fazes of this project. Please refer'to document submitted on January 10, 2013 for the agreed details ort the procedures for the nightly construction work. When the horning Panera shift affives each day after construction, they must assume that the contractors Have not sanitized food contact surfaces. Please assess each food contact surface daily,and sanitize each morning before beginning the daily preparation. If Panera staff encounters any deviation from this procedure upon the morning arrival, they must report it to the ;job supervisor so that it Kill be corrected the next evening of construction.. Please advise 'the Health Department of the work schedule so that inspectors may do inspections on the.project. When work is completed, please call the health office to set up an appointment. At that time if there are any outstanding issues apunch :list will lie provided. This.list must be completed prior to receiving;a Building Card Sign off. Ms itis difficult to anticipate details as this is a night time construction site only,;please stay in contact with the Health Inspector, Michele Grant. She will. instruct you on the expectations for this particular innovation that may not be listed in this letter. Note on Page A -i of the plan that the "entire space" ,into be "commercially cleaned". This includes "floors, walls, equipment etc." 1600 Osgood Street„North Andover, Mmothwtetts 01845 Phone 978.688.4540 fox 978.688.8416 Web tvw0ovrndhorthandover.com 1I I P a g e 1600 Osgood S.treet,'North Andover, Mossocbsetts 01845 Phone 918.'688.4540 fa, x 918.688.8416 Web www.townofnorlhandoveram 2IPage FOOD SAFETY PROCEDURES FM CONSTRUCTION Nightly Set Up Procedures: 1) Construction work will not. begin each night until Panora's staff has completed there normal shut downand cleaning procedures, and removed any necessary product and small wares Rom the work area (Where applicable): 2) All fixed in place food preparation surfaces are covered with plastic; and any food preparation surfaces that can be removed from (lie work area are relocated while work is taking place (where/when applicable),. 3) The area where baking is to take place is ttotected with a plastic barricade. Nightly Clean Un Procedures: 1) General clean up of all construction tools, materials, dust, and debris to be completed prior`to removal of airy plastic barricades or covering. 2) Alter: general clean up is complete, plastic coverings are removed from the fixed in place food preparation surfaces, and any food preparation surfaces that were removed from the work areal are put back in place: 3) ALL surfaces in the work area are Wiper down. 4) Floor is swept a second -time and mopped. 5) Plastic.barricade is then removed. 6) Prior to restocking product or small waxes, Panera's staff performs a final, sanitary cleaning of all food preparation surfaces, and second mopping of the floor. North Andover Health Department fommunity Development Division January 11, 2013 Panera Bread 58 Peters Street North Andover, MA 01845 Re: Plan review— Panera Bread remodel, North Andover Dear Food Establishment Operator, Tile Health Department has received your application for a remodel of multiple service and display areas within Panera Bread. This plan has been approved. This establishment will continue to serve the public through various fazes of this project. Please refer to document submitted on January 10, 2013 for the agreed details on the procedures for the nightly construction work. When the morning Panera shift arrives each day after construction, they must assume that the contractors have not sanitized food'contact surfaces. Please assess each food contact surface daily and sanitize each morning before beginning the daily preparation. If Panera staff encounters any deviation from this procedure upon the morning arrival, they must report it to the job supervisor so that it will be corrected the next evening of construction. Please advise the Health Department of the work schedule so that inspectors may do inspections C on the project. When work is completed, please call the health office to set up an appointment. At that time if there are any outstanding issues a punch list will be provided. This list must be completed prior to receiving a Building Card Sign off. As it is difficult to anticipate details as this is a night time construction site only, please stay in contact with the Health Inspector, Michele Grant. She will instruct you on the expectations for this particular renovation that may not be listed in this letter. Note on Page A-1 of the plan that the "entire space" is to be "commercially cleaned". This includes "floors, walls, equipment etc." ---------------------- 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 fax 918.688.8416 Web www.townofnorthandover.coni 1IPage The inspector will assess the completion of this task as well and make any comments for additional cleaning. Thank you for your cooperation in this matter. We look forward to working with you in the effort to provide safe food to our citizens. Sincere' , usy n S HS/ Public Healtl Direct r Encl: Food Safety Procedure document dated .1/10/13 Cc: N. Andover Building Dept. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com 2 1 P a g e 1/10/13 Panera Bread #3410 58 Peters St. North Andover, MA 01845 FOOD SAFETY PROCEDURES FOR CONSTRUCTION Nightly Set Up Procedures: 1) Construction work will Piot begin each night until Panera's staff has completed there normal shut down and cleaning procedures, and removed any necessary product and small wares from the work area (where applicable). 2) All fixed in place food preparation surfaces are covered with plastic, and any food preparation surfaces that can be removed from the work area are relocated while work is taking place (where/when applicable). 3) The area where baking is to take place is protected with a plastic barricade. Nightly Clean Up Procedures: 1) General clean up of all construction tools, materials, dust, and debris to be completed prior to removal of any plastic barricades or covering. 2) After general clean tip is complete, plastic coverings are removed from the fixed in place food preparation surfaces, and any food preparation surfaces that were removed from the work area are put back in place. 3) ALL surfaces in the work area are wiped down. 4) Floor is swept a second time and mopped. 5) Plastic barricade is then removed. G) Prior to restocking product or small wares, Panera's staff performs a final, sanitary cleaning of all food preparation surfaces, and second mopping of the floor. gg��, o ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) DAMID2o12 THIS CERTIFICATE IS ISSUED AS A MA'K'ER 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 pollcy(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 Newport Insurance Agency, Inc. 460 East Main Road Middletown, RI 0294Z NAME: A/HCMN Ekr.401.619.1660 N,;40I.G19.2689 ADDRESS: INSURER(S) AFFORDING COVERAGE MAICI _ INSURER A: St. Paul/Travelers Ins. Co. ITKO01 INSURED Cornerstone Design Build Services, Inc 163 GAR Hwy Swansea, MA 02777 INsuRERe: IMSURER C IMSURERD: INSURER E - INSURER F: COVERAGES CERTIFICATE NUMBER: new ZU12 trav 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 SUOJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LSR TYPE IHSR WVDI POUCYNUMBER MM/D MMMO LIMITS A GENERALLLABLLRY i OMMERCIALGENERAL LIABILITY I Xac— CLAIMS -MADE FKOCCUR I j GEN AGGRE3ATE LIMIT APPLIES PER: POLICY 1 �El LOC I DT-GO-978K7518-COF-11 07119/2012 0711912013 I EACH OCCURRENCE $ 3.1000,000 PREMISES Eaoseurtenoe i$ 300, MED EXP jAny am person) S 10,0 PERSONAL d ADV INJURY S 1,000,000 Gl74EFtAL AGGREGATE S 3,000,000 PRODUCTS - COMPiOP AGG ; 3 , OQ(), 0D S A AUTOMOBILE UASIMY X ANY AUTO ALL OWNED SCHEDULEDi NON -OWNED AVTOS AUTOSHIREPAUTOS ( I I D 0-810-97BK7518-COF-1 i 0711912012 0711912013 t 11000,00 BODILY IW URY (Per Pawl 5 BODILY INJURY (Per accident) S Peraccident s t A UMBRELIALIAB EXCESS LtAB oCCVR CLAIMS.MADEI, j 1 DTSIN-CUP-42171829-TIL-1 1 07!1912012 01118/2013 bACHOCCURRENCE S 5,000,000 AGGREGATE s 5100010 DEO I x I RETENTIONS 10,000 S A WORKERS COMPENSATION AND EMPLOYERS'LLWUTY YIN ANY PROPRIETOR/PARTNERIEXECVTIV OFFICERIMEMBEREXCLUDED? t(Mand" In MR) I DESCRIPTION OF pPERATIDNS below MIA' I DTHUB978K751-9-111 D711912012 0711912013' TORY LIMITS ER E.L. EACH ACCIDENT S 1,000,()00 r000,00 E.L. DISEASE • EA EMPLOYEE S 1. D00 , 00 E.L. DISEASE - POLICY LINT S 1 000, 00 I DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Addldonal Remarks Schedule, 9 rn r space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ann Rvmszewicz ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):-CC;.-ryj eieA /_, Address: 1 City/State/Zip:,�La N C O INA QZ_ 7 -2 -2 Phone 67 g_ 2 2:2 V Are you an employer? Check the appropriate box: Type of project (required): 1. UI am a employer with / �S_ 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7•Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y P ty• workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL II -E] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 91 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ / Insurance Company Name: �" %'9 y "1 / . / /'q 1s PiI P✓ Policy # or Self -ins. Lie. #: VrtlQ_6 97 �-/<75 I- Y`Expiration Date: /"9,44_4- /s/28 I Job Site Address: �s S ; A) Aur c, wIr� City/State/Zip: ,2 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern un#er tre pi#ns apd p1paldes of perjury that the information provided above is true and correct Phone #: S GY Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone aMassachusetts -Department of Public SafetyBoard of Buitcling Regulation;s, and Standards Const ruction Stfllk.r% ISOV License; CS -053393 .T FXS ROBERT E SANFIiRD ,TR �� d 0 ARCHITECTURAL SERVICES 0 50 Holt Road, Andover, MA 01810 (508) 380-8460 January 14, 2013 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 Re: Panera Bread, 58 Peters Street, North Andover, MA In accordance with section 116.0 of the Massachusetts Building State Code, I, Kevin T. Triplett, Registration No 4530, being a registered professional Architect hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning the above referenced location, and that to the best of my knowledge such plans, computations and specifications meet all applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy. Furthermore, our office will provide the necessary site visits on a regular and periodic bases, to determine that the work is proceeding in accordance with the documents approved by the Building Department. We will also provide a final affidavit confirming that the project has been completed and ready for occupancy. Sincerely, Kevin T. Triplett -13 Date I.TRIp� TFp� I °o. x+530 IHOF�% ,RI 51 Ilk WON I My Commission Exies L:�cc iv is vONOVAN Notary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires June 15, 2012