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HomeMy WebLinkAboutBuilding Permit #858 - 58 PETERS STREET 6/28/2007Permit NO: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received 7 _ DESCRIPTION�QF WORK TO BE PREFORMED: Identification OWNER: Name:Z Address: 7-t� Type or Print M hone: t, / ARCHITECT/ENGINEER66euir') r /e 1)Phone: S-61 3�70 Address:.5-0 ra�T' �, 14 IJ —er_ 14,4 QI Y/0 Reg. No. � C� FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project�Cost:_$ ���(�, 000 FEE: $ �,00 +� Check No.: �� �" Receipt No.: D 3 0'? NOTE: Persons contracting T4h unregistered contractors do not have access to the guaranty fund e Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan TYPE OF SEWERAGE DISPOSAL Public Sewer �"1. ��❑ Tanning/Massage/Body Art ❑ Swimming Pools ,'- Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION ❑ COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED ' DA E APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Bord Decision: Comments Conservation Decision: Comments T 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 Doc.Building Permit Revised 2007 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 uilding Permit Application 0 orkers Comp Affidavit ❑ Photo Copy O'.. And/Or C.S.L. Licenses 3 Li Copy of Contract ;YFloor 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 X ❑ Photo Copy of H,I'.C. And`C.S.L: `Licenses` ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o 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 o 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location ?7-// en6ml- No. tf,� �— Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ /00 *Argo Building/Frame Permit Fee C" Foundation Permit Fee Other Permit Fee $ $ TOTAL Check# 03 ?- 2 0 3 14 3 \�A Building Inspector 4 Ink I 'O G A TA -LA , Document Al OF - 1 q Standard Fornn of Aigreement Between Owner and Contractor fora Smelt Project where the Basis of Payment is a S TIPULA TED SUM ' This AGREEMENT is made: June 04, 2007 (Date). fn ADDITIONS AND DEL"ONS � The author of Ihfs:docurnarn has OEMEN the Owner. (' W added intonation needed for Its V\ completion. The :author may also )x Restaurants LLC( have reviised the text of The original ^109 Oak Street ALA standard form. An Maims and �icwton, MA 02464 Deletions Reortthat rotes added information as well as revisions to and the Contractor the standard form tern is available from the author and should be Cornerstone'Design Build Services, Inc. reviewed. A vertical fine in the left 153 Grand Anny Highway - Swansea, MA 01777 margin of this document Indicates where the author has added for the following Project: necessary intomtation and where the author has added to or deteled Panera Bread North Andover. MA from the original AIA text. 5$ Peters Street This document has important legal N. Andover. MA 01.845 comequences. Consultation with an attorney is encouraged with respect The Architoct is: to Its completion or modiftation, pPR Consulting Services 24 Rockridgc Road Hopcdalc, Ma. 01747. The Owner and Contractor agree as follows. it A A1A Document Af05--1003. Copyright 0189Ci; by The American InMiMe of ATK'*ptS All rights reserved. WARUNG: This A10 Docraeerrt is Apr r by u oyr M lift.18 10"TVINIU . Unwthorizw rgrroduc"M pr dMr of this AIO 00OUVO L o MY portion IN it, � mvem peMtIgs, trill vAli be prearwted ro tbe:rnaxtmmn extent ponlMo under the taw. This docUmerA was producod bis AIAs*Itwe 4 t t 024;5t on 06K701$007 ur*rArder No.t0on2ssol l_1 which ec !es on 11142007, and is not W rosaic. U%V Notal, {1120419003} r. �C `Cad CERTIFICATE O LIABILITY INSURANCE `0 MAY PEVTAIN. THE W5~0EAFFORDED BY THE PWCWS MCfiM HE KI IN IS SUBJECT TO AU W TERMS. EXCLUSIONq AND CCWWTIDNS OF WCH 7 gotcauten Vlteb THIS CERmICATE IS ISSUED ASA MATTER O?*F13XMA=N ter Insurance, CIL ONLY AND CONFERS NO FUGHTS UPON THE CER:TI, RC ?e 380 &arrsee *all Drive HOLDER. THIS CERTIFICATE uOEs NOT AmENO, �Ib OR ALTER THE COVERAGEA,FrORDED 8V'INE pOWG(ES OlrlLtiaAl.-. SvvansQaB MA 0GI �i A 5082354740 INSURERS APFdRpIK COVERAGE NAIC "WVR" - aaSUAERA-Acadia Insurance Cfmr an _. Camerstorm Vesl9rdBugd, Services. Inc rasuaeA t - 163 C A R Mlghwiy dkSUR;R Ci !Stirtnna, RIA 02777 KSalaffi 4t tE MStifiEati" TKE POLICIES OF INSURANCE LISTED BELOW HAVE MN ISSUED TO 1*6 INWMD NAMED ABOVE FOR Tl* POUCY PEF400 MCATED. NOTVMSTAfMWG ANY REQUIREMENT, TERM OR CONDITIOO OF ANY CONTRACT 00 OTKR ROCU MWt WITH RESPECT TO WtACH TmtS MnAcATE mAY,Idle ISSUFO OR MAY PEVTAIN. THE W5~0EAFFORDED BY THE PWCWS MCfiM HE KI IN IS SUBJECT TO AU W TERMS. EXCLUSIONq AND CCWWTIDNS OF WCH POLIMES. 04GRECAU LIMITS SHOUea! MAY HAVE MEN REO C;ED SY PAID CLAIMS, X3R. 0 r0tGFRI3URANC* roueYNUN�IIA _.. � ►-:-.e L t roueTex 4irITiB. _. A RiNEgAltllAllaRY 0153628 071191Q6 07118lA7 EiCNOCCURaeNee a dQ0 0 COrMERCIAl OENEP�LL uAs+tlT1 w ce ro RE91tcD lI OlAm MADE OCCUR ttJ tAEO cIm &$CDO ONALaa�rmw� t1 G.J, O�a00_ '� � � GEOE"I AGGRIGATE 42 0040 rill N�Ar.+�rtEt,ATELIranArvuEsaF�rc .noauCrs.co�w�acc s2' 00000 ' POU r LAe A aUTOa+O6xe uAsxrvY MiAA013►856411 DIItSI#16 07118taf Axe auna Car srct> cIF Iia atom") $1,000,000 ALL OwNi< AUMS X SCMCClUkVAUTQT 60ORr.tlCileY i 11+'wae��r - X MRED AWfOS Np�a-pWNi[f at/r03 BODILY MC71tnv 1 iCridaA} . S ��IOAAIA;E 9AVJICE iAi i3WTY 0.trp Cm F- J -A ACCIVEHr i OTiaEaTNAN. - EAAOe''>I ' AAYAUTO $ AUTO ONLY: A6G' mlasIUAIBR uA ul#aUflF "Ck Oevi REIt E S AGGRIf:ATE�.`� S 1 -OGLUat. CLAWS WRIi.. i ra>DUCTapV!� i A WCA017858611 07119106 01119107 A+tsTATu o VOLOY" r LIAiIaJTY EA IAc�i ACtrdlut sl Qfad AW PRO" TORIVAP.NGR;—,viCUftE G1scICrrWi EvpsR Et[OLUOtOs � AtSEA51it 'w pL�dYI S7 li0 �Qll - �asl,c ISIaNS - E.L.OISEaa gOLiCYt4M11'.xiQQQ Q OA'SCR9[WNOfOPIRAnONSII,OCATOwlIVEMCLESiactusimmA0O>r IVtwom-g-91p"Iptet"t1l0abm 'TOWN of NORT14 ANDOVER, MA 120 NORTH 'MAIN STREET NORTIH ANDOVER, MA M45 i I 25 laQ1t09} i of.2. 089525 CANCELI.ri TION S3 W -U Alit Of TK Alaft OeSClken'p0UtIn K "MCILIAO6'1TORI TI# Ext+taA-n*% OATETlICR"p,TwErTsuiil PMRtAWILL "dM VOR TO MAIL �n GAYSffRrMM NOT'"t6"aeCEMA"TeHOLM IJA15OY61019LUT. 80FAi ill TO 00sOz"kL IMPOSE NOOKICATIONOaLIARVIA"OfAftFaamOU.ONT1aE;LfFtI1�!ER,tTTA fW&OR RE ANS"TATNUI J/ a tm0&IZEDna11la€INTATivjl .r/ . d.0 ACS m ACORD CORPORATION 1988 OORULSSM + 3XtUrSNI e-USUM ev-m Me/m/90 ARTICLE 1 THE CONTRACT DOCUMENTS "The Contractor shall complete the Work described in the Contract Documents for the project The Contract11;. 'Documents consist of: .1 this Agreement signed by the Owner and Contractor, .2 AIA 'Document A205, General Conditions of the Contract for Construction of.a Small :Project current edition, ii .3 the Drawings and Specifications prepared by the Architect, dated March 2G, 2007 , and enumerated as follows: Drawings: Number Title !Date GCS -GABA -Di -D2 -A2,1- Architectural Drawings 3i26J2007 A2.2 -A2.3 -A3, I-A3.2-A3.3- A4.2-A4.3-A4.6-A4,8-SG2.1- S G4. I-SG4.2-EQ2.1-EQ4. I - EQ4.2-1r0-PO.I-PO,2 Specifications: Section Tale Pages On Drawings. ,4 addenda prepared by the Architect as follows: 4 Number Date Pages None .5 written change orders or orders for tninor changes in the Work issued after execution of this Agreement, and .6 tither documents, if any, identif ed as follows: AiaT ICE 2 DATE OF COMMENCEMENT AND' SUBSTANTIAL COMPLETION DATE The date of commencement shall be the date of this Agreement unless otherwise indicated below. The Contractor shall substantially complete the Work not later than Sixty (GO) days , subject to adjustment by Change Order. (Insert the date or rurmiber of calendar days after the date of rnnu» encement.) Ii ARTICLE 3 CONTRACT 'SUM § 3A Subject to additions and deductions by Change Order, the Contract. Sum is: j One Hundred Ninety'Thousand Dollars and Zero Cents ($ 190,0100 § 3.2 For purposes of payment the, Contract Sum includes the following values related to portions,of the Work: PwiJon of Work See Bid Breakdown 4 Value (S 4.00) § 3.31he Contract Sum shall include all items and services necessary for the proper exectnion and completion of the Work. ARTICLE 4 PAYMENT §0 Based on Contractor's Applications for Payment certified by the Architect, the Owner shall pay the Contractor as follows: (Here insert payment procedures and pravisivns,fbr retainage. if any.) Monthly Billing 'based on work performed. AOA DdcumeM Ai09o+-1998. Copyright Q t9�a by The Arr -imn kmft a of Architects. Ail i ors i isavea WAfl4M: TM3 AtA; DOC~11s Init. protected by U.S. Copyright rev sed anternstionel "trestles. Unauthorized reproduction or distribrnon of rhls A10 Document orof i areay reeun in severe advtl s«ntl as WnW peaaslties. end will be pnoisetltb4 to the meltirnalm ortent pa"N* under the eery. Thl$ document wino. portiproduced 2 It %At at t0 8.5f on 0610 r4W? untler order No. I00098 1 Q which eq*es on 111 7,.and is not for resale; (t720119Q08j 1; § 4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is •due at the rate of One and ane -half percent (1.5041;) monthly, or in the absence thereof, at the legal rate prevailing at the tsplace ofthe Project. "(Usury laws and requirements under the federal Truth in Lending Act, similarstate and local consumer ct=edit laws either regulations at the Owner's and Contntrtor's principal plates -if business, the location of the Project and oelsewhera inay affect die validity, of this provision.) ARTICLE 5 INSURANCE § 5.1 The Contractor shall provide Contractor's Liability and other Insurance as follows: JInseri spree insurance requi Document Al OF -1993 Standard Form of Agreement Between Owner and Contractor for a Small Project where the Basis of Payment is a STIPULATED SUM This AGREEMENT is made: June 04, 2007 (Date) ADDITIONS AND DELE71ONS: BETWEEN the Owner: The author of this document has added information needed for its completion. The author may also PR Restaurants LLC have revised the text of the original 109 Oak Street AIA standard form. An Additions and Newton, MA 02464 Deletions Report that notes added information as well as revisions to and the Contractor the standard form text is available from the author and should be Cornerstone Design Build Services, Inc. reviewed. A vertical line in the left 163 Grand Army Highway - Swansea, MA 02777 margin of this document indicates where the author has added for the following Project: necessary information and where the author has added to or deleted Panera Bread - North Andover, MA from the original AIA text. 58 Peters Street This document has important legal N. Andover, MA 01845 consequences. Consultation with an attorney is encouraged with respect The Architect is: to its completion or modification. DPB Consulting Services 24 Rockridge Road Hopedale, Ma. 01747 The Owner and Contractor agree as follows. Init AIA Document A105TM —1993. Copyright ©1993 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and international Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced / by AIA software at 10:29:51 on 06/08/2007 under Omer No. 1000266011_1 which expires on 11/4/2007, and is not for resale. User Notes: (1720419008) ARTICLE 1 THE CONTRACT DOCUMENTS The Contractor shall complete the Work described in the Contract Documents for the project. The Contract Documents consist of - .1 £.1 this Agreement signed by the Owner and Contractor; .2 AIA Document A205, General Conditions of the Contract for Construction of a Small Project, current edition; .3 the Drawings and Specifications prepared by the Architect, dated March 26, 2007 , and enumerated as follows: Drawings: Number GCS-GADA-D 1 -D2 -A2.1 - A2.2 -A2.3 -A3.1 -A3.2 -A3.3 - A4.2-A4.3-A4.6-A4.8-SG2.1- SG4.1-SG4.2-EQ2.1-EQ4.1- EQ4.2-EO-PO.1-PO.2 Specifications: Section On Drawings Title Date Architectural Drawings 3/26/2007 Title Pages .4 addenda prepared by the Architect as follows: Number Date Pages None .5 written change orders or orders for minor changes in the Work issued after execution of this Agreement; and .6 other documents, if any, identified as follows: ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE The date of commencement shall be the date of this Agreement unless otherwise indicated below. The Contractor shall substantially complete the Work not later than Sixty (60) days , subject to adjustment by Change Order. (Insert the date or number of calendar days after the date of commencement.) ARTICLE 3 CONTRACT SUM § 3.1 Subject to additions and deductions by Change Order, the Contract Sum is: One Hundred Ninety Thousand Dollars and Zero Cents ($ 190,000.00 ) § 3.2 For purposes of payment, the Contract Sum includes the following values related to portions of the Work: Portion of Work See Bid Breakdown Value ($ 0.00) § 3.3.The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. ARTICLE 4 PAYMENT § 4.1 Based on Contractor's Applications for Payment certified by the Architect, the Owner shall pay the Contractor as follows: (Here insert payment procedures and provisions for retainage, if any.) Monthly Billing based on work performed. Init. AIA Document A105Tm —1993. Copyright ©1993 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document Is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result In severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced / by AIA software at 10:29:51 on 06/08/2007 under Order No.1000268011_1 which expires on 11/4/2007, and is not for resale. User Notes: (1720419008) § 4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of One and one-half percent ( 1.50% ) monthly , or in the absence thereof, at the legal rate prevailing at the place of the Project. (Usury laws and requirements under the Federal Truth in Lending Act, similar state and local consumer credit laws and other regulations at the Owner's and Contractor's principal places of business, the location of the Project and elsewhere may affect the validity of this provision.) ARTICLE 5 INSURANCE § 5.1 The Contractor shall provide Contractor's Liability and other Insurance as follows: (Insert specific insurance required by the Owner.) Type of insurance Liability Workers Comp Vehicle Liability Limit of liability ($ 0.00) $2,000,000.00 $1,000,000.00 $1,000,000.00 § 5.2 The Owner'.shall provide Owner's Liability and Owner's Property Insurance as follows: (Insert specific insurance furnished by the Owner.) Type of insurance Building Risk Liability Workers Comp Limit of liability ($ 0.00) $1,000,000.00 $2,000,000.00 $1,000,000.00 § 5.3 The Contractor shall obtain an endorsement to its general liability insurance policy to cover the Contractor's obligations under Section 3.12 of AIA Document A205, General Conditions of the Contract for Construction of Small Projects. § 5.4 Certificates of insurance shall be provided by each party showing their respective coverages prior to commencement of the Work. ARTICLE 6 OTHER TERMS AND CONDITIONS (Insert any other terms or conditions below.) This Agreement entered into as of the day and year first written above. (If required by law, insert cancellation period, disclosures or other warning statements above the signatures.) OWNER (Signature) Mitchell Roberts - Owner (Printed name and title) 6IV6uo CONTRACTOR (Signature) Robert Sanford - President (Printed name and title) LICENSE NO.:053393 JURISDICTIOMMA Init AIA Document A105Tm —1993. Copyright 01993 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of It, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This document was produced / by AIA software at 10:29:51 on 06/08/2007 under Order No.1000268011_1 which expires on 11/4/2007, and is not for resale. User Notes: (1720419008) ` � ✓/tP, TyA9)r91CMFll, of �l(.� = s BOARD OF BUILDING REGULATIONS 4 License; ,CONSTRUCTION SUPERVISOR .►* c` Number: CS 053393 Birthdate: -92!39'1963 tExplre§ 1y2t30. D07 "fir. no. 11477 'Restricted06� , ROBE R P E SAWORb A 100 SAWYER. A 4"l-/ � MANSE, m027i7"' Commissioner The Commonwealth of Massach usetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ot' www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information/i }� Please Print Legibly}- Name (Business/Organization/Individual): G6ANEAJ'r0NE 0Mi&N / % V V;%0 J1/UICES .{-Ne. Address: 4*' ? tC9 0%apU City/State/Zip: S w A N , ►r1$ 6 2.77/Thone #: -To S-& 7 1- 2 5 0 o Are you an employer? Check the appropriate box: 1. E'I am a employer with 1 S5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [ t] eemodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. :Contractors 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: -1:7Ns we AN zz Policy # or Self -ins. Lic. #: W G 8017 8 5 e%!% Expiration Date: I l iq I07 Job Site Address: P"9 4A $IWAV — 3 a Pe'YUgf S T • City/State/Zip: N * A14 001/E't9- I MA O I bog 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 certify underrttIhe pains and penalties of perjury that the information provided above is true and correct. A&_S - Phone #: 168 - 6 1_t? • 2-!5 00 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # &/ 7/e Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #• 11 0610712007 09:43 7814077733 HORIZONS MGMT PAGE 01101 i NORTH AN DOVER.VENTURES LIMITED PARTNERSHIP 990 Washington Street.- Suite 11 Dedham, MA 0.2026 781-407-7799 'Fax 781-407-7733 June 6,'2007 PR:Restaur0nts7.LLC 109 Oak Streefi - Newton; MA 02464 Ro: North Andover., MA Gentlemen: In. accordance -with :your request, -please consider this letteras.o.ur permission for you to: perforrn: the interior work outlined in plans recently provided to me. it is understood that you will be. responsible for obtaining a(l permits and permissions from authorities. having jurisdiction; thatall work will be done in good workmanlike manner and in' co66rmity With all laws and ardinances an6 that you are responsible..for all costs associated with this work, all in accordance with the terms of our lease with your., co.mpany.. It, is further understood .that this approval is for interior decoration/renovation work only; 'No work of a structural nature is to be performed without submitting . additional' information tomy office- No penetrations are to .be made through any. outside Walls `and /or the roof without'submitting additional inform6tion to my. offiee. Based'on the:above, uve; as'Landl.Ord; give our permission for the work as . described. Further; based on .the above, and with your permission 'if granted, and- under Your .direction, dpb Consulting Services can execute..the application for the Building Permit as,our agent. i. Sincerely; . NORTH ANDOVER VENTURES LTD:PTNRSHR RTH ANDOVERV TURES, INC. n .M'. Moreno .: . Director of Real: Estate Cc: dpb Consulting Services i The Commonwealth, ofMassachuseft Department of industrial A ecidents Office of -investigations 1600 Washington. Stred Boston, MA 021-11 www.mangovlifia Workers, Compensation Insurance Affldawit: ]Builders/Contractorv*/]Pilectriciani/Plumben ARglicant InformationPlease Print Legibly Name (Bitsinemkirgk�zationgndividual)4 Address: ;VA All 4-1Vhne`#: --09-671-2:!500 Are you an employert Check the appropriate box: Type of project (required): I.Eiyl am a employer With S 4. [] I am a general contractor and I i employees (full and/or part-time).* have h ired the stib-contractors 6. 0 10 1 am a sole proprie"tor or partner- listed on the attached sheet 7. [P-We-modcling f ship and have no 6mployees; Thesc sub-mritractors have S. O'Demolition workinm working .for e in' any capacity, [No workers' comp. insurance emploY ecs and have workers' comp• insurance.T 9. [1 Buildingaddition . required.] :5. ❑ Weare a corporation and its 10.0 Electrical repairs or additions 3,0 lama homeowner all work officers have exercised their I LCI Plumbing repairs or additions myself. [No workers' camp, right of exemption per MGL 12.E) Roofrepairs insurance requiredx) t c. 152. § 1(4). and we have no 1111 fter employees. [No workers' comp. insurancereauired.1 *Any applicarit that checks box il must also Mout the section below showing their woftfs'compensation policy information. t Homeowners %xto submit this iffidavit indicating they arc doing all wotL and then hire outside contractors must submit a new affidavit indicating such, :C;ontwors that dwa- this box 'must attached an additional sheet showing the name of the sub-contractom and state whether or not those entities have employees, lfthc sub-contrWori,:have emp4oy=, they must provide their wVr cjs, comp, policy number, I am an eniployerthat isvidin Fro g workers cOn-y-MRSaflOn in-Swranceforno, empkyees. Beldw is thepolicy and job site information. Insurance Company .Name .L-- Acave-qA —ts -X Policy # or Self -ins. Lie. #:-, WC001795b(off Expiration Date:. 171 jat of Job Site Address: -&KOM UMV PUMM Seo City/State/Zip:14# A9V6Ve0-=M1AA aie,46 Attach a copy of the workrst compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage a's required under Section 25A of MG1. c. 152 can lead to the imposition ofcriminal penalties of a fine up to $1.500.00 and/or 6ne-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe, forwarded to the Office of Investigations of the DIA foie insurance coverage verification. I do .hereby cert yy', under the pains and penalties ofteilmy that the information provided above is true and correci. &/71-o am Official.useonly. Do not,write in this area, to be completed by, cfty- orlown offidaL City or,Town : Permit/License # Issuing Authority (circle one); 1. Board ofHealth 2. Building Aepartment 3. CityfTown Clerk 4. Electrital Inspector S. Plumbing Inspector 6, Other Contact Pemom PhoneM. Cent#: 47810 CORNDESI ACORM CERTIFICATE OF LIABILITY INSURANCEDATEIMNUDDfY" PRODUCER 06/08107 Webster Insurance CIL THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATI! 330 Swansea Mall Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Swansea, MA 02777 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 508 235-1700 INSURED INSURERS AFFORDING COVERAGE NAIC 0 Cornerstone DesignlBuild; Services, Inc INSURERA: Acadia Insurance Com an 163 G A R Highway INSURER B; Swansea, MA 02777 1 INSURER C; TOS MS9'ON 009E6L9809 F 30NuanSNI d31SUM 8b:0T LOOS/80/90 COVERAGES INSURER E: I THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER MAY PERTAIN, THE INSURANCE AFFORDED BY THE DESCRIBED DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR BPOLIC POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN RRIES HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH EEN EDUCED BY PAID WN D CLAIMS, R TYPE OC INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION A GENERALLIABILRYUMITS 0153628 07/19106 07119/07 EACH X COMMERCIAL GENERAL LIABILITYDaMA OCCURRENCE 111000000 CLAIMS MADE X OCCUR s250 000GE TO RENTED MED EXP (Any one parson) 16,Q00 PERSONAL & ADV INJURY 211,000,000 GEN•LAGGREGATE LIMRAPPUES FER: GENERAL AGGREGATE s21000,000 POLICY JEC LOC PRODUCTS-COMP/OP AGG s2,000,000 A AV MOBIL@ LIABILITY MAA017858411 07/19/06 07/19107 i ANY AUTO COMBINED SINGLE LIMIT $1,000 Ira octldent) ,000 ALL OWNED AUTOS x SCHEDULED AUTOS BODILY INJURY $ (Per person) X HIRED AUY05 x NON-OWNEOAUTOS BODILYIN,IURY f (Per aceldenll 111 PROPERTY DAMAGE 5 (Pot ecadenl) GAPAGE ILITY ANY auto AUTO ONLY- EA ACCIDENT E OTHER THAN EA ACC f EXCESS/UMBRELLA LIABILITY AUTO ONLY; AOG S OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE y DEDUCTIBLE _ RETENTION b E A WORKERS COMPENSATION AND WCA017858611 LIABiIr►Y b 07/19107 0TH - 07/19/06 we sTATu-EMPLOYERs• ANY PROPRIETORRAMERIEXECUTIVE OFFICEfLMEMBER EXCLUDED? �E.L.ECH s1 000 000 If YYoe, 03COIlm under SP E.L DISEASE - EA EMPLOYEE $1,000,000 lal PROVISIONS OM OTHER E.L. DISEASE - POLICY LIMIT 10,000,000 OESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIOND A00E0 BY ENDORSEMENT 1 SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER, MA SHOULD ANY OF THE ABOVE DESCRIBED POucIES BE CANCELLED BEFORE THE EXPIRATION 120 NORTH MAIN STREET OATETHEREOF, THE ISSUING IN9URERWILL ENDEAVOR TOMAIL —10— DAYS WRITTEN NORTH ANDOVER, MA 01845 NOTICE TO THE CERTIFICATE HOLOER NAMED TO THE LEFT, BUT FAILURE TO 00 SO s11ALl IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TME INSU ER, ITS AGENTS OR REPRESENTATIVES. AUTHORIEEO REPRESENTATIVE ACORD 2512001!09)1 of 2 #89525 A v ACORD CORPORATION 1988 TOS MS9'ON 009E6L9809 F 30NuanSNI d31SUM 8b:0T LOOS/80/90 d'nv� - DO - ARCHITECTURAL SER VICES p--Ij b 50 Holt Road, Andover, MA 01810 (508) 380-8460 June 1, 2007 Town of North Andover Building Department 400 Osgood Street North Andover, MA 01845 RE: Panera Bread Remodel, 58 Peters Street, Rte 114 and 133 To whom it may concern, In accordance with section 116.0 of the Massachusetts Building State Code, I, Kevin T. Triplett, Registration No 4530, being a registered professional Engineer/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. Please do not hesitate to call myself or Daniel Brennan, Project Manager, if you need any additional information. Sincerely, 1 fro.453:, Kevin T. Tri THOFM Date Notary Public My commission expires: & EILEEN F DONOV{AN Notary Public wommonwealth ot.Massachusetts My Commission Expires -� .lune 15, 2012