HomeMy WebLinkAboutBuilding Permit #95 - 660 CHICKERING ROAD 8/7/2008Permit NO: �g—
Date Issued:
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
'0
I IMPORTANT: ADDlicant must comDlete all items on this Da2e I
LOCA
9
PROPERTY OWNER Print
Print
MAP NO: el� PARCEL: 0062 ZONING DISTRICT: Historic District yes no
Machine Shop Villaqe ves no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
(X—ter—at-ion�)
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO -RE PREFORMED:
, 'T A�' Em IRL"I
tW Or- WAtLAtJb CW&PF19P,- -rd &A I rA
It 0 1
C16S Mtt FDkQASP6-LACTY (-PFF(a-�-' tVACJt1k)E LOM -Pio mc-pa\,�D�
STof-C- No fo%Z L0CP&-:`b AT 660 CW(*�GWJ NLT P-0 1�jc). &OD4<
Identification Please Type or Print Clearly)
OWNER: Name: L:JJJy,
Address: 11 SLAN%ET
R
Phone: 9Z -601 - 302Z -
CONTRACTOR Name: SIE= CW-PbM1U)4 Phone: r161 - q'14- -12-t�Q
Address: 321:E' WDSQ KM t MA 0 180 1
Supervisor's Construction License: 0137qo —Exp. Date: ()2� 26 to
r
Home Improvement License: KI/A
ARCH ITECT/ENG I NEER—LAKICRY AJCO+IT�� Phone: CoO3-610-G444-
Address: 3b9 MAIKArl �� NI -R =1 Reg. No._ 0
FEE SCHEDULE: BULDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTIBASED 25.00 PER S.F.
n,:%
Total Project Cost: $ 5� 10157 FEE: $—q 0(v
Check No.:—� -�3 ego Receipt No.:
NOTE: Persons contracting with unregistered contractors do not hve access I ih raLnf nd
Signature of Agent/Owner gnature o co r t r
4
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Date. (7
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
rwU
This certifies that ..... .......................... 41
...........
has permission to perform .............
plumbing in the buildings of�? ............... :.! ...........
I,
Z' '/" 0 C !, � &'� � 4v-, North Andover, Mass.
at........................... ... ........
Fee. Lic. No. ........
L>LUMBIN�X�CTOR
Check #
7 8 C 2
Location�� 0�rl.
No. 9r- Date f ?
TOWN OF NORTH ANDOVER
Ark' &
Certificate of Occupancy $
00
-,Go Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
".—)Building Inspector
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/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Sicinature Z1115"ll,
)4'-1
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Planning Board Decision:
Comments
Conservation Decision: Comments
Zoning Decision/receipt submitted yes
Water & Sewer Con ne'ction/signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locateci 364 USgOOa btreet
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
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 21 A —F and G min.$100-$l 000 fine
NOTES and DATA — (For department use)
13 Notified for pickup - Date
................ . . . . . ........... . . ............... . . . . ............ . . ....................... . . . ......................... . . .................. . . . ...... . .. . ...... . ........ . . .... . ........................ . . . . . ................... . . . ... . ..................... . . .... . ............. . . .... . ... . .............. —
Doc.Building Permit Revised 2008
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
j Workers Comp Affidavit
a Photo Copy Of H.I.C. And/Or C.S.L. Licenses
u Copy of Contract
Ei Floor Plan Or Proposed Interior Work
13 Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
Ei Building Permit Application
Li Certified Surveyed Plot Plan
Li Workers Comp Affidavit
ii Photo Copy of H.I.C. And C.S.L. Licenses
Ei Copy Of Contract
Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
ii Mass check Energy Compliance Report (if Applicable)
Li 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)
a Building Permit Application
Li Certified Proposed Plot Plan
Li 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
Lj 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 2.2008
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO I'LLMING
(Type or print)
NORTH ANDovER, MASSACHUSETTS
gg_/&)Date 41-C)'/I'
Building Location (fk�iet-t�4 41 0 wn e rs N am e- �&Y, AIV (r,
Permit# ---ye if -;,-
Amount
TypeofOccupancy CokwQV�
New ri Renovation Replacement Plans Submitted Yes No
. El
(Print or type) -
-1 Check one: Certificate
C, "/!�
InstaIling Company Name IVY 4 Corp.
Address 1-341,-c Irl— k Partner.
F1
Business Telephone
970 -aa 2 Finn/Co.
Name of Licensed Plumber: r—e,14, 6;,r ) Z-ec,,1 s
Insurance Cover-aee: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance Policy Other type of indemnity Bond
rl F1
Insurance Waiv I, the undersigned, have been made aware that the licensee of this applicatio'n does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Ch Ir A,
I By:
Title
City/Town
APPROVED (oma usE oNLy
1� � -P I'll 11 -.1 y e Genend Lzws.
Type of Plumbing License
:?�/33 Tf
License Nurntier — Master IT`/ Journeyman ri
MMMMM
MMMMMM
MMW
W
=WWWWWWW
MMMOMMMM
momm,
(Print or type) -
-1 Check one: Certificate
C, "/!�
InstaIling Company Name IVY 4 Corp.
Address 1-341,-c Irl— k Partner.
F1
Business Telephone
970 -aa 2 Finn/Co.
Name of Licensed Plumber: r—e,14, 6;,r ) Z-ec,,1 s
Insurance Cover-aee: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance Policy Other type of indemnity Bond
rl F1
Insurance Waiv I, the undersigned, have been made aware that the licensee of this applicatio'n does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Ch Ir A,
I By:
Title
City/Town
APPROVED (oma usE oNLy
1� � -P I'll 11 -.1 y e Genend Lzws.
Type of Plumbing License
:?�/33 Tf
License Nurntier — Master IT`/ Journeyman ri
m
AGORD,. CERTIFICATE OF LIABILITY INSURANCE
n.^ — ^��
HARTFORD FIRE INS CO/PAYROLL ASSOC
250760 P:(877)287-1316 F:(877)287-1315
308 FARMINGTON AVE
FARMINGTON CT 06032
–.1—
R S LEWIS PLUiiqBING & HEATING, INC.
,13 NICKERSON DR.
LBILLERICA MA 01821
COVERAGES
DATE
n?_,)r,_onno
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
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
- INSURER A:Hartford AccidepLt::& �Ind[emrid�tyco�
INSURER B:
INSURER C:
INSURER D:
INSURER E:
—THE_rULIUIt:b OF INSURANCE LIST–ED--d-ELOW —HAVE BEt-jj IbbULD 10 1 HE INSURED NAIVItU AIJUVIL I -OR THE PO[ ICY PERIUD —INDICATED. NoTwITI-fS—TANDING
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
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
INSH I
LTR TYPE OF INSURANCE FO–LI EFFECTIVE I
POLICY NUMBER DATE IMMIDD/YY) I
POLICY EXPIRATION I
DATE (MMIDpty I LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL(" ENERAL LIABILITY
--t-1
!-FIRE DAMAGE (Any one fire) $
i CLAIMS MADE E OCCUR I
MED EXP (Any one
person) $
PERSONAL & ADV INJURY
�GENT AGGREGATE
GENERAL AGGREGATE $
LIMIT APPLIES PER -
I POLICY I' PE,0�
PRODUCTS - COMP/OP AGG $
AUTOMOBILE LIABILITY
I ANY AUTO
COMBINED SINGLE LIMIT
$
(Ea accident)
ALI. OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
Per person) $
HIRED AUTOS
NON -OWNED AUTOS
BODILY INJURY
I (Pet accident)
PROPERTY DAMAG
I
i GARAGE LIABILITY
(Pet accidenO $
I
ANY AUTO
LAUTO ONLY - EA ACCIDENT
I
OTHER THAN EA ACC $
AUTO ONLY:
EXCESS LIABILITY
AGG $
OCCUR CLAIMS MADE
EACH OCCURRENCE $
P
$
I
DEDUCTIBLE
L
RETENTION $
--T,-.
----------------
I $
C
W... '.MPENSATION AND
EMPLOYERS' LIABILITY
A 76 WEG TQ8381
V WC STAT 0_T_H__T_
TORY LIMITS ER
04/01/08 1
04/01/09 El, EACH ACCIDENT $100, 000
------------- 7
E.L. DISEASE - EA EMPLOYEE 10 0 000
OTHER
E.L. D�SEASE - POLICY UrAIT $500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEH ICLES /EX CLUS IONS Annrn nv
:Those usual to the Insured's Operations.
I
CER: fIFICR11�EH0_L_D_ER 3fTIONAL INSURED, I S�RER LETTER: _��A_NCELLATION
I - _�N __ __
IHOWARD ALLGIAER JR
12 Violet Rd.
I Billerica, MA 01821
HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
XPIRATION DATE THEREOF, THE ISSUING INSURER WILL. ENDEAVOR 10 MAIL
0 DAYS WRITI EN NOTICE 0 0 DAYS FOR NON-PAYMENT) TO -THE CERTIFICATE
01-DEFI NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO
BL.IGAT!ON OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
EPRESENTATIVES.
�'_'wnu
ACORD CORPORATION 1988
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Wit
600 Washington Street
Boston, M4 02111
Www-nzass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiv
Name (Business/Organization/individual):
LSA/� �,c 'f, 4
Address:- A// 4 -A -c- (I -
le I / I/ I
City/State/Zip: 0:7-, AV,019V Phone#:
79 (�e, T 3912
Are ru an employer? Check th ropriate box:
TP app
1. 1 am a employer wi . th /V—/ 4. F� I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.7 1 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.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3.7 1 am a homeowner doing all work
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type Of project (required):
6. E] New construction
7. Remodeling
8. Demolition
9. Building addition
1 0.0 Electrical repairs or additions
I I -ePlumbing repairs or additions
12 -El Roof repairs
13.0 Other
-I'.-.- ... .. MUM Who im out ine section Delow showing their workers' compensation policy information,
Honieowners who submit !his afflidavit indiefitillo VI)at, ale djuilig ap W&K allid ffien hire outside contraciors musi submit a new am—davit indicating such.
lContractors that check this box must attached an aodditional sheet showing, the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andiob site
infornmdon.
Insurance Company Name:_
Policy 9 or Self4s. Lic. #: 76 k,�� 9 391 Expiration Date:
Job Site Address:
City/State/Zip
D Dinky declaration page (sbowincr the policy number and expiration date).
Attach a copy of the workers, com ensati An��
el
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 under the pains andpenalfies 0fPeriu`Y that the information provided above is true and correct.
Si-c,nature: Date:
Official use only. Do not write in this area, to be compileted 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 t�
Contact Person:
Phone #:
�0�
LA
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ICOBRPCORATION
10 STATE STREET, WOBURN, MA 0 1801 TEL: 781-994-1260 FAx: 781-994-1261 WWW.NECCCORP.COM
August 5, 2008
Mr. Gerald Brown
Town of North Andover Building Department
1600 Osgood Street
North Andover, MA 0 1845
Re: Application for Permit to Build — Installation of a wall and counter assembly to suit a "CBB
Cell" (for a specialty coffee machine) within McDonald's National Store No. 6762 — 660
Chickering Road, North Andover, MA 01845
Please find the attached documents in support of our application for a building permit:
Application for permit to build dated August 5, 2008 complete with relevant inforniation.
Debris Disposal Form duly signed by NECC Corporation.
Certificate of Liability Insurance from Concord Insurance Group, Inc dated August 5, 2008,
nammg the Town of North Andover and the relevant job location.
The Commonwealth of Massachusetts, Department of Industrial Accidents, Workers'
Compensation Insurance Affidavit dated August 5, 2008 duly signed by NECC Corporation.
Copy of Contract between NECC Corporation and Chuck Lietz dated July 22, 2008 (3 pages).
Photocopy of Construction Supervisor's License # 093770 (expiry date 02/25/10).
McDonald's CBB Program Design Overview.
McDonald's specialty coffee machine equipment cut sheets (8 pages)
Two (2) sets of the following drawings:
• Architectural drawings A-1, A-2, and A-3 (no revision) dated 07/11/08 prepared by
Landry Architects.
• Engineering drawings E- I and P- I (no revision) dated 07/11/08 prepared by James
Conway Engineering, Inc
If yp4ave any questions or require any further information, please do not hesitate to contact me
on fiiy cNI phone at 781-953-8676.
Y
NE54(del J. Leyne
XECC Corporation
Senior Project Manager
A FULLY INTEGRATED FACILITIES SERVICE COMPANY
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
A-�
This certifies that ...... 7'i-__-: E4.4�KZ�t ... 6� ................................
has permission to perform ...... em,'///mP.7 --- — -------------
wiring in the building of ........... ........ 12K.i . . ...................
at. Ar,59. ....................... .. No Andover, Mass.
fegF-
-5
Fee ... /.�� ......... Lic. NoAR46 . .................
Ric�rwcAL �INsPEcrok
Check # PLA15-
?ED
ELECTRIC, INC.
Chlristopher Tully
Project Manager
3 Industrial Drive
Windham, NH 03087
Tel. (603) 898-8058
Fax (603) 898-8350
ctully@conversent.net
Electrical Construction
& Engineering
Energy Management
Systems
Li
Officiaf Use Only
N Commonwealth of Massachusetts
Fq -7 2—
Permit No.
L6nt of Fire Services
Departm Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS J[Rev. 1/071 (leav, blank) _ _
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MTC), 527 CMR 12.00
(PLEASE PRINTININK OR TYPE ALL INFORMAIYON) Date: ( ( — 10 — c)z
City or Town of: NORTH ANDOVER To the Inspector of Wires:
erf irm the electrical work described below.
By this application the undersigned gives notice of his or her intention to p o
Location (Street& Number)
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes [Er— No (Check Approp 'ate Box)
Purpose of Building G� Utility Authorization No. 7YA
Existing Service Amps I Volts Overhead 0 UndgrdF'� No. a Meters
New Sery Amps I Volts OverheadE] - UndgrdE1 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
KAZZ.4
ii— f th. fAllnujina, t1rhAp mav he waived hv the InsDector of HIM.
No. of Recessed Luminaires
No. of CeiL-Susp. (Paddle) Fam
No. of - Total
Transformers KVA
No. of Ltiminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above [] In- r -i
Swimming Pool grnd.
N_0_._0T Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of OR Burners
FIRE ALARMS
No. of Zones
No. of Detection �an
No. of Switches
No. of Gas Burners
Initlatinu Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
Beat Pump
No. of Self -Co d
No. of Waste Disposers
Totals:
Detection/AlertinlZ De vices
No. of Dishwashers
Space/Area Heating KW
Local 0 Municipal [_1 Other
Connection
No. of Dryers
Heating . Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaten
Signs Ballasts
I No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors ;* Total H P _11'elecommunications
wiring:
No.9 Devices or Equivalent
OTHER-. kca tED 4, ?,-j C. . . . 1 -1
Estimated Value Electrical Work: (When required by municipal policy.)
Work to S - It lo� 0!5 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSU C VERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or ib; mbstaritial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. I-oJ 116� A.
CHECK ONE: INSURANCE 2—BOND [] OTHER n (Specify-)
I cerI45� under thepains andpenallies ofperjury, that the information on this application is true and complete.
FUMNAME-.TL-�:� sm—AACA& � — LIC. NO.: "UK
Licensee: ;9m!t.* -:x- -rvk- Signaturee--
LIC. NO.:_A,'FjL0-T
(Y'applicuble enter "exempt " in the ficensp namber line) e,*� Bus. Tel. No.:PjLQ- R&M#3
Address: �b A-)� kn9,0 W r�JLS�L" &?b Alt. Tel. No.1003 -999 -&-56
*Per M.G.I. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement I am the (check one)E] owner El owner's agent.
Owner/Agent FEE: $
Signature Telephone No.
M
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
600 Washington Street
Boston, MA 02111
www.mass-gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/OTganization/Individual).��
Address:
Gty/State/Zip:_&&,g;�A'f " 03z�j Z Pbone #: 4�S 9,0F S42-�_R
Are you an employer? Check the appropriate box:
1. E�'l am a employer with
4. [3 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
listed on the attached sheet.
2.0 1 am a sole proprietor or partner-
Job Site Address:_Z_zt2__z
ship and have no employees
These sub -contractors have
working for mein any capacity
workers' comp. insurance.
[No workers' comp. insurance
5. E] We are a corporation and its
required.]
officers have exercised their
3. [11 am a homeowner doing all work
right of exemption per MGL
myself [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.)
employees. [No workers'
comp. insurance required.]
Type of project (required):
:6. [] New cons-truction.
7. B'Remodeling
8. [] Demolition
9. []Building addition
10.�Electrical repairs or additions
I I. E] Plumbing repairs or additions
M
12.n Roof repairs
13.[3 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidaviL indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
-contractors and their workers' comp, policy information.
'Contractors that check this box must attached an additional sheet showing the name of the sub -
I am an employer that is providing workers' compensation insurancefor nV employees. Below h the policy andjob site
informadom
Insurance Company Name: /2i�� 6 �_)aa
Policy # or Self -ins. Lic. #
?
Expiration Date:
Job Site Address:_Z_zt2__z
�IA
7:)
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PSq i ty/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 thisstatement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerdfy under the paw's andyenaWs of perjury that the information provided above is true and correct
�Z/K r,%,AtP-
OffkW use only. Do not write in this area, to be completed by c4 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. Plumbiner Inspector
6. Other
THE POUCIES OF INRURANCE 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 13Y THE POLICIES DESCRIBED HEREIN 18 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUC14
POLICIES, AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
I POLICY NUMBER I n2��ffq!Y U_C_yEX_P_tRA_'nDN-7—
GENERAL UAsiuTY
X COMMERCIAL GENERAL LIABILITY
ON
CLAIMSMAM 7x OCCUR
A CMP6008662
L2��l AGGREGUATt LIMlIT APPL93 PER:
PRO.
POLICY FX7 JECT F7 Loc
AUTOMOB19LIASfUTY
ANYAUTO
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B x HIRED AUToB CAPS596875
X I NON-OVY149DAUTOS
I i ___ - I -
OARAGE LIABILITY
09/23/2008 18:05 FAX 19786833147 M.P.ROBERTS INSURANCE 2001
ANYAUTO
CERTIFICATE OF LIABILITY INSURA OATEWMarerM
NICE
EXCEGS(LIMERELLA LIABILITY
PRCOU Cv � 9/23LQDB
X OCCUR cLAImsMADF
�CUP9065280
THIS CERTIFICATE IS ISSUED AS A MATTER Oi INFORMATION
M.P. ROBE:RTS INS AGCY INC ONLY AND CONFERS NO
DEDUCTIBLE
RIGHTS UPON THE CERTIFICATE
1060 Osgood Street HOLDER. THIS CERTIFICATE DOES NOT AREND, EXTEND OR
I X RETENTJO,q 10 000
I—ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
i North Andover, MA 0184B
WORKERSCOMPENSATONANO
(978)683-8073
qMPLOYERS*LIABIUTY
WSURED T C I ELECTRXIC INC A/0 706gpa a T=y INSURERS AFFORDING COVERAGE NAJC#
ANY FRGPRlEMR434RTNCARdNCWTfVe WCA6141190
L RFA A: MERCHANTS INS CE EGROUp
A/C TULLy ELECTRIC SERVICES
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INSURER 8� Up
MRCHANTS imsuRANCE GROup
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MERCHANTS INSURANL.E (3ROTjp
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WMHM, NH 03087
SPECIAL PROMSIONS r*lvw
INSURER 0: MRICHANTS lNSuWCE -ROUP
OTHER
INSURER E:
COVERAGES
THE POUCIES OF INRURANCE 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 13Y THE POLICIES DESCRIBED HEREIN 18 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUC14
POLICIES, AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
I POLICY NUMBER I n2��ffq!Y U_C_yEX_P_tRA_'nDN-7—
GENERAL UAsiuTY
X COMMERCIAL GENERAL LIABILITY
ON
CLAIMSMAM 7x OCCUR
A CMP6008662
L2��l AGGREGUATt LIMlIT APPL93 PER:
PRO.
POLICY FX7 JECT F7 Loc
AUTOMOB19LIASfUTY
ANYAUTO
ALLOV*EDAUTOO
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B x HIRED AUToB CAPS596875
X I NON-OVY149DAUTOS
06/30/08
I i ___ - I -
OARAGE LIABILITY
wfirrs
ANYAUTO
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WORKERSCOMPENSATONANO
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ANY FRGPRlEMR434RTNCARdNCWTfVe WCA6141190
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SPECIAL PROMSIONS r*lvw
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06/30/08
06/30/09
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4
06/30/08
06/30/08
06/30/09
06/30/09
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Ot!SCFUi-TIONOPOPERATIQN$iLOCA'nDNS/Vrj4lCLESI EXCLUSIONS ADDED BY ENDORSgmemri SPECIAL PROVISIO.NS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DEZCRIBEI) POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TD WIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFY, BUT FALURI! T'O 00 SO .?(ALL
IMPOSE NO OBUCATION OR 41AUILIYY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
r OR �ED Rr;pkg TArl
NCOR026(2001/08)
P;:� %bACORD CORPORATION 1988
a
KITCHEN
RM- PROVIDE A CIRCUIT FROM THE NEW
ELECTRICAL PANEL TO SERVE THE NEW MNU
BOARD. THE NEW CIRCUIT SHALL BE 120
VOLTS, SINGLE PHASE AND 1.5 FULL LOAD
AMPS TO FEED A SINGLE RECEPTACLE.
WIRING SHALL BE 2 #12. BREAKER SHALL
BE 10 AMPS. VERIFY EXACT LOCATION OF
PLUG AND MENU BOARD IN FIELD MENU
BOARD TO BE CIRCUITED TO CBB-5.
0 a
1/2HP,l 20V1 P2W
0 CEIB-8
PROVIDE PULL BOX FOR FUTURE CUSTOMER
CONNECTION OF POS MONrrOR POLE. SERVICE
PRESENTER
4 El )K
XfFr��CBB-1 r-(§�M24 MW AG9050unm
1/6HP,
CBB-7
00 E
3—Mi—, NH
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PROVIDE PULL BOX FOR
CONNECTIONS TO CASH REGISTERS.
PROVIDE ZV2' PVC CONDUIT IN WALL 12"
AFF WITH PULL STRING. CONDUIT
PROVIDED FOR POS INSTALLATION.
PROVIDE CURVED BACK
FITTING AND PULL STRING,
TERMINATE 2 1/2- PVC
CONDUIT AT LOCATION
OF STEEL DATA CHASE.
DINING
ELECTRICAL PART POWER FLOOPU Wi:'_�'
N.T.S.
PROJECT: MCDONALD'S NORTH ANDOVER, MA (CBB-106)
DESCRIPTION: INSTALLATION OF PUMPS
ligialp 09-23-08 SCALE: N.T.S.
I DATE:
DRAWN BY: DWM I CHECKED BY: NV SHEET: ESK-1
ESPRESSO SPECIALISTS
a FRANKE Company PRO
Installation Guidelines
McDonald's Specification Sinfonia, Model M2MCF/2MUT
19"wide
The machine includes one hose for milk
and one for steam, each 65 inches long. It is
recommended that the machine sit directly
over the holes cut in the refrigerator and/or
counter OR within reach of factory provided
hoses.
24" deep
MUT
electrical box
(6" square) -
Milk/Steam supply tubes
MUT electrical wires-�
3/8" Braided Stainless___,:_,�
I cold water supply line
3/8" drain
Floor drain (within 5')
Espresso Specialists
5601 1 st Ave South
Seattle, WA 98108
206.784.9563 tel
800.367.0235 toll-free
206.784.9582 fax
www.esiespresso.com
000
0 -
0
5" of clearance
recommended
above the grinder
31" high
Beverage Air Refrigerator
UCR20=
20" wide x 20.5" deep x 31" high
115 volts, 3.5 amps
UCR27=
27" wide x 29.25" deep x 34.5" high
115 volts, 4 amps
r
Thei
and
Receptacle
within 3'
208V, 30 amp single phase circuit
for espresso machine. Ensure the
receptacle configuration matches
the NEMA# 1-6-30 plug supplied with
the machine.
11 5V, 4 amp
power for
refrigerator.
Receptacle
within 3'
COUNTERTOP VIEW
Back edge of countertop
4 -
This hole drilled through cou
,e � ok s through counter 718" only and 0ould not be drille,
vt ge ator �-� T)*2 until the in�taller determines
2.5" 1-1/8- distance b tween the top of
refrigerato and the counter i
adequate r utility hook-up
.0,2'
17"
91
Center line of machine
All electrical and plumbing work must meet local codes.
Franke Coffee Machines.
Sinfonia 1 -Step MUT
Th c1p ENP( mmm-
Sinfonia 1 -Step MUT:
Facts & Figures.
a
The Sinfonia MUT produces 20 -ounce drinks 20-30 seconds faster than its former
specification. It is designed for self -serve, quick -service and minimal training
capacity applications.
Features:
• Two boilers; both the brew boiler and steam boiler are stainless steel
• Speed — The fastest Franke superautomatic espresso machine maintains its
standard milk texture quality
• Two milk options — Typically non-fat and 1%, 2% or whole milk
• Triple espresso shots — Up to 22 grams of coffee fit in the brew cylinder
• Consistent, high-quality espresso shots - Heated metal brew group
• Standard -setting sanitation — The NSF -approved Franke MilkSystern (also
available on mid -volume Franke Evolution models) operates on a pump system
that systematically rinses the entire milk delivery system - from the refrigerator
through the foamers; daily cleaning is fast and easy
• I nvento ry/ Controls — Complete accounting of drinks made and cleanings
• Americanos/caf6 cr6mes — One7touch fresh brewed espresso
• Optional 3rd grinder/hopper — For high volume use or fresh espresso
• Up to 28 programmable drink options - Espressos, lattes, cappuccinos, iced
drinks, americanos, or caf6 cr6mes ... all at the touch of a button
• Any NSF approved refrigerator can be used with the Franke Sinfonia 1 -Step MUT
*Optional 208 volt three phase, 30 amp or 208 volt single phase, 30 amp
(recommended for 1 -step only) electrical configuration available
Franke espresso machines are UL approved to electrical safety and sanitation standard NSF 4.
- j "� eki�xut �tk"tltw All. !4*jt'_
F?U�'M
C & LISTED
1 -Step Sinfonia
Refrigerator
Height (nsf)
31"
34.5"
Width
19"
27"
Depth
24"
29.25
ShippingWeight
200 lbs
176 lbs
Steam Boiler
2.851
n/a
Coffee Boiler
1.21
n/a
Cup Height - Adjustable
3 - 7"
n/a
Voltage*
208 V
Single Phase
115V
Wattage
6900 W
9, W
F7;;rnmended Circuit Rating*
50A
7 A
*Optional 208 volt three phase, 30 amp or 208 volt single phase, 30 amp
(recommended for 1 -step only) electrical configuration available
Franke espresso machines are UL approved to electrical safety and sanitation standard NSF 4.
- j "� eki�xut �tk"tltw All. !4*jt'_
F?U�'M
C & LISTED
BEVERAGE -AIR
Undercounter and Worldop units feature new, robust
cartridge style hinges
• Stainless steel exterior front, top and sides.
• Anodized aluminum Interior to prevent corrosion.
• Self -closing doors on cam lift hinges with 120o stay open
feature for easy product loading.
• Snap -in magnetic gaskets for a positive seal,
• Two inch CFC free foamed -in-place polyurethone
insulation, for added strength and energy efficiency.
• Balanced refrigeration system operates at 36-38OF for
optimum food preservation.
• Freezers operate at 01.
• Adjustable epoxy coated steel wire shelves, standard (two
persection).
• Six inch casters, two with brakes standard.
• Refrigerators utilize ozone friendly Rl 34a refrigerant.
• Freezers utilize ozone friendly R404A refrigerant
• Foodservice pans are not Included.
• Consult factory for availability of optional glass doors,
pullout drawers and/or tray slides.
• New, robust cartridge style hinges provides positive seal
and eliminates door sagging issues
(excludes glass door units and some special units).
Indicates ADA Compliant Model.
Contact factory for more information.
ADA
Ali undercounters and worktops
offer field reversible doors. (Except UCR34)
UNDERCOUNTER AND WORKTOP EQUIPMENT ALLOW TOTAL
FLEXIBILITY IN YOUR ORGANIZATIOdS DESIGN, WHILE
MAXIMIZING EFFICIENCY. THAT'S WHY OUR UNDERCOUNTER/
BACKBARS - INCREASING YOUR WORKSPACE AND VERSATILITY.
Ki�
McDommas Espusso C,0,pMM
BE VVIERAGE-AIR
PRODUCED ESPECIALLY FOR
27"DEPTI
MXPICOUNTERMORKT01
REFRIGERAT01
V6xkwpCmo1ers
VsfsatilG, Oxnpact models whh stainimstaeo vKw
" and mirigerated st0fage of food products.
Working heigN is 36 3V on So casters.
McDonald's Specialty Coffee Cooler mocM
WrFt27A-SR Cooler Includes a modified tM with
holes for milk tubing Knes, so Castm, right hand
hinged dow. Whill Cream holder assamNy Syrup
Speed Rall including Cocoa bass holder.
Cabinet Consuvctiotu
He" duty CDMVUCd*n includes 03 finish Mderfor
stainless 311901 on Wrt sides. door(s) and grole.
Cabirw back &W bown am galvantad steel.
Interior liner is made of Conosion resistant
W%XruBd alUminum. Interior thermomeler is
standard.
CabInats ate roWated with 2- gw& kwradff,,
PlaCe PQIYIjreftrw insulation- Sub4op insulated
WIM 1/r baffled4j)-pkice polyured4ft inSUIeffiM.
Sub -top insulated with lfz, foamed in plaoo
POIYUMthane irmulation. Doon; are mounted 10
cabinet on seff d08ft door with cartridge hfte
syclern with 120dogeft 9W Men feature. Do=
are equipped with a snWln-plaCs, vinyl magnetic
ga&ket for a Positive S". C0M9*M dotft pug
Slyle door handle is made of black anondized
aluminun 20 and 5" casters am sWxlard. 2 include
brakes. An V cord set Is provided with I 15 volt
models. Cabinet interior standard with I steel wire
epoxy coated shelves per section. Interior fight with
manual switch is provided with glass door models.
Refriga-arion!
Refrigeration system utilizft F11134a refrWrant
governed by a capillary Ube sysilem Aubmadc
(non -electric) condemate evaporator is provkbd.
Uriquo front venting MMUM grillift boalml below
doors permits units to be installed &piffit back
waft and curbs. lrftrbr broad aV system with high
humidity evaporator cols, provides me ideal
environment for bod preservation.
WWW.BEVF.1kAGE-A1R,C0M
JL
-44k,
.7-
m-aki
. . . . . . . . . . . . . . . . . . . . .
TEMe
.7-
m-aki
McDoNALDs Espusso CoIFFFE
BEVERAGE -AIR
PRODUCED ESPECIALLY FOR
27" DEM
UNDERCOUNTERMORKTOF
REFRIGERATOF
Worktop Coolers
Versatile, compact mod" with stainle33 steel work
tops and refrigerated storage of food products.
Working height is 36 3/6' on 5" rasters.
McDonald's Specialty Coffee Cooler Model
WTR27A-SR CWer Includes a modified top with
holes for milk tubing line*, 5" Casters, right hand
hinged door, whip cream holder assembly. Syrup
Speed Rail including Cocoa base holder.
172binet Czastruction:
Heavy duty consncton includes #3 finish exterior
stainless steel on front, sides, door(s) and grille.
Cabinet back and bottom are galvanized steel.
Interior liner is made of corros�ion resistant
anodized aluminum. Intedor thermometer is
3tandard.
Cabinets are insulated with 2' thick foamed -in-
place polyurathane insulation. Sub -top Insulated
with 112" foamed -in-place polyureffmm insulation.
Sub -top insulated with 1/2"fosmad in plate
polyurethane insulation. Doors are mounted to
cabinet on self closing door with cartridge hinge
system with 120 deWee stay open feature. Doors
are equipped wtth a snap-in-placs vinyl magnabc
gasket for a pos4ye see]. Conven;ent double pull
style door handle i3 made of black anondized
aluminum. 3' and 5' casters are standard, 2 include
brakes. An Fcord set is provided with 115 volt
models. Cabinet interior standard with 1 steel wire
epoxy coated shelves per section. Interior light with
manual switch is provided with gkws door models.
Rchigerarion:
Refrigeration system utilizes R134a refrigerant
governed by a capillary tube syslern. A;Aomafic
(non -electric) condensate evaporator is provided.
Unique front venting through grilles located below
doors permits units to be installed against back
walls and curbs. Intedor forced air system with high
humidity evaporator coils, provides the Ideal
environment for food preservation.
WWW. BEVERAGE -Al P, C01M
6 1 5 & - A 1 0
11-
Cafina c5 -12C FF
Superautomatic coffee machine
Short form Specifications
Fully automatic coffee machine for combined coffee and milk serving withoi t moving the cup.
Special fully automatic cleaning system, through what no machine parts mL -,t be dismantled
or fitted (CIP a Cleaning in place).
The machine contains sub -assembly parts like: 1 brqwft-unit, 2 gMders, o water pump, 2
boilers and a mlIk system,
The outsidors case and the product outlet are made of synthetic material (H ;using PUR KI 10
MF painted, dreg drawer A13S type, bean hoppers PET "e, Human-Machil ie -Interface PC
type), stainless steel (cup plate AISI 304, drip grid AISI 304).
Machine stands on 4" feet on stainless 3teel (AISI 304)
Electrical und hydraulic connections
• Electrical connections shall be 208 volt, 6.0 Hertz, single phase with 30 amp ire fuse
Protection. Unit have a cord with 5Gr (1 .5 m) length and one InstallatJon box at the end.
• Water inlet with minimum 1 bar pressure (Machine is for pressure less mod( ) and with 3/8"
connector.
• Drain hose with outside diameter 0. 75" (19 mm) in silicone.
Coffee machins c5 -12C FF Milkbox in [he fridge
.0-N.
r
c us C E
(W (Nv 6—'
Cafina AG. R6merstrasse 2, 5502 H
nschwil , Fon +4162 889 42 42 - Fax t4 62 889 42 09
www.cafins.ch I
Power and plumping requirements
WATER FEED
G 3/8,
MAIN TAP
HYDRAULIC AND
ELECTRIC CONNECTIONS
ni f�' 4�'.
L77 -
'.j
I MAINS PLX4SOCKET
AC 208Y 30
DRAIN WITH 3 2-
MILK8C1X IN RIDGE
0 SUFFL I ED W MACHINE
M
T
0 BE PKROV I BY CUSTOMER
A MAIN SWITCH ST BE PROVIDED
FOR SWITCHINGG, MACHINE OFF,
1. DIAMETER I W FOR FEED AND
M
ORA114AGE
Cafina AG, Rbmefstrasse 2, 5502
nschwil - Fon +4162 889 42 42 - Fax +4 62 889 42 89
wvvw.cafina.ch I
Sinfonia 1 -Step McDonald's Ve
f C-.'. �I r I[ S ?-�. F 19 [ j 1, e S
Stambrds
• Electronic control board with illuminated grapi
Programming
• HO-penbirmance piston coffee machine with
• TWO Predsion grinders (regular and decaf beai
Under counter milk pump scilution for up to tw
Hot and iced espresso based beverages
Easy opmtion panel with pre-se(ection boons
second milk type, decaf beans and syrup optic
Automatic wash, rinse and sanitize cVcle
,P Bean level monitorins
• HeIght-adjustable coffee and mHk dispenser
• Dry coffee- grounds container for up to 40 puck
• internal counter function for each product
• Stainless steel frame
• Two year parts and labor warranty
w . Ow c9ratcu" SUP* unt
MeW halt
watwIlowess
max- 3SPS
Aop a6 CL WOJL. Nw. aw aMWOWE0610
Franke espresso machines Bre UL approwd to electrical safety and sanitation standard NSF 4.
ion:
Ics display; chip -card
re-onrusion
with dir"t grinding
different milk types
four different drink sizes.
G Ite elut, L -4.9r (1.5m)
IKIt�%Ab,4
EPRESSO SPECIALISTS
a FRANKE Company
Installtion Guidelines
McDonald's Specification Sinflonia, Model M2MC
19"wide
24" deep
The MdOhirm incluaes one hose for rwtk
and one for utearn, 98C1155 inches long. It is
recornmenoecl that (tie machine sit directly
over the holes cut In the reffig"tor and/or
countor OR withln reach of factory provided
hoses- MUT
e1wrical box
(6' squarg) N
A
?AlktStS= 3UPPty tubes
MUT Alectricall wIres
318* Oraid6d Stainless El
cold water supply line
318' drain
Floor drain (w4hin 5)
Esplesso Specialists
56D1 IstAveSc>uth
Seatife, WA 98108
206.784.9563 lei
SCO -367.0235 toll-free
206 784.9582 fax
www-esiesp,r"6o.com
tor
000
0 -
0
S" of clearar
recommend
above the Q
31' high
Beverage Air Refrigerator
WR20--
20' wide x 20,5- deep x 3 1' high
115 volt�. 3.5 amps
UCR27=
27- wide x 29-25- deep x 34.5' high
115 voftfi, 4 amps
— da e- I Receptacle
within 3'
201, 30 arnp single phase circuit
for SSO Madhine. Enture the
too Plade COA"tion Matches
Iris JEMAS 1-6-30 Plug supplied with
the racNne.
115V, 4 amp
power for
refrigerator.
Receptacle
within 3'
COUNTERTOP VIEW
Back eV counterlop
I MIS 11018 - dnilled through cm
Thme Ir * S through unter 3��
and retr ;le'ator ICZ::Z�, 71tl. Y OnTs�ould not be drille,
Jr4ll the ir*lialter detilmunes
I.i/r Itstence b"p the top of
),0 efrigeralot and the counter i
daquato lo, ublity hook-up
ir
lip
QWW " Of
Ah aleddeal and plumbing work nhu�t rnftt joc-aj codes.
10,
Bracket Installation Instructions
Use
FOODSERVICE
SYSTEMS
Place brackeTn machine as shown
Note -
Lip on leading
of mntrol pan�
ge fits behind edge
I
Us,
Bracket
Note how
FOODSERVICE
SYSTEMS
� booklet mounted on
i machine
�p View
s positioned on bracket
9
ZK
6 al
u
CO
C4
o
fd
i
BOSTON REGION
McDONALUS
'5:::BB PRO"�,RAM
L:, �ff
The CH cell will create an iconic presence with the McDonald's Restaurant,
and help showcase the offering of specialty coffee drinks, The design of
the cell utilizes a layout and aesthetic appearance determined by
McDonald's US Operations and McDonald's US Restaurant Design Group.
The rendering above represents the design Intent for the CH cell as
envisioned by McDonald's CB5 team. To ensure the best possible
appearance in your restaurant, ISI asks that each Owner/Operator choose
the color scheme for the CH counter and branding elements. From the
following pages, please select a component package that will best fit your
restaurant. Special consideration will be made for custom needs. Please
contact your ISI Regional Market Manager for additional information.
COUNITE11 AND DECOR SC.112-2N OPTIONS
Select Package A, B or C.
ON
1-01
Dim Screen
Wilsonart Kensington Maple
Counter Top Finish
Corian Concrete
Counter Vertical Surface
W;lsonort Cocobala
136cor Screen
Wilsonort Kensington Maple
Counter Top Finish
Corion Raffia
Counter Vertical Surface
Wilsonart Wild Cherry
CBB Order Form
Page 2
11111 lob
A010
COUNTRII AND DtCOR SCREEN OPTIONS
Select Package A, B or C.
a
Dbcar Screen
Wilsonart Cocabala
Counter Top Finish
Corian Rice Paper
Counter Vertical Surface
Wilsonart Kensington Maple
CBB Order Fofm
Pcige
A
I
, ) W K! IT', - ITI
PA i RM
Soffit and soffit lighting help define and visually
integrate the CH counter with the existing front service
counter. ISI offers two options for a prefabricated soffit
that will compliment the shape of the counter and
provide marketing support.
NOTE: This is a standafd component to the CBB
package.
F1 Yes (If yes, which design?)
Rectangular Soffit
L Soff it
A' wide x 2' long x 8" deep.
7 No
Designed to adapt existing store conditions while
enhancing the visibility of the CBB counter.
Pearl bisque laminate finish.
2 can lights (included)
"McCafe" blade sign is stamped metal with a
brushed finish on a dark laminate background.
E3 ,
Laminale: Wwart
3489-07 Pearl Bisque
LaMinatf:Wilarwl
7942-eO Cacobalo
CBB Order Form
Wilsonart Cocobala Wilmart Pearl Bisque
5'-0" wide x 6'-2" long x 8" deep.
Designed to enhance the shape and visibility of the
CBB counter. Better suited to locations without an
existing soff It over the Front Service Counter.
Pearl bisque laminate finish.
4 can lights (included)
"McCofe" blade sign is stamped metal with a
brushed finish on a dark laminate background.
Page 4
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 093770
Birthdate: 02/2511962
Expires: 02/25/2010 Tr. no: 93770
Restricted: 00
MICHAEL J LEYNE
106 CHESTNUT ST
ANDOVER, MA 01810
Commissioner
�nd,rd,
HOME IMPROVEMENT CONTRACTOR
Registration: 154180
Expiration: 2/13/2009 Tr# 254234
lype: Private Corporation
NECC CORPORATION
MICHAEL LEYNE
10 STATE STREET
WOBURN, MA 01801 Administrator
C EOR r OCR A T 1 0 N
10 STATE STREET, WOBURN, MA 0 1801 TEL: 781-994-1260 FAx: 781-994-1261 WWW.NECCCORP.COM
July 22, 2008
Mr. Charles Lietz
19 Sunset Rock
North Andover, MA 0 1845
Tel: 978-809-3022
Re: McDonald's National Store No. 6762 — 660 Chickering Road, North Andover, MA 01845
Installation of wall and counter assembly to suit CBB cell (for specialty coffee machine supplied
& installed by others) in accordance with the architectural drawings A- 1, A-2, and A-3 (no
revision) dated 07/11/08 prepared by Landry Architects and the engineering drawings E- I and
P- I (no revision) dated 07/11/08 prepared by James Conway Engineering, Inc
The Scope of Work shall include the f6flowing:
Demolition, construction, electrical and plumbing work as per the above drawings.
Cut-back existing counter top to suit the installation of the CBB cell and the walk-through on the
opposite end of the counter.
Remove glass fronted display cases and set aside for the Owner.
Repair ends of existing Conan counter top at walk-through.
histall Owner supplied finish materials to the front of the existing counter and the sides of the
new walk-through.
• Patch and repair existing holes in Corian countertop. Drill holes in new locations to suit the
revised setout of the cash registers.
• Install new timber fimning, sheathing and FRP lining to rear of CBB walls as per the above
drawings.
• Saw -cut existing floor tiles, demolish and remove concrete base to install new drain fines,
cleanouts and floor sink.
Install Owner supplied floor tiles and base file for front and rear of new CBB counter.
histall new POS and electrical cables to suit the new positions of the relocated cash registers.
0 histall Owner supplied d6cor items including CBB counter wall laminate linings, horizontal rails
and threaded rod, Corian top, pre -fab soffit, signage and d6cor panel, etc.
Exclusions and / or Clarifications:
I . All workmanship will be performed in a professional manner in conjunction with industry
standards and manufacturer's recommendations -
2. Any alteration or deviation from above specifications involving extra costs will be executed only
upon written change orders and will become an extra charge over and above the estimate.
3. Owner shall be responsible for liaising with the store manager to provide access to enable NECC
to perform the work.
4. NECC will supply a 20' container for the storage of construction materials and equipment
supplied by the Owner, located in a place acceptable to the Owner.
5. NECC will supply a 20 yd dumpster for the removal of all demolition debris and construction
waste materials, located in a place acceptable to the Owner.
A FULLY INTEGRATED FACILITIES SERVICE COMPANY
4
6. NECC will use best endeavors to control dust during the floor saw -cutting and construction
works.
7. Owner shall be responsible for the supply and installation of all equipment including, but not
limited to, the specialty coffee machine, the KVS monitor and bracket. NECC will accept
delivery of and assist with installation of all new equipment.
8. Owner shall be responsible for the relocation of the existing fire alarm, temperature controls and
security keypad by others. NECC will assist with the coordination and timing of these works.
9. NECC will coordinate the camera inspection of the existing drain lines to be paid for separately
by the Owner.
10. NECC will provide all necessary equipment, tools, materials and labor to carry out the works
except as noted (and / or clarified above).
11. NECC has excluded the replacement of the suspended grid ceiling and ceiling tiles except those
affected by the pre -fab soffit.
12. NECC has excluded any works associated with the smoothie machine shown on the drawings
noted above including any electrical and plumbing works.
13. NECC has not included for the new supply and return air diff -users; recessed or ceiling mounted
fluorescent fixtures, pendant down lights, incandescent lights, recessed downlights, exit signs
with emergency battery back-up or emergency lighting as noted on drawing A-2.
14. NECC has included for the specialty coffee machine water connection into the existing reverse
osmosis water treatment system installed by others.
15. NECC has excluded work associated with the replacement of the existing floor drains and
cleanouts.
16. NECC will use best endeavors to install a new vent line that connects to the existing vent line for
the new specialty coffee machine. If it is not feasible to do so, we shall run a separate vent line
through the roof in close proximity to the new equipment.
17. NECC will supply and install I OK AIC breakers to match the breakers in the existing panels and
not the 22K AIC breakers as noted on drawing E-1.
18. NECC has not included for the new counter top for the cash registers as noted on drawings A-1,
A-2 and A-3 beyond the repair works noted above.
19. NECC has not included for the new menu valance as shown on drawing A-2.
20. NECC assumes that the kitchen drawings K-1, K-2 and K-3, revision B, dated 06/12/07 prepared
by Franke Inc are for information only and have been superseded by the architectural and
engineering drawings noted above.
21. NECC has not included for the installation of new equipment at the rear of the counter including
cup holders, cash drawers, tray carts, condiment carts and the like.
22. NECC will not be responsible for pre-existing conditions including the removal of contaminated
material and any required abatement. The Owner shall compensate NECC for time and materials
for the removal of any of the above and any consequential delays to the project affecting NECC
personnel and machinery rental.
23. NECC has excluded any work associated with the existing drive-thru windows.
24. Owner shall be responsible for the payment of any fees associated with a building permit and
Board of Health approval. NECC will assist 'in the preparation of the application and obtaining
the permit and approval from the Andover Building and Health Departments.
25. Owner shall be responsible for the commissioning of consulting Architects and Engineers and the
preparation of engineering reports, as -installed drawings and completion certification related to
the works (if any of the above are required).
26. All work to be carried out generally after normal business hours (e.g. 8:00pm to 6:00am).
27. All agreements are contingent upon strikes, accidents or delays beyond our control.
28. All workers are fully covered by Workmen's Compensation Insurance.
Estimate inclusive of all materials, labor, machinery hire, taxes and insurances: $34, 987.00
Z�0 R P OR MAT I ON
This quotation is good for a period of thirty days.
Please acki�wledge your acceptance of the proposal by signing where noted and returning a copy by
faqsin-ffle tol781-994-1261.
I I Leyne
Corporation
Project Manager
Z�0 R PO R MAT I ON
Authorized By:
Charles Lietz
McDonald's — North
Owner
10: 7P FROM: 70: 1781 �&41261 2
,iA_C0RD, CERTIFICATE OF LIABILITY INSURANCE DATE (MIVIQQY�
1 08/05/200 "
PRODUCER (222) 222-2222 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
CONCORD !NSLTRANCE GROUP, INC. HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.C. i59 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOvy.
t : I
B F LM ON'T MA 04778- INSURERS AFFORDING COVERAGE NAIC Ilt
INSURED 1 NSURER A QUINCY MUTUAL INSURANCE 1
NF,CC CORPORATION NSLRER 9: THE HARTFORD INSURANCE
10 STATE STREET : "NSURER C:
_NSURER 0�
MA 01801- NSURER E:
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R=Q,IR=%',ENT TERM OR CONDITION OF ANY CONTRACT OR OTHER COCljYEN-'NI7H RESPECT TO WHIC- T- S CERTI=ICA7E MAY BE ISSUE� OR MAY PERTAI�.
-HE INS�.PA41E AFFORDED BY THE POLICIES OESCRIBED HEREIN IS StBJECT -0 ALL THE TERMS EXC.USIO.k4S AND CCN:) -IC145 0;; SUC- PC_IC Eyt
UY!-S SHOWN MAY HAVE BEEN RECUCED BY PAID CLAIMS.
_A�GGREGATE
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4CDCSALDS RESTAURA\ITS, TO;4-4 OF NOR . AN:)OVER AND CHARLES L:ZTZ ARE INCLUTOED AS AZD:T:CN INSJ
LjAz:jjTy CpzRAT:CNS AA:ST-NC OUT OF THE NA -MED T-NSL-AED.
CERTIFICATE HOLDER CANCELLATION
SwOULD ANY OF TH-_ ABO�E CESCR;BEC POLICIES BE CANCE-LE0 BEFORE 'o,E
EXPIRATION DATE TH-;='_; 7-E ISSUING NSJRER W LL Ek,_�=_AVCR TO MiliL
10 DAYS WRITTEN 1.0 -NCE TC: TkE CERTi;:CA7E HOLDER -4AV!: TO -,HE LEFT. E�_-
FAILURE TO 00 SO SHALL IV; --SE 40 08-IGATiCN OR - AE! -!-,Y S= ANY KIND UPON
TC'AN OF NORTH A1,MOVZR NSURER, ITS AG�TS.PR R=_:;;-.4TATA
AUTHORIZED REPAVJI�-A71v
JE00 OSGOOD STREET
NORTH ANDOVER YA 01845— Z ACORC CORPORATION 1 . 8
ACORD 25 (ZO01/08) v
INS025 E�ECTRCVC I.ASER FORMS, INC .(800)327-C!-5
G - 2 2 *2'_Z 10: !Sc� FRID11:
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T0:17e19941261
AWORD, CERTIFICATE OF LIABILITY INSURANCE DATE (4MIQO")
1 08/05/2000
PRODUCER (6177) 484-3090 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION)
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATe
Concord insurance Group, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND Ok
P.O. Box 159 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
385 Concord Avenue, Suite 200
Belmont MA 02478- INSURERS AFFORDING COVERAGE NAIC A
NSURED NSUR5R A; SCOTTSDALE INSURANCE
NVECC c0=0ration FNSU iE.R 9,
10 State Street NSURERC
2nd Floor NA�]RrR 0*
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T -E POLICIES CF ' NSURANCE LISTED BEL"t,' HAV� 2EEN ISSUED 70 7HE INSUREC NAIMEC ABOVE =OR THE POLCY PERIOD INDICATE:) N0T1N'THqTA"C:'4G A�.'-
RECI, REVENT TERM OR CONCIT16N OF A'NY CCN7RACT OR OTHER DOCUMENT WITH RESPECT TOV%'�-ICH -HIS CERTIFICATE MAY BE ISSI,=-C OR MAY PERTAIPI
THE NSi RANCE APFORCED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCILLSIONS AND CONDIT IONS OF SUCH PO_ C qS
ACC -R -G -E LlKI17S S�-C41N MAY HAVE BEEN' RECUCED BY :'AID CLAIMS,
NSR AC' 11
EXPIRATION DA7E THEREO� THE ISSU14G INSURER WiLL ENDEAVOR TO M��L
EIIECTIVEJPOLIT
Y,1XP,..1,RAT1,C11j
LTR NSRO TYPE OF INSURANCE
1POUCYMM,OO1yYj
PCLiCY N�;MBER
DATE
OA� M4 LIMITS
L,ABiLiTY
1600 Osgood Street
Nort- Andover MA 01645-
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10/01/2007
10/01/2008 MED EXP (Any or�e crec- � S
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ANY AUTO
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10/01/2007
10/01/2008
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EYPLOYERS'LIABILITY
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t nal Insureds with respect to
mc-Donalds Fsstaurant, Towr. of North Andover and Charles Lietz are named as Addl 10
and a-ectrical work PG=fO=Qd by the vaurAd Insured with regard to General LiabilitY,
carps.-itry
CERT!FICATE Hn0LDER
SHOULD ANY OF THE ABOVE CSSCRIBED POLICIES 13E CANCELLED BEFORE .;H E
EXPIRATION DA7E THEREO� THE ISSU14G INSURER WiLL ENDEAVOR TO M��L
10 DAYS WR TTEN NOT:CE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, UT
FAILURE TO 00 $0 $HALL YPOSE 40 OBLIGATION OR LIABILITY OF ANY KIND UPON jHE
Town of North Andover
INSURER, ITS AGENTS JR REPRESEN IVES.
AUTHORIZED REIR
1600 Osgood Street
Nort- Andover MA 01645-
I L1.Arr)Rnr_CRP0 ATIONM988
ACORL) 25
�__ INS025 :1:: :5
V
ELECTRONIC LASER FORMS, INC, .(800)32-, -05445
The Comnwnwealth ofMassachusetts
Departownt of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
qV www.mas&gov1dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): NECC C0r1P0K2ATLCM
Address: 10 SIM -6 !SJK 6,t -T
City/State/Zip: VJ012;tA PJ , MA 0 1 N) t Phone '15 f - c[ci +- 12.& 0
A; pu an employer? Check the appropriate box: Type of project (required):
1 1
,1 1 am a employer with SSO 4. [:] I am a general contractor and 1 6. [] New construction
employees (full and/or part-time). have hired the sub -contractors
2,E] 1 am a'sole proprietor or partner- listed on the attached sheet. 7. �Remodehng
ship and have no employees These sub -contractors have 8. Demolition
working for me in any capacity. employees and have workers^ 9. Building addition
4 -
[No workers^ comp. insufatice comp. insurance,
E] We are a corporation and its 10A E ectrical w+aLmmw additions
required.]
3 officers have exercised their I I Plumbing ropakmi-or additions
3. 1 am a homeowner doing all work right of exemption per MGL
nkyself. [No workers^ conip. c. 152. § 44). and we have no 12,0 Roof repairs
insurance required.] t
employees, [No workers' 13,E] Other
conip. insurance required]
*Any applicant that checks box #I 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'conWensadon insurancefor my employees. Below is thepolity andjob site
information.
Insurance Company Name: I �A%OeAtJCG CD -
Policy # or Self -ins. Lic. #: 05WE D 0 P) 1 (0 1 _ Expiration Date: 12 1 ; i
Job Site Address: GG 0 C-R1CM-1e,4r0& JZ -0 citv/state/zip: 01D ANQDX:7K MA 0 1 b+S-
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requircd 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 kereby ceyfi&ynder Me F
: T pa7dpenahies ofperJuy tkat Me information prov&W above is true and correct
Signature Date: C810
5 [Db
Official use onb�. Do not write in this area, to be completed by cit)� or tmwi 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 #:
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with theyrovision of MGL c 40 S 54, a condition of Building Permit
at: (OW C41LkL:;W1�&kb, is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
I OA.
The debris will be disposed of in:
CAGLLA VQA5TE 5�, Pc--,;-L4kM Pig
(Location of Facility)
WH 0301C1
Permit Applicant
081 0,51 C)E)
Date