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HomeMy WebLinkAboutBuilding Permit #492 - 93 MAIN STREET 2/22/2008Permit N0: BUILDING PEKM11 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial .KAlteration No. of units: ;<Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other »Y Mgt $.. �ws'' hF ,� ty: 50 5'.'.'Y ,.zw,_ds`5�`%) `� A�3 ��,�,tt�z r 0�'�s tom, ,.7a,'F �: 6�.� DESCRIPTION OF WORK TO BE PREFORMED: _,4y2'5 � � r< 4yC',V6e- Identification Please Type or Print Clearly) OWNER: Name: Phone: A.4A. --- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER a �$$1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Q Total Project Cost: $ T� i C.�v` FEE: $ 1--�_ Check No.: l Receipt`No. C�01 S'(- NOTE: Persons contracting with unregistered contra s do, access to the guaranty fund 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 PLANNING &-DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED DATE APPROVED HEALTH ❑ ❑ ,,COMMENTS 4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit Located at 384 Osgood Street 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 ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot 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 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 9 5 N, j No. Date 401VTh TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ �U''� JAcMuse 9 > Foundation Permit Fee $ '` Other Permit Fee $ TOTAL $ Check # I 209 V Building Inspector BUILDER SERVICES ASSOCIATES, LLC P.O. Box 2508 Acton, MA 01720 TO: Stephanie Palmer 21 West Calhoun St. Salem, VA 24153 RE: INTERIOR RETRO -FIT Bus: 978-264-0669 Fax: 978-264-0669 Cell: 978-828-7978 PROJECT: Edward Jones 95 Main Street N. Andover, Ma. PROPOSAL We are pleased provide you with our proposal for the following scope of work. - GENERAL CONDITIONS: $ 900.00 Permit Allowance ($150.00), Supervision ($500.00), Cleaning ($250.00) - DEMOLITION: $ 930.00 Provide protection and debris removal thru out the construction scope. Remove the existing walls and door units as noted in room #104. Save door units for re- use. Construct a new door opening as per plan for room #104. - GWB / FRAMING $ 1,595.00 Patch the existing walls after demolition. Frame in a new door opening with wood studs. Closet: Construct a new closet as per note #3 to the dimension per Richard Ebbert ( 5'1" x 2'1"). The closet will contain the small refrigerator on the right side along with fixed 3/4" plywood shelves above. Construct a new door opening for the right hand door unit from the previous closelZI t BUILDER SERVICES ASSOCIATES, LLC P.O. Box 2508 Acton, MA 01720 ELECTRICAL Bus: 978-264-0669 Fax: 978-264-0669 Cell: 978-828-7978 $ 1,960.00 Perform demolition as necessary. Relocate one switch and install one new switch for the new closet. Install four (4) outlets, one (1) phone/Ethernet line, and CAT 5e wire. Furnish and install one new surface mount fixture for room #104 and one fixture for the closet. "T T TA /Tl Tl T!N $ 480.00 Drain the existing boiler. Remove and relocate the existing baseboard from the interior wall to the exterior wall. Purge all lines. - HVAC - DOOR UNITS / HARDWARE NIC $ 250.00 Re -install the two (2) existing door units, one for the new closet and room #104. - ACT CEILING - ELOORING NIC $ 675.00 Install new carpet as per EDJ specifications in room #104. Wood base to remain. - PAINTING $ 925.00 Apply two coats of primer and finish to room # 104. Clean relocated door units with Minwax sealer. SUB -TOTAL: OVERHEAD & PROFIT: TOTAL: $ 7,715.00 925.80 $ 8,640.80 w BUILDER SERVICES ASSOCIATES, LLC P.O. Box 2508 Bus: 978-264-0669 Acton, MA 01720 Fax: 978-264-0669 Cell: 978-828-7978 ALTERNATE (S): Room #106: Install adjustable shelving on White standards as per walk thru. Four (4) 6' shelves and four (4) 4' shelves will be installed. The standards will be mounted to six (6) 1 x 3" pine cleats screwed to the existing wood studs for additional support. ($ 945.00) NOTE: All existing millwork to remain as is, no repair/replacement and finishes included I this proposal. EXCLUSIONS: • Architectural / Engineering Design • Existing Code Issues • Fire Alarm / Sprinkler Shut Down (s) • Low Voltage Wiring / Connections (phone, data, network, etc.) All material is guaranteed to be as specified according to drawings and/or relative documents and/or conversations. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the proposal. BSA due to the current increasing market conditions reserves the right to re -bid and re- adjust the material costs at ten (10) day intervals. This proposal is valid for thirty (30) days. I would like to thank you for this opportunity and am hopeful that we will be working together on this project. Sincerely, Paul J. Fontas BUILDER SERVICES ASSOCIATES, LLC P.O. Box 2508 Acton, MA 01720 ACCEPTANCE OF THIS PROPOSAL: -- A (Owner) Bus: 978-264-0669 Fax: 978-264-0669 Cell: 978-828-7978 (Date) ¢I+CORD CERTIFICATE OF LIABILITY INSURANCE 01" 4ATE(h16TlLTOIYYYY) PROD0 R BUii3O-3 02/20/08 THI& CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LJM Iif57iXaAC@ Agency,, Inc, ONLY AND CONFER3 NO RIGHTS UPON THE CERTIFICATE 327 Union Avenue HOLDER. THIS CERIIF1GATE bOEB NOT AMEND, EXTEND OR Framingham M 01702 ALTER THE COVERAGE AFFORDED By THP 0OLICIe BELOW. Phone:508-872-0662 r8x:508-879-5299 wRUR�D ___...... - ......... - rNSURERSAFFORnINOGOVERAGE NAIC # -- ... .... _.................... _ -- INSURf-:AA nautilus InsuxariCe Company IN;IIRI=R Ii ._......_ ..... ... Buil&'' Services Assoc, LLC rNSURCR C 2 Rex Late ACCOn MA 01720 INSdR1:R 1) COVERAGES fd;llRf;R I: TI Ir PCd.I(IFS or Irj,,,IIRANr1` I I$TrD 9E1.OW I{AVF R=1 fI ISSUED TO THC INSIIRPr! RAMFDASOVE 1--OR 4P PDI, ICY f ERInn MID r/ fFu Ng7vuR}ISTANDIIJG nnM Rf.:rA1.IIRr-h{Rm1T TERN CIA CnNDII nN Op ANT CCIHTRAC' (5A nrHI:R nOCUNFNT WITH f1ESr+FCT TG N/l Nr4I TNIr, !:P11 'RIF NAY PERTAIN, rIF17ATE MAY Dr 1,"-IP. N (qt I61911RAN CE AFroRr*n nY THE PIILICIFS f)FRCRIR(;11 HEREIN IS SlIAJ6Cr ig AI.I TFIE "'EPMS. F (CI LliauNS ANn CnNDl1'IONS P F 4(iril POLICIES AGGRFrWE LIMITS 11i( IN WAY HAVE: KEN R61itIQ'rI eY PAID CIAIM INR1YD _......_._._........ ..................."...... ........_.__._._....._....._.._....... _ L SR TYPE OF INIURAN110 POI.tDY NUMBER - PA RTi1UN_ ....-... ......... .... .... ____..... FFSCTRIF p3A7 GENERAL LIAFuuTY Ep KM.I Tie (M OATF (MMIDD1YY) dA1E MM!ODIYY) LIA'k7S ----EACFI/X.:CLIRI{F;nI+,:= A $ GVNPfrn1IKBILITY NG679138 $1000000 / r/ / ..rrAVCT.7ETOli[7fTfltr--" " 5 X 8/07 q$ 0� 1$ ...I f:InrM, MAnF $ J (#x:11R - I IEMI ;i(1-.- Mrllhib:(rl X 50000 RR..__._-_.._._.... ... .............. -- - Earn ExP (A�,y mm "1"' 1: 5 5000 Pl-Tr.+t0ALAADV lKhVY $ 20_00000 ..__.. ., ._........ OF?I'I AGGRy:?CAII� LlfAll'APPI IG; PhA GFNFftnl Ar; �d{ECA7.. $ 2000000 POI. CY I 1110XICT3•CGMI"OPAOG $2000000 _...___._•.-•------. j Jff:1 LOC . AUTOMOBILE LIAaLIty ANY AUI O COWIVINj ;; NI_dE L IPP 11701#A 0011 l nt.I CIWNHI Al IT-7),,.._..._.__......... __........ __... . SCHETNII.Ff.I AURni - IIODII.Y INJURY 04m prinnnI S WIN OWNCrI At 01 nODILY IRIUAV PROPERTY F AMAr3F, _ (Poll A"W'1111 S C ARAGE LIABILITY '" ANY A111 0 AUTOONLY I_AACCIDrNT f• 0T11Ef{T'IIAN EA ACC $ EXCESSRIMBRELLA I,IAIIILITY AtfIOAMIIY ...._...-. ..................... ACI $ -'"" 1 nC(I IR I- to 4lrrs MAnF EACI I OCCLIRRENt:� _ .__..-...._........ -- - AGGRPt;Ar> $ r NICTIOL E ftl.lrNr401! $ .......... ...... ..,....,....__�.. _... ......... WORKERS COAIPFNSATION AND S EMPLOYER$ LIABILITY f(P'yLIMtTS ER nnrrPROPRIrTCNtn'gT<fNt;RrEX=Ce'IW} OhF1CFR.MiLAIDFR 1{kal t6FI)'7 EL FJ(CNIAf;CIDENT 5 ._�_... . If "..:. rin,rrlhf Urp]nt SPECIAL PRIrvt51ONS Iplbw F I. DISEAC,F FA rMrl.r 5 —. _... , _ _.. . ER 1: L. DI.RASE - POI.I(;Y I.IMIT 1 - -- ON OK OPERAIIONR ( LOCATIONR /VEHICLES) PXCLUSIONR AOQED BY CNOORREMF,,NT 1 SPECIAL PRUVIEIONR FE1)JOffice, 95 North Main Street, N. Andover CERTIFICATE HOLDER CANCELLATION EDNAPmj JonesStephanie BHOUW ANY OF THE ABOVE OE4GaIMEO POLICIES . CANCELLED "Et-ORE THE F-XPIRA71OR Atte:Edward eInvestment P.ttri : SteQihariie Palmerpax OATS THEREOF, THF, 1"ITINC INSURER WILL ENDEAVOR TO MXL 30 13AY9 WRITTF_N 12,.$ J.J'. Kelly Memorial Or, NOTICE TO naCCER11Ft[AfF HOLDER NAMED It 1NE AW FAILURE eFAILURE TO co 80 SHALL 2nd Floor WORT NO OBLIGATION 014 LIARPJTY OF ANY KINK UPON THE INSURER, St. Louis MO 63131 ITS AGENTS OR REPRESENTATIVES. AUTHOR12E _pRFS ACORD 25 (2001mA} � ACORO CORPORA71ON 1988 2088-02.22 00:07 Page 3 A -COM, CERTIFICATE OF LIABILITY INSURANCE DAT1?(IAMTDD009 oz1zo1zoos PRODUCER (978)897-620p FAX (978)897-6349 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION RtWal ter -Volunteer Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 81 Main St, HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR Mn n d MA ALTER THE COVERAGE AFFORDED OY THE POLICIES BELOW. y ar 1 01754 7Oanne 5aulnier -ii UREn''"Builder'�irvices Associates, LLC { P.O. Rex # 2508 Acton, MA 01720 INSURERS AFFORDING COVERAGE Ir, nti,r,n AIM Mutual Ins. Co. IhFJ Jh'EI7 tj lfll$ aRFP 1: ira'I Pr•.F 1 IIN 1.1PEP F.: NAIC # O. YERAG S THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO PERIOD INDICATED, NO'nAM$TANDING WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH i1VSR D'L ............... TYPE OF INS CE _._........ — - POLICYE ELIABILITYOLICYQXPIRATION — —_ — R -_.._.._.._........._............ 11RANPOLICY NUMBER GENERAL LIABILITY - 71 EACH 0Ci-.IJRrCP r'1 FT r'OMna,l'raAL�ENFFtN IInPII,iIv 6nMn?I: 10RF.PrrCb E8EMl5@S.lCr�oc�.ul:atrs}__ .�._._. _. MED Er;P Vviv m- p'r9 i11) F 1'EF7PU11. :low na:ntry F 14=:1'fl. A' �i=PFGnTP LIMIT nFf I IE`'. f r•:r. GCNFRA k.;ATT ¢ rrrr, Pt:��N,lr•T�':. C:i}MPrOr qrr, � .01 Iry AUTOMOBILE LrAStLITY nHY' Ai.RC� r'QMf?iNl'=1'r ;:;Ir,p?LE LIMIT IE,,, ucr.idenll �' All. "PAiI:DAILIT-_ : A_...........-----...., �THFIN rf.E:G AUTi LKVILY IN.A_IRY If -M ppr,nn) $ fIIF'r'I"I nt IT(x; __—._.._.................... - ----—._.._..._..... Nl'ra. r NRIEL'' ^,! Ip,r� Pi![II! r' IPl,ll!Iw (r-'r•r .xaAgnl l T r. Rrn:,CRTY DAMAO, ....... _.............. .... W " (PAr W..60pnr) FARAGELIARTUT /4UTOOM.Y-LAAIC.10[N'r nNY A1 nr•r CORER THAN EA Arr: g _ n rr0 )n4v -- AC-K; — _...._._.....- -- EXCf!'% MgRELLALIABILIY i.:i tl' , ;I.nIWL, MAPF, FAC) Iff:I.Iplatn,i_E AOOREI ;ATC Z r RL'Tfl•ITh'* f WORXERS COMPENSATION AND VWC6009867012007 07/15/2007 07/15/2008 XTWMIT.f..-- EMPLOYERS' LIABILrTY _Tr;_.........._..._.._._....._ A nrtvrsa?PPIr.Tr::a>,rvu;tona:n-xk'rLmVE nr•r-n-rr,MlFMnr-r.' 1:,.; -:LLA �L�r,', . E.I.EAFTHArr' -_Ir.>rN1 ,I 100,000 u w: -s, rinsrnb-1 unrlgr r I. L,c;r,n:;e - r_r FMFM r;;Y(,F' # i00 00 r`Py:rWSu]nrignlnw OTHER QT1i£R El CILSEA f-' Fr71.h;YLIMIT x 500,000 BESCRIPTIbNrWOPERATIONSILOCATGNRIVEMMLESfEXCLUSION8ADDED BYENODRBEMENfjRPFc1AI,PROVfgfONg NO PARTNERS ARE COVERED BY THE WORKERS' COMPENSATION POLICY Job: 95 Main St, North Andover MA CERTIFCCATC; unr men SHOULD ANY OF THE ABOVE DESCRIBED POWCS BE CANCELLED BEFORE THE Edward cones Investment EXPIRATION DATE THERMP, THE MglII ,,.INSURER WILL ENDEAVOR TO MAIL Attention Stephanie Palmer 10 DAYS WRt nN NOTICE TO THE CERTIFICATE NOLbER NAMED TO THE LEFT, 1245 33 Kel 1 y Memorial Or BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OALIC-ATION OR LIABILITY Second Floor OF ANY KIND UPON THE INSURER, ITS ArUn OR REPRESENTATIVES St LOUIS, MO 63131 AUTHORIZEDREPRESENTATTVF AC:ORn !FF l7nn-unoi FAY- rSAA%2QA-Ge:ac ©ACORD CORPORATION 1988 2003.112-2103:18 MCWALTER VOLUNTEER Page 2 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." r An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the .occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to,operate�a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." `, Additionally, MGL chapter 152, §25C(7) states "'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for, the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage: Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if youare required to obtain a workers' compensation policy, please call the Department at the .number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town .Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or per it to bum leaves etc.) said person is 1-�OT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number: The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Revised 11-22-06 Fax # 617-727-7749 w.mass-gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents • Office of Investigations d 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers Name (Business/Organization/Individual): vy/L,� A Address: f2 L.7�vz�yN City/State/Zip: Areyou an employer? Cheek the aPpr 1. ❑ I am a employer with ' employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees 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 Phone.#:iQZ '2ej. j. 101/1 late box: 4.7 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have 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 reauired.l Type of project (required):. 6. ❑ New construction 7. Remodeling 8. E] Demolition 9. 0 Building -addition 10.7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Horneow;�ers who subnat this affidavit indicating they aro 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: lS/i u n f u3 S Policy # or Self -ins. Lic. #:' '41e Expiration Date: �' g Job Site Address: f'City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure_ to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coyel e verification. I do hereby certify under t eepginsa penOdes of perjury that the information provided above is true and correct vjj1cial. use only. Do not write in this area, to be completed by city or town official City or Town:' Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4 6. Other, . Electrical Inspector 5. Plumbing Inspector ct Person• Phone #: x w A CSA aG O LE cn v cn 0 � w P., z z or p w O w v .0 U cd G w 0 � w `� p w G w a � a U w w p a4 s 4 c G u. x o a 0 cL G w z w w r. ° 2 mC/) Q O 9 v O a� L Z CLW O y � C w' W cm ca M E m m CD CD .0 � .a 3.0 0 Q C* d cMQ ca o .0"� C cvcc co C Z CD CD V y � C C c CO2 u c c w 30� L O wm-ov c. c c �w J: D o GO m E a LO co o v J Cf) ) : 40 D a H Z E c O-1 c3 o r I V�u CM of -4 o c �p C� aw E L • Z v/ lo � m y r� w` = m .a • ZC y O C Em � Fri CD o a.cJ m 3 1 o:ym� CM V y O p ;oOZ +r :coo a c •O Q i � m C 3o = m � : ams N H W O .O O Z "� m r=-. LL .. c «. O C M .Lm J CD•N Z O v m v cm 1 - l ti a A CD O� OL y g C = O v O a� L Z CLW O y � C w' W cm ca M E m m CD CD .0 � .a 3.0 0 Q C* d cMQ ca o .0"� C cvcc co C Z CD CD V y � C C c CO2 cense TO 10564 nmissioner ` 6912008 15:28 9783710765 NORTON INS PAGE 06107 FDWARD JONES GENERAL NOTFS I. All items are to be completed per Edward Jones Specifications (see Exhibit B) unless noted otherwise. on these pages. 2 CONTRACTOR to field verity all existing conditions; if there are any changes, revisions or discrepancies please tail! 314-515-3936 *Existing and new partition dimension maximum tolerance is 4" unless noted as HOLD. 3. Landlord/Contractor to provide separate HVAC controls for Edward Jones space. 4. Contractor to provide new electrical devices as indicated on plan if on existing device is not within 36" of device indicated.: Do riot remove devices that are existing in remaining walls, unless noted. Verify existing devices are in good working condition. 5_ A switch shall occur at each egress door, and shall be 3 -way if applicable for multiple entrances. 6. Mechanical. Electrical, and Plumbing (MEP) ore ail Design/Buiid; MEP contractors are required to obtain all required drawings, permits, etc. related to their work 7. Contractor to provide and install Exit/Emergency lights as required by local building codes. 8. ONLY IF BOC IS BEING RELOCATED, Contractor to install CAT5E phone lines (number as shown on Sheet 2 of 3) in f conduit as required by local code from building source (OMork) to BOC server location as indicated on plan by symbol. Any requests for modification to these plans must be sent to the Edward Jones Goodknight Coordinator for review & approval before proceeding. No costs will be accepted for unapproved changes. KEY PLAN *PLAN NOT TO SCALE* ** CONTRACTOR MUST HAVE (3) PAGES FOR THIS SET OF DRAWINGS. IF YOU ARE MISSING ANY NOT AVAILABLE PAGES, PLEASE CONTACT DESIGNER AT 314-515-3936 EdwardJones BRANCH FACILITIES BUILDING INFORMATION (STOREFRONT) 2— Story, BRANCH OFFICE 17469 95 Main St. OCCUPANCY USE GROUP: B -Business OCCUPANCY LOAD: 820 sf 0 100sf/Person 9 Persons North Andover, MA 018 LEASE so. Fr. 820 BUILDING OWNER/PROPERTY MANAGER CONTACT:ISSUES Ralph Joyce 508-662--4842 DESIGNER Stephonie Palmer 314--515--3936 RM96 +N& DATE I WSW"" -SW 12MI01 raped close! in tat oar sr� EXHIBIT A IGOODKNIGHT P ROGUR:AMj2W ;2';$o7 NL kN TH PARTITION PLAN 1/8"=1'-0" KEYED NOTES: OINSTALL NEW ELECTRIC AS SHOWN UNLESS EXISTING WITH 36". O2 INSTALL NEW S-0" SOLID CORE DOOR. STYLE, HEIGHT, AND FINISH TO MATCH EXISTING. 3< INSTALL NEW INSULATED PARTITION ON TOP OF EXISTING CARPET AND EXTEND TO CEILING GRID. INSTALL WOOD PANELING TO MATCH EXISTING IN THE HALLWAY. **ALTERNATE BID: INSTALL BI -FOLD DOOR TO CREATE CLOSET. CONTRACTOR NOTES: 1. SPACE IS AN EXISTING EDWARD JONES BRANCH LOCATION & IS CURRENTLY OCCUPIED. BIDS SHOULD TAKE INTO ACCOUNT STAGING (NIGHT & WEEKEND) WORK AS REQUIRED TO KEEP THIS BRANCH OPERATIONAL WHILE THE WORK IS BEING PERFORMED. 2. ALL ITEMS TO BE COMPLETED PER EDWARD JONES SPECIFICATIONS (SEE EXHIBIT B) UNLESS OTHERWISE NOTED. 3.RELOCATE SWITCHING FOR 104 AS SHOWN ON PLAN. 4. INSTALL (OR INSTALL/RELOCATE) 2'X4' FLUORESCENT LAY -IN LIGHTS AS REQUIRED BY NEW PARTITIONS. 5. INSTALL (OR INSTALL/RELOCATE) SUPPLY & RETURN GRILLES AS REQUIRED FOR COMPLETE & BALANCED WORKING SYSTEM. LEGEND: ­: 3 DEMO PARTITION —EXIST. PARTITION ®EXIST. DEMISING PARTITION —NEW PARTITION ®NEW PARTITION/ INSUL. ®NEW DEMISING PARTITION /\ \ EXISTING DOOR NEW DOOR DUPLEX RECEPTACLE QUADRAPLEX RECEPTACLE DEDICATED SIMPLEX RECEPTACLE W/ ISOLATED GROUND TO BE MARKED WITH "D" & ORANGE A SINGLE GANG PHONE/DATA BOX t DOUBLE GANG PHONE/DATA BOX SWITCH E EXISTING o ELECTRICAL PANEL OT THERMOSTAT LOCATION O WATER HEATER EXIT/EMER. COMBO ** CONTRACTOR MUST HAVE (3) PAGES FOR THIS SET OF DRAWINGS. IF YOU ARE MISSING ANY PAGES, PLEASE CONTACT DESIGNER AT 314-515-3936 D—Mark extension work per Detail on sheet 1 of 3. to be completed on the first day of construction. Email photo to Leasing Coordinator to confirm work completion. EdwardJones BRANCH FACILITIES BRANCH OFFICE 17469 15 Main St. Jorth Andover, MA 0184`. LEASE SQ. Fr. 820 ISSUES REVISIONS NO. I DATE I DESCRIPTION -SRP h2/07/01 Added closet in 107 DRAWN BY. SRP EXHIBIT A 314-515-3936 SHEET DATE 12/16/07 2 of -0 01/09/2008 15:28 9783710765 NORTON INS FURNITURE/EDJ EQUIP. 1N 44, EXIST = EXISTING FINISH TO REMAIN MATCH = NEW FINISHES TO MATCH EXISTING NI C. = NOT IN CONTRACT FOR FINISHES NA FINISH NOT APPLICABLE TO THIS ROOM A ACCENT WALL TO BE PAINTED WITH CUSTOM 'EDJ GREEN" SEE BELOW FOR CONTACT INFORMATION EDJ EQUIPMENT „LEGEND (NtC): COMPUTER TERMINAL ID LASER PRINTER W/ DEDICATED OUTLET COPIER/FAX/SCANNER BOC—(Brunch Office Controller) *DIGITAL INDOOR UNIT *INT REC DECODER L_j*PHONE SYSTEM 8 TV/VCR CABINET TV/VCR LOCATION RJRNIIURE ORDERED FOR G F FA CHAIR 2 CLIENT CHAIRS UPHOLSTERY: GREEN + + ALLOWANCE UP TO X300 FOR +}+ LOCALLY PURCHASED 3O'x60" DESK SPACE IS INSUFFICIENT FOR GKBOA NOTE: ALL FURNITURE ITEMS SENT FROM THE EDWARD JONES STANDARD FURNITURE PACKAGE WILL RELOCATE WITH GKFA ** CONTRACTOR MUS - HAVE (3) PAGES FOR THIS SET OF DRAWINGS. IF YOU ARE MISSING ANY PAGES, PLEASE CONTACT DESIGNER NOTES AT 314-515--3936 Edward Jolnes SEE NOTE ;N BRANCH FACILITIES BRANCH OFFICE 174gg ID _. TU ---d 95 Main St, FINISH SPECIFICATIONS North Andover MA 01845 !NISH SCHEDULE RM,NO. 101 PAINT EXIST CARPET BASE EXIST EXIST VC1 N/A 102 EXIST EXIST EXIST N/A 103 EXIST EXIST EXIST N A 104 P3 C8 MATCH 105 EXIST N/A EXIST __N/A EXIST 106 EXIST EXIST I EXIST N/A A ACCENT WALL TO BE PAINTED WITH CUSTOM 'EDJ GREEN" SEE BELOW FOR CONTACT INFORMATION EDJ EQUIPMENT „LEGEND (NtC): COMPUTER TERMINAL ID LASER PRINTER W/ DEDICATED OUTLET COPIER/FAX/SCANNER BOC—(Brunch Office Controller) *DIGITAL INDOOR UNIT *INT REC DECODER L_j*PHONE SYSTEM 8 TV/VCR CABINET TV/VCR LOCATION RJRNIIURE ORDERED FOR G F FA CHAIR 2 CLIENT CHAIRS UPHOLSTERY: GREEN + + ALLOWANCE UP TO X300 FOR +}+ LOCALLY PURCHASED 3O'x60" DESK SPACE IS INSUFFICIENT FOR GKBOA NOTE: ALL FURNITURE ITEMS SENT FROM THE EDWARD JONES STANDARD FURNITURE PACKAGE WILL RELOCATE WITH GKFA ** CONTRACTOR MUS - HAVE (3) PAGES FOR THIS SET OF DRAWINGS. IF YOU ARE MISSING ANY PAGES, PLEASE CONTACT DESIGNER NOTES AT 314-515--3936 Edward Jolnes SEE NOTE ;N BRANCH FACILITIES BRANCH OFFICE 174gg ID _. TU ---d 95 Main St, FINISH SPECIFICATIONS North Andover MA 01845 PLANT sHEIM WOW --BRM 891501+- M -32i -m P3- AGREEARLE GRAY w7m ACMIT HALLS- CUSTOM Tw C( Dr LEASE SQ. FT. 820 I uCs REiASiONS CARPET SW PRMgE LABEL PRODUCT C8 - COL01i 11PW CO FXT RIR AIL FIAORIYG: ROOFSCbtAS 800-282-4957 OR 314-997-3438 NO, WE I DESMOBox 1 -SRP 12M/071 AdW dpwt In 107 NST T1- AWMNG SiAMW }=AN O MMERCWOMPSK 12"X12' 1ANYL C0AMPON ti1F #51911, CLw *ft 72- AWMISTRONO MNNEi:fINl CORLON SHEETwNrt A*m wtm cuffs W ROPPE 4' VIK WE @ASE 81 -pm PEM On swEXHIBIT 314-515-3936 _ - -- A sNa:T 7 PAGE 07/07