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Building Permit #898-14 - 109 MAIN STREET 6/10/2014
' � c NORTH BUILDING PERMIT ��°�s'`c "oA TOWN OF NORTH ANDOVER A6ff APPLICATION FOR PLAN EXAMINATION 41 a Permit NO: l .� Date Received 4 Date Issued: SACHUS�t� IMPORTANT Applicant must complete all items on this page >e 5 109 PR,QR ER :OWN 0'1 411�a u "liky Imfib � NSTII�'C ry IIc�rlc� �t cf q TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building ❑One family ❑Addition ❑Two or more family ❑ Industrial IN Alteration No. of units: 13 Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other t A ❑Sed]c ,. dpl >< �etlan ❑ Wt�rshedc _ w k-I Interior remodel-no change in Use or Occupancy-Floor finish changes-rework Photo lab reloc a few floor fixtures.Add/relo light fixtures Identification Please Type or Print Clearly) OWNER: Name: CVS Caremark,LLC Phone: 401-765-1500 Address: 1 CVS Dr Woonsocket R102895 CONIR-A !oawl6 �if4 .a- _ �h r. 2- x 3 .m $W Ted 1615 N A�#?°tI a ellde;T+ Ct6� s � a vSit lsEk 7& 6h � "fidn Licei � � e7777, 17 .;, t � �� L.F4',�� �,$ 4 ��� � 5 6 ° ' kw a, © e� ARCHITECT/ENGINEER John Mioldgos-WD Partners Phone: 614-634-7000 Address: 7007 Discovery Blvd Dublin OH 43017 Reg. No. 9174 8/31/14 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 35,310.00 FEE: $ 43.q.- Check No.. 1-1? cps Receipt No.: Q1 (0 tp`�3 NOTE: Persons contractiAg with unregistered contractors do not have acce s I'My fund Stgratlfer� x �,. noof, coact ': _s, ,AORTH O� t�eo , '6 BUILDING PERMIT 3? g6�', .'r,6•b�O0 TOWN OF NORTH ANDOVER ° t p APPLICATION FOR PLAN EXAMIN TI N Permit NO: Date Received Date Issued: S^CHUS���9 IMPORTANT: Applicant must complete all items on this page LOCAT Q < 1f39%n St 1 Ander MA G1845 . rint ':_ .. - r< .• �s " ''' a PIOf�;E1 OWNIian baa EaitV ti 3e darnrnes x AVt.Prim:.= f � tlAP JPO _ PARCEL1Q': Z©NIhFG DISTRICT �Nlstorc District Mcm kinehopIla �y Vl ,ge es TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial 19 Alteration No. of units: 13 Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other t et F`116 hi �et�ds D , "I A ershtDis rioJA t " rIa r, ADV mer Al, a Interior remodel-no change in Use or Occupancy-Floor finish changes-rework Photo lab reloc a few floor fixtures.Add/relo light fixtures Identification Please Type or Print Clearly) OWNER: Name: CVS Caremark,LLC Phone: 401-765-1500 Address: 1 CVS Dr Woonsocket R102895 E C0 'TOR Na'Me h6he:gi 16 650 . InLlACl1 clGwill nC a.a .. .. 1f 1 fi M7 i ii efence,fir,664` 6 :. SMp,e� �rs Ccstructll Lreese °Exp3ete . 1.;:•E [iJ £ t' xf fto en., y kde"p :XP to Pa ARCHITECT/ENGINEER John Mioldgos-WD Partners Phone: 614-634-7000 Address: 7007 Discovery Blvd Dublin OH 43017 Reg. No. 9174 8/31/14 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $— 0 3S,26 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access t the guaranty fund ighature"of Agoht/Owne>" Sl nature ofi cantrac n !� TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION _ Print. PROPERTY OWNER Print loo Year Old Structure yes no MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT, PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date:- ARCH ITECT/EN GI NEER ate:ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Y Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner �- Signature of contractor Plans Submitted Fj Plans Waived ❑ Cervied r-lot Plan ❑ Stamped Plans v w -: Plans-Submitted ❑ -`Plan s Waived 0_- ;_.Certified Plot Plan ❑ Stamped Plans ❑ TYPE—OF SEWE GE-DISPOSAL' .Public Sewer ❑ Tanning/Massage/BodyArt ❑ Swimming Pools ❑ Well ❑ . .Tobacco Sales ❑ Food Packaging/Sales ❑ Private-(septic tank,etc._ ❑ = Permanent Dempster onsite THE_FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED . DATE-APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on_ Signature COMMENTS HEALTH Reviewed on Signature COMMENTS I j Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: :Comments Water'& Sewer Connection/Signature c Date - Driveway Permit DPW'ToNvO ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTRF.; IT - Temp Dumpster on site yes no Located-at 124 Mair Street -Fire Depgrtine►it-signature/date`' COMMENTS � L Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. _Total land-area; sq. ft. ELECTRICAL: -Movement of.Meter.locatFon, rr ast-or service drop requires approval of :Electrical Inspector Yes No DANGER ZONE LITERATURE: -Yes No MGL.Chapter166.Section 21A--F and G min.$100=$1000.fine NOTES and DATA— (For department use ..vr'r I El Notified for pickup - Date I Doc.Building Permit Revised 2010 Building Department :_The following i"s-a list of-the requited.forms to be filled out for.:the appropriate.permit to be obtained. Roofir;,g, Siding, Interior Rehabilitation Permits o B.ailding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I:C. And/O'r-C.S.L Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits Fi require sign off from q g ire De artm p ent prior to Issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan a 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 a 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 ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals that the apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Building permit Revised 2012 T _ a M 0 �5 Location No. Date ('110 l • • TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $�-c Foundation Permit Fee $ Other Permit Fee $ TOTAL $ q Check X1 3(o L" r �JBUilding lnspectgfi Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 35,310.00 m $ - $ 423.72 Plumbing Fee $ 52.97 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 52.97 Total fees collected $ 629.65 109 Main Street - CVS 898-14 on 6/10/2014 CVS Remodel i i � NORTF/ own of A 0o h ver, Mass 10A COC MIC Mf WICK 01. R�TEO U BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT .......... PERMIT RtL , BUILDING INSPECTOR �®q + a Foundation has permission to erect .......................... buildings on . ...... .......... .................................. temAmAw Rough p' u"�..... y t0 be OCCU led as ....... ....... ..................................................................... Chimney provided that the person accepting this permit shall in eve respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and2By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ................ .... .���:{ �.....,....................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in .a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. OP ID: MS CERTIFICATE OF LIABILITY INSURANCE DATE04/04/201 Y) 04/0412014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Gliem&Associates Insurance NAME: Mary Schneider John Ryan aCNN E,�:913-744-2242 ac Nu:913-681-1305 8717 WY 110th St.,Ste 420 E-MAIL id hneer Overland Park,KS 66210 ADDRESS:mschneider@ggins.net PRODUCERProperty&Casualty Brokerage CUSTOMER ID#:DIAMO-3 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Diamond Contractors, Inc. INSURER A:Hartford Fire Insurance Co. 19682 1615 N.7 Highway INSURER B:Twin City Fire Ins Co 29459 Independence,MO 64056-4035 INSURER C:New York Disability INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL BR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A NCOMMERCIAL GENERAL LIABILITY X 37UUNQT9237 12/09/2013 12/09/2014 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,00 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A X ANY AUTO 37UUNQT9237 12/09/2013 12/09/2014 (Ea accident) $ 1,000,00 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) $ X NON-OWNEDAUTOS HCar PHY $ 75,00 X HNO Ded$1,000 $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 9,000,00 EXCESS[ CLAIMS-MADE AGGREGATE $ 9,000,00 A 37RHUQT9239 12/09/2013 12/09/2014 DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPNSATIONTH- AND EMPLO ERSEL LIABILITY X ORY LII ITU TS OER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y I❑NN N/A 37WBQT9238 12/09/2013 12/09/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA E4PLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 A Leased&Rented 37UUNQT9237 12/09/2013 12/09/2014�LR Limit 100,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is rewired Limits shown are those in effect as of policy inception, RE: CVS #8129 �95 South Broadway, Lake Orion, MI 48362 CVS Caremark, Inc. , its directors, officers, employees and shareholders, and CVS Caremark Landlord, if any, are named additional insured for above job. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CVS Caremark THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CVS#8129 ACCORDANCE WITH THE POLICY PROVISIONS. 1CVS Drive Woonsocket, RI 02895 AUTHORIZED REPRESENTATIVE t� ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD t CVS'Re"11ty CO, One CVS Drive ' Woonsockal•R! 02895 -. _. •401.785.1500 - Do not change the formulas- -- _ - SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM By accepting this bid invitation and submitting your bid you are confirming you have read and agree to all bid documents Including but not limited to Invitation to Bid,Contractor code of conduct,Contractor Qualification Questionnaire,Invitation to Bid-General Instructions,CVS Project Specific Drawing Package Including specifications. CS Project Number - -_ 84145 Date 5119/2014 Stour Number -- - 209 - - Project Category 103 Main St.,N. Full Addristl,st2,dty,st,sip,country) Andover,MA 01845 Project Type Remodel -- -- - Cap Codo BM Documents - -- -. --- - Total - - - - - __- -- - GC NAI FIFE Costs -- aids-Due Date - -. - .Total Contract __ W19l2014 Constructlon Start Date: - CVS NAI FFE Costs In Service Date 1A&E Services -Area Dlrectoi of Consfruction - Project Managar _ Store Sot Up Setup Manager Project Total - - General Contractor Name Lori P .Original Budget - - Genorol Contractor Company Diamond Con radors Inc. Variance b Singlo eld7_ - - Varbrieo% _ - - Quallnoci eid7 -- - - i - - - royal Comments - - - S.OX so BUILD.EXTJSITE WORK _ __ $0 PHARMACY - $4.510 - VESTIBULE _- $0 1EMPLOYEEAREA S0 CHECKOUT - $�0 - RECEIVING AREA E0 PHOTO LAB - _ $8.250-_ RESTROOMS $0 MINUTE CLINIC _ $0 1GEN.CONDITIONS $3.500 RETAIL - - $15,040 - Ovarhead I ProOt 53.210 -- - -. -. Taxes $0 - __ -- -- Insurance $0 _. Description _ Material Labor Old Amount Comments _ - - Total of Material BUILD.EXT -- -- JJ - - -- - - J SRE WORK - - Total of Lobo/ (Total Of Division - Tatal ADA Costa=50 __. __ r,-,:�i!i�liy"���`;iSS P'S:r:;" '�%JYt'1•::r :I��j:!fi• ,.! Paving 8 Surf--m Fences d Gates_ - 0 0 - - - -- Cc=Rostr/Clean 0 !- Mortar - - 0 0 - Masonry Accessories 0 0 - - Unit Masonry - 0 0 - - Stony Cast 0 0 _ Masonry Restore0eaning - - 0 0 - - EnUanoW Storefronts - 0 0 - - Roofing/Mold Trim o p - - -- !--- EIFS I STO 0 - DrywaO Avood blodd. 1plywood 10 VESTIBULE - - (Total of Material iTotal of Labor Total Of Olvislon ICommenta -- .. ..:........!..,;:•. . :,,,.:;:•:�;. _�;:;: ,;::...:�-:.: co __ DA �ftn 10 10 its i cvsilealt�� __.. One CVS Drive WoonsodeL RI 02895 _ 401.765.1500 Do not change Ore fomnAas _ - --- - -- SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM Cleanup 0 0 Laminate 0 0 Air Barriers 0 p MSulaban 0 0 - Door Installations 0 0 Special Doors 0 p Well Prep 0 0 - GWB Ceiling - --- 0 p - Acoustical Ceilings 0 0 Vary!Base 0 0 --.-;- Ftoor Prep 0 0 - caw 0 Pa�,ti„g 0 0 Wau Covertnps — 0 0 Asbestos Abatemem -0 0 Fire Protacbm -- 0 0 HVAC 10 0 - Electrical 0 0 I CHECKOUT -TotalolMaterial Total of Labor ITotalOfDlVlsion iComments Total ADA costs=$0 Demolition 0 - 200 Cleanup - -- 0 0 -- Roup Carp" 0 0 Finish Carperhtry- - -- 0 0 ---- laminate 0 0 - - --- Gypsum Board-Interior 0 0 Wall Prep --- - -0 p Acoustical Ceilings 0 p - — Vmyt Base 0 p Floor Prep 0 0 Carpet - 0 800 - -_ Painting - 0 0 - Asbestos Abatement 0 0 Fire Protection -- 0 p HVAC 0 0 Electrical 10 p Communications 0 0 - - ----j Cash Drop boxes 10 0 PHOTO LAB Total of Material Total of Labor Total Of DlWslen Comments - - — yr;/7"'.%'.': ..`;;iTO =.::'';'.. .•• 0>GB0`-_ .. Total ADA costs=f0 Demolition 0 low Cleanup — --- 0 0 Water Distribution 0 p Concrete Cutting 0 0 Cast-in Place Concrete _ — 0 0 Finish Carpentry p p - Millwork 040 980 _._.. Laminoter Plastic Fabrications O p --- Gypsum Board•Intedar 0 p - - --- Won Prep - - 0 0 Aeousbeet Ce rVw - p 0 — VCT 0 350 Vinyl Base _ 0 O --- Floor Prep - - 0 0 -- Pointing - 0 0 - Won Coverings 0 0 - i CVS'Rcalty Co. _... One CVS Drive , Woonsocket,RI 02895 -I X401.765-1500 } I Do noi change the formulas SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM Fire Extinguishers 0 0 Manufactured Casework 0 0 Asbestos Abatement O 0 Fire Protection 0 0 Plumbing 0 0 HVAC 0 0 Electrical 1980 11695 Communications 1980 11746 MINUTE CLINIC Total of Matorlal Total of Labor Total Of Division Comments 0 0 0 Total ADA costs=$0 Demolition 0 0 Cleanup 0 0 _ Water Distribution 0 0 Concrete Cutting 0 0 Cast-in Place Conaoic 0 0 -- Finish Carpentry 0 0 - Millwork 0 0 Laminate/Plastic Fabrications 0 0 Gypsum Board-Interior 0 0 Wag Prep - 0 0 Acoustical Callings 0 0 VCT 0 0 Vinyl Base 0 0 Floor Prep 0 0 Painting 0 0 Wail Coverings 0 0 Fire Extinguishers p 0 Manufactured Casework 0 p Asbestos Abatement 0 0 Fire Protection 0 0 Plumbing 0 0 HVAC 0 0 Electrical 0 0 Communications 0 0 RETAIL !Total of Material Total of Labor Total Of Division Comments ?4B0' 12560 15040 Total ADA costs=$0 Demolition!(old welkin cooler demo) 0 1000 Cleanup 0 0 Finish Carpentry 0 0 MdMft 1320 1880 Laminate/Plastic Fabrications 0 0 Metal Doors and Frames 0 0 Metal Windows 0 0 Gypsum Board-Interior 0 0 wan Prep 0 0 GWB Ceiling 0 0 Acoustical Ceilings 0 0 VCT 0 350 Vinyl Base- - 0 0 Floor Prep 0 0 Carpet 0 0 Painting 0 0 Asbestos Abatement 0 0 Elevators 0 0 Lifts 0 0 Mechanical Insulation 0 0 Fire Protection 0 0 Plumbing 0 0 r Cv$ Rcalty Co. _One CVS Drive ' Woonsocket.RI 02895 ,4017651500 Do not change the formulas SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM - HVAC 0 0 Controls 0 0 Electrical 1160 3740 Communications 0 0 Cart Corral p 0 Walkin Cooler(materia!labor) _ 0 0 Gondola train-relocate/slide gondolas 10 15490 S.O.A. Total of Material Total of Labor Total Of Division Comments 0 0 0 Total ADA costs=$0 Demolition 0 0 Cleanup _ 0 0 Mdhvork 0 0 Lamlrtatel Plastic Fabrications 0 0 Door installations 0 0 Gypsum Board•Interior 0 E0_ F Watt Prep 0 Acoustical Ceilings 0 Vinyl Base 0 Floor Prep p Carpet p Painting 0 0 Asbetos Abatement 0 0 HVAC 0 0 — Controls 0 0 — Electoral 0 p Sound System 0 0 Ctock 8 Program System 0 0 Comm inice6ons 0 0 Modify fire suppreslon system 0 0 Temp mlo MGR to Bmakroorn _ 0 0 R_elocoto Verbw Phone system — 0 0 _ Relocate/Reduct HVAC for office 0 p Roof penetration for Welkin or HVAC 0 10 PHARMACY Total of Material Total of Labor Total Of D!vlslon Comments 0 4510 4810 ITotal ADA costs=So Dema'fron 0 000 Cleanup 0 0 Flow TrendVExcavation 0 0 Materials(carpentry) 0 0 Cutting 8 Patchingconcreto 0 p Misc.Metal 0 0 Rough Carpentry 0 0 Finish Carpentry 0 0 Millwadc•Install only 0 0 -- Laminate 0 0 Door Installations 0 0 - Gypsum Board-Interior p 0 Wag Prep 0 0 _ Acoustical Ceirmgs 0 0 Vinyl Base 0 0 _- Floor Prep 0 0 Carpel-install only 0 3910 Painting _ p 0 t - Chalkbrds/Tackbnds _ 0 0 Asbetos Abatement - 0 0 Fire Protection(sprinkler) _ 0 0 Plumbing 0 0 - - CVSR( 1�('<(lt1' Co. One CVS Drive Woonsocket.RI 02895 401.765.1500 Do not change Oro fomn las SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM HVAC 0 0 Electrical 0 0 Communications 0 0 RX Gntlo 0 0 Scanmaster 0 0 Cash Drop boxes 10 10 EMPLOYEE AREA Total of Material Total of Labor Total Of Division Comments 0 0 0 1 Total ADA Costs n SO Demolition 0 0 Cleanup 0 0 Rough Carpentry_ _ _ 0 0 Finish Carpentry 0 0 M7Mrork 0 0 DaolslFrarnos - - — 0 0 Gypsum Board•Interior 0 0 Acoustical Ceilings - 0 0 VmylBase 0 0 Floor Prop 0 0 Carpel•insia0 only 0 0 Panting 0 0 Asbetos Abatement O 0 Plumbing 0 0 Electrical 0 0 HVAC 0 10 RECEMNG AREA Total of Material Total of Labor Total Of Division Comments Total ADA Costs=SO Demolition 0 0 Cleanup 0 0 Cast_M Place Concrete 0 0 Cutting&Patching 0 0 Meted Fastening 0 0 -" Structural Metal Framing 0 0 Metal Joist 0 0 Metal Decking 0 0 Cold-Form Metal Frame 0 0 - Mise.Metal 0 0 I - Finish Carpentry - 0 0 - - Insulation 0 0 - Flashing&Shoot Metal 0 0 Joint Sealon - O 0 Metal Dann aid Frimss O 0 - Floor Treatment O 0 Special Coatings 0 0 Painting D 0 Loading Dock Equipment 0 0 Asbetos Abatement 0 0 Scaffolding 0 0 Basic Mach Mater&Methods 0 0 Fire Protection 0 0 Plumbing 0 0 HVAC 0 0 Basic Elect Mat&Methods 0 10 RESTROOMS - Total of Material Total of Labor !Total Of Olvislon [Comments Demolition o 0 ' - 0 °Total ADA Costa $0 - Cleanup 0 0 Cutting 8 Patching-concrete 0 0 S'llealty Co: SINGLE SPECIAL PROJECT GENERAL—CONTRACTOR BID FORM 0— n,lanvork -0 0 0 Gypsum Board-Interior 0 0 _0 0 0 0 Ra;T t Fborfng IVU0BQss--__._a 0 Eb—H P(" 0 0 PaInting 0 0 Loleu Bath Acega9. 0 0 Asbetos Abatement 0 HVAC Eted ricaj 0 GEN.CONDMONS li-061 0i_Motorial ictal-a-l-Labo—rjai To Of Division :Comments -3500 35W 7 7. ITotal ADA cos =$0 at w .__ _ _ —. —-P- iom Vos 0 0 Project Hager 0 0 Field Suprvislon 0 0 Parking/Travel 0 Permits 0 0 Material&G44ment 0 Maintenance 0 Demobtion 0 0 Cleanup 0 0 3500 Dumpsters 10 �Sub_Total,_,_ 32100, Overhead I Profit 3210 ITaxes 0 Insurance 0 Total GC Bid Amount ns On PrOlOct Manager Offica:401.770-72821 mobile:40t.524-0743 I address:I CVS Drive,Woonsocket,RI 02896 i small:johnjajjj&pgCVSCoroma&cOM Signori Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8t" edition of the Massachusetts State Building Code, 780 CMR, Section 107 p�M SVOv Project Title: INTERIOR REMODEL -CVS, Store #00209 Date:09 May 2014 Property Address: 109 MAIN STREET,NORTH ANDOVER, MA 01845 Project: Check(x) one or both as applicable: New construction X Existing Construction Project description: SALES AREA: Update wall graphics;paint walls;new floor finish; reconfigure photo lab; relocate/replace sales fixtures; minor relocation/add of lights&power poles. I John Miologos MA Registration Number: 9174 Expiration date: 08.31.2014 , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning': X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or P�G�StERED.,tq electronic signature and seal: �pµN M101pcy�� Ab. o � Phone number: 614.634.7176 Email: david.morrison@wdpartners.com----' OFMA Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an `x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen, Provide a description. Version 06 11 2013 Massachusetts - Del}ailment (if Public S lf'ets Bom-d of Buil€lin-2 Rea-Mations and Statntlal-ds Construction Supervisor License License: CS 105576 . .. ,JOHN PERRY 1615 N M7 HIGHWAY INDEPENDENCE, M© 64456 Expiration: 9/3/2013 t i� i>d +ie'r Tr=: 105576 1 Commercial Property Record Card PARCEL ID:210/029.0-0048-0000.0 MAP:029.0 BLOCK:0048 LOT:0000.0 PARCEL ADDRESS:109123 MAIN STREET FY:2014 SKETCH PHOTO 23 .. � 32 1W2 q. 121D 138 e , { 48 6 149 39 � 3� SR 52 52q. 1 6 J <i ixt 61 B1 � .:, .. 1 -'� -4,z"4 1 � �� � �. . Sq.Ft 46 46 109 123 MAIN STREET '• F 42 Ft s .�•, _... i III Parcel ID:210/029.0-0048-0000.0 as of 5/14/14 Page 2 of 2 I Commercial Property Record Card PARCEL_ID:210/029.0-0048-0000.0 MAP:029.0 BLOCK:0048 LOT:0000.0 PARCEL ADDRESS:109123 MAIN STREET FY:2014 PARCEL INFORMATION Use-Code: 323 Sale Price: Q `.- _ Book: W01 11&"':a Road Type: T Inspect bate: 0..5/3012012 Owner: Tax Class T Sale Date: 12/31/68 Page` 0403 Rd Condition: P Meas Date: 05/3072012 SAN LAU REALTY Tot Fin Area,: :;,X65802 Sale Type::. , � _ 'Cert/Doc � � �� Traffic:. � M Entrance:. C/O THE MEG COMPANIES Tot Land Area: 3.35 Sale Valid. N ,, Water: Collect Id: RRC _ __.. _ Address: Grantor Sewer:. Inspect Reas: C, 25 ORCHARD VIEW DRIVE LONDONDERRY NH 03053-3376 Exempt-B/L% / Resid-B/L% / Comm-13/1-1190/1 00 Indust-B/L% / Open Sp-B/L% / COMMERCIAL SECTIONS/GROUPS LAND INFORMATION Section: ID. 101 Use-Code: 323 NBHD CODE: 35 NBHD CLASS: 5 ZONE: GB Category Gr6d-F14-reaStary Height.Bldg=Class Yr-Built Eff-Yr-Built Cost Bldg Seg-"- Type Code IVlettiod Sq-Ft Acres Influ-Y/N Value Class 2 18116 1.0 C 1967 1982 1,191,500 1 P 323 S\ 145893 3.349 598,161 Groups: DETACHED STRUCTURE INFORMATION Id Cd B-FL-A Firs Unt 1 323 18116 1 0 Str .Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%Good P/F/E/R Cost Class 2 323 1520 1 0 AS S 93000 0.00 1972 A A 50/150 113,900 3 3 323 680 1 0 LI C 11 0.00 1972 A A H170 13,700 3 VALUATION INFORMATION Section: ID: 102 Use-Code: 323 Current Total: 4,801,500 Bldg: 4,203,300 Land: 598,200 MktLnd: 598,200 Category Grnd-Fl-Area8toryHeight Bldg-CTass,Yr-Built Eff-Yr-Bui It.Cost Bldg Prior Total: 4,801,500 Bldg: 4,203,300 Land: 598,200 MktLnd: 598,200 2 17022 1.0 C 1967 1982 1,038,400 Groups: Id Cd B-FL-A Firs Unt 1 323 17022 1 0 Section: ID: 103 Use-Code:323 Category Grnd-F1 AreaStory Height Bldg-Class*-Built. Eff-Yr-Built Cost Bldg ; 2 7116 2.0 D 1986 1986 1,068,900 Groups: Id Cd B-FL-A Firs Unt 1 323 7116 2 0 Section: 0: 104 Use-Code: 323 Category`. Gr id-Fl-AieaStory Height Bldg-Class'Yr-Built Eff-Yr-Built Cost,Bidg". 2 13008 1.0 D 2007 2007 918,000 Groups: Id Cd B-FL-A Firs Unt 1 325 13008 1 0 Parcel ID:210/029.0-0048-0000.0 as of 5/14/14 Page 1 of 2 Premises,it being understood that the purposes for which transferee;intends to use the premises may not be in violation of this Leasc; (iii) a transfer viii result in there being more than a reasonable and safe number of occupants per floor within the Premises,including Tenant and all transferees; thereof);or (iv) the proposed transferee is either a government(or subdivision or agency (v) Tenaais in default under this least:beyond any applicable curt:period. (g) If Landlord shall grunt consent: (i) the terms and conditions of this Lease,including;among oder things, Tenant's liability for the Premises,shall in noo way be deemed modified,abrogated or amended; (ii) the consent shall not be deemed a consent to any further transfer by either "Tenant or any transferee; (iii) such consent shall not relii°vc any Guarantor of its obligations under any gnranty or this[,erose. (h)Exnenscs of Consctzt. "Tenant shall Tay Landlord Landlord's expenses tipt not more than$1000.00,for each transfer submitted to cover the legal,review and processing expenses of Landlord,irrespective of whether Landlord shall grant consent.() Fail=to Comply. Any arrangement for a transrer which is not in compliance with the provisions of this Article IS shall be of no effect and void. Landlord shall not be obligated to pay any fees,commissions or amounts in respect of any transfer unless Landlord shall agree to such obligation in writing. a Tenant hereby assigns,and Tenant shall pay over,to Landlord,50%of any increase in rent which Tentattt is entitled by reason of any subletting under this Article 15 which is in excess of the monthly Fixed Rent and additional rent payable by Tenant hereunder,such excess to be payable as and when received after first subtracting Tenant's out of pocket reasonable costs in such subletting,such as legal and broker's fees and advertising. ALTERATIONS- 16. Tenant shall not make any structural or exterior ulteradons to the Building without,in each instance, obtaining Landlord's tvlitten consent, which consent Landlord agrees not to unreasonably withhold,delay on condition. However,Tenant may, without Landlord's consent, matte non-structural alterations to the Building;interior which in any 12 month period do not exceed $100,000 in cost. 15 IN WITNESS WHEREOF,Landlord and Tenant have duty executed this Lease on the day and year first above written. LANDLORD: ATTEST/WIT'NESS: PETERS STREET REALTY,LLC -mcBY: N :Irving E.Rogers,III TITLE:Manager TENANT: ATTEST: TURNPIKE STREET CVS,INC. BY: ' .ti• ASSISTANT SECRET F lS!.HALL VICE PRESIDENT CVS LEGAL APPROVAL: I 34 Do not change the formulas - SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM By accepting this bid invitation and submitting your bid you are confirming you have read and agree to all bid documents including but not limited to Invitation to Bid,Contractor code of conduct,Contractor Qualification Questionnaire, Invitation to Bid-General Instructions,CVS Project Specific Drawing Package including specifications. CS Project Number 84145 Date 5/19/2014 Store Number 209 Project Category 103 Main St.,N. Full Addr(stl,st2,city,st,zip,country) Andover,MA 01845 Project Type Remodel Ca Code Bid Documents Total GC Bid Amount GC NAI FIFE Costs Total Contract '7777 y =-- Bids Due Date: 5/19/2014 Construction Start Date: _ CVS NAI FFE Costs In Service Date _ A&E Services Area Director of Construction Project Manager Store Set Up Setup Manager Project Total General Contractor Name Lori Perry Original Budget General Contractor Company Diamond Contractors Inc. Variance$ r Variance% Single Bid? Qualified Bid? Approval Comments — — — - S.O.A. -- BUILD.EXT./SITE WORK $0 - PHARMACY $4,510 VESTIBULE $0 EMPLOYEE AREA $0 CHECKOUT $800 RECEIVING AREA _ $0 PHOTO LAB $8,250 RESTROOMS $0 MINUTE CLINIC $0 GEN.CONDITIONS $3,500 RETAIL $15,040 Overhead/Profit $3,210 Taxes $0 Insurance $0 Description Material Labor Bid Amount Comments BUILD.EXT./SITE WORK Total of Material Total of Labor Total Of Division Total ADA costs=$0 Paving&Surfacing 0 0 Fences&Gates 0 0 Concr Restr/Clean 0 0 — Mortar 0 0 Masonry Accessories 0 0 Unit Masonry 0 0 - Stone Cast 0 0 - Masonry Restore/Cleaning 0 0 Entrances/Storefronts 0 0 - Roofing/Metal Trim 0 0 EIFS/STO 0 0 Drywall/wood blocking/plywood 0 10 — VESTIBULE Total of Material Tabor Total Of Division Comments t 0 411 � Total ADA costs=$0 Demolition 0 0 - Cleanup 0 0 Laminate 0 0 Air Barriers 0 0 Insulation 0 0 Door Installations 0 10 Special Doors 0 0 Wall Prep 0 0 Do not change the formulas SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM - Painting 0 - 0 -- -- -- Asbetos Abatement 0 0 HVAC 0 0 Controls 0 0 - Electrical 0 0 - Sound System 0 0 Clock&Program System 0 0 - Communications 0 0 - - - Modify fire suppresion system 0 0 -- - Temp relo MGR to Breakroom 0 0 -- - Relocate Vertical Phone system 0 0 Relocate/Reduct HVAC for office 0 0 — Roof penetration for Walkin or HVAC 0 0 PHARMACY - - -_ Total of Material Total of Labor Total Of Division �Comments 0 �� 46f0 ..,.., $690^- - N Total ADA costs=$0 Demolition _ 0 600 Cleanup 0 0 Floor Trench/Excavation 0 0 Materials(carpentry) 0 0 Cutting&Patching-concrete 0 0 Misc.Metal 0 0 Rough Carpentry _ 0 0 Finish Carpentry 0 0 - -- Millwork-install only 0 0 Laminate 0 0 Door Installations 0 0 - Gypsum Board-Interior 0 0 - Wall Prep 0 0 - Acoustical Ceilings 0 0 Vinyl Base 0 0 - Floor Prep _ 0 0 --- - - - - --- Carpet-install only 0 3910 --i - - -- - - Painting 0 0 - - Chalkbrds/Tackbrds _ 0 0 - A_sbetos Abatement 0 0 - - - Fire Protection(sprinkler) 0 0 - - Plumbing 0 0 - -- - --- -- - -- -- HVAC_ _ 0 0 -- - - - - - - Electrical 0 0 Communications 0 0 - - -- RX Grille - 0 0 - - - - Scanmaster 0 0 Cash Drop boxes 0 0 - EMPLOYEE AREA Total of Material - Total of Labor Total Of Division Comments 0 :. dx Total ADA costs=$0 Demolition 0 0 - Cleanup - 0 0 - -- - Rough Carpentry 0 0 Finish Carpentry 0 0 - - _ Millwork - -- - -- 0 p - - -- --- - - - Doors/Frames 0 0 — Gypsum Board-Interior 0 0 - Acoustical Ceilings 0 - Vinyl Base 0 0 - Floor Prep 0 0 - - -- -- Carpet-install only 0 0 - - Asbetos Abatement 0 0 -- - - Plumbing— - -- 0 - Electrical -- - - 0 HVAC-- - ---0 RECEIVING AREA Total of Material Total of Labor Total Of Division comments % Total ADA costs=$0 - - - Demolition 0 0 - - - -- - - - - - Do_not-change the formulas I - SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM ~ Cleanup 0 0 Cast-in Place Concrete 0 0 Cuffing&Patching _ 0 0 Metal Fastening 0 0 Structural Metal Framing_ 0 0 _Metal Joist _ 0 0 Metal Decking 0 0 - Cold-Form Metal Frame 0 0 --- Misc.Metal - 0 0 - - --- - - - - Finish Carpentry 0 0 Insulation 0 0 Flashing&Sheet Metal 0 0 Joint Sealers 0 0 Metal-Doors and Frames 0 0 Floor Treatment 0 0 Special Coatings 0 0 - - - Painting 0 0 - - - - - - - - -- - Loading Dock Equipment 0 0 ----- - - - - - - - - - Asbetos Abatement 0 0 - Scaffolding - - 0 0 - ------ . - -- - - Basic Mech Mater&Methods 0 0 l Fire Protection 0 0 Plumbing 0 0 HVAC 0 10 -- - - -- - - Basic Elect Mat&Methods 0 10 RESTROOMS Total of Material Total of Labor Total Of Division IComments 0 r.. 0: .. 0� :. <._ Total ADA Costs=$0 Demolition 0 0 Cleanup 0 0 Cutting&Patching-concrete 0 0 Finish Carpentry 0 0 Millwork - - -0 0 --- -- - - -- Laminate/Plastic Fabrications 0 0 t Door Installations 0 0 - - Gypsum Board-Interior 0 0 ---- - Wall Prep - 0 0 --- - - - - Acoustical Ceilings 0 0 - - Resilient Flooring 0 0 - Vinyl Base 0 0 - Floor Prep 0 0 -- - Painting 0 p - - - - -- - -- Toilet/Bath Access. 0 0 - - Asbetos Abatement 0 0 - Plumbing 0 0 - - - -- -- - I HVAC 10 0 - Electrical 0 p -- - - - - - - GEN.CONDITIONS - Total of Material Total of Labor Total Of Division Comments Total ADA costs=$o Alternates/Altematives 0 0 "-- -- - Project Manager 0 0 - Field Supervision 0 0 - - -- - -- Parkingfrravel 0 0 Permits _ 0 0 -- -- - Loading/Unloading 0 0 - Material&Equipment 0 0 Maintenance 0 0 Demolition 0 0 Cleanup _ 0 0 - Dumpsters - - -- 0 3500 - -- --- - - --- - Painting 0 0 - - - + -- - - - - -- --- - -- --- —--- - - --- Sub Total77777-7 -- — -- - Overhead l Profit - 3210 -- - - - _ Taxes - -- - 0 - - - �Insurance _ - - 0 —- Do not change the for j SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM Cast--in-Place Concrete 0 0 Finish Carpentry 0 0 Millwork 0 0 Laminate!Plastic Fabrications 0 0 Gypsum Board-Interior 0 0 -- Wall Prep_ 0 0 Acoustical Ceilings 0 0 VCT _ 0 0 - - - Vinyl Base 0 0 Floor Prep 0 0 Painting i 0 0 Wall Coverings 0 0 Fire Extinguishers - - - 0 0 --- --- ----- ----- - Manufactured Casework 0 0 - Asbestos Abatement 0 0 Fire Protection 0 0 Plumbing_ 0 0 HVAC 0 0 Electrical 0 0 - - Communications 0 0 RETAIL Total of Material Total of Labor T Division Comments Total ADA costs $0 -- Demolition/(old walkin cooler demo) 01000 + -- Cleanup -- - 0 0 -- - - - -- + - - Finish Carpentry 0 0 - - Millwork 1320 1980 -- Laminate/Plastic_Fabrications 0 0 - Metal Doors and Frames 0 0 Metal Windows 0 0 -- Gypsum Board-Interior 0 0 Wall Prep 0 0 GWB Ceiling 0 0 Acoustical Ceilings 0 0 VCT 0 350 - Vinyl Base 0 0 Floor Prep 0 0 Carpet 0 0 - Painting 0 0 Asbestos Abatement 0 0 Elevators 0 0 ---- Lifts 0 0 - -- - -- - Mechanical Insulation 0 0 - Fire Protection 0 0 - - Plumbing 0 0 - ---- -- HVAC 0 0 - - - -- - Controls 0 0 — Electrical 1160 3740 Communications 0 0 --- - - - Cart Corral 0 0 --- - Walkin Cooler(materila/labor) 0 0 - -- Gondola train--relocate/slide gondolas 0 5490 - -- I S.O.A. Total of Material Total of Labor Total Of Division Comments - --- � 2,Total ADA costs=$0 Demolition 0 0 -- -- -" -- Cleanup 0 0 - Millwork 0 0 Laminate/Plastic Fabrications 0 0 - - - Door Installations 0 0 - Gypsum Board-Interior 0 0 Wall Prep 0 0 Acoustical Ceilings 0 0 - Vinyl Base 0 0 Floor Prep 0 0 - Carpet 0 0 - Donot change the formulas SINGLE SPECIAL PROJECT GENERAL CONTRACTOR BID FORM GWB Ceiling 0 0 Acoustical Ceilings 0 0 Vinyl Base 0 0 Floor Prep 0 0 Carpet 0 0 Painting 0 0 Wall Coverings 0 0 Asbestos Abatement 0 0 Fire Protection 0 0 HVAC 0 0 Electrical 0 0 CHECKOUT Total of Material Total of Labor Total Of Division Comments 0 Total ADA costs=$0 Demolition 0 200 Cleanup 0 0 Rough Carpentry 0 0 Finish Carpentry 0 0 Laminate 0 0 Gypsum Board-Interior 0 0 Wall Prep 0 0 Acoustical Ceilings 0 0 Vinyl Base 0 0 Floor Prep 0 0 Carpet 0 600 Painting 0 0 Asbestos Abatement 0 0 Fire Protection 0 0 HVAC 0 0 Electrical 0 0 Communications 0 0 Cash Drop boxes 0 0 PHOTO LAB Total of Material Total of Labor Total Of Division Comments 56W Total ADA costs=$0 Demolition 0 1000 Cleanup 0 0 Water Distribution 0 0 Concrete Cutting 0 0 Cast-in Place Concrete 0 0 Finish Carpentry 0 0 Millwork 640 960 Laminate/Plastic Fabrications 0 0 Gypsum Board-Interior 0 0 Wall Prep 0 0 Acoustical Ceilings 0 0 VCT 0 350 Vinyl Base 0 0 Floor Prep 0 0 Painting 0 0 - Wall Coverings 0 0 Fire Extinguishers 0 0 Manufactured Casework 0 0 Asbestos Abatement 0 0 Fire Protection 0 0 Plumbing 0 0 HVAC 0 0 - Electrical 980 1595 Communications 980 1745 MINUTE CLINIC Total of Material Total of Labor Total Of Division Comments Total ADA costs=$0 Demolition 0 0 Cleanup 0 0 - Water Distribution 0 0 - Concrete Cutting 0 0 r' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Waskington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibiv Name (Business/Orpnirntion/Individualy Diamond Contractors Inc Address: 1615 N. 7 Hwy Cit}'/State/Zip: Independence, MO 64056 Phone#: 816-650-9200 Are}ou an employer?Check the appropriate box: Type of project(required): I.0 1 am a employer with 15 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. �• ®Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'camp.insurance. Y9. [:]Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its 10❑Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myseif.(No workers'comp. c. 152.§1(4),and we have no 12.❑Roof repairs insurance required.) employees.(No workers' 13,❑Other comp.insurance required.) •Any applicant that checks box 01 must also rdl out the section below showing their%%=hens'convmsation policy information. t I lomeoaners who submit this allidevit indicating they art:doing all work:and them hue outside cnnwictots must submit a new allidavit indicating such. Cam odors that cheer this box most attadted an additional sheet shouing the name of the sub•contructom and their►,orkers'comp.policy in formation. I am an employer that is providing workers'compensallon Insurance jar my employees. Below is the polier and fob site Information. Insurance Company Name: Twin City Fire Ins Co Policy h or Self-ins.Lic.#: 37WBQT9238 Expiration Date: 12/09/14 lob Site Address: 109 Main St City/Stale/Zif,Porth Andover, MA 01845 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 ora fine up to$1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of 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 DtAfor insurance coverage verification. 1 do hereby cert f, der th palms and penaltles of perjttrr that the information provided above is true and correct. Si a ore• e• 5/28/14 Phone 816-6 0-9200 O ciai use only. Do not write in this area,to be completed by city or town ofJ'lclal, City or Town: Permit/License d Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other rnnfact Perenne Phnnr V! 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." 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 cmplovees. 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"every state or local licensing agency shalt 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 uthority.'Applicants —` Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and. if necessary,supply sub-contmclor(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 may be 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 you are 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 Ofllcials 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 pennitAicense 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 atf idavit 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 permit to burn leaves etc.)said person is NOT 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 tog ive 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 5-26-05 Fax#617-727-7749 www.mass.gov/dia