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HomeMy WebLinkAboutPermits - Permits - 203 TURNPIKE STREET 2 Commonwealth of Massachusetts official Use Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev, 9/05] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M1C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: February 18, 2014 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 203 Turnpike Street 2"4 Floor Owner or Tenant Lowell General Hospital Telephone No. Owner's Address 295 Varnunr Ave.Lowell MA 01854 Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) d Purpose of Building COMMERCIAL MEDICAL SPACE Utility Authorization No. NONE REQUIRED Existing Service Amps Volts Overhead Undgrd No,of Meters New Service Amps Volts Overhead Undgrd No.of Meters Number of Feeders and Antpacity Location and Nature of Proposed Electrical Work: New X-Ray room in within the suite. Cont letion of thefolloiting table ma y be wadi ed b the Inspector of Wires. No. of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lninaire Outlets No.of Hot Tubs Generators KVA tu _ No.of Luminaires Swimming Pool Above In- No. of Emergency Eigliting rnd, grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No,of Gas Burners No.of Detection and Initiating Devices No.of Ranges No. of Air Cond. Total No. of Alerting Devices g Tons p No. of Self-Contained No.of Waste Disposers HeatTotals: Number Tots i{�'�',,,... Detection/Alerting Devices No,of Dishwashers Space/Area Heating KW Local❑ Mun"'pal ❑ Other Connection No.of Dryers Heating Appliances KW Security S stems:* y No.of Devices or Equivalent No.of Water No. of No. of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent l o.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent OTHER Wiremold voice/data blank inserts Attach additional detail if desired, or as required by fire Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 2/24/14 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the pennit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER (Specify:) I certify, under the pains and penalties of perjury,that the informationxirly'y' io t is tare and complete. FIRM NAME: MEC Electrical Contractors,Inc. LIC.NO.: A16833 Licensee: William Lemos Signature LIC.NO.: E26175 (Ifopplicable, enter "exempt"in the license nurnber line) Bus.Tel.No.: 978-244-9301 Address: 131 Stedman Street Chelmsford MA 01824 Alt.Tel. No.: 978-490-0231 *Security System Contractor License required for this work; if applicable,enter the license number here: 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)owner owner's agent. Owner/Aggent rPERMITFEE Signature Telephone No. 00 Of Na oTl+'�A h TOWN Or NORTH ANDOVER ELECTRICAL PERMIT FEES 51CHll94 , Fees adopted by the Board of Selectmen: 6-24-2002 ,Effective 7-1-2002 "PLACE UTILITY AUTHORIZATION NUMBER ON PERMIT APPLICATION 1. Rate schedule for New Building,Additions and Alterations(Residential,commercial or Industrial&Education) 1/10"'of 1.5%of the estimated cost. 2. Residential(One(1)permit per buildinglunit required) Minimum Fee Minimum Fee per Building/Unit $55.00 New Service Single Family Dwelling/Unit 85.00 New Service Condominium,Townhouse,Apartment 85.00(per unit) New Service 55.00(per unit) Service Change--Up to 100 Amp 45.00(per unit Service Change—Over to 100 Amp 55.00(per unit) Temporary Service 55.00 Panel Change 30.00(per unit) Electrical Outlets,5 switches,fixture(all count as outlets) 1-15 outlets $35.00 16-25 outlets 50.00 2 6-100 outlets 85.00 Over 125 outlets 175.00 Reinspedtion Fee 30.00(per trip) 1 Commercial&Industrial(One(1)permit per building/unit required) Minimum Fee--per Building/Unit 25.00 New Service 170.00 Service Change 85.00 (l)er unit) Temporary Service 85.00 Panel Change 85.00 i Motors—Less than 3 HP / ' &X. �1 45.00(pe unit) Motors—Over 3 HP Reinspection Fee $ 30.00 l70 Client#,.26438 MECEL ACORM, CERTIFICATE OF LIABILITY INSURANCE DATE 7l15r2013 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 pollcy(les)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 Ileu of such endorsement(s). PRODUCER E: T NA Sullivan Insurance Group,Inc. P ° E 508 791-2241 FAX 508-797-3689 10 Chestnut Street E-MAILo ExI, Arc No; ADDRESS: kauclalr@suliivangroup.com Suite 1010 Worcester, MA 01608-2804 INSt1RER(8)AFFORDING COVERAGE NAIC q INSURER A:Ohio Security Insurance Company INSURED INSURERB:Ohio Casualty Insurance Company MEC Electrical Contractors, Inc. & INSURER c:The Hartford MEC Technologies, LLC PO BOX 158 ENSURER D Chelmsford,MA 01824 INSURERS: 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 CONTRACTOR 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR D POLICY NUMBER MMfDDNYYY MM1DDNYYY A GENERAL LIABILITY BKS55548008 6106/2013 06106/2014 EAACMHH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES EaEoNcTTurrenoe 000,000 CLAIMS-MADE OCCUR MED EXP(Anyone person) $15 000 X XCU Hazards Included PERSONAL&AOV INJURY $1 000,000 X lanket Contractual GENERAL AGGREGATE s2,000,000 GEN't.AGGREGATE LIMIT APPLIES PER; PRODUCTS•COMWOP AGG s2,000,000 POLICY X PE LOC $ A AUTOMOBILE LIABILITY BAA55548008 6/0612013 06/06/201 °esatlet tsINGLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED AUTOS AUTOS BCDILY INJURY(Per accldenl) $ X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per scGdenl $ B X UMBRELLA LIAB X OCCUR U8055548008 6/06/2013 06/0612014 EACH OCCURRENCE s5,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $5 00O 000 DED I X RETENTI014$10 000 $ G WORKERS COMPENSATION OBWEQCM9505(MA) 6105/2013 06/05/201 X WC STATU- ER AND EMPLOYERS'LIABILITY ANY PROP IETOR XC UERE ECUTIVEF NIA 08WECCF2651 (MA) 6105/2013 06/05/209 E.L.EACH ACCIDENT $1 000000 (Mandatoryln NH) E.L.DISEASE-EA EMPLOYEE1$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A LeasedlRented BKS55548008 0610612013 06/0612014 NO ONE ITEM TO EXCEED Ecluipm`t'nt $15,000 IN VALUE-ACV DEDUCTIBLE$1 000 DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES(Attach ACORD 101,Addltlonat Remarke Schedu€e,If more space Is required) Evidence of Liability Insurance for the Named Insured Issued as evidence of Insurance CERTIFICATE HOLDER CANCELLATION Town of North Andover,Inspector SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN of Wires ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE d"AL& ©IOBS-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S204288rM203361 KJA r / ALDAROLA DESIGN A 5 S O C: I n T F S , P C" ni( kOlcelui (' it Irleiim Uesii)ii May 1, 2014 To: Brian Leathe Local Building Inspector Town of North Andover 1600 Osgood Street Building 20, Ste.2035 North Andover, MA 01845 Re: Lowell General Hospital 295 Varnum Avenue, Lowell, MA 01852 Renovations to Lowell General Women's Health Center 203 Turnpike Road - Second Floor North Andover, MA 01845 Field Report No.: 2 Date: 3/26/14 & 4/16/13 Architect's Project No.: 3313 Time: 10:00 am Observations Action Required Rough plumbing&electrical complete.te. None. 2, Lead & gypsum Board being installed. None, 3. Tel/data wiring being installed, None. Report prepared by: Joseph V. Caldaroia, AIA i No a Cc: Bill Charette (LGH) 4 Birch Street, Derry, NH 03038 (6031 432-8404 (Fax) 432-2706 i Ax MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �19 Ff CITY1 MA DATE ._ "l �.` _� PERMIT# JOBSITE ADDRESS _2t ' ---- • __- OWNER'S NAME -L o;k) t k__- OWNER ADDRESS L H +.. Via__ - _ _ TEL 7 LL �f- S-Z J FAX . TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL Q PRINT CLEARLY NEW:0 RENOVATION:§R REPLACEMENT:D PLANS SUBMITTED: YES[I NOW FIXTURES-1 FLOOR- BSM 1 2 3 4 6 6 7 6 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE -- I J MEDICATED SPECIAL WASTE SYSTEM DEDICATED GASI01USAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I _l _ J _•..._! I ^ -! ' .._-) DEDICATED WATER RECYCLE SYSTEM _.J — - - DISHWASHER DRINKING FOUNTAIN _. _.I _.._. I .---•-! -•--- -.___ _I ^..__I ........_ _._..._.f _J ._..... _I ......J ...._ FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR _ i _ -•__l _ -- _.1 --.1 .. ! ! _ _I _l ._ __I KITCHEN SINK _1 I LAVATORY lkvwo v 1 -€ ROOF DRAIN SHOWER STALL SERVICE lMOP SINK -_.__J TOILET URINAL WASHING MACHINE CONNECTION WAT ER HEATERALL TYPES WATER PIPING _.? OTHER INSURANCE COVERAGE: I have a current Ilahility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES�' NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the ilcensee does not have the insurance coverage required by Chapter 142 of the Ma Chu ON General Laws,and that my signature on this permit application waives this requirement, CHECK ONE ONLY; OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereb certify that all of the details and Information 1 have submitted or entered regarding this application are true and accura e'`o the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in co lia Vp rtl t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General taws, ti PLUMBER'S NAME LICENSE# .. _! SIGNATURE MPD JFN CORPORATIONEJ# PARTNERSHIPM#1 LLCD11 _ COMPANY NAME ADDRESS > '� I C1TYl� 'W ,.. - - STATE ZIP C#) S / . - - -1 TEL .- - FAX iir%' �?. _�. CELL 5o`6 3,q '. ;�SLI EMAIL '`' CERTIFICATE OF LIABILITY INSURANCE 1Dlo"2o 3"'M'°D'YY"' 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(les) 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 Dorothy A.Corlelt,CIC,RPLU Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 978 32272311 1 FAX (978)454-1865 Lowell,MA 01851 _OLQ No.Ext1• AIC No EMAIL dcoriell@fredochurch.com (80D)225-1865 ADDRESS: INSURERS AFFORDING COVERAGE NAIC N INSURER A: Medical Professional Mutual insurance Company 10206 INSURED Lowell General Hospital INSURER B: 279-319 Vemum Ave INSURER C: Lowell,MA 01854 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:2752e REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 13E 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. INS" TR TYPE OF INSURANCE ADOL SUER POLICY EFF POLICY EXP POLICY NUMBER MM10DlYY'!Y MMIDDIYYYY LIMITS GENERAL LIABILITY EACW OCCURRENCE $ 2,000,000 X DAMAGE70 RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50.000 CLAIMS•MADE I X1 OCCUR MED EXP(Any one person) $ 5,000 A 13356701- 10/112013 101112014 PERSONAL&ADV INJURY $ 2,fl00,000 GENERAL AGGREGATE $ 20,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 20,000,000 POLICY PRO. LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT t;a accident ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE _ $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU• I OTH- AND EMPLOYERS'LIABILITY YIN O Li E ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFIOMMEMBEREXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-FA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Medical Proresslonai Liabifily A Medical Professional Liability 133567 1011/2013 101112014 $2.000,000 per claim 1$20,000,000 annual aggregate (shared Ilmit);Claims Mann Form-Relroactive Date 01-14-1976 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 101,Addltlonat Remarks Schedule,if more spaca Is required) CERTIFICATE HOLDER CANCELLATION Lowell General HosplIM Nancy Guilbeaull 295 Varnum Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE Lowell,MA 01WA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE:POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE csenta 21110 Mat# 27528Cert Holder# 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD t r i 1:1> a g C 3: I 'P➢F�'F%Jf..% 1, _ d t k, Rpp s.e � f , Y. s w. IJ :: .. X^ o� �Y sr F we _ a.. S i L f�cv T rt. .d;. w.K. � rrn f %AORTFI BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page 14-1 22E '(00 1EM-, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential E) New Building El One family D Addition u Two or more family El Industrial ig Alteration No. of units: Commercial El Repair, replacement E3 Assessory Bldg El Others: El Demolition n Other 6vu Identification Please Type or Print Clearly) OWNER: Name: I�Oewl!5el—L 66V- 6-Kq4 &Sz��Phone: Address: V4W W') /YA Abc LD 'L)el rr, V.. .......... ............ ............. .. ................. ARCH ITECT/ENG IN EER 2:05( Uadat)Lq .EST Phone: 603- W-2-410' !� Address: Z2.3 0 FEE SCHEDULE;BULDING PERMIT.$12.00�ER$1000.00 OF-ZHE!�TT-QOTTA&IL MATED COST BASED ON$125,00•PER S,F. 60 o Total Project Cost: $ �Ll ej�, do 1_62,d'C" //�FE-?: $ K 4t�±L Check No,: Receipt No.: rat, i NOTE: Persons contracting with unregistered contractors do not have access to the gitarantyfiind lg gna of 0htr.act('j ,;. .:. noao"�A- - "0" r -S J V 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 DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS I Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Hoard Decision: Comments Conservation Decision: Comments Water & Sewer Con neCtlon/Signature & Date_ _ Driveway Permit Located at 384 Osgood Street I Gll1EN '�ernp Aurppste orIlte ye$ ` w 3 �}yyr ��`��?�r rP^i�sq `Arx� �=+� 's , � �y _. y ^" i, ✓ rya �m�" Fyn u s ��'T`^��'J"''��^, �x kd i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 1 1 100.0.QQ ' m $ - $ 1,356.00 Plumbing Fee $ 169.50 Gas Pee 100 comm. $ 100.00 Electrical Fee $ 169.50 Total fees collected $ 1,795.00 203 Turnpike Street 530-14 on 118l2014 X Ray Buildout for Lowell General Hospital-Second Floor ALDAROLA DESIGN C.' 1 A I D I Maroh 17, 2014 To, Brian Leathc Local Building Inspector Town of North Andover 1600 Osgood Street Building 20, Ste-2035 North Andover,MA 01845 Re; Lowell Gwetal Hospital 295 Vamurn Avenue, Lowell,MA 01852 Renovations to Lowell General Women's Health Center 203 Turnpike Road-Second Floor Nox-th Andover, MA 01845 Field Report No,: I Date- 3/7113 Architect's Project No.: 3313 Time: 10:00 am Observations Action Re aired I� Demolition complete. None. 2. Framing complete in accordance w/approved documents. None. 3, Existing lighting in the new radiography room will be re-used. CQordinatcd w/electrician. 4. Lead-limed gyp. bd.not required on exterior wall. Verified w/physicist. Report prepared by: Joseph V. Caldarola, AIA LONVOND C Bill Charette(LGFI) 4 Birch Streal, Dorry, NH 00038 (603)432-8404 (Fox)432-2706 T. J. CARBON JR. CARPENTER& BUILDER, INC. 91 NEWBURYPORT TURNPIKE, ROUTE 1 IPSWICH, MA. 01938 (978-356-7707) PROPOSAL SUBMITTED TO: Lowell General Hospital 295 Varnum Ave. Lowell,Ma. 01854-2134 3 ARCHITECT DATE OF PLANS JOB PHONE j Joseph V. Caldarola December 16, 2013 We hereby submit specifications and estimates for: Renovations to existing Outpatient Diagnotic Center at 203 Turnpike St. Second Floor North Andover, Ma. Per plans of Caldorola Design dated 12/16/13. Install dust barriers and heapa filters. Remove walls and doors as indicated on plans. Frame and insulate new walls with soundbatts. Framing to be 35/8 metal studs with 5/8 firecode sheetrock taped and finished. Shectrock to be lead lined to seven foot height in Radiology room. Install new doors and hardware. Install new cabinets and sinks per plan. Relocate and install new lighting per plan. Remove and dispose of all debris. We propose hereby to furnish material and labor in accordance with the above specifications for the sum of, Fifty thousand dollars. ($50,000.00) Payment to be made as follows: $20,000.00 after tough inspection $30,000.00 upon completion All material is guaranteed to be as specified. All work to be completed in a workmanlike manor 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 estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. Authorized Signature ACCEPTANCE OF PROPOSAL-The above prices,speci nations,and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be i ade as outlined above. )//4' Date of acceptance / Signahne Wit•-'!�(C��'�f�,�.. �� �-f�r'���f"".� d� The Conintor' ivealth of Massachusetts Print Form Department of Industrial Accidents R " Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 s wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� l Please Print Le ibl Name (Busin .ess/OrganizatioiV[ndividual): �, 4.41 )xv ✓lt . L-�Akenle Zej,, 44# � Address: eA e4, G t �n City/State/Zip: Cl a/11�9 Phone #: V 7Y- 23 G _ i 7,�) 7 Are you an employer? Check the dpproprinto box: Type of project(required): 1.Q 1 am a employer with—Z� 4. ❑ I am a general contractor and I 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. 7. Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp. insurance.) 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp, tight of exemption per MGL 12.❑ Roof repairs insurance required,] t c. 152, §1(4), and we have no 13.n Other employees. [No workers' comp, insurance required.] *Any applicant that cliecks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box mast 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 run an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: 7, OC `1q.-9P/ Expiration Date: l/ Job Site Address: Z 03 lula.))P City/State/Zip:/,t t , Ar,/d"e L X/P. ewn 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 forth 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 elo hereby certi under the «ins and! enalties o(Xe!Zrii;E that the in ormation provided above is true and correct. Si nature: Date: Phone#: 9 7 -G 2 I` 7 S Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4, Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone#: i ALDAIZOLA DESIGN A S S 0 C I A I C 5 , P C Archilecture n ktoiior Deskjo ARCHITECTURAL AFFIDAVIT Project Number: Date: Project Title: /,r&%F&Hp �A110 i�Xlg1?rdG Dui�A 11 'f?IVWq�K Project Location; Name of Building: Scope of Project: KIMAO � all� N6tUi�Mt �l 1 ival� 1, Joseph V, Caldarola, MA Registration No. 7728 being a registered professional architect have prepared or directly supervised the preparation of the architectural design plans, computations and specifications for the above named project and that, to the best of my knowledge, belief and understanding such plans, computations and specifications meet the applicable provisions of the 8"' Edition of the Massachusetts State Building Code. I shall perform the necessary professional services and be present on the construction site as needed to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following: 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 Chapter 17. 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, in general, if the work is being performed in a manner consistent with the construction documents and this code. Upon completion of the work, I shall submit a final report as to the satisfactory completion and readiness of the project for occupancy. Signed by: Date; Architect's stamp: AAA No.7728 dtB C) 4 Birch Street, Derry, NH 03038 (603) 432-8404 (Fax) 432-2706 ASSOCIATED X-RAY IMAGING CORPORATION G� 49 Nexvark Street Ha-verlA, IVIA 01832--1317 800-356-3388 r®j��,®R�4�® Fax—978-521-2214 MEDICAL X-RAY SYST13MS �v\vw.associatedxray.Com EQUIPMENT•SUPPLIES•SERVICE sales@associatedxray.com Date Quote N Lowell General Hospital—N. Andover December 11,2013 J-4294A Phone H Terms 295 Varnuin Avenue 978-788-7149 20/80 Shipping Dale To Be Shipped VIA Lowell,MA 01854-2193 30-45 Days ARO Best Way Ann: Salesperson FOB Judy Canal, M.S.,Director of Imaging Services 005/019 Chicago, IL THIS IS OUR QUOTATION ON THE GOODS NAMED,SUBJECT TO THE CONDITIONS NOTED CONDITIONS: The prices and terms of this quotation are not subject to verbal changes or other agreements unless approved in writing by the Home Office of the Seller.All quotations and agreements are contingent upon strikes,accidents,Tires,availability of materials and all other causes beyond our control. Typographical and stenographic errors subject to correction.Purchaser agrees to accept either average or shortage not in excess often percent to be charged for pro-rate.Purchaser assumes liability for patent and copyright infringement when goods are made to Purchaser's specifications.When quotation specifies material to be furnished by the Purchaser,ample allowance must be made for reasonable spoilage and material must be of suitable quality to facilitate efficient production.All references to this quotation will encompass model,type,physical characteristics and all technical specifications,as well as terms and conditions. Conditions not specifically stated herein shall be governed by established trade customs.Terns inconsistent with those stated herein which may appear on Purchaser's follow order will not be binding on the seller. QUANTITY CAT.NO. DESCRIPTION PRICE DEL MEDICAL DFMTS SYSTEM DM-DFMTS The Del Medical DFMTS system is an ideal choice for a complete range of radiographic procedures and eliminates the need for costly room modifications. This tube stand only requires a floor mounted rail for support and can be installed in rooms with ceiling heights as low as 87"(221 crn). DM-DFMT Del Medical DFMT,Floor Mounted Tube Stand with Digital SID Display Specifications: - 10ft.(305cm)Floor Plate -Platform tube mount standard(Trunnion Rings Optional) -Focal spot travel: Transverse travel range, I I"(28cm) Vertical travel range,64.5"(164cm) -Minimum ceiling height, 87"(221cm) -Pressure activated 1800 column rotation -f 180'tube rotation about the horizontal axis -Angulation display of: Focal spot-to-tabletop SID distance(for table or wall studies) Focal spot-to-bucky SID distance(for table or wall studies) Tube angulation -Control buttons for the following actions: (located on the control handle) Longitudinal lock,transverse lock,vertical lock,column rotation roll lock, all locks and automatic detent stops(both horizontal and vertical) -Centering detent aligns focal spot to image receptor -Electromagnetic locks QUOTE VALID FOR 30 DAYS BY Jason Olenio 1 December 11,2013 Lowell General Hospital Quotation#d-4294A Page 2 COL-RALCO-M Ralco Certified Manual Collimator -External adjustment of mirror angulation -High luminosity power LED for light field projection.LED cluster if 50,000 hours -Timer that limits cluster ON time to 30 seconds - Radiation shielding; 150 kVp-4 mA -Minimum inherent filtration 2mrn aluminum equivalent. (lmm on request) -Continuous film coverage from min. 00 x 00cm to max.48 x 48cm at 100cm FFD(SID) DM-CM50 Del Medical CM Series 50kW,630mA,High Frequency Three Phase Generator Item Features: - 150 kVp -Anatomical Programming with 768 programmable technique selections - Operator Console with Pedestal and Handswitch -One,two,or three point technique selection -Two Bucky Capability Power Cabinet with Auxiliary Power Supply -Tube Protection Circuitry Integrated service software assists in calibration and service Self-diagnostic circuitry with error code recording for fast trouble shooting DM-AEC-INT- AEC kit with interface board and two(2)Three Field Ion Chambers 21ON TUBE-VR14-90 Varian RAD 14 Tube-90'cable arms,0.60.2mm FS,300kHU, 150kVp, 121 target,3" anode DM-CAB-HV- 30' Generator High Voltage Cables, 150 kVp 30 DM-EV800 Del Medical EV800 Elevating Table with Four-Way Float Top Item Features: -800 lb.(363 kg)patient load capacity -86.5 (220cm)x 31.9(81cm)fiber resin table-top -Height adjustment:21.75 (55.25cm)to 33,77(85.8cm) -Table top movement:+/-21.25 (54cm)longitudinal,+/-4.5(11,4cm) transverse -Bucky travel; +/-8.5 (22cm)longitudinal -Quiet duty motor with efficient elevating action -Recessed foot treadle lock controls for longitudinal and transverse,table top up/down movement -Tableside hand control provides an additional source for all table movements -Integral collision safety sensors December 11,2013 Lowell General Hospital Quotation#J-4294A Page 3 DM-TBL-RB- True-speed bucky, 17"x 17"(43cm x 43cm)and One deluxe, heavy- TRAY duty manual cassette tray DM-TBL- Table top hand control,controls all table functions(elevation and four- REMOTE way float of top) GR-103-10-34- 103 Line, 10:1 Ratio,34-44" Grid 02 DM-VS300 Del Medical VS300 Wall Stand -Slender Column Design -Electric "Nail Safe" locks;only require power to move column -Ergonomic release handle -Lateral patient handgrips included(standard) -Height: 84"(213.4cm)(includes vertical travel) Depth: 13.4"(34cni) -Width:24.6"(62.5cm) -Weight(with receptor): 200 lbs(91kg) 0.41nni front panel aluminum equivalency ETL listed DM-WALL-RB- True-speed bucky, 17"x 17" (43cm x 43cm)and One deluxe,heavy- TRAY duty manual cassette tray DM-VS200- Overbead Patient Handgrips for VS200 OVHGRP GR-103-10-40- 103 Line, 10:1,40-72" Grid 02 Note: Price includes delivery and installation of customer's existing Konica CR system currently in storage at Associated X-Ray Imaging Corp. INSTALLED PRICE $63,600.00 Plus Freight ........ Vzo R Town of _v r Andover ® - 10 No, ! _ ■Yy • - v.^+Y Coe"'C"t wtc K ! Mass, aaa Gs1(o1 BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT .. •••• - •• ..., BUILDING INSPECTOR J_ L buildings on ���....���.��. . . ..�� Foundation has permission to erect.......................... g ,•.• . � �/ .-^ Rough to be occupied as .V 11+�M�!. •�- . ... ....., .... ........................................•........•.,.....,...... Chimney provided thaf the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-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 �00 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR .� UNLESS C®NSTRCTI S,T S Rough Service. .............. .... ......... ...................................... Final BUILDING INSPECTOR GAS INSPECTOR QccupanLE Permit Required to Occupy By 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. IL Smoke Det. SEE REVERSE SIDE