RAINBOW TER - BUILDING INSPECTION What is tM cwmj use of the Building? . M u rl Fiwr�W Nor�r��
Mats"of Building? - i di M dwoMM&how many units? i 36
yyB to 8uildnp Conform to t.aalr
YEs Asbestos? yEs
grchioed'sName sNIKJ14 - � �
'
Address and Photo "r
A•I%I6Yi•1�1 S? A41VrzV M4 02^ _�6�7� 3G0'4 19
MwhmWs Name Assouar
Address and Phone 132 C. st t�srbrr A� ourr 6r7-�So-77/lr _
Construction Supervisors License is r5
n �6?S HIC RegistrationB
Estimated Cost of Prolerd=�Uo•z� Pam*Fes C°IadtUon
Estimated Coat X$741000 Residendd
PertnR Fee i��=�0
tstYnabdE:ostXS11/:1008Cbmme►dat------._ .
An Additional WOO le added as an
Administradve sharps.
i
Make sun that all fields are property and WOW wfin to avoid delays In processing.
The undersigned does henby apply fo►a Building Permit to build to to above stated
speditatkm Signed under penalty of parlay
Date 03 Or,-'• 2007
�I
o
_. _ .... �..
1 �+
CAA A% O
- PUBLIC PROPERTY.
DEPARTMENT
SWOR tooavenurw; �Mear•sumY Da cr�sm97o
the s».Ti&M•Foe M744-96e
APPLICATION FOR TRZ REPAIR. RENOVATION.CONDUCTION
DZN10L112ML R CAANGE OR USE 08 OCCUPAMCV FOR ANY ZX=XG
STRUCTURE OR A&3LDING
O SITE INFORMATION p...
Location NdrrmP I.v&w lroz ec Ilow N FhVert
Y _
sAZZ.-J, MA elg70
Propugr Y bcabd in a;Cordwvagon Ana Y►N N Historb District YIN oy_.
2.0 OWNERSHIP INFORMATION
9.1 Owner of Land _
Name: S 4F-m Pbr<5w(s ActrNoR�r
Address. 27 GNAereZ .9r.
$ALLE.4, MA 0147o
LT"=~.. 179-74q- 51431
&&COMPLETE THIS SECTION FOR WORK IN Owt$X1d0-BUILDINGS ONLY
Addition Existing 2
Renovation X Number of Stories Renovated Z
Change in Use Now
Demolition Existing ys�
Approxinmate year of 17r floor(at) Renovated ySoa
construction or renovation
of existing building ►qo,2 New Ff
Boat Description of Proposed Work:
L�ZJPJ"4
2.)WiNAoeJS
a.)1toa=,NG .
s.)Misr—lurks P�PAIzs to
--------Mail Permit to:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I�al.r, Us l•,L
at,,.+ t+�tln..a,t�::.x►f lrat•i�u r.�I.�vcv::,�.r 11 s;:ar.
'ht:tIJf7 �f.�971Ja6'rW
Construction Debris Disposs Aff[dayit.
(required for all dennlitioa and mmvatieet wotlt)
•
In acconlance with the sixth edition of the State 13niidi05 Cods,,7So CAUL seetioe 111.5
Debris.and the provisions of M. GL a 40.S SIC
Baildin{Pemtit M _ is issued with the eanddon that dw debris rmddnj fi:em
,his wa t shall be disposed of in a properly licensed waste disposd fheility as defined by M. GL e
111.S 15OA
The debris will be transported byt
AWED WAS7E INDuSTizJ6S, IN
— — tnam of haWod
rho debris will be disposed of in
gpi -rRANsA62- SrArrio'J
' r a+rne of iaallty)
V ✓ O r 1 .
..4W
Azr
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
61a1aral F.Y Da1:a:01-1.
M.vvtat 12C VfAWNG roN SmeET a SALEW.WASSAC1 a w:'rf+01973
'r1u:97$.743.9595 0 FAX:971P740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
anallcaut information TPlease Print Leeibly
Name tauaii/iw. orgtnization/individuul): /V d{�/T
city/smm/zip:&Cairt4i2LOe, M,4 Oa /ieV Phone#: (790 35cla - `J&ea- �O
,%,r..c�{you an employer'Check the appropriate box: Type of project(required):
1.121 1 am a cmploycr with �D 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time)., have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t �• Remodeling
ship and have no employees Theta sub-contactors have a. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
f No workers'comp. insurance 5. ❑ We are a corporation and its
lo.❑Electrical repairs or additions
required.] officers have excrcixell their i
3 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
•❑ g
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance requirtd.j r employees.(No workers' 13.❑Other
comp, insurance required.)
'Any applicaat dial ehscks has el men also fill our the section bL•lilw showing their wurkaa'cumpeniatiwt Policy in6,rmatiwi
'Ilwnwrwnsts who submil this affidavit indicating They an doing all watlt and thm him outtMe eonlmcion mail submit a new anidavil indic ling Mich.
Zincwrs that chuck this box must anachod an additional Alm slowing raw nano of the Subcontractors and their workers'comp.policy infti madue.
1 um an employer that Is providing workers'rompdnsadon Ltsarance for my employees. Below is the paliry and Job site
iuformurion /c f
u��IOV\Q t �VSUR AVIC�
Insurance Company Name:
4 .
_. .._ ...._/ /
Policy g or Sclf--ins. Lie.N: }n IJ A 09-7 4,f 57 Y Expiration Date:02 05 a oo g
Job Site.Address: 1(i�, /CQ.(/'( big 60 2`e l-rQ 0-Q/ Cily/Slate/zip: 1, <'emf m
Attach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A of.1GL c. 152 can lead to the imposition of criminal penalties of a
tine tip to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. fie advised that a copy of this statement may be forwarded to the Office of
Iuvaangmiuns the DIA for insurance coverage vcritication.
i do hereby r tify nns4r ! pa' and p'nai r pc ury that the infonntattion provider/above is true and corrcea
O/f icial use only, Do not o dre in this area,to be completed by city or town o/Jichd
City or Town: PcrmiVIAt ense ll___- _.
Issuing Authority (circle one): _. ... _..._ . . .
1. Hoard of Ifealih 2. Building Department 3. Citylrosvn Clerk a. Electrical Inspector 5. Plumbing Inspector
6.Othcr
Contact Person: _ Phone p:
Infor
mation and Instructions
chapter 152 requires all employers to provide workers' compensation for their employees.
pursuant
sea nt to thi statuteeneral Laws plperson in the service of another under any contract of hire.
Pursuant m this solute,an aerployie is defined as"...every
express or implied.Ural 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 rJoy
epresentatives of a deceused emp tes.loyer,or the
However
receiver or trustee of an individual.partnership,association orother
and whoentity,employing emp
es therein or the occupant of the the
owner of a dwelling house having not more than three apartments
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,¢2SC(6)also states that"every state or local licensing*Ron"shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings Is the commonwealth for any
spitucaet who line 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-convactor(s)name($),addreas(es)and phone number(s)along with their certificate(3)of
insurance. Limited Liability Companies(LLQ o rLimi compensation[� Partnerships
a t erships(If aa)with
or L Ppll does have�the
members or partners,ate not required to carry
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance covurage. 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 Deportment of
Industrial Accidents. Should you have any questions regarding the low 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 a ro riate 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 rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the purnittlicense number which will be used as a reference number. In addition,an applicant
multiple Pc applications in any given year,need only submit one affidavit indicating current
that must submit m
policy information ult(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
cially stamped or marked by the city or town may be provided to the
town)."A copy of the affidavit that has been offi
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled 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' OT required to complete this at'rrdavit-
['he Otjice 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
O®ee of Invadpillons
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5.26-05 www.mass.gov/dia
OWNER-CONTRACTOR AGREEMENT
Coin momvealth of Massachusetts
Department of Housing and Community Development
This agreement made the 61h day of August. 2007 by and between Salem Housing Authority hereinafter
called the -Owner, and NorthEast Interiors, Inc. hereinafter called the "Contractor" {i7hresseth. that
the Owner and the Contractor, for the consideration hereinunder named, agree as follows:
Article 1. scope of Work: The Contractor shall perform all Work required by the Contract Docmnents
for Exterior Envelope Renovations, Interior Repairs and Improvements at Rainbow Family
Development,DHCD FISH # 258033, State Aided Project 200-2 referred to in the Contract Documents
prepared by Architectural Solutions, Inc.acting as and referred to as the "Architect'
Article 2. Time of Completion: The Contractor shall commence work under this Contract on the date
specified in the written "Notice to Proceed" and shall bring the Work to Substantial Completion within
365 calendar days of said date. Damages for delays in the performance of the Work shall be in
accordance with Article 9 of the General Conditions of the Contract.
Article 3. Contract Sum: The Owner shall pay the Contractor, in current funds, for the performance of
the Work, Four Million Six Hundred and Twenty-Three Thousand Eight Hundred Dollars
$4,623,800.00.
Item 1: The Work of the Contractor, being all Work other than that covered by item 2
$3,110,200.00
Item 2: Subcontractors as follows
Section — Trade Subcontractor Amount
1. 07311 — Roofing & Flashing Capeway Roofing Systems, Inc. $886,800.00
2. 09900— Painting NorthEast Interiors, Inc. $199,000.00
3. 15600— HVAC Robert Irvine& Sons $248,000.00
4. 16000— Electrical J.W. McCarthy $179,800.00
Total for Item 2 $1 513 600.00
Article 4. The Contract Documents: The following, together with this Agreement, form the Contract
and all are as fully a part of the contract as if attached to this Agreement or repeated herein: The
Advertisement, Bidding Documents, Contract Forms, Conditions of the Contract, and Specifications as
enumerated in the Table of Contents, the drawings as enumerated in the List of Contract Drawings.
DHCD publication known as the Construction Handbook, and all Modifications issued after execution of
the Contract. Terms used in this Agreement which are defined in the Conditions of the Contract shall
have the meanings designated in those Conditions.
Article 5. Alternates: The following Alternates have been accepted and.their costs are included in the
Contract Sum stated in Article 3 of this Agreement: Alternate No(s): None
DHCD $1001<41 OM Owner Contractor Agreement
C 149 4/2007 1 of 2
i
OP ID S DATE IMMIDDrrM)
A ORD_ CERTIFICATE OF LIABILITY INSURANCE NORTH-8 09 1e D7
' PRODUCER - THIS CERTIFICATE S ISSUED AS A MATTER OF INFORMATIO
ONLY AND'CONFERS NO RIGHTS UPON THE CERTIFICATE
smith Brothers Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
National Drive
.astonbury CT 06033 i
Phone: 860-652-3235 Fax:860-652-3236 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Traveler. Indemnity Cosrvaoy
INSURER B. Charter oak Pixe nuursnee Co
Northeast Interiors, Inc- INSURER C: TavaVelere vxoverty Casaal 25615
ty
41 Brooks Dr1vV� $ul to 1005 INSURER D: Star National Insurance Cc
Braintree MA OZiBA INSURERS Hanover Insurance CanyoAny 22292
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 15 SUED 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 MICH'iHIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH -
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IT
TRWWOT
LTR NSRE TYPE OF INSURANCE
POLICYNUMBER DATE MMd)OTYY DATE MWDD(YY LIMITS
EACH OCCURRENCE f 1,000,000
I
GENERAL LIABILITY j
A X COMMERCIAL GENERAL LIABILITY DTC0977R7586IND06 03/05/07 03/05/OB PREMISES Es osournncs s 300,000
CLAIMSMADE 7XOCCUR MED EXP(MY one Person)_ $ 10,000
PERSONAL&ADV INJURY S1,000,000
GENERAL AGGREGATE s2,00
AEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $2,000,000
POLICY[X-1 JECT LOC
AVTOMOSIIP LIABILITY COMBINED SINGLE LIMIT $1,000,000
B X ANY AUTO DT-810-977r1586-COB-06 03/05/07 03/05/08 (Ea enoldent)
ALL OWNED AUTOS BODLY INJURY S
(Per person
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY f
(Pereociden8
X NON-OWNED AUTOS ("
PROPERTY DAMAGE
(Per accident) S �`
i
AUTO ONLY-EA ACCIDENT f
GARAGE LIABILITY
MYAUTO OTHER THAN EAACC S
AUTO ONLY: ADD
EXCESSRIMBRELL0.LIABILITY EACH OCCURRENCE S 10,000,0O0 -
C X OCCUR � CLAIMSMADE DTeSLTIP-97TKTS86-TIL-06 03/05/07 03/05/08 AGGREGATE S10,000,000
S
DEDUCTIBLE f
f
X RETENTION $lO,OOO -
WORKERSCOMPENSATMNAND X TORYLIMMS ER
EMPLOYERS LIABILITY L.DA0274574 03/05/07 03/05/08 E.L.EACH ACCIDENT $ 1,000,000
D ANY PR PRIETOR EXCLUDED?
CUTIVE E.L.DISEASE-EA EMPLOYEE f 1,000,000
OFFICEN Yes,deed&a under E.L.OI SEASE-POLICY LIMIT $ 1,000,000
SPECIAL PROVIa0N5 below
OTHER
E Installation B#922810-6-07 10/06/07 10/06/OB Oat $42 500
6000 I--
All Risk
OESCRIPTIDN OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Re: State Aided Project 200-2; DCHD Project A 258033, Exterior Envelope
Renovations, Interiors Repair and Improvements at the Rainbow Terrace Family „-
Development located at 16 Rainbow Terrace, Salem MA. Salem Housing
Authority and the Department of Housing Community Development are included
as Additional Insured's with regards to General Liability and Automobile
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYSWRITTEN i-
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Salem Housing Authority IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AG PLATS OR
27 Charter Street REPRESEITTATNES.
Salem MA 01970 AII '.RI DR I
ACORD 25(2007f08) ®ACORD CORPORATION 1
f