331 HIGHLAND AVE - BUILDING INSPECTION (4) I
'CITY-Or �XLE
PUBLIC PROPERTY .
DEPARTMENT
KiNmEau.EY oRrscou
a
MAYOR I?0 Wxijiw mN STREET•$ALLK\tA1SACHLSE--1'IS 01970
TFi 978-745-9595* F=97&740.98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION -
Location Name: RiCA-a,. (Y\gjAc�& Building:
Property Address: 331 pj-te�u_e
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land d
Name: "so 2
Address: u 1�\ t�Q M
4'4 D (47O
Telephone: t r f J�77 O
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
DEr-:oiiti n Existing G�
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building 1 q 7 New
Brief Description of Proposed Work:
2QM 3 04
C, I b C e �iarr.s.
Mail Permit to: NVUS x ` �p �n (Y)F� Ogg
What is the current use of the Building?
Material of Building? b If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
o
Architect's Name �
Address and Phone
Mechanic's Name
Address and Phone
Construction Supervisors License# c�"13 j HIC Registration# 12917 7
Estimated Cost of Project$ 39, -11 Ab Permit Fee Calculation
Permit Fee $ 421 f oa Estimated Cost X$71$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building
�Permit to build to the ve stated
specifications. Signed under penalty of perjury X
Date ►1 `t 6
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CrrY OF SA Em
' PUBLIC PROPERTY
DEPARTmENT
w.raa I�wwm�.to„srsast.sat.awxaoaoamsat!'fa
Construction Debris Disposal Affidavit
(requires Let all demoudos.od caiovadas wad*
In accordance with the sixth edidos of dw State Buildins Cods.780 CMR secdoe 111.11
odmist and dw psovisiom of MCI.a 44 9 54
Buildit Pencil A is iswed with the cocAddoo that the dahlia taatlting Ass
this wart dball be disposed of(s a pwpatllr Bcensed waste disposal&ciUW a.deAned by MCI.a
111.s 1J0/1.
The dells will be A transpooned by:
�6 ME' s�Ea VS 120
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The debris will be disposed of in:
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(nam of ftcwty)
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIM1tER1FY DRLSCOLL
MAYOR 120 WASHmTONSTRm•SALEM,MASSACHUSEM01970
TEL.978.745.9595 •FAX:978-740.99"
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aaulicant Information Please Print Legibly
Name (Business/Organiaation/Indivi&W): t4E us 11 si:a-V XeI&
Address:_?_ ® . 3oa4 2g2.S
City/State/Zip: (00b vS C\ m A o I is Phone#: -'79 1 -7 66 201
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction
(full and/or part-time).* have hired the sub-contractors
2A 1 am a sole proprietor or partner- listed on the attached sheet t 7. KRemodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers' comp. insurance. 9, ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required]f employees. [No workers'
comp. insurance required] 13.❑Other
*Any applicant that checks best C must also all art the ration below abowing am4 workers'compoustion policy interm lion.
t Homeowners who submit this atf dsvit indicating they aka doing all work and then hire outside contenders must submit a new affidavit indicating such.
:Conuwtor that check this box neat sttuhed an additional sloes showing the name or the sub-contractors and their workers'comp.policy information.
/am an employer that le providing workers'compensation insurance for my employees. Below if the policy and fob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and exph attoa 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
J do hereby certify ander fhs and penalties ofperfury that the Mformadon provided above(L true and correct
Sianat : Date, t t Q I d 6
7'
Phone#: 81 760 ,Z03
seess
OJJleial use only. Do not write in this area,to be completed by city or town oJjTciaL
City or Town: Permit(License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/rown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
Information and, Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fortheir emplo
yem
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 employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or toed licensing-agency shall withhold the issuance or
renewal of a license or permit to operate a bushuess 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 I52;§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 bien presented to the contracting authority.
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if
necessary,supply sub-contractor(s)name(s),address(es)and phone numbe:{s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other titan 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 a r nate lire.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicerse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fittuae,pecxntte..orlicenses. 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 bum 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 to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts `
Department of Industrial Accidents
Office of Investigations
600 Washington skeet
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 wwwmm.gov/dia
Nexus II Carpentry and
Construction Design
P.O.Box 2823
Wobum,MA 01888
781 760 2031 or 978 688 7929
Fax 978 975 1263
Contract
This is a contract proposal dated November 9th, 2006 between Puritan Medical
Center, 331 Highland Avenue, Salem, MA, 01970 (hereafter referred to as "Puritan")
and Nexus II Services (hereafter referred to as "Nexus") to carry out work at the above
address.
GENERAL SCOPE OF WORK DESCRIPTION
WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: interior work as
directed during site visit to create 4 exam rooms
Scone of work:
General
- Remove and trash interior walls and framing in the radiology/viewing room/dark room
and treatment rooms
-Remove and trash existing carpet where necessary from this area
-Repair existing walls with compound to blend
- Remove existing plumbing and prepare for new plumbing required
- Furnish and install new plumbing to code
- Furnish and install electric to code (inclusive of outlets and one fluorescent ceiling
fixture per exam room)
-Rework plumbing to accommodate current locations of drainage
- Rework existing sprinkler system to accommodate code for each room
- Rework existing HVAC system to accommodate new exam rooms
- Furnish and install framing to create 3 new walls to separate new exam rooms
- Furnish and install sheetrock with plaster finish to new framing
- Open up entry door for access to one of new exam rooms (existing 3 doorways to
remain and be utilized)
- Furnish and install 1 —2 foot countertop to each exam room(white laminate in color)
NOTE: area under sink to be left open for trash barrels etc.
- Furnish and install 1 stainless steel sink(single bowl) with faucet to each exam room
- Furnish and install 1 —2 foot wall cabinet(white laminate) over new countertop in each
exam room
- Furnish and install door and frame to new entry opening
- Repair existing suspended ceiling tile system to accommodate each room
- Furnish and install new VCT(vinyl tile) to each new exam room
r'
-Furnish and install new cove base to new VCT
-Paint new walls and trim to color to be chosen by "Puritan"
- Removal of site debris created by Nexus II Services
Work not included in this contract
Permit costs
Unseen conditions
--Upgrades to sprinklers
Upgrades to HVAC systems
Additional thermostat systems (one thermostat will service all 4 exam rooms)
Upgrades to Electrical panels
Changes to above scope of work
PERMITS
"Nexus" will accept responsibility to obtain the necessary building permits. "Nexus"will
act as a GC and work in accordance with fair and reasonable practices, and cooperate
fully and under the guidance of the "Puritan" and authorized parties. Any costs of
necessary permits will be added to overall contract price at second payment.
Standard Exclusions:
Nexus II Services will not be responsible for the existing structure or previous work
associated with the existing structure. It is understood from the manufacturer that
the structure will support the new glass roof system.
Unless specifically included in the"General Scope of Work" section above, this
agreement does not include labor or materials for the following work (any Exclusions in
this paragraph which have been lined out and initialed by the parties do not apply to this
Agreement): Removal and disposal of any materials containing asbestos or any other
hazardous material as defined by the EPA. Custom milling of any wood for use in
project. Moving"Puritan"property around the site. Labor or materials required
repairing or replacing any "Puritan" supplied materials. Repair of concealed
underground utilities not located on prints or physically staked out by "Puritan", which
are damaged during construction. Surveying that may be required to establish accurate
property boundaries for setback purposes (fences and old stakes may not be located on
actual property lines).
Final construction cleaning ("Nexus" will leave site in"broom swept' condition).
Landscaping and irrigation work of any kind. Temporary sanitation, power, or fencing.
Removal of soils under house in order to obtain 18 inches (or code-required height) of
clear space between bottom of joists and soil. Removal of filled ground or rock or any
other materials not removable by ordinary hand tools (unless heavy equipment is
specified in scope of work section above), correction of existing out-of-plumb or out-of-
level conditions in existing structure. Correction of concealed substandard framing.
Removal and replacement of existing rot or insect infestation. Construction of a
continuously level foundation around structure (if lot is sloped more than 6 inches from
front to back or side to side, "Nexus" step the foundation in accordance with the slope of
the lot). Exact matching of existing finishes. Repair of damage to roadways, sidewalks,
or driveways that could occur when construction equipment and vehicles are being used
in the normal course of construction.
The "Puritan" is to enter into contracts for all of the above-mentioned services and
provide direct payment to "Nexus" for all of the services we are to provide.
"Nexus"will be responsible for removing all components and all construction materials
relevant to the "scope of work" in this contract.
Nexus will not accept or assume any responsibility or liability for the structure or for its
manufacturer's warranty.
Trailer and Dumpster notices
"Nexus"will make arrangements for removal of all site debris created as part of the
above scope of work and will coordinate with the local building department to confirm all
guidelines are followed. Throughout the duration of the scope of work "Nexus"will have
park on site their own trailer vehicle which is utilized to store materials and tools required
to complete the work noted. This trailer is the sole responsibility of"Nexus" and will be
appropriately insured under the company insurance policy of"Nexus".
Warranties
All the components supplied by"Nexus" as part of the original order are covered under
the warranty exercised by "Nexus" and supported by the vendors.
All labor and materials purchased from other suppliers to achieve completion of contract
are warranted(1)one year on labor costs from completion of the construction.
The glass panels are warranted for 10 years by the manufacturer.
Expiration of this Agreement:
This Agreement will expire 30 days after the date at the top of page one of this agreement
if not accepted in writing by"Puritan" and returned to "Nexus" along with the necessary
deposits within that time frame.
People Authorized to Sign Change Orders:
The following people are authorized to sign Change Orders:
"Nexus": Mark Gotobed or Ged White
""Puritan": Deb Phelps or Dr. Fischer for and on behalf of Puritan Medical Center
Concealed Conditions:
This Agreement is based solely on the observations "Nexus"was able to make with the
structure in its current condition at the time this Agreement was bid. If additional
Concealed Conditions are discovered once work has commenced which were not visible
at the time this proposal was bid, "Nexus" will stop work and point out these unforeseen
Concealed Conditions to «..Puritan„., ««so that Puritan.... "Nexus"Nexus can execute a
Change Order for any Additional Work.
Changes in the Work:
During the course of the project, ""Puritan"" may order changes in the work(both
additions and deletions). "Nexus"will determine the cost of these changes and the cost
of this additional work will be added to "Nexus"profit and overhead.
Schedule of work
It is agreed by both parties that this work will be coordinated with the ""Puritan""
and "Nexus" to be undertaken in various stages to avoid complete disruption of the
home or Office environment and also to allow coordination with existing projects.
"Nexus"will give""Puritan"" no less than 2 days notice prior to arriving on site for
commencement of any of the agreed stages of work to allow ""Puritan"" to prepare.
""Puritan'... commits to have sites identified for construction work available for
start at the beginning of the scheduled day so as to avoid any unnecessary delays.
Contract Cost and Payment Schedule:
Total cost of work description and materials included in the proposal (except
materials/work stated) - $38, 471.00—(Thirty eight thousand four hundred and seventy
one dollars zero cents)
PAYMENT SCHEDULE
First payment due upon signing this contract
TOTAL $12, 823.67
Second payment due upon completion of first week of work
TOTAL $12, 823.66
Final payment due upon completion of scope of work
TOTAL $12, 823.67
Total due upon acceptance of this agreement $ 12, 823.67
(All checks to be made payable to: Nexus II Services
I have read and understand, and I agree to, all the terms and conditions contained
in the proposal above.
Date.............................. "Nexus"Authorization............................................................
Date.............................. Puritan Authorization.....................................................
Date..............................."Puritan" Authorization......................................................
SPECIALIZING IN QUALITY FINISH CARPENTRY,REMODELING,SPECIALIST ROOF SYSTEMS,SITE AND
PROJECT MANAGEMENT
BOARD OF BUILDING REGULATIONS
gonswuchon-Cas,
cense: CONSTRUCTION SUPERVISOR
Number: CS 073991
hdate: 04/07/1962
Expires: 04/07/2008 Tr.no: 21477
Restricted: 00
GERALD WHITE
54 EMERALD DR
LYNN, MA 01904
Commissioner �'
7/. "(0o72/Jwlefaexzt!Vt 0�'✓1�/aa:,¢r/xuorlJn
License or registration valid for individul use only T Board of Building Regulations wad Standards
before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR
Board of Building Regulations and Standards
One Ashburton Place Rot 1301 Registration: 129177
Boston,Ma.02108 Expiratloui 7/19/2007
Type: Individual
Gerald White '
Gerald White
54 Emerald Drive
Not valid without signature Lynn,MA 01904 - Administrator
1� V C
�.3i
11,;Q9/2006 09:44 FAX 978 531 4857 B H MCCARTHY 0002
ClienHF:26558 NEXUS
ACORD. CERTIFICATE OF LIABILITY INSURANCE +;i09/ro6 "'�'
PR6pyi56 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Conifer Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Peabody ,MA 01960
978 532.5445 INSURERS AFFORDING COVERAGE "Go
NEURED S suRERA ProBuliders Speciality Insurance Co. 33618
Nexus II Services LLC INSURERS: Safety Indemnity Insurance Co.
P.D,Bpi 2823 INSURERG
Wobum,MA 01888 INSURER D:
INSURER e
COVERAGES
THE POLICIES OF INSURANCE L STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWrW5TANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERYAIN.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.
LTR N
TYI4 of d8URANCE POLICY NUMBER DAIS M p" POLICYEXPIRATION UMITS
A GENERAL LUUIIUTY 5010894 011/12/06 OBf12/07 EACH OCCURRENCE $1000000
X CAMMQiCUK GENERAL tUBIUTY DAMAGETORENTED $50000
CWMGMADE OCCUR MEDEXP one Nan) E$000
X BI/PDDed•1.500 PERSONALAADVINXURY $1000000
GENERALASOFEOATE E2090000
GENL AGGREGATE UNIT APPLIES PER PR0DUCTS-COMPIOPAO0 $t 096000
POLICY P� r7 LOC
B AUTOMOBILE LIABILITY 3116632 11/10/06 11/10(07 COMBINED SINGLE LIMIT f
AnrAvro Me eaddePO
ALL OWNED AUTOS `POvDI YIINNNRY E250.000
X SCHEDULED AUTOS
X HIRED AUTOS BODILYINlVRY $500,000
X NON-0WREDAUTOS INramdenD
PROPERTYOAMAGE S100,000
(PoferceenD
6ARAEE LMBIUTT AUTO ONLY-EP ACCDENT S
ANYAUTO OWERTHAN EAACC S
AUTO WILY: ADD S
EXCESSNMBRELW LIABILITY EACH OCCURRENCE $
OCCUR CU IUS MADE AGGREGATE S
8
DEDUCTIBLE S
RETENTION f
WC SLIMIF Oa
vrOHMEwB COMPENSATDM AMD
ETPLOTFIS'LWBIIffY EL EACH ACCIDENT S
ANY PROPRIIFTOIVPARTNER ECUrIVE
OFRCERIMEMOEA ENCLUDEW E.L.DISEASE-EAEMPLOYE S
Ir"e.dow"W K E.L.DISFASE-POLICY OMIT S
SPECOTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONSAODED BY ENDORSEMENT I SPECIAL PROVISIONS
Job:Puritan Medical 331 Highland Ave.Salem,MA 01970
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY W THE ABOVE OESCRI EO POLICIES BE CANCELLED BEFORE THE E%PWATION
City of Salem DAWMEREOF.TMEIGSVIMGNEURERWULENOEAVORTOIWL _10— DAYS WItliTEN
Public Properties Department- NOTICE TO THE CEmBri:AYE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO sRAu
Building Office erpoSE ND OBLIGATION OR LIABILITY OF ANY KIND UPON WE INSURER.ITS AGENTS OR
Salem.MA 01970 REPRESEI(TATF/ES.
A�rHORQEO REPREGEf1unVE
ACORD 25(2001/08)1 of 2 #52611 RBU 0 ACORD CORPORATION 1953
11/19/2006 09:44 FAX 978 531 4857 B H IttcCARTBY Z005
n
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. Astatement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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)-
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer,and the certificate holder, nor does it
afrnmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACOR0255(20otlo6) 2 of n2811
34 -6411
Exam Exam Exam Exam
Room Room Room Room
O O Li
O O
--- - --
z'-10. z'-id' 2'-10" 2'-10"
Projected layout
34'-fo"
'-6"
12I-0" 10 12'-01
I
storagle
2'-10" -
Exam room Radiology
common arsa
2'-1011
Existing la-yout