250 JEFFERSON AVE - BUILDING INSPECTION $ 5c7q
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The Commonwealth of Massachus 4tJERVICES
Department u Public M(Fk ��y
4� Massachusetts State Budding Code(780`CS41Ri 9 q Ck II,,
Building Permit Application for any Building other than"a One-or Two-FaLlly%welling
(\ (This Section For Official Use Only)
�--+� Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
�?S0 J e dLrs on CC c-)e-
_ No.and Street City/Town Zip Cade Name of Building(if applicable)
1 SECTION 2:PROPOSED WORK. _
Edition of MA State Code used_ if New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ TAddition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
I Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review requirgd? t4 /1 e / Yes ❑ No ❑
Brief Description of Proposed Work: -D n-20 ,`Z'.'9 0 f 'T"'r �X l ('l✓/ / "
G r ✓! '
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq,ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable) -
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business 12' E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check asap licable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
h Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench �l Site❑os Licensed Disposal Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P s
required❑or trench or specify:
Private❑ or indeatify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: i�\_I h t is(-mnpo„nn Rov,,!w i ru,e s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the builduug can Lain an Sprinkler System?: Special Stipulations:
7 / � �—
c
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Pr ) No.and Street City/Town _ Zip
Property Owner Contact Infonrintion:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby autho tzes
LAG ✓-kkS �J/jS 8ryy�.t 1 ,lJ jj'y/.!�
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix2) - -
If budding is less than 35,OW cu.ft.of enclosed space and/or not under Construction Control Then check here O and ski Section 10.1
10.1 Registered Professional Res p onsible for Construction Control - - -
i.iu / l6rce.L L� J 3 f%73�
Name( rstra t Telephone No. e-mail address Registration Number
rl sn�rr� I
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name s
Name of Person R onsiblejfor Cons ction License No. and Type if Ap Tic( le
uj�_Ie_ r Vt cl s sq 6" V� r 6/�r/:
X
Street Address City/Town State Zip
?61_Jlj —32<y --
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4l'0I:KH6'(_-0AIPISNSA I ION INSUItAN J:AFF11)AVI,I M.G.C.c.152.6 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No O
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE:
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other S Enclose check payable to
6.Total Cost .$ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to thebest of my knowledge and understanding. ppI ., /' /
Please pr' t and sI'gK��r name Title Telephone No. Date
f� c :l1cw c� S� S9✓� Af�'SS, l� a 7 0
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Department oflndustrfalAccidents
i I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgaru tion/Individual): [��' S S•T ,
i ry�
Address: p—
City/State/Zip: �5 1961)� ((�t<iss phone#: 2
Are you an employer?Check the appropriate box:
[8.
ype of project(required):
154.a employer with employees(full and/or part-time).*
. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] ❑Remodeling3.❑1 am a homeowner doing all work myself[No workers'comp.insurance required.]1 . ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on m 0❑Building addition
ens are that all contractors either have workers'compensation insurance or are sole
I wdl
Proprietors with no employees.
1 L❑Electrical repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 12.❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.= 13.❑Roof repairs
6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp insurance required.]
'Any applicant that checks box#I 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 must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: J Expiration Date:
Job Site Address: 0�5� , Q Sum , '- City/State/Zip: S,-y4- k [ a-e$s
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c
ertify under t pa' sand penalties afperjury that the information provided above is true and correct.
Si atur
Date:
Phone#: tIl r 3 2 4'F
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 o Health 2.Building Department 3.City/Town 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 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 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 local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit 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 Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/licrose number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA MASSAMUSE M
a . BUIDMG DEPAYMENT
120 WWgmcMS4MEET,311DRD x
M!L(978)745.9595.
PAY(978)740.9846
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MAYOR 7hias STYMW
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Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
jOs/,IL-
(name of hauler)
The debris will be disposed of in:
L� vl
(name of facility)) /
(address of facility)
Signa// r/e/ of applicant
Date
Dante's Construction
8 Wheatland Street
Salem, Mass
1-781-715-3298
dantesconstruction12@yahoo.com
Construction Supervisor, Raul Baez Jr.
Construction Supervisor Lic. # 106464
Home Improvement HIC # 173214
This agreement is made this 1/11/2016 by and between Raul Baez (hereinafter"Contractor")
Classic Automotive 250 Jefferson Ave Salem, Mass (hereinafter "Owner").
Scope of work
The owner does hereby employ the Contractor to do all the work and provide all the materials, tools,
and supervision necessary for the renovation of the existing Bay garage ,we will remove all of the
steel beam on the loft side including the beam on the center of the bay.
We will also frame to extend the office space as discussed, install new ceramic tile (your choice) and
the bathroom.
Demolition of plywood attach to the wall
Frame all the walls with 2x4 metals stud
Installation of% cdx plywood 25 sheets
Installation of 5/8 type x fire rated sheet rock
Concrete slab for the spray booth (allowance only
Tile for the bathroom, and the office dz;:,x i �
Installation of fiber glass paneling (fiber glass reinforced panel)
Framing for 5 windows labor and material
Power steams the floor& paint'.
Installation of 1 solid metal door fire rated
Installation of 2 solid core doors
Re- does the one office and the small
Permit fee
Overhead and profit
The total sum of: $53,800.00
THE TOTAL.SUM E OF $53800.00 IN 3 PAYMENTS OR INSTALLMENS,
FIRST PAYMENT OF 20,000.00. SECOND PAYMENT 20,000.00.00LAST PAYMENT 13,800.00
100% JOB COMPLETACION.
The Contractor shall commence the work to be performed within 7 days from the date of the Notice to
Proceed, and shall complete the work 60 days thereafter,
The Contractor shall carry liability insurance with the limits of 1000,000 for injury to or death of one
person, 500,000 for injuries or death suffered in one accident and 1000,000 Workman's compensation
insurance and shall provide Owner with proof of such insurance.
Chapter 6-1
Hold Harmless
The Contractor agrees to defend, indemnify and hold the owner harmless from any liability or claim for
damage because of bodily injury, death, property damage, sickness, disease or loss and expense
arising from the Contractors' negligence in the performance of the construction Contract. Each
Contractor and subcontractor is acting in the capacity of an independent Contractor with respect to
the Owner. The Contractor further agrees to protect, defend and indemnify the Owner from any
claims by laborers, subcontractors or material men for unpaid work or labor performed or materials
supplied in connection with the Construction Contract, unless home owner have hired the sub-
contractor, or order the materials on their own.
Assignment of Contract
The contractor agrees not to assign the Construction Contract without the written consent of the
Owner.
Change Orders
The Contractor agrees not to make any changes in the schedule of work, design, or of the
specifications without written authorization by the Owner. The Home owner is not allowed to ask any
employee nor sub-contractor to do any changes without notification to contractor. If when we start to
do the work and we discover a problem not seen with the naked eye and additional fee will be added
to the scope of work, before doing the work a signed agreement would have to be done prior to the
work being started.
Lien Waivers
The Contractor shall protect, defend and indemnify the Owner from any claims for unpaid work, labor
or materials. Unless agreement was made outside of this contract and hire by you the home owner or
agent.
General Guarantee
The Contractor shall remedy any defect due to faulty material or workmanship and pay for any
damage to other work resulting therefrom which shall appear within the period of one year from final
payment. Further, the Contractor will furnish Owner with all manufacturer's and supplier's written
guarantees and warranties covering materials and equipment furnished under this Contract.
Permits and Codes
The Owner shall obtain ail necessary building permits, including those required by the Massachusetts
and Act 250 as applicable. The Contractor will secure at his/her own expense any other necessary
permits and licenses required to do the work and will comply with all building and code regulations
and ordinances whether or not covered by the specifications and drawings for the work.
Chapter 6-2
Work Performance
1) The Contractor shall protect all work adjacent to the Contract site from any damage resulting from
the work of the Contractor and shall repair or replace any damaged work at his/her own expense.
2) The Contractor shall replace and put in good condition any existing conditions damaged in carrying
out the contract.
3) The Contractor shall take all precautions to protect persons from injury and unnecessary
interference or inconvenience.
4) The Contractor shall conduct his activities in a business like manner and adhere to the reasonable
wishes of the Owner in relation to his working schedule.
Condition of Premises
The Contractor agrees to keep the premises clean and orderly and to remove all debris as needed
during the hours of work in order to maintain work conditions which do not cause health or safety
hazards.
Use of Utilities
The Owner shall permit the Contractor to use, at no cost, power and water necessary to the carrying
out and completion of the work.
Use of On Site Loam
Owner Agrees as part of this contract to allow the Contractor use of on-site loam to the degree
available as necessary for the completion of the project.
Inspection
The Owner shall have the right to inspect all work performed under this contract. As well it shall be a
condition of this contract that all work that needs to be inspected or tested and certified by the
engineer as a condition of the Dept. of Environmental Conservation Permit, (or other State agency), or
inspected and certified by the local health officer, shall be done at each necessary stage before
further construction can continue. All inspection and certification will be done at the Owner's expense.
Failure to follow this requirement will be grounds for termination of the contract.
Chapter 6-3
Right to Stop Work
If the Contractor fails to correct defective work or persistently fails to supply materials or equipment in
accordance with the Contract Documents, the Owner may order the Contractor to stop the work, or
any portion thereof, until the cause for such order has been eliminated.
Payment Schedule
Payments for work shall be as follows: To be discussed
Payments shall be disbursed based on the attached schedule of values. Within three days of
notification by the Contractor of each stage of completion, the Owner or its designee will inspect and
approve the work, or request any necessary adjustments in the work. The Owner agrees to make
payments to the Contractor within ten days of approving work.
Arbitration
All claims, disputes, and other matters in question arising out of, or relating to, the Contract
Documents or the breach thereof, except for claims which have been waived by the making and
acceptance of final payment, shall be decided by Arbitration in accordance with the construction
Industry Arbitration Rules of the American Arbitration Association (or other arbitration rules). This
agreement to arbitrate shall be specifically enforceable under the prevailing arbitration law. The
award rendered by the arbitrators shall be final, and judgement may be entered upon it in any court
having jurisdiction thereof. Any award shall provide for payment within 30 days of the date of the
award, unless agree to do otherwise.
Retention of and Access to Records
Authorized representatives of the Secretary of the Agency, the Secretary of HUD, the Inspector
General of the United States, the U.S. General Accounting Office, the Common Wealth of
Massachusetts, or other pertinent party to this VCDP Grant shall have access to all books, accounts,
records, reports, files, papers, things, or property belonging to, or in use by, the Grantee pertaining to
the receipt and administration of Massachusetts Community Development Program Funds, as may be
necessary to make audits, examinations, excerpts, and transcripts. (Only if applies)
Financial records, supporting documents, statistical records, and all other records pertinent to this
VCDP-FUNDED project shall be retained in separate records and for a minimum of three years after
receipt of a Certificate of Program Completion.
The above requirements shall apply to all sub-grantees, contractors, and subcontractors who enter
into contracts or agreements with the Grantee.
Chapter 6-4
Conflict of Interest
No person who is an employee, agent, consultant, officer, or elected or appointed official of the City of
Salem or other pertinent party may obtain a personal or financial interest or benefit form, or have an
interest in, this contract or the proceeds hereunder, either for themselves or for those with whom they
have family or business ties, during their tenure or for one year thereafter, if they exercise or have
exercised any functions or responsibilities with respect to the program or are in a position to
participate in a decision-making process or gain inside information with regard to the program or job
performed at the address mention above.
This Contract shall be construed under the laws of the State of Massachusetts and may be modified
or amended only by a written instrument executed by both the Owner and the Contractor.
IN WITNESS WHEREOF, THE OWNER AND THE CONTRACTOR HAVE EXECUTED THIS
CONTRACT AS OF THE DATE FIRST WRITTEN ABOVE.
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CONTRACT
X ,
NAME
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AUTHORIZ SIGNATURE
Chapter 6-5