5 LANGDON ST - BUILDING INSPECTION � ,
, _
The Commonwealth of Massabhuseft§ ""� � ' CITY OF
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� BoazdofBuildingRegularionsandStaii`������ . gAT.AM �
Massachusetts State Building Code,780 CMR ' �ev�sed Mar 2011
Building Permit Application To Construct,Repair,Ra��at�rT�me�1 sh�
' One-or 71vo-Family Dwelling
� ` � �T�sSeeEJon�Fur(j�ciat:Use�Onl � � - °'
� Buil��diug Petmit,hfumbe�': . � 1��:
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� �,�g o������� s�,� ' �
_(1 ��czzo�v i:sar�nv�o�rn�or�
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1.1 Property Add ess: 1.2 Assessors Map&Parcel Numbers
I— ..5' la nr,efr�n S�'
l.la Is tl�is an accepted street?yes no M�P N�°�'� P��Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning DistriM Proposed Use I.ot Area(sq R) Fmntage(ft)
1.5 Building Setbacks(fl[)
Front Yerd Side Yards Rear Yard
Required Provided Requ'ued Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outtide Flood Zone? -M���p�� pn site disposal system ❑
Public❑ Private O Check if yes0 . .
SECTLDN 2: PROPElt3'Y O'R'AtERSHI`P'�
_ : ' .
.. 2.1 Owner�,�f Record: cr � � ...����� ��S5' , � �
.D¢n �
Name(Print City,State,ZIP
5 � , S�' 78/��/J=�Zs�'
No.and Street Telephone Email Address
3EC1'ION 3:DESCRIPT[ON OF PRflPO�ED WORK'(cliecJc all that aPP�Y)
New Construction❑ Exis[ing Building❑ Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units_ Ot1�er ❑ Specify:
Brief Description of Proposed Worl�: _
m0 — ss2 .' ,' u�o1 — L �
yt G 1J+� �
� � �r/L� ��Y^ GU -' � . X M�
SECTION 4:ESTIII'IATLD COIHSTRUC'1'ION COSTS
Est'unated Cosu: Offielal Use Oaly
Item abor and Materials � - . . .' .. `.
1.Building $ l Od0, 1. B�}�g gen°i�Fee'$ ` IndScace how fee is detecmined;
❑Stendazd City/Town Apglication Fse
2.Electrical $ b 0. D J p-T�p�e��y.��tern 6)x e�ultipfier x
3.Plumbing $ 2. Othw Fees: $ � _��
4.Mechanical (HVAC) $ List:. .. . � �f'�- �� .
5.Mechanical (Fire $ 'Fotat All Fees:$
Su ression - � � - � �
C�eck No. (;heek Amoum: Cash Amo�t:
6.Total Praject Cost: $ p� . � O Paid in Ftiil1 ❑Q,��&� �eII��'
CG�'l.'1 �G�°/" '—
`Y�-G�(e� �— l� /�
: .s�crco�r s: co�vs�u�sox s�vic�s 1
51 �Constructiou�SupervisorI:icense(CSL) /tr ��6� �� .� �
1/'L�c t// � .�c� Z License N�ber Facp�
Name of CSL Holder':' �� t'i ;t— '''? �- '
� I .� �/ l� � /] •�� I ; List CSL Type(see below)�=
f�-,e f'f. �i Y � �.Deaar�tiun�
No.az,d Street �
5/�/��-,-, �G SS- O/�'7 b u U����a ,�a� u to 35 000 cu.ft.
Restricted 1&2Femil Dwellin
City/I'awn,State,ZIP � M Maso
RC RooSn Coverin
� ws w�aoW�a s,a;�
SF Solid Fuel Biuning Appliauces �
1�7� -3z Sy t Insuta6on
Tel hone Email address D Demolition
5.2 Re�stered H/ ome Improvtement Controctor(ffiG� J � �Z�� �_��_j
)/ C�t/��J�' �2 J t� " HIC Registretion N�ber F�cpi`ation Date
HI c6�W1'l-L4.`I�IC.r.��� �e
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No.and S t Email address
sr��� G�,Lc.S5 . ot �?o '7� /-7(a"-g z 5�
Ci /Town State Z.IP Te] hone
SECTIOI�6:WORKEt23'CO1t�IFEl!t$AT[fliV II�iTRANCE.AP'P'H�AVIT(A3.G.I:,c.152.§2SC(+Sj� .
Workers Compensation Insurmce affidavit must be completed and submitted with this application. Failure to provide
Uils affidavit will result in the denial of the Issuaoce of the building permit.
Signed Affidavit Atiached? Yes .....� No...........❑
SLC1'tON 7s:OWNER.11YfHORtZ?i�'lOTYi TO B�CO�IPLETED�iV .
OW1wER'S NT OIt�(>PV'i'RACTQR �¢R II3G PEttMT1'
I,as Owner of the subject property,hereby authorize �� [/r �Ct ��
to act on my behalf,in all matters relative to work authorized by this building peimit application. °
��D/� �.. _ �S �
� � 7 �
Print Owner's ame(Elechonic Si�ature) . Date
SECTION 76:OWPIER' (}It AUTHaRIZED AGENT I}�CLARATIOM
By entering my name below,I hereby attest under the pains and penalties of perj�uy that all of the information
contained in this ap lication is true and accurate to the best of my Imowledge and undentanding.
� �a � �— `7 - �--�� cP
Print Owner's �Authorized AgenPs Name(Electronic Si�at�e) " Date
FTUTF'S:
1. An Owner who obtains a building permit to do his/her own work,or an owner who Irires an unregistered contractor
. (not registered in the Home Improvement Contractor(ffiC)Program),will not have access to the arbitration
program or guazanty fund under M.G.L.c. 142A.Other important infotmation on the HIC Prograrn can be found at
.��v�v.mass.sov.'oca InformaUon on the ConsWc[ion Svpervisor License can be found at w�+�wn�ass.eov/dos
� - 2. W6en substantial work is planned,provide the informafion below: �
Total floor azea(sq.ft.) (including garage,Snished basemenUattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of firepJaces Number of bedrooms
Number of bativooms Nutnber of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
� 3. "Total Projed Square Footage"may be substituted for"Total Roject Cos[", `. "' . L � �
� The Commonwealth ofMassach�set�s
Deparlment ojlndustrialAccidents
I Congress Street,Suite I00
Boston,MA 02114-2017
ww►v.massgov/dia
Workers'Compeasation Inaoranu Affidavih Builders/Contractors/Eleetricians/p�timpers,
TO BE AILED VVITg Z'gE PERNIIIT7(�G ADTHORTI'Y.
A licant Information Please Prfat b
Name(aminess/ogem�aon?�iviauan: �4✓G S ���2.c�
. Address: �w h-P��-�c, ,.. d S �
City/State/Zip: �S Y� l i� /�G S 5 Phone#: ��' ���� � Z /-�,�
Are yoa ao empbyer!C6erg fpe approP+lalc 60�:
Tfp!OlplOjCC((7C(�II�II'�;
' e emP�oW wit6 �byeea(full mNmpmt-Gme),•
z.p��,soi��,w��oI ro��n�a n8.2� �. ❑rlew camstruction
�r�ve��Y�[No wwl�as�. ��s a��Os torme m 8. Remodelia
wmP. 'v�smance m9u"ved.) ❑ B
3.❑I am a homeowne dowg ell wmk myselL[No wmke+s'comp.m+�oance requfred.)t 9. ❑Demolition �
4.❑I am a homeowna and vnL he h'vipg wntractors b cmduct all woik on mY ProPWY. 1 wi0 10❑BIL��Dg edalhon
meive that all oomtraama eithahare wvrkers'compe�et�an m,a�ce w me sole
popcietms witL no employx,. 11.�Electrical repai[s or addilionS
s. I em a 12.�Pl�bing repaas or additions
❑ 6�1 w�aam md I 6ave Lirtd t6e subsontreGois 1$ud on the anaehed shcet.
7bese sub-ronoacmra nave emNoym ma eave wo.tas•c�p.�sivance.: 13.QRoofrepairs
6.❑We me a co�ymatlm and its ot6cas have aacised t6e'vrigM of ue�ipn DaMGL c 14.❑OthL7
IS$$1(A),aod we have no emNoYKs IA�o wmkas'e�p.msiomce requurA.]
'�Y aPNicml Nat checla boz i/l must nlm SD out t�secbon below ahowIDg the'v wmtas'comPmaey�Ppb�Y mfmmauon.
t Homwwnvs who suMmt this et5davit iodicauo8 t6eY a�e�mg aD work md t6m�e wfside�ontr+aom m�st au6mit a new a6�davit mdicatiog sueh
�Conbactors that c6e[Ic Nia 6wc must+t��ed m addiuonal sheet showing the n�e ofthe mbsontrecton and su4 whet6c w not Wose mGtia have
empbyces. ffthe wbkontraztms han empluY�.�Y m�tpmvide Mefr svorkaa'comp_Po7icY muuba.
I am on employer[hof rs providing workeis'con'pensation uasurance jor my empJoyecx Belnw is the poGry andjob si[e
tajormarton. /--' �� A ✓�
InsuranceCompanyName: ��G /i ��
Policy#or Self-ias.Lic.#: �
/ Hxpfration Date:
Job Site Address:_.� ` Gtt? f.� � s� ��,��:�y�.� �� S (
AttacL a copy ot tLe workers'eompensatlon poGry declaration page(s6owing the pollcy namber and ezpiratioa dah).
Feilure w sec�ue coverage as requirad imder MGL c. 152,§25A is a ciim'urai violation puoishable by a Sne up to$I,500.00
and/or one-yesr imprisonmeny as well as civil penalties in tLe fom�of a STOP WORK ORDHR and a fine of up to$250.00 a
day agamst the violator.A copy of flvs atatement may be forwerded ro the Office of Invespgations of the DIA for insurance
coverage veri6cation.
7do nereey�uMer e p aadpenahtes cjper�ury Ihat the mjormatron provlded abore is d�re and eonect
i ature• �'\ . Date• — 0 '/
Pho #: ��� �l� � ',3 2 rj�—
O,B'itia!ase only. Do not wri�e in tlris areq to be copip/ded by city ortowa of/PciaL � � �
City or Town: PermiULicense i!
Issuing Aut6orlty(cirde one):
l.Board of Healt6 2.Building Department 3.City/Town Ckrk 4.Electrica!Inspector 5.Plnmbing 7aspector
6.Other
ContaM Pecson: Phone#•
Information and Instructions
Massachusetts General I,aws chepter 152 requues all euq�loyas to provide workers'compensation for tLeir employees.
Piasuant to this stetute,en emp/oyee is de5ned as"...every person m the service of another under any contract of h've,
express or implied,oral or written." -
An employ¢r is de5ned as"en mdividual,ParinershiP.association,cmporation or other legal entity,or any two ar more
of the foregoing engaged in a joint wtaprise,and'mcluding the legal represeartatives of a deceased employer,or the
receiver w trustee of an individuel.PartnerehiP,association or other legal entity,emP�oYmB�Ployees. However the
owner of a dwelling house havmg not more then three epartrnents�d who resides therero,or 1he occupant of the
dwelliag house of anotha who employa persons to do meintenence,construction or repair work on sucL dwell'mg house
or on the gro�ds or building appurten�t thereto shall not because of such employment be deemed to be sn eeu�loyer.�•
MGL chapter 152,§25C(6)also atates that"every state or local licensing agency shall wit6hold tLe issuance or
renewsl of a Hcense or permk to operate a Dusiness or to rnnstrvM buildings in the commonwealtL tor aoy
applicent wLo has not prndaced aceeptable evidenee of complianee with the insorence cm'wage reqaired."
Additionally,MGL chapter 152,§25C(7)states"NeitLer the cormnonwealth nor any of ifs politica]subdivisions aha11
enter into any contract for the perfomiance of public work imtil acceptable evidence of compliance with the ms�aance
raquirements of this chapta have been presented to the contractmg autbmity."
Applicants
Please 511 out the workers'wmpensation affidsvit complMely,by cheddng the boxes that epply to your situstion end.if
necessarY>�PPIy subcontractor(s)na�(s),sddress(es)�d phone number(s)along with theu ceti5cate(s)of
insurance. Limited Liability Comp�ies(I-LC)or Lvmted Liability Parmerships(I.LP)with no employees other than t1�e
members or parhiers,aze not required to cazry workas'compensation ins�vance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the DepaAment of Industrisl
Accidents for con5rmation of insurmice coverage. Also be sare ro slgn and date the s�davit Tbe affidavit should
be retumed to tLe city or town thet the application for the peetmt or]icense is being requested,uot the Depa�trnent of
IndusOria]pccidents. S6ould you have any questions regacding the law or if you are requfred to obtain a warkers'
. compensation policy,pleese call the Department at the number listed below. Self-msured comp�ies should enter theu
self-insurance license number on the o 'ate 1'me.
City or Town OH'icials
Please be siue that the atfidavit is complete�d printed lepbly. The Depazm��t has provided a apace at the bottom
of the af5dsvit for you W 511 out in the ev�t the Office of Investigetions has to contad you regarding the�applicant.
please be sure ro fiII ro the pmniU�icense number whic6 will be used as a reference number. In addition,an applicant
that must submit muluple peimit/license applications in any Avr�year.need only subffit one effidavit indicating current
policy infotmation(if necessary)and imder"]ob Site Address"ihe applicant ahould write"sll locations m (city or
town).•,p wPY of the af5davit thet hes been officially stamped or merked by t6e city or town may be provided to the
applicent as prooithat a valid affidavit is on 51e for fuwre penmts or licenses. A new at5davit must be filled out each
year.Where a home owner or citiun is obtaining a license or pamit not related to�y business w commercial venture
(i.e.a dog license or pemiit W bum leaves etcJ said person is NOT requ'ved to complete this affidavit•
The Departrnent's address,telephone md fu numb�:
1'he Comu►onwealth of Massachusetts
Depariment of Indus�ial 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.mess.gov/dis
C�TY OF SALEM, MAS'SA�I[,�ETP'
, Br�vna�D�r�s�Nr
l20 WASFIDaG70niS7R�T,31DFlo�t
7�1.�478)74.5-9595. '
F�7[ �7�49846
SI�ERIFYDRiSaL'�I,
MAYQR 71�ioi�iSS'f.P�
D�ac�c c�+r�uc�dsr.�a�c�t
Construction Debris Disposa/Af rdavit
(required for all demoliiion and,.renovation wo►�c)'
In accordanoe wfth ihe sbcth edition of the State 8uilding Code, 780 CMR, Secticn 111.5 De�is,
� and ihe provtsions of MGL c40,S 54; Bufidir�Permit#I ��y����
condiLion that the debris newfting from this wor�c shall be dlspased of in a propPrJy lroer�
waste deposit faality as defined by MGL c 111,S 150�1. �
The debris will be transported by: �
.� a �L..(�-r�' (�x �� �
(name of hauler) '
The debris will be disposed of in: .
L y� �'t i,r�� s�. �y1�� ��
(name of facility)
c�S U� Co1�.c� �cL � S�
(address of facility) �
��—
Signat re of applicant
Date
Dante's Construction
8 Wheatland Street
Salem, Mass
1 -781 -715-3298
Dantesconstruction 12@yahoo.con
Construction Supervisor, Raul Baez Jr.
Construction Supervisor Lic. # 106464
Home Improvement HIC # 173214
This agreement is made this 07/02/2016 by and between Raul Baez (hereinafter "C
(Owner) Denis Vigneault 5 Langdon Mass 01970 (hereinafter "Owner").
The owner does hereby employ the Contractor to do all the work and provide a
tools, machinery and supervision necessary for the building of a dormer on the
house according to the plans..
Scope of work
1- Contractor to obtain Building Permit from City of Salem, Mass.01970.
2- Demolition of the intire in close stairwell.(26'-2 7/8)
3- Demo the intire foundation (existing Concrete footing)
4- Re-do the intire in close stairwell with framing wall, 2x4 pine kd or 2x6 p
discretion of the building inspector(26'-2-7/8)
5- Framing with 2x10 pressure treated wood.
6- Install 5 footings (12x48)concrete.
7- Framing a new deck 4'-9" X 5'-0" with set of stairsand realing. (PTmatyei
8- Framing a new set of stairs to mass code.
9- Install new white siding with accessories, J channe�s, stater strip, alumi�
install new roof and also framing of the new bulkhead and roof.
10- Install 32x80 exterior door, (standar)
11- Install a new storm door 32x80.
12-Shet rock and paint.
13- Contractor responsible for the debris removal.
The Contractor shall commence the work to be performed within 15 to 20 days fror
Notice to Proceed, and shall complete the work 150 to 300 days thereafter,
The Contractor shall carry liability insurance with the limits of 1 ,000,000 for injury to
person, 500,000 for injuries or death suffered in one accident and 1000,000 Workn
insurance and shall provide Owner with proof of such insurance.
Hold Harmless
The Contractor agrees to defend, indemnify and hold the owner harmless fror
claim for damage because of bodily injury, death, property damage, sickness,
and expense arising from the Contractors' negligence in the performance of tl
Contract. Each Contractor and subcontractor is acting in the capacity of an ir
Contractor with respect to the Owner. The Contractor further agrees to protec
indemnify the Owner from any claims by laborers, subcontractors or material
work or labor performed or materials supplied in connection with the Constru
unless home owner have hired the sub-contractor, or order the materials on tf
Assignment of Cohtract
The contractor agrees not to assign the Construction Contract without the written coi
Owner.
' Change Orders
� The Contractor agrees not to make any changes in the schedule of work, design, or �
specifications without written authorization by the Owner. The Home owner is not allc
employee nor sub-contractor to do any changes without notification to contractor. If v�
do the work and we discover a problem not seen with the naked eye and additional fe
to the scope of work, before doing the work a signed agreement would have to be do
work being started.
Lien Waivers
The Contractor shall protect, defend and indemnify the Owner from any claims for unF
or materials. Unless aareement was ma�lP r,��t���A .,f r►,�� �.,n+���+ �„�, h;... �.. ..,.. . .w_
Permits and Codes
The Owner shall obtain all necessary building permits, including those required by t
and Act 250 as applicable. The Contractor will secure at his/her own expense any c
permits and licenses required to do the work and will comply with all building and cc
ordinances whether or not covered by the specifications and drawings for the work.
Work Performance
1) The Contractor shall protect all work adjacent to the Contract site from any dam�
the work of the Contractor and shall repair or replace any damaged work at his/h
2) The Contractor shall replace and put in good condition any existing conditions d�
out the contract.
3) The Contractor shall take all precautions to protect persons from injury and unne
interFerence or inconvenience.
4) The Contractor shall conduct his activities in a business like manner and adhere
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 det
during the hours of work in order to maintain work conditions which do not cause he�
hazards.
Use of Utilities
The Owner shall permit the Contractor to use, at no cost, power and water necessary
' 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 th
' available as necessary for the completion of the project.
Inspection
Right to Stop Work
If the Contractor fails to correct defective work or persistently fails to supply materia
accordance with the Contract Documents, the Owner may order the Contractor to s
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 thrE
notification by the Contractor of each stage of completion, the Owner or its designee
approve the work, or request any necessary adjustments in the work. The Owner a�
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, th�
Documents or the breach thereof, except for claims which have been waived by the
acceptance of final payment, shall be decided by Arbitration in accordance with the c
Industry Arbitration Rules of the American Arbitration Association (or other arbitratior
agreement to arbitrate shall be specifically enforceable .under the prevailing arbitratic
rendered by the arbitrators shall be final, and judgement may be entered upon it in ai
jurisdiction thereof. Any award shall provide for payment within 30 days of the date c
unless agree to do otherwise.
Retention of and Access to Records
' ,9uthorized representafives of the Secretary of the Agency, the Secretary of HUD, the
General
of the United States, the U.S. General Accounting Office, the Common Weai
Massachusetts, or other pertinent party to this VCDP Grant shall have access to all b
records, reports, files, papers, things, or property belonging to, or in use by, the Grani
the receipt and administration of Massachusetts Community Development Program F
necessary to make audits, examinations, excerpts, and transcripts. (Only if applies)
• � .
Conflict of Interest
No person who is an employee, agent, consultant, officer, or elected or appointed of
Salem or other pertinent party may obtain a personal or financial interest or benefit f
interest in, this contract or the proceeds hereunder, either for themselves or for thos�
have family or business ties, during their tenure or for one year thereafter, if they exe
exercised any functions or responsibilities with respect to the program or are in a po:
in a decision-making process or gain inside information with regard to the program o
the address mention above.
This Contract shall be construed under the laws of the State of Massachusetts and n
amended only by a written instrument executed by both the Owner and the Gontractc
IN WITNESS WHEREOF, THE OWNER AND THE CONTRACTOR HAVE EXECUT
CONTRACT AS OF THE DATE FIRST WRITTEN ABOVE.
DANTE ONST C ON � � � �
> -.
X �
CONTRACTO
x RAUL BAEZ �- �
NAME
x Denis Vi neault �
AUTHORIZED SIGNATURE � � �' I �
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"'_______' _ ___' "'_ ____ _______ '_' '_____________ _ '___'_ ________'_"__"'____'______
_ DATE:
_______________'_ '
--� �------ --------- ------- ---- - ---- 6/27/2016
�
o . . " SCALE:
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� 14'35l16" � 4'31/7' SHEET: .,
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