23 GREEN ST - BUILDING INSPECTION .-nen r
The Commonwealth of MassaF�ii�@tts: :.=
Department of Public Safety
Massachusetts State Building Code(780 CMflj)C ,1n� O P 3:
Building Permit Application for any Building other than a On amily Dwelling
_ \ - (This.Section For Official Use Onl )
Building Permit Number: Date Applied: _Budding Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
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 ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineerin Peer Review re uired? 3�j o Yes ❑ No ❑
Brief Description of Proposed Work: e Q. r O P
CG e
Q Q
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) O
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 aplicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 Gr F2❑ - H: Hi h Hazard H-1 11H-2❑. H-3 13H-4❑ H-5❑
I: Institutional 1-1❑ 1-2 13I-3❑ 14 13M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use Cl and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Rr III __PIA 13 118 I IIIA 13 IIIB ❑ 1 IV 1 VA 13 VB 13
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposab Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: _�i_\I listoric,Cmnmission�te.�n;�e l�rtx_ss:
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:
Dues the building contain an Sprinkler System?: Special Stipulations:
Mf�.Lt.._. -its C-®tJ"rTz.t�L�ao� mfatt.� l z..ly
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) fix"�(J_4 1 No.and Street City/Town Zip
Property Owner Contact Information:
C jVAfnhea-�, 1papi r, _
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fillout Appendix2).
f buildih is less than 35,000 cu.0:of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control -
i1VI �1TP� Cr t9 Z �t �1- , ti?
Name(Registrant) Telephone No. a-mail a idre s Registration Number
f 1 N� k <i �/P�i'c=� fyl -
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor- -
MaQ'S �. Qhcran�i cc-GiD
Company Name
maa l!o toY`(f2
N1me of Person Responsible for Construction License No. and Type if Applicable
t T;:�rarnrl� � i:Uei'Q`� � o2fya
-71
Street Address ` City/Town State Zip
Telephone No, business Telephone No. celle-mail address
SECTION 11:WORKERS'COMPENSAI'[ON INSURANCE AFF'IDAVU M.G.L.c.1519 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.ANDPERMITFEE. .
Item Estimated Costs:(Labor 6.
� C, 00 10and Materials) Total Construction Cost(from Item 6)=$ Irl
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 $ Enclose check payable to
6.Total Cost $ �p (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accu 1e-E the best of my knowledge and understanding.
Cr�l�l�lY r113F1_�.����
Please print did sign n. J Title Telephone No. Date
I t r7 ,htanroer, �1 01 6, 6,6 tJ 1-6110,- 1,3)/k19
Street Address City/Town State Zip I
Municipal Inspector to fill out this section upon application approval:
Name Date
1
[,jassdchusetts -�Pa'sment .3•-P+'`'=lye-5a'tez= . ..
'_.tcenserCS-090869 .{
MARIO CRUZ '-
PO BOX 638
East Boston MA 02128 4 $
Exp?r;r;�c
� .�^• 04/30/2016
Gor1e'�15sio�e� t
I
V
/zc L�a»zlltn.YrWea�fl cCA�c�.1�c�cfccJe
Office of Consumer Affairs and Business Regulation
} 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
_ Registration: 173803
Type: Corporation
Expiration: 11/15/2016 Tr# 260297
MARIO'S LANDSCAPING, CORPORATION
MARIO CRUZ — --
117 HANCOCK ST #1
EVERETT, MA 02149
Update Address and return card.Mark reason for change.
=i Address Renewal ❑; Employment J Lost Card
0 20M-05!11
License or registration valid for individul use only
o,
Office of Consumer Affairs&Business Regulation
'��, (OME IMPROVEMENT CONTRACTOR before the expiration date. a found return eg
gistration: 173803 Type: Office of Consumer a 5170s and Business Regulation
10 Park Plaza-Suite 5170
` Expiration: 11/1512016 Corporation Boston,MA 02116
10'S LANDSCAPING,CORPORATION
10 CRUZ
-IANCOCK ST#1
RETT,MA 02149 Undersecretary Not valid without signature
The Common] a ofMassachuseds
Deparomenl of 1x&strfklAcddents
I Congress Sassy Suite 100
Boston,M,4 01114-2017
www.massgoY1dia
Workers'Compensation Insurance Affidavit:Builders/CoMradors/FJwWciam/Plumbers.
TO BE MED WITH THEE PEWV➢ITING AUTHORITY.
Aoollcantlnformation Please Pilot 1A47y
xaD>e(Das;neasro,�atioa�mhaa�ir�4x'iO'S L�n����� nr� .
Address: 14 4 Uah -K sT
cityistattazip: �1)E'.r��TT_ AA • Phone#: 6 PT .9 6 L :S 2 17
AMY" employer?Chak Poe apprgp(Ne par: - Of To ed
P i Glared):
l.7 employer wim enpbyeer(1w]and,krp t-time).' - 7. O N, construction
2.plam9k801epopiebrap,naoshyaotf have no w1prarworl�mp for. a*
mYeopu9tY•INo wdhge' •faaotmee tequved7
3.p,em a homewmeraoingan workmwff.fNo wwkm*imp:in5maocemquWdJ l s. ODaIDbitlon
10 0 Buildmg'addition.
4.01mahomeownerandwillbehyingaaoaetmamcmludairwe>kmmypopvty. twill
corms dmf all connno nz eieurhave workms'comp®sauou msmaoce urns axle 11.0711ectrieal repairs or additions
Palm"with no MVIDym. aius t.. ..
12.01'lumbing epr additions
a
5. amagenwWc aad lheve hind die eubeautraetaa listed O Poe xuic daimat:
0I7fareatb..tonOemoahaveamployees aad have wor)rgs•ofmp%�^s^»+ - . 13.ORoofrepans.
6.Q We meormaod sffeaeeeieergota ® 1D Other
i
]sZ,§7(4),aod�tieoeiio emptaYeea.'[Alo wackeis'Cumpimiumce.l�ad•7,,' - -
. pwMGL 0.
eAnyWHcNA teheeb bas Nl mfiq dao 80 am the wain bdmr Poefrwmlooe cmpIDsoiim pohry as
I xomaowa,s who=tha aisl `i[iurtiicaimg Posy are dbieg an work and drahhe outride emoo au�il9nswatndevA rodimfmgsues".
tC=vactm that chwk thii bw must sw1od wladdidoml shoe Arcing fim mme,afPop sub-wmmdoi and nue.w)ialwm nD1 anma have
employees,lfthc aubahave.emD1.?ysa!heY,mu�Laovida8cefr w'orins".camP•Ponc9nm4bq., :°.: = .�-., . . .: _ .-
.Tam apmrloyarAWIsprovidingteorkers'conipona4vninswvaaaformyempl� B40WM1 4eponeyand sin
injoimeNon. c 6
Insurance Company Name: ma.r f 1 cJ —cin SC a i n C( Cn(-o —
Policy#or Self-ins.Lic.#: r–_ +o �� Expuatron Dste: O
Job Site Address- a!"MD GT a� Z'm tl. City/Statepp:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and ezpingion date).
Failure to secure coverage is required under MGLc. 152,§25A is a criminal violation punishable by a Sae up to E1,500.00
and/or one-year impm onm®t,as well as civil penalties in the form of a STOP WORK ORDER and a fine of rap to$250.00 a
day agaivat the vjollitor.A copy of this etateixient may be forwarded w$e Office of)nveatigat ono iridis DIA for msarana
coverage verification:
I do hereby terrify ander tbepains penahies ofperj„ry thel the information provided above is one and carred.
Date:
Phone# al)-7 12�d/S Z /2–
OJrseia/ase only. Do am write In this area,to be eoeiplded by eery or town o daL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
kir
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 writtep"
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 in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more then 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 badness 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,§250:(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 insuence
requirements of this chapter have been presented to the contracting authority."
Applicants —
Please till out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nainc(s),addresses)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'enmpensation insurance. If on LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Departawnt 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-insuredcompanies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be she 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 pemrit/license number which will be used as a reference number. In addition,an applicant
that rarer submit multiple permit/license applications in any given yea,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 proofthat a valid affidavit is on file for fiture permits or licenses. A new affidavit mud be filled out each
year.Where a home owner or citizen is obtaining a license or perrrnt not related to any business or commercial venture
(i.e.a dqg 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.#617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/clia
I
1
23 Green St Salem MA 01970
Scope of Work and Work Contract
Chambers Family Trust LLC and Juan C Giron
Contract Terms and Conditions
NOTE: all permits must be signed off by the Building dept. /punch list items must be corrected
prior to final payment.
Insurance
Contractor Agrees to carry necessary liability, property and workers compensation insurance.
Contractor requires sub-contractors to carry necessary liability and workers compensation
insurance. Insurance must be coverage in the amount of$1,000,000 liability insurance and
$500,000 workers compensation insurance.
Hold Harmless
The independent contractor hereby covenants and agrees to defend, indemnify and hold
harmless the owner, its agents, officers, directors and employees of and from all liability, claims,
actions, causes of action, lawsuits and demands including attorneys fees and costs, fines and/or
penalties for personal injury, bodily injury, death (including personal injury, bodily injury or death
of the Independent contractors own employees)and/or
property damage arising out of or in any way related to the independent contractor's work or
operations for or on behalf of the owner on, about or away from the owner's premises or
associated with the breach of the construction agreement or the construction specifications.
Contractor to accept all deliveries, i.e. cabinets, appliances, etc. Contractor must be available to
correct any necessary defects originated by city/town inspector, Chambers Family Trust LLC
inspector or Buyers Inspector
Scope of Work
- New Roof
- Replace windows
- Repair rear steps/front steps
- Remove garage front and side walls
- Remove Chimney
- Side House
- Install Cabinets and the(4)kitchens
- Install tile and vanitiites(6)baths
- Frame out(2) '/x baths
ACCEPTANCE
`i`
By signing below,Juan C Giron and Chambers Family Trust LLC agree that the above
work will be completed for the agreed upon price noted below and in the agreed upon time
frame noted below. Chambers Family Trust LLC will allow a 5 day grace period above and
beyond the agreed upon date below to complete the work. Chambers Family Trust LLC
agrees to pay for the work In 3 payments. 1/3 of the work is to be paid on the project start
date. 1/3 at halfway point and 113 upon completion of approved work.
Project Start Date: 11/23/15
Price: $83,000.00
Payment Schedule:
$16,600 Due upon signing of contract
$16,600 Due upon 25 %completion of contract
$16,600 Due upon 50% completion of contract
$16,600 Due upon 75% completion of contract
$16,600 Due upon 100% completion of contract
Amount Of Days To Complete Project: 120 Days
Additional days of work due to approved overages:
Contractor Name:
Juan C Giron
Print Sign Date
Chambers Family Trust LLC
Print Sign Date
CITY OF SALEM, AWSACHUSEM
BuLDnac DEPAR7mw
120 WA9MV7MS7WT,3"FioOR
7kL(978)7459595.
FAX(978)740.9846
" KIIvJBERLEYDRISQ7LL
MAYOR TEAS ST.PMM
DnuicrcaorPmucrRoPERTr/Bumf) c SSIoi,=
Construction Debris Disposal 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 c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 156A.
The debris will be transported by:
MU/.
(name of hauler)
The debris will be disposed of in:
Domp � �
(name of facility)
(address of facility)
Sign of applicant
Date
-CITY OF SALEM
'DEPARTMENTAL INVOICE FOR CASH PAYMENT
Please Remit to Treasurer's Office, 2nd Floor, 120 Washington St., Salem
Departmenn�t::� �
Date: �J —
i3
Individual/Company Name: ► " ` k(Z-t o
Payment For. Q
s ]o °
S
$
S
S
S
8
Cash Invoice Total: s -7 2-(::)
Other Information:
if needed)
)epartmental Signature:
reasurer's Office:
Date Received:
Signature: