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80 MOFFATT RD - BUILDING INSPECTION (2) C k ^\ The Conunonwzalth of ti1assaehusetts I'c d: (� Board of 131.111ding RCgulutions and Standards \II Nlt ll'.\I I Il h y F MUSSachusrtts Stutz 13wldine Code. 7511 CINIR. 7" Cdition I '.S1: V p. R,ne.il.hnm u: Building Permit ,-application To Consu'uct. Re un'. IZenocutz Or DCmulish :t / ,ttn,\' One- or Tiro-Fumilr Dtrrl(ittg, Phis Section For Official Use Only — (3uilding Permit Nu her:: _ Date Applied: Signature; a ------------ Buildine Convnissim er/ Inepector of Bmldings Date SECTION 1: SITE INFORMATION L1 Proper \ddres': 1.2 Assessors Slap & Parcel Numbers P Number Parcel Number -- I,la is this an accepted s[ree['?�Uyes_ no bla _ 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy 1'U Frontage Uil y ' 1.5 Building Setbacks (ft) Fcunt Yard Side Yards Re® Y'mId I Required Provided Required Provided Required Pf 0 1 J e J 1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'? Public❑ Pri%ate❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP[ 2 Owne�t of Record: fY\� O i R7 D Natne(Pr ntl Address for Service: p f78' 7 "-7$ /� - 'Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ AJdi11011 ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': _--- - S SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only I- Item (Labor and Materials) 1. Building $ and 1. Building Permit Fee: 5 Indicate husv fze is detzrnuned: ❑ Standard City/Town Application Fee 2. Electrical $ ❑ Total Project Cost (Item 6) x multiplier x 1. Plumbing 5 2. Other Fees: $ 4. Mechanical tHVAC) b List: j 5. Mechanical (Fire ti --- 'fatal All Fees: S Su ressiorl) Check No. Check Amounr Cadl Amount:_---_- b. Total Project Cost: '� p�t i J ' � ❑ Paid in Full ❑ OutsrmJing. Balunre 90 SECTION 5: CONSTRUCTION SERVICES 5..1 Licensed Construction Supervisor (CSI_) r Llrenn Numher I:xpi ruunn D:uc Named CS I_- Iluldcr - � I_ut CSI_Type Isa• helnal \d r sr l v e Descri vwn inlo t t'nn•suuted nl i m i;,llUO Cu. PI.i I R Resincled L\c'_ Fanuls Dskclling Slut it e S1 slasonrs Only RC Restdrnnal Rooting l -cnm! Telephone \1'S RC>Idenhal N`indua .ind Sidme SF 12cs1daiuial Solid Fuel liuni m_ \11111han,c IIh61hall,C1 j D Residenhal DelnUlmu❑ 5.71 Regi'tered Ilon Improvement Contractor 011C) rVIC D e, j©'w9 ft�� SF . Re_tstr 40 Number li IC Company Namc or FII Registrant Name - Ad c s � �y--r�i ��a'Crz r ICJ �ql I D 7�I'D�d9� Expiration Date " Signature Telephone - SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. § 2506)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prucide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached'? Yes .......... ❑ No ........... SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I %-0— L)-V\ yy ri 0\ - as Owner of the subject property hereby authorize Chrl oh r—ZLA to act on my behalf, in all matters relative to work authorized by this b 'Idi permit application. _ x I _1 a3 a 'Sienawre ul'"Owner 1 Dale' ` SEC ON 7b: OWNERt OR AU ORIZED AGENT DECLARATION 1, v- as Owner or Authorized Agent hereby declare that the statements and in(Jrmation on the foregoing application are true and accurate, to the best of my knowledge and behalf. clt Print VAY Signature Jt7okvner or Vuthorized .Agent Date (Signed under the pains and penalties of perjury) - NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unre_iuered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to.the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing tCSL) can be frond in 780 C•MR Regulations I IO.R6 and 110.R5, respectively. _'. When substantial work is planned, provide the intormation below: Total floors area(Sq. Ft.) (including-garage, finished hasement/attics, decks or porch; Gross living area ISq. Ft.) Habitable room count Number of tireplaces Number of hedrnnms -- Number of bathrooms Number of ImWhmhs rope of heating system Number(lt decks/ p�achcs __--- _ Type of cooling system Fnch)scd Open __ _ _- _ - 3. "Total Project Square Footage" may be substituted lot "Total Project Cost- CITY OF SALEM PUBLIC PROPRERTY �r DEPARTMENT YR; � ,7;141i1I11�H[it .'II Vi.A1�'H 12Z' ACVslI'V1.:�'�;Iah( l • $.AI iAI. A1.A�i,At I!1 .h1 ;�=i'I I'1l1: 9'8- 4;-9; F\x: NN'orkers' Compensation Insurance Afffdasit: Builders/Contractors/Electrise Print Leb'hly t nhtant Information l -e n CjQYVtCJzS �i�C \;l[nx: lnu.mcs; ttr_:uu[au,nt ndn:du.d.0 n� 7 t'y Address: Nor+h Sf►rf f — C'ity'•State.'Zip: Salf VYl IM Diq:zn Phone Are coo an employer:' Check the appropriate box: Type of project (required): I.U/I am a employer with ,2 4, [11 am a general contractor and 1 6 ❑ New construction _ employees(full and/or part-time).' lisle on ti the ache sheet. ❑ Remodeling '.❑ I am a sole proprietor or partner- listed on the attached sheet. ,hip and have no employees These sub-contractors have 8. ❑ Demolition working tax me in any capacity. - workers' comp. insurance. y. ❑ Building addition [No workers' comp. insurance 5 ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised [heir required.l Plbin airs or additions }.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1,❑ um g repairs myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs . insurance required.) } employees. [No workers' 13 M Other comp. insurance required] •Any applicam that checks box#1 must also[ill out the section below showing their workers'compensation policy in(ortnalion. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :('ontractnr3 that check this box must attached an additional sheet showing the name of the sub-contractors and their workers comp. policy information. t 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. c�L(ic. #: D/U�� In1� u� Expiration Date: Job Site Address: U� M (2- City/State/Zip:�d ✓t t P"t �� ( %-7O .1mach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of hiGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.0o and/or one-year imprisonment, as well as civil penalties in the farm of a STOP WORK ORDER and a fine ,if up to S_2ii).00 a day against the violator. Be advised that a copy of this statement may be tbrxvarded to the Office of In\eslip:uions of dte DI:\ for insurance coxerage x'crificanon. 7do hereby cerlif-i nd r the pea'is andpenalties ofperjury dintthe infbrittatiorrprrrvidedabove istrue andcorrect. Datetnue: t (— O 1 G / 01/icial use only. Do not write in this area, to he rourpleted by city or linen oJficiaL Cite or -fuen: --.--- Issuing authority (circle ( ne): I. Board of health 2. Building Department J. C'itstTown Clerk 4. kaectrical Inspector 5. Plumbing Inspector G. Other .--___-- — Contact Person:__-__---- ._ Phone Information and Instructions `,I.is,achusens 6onertl I_iwvs chapter I5' rrywreSali enlplosers to pros ide �%orkcrs' compensation lix their ennploNees. !'unu.ult to this statute. an employee is ,dined as " entry person in the .mice of.utolher under Inv contract of hire, .gyp;e<s or implied, oral or urines." \n emp6rrer is delined as "art indis dual. p.irtnarship. .jssociation, corporation or other legal entity. or any mo or more of the ibrcgoing engaged in a joint enterprise, and including the legal rcpresentati%es of a deceased employer, or the rccci�cr or trustee of.m individual, partnership, association or other Irgal entity, e1Ilp10%im, cnlployces. Iluwever the o•.t ner of a dwelling house h;n ing not more than three ipartnicrits and who resides therein, or the occupant of the - dtt tilling house of another who employs persons to do maintenance. construction or repair work on such dwelling house or 011 the _rounds or huilding appunen:mt [hereto Shall not be.•:mse of such employ went be deemed to he an employer." \I(iL chapter 1 i?, i25C'(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, \K;L chapter 152, i 25C(7) .States"Neither the cortunonwealth nor any of its political subdivisions shall enter into any contract for the perfbrmunce of public work until acceptable et ide_nce of compliance with the insurance 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) nanle(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 dues 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 permidlicense number which will be used as a reference number. In addition• an applicant that must submit multiple permivlicense 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 burn leases etc.) said person is NOT required to complete this affidavit. The (Mice of Imesrigations would like to thank you in advance for your cooperation and should you have any questions, ple;ue do not (hesitate to give us a call. I lie Department's address, telephone and tax number: The Commonwealth of Massachusetts Department of Industrial Accidents OMce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE to <ed 5-'ti-u5 Fax # 617-727-7749 www.mass.gov/dia ACYa e ,A.�, A & A SERVICES, INC. A&ASERVICES 115 NORTH STREET,SALEM,MA 01970 ffyel"Wdmzlze o Telephone:(978)741-0424 Fax: (978)741-2012 Contractor Registration No. 101609 Federal EIN:04-3090162 Construction Supervisor No.CSO57733 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Buyer(s)Name Date of Contract ROSE Du»nirt //6 Buyers)Street Address,City,State and Zip Cade d /✓i �d- Spa . 019'Z7 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address: me 73— The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed an the accompanying specification sheets,in accordance with - Me prices and terms described on the from and the reverse of this agreement and any specification sheets(this'Agreemern,and Buyer(s)have requested that such goads or services be installed or provided at Buyer's address listed above.ASA Services,Inc.("Contramorl,hereby agrees to install or cause to be installed the products or services listed in this Agreement at the Buyers)address written above. This Agreement represents a cash sale of goods and services. The Buyers)agree to pay in casIT the cost of the goods and services purch ad as described herein,regardless of timing or approval of any financing Buyers)may seek for their purchase. S Purchase Price: Est.Starting Date: ' Down Paymi 3 Est.Completion Date: 7' ff O Casghp Amount Due on Start of Job: / CYCFeck O Credit Card Amount due on of Completion: � No. Amount Due on of Completion: Expiration Date: e% Balance Due on Upon Completion: CVC Code: It is agreed and understood by and between the parties that this Agreement,front and back and any addendum, constitute the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms of this Agreement. - Buyer(s)hereby acknowledge that Buyer(s)has read the front and the reverse of this Agreement and has received a completed,signed and dated copy of this Agreement,Including the two attached Notice of Cancellation forms,on the date first written above. Buyer(s)also (1)acknowledge that they were orally Informed of their right to cancel this transaction;and(if)request that they be contacted via their telephone numbersor e-mall; as listed above, in the event Contractor believes Buyer(s)would be Interested in any additional quality products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES. A&A Services,Inc. Buyers) - Signature `�",vL1„r Signature Print Name Print Name - Signature - Print Name - You,the Buyer(s),may cancel this transaction at any time prior to midnight of the third business day after the date of this . transaction. See the following Notice of Cancellation form for an explanation of this right. - ARBURATION:The mmrumM and me Mmmwner hemby mNuelry agree In edvenw Pal in Ne event NWer early nee a eispum concaml,g Mis mntracl,ewer each mar submit suchaupute m e pdvero uUAnl'wn seniro Mlkh Ma Eean eppmve]by iha Sectehry al Me Eaecvtive Olflce of Cgiqumer Aflars antl Buvnasa Regulfltiorw end Me Wber peaky shah be reauired to womb m such of itummi m paved In M.GL c.109A X. PAO Der,, mix euyv'f lry bate: Du: Ovfly NQTIQp OF QANi I AnON NOT CE OF CANCELIAT ON - Oeb of TrenM n IN ,Ina O You may—1 Pia trucermo.,without any penalty or Dark m Tranmmion .You may,cancel"a tren rumbon,wiWut arty panaly or - obli9mim,wiMlnM,aeb yslmm Me broke date.a you urcel,any pmpcM beaked in, obYOarlo^.wiMi^Nree buyna5adays hark Me mrnre data. g'momel,a,rypc'n,cedeIm, any peymenls made q you untlarue Cantraul or Sam,and any ne0otiable inabumem eaeculed and payments made by you under Pe Cbnbem or Sale,and any ropmable Insbumenl executed by you we ba rearmed wiNln 10 deya blmwmg mroi,by Me Date of your wncellm m mak:e, by you will be mlumed within 10 days blowing receipt by Me Smear of your cancellation natice, and try aecuMy Me mar,arising M of Me urchaddion will be cencaded. If you canal,you mum end any secumy inbrem mixing out of the bansbctlon will be cancelled.if you cancel,you mum - makeevetlaNamMe Sake alyourreeNuwre,in mbmencifytie good mrkson as amen received, make rvaMbb m Pe Seller at your moderate,in wbearmary m good wMlWn ad wMMreteWed. any goods dmivmed to you under me contract or sae:or you may,If you wish,comply wM Me any gootls del'nmem to you under Mu contract w Bme;or your may,ff you wham,mmpy,wind Me Insmucmbns m Me Seller regadllg Pe mum Mipment of the goods m Me Sellem expense and inatrallons of the Smkr n making Me rem.mnlpm cad or Me Book.m Me Seller am enae and mi If you W make the g ad awmiarla In Me Seller and Me Sella odes not pick them up risk. If you do make Me goads avertable to Me Seller and Me Bear data not pick them up within 20 days of Me dam of your Notice of cancellation,you may relmn or mamea M the goads warm M days of Me dear of your Notice of Cancellation,you may ratan or dlspom M Me gaMS arboutanympherobligabon.Ifyoufmllomeke Mega waileblem Me Shccr,ordWuegree wlMumanymMeroblgatbn.f1you M111mmake Megwdaaval=lem Me Seller0,R wegrea b ream Me goods to the Seem end oil to aka Or then you remain liable be per(omanm mall m mmm Me goode m Me Baler and Imi to do so.Men you remmn park for perbmame m all mentors under to Cantratt To mlml Mid bafrommon,mail or delivm a signed and timed copy obligations under Me Camfem.To cancel Mu transaction,mail or deliver a signal mar dated Mary , m Pe canmlktim mfiro or my men winter entice,or send A kk9mm,m AAA Se�roe.115 of Me cancellation notice or any offer wMmn notice,or send a mlegmm,to A6A servant.11s N.Sbem,smear.Mmmchuwas 01970.NOT LATER THAN MIDNIGHT OF North Street Smear,Messy ..01970,NOT LATER THAN MIDNIGHT OF (Darin (Dam I HEREBY CANCELTHIS TRANSACTION. Conmmerasignamre Data I HEREBY CANCEL THIS TRANSACTION, Consumm's Sigmamre Date a-,so A & A SERVICES, INC. fez A&ASERVICES 115 NORTH STREET,SALEM,MA 01970 • • • Telephone: (978)741-0424 Fax: (978)741-2012 Contractor Registration No. 101609 Federal EIN:04-3090162 Construction Supervisor No. CS057733 WINDOWS AND STORM PRODUCT SPECIFICATION SHEET Buyer(s)Name Date of Contrail s)� RoSE_ i>a Baryons)Street Address,CityStState a ip Code Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address - The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification Sheet is a part. WINDOW REPLACEMENT jJ Remove and dispose of# �l L9�' existing windows. �t Install # 1 I9 n- 4 new .3411lf S£ yo;xrU �4 windowsOJinyl (Wood '� (Manuf turer) Options: style 7buble Atvl Grid pattern Sf 7< cs VeS_ S% Color Interior W(7 r ("2— Color Exterior Glass Type Wrap exterior trim with aluminum: Style W h 1+,e— Color L. 01AV-D QAll windows will be installed according to the installation procedures in the portfolio. OCaulk all interior and exterior edges. Insulate where possible around new units. f Insulate window weight pockets if exist,and around new window units where possible. (:F)ncluded in this proposal are set up,clean up, Hens vacuum and cleaning windows inside and out. G Building permit included. BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS f Create new window opening by cutting through existing home and framing in opening. f Remove and dispose of existing unit(s)in its entirety. . Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with. f Install window(s)into opening(s). Note: If Bay or Bow installation to include cable suppon system,new roof system(matching color as close as possible) - or tie into existing soffit system. f Bay f Bow If Casement f Other window(s)to include new interior style trim and new exterior style trim and head _ flashing as needed. _ T Note: Painting and staining not included. STORM PRODUCTS f Remove and dispose of# existing storm window(s). t Install new storm windows# Manufacturer Style Color Option t Remove and dispose of# existing storm debris). f Install new storm doors# Manufacturer Style Color Type: t Aluminum t Solid Core SPECIAL INSTRUCTIONS: E 6�;ram" �4151 lmr I 1 N k4c tr2:V //` ,,Ar LVilijxiv) Z.in AeA It Is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT constitutes the entire understanding between the Denies,and there are no verbal understandings changing or modifying any of the terms.This contract may not be changed or Its terms modified or varied In any way unless such changes are in writing and signed by both the Buyens)and the Contractor. Buyer(s)hereby acknowledge Out Buyers) has read tie Specification Sheet �7Fj Contractor Initials: Date: A&(� Buyer's Initials: Date: i � �/ee-�iomvnxoauoea/.1/c o��/�amarli<ieetla '. Board of Building Regulations and Standards j Construction Supervisor License License: CS 57733 &rthdate.._5/2 611 9 5 8 j Expiration -5/26/2009 Tr# 13739 i- � Reslrtctmn 00,'� f CHRISTOPHER ZQRZY }: f 115 NORTH ST SALEM,MA 01970 Commissioner " ✓'� {ior�alG4 0�./�,onaacyuoettn Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101609 Expiration:, 6/26/2010 Tr# 267870 Type: Private Corporation A&ASERVICES, fNC - Christopher Zorzy 115 North Street Salem,MA 01970 "" Administrator Commonwealth of Massachusetts Division of Occupational Safety - Laura M Marlin,Commissioner Deleader-Contractor CHRISTOPHER ZORZY Eff.Date 04/09/08 - Exp.Date 04/08/09 R�" D00004400Memheref C.O.N.ES.T.BO (IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII BOSfON RENEW i DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of M. G. L. c. 40, Sec. 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed facility as defined.by M. G. L. c. 111, Sec. 150a. The debris will be disposed at: Salem Transfer Station owned by Northside gartina - Signature of Pe it Applicant Date Christopher Zorzv Name of Permit Applicant A & A Services, Inca Firm Name 115 North Street. Salem. MA 01970 Address, City, State, Zip Code