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25 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations 600 Washington Street 0 Boston,MA 011ll r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl E V Name(Business/OrganizatiorOndividuaq: _A Address: I I S ►I o r+h Str6 to+ City/State/Zip: D. Mn 01970 Phone #: I crn q tl I —OH A re u an employer?Check the appropriate box: Type of project{required): tYl I am a employer with�J 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no.employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition on [No workers'comp.insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions myself. [No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees.[No workers' comp,insurance required.] 13.dOther "Any applicant that checks box#I must also rill out the section below showing their workers'.compensation policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. tComnictors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for fily-employeei Below is the policy and job site information. Insurance Company Name: -The—le— Tro ye 1.P lr c) Policy#.or Self-ins.Lic.#: w C q 3q X [ a h b Expiration Date: Q �13�O Job Site Address:_6�5- City/State/Zip;L501 m. MP 0/91 7O Attach 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 MGL c. 152 can lead to the imposition of criminal penalties of 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 fie 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. 71dohrferebyce rtf u r the ai sandpenalties of perjury that the information provided above is true and correct Date: j Phone#• (9-75) r7,q 1 D"A P J-4 Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# ------------- Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G.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 of more of the foregoing engaged in ajoint 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 numbers)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 petmit/license 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 ofthe 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 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 Street _ Boston, MA 02111 "a.. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 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 Carona Signature of Permit Applicant Date Christopher Zorzy Name of Permit Applicant A &A Services. Inc. Firm Name 115 North Street, Salem, MA 01970 Address, City, State, Zip Code ,y J/re'�omvnwouoea.�c o�.�am¢c%aaeld Board of Building Reguladons and Standards Construction Supervisor License LlcAse: CS 57733 9iGhd__a'tp /26/1958 F/200g Trli 13739 . jJL pl CHRISTOPHER Z 9_ 115 NORTH ST . SALEM,MA 01970 Commissioner Commonwealth of Massachusetts Division of Occupational Safety Robert J.Prezioso,Commissioner apt Deleader-Contractor 1lt CHRISTOPHER ZORZY �a Eff.Date 04=07 Pit.Date 04/01/08 w DCOOD440 -+ Wamberd C.O.N.ES.T. 1 BO IIII IIII II��. IIII IIII IIII '.. .,. ..;'z 's lO�l��l�lul��ul�llul II�IOI�IllI� u� BosrOri.at=NEwti �V �e 'o�aurnwrw�ea�C o�.J�aeiarfwaelld Board of Building Regulanons and Standards HOME IMPROVEMENT CONTRACTOR Rp91sti-ation 101609 E:cpvadon 6/26/2008 "type 0:"is Corporation A&A SERVICES INC Christopher Zorzy 115 North Street.- i Salem.MA 01070 - Deputy Admimst for N� send. nAc��e ^�� A & A SERVICES, INC. A&A�7O M 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 ROOFING SPECIFICATION SHEET - Buyerts)Name Date at Contract Buyei Street Address,City,State and Zip Code eu AIA O 7l Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address I f]—© _ The Guyette)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 Most and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification Sheet is a pad. ROOFING SPECIFICATION Strip R of* Mayers of shingles nstall 6'Gf ice and water shield at base of roof where nstall 15.b felt paper to roof. possible. Install 18-24"of ice and water shield in valleys. Flash chimney as needed(no repointing included). nstall�pIs imeter drip edge to rakes and fascia areas. nstall vent pipe boots and seal as needed. ❑Flash valleys as needed . ❑ Install rollout type ridge vent. Planks/plywood replacement under 32 SO FT included, � � 'If more is needed there will be an extra charge of$ WIT ( 3'W iCZii-w4ec .t��}l'� ( k2S per hour for labor plus the cost of materials. r/Disposal Included: ❑Other: Location: Glt[,$°f' re Install new roof: Manufacturer cer4A nh�_ _&C yr Style/type 3 f-.49 cluded in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. RUBBER ROOFING SPECIFICATION)L1.Cq'�-OYI F OOY ❑Strip Roof ❑Not Strip Roof - - Install 1/2" Density Fiberboard to existing roof using ❑Flash obstacles as needed. screws and plates. Install.060 membrane EPDM(Black)rubber roofing to ZrInstall 3x3 aluminum drip edge to perimeter of roof with fiberboards seam tape. Flash up sidewall as needed. - Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. a SPECIAL INSTRUCTIONS: `i2y T 4gr.*.A %irdS 1W_+V1,U0V +V_'014A91,S road ups/LaiiK.) 9 Rr6a-5 +0 to rP c ivicliwAug M vl )n tX Ij Sect;OnS � wdA�kSOY1�4� N 1fi vlGludecl • s lails{yPer rvb�1 rrn_t xoHocJudeA + TA1.sirY1/ Tce fi i,v fzr F• fE-ter'tde� secfi'o�rs oFrw wi tl - sl�aL�_ t Dt�fclz It Is agreed and understood by and between the panted that Mile Specification Shoot,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT cenetltutee Me entire understanding between the pai lies,and More she ma verbal understandlogs changing or modifying any or Me terms.This contract may net the changed or Its terms modified crvadatl In any way unless such changes are In writing and signed by both the Buyers)and Me Contractor,actions)hereby acknowledge that Buyers) has reed Mie Specification Sheet Contractor Initials: Date: I D g Buyer's Initials: A & A SERVICES, INC. A&A SSWES 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 - CUSTOM REMODELING AND IMPROVEMENT AGREEMENT - Buyer(s)Name ii., Date of Contract > ✓ a(IT Buyer(s)Street Address,City,State and Zip Code - as 5 e_0 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address: The Buyer(s)listed above hereby jointly and severalty agree to purchase Me goods and/or services listed an Me accompanying specifcadon sheets,in accordance om to prices and terms described on the front Bud the reverse of this agreement and any specification sheers(this"Agreement,and Buyers)have requested that such goads or services be installed or provided at Buyer's address listed above.AAA Services,Inc.('Contractor),hereby agrees to install or cause to be Installed to products or services listed in this Agreement at Me Buyer(s)add..written above.This Agreement represents a cash sale of goods and services.The Buyer(s)agree to pay In sash Me coad of Megoods and servlcea purchased as described hared,regardless of timing or approval of any financing Buyers)may seek for their purchase. `( -7 r 4k(-Purchase Price:AZWO, 6� Est.Starting Date: 1b 7C Down PaymenC___�2_L{A� cu Est.Completion Date: 5t Wt d po a Cash Amount Due on Start of Job: � ❑Check Amount due on of Completion: ❑Credit CardNo. Amount Due on_of Completion: Expiration Date: Balance Due on Upon Completion: CVC Code: - It Is agreed and understood by and between the parties that this Agreement,from 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 euyer(s)has read the from 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(II)request that they be contacted via their - telephone numbers or e-mail,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 TBIS CONTRACT IT IT CONTAINS ANY BLANK Si==� A&ASe 'ces,Inc. Buy (s) By: 4 i4A Sign ure U+Aj Signatur Print Name Print Name Signature Print Name You,the Buyer(a),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 term for an explanation of this right. a u+emunoN:me mnllumreat ure nmmmwmrnereW mmumN aambednme rwmma meat alma,parrytopeamove, mmemlrq min mmrmL eimmIwdr may eubmd auto dmpmam pemm so expend M a con wen wpmmlmy me sscremryabe aamwm anai mcanmmarm..and matt Rd9ubuare.ad ma aver pmlyatoml eermmred m mbmam cow mmisup wheal mmichdmsion cwm.rm," ammv tame.: cam: cam: IdQcdE OF I NOON Deb a Tmmmvon .You mar worm add o-mawma,wlmom am rival or Dole a Tmmown .You mar wnam ale commuc �,wbmm any pmmm,m pbnam9on,wimmmm days cam ma acme dare.nyouwrm',mnyrrwanN o-ed.d ln, obn9eamw.mm was rnumendaya tam memmamm.nrouwewl,mywood nadpoh my parmem mesa My�u m,m.comreamsm.,ma my mpmuabb trewmem maimed dnr pwmmme made IN rw ume,m.cano-em msm.,nna mN wpou.mm metnmrml e..wred . by>m wioamwmed wnmm Copan mlmw^9 rewipiryme sdnerayour wnmlbWncorks, M you can bat remead wamm to day,pma ya rq remlpt try mat selw mrymr maedmmnronm, and erry ammN mmreu uiairremame o-annmmn wfuwww.uae.ntou air®I,you mum eat enremvnN lmmel encore dam.o-enoaabn wluwwmeum.nya,wnail,you mum mwmeoauemme saommrom mme�,m.mrtamismM mpom mmlpmwwhm maNmd,- mexe mailebm come snummyowreeum®,con,mm„u.INa+9mdrnmulw p,wen remNae, BM9opme ahmedmpuuMer ml9 mping ma deaMdeme:N YWidd arrow or Om adds examme and yrygwds of meWmerappper cobLdani waele:«pueptn T "Nmeple re rd asWpbnu Wee smOomer rn9pab mMorebur aNpmeaalM eMmaidecom ra egroremmd IrsWpmiummesNlm regWhgme rdeW me Roland Meal comaorod eagnm end opium It Youd m mMe me 9w]e Nifice e C M aenmr eM the Balm dwp air pot me made de voO It di w make me gpWe Nammde m me con,you me ostler dim air due meat up MmN 20 wpamB data Wymu NalmaCenwllelgn you my mean mrmemeedme0�d wlWn al deymme 6ele or your Nat4roaCenCeDatl^n,you may mime mrdbemedmm Middle W ouppe ,Bi Home,0 to yrmlon.oyeulmlbmke tromYou o memo miMarpa,orX9vu rpm tomwmM colorer me S.ar am met mekeme gm You raem name it pererayw rpm p munmmgmde Damon,To let prmmumen, uremain lbbb air per do,arwmml bmrmomat"mtlre Bnllerem lulmde A,man ya remain noble air mrrme^enaB mail abrpetlmreuMerWContram.Ta ranmlmbbenaeclbn,mmllmblNxem9^eU mTm daia]m91' abllpatlmm uMxme Gmtrmf.TatwnmlmbVwBmCn,malladenreres�ad Mm dmMmq a Va tavzllatkn mtlm pr any omn wrl0en rwtlm,wmM aleb9rem,bP&P �y of me mrcenalkn ro@e or Bay mmm women nape,amoata temporal toAse Barmaid,115 Noam BweL Boom.M umNd 01 M NOT LATER THAN MIDNIGHT OF Norm SRwl,seem,MfleseMumN 01970,NOT t.ATER THAN MIDNIGHT OF (Deal (Dab) I HEREBY CANCEL THIS TRANSACTION. CoreumerIeSgnabb ON I HEREBY CANCELTHG TRANSACTON. Consu %Slnaiure Dale i DATE: �itp of 'rsar9m, aE;E;aLbU!5Pt$5 %2 r PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Location of Building 2,i A U%� e Z1 Building Permit Applicatio or: '(Circle whichever applies) oof ,eroof, Install Siding, Construct Deck, Shed, Pool Addition, Alteration, Repair/Replace, Foundation Only, Wrecking Other: PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING To the hrspector of Buildings: The undersigned hereby applies for a permit to build according to the following specifications: Owners Name:(` Q' I I n t l LDYVL9 Contractor: A e A Sr rvica 5lo7Y1>p r7 Street Ll" 5 rP I City Street .l i 5 N Qr4h ,J{. City I cm State {�- Phone eq S1 I -Cqq State M A Phone Architect: City of Salem Lick- N 05 Street City State Lic D 57 HIP# I©Ito 09 State Phone ( ) Homeowners Exempt Form __yes no Structure: (please circle Sin le Fami - Multi Family# Other Estimated Cost of job S 7 Will building confirm to law?_ Yes no Asbestos?_yes / no /11 Description of work to be done: I n Q X I YlG1 Y 1 )1 01- Q I ( Q V IF-r5 SnSf�ll PI?Vyn ( II ) a ^ hear f . A&A SERVICES, INC. Drawin Su fled' '_-yes n0 Mail Permit f0: 1 SA.LEM, MA 01970 �741-Od2d. X W W W.A-AaEF�V� Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX MONTHS OF PERMIT ISSUED DATE , p No. U - APPLICATION FOR ' PER TO S7P'P Q4lvZ`6 4- LOCATION PEIMIT GRANTED APPROVfD r"'6 INSPE O�j OF UILDINGS _ •: CERTIFICATE OF OCCUPANCY . YES NO � • � s,