37 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
WDepartment of Industrial Accidents
Office of Investigationsg600 Washin ton Street
Boston, MA 02711
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information t� Please Print Lezibly
Name(Business/Organization/Individual): A � k `jor yi (Q
Address: 115 Q o I'+P-)i e� `
City/State/Zip:_5� D,V11 M K1 012-70 Phone #: ( 925 1 2A I — 2A 2;A
A,r_e,�°u an employer?Check the appropriate box: ' Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 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. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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' 13.Z'(0ther W aJQW 5
comp.insurance required.]
'Any applicant that checks box#1 must also fill out.the section below showing their workers'compensation policy information.
t tlomcowners 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_ t r te__ Trayp i -e
Policy#or Self-ins. Lic. M.WC q Sq X I a!j(p Expiration Date: q f I'3
Job Site Address: /V or�Pnd lreel, /�[4- 1 City/State/Zip: / 70
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 fine
of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify u d r t e painsZanpenalties ofperjury that the information provided above is true and correct
SiLitature• ( I/]�t'1F Date q'/7 Q 7
Phone#: C1 1$) '7Lq I — a H a)A
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 of 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 permitllicense 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 bur 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
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 Carting -
Signature of Permit Applicant
9-17-07
Date
Christopher Zorzy
Name of Permit Applicant
A_& A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
�/ee '�amarcoaweall� a�./l�Ladd¢Cfuae�
Board of Building Regulations and Standards
Construction Supervisor License
LicAse: CS 57733
Bintildath:_5/26/1958
} gip tton.-55/2f�/2009 Tr# 13739
. 1�Rrstfiot<ott OO�x .
' CHRISTOPHER ZQWTYU—•l7
. 115 NORTH ST
SALEM,MA 01970 "�J Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/02/07
Member of C.O.N.E.S.T.
Exp.Date 04101/08
DC00044008
'
j
a!y`
BO
�BOSTON-R NEWS
q ✓�e¢ iDa9l.AJCn..... a�✓lZadd [lQe .''':
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration -.101609
EzptraEion.:,.6/26/2008 1
Type Private Corporation
-A&A SERVICES,INCi - -�'
Christopher Zorzy, - -
115 North Street
Zalem,.MA 01970 Drputy Admimstr;o-;r`: .
a
A & A SERVICES, INC.
AeA ICES 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 - -
Buyerls)Name Date of Contract
B"'WAI9 O
Buyer(s)Street Address,City,State and Zip Cade - -
57 AlortA eAja S . c e
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
ro9S—
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with Me prices and terms described on
this Specification sheet and the front and Me reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is apart. ,
c7�� WINDOW REPLACEMENT
2'�er a and dispose of# d L/ existing windows.
[d Install # a.O new .Sim 1.S5;_� windows: Vinyl ❑wood
(Manufacturer)
Options: Style N IBS'>rr12 Grid pattern
//Color Interior W ,�1�2— Color erior WLl r��� Glass Type P
rap exterior trim with aluminum: Style LRP.LL✓. AL}Q,[I� �E. Color
All windows will be installed according to the installation procedures in the parffolio.
:tf�euIk all interior and exterior edges. ---G)04f/j V)'12P I+�Y•
/Fatale where possible around new units.
ISM 111.ulate window weight pockets if exist,and around new window units where possible.
0' Faded in this proposal are set up,clean up,Helps vacuum and cleaning windows inside and out.
®/Building permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
❑ Create new window opening by cutting through existing home and framing in opening. -
❑ Remove and dispose of existing units)in its entirety.
Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
❑ Install window(s)into opening(s).
Note: If Bay or Bow installation to include cable support system,new roof system(matching color as close as possible) "
or he into existing soffit system.
❑ Bay ❑Bow ❑Casement ❑Other window(s)to include new interior style trim and new exterior style trim and head
flashing as needed.
❑ Note: Painting and staining not included. -
STORM PRODUCTS -
❑ Remove and dispose of# existing storm window(s).
❑ Install new storm windows# Manufacturer
Style Color Option
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: O Aluminum ❑Solid Core
SPECIAL INSTRUCTIONS:
• aaiF ronan u, e7Aau-�a be jdic fgl/ed 62241 2xfer,oar 4&cjV io ivrclude ZA-_ .V
exter�ot P��w.ud /x c;fnckc,esjv,ar
rS{v(o LJ l��ke A`InM ifn tntit .ems-�6'i4Cf `�T'�wxca ue ftlJ><�
No tubs rMua,d
c ltral=Gn of w\nAays lei Ma f��� -a011 Oorab le Ftv.,d�vl i+s on Isfi'FL 'nela.l'n� feAf�Afj
It Is agreed end understood by and between Me parties Mat this Speclticanan Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,coastlines -
the entire understanding betwsen the parties,and them an no vmbel understandings changing or modifying any of the since.This contract may not be changed or its
terms modified or vented In any way unless such changes am In ending and signed by both Me euyens)and the connector.Battens)hemby acknowledge Met Buyerls)
hem read Mie Specification Shoet. p
"mi actor Initials: 5. L Date: 450-1
7 Buyer's Initials: DAM. 16 r Date:
swetess A & A SERVICES, INC.
A VICES -.115 NORTH STREET,SALEM,MA 01970
Telephone:(978)741-0424 Fax:(978)741-2012
r
A
Contractor Registration No. 101609
Federal EIN:04-3 0 901 62 Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(s)Name Date of Contract
Buyers)Street Address,City.State and Zip Code
27 No ev
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
q%�:sr1y`O
Tres...re)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,In accordance delhf
the prices and terms described on the front and the reverse of this agreement and any specification sheets(this"Agreement),and Buyers)have requested that such
goods or sera ces be installed or provided at Buyer's address listed above.ABA Services,Inc.("Contracti hereby agrees b install or cause to be installed one products
or services listed in this Agreement at the Buyers)address written above. This Agreement represents a cash sale of goods and services. The Buyerho agree to pay in
casM1 tM1e ost of tM1e ootls antl entrance,pumhesetl es described herein,regaNless of timipg or approval of any financing Buyer(s)may seek for their purchase.
I I ZO L� 'SrJ3 CAP +CO to O
Purchase PricerISbB6, Est Starting Date: (0:-'t _
Dawn Payment PALEst.Completion Date: w
- ❑Cash �/„�
Amount Due on Star)of Job: El Check
Amount due on_ of Completion: ❑o redxC_ard�. 9��
Amount Due on_of Completion: Eli iration Date: T
Balance Due an Upon Completiom� 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 Buyers)has read the front and the reverse of this Agreement and has received a completed,signed
and dated copy of this Agreement,including the type attached Notice of Cancellation forms,on the date first written above. Buyer(s).also
(1)acknowledge that they were orelly informed of their right to cancel this transaction;and(11)request that they be contacted via their
telephone numbers or a-mall,as listed above,in the event Contractor believes Buyers)would be Interested in any additional quality
products or services of Contractor. DO NOT SIGN THUS CONTRACT IT IT CONTAINS ANY BLANK SPACES.
A&A Service Inc. �� ��Jj _ Buyer(s)
By; L.d� fi 61✓1 s�Sz LS s
Signatin p - Signature I^
SL. Mi4Q.0 ty QOWA)
Print Name Print Name
Signature .
Print Name
You,the Buyer(s),may cancel this transaction at any true 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.
aaermu'll:ma nor al and Me homeowner hones Execratemutualmutualityre inage advanw that in Me aver eiu,er p.lty has a decide w wmim, e e da oohed.ever pony may submit such broad ro
0 or ate wilydtlon frontier M ..eppm.Iry a Secretary of Me E[wue Offer of Consume me home and amine ar.1 tbna and mail per shall be morns.myaddem do
9.a,Eibatbn es pored N Ma.1-t16[A
Conmc,m tnitinl eey<r's Initials:
Oe¢: nue: O
Hal OF rtandri'l I ACTION T.at.adTreneavgon You may calcel Nla benuNon,wiNout a,ry panehy or Data of Trenucom .You may cargo Nis done n,without my I>ellalN a
oblel within Items b.7,?.isdaw horn Me aL ue date.lryd.dmdd enypmpem Naaed in, oblgffion,print.Nree business days ham lM a[ave bob.0yw®IVl.any properly..n.
any women.made or you tWer no emaad or aeon,and any negotleble lnSWmenlexanhed any payments more by you under Me confirms b,act any negpMwle informal ydumudh
by red Ma de.Nmed whom 10 days blowing maeid by Me Seller of your monsoon nNiG, by you will be monad wMln 10 days blbwir,warpt by one Sneer N Your amdwIwvn nicer,
aManyse inbreal ariamp oN of one tr9rlEaclim vnll be rarleelled. gyouwwd.youmust nM any usual lntommanend out of me trances-win be somud.it you consul.you mine
mesa Member rota satbranyour workers.hsu Mlib wgoad mndimn an when lewwad, modww,yMCM M that sellenat your lwmml in sub.bnmw or EstdxyMdn a.whm lsuNm.
morxiss alivamd to .uMw Nla comralor aye:or wu may.n yw war mml who Me my OaWa delayed to you underine comment or Sale:or ybu may.If you wish,cenpr wrap one .
Imal of Me Retirement the rewm wripmerd N.goods at the sewn e.pensa and inmummaradlne seler madame Ne mmmmsmwr al the.dodo n Me Were e.peue ern
not, If you der maw Ne g row—,ad.re Ne Seller and Me Seller doea not pow Nam up Mk. II you by mane Me goods.1..to Me S f.and Ne cellar due of pale Nam up
within a.dap of the dell your Notlubf Cerce144on,you may ream a dispwe 0 tier cal ways,20 days of the dab Of your Nol of C Ileum.you met n or Eboose of Me goods
W.Y YNMeoblgybn.OYou M1ilro ltlaha Ma grade evtllableb Ne actin.ordyou egad wiNoulanyNMaookabon.Ilym lylto mGelM gm]a evyledeb V95911er or ilpn Bpru
to retwn one grad.M Me Selo,act fat by do m,Men you wmaM liable for lRrb,manu of of MmWm Me goon.b the Sewer act at m.of Nan you umyn Vedas br pm.— yl
ablyawmund.rmeeomaoe mwrceNniso-e,.ama mabaaelN.raaglwa am a.ma wpy ob%amme derMeeonbaa.r wnwl Mubal,.aatoly.mail brdelMereagnea end damdwpy
el the—.I.-notice or anyo1Mr wnwn mmu,or and ableg2m,M Atli Se its of Me containment also,or airy miner wylm mllm,aurd a Ideal toa so Serv'rere Its '
NoM S..Est MavaNmmlb Oral NOT ATER THAN MIONIOM OF Hornel45yem,amendment final NOT LATER TUN Modern OF
Iorka lover
I HEREBY CANCELTHI3lAANSACTION. Consumer§Manuel oeM I HEREBY CANCEL THIS TR.SACTION. CmnumaiSym Oy. -
DATE: q-l.Z—a7
f
Citp of Cq)a1'EM1' a �aL U�Ett
�a i
r
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building Permit Application For: Location of Building 3`1 /1Na'me/7(� ST /�nif
'(Circle whichever applies) Roof, Reroof, Install S' ' ct Deck, Shed, Pool
Addition, Alteratio Repair/Replace, oundation Only, Wrecking
Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name,Jason &-ot c n Contractor: A e A 5 r ryi c a 5 Mhn t> 6 r7,
Street 37 IV06 Ct ld 0012 City (SO I On Street .115 d nr+h 2, City �
State-m� Phone (�J$)�9�1 -109.5 State M A Phone 78) 7-9 l -_DM A H
Architect: City of Salem Lic4- 1 kiD5
Street City State Lic b57 HIP k 10HO09
State Phone ( ) Homeowners Exempt Form_yes--�Lno
Structure: (please circle) Single Family, Multi Family o Other
Estimated Cost of job S
Will building confirm to law?— yes no
Asbestos?__yes Vno
Description of work to be done:
Z�Sfall 4werfu (ap_Ti Ul re- lacjMaa�
iAJI�dDW5 .
A&A SERVICES, INC.
STREtl
Drawing b itted:_yes no Mail Permit to: t SALEM,MA_01970
}( f VVVVW���.
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
AP,PLICATION FOR
' PSRMr TO r,
LOCATION
PE MIT GRANTED
AP ROVFrp
CERTIFICATE OF OCCUPANCY .
YES
N0 . a