92 NORTH ST - BUILDING INSPECTION (2) ApPLICATION FOR
PEAWTO
A-1,
LOCATION.n
PEIMIT GRANTED
APPRO pD
TOn OF BUILpI GS E -
CERTIFICATE OF OCCUPANCY .
YES
DATE:
Citp Df �rP1TC, aaL�juPtt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building Permit Application For:
Location of Building 7o2 AIQII� `S A"- -e-f
'(Circle whichever applies) Roof, Reroof, Ins ct Deck, Shed,Pool
Addition Alteration, epatr/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: �t L
Ownersm Nae: MC( G( j3:'Swir)Cf1 Contractor: Ag, A 5je-YVIGe5/v1Y15 bf7
Street q A N 0(4) ` von} C4511CIL,, Street A 15 N arlh �—C*. _City—IL if
State U Phone 6%:7 4)4 _ (A-a--3 State M A Phone- M79) 79 j.-,0-1,;t H
Architect: City of Salem Lic# I ()5
Street City State Lic 057 HIP# 1 OI(0 09
State Phone ( ) Homeowners Exemp�ty Form_yes /no
Structure: (please circle) Single Family, Multi Family# Othe CDiYI/nerG/GZ
Estimated Cost of job S_ 33Oa, OD
Will building confirm to law? ✓ yes no
Asbestos?__yes no
Description of work to be done:
laces onP
A&A SERVICES, INC.
Drawiniv$ubmitted, es no Mail Permit to: SALEM,MA 01970
% lg7R174J__O'f 4-"
}( WWW.A-As l=t W
Signature of'Applicidon,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
I -
The Commonwealth of Massachusetts
t Department of Industrial Accidents
1 MpIAi !1 Office of Investigations
ills 600 Washington Street
0.s Boston, MA 02111
r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibiv
Name(Business/Organization/Individual): A k 5e—r VI(Q S Yn
i
Address:
City/State/Zip: 501 D 6_A 111 Of�f 70 Phone#: l 2231 7,9 J-4
A
re youployer?Check the appropriate box:
Type of project(required):
ployer with 4. ❑ I am a general contractor and I
s(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
e proprietor or partner- listed on the attached sheet. t 7• ❑Remodelingave no employees These sub-contractors have 8. ❑Demolitionfor me in any capacity. workers' comp.insurance. g, ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑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.QrOther
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tCon tractors that check this box must attached an additional sheet showing the name ofthe subcontractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information. —r�"`
Insurance Company Name:_ 1 r e__ TM O
Policy#or Self-ins.Lic.#:_ aQ X I a /h/n Expiration Date: !2 J 1'3 ) O"7
Job Site Address:_Qa /yO// /7 j lS'fj—��7 City/State/Zip:c46 l�jar "lq Oy`r 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi P
de the p ins and penalties ofperjuiy that the information provided above is true and correct
Signature, Date: 0 7
Phone#: (q7$) rM l _ Q.44 I i.4
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-contractors)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 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 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 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 Carona
IA/
ignature of Pdfmit Applicant
1 -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
*t' Board of Building.Regulations and Standards
Construction Supervisor License ;
Lic nsee: CS 57733 i
Birtii'rTate-5/26/1958 -
I
;a agw1c i 5/26/2009 Tr# 13739
g
Ji
_ CHRISTOPHER
115 NORTH ST
SALEM, MA 01970 `'�� Commissioner _
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/02J07
Date 04/Ot/08 DC O
DC 40
ber
- mberof C
Me of QO.N.E.S.T.
8
80
I IIIII IIIII III IIII I IIIII IIIII IIIII III I IIIII IIII IIII B=ON RENEW
�KE L/OY/LbE00EtUEO�L2 6�✓l�LU06C�1tUQ¢C�b .'.
Board of But Iding Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
lug Expiration: 6/26/2008 - I
3,Type: Private Corporation _
A&A SERVICES, INC'
Christopher Zorzy` -
115 North Street -
Sal6rn, MA 01970 Deputy Admmistr atom'. .
A & A SERVICES, INC.
A CES 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
ENTRY DOOR SPECIFICATION SHEET - -
Buyeys)Name - Date of Cont t -
�qCCAI
Buyers)Street Address,City,State and Zip Code -
9a 7
Daytime Telephone Q ` Number Evening Telephone Number Mobile Telephone Number E-MWI Address
�v tT
The Buyerto listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in aaordance with the prices and tens described on
this Specification sheet and the front and line reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet Is a part. ,
ENTRY DOOR
iy/Re ove and dispose of# d/U'� existing entry door units.
i ZZll new entry doors# o/vex Manufacturer /it 7e ill I/•14
-Location rlGY1r 13 4-' $ dP O ( d Y h
Type: ❑Steel moothStar (I Fiberclassic ❑ClassicCraft ❑Sliding Patio Door ❑French Hinged
Patio Door
Model# .�/T Sidelight(s)#2._ Sidelights)type/model# `YaD 3 SL— C2si n s' o
OPT' NS:
Adjustable threshold for ThermaTru Door ❑Grids for patio doors: Style:
❑ Stain Kit: Supplied to owner 7 //
W Expand or shank the size of the opening Details Skiok F'(aM Me ZfY-710 �j r
❑ Cover exterior trim with aluminum coil stock: Style Color
Hardware: sa<andelset 25atlbolt ❑Footbolt ❑Mail Slot ❑Peepsite <,�h//J.2� j>1tlMo'Kr 9-4)
9 Install oak strip at floor as needed. .% r
U<Caulk interior and exterior edges.
LY�Insulate around new door unit where possible. Trot" —
�Painting is AW included, CA?e1 q red Fi Nish •m ex•feriar/W 11 i�colertd'F;H �1 141c 1..1,
.,2
cluded in this proposal are set up and clean up. I ;#ti
!W"F�f7n iF i t�c�l[glPd
STORM DOOR
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
❑ Location:
SPECIAL INSTRUCTIONS:
I M sm 11 IF-I p'.>Je 1Y S*nr -I mi-erc was nvs Lo i-l�i Rest x-a-+K T8AAI4 ii
'T A)SAA I - �— 73 �i n
its nI-a2dpd -
g Is agreed and undmetood by and between the perUee net this specification Shea(along with this CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,sense-
from the.run.umWastanding between the p.m.,and there ere no verbal Understandings changing or modifying any of the sane. ThIs cnmracf may not he changed
or Its,tens ma ill or varied In any wry unless such changes ere In wMing and signed by been the Buyers)and the contractor. Buyers)hereby acimowledge Net
Buyer(.)has read this Specification Shael.
Contractor Initials:_ Date: 13 07 Buyer's Initials:I,1 Date: __
Alope had
A & A SERVICES, INC.
115 NORTH STREET,SALEM,MA 01970
z IS a• Telephone:(978)741-0424 Fax:(978)741-2012 _
Contractor Registration No. 101609
Federal Ell 04-3090162 Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT -
Buyers)Name .L Date of Contract
/h�C/!El vi 1ys�ltf�ille 400
Buyers)Street Address,City,State and Zip Code for
-
ya ai iiii. Qq Aqu i d
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mall Address:
9�
The Buyerts)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with
Me prices and terms described an the front and the reverse of this agreement and any specification sheets Me"Agreement),and Buyer(s)have requested Nat such _
goods or services be installed or provided at Buyer's address listed above.ABA Services,Inc.("Contractor,hereby agrees to Instal or cause to be installed Me products ,
or services listed in this Agreement at the Buyers)address winter above. This Agreement represents a cash sale of goods and services. The Boyerts)agree to pay in
cash the coat of the goods and services purchased as described herein,regardless of timing or approval of any financing Buym(s)may seek for Moir purchase.
s -e [m
Purchase Price Est.Stoning Date: �1 9�,
Down Payment: `'+
Est.Completion Date:�ISt-1- -
❑Cash
Amount Due on Start of Jab: ❑Check
❑Credit Card
Amnlmf on,herof Onmpleten7 ND.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion: CVC Code:
R Is agreed and understood by and between the partles that this Agreement,front and beck 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.
Buyers)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 data first written above. Buyor(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 a
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 THIS CONTRACT IF IT CONTAINS ANY BLANSF7ACES
A&A Services, nc. rail Buyer(s) !/�//,I
By: —. 1- f'� 4i -
Signa-tu�C/'yK'U,1Ay Si re
Print Name Print Name�,p(IMy- qZp. .Q LA'Zo a/'—'
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. Sae the following Notice of Cancellation form for an explanation of this right.
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North Sol Barren.
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Rodin ioato
I HEREBY CANCELTHE TANSACTON. Conaumefa5ignesure Date I HEREBY CM'CELTXIS TRANSACTION. Con¢umar4algnadre Dow
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