115 NORTH ST - BUILDING INSPECTION (3) The Commonwealth vfMassachusetts
t Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
r 1) www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Leeibly
Name (Business/Organizatiorondividual): A 4 A `je j"Vi e' 1 TY-)O—
Address: 11.5 1 I D I'f 1 �}YC e+
City/State/Zip: `501 p.W1 . M lq Org70 Phone#: / q251 7/ ► I ^ D<I
Fsupraf
an employer?Check the appropriate box: Type of project(required):
a employer with 4. ❑ I am a general contractor and 1loyees(full and/or par[-time).• have hired the sub contractors6. ❑New construction a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
and have no employees These sub-contractors have 8..❑Demolition
king for me in any capacity. workers'comp. insurance. 9. ❑Building additionworkers' comp. insurance 5. ❑ We are a corporation and its
ired.] officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additionslf. [No workers'comp. c. 152, §1(4),and we have no 12. Roof repairs
ance required.] t employees. [No workers'
comp.insurance required.] 13.Z Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Ilomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached.an additional sheet showing the name orthe subcontractors 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:_
Policy#or Self-ins. Lic. #:_We q �;Q X 12 Expiration Date: q �I 0_7
Job Site Address:_ City/State.Zip: 3� V M "M 11170
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 insuran to coverage verification.
I do hereby certify a thlRants nd penalties ofperjury that the information provided above is true and correct
Si'nature .
Date: O
Phone#
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 Ell in the permittlicense 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 cooperatiori 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 Cartinn -
Signit4e of P rmit Applicant
Date
Christoaher Zorzv
Name of Permit Applicant
A & A Services, Inc.
Finn Name
115 North Street. Salem. MA 01970
Address, City, State, Zip Code
92.
Board of Building Regulations and Standards
Construction Supervisor License .
License: CS 57733
Blrthtlat26/1958
t� Expiration 577�612009 TI# 13739 ;
R
:1estrw41on -tPi
CHRISTOPHER Z RzYU IS
115 NORTH ST
SALEM,MA 01970 Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J Prezioso,Commissioner �Y
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 040 /0 O
Exp. Date 04/01l08
DC000440
FAemberol C.O.N.E.ST.
8
BO
BOSTONRENEW
�.. �/ze l�ornnra�ruuc.¢l� of✓�uaelta -�
. Board of Building Regulations anJ Staudards
HOME IMPROVEMENT CONTRACTOR .
Registration: 101609
Expi■-tion. .6/26/2008
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
_115 North Street
Salem,MA 01970 Deputy Administrator,'`
^ w ^�c A & A SERVICES, INC.
A&A S CES 115 NORTH STREET,SALEM,MA 01970
11MMITOWITMAMMIMP307d Telephone:(978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733 - -
ENTRY DOOR SPECIFICATION SHEET
Buyer(s)Name Date of Contract
COOWAY
Buyerls)Street Address,City,State and Zip Code -
�" /1M e S+• S fir Ails .O't9 7d
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
The Buyegs)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 Me accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet Is a pan.
ENTRY DOOR
❑ Remove and dispose of# 11/✓n/'� existing entry door units.
❑ Install new entry doors# nN'e— Manufacturer -771-eA�F
Location
{'d�✓I
Type:U Steel
����IB/�'SmoothStar ❑Fiberclassic ❑ClassicCraO ❑Sliding Patio Door ❑French Hinged Patio Door
Model# 1 Sidelight(s)# Sidelight(s)type/model# _
OPTIIIO S: CS+t(LO 5'iy io`W vicer>
/Adjustable threshold for Thermal-nu Door ❑Grids for patio doors: Style:
❑ Stain Kit: Supplied to owner
❑�Erpand or shrink the size of the opening Details
9'Cover exterior Min with aluminum coil stock: Style�c/�//A//'/R,� Color
Harrddv�ara. ❑HandelseI ❑Deadbolt ❑Footbolt ❑Mail Slot ❑Peepsite
B' Ins II oak strip at floor as needed. fl S 1114-rp t R�.�,l.n// ,,�,�/_�1�gd 7 _
Caul interior and exterior edges. f �r''l4qe l� /�f,I�'tSJ 1 f�7 1�'=1 f /J�('� n u,nsulate around new door unit where possible.B�- #-I pI ive I I h' rI m 1wolt7 rp�l�`I IVQ�
aann is not included. �,1....;O r � 5 AS �j�
Oilncluded in this proposal are set up and clean up. �G�XNI'H�// 11� !TC
�Perh+it inc/yde� /t! c �C�' �1f d
STORM DOOR ,
❑ Remove and dispose of# existing stone door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
❑ Location: -
SPECIAL INSTRUCTIONS:
N Is agreed and undantood by antl between the P.M.Met Mis Specincatlon Sheet,along wife the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT torten -
tutae Manor.umleistarch,between Me partleA and Men an no verbal understandings chan,ing or mudltying any of the forms. This contract may not be ohanged _
or Its farina matlifled or varkM In any way unless each changes an In writing and signed by boM Ma Buyene)and Me Contractor. Buyer(.)hereby ecknawbtlge Met
Ruyan.,has nad thus SWIficstMn Sheaf
Contractor Initials: Date: _-��;cG' Buyer's Initials: �� ` Date: W)
I
AGal
]�IJ, Baka
A & A SERVICES, INC.
A&AWMICES 115 NORTH STREET,SALEM,MA 01970
111011111 ASEHERSIREM 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 Date of Contract
11 CohW�t 3/
Buyerts)Street Address,City,State and Zip Code -
8IMPk- S , S /t. o O
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Add..
The Buyegs)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with
the prices and terms described on the front and the reverse of this agreement and any spediication sheets(this"Agreement"),antl Buyerts)have requested that such
goods or derives be Installed or provided at Buyer's address listed above.ASA Services,Inc.('Contraction,hereby agrees W insist or cause to be installed the products
or services listed in this Agreement at tine Buyers)address written above. This Agreement represents a cash sale of goods and services. The Buyegs)agree to pay in
cash Rae cost of Me goods and services purchased ann it�...ribed herein,regardless of timing or approval Of any financing Buyers)may seek for their purchase.
Ad A I——IcAlfc-
Purchase Pdce:Y1S1LL _ Est.Starting Date:
Down Payments w Est.Completion Date:
J p
Amount Due on Brad of Job: �v �.I Check
❑Credit Card
Amount due on of Completion: No.
Amount Due an of Completion:(rj '�//^ya��j/)l Expiration Date:
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(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 THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services,lac. Buyer(s)
By. Signature t Signatur
Print Name J 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. -
ARBITRATION:The wori and Me nomam'rer nermy mutualre agree In mr-ram math Me event offer mv,free a vapme diamemlrq info venoms clover pram,may ammn in maxim to
a pmam eNmatlom—wnkv name been epprwm w 1.semmmry Wma.—ty.OR.of Consumer Admireand BU sm a«JUlan adtheoMmiouTy¢pallberarePm MaUbmhb
au;n vnlVerm ee prouN'm M.G.L a1aPA.
C000azmrmitiala: euyv9lrv,iW:
Art: UNIF
: � .
NOTICE OF CANOF�QN OT f.F
Rate of Timmerman .you may marvel Mu bevanbn.WMM any Memory or Oaoe M Tranewcon .You fry cents are oaraeNan,exand enr pmuly or
mlrerem tllln Nfeinmen—Biewmarm.. vede0.kywcan-immumealaamin, obllperbn.wlMm Wee malmom days kam Me mime deco.ll you coned,vry prcpeny males in
any laymwM1e made by you under to cmtratl or sale,aM may meadow excrement aiecuW any peymenm m&m nay yw under me comer,or sale,and my nepoWOb inaWmanl ezmrtp
ey you var W returned aMnn 10 di inuman,rmavN M marimiar n1 M"r mneallet4l add by you pal be oMnN...IRaeys...a,reaps by the Sellerd(your CenCeI.-mliw,
am,mymmay,Interest Maine oN o,in.baireacrm will ne wvelW,11 you mama,yam muse yk eny 9eWdy lnten¢t Bdsiy ON of Mebenaectlm vNl be mrcelled.Ilyouvemm',ywmWn
maxa vvailabamMen roman your read«W,m mm¢oMelys¢cob I a.wild.
il Ta'Me any
oemeYeeareme SMMu ua,You der Mdommad or sale;or you lar,you war.
wnaply with
Me
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lv. d youo1me Se,in.
Me o. my Bar,and
Me Bare me came Moe up rid, na of Me sNNr raJeNMy Me remm snipmem d1 me geode el me sN1en e¢ense uk
men. n you m maxe Me gams a+e of a m.senor end me Senor mea n« of mom up cox. n yoo m Mxe Me awaa emvleme a Me seller one sae sou«ao..r,m w.x Mem up
mduunmmramMeemolro.r Nomemc«amuemn,you mar retalnaeleprcamm.puma w,tmnmear¢mfe gammon, ,Nma,mearneu.r n.roefey aeon«mwom mMe Wede
of wrimfirgoods w MeomuroUfam to do ra,man
roman msefora,ormyw apse nova. geode. eSemanalmmmdo yo, any aa..—in Iaid seler,anyaa epme
eretummapwdarome polar
s,ri,ral«Immm,Ooeyavme rdehere iOned and sameWyr mremo ModerMe M.St.Toca tealMsm,May,mal meievera fapemmmer,a man
of Heonaumermecoe of arm driewlmis broves.
oe.ortmMlaaeumina. ned and aged copy omgammumerMe contract.Towwel wao-a,eecna.rwladalyer.syrm one eamewq
of ire commission Ma noun a arw of«.amen nor s,a TH a Me NIMM m AaA s��'arvkkkaaa���s of
e w�Neleda„tmw or enr omen wdden mdm,a eem a t«epram,m F sermice.,n.
NpM abael,selem.MeuedrWelb 0191O,NOT LATER THAN MmNIGXT NOM Bnee4 5elem.M04oetivset6018J0,NOT LATER THAN MIONIGM OF
l0«.) cal.)
I HEREBY CANCELTHIS TRPNSACTION, Gmumereslgnedure Oeb HEREBYCANOELTHISTMNSAcri cvmmirmrr vp ma of
DATE: 7
.� �itp DfaY�m, aa�juEt b
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
m/l�(y ,.Y e f
Building Permit Application For: Location of Building
'(Circle whichever applies) Roof, Reroof, Install Sidin ct Deck, Shed, Pool
Addition, Alteration eparr/Repla e, undation 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. I t 0J I l dIj Contractor: A 9� A Seryig5 f C} n6 b r;�t
Street MQ J21 0City ` Q Streeter Nnr4h _City ! aQ If
State. HAr Phone (q%) ' ,q5 -31-I D E) State lM A Phone- M'9) 7!11-_D<I A N
Architect: City of Salem Lic# l HD5
Street City State Lic 057 7&3-1111?# 1 D I to 09
State Phone ( ) Homeowners Exempt Form—yes L—no
Structure: (please circl Single Farniiy Multi Family# Other
Estimated Cost of job S (,�'Un,
Will building confirm to law?des no
Asbestos?__yes_.Luo
Description of work to be done:
��nfor0 on e-- (t ) -en a doer-
P n fn a �r5-Dt'
A&A SERVICES, INC.
Drawings ed:_ yes no Mail Permit to: SA.LEM, MA 01970
% rg7a1741-0424- `
Signature of AppAcallon,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
No.
APPLICWATTION FOR
LOCATION
PEqMIT GRANTED
APP OVfp
S)' CTO(� OF ll INGS -
CERTIFICATE OF OCCUPANCY .
YES
NO