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115 NORTH ST - BUILDING INSPECTION (4) Thl,Commonwealth of Massachusetts I i l Department of Industrial Accidents Office of Investigations ouyt 600 Washington Street tgY Boston,MA 02111 r I www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /t Please Print Legibly Name (Business/Organization/Individual): _ A. A� `jo VI Lg Address:. I i.5 ►J D r+h Sire e-I ` City/State/Zip: ��a 2, M13 Df970 Phone#: I �I7� 1 q1A 1.—Q/A j-4 Aree an employer?Check the appropriate box: Type of project(required): 1.UV I am a employer with�� 4. Q I am a genera!contractor and I employees(full and/or part-time).* have hired the sub contractors 6. El New construction 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 required.] officers have exercised their 10.0 Electrical repairs or additions 3.011 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.❑ oof repairs insurance required.] t employees. [No workers' D comp.insurance required.] 13. Other / U_ *Any applicant that checks box#1 must also till 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 mustsubmit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name ofthe subcontractors and their workers'comp.polity indicating such. !am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. —f� Insurance Company Name: t v�� T{'" VP P r'S Policy#or Self-ins.Lic.M. 34 X I a Expiration Date: q J i3)0 7 Job Site Address: oZAs Nat-fh City/State/Zip: A413 Q/q70 Attach a copy of the workers'compensation policy declaration page(showing the policy number and elpira.tion 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. 71doh,ere:hyce rtif u the sins nd penalties of perjury that the information provided above is true and correct nature Date: o� Q Phone r7,H I Official use only. Do not write in this area,to be completed by city or town officfait 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 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/icense 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 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 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 Pe it Applicant Date Christopher Zorzy Name of Permit Applicant A &A Services, Inc. Firm Name 11S North Street, Salem, MA 01970 Address, City, State, Zip Code Board of Building Regulations and Standards Construction Supervisor License License: CS >1 57733 E 9irBif`ate;_5/26/1958 fi-Ex ion 5(26/2009 Tr# 13739 Resf 3'tion OOI' CHRISTOPHER 115 NORTH SALEM, MA 01970 `-'''� Commissioner Commonwealth of Massachusetts Division of Occupational Safety Robert J. Prezioso,Commissioner Deleader-Contractor CHRISTOPHER ZORZY Etf.Date 04/0 /0 0 Exp. Date 04/0 1/08 DC000440 - Member of C.ON.ES.T. DO IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 8 a OWRENE . � . y� �'/ze -�ommzo�uuea/,C/e o�'✓�aooac/zuaetYa-:', Board of Building Regulations and Standards - HOME IMPROVEMENT CONTRACTOR Registration: 101609 Expiration: 6/26/2008 I <:Type: Private Corporation A&A SERVICES, INC' Christopher Zorzy ' 115 North Street : Salem;.MA 01970 Deputy Administrator. Which High-Performance skF Glass is Right for You? u = FIVE DIFFERENT GLASS SYSTEMS FOR ENERGY EFFICIENCY, v SOUND REDUCTION, UV PROTECTION AND SECURITY. There isn t one glass system that's right for { ® x F rmal, Excellent ry FVery Good e V S GGoiu Two Zr Good 4 Hghest en fic ency every S1tUatlOri. That's Why Whole Wmdo glass panes and - SolarControL„ •Three panels of properties Bestal}c7�mate ter 111 U va ue 017 1tw¢9/32 rich' ' r coahngS reducex tgl, and heavys choice Retains heat in GOrell Ives OU SO mall x P i a u sulatmg spaces light t ansm ssion duty window; ,cold weather ienects j g Y Y a - a Center of-Glass .}.. k y r r r r xsra s iandfiltei 90k of fconstruchon ,c extenoc.heaEm warm `+ i + U value 010 f & w x {+ different choices. Depend4. ing a � w radiation hat weather _'1`x 4 " a > .76N- ` r x + causes fadm 'x ,�. 'y 1 i +•^ On various factors—like the z ,t, ,' r 'v i�� � '� a` ' 7vs,., xi ,x ,�;`vo q.•^ n -s .,< ay ly�`a .3` f{ � part of the country you live Energy Excellent-. Very Good: Three Very Good: Two very Good: Excellent energy-efficiency ® Whole-Window glass panes and SolarControlTM Plus Three panels of properties.Very good in, issues important to you Master III .U-value=0.23 two 9/32 inch coatings reduce glass and heavy- all-climate choice.Retains Centex-of-Glass insulating spaces. light transmission duty window heat in cold weather, (e.g., Security,energy Costs, U-value-0.16 and filter 90% construction. reflects exterior heat in of UV radiation warm weather. etc.), even the amount Of - that causes fading. - sunlight your new windows y,a,a ,, J� �Ve Good®t Eicellent Two Ex"ce�llent�0060 (Excellent 0060 Detersinetrusron'deadens, will allow into your home /4rn7Gr2. Wl ole Window Sglas`s'panes includ t�mch PVB mterlayer 7 inch PUB inter (sound lowers energycos s cG_lass® +t n `U value 0 27 }ing,7one made of 5"and SolarControIn'� layer plus heavy and filters UV radiation y you'll want to be sure you s $ a two sheets of glass FPlus coating filter duty window Best Securi y option and µ PIPS sCenter of-Glassr ° s "a t and a polyvinyl 99/o of UV fight r construction very good energy efficiency., 3 x U value:. 0 24 : N Select a glass System that S ': " T i Albut'yral mterlayer that causes fading 'trr K An excellent choice For x fi ,ny.ic t § i rand 9/16 inch , L i `$ a f Nr v f homes in most climates for you. Gorell offers ' w r A ins lating space. y k yi t i r _.k ELL-- right five high-performance glass AC Very Good: Good. Two glass Good: Solar- Good: Double- Excellent for use in Stems. Each performs Whole-Window panes,11/16 inch ControlT Plus pane insulating practically all climates. systems. P Master's U-value=0.29 insulating space. coating filters 75% glass and heavy- In cold weather it retains, different) and meets - C.enterof-Glass of UV light that. duty window interior neat.Its good Y U-value=0.25 - causes fading. construction. shading coefficient and _ ability to reflect exterior unique needs. - - heat make it strong performer in warren weather. Use the chart to the right to g Climate &. Very Good Good rwo glass Good Solar se Good Double {EXMIFeatvalue All ft Whole Window panes,il/16 inch_ Control^".Plus $ ane msulatui 4 around choice for the5mal+ help Select the right glass Master® =rl'x �U value 0 30 ¢insulating space`^ coating filters 75% glass and heaary t �etficienry and miproveds„ >} s xCente-ofGlas ,�r:rs gof UV.light that,+ ,,duty windows,, home comfort Its solar f System for your home. + . o { rcauses fading construction =ti heat gaui properties.y, z 3�,v- ' :r Uvalue 025 � 'na s ^r Cr vfi ve s, ,ap� ead�V,`t �.� ,q�, to select Clunate�Master For js.� f°� 6 ¢S"su e- �,,sF Whole-window U-values shown above are based on a 5301 picture window without grids,using single-strength glass. 'Ultraviolet light(UV)is one factor of many that can fade upholstery,furniture and wall coverings.The percentages shown in the chart above represent the filtration of UV in the part of the spectrum that causes fading. WINDOWS 6 DOORS sssnaivcnsaa-zsM - w ..gore/Lcom. Axa;ia A & A SERVICES, INC. A,, /� �+ &A SE WCES 115 NORTH STREET,SALEM,MA 01970 II let fiffintlylni Ing if 7;jMjrp3M 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 - Buyers)Name Date.of Contract a S�1 e — Buyer(s)Street Address,City,State and Zip Code 04 1, 5/ . Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address - J� 59y_o�bo 9�i1-y�0-753 The Buyer(s)listed above hereby jointly and severally agree to purchase the goods anchor 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 Mis Specification Sheet is a part. - WINDOW REPLACEMENT Remove and dispose of# .9— existing windows. Install # new (-vs r SI0 windows: Vlnyl ❑We 1/�(Manufacturer) Options: Style C7I � If /-R/Y/1(,�Grid pattern & 6l/LrL ld 19 Color Interior LA/,11I nor IA Als�— Glass Type _ O//Wrap exterior trim with aluminum: Style Color . U It windows will be installed according to the installation procedures in the portfolio. n_���) Id Caulk all interior and exterior edges. /�/y( sulate where possible around new units. / / �f 6 d � C /, 1Lr0 Vic window weight pockets it exist,and around new window units where possihle. / ram.O�sl�� icded in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and ouV f may; uliding permit included. K BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS ' ❑ Create new window opening by tuning through existing home and framing in opening. ❑ 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. ❑ Install window(s)into opening(s). Note: If Bay or Bow installation to include cable support system,new feet system(matching color as close as possible) or be into existing soffit system. - ❑ Bay ❑Bow O Casement ❑Other window(s)to include new interior style trim and new exterior style trim and head Clashing 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 pearls). ❑ Install new storm doors# Manufacturer Style Color Type: ❑Aluminum ❑Solid Core SPECIAL INSTRUCTIONS: N Is agreed and understood by and behvam Me pries that ibis Spedfication Street,along Man CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,communities Me entire understanding bebsesn Me padles,and them am no wheal understanding.changing or modifying my of the terms.This contract may not be changed or as ' arms Madil tl or varied In—any y@w9r1waayy�y uuunnnllless—such changes ere In writing end signed by both tee Surface)and Me contractor.solicits)thereby acknowledge that Buyer(.) has read this Specification n/ Contractor Initials:als: Date: �(�o/ Buyer's Initials: -16- Date: ����� salt, wo A & A SERVICES, INC. A&Asemm 115 NORTH STREET,SALEM,MA 01970 ivillikileTsTelephone:(978)741-0424 Fax:(978)741-2012 Contractor Registration No. 101609 Federal EIN:04-3090162 Construction Supervisor No.CS057733 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Buyers)Name Date of Contract �f^rctr �O-�I- Q Buyer(s)Street Address,City,State and Zip Code -;ia or(L, C. . d Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:. 97��9�/d'��o0 978 TFiCrr¢rgfl �h The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed on to accompanying specification sheets,in accordance with fine prices and terms described on the front and the reverse of this agreement and any specification sheets phis"Agreemenrj,and Buyers)have renuested that such goods or services be installed of provided at Buyer's address listed above.A&A services,Inc.('Contractor,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 cash the cast of the goods and services purchased as described herein,regardless of dming or approval of any Silencing Buyers)may seek for their Purchases. Purchase Price: /lr�s L Est.Starting Date:e—2— � Down Payment: �51J0 f L �� v4� Est.Completion Date:?—z f— L� O Mesh Amount Due on Stan of Job:— r v Check ❑Credit Card •7 °"f ' Amount due on of Completion: f No, c7 d� Amount Due on Of Completion: Expiration Date: Balance Due on Upon Cempletion.�1. CVC Code: R Is agreed and understood by and between the partles 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 two attached Notice of Cancellation forms,on the date first written above. Buyers)also (q acknowledge that they were orally Informed of their right to cancel this transaction;and(H)request that they be contacted via their ° telephone numbers or e-mail,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 BLANK SPACES. A&A Services,Inc. / Buyer(s)/� J) o By. Signature / Signature/ ® - Print Name Print Name Signature - Print Name You,true 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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II you do make Me good.svplBNe to me$dpr and Ne Sall.,tloea M pick met up me. It red M make Ne gLWe evalege p in.Sailer Out me We.,dace M pier,morn up wlmin'St deye of Ne data of yea Notice 0 comb lNXon,you may max—ro me to NagoWe wXhM 20 clan Nan a dap M your Nadu ad canulldbn.you may turn or Rmml Ne good. M.any pMP cdi...an.ll ynu bllbm¢Fe NegMtl98vpbWebNe S¢Ibt,ailyou dgree ya mmOMyNamparleaMn.Ilyw lotto mekeme g]M9avp18bb WNa$elbt,wnyw apru Mom Xn gcEs to due Sear send cal m do an men you reran fade be uMmarce of all an,mwmore gu]e b Or Selier and rdl to do u,clan you remem abode me pmbmarce a all ap'g9bns under me Carted.To owel the transaction.mall or dealer a scrod and dated ropy ableaoomunda Necmmust Taurwel miseansecXon,mallwdelbrereygreda,dtlabticop) at hat umulltlbn make or vy aNer'.MXen real or und a pbJram,b MA Send ��{{11a a1tle Is.natlu a any oiler mr.ram .or NM te Mayan,to.a.'7.it North$eael,$rdi MessechuseM019>p NOTIATERTIANMIDNIGNTOFir_'r 'II North Same.Suen.Massatlautts DIM,NOT LATER nvul MIDNIGHT OF -1 �� . Icaps) (Dame) HEREBYCANCELTHISTFANSACTON. Comuma}GgreNn Doe IN EREBYCANCELTHTSTRANScTI)N. Comumag scmNre Dea i DATE: ems, �itp of aAYPIYi, ASftL�UPtt PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED / Location of Building Z,S Alo f� 6-,af:T Building Permit Application For: `(Circle whichever applies) Roof, Reroof, Install Sidin ct Deck, Shed,Pool Addition, Alteration, epair/Replace, oundation Only, Wrecking Other: PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Buildings: The undersigned hereby appliees�for a permit to build according to the following specifications: n� Owners Name: JDLL (7��r/j/ � Contractor: A e, A Srr"yi&51( n5 br-7, Street_AoZS AInI (SypP>' Cit} Street II5 No6h 5f. _Cityy State. MA Phone (99S) 59y —071Dn State lylfl Phone- (CM) Architect: City of Salem Lick- 1 JJQ5 Street City State Lit 01133 HIP* I©I io t79 State Phone ( ) Homeowners Exempt Form_yes ✓ no Structure: (please circle Single Famil • Multi Family# Other Estimated Cost of job S //L3-7(p� Will building confirm to law? ✓ yes no Asbestos?__yes V/ no Description of work to be done: (oU l van .161 rv,�1�Jc�r»en� /A)inLJQ(,J5 . A&A SERVICES, INC. DrawiiLu/g's/ r itte S_yes no Mail Permit to: 1 RMA 01970 -� -- ALEM, CTS. L41-0424. }{ VWUW.A-ASEgV� Signature of Appligition,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE Y • • I - APPLICATION FOR _ - ' PEAW TO LOCATION E PE MIT GRANTED x APPROVfD I li P CT0n1 OF BUI DINGS CERTIFICATE OF OCCUPANCY , YES . NO