21 NORTHEND AVE - BUILDING INSPECTION 15�VTheCommonwealthofMassachusetts
%7e Department of Industrial Accidents
Iv d Office of Investigations
600 Washington Street
J% Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): A A 5orvias
y
Address:
City/State/Zip--5 V M Iq D1�f IL Phone #: / °[7$ 1 2/- 1 - 2J P,J-4
.Are pu an em:tih
?Check the appropriate box: ' Type of project (required):
1.1� I am a emwith 4. Q I am a general,contractor and I
employeesnd/or part-time)." have hued the sub-contractors 6. New construction -
2. I am a soleetor or partner- listed on the attached sheet. $ 7• ❑Remodeling
ship and haemployees These sub-contractors have 8. Demolition
working fon any capacity. workers' comp.insurance. 9. Building addition[No workerp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.0 1 am a hom doing all work. right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [Nors'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance re .]t employees. [No workers' ,�
comp.insurance required.] 13.0 Other
•Any applicant that checks box#I must also fill out.the section below showing their workers'.compensation policy information.
t tlomeowners who submit this affidavit indicating they are doing all work said then hire outside contractors must submit a new affidavit indicating such.
tContmcioa that check this box must attached an additional sheet showing the name of the 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:_—F�Ae__ T aye j e
Policy#or Self-ins.Lic.#:_�/L' Ct :3A X [ `o] (� Expiration Date: q 113.) Old
Job Site Address: l /�l�Yfh?i�f1
City/State/Zip: 130 [� 127 6 j �7U
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 certify 7zd r the pains and penalties ofperjury that the information provideed above is true and correct
Signature: j Date: 0 9/
Phone#• 16 r)rJL� i]M 0
EQfjf1claluse only. Do not write in this area,to be completed by city or town official
n Permit/License#hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theirremployees.
Pursuant to this statute,angmployee 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 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 tine 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/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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Offce 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 P rmit 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
t '
_ Board of Building Regulatioiks and Standards
Construction Supervisor License
LI ens`: CS 57733 ,
Tr# 13739
I°
CHRISTOPHER 40
715 NORTH ST
SALEM,MA 01970 Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
' Robert J.Prezioso,Commissioner apt
Deleader-Contractor llhd
CHRISTOPHER ZORZY �➢tl
Eff.Date 04/02/07 -
Exp.Date 04/01/08 -
DC000440 08
. NemhPlof CO.KES.T. '
Bo
�IIIIUI��O�IIIIIIOIIIII�II�IIfl11110� 30sroµRS4EW{:
Board oGBuliding Begula[iges and Standards
- � HOME IMPROVEMENT CONTRACTOR
Registration '101b09
Exji r*1075-:<6/262008 ... 1
Type 2nSate Cotpora0on
ABA SERVICES,INC -
Chdstopher Zorzy.
115 North Street-
SSalern;.MA 01070 Deputy Admimstra'tar
I
�� A & A SERVICES, INC.
A&A FYqg ICES 115 NORTH STREET,SALEM,MA 01970
Wyllol Telephone:(978)741-0424 Fax:(978)741-2012
• Contractor Registration No. 101609
Federal EIN:0 4-30 901 62 Construction Supervisor No.CS057733
ROOFING SPECIFICATION SHEET -
Buyer(s)Nam. Data of C..notrart
QA2R`I + IAN1N MJIIZIV .l0#,VSon/ 2-7(0—OS
Buyers)Street Address,City,State and Zip Code
21 Nva--ru�T� FF�� Se4L� M�1 Di9�0
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address .
q76-7N5--yo&o 1 1 a s 7"— 9r&q
The Buyers)listed above hereby jointly and severally agree to purchase the goods an llor 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 this Spermcation
Sheet is a part.
ROOFING SPECIFICATION _
Strip Roof of# for bee 7, layers of shingles
®'Install 6'of ice and water shield at base of roof where install 15.b felt paper to roof.
/po`ssible. Install 18-24"of ice and water shield in valleys. !(�_'
Xhash chimney as measeed(no repointing included). nstall 6"perimeter drip edge to rakes and fascia areas.
,,..Ik, Install vent pipe boots and seal as needed. lash valleys as needed
yy-Install rollout type ridge vent. tanks/plywood replacement under 32 SOFT included,.
// 'If more is needed there will be an extra charge of$
per hour for labor plus the cost of materials.
XDumpster/Dispposal Included: - Other. C.OLorr. "F'o a�
Location: V2t y6ir-"
Install new roof: Manufacturer LI G�'r-7�-rN7b'z .3fl yr Stylettype F}2C#7#
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
RUBBER ROOFING SPECIFICATION
❑Strip Roof O Not Strip Roof
❑ Install 1/2"High Density Fiberboard to existing root using O Flash obstacles as needed.
screws and plates.
❑ Install .060 membrane EPDM(Black)rubber roofing to ❑ Install 3x3 aluminum drip edge to perimeter of roof with -
fiberboard.s seam tape.
❑Flash up sidewall as needed. _
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. -
a -
SPECIAL INSTRUCTIONS: �' If
NCL u7O r�S ,
IA)sr-mi,l� 2 At,uwl flyum VelvT oW '(Srrt�tDr SIDLE
It Is agreed and understood by and between the partlas that this specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the entire underatinufing between the partlea,end Mara aro no verbal understandings changing or modifying any of the terms.This contract may not be Changed or its
terms modified or varied In any way unless such changes are in writing and signed by both the Biennia)and the Connector. Buyers)hereby acknowledge that Buyer in
has read this Specification ShCeet-
Contractor Initials: O" Date: z -Z6-�� Buyer's initials: Date: X-Q�
I
gragnao A & A SERVICES, INC.
A W 'C 115 NORTH STREET,SALEM,MA 01970
itlyfflikill 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 -
Buyers)Name Data of Contract _
&A-a-91 -1' AfdN Mil iE 2 - Z(o-fig
Buyer(s)Street Address,Cry State and Zip Code
Z l P/rnzTH eN /E✓ls .SRL&Y l Mn- J l97 O
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
�78-7YS-�1a60 R 8
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods motor services listed on the accompanying specification sheets,in accordance with
the prime and terms described an the front and Me reverse of this agreement and any specification sheets phis"Agreement,and Buyers)have requested that such
goods or services be installed or provided at Buyer's address listed above.ASA Services,Inc.(•Contractor•),hereby agrees to instanor muse to be installed the products
or cervices listed in this Agreement at the Buyer(s)address written above. This Agreement represents a cash sale of goods and services. The Solicits)agree to pay In
an the cost of the goods and services chased as described!herein,regardless of timing or approval of any financing Buyers)may seek for Bleb purchase.
aid �g0 p
Purchase Price: /ZOt _ Est.Starting Date:q 3o
Down OR Est.Completion Date:S -
❑Cash
Amount Due an Start of Job: � _
❑Credit Card ,
Amount due an of Completion: No.
p Amount Duo on of Com letion: Expiration Date:
Balance Due on Upon Completion: 7Z8 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.
Buyers)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. Buyer(s)also
(I)acknowledge that they were orally informed of their right to cancel this transaction;and(11)request that they be contacted via their
telephone numbers or e-mall,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,Inc., B! i yAA
By: 6 05 v ,
Signature 'CaD at,, L ignatu ���y /� /RS A�
Print Name
_.-7 rPrint Name e J �1
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. a
ARBITRATION:Too mmredo•nM fine M1omming,hereby m grapy All In eOvenx tom N fire evom All part,has a mmk ours—ing Iola woman.other pi may doing vum eiaq,b W li
e pMeW eRNallon 9ervke wM1kh hem mean approvaE b/to Secretary of the Eaecutlro office of LCnaumm Again dean Reguiw*w antl t other party shMi be require]W eubmlt W
NM mil..By qWe]M M.G,L 0.1JPA. /
Conoum wn ORielw't'u R a:
Sara: a:
rA�x A"I r
San of vawaadon 7-2�i-�&or may cars.mio o-wa.,.Hhom any penalty aH oaa a mommodo Z-Zfe-� Yoe nay oarcal mid vansaatlon,whom.N ranalro or
obflgauon.wimin Mmeeumnowdephommeew dM kwhosrcm,arri Pmerrybadaein, obdgatkn,mtwnmreebuameaadantmm Naebovaban.lllunanm,Btry popeM o-aaBtl in.
enr paymenW made by yo anaorme common.sale.end any nagatiebW mawmanf a.ewNe am payment mace by you under me Conran or Sale.find any oeg.WMa aawmmt eaeawatl
iy You mar w rawmeat marin 10 days bro.W.g moss,M ma seder of your ammunition rural. by you-11 ee rewmad withlh 1.don rogo nlq Hamlin Iry the Sao,of your,aanoexx n val
and any aecvr'lly harem analog sin of Ne haneadkn awl of aanMded.If you cancel you mug and any meant,lnrerem arising out of metMsdclbn mill be Cmlmoed.if you c9nml,You first
mac ar ..Wtlre 5,.a our raslderce,N auCsrantlelly.grou wheagn.xTa.Heaved, medm'aikde do day mor.your rem.—.hauboadm ly as¢W mMltpn do xlan resRxtl. .
any,.dalWehad ayOo aNer ma LonmMdOfdro:or you may,H you wioo,simply"in me airy got.did.s..I and.this conM1en or Salo.or you may.if you wlN,simply wihlM
InawNom of this Seller he ardly me mount sMpment of fine goods.me S&aa mpenae and IrSbuNona M me Sell.agYNng me nNm shlnmant W me time at tin Sailers egnma aM
has It you do make 1M geode avaleble fo the Seller and Ne Sell.tloea vim pIG seem up not, If you do meMe ma goods gangs to the seller and ma solde bxa Out pint Nam up
whin at do,of ma it.of,Our NOE®of Lroalfame,you may man or dbpoae of Na gods wlNin A di of the data 0 hour NoYw M Lmxellagon,you may retain or formed Nep oil.
hermanyNMingla,om,Hyou ladW make the OCMdevmleHeroNa Seller.arily0u agree wiNon cry NnM1er obllgatlon.IfyoutallWmMethegoutlaavWlaeWmeSnW..orltynuagras
W alum he Smile W the solar and IN a do an,men you remain use@ for Pragmatist N all a.ough Ne Bodea may Solar,.fall W do w.man you ramain liable farperlgmarW. Gall
oblgetlonaun�rme Lono-a M e tr cl.To mfineavtion.mail ortlelM¢HeOignM and doing gray obIIS.Iona untlm Ne Ca mad.Tocancelmla bendaztion.mBllor delMraalpnW and datlMwpy
of may rdngllNon lntiw or any Star wmmn rmthas or send a higher W AaA Servke.Its of He asncelleWn lWhe or any aNer wdtlen nolke,or-1 a 1IYJRm,1. tts
No Short Salem.Massachusetts MI
m9T0.NOT LATER 11NN pNIGIR OF NoM Brom Sam.MmsBUudees.1170.NOT LATER THAN MION TOF
North r� z4
bare) Sam
I HEREBY CANCEL THIS TRANSACTION. comaumrssegaim Sea I HER
EBY CA NCELTHISTRANSACIRCN. Consumer's SpneNre p&a
DATE:
-
�itp ]if , HE;'5ALbU'5Ptt5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building JI A101 '1 er,a' �nue
Building Permit Applicati r:
'(Circle whichever applies) Reroof, Install Siding, Construct Deck, Shed,Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
r
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name:_&LLY e A% F'ar,e JDI1Vl5t n Contractor: A e A 5r'-rvtCe51e ?1- Q r7
street,21 ►�iW,�1�r1 �h!e City , Street .115 ► 12C4h 5�, city l y
State.HA Phone (19$)_q�h- q0 (00 State M A Phone, N 7$) 1 z.D-9 0,)-I
Architect: City of Salem Lic1(_j 0
Street City State Lic U`J I HIP# 10I to 09
State Phone ( ) Homeowners Exempt form __yes ,/no
Structure: (please circle) (' le Famii • Multi Family# Other
Estimated Cost of job S /� 7a$", &--0
Will building confirm to law? ✓ yes no
Asbestos? yes 1/ no
Description of work to be done: g X l kirt9
D cu ( 0 VW �4rcG,rfyCh/i U � Sly/ a� �
U
A&A SERVICES, INC.
Drawin ub fitted:_�es no Mail Permit to: 1 S,BEM,MA 01970
J{ ViI W W.A-ASEflV�E•S".
Signature of Appli ation,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(t7 MONTHS OF PERMIT ISSUED DATE
a • . . t1 r T-.�
APPLICATION FOR
PERWIT Td
LOCATION
PEqMI GRANTED
APPpgV 'D
1 �I
INSPECTOfl BUILDINGS _
CERTIFICATE OF OCCUPANCY
YES
NO - 1