32 NORTHEY ST - BUILDING INSPECTION �✓ �v ��� DATE: 8 '/9 '6 "I
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building_3a mo(+hey slree-+
Building Permit Application For:
`(Circle whichever applies) Roof,Reroof, Install Si ' Construct Deck, Shed,Pool
Addition, Alteratio Repair/Repla e,Foundation Only, Wrecking
Other.
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
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To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name: -DOt kilos sn in n Contractor: A e A Serviu5/(24n---6.ZzLQ rz,
Street_3� I�r7V P u S+ City , / PM Street 11 nrlh
State. MA Phone (R7g)q)15 d,�i 0 8� State KA Phone- NV
Architect: City of Salem Lic# I HD5
Street City State Lic 057733 HIP k I D I(o D9
State Phone ( ) Homeowners Exempt Form_yes no
Structure: (please circle) Single Family, ulti Family a Other
'�. Estimated Cost of job s_3g'b7,0V
Will building confirm to law? ✓ yes no
Asbestos?_yes v/o0
Description of work to be done:--z'7'5—Ga�� ✓� �J`� V/i71�/ Yz��CrGe/Y�er�
_ 1 ) ra0- COS-
A&A SERVICES, INC.
Drawin ubmitted- es no Mail Permit to: t SALEM,MA 01970
X �L41`-Od2d:
ERVFG .
Signature of Applic 'on,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning ]vlep/Loi
Permit fee S
COMMMS:
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NO.
AFPLICA ION FORP58M TO
_
LOCATION
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PEIMIT GRANTED
19
APP, OV p
INSPECT , OF BUILDINGSel
CERTIFICATE OF OCCUPANCY .
YES
NO 1
The Commonwealth of Massachusetts
WDepartment of Industrial Accidents
Office of Investigations
600 Washin ton Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavii: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/individual): A A `jor yi 6z,5 .Ty-)o
Address: 1 I,5 rJ o r+h Sire e+
City/State/Zip:_50 l y.yA M fa OI cl-7D Phone #: 01
r 231 2-I 1 -off a)-J
Are u an em
pto yer. Check the appropriate box: Type of project(required):1.IJ JI am a er wit employer h 4. ❑ I am a general contractor and I P y � g ti. ❑ New construction
era part-time).*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
required.] officers have exercised their 10.❑ Electrical repairs or additions
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.QIO.ther (�O/!?�D(i�5
comp.insurance required.)
I An applicant t y pp that checks box#1 must also fill out the section below sho
wing their workers compensation policy information.
I I lomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatingsuch.
:Con
tractors that check this box rams.t attached an additional sheet showing
o m the name f th
g o the and their workers comp.polity information.
I am an employer that is providing workers'compensation insurance for my employees. .Below is the poffey and job site .
information.
Insurance Company Name:_ _ t r fe_ Tro yp I y7c�,
Policy#or Self-ins.Lic.M W C Q 3q X 19, 67L0 Expiration Date: 9 11'' )O7
Job Site Address: 6L✓f�1e-u Vvee_-1- City/State/Zip: >// `p
Attach a copy of the workers'comp sation 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 Ader the pains and penalties ofperjtay that the information provided above is true and correct
Suture: Date 1'/1r 'd /
Phone#: (q18) rM I — Q H,114
Official use only. Do not write in this area,to be completed by city or town o�ciaL
City or Town:
Y Permit/License# _ s
Issuing Authority circle one):
-
Y( )
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 persons employs to do p maintenance construction or 1'repair work on such dwel
ling 1 to house
g
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 aiiy.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 pennit/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 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
Date
Christopher Zo D R1/
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
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AjBoard of Building Regulations and Standards
Construction Supervisor License
Llpidse: CS 57733
611958
E�i�Crafl5V—�126/2009 Tr# 13739
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CHRISTOPHER 7Q ,
115 NORTH ST
SALEM, MA 01970 Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prezioso,Commissioner �u
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/02/07
Exp.Date 0, 01/08
DC0004C
- _ - MemhPrW C.O.N.ES.T. 08
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IIIIIIIIIIIIIII�IIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIBOSTON4ZENEWJ
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Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration 10160E
Expiration•`6/26/2008 - 1
•. Type: Private Corporation
A&A SERVICES, INC - " -
Christopher Zorzy -
115 North Street .
Salem;MA 01970 Deputy Admmutr;ior ,
PROPOSAL, fq-
A & A SERVICES, INC.
115 North Street
Salem,MA 01970
Tel.:(978)741-0424 Fax;(978)741-2012
MA Home Improvement Contractofs License No.1016091 MA Construction Supervisor License No.CS057733
Submitted to: Work-to be performed at:
Street: Street:
city
C i . ty
ty.
State: Z State: ZIP:
Home Telephone: Work Telephone: - -
We hereby submit specifications and estimates for: -
WINDOW& DOOR REPLACEMENT
WINDOWS:
Storm Windows:# Carefree: ❑ Tru-Channel:
Color:
Vinyl Windows:# Slimline:: � Comfort Plus: Majesty: (o5"P.h'� J
Color:�- Other:I '�I I 5�7b
Options for windows:
Grid Pattern__J�/_,& Low E I Argon Gas: Foam Filling:
Wrap Exterior.Trim with Aluminum Coil Stock:❑ Other:
i DOORS:
Storm Doors:# Aluminum: Solid Core: ❑
_ Style Name: Brass Hardware: Beveled Glass:El
E SPECIAL INSTRUCTIONS: �3 2,
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I` All material is gua teed to be as specified, and the above.work to be performed in accordance with the
I specifications submitted for above work and completed in a substantial workmanlike manner for the sum.of.
Dollam(s 3'q/7A0Q
with payments to be made as follows:
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Any alteration or deviation from above specifications involving Respectfully submitted
extra costs,will be executed only upon written orders,and Sales Representative
will become an extra charge over and above the estimate. All Agent for A&A Semi ,I
agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tomado and other necessary NOTE: This proposal my be withdrawn by us it hot scooted
insurance upon above work. Workmen's Compensation and within ninety(90)days.
Public Liability Insurance on above work to be taken out by
A b A Services.Inc. f(�+p[`- F'�
ACCEPTANCE OF PROPOSAtr -
I The above prices,specifications,and conditions are satisfactory and are hereby accepted. You are .
\authorized to do the work as specified. Payment will be made as outlined above.
l a4I.�Ja a4 8" 2Do7 �t( A/
SigSig a�• ate f
Signature Date p V
"You may cane.[this transaction,without any penalty or obligation,within three business days horn the signing of
this proposal.—