34 NORTHEY ST - BUILDING INSPECTION DATE:
r
Citp Df '45alpin, aE;5arbU5Ett5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building Permit Application For: Location of Building 3N N l7f'-(haH S{-t-ne-4
'(Circle whichever applies) Roof,Reroof, Install Sidin Construct Deck, Shed,Pool
Addition, Alteration, eps rr.. gce, 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:
Owners Name Contractor: hi�-{} E>erVIU OhriS Z—S r�zU
Street 3H rJ()r4l-,v. 1 5�q J-City i Street J(.ri Kti t)eh 5�, _City, G �UV1
State 1Y r Phone 0%) State M Pr Phone•97t,-7/ ( --DLj 4
Architect: City of Salem Lic# N 0 5
Street City State Lic DJ7 7 3.3 HIP t: 101 0009
State Phone ( ) _ Homeowners Exempt Form_yes a/ no
Structure: (please circle) Single Family, Multi Fame # Other,.,—
Estimated -•
Cost of job S 1 o2'7, U0
Will building confirm to law? yes no
Asbestos?_yes_�[.no-
Description of work to be done:
�v-iS+rall -�tv2. � lnul tr'P,i'�Ir/ 2hnnt�cl' 1 �I�Jf�t 1S
A&A SERVICES,R INC.
115 TH ST EE
Drawings ub fitted:_yes no Mail Permit to: SALEM,-MA O1$70. -
,{ GVWW1MSER II-O °COM
Signature of Applicatikin,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning -Iviap/Lot
Permit fee S
COMMENTS:
f
A f PLIC�ATION FOR .
PER TO
LOCATION
PE MIT GRANTED
c 1- 19
f APPR f0
INS ECTOn O BUILDINGS - >_
CERTIFICATE OF OCCUPANCY .
YES
NO i +.
i • i
The Commonwealth of Massachusetts
I Department of Industrial Accidents
I
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly.
Name(Business/Organization/individual): Q A e-r Ui to5 _'n a
r
Address: 11 y 1 I o r+h Ohre e±
City/State/Zip: _50 YVl M t::j DI q70 Phone #:
Are an employer?Check the appropriate box: Type of project(required):
1.l�l I am a employer with�� 4. ❑ 1 am a general contractor and I
employees(full and/or part-time)." have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t �.
❑ 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.❑ 1 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'
comp. insurance required.] 13.�ther V0 t/1(5
"Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t I lomeowners 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 of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site
information. —t�"
Insurance Company Name: t v e—
Policy#or Self-ins. Lic. #: L' C] �q X 1 a Lj o Expiration Date:_'131 Q-7
Job Site Address: H klotAJoio City/State/Zip:_�j('�lem yam.A p(C[7b
Attach a copy of the workers' compen tion 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* u de the pains and penalties of perjury that the information provided above is true and correct. i
Si nature: Date
Phone#: (�-i8) rlH I — D l-I c .
0 -cial use only. Do not write in this area,to be completed by city or town ojjiciaL
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 I52, §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 untiI 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 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
_
Fax# 617-727-7749
Revised 5-26-OS 't
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 Cartina -
>I
Signature of Pe it Applicant
ID•.31- a�
Date _
Christopher Zorzv
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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ABOARD O�rry OF BUILDING REGULATIONS
License. CONSTRUCTION SUPERVISOR
.. Number:'CS 057733
I q Blrtltdata:05/26H OOS
Expires
0526�'2007 P Tr.no: 12633
- Restrlciadl 66
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CHRISTOPHER ZORZY i ,j/, -'
115 NORTH ST ' /
SALEM, MA 01970�
Commlaeloner i
.. _ -_.�.�___.✓/la f/lo9lLAtpnrcers�o�✓Nnaw�NJe((d .•
Board or Building Regulations and Standards
$ HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2006
Type: Private Corporation
A&A SERVICES,INC
Christopher Zomy
115 North Street
Salem,MA 01970 Administrator
�iCOMMOnwea/th Of Wa s
ssec husetts
Division Of_ Occu tiona/Safety.C Eery
Deleatler-Contractor
CHRISTOPHER ZORZY fl\ate®V/
EB.Date 02/OBr06 O
Exp.Date 02N&07 •�x
DCOW4Q
MemMdCO.N.ES.T.
�nI,111II 11�IyII11 IIIIIII�N1I II'IfI,1II r'1r'11''ryry1I�I�I�p1'1,,pp1�I� i' i{
IIu1�I�Y W��YIYIIW��II II,I I��,Yll,ll BOSTON.RENEW
Ba Shore GREAT L&KESO
. 'y WINDOW
NFRC Cert-Med Solar Heat
Product Directory Gain Visible Light Condesation Energy Star
Product Type/Popular Glazing Options Number U-value Coefficent Transmission Resistance Approved ReDort# Expiration Date
Double Hung GLWOH-131 ETC-04-552-15669.0 11M2008
Clear IGU 0.47EO1.30
0.62 42.00 No
All Grids idth<7' 0.47 0.55 42.00 No
Hi-R Plus Low E n IGU 0.31 0.55f
.00 Yes
All Grids idth<7' 0.31 0.49 .00 YesMaxuus Double Low E n IGU 031 0.49 .00 Yes
All Grids idth<t' 0.31 0.43 .00 Yes
Slider GLWSL-131 ETC-04.552-15791.0 12/28/2008
Clear IGU 0.47 0.56 0.59 .00 NoAll Grids idth<7' 0.47 0.50 0.52 .00 No
Hi-R Plus Low E n IGU 0.32 0.28 0.52 .00 Yes
All Grids idth<t' 0.32 0.25 0.46 .00 _ Yes
Maxuus Double Low E on IGU 0.31 0.26 0.47 55.00 Yes
All Grids idth<7' 0.37 0.24 0.41 55.00 Yes
Picture GLW-0I-131 ETC-04552-15753.0 12(1012008
Clear lGU 0.47 0.59 0.69 44.00 No
All Gnds idth<7' 0.47 0.59 0.62 44.00 No
Hi- Plus Low E n IGU 0.30 0.33 0.61 56.00 Yes
All Gnds idth<7' 0.30 0.30 0.55 56.00 Yes
M UUS Double Low E Argon IGU 0.29 0.31 0.54 1 57.00 Yes
All Grids idth<i' 0.29 0.28 0.49 1 57.00 Yes
Casemen GLW-N-033
ETC-02552-12497 11/7/2006
Clear lGU GLW N 033 001 0.45 0.51 0.54 No
All Grids idth<i' 0.45 0.47 0.49 No
Hi-R Plusr Low E IGU GLW N 033 083 0.30 0.27 0.47 _ Yes
All Grids idth<1 0.30 0.25 0.43 Yes
Fixed Casement GLW-N-001 ETC-02552-12499.0 1102006
Clear IGU GLW N 001 001 1 0.50 0.63 0.67 No
All Grids idthci' GLW N 001 002 0.50 0.57 0.60 No
Hi-R Plus Low E n IGU GLW N 001 005 0.31 0.33 0.59 Yes
All Grids iddr<1' GLW N 001 006 0.32 0.30 0.53 Yes
Awnin GLW-N-034
Clear IGU GLW N 034 001 0.45 0.52 0.54 No ETC-02-652-12497 1177/2006
All Grids idth<7 0.45 0.47 0.49 No
Hi-R Plus Low E n IGU GLW N 034083 0.30 0.27 0.47 Yes
Bayshore
Ba Shore (TREAT
r ry WIND
NFRCCertiF/ed Solar Heat
Product Directory ' Gain Visible Light Condesation Energy Star
Product Type/Popular Glazing Options Number U-value Coefficent Transmission Resistance Approved Report# Expiration Date
All Gdds idth<1" 0.31 0.25 0.43 Yes -
SlidingPao Door ..
New Construction Door(AFD) 'GLW NO50 - ETC-03552-14461J 11118/2007
Clear IGU - 0.47 � 0.62 0.66 M46.00 NoAll Gdds idth<7" _ 0.47 ,0.55 0.58 NoHi-R Plus Low E n IGU 0.30 0.32 0.58 All Gdds idN<7" 0.30 .029 0.51 Yes
Footnotes: Residential values sin le strength lass U-values w/o gnus --
total unit values DS or TS worst U-value w/9nds
.. BayShore
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Seabrooke RETKF
- INI
NFRC Certified Solar Heat Energy
Product Directory Gain Visible Light Condesatfon Star
Product Type/Popular Glazing Options Number I U-value Coefiicent Transmission Resistenee Approved Report# Expiration Date
Double Munn GLW-DW135 ETC-04-552-15675.0 12/182008
Clear IGU 0.47 0.57 0.60 42.00 No
All Grids <1' . 0.47 0.51 0.53 42.00 No
All Grids >I- 0.47 0.45 0.47 42.00 No
Hi-R Plus Low E Argon IGU 0.32 0.29 0.53 52.00 Yes
All Grids <t 0.32 .0.26 0.47 52.00 Yes
All Grids >1" 0.32 - 0.23 0.42 52.00 Yes
Maxuus(Double Low E Argon IGU 0.31 0.27 0.47 53.00 Yes
All Grids <I' 0.31 0.24 0.42 53.00 Yes -
All Grids >7' 0.31- 0.22 0.37 53.00 Yes
Maxuus 7.8(Triple Pane Double Low E Amon IGU 0.26 0.25 0.43 60.00 Yes
All Grids <t' 0.27 0.22 0.38 60.00 Yes
All Grids 1' WA - WA WA WA WA
Slider GLWSL-135 - - _ - ETC-04-552-15793.0 1/42009
Clear IGU 0.46 10.25
1 0.59 42.00 No
All Grids <1" 0.46 0.52 42.00 No
All Grids >t• 0.46 0.46 42.00 No
Hi-R Plus Low E on IGU 0.30 0.52 55.00 Yes
All Grids <I" 0.30 0.46 55.00 Yes
All Grids >1 0.30 0.41 55.00 Yes
Maxuus Double Low E on IGU 0.30 0.46 55.00 Yes
All Grids <1' 0.30 0.24 0.41 55.00 Yes
All Grids >I" 0.30 0.21 0.36 55.00 Yes
Maxuus 7.6(Triple Pane Double Low E Argon IGU 0.25 0.24 0.42 60.00 Yes
All Grids <7' 0.26 0.22 0.37 60.00 Yes _
All Grids >1' WA WA WA WA WA
Picture GLW-PI.135 ETC-04-552-15755.0 12/112008
Clear IGU 0.46 0.66 0.69 43.00 No
All Grids <t' 0.46 0.59 0.62 43.00 No
All Grids >I" 0.46 0.53 0.55 43.00 No
HI-R Plus Low E Argon IGU 0.28 0.33 0.61 55.00 Yes
All Grids <I" 0.28 0.30 0.55 55.00 Yes
All Grids >I' 0.28 0.27 0.49 55.00 Yes
Maxuus Double Low E on IGU 0.27 0.31 0.54 56.00 Yes
All Grids <1" 0.27 0.28 0.49 58.00 Yes
All Grids >t 0.27 0.25 0.43 56.00 Yes
Maxuus 7.6(Triple Pane Double Low E n IGU 0.19 0.28 0.49 85.00 Yes
Seabrooke
f
Seabrooke
GREAT LADE
NFRCCer6tied Solar Heat Energy
Product Directory Gain Visible Light Condesation Star
Product Type/Popular Glazing Options Number U-value Coeftent Transmission Resistance Approved Report n Ex pi Date
All Grids GLW N 063 00001 00001 0.43 0.46 0.48 43.00 No
HI-R Plus Low E Argon IGU GLW N 06300003 0.29 0.27 0.48 66.00 Yes
All Grids GLW N 063 00003 00001 0.29 0.24 0.42 56.00 Yes
Maxuus 7.8(Triple Pane Double Low E on IGU GLW N 063 00008 0.23 0.23 0.38 83.00 Yes
" All Grids GLW 1063000018 0.24 0.21 0.33 63.00 Yes
Hopper GLW-N-005
Clear IGU Old design not abating,Not Tested new desi n 01-33259.01 Not Labeling
Hl-R Plus Low E Argon IGU
S al Sha es
Clear JGU
Hi-R Plus Low E Argon IGU
NFR
Footnotes: Residential values single stren lass U-values w/o rids
total unit values DS or TS worst U-value w/ rids
M111Seabrooke