2 NURSERY ST - BUILDING INSPECTION (2) t - �
The.(lxtunomce;tlth of Massachusetts
y Board of Budding ReI'u lilt iOnS and Standards Nit'NR 111 \I I I )
1� ' t tilasSachuscttS State Building Code. 7511(TIR. 7n,edition SI.
Building Permit Application To Construct. Repair. Rrno%ate Or it
R, o,,l.liuuo,rt
One- or Tun-Family Derlling 1. _oos
This Section For Official Use Only
,( Building, Permit Number: I ,/3,,,�-• Date Applied:
C`
Stgnatwe:
Building Commissioner/ Inspector of Buildings Date
SECTION I: SITE INFORMATION
1.1 drop rty ddre s: S ,�1 1.2 Assessors :Ntap & Parcel Numbers
�l Cam'
—a ,
I.la Is this an accepted reetf yes_ no_ Map Numher Nicol Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed List Lot Area(sq 11) Frontage(11) .
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Requied Provided Required Provided Required ). Pros idea
1.6 Water Supply: (M,O.L c.40, §54) t.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? Municipal On site disposal system ❑
Public❑ Private❑ Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' f d Recor :
r S _ a AJl Gr�r rp
Nume(Pr t) .Address or Service: 4
1 o-e�GL 9If-7!y - 599 6 _
Si nature' Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Rzpairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Pro use Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
i fie m Estimated Costs: Official Use Only
(Labor and Materials)
I. Building 'S 3 �5 M I. Building Permit Fee: $ Indicate hum fee is determined: i
❑ Standard City/Town own :\pplicadon Fee -
Mechanical
al" ❑Total Project Cost' (Item 6) x multiplier x
g . . S 2. OtherFees: Sical (HVAC) S - - List:(Fire nl Total All Fees: S
Cheek No. Check Amount: (':oh Annuun:_----
j b, Total Project Cost: Sr tro ❑ Paid in Full ❑ Outstanding Balance Due:____:____•
i
SECTION 5: C'ONSTRUC'TION SERVICES
i.l Licensed Construction Supervisor(CSL)
S/lr r 1-7
L- L ivesti mcJ nt+tu. S.11U0 Cu. I't.t
-I - _- R Resiniicd f&_' F:ntnls'D%telloo, -
._ S�gi nmune \1 Nlasonrs Only
7 7P W I- U 1 Z RCTResidennalu..Im"Cm cn iteTelephnne - 11'Svtndmo .utd 5nhn'.
SFAO Fta-1 Bumme \1 tlanecD5.2 e is red Ilon In e n nl Cu t a• or(11100 eo
ompany Name ur IIC R•�istrat an • euuatiun Nunther
AJ rc: �d I
9��7YIeE xptranu Date
St@nature V Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it)provide
this affidavit will result in the denial of the Issuune of the building permit.
Signed Affidavit.Attached'? Yes .........•. No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S.AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
f, /' C as Owner of the subject property, hereby
authorize to act on my befialf. in all minters
-relative to work- thurized by is bui ing permit application. A
lbehalf.
atureol tuner. Dates �U
SECTION
L7b:O�WNERt OR AUTHORIZED AGENT DECLARATION
n/'./s �C JAX.! r� �f as Owner ur.Authorized Agent hereby Jeclare
the statements and info mation on the foregoing appli�rue and accurate, to the best of my knowledge;nd
Pn t . am
Signature ot'Owner or A thorized .Agent Date
((//
(Signed under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires in unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Pro@ram), will not haN'e access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regolatiims I IO.R6 and 110.Ri, respectively.
' When substantial-work is planned, provide the information below:
Tutai11i;ors area(Sq Ft.) fincludinggarave finishedhasement/attics decks orporchi
! Gross living area (Sq. Ft.) Habitable ruum count
Number_uf.fueplaces . . - . - VUnlherufhedr)hnn,
Numbefuf'hathroums- .. Numberotli•dt/haths __ --......_ .
fvpe tit heating systern Number ni decks/punches --_—_—_--.
Type of cooling s}�stem Enclosed Open ----- — --
3. "Total Project Square Footage- may be substituted titr"Total Project Cuss"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
%IA),�K
I 2,'. lt'.lilli\i,l',A ti;1tFF I 0 $.11 il\I,\l,l,,.N III If I
I'l:1: 9-8.74 9j9i # FU:: '1-$•-7:9$�n
Workers' Compensation Insurance AfGdarit: Builders/Contractors/Electricians/Plumbers
ADnlicant Information / / / f /. Please Print Le:ibly
\';1t11t' tDu.,incss I lfganuauon Inds nhlal.l: A 'C A S el V lJc� J-I�l2,
Address: tgor+f) 5trP e—+ \
City,S talO,'Zip C�]rm. Mq DIT70 Phone #: Lg7Ss� 71II - �Ho>*�
Arre/'on an employer?Check the appropriate box: Type of project(required):
I.Ll I am a employer with 4• ❑ 1 am a general contractor and t
6. New construction
employees(full and/or part-time).' have hired the sub-contractors Remodeling
2.❑ 1 :un a sole proprietor or partner- listed on the attached sheet. 7.
ship and have no employees Thesesub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' romp. insurance. q, ❑Building addition
[No workers' Gump. insurance . 5. ❑ We are a corporation and its
required.] oflicers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LED Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no I ZYX Roof repairs
insurance required.] ' employees. [No workers' I3.❑Other
comp. insurance required.]
•,1ny applicant that cheeks box#1 must also till out the section below showing their workers'compensation policy information.
r I lumeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
:('untracmrs that check this box mustattached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l urn an employer that is providing workers'compensation insurance for my erirployees. Below is the policy and job site
information. 1 /
Insurance Company Name: rt'I p
Policy#or Self-ins. Lis D-,:2�14 H 5 t r U L3 Expiration Date: 110
Job Site Address: /11/ r.1JVT u- City/State/Zip' ' 'T V / 9 70
A teach a copy of the workers'compensat' n policy declaration page (showing the policy number and expiration dale).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1.500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
hncstigatiuns of the DtA fur insurance cuxerage verification.
l do hereby c•errif t rd,r the pain curd penahies of perjury that the information provided above is true and correct
LCien„Intrr: ,{� Date: / /v
Phone = "/// -O I
UlJirial use only. Do not wrile in this area, to be completed by city or town oJJiciaL
('ity or I(Mn: , —,--_.-_.--__----- PermitiLice'nse #---,----.-----
lisuing .luthurity (circle one):
I. Board of Health 2. Building Department 3. Cit} faisn Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Information and instructions
%Iassachuseus tleneral Lnvs chapter I5' requires all cntpluteis to pro%ide leorkers' compensation lilr their eniployccs.
Ptusu.uu to Ibis statute, an e•urph{tee is IVI!net]as".. Cleo person in the Seri,lie tit',inolher Under at iv contract of'hire.
espies or inipIied.oral or It ripen.-
,\it :rnph)rer is IeFnedl as "an indi%:dual,pdrIncr.ship,,issociation,corporation or oilwr legal entity. or any two or more
,,I the Iorowi❑-i-'orip-ged in a)tnrlt enterprise,and including the legal repreientaii\es of a deceased employer,or the
r.ceiter or trustee ofan individual,partnership•association or other le_aul entity,employing employees. llouever the
u•.e icr of a dwelling house having not more than three apartments and a ho resides therein,or the occupant of the
d%%ellim_house oranorher who employs persons to do maintenance,construction or repair isurk on such dwelling house
01,4111 the grounds or building appurtenant thereto shall not because of such enlpiny ruent he deemed 10-he-an-employer.
M(iL chapter 152, §2506)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 uf"compliance with the insurance coverage required."
.Wditiunally, NIGL chapter 152, §25C(7)states•'\'either the commonwealth nor any of its political subdivisions shall
ciudr into any contract for the performance of public+fork until acceptable ee idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation alftdavit 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 affiil The affidavit should
be retumed 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 till 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 ftiture permits or licenses. A new affidavit must be tilled 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Of ice 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.
File Deparunent'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
lie%iscd 5-'6-05 - _ Fax # 617-727-7749 -
www.mass.gov/dia
DISPOSAL OF DEBRIS AFFID-AV6T
Bn 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 wrork 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 St eflon
owned by Northside Carling
Signature of PbrmitAppffcant
-7'w
Date
Christoaher Zorzv
Name of Permit applicant .
A &A Services. irtc.
Firm Name
Mori h Street Salem. MA 01970
Address, City, State, Zip Code
r
Massachusetts- Dcp:n-tmcnt of Public Safety
Board of Building Re,,ulatione and Standards
' ( Construction Supervisor License
License: CS 57733
Restricted to: 00
CHRISTOPHER ZORZY
115 NORTH ST
SALEM, MA 01970
Expiration: 5262011
j ('onnnk kmer Tr»: 14751 I
- � - - -_^•--'^-" - Boad of Building)tepulations and Standards
. , HOME IMPROVEMENTCONTRACTOR
Regishat on 101609
E piretion 62fi/2010 Trt 267670
_Type; pnv,-te corpor.Un
A&A SERVICES, - _= y
Christopher
115 North Street
Salem,MA 01970 Adrainisn'ator
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Martin,Commissioner W(,�
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date M01/09
Exp.Date 0410W0
Member of Co.N.ES.T.
aillill Illllifil! li Illi i�illllll ill eosSo REN.W .
1 : . 3 'AAsi a, A & A SERVICES, INC. ��
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
r40 rd I FAT FliffillTelephone:(978)741-0424 Fax: (978)741-2012
Contractor Registration No. 101609
Federal Ell 04-3090162 Construction Supervisor No.GS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Butane)Name Date of Contract
f"d
Buyers)Street Address,City,State an ip Code
Z N tic
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
97S- 7 4—.T`?96
The Buyers)listed above hereby jointly and severally agree to purchase the goods andlor 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 specification sheets(this°Agreemeni and Buyers)have requested that such
goods or services be installed or 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 Buyet(s)agree to pay in
cash the cost of the goods and Servl�purchased as described herein,regardless of timing or approval of any financing Buyer s may seek for their purchase.
'7��� 2a o neilh-'i cerS Ct(f Ccl.Bwot f}-tw.✓tdi�c,
Purchase Price:�[.(QL Est.Stating Date: f Down Payment: Est.Completion Date: Aa()
a gisel
Amount Due on Start of Job: Check
❑Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion: '� '�r�,,�a'� 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. Buyers)also
(0 acknowledge that they were orally informed of their right to cancel this transaction;and(if)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, Be. /j�,/,, Buyer's
By:
Signatures4N k c��}� Signal
,e ._ g o a�
Print Name 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:me canto r and tie homeowner M1ereby mutually agree in ach awe that is the..at aInner party has a dispute concerning He damn either may may submit such dispute to
a private arbltretim mrv'rz I.has been aparwed by the Secretary of the Executive Office of Consumer Afford eM Business Regulations and the other army shall be wouirM to submit to
such aNitration as proved In M.G.L,c.162A. Co b/
mnctor initials: Buyer lnirie6;¢i_
De¢: Oatt:.� M/Il
NnTICF OF CANCE1 I eTeN NOTICE OF QANCFlsa_TON
Dale cl Trensallon V You may attract this Iransaclnn,without any penalty or Dale 01 Transaction .You may wnml this mansaarde,volume any penalty or
obligaliogwiZ Mrea sin slays loom the eNvari IfwuwrceLvryproeB tradm in, enlighten,within three business days from Me above date.RAN
cart arty propemy mora ln,
any payments made by you under the Carolor Sale,and arty negotiable instrument executed any payments made by you under the Contend or art,and any regonabte instrument executed
by your wilt be coma d within 10 days following receipt by the Seller of your cancellation heads, by you will M relumed within 10 bays bllowing receipt by the Seller of your cancellation aline,
and any security Interest arising oW of the transaction will be cancelled. If you cant,You must and any mouriy Interest arising but of the moral will be cancelled If you cancel,you must
make wettable tote Seller at your residence,InsuM tlalty a cferdconditionaswheareeved, make available to trod Seller effect residend,in sultaMially es good condition ardwM1en receive,
any goods delivered to you under He Compat or Sale;or you may,it you wish,comply with the any goods makarredto you under this comacl or Sale;or you meg if you wish,comply wit the
instuNoos of NB Seller regarding me return Shipment of in.gxi an the Better,wide 6 and Instructions of in.Seller regaNlng the rBW m shipment of me goods at the Sellers expense and
area If you do make the gaols available to the Seller and me Seller does not pick them up hsk. It you do make the goods available to me Surge and the Seller does nor pick them up
wiMln 20 days of the dale of your Notice of CmcellMion,you may retain or dispose of the goods within Nl days of the date of your Notice of processor,you may coman or disease of the goods
whumt any human ethical If you fail to make the goods available to the Seller,or 11 you agree wdfmutavyWMerobliglation.Il you tail to make lM1e goods available to Oe Sellep or if you agree
to return the goods m the sever and tail to do so,ten you remain rmle for pedwmance M all to return the goods to fire setter and fail to do so,men you remain lable Sir performance of an
tria was under the Contract.To careful this taneanior,mail or deliver a signed and dared copy oeligalions urgertlre Convan.To cancel this transaction,man or deliver a signed and dated copy
of me cancellation notice or any other whom mail or used a telegram,to A6A���So,```''' ��� 115 0 the cencellaton notice or any other wriben notice,or send a telegram,th A&A Secured 115
Noon Some,Salem,vocational 01970,NOT LATER TIAN MIDNIGHT OF /d�/y Non,Smard,Selem,Massachusetts 01970,NOT LATER THAN MIDNIGHT OF
(Date) / (Date)
I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Data I HEREBY CANCEL tri TRANSACTION. Oorsumers Signature Date
sms,m A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
• Telephone:(978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
MISCELLANEOUS SPECIFICATION SHEET
Buyers)Name Date of Contract
S �I [ )a
Buyer(s)Street Address,City,State and Zip Code
Daytime Telephone Number 1 Evening Telephone Number Mobile Telephone Number E-Mail Address
The Buyers)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 fine accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a part.
SPECIAL INSTRUCTIONS
a o 1 s
_�4-t,T7'�111,L,,V f II g1r.-t� U6eE' fC�`�' / `''
�A�SYN-l` AJ,--U-) � C� 'L 0l7P A A*e r7 %%mac
T :2 o5t oA) 2iA ot�
P"I RAM
c t t'a8oNe t- f fTv�S I( i-ofM NI-i1�t_K'
i PJlOVe -F _XGAS14e( -&S�Eoq e ?Ef
A'yfAA S
�Z P�N 2 -�-- nl•eu1 ��4 i=�AS h^2g �c41�I kse,�aa5
it Is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT constitutes
the entire understanding between the Parties,and there are 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 ere In writing and signed by both the Buyers)and the Connector. Buyers)hereby acknowledge that Buyer(.)
has read this Specification Sheet
i
Contractor Initials: Date: 7 I/�/�C'/ Buyer's Initials: JCS)�D Date:1—
a�
tso A & A SERVICES, INC.
AAA SERVICES
115 NORTH STREET,SALEM,MA 01970
• • • Telephone: (978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
ROOFING SPECIFICATION SHEET
Buyers)Name Date of Contract
JArd CA os oE)4 t p
Buyer(s)Street Address,City,Sta and Zip Cade
&K-sec } S I d
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
97,�— 7'f Lf-S 6
The 9uyer(s)listed above hereby jointly and severally agree to purchase the gcods and/or services listed below,in accordance with the prices and terns described on
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet Is a part.
2
ROOFING PE IFICATION SnnA�lc Ritbbd �� oV1 ��- eo L
Strip Roof of# r layers of shingles
* Install 6'of ice and water shield at base of roof where 4 Install 15.b felt paper to roof.
possible. Install 18-24"of ice and water shield in valleys.
f Flash chimney as needed(no repointing included). T Install 6"perimeter drip edge to rakes and fascia areas.
$ Install vent pipe boots and seal as needed. f Flash valleys as needed
t Install rollout type ridge vent. t Planks/plywood replacement under 32 SO FT included,
'If more is needed there will be an extra charge of$
per hour for labor plus the cost of materials.
4 Dumpster/Disposal Included: 4 Other:
Location:
Install new roof: Manufacturer yr Style/type
Included in this proposal are thorough cleanup, building permit,and company/manufacturer warranties.
RUBBER ROOFING SPECIFICATION
If trip Roof 9'Not Strip Roof B S O0— 41l ft
$ stall 1/2"High Density Fiberboard to existing roof using f Flash obstacles as needed.
screws and plates.
nstall .060 membrane EPDM(Black)rubber roofing to Y tall 3x3 aluminum drip edge to perimeter of roof with
fiberboards seam tape.
A#t
d. need, APM,1{.�-I, fY1Dsal are thorough cleanup,building permit,and company/manufacturer warranties.
SPECIAL INSTRUCTIONS:
U f Ij Pff tllse ,
It Is agreed and understood by and between the parties that this Specification Shed,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the code,understan
ding between the parties,and there are 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 Buyer(s)and the Contractor.Buyers)hereby acknowledge that Buyers)
has read this Specification Sheet. q Jf�cry7� 1 �(
Contractor Initials:_ �_ Date: J I9 I� Buyer's Initials: V-`u O Dal�� )( l8