5 NURSERY ST - BUILDING INSPECTION The Comntunvicealth 01 NIaSS.lChusettS I (IR
Bo:ud OI 13uildin g RcguLuiunS and Standards. \ b ,�, \II NI(IP.\I.I'll '
�A 9 Massachuscns State Building Code. 780 CMR, 7 Cditinn I '.Sl:
Building Permit Application To Construct. Repair. EZeno%ate Or I)enurlish a R,ru,,l.Luur n,
One- or Tnv-Fumilt- Dwelling run,v'
This Section For Official Use Only
Date Applied: - ---- _._�
Building Permit umher: --- --
13 mp C'onunis,ioncr/ i pec(or(11 B uildnws Dale
SECTION 1: SITE INFORNIATION
1.1 Proper", Address: 1.2 Assessors Nlap & Parcel Numbers
xi All )r'Se rU is eP p ----
Ma Number P:ucel Nunther
I.la Is this :m accepted strcrt7 yes_ nu_
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use 1_ot Area tsq 11) Frontage t1l) .
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required PT...Jed
I
1.6 Water Supply: (M.G.L c. 40, §54) L7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Pri vale❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
u�t4+ tr 1 11r IC�r�_ 5 ►Jursen4 57vree+
Name Pri 1 Address fur Service: -
��r�t,l�l-� C91g\ �10
.%'ienaturel Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairsls) ❑ AlterationO AdJilinn ❑
Dem0liliun ❑ Accessory Bldg. ❑ Number of Units Other dSpecily:b/)110 s5
Brief Dzscription of Proposed Work':
SfQ/1 on nloLDiYlor�f --
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item - (Labor Materials) -.
I. Building $ , I. Building Permit Fee: $ Indicate how fee is determined.
❑ Standard City/Town ;\pplication Fee
2, Electrical S ❑Total Project Cost' (Item 6) x multiplier x
i
1. Plumbing 5 2. Other Fees: $ -
4. Mechanical (FIVAC) $ List:
i. Mechanical (Fire S Total All Fees: S
Suppression)
p q I Check No. Check :\mnunt (':uh :\nun�ur.
j b. Total Project Cost: b ,�j�G/aL,. 0 Paid in Full Balance Due_= -=
SECTION 5: CONSTRUCTION SERVIC'F.S
5.1 Licensed Coiistruction Supervisor (CSL) jnQ
hr e,krvnlnor Z�I''7" Litime Nuinher I:vpu:wnn Date
:Name of C'S L- I folder
I Linl CSL'P%lie tsrc before)
WJ rss I v r Descri tam
C t'nn•stru9rJ nt i to?;.UUO Cu. fL:
- R Restricted l&_2 Fount D �elbn_
Si¢n:uu-e \1 \I a,onn Unly
8 7 l " CY4AA1 R\\C I2rsiJrnti❑I Bottling ('ur rn nC
I Clephone 'S Kra Jenual \\'I tlJorr .uW lnluw __
Sf Rcsidemi:d Solid f.irl Iturnine \pplemre 11 1,111,awn~
D Remdenual Drmohuun
5.2 Re 6i%red 11ome Improvement Contractor (IIIC')
A �O a�Vv
HIC Cont any Name or IIIC Registrant Name 12egistr:uuni Nunthrr
AJdr•ss ( '�a CpnabUn Date
Seer rr 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 to provide
this affidavit will result in the denial of the Issuance of the building permit. -
Signed Affidavit Attached'? Yes .......... [3� No .......... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWN
ER'S
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
ar-z. as Owner of the subject property hereby
authorize lit act on my behalf, in all matters
relative to w rk authorized by this building per application.
♦ • - -1l -
Sienature caner Date
�SECTION 7b: OWNEW OR AUTHORIZED .AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the 46e.going application are true and accurate, to the best of my knowled,-,e and
behalf.
ZarztA
Print
2//i /D J
Sienature of Owner or Ihorizcd Agent Dale
(Signed under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an o%%ner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HiC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important inkormatiun on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.RG and 110.R5. respectively.
When substantial work is planned, provide the intitrmation below:
Tural floors area ISq. Ft.) (including garage, finished hasemenuattics, decks or porcht
I Gross living area ISq. Ft.) Habitable room count
Number of fireplaces - :Number.of bedroom, -- ---
Numberofbathr�oms Numberoflmit/hxh, ___--
fvpe iof he:tine,system - Number of decks/ pr,rchcs -- -------__
Type of cooling system Enclosed Open
1 "Tool Project Square Footage' may be substituted titr "Tntu1 Project Cost"
J
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.,�I al HI P1 I�11I�t „I I
>Ls• ,n. 1_'� \C'�,I i;��,I,���I a1-r l • �s1 fst. \Ls"st III ,r I :, :to^
Workers' Compensation Insurance :Affidavit: Builders/Contractors/Elel'le ise ctricians/PlPrint umber v
f thkant Information
A !2 A S e,r( U,5
- V:ImI tnu.mcs t 1rC.uu l.:mutr Inds tduul l:�.,,.
V r I V) 5J1 Y e e—+ \
e.'ity,Sw,,;Zip: M{a [}I92D Phone #:
Are Nou an employer'.' Check the appropriate box: Type of project (required):
I.LJ I ant a employer with_!_ 4. 01 am a general contractor and I 6. 0 New construction
cmployees(full andlor part-time).* have hired the sub-contractors 7. ❑ Remodeling
I
],❑ I an, a sole proprietor partner- Demolition
;h have no;hip and hao employees
listed on the attached sheet.Thrst sub-contractors have g.
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
n ght of exemption per NIGL 11.0 Plumbing repairs or additions
t.❑ I :un a homeowner doing all work c S15?, $1(4),and we have no 1_'.❑ Roof repairs
myself. [No workers' comp. �-,/
insurance required.] f employees.anc workers' 13.Li Other
comp. insurance required.]
'Any apI,I,cnn IIILLt clwcks box n I most also till out the section below showing their workers'compensation policy in fomation.
t I Imneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Contractnrs that check this box must attached an additional sheet showing the name of the sub-cuntractors and their workers'comp policy information.
l aat an employer that is providing workers'compensation insurance Jar my employees: Below is the policy and job .site
inJannation. —r1�� /
Insurance Company Name:- 1 Y X� T(A V e ��r�
al va
Expiration
Policy # orSelf-ins. Lic #: wC—I t�x I r� �]I D Date:
p + n �q
.L)b Site Address: 5 n/yrs e—rq �S�Ye e4- ___City/State/Zip: l �Ph') / 0t9f7D
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 NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I.i00.00 :md;'or one-year imprisonment. as well as civil penalties In the time of a STOP WORK ORDER and a tine
ttf up to S2i0.110 a day against the violator. Be advised that a copy of this statement may be tbrwarded to the Office of
I ns csti_alions of the DI:\ for insurance an crags vcritication. .
/Jo herehy ccrtily- toile the pains unol penalties of perjury that the infirntrntion prtn,ided above is true and correct.
�icnwurc
Phnnt =
��-U1fia'tool rive onlr. Do not write in this area, to he completed by city or town official
Cite or Toe it: _-- —..- _ -- - PermitiLicense
issuimo \uthority (circle one): -
1. Board of health 2. Building Department i. Cih/fawn Clerk 4. Electrical Inspector r. Plumbing Inspector
6.other
Phone #:__
Information and Instructions
�I,I:,.I c h ll>e I is General Lams chapter I Icquu es A! cIIII, o%ers to pro%ide as orkers' conlpensat ion tier their employees.
I',,IIrsu.uu to this =tarlte, an rinplovee is Jclu:ed as ea errs per in the ;cn ice of.uu)t her under:Inv comract of hire.
cs III cas or implied. oral or aarinen.-
it emphtrer is defined as "an Ind 1%ideal. p,otnership. .lssoclanon, corporation or other Ie,al entity. nor and nco or nwre
ut the tore Koine eft gaged in ajolilt enterpri.,e, and inc ludinu the Ie�,aI Icpresen tat i%es of a deceased rmployec or the
I ecei%er or truace of an indlvnfual, pal'tlterjhIII. association or or her local entity, employ in_ cnaployces. I ILMC%er the
w.k tier of a dwelling house has ing not :none Than three apartments and ka ho rc;ides therein, or tire occupant of the
d\%clline house of;Inother who employs persons Io do maintenance, construction or repair work on `ouch dwelling house
It 011 t Ile ''rMinds or bit ildiII appurtenant thereto shall not because of such employ ment be deemed to be an cmplo%er.
NI( L chapter 1 ?, i- CIF) alto ;fates Ihat "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 corn pliance with the insurance coverage required." -
.Udirionally, %IGL chapter 152, st25C(7) states "Neither the conmtonwealth nor any of its political subdivisions shall
enter into any contract for the pertLrntance of public ..ork until acceptable e%i.lence of compliance with the insurance
requirements of this chapter has e.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) uame(s). address(es)and phone nuniber(s) along with their certificate(s) of
insurance. Limited Liability Companies ILLC) 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 he sure to sign and date the affidavit-. The affidavit should
Ile 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
,f 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 penmiUlicense 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
Iow-n).- 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 -
Near. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
a dog license or permit to burn leases etc.) said person is NOT required to complete this affidavit.
The t office of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give Its a call.
the Department's address, telephone and Iax 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
I(e�l<cd ;-10-o; Fax # 617-727-7749
www.inass.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 it Applicant
7///ILK
Date
Christopher Zorzy
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
r
i - T� �oommoreu�ea//�C �✓Glo�o��
Board of Building Regulations and Standards '
Construction Supervisor License
- - License: CS 57733
B.irthdate::__:5/26/1958 }
Expiration 5/26/2009 Tr# 13739 k �
R9k4ctlon 001_ r _
CHRISTOPHER ZQRZY
115 NORTH ST
I SALEM, MA 01970 Commissioner
. ✓/cP, -Pio�mmeujemlC,� a�.�amar�umetYa
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:on: 101 10160909
Expiration: 6/26/2010 Tr# 267870
Type: Private Corporation
A&A SERVICES,INC '
Christopher Zorzy J=...
115 North Street
Salem, MA 01970 -- Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Marlin,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 04/09/08
Exp. Date 04/08/09 I
DCW0440
Omher of C.O_N.E.S.T. 09
IIIIII IIIiIIIIIIIIIII IIIII IIIII IIIII IIIII IIIIIIIIIIII BOST0 RENEW 555
l
U
PROPOSAL �5 s
A & A SERVICES, INC. (9 /sr
115 North Street
Salem,MA 01970 _
Tel.:(978)741-0424 Fax:(978)741-2012 - -' -- -- - ""-
MA Home Im ement Contractoes License No.101609/MA Construction Supervisor License No.CS057733
Submitted to: ,e Work to ti erformed at:
Street: -eWSr' Street: /YNrsl -
City: City le,
State: Zip: end State: Zip: p eJ
Home Telephone: 8- D Work Telephone: -We hereby submit specifications and estimates for.
-4NNMlBMF5OOOR REPLACEMENT
WINDOWS: - - -
Storm Windows:# Carefree: Tru-Channel: ❑ -
Color.
Vinyl Windows:# Slimlinle: Comfort Plus:❑ Majesty:
Color: Other:) I
Options for windows:
Grid Pattern_/_Low E/Argon Gas: Foam Filling: ❑
I��
Wrap Exterior Trim with Aluminum Coil Stock:❑ Other: II
DOORS:
Stone Doors:# Aluminum:El SolidCore: El
Style Name: Brass Hardware: ❑ Beveled Glass:❑
SPECIAL INSTRUCTIONS: i -
e
-
Cosc ' b r.✓i`
�NS{79 I1 � I �p/e 1 X Sfcr/C /U i of C�95r'MGj�` _ -
II V,f�ae LOc/c sf�f rid n/ecU
s au iN ro ��n+Sttf>F rtro d,r,r. c1e.�..vuD � �2G.rl_-f-.vel
Q,4cr��',>2� Not ,rcl
All material to be as specified, and the above work to be performed in accordance with the
__. specifications submided.for above.work and completed in a substantial workmanlike-manner-for thesum�of.
.__._. —Dollars .. &294a .. . ._
with payments to be made as follows: ci— tfi2:1
fZy�ki 1 l t1f`�c� Z Lf I I 7
yo'lo scov.AA .�� Rfk�4y � /ra $6�✓
cflNw1:'FkQM} D� 1
Any alteration or deviation from above speaficallons 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 Services,Inc. _
agreements contingent upon strikes,accidents or delays beyond
our control. Owner to carry fire,tomedo and other necessary NOTE: This proposal my be withdrawn by us if not accepted
insurance upon above work. Workmen's Compensation and within ninety(90)days.
Public Liability Insurance on above work to be taken out by
A d A Services,Inc.
ACCEPTANCE OF PROPOSAL
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.
l0-
Signature 7 Date
Signature Date
—You may cancel this transaction,without any penalty or obligation,within three business days from the signing of
this proposal.—