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7 PATRIOT LN - BUILDING INSPECTION 1 The Comntumi ealth of N4LISSuchLISCHS I ( Ht Board o113Lulding Regulations and Standards \II'NI('ll' I.III {4' MaSS:ICllLISettS Stdte 1uilding Code. 780('MR, 7'It edition tin[ Ili ru 'J htuu,n-I [3uilding Permit Application To Construct. Repair. IZrno ate Or I)rnudish a One- or Tuv-Famih, Dot elling 1. _uu8 This Section For Official Use Only Building Permit Number. Zt SI_L'natol'e: Building Commissioner/ Inspector of Buildings_ Date SECTION 1: SITE INFORMATION 1.1 P�t�iln+nL 1.2 Assessors Map & Parcel Numbers �hP — -- Numhcr I.Lr IS this an accepted street? yes n Ma o_ Map Nwnher P:Ireel 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area tsq fU Frontage (li) 1.5 Building Setbacks(f ) Front Yard Side Yards - Rear Yard I Required Provided Required Provided Required Prodded 1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone" Municipal On sit,disposal system ❑ Public ❑ PH rate❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner[ofRecorqd {7'l l y41^ �InnKl -7 96Hyt0I Wee, ( Name(Pnlitt) Address for Service: X (Mfu / ( 978� -7�15 - 109� � _ Signature y Telephone - SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(s) ❑ Alteration(s) li,}� Additinn ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed W J�SFuil 4WD er>" t,�Icr2r5 SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Casts: Official Use Only Item - (Labor and Materials) L Building $ I. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project CosC ( em6,_�x multiplier .x I 3. Plumbing $ 2. Other Fees: $ n �L/� 4. Mechanical (HVAC $ List / [ -- 5. Mechanical (Fire $ I Total All Fees: S ---- Su . resi,m) - n Check No. Check :\moune (',sh j (�. fotul Project Cost: 'h �J� , 0 Paid In Full ❑ Outstanding, 13alance Due:___..____ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSI_) hr-1. Into-r 7 Numhet 1f\hir:w1ni Uatr . Na�inC of CCSL- Ifolder 1-m C'SI."r)' r Iser helurcl i'}�1 51 YeP p _ � T\, e Drscn nun Cil It rC5l1 CICJoili lu 35.000 Cu, FtR Resu"ictrd L@2 Fanul\ Drtellme . .Sienautr . V 1 S1 %N,onrs Only q1SL� RC Residential Rook',C •dole Telepinme q'S Readential \\'i nduor .'rid Sidins SF Residenti.d .Solid Furl Boob ' 1 rrlmure In.LilLwon D Re.idrnlml Demolition 5.7 Registered Home Improvement Contractor(f11C) 1 C)lo09 �y' Se�rvlrl Sn� -- HIC Company. Name or HIC R,Ostrant Name 12eguuouun Number _ l��0/09 41n Fs Irntiun U:ue['Sgn "t - Teleph>T. 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 .......... ❑ No ........_. ❑ - SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR`CONTRACTOR APPLIES FOR BUILDING PERMIT 1, � }�1^t IYY) I h1C�l(Y1K1 as Owner of the subject property hereby authorize ri5jrphf r 'Zor ./` to act un my behalf. in all matters relative�t(Xvor horized by this building permit application. X Iola�o Signature titC<ner Date SECTION 7b: OWN,EW OR AUTHORIZED AGENT DECLARATION r i, Chri fnphe Zr)rZ�1 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knots ledge and behalf. r _—f— / Print. �!1 �t o C/ .Signature of Owner or Aut rized .Agent Date �/(J/—�T t/dd (Siened 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 an unregistered contractor (nut registered in the Home Improvement Contractor (HIC) Program). will not have access to.the arbitration program or guaranty fund under M.G.L. e. 1-42A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 750 C'MR Regulations I l0.R6 and I I0.R5. respectively. 2 When substantial work is planned, provide the information below: Total flours area ISq. Ft.l Im0udi ng garage, finished hasem u enlJattics, decks r pur chi 1 Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number tit bedrooms ----_—_ Number of bathrooms Number of halt/hulhs rvpe of healing system - Number tit decks/ p aches -- __._---- "rvpe of cuulinL s.'stem Lnclused Upon ----- — -- - }. '-Total Project Square Footage- may be substituted for "r,ioi Project Cost' � J CITY OF SALEM PUBLIC PROPRERTY T DEPART-NIENT n.VIIb Y.Ihl I�H lii ,`I1 \L\?` -H 12 \\•Ali liN',,I,`N Si al lh 10 j\I 1*11: 9-8- 4i-9i9j ♦ F\F: Workers' Compensation Insurance Af idacit: Builders/Contractors/Electricians/Plumbers ,kl> tliiant Information Plec+se Print Leclibly �allle t 13u,mc.; I lr_,uutuwnt IuJtt uhtel l: A e A S erV( U,5 11�c "Iddress: 11q Nor+h fif e—f C'ity,State,`Zip: AlPm�M� DI9�Q Phone #: � �7 - ©� Are pion an employer? Check the appropriate box: Type of project (required): 1. 1 am a employer with_ ._— 4. ❑ 1 am a general contractor and I 6. ❑ New construction art-time). employees (full and/or p ' havc hired the sub-contractors I :un a sole proprietor or partner- listed on the attached sheet. 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 10.0 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL I I.❑ Plumbing repairs or additions i.❑ I am a homeowner doing all work 6 p p 1_ Roof repairs myself. [No workers' comp. C. ploy . [ and we have no f employees. nc workers' I}. Other_ 15 insurance required.] r�LLi� D� comp. insurance required.] •:\uy,applicant that checks box#1 must also lilt out the section below showing their workers'compensation policy information. t Ilumcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :('ontracors that check this box must attached an additional sheet showing the name of the sub-cuntractors and their workers'comp policy infomtation. it con air employer that is providing [workers'compensation insurance for uty employees. Below is the policy and job site information. / Insurance Company Name: Policy #or Self-ins. Lic�j#,:,_'y�� H 5L U 13 Expiration Date: Job Site \dJress: Yy1 f t' (c>j l� P City/State/Zip: GCAI Rw, r (q70 .kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure 10 Secure coverage as required under Section 25A of hIGL c. 152 can lead to the imposition of criminal penalties of a line up to S 1,500.00 ;md'or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine of up to S250.00 a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Ir»c.+tivationS of dye DIA titr insurance eo\erase Verification. l to hereby enil' inl•r the pains and penalties uJ perjury that the infortnutimt provided above is true and correct —1DateWM�g/ IF \i c,,,ttnt Ph„nc official use only. Do not write in this area, to be completed by city or town official ('ih• ur luwa' Issuing Xulhority (circle one): I. Board of Health 2. Building Department 3. cih7rown Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other -- — Contact Person: --------_---- — Phone #: - Information and Instructions \las,aehtlTCtts (icneraI I_:nvs chapter I i" rrgwres a I I coiplotcis to prof ide ttorkers' ctnnpcnsation Ibr their employees. I r s U.i t 11 m this ICml t e. Jn eutplu tee is Kali ned as ".. ct en person in the sett ice of,un it her under anv attnrict of hire. c\l,ress or implied. oral or \%i'it(en. ' \n entlrlurer is dell tied as "aft iudit tJua1. It'll niership. .issociatiou, corporation or other legal entity', or mip two or inure the Iorcgonlg engaged in a joint Cruel prise. and i Ile luding the legal representatives of a deceased culployer, or the reecit er or trustee of an individual, partnership, association or other legal entity, employ ill,, cnnployees. I-lowever the „.t tier of a(itelling house ha%ing not :note than three :ipartinents and vt ho resides therein. or the occupant of the du elling house of,another tvho employs persons to do maintenance, construction or repair work on such dwelling house or Jn the wounds or building appurirnant thereto Shull not because of such employ nient be deemed n, be in employee" NI(iL chapter I i?, ss25C(b) 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 (he insurance cuverage required." Additionally, %1(iL chapter 152, �2i('(7)states "Neither the commonwealth nor any of its political subdivisions shall riucr into any contract for the pertbrmanee of public+cork until acceptable ev idence of compliance with'the insurance requinntents 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-contractors) namels), address(es)and phone number(s) along with their certificates) 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 sore 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 petmit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pernoulicense 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 ),ear. 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 ()fficc of Investigations would like to thank you in advance for your cooperation and should you pace any questions, ple;ue do not hesitate m give its a call the Drparument's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington Street Boston, MA 02111 Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE Fax if 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, Seca 150a. The debris will be disposed at Salem Transfer Station owned by Northside Carting - ignature of Pe it Applicant ID Date Christopher Zorzy Name of Permit Applicant A &A Services, Inc. Finn Name 115 North Street, Salem, MA 01970 Address, City, State, Zip Code Board of Building Regulations and Standards Construction Supervisor License License: CS 57733 , Birthdate_-,5126/1958 Expiration 512612009 Tr# 13739 ,I J .Restnctlon ^90'. CHRISTOPHER Z!, 115 NORTH ST SALEM, MA 01970- Commissioner j 9;7e {iomnxoaes�aa.LG -o�./✓��aaeac�aeeetta._. ... Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR UV Registration: 101609 Expiration` 6/26/2010 Tr# 267870 Type: Private Corporation A&A SERVICES, INC Christopher Zorzy,_r 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 0 9 DC000440 z� Nemberof C.O.N.ES.T. °{ }� BO IIIIIIIIIIIIIIIII IIIII IIIII IIIII IIIII IIIII IIIIIIIIIIIII BOSTON-RENEW y A & A SERVICES, INC. Pj z AgASMICES 115 NORTH STREET,SALEM,MA 01970 t Telephone:(978)741-0424 Fax:(978)741-2012 Contractor Registration.No. 101609 Federal EIN:04-3090162 Construction Supervisor No.CS057733 .- ENTRY DOOR SPECIFICATION SHEET Buyer(s)Name Date of Contract RAO f}ddAlnki I 'f 30 �? Buyers)Street Address,City.State and Zip Code Daytime Telephone Number 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 antes and tents described on this SpechIcatlon sheet and the from and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification Sheet is a part. ENTRY DOOR ❑ Remove and dispose of# TWO existing entry door units. , ' O Install new entry doom# 1(1)6 / Manufacturer ✓`Z Location Fran�-� ��r (�hrn2[. 17 Type: ❑Steel ®'SmoothStar ❑Fiberclassic ❑ClassicCraft ❑Sliding Patio Door ❑French Hinged Patio Door - Model# 1WWSidelight(s)# Sidelight(s)type/model# OPTONS &itll49lAss�m;niblio'AA&Y� A9PT djustable threshold for ThermaTru Door ❑Grids for patio doors: Style: ❑ Stain Kit: Supplied to owner - ❑ Expand or shrink the size of the opening Details ❑ Cover exterior/I with aluminummccg�LStock: Style Color Nar/O�yBre �-Fiand{$et eIBD atlbolt ❑Footbolt ❑Mail Slot ❑PeepsiteAB�$� ®'�Install oak strip at floor as needed. �jrfn2. 0-C/aulj"gterior and exterior edges. IIY�nsulate around new door unit where possible. i nting is not included. cl in this proposal are set up and clean up. �Mi+inGlbfd STORM DOOR O Remove and dispose of# existing storm door(s). ❑ Install new storm doors# Manufacturer Style Color Type: ❑Aluminum ❑Solid Core, _ ❑ Location: SPECIAL INSTRUCTIONS: • 7�s I a l 1 pr�n n',�d 90 S�s/ule���erior'CrQs f n�LS' .a�✓� ���n��� ;nFcn�af � I v_ Am 54cuA bnD2S h is agreed and understood by and between the aartles Net this Specification Sheet,along with the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constF tabs the entire undeistaMing between Me parfiee,end Mere are no verbal undercforWings changing or modifying any of the farms.Tub contract may not be charged - or Its forme modRed or varied in any way unless each changes am in writing and signed by both Me Buyer(s)and U Co M Buyer(k)hereby acknowledge that Buyers)has read this SaxMconon Sheet Contractor Initials:�� Date: _��/J��� Buyer's Initials. " Dater A & A SERVICES, INC. A&ASWCES 115 NORTH STREET,SALEM,MA 01970 Myllolas a Telephone:(978)741-0424 Fax:(978)741-2012 Contractor Registration No. 101609 Federal EIN:04-3090162 - Construction Supervisor No.GS057733 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Buyer(s)Name Date of Contract Buyers)Street Address,City,State and Zip Code"" -7 Brio-� Lkue- StlPvt. /IAA _O(qZc Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mal Address:. 97$ 74S-6q The Buyers)listed above hereby jointly and severally agree to purchase Me goods andlor services listed on the accompanying specification sheets,in accordance with he prices and terms described an the front antl the reverse of this agreement and any specification sheets(rus-Agmement'-).and Buyer(s)have requested Mat such goods or services be Insaled or provided at Buyer's address listed above. A!A Serves,Inc.CGontrarxon,hereby agrees to instal or Cause to be installed the products or services listed in This Agreement at Me Buyers)address written above. This Agreement represents a Cash sale of goods and services. The Buyers)agree to pay in rasIn the cost of M goods and se . e Purchased as desedbed herein,ragartlless of fi n�or a royal of any fin ng Buyer(s may seek for Meir pumhase� PC cawfl' � /S� e; a a�ic o/1�' rcJti. Pu¢hasa Price Est.Starting Date:" O�/✓ � Down Payment: Est.Completion Date: IVOVI ❑Cash Amount Due an Stan of Job: O ck Y� 'O Ilb{2 200 Amount due on of Completion: No. Amount Due onof Completion: ''gy�pp�er Expiration ate: Balance Due on Upon Completion:�LW CVC Co a- It Is agreed and understood by and between the parties that this Agreement,front and back and any ad endure,conatitu[e the entire understanding between the parles,and there are no verbal understandings changing or modifying any of the terms of this Agreement. Buyers)hereby acknowledge that Buyers)has mad the front and the reverse of this Agreement and has reeelved a completed,signed and dated copy of this Agreement Including the two attached Notice of Cancellation farms,an the date that written above. Buyer(s)also (q acknowledge that they were orelly 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 ff IT CONTAINS ANY BI-AN1C SPACES. A&A Serviges,Inc.q - Buyer(s) sYYtlyN�c.GJ.c/�r�Y/GLJ9/ !gnC p By. Signature 1?6al / , ,j , S7 t ky �A 7d n�K / Print Name (t�J� Print Name —� Signature Print Name You,the Buyer(s),may cancel this transaction at any Bme 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. AReMANTON TM so.,erd Me ream yor lb20y,murshy'my In advance Nei In me event eimer aarN ealspNe .-man,rocs wn0ad.ether gory may shot .n dear. s � a prvab udIt.-urn®...Ms Caen apprised sy me Bevabry or Me Eischi Ceded of rAneumOr Anal9 usln RepuI...and me oNer party snail Me rephoo to act.to surn artypeen a0 proved m M.G.L c.142 Geaerwieitie r^ pass: oNa: o.¢: rF rlr r.ANQFI I ATIGN NGTI�F OF�AN Gale d menuca n Ycu mry mnml rocs I m—on,xi1Mu1 arty pnalry a Dab of TMLcLoo .You may aanml rob eion-cen,whoul any grab,a Mllgauon,wMln mre uyn mden rmmmeaWwdab.n You mnml,arrypapaM Cadad ln, oWi9a40n.wnNn Mree bu.inW den lr0m M9 eCW0eye.Il yCU WCN.erry popMylraaN in, anypay enfroade you uN.,Ma ConbectorsaN,aM env negJ4'9Ne inso-umem avecumd any Parlrlanh nrede Myyou uMx the Cmleectm aale art any no..loslrumam esewle] MY you MII Ce......1.days tallowale revert Icy Me Seller ul"arsellalba Mnw. to yell will M rewmM wimin I days b rayina receipt Cy he Seer W your ayrCeI..mLkO, art any sourlly inbRst recent,oN of me davaurch col M aercelled, if ym asset.you must and any sysi Interest wine MA a Me Mussel All de careclea.If Call owes'.you must nuMe h istade to an sell At your res brlOe.M MM18Many as 9Sd TMIWn as wed RaNOd, menu haffai b has Sdbr al Your resderess.in wbpmil IN As¢W NpNn of sten mxiyed. anyJ^^fO dshered to you oNer M4 Camas or Salo:Or 1 mo1 it you woh.¢mpN wiry Me ury,rhyl delNmM to ynuurvW to Can..ar cab:or you may.it you wlM,.,NCalm Me ' instr lima M me Seller regaztlin0 Me realm Mayhem W Me goaps or he SHbrs essence and in froxfore of Me Salter repard,Me realm snipmem of the ports At Me SeYm w eree eM Mk If you do rove Ma gmds avi ilade b Me Bader rota Me Sell does M pi than up fast, If you do mMte Me OCWs Owasso to Me Seller and Me SNMr dins sal ass,Mem up vilhin al day of May date of your Notice of devast ilrr,you may Oman or d¢pose of he gmds yal aT days of he dab of your Naive of Cenalll you may ubM Or scows of Me Social warviso'horwnn"Re,.11ynu ltllbmaM Me yLd9 avylaCleb Me 5911er,ar llyW ague wfforranyhrocodlpsMn.nl you lailb mate MagcWaavallebN to Ne Seller.or Hyou agree auNm Ma MyA`b me seoart a red ado an,Sam ym rem a ain osis farpstormamx of au to realm Me peas a Me sNbr and roll V do Or,Man you realty liable for u perfamMg of ell ouseblu faster the CaMatt To corce]his CsnwNn.mall or ashes a sVW ant damd ropy hiiaalbns ardor Me CwN'M.To chlml NO o-msacnon.mat Or sure a signed and dated Cagy v ofine—shtim matt or arty Or Carmen was,or sand A aser"bPdAA� of me rescission Mna m or when mace,or seed a w cram,aM A saniree,its No.Street Salem,Muvchusens Ot Im.Nor LATER THAN MIONSO T OF Nout Street Seem.MeesarhuseM WMAM Nor LATER THAN MIDNIGHT OF - Costs) (Dab) I HEREBY CANCEL MIS TRANSACTION, CasumaaSynmun Date I HEREBY CANCEITHISTRANSACnON. Co—risrt SYdnatue Gem