2C RUSSELL DR - BUILDING INSPECTION (3) r
cf, Zen 9
(� The Commonwealth of Massachusetts
Department of Public Safety
r Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
1� Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
(9 C— PUA, ell Ve mLP-m Bi lk 019-7o
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑ or check all that apply I in the two rows below
Existing Building❑ Repair❑ Alteration Ef I Addition❑ 1 Demolition Cl (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy - ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? _ rr `` Yes ❑ No C�
Brief Description of Proposed Work: -fn �(( Q i q brl'"�B� I AY/ l e h At,
r.?p I Cnf co-nstvt-f'
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) -
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ElH-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Conunission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
r Al (01 3C)
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
C"rtn 3u/nS aC4_5Y-el/ G7� 5alent M /t_ 0/ 970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Dti,y-✓ 7g1 -25-q- 39 a-
Title Telephone No. ()tusiness) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes C-I 1
Ckri S :Z ory.J /VorA 5:(- Salem Mfg - 0 /9.7y
Name f Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
A -t- Ft- S.er-li c-5 ti c
Company Name
C_hri-3 -Z-orz4 G.S 05-7-733 7
Name of Person Responsible for Construction License No. and Type if Applicable
47,12'r Nor't % 5+ f2o\-l-e-r^ tnt — o ►970
Street Address City/Town State Zip
qs_-NJ_0q,?_q
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes O No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 1g 3 1 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ $3 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accu tte o th best of my knowledge and understanding.
97$-7Yl _ 0q, `f
Please printand as sig
n name Title Telephone No. Date
11 S ao-/fi). S k-- f . At D !9-1 U
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
American Properties Team, Inc.
TO: 2C Russell Drive
FROM: Jennifer Pappas, Property Manager
RE: Window Replacement
DATE: June 19, 2015
Please be advised that the Board of Trustees for Pickman Park has approved replacement
windows for the above referenced unit. This approval is contingent upon them matching the
existing windows and that they fit in the existing opening. Installation of the windows must be
completed from the interior of the unit and they must be the same in appearance from the
exterior. Should the installation be completed from the exterior of the unit, you will be
responsible for any damage that your contractor might cause(this includes painting). The Board
will not allow windows with grids, crank outs, etc. Should you contractorfind any rot or
damage during the window installation,please make sure that it is reported to my office
immediately.
We also require that permits be pulled in advance(regardless of what your contractor may tell
you), and then a copy of the final approved permit once completed must be sent to APT for the
unit file as well. We also recommend that owners obtain a certificate of insurance from the
licensed contractor.
You will need to bring a copy of this letter to the Salem Building Department in order to receive
your permit.
Should you have any questions or require additional information,please feel free to call me
directly at(781)569-2675.
cc: Unit File
500 WEST CUMMINGS PARK•SURE 6050- WOBURN -MA -01801-781-932-9229 •FAX 781-935-4289
v �+ �=etl� A & A SERVICES, INC. ?J
A&A$ERVI�:ES Telephone: (97)741E-0 24 Fax:(978)741 20012
• IM•
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyers)Name Date of
Contract
�-r f uOV
Buyer(s)Street Address,City,State and Zip Code
C RUS50 DIll AAA,
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
8 f J 1 a7
The Buyer(s)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 the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a part.
WINDOW REPLACEMENT
emove and dispose of# existing windows. SqSAlY,'�-C[:51yJ JS
f nstall # 8�i new .Su N fiSff ilmi GI.Ad window f myl T Wood
(Manutactur' )
Options: Style �.Ir)?�2 "VU C1 Grid pattern / ram,., L,/o 7y.n
Color Interior W 11 I }-Q. Color Exterior �,}) r�1� Glass Type
T Wrap exterior trim with aluminum: Style Color /V 6&
tf All windows will be installed according to the installation procedures in the portfolio. �N�'Y' (7 S-f'Rj-
Caulk all interior and exterior edges �}p�j+{ i 1_
OInsulate where possible around new units. l% ' rt Pik ' " rsf tMh9 L /
�TtiJ�Insulate window weight pockets if exist,and around new window units where possible.
LPIncluded in this proposal are set up,clean up, Helps vacuum and cleaning windows inside and out.
Building permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
T Create new window opening by cutting through existing home and framing in opening.
T Remove and dispose of existing unit(s)in its entirety.
Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
T Install window(s)into opening(s).
Note: If Bay or Bow installation to include cable support system,new roof system(matching color as close as possible)
or lie into existing soffit system.
T Bay T Bow T Casement f Other window(s)to include new interior style trim and new exterior style trim and head
flashing as needed.
f Note: Painting and staining not included.
STORM PRODUCTS
f Remove and dispose of# existing storm window(s).
f Install new storm windows# Manufacturer
Style Color Option
f Remove and dispose of# existing storm debris).
If Install new storm doors# Manufacturer
Style Color Type: f Aluminum f Solid Core
SPECIAL INSTRUCTIONS: I I
��(--r�riar I yt S"flJ�/5 fPgildlL� PX r2Yior line ToplS Cij+'9L7d
S l i fe t!c e a S!6�S
It is agreed and understood by and between the parties that this Specificatlon 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 are In writing and signed by both the Buyer(s)and the Contractor. Buyers)hereby acknowledge that Buyer s
has read this Specification Sheet. ��. ( )
Contractor Initials: J � Date: j� �� Buyer's Initials: p, 4//' —� Date' `/l
v� 4 A & A SERVICES, INC. �y -
AsI:A SERVICES 115 NORTH STREET, SALEM, M.A 01970
ff • ' • Telephone:(978) 741-0424 Fax: (978) 741-2012
Contractor Registration No. 101609
Construction Supervisor No.CS057733
Federal EIN: 04-3090162
CUSTOM REMODELING AND IMPROVEM! ENT AGREEMENT
Bu nkle Name Dale of Co tract
(
Bu ergs) Street Atltlress, Ci .State and Zi Code
S � C�✓
Da ime Tele hone Number Evenin Tele hone Number Mobile Tele hone Number E-Mail Address
The Buyerls)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specifcation sheets,in accordance
win the prices and terms described on the front and the reverse of this agreement and any specification sheets(this'Agreement"),and Buyerls)have requested
that such goods or services be installed or provided at Buyer's address listed above.ABA Services,Inc.('Contractor'),hereby agrees to install or cause to be installed
the products or services listed in this Agreement at the Buyerls)address written above.This Agreement represents a cash sale of goods and services.The Buyerls)
agree to pay in cash the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyerls)may seek for their
purchase. �n
Purchase Pri e: -T �^1 � S tt�� 11 t.Stoning Date: �/ I
Down Paymerd� / � hb W-r r�IN� st.Completion Date:
Amount Due on Start of Job: Check
-�i-y1 �01� 0(Credit Card
Amount Due tut f Completion: / l.lJ 7 No.
Amount Due on_of Completion: � E� /� �/�- Expiration Date:
Balance Due on Upon Completion- L 1 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.Buyerls)
hereby acknowledge that Buyer(s)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 farms,on the date first written above.Buyeds)also(1)acknowledge that they were orally
informed of their right to cancel this transaction;and(it)request that they be contacted via their telephone numbers or email,as listed above,in the event
Contractor believes Buyerls)would be interested in any additional quality products or services of Contractor.00 NOT SIGN THIS CONTRACT IF IT
CONTAINS ANY BLANK SPACES.
A&A Services,Inc. Buyer(s)
By:_ 5,/
Signature
Signature
Print Name
Print Name
Signature
Print Name
You,the Buyerls), 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:The mnlratlm antl Na Mmeowner nerehy nu Wally agree in eEvanm mad m the doing ether path Ims a dispute mnmming this mmracLesherpan,many sbaskil such dispute too
private arOitralian service...has been approved by Ne say..,.r the'uecutive Ofim of Consumer Affairs and Business Regulators and Me Oder path shall 0e rmuired W some to such
brummun as proved to M G.L c 1e2ABuye.
onlnnor inilu----� Car: lnilicb:
ro .�
le ou¢: 8
`NOTIC OFCANCE TION NOTICE OF CANCELLATbN
care M nanmcton d You may mncel Nis hanYcton vol out any pMelly or Date oI Transaction You may canal this Vanfiactm,vnNON any penally m
oEligadcn,vnthin Nree Ou ess eye hors The aWve dale.Il was mnml,any proceMtraded in, magaton.Yourn Nree u6i ss hays trom the soul date.IT you mnWr any properly traded in,
any payments made by you at the Conan orSate.and aM negtmameinswrmnt aaeatm any paymentsmade by was borer Me contract at sale,and any negouaae mswment assured
by you Wll be mwmm mNin 10 don Mgoving aneepd by Ma Scher of or mnmuawn macs by you Wtl the rewmm Wove 10 days ruleWng remdk by as seller of or mnmlla(n norce.
I
any-.no..,a.arising N OI Me tfenuc40n well be mncNkd.II You mncel.was—In and any warily engaged among Our N me bmmcdm antl be Damaged.11 you mucks,you musk
mske avagatte w the Seger at yWr response.e.and summ,oally in as good mnGton as Men make availiole to the Serer m or residence,and sub9antiagy In a6 good comemm es be
Rived.any good%d¢4vered to yw undo love Contra.or sale;or You may,ff,-vAW eirol nothemsed,any goods covered N you under Nrs Contact or Sak:orym may.if You sigh,amply
WN the insponfons OI me Raper.,a..,Me aWm sFip—el of Me gads at Ne Sellers MM me imndons of me Sell.,regaNinp Me return sMpment of Me gads at Me Sellers
emend and risk.If you do make Me goods avaroble to Me seder and no SeLar tlms ml pIG espense and NI If you d0 make we goods wmabk b Me seller and Me Seller dins not pith
Mom up WMin 20 data of Me date of your Name 0 Sometimes.You Ivy retain or places M Me Mom up Mom 20 data OI Me date of Your Notice of Canmllmon,yw holy resin or dispaed
goods Wthoul any books,odigaton_It you lag to make the goods avwlabk to the Seller,or 6 was Na goW6 viMWl anyfuMer ObligetOn.llyoulabtonake MegmdsavaelaNetalho SMiaroref
agree to hours Me goods to me Seller and AD to do so,than you mr n hable for peMmame W you agraktorawm Me goods to Me Selkrand fail to do so,diet You remain liable for mdormance
an FmIb,mms under the Conrad,To....i1 hemecdon,—it or didaa signed and dated of at obligabons under he Cooll To mnmJ this oansacton,mail or deliver a§�a knonddated
ropy of Me mnmlation norm or any other Mtlen norm,is seM a IelBgr In..
A se copy d no mnessymen noem or any ama ands"notice,m sand a sheep go Mzl
I IS NoM Spas,Salem M4 d000.NOT Urce TIUN MI ONIGHr OF I15NeMSeeitsakm MAotg)O,NOT LITER THAN MIDNIGHT OF+r/ „eJsl
—
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANaACTION
Consumers Signature Date: Donsulvrs Signature Dale
ADDITIONAL TERMS AND CONDITIONS
Contractor Responsibility.The Contractor will issue its formal warranty upon full payment,which shall constitute the
Contractor's warranty for the labor and materials provided to the Buyer.Contractor agrees that all work done pursuant
to this contract shall be of a workmanlike manner using professional quality materials and supplies.Warranties are
available for inspection at the time of signing of the contract.Contractor accepts no responsibility for any damage
resulting from structural or other defects in the properly at which the installation is canted out.Buyer acknowledges
Contractor's products do not correct or cure structural problems.Contractor shall not be responsible for(a)any
damages arising in whole or in part from strikes,fires,accidents,Floods,governmental actions or any other causes
beyond control of Contractor or(b)any damages including without limitation,lost profits or reduction in value of Buyer's
property,arising from Contractor's delay in performing under this Agreement or due to its breach of this Agreement.
Condensation/Mold:The contractor is not responsible for conditions beyond its control,such as condensation which
may form on or within a window or between windows resulting from pre-existing conditions in the Buyer's home and
external temperatures.Some condensation may also form on the frame or portions of the roof.Reducing the humidity in
your home will often remedy any condensation problems.The Contractor is also not responsible for existing or
developing spore or mold growth.Mold may be due to condensation which may form on or within walls or other surfaces
resulting from[pre-existing conditions in the Buyer's home and internal or external temperatures.Buyer indemnifies and
holds Contractor and its employees,authorized contractors and their subcontractors from any claims as to the
identification,detection,abatement,encapsulation or removal of mold,asbestos,lead based products or other
hazardous substances inside or outside of the structure being improved.
Permits:In Massachusetts,the Contractor is responsible for applying for and obtaining any and all necessary
permitting.Homeowners who secure their own permits will be excluded from the guaranty fund provisions of
Massachusetts law.
Delay/Unknown Conditions: Events beyond the control of the Contractor,such as Acts of God,labor strikes,
inclement weather,material shortages,Buyer's inability to qualify or obtain financing,delays by local government
authorities in issuing or otherwise approving inspections,permitting or other required authorizations for the job,or other
events resulting in delays in performance of this agreement do not constitute abandonment and are not included in
calculating time frames for performance by Contractor. In the event the Contractor determines that this Agreement
cannot be performed as intended by the parties due,for example,to incorrect pricing,unforeseen structural defects or
pre-existing conditions to the Buyers property,the Contractor may cancel this Agreement within 30 days of its
execution,notify the Buyer of such a cancellation in writing and return all monies paid by the Buyer.The Contractor and
the Buyers)have determined that a definite completion date is not of the essence to this Agreement.Contractor will not
be responsible for any work not specifically listed in this Agreement or the Addendum.
Late Cancellation,Late Payment/Default:If Buyer attempts to cancel this Agreement at any time subsequent to
midnight of the third business day after the date of the Agreement,as more fully described on the Notice of Right to
Cancel forth,and Contractor accepts such late cancellation,then Buyer agrees to pay Contractor a cancellation fee
equal to(i)15%of the Agreement's purchase price to offset Contractor's incurred labor,administrative fees and
material costs;plus(ii)the Contractor's costs for any specialty orders or any custom manufactured items.Buyer agrees
to pay 1 'h%per month on all amounts due and owing from the buyer to the Contractor accruing from the date due and
running to the date the payment is made.If Buyer is in default of this Agreement,Buyer agrees to pay Contractor's
attorney fees equal to 15%of the defaulted amount or as otherwise allowed by applicable law.Buyer also agrees to pay
any other costs or expenses of repossession,collection,or realization on any security including court costs,to the
extent not prohibited by law.
Security Interest:This contract may result in a lien on or security interest on your residence.Buyer grants Contractor a
security interest under the Uniform Commercial Code and other applicable law governing security interests in the
property purchased pursuant to this Agreement,including a security interest in any proceeds from the sale of such
property.Buyer agrees that the property purchased under this Agreement is,and will remain,personal property,
regardless of the fact that said personal property may become attached to Buyer's real property.
No Set-Offs or Retentions.Upon substantial completion of the Contractor's performance,Buyer shall pay all amounts
due under this Agreement in accordance with its terms without any right of set-off or retention.Substantial completion is
defined as the job being materially completed,functional as intended,and a final inspection,permit or occupancy
certificate,as the case may be,having been obtained. If after making full payment,the Buyer alleges that the work is
defective in any respect,the Contractor,without waiving any of its rights,shall cause an inspection of the premises and
perform any remedial work to the extent the Buyer is entitled thereto under this Agreement or the Contractor's warranty
at no cost to the Buyer.
Buyer's Representations:Buyer represents and warrants that(a)any credit information furnished by Buyer in
connection with this transaction is true and complete;(b)no person has promised or offered to pay,credit,or allow to
Buyer any compensation or reward for the procurement of an Agreement with others as an inducement to enter into this
Agreement;(c)no person has offered,delivered,paid,credited,or allowed to Buyer any gift,bonus,award,money,
merchandise,trading stamps,or cash loan as an inducement to entering into this Agreement;(d)Buyer is the owner of
the property where the goods and services are being provided.
Miscellaneous: Problems and inquiries can be directed to the Contractor,who may be reached at the telephone
number on the front of this Agreement.In construing this Agreement,the gender and number of words used may be
changed to meet the context.Any part of this Agreement contrary to law of this State shall not invalidate other parts of
this Agreement.This Agreement is to be governed by the laws of the State in which it is performed.All contractors
and subcontractors must be registered by the administrator of the Massachusetts Board of Building
Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration
should be directed to the Director,Home Improvement Contractor Registration One Ashburton Place Room
1301,Boston,MA 02108 Tel:(617)727-8598.This Agreement and any accompanying documents represent the
entire agreement between the parties and there are no prior or contemporaneous oral or written agreements or
representations on which either party is relying.Any modifications to this Agreement shall not be effective unless in
writing,signed by the Buyer(s)and a President or Vice President of Contractor.The section headings contained in this
Agreement are inserted for convenience only and shall not affect in any way the meaning or interpretation of this
Agreement.
=1e,v� r�0 3000
THE COO-'.1'D.NV1 EALTH OF i!\LASi4CFPUSETT
E:_ci_Tr•.LO„r_EnrL-v, z>;rlYl:or. ror.C- D t=Lop`.is :T
-_ DEP.ART!MEt\T OF LABOR ST.LNDARDS
-, -:-
- 19 ST.-o:I`nf:D 5 rR=EL. BOS rpV. t�{.4S5 ACHUS ETTC 0 2 114�
DELEADER CONTRACTOR LICENSE
A &- A SERVICES, INC.
115 NORTH STREET
SALEIM NIA 01970
LICENSE: DC000440 EXPIRES: Sunday, June 07, 201- 2�
IN .ACCORDANCE VFITH IkI G.L. CH I 11, 3 1976(b) AND 454 CMR 22,03, THIS LICENSE IS ISSUED BY
THE DEP,\PTMEE 7 OF LABOR STAx,-L)\RDS TO THE CC)NTP_4CTOR A 5 0 V E FOR. THE PI POSE OF
ENTERIyIG INTO OR E?iG,AGFNG FN DELEADFNG WORK.
THIS LICENSE 15 VALID FOR A PER10D OF ONE YEAR.
THG LICE\:'SE M 'ST BE \.IAP%TAC;ED BY' THE (-o>,TP_ACTOR 1,VHEY EtiGAGED I`i DELEADI4(j-
WDRK IN ACCORDANCE WITH M.G.L. CH. I 113 1978I_b)(7),AND 454 CAMP,22.03.
- Hc,\Th'ER. E. ROs DI"EC-,R-
—_ Oifice ot'Can;umu.a flair,&gu;ines R ;il:al-n❑
CS-057733 ,d_?IT CO`RR,1CT7�
r!a
CEGUSTOPHERZORZY 1`T'.
115 NORTH ST - r + A.3A 5 zR'/ICES, IAIC
SalembL401970"
- Cnristophar Z,n_y
113 Mcf1h Sir'_ei
Salem, MA 01370 � _—
rr,;: - 0512612015 CnJervccretnr
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnuesffgatlons
}
600 Waslfington Street, 7"Floor
- /�
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
ADDlicant information:
Please.PRINT legibly
name: _li�`✓inS'_l L'P�1�C' �.G`712 .
address/ ��J lVO✓" t lSfi�2P�' Qiy (/ r,
city J Ot I2 (I state: MA
zip: 0/9-70 phone# �/y
work site location(toll address)— (ti5 SR_t( '{D_I yQ, �Q M I In+ dl -I 76
❑ t am a homeowner performing all work myself. Project Type: []New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
F� I am an cm ployer providing
�w^orkers' compensation`for my employees working on thisjob.
company name: A 'l-- 4 - S-k V ! -
/ �L
address I l 66,��j l t/O ✓�n6 y��l �+• (] p �7�[ /�+ / �7
city: Sa i e tom. .�7/-6'Tl phone#: �-yt�7t 9-�]tt�r]t / —O Y ;LV
insurance co. I f-�.X_ f ;-a u e I-e r lS policy# l J llLt 3 A l U f S
❑ 1 am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city' phone#:
insurance co policy#
company name:
address:
city: phone#:
insurance co policy#
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MG1, 152 can lead to the imposition of criminal penalties of it fine up to SI,mo.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S10o.00 a day against me. I understand that a
copy of this statement maybe Forwarded to the Fice of Investigations of the DI:\for coverage verification.
l do hereby/certify unu a th pains and p nallies of perjury that the information provided above is true and correct.
SignalurcV Date p '�n�
Print name /�fi`�1 l YZ 2oa../ Phone# 7O -7 T
official use only Jo not write in this area to be completed by city or town official
city or town: permit/license H ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone H; ❑Other
(revised Sept 2003)
ti1p
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Phone: 978-74 1-04 24
9 INSPECTIONAt SERV1C Fax: 978-741-2012
ww .a-aservies.com
p&p SEM `= JUN 29 30 North Street
Salem,
MA 01970
June 24, 2015
City of Salem
Building Dept.
120 Washington Street
Salem, MA 01970
To Whom It May Concern:
Enclosed please find the permit application for Erin Burns, 2C Russell
Drive, Salem, MA.
I have enclosed a check for $77.00 based on your fee schedule of$11.00
per $1,000.00. The job was $6,831.00.
Please send the completed permit to A & A Services, Inc. at 115 North
Street, Salem, MA 01970.
If you have any questions, please contact me at (978) 741-0424.
Thank you for your assistance.
Sincerely,
�0-�)
Barbara Zorzy
Office Manager