5 ST PAUL ST - BUILDING INSPECTION (2) The Conimomvealth of N1assachuseltS K
Board of Building RcUuLuionS and StandardS apt N'It III \I.I'll
MaStiaehLlSettS State Building Code. 780 (•;SIR. 7°i edition ''.tilt
f. +
I
Building Permit Application To Construct, Repair. Renovate Or Demolish a Krn„
One- or TourFurnih- Dtrcl1mg
This Section For Official Use Only
Building Permit Number: Date .Applied: —_ ----_ _�
Signatwe: - �---------
13uilding Commissioner/ Inspee or of uddings Dale - —.--
-1
SECTION I: SITE INFORMATION
1.1 Prppertv Ad re}"' n 1.2 Assessurs ,%lap & Parcel Numbers
.w er
-
I.I a Is this an accepted sit yes_ no kla_ P Number P:acel Numb
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq t'If Froniage it!)
1.5 Building Setbacks(fq
Front Yard Side Yards Rear Yard
! Required Provided Required Provided Required Pro<idcd
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 El On site disposal system ❑
Public ClPrivate❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' .
tra
ner'of ecord: C cy n+ Rat �}{ p n-f
intl - r Address for Servi—ce1: 1/ 1 p� '
903-- l L4t4 — —7 594
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ .Alte ration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_- Other ❑ Specify:
Brief Descri Lion of Proposed W xk'": ---- -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofricial Use Only
Item (Labor and Materials)
I. Building $ 7 zl--) 1. Building Permit Fee: S Indicate hose Ice is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑ Total Project Cost' (Item 6) x multiplier x
1. Plumbing S 2. Other Fees: S
4. Aechanical iH\,':1C) S List: —
S. Mechanical (Fire 1 ---
� � Total :yll Fees: $
Su. ressiun) -
Check No. Check Amount: Cash :\nvuutt:
j b. Total Project Cost: $ 1 ❑ Paid in Full ❑ Out.standing Balance
i
SECTION 5: CONSTRUCTION SERVICES /
5.1 Licensed Construction Supervisor (*ephone
r��' br7_t on,e.NLumher I�i`vl"lilalioi Daly
IN o• CSL..Il i der - l CSI_l'cpe tsee hcuul. e L L'nreslneted(u t to is.000 Cur Ft.1
R Restricted L@_' F:uwh DwClungn \9 >lamnrs UnlyI � C RCoiJenual Kaoline Cmerm_Telephone '5 ReNidCuual {{indoa and Sidm_.F Rrsidcntial .Solid Fuel 9umme 1 i 1InmcrD Residential Demolition
5.2 ego' er• Ilo to Improvem n nI A Ilit 1 tp;u Yam• r IIC Rcgs rant NamRegtstration Number
II II �01aZb lain tn
Fx [ion Da�Si uture
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. F ilure 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
I' ' WrMQ4 In Poinbe as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by t building permit Viplication.
Sig nature of Owner Date
SE
t
N 7b: OWNER OR AUTHORIZED AGENT DECLARATION
SECTION
I, cipS . as Owner or Authorized Agent hereby declare
that the statements and information on the regoing application are true and accurate, to the best of my knowledge and
behalf.
Z
Print Name U O
Signature of of Owner or Authorized#ent Date
(Signed under the pains and 2enalties of er'u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner who hires Lin Lint
negistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to.the arbitration
program orltuaranty fund under M.G.L. c. 142A. Other important information on the HIC Progrun and
Construction Supervisor Licensing (CSL)can be found in 730 C'MR Regulations I I0.R6 and I IO.R5. respectively.
'. When substantial work is planned, provide the information below:
- I
Total_flours area;Sq. Ft.) (including garage, finished hasement/attics, decks or porch!
I Gross living area(Sq. Ft.) Habitable room count _
;Number of fireplaces Number of hedrooms
,Number of bathrooms Number or half/h:uhs
rvpe of heating ,ystem - Number of decks/p�arches -----_--
Type of cooling s)'siem FnClused _Open .---- _ _-
3. "Total Project Square Footage- may be substituted for ""Food Project Cost-
CITY OF SALEM
3 PUBLIC PROPRERTY
DEPARTMENT
• 5V�xt.
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPlumbers
A l yl ltant information Please Print Le�ihlV
\,tile dlu,me,s l h¢anitanuln 111d1UdIWl l: n T A
Nor+h S-+Ye e-+
a�l�ress: \
C'ity'•State,Zip: 1PYY1� M� d19-JD Phone #: C 17S5 ) 7N I - OH 20
Are sou an employer?Check the appropriate box: - Type of project (required):
1. I am a employer with
�/ 4. ❑ 1 am a g 6. ❑-general contractor and I New construction
Ls_'J �—
employees (full anchor part-time).' have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. :
ship and have no etnplovees rhese sub-contractors have ii. ❑ Demolition
working for me in any capacity. workers' comp. insurance. _q, ❑ Building addition - -
5. ❑ We are a corporation and its
[No workers' sump. insurance lo.❑ Electrical repairs or additions
officers have exercised their
rcyuired.] I I. Plumb in re airs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL ❑ g P'
thyself. [No workers' comp.- C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] ' employees. nc workers' I Other ���,✓)
comp. insurance required.]
•:\ray applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Cmitrucmrs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
r inn an employer that is providing workers'compensation insurunc•e for my employees. Below is the policy and job site
information. / �y
Insurance Company Name:
Policy #or Self-ins. Lic. #: '-�/D), ���J l 1 J U�/� Expiration Date: 19.2t .yl�/y_�—
Job Site Address: � 12U ro ra a (� City/State/Zip: <�( ��I/ Im /'/7�
:kttach 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 MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S I,Soomo and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine
4 kip to S_'S(L UO a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Inccstivauons of the MA for insurance cucerage verification.
Ida hereby certify a ter the pains and pen allies of perjury that
the inforruation provided above'is true and correct.
Date: �
\I'l ILll lire:
1 ' a
0/ficial use only. Do not write in this area, to be completed by city or town aj Liat
('itv or -Foe.it: " — _.-.-------------- Permitil icense #----,—_—.--.- ---
Issuing Aulhority (circle one):
1. Ifoard of Health 2. Building Department 3. C'itN/rown Clerk a. Electrical Inspector 5. Plumbing inspector
6. Other --- —
Contact Person:_----_-- — Phone #:_—
Information and Instructions
\I.iS,ac I It isms General Laws chapter I5' requres-all cnlp Io�ers to pros ide workers' compensation fix their employees.
11-111 suaut to this aattue, an eetploree is defined as ".. et ers person Ili the ser%ice of another under any contract of hire.
cxl,r im n ess or plied, oral or r n ine ."
.\n a mltlorer is defined as "an indis;dual, partnership, a.asoc:ation,corporation ur other le gal entity. or:my mo or more
,,I the foregoing engaged in a joint enterprise, and including the legal representatis es of a deceased employer, or file
reecis er or trustee of.m individual, partnership• association or other Iegal etnnv, etnplo\nlg eittployees. llow'eler the
uts ner of a dwelling house haling not more than three apartments and who resides therein, or the occupant of the
duelling house of:mother whu employs persons to do maintenance, construction or repair work on such dwelling house
0x on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
\16L chapter 152, �25C(6) also states that "every state or local licensing agenev 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, \IGL chapter 152, sS15C(7)states'*either the conlnlonwealth nor any of its political subdivisions shall
enter into any contract for the pertomlance of public+pork until acceptable es idence 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
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 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"t s he 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
6.c. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. -
The ()thee of Investigations would like to thank you in advance for your cooperation and should you haze any questions,
please do not hesitate to give us a call.
the Depalvnent's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Itc.�:ed 5-'6-u5 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.
15Qa.
The debris will be disposed at Salem 'transfer Station
owned by Northside Carting
Signature of P rmlt Applicant
Elate
�BIrISt09her ZOrZy
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street Salem. MA 019i0
Address, Crty, State, Zip Code
Massachusetts - Department of Public Safety
444 Board oi'Buildin- Regulations and Standards
Construction Supervisor License
License: CS 57733
Restricted to: 00
I
CHRISTOPHER ZORZY
115 NORTH ST
--------- ---
SALEM;MAD1970
Expiration: 526/2011
('onunivsiuner Tr#: 14751
...... ._._.Vic•.._
" .
. .• _ _ _ .._. an
Board of Building Regulationsd Standards
HOME IMPROVEMENT CONTRACTOR
• Registration: 101e09 ug upiration , d262010 Tr-� 287870
Type; Private Corporation
A&A SERVICES,iNtt
Christopher Zo_y: . —=
115 North Street
Salem,MA 01970 Administrator
_ Commonwealth of Massachuse=
Division of Occupational Safety
Laura M.Martin,Commissioner >
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date. 04/01/09 _
Exp.Date 04/08/10 '
e
DC000440 r_
Memherof cc.N.E.S.T. "
IIIIIImIIIIIIIIIIiIIIII IIIIIIIIIII IIIIIIIIiII aOSrOWRENEW�_
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I • I •• • • • I: : I. • • .
" A & A SERVICES, INC.
A. B
A&ASERVICES 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
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(s)Name Date of Contract
Li L.4 L,41V4L_F,9 /o o9
Buyers)Street Address,City,State and Zip Code
3o - L47fi 01970
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mall Address:
9-784Yt-31 S$
The Buyerts)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with
the prices and terms described on the front gad the reverse of this agreement and any specification sheets(this"Agreement"),and Buyers)have requested that such
goods or services be installed or provided at Buyer's address listed above.Assisi Services,Inc.("Contractor"),hereby agrees to install or cause to be installed the products
or services listed in this Agreement at the Somalis)address written above. This Agreement represents a cash sale of goods and services. The Buyer(s)agree to pay in
cash the cost of the goo tls antl services purchased as described herein,regard ese of tlming or approval any financing Buyers)may seek for their purchase.
3�8 s c6
Purchase Price: g[Z Ml l 2c'F�itnAa-�(�j 20 SD Est.Starting Data: LL-LS LL�3
Down Payment: .&601 +"r `, e Est.Completion Date: -3o-
❑Cash
Amount Due on Start of Job: blerheck
❑ redit Card
Amount due on of Completion: No.
Amount Due on of Completion:. Expiration Date:
Balance Due on Upon Completion:Ol CIVIC Code:
It Is agreed and understood by and between the parties that this Agreement,front said 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 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 forms,on the date first written above. Buyers)also
(1)acknowledge that they were orally Informed of their right to cancel this transaction;and(II)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,Inc. Buyer(B)
By: ^ � vl
re
4 QLAe�--
Si nature Si natu
g 9L
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. Sae the following Notice of Cancellation form for an explanation of this right. _
ARBImATON:The mntrector end tip Npmeamer ImreOy mutually Opera in aEvance that in tit event either perry has a disputeconnming this codmill either party may submit such Museum to
A
pMe1e eNlvOtion aeMca xTictl has peen epgovad try Ne Secrepry M tlp Eaecudve Office Ot Consumer Afmlre eM Busl rss Rego mass ant the other pay shall W required to submit to
such artheavon as pro+ed in M.G.L. .N2A.
Conoenm ioidalc buyer"fnieW:
DialDow
NnTCE OF CANCEI I ATION NOT(` OFF fF ANE`-`I nTON
Data Of Thureformin .You may normal Me hasuectron,u+tdout any Mail or Data of You may mncel She MoNesp on,Ahmed any peramy Or
pMigetkn,within theta pwimas da1man the al date.It you mead,any pmpsM traded In. eMorder.within a—business dime tram the Sol data.a you mrcal,any prepay traded in,
any payments made by you under the Commd or Sale,and any Npatiabb interment emismad wry payments made by you antler the Contract or Sale,And any negehapb instmm M erecNetl
by yw WII IN retumed within 10 days lollmving mesa by the seller of your ceocell lion mark, by you HII be moral Aimin 10 days follow all re io by the Eager of your corneal norke,
and any security museum Along out of the normaclion will Ip wncellM, It you caul yw must Ord any somas,(merest arising out of the bane n wit be[recalled. If you cancel,you mutt
make avases,w the BODY AtWar residents.m rumfantielly AS good¢^ddon as Men rewNm, make awailmle m tie Seller A,vur revmnm,in summntimly as good computed as when amended,
any goods reserved to you under No eontreo or Sal«you may,If you Wed.comply All the any goods deliverad as you under the bWdl or Beer;or yeu may,if you When,pool with IN
iher Yiona Ot the senor regrading the serum shipment of Me goods of the severe expense and ivftMns of the Saller reaardim,the Name shipment of Me goods at me so mme e.panw and
risk. If you do make the goods evalWle to Me Seller and me seller does not oak them up ark, If you da make the goods aveilede to IM Beier and the seller doss rat per them up
MMis 2D days N the date of your Notice N Cammutron,You may andn or disease of the goods w10in 20 days of the date M your Notice of camperAron.you may mein or disease at the goods
wlNoul any hirer obligation.It you tail M real Me goods available to the Ballet on if you agree MrhoNarry WNprablilmipn.ll you tall to make the goods eveileblO to the Selle[pr It you apnea
In rather Me geode m the Seller end feu to As so,Men you remeln'Win her parfomlancs M all io deem the goys the the Seller And fail to but we then you armed liable for Wdop A of At
ahiigrmm under the ConVoO,To mnmlthis MMrmMn,mat ordersda signed and mad may obligations under Me Centsel rorareel tratrennal mall or braver saigned and dated may
of IN cancellAmn Name or any ether written Name.or sand a mbgmm,to AllBemcea,115 or the eerie., ny the ceatme e or a Other coition a lime,or aond a telegram,to"sA Barrows,I
NorthStreet,Salem,Maasechuserk 01970,NOT LATER THAN MIDNIGHT OF fQ� Norm Shern.Salem,mMwmI mNm 01970,NOT LATER THAN MIDNIGHT OF/O-/9-O�J
(Date) (Dam)
I HEREBY CANCEL THIS TRANSACTION. Consumers,shoure Date I HEREBY CANCEL THIS TRANSACTION. Cweumer's Signature Date
�n � �� A & A SERVICES; INC.
d CES 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
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyer(s)Name Date of Contract
1,'L,9 Lfv�InGFq to -is - off
Buyers)Street Address,City,State and Zip Code
30 VvA&aA LoAlo- S;yTtW MR 0/970
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
978-7Y-S-3lSS
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 franc and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet Is a pan.
WINDOW REPLACEMENT
Remove and dispose of# existing windows.
Install # 7 new SUAIAJ-S IF windows: *inyl ❑Wood
(Manufacturer)
Options: Style SLI 0 E'Y1-S Vhj1!0 Grid pattern
/��//''NTT ��✓LL S'CRVV.✓J )
Color Interior IVA1 TLf %/Color Exterior W ,T?r Glass Type 1-4-90 -�P«
Wrap exterior trim with aluminum: Style Color
All windows will be installed according to the installation procedures in the portfolio.
Caulk all interior and exterior edges.
Insulate where possible around new units.
,C(Insulate window weight pockets if exist,and around new window units where possible.
Included in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and out.
�^ Building permit included.
- BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
❑ Create new window opening by cutting through existing home and framing in opening.
❑ 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.
❑ 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 tie into existing soffit system. -
❑ Bay ❑Bow ❑Casement ❑Other window(s)to include new interior style trim and new exterior style trim and head
flashing as needed.
Note: Painting and staining not included.
STORM PRODUCTS
❑ Remove and dispose of# existing storm window(s).
❑ Install new storm windows# Manufacturer
Style Color Option
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
SPECIAL INSTRUCTIONS:
/-Yl,� L AI&W
�) Pao= F/?-,^4en S(oF saps 7D e Knorr .
it Is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the eralre understanding between the parties,and there are no verbal understandings Changing or modifying any of the[arms. This contract may not be Changed or its
terms modBled or varled in any way unless such changes are In writing and slgnetl by both the Buyens)and the Contractor. Buyers)hereby acknowledge Net Buyer(.)
has read thee Specification sheet. / p
Contractor Initials:_-Y;s Date: /b'�`r Q/ Buyer's Initials: 1C;eYz Date: