24 SAINT PETER STREET - BUILDING INSPECTION A6 1-n
The Commonwealth of MMMW44 RVICES
UlfDepartment of Public Safety
Massachusetts State Building CoAMB(O-01IIT 3 A
Building Permit Application for any Building other than a One-or Two- am y Dwelling
(This Section For Official Use Only)
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)
aySf P21crs 5�'N(.e ", Mth (3kg-7b
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 in the two rows below
Existing Building❑ Repair❑ Alteration 2' 1 Addition❑ 1 Demolition ❑ (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 112"
Is an Independent Structural Engineerin Peer Review required? //Yes ❑ No L9�
Brief Description of Proposed Work: til 5-�Q& Si X ((a /12.cn/ i !rt t/ �t rn b 61.v a
(c n t a t o w vv�1- t u i vtA--,.r; s / cl urf q Ale t.�/
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: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 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 ❑ IV ❑ 1 VA ❑ VB O
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: ail
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: MA Historic Commission 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Sf. P2><C✓✓'���i scoGttlG/iu,tncll a y Sf: IQe�Pr's 5�- ��(er� �l9- O/970
Name(Print) I� No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) , Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes L �` I
lI Jr f' h 1 NS'T : PAA- Q 6-7.
Name 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 0 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
/t w-1,1- 7C.1/✓r CaS IV'C
Company Name
C kj✓, S ?Zy-Z
me of Person
ible
for Construction License No. and Type if Applicable
1/ .5- No/thy ,�ia �ew —1- 6197D
Street Address City/Town State Zip
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 13 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ -7 -7--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 $ -? f � (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 accurate to the best of my kt wledge and understanding.
C�, v- s V s i deter{— 9IC_1y! _ o�(ay
Please print and sign na re Title Telephone No. Date
l/5 �o rtlr"- S-F- ;e;c,-Le-vvx m41�- o f97d
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: // �O�w
Name Date
A & ASERVICES, INC.
A&A SERVItSS I IS NORTH STREET, SAL ENI. MA 01970
• ' f Tclephoue-(91-3) 731-04'4 Fa:c 1973i 741-'_012
Contractor Registration No, 101609
Construction Supervisor No. CS057733
Federal FIN: 04-3090162
MISCELLANEOUS SPECIFICATION SHEET
auyenal Nam pe'^^r noort�
ike s a'D??�E � L;url7
3uvensi Street Address, Clb.State and Z'.o Cade
Q4 AM. c197;
^a•!me Tel=_ Kona Ncmber = =nin^ Te!=_^here ?Icmdar hlc[ile Talaphcne ^Icmder -rm it A:dr=_ss
t If;O SS�(v�� AFL bd45-t— a, 1,lis c^
f
The Buyer(s)listed above hereby jointly and severally agree to purchase are goods andlor sertices 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 Spaciflcalion
Sheet is apart.
SPECIAL INSTRUCTIONS
, y f !Y({'�-ln/1 i tV�kl Yl C61 1""h �' l 1 � in" L��^"'I Sr�O �ajZ,J�'� � .l YIc�,•9 l`i• .
LA� Ai'-{S
AP
r f�Jn.l_ CLU F-�Lt.l��t'n n2u r'a r,o k�;{. : Cf,t-.,can, - rr r'a ir�unr F
.+ /-a-p-f- j)'i a /1 _ g- tam
/ / L
LlG•j/iv � rt n k?
J
r 1;1;5+--t�� A;:J�U v y^r di-'ter��;r_r S' �'•' !'>OI.a_.._J /'^t�?����it•7fn ar{ �?,t'v�j
-T- o,�r L ELunll�" �3� Brad /'iy�it/'ciit- C/ tc.. , n r�fc' lxsfiJ-�,
LiVS4AU /t�.ALLI tlJ iYl��i[•U h1:<1 rt,i;Z Lr �ot' f✓( /J.�rl f7� L[vrt'�
xI
USiutq 2X5I cSIL— fts ? + SillA%YRw� T-� C� y{z
r�
1 G,V F17
° �--rlr5 f.°F I 1 :i�LCi .D'✓'i; J k r�f i O r / iC j tCG� C/{S'I vt us �^ c.LJ Fi( f,[,1 A- �'�
0 � _
l,teS=/��� SiV ,11�LLi -Stl/If15£ f/fFJagc[.�d .i�.rrv� I,`.vt�r ( c�tL�7iehc6>,eQ
!'P o 1.&C.c•b[21l'r- (�U i YIc�GI:i)S i rt �� 5 i x o�V i Yi q,_, �:f-C, `
ub fz fericf� $R✓71S�oni2 mrr 2 o s 4 L,o IrP 'i bttot+e(
RY��, 1s heFu ems' E� nIR �1� r�(A=5 (av,— a SHIT
I�tr�cd {-i n5"�-t 4PS- �✓����:r-> > t=(A vtu:=� n �ti 1'i�u` `F-�f").7.55�zSCi�US N+t1 -
e
It is agreed and understood by and betwean the parties that this Specification Sheet, along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT.constitutes
the entire understanding between the panics,and there are
an verbal understandings changing or modifying y or the!arms, this contract may not be changed or Its
terms modified or,.tied In any way unless sash changes are in end signed by both the Buyeds)and the Contractor.Guyeds) hereby acknowledge that Buyedel
has read this Sp norcrame Sheet. [
Contractor Initials' -)I Date: 417� Buyer's Initials:_�)E'vY°Y Y Date:V�Ajj fifk —
2' A & A SERVICES, INC. Y
A&A SERVICE 115 NORTH. STREET, SALEM. >Lk 01979
• LlcphOnc 19731 741-11421 Fat' 19-3, 741-101'_
Contractor Registra[ion No. 101509
Construction 'Supervisor No. CS057733
Federal EN: 04-3090152
:MISCELLANEOUS SPECIFICATION SHEET
9uvarisl name �<,.i c,.nmact
Buvertsl Strut Address, CID,State antl Zlo Oode
�)-q- J . Pk{2i- 5 t p l t,, 41,F_ (D /=/Z)
Oa,time T�1'nrone:Numbe. ^ Tele^ e Npmter 1,Icbe ra crone Ncr.cer c-Mai Address
S q73 ( U The Br,rna)lined above hereby fspa,antl severhily sgrao td purchase the 3oobs andlor services listed below,in accordance with:he prices antl terms].scribed on
this Specification shaet Intl the front and the revers.of'an a¢dmpampng CUSTChI.REMODELING AND IiiMPROVENIENT AGREEMENT,of writ,this Specification
Sheet is a part.
SPECIAL INS"PRUMONS
L
;,t;�nZf-P ;; ;.Old +i�U.n-A ( I!/_ k/ IU1/!w\,L' U /11 s
G 11 C:ZL: tr:=i nl/l'i— OJgi l 1 ,V J w LFt- I z:>; 111` +I'i/w CL:
t J I
C ;A��i rr;}_Pf_'1 vti?:� =r:12f��: IM ,a.:�2� ?-nJ• ru'i 7l c!t'C:' LC 1, t'C
yV:•rl.v.�:_ ..;t�P,%S:,_r:`S l;r boa+ �I�% It,l� -1-t.:'4 .
_ 4
1 (
L/ 1 •r—ta �f fJ I p jCl_I�4 / I >,=�'Vt�=Cs.
k f Y
I J Q J -
L\>r'•.0 �
It Is ,reed and undarstood of and herv•een the parties that Ihis Specification Shaet,wrong ninth CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the entir5 understanding hs..n the p.nias, And Mars arererbal understandingschanging or modifying any of the tarns. This contracLmay not as Uanged or its
terms modified p,varied•n Any nay unless such:hangea Ira insinting antl signed or both the Buyeos) and the Comray., Buyeral hereby ACknowtedge!her Buyerfsj
nas read Ihis Specification S//he/et.
ContractmrIni[ials'. Dam: qQ /)� Buyer's Initials:art// Da[a: "r)/,'Y
��gg � yy�{ < ej,-:. A & A SERVICES, INC.
P' &A SERVICES Ili NORTH STREET, S.ALFIff. NIA 01970
• • Talephone:(973) 741-04'_4 Fos: (973) 741-701_'
Contractor Registration No. 101609
Construction Supervisor No.CS057733
Federal EIN: 04-3090162
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
offer .) Name Date of Conlra t
S� P42+z-, 's s'� camel Clt rhI /0/2p//�
Buvadsl'Sttrreet Address, City,State and Zip Code f I
Cadman Telephone Number Evenin Telephone Number Ni Tele hone Number E-,blail Address
The Buyerls)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 and:he reverse Of this agreement and any specification sheets(this'Agreemenr),and Buyers)have requested
that such goods or services be installed or provided at B over'a address listed above.AdA Services,Inc.('Contractor),hereby agrees to install or cause to be installed
the products or services listed in this Agreement at the 9uyerts)address wntten above.This Agreement represents a cash sale of goods and services.The BuyegsI
agree to pay In cash the Cost of the goods and services purchased as described herein,regardless of timing or approval of any Financing Buyeral may seek for their
purchase.
ZPurchase Price!—JL=,—J L7/ai 7y I Est,Starting Dale' (
co
co
Gr—r
Down Paymeri> LO P_o �I` Fa Esc Completion Date: / J�
i .7liC ti!/,L'4(t4:-rE Q'-.Cash [
Amount Due on scan of Job: :-,L1fYZf*iygKVIK2 7;1fl Check
Credit Card
Amount Due an_of Completion: NO.
Amount Oue an of Completion: �✓-[TrrCtl! J E7 J �y
`/ ZZ` Expiration Date.
Balance Due on upon Completion:
C 773 VC 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.Buyer(d)
hereby acknowledge that Buyerls)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 dale first written above.Buyerls)also(I)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. DO NOT SIGN THIS CONTRACT IF IT
CONTAINS ANY BLANK SPACES.
A&A Services, lnc. Buyer(s) \�
By
Signature rT
Signet
Print Name L Cz
Print Name
Signature
Print Name
You,the Stayeds), 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 night.
ARmIRATION:rn.-11 clpr out me nomeowder falls,minuet',agree m auvana lnal.n'.he saustafflari Parry has alispute cancemtng this mnuaa.ailen Pam May.uamr su[n dispute UP
ai eieavon saran.main nos been approvM ay dla secass,arm.Exonspitve Olfi[e Of Consumer Oryad.and Business Raguta one and Ile Otter party small be m almand:o broad to sued
atbltabon 3s prayed In N O.L:.IJ$A.
Chide.,..r Paul,
;SL-- m B • �/ au
Om, 1. 101,30 /7 odes-4 / 6/ So(-litaxeF
NOTICE OF CANCELLATION NOTICE OF CANCELUT ON
Ome o1 L,anaclidn Noy once Inis vansacuan,'minom any penalty a Dalo al rransadion ,Wi�-y=I(/—�you may ancel Inis vanvcuon.'Mtnwl any penalty or
adigannn.mail.three bused as Ifominis above Gate Il you[ante T.,prm.,creauee, Opligation.vnlnin lMae'u51rti5�1ay91rom the adore]ale.It,onceddrypNpanyeaeedin.
any Pbymm,y moos by yell Unbar t e select o,said.and any nmduabm mawmem exe.me any payments moos Myyou maenne cdntrut or sale,one any rogotiabm irevumem me.,aa
by rout ell be re forms P elm IF days appears macaipt by me sane Or Ur arrenaann notes, by Art sill be rebound same to Move m kid ing rmemt by the solar of your areenaam nooica.
and day ounac imerou anam,out of me banamoe me be ananea.a yen meal,you must and any se-dry,tmareet adsng of al me bOOa.c,.n let be ananm.a you ad[eI.you mv.al
max.a.aaame to me saver n ym,r.ywmce,and PUU5wdMN it as goad mr as-see r make avadmme o the sen ra Sailor at your m rm .and ardamntibny In nmtion as goes[a as anor
hen many addeddeaveraato you Under many Cmmm o,Sala:or you may a YOUR main.rramay ived.anv,dde am,oven wm to you rhai sCoruao an Sam over,:or you of you n comply
e marmantion.l Ih.Savo,agardmg In. .lure shmmem al m. .its a Ine Milan. me.ma mowcmns.l'he saner regbmmg m.,awed amPdteer of are 1...1 Ine Sid.,'I
alums,and rem Ir sou do make me goods avauame to its Server and Me Sauer ads not .,it expense am ask_:rye r Is make the goods Roduam m me safer and Me Miner does no,Pick
m.mup mathm 1.ame d m aatr ol,on.Naeceol Cananaddn,IU may r.lalt a,elsase m In. them Is suits go days if data of your Nonce of Camarai dn.rout ray reatn o,typ.e of
groin marble any canner oaigauarIf/no fail to maka the goods avaimble mine sorter,or a... me gmds'smom any mnhe ob.gad.d.Itya mil to mare In.qmm avaaeme m In.Se.m.or.,
bgr.e d In.,odes 1.if.Man,add red m en do an.m roo,ae m Tide firappwlmma of uagr the goads to the seller and fan,to do so,man your in liable forpenm,aa oe
all obvganoesum.,the convect.To about the transaction.read ver aelNer a signed add mesa em m au.'.,.s do.,1.Giuliani.To aeaared.F.m.emn.mad.1Mae-'.Aimed and ratan
ropy if he:anauaean non.Or any order..item nonce,or Send a telegram, q.il Services. mpy or she cancellation notice of any order-asitlm nonce,of send a telegram b ABA Services.
Its Y.an 3......Salem MA Blain.NOT LATER THAN M IDl=Or } around Street Salem MA p ei NOT LATER THAN MIDNIGHT OF 1[� j�tay'
I HEREBY CANCEL THIS TRANSACTION I HEREBY Came EL THIS TRANSACTION ••/fy /o( ,
Conxi mera iigneulo Dale Consumers suns Oa,e:
•d� e
x � 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
In this contract shall be of a workmanlike manner using professional quality materials and supplies.Vlarranties 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 property at which the installation is carried 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 otherrequired authorizations for the job,or other
events resulting in delays in performance of this agreement do notconstitute 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(lie 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 Buyer(s)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 form,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 '/:%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 night 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 parry 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.
-,.r^ ,r f.{,^rrf r• f.}rj,` � L �-� ✓•. , _Lr_��r-S in�r:it;Sr,7�✓l[LL�f-?�:1}�� `,(�U iIJ
The Commonwealth of Massachusetts
a ('' Department of Industrial Accidents
1� Office ofinvestlgations
600 Washington Street, 7th Floor
a Boston, Mass. 02111
4z=t_ '
'-- Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information: t �, / Please PRINT legibly
name: _l..Ka // .5-bp_ kx 1-- Lr)
address:/ �I NO/r! rl 7l -e!q �y�/ / r/
city 5C'n 12 +'r state: MA zip: D I970 phone / / D --7!T 7 f'a (9
work site location(full address): of h6k✓S 5�- 6a,l e rn Nlf O/%70
❑ I 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
[� I am an employ/e�r providing workers' compensation for my employees working on thisjob.
company name: /-,f, -z- ���' LQ-a--V/ ��S /ail C
address: ( /05- !W o v' 6 �,�y'1 S+- �'] p ( �5 i / �7
city' Sa 9 e (MP /1`1 ( phone#: -f 79- 7A^7 / —Q `Y 2::Y
insurance co �a -F;h aV2 I -e r- l5 policy# 0-)-L 3 IL l (S 15
❑ I am a sole proprietor, general contractor,or homeowner(circle ore) 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 iMGL 152 can lead to the imposition ofcrimin:d penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that it
copy of lh is statement may be forwarded to the ice of Investigations of the DIA for coverage verification.
I do berebt,certify un th pains and p nalties of perjury that the information provided above is true and correct.
Signar Date it t3 �Z l�
Print name ✓I t -To� 2OY2.�./ Phone# 7 Op-7 v�} / it
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department _
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
[-]Health Department
contact person: phone#; ❑Other
(revised Sept 2001)
Control No: 33262
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
DIVISION OF OCCUPATIONAL .SAFETY
19 STANIFORD STREET, BOSTON, MASSACHUSETTS 021.14
LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER
A & A Services, Inc.
115 North Street
Salem, MA 01970
WAIVER: LW 000318 EXPIRES: February 12, 2015
IN ACCORDANCE WITH M.G.L. C. 111, § 197(B)(b) AND 454 CMR 22.03(3)(b),
THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER IS
ISSUED BY THE DIV. OF OCCUPATIONAL SAFETY TO THE CONTRACTOR
ABOVE FOR THE PURPOSE OF PERFORMING LEAD-SAFE RENOVATION
WORK.
THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER MUST
BE MAINTAINED BY THE CONTRACTOR N ACCORDANCE WITH M.G.L. C.
111, § 19713(b) AND 454 CMR 22.04 WHEN PERFORMING LEAD-SAFE
RENOVATION WORK.
;
HEATHER E. ROWE,ACTING COMMISSIONER
Massachusetts - Department of Public Safety AllI
„ y
Board of Building Regulations and Standards ss ' • - '•
Program
Cnmstrucnnn Supen s>r 3 j'
License CS-057733 -i
F Cement Siding
CHRISTOPHER ZORZY,. _ak I
115 rtoxTH ST _ Christopher Zorzy 111201213426000840
NI Salem A 01970 iy A 8 A Services Inc Exp 4262017
115 North St
Salem, MA 01970 (�'-;;• .-,-_.
J �,`.- s nr • Expiration
'!T O5%2612015 Matthew J Gibson
Commissioner nwy cweac.a,gas
Administered by Data Works International,Inc.
>.-Office ofCinsumerAf6rirs& Business Regulation
"`" 'MOM E IMPROVEMENT CONTRACTOR
� _Registration: 101609 Type:
Expiration: 626/2016 Private Corporatic
A&A SERVICES, INC
Christopher Zorzy
115 North Street � �•�__.,. �_
Salem, MA 01970 Undersecretary
sf� s 7y Pro%,'; or's 9i M. G, L 'o &m day a c99p16uon oi
BLI119ing N 6' JID�dP E� dla's 5y d d� result 9 &oai �» +1� _ -jl
-,Win_
f 9 ,
s ,