10 STORY ST - BPA-16-1331 Zb C�= ' 5S
The Commonwealth of Massachu-� Al #"
Board of Building Regulations and' fidat s CITY OF
,t'oP,J Massachusetts State Building Code, 780 CNIR SALEM
�Oib NOV 14 P 4- 43 Revised Har?011
Building Permit Application To Construct, Repair, R novate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied:
1 Building Official(Print Name) Signature Date
(� SECTION 1: SITE INFORMATION
(_ 1.1 Propefty Addreess L2 Assessors Map& Parcel Numbers
1 /O 779 S�--� ! -
1.1 a Is this an acis an eh pted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard - Side Yards Rear Yard
Required Provided Required Provided RequiredMSystem:
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage DispPublic❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On si
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Orwner'q^f R/ecIord:of-,A MAt 4 (\�� /n Q 019
Name(Print) - City, tate,ZIP
1 1 �+41hCogo
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Wo '
�T tC y S l,ilyvles v
SECTION 4: ESTIMATED CONSTRUCTION COSTS _
Item Estimated Costs:
Labor and Materials) Official Use Only
MN
1. Building $ 3 1 (b L Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ V�Standard City/Town Application Fee
❑Total Project Cost' Item 6 x multiplier x
1 ( ) P
3. Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $
3 7, Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1 ❑ Paid in Full ❑Outstanding Balance Due:
l ,
SECTION 5d CONSTRUCTION SERVICES.:
5.1 Construction Supervisor License(CSL)
C,HV I( r) Liccnse(—)-aS ) 33 Expiration Date 7 0
Name of I p� T Description
N � 34 o l�r 1 17 U Unrest ichd to 35,000 Ch Ft)
Ad Restricted 1&2 Family Dwelling
M Masonry Only
i ' / RC Residential Roofing Covering
9 �/1C_ -7 y -D Y l f` w5 Residential Window and Siding
017 SF Residential Solid Fuel Burma Appliance
Telephone D Residential Demolition
51 Home Improvement Contractor Registration(HIC) /
Q .Se g yf'C p S &&ration�I ()I n / Expiration Date 1p 6
HIc Com yN eorlUC tName
T. S' �
Adl6s-
Signatpre
7 -7N1 - o Ufa�
Telephone
SECTION 6: WORKER'S COMPENSATIONINSURANCE AFFIDAVIT(M.G:L.c.152.§25C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affi vit may result in the denial of a building permit
Signed affidavit attached? Yes No 0
SECTION 7ac':'OWNER AUTHORIZATION TO B.F COMPLETED WHENIOWNER'S AGENT.OR
CONTRACTOR APPLIES,FOR BUILDING PERMTT
I, as Owner of the subject property,
hereby authorize �n/2 V I�PS to act on my behalf in all matters relevant to work
authorized by this building permit application.
So
Sigsre of Owner o
nah Date
SECTION 715: OWNER OR AUTHORIZED_AGENT DECLARATION.;
I, r Z as Owner or Authorized Agent,hereby declare that the statements
and information foregoi application are true an_di accurate,to the best of my knowl ge and belief.
Signahne ofOwuer arA orized ent (Signed under the pains and pemlties ofpajury) Dare
SECTION 8: DEBRIS DISPOSAL'
All dumpsters of six(6)cubic yards or more are reanired to have a permit from the Marblehead Fire department:call 781-639-3428.
In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris
resulting from any work performed shall be disposed of in a roperly licensed soli¢waste disposal facility as defined by MGL c111,§
ISOa. zurf�t ��S �9t! t , s'af2
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT 6 9Z A
NOTE .
An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor(not registered in
the Home Improvement Contractor(HIC)Program)will not have access to the arbitration program or guaranty fund under M.G.L.
c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR
Regulations.
\ rs�� n* nc e
/�V,,�,, //�� �p' /7 ` A & A SERVICES, INC. �� e
/'1&A SERVICES 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
ROOFING SPECIFICATION SHEET
Buyers)Name Date of Contract
WIL.rA&D ; 6L-oRI,4 MarroAJ
Buyers)Street Address,City,State and Zip Code
/O 15TDY1,,f 5T. <5)qI,L'wl I"94 D1970
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
7i? -Z0-Z0YD
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 front and the reverse of t e accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a pal, P,1 /4 77A1 44PHP1-(.-T 12��15—
ROOFING SPECIFICATION
Strip Roof of# Awl layers of shingles Der-K a Nm'
f nstall 6'of ice and water shield at base of roof where I f nstall kS-Wek-peper to roof.Ay, Yo+-cotai al
possible. Install 1 -24"of ice a d water shie vall y S M d
lash chimney as nee ed (no repointing included). Install8'perimeter drip edge to rakes and fascia areas.
nstall vent pipe boots and seal a3Kneeded. lash valleys as needed
Onstallseileet type ridge vent. � � lankS/plywood replacement under 32 SO FT included,
&Ar—, 'p��•rc 'If more is needed there will be an extra charge of$
�g1f(1y CpFS per hour for labor plus the cost of materials.
-ze�T Total
umpster/Disposal Included: f Other: Lt oLzy;—, : Ep
Location: Doi TrL✓e-K
Install new roof: Manufacturer l9' Li yr Style/type ✓Ls4�L._
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. a
RUBBER ROOFING SPECIFICATION
f Strip Roof f Not Strip Roof
f Install 1/2"High Density Fiberboard to existing roof using f Flash obstacles as needed.
screws and plates.
f Install .060 membrane EPDM (Black) rubber roofing to f Install 3x3 aluminum drip edge to perimeter of roof with
fiberboard.s seam tape.
f Flash up sidewall as needed.
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
yie*0 � ,.7�
SPECIAL INSTRUCT IONS: �CF—yam �q4.(� Li Djaj,f /T✓✓Wlfh/VM l?✓f"S�fN�J �OUfV�
B`s,o1s stcy zfr��r-t- roS�� �,v,�4,c�gPr sh'a1 .�o in��ash;�
wOrg i
A-"i+C(7nl�2S{crL(�
Rom, 012 3,y 07 , =
0iSiat�wTAI- =$ 3f0`T7t
30 ,
f f
It is agreed and understood by and between the parties that this Specification 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 Buyers)and the Contractor. Buyer(s)hereby acknowledge that Buyer(s)
has mad this specification Sheet. / ,�,� q`
Contractor Initials:_ Date: -/% �(o Buyer's Initials: �?" `+ " Date: X /^'
�,.rar A & A SERVICES, INC.
A8rA SQtVCES 115 NORTH STREET, SALEM, MA 01970
•• Telephone:(978) 741-0424 Fax: (978) 741-2012
Contractor Registration No. 101609
Construction Supervisor No.CS057733
Federal EIN: 04-3090162
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Bu e s Name r Data of Contract
Bu a s) Street Addreesss.City,State a d Zi Code
J
Da ime Telephone Number Evenin Telephone Number Mobile Teylechone Num)b/ar E-Mail Address
G — TAAD
The Buyers)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 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.A&A Services,Inc.('Contractor'),hereby agrees to install or cause to be installed
the products or Services listed in this Agreement at the Buyers)address cantles above.This Agreement represents a cash sale of goods and services.The Buyer(s)
agree to pay in cash the cost of the goads and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their
purchase. IT
� (
{¢ry [trryy Purchase Price J U[ `G I7
0 Est.Starting Date:
}Down Peymen! Est.Completion Date: '
EV Cash
Amount Due on Start of Job: El�Check
Q Credit Card
Amount Due onof Completion: No.
Amount Due on_Of Completion: Expiration Date:
Balance Due on Upon Completion: CVC Cotle'
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.Buyers)
hereby acknowledge that Buyers)has read the front and the reverse of this agreement and has received a completed,signed and dated copy of this
Agreement,including the We attached Notice of Cancellation forms,on the date first written above.Buyers)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 Buyers)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 Servi s,Inc. Buyers) /���
4,64M
Signature Sign�atue -�
)Qc-to2r ;P.���
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 dale of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION:Than wmracbr and Inn homeowner heresy muwally agree in a n anca thm'm Ise evernedrearytirvina.a domie cmwal this mnuect,either party may subInt such dispute nt e
pivate arbitration wrvitt shiU,has been approved bytes Senetary Pfren Executive OffirolofForearribrAfferhand Business Regulations and me matters dull boreal to suppensi uch
abuse.as spread In rA.G L c.102A.
Crmruarmlral:: days,
Oats
N TICE OF CA EL O ELLATION
rate W iansallon y cencel this hansacuan,w•inout any penalty or Date sl Trato on You may cancel tads vansallon,vnNout any sanely or
obligation,witMnthree us
ass ys M1omulneabore date.If cancel,any prrpertY traded m, obligaOorL MMinMreebi days fir^mtee anove date.ayw cancel.any property PatlM in,
any payeare 3de by you and fine Contract or See,and any negotiable Instrument executed any payments medeby ^nundertnepmtntlor sale,and anynegodablenhadmmenteerauted
by You¢ill be returned wards to days following receipt by Me Seller of you(pncelreen w6ce, by you will ba returned sable 10 days(plowing resist by Me Seller of your cancellation deal
and any weary interest an9ng out of re transaction will be wnreged,If you cancel,you moat and any ee unry interest aging out of re transaction All be wncdled.If You ce^r,you oust
make available 0 the Seller at your resides®,and MxRmbally in as good condition as an make available to the Sailer at your reverence,and substantially in as goad condition as ashen
herself any 9oada delivered to you under this Conrad or Sale:or you may.it you vash,aspic remsed.any goods Managed 0 you under cis crntrad or Sale,or you my if you tell amdy
wain be mstrutlirns of the Seller regaNmg re retain Shipment or Me goods at the Sellers with the Instructions of has saner regaMmq be mWm aHmrrent Of the goods at re Seller's
earnings and ask.H vain do crake the goads avdlable to the sever and the Sale,does not pick expense and risk.If you do Make re goods available to be Shcer and re Seller does not all
Main up warm 20 data of re date of Your Notice of Carrollton you may retain or dispose Of Mein up warm 20 days of re dater(your Norco a correlated.you may retain or Morgan of
goods shout any NMeredigadon.Ityoutailtomakeregoodsavailablebre Sellegarifyou Me goods damp any further obligall if you mil to hake the goods evanable to all or if
agree to return Me goods to Me Shcer end cal to do so.rise yw remain table for pedrmanw d raw agree to return the goods b the Seasonal Oil b do so,Men you resets liable Or pMamance
all obligations under re LanPad.Tr cancel iha Van58cti^n,msil or delivers wig it do Wtl of all oblgeons under the Contract TO m armed this transaction, ail or deliver a signed and dared
copy at MeHariranrelOtion notice or any ocher wren notice,or no
a releBra n so of re rancelation notiw or any radar written notice,or send a tele9 m,to A6A s,
115 NM1 Spart.began LITER THAN MIDNIGHT OF MA 01970,NOT TE 1t5 NorM BireaL seism M1U 01910,NOT LATER TNAN MIpNIGHT OF
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCELTN6 TRANSACTION
Cwaulat's Senawm Ove consumer a Signature Data:
CITY OF &U AM, NWSACHUSETTS
BL•ILDINIG DEPARTMENT
\ E 120 WASHLNGTON STREET, Sae FLOOR
T EL (978) 745-9595
FAX(978) 740-9W
C<1\BF_RLEY DRISCOI.L
MAYOR T HONw ST.PmnE MM
DIRECTOR OF PUBLIC PROPERTY/BUMDo;G COISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Plectricians/Ptumbers
Applicant Information Please Print Legibly
Name (Busi=&Organizationilndividual): LF-t
Address: I� � N A g.. h is \
City/State/Zip: Phone #:__ — [I —® yam_
Are you an employer?Check the appropriate box:
1.❑ 1 am a employer with[ 4. Type of project(required):
❑ !am a general contractor and i
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2-❑ 1 am a sole proprietor or partner- listed on the attached sheet, t 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'comp.insurance.
(No workers'comp. insurance 5. ❑ We are a corporation and its 9• ❑ Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.[]Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.❑Other
'Any applicam that checks box d t must also fill out the section below showing their workers'compensation policy infun ation.
'Hexnsnawners who submit this attidavit indicating they are doing all work and thco hire outside e,,nm 1m most mbmit aw ne alBdavit indicating suck
:Cuntraton,hat cheek this box must anachai an additional sheet showing tea name of the subcontractors and their workers'comp,policy information.
l am an employer that is providing workers'compensation insurance far my employees, Below is the poilcy and fob site
information. ---}— l
fnsurance Company Name:_ I k] 1Pi�
Policy 4 or Self-ins. Lic.f#:���I �/"✓� Expiration Date:
Job Site Address: City/State/Zip: �G]_ t5'&L Ql 70
Attach a copy of the workers'com nsatiou 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
Fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER a aline
of up to 5250.00 a day against the violator. Be advised that a copy of this statemettt may be forwarded to the Office of
nderification.
Investigations of the DIA for insurance coverage v
l do hereby certify under the/p7ains and penaldes ofperjury that the information provided abov is t ue and correct
"i=nut tre• i✓"� r�/Y' ,/ /�
Date: '7
Phone y: — —
01TIcial use only. Do not write in this area,to be completed by city or town official
City or Town: PermitiLlcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
3 Phone: 978-741-0424
Fax: 978-741-2012
ies.comA &I SERVf 115Nortth Street: Salem, MA 01970
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 property licensed facility as defined by M.G.L.c. 111, Sec. 150a.
The debris will be disposed at: Waste Management 877-515-2845
c/o Melrose Transfer Station
740 Broadway
Melrose, MA 02176
or
Waste Management, Dumpster Service
at
115 North Street
Salem, MA 01970
�•
Signature of rmit Applicant
Christopher Zorzv President
Name of Permit Applicant
0
Date
Massachusetts -Department of Public Safety
A&A SERVICES, INC Board of Building Regulations and Standards
Christopher Zorzy
_=
115 North Street License: CS-057733
Salem, MA 01970
CHRISTOPHER 7,, -_
115 NORTH ST f
Salem MA 019707 1�+
i
r // lr nrn.i ,n.rn�/�.r� ��ruun�in.:r//-1
J� �j � Expiration
Otlice of C onsnmer Aff urs&Ilusnass Keguiation Commissioner 05/26/2017
+ r �a HOME IMPROVEMENT I� CONTRACTOR Registration '. 101609
Expiration 6126/2018 Private Corporation
A&A SERVICES, INC!
I."
Christopher Zorzy
115 North Street _ -
Salem, MA at 970 tlnAersecretary