6 SUMMIT AVE - BUILDING INSPECTION No. �
APPLICAjION FOR
PEAWTO
LOCATION
PE"MIT GRANTED
Z
iPFRIVPD
IN TOM OF BUIL GS <. -
CERTIFICATE OF OCCUPANCY .
YES
NO .
DATE:
Citp of a��YQl7Y, fiaacLjuEtt
r
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED "
SUmm i 7 �v�Y1U �_
Building Permit Application For: Location of Building (p
`(Circle whichever applies) Roof, Reroof, Install Si ' ct Deck, Shed,Pool
Addition, Alteration epatr place, undation Only, Wrecking
Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name-. OcArihIQ t Contractor: A9- A Sr_i"viu5i(I}1rt5 bra
Street p 5ummi-� & e City 501CM Street__I1_ ND(4h 5 ". _City
State, HA Phone 0%)_�/15 _ bg to 44 State IyI R Phone• (R7g) 791 H
Architect: City of Salem Lic# 1 W 125
Street City State Lic b57 HIP k I D f to 09
State Phone ( ) Homeowners Exempt Form_yes—V—/ no
Structure: (please circle) Single Family, ulti Famil 02 Other
Estimated Cost of job S I D, 1-I g L o D O
Will building confirm to law? ,/ ves no
Asbestos?_yes ✓ no Description of work to be done: n I C C2 Dr 1� l�> C 1Q 1 C1 '/Z 1 1 tsa )a (7-r
V1JI�hel' rnD L4 AAA a •t ) (�IO(0 Pxt
((p X Lo DI e-GiL IA), I I1 1211J ( AP( i� IG�P �i() fVIIL /fit .on 16Yf5
A&A SERVICES,,INC.
Drawin miffed:_des no Mail Permit to: SALEM,MA 01970
A " �o9gi741-0424,
X WiNN/.A-Ab
Signature of Appli lion,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
' 1
4
The Commonwealth of Massachusetts
Department of Industrial Accidents
(.4 Office of Investigations
t,itlfi / 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leetbly
Name(Business/Organization/Individual):-_A. Q A 5p_r VI a S z"y')o+
i
Address: Q 0 r+h frhre e.+
City/State/Zip:-50 p,M r M19 01�f7D Phone / g7$1 211 —DL{ 9,J-4
A
reployer?Check the appropriate box:
to er with�_ 4. [8.
pe of project(required):P Y ❑ I am a general contractor and Is(full and/or part-time)." have hired the sub-contractors ❑New construction.
le proprietor or partner- listed on the attached sheet. t ❑Remodelingave no employees These sub-contractors have ❑Demolition
for me in any capacity. workers'comp.insurance.
No workers' comp. 5. ❑Building addition
p ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no ME]Roof repairs
insurance required.] t employees. [No workers' ,
comp,insurance required.] 13.(J Other nPl�l�
*Any applicant that checks box#1 must also fill 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.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/am an employer that is providing workers'compensation insurance jar my employees: Below is the policy and job site
information.
Insurance Company Name_jhe__ Tra Ve I_e ycc.�
Policy#or Self-ins.Lie.#:_�/L' L{gq X 12 510
Expiration Date: 9 I'' .1 0_7
Job Site Address: 10 Ay en U-C City/State/Zip: S-Unq 01 q70
Attach 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 tine up to$1,500.00 and/or one-year.imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a lane
of lip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do Hereby certify u der the pains and penalties of perjury that the information provided above is true and correct
Si mature:
Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence 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
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemilUlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperatiorf and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
r
DISP OSAL 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.
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northside Carona -
Signature of Pe it Applicant
Date
Christopher Zorzy
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 57733
Birthdate-_5/26/1958 i
Tr# 13739
;
sI
i��(tesfnction.-00t '�
CHRISTOPHER
115 NORTH ST �"G--
\ . /
SALEM, MA 01970 Commissioner
Comdidnwealth of Massachusetts
Division of Occupational Safety
Robert J.Piezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Ell.Date 02/09/06
Exp.Date 02/08/07
DC000440
Wemher0(CO.N.E.S.T07,
;8I0 II III ,, It
�. l IIIIII II II IIIII III IIIIIII II IIIIII III II III BOSTON-RENEW
✓� IDO�YviILO�G[Ii¢¢G4L a�✓l�LaddaC�ulQe�d '�.
! Board ofNuilding Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration 1,01609
Expiration: 6%26/2008
'Type. Private Corporatlon
A&A SERVICES, INC -.
Christopher Zorzy
115 North Street
'.Salem MA01970 Deputy Admimsb tor:.
i� A & A SERVICES, INC.
A&A SS ICES 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 -
t aCk ,J— ROOFING SPECIFICATION SHEET
euyean Name Date of Contract - -
C N lhir} Cecelski S/o a7
Buyenn Street Address,CM.State and Zip Code
SN a1lr �1F� Qrl?70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
g7S745=6 6 q
The Buyens)listed above hereby jointly and severalty agree to purchase the goods anclor services listed below,in accomance with the prose and terms described on
this Specification sheet and the front and to reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a pad.. -
ROOFING SPECIFICATION
Strip Roof of# layers of shingles -
❑Install W of ice and water shield at base of roc where O Install 15.b felt paper to roof.
possible. Install 18-24"of ice and water s d in valleys.
❑Flash chimney as needed(no rep nting included). ❑ Install 6"perimeter drip edge rakes and fascia areas.
❑Install vent pipe boots ands I as needed. ❑Flash valleys as needed
❑Install rollout type ridg ant. ❑Planks/plywood re cement under 32 SO FT included,
9f more is needed ere will be an extra charge of$
per hour for lab plus the cost of materials. -
❑Dumpster/Dis sal Included: ❑Other.
Location: -
Install new roof: Manufacturer yr SryleAype
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
RUBBER ROOFING SPECIFICATION / pli7W RiV�J: Zrh
Strip Roof ❑Not Strip Roof D15lbs4/ i n[l.rded I kX$1
Install 1/2"High Density Fiberboard to existing roof using arFlash obstacles as needed. AIewe)Fa
screws and plates.
W Install.060 membrane EPDM(Black)rubber roofing to Wfonstall 3x3 aluminum drip edge to perimeter of roof with
fiib✓erboard.s seam tape. -
ur Flash up sidewall as needed.
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
peck rePIA«N}� rk1;eN �«�r+aA�: zrdF� Front
SPECIAL INSTRUCTIONS:
�nshaff wr.,.LrlkgrdsdfwtgP o f' rKbberrco
Pl j??oar, e+pso� fatt, s krra'�
��usFAl/ 9Y FrA-Ate;.gork 6_1e sP -fo codg_
` _TAusfHll Prow arE;�t� E;eTa BotWan j 4�I k strip3 bet4,a2ll
bAIU$�9&+Rit1� Rc-IrLve&Rnlusfe45.� -rornd-e
• s`,�}g i l 7 raa�E 6 X(o Yes IJrIA TjdAaaff k 6>4, 94
c e
in/v 1 tF7-e fJltie �m p2tr-_e !X S W�rJbDsAV3 oo}
�QAN u��,c lu ���`fY1'{i n4�c�baintno t�cludec�• .
H is agreed and understood by and between the parties that this Specification Sheet along with CUSTOM REMODELING ANU IMPROVEMENT AGREEMENT,con.tltute.
Me entire understanding between the prefer,and Mere are Fro verbal understandings changing or modiMng any of the lama.This common may not be changed or Its,
term.madHled or varied In any way unless such changes are in writing and signed by both the Boyens)and the Contractor.Buyens)hereby aclarwwledge that Buyer(.)
has read this Spsdgratlon Sheet
Contractor Initials: Date: _f�ss�y�/�OY17 Buyer's Initials: -(rA4 Date: T 5//B. p�_/
/ � '
A & A SERVICES, INC.
115 NORTH STREET,SALEM,MA 01970
r 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
Buyers)Name Date of Contract
C 'e
Buyer(s)Street Address,City,State and Zip Code
Su.lvk ' e [ d
Daytime Telephone Number Evening Telephone Number Moblle Telephone Number E-Mail Address: _
69 ktl
The Buyers)listed above hereby jointly and severally agree R purchase to goods and/or services listed on the accompanying specification Sheets,in accordance with
Me prices and terms described an the front antl the reverse of this agreement and any spedfication sheets(this"Agreement'),and Buyer(s)have requested that such
goods or services be Installed or provided at Buyer's address listed above.A&A Services,Inc.('Contracti hereby agrees to install or cause to be installed the products
or services listed in this Agreement at the Buyers)address written above. This Agreement represents a cash Sale of goods and services.The Buyer(s)agree to pay in
.an Me at of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their purchase.
Pureness Price: O Est.Slatting.Date
Down Payment Est.Completion Date:1119.LtYA
❑Cash
Amount Due on Start of Job: OCR eck
O Credit Card
Amount due an of Completion: No. '
Amount Due on of Completion' Expiration Date:
Balance Due on Upon Completion: 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.
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. Buyer(s)also
(i)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 Buyers)would be Interested in any additional quality
products or services of Contractor. DO NOT SIGN THIS CONTRACT IE IT CONTAINS ANY BLANK SPACES.
6y: Services,Inc�t Buy - - i /}`
y: 9YUC8lLl _Kure /O
Signature Sin ere
<atff Gydd ��t��xa 2 C�eFLse�
Print Name Print Name
Signature -
Print Name
You,the Buyere,may cancel this transaction at any time prior to midnight of the third business day after the data of this
transaction. Sea the following Notice of Cancellation form for an explanation of this right.
AflennorM The arbaMr and the Mmeawner hereby tumor y agree In eManu NN in the even eiMer a,has a of,.mrremilg the anrracL eHMr pam may submit Bunn dlspW b
B plvate udi,..a aervva,huh has whe aam.by the Semetary re to Gatti day.of canme,Alan and Boathouse flegutvbns and the other Mary shall M real to susenit to
auah..on as prawn In se G.L.dr.1
Coemcwr mida' auycl WitiW: .
paz: 6Je:
Ni OF CAN NOT CE OF CANCELLPT-
Data of Translation .You may.1 Mk trvueetian.keHeat art,penal,M Bata of Traneamon .You may aaeI His bansanlan,wlMat any peed,M
obligegan,.inO—busi—daysl,mn.a Wdate.Iryoussaganyouxurtookk in, ablkaN.wMinthreebusnevdayshamtyaN dA.Hyw wh®I,any gopeMtraded in.
empaymehmmaabvyoauhmmuecabenarsme,wdenymgauamelnebumamesxut.d wymmenremadebywuundarmacomremorsne.wdmyneAamaihum,mentw ted
bywuvnnberelumadvnw'm to mw mlladne reaiptMMa smlarmvmhraaallelion nwa, byyouwillberewmedwimb,lodanlalawingreaelptbylbesellnmyaur�latnnnnme,
and arty securlry LMresl srLa'ng oN of Ve bansadon will he ahcallM.if yeu di you must wdwysewd,imares"neoutot Natransanlonwinbemg IIled.Hyoucaeparycumhm
nWaauabalebtlre Segx LyWrreSlenX,In subslMNallyae ga<' a'hdNon Sv xfian reai.YE, make avalaMeto Me$elprgypur rBavkrcg,In PLMUntlalfy a9 pvi gMitih4hazwhen f0mrv9d.
a nygoadsdelM1reredtoyauuwerfts Lontrantorsale:orynumay,iF} wish,amplywith Pq anygwdedelNere WwuuMer Nis Condanor Sae;oryamayilynu Msh.complyw He
InetuTore al Me Seller reporter,the reNm stile ent of Hb Reds to Ne sealers eadense arp Instructions of He Seller rega,d'mg Muhl Niprgnt of Me¢adv at Be Stairs Mora e w o
ht, If you do make Na Goods Several to Ma Box,.Me Soler sees not peak them up MR. If you Be make the goads avalffile b ft Bello and He Behalf dace her pick Nem up
wiMN A days of He data of your Nata 0 Cardalood,you may reran or disyu M.goods wlhin aJ three al.data of your Notice N Canalleflaq you may retain or ahpow of Me goof
wMous arty NMer obllgation.If WU lei to make Me gads Matisse to Me Staler,or ll you agree nupoolaeryNMuoblga4an,Ilyoufmib ketMgM avOebYb Ne Seler,orifyouagme
to realm Me grade he Me Bailer aM hO to W so.two yw remain leek for pmbrmarce of all the sWm Me gokle to Me Soar aM tail b do ad.Na you remain Will for pede'mana of hil
callgatloa urder the barrel To anaal this namatudi mail or delNer a sighed aM dated mry obligations haler Me Cartraol.To anal Buy tharaeslla,mat m ael'hea,a tuned and,ktutl ary
of to aaelleaan rwtia or any other wMten atice,a aM a taegrem,to ALA 15 of Me arhallafon rood[,or Saw Mar Make nods,or wend a teu rim,re A&A Growers,115
Fault S.,Sekm.Meaty]...nl BTo,NOT LATEB THAN MIDNIGMTOF Na-Stral.Salem,..us.ol.,NOT tATEfl THAN MIDNIGHT OF
IDoon loakl
I HEREBY CANCELTHIS TRANSACTION. ConsumaasignaWs Dare I HEREBY CANCELTHIS TMNSACTION. ConmmahsignaWre Dem