14 SUMMIT AVE - BUILDING INSPECTION The Commonwealth of %Iassaehusetts
t Board of Building Rc�ulations and Standards
I( NIl'll'.\I I 1"
(� 0 CNIR. 7"' edition
M.tssachusctts State 13uildin� ( ode. 75 ( ti(
Building Permit .application To Construct. Repair. Renovate Or Den,ol ish :l Kri, rJ l,rnu in
One- or Tan-Family Dwrllin,q 00S
_ phis Section For Official Use Only
l\ Buildine Permit Number: Date Applied:
Signature: '--"r---
Building Conunissioncrl htspcetnr of Buildings Uarc _—_--�
SECTION 1: SITE INFORMATION
LI Property :\illness: 1.2 Assessors Map & Parcel Numbers
uleiy) --
Ma �umher P:ueel \umhrr
1.Lt Is this an accepted street? yes�no_ p'
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Fromagc rlit .
1.5 Building Setbacks(ft)
Front Yard Side Yards - Rear Yard
! Required Provided - Required Provided Required Pro�idud
1.6 Water Supply: (M.G.L c.40. §51) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'? - ,Municipal ❑ On site disposal syslcn, ❑
Public ❑ Pri%ate❑ Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2. °hey f P-eeO :-��hY 5akz Mm
Address t'or Service:, 17
X--ort6 'P. f�i °7 7 V 7 / 9- -
=.� r Telephon
�. Signature" e
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 1.
Addition ❑
Demolition ❑ Accessory.Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description. of Proposed Work'-�yt f2,�-6
C S U
SECTION 4: ESTIMATED CONSTIkUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
1. Building $ d 51y UD I. Building Permit Fee: $ __ Indicate how fee is de(ernuned:
❑ S(andard City/Town ;\pplication Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing S 2. Other Fees: $
a. Mechanical (HVAC) $ - List:
5-5. Mechanical (Fire , "fatal All Fees:
Check No. Check :\mount Ca h
j b. Total Project Cost: 11 d`� 5O 5.0 O 0 Paid in Full (:3 Outstanding Balance Doc:---. -_
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
'5-7 7um3 ��
Llcensc N'unlhet —. ynr:u. n l�.ue
Naruo ill CSL- Iloldcr
1 Lul CSL 'I'.IpC Isee heluwl —
WJrcs� 1 v e Dascn uuat
L t 111c, l'IC(CJ I❑l in�i3OOtt Cn. I'1.�
R Resumed L@'_ Famlh D%kellin_
1 Sienaw.e \1 \lunonn Onto
"b I ' ReelJenual Ruul'ine('ol eon_
`7 1W
Trlrph.ne - _ \l'S Ite+iJen(l.:l \VInJu�s .utJ SiJule _-
SF RC.,IJelltlal S.hd Purl ....nine \ 1ili:nce In.l.dlatl,rcl
D Re,IJellllal Denlohuun
5.77 Regiaa'tered Home Improvement Contractor 011C) ID)
l.Od-1
its HJPfVI(f1ST=i'1C --
HIC Cl�i p; Name or 1-11C R`glslrant Name fteg6tlHtloll Nuniher
Addressp .
- - Ex uati.n Date
Signature. Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit 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. -
Signed Affidavit Attached'? Yes .......... ❑ No ........... ❑ -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I A�- - , as Owner of the subject property hereby
authorize I Ph& Zorz.LAto act on my behalf, in all matters
relative to work authorized by this building permi n p lic- tion.- -
, Y
S—Si-nature_ul_Osvner ea
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, t�hrl SaT'�(�Ir1P r ZorZLh , as Owner or Authorized Agent hereby Jecl:re
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
rZ
Print e
� .Signature-ol Owner-o Authorized Agent Date -
ISiened under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an itnregis ter ed contractor
(nut registered in the Home Improvement Contraclor(HIC) Program), will not have access to.the mbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be tound in 7SO C'MR Regulations I I O.R6 and 1 IO.R9•.respectively.
1 '. When substantial work is planned: provide the information below:
Total floors area (Sq. Ft.) .including garage, finished basement/attics, decks ur porch)
Gross living area (Sq. Ft.) - - Habitable room ci;unt
Number of fireplaces - Number of bednnnn, --_
Number of bathrooms Number of halt/hwli,
rvpe of heating systern Number of deck,/ perches -------__--
Type of cooling syslcm Enclooed Ope❑
3. "Total Project Square Footage" may be substituted ro, -rntai Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
L DEPARTMENT
\L;t, :n I_': \1'�;n;�t,:,�� Sntrrl • SUfV. \Ls�;�; t�,t .ri :.=11-_
1'h.1: 9'8--�;.•i;15 F k X: '/"8--4_-9840
Workers' Compensation Insurance Affida%it: Builders/Contractors/Electricians/Plumbers
A t li -ant Information Please Print Le is blY
.\:Illy I nu.:ne.; l h_.uucuton Inds tdu.dl: ke A 6erv( C15 Inc
\ddreSS: 11 ;5 ►Joe+h 51e ff
Cityst:ue/zip: alPrn Mtn DIg7 Phone
Are von an employer:' Check the appropriate box: Type of project (required):
1.U
�-,/! am a employer with J. ❑
❑ 1 am a general contractor and 1 6. New construction
employees!full and/or part-time).' have hired the sub-contractors listed on the attached sheet. 7. 0 Remodeling
'.❑ I .,in a sole proprietor or partner-
ship and have no employees -Fhese sub-contractors have _ 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
]No workers' comp. insurance 5. ElWe are a corporation and its 10 ❑ Electrical repairs or additions
iequired i officers have exercised their
right of exemption per MGL 11.0 Plumbing repairs or additions
t.❑ 1 ys a homeowner doing all work 6 p P 11.❑ Roof repairs
myself. (No workers' camp. C. 152, §1(3),and we have no
insurance required.] t employees. [No workers' 13.® Other W117o(fh....S._
comp. insurance required.]
\ny applicant Ihat checks box#1 must also till out the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet shuwing the name of the sub-contractors and their workers'comp, policy information.
t um an employer that is providing workers'c•onrpen.cation insurane•e for my employees. Below is the policy and job site
information. —f1�� �•r� / 1
h oraricemati Company Name: 1 Y K,. I r l V e-1 c 2?
Policy # or Self-ins. Lic. #C: ' O_J' H %p u L.� Expiration Date:_
Job Site Address: l y 5UMM l (Hi City/State/Zip: ]
:4,ttach 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 NIGL c. 152 can lead to the imposition of criminal,penalties of a
tine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a tine
Of up to S250.00 a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Im cslivalinns of the DIA tin insurance roxerage verification.
/do hereby a err, order the pools and penulrie.v of perjury rhut the infinrrnation provided❑bore is true and correct
---U%ficiul use only. Do not write in this area, to be completed by city or town official
City or I own: PennitiLicense #_._._._
(suing Authority (circle one):
I. Board of Health 2. Building Department 3. Cih7Town Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other ----_
Contact Person:---__ -.—. —, Phone #:__
Information and Instructions
N las,aC hu set is General Laws chapter I5' requ uesa 11 crttplo%crs to pro%ide workers' compensation fix their employ-ees.
I'ursu.mt in this >utute, .fit emplgree is dcGned as c%cq person In the set ice of.mother under anv Contract of hire.
,•\hrc,s or implied, oral or Imrten."
\n einphtrer is dclined as "an indite;dual. p.tnnar.hip. .1;sociation. corporation or other legal entity. or any two or more
,,1 the foregoing engaged in a join t cntcrprise. and including the leg aI representatives of a deceased employer. or the
rcCcikcr or Iru,tee of an indivtduaL partnership, association or otter legal ennty, curpIoving employees. I towe%er the
w•.,ter of a dwelling house has ing not more than three apartments and hs ho resides therein, or (Ile occupant of the
dI%ailing house of;morher who employs persons to do maintenance, construction or repair %%ork on such dwelling house
or ant file grounds or building appurtenant thereto Shall not hCt;w,e of>uch employ men[ be deemed to be an employer."
NI(iL chapter 152, �s25C(6) also states that "every state or local licensing ageney shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the contmon.vealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, '.I(;L chapter 152, ti'SC(i) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract fix the perfor'nhance of public«ork until acceptable evidence ofcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) namels), address(es) and phone number(s) along with their certiticate(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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permidlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permiulicense applications in any given year, need only submit one affidavit indicating current
Policy informhation (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 lileense or permit not related to any business or commercial venture
(i.e. If dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
rho ( It fice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do mn hesitate to give us a Call.
I ile Department's address, telephone and tax 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
itev set 5-'0-05 Fax # 617-727-7749
www.mass.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.
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northside Carting
CSignature of.PermitApplicant
OZ
CDate
Christopher Zorzy
Name of Permit Applicant
A &A Services, Inc
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
USUNRISE1-mok for the
'l _ WINDOWS®
The Difference is ClearL NFRC L,abel
The National Fenestration Rating
Council's (NFRC) Energy Performance hn„Exrruded.0.�; Argon Fell
�� Uma U Mos.Warm EOge Spier
label is designed to help consumers ® wpa tyMeeiape:vemoi sneer
CITY MPG HWY MPG measure and compare the energy ENERGY PERFORMANCE RATINGS
�6 33 Performance of different window IYFaaorN3hPm SararaeatGalnCodfident
brands. Just as the EPA sticker on a 0.31 0.37
new car will give you a guideline to the ADDITIONALturce PERFORMANCE RATINGS
ACWI MIMegev/peerywloesullna,emWrySponENpm, 9 Y g' Visible Tnnsmltronce. Air lealmge NShP)
eMEPA inebae see thermlieftp e�,pepmpp�pd 0.54 0. 1
dEpaina�.UnU•mmse.„ .e„30m,1u�p ears fuel economy, the NFRC label on
eeumems xie ecbiwe beNreen 23 ene 3o mpa In Vre
dr,eM betwee^26 arM 3a mp0 on Me hi ro ly a window gives consistent ratings that Condensed naesisbixe
The higher me gas mileage the better. can help consumers determine both 54
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deldreded.doemselinter and Summer performance .m,..m.�.,,_...,..,...,„��.,
characteristics. -�^'
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CNFJ The Difference is Cleary * summer- x
U Fa or Sunrise Windows Solar Heat Gain-
Vinyl Extruded, Dual Glaze, Argon Fill v 4+1 oeffCient` I
In the WINTER,the Naaona Ferlestraeon Ultra U Plus, Warm Edge Spacer
lower a window's overall Raft Cour ca .(SH43C)
Product Type: Vertical Slider
youU-v lue,will the less lose
t Product Number00037 In theSlliVfikIFR,f
you will lose throu
that window. owes oS�G�means les's
ENERGY PERFORMANCE RATINGS `
-va solar 6do
rade eorionts *t r(U.S✓I- iei�-leat Gain Coe tlCic t f �yindow Your home
ur saving y
more,si ou ace �4h¢ will remain cooler and
nce your furn s our air conditioner will
isn't running as much. Y 3 1 0 ■ 3 not have to work as hard.
ADDITIONAL PERFORMANCE RATINGS
Visible I r I -J�
M-a smiittance irisibleTransmittance eakage (U.S
Visible Transmittance 0 5 4 Owl E
' ower the iirir a,
(VT)measures how • ess '. ^and'air`
much light comes Condensation Resistance do The lowest
through a product. The number the government
higher the visible assigns is a.1 and
transmittance,the less Sunrise Windows
tint there will be to the actually are even lower.
glass. A higher VT rate Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole Windows with an air
ensures a clearer piece product performance.NFRC ratings are determined for a fired set of environmental conditions and a leakage number
of glass. specific product sae.Consult manufacturer's literature for other product performance information. above.3 fail this test.
www.nfrc.org
Actual test sample .03 air leakage.
041107 SS7-V3
' i ✓>fg T009n J,t6➢Effl¢dLIIE O ✓�(�d�ud�
- Board of Building Regulatio'ns and Standards
Construction Supervisor License
License: CS 57733
AIr d_k1eL_526/1958
! piers oH-n iz6Y2009 Tr# 13739 1
11^�
-�S�tnzctlar�—UO!
CHRISTOPHER
115 NORTH ST
I SALEM,MA 01970 Commissioner
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609 `
Ezpirationc, 6/2 612 0 1 0 Tr# 267870
- ;Type;_Private Corporafipn
A&A SERVICES,'INC=
Christopher Zorzy%'4 ' y,';'�•
115 North Street � `
Salem,MA 01970 Administrator
Commonwealth of Massachusetts
Division of Otxuparional Safety
Laura M Men Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eli.Date 04/09/08 N
Exp.Date 04/08/09 �{
09
D0000440
Nemberof C.O.N.ES.T:
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