10 SUTTON AVE - BUILDING INSPECTION (9) ` t
%� The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
TX Massachusetts State Building Code, 780 CMR SALE
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D p
Building Official(Print Name) Signa ure Date
SECTION 1:SITE INFORMATION
,.,(Pro erty Address: Q 1.2 Assessors Map& Parcel Numbers
��J5+- n I l V2
L l a Is this an accepted 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 Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes0 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record:
�nne�EeCsl ► e ,CLlrr�r. MI� oc47a
Name(Print) City,State,ZIP
LO 1S-,*bt1x Avc, 97 S-7 yS=7a77
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Des iption of Proposed Work': In sfa / x Y? Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ LA SOQ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cos[ (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression, Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1..1 SO 0 0 Paid in Full 0 Outstanding Balance Due:
1 SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C 51-1 ,3 3 5-a6_! S
C,h t—S 20 r" License Number Expiration Date
Name of CSL Holder
�t List CSL Type(see below)_—A4
A Na
No.and Street Type Description
�l q U Unrestricted(Buildings up to 35,000 cu. ft.)
4.,.2Yvt a�tT ( l70 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
'L �f SF Solid Fuel Burning Appliances
A
-7?-- -6 l a I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
A'� l�zlsd i C S ,^C- b D (npirationD
C Registration Number Expiration Dale
HIC Cyan y Name or HIC Registrant Name
(I5 Nof 11� J5+-
No d�treet� Email address
CAA
0 1 9-7 �sr �a a -
City/Town,State,ZIP 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 .......... T( No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Y'.S o e--Z
to act on my behalf,in all matters relative to work authorized by this building permit application.
c ov- +&C+ -7-30-13
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained i his lication is i e and accurate to the best of my knowledge and understanding.
Print Owner's or Auth rize gent's Name(Electronic Signature) Uate
NOTES:
1. An Owner who Xtains 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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U.F. i NLA SSACHUSETTS
BL'II.DING DEPARTMENT
�+ N• 120 WASHINGTON STREET,3-FLOOR
j TET_ (978)745-9595
FAX(978)740-9846
KINfBFyJ FY DRISCOI..I
MAYORTriOhtAS ST.PIF44r`
DIRECTOR OF PUBLIC PROPERTY/BCD-DING CO.NDIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businessiorganizatiotvindividual):
Address: It S NO f tAn, St .
City/State/Zip: �0.�vv� m ft- O k910 Phone #:_91 R-- �7 41— 64XI
,%r_e,(�on an employer?Cheek the appropriate box: Type of project(required):
1.i'�i 1 am a employer with— 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor nr partner-
listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
workingfor me in an capacity, workers'comp.insurance.
Y9. [] Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised thew 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L[I 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' 13.❑Other
comp. insurance required.]
•Any applicant that checks box dl most also till out the section below abowing their wmkas'compensation policy information.
}I lom.:owncra who submit this affidavit indicating they are doing all work and then hire outside contractors meal submit a new arrdavit indicating such.
:Contraion;that check this box mast attached an nkffonar.brat showing the name of the cub-contractors and thou workers'comp,policy information.
l am an employer that is providing workers'compensation insurance jar my employees. Below is The policy and jab site
information
t
Insurance Company Name: kX r(am--cQSf_r -e ✓ S Policy#or Scif--ins.Lic.0:_ �t�-� 3 My � Expiration Date: q l'[ 3')
Job Sire Address: kO 1 i,4p✓ City/State/Zip: ';t.l2yvy (A)tt-O [y-7a
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
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ufthe DIA for insurance coverage verification.
i do hereby certify under the pains and penalties of perjury that the information provided ab is true and correc4
Sientture Date' -7' 3f7
' ( 3
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/I.1cense# _
Issuing Aul hority(circle one):
1. Board of Health 2. Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Olher
Contact Person: Phone#:
THE COMMONWEALTH OF MASSACHUSETTS
-3 'EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT
DEPARTMENT OF LABOR STANDARDS
6 f' 19 STANIFORD STREET,BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A&A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Saturday,June 07,2014
IN ACCORDANCE WITH M.G.L. CH. 111, § 197B(b)AND 454 CMR 22.03,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
ENTERING INTO OR ENGAGING IN DELEADING WORK.
THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L.CH. 111 § 197B(b)(2)AND 454 CMR 22.03.
HEATHER E.ROWE,DIRECTOR
�,/J f.Wg(- Massachusetts - Department of Public Safety
V1se 100lJaoRo74[O6aLl�of(-a> [ aj;aC11[eJECCJ �Wf
Office of Consumer Affairs fir.Busifiess Regulation Board of Building Regulations and Standards
IMPROVEMENT CONTRACTOR Construction Supercisor
VOME
egistration 101609 Type: License: CS-057733
xpiration: 612kb14. Private Corporatio !
' CMUSTOPHER ZORZY r
A&A SERVICES INC! 9
115 NORTH ST
Salem MA 01970� ,C _
Christopher Zorzy
115 North Street
Salem, NIA 01970 - 15' " "'' Expiration
Undersecretary I -'�°'"' ��- 05/26/2015
Commissioner
F L6 : .1 e_i
r + Ce IT,
ifrograIn
to 1 r 1
5
r , Christopher Zorzy a20120426000840
A&A Services Inc Exp 4/26/2017
115 North St
CHft*S ZC'RP) Salem, MA 01970 ;�'u-"}k�--`
iB€Y Z- c eer-o 1 .t _ .
tc Ivlatthew J"Gibson
. — , Fg,xSer CwvaCo-RwP^s
DISPOSAL OF DEBRIS AFFMAYM
in accoedanoe tvith goo provisions of M. Ga L. m 40, Seoo 540 a oondi6ion'of,
Building Permit Number— is that the debris resulting from this Work shall
be disposed of.in a peopePiy.frensad facility as defined.by fA 0. Lc. I I9, �90.
be debris debris will be ®ispo- d at., Uam Travisfiee Stalon
ownad by NoFfs¢do Cavbnq
ftnatoro V, PAMMOApplicant
Date
gy
Name of Permit A0p6oara4 .
A & A Sag eves. gav
Finn kGa.
B Mth gtFaaL Spesmo MA 04gc6