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55 TREMONT ST - BUILDING INSPECTION The Commonwealth ofMassachusetis WDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information //�� Please Print Legibly Name(Business/Organimtion/Individual): A Q A Se.r yi a e t Address: I I r� rJ o r+h Stre e� ` City/State/Zip:_ �)O l e,VV� M K) DI c1-7O Phone M / q23 1 '/A I - C),q a J 4 Aree an employer?Check the appropriate box: I Type of project(required): 1.UV I am a employer with_� 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. required.] officers have exercised their ❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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. 11 comp.insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContmctors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. -f� Insurance Company Name: t r te— Tr(aVO I e r'S Policy#or Self-ins. Lic. #: �L' C]og X 191 510 Expiration Date: q I I'-' l 0-7Job Site Address: Me)/* te to— 1emi IM 0/7 7O 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify n e e p sand penalties ofperjury that the information provided above is true and correct Si nature: Date: Phone#: (91$) 7,q I — D H P)A Official use only. Do not write in this area,to be completed by city or town oJrciaL 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#: e 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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license 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 cooperation 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 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 - Signature of Pe it Applicant ?/7/07 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 Linen e: CS 57733 �Birtfiffitp:__5/26/1958 - Exatron 5/26/2009 Tr6 13739 T= , I i CHRISTOPHERQRZS��t� -115 NORTH ST SALEM.MA 01970 Commissioner Commonwealth of Massachusetts Division of Occupational Safety Robert J.Prezioso,Commissioner Deleader-Contractor CHRISTOPHER ZORZY Elf.Date OM02/07 - Exp.Date OMD1/08 '�� DC000440 � Memberof C.O.N.E.ST. 08 Bo IIIIIIIIIIIIIIIIIIIIII IIIII IIIII III II IIIIIIIIII IIIIIIII BO5TON RENEW? . ,..._.._ - ... . . � �/ee 1°iomvnsanureaCC/ o�✓�¢mac�iueelYa—_��� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration. 101609 Expiration: 6/26/2008 1 " Type: Private Corporation A&A SERVICES, ING Christopher Zo¢y 115 North Street (((� Salem MA 01970 Deputy Adm,mst, for - A & A SEAVICtS, INC. A&ASBMICES 5 NORTH STREET, LEt4770 8 41 Contractor Registration No.101609 Federal EIN:04-3090162 Construction Supervisor No.CS057733 ROOFING SPECIFICATION SHEET Buyers)Name / Date of Comrectt o/'C v garp A/ 9uyer(s)Sheet Address,City,State and Zip Code 3-3' repo l -- 9*. em c S. Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address 9?�-993-d96q 9&J-da�gdio The Buyer(s)listed above hereby jointly and sevareliy agree to purchase the goods mullor services IhNd below,in spmroanca with the prices and terms described on Nis Speciaceaon sheet and the from aM me reverse of me accomperrylig CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specula - Sheet is a part. ROOFING SPECIFICATION Strip Roof of# layers of shingles ❑ Install 6'of ice and water shield at base of roof where O Install 15.1h felt paper to roof. - possible. Install 18-24"of toe and water shield in valleys. - ❑ Flash chimney as needed(no repointing included). ❑ Install 6"perimeter drip edge to rakes and fascia areas. _❑ Install vent pipe boots and seal as needed. ❑ Flash valleys as needed ❑ Install rollout type ridge vent. ❑Planks/plywood replacement under 32 SO FT included, "If more is needed there will be an extra charge of$ per hour for labor plus the cost of materials. - ❑ Dumpster/Disposal Included: Q Other: Location: Install new roof: Manufacturer yr Style/type Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. Ali RUBBER ROOFING SPECIFICATION ❑ St' Roof Not Strip Roof Install 1/2"High Density Fiberboard to existing roof using Flash obstacles as needed. screws and plates. Install.060 membrane EPDM(Black)rubber roofing to Install 3x3 aluminum drip edge to perimeter of roof with fiberboard.s seam tape. ❑ Flash up sidewall as needed. Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. SPECIAL INSTRUCTIONS: �r1S 6v er S v e 7) Wooh of oUse L614.4214C G+t/ers2 ,CbWA D fr (-^/Of- WE$e n Svc N b agreed antl uMenNM by and between fhe pa ass NM this specification Sheet,along wah CUSTOM REMODELING Me IMPROVEMENT AGREEMENT,comminute. Ne entire uMentl ing between Ne pWe&antl Nero ere no verbal under Mlrge changing of motlaying ary arms term&This confect may not In changed ar as terms m ffie w wdetl in any way unless ouch change am In writing end sigmd by Wo Ne Buyerte)antl Ne Conhector.Buym(a)hereq aeknowletlga that Buyerte) . .. hea nasal the swill eao/nrSnem. /�, Contactor Initials: / ' Date: /-n-07 Buyer's Initial4iff— Date: 1 'I �__o A & A SERVICES, INC. 115.NORTH STREET,SALEM,MA 01970 as 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 Buyer(s)Name - Data of Contract Buyer(s)Sheat Address,City,Stare and Zip Code 3-S TrentoD f Si. ,S q PM /ASS Daytime Telephone Number Evening Telhol4one Number M Ile Telephone Number E-Mall Address: 603-00V0 The Buyer(s)listed above hereby jointly and severally agree to purchase the goods sndlor seedoea listed on the eccampanyilg spedfication sheets,in accordanco with Me prices and terms described on the from and the memo of this agreement and any specification sheets(dtis'Agro morn,and BW r(s)have requested that such goods or asrviees be,installed or provided of Buyers add..listed above.AaA Services,Inc rCDmractor7,hereby agrees to Install or eauso W be installed the amducLs , or services hexed in this Agreement 0 Me Buyer(s)address veitlen some. This Agreement represents a cash sale or goods and services. The Buyer(s)agree to pay In cash me cost of the goods and services purchased as desodbsol herein,regardless of liming or approval of any branding Buyer(s)may seek for their purchase. Purchase Price Est.Sterling Dal.8—0-0 TT Down Payment ©O n o [�] WO!// yL.C//fCn/C`Bl!/ Est.Completion Dat��J-0; , )9,t jDfLs' ..P QWTer /r{r ❑Cash Amount Due on Start of Job: ❑Check 2n HClMQ Amoum due on of Completion: ❑Crank CabNo. Amount Due on_of Completion: Expiration Data: Balance Due on Upon Completi /` 46l1�� Wew1 df CVC Cade: B 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 farms of this Agreement. - Buyer(s)hereby acknowledge that Buyer(s)has mad 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 forme,on the date first written above. Buyer(s)also (1)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 IF IT CONTAINS ANY BLANK SPACES mce By: rg rre iylerc /on S19natur�e��fi/ore R0UrCn QfW G Print Name Print Name Signature Print NameI', You,the Buyer(a),may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. 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DATE: 8/ /,/) 7 Citp Df rbUgttt5 PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED L Location of Building_ T/�Ph10/7 f S�7'P T Building Permit ApplicatioEitimi, '(Circle whichever applies Reroof, Install Siding, Construct Deck, Shed,Pool Alteration, Repair/Replace,Foundation Only,Wrecking Other.- PLEASE FELL 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: ftI 60/ e'h1�,ln-1 Contractor: A e A 6e.rviu5/Chn_6 r—A Street 557rerno 4f Citylem Street -1(5 iJnt +h City � State.m, Phone c99a State MA Phone. 07`d} Architect: City of Salem Lich I W a5 Street City State Lic n57 HIP# 1©I to 09 State Phone ( ) Homeowners Exempt Form_yes__I/no Structure: (please circle) Single Famii Multi Family# Other Estimated Cost of job S 3UD OD Will building confirm to law?_yes no Asbestos?_yes_t/ no Description of work to be done: S�s�all y '/a 50udreS n fiber ✓on n'q A&A SERVICES, INC. 115 NORTH Drawings Submitted:_�es,� no . Mail Permit to: , . SAI_EM,MA 01970 J{ Al tNtNVV.A-ASEpVIC�S. Signature of App cation,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE Department use only: Permit# Zoning Mep/Lot Permit fee S COMMENTS: ^x V. No. �� A P pLICATTION FOR _ pI=RMI1 TO � LOCATION ;4 PEIMIT GRANTED APPR V p r S CTOn OF 8 ILDINGS CERTIFICATE OF OCCUPANCY - YES