102 TREMONT ST - BUILDING INSPECTION (2) 1Zc33�S
The Commonwealth of Massachusetts
Board of Building Regulations and Standards �w7 S � ;eF
tr Massachusetts State Building Code, 780 CMR A
��pp !! � /�evised Mar 2011
(J Building Permit Application To Construct, Repair, Renovate Or Bib ... A C 1
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applie . nn
Building Official(Print Name) Signature VDate
Ca SECTION 1: SITE INFORMATION
1.1 Propert EiMD Address: 1.2 Assessors Map& Parcel Numbers
� f S
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
ZoningDistrict Proposed Use Lot Areas ft Frontage ft
P ( 9 ) ( )
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
r�rr nla4 S�o 0
Name(Print) J� � City, State,ZIP
1a�Irenlr) + q�V G/d(K
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 ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
Ac, t Porck S-fat Clot
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
L Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical
❑ Standard City/Town Application Fee
$
❑Total Project Cost (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: $ l—�3 ❑ Paid in Full ❑Outstanding Balance Due:
v m-PA,L-c-:D vo A t i� SE:W ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction'Supervisor License(CSL) cs _o�'� a(o 1
T
0(,7/'o License Number Expiration Date
Name ofCSL olden
! E' List CSL Type(see below)
leg
o. and Street _ Type Description
S LOW)� n„ 4 I �O U Unrestricted(Buildings u to 35.000 cu. ft.)
�/ R Restricted I&2 Family Dwelling
Ciry/Town, at ZI M Masonry
RC Rooting Covering
INS Window and Siding
r SF Solid Fuel Burning Appliances
I� I Insulation
Telephone Email address D Demolition
5.2 Registered Improvement Contractor(HIC)^ 7 ,Q
4/ / aJ,-Rt�tCe� ` l�VI�t J�t� �!'� /.,o K-2� HIC Registration Number ExlpJiration ate
HIC Comp ny Nam r HIC egistrant Name ' /
0 &4,
No.and Street s, e lj Email address
City/Town, State,ZIP V 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, as Owner of the subject property, hereby authorize (J �P�U IC'2
to act on my behalf, in all matters relative to work authorized by this building permit application.
� cOK4yta - 7 dl b
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER` OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
containe t s application is true and accurate to the best of my knowledge and understanding. 16
a �
rint Owners or Auth zed Agent's Name(Electronic Signature) Date
NOTES:
L 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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
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 halfibaths
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"
A & A SERVICES, INC.
115 NORTH STREET,SALEM,MA01970
A&A SERVICES Telephone: (978)741-0424 Par: (978)741-2012
Contractor Registration No.101609
Federal EIN: 04-3090162 Construction Supervisor No.CS057733
MISCELLANEOUS SPECIFICATION SHEET
Buyer(S)Name Date of Contract
�;W C + l`V1,hlyz7)I-,1 Sir t 7- i 9 - l E•
Buyers)Street Address,City,Slate and Zip Code
u 2 I-M�7-M u,7, r S T S9 L e1N1 1"14 t7/57 L)
Daytime Telephone Evening Telephone Mobile Telephone Number E-Mail Address
978-7 OVI9
The Buyers)listed above hereby jointly and severly agree to pureness the goods and/or services listed below,in accordance with the prices and terms de-
scribed on this specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which
the Specification sheet is a part. '�
r'A _i:Or roo--H S"�/�5 rO�rrfLINSS
SPECIAL INSTRUCTIONS
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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 and 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. Buyers)hereby
acknowledge that Buyer(s)has read the Specification Sheet.
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Contractor Initials: 4'J Date: 7 -I —/� Buyer's Initials: X ! AAA Date:
/�,, w �p����/(P(�1 =ir A & A SERVICES, INC.
A&A SM ICES 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 Date of Contract
Dc�vG- -c /tit✓t2Ur
Bu ors Street Address, Cit State and Zi Code
/02 T72ca1oNT _ST SA( citi7 DW 0/`f7L7
Da ime Telephone Number Evening Telephone Number Mobile Tele hone Number E-Mail Address
�71�-�1/� z N T71-A A /W C 73 GCloy'r-tG ST,
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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 pravided 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 written above.This Agreement represents a cash sale of goods and services.The Buyers)
agree to pay in cash the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their
'purchase. o
Purchase Price. y/33 Est,Staling Date F-1a1 / _
his
Down Payment: /37S' Est,Completion Date: /
❑:Cash
Amount Due on Start of Job heck
C
CCredit Card
Amount Due on_of Completion: No.
Amount Due on of Completion: Expiration Date'
Balance Due on Upon Completion: Z7�f" r 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 antl 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.Buyers)also if 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 Buyerte)would be interested in any additional quality products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT
CONTAINS ANY BLANK SPACES.
A&A S is/Jos,Inc. Buyer(s), `/-p
Signaturr�e-y�
G b //3✓/L 4 i Signature /' /i
h- r 1 a2'�'�� /�
Print Name Print Name
X
Signature
k
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,The commcbr and the remember hereby mutually agree in advance that in 0e event either patty des a dispute mnceming this contrad either parry may submO such dispute to
private arUlretion service wfiiU prava V has De¢n aptl Dy N¢5¢ elry eol the Fjecuive re mer t Om of Consu Affairs and Business fte0ulations antl me alter patty stall TO required
srrvl to such
ernitfa4on as proved in M G L c 102A. Bully,
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Onu. ','- "-'," /CCU"— _
NOTICE OF CANCELLATION NOTICE OF CANCE N
m LLATIO
Dale of Tovanomn-'''TT—(51 You rvy beneficial.el this benefial.wimote any penally or Dale of Transacuan — 4/ 1 You may cancel this transaction.Mmom any penalty or
obligation,within mice business data fear the a be.dote, Ifyou cancel,any property traded lit, obligaYon,within Neer,rosiness days from the above date.Ifyouranmi,nnypropenylmd..n.
any payrMnls matle Dy you antler the Contract or$ale.antl any nagoeade instrument¢aeWl¢tl any payments nestle by you under the Contract Or Sale,and any negotiable insirumenl executed
by you
vnll the r¢tumad Marm 10 data returns,receipt by the Seller of your Cenceff.m.notice, by you vin be returned euflhin 10 days b ideving receipt by ma Seller of your cancellation Make.
and any se only interest along out of the bamection will De wneelled.If you cancel,you Man and any secrany molest ardes,out of the transaction will be cancelled If you cancel you must
treke.-,.his I.Ina Seller at Your readdr nds and Indiscreetly in as good mntlition as wfien make avalade to the Seller at your residence,and substantially in as good condition as vfien
received.any gods delivered 10 You under this Contratl or Safe or You may,it you and mmply received.any goods delivered In You older this Conhan or sale;or you may,it you Yiah,comply
will the Imanicltons of the Seller regarding the return shipment of the goods at me Sellers with the insWetions of the Seller regarding the return
common or the goods at the Seller's
expense and risk.If You do m m ake e goods available to the Seller and Is oo e Seller does nor pick expense and risk.II you do nala the gds variable to the SNbr and me Seller does dal pick
them up wthin n days of the date of your Notice o1 Cancellation.You may retain or dispose of the them up within 20 days of the tlab W your Notice of Cancellation.you my retain or dispose W
goods xithout any further obligation Il you tat to make the goods available to the Seller,aril you the goods vimoul any fudrar collision If you fan to make the goals available to the Seller,wit
agree to Mum the goods to are sell and tail to do so,then you mean liable for performance,of You agree to return the goods W the Over and caul W do so,then You remain liable for pedotnance
an obltgamns under the contras.To banal this amndvdn mad or deliver a signed and dated of all obligations Under Inc CombinL To cancel this transaction,rare or deliver a signed and dated
copy of the cancellation nonce or any other Yemen norm.or send a lee m m AaA sarwicea copy of me concenation hours o,any other edition notice,at send a telegram.U A&A
115NOMSayst Salem MAn1970,NOTI-ATERTHANMIONIGHTOF 115 North Street,Salem MA 01970,NOT LATER THAN MIDNIGHT O Fy-Z I-/I� l¢
mi
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION
Consumer's SignaW,e Date: Consumr s Signature Date:
The Commonwealth of Massachusetts
Department 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 Leetbly
Name(Business/Organization/fndividual): �ry�L;Z=S /n C
-Address -
City/State/Zip:_ �a l�.v MdI9�Ga Phone
A
re you employer?Check the appropriate boa:
em to er with 4. FO
roject(required):P Y ` ❑ 1 am a general contractor and Iyees(full and/or part-time).' have hired the sub tcontractors w construction sole proprietor or partner- listed on the attached sheet.1 a delingnd have no employees These sub-contractors have olitiong for me m any capacity. workers'comp. insurance.orkers'comp, insurance 5. ❑ We are a corporation and its ding additiond.] officers have exercised their trical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no
insurance required.]t employees. [No workers' 12-❑Roof repairs
comp.insurance required.] 13•❑Other
Any applicant that checks box#1 must also fill out the section below showing[heir workerscnmpewdon policy information.'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afFidavi[indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.polity informadon.
I am an employer that is providing workers'compensation insurance jor my employees. Below is the policy and job site
information.
Insurance Company Name:=ra 1i Q-I-R r-s-
Policy#or Self-ins.Lie.#: C)a`f 3 Kb (
Expiration Date:Y-( �
Job Site Address:_ Ty.+p�� City/State/Zip:- .e-I'✓1 j Mq fl
. 019-70
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 irnprisonrnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up 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.
71do ereby certify n er apains andpenalties ofperjary that the information provided above is true and correct:ure:
�r Date:
Phone#:TW_- 2`4 j- V A-J-�f
[Contact
cial use only. Do not write in this area,to be completed by city or town offrciaL
or Town: Permit/License#
ng Authority(circle one):
ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
her
Person: Phone#:
Phone. 978-741-04)4
98= ' Fax 978-741-2012
& S E E vrv:v.a-th Street
1R�II_ 115 North Strset
s N 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 P' rmit Applicant
Christopher Zorzv President
Name of Permit Applicant
Date
,I
1
Massachusetts -Department of Public Safety
A&A SERVICES, INC Board of Building Regulations and Standards
Cousti uiiuni Su
Christopher Zorzy
115 North Street License: CS-057733
1Is 4 X. ,
Salem, MA 01970 CMUSfOPHER TOR
115 NORTH ST q f s
Salem KA 019707
SCA 1 C, 20M-05111
c— " Expiration I
A C`/�r. �nia.iumvu��;o�/�r�JfI idori�r��tc�eLC J..� OS/2W2017
office of Consumer Affairs&Business Regulation Commissioner
HOME IMPROVEMENT CONTRACTOR
Registration 101609 Tye'
Expiration 6 26/2018 Private Corporation
A&A SERVICES, INCI�
Christopher Zorzy {`�--
115 North Street
Salem,MA 01970 Undersecretary