21 VARNEY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
� CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
r Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Secti or rcial Use Only
Building Permit Number: D to Applied:
Signature:
Building Commissioner/Inspector it ' Date
S : SITE INFORMATION
li P open Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an acc%o 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 I 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 r I.
D�a a l l/irr i2e Ss�
Name(Print) Address for Service:
9 '7e- 7gV- 6/ X-9
Signature Telephone
SECTIO 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workz:
az
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
ElStandard City/Town Application Fee
2.Electrical $
❑ Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ '*06 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
ZLicense Number Ex tion na ate
Name f SL- old
List CSL Type(see below)
Add re J Tye Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 Registered Home Improvement Contractor(HIC)
HIC Company Name or �IstrantN e _(' Registration Number
Addre /
ie W
9 / Ex ration Date
Si a ure F ' * 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 Issuan 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, &Asll! r as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative t vo k authorize by this building permit app: ation.
Signature of Owner -{— Date �
n r� p �SE�,C.TI/ON— 7b: OWNE�W O7RJAnUTHORIZED AGENT DECLARATION
I, ( �/ Ip Z ? e 2)/ 7 v) ,as Owner or Authorized Agent hereby declare
that the statements and�information on the foregoing plication are true and accurate,to the best of my knowledge and
behal
1
Print N n
�7 :/,7
Signa e o caner or Au rued Agent DaDa—�
Si ned under the airs and enalties of er'u
NOTES:
1. 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 and
Construction Supervisor Licensing(CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"
1 I
The Commonwealth of Massachusetts
r Department of Industrial Accidents
Office of Investigations
F
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/Orgmization/Individual): a a o)X,I n u 11 1 na
Address: I !-b- Mork situf•
City/State/Zip: I ' 1H O I I O Phone #: 9 9 6
A,rree7Y,"u an employer?Check the appropriate box: Type of project(required):
1.lj� I 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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have.workers' 9. ❑Building addition
[No workers' comp. insurance comp.insurance:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plu bing repairs or additions
myself, [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box 41 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 hive outside contractors must submit a new affidavit indicating such.
iContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I anz an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
inform
Insurance Company Name: �' +Q T��! r)p —
Policy#or Self-ins. Lic.#: Expiration Date': 3 �c 1 z
19,
Job Site Address: City/State/Zip: V 1970
Attach a copy of the workers'-compen a ion policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required un er 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 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.
I do hereby certify ura er th pains
penalties ofperjury that the information provided above is true and correct.
Si nature: (� `j r ' n Date'
Phone#: q i - 1 ''I 0 g a y
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 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 burn 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 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions ®f M. G. L. c, 40, Sec, 54, n condition®f
Building permit Number is that tFie debris resulting ' thls �,vcrk shall
be disposed of.in a properly licensed facility as desined.by M. G. L co III, sec.
Th
e debris writ!be dispose at., Sele u ee�sfee S oon
owned Ly lmces��i�e
Signature ®f P9,fitAvIlcant,
lame of Permit Applicant .
A A A Services. Inc.
�irrrt lvern®
l � C eetE� teeet, Sale. MA 0l970
Address, City, State, Zip Code
Control No: -4 5 1 9 3
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
DIVISION OF OCCUPATIONAL SAFETY
Ulu - ,. .19.'.S'TAMFORD STREET, BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A & A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Wednesday, April 11, 2012
IN ACCORDANCE WITH M.G.L. CH. 111, § 19713(b)AND 454 CMR 22.03,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR, DIVISION OF OCCUPATIONAL SAFETY 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. 1 I 1 § 19713(b)(2)AND 454 CMR 22.03.
HEATHER E. ltowE,ACTING COMMISSIONER
i
Printed on Recs
ycled Paper
'q. ✓1:e 'IDomvuzO�,etueaL[lz a ✓l�aouecluaelta " ��Iaa:rchu.retn - Dep:u-tmen[ of Public $;rFet�
Office of Consumer Affairs&B Siness Regulation Board of Bnddinr Regulations and Standards
(� HOME IMPROVEMENT CONTRACTOR VVI Construction Supervisor License
Registration:- 101609 Type' Licenser CS 57733
_ Expiration 6/26/2012 Private Corporatio'
i
SERVICES,1NC CHRISTOPHER ZORZY y:�
115 NORTH ST
Christopher Zo¢y - SALEM, MA 01970 '
115 North Street _ 4
Salem, MA;01970 Undersecretary
��- Expiration: 5/26/2013
(',nnm iasiunrr Tr4: 15935
+ AG m
mpol
A A & A SERVICES, INC.
8 A SERVICES 115 NORTH STREET,SALEM,MA 01970
s • 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
euyer(s)Name - Date of Contr t
Buyer(s)Street Address,City,State and Zip Code C �l
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-mail Address
� :
q _7glvo1I
The Buysit listed above hereby jointly and severally agree to purchase the goods and/or services listetl on the accompanying specification sheets,in accordance with
the prices and terms described on the from and the reverse of this agreement and any specification sheets(this"Agreement and Buyers)have requested that such
goods or services be installed or provided at Buyer's address listed above. A&A Services,the.("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
�oftiming or approval of any financing Buyers)may seek for their purchase.
Purchase Price: - 3! ft3�jU rfr Cci C Est.Starting Date:
Down Payment: 71 �Tj G Est.Completion Date: I
A /Cool ❑Cash
Amount Due on Stan of Job: / Adyk Hit .5/,�Y�ajy ❑Check
p dG� �ur, 0 Credit Card
Amount due on of Com letion: 7757
Amount Due on of Completion (�Sr Expiration Date:
Balance Due on Upon Completion:� Owl CVC Code:
�7
It is agreed and understood by and between the parties that this Agreement,front and back and any addendum,constitute the entire
understanding behveen the parties,and there are no verbal understandings changing or modifying any of the terms of this Agreement.
Buyer(s)hereby acknowledge that Buyers)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
(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 Buyer(s)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 Services,Inc. Buyere , / A
J.
Signature Si ayre_
l>s1Vi� �ine���x
Print Name If Print Name
Signature
Print Name
You,the Buyer(s),may cancel this transaction at any time prior to midnight of the third business day after the date of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATOR:The mural and Na homeowner hereby mutually agree In advance that In He event either paTy has a dispute roaming this contrail,either each may submit such dispute to
a private romontionstores M.CM1asbeen approved by Na Becretary elN E rive 011im of Consumer Affairsumer Agdrs an defons antl IM1e otM1er PaM shall Ce re9uiretl to submitb
sucM1 aNitation a4 pmvatl in M.GL c 162A ��`�
Coohecv riul[; v clo Sareas'
Droo 1
NOTICE OF Elf nTGN
Date of Traneaclion .Vou may ev day,
i bou worse any
proper,
ro any penally or Dale of Trensatli- / You may cancel thin transaction,without any penalty or
Coplicalso within tree ss dayz hom Naebove dale. Ilyouw cah anypropeM(raded ln, oblitne",wl."tbreeb sunup tlays fmm me above dale.If 1.-e 1,any preach traded in
any amrs M1s madeb you antler Ne ConlracI or Sale,and any negotiable insWmenl executed any payments made by re der no Contend or Sale,and any negotiable irstmment thermal
by you will be reNmad with 10 dery following receipt by to Seller of your cancelkson notice, by you will be InWmed within 10 days following wasepl by the Seller p your campollation space,
and any security lowest ants,out of the travel will be cancelled P you rood,you must "any security interest ansing oN of lye transaction will be cancelled. II you cancek you must
make available b lye Seller at your resitlenca In substantially as good mMilion as when thermal make awllabB blye Seller at your residence,'i suMtantially as gone mMllion as when revive],
any goods delivered to you under this Contract or Sale;or you may,tl you wish,comply win the any goods delivered to you unbar this Contract or Sale;or you may,if you wish,comply with the
irearudwns of the Seller regvdied to realm shipment of to goods at the Sellers expense and intwHons of the Seller axon ing the reNm shipment of the goods at lye Sellers expense and
risk. If you do make to goods available to to Seller and me Seller tices not pick them up risk It you do make the gourds avalable to to Seller and the Seller does not pick them up
within 20 days of to dale of Your Notice of Ca sedletlon you may totem or purpose of the goads within 20 days of the date of your Notice of Caremortlon,you may mton or ordered 0IM1e goals
without any turtherobliga6on.Il you fail to make tegonesavdMble to ne Selleq or tlyou agree WdM1ONery Wnherobtgation, it you fail to make the goodsavailable to the Seller,or if you agree
b return the g.do to the Soule,and foul I.do w,tan you remain liable he sale---of all to return the goods to the Seller and fall to do so,then You reran liable for performance of all
obligations under the Contrail.To cancel has marmantion,mill o,deliver a signed rich dated copy oblips had under the Carl2R Tr cancel this footweYon,mail rromessr a signed annual copy
of the cancellation notice or any other written notice,or ward a telegram,to AdA Suressersil 0 the complain on notice or any other when space,or send a telegram,b A. 5
Noh Shed,Salem,thelanhusets ones NOT LATE.THAN MIDNIGHT OF North Street,Salem,Massachusetts 01g]0,NOT UxTER THAN MORIGHTOF
77
(Dater (Dater
I HEREBY CANCEL THIS TRANSACTION, Corsumer§Slgndum Data I HEREBY CANCEL THIS TRANSACTION, Comsumers Sgroure Dale
;{,,,, //�� gyp`' } A & A SERVICES; INC.
-A&A SLAY 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
ROOFING SPECIFICATION SHEET
Buyers)Name Data of Contract
ul
G l <l < l
Buyer(s)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
479 7 -a 63 0 1 /,K
The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described an
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a pad.
ROOFING SPECIFICATION
i
Strip Roof of# layers of shingles F,
Install 6'of ice and water shield at base of roof where Install 15.b felt paper to roof. rw se
possible. Ii S
FI 'chimney ed(no repointing included). I sliAd_ nstal9 perimeter drip edge to rakes and fascia areas.
Install vent pipe boot/and seal-mgWi9iX ❑ FI sh valleys as needed
O Install rollout type ridge vent. 57-1 bNafew, UY 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.
er/Disposa Included: ❑Other:
Location:�.$ ���ke d�hIA�Kl
Install new roof: Manufacturer �yr - Style/type
Included in this proposal are thorough cleanup, building permit,and company/manufacturer warranties.
RUBBER ROOFING SPECIFICATION
❑ Strip 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
fiberboards seam tape.
❑ Flash up sidewall as needed.
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
SPECIAL INSTRUCTIONS:
- Gt�} t to s i d �I,g�1� i�i( ✓2/l7 5hiWJi!2-yeN'Fr BEq--P'P--A-
s ®a c -f-
WAIAi
G. t.L11WnUAFIA
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 any 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 Buyers)
has read this Specification Sheet ),L /
Counselor Initials: Date: /7 /t Buyer's Initials: /_ Datelif