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4 WALTER ST - BUILDING INSPECTION The Conmtomcealth Of tilasSachusettS r Board of Budding RCgulalitinS and SWndal \It Nk'IJ'.U.fll t Massachusetts State 131,111ding COde. 780 (',\112. 7°i edition I SF P, Rrro,�/Lnuidrt r - - . � Building Permit Application To Construct. Repair. Renovate Or DCnwlish u ) _uu,C One- or Tiro-Family Drrelfin,g This Sectio For Official Use Only �\ Building Permit Number: Date Applied: -------- _� \VI - Si_nature: �� --�----- Building Contn S.iune Inzpccto r I uildings Dam S 'TION I: SITE INFORMATION �� Ll Pro crty :\ddress: 1.2 :\ssessors ;11ap & Parcel Numbers --—_- St r,0e hla Numher Farrel Nwnhcr. I.la Is this an accepted street? yes_ no— P 1.3 Zoning Information: 1.4 Property Dimensions: i Zoning District Proposed Use Lot Area Isy li) Frontage Uil 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Pro<idcd 1.6 Water Supply: (M G.L C.40. §n4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: — Outside Flood Zone'. Municipal-❑ On site disposal system ❑ Public El Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' Name i Print) /J Address for Service: r18--1 �A �0-s»`l I - Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)axl AddiliOm ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Spec,IY: Brief Des cri tion of Pro used Work': C, CA Ck] SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item - (Labor and Materials) E221. E lding $ 60 I. Building Permit Fee: $ Indicate how (ce is detcrnuned: ❑ Standard City/Town Application Fee ctrical $ ❑Total Project Cost' (Item 6) x multipliermbingg $ ?. Other Fees: $chanical (HVAC) $ List-. — - S. Mechanical (Fire S T al All Fees S Su . ression) heck No. Check :\mount Cash 6 Total Project Cost $ 66 ❑ in — �.-' ��G . Paid Full Outsuming J Bal:mre Uue:_—_.."_-- SECTION 5: C'ONSTRUC'TION SFRVIC•F.S F Licensed Construction Supervisor (CSL) ti 7,33� � �License .\'umber I:api fall ni Date of CSL l folder I_ul CSI.7\pc (see hcloal . Wdre 1 v c - Descri nnm L ('oCsuiCled(up to 35.(IDU Cu. Ft.I I R Restricted I.\C_' F:unth D%kclbne Slenaut'(�1g 1 M \la.onn Only 4: RC Rnldennal Routine('ukrnne R•Icphunc \1'S Renidrnual \\'md,m .old ]idol_ SF Re,idenual Solid Pucl Burnme \ 1ilianCe 11h Llllatlull D Re,ldeuoal Demnhuun 5.� RegG�o Yerg Home lntprorement Contractor(HIC•) `©)�.Od-t PrVif 0c, nr -- Ii1C Company Name or HIC R•glstmnt Name Regauation Number InAddrcs _ (-1 /(jl /M-bA;N Expiration Dac Signazure Telephone - SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be Completed and submitted wish 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 1, J �.. as Owner of the subject property hereby authorize {��Jl tltY7�"1f r ( z1) to act on my behalf. in all m;mels relative to work authorized by this building permit application. x Signature of Owner Date SECTION 7b: OWN,EW OR AUTHORIZED AGENT DECLARATION /e I, l ht-1STC)LDho r Z(-)r7— A , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. r Print Na ST Signature of tuner or oriuJ Agent (Signed under the pains and penalties ofperjury) NOTES: I. An Owner who obtains a building permit to do his/her own a ork, or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access it) 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 730 C•MR Regulations I I0.R6 :tad I I0.R5, respectively. '. When substantial work is planned, provide the information below: Total flours area (Sq. Ft.) iincluding garage, finished hasement/attics, decks or porch) Gross living area ISq. Ft.) Habitable room count Number of tueplaces Number of bedroom, Number of hathrooms Number of hall/hnth, fvpe of heating systern Number(It decks/ p,nchcs __---_---- fype oil cooling s}stem Encfused Open 3. "Total Project Square Footage" may be substinaed to, -total Project Coot' � CITY OF SALEM PUBLIC PROPRERTY -� DEPARTMENT VlA Is A%.v,I • S.tI: v1, - Il.l: 9-8-74i.•)n`!; • Ftx. '1'1--4.9S8lo Workers' Compensation Insurance :V7idacit: Builders/Contractors/Electricians/Plumbers • e ibly k m rlic•rnt Information I Icase Print L `;1I11C t Bu,iness t hg:uu1,auun InJts:dual C A eA SQl'V[ cJzS��� Address: "5 12r+h Sire C (,'ity,State,'Zip: i:;0lpmy_MA I)ILI-7t) Phone #: ( 97s5 ) Are sou an employer:' Check the appropriate box: - Type of project (required): 1. I am a employer with�� 6 4. ❑ 1 am a general contractor and 1 New construction LJ ❑ employees(full and/or part-time).` have hired the sub-contractors Remodeling '.❑ I :un a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees rhese sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions iecluired ] officers have exercised their - ri ght of exemption per MGL I I.[] Plumbing repairs or additions 3.❑ I ys a homeowner doing all work c g152 $1(4) and a have no 12.❑ Roof re airs myself. [No workers' comp. insurance required.] 1 employees. [No workers' 13.If9ther r comp. insurance required.] •:\ny applicant that checks bus#1 must also till out the section below showing their workers'compensators policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating a such. :G)n1ractors that check this box must attached an additional sheet showing the name of the sub-cunlractors and their workea rs'comp. policyy information. /am an emphtyer that is providing workers'cottnpensation insurance for my employees. Below is the policy and job site information. f1 / hsurance Company Name: 1 Y 1[.� �rCAV Policy #or Self-ins.lLic.1#: ' 0 H_$ u 8 - Expiration Dates:,.0 1�1'�'-(� j� L� (� .lob Site Address: _I 1 A l tr 5f r e City/State/Zip: Y J1 I( I JM 11-7o 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 25•A of MGL c. 152 can lead it) the imposition of criminal penalties of a tine up to S 1,500,00 and/or one-}'car imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S2ip.00 a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Imc.,li_ations of dte DU\ ter insurance cotcrage scritication. /do herehy certify i ter the pains and penalties of perjury that the infiwinutiort provided above is true and correct. PI: t,c O(-I 29 official u.se only. Do not write in this area, to be ronrpleted by city or town official, ('itv or I ov%u:Issuing Authority Authority (circle one): 1. Board of Health 2. Building Department 3. Ciq,town Clerk 4. Electrical Inspector 5. plumbing Inspector 6. other _-- — ('ontact Person:__ _ -- Phone #:— Information and Instructions \I.i-achu.,ens General L.aw-s chapter I>' requnes all crttplo crS to provide workers' compensation for their employ-ees. Pursuant to this Statute. .ut einpluree 1s Joined .is ".. ct crh person in the scrs ice of.mother under:Inv contract of hire. cy,rrSS or implied. oral or written." .\n rnt/rfrrter is delincd as ";tit indite;dual. partnership. .usocuation, corporation or other legal entity, or am two or more ,it (lie tiue_oing engaged in ajoint enterprise, and including the Icgal represcntatises of a deceased employer, or the ,even cr or rru,rce of an indicrdual, partnership, association or other legal cumv, crnploy in,,employees. I luwe%er the „.S ner of a dwelling house hav ing nor store than three apartments and who resides therein. or the occupant of the dtt ellin_ house of another who employs persons to do maintenance, construction or repair work on such dwelling house or ant the _rounds or building appurtenant thereto Shall not because of Such employment be deemed to be an employer" \I(IL chapter 152, s25C(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, %IGL chapter 152, SS25C(7)states"Neither rile conntonwcalih nor any of its political subdivisions shall enter into any contract fix the performance of public +cork until acceptable eh idence 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-contrector(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 permivlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiblicense 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 (J.c. a dog license or permit to burn leases etc.)said person is NOT required to complete this affidavit. The (Mice of Investigations would like to thank you in advance for your cooperation and should you have any questions, ple;ue do not hesitate to give its a call. I he D) parnuent's address. telephone and t:lx number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Iteh;Set -'6-u> Fax ff 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 Statlon owned by Northside Carlfno Signature of Permit Applicant Sr- ld -off Date Christopher Zorav Name of Permit Applicant A & A Services Inc. Firm Name 115 North Street Salern MA 0tg70 Address, City, State, Zip Code Dcp.u-tmcnt of Public S,tfet) Board of Builtlin- Rc0ul.tiiom and Standards i . �� Construction Supervisor,License License: CS" 57733 i Restricted to: 00 I CHRISTOPHER ZORZY 115 NORTH ST - - - --- - - - --------- SALEM.-MA01970_.. ---- -" ., Expiration: 526/2011 ('ummisiuner Tr#: 14751 . .. _ .-. ... . - Board of Building P.e Iations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101609 kill Eipirationc, 6/26/2010 Tr# 2M70 -;;Type:_Private Corporation A&A SERVICES,INtt=-r:== • Christopher Zor*:;.=__= =;'• - 115 North Street - Salem,MA 01970 " Administrator Commonwealth of Massachusetts Division of Occupational Safety a� Laura M.Marlin,Commissioner a Deleader-Contractor CHRISTOPHER ZORZY Eff. Date- 04/01/09 Exp.Date 04/08/1010 y u Memberof CO.N.E.S.T. ac II�IIII�II�I III�IlIII�IO�IIIII I��II I�I��I�I ����OI Y "+� aOSTON RENEW - i " w A & A SERVICES, INC. A&A SERVICES 115 NORTH STREET,SALENL MA 01970 • e Telephone:(978)741-0424 Fax:(978)741-2012 Contractor Registration No. 101609 Federal EIN:04-3090162 Construction Supervisor No. CS057733 (`iJSTOM REMODELING AND IMPROVEMENT AGREEMENT Buyer(s)Name Date of Contract LxN Buyer(s)Street Address,Ciry,State and Zip Code y VJA1, ST 54.1,9M 111)9 0/970 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mall Address: 478-7 yyS—677 The Buyers)listed above hereby jointly and severalty agree to purchase the goods anclor aervicos listed on the accompanying specification sheets,in accordance with the prices and terms desedbe l on the front and Me reverse of this agreement and any specification sheets(this'Agreement'1,and Buyerls)have requested that such goods or services be installetl or provided at Buyer's address listed above.A&A SeMoes,Irk.('Contractor),hereby agrees to install or cause W be installed the products or services listed in this Agreement at Me Buyer(s)address written above. This Agreement represents a cash sale of goods and services. The Buyw(s)agree W pay in cash the cost of Me good antl services purch sed m describe approval rein,regardless of timing or of any financing Buyerls)may seek for their purchase. TR-? AL Purcha Price: 6 0, Est.Starting Date: 9-73 830 Down BePayment: S.�A Est.Completion Date: ❑Cash Amount Due on Start of Job: >LrCheck ❑Credit Card Amount due on_of Completion: No. Amount Due on of Completion: Expiration Date: Balance Due on Upon Completion: '3/z De 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. Buyer(s)hereby acknowledge that Buyer(s)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 (0 acknowledge that they were orally Informed of their right to cancel this transaction;and(10 request that they be contacted via their telephone numbers or e-mail,as listed above, In the eventContractor 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. ABy&A Services,Inc. �// o Buyer(s) Signature Signature k c//m YL�vt.n Print Name Print Name Signature Print Name 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. See the following Notice of Cancellation form for an explanation of this right. ARBITRATION:TM damneder mtl Me lmnxna nor Mred,mWu01ty stand in etrarcn Nat M me event aMm pod,Ns a dlapNe mrcernily as earned,eNnr pent may commit aunt NagM to e prvab arometbn aervke wM1CM1 has teen approved by Va eeaetery m tM EUMM ofllw of Gmsumer Mats and,Blrireae Repiratwu mM me dear Pony atoll ba mdMre]m amanX to sM eNitretion upwedm M.GLe.1atA 'PS a fmartm ioiliel,.-a •�'S auyv',InidW' D. ! one upTl- or CANQELLAnON y N0TcrQFQANQF1AT1QN Oam DI Trenaaz9on7-zY a9.Tau may tanml Mb transeNm,wINON any perded a peb W TranaecWm/-z .TDu mry urcel Nls OenaeclNn,v.Wwf vry pneM ar an,torments a,year ai,reae Oeya con Neebaedete.Xpueveala,mrypmamly tndMln, arr, imnd,aded b WYmss Eaya han Neabowrs or o,an Xnyne raeremorman,ty ballNln. byypiantre readeby yean 10 days Colowm meet,WtaxB stud year cameraman ameramnrade.ndeal anyou M11 Smatleby raaut10 ays Comfefolion,ingRaddre and ad yam ingWmem eaedlm by yoyeacteretumaOwlNml..ortoraded ceml 11 tax Bearflour y,lMl 1r,r any byyou wieend,mm..darx days memanemear it me same rar.1,,yw and dowsmaecu,iry ld.searrire year iwomNmy as,rox,o nrou[ester eau moat eM aMoarce ra me lme,BodMltpMOlNner,in on xin Ce asrvxlW.nyw tercel,pumas. mygoddibNemtM aNlm mron dsldNm,Inontreed or somnmlyu BOM eaMor Yam,coor,ereNm, anynod ynar dwiveeei to.ra. .r ter ,corce,N-sNanYtlNu p%A donation asomenMwiih me any Bends Odivere]m resetou unow m des.smsxd of. may,on and Sah,mmgywM me any BOcddame sak wand, an CaNMprerew pu meY.or m MM,m examas rd for aynMNe Seer odes atrealm eNpmm NNe and S el a ayWmak me,N Idr. ryoum me eel r indorq Xs met srigren.ofno nor or me Selma evpenw eM rbk. X pu M meal me Bxds Nateo,e m Me Belle,and o Seller or di an qd 1Mm tooes risk n you u Ireka ero II,IOda avellede m Ne selm,ant to saint area real risk Nam up vominnaryknNmadamoly ll utX]W keft Xr avWayremlMS0lr,oro agar� vdNb BOOeyeINNe daleMyw, faol CemalmXon,yavWawmlftr 1pdaealNuBOOds wMONem luMmoMgati B e pu Wlmmaka NapomysavmlWb wele Belle,.o,Xyw eO,all wXKonar'.Mar to me n.sputNd tmake Naantryavea.noVae,'OrXpu spree m,eaun Me BmOa m on Salle,and mil b sv en,Nen. remvn corn 10r Porfam d all m realm Ole m IM Sellm eM mA t0 W n Nan pu nmvn 4ebm m,PotaWm Lae of ell of metimd other Nntoodoro.To rsncelNm Vvueeaan, ard.deli—PpreOeM OdM w1 aideonaurAm Kenos or wroo Oenwdbrwere a dxxodr.to PAA M0medmp) 01 me St.,Sad nWceea arty WMr w70,NOT A m TH a MIDNIG,to F SeMOm,it aide Om Sarddn no0w m any deco v 70, norm,m Rend a lMIDNIG T F Services.lla NOM Btreef,Semm,MeaeeMuaetb o1B]B,NOT UTEa THAN MIDNIGHT OF�� NOM SttM,eebm,MevechuseN 01 BT11,NOT LATER MAN MIDNIGHT OF�7�Q^�. (oam) (Dde) ^•^� I HEREBY CANCELTHS TMNSACTION. conermark Bgnamm Date I HEREBY GANCELTHIS TiWN$AGTION, ConormeYSSlpnam,e Data nee A & A SERVICES, INC. A&A SERVICES 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 MISCELLANEOUS SPECIFICATION SHEET Buyer(s)Name Date of Contract `v,/M 0/wq 0 7-2 `f-6f Buyer(s)Street Address,City,State and Zip Code y W*t,-)M ST Sr1Lat1 M4 011`70 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address 478-7y5-a77/ The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance win the prices and terms described an this Specification sheet and the front and the reverse of the eccumparylng CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification Sheet la a part. SPECIAL INSTRUCTIONS F/tmt.T PARCH ItPr f/2 )q&_MavP'_- DrsP6s9_ aF ; QasWVv !x47 /00.sTs &7V ewCH w are- clic P&CH 1 (5) F/& D,-C M" 604&bs ow 4_we//S/o6; AWQ 04/sC, /x8 Ae -P/Z/,v1973 L«.veY4_ 72241-1 &79�s AA,-O /1x y Ut�T2C�L Lu 67Z- 77 ,141 , • /2emol2s -f- KE-/,,b f ofLL koy /207\_/ /4*voA4/L O7t/ AA10 (7-) /A4W T 00L11/US,11"OYIS • 1A1s771-k4_ (2) N&I^J (; x(o 77igv7F6 svpPonr� POSTS Olt/ 94CH c&A"w- a :E "i P 1A1SMLLL 1v6Av lk-V Prks-Pa,/•-tom I/EX77CA-(_ LoWD_X_7¢/M Ai'10 NG-P� /x €3 Pi/ _- PiuWf:� Loz t.eW- 77z/oT7 nvS 7714 I_ /o) N6-1&j /x v Fi/z b 6 z k 160"qAv o v c�,vey'nS 67U L_ c�ABy; W./'t an,; mil - Ue 4UV ct ta�ry - v10 1A1CZ410[F4P:) it Is agreed and understood by and between the parties that this Specfication Sheet,along min CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,conetiMtes Ma afire understanding between the parties,and More am no verbal understandings changing or modfiying any of the terms.This comrem may not be changed or he term,mopped or varied In anyway unless such changes era In vatting and alined by both Me guitarist and the Contractor. Buys)hemby acludeledge Met Bu ns) has read this Specification affect. 7 t/ Contractor Initials: a Date:-7——z/—0(4 Buyer's Initials:X/g ,e 9- Datd�<7/e7-r//y9