15 WEBB ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
f Department of Industrial Accidents
W
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 Le ibly
Name(Business/Organization/Individual): A Sor V1
Address: 1 15 .Q p r+h j-hre.e
City/State/Zip: 15t,,� ( e,M Mn OIGi-70 Phone #: 1012s) r/H 1 — DH 2 H
[2.
epu an employer?Check the appropriate box: Type of project{required):
/I I am a employer with�_ 4. ❑ 1 am a general contractor and I 6. El New construction
employees(full and/or part-time).' have hired the sub-contractors
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. 9, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.El Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no
12.❑ Roof repai"^rs,^,insurance required.] t employees. [No workers' 13.2'Other /�(JT7✓�
comp. insurance required.]
•Any applicant that checks box#1 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 hire outside contractors must submit a new affidavit indicating such.
tContruclors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. ,Below is the policy and job site
information. v-r�
Insurance Company Name: I e— Tro Vf2 1 -e f'<
Policy#or Self-ins.Lic.#: C a 4X 12 3"�O Expiration Date: q�f"1 . -7
Job Site Address: 15 We bh 5 heel City/State/Zip: 6a(.e/f(m/ q7D
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/7dohtere7bycertf nder�he ins andpenalties ojperjrrty that the information provided above is true and correctS -` ! - ] Date `'J a y-67
Phone#• (91$) '7,1 I - iA of H
O
fficial use only. Do not write in this area,to be completed by city or town official
or Town: Permit/License#
Authority(circle one):
ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
her
act 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 permittlicense 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 cooperatiori 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 -
I���1
Signature of Pe it Applicant
7- a q- o7
Date
Christopher Zorzy
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street, Salem MA 01970
Address, City, State, Zip Code
/
� J1.
Board of Building Regulations and Standards
Construction Supervisor License
LiceAse: CS 57733
BirtfidaCe_-5/26/1958
7 f5 rural n -:5/26/2009 Tr8 13739
IL
F
ftetftttto OO,r
CHRISTOPHER Z,Q �
115 NORTH ST
SALEM,MA 01970 "--'"l Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J. Prezicso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/02/07
Exp.Date 04/01/08
DC000440
Mmberof CO.N.E.S.T. 08
BO I c
IIIIIIIIIII IIIII IIIII IIIIIIIIII IIIII IIIII IIIIIIIIIIIII BOSTON ENEWr•
'/ae -�oon�morewe¢l!/c o��/�a4aar,/ze<ee%ta
Board ofBuilding Regulations and Standards
- HOME IMPROVEMENT CONTRACTOR
Registration: 101609
ExP'riiqdrr 6)26/2008
- -, Type., Private Corporation
' A&A SERVICES INC
Christopher Zorzy
115 North Street' Q��+_.
Salem MA 01970 - Deputy Admrmstr tor:. ,
g�®"v�,q �a A & A SERVICES, INC.
A SEER V IC 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 - -
Buy.qs)>Ei Date of Contract
Buyer s ireet Address,City,State and Zip Code -
�s �6MA
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
9-7-74/437/
The Buyens)listed above hereby jointly and severally ,as to purchase the gmad.anmor services listed below,in accordance with Me prices and terms described on
this Specification sheet and the front and Me reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a part.
ROOFING SPECIFICATION
Strip Roof of# layers of shingles
❑ Install 6'of ice and water shield at base of roof where . ❑ Install 15.b felt paper to root
possible. Install 18-24"of ice 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.
RUBBER ROOFING SPECIFICATION
St'p Roof ❑Not Strip Roof
Install 1/2"High Density Fiberboard to existing roof using WrFlash obstacles as needed.
screws,and plates.
Vista 1.060 membrane EPDM(Black)rubber roofing to nstall 3x3 aluminum drip edge to perimeter of roof with
fiber ard.s seam tape.
Flash up sidewall as needed.
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. -
SPECIAL INSTRUCTIONS: S S`J%(4t AreS
Lvl'
IL 2Z
It is agreed and undermined by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitute.
the enUm understanding between the parties,and there are no verbal undemtandinga changing or modifying any or Me term..This contract may not De changed or its
temt.modified or ni ed in..wa..nice.such changes are in writing and signed by both the Buyaga)and the Contractor. Buyens)hereby acknowledge that Buyegs)
has mad this Specification sheet.
D
Contractor Initials: Date: 7 Buyer's Initial Date:
p,�p�¢9g��a0CES A & A SERVICES, INC.
G9 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
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Bavaria)blaral Date of Contract
Buyers)Stre dress,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
"--721/-13-7 978-31,-7z- /�
The Buyers)listed above hereby jointly and severally agree to purchase the goods are for services listed on me 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 insisted or provided at Buyer's address listed above. ASA Services,Inc.('Contractol'),hereby agrees to install or cause to be installed the produces
or services listed in this Agreement at the Buyers)address written above.This Agreement represents a cash sale of goods and services. The Buyegs)agree W pay in
cash the cost of the goods and services purchased as deacreed herein,regardless of timing or approval of any financing Buyers)may seek for their purchase.
Purchase Price: �f / Est.Starting Date:Ahr, a0
Down Payment:/ QllBCpS� QplMi Y'i LAb Est.Completion Date: y
/1��ifz/M 1,�CiEI�
Amount Due on Start of Job: / Nd'Check .
I/ ❑Credit Card
Amount due on%�of Completion: No.
Amount Due on of Completion /:� o Expiration Date:
Balance Due on Upon Completion:/3 o 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 and the reverse of this Agreement and has received a completed,signed
and dated copy of this Agreement,Including the Me attached Notice of Cancellation forms,on the date first written above. Suitable)also
(i)acknowledge that they were orally Informed of their right to cancel this transaction;and(11)request that they be contacted via their -
telephone numbers or a-mall,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.-
A&A Services,Inc. Buyer(s)
By: f
Signature �.t-r N n-Q Signature ILj_ - -
__ ✓o,'l bx gam
Print = c ✓L,l n r
Name 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 Sate of this
transaction. See the following Notice of Cancellation form for an explanation of this right
Aaamayinorv:me mnbeMreM the nomwwnar nerenY mmuallY agree in eavanca tnvmtneennt enter mrry nv eekWm mnremin9 m's wnhazt eilner oeM mev%tbmil aurJl elaolne -
a unwise annamon mMou IIII tax been approved by the sommon,Nd t ee of Comumer Allan am Business Pagula(ns er-0N ty an e other paral)he wouiA b w e bmn to M
sucn arriorkn as prow9e In M.G.L of aaA. `
Cmanythr imat" auya'v Write:
7-1-7 Oa¢:
In
!] ��JNOTeF or r.ANC ()TIfE do CANC.FI ATION
Oasa 01 Tranaeetlm L_L you may orlml Mb Oaneaenm,wiMoul arty,mi d Oate M nexavibn 7-17
.You may cancel Nu henmelbn,witlqul any perlelry or
xi,bon.wllnln thane a..it,lmm In.above there.Ilyoa..l,any pmpeM berano in, obrgallon,warm Nrea b mwl ran teem to abve eats.If you corm,any prPoet,thart,ln,
my paymal me0e by you noel the cannot or sale.of any negoeabb lmooment ww . my payment mare W you unrar the Cmhaot or arm,end any negotiable Instrument weaved
W You will be returnee worm 10 heye babwire human by no Seller of your oatmeal nonce, by you will be real whin 10 bays bllovnng racast by to Sella W your mmNlatbn note,
ala any maurry Interest anyrg out of the transaction will N mooed.If you mnml,you main v wyeV nlymwroMMmlrgouteuob mto,wiibe calar,fi,mia ncal.mum in
make avaMnb b but samr of your wal an,In mbdamwn we poW-.him as wMn mmivee. make avellmb to the Swen M your tKWmw in substantially as gam Wrtlhn ae when newho].
any III reJi .to ya unror uu cal u.al or You me,if you an mmoy with In a my9.deliwrel to you under to.Cmbaeld vat o11 may.If you whole,conni win the
insbuNone of Sella them.,the nNm enigmas M Me a..at Na Sellem evmnae who IneWcturte of the Seller ralwarg IRA mWm shipment of Ma Boom of tna senors akeo end
risk. II you W make Me golds ayallabb to the SyNr vk the seller those not pIX Imm to off, II you d0 make Ma a..ev®fill to the seller and Ina salt,tloea IRA pck them up
wlerin 20 days at the dale of your Notlm of Cancellation.win may Atin or disWm of to Om]e within 20 days of Na dab of your NAm of CarcNlereir you may..in of thlsmm of Ne soars
MthoNanyluMaobllgatbn.IlyW lylbmeke the gmtl9 avatNeblM$sliced Myou agree wilnoul any lunMr obligation.nyou hill make the gores armusew to bee salt,orif You eO
to mtum the gOoes b Me Belwr eM fall to do an,than you rembn Recta M mrfoor atva of all a rebm the gmtla to the salver aM fail b do aD,then You na In fbble for material OI of
.1 is.to no...r to Contrecl.I--I now bemetrom mall or m1iwr a me..-a it..copy Obllgeelow under the cannot To cant N w moon n,mail or mWm a algnM aM deed may -
olNa—.,, an-a-Or any ONe,—ben-am,dsend a bleg2m,to A =e,11 of me twomotion mtka or any Other whoa,ally,m send a bb9ram,toA&�
North setae,III Maseaehumlb 01970,NOT LITER Thi M 10NIGy?OF W ho stMl,sekm,MasyGruylla p is .NOT LATEP THAN MIDNIGHT OF L(L.
ioenal - (pbe)
I HEREBY CANCEL rule TMN54eTON. Consumed equabra pane I hanial CANCEL THIS TRANSACTION. CansumaS Sgnqure any
DATE: ?'a?
Cftp of a�?AYPIU, a aL�U Pft
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building /5 We-b)o 15/7"e e f
Building Permit Application For:
'(Circle whichever applies) Roo0imiD Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace,Foundation Only, Wrecking
Other:
PLEASE FILL 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:-Q{'YX5 0 Dgn.ro lahp5 Contractor. A eA Sr'.xvlCe5hjt ! 15 drA _
Street_ 18166 b 6fre& City 5&Lefil Street .115 N n(+h S . City—.'.a m
State_HA Phone (q%_2q1-13r71 State M A Phone- (Q78) 79 L7,21 a'-{
Architect: City of Salem Licq 1 W Q5
Street City StateLic p57 H1P4 I DI(oD9
State Phone ( ) Homeowners Exempt Form_yes_.kl no
Structure: (please circle) Single Family, ulti Fat ' Other
Estimated Cost of job S 38 9 9, DO
Will building confirm to law?✓_yes no
Asbestos?_yes ✓no
Description of work to be done:
R�alace Iry� �5 ) SCE uLres D� gib ✓ �n _
A&A SERVICES, INC.
Drawiu ubmitted:_yes no Mail Permit to: 11
sAt EM, MA 01979
4�1W W W.A-AbS
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
APPLICATION FOR
PEAW TO
IAI LEC A(VJJ 1gJ9aE,2- P&ar(Ot, ~
LOCATION
PE MIT GRANTED
APP VPDQ
i P CTO�j OF 6UIL NGS
CEMVICATE OF O CCUANCY -
YES v
NO ? �'