4 WEST TER - BUILDING INSPECTION (2) 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Ulf Massachusetts State Building Code, 780 CMR, 7"' edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
`? / Signature: . l/f lfi�y
Building Commissioner/Inspector of! ildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Vf we )lrf f Sa�i�,,129� Oli7d
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(8)
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 I cord*
is -o% 01 e� 4 ;IVe �OA,-176 V 0&5-t ��i9R/�lf sale,, !//'lam} ors>o
Na Pr Dt) ,(,/ Address for Service:p p/ I
4Signatur / Telephone
SECTI N 3: DES RIPTION 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 Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $1 j LI?l 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑ Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
,6. Total Project Cost: $ 37 y f�OCJ ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
/5.11Licensed Construction Supervisor(CSL) S77` 3
l X'j,54ophP� z0/'�� License Number Expiration ate
Name of CSL-Holder
/( List CSL Type(see below)
Addr s Type Description
U Unrestricted(up to 35,000 Cu. Ft.
Signatur VR Restricted 1&2 Family Dwelling
M Masonry Only
7 � RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reeistered Home Improvemennt,Contractor(HIC) /D/6O,p
SN, i j cis", V
HI Company Name or IIC Registrant e Registration Number
/% Piry ✓f/ e) <o�a Addr
S7,p-2 y/_o y 1 Expiraflon Date
Signature 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
�l I, a e,0 y/ d )Oa-/e/',,J e as Owner of the subject property hereby
authorize (24/') to act on my behalf, in all matters -
relative to work authorized by this building permit application.
-Si nature of Owner-��-D--- - _:Date
/ SS�EECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, �/q/ } S ?o r Z 1 , 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.
(�!,/ zor24
Print e
w
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halFbaths
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
S�
Office of Investigations
k ,; 600 Washington Street
Cr Boston, MA 02111
s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� /� /j Please Print Legibly
Nam pa e (Business/Organization/Individual): AEG l �' u s ' e
Address: U Mork _Sif +'
City/State/Zip: I'll H O I Ip O Phone #: 9 n u a
A,rree7y,�u an employer?Check the appropriate box: Type of project(required):
1.IyJ 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.t
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 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof 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 hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. —��/� T'/�rf ` ) !I ' C
Insurance Company Name: 1► 1Q 11yf�lQl�Q1Y�C/�� —
Policy#or Self-ins. LLiic.##: Oa �I IpU/1`5��1/.)/1�.7� Expiration Date:
Job Site Address: "7 /�f// � �zlxl City/State/Zip:
Attach a copy of the workers'-compensation policy declaration page(showing the policy 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 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 u er he pains and penalties ofperjury that the information provided above is true and correct.
Signature �- (�G�'") rA1/ n ' J I ' Date, // 11 10
Phone# I o / ' 1 0 v'1 I1 `1
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
Fax # 617-727-7749
Revised 4-24-07
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 Dumber is that the debris resulting from this Work shall
be disposed of in a properly licensed facility as des►ned.by M. G. L. c. 111, Sec.
►he debris trill be disposed at: Sales 'Transfer Stataon
owned by fvor`haide Caring
Signature of P-31 m it Applicant
Date
�IarlstsoE�ar zmn►
Tame of Permit Applicant .
Firm Name
115 North ttraet. Salem. MA 01970
Address, City, State, Zlp Code
1lassacbusetts- Depal'ituent of Public Safet}. .
Board of Huilditih Regulations and Stanilards,
Construction'Stlpervisor License
. License: CS 57733 ,
�- Restricted to: 00
CHRISTOPHER ZORZY n
115NORTHST
SALEM, MA 01970
Expiration:.512 612 01 1
('ununissiva¢•r Tr,-: 14751
✓fC nsumerzaouoealC/z ae✓r'iG'.macfwQetla -
Office of Consumer Affairs&B siness Regulation
HOM E IMPROVEMENT CONTRACTOR
Registration 101609 Type:
Expiration 6126/2012 Private Corporation
i
A&A SERVICES INC
1,
Christopher Zor y 1
115 North Street 4
Salem, MA 01970 --- --
Undersecretary
Commonwealth Of Massachusetts
Division of Occupational Safety
Laura M.Marlin,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/14/10
Exp. Date 04/13/11 �
DC000440
MemEerof C.O.N.E.S.T
BO
IIIIII��I�I IIII�I�III III�II II IIII�III�IIIII��I ��I
BO 0 SrON-REN-R $,EW r
vanguard Performance .
W I ND D W S specifications
A view that works
vanguard
Our windows are tested and certified to National Fenestration Rating
Council(NFRC)standards. Product testing data can be viewed by going
ENERGYPMFORMANMRAnNG5 ,to NFRC'S web site, www.nfrc.org, and entering the appropriate Certified
Product Directory(CPD) number.
'A[IRTGNAL PERFORMAx¢PAnNGS
^� `•—~� Double Tilt-in Standard Casement Sliding
Slider Casement Awning
Hung Slider Picture Picture Door
NFRC CPD No. SUW-K-1- SUW-K-2- SUW-K-6- SUW-K-7- 8UW-K-4- SUW.K-B-. SUW-K-3- SUW-K-S-
O0083 00045 00047 00010 00038� 00010F. 00038 00004
t
Clear �r�a�s.,1-':�1 �a � �a� r ��.x .. •dit� ��''DP'� I 'Ta.^r� � �Zbjr"ir 0 �� rid,
Glass
.. La+r-fi 51,1�iA ..;
NFRC CPD No. SUW-K-1- SUW-K-2- SUW-K 6 SUW-K-7- SUW-K-4- SUW-K-B- SUW-K-3- N/A
00086 00048 00050 OOD12 00040 00012 00040
Sun-
Smart
Glassary {' Di �#9bSd5 � D 324 �
NFRC CPD No. SUW-K-1- SUW K-2- SUW-K-6- SUW-K-7- SUMSUW-K-S-
OD085 00047 D0049 00011 O0039 00011 00039 OODO5
to �, r-, �r� _ •� v,'�'� '°
U1/SS 1
, n .y.'I�'.��,'����6:',,,a ib m;,'�m�-',a ero-.�:�,. ... - ��.-`m _ rU�d »"'3F; CC. i .-1 si;.:R.�-r_u•,3. .k. _ t ,. ..
NFRC CPD No. SUW-K-1- SUW-K-2- SUW-K-6- SUW-K-7- SUW-K-4- SUW-K-B- SUW-K-3- SUW-K-5-
00088 00050 00045 00014 00042 00014 OOD42 00005
x
_W
T
Glass
� 1-a„-�� � a -j t� Dip �..,r� .F� Aw.,� �Y 3��fi �D�`^.��' iu�ffrr er•
{aNk,Z': k 'L#.q•i4.�2s>' $' F`"
All performance values are for windows without grids in between the panes of glass.
070507 SS15-V3
A6atle
` _ d A & A SERVICES, INC.
A&ASERVICES 115 NORTH STREET,SALEM,MA 01970
a e •RNMEW Telephone:(978)741-0424 Fax: (978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.03057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(s)Name Date of Contract
1-U /6 l�
Buyer /St/reet Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
Y wm�/- eeey I I ?Z'iy O-/-D5-
The Buyer(s)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 Buyer(s)have requested that such
goods or services be installed or provided at Buyer's address listed above. ABA 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,
dY2 zG/�ri Purchase Price: // Est.Starting Date:
`l�(o rfi � ov Down Payment: Est.Completion Date: �l
E' O C SITAmount Due on Start of Job: heck
/yam J, O Credit Card
Amount due on of Completion: !�/'� ( No. Y AC9
Amount Due on of Completion: z Expiration Date:
Balance Due on Upon Completion: 9n�// / 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
(1)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 e-mail,as listed above, In the event Contractor believes auyerial would be interested in any additional quality
products or services of ConI tor. DO
NOT SIGN T �ONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services VS. / / Buyer(s) ¢ -
Signatu e �- Signatur
Print Name L / "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.
ARBITRATION:The wntraMr antl the homer r hereby mutually ag In the event eltM1er p M km a dispute wnceming this contraed,either pan may submit such dispute to
a private..,radon serve which has ode.0,poved by tie Bec. oft cutWe e ot Consumer AMai go Business Regulations and 1M1e other pen shall be required to submit to
such arbouraticn as proved In M.G.L.c.N20.
Coe !/Y Byv'v lnidl
�ueuori I
Date of resembled l L GJ .you may cancel his transndion,without arty penalty or Dale of Transaction 0 O .You may cancel tots transaction,."hear any penalty or
oEligation,witM1ln Mree Odin ss days lmmihe shwa tlale.if you cancel,any properly traded in, obligelgry wlNin Mr e ass days
hom the shwa tlate. Il you cancel,arty PmpeM waded in,
any payments made by you under the Contact or Sale,and any negotiable instrument propose airy promenis made by you under the Contract or sale,and any negotiable instrument eaewled
by you will be returned within 10 days Following receipt by the Seller of your sencellarron notice, by you will be returned wlthln 10 days fallowing receipt by Ilea Seller of your cancellation nonce,
and any secuny interest Made out of Me hansallon will be cancelled II you cancel,you must and any securlry interest arising out of Me transaction will be cancelled 11 you cancel,you must
make available to the Seller Wyour resltlenb,in sulsaia "I as good apreaton aseeden iaod, make meakese to Me seller at your maiderxx,in substantially as goes common asserted mocked,
any goods delivered to you under this Conhad or Sale;or you may,if you wish,compty with the any goods delirered to you under this Contract or Sala;or you may,if you wish,comply with the
Insinuations of the Seller regarding Me return shipment of the goods at the Sellers expense and Interactions a Me Seller regarding Me return shipment of the goods at the Sellers expense and
risk. If you be make Me goods avaiddle b the seller and Me Seller does not prok them up red. It you do make Me goods available to the Seller cad to Seller does not pick them up
wood 20 days M to date of your Notice Or Cancellation,you may Orion or dispose of the.... within 20 tlays of the data of year Notice of canceflation,you may renal.or dispose of the goMs
Wharf any tuner drill lfwufallbmake Negomsavellabla Nth.Sellaporff,ua,ree witlpNanyfurMerobll,anion.ll you(ail to make Ne goods avalladleto Ne Seller,or if you agree
to return the goods to Me seller and rag to do OF Men you remain fable for pedomarce M all W realm the goods to Me Seller and fail to do so,than you deal liable For padonnance of all
obligationsuMer Me Comract.To coral this transaction,mail or delNer a signed and dated copy obllgatbm under Me contract.Tocancel this transaction,mail ordelivern signed add dated copy
of the cancellation notice a any other writlen unfair,or send a allagnm,to A&A Servi s 15 of Me cooperation notha or par,Other worsen notice,w send a telegram,b ABA Scon s, 15
Norh Street,Salem,Massachusetts 019]q NOT LATER THAN VoteHr OF r IG North Street,Salem,MassadluseRa 01970.NOT LATER THAN MIDNIGHT OF 4 .
(Date) (Dote)
I HEREBY CANCEL THIS TRANSACTION. Consumer's SlgnaWre Vale I HEREBY CANCEL THIS TRANSACTION. Consumerk Signmure Date
/�_° 9� A & A SERVICES, INC.
A A S ,e VICES 115 NORTH STREET,SALEM,MA 01970
• MRSUNNIMEN Telephone: (978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No. CS057733
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyer(s)Name Date of Contract
O
Buyers)Street Address,City,State and Zip Cade
{ lz// � a�
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods anclor services listed below,in accordance with the prices and terms described on
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.
_ WINDOW REPLACEMENT
t Remove and dispose of#�115— existing window V
t Install # �� new lG�,�a�c.� lZZ � windows: Vinyl -)t Wood
(Manufacture
Opt1oBS: Style Grid pattern �.� 6��
Color Interior OK-e olor Exterior Glass Type a14 U�
t Wrap exterior trim with aluminum: Style Color
ep All windows will be installed according to the installation procedures in the portfolio.
Caulk all interior and exterior edges.
Insulate where possible around new units.
h-� Insulate window weight pockets if exist,and around new window units where possible.
JP Included in this proposal are set up,clean up, Hepa vacuum and cleaning windows inside and out.
Building permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
t Create new window opening by cutting through existing home and framing in opening.
t Remove and dispose of existing I units)in its entirety.
Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
t Install windows)into opening(s).
Note: If Bay or Bow installation to include cable support system,new roof system(matching color as close as possible)
or tie into existing soffit system.
It Bay t Bow t Casement f Other window(s)to include new interior style trim and new exterior style trim and head
flashing as needed.
It Note: Painting and staining not included.
STORM PRODUCTS
It Remove and dispose of# existing storm window(s).
If Install new storm windows# Manufacturer
Style Color Option
t Remove and dispose of# existing storm door(s).
If Install new storm doors# Manufacturer
Style Color Type: *Aluminum t Solid Core
SPECIAL INSTRUCTIONS:
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 i n es anges are In writing and signed by both the Buyer(s)and the Contractor. Buyer(s)hereby acknowledge that Buyers)
has react this spec) on Sh t
t
Contractor Initial ^' Date: f`� J 1 Buyer's. Initials: Date: �� t ,'nl+•