4 WEST TER - BUILDING INSPECTION $3 cif
The Commonwealth of Massachusetts RECEN \!JCE
5 fd� Board of Building Regulations an Sj1r@5xfl Ct C " CITY OF
6\� �� e,7 ' SALErVI
0 \i- - Massachusetts State Building Code, 730 CMR
�. QQ P �: h, Revised Mar 2011
Building Permit Application To Construct, Repair, R�j(jv�'007§emolish a
I One-or Two-Family Divelling
' ^ This Section For Official Use Only
ll ' Building Permit Number: Date Wied:
Building Official(Print Name) _Signature - pate
SECTION 1:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
L-1 t,t e c� -r e r�
1.la 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(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply: (ivCG.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ ;Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2tOwner'of Recur
f,t . I i�P d -ePXS� _ `e r" /ntl-G 19-1 b
Name(Print) City, State,ZIP
`� W-�S� (-e ✓IACQ
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
tree
SECTION 4: ESTINUATED CONSTRUCTION COSTS
Item Estimated Costs:
j (Labor and Materials) Official Use Only
1. Building $ I '1 3 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. Nechanical (Fire $
Suppression) Total All Fees: $.
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
,t 5.1 Construction Supervisor License(CSL)
2 GS-r�is&
S GOv'-,z License Number Expiration Date
Name of ESE of CSL Holder
/ S List CSL Type(see below)
/ p Ith 5-1 U
No. and Street Type Description
C r 6 U Unrestricted(Buildings u to 3i3O"cu. ft)
a- I •l R Restricted I&_ Family Dwelling
C y/Town, State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding.
G �C� t� SF Solid Fuel Burning Appliances
/ Lp �W-0gJ-/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�J LD( 1a09
HIC Registration Number F,xpirat Datz
HIC Company Name or HIC Registrant Name
// 5- do ✓1h. �y
No. nd Street Email address
�a L�>� I)'l�4- o ��trl a y�-a�f a�
City/Town, State,ZIP 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 .......... Er 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 C A y r S 20✓2-
to act on my behalf, in all matters relative to work authorized by this building per it application.
5a� (o OCT 2 8 2015
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
Bye ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
cont ' d this arlTv,
lication is true and accurate to the best of my knowledge and understVifi-02 8 2015
Ull
Print Owner's or Authorized gent's Name(Electronic Signature) Date
NOTES:
I. 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 mL% .mass.eov/dps
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 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"
w Phone: 978-741-0424
9 ins=--oz Fax 978-741-2012
/, &A SERA / /� 115 North
Street
ii'.!L \V/ ■V_ 115 North Street
O 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: Republic Services
320A Charger Street
Revere, MA 02150
or
Republic Services, Dumpster Service
at
115 North Street
Salem, MA 01970
ej
Signature of Pe it Applicant
Christopher Zorzv, President
Name of Permit Applicant
ocj 2 a 2015
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 Legibly
Name(Business/Organization/Individual): L C
Address: I (S f u o
City/State/Zip:_ SG l�v� M �d�97U Phone#:_/_1 —'_7 tf/
Fe
employer?Check the appropriate box:
ra to er with q. Type of7:mod
quired):P Y ❑ 1 am a general contractor and I 6. Ntion
ees(full and/or part-time).* have hired the sub-contractorsole proprietor or partner. listed on the attached sheet.t 7. 2v R have no employees "these sub-contractors have g. �D for me in any capacity. workers'comp.insurance.rkers'comp.insurance 5. ❑ We are a corporation and its 9. Bitionrequred.] officers have exercised they ]0.❑Eairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.❑Other
Any applicant that checks box al must also fill out the section below showing their workers compensation policy information.
t Homeowners who submit this affidavit indicating they um 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 subcontractors m their workers' of 11 Waling such P policy
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:I-VV C.K V(Z-I-R S
Policy#or Self-ins.Lie.#: C)o Kg' ( � Expiration Date:J-( �
Job Site Address: Lf w 'e rr'O_t—� City/State/Zip:_S� t cl 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 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 fure-
Date,ccc' n er he pains and penalties of perjury that the information provided above is tr�f��+d correct
SSi OCT 2 8
Phone
Official use only. Do not write in this area,to be co=offleiaL ofJleialCity or Town: #Issuing Authority(circle one):1.Board of Health 2.Building Department 3.Cittrical Inspector 5.Plumbing Inspector
6.OtherContact Person: #:
Certificate No: A044298
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT
DEPARTMENT OF LABOR STANDARDS
k�n
19 STANIFORD STREET,BOSTON,1MASSACHUSETTS 02114
is
DELEADER CONTRACTOR LICENSE
A&A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
i
i
i
i
LICENSE: DC000440 EXPIRES: Saturday,June 25, 2016
IN ACCORDANCE WITH M.G.L. CH. I 11, § 197B(b)AND 454 CMR 22.03, THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS 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.
I
I '
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L. CH. l l I § 197B(b)(2)AND 454 CMR 22.03.
I
WILLIAM D. MCKINNEY,DIRECTOR
.�� tit Massachusetts Department of Public Safety
Ofrce of Consumer Affairs& Business Regulation Board or Building Regulations and Standards i
a ;ROME IMPROVEMENT CONTRACTOR 'uf
3 , ,Registration: 101609
Type: I License: CS-057733
`"
. _ ;r
r Expiration: 6126/2016 Private Corporatio� sp t
'
j CEMSTOPFIER 7,6 i
PIa, 4&A SERVICES, of 115NORTHST : 9 ¢ i
1 a Salem MA 01970%Christopher Zorzy
115 North Street ��..6--->6 i� r`
Salem, MA 01970 Undersecretary ��'^• Expiration i
Commissioner 05/26/2017
I
A&A SERVICES, INC.
115 NORTH STREET
ISALEM, MA 01970
26M
�N /�C°c A & A SERVICES, INC.
A&A JEjy ICES 115 NORTH STREET, SALEM, MA 01970
Eslinkmal '• 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 arts) Name Date of Ce tract
Buyer(s) Street Address, City State and Zip Code
es sz S ( 7
Da me q � Number -8 Tele hone Evening Telephone Number Mobile Telephone Number E-Mail Address
The Boyers)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.ASA Services,Inc("Contractor'),hereby agrees to install or pause to be installed
the products or services listed in this Agreement at the Buyers)address wriden above.THIS Agreement represents a cash sale of goods and services.The Buyegs)
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 fortheir
purchase.
(� Purchase Price� 73 JC'(U� r(T
rT� Est.Staling Dater
wn P Doaymenty¢�fi��� Est.Completion Date:
lI _ rill' vy'QQ'o"T, stiff000ff Cash
Amount Due on Start of Job: C/rt(bl L'J; Check
l ff•'in E r}Credit Card
Amount Due on of Completion: O j, N o,
vlv�pic 'ram _
Amount Due on of Completion: 1� Nielaj}2 xpimtion Date:
�jjSL Ca, �,iersiur�
Balance Due on Upon Completion 7yC 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.Buyerls)
hereby acknowledge that Buyerls)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.Buyerls)also(i)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 Buyerls)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
By:
ignature
Signaturepp
Print Name 5L Of%U�aVC
Print Name
Signature
Print Name
You,the Buyerls), may Cancel this transaction at any time prior to midnight of the third business day after the date of this
transaction. Be.the following Notice of Cancellation form for an explanation of this right.
ARBITRATION:The rdromportme Ne however—heredymutuallyagreein ind—roe Natin the event enter party has adlsWMconreming this wnbecreitherparry may grand Such dispute on
private activation serNca whits hem been approved byte Sevess,co the Exchave OMm nl ConsurearANairs and Business Regulations and Ina mom pony shall be reported to submit Issuer
..Mason as proved in M G.L c 14SA,
coot t rt SL yrr.maI: /
Dae:�_ BaDtlr: /S
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
Dale d Tmnmmm ne59 a/ You may cancel this lansactian,wltout eM P¢naly or Date of Transatlim Ds'n nS .You may ante/his bansallon,vAtM1oul any penalty w
cDlipatian.Munner d ys hom Ne aWvx date.Il you anreL any proceMveded in, oEligadon.nitin tree don hom to aMva date.Il you canto/,any pmpeM Vsdatl in.
any payments made by you under Me Contract or Sala.and any negotiade instrument exemled any payments matle by you dart¢Contratl or Sale,end any negmieble inavlrent execumd
by you AT be demand whin 10 days following receipt by to Seller of your mnmilauon notice, by you will be returned Ann 10 days Itlleving receipt by Me Seller nl your cancellation notice,
and any andarG eterest antlng out of the irensec(n AT be cenrAlbd II you cant¢,you must and any sect/iy intesl an9ng out of Me transaction will be cancelled,II yet can y you must
hake available a to suggi at your ravdenls,and substamally in as Sued dooda n as wren crake available to the Seller at Your residence,and substervally In as pml mndoon as when
received,anygmtlsde4vemdt0youunderihisCmuacfor5ale:arynum¢y.iffy Msh.mnply anuffeed,anygoMsdd,w,e wwuundertlsembatl IXS le:wyw ma y.n you vas.,wmpiY
ev to in d not,if of to aim er regarding the return elle after
of Me grads at the Sons pick
wit to in d mk.1s Or Ne maker regarding the velum the Safe of the a See at the Seller s
them
pens¢and nse n yso do make the goods available b ran e,you
and the Seller doesoppo e o ftihe ahemup and n 20 a you do a data
be yours Home
of i to Seller antl be maratdoes not pick
Nemup 311 days ofither te date al your Noto an Mary Megood youmaheret
ain he Selpose it the them goon tinct nysartedallor your Nfalof Caethe4od.oyou may relade dlspmeN
Boss Abdul to any goodstGMeon.le/you tll to mole¢MegoWsevauade to the m emoril,of the goods Attracttour any further to ieesellerlywleilbmas then A,muupseds elaterformnc seller or e
all se crbg return index Me to pa SHlerand e todow,Men yw residue in/node farwpedand dated
you egregation ra the gmdsloact Toearmtt and its areachorn yotorepinliabd vor ls,rand dame¢
elly ofthonsuMerta Compact or any
wnml tisbansacdon.nee ordeliebasigned anddt . or oyMithecarerac Netestad,opper-m this xcmropmdabeIellverevgnedandtlaled
mpy Mor Geer SioievndAi oranyot¢r mon"TENTnotice,myesalele copy of topard,Seem
noticeorany OTL TER notice,or SendatF— tale BA )a%yef
/noror
115 North Sbee,Salem MA p1910,NOT LATER THAN MIDNIGXT OF ) 115 NOM5beel.5alam MA 01910,NOT LATER THAN MIDNIGHT OF �✓4
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION
Cmsumeis5igro pale: Consumer's Sigma a Oat¢:
\0� + (�(oQZ
d
aQ C �( (� �° A & A SERVICES, INC.
115 NORTH^&^v�a ICES Telephone:::(97)74�1-0 24 Fax:978)741 20EM,MA 012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyers)Name Date of Contract
�X Lark tt.tDa_A"r,cemcv
Buyers)Street Address,City,State and Zip Code
L gs�— I-lef cp_ ti /t/w.
Daytime Telephone
�Number Evening Telephone Number Mobile Telephone Number E-Mail Address
�70 7`a)—
The Buyers)listed above hereby jointly and severally agree to purchase the goods acolor 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 pan.
'n WINDOW REPLACEMENT
Remove and dispose of# F existing windows.
llllll//////E9nstall # 1i new (b 1ST IVA1,10i 5GOP5windoi*inyl f Wood
(Manufacture
Options: style Pcu}T��- bW�' Grid pattern SiX6 P1C �CY�k
Color Interior lAl V,fe Color-Exterior W lfl t bF Glass Type .6 Z
f Wrap exterior trim with aluminum: Style Color Ct OW E
cAll windows will be installed according to the installation procedures in the portfolio. fi-1goNy'r�s
o ublepkti'�
baulk all interior and exterior edges. �j _
It D
9 Insulate where possible around new units. I l i�
If nsulate window weight pockets if exist,and around new window units where possible.
f nickeled in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and out.
f Building permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
I Create new window opening by cutting through existing home and framing in opening.
I Remove and dispose of existing 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.
f Install window(s)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.
f Bay t Bow If Casement If Other windows)to include new interior style trim and new exterior style trim and head
flashing as needed. ,�.,,��{{
It Note: Painting and staining not included. C �2 Scf�21✓S C♦•'I ��ASS'j�f'it"t1
STORM PRODUCTS �� Nih)yg ffl1 �S' i
It Remove and dispose of# existing storm windows). t` �C�}6:;j�l/rlg
If Install new storm windows# Manufacturer LC?.�-`S(f>'�'ng
Style Color Option
It Remove and dispose of# existing storm poetic).
If Install new storm doors# Manufacturer
Style Color Type: f Aluminum f Solid Core
SPECIAL INSTRUCTIONS: �4A i f WAt./
{ 4:4 9 1*0AI : olye2 6n� -.211 -FL //Ayll)1G ll
o Lo rvk r /2 Ff Bed cool i
-
'Z7 n/AOUSPij�ull1(y iACTlr�c1 Li P
�hlv.P f!/A!P 1(-,225 TU A-! i Pox �C"IM1 AZ 6L(-15r,4- ✓1 CC) �. qe," �i fO It W1+
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 Buyeda)and the Contractor. Buyerfs)hereby acknawledge that Buyers)
has mad this Specification Sheet.
-
Contractor Initials: 52— Date: /U Buyer's Initials: � Date:
v