3A WILLOW AVE - BUILDING INSPECTION No.
APPLICATION FOR
' PPRMi TO
LOCATION
PE MIT GRANTED
APPROVfp
CTO� OF BU DINGS
CERTIFICATE OF OCCUPANCY .
YES
NO
NThe Commonwealth of Massachusetts
1 G Department Of Industrial Accidents
t i1 •t� j Office of Investigations
600 Washington Street
v° Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADDlicant Information
/� - Please Print Le ibl
Name(Business/Organization/individual): A St✓r vi 6e ,5 x1n a+ ICI
t I
Address:_ 11.5 tJ O r4-h '5- l•r e-�.
City/State/Zip:—sal p M Mn 01970 Phone #:
Area an employer?Check the appropriate box:
1 IJ I am a employer with 4. F
project(required):
employees(full and/or pars* ❑ have higred the beneral tconttactoractor ast
ew construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t emodeling
ship and have no employees These sub-contractors haveworking for me in any capacity, workers'comp.insurance. emolition[No workers' comp, insurance 5. ❑ We are a corporation and itsuilding addition
required.] officers have exercised t I O•❑ Electrical repairs
their p or additions
3.❑ 1 am a homeowner doing all work right of exemption MGL per 11.P ❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have
insurance re uired. } no 12.❑Roof repairs
9 ] employees. [No workers'
comp,insurance required.] 13.0 Other
*Any applicant that checks box#1 must also fill out t
}tlomcow he section below showing their workers'compensation tiers w ration who submit this affidavit P Policy information.
idavit indicating they are doing all work and then hire outside contractors must submit a new,affidavit'
tContrictors that check this box must attached an additional sheet show' t indicating such.
mg the name of the subcontract�rs and their workers'comp.polity infonnaoon.
I am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site
information. -�"
Insurance Company Name: t r te— Tra f {�
Policy#or Self-ins.Lic. #:_ sp X I a ti
Expiration Date:,t310 7
Job Site Address:A W/I lD W l'tyej-)tCity/State/Zip: C ^ ^ rn ic I ,9 Qt017D
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
tine 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 ttp 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 n er a pains a d penalties ofperjury that the information provided above is true and
correct.
Signature:
Date: - -Q
-Phone
Official use only. Do not write in this area,to be completed by city or town 0J icial,
City or Town: Permit/License#
Issuing Authority(circle one):
I.
Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
G.Other
Contact Person•
Phone#:
Information and Instructions t '
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,of 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 thew
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 pemtit 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 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 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
Signature of P rmit Applicant
- / - D7
Date
Christopher Zorzv
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
BOARD OF BUILDING REGULATIONS,
C` a License: CONSTRUCTIOWSUPERVISOR
NumberfCS 057733 - a
Brrthdate 06/6/1958
res OS726/2007 Tr,no 12633
�.Restrr`ct�ed1 p0 ;
~
NO OP ZQR 115
. 115 NORTHS T ``�\\,d C
SALEM, MA 01970 •`'ems
Commissioner
m � ✓lee o9te//ee>�[�L �,�aelieeaa<lta
BoardoTBuilding Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: .612612008
Type: Private Corporation.
�. A&A SERVICES, INC .
Christopher Zorzy�
115 North Street:
Salem,MA 01970 Deputy Admrmsh-Aq
----__ -----------
Commonwealth
of Massachusetts
Division of Occupational Safety
Robert J.Prezioso,Commissioner t5�,
Deleader-Contractor V�yQf
CHRISTOPHER ZORZY
Eff.Date 04/02/07 a
Date 04/01/OS
DC O # a'
DC000440 J` .�
Member of CONES T.
8
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IIIIII IIIIIIIIII IIIII IIIIIIIIII III�IIIIIIIIII IIIIIIII BOSTON-RENEW
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� A & A SERVICES, INC.
/" &A SEMCES 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
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyer(.)Name Date of Contract nt
a� 6 �F
Buyer(.)Street Address,City,State and Zip Code
3A Alpl 4w--. O1 0
Daytime Telephone Number Evening Telephone Number obits Telephone Number E-Mail Address. '
27$-795'41 I a
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods ani 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
E! gemove and di po��se of# fisting wintloy+s.
Wr/Install # new (I�.6I I windows: b/Vinyl ❑Wood
(ManUfacWrer��
Options: styeg 5 / S S Grid pattern a 04,111
Color Interior Color Exterior (N Ift Glass Type dMiQ — 64SIPA -
❑ Wrap exterior trim with aluminum: Style Color
VAII windows will be installed according to the installation procedures in the portfolio.
id"Catfilk all interior and exterior edges.
V Insulate where possible around new units.
0/insulate window weight pockets if exist,and around new window units where possible.
IK II cfuded in this proposal are set up,clean up,Helps vacuum and cleaning windows inside and out.
®' Building per included -
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
❑ Create new window opening by cutting through existing home and framing in opening. _
❑ 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.
❑ Install window(s)into opening(s).
Note: If Bay or Bow installation to include cable support system,new root system(matching Color as close as possible)
or tie into existing soffit system.
❑ Bay ❑Bow ❑Casement ❑Other windows)to include new interior style trim and new exterior style trim and head
flashing as needed.
❑ Note: Painting and staining not included.
STORM PRODUCTS
❑ Remove and dispose of# existing stone window(s).
❑ Install new storm windows# Manufacturer
Style Color Option
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: Of Aluminum ❑Solid Core -
SPECIAL INSTRUCTIONS:
9� a
a _
A Is agreed and underatoad by and between the Parties that this Specification Shes4 along wit CUSTOM REMODELING AND IMPROVEMENT AGREEMEW,,consulates'
the entire underetereling between the pertlea,end there are on wM.i understandings changing or modhying any of the lama.Thla m ttrect may eat be changed or Its
tmmamodMedorvarledinenyw Ieae sUchidsm a are In wrhing and signed by both the Buymp)and the Contractor.Buyens)herabyackrawledgethet Buyers)
hoe reed this SPecMaeU
' Control Initials: Dale: �� Buyer's Inilials:� Date: Z5 D
LJ
snm,� A & A SERVICES, INC.
A&A S CES 115 NORTH STREET,SALEM,MA 01970
a a a 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 -
Buyers)NESIDSISS., Date of Contract
rC FF•'All I/Ap
Il
Buyers)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
The Buyer(5)listed above hereby jointly and severally agree W purchase the goods andlor services listed on the accompanying specification sheets,in accordance with
Me prices and terms described on the front and the reverse of this agreement and any simmu ation sheets firms"AgreemenYl,and Buyer(.)have requested that such
,.dean services be installed or provided at Buyer's address listed above.MA Services,Inc.("Contractor'),hereby agrees to install or cause to be rival the products
or services listed in this Agreement at the Buyer(.)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 pummel
AS ddaee�mbed herein,regardless of timing
or approval of any financing Buyw(s)may seek for their
purchase.
Purchase Price, p�� /Hr 11 /r'�Y al Est.Starting Date:
Down Payment: III,fM��, L.Ab �� Est.Completion Date: ,- b'
❑Da.h
Amount Due on Start of Jab: /r Check
❑Credit Card
Amount due an of Completion: A/, No.
/ ,
Amount Due on of Completion: `I ll� Ll b e —1 ✓n Expiration Date:
Balance Dusan Upon Completion: S/s 12A diA�e_--6All 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. Buyers)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 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. RYYey[s)
By: �r'Ji c —
Signature g�y�ure
t Cnv nljAAi !ST6w.tj2�j
Print 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 date of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION'.Tie mmravmr anE be Mmro'.rnar M1eraby muNallY agree In octants Mal in be arent slitter Nary hfla a G¢pula mncernbg bra wrNacl,enter party may aubma¢uch Espule b
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arch MNBtion AS paved In do L F142A.
Cemancriiriels: aivarsloi4el
anal OF GANCELI ATON Sol nn CANCELLATION!E
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WNecancew Wrwfmaany othmwrnwn OT"w�ntla MIDNIGHT
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HEREBYCANCELTIISTRANSACTON. CwaurnesslBnatura Oaw I HEREBY CANCELTHIS TRANSACTION. Cmwmer§So.. Dad
DATE: � /-0 7
itp Dfa`7A�PTTT, JaaLjuEtt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
I�ver1�
Location of Building 14 Wi (In w
Building Permit Application For:
YCircle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, epair/Repia 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: wQ,)'-f- Contractor: 1 9-' A SeryIC¢S f a 1 Ab rA
Street 3>q Wt l City S(t(Pm?m Street 1 Nnr4h -"k. _City ., 1 m
State-R Phone (R78) 25 - W-I( State M A Phone• 07S) 7,1 t,-.A<-1 a�j
Architect: City of Salem Lic# 1 H D5
Street City State Lic D57 HH'k 101(00 09
State Phone ( ) Homeowners Exempt Form___yes t/ no
Structure: (please circle) Ingle Fa Multi Family# Other
Estimated Cost of job S—J 07cq _ 0-0
Will building confirm to law? ✓ ycs no
Asbestos?_des ✓ no
Description of work to be done:
Znsfzt l l Sly- LOJ Vlntdl rP (a a nt (AJ I t-),-1 U-)5
A&A SERVICES, INC.
Drawings ubmitted:_yes n0 Mail Permit to: t SALEM,MA_01970
X r d WWW.A-A
Signature of Appl ation,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE