5 WINTER ISLAND RD - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION Y
1.1 Property Address: 11 1.2 Assessors Map&Parcel Numbers
UIe1 �IIS
Lla Is this an accepted street?yes no Map Number Parcel Number t
1.3 Zoning Information: 1.4 Property Dimensions:
v
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
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 Record: C "
aMcntiV :EckIl0 1 „txVrh 1114—U 70
Name(Prung City,State,ZIP
5-[Ji 5la ti- TTW�-'IYV-o!oa
No.and Street Teleplione Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) QKJ Addition ❑ a
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief 1Description of Proposed Work': /h -0.. r--Q.. e fc_cv-W,0_r
rl rb AC4 Lo,S S erv.-l•-rJ Oc)/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ � 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee t
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:,$
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ a I���_ ❑Paid in Full ❑Outstanding Balance Due: -
t
„
SECTION 5: CONSTRUCTION SERVICES
` 5..1 "�Constructiioo7nSupervisorLicense(CSL) QS-�-733 �.�;Cn��S
l jyt✓l f "Tor r y License Number Expiration Date
Name of CSL Holder
'15' ^Iv / S fi List CSL Type(see below)
No.and Street Type Description
����✓✓t Nq.� !C]-70 U Unrestricted(Buildings u to 35,000 cu.ft.
I° ` I l — R Restricted 1&2 Family Dwelling
City/roN State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
JD1 to
lhr� [-.'�✓i GQ-S `V�G HIC Registration Number Expiration Dale
HIC Company Name or HIC Registrant Name
N d Street �'` I �I r
lA A-0 t R'(O D� 7 Email address
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 .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize S 2 ar z y
to act on my behalf,in all matters relative to work authorized by this building permit application.
1i1e (, o ,- rM J I -71 ' I'
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contai e 1 in hiss application is true and accurate to the best of my knowledge and understanding.
1-3 ( 14
Prin Owner's or Auth6rized Agent's Name(Electronic Signature) Date
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(H IC)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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
The Commonwealth of Massachusetts
� ('' Departnient of Inrhfstrial Accidents
> t� Office of6Nesdatffens
o
600 Washington Street, 7 l'Floor
Boston,Mass. 02111
--�" Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information: Please PRINT legibly
name: _1. ✓r S �P/.q Zc't✓Z .
address: ��� �O Y / N 1SY-�--e{e:t [ r/
city SLR I2 /-, stale: M1`'i zip: 0/9-70 phone# /dy-7111—er/av
�c( �� 1 work site location(full address): `� t.C1,I+ u ( S(-Id M4 ai9Z0
❑ I am a homeowner performing all work myself. Pro ect Type: [_]New Construction ❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
PI I am an employer providing
�workers' compensationg for my employees working on thisjob.
compan name: A 1"- ,��S'Z t-V 1 e_�,
address: I l .s A/O ✓-- �1y1 S+• (]�1 p 7�[ /�+ / �1 /
city: o, ( e (�, /'G'�I phone#: —t 7 — /�n7 �Q—V `7 a'-7 p
insurance co. �_ 7rQV{e I{ r 'S policy# C)�L� 3 A l O 1 S I . t—1 3—f
❑ 1 am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: Phone#:
insurance co. policy#
company name:
address:
city: #:
insurance co policy#
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of.NIGL 152 can lead to the imposition ofcriminal penalties ofa fine up to SI,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a]-me of SI00.00 a day against me. I undersland that a
copy of this statement may be forwarded lu the lice of Investigations of the DU for coverage verification.
I do hereby
/certij�note tit pains rtnrl p patties of perjury that the information provider/above is true and correct.
Signatu I Date
Print name �—KI-✓ % C-�OO / OYZ / Phone# 7 O T
- official use only do not write in this area to be completed by city or town official 7
city or town: permit/license N ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑selectmen's Office
❑Ileallh Department
contact person: phone N; ❑Other
(mVised sept 2003)
o DISPOSAL OF-DEBRIS
a AFFIDAVIT
In accordance with the provisions of m. e, L. a, 40, Sao. 64, a con ' ion ref
Buii ng Parma member is that the debris resulting from this Work Shall
be disposed ®f:in a pr®p�Ply.11emnsed Wiiitr as da%in®d,by RA L.C. III, &eao.. : . .
Jbd debris wiii be®ispoSBd at Mom Teatisfoe Sftbon
by HoedrigHe Caft
8i nawre ®f NOW applicant
A A SeMge& o
i=6 ri ei R� 8
€10 Mth Steeata Salem. MA 01970
Address, Ch%y, Stator, ZIP Code
/� �+�p�/� s A & A SERVICES, INC.
A&A SERVCE$ 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
Bu eqs Name
Date of Contract
Bu ers Street Adtlress, Cit ,Stale and Zi Code
fN/A/-ff"L_ / 5L/fv0 20 ,SWL( l N/l9 0/970
Da ime Tele hone Number Evenin Tele hone Number Mobile Tele hone Number E-Mail Adtl —
926-7Y -olea IR a 01- �,N t
L6 UO�C'cwc
The Buyers)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 Buyers)have requested
Mat such goods or services be installed or provided at Buyers address listed above.ABA Sorties,Inc.('Contractor"),hereby agrees to install or cause to be installed
the products or services listed in this Agreement at the Buyerls)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 Buyerls)may seek for their
purchase. //((
Purchase Price# Z 777r 7Check
-30 ��/
/ Esate:Down Payment: 9ZS' Esn Date: 3—/S"JyDAmount Due on Start of Job: rdAmount Due onof Completion' NoAmount Due on_of Completion: n/ Exe:
Balance Due on Upon Completion: I of ZA
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.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 Servicev Butter(s) �y
By:_Signature Si lure
Sig> e
ED (3rr2(ie X �Qe
Print Name 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. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION:The wneadorand Ne honbovmer hereby muwally agree in advance that m the evem amer pony nos a dispute W entrong Iris cono-ecLeilher paM n'ay ommil stun troubled
pivate arbitration eetaca erirh has been lone tl by the Be..,of Me Executive office of Consumer Arnold and Business Reglda4..and the other paM snail be reavired to ambe l to such
aNltration as ptovN in No c 14Y. Co �ji l ^t�
nrnnnriniinle ✓• 6uYYS Inin 6 X r1"
Derr: 1-3to-/Sr He,
NOTICE OF CANCELLATION NOTICE OF CARUJI-Afichil
Dale w Transitions, —3) O-!Y Tom may cancel this reasonable Winter any panauy or Date el Tramadmn I—30 y You may danr¢I this transaction.vAhoul any penalty or
ohligatlon more three business days from the amve data g,oh—mof anypmcerymbeediq obligation,vnNin tnree business days wmine above oats.XyacancekanyproceMtradN in,
any payments trade by you under the Come t or Sale,and any m ounde Insautrentersatetl any payments made by yw untler the Centred or Sale,antl any negotiade Instrmrent executed
by you MII be hatteme xithe 10 days helps,receipt by mg Sella of your damenhlaton notice, by you all be returned wh in 10 days follows receipt by the Soller of your cancellation notice,
and any secun,interest adding out M Me transaction all be cancelled.It yeti cancel,you most and any secunry interest..sine oat o1 me pansamon¢in No,csnaned.If you canrel you east
crake available to the Seller at your readenca,and subitanSNly in as good condition as when make available to Me Seller at year residence,and sudslontially In as good conditional arer
anoitbee,anygwds delivered toyou ImMolks Comeau or Sale:or you 10 ya WSR comply roodeved,any goods oelivxred to you under this Contact Or ser;m you may.Il you vnsh,comply
who the imams lens of the Seller regains,the return shipment N One gootls at the Sellers WI the emotions of Me Seller regarding the realm shipment of the gaps at the Sellers
expense and not.II you do make the goods available to the Seller and the Seller does no pid, expense and risk.If you do Mite the goods available to Me Seller and Me Seller does not pick
themup..in20 days of the time Of Ica"'of CaneHlamor you may reNin or disease of the them up enNin 20 days of the data of your Notice of Canrdladon.you may retain or diseased
gouda mendut any further obligation.If you tail to make the gwds available to the Soler,or if you thepodswiMoulanyfuMercmigedon near fail to Make the goods available to the Seller or
agreetorelurn NegoodslotheSelwaMtailtodosO,then you retrain liable for pedpmenca of lemagrre torelum the gocdsto the Sainerand fail modum Nenyouremainlladeforpedamance
an diagrams under the Contras.To cancel this transaction.hail or delbar a signed and dated of all obllpfichs under Me Compact.To cancel this vaneactiogMet or deliver a signed and mind
ropy of Me cancellation notice or any orer,,mrse canes,or send a telegram to Pee SeMws, copy of the cancellation.Dude or any other wnMn notice,or send a telegram,to AAA Semites.
115 North Speer Salem MA 01970.NOT LATER THAN MIDNIGHT OF 2-I -1y. 115NonhspeeLSalemal l9ID,NOT LATER THAN MIDNIGHT OF
Inerel Inalel
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION
Cmavmer's Signature Date: C-aternre Signature Data:
{ A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
lim I Sm•'• Telephone:(978)741-0424 Fax: (978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
ENTRY DOOR SPECIFICATION SHEET
Buyer(s)Name Date of Contract
cMwRK 6oc,I-oL-1 —3a—iY
Buyerjs)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
97g-74y-01oo
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or 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.
ENTRY DOOR
Remove and dispose of# existing entry door units.
>Z' Install new entry doors# Manufacturer _77t�944 /series__5P"oy 7h,Sl Iz
Location %-2PN N7v L/
Type: ❑Steel Fiberglass ❑Sliding Patio Door ❑French Hinged Patio Door
Model# Zq(P Sidelight(s)# Sidelight(s)type/model#
OPTIONS:
*Adjustable threshold for door. ❑ Grids for patio doors: Style:
Prefinished ❑yes �"no color: interior_ exterior_
Expand or shrink the size of the opening Details
Cover exterior trim with aluminum coil stock: Style Color
Hardware: K,Lockset doeadbolt ❑ Footbolt ❑Mail Slot ❑Peepsite Detall_ (J/CtGH-%
k," 67D A-L-J K p r
( Replace interior trim as needed. Details F.li 7>96C- #/ S17LLTL T O/w LT 3 401- 9 G_
Replace exterior trim as needed. Details //"5 71q-t�L P2J-/�j/�ry c�TJ Z" /,j/L!6 Lr�r cy
Install oak strip at floor as needed.
Caulk interior and exterior edges.
Insulate around new door unit where possible.
` Painting is not included. Details
Included in this proposal are set up and clean up.
STORM DOOR
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors It Manufacturer /series
Style Color Type: ❑Aluminum ❑Solid Core
❑ Location:
❑ Hardware style Color
SPECIAL INSTRUCTIONS: /�
/C L31M01/Ej — /(L3-I/VS/7';'GL Plc lS i7/V(� ALV+^� NVM � r✓l O4yitz—
It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,conatl-
himtheentire 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 Buyer(s)and the Contractor. Buyena)hereby acknowledge that
Buyers)has react this Speciification Sheet.
Contractor Initials: y, J Date: -30 -� / Buyer's Initials:x 11'21-1) Date: 3��
f
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT
=,l DEPARTMENT OF LABOR STANDARDS
19 STANIFORD.STREET,BOSTON,NLASSACHUSETTS'021'14
DELEADER CONTRACTOR LICENSE
A&A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440; EXPIRES: xSatuMay,June 07,2014
"
IN ACCORDANCE WITHM.G.L..CH. 11.;1, § 197B(b)AND 454 CMR 22.03,,THIS LICENSE IS ISSUED BY _
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR TI-IE PURPOSE OF.
ENTERING INTO OR ENGAGING IN DELEADING WORK:
THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L. CH, 111 § I OB(b)(2)AND 454 CMR 22.03.
HEATHER E.ROWE,DIRECTOR
Massachusetts -Department of Public Safety
fee rPanvnzmzuea�lFc oy° ¢mac�irmea f
Office of Consumer Affairs&Bust ess Regulation Board of Building Regulations and Standards
OME IMPROVEMENT CONTRACTOR Construction Supervisor {
egistration 1P1609 Type: License: CS-057733
xpiration 6126/2014 Private Corporatio
CHRISTOPHER Z}ORZY
A&A SERVICES,INC x e 115 NORTH ST - dt
r't r i Salem MA 01970- _
Christopher Zorzy 'VO
115 North Street -�"
o
- - J,,�,,,. Expiration
Salem, MA 01970
Undersecretary 05I26/2075
Commissioner
NnIZ3 My 120i"i Program
(8i1) i4 127.t l 'v
7Fiber Cement Siding
#� #20120426000840
Christopher Zorzy
:q, I A&A Services Inc Exp 4t2612017
115 North St
� E1�9 %I•iRr4 ZORPS' Salem, MA 01970 wS,
17 11 Cs4o.oxi:i9 _ t- 5�s � Phtthew JGibson
r• nor cvo-a�.a q+,.a I ,
30
93:
A&A �� Phone: 978-741-0424
Fax: 978-741-2012
2012
www.a-aservices.com
• • 115 North Street
Salem,MA 01970
January 31, 2014
City of Salem
Building Dept.
120 Washington Street
Salem, MA 01970
To Whom It May Concern:
Enclosed please find the permit application for Mary Ballou, 5 Winter Island
Road, Salem, MA.
I have enclosed a check f/$26based o)your fee schedul�$7 per$1,000.00
plus a $5 administrative fee.�Tl�e total for the j ib was $2,777.00. '
Please send the comp'leted permBit to A & A Services" , Inc. at 115-No'rth Street,
Salem, MA 01970. I �.�I
If you have any questions, please contact me at (978) 741-0424.
i d LJ
Thank you for your assistance.
- t ,
i
Sincerely,
Barbara Zorzy
Office Manager
� V I
. h