19 WOODSIDE ST - BUILDING INSPECTION (2) 2� 35 ('S
The Commonwealth of Massachusetts rlt "+LIrc'
'n Board of Building Regulations and Standards C Y OF
(v 1 Massachusetts State Building Code, 780 CNiR 20tb OCT 2 1 ,$Mar
._ cs �blcrr 10/!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Offi 'al Use Only
Building Permit Number: I Da Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property A dre s: 1.2 Assessors Ma & Parcel Numbers
R Gino 2,
� �'Lf✓�P{' p
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: lA 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
1.6 Water Supply: (NLG.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1� pwn r'of Re d: II
IN�IPee SSrMc) d �SGlew! 4AA970
Name(Print) City,State,0A(JgtJ [she UF-97ff- oocL
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK!(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ m(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
place _ u 1�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official se Only
1. Building $ 3 J 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. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
M�t `��7 IO�ZS
SECTIONS: XONSTRUC.TION SERVICES.
5.1 nCo/nstruct on��--Supervisor License(CSL) -
( VI Y < l e /� • :�C)!2 Z`f License( 03 Expiration Date
Name of I ,Si—" n,� (�-7/` T Description
N S Q l lv1 ' l /v U Unrest i t d to 35,000 Lh Ft
'A Restricted 1&2 Family Dwelling
M Masonry Only
/ RC Residential Ronfin Covering
r fl �'7 G_ � (1� �M C/'1�j ws Residential Window and Siding
_/ / 0 -1 V /Of`�'' SF Residential Solid Fuel Burning Appliance
Telephone D Residential Demolition ,
5.2 Home Improvement Contractor Registration(HIC)
H,L� Vf 77 S Registration 1 O I(�n 5 Expiration Data 6
HIC Com y N a or MC R.cgistrant Name
tAda&ss-
Signature`� 7Y-7ql OYUelephone
SECTION 6: ;WORICER!S COMPENSATIONINSURANCEAFFrDAVIT(M.G:L.c-152. §25C(6))
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affi vit may result in the denial of a building permit
Signed affidavit attached? Yes No O
SECTION lac,: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER S AGENT,OR '._, ,;
CONTRACTOR APPLIES FOR BUILDING PERM
I, JI 1()3 as Owner of the subject property,
hereby authorize in 4 1 rr, ,R 01 CPS to act on my behalf in all matters relevant to work
authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I, r y1fZ as Owner or Authorized Agent,hereby declare that the statements
'r-
and information foreWi application are true at_d accurate,to the best of my knowle4ge and belief.
signature of Owner ar A tlrorized Agent (Signed under the pains and penalties of perjury) Dare
SECTION 8: DEBRIS DISPOSAL
All dumpsters of six(6)cubic yards or more are re uired to have a permit from the Marblehead Fire department call 781-639-3428.
In accordance with the provisions of 780 CMR and MGL c40,§54 a condition of issuance of this building permit is that debris
resulting from any work performed shall he disposed of in a roperly licensed soli¢waste disposal facility as defined by MGL clll,§
150a. zup�� Al li'S�OiCIh �, S'ot(eiy MA 01970
DEBRIS DISPOSAL LOCATION
SIGNATURE OF APPLICANT
NOTE .
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.
3d
//��,�, � �+�'p`/�''/(1`^�w^, A & A SERVICES, INC.
AAA JG�{Y US 115 NORTH STREET, SALEM, MA 01970
• M e• Telephone;(978) 741-0424 Fax: (978) 741-2012
GIZv SK+� APP, I.D, - ib091(938SL
101609
SY 9z 0 9 3 7- 3 qq 5- 3((o Contractor Registration No. 057733
8 �u Construction Supervisor No.CS057733
Federal EIN: 04-3090162 0 )- 1 7 C.V G s o 1
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Bu e s Name Date of Contract
_k FA/77_/
Bu er s Street Atldress, Cil ,State and Zi Code
s D s 7- S/9 L EAM N4a 0/ 70
Dayfirme Telephone Number Evening Tele hone Number Mobile Tele hone Number E-Mail Address
978-57 ie-o,1/ w&,K-it
The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance
arm the prices and terms described on the front antl the reverse of this agreement and any specification sheets(this"Agreement"),and Buyer(s)have requested
that such goads 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 sate 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.
Purchase Price: 37 i Sf
Down Payment 7N0a F
Amount Due on Start of Job:
Amount Due oof Completion: 217 l0,W17 8
Amount Due on of Completion: Q �evol w,N 1M Expiration Date:
Balance Due on Upon Completion: I �r- — Z(OSr Go B-N V i&4 CVC Code: Z Z Z
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.Buyents)
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.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 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 Servi s,L Buyerls)
Si
Signature Signature
�' //
fr
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 n6ht.
ARBRRATION.Tie amal orandtie hommane M1erepy,ruluallyagree In advance Malin Ne eventtlNmpathastedimub m,nmi,g 1M1Is wntrad eill,erpeM moY%uOM,suUi alumiabe
Amass emltraYon seMce vridihasbeen sprayed by Me Beael dtie Exeative OMceWConsumer AAaimand ersomma Ruguladoernd lireoMmper,shall berequired m subm bsutl,
arandom is pmvPoIn k1.GL ct<'1A
Conwnarini,uls:� Bu 1 i h X(.yE✓
yeJx n
aaa. /0-14-1La Due: Y/1(a
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
Dole of Transa lion/ I'll' You may cencel this lrensactim,MtlwN any penalty or Dare of Trenam n ll!4-/1a Y may rel this national MMoul any penalty or
obligation,Affair three business days from the above data Ilyouwnw,anypmpe tb ¢din, obligation,adan Mree bueness days from the above date,N you same.any property traded in,
any pos"has made by you under the Convector Sete,and any negotiable instruned executed any peprenn cede by you under Me Contractor Sale,and any negotiable instrumentemoted
by you WII be renumxd a min 10 days bllowmg main by the Salle of your cencellabon notice, by you.11 he reNmed indoor 10 days lollovfrq recMpl by F.Seller of you,wnrellmom notice,
and any a..,inlet¢.ed9ng oN on Me bansactlm vfll be fznnlled If you T.I.you must and any sectors interest ensing not of Me minimal etll be cenmlled II you rantak you in
rreake available to the Seller at your handeal and submdMFy In as good w,O,Oon as wfien mine available to Me Sager at your evidence.and substantially in as grand common ea area
mover.any goods delivered to you under this Contract or Sale:Orion may,1ymvfsh,¢nply reree ygo sdeliwmdtoyauunder0'ISContedor Sale',oryWrNgllyouvfsh,comply
wah He instmNws of the aelles regaling Me notion shaman of Me goods at the War xtm the ia.h.11 M me SNIm m mo ng the reNm sM1lprrent M the gootls at Me Senate
e sense and risk.If you do make as goods available to Me Seller and Me Seller dames nor eel, expense and Oak.If You do make Me goods.vailahle to to Seller and the Sell.,does col pick
them up vain 20 days of nM data of your Notice of Cancellation,you may retain or dlsoose of the them up soon gO days 0 Me date 0 your Notice of Colorf tiro,you may rennin or dispose of
giants wWoad any further obligation.Vyou for to make the goods available to Me 5ellot or it you fie go Ws xiMmrt any turner odignion.If you fail to make he goods averbe to the Seller or
ctme to mound Me goods to no Seller and fail W do so.Men You harrain liable for peramanm W you agree to return the goods to the Seller and tell to do so than you remain liable for perfamence
all Migration,under the CmVact.To w cel Mb mnmdw,nryl Or deliver a signed and dated of allebligaal utter the Cormor,To cancel this deduction,trail ordeliver a signed and dated
ropy of Me mnmlladon nodro or any omet,MMn randy or send a rile rim,to A"Small dopy Of he wmwlibuto hared w any Other mean notice,or sam a Rl r to
115 North Street Salem MA01970,NOT LATER THAN MIDNIGHT OP�d_ _I 115 North Saver,Salem MA 0197,NOT II-AM THAN MIDNIGHT OF� �re
maw, mewl
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION
Cmmu aSiminum Date: Consunera Strauss Dale:
A' A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA01970
Telephone: (978)741-0424 Pax: (978)741-2012
Contractor Registration No.101609
Federal EIN: 04-3090162 Construction Supervisor No.CS057733
MISCELLANEOUS SPECIFICATION SHEET
Buyer(S)Name Date of Contract
ALKBn- 4-6741TY . iMV7V-S
Buyers)Street Address,City,State and Zip Code
19 LU00D5/D9_ Sr SAL,6^1 Yz414 0/5`7D
Daytime Telephone Evening Telephone Mobile Telephone Number E-Mail Address
B-S -0 l7-
The Buyer(s)listed above hereby jointly and severly agree to purchase the goods and/or services listed below,in accordance with the prices and terms de-
scribed on this specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which
the Specification sheet is a part.
Rv3GC;L'-I2. 20aJ'I A/Zj
SPECIAL INSTRUCTIONS
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p l,s covNTPiL,u�= 3715,
QG�vse i = �Z '�Or
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 and 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 Buyers)and the Contractor. Buyers)hereby
acknowledge that Buyers)has read the Specification Sheet 65
r �0-W� I(p Buyer's � � ,,���. �
Contractor Initials:� Date: yer's Initials: Date: !Gr/171/
CITY OF S.V_E.M2 KNSSACHUSE-M
BUILDING DEPARTMENT
p 120 WASHLNGTON STREET, 3w FLOOR
TEL. (978) 745-9595
Kr BERIEY DRISCOLL FAX(978) 740-9846
MAYOR THOmAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BU;ILDLNG COSL%asSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Le ibi
Name (Busintss:Organizatiorvindividual):
Address:
City/State/Zip: Phone #:
Are you an employer?Cheek the appropriate box:
I. 1 am a employer with 4. Type of project(required):
❑ 1 am a general contractor and 1
employees(full and/or part-time).' have hired the sub-contractors 6. El construction
2_❑ i am a sole proprietor or partner- listed on the attached sheet.: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for me in any capacity, workers'comp.insurance.
[No workers'comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself[No workers'comp. a 152,§1(4),and we have no I2,❑Roof repairs
insurance required.] f employees. [No workers'
comp. insurance required.] 13.❑ Other
'Any applicant that checks box al must alw lift out the s tfnmeawrs m'm below showing their workers'mmpensation policy information.
:Camsaraoa that
who submit this affidavit indicting they ate suing aII work and thm hire outside contractors must submit anew affidavit indicating such.
hat cheek this box must anachat an additional sheet sbowing the name of the sub.com ractors and their workers,comp.policy information.
I um an employer that is providing workers'compensation insurance jar my employees
informordan Below Is the policy and Jab siteI
Insurance Company Name:_ A
Policy#or Self-ins. Lic.#: � � �i I4�
[� _ Expiration Date: —
Jab Site Addr ss: (!� [(J fit City/state/Zip: fGl'P14 4 ) I?�O
kttach 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 S 1,500.00 and/or one-year imprisonmenit,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
Invesligaliuns of the DIA for insurance coverage verification.
I do hereby certify under theeeppains and penalties of perjury that the irrformutian provided above is true and correct.
Sienunrre'1C � '
Date:
Phune — —
Official use only. Do not write in this area,to be completed by city or town off
ciaL
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
6.Other _
Contact Phone#:
CITY OF S UEM) N'L1SSACHUSETTS
BuILDL\G DEPARTMENT
• 130 WASHLNGT STREET,ON 3iO FLOOR
\ �`b� TEL. (978) 745-9595
FAX(978) 740-9846
KI3tBERLEY DRISCOLL
MAYOR THObtds ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I It, S 150A.
The debris will be transported by:
'(nameofhaWerjl
The debris will be disposed of in :
(name of facility)
� C . I �Iv� S �ev-uico� S
(address of facilit
I S /v G V�-}-�1
S Ole M M-4
signature of permit applicant
dat
Jcbrisatl Juc
1 ��y) Massachusetts - Department of Public Safety
A&A SERVICES, INC Board of Building Regulations and Standards
Christopher Zorzy C ` yb,d s ""'
115 North Street License: CS-057733 "
Salem, MA 01970 ctHusrortER 70RZY„-
115 lYORTH ST 9 f
Salem MA 01970%
SCA 1 0 20M-05/11
Expiration 1
r/�e u�rr.ri ruiinrul/I ��Jllrraaar�air,CC J. � osrff 017 I -
^. Commissioner
�\ Office of Consumer Affairs&Business Regulation I
lT q HOME IMPROVEMENT CONTRACTOR
hl Registration 101609 Type:
`'� Expiration 6 26I2018 Private Corporation
A8A SERVICES, INCr { �k
ur;
Christopher Zorzy
115 North Street --—
Salem, MA 01970 - Undersecretary