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23 FRANCIS RD - BUILDING INSPECTION The ('tilnnwmNealth of llassachuSetts t\ Board of 131Atlding RcL_ulationS and Standards olaSSl1ChLISCttS State Building Code. 780 CMR. T' edition til( Building Pcimit Application To Construct, Repair. Renosate Or Demolish a R,ru J ow , One- Or Tow-Fanidv Dnrellhrq =tln.4 Phis Section For Official Use Only Building Permit Nurnher: Datz Applied: ------ __� SI,. 1111'e: , -to • O- Building mnmissioner/ Inspector of Bwldines Dale ---._-- --1 SECTION 1: SITE INFORMATION 1.1 r cr v :yddressc 1.2 Assessors Map & Parcel Numbers -5 Eooirl I.lu Is this an accepted suee['? yes_ noMa_ P Number Panel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(it) 1.5 Building Setbacks(f0 Front Yard Side Yards Rear Yard ! Required Provided - Required Provided Required Pru�tdcd 1.6 Water Supply: tM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone:' Municipal-0 On site disposal system ❑ Public❑ Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' ENmn r'I of R ord: innnoever (Q ncr s ed c ri l0' Address for Service: � ,M-� ' Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) ruction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteratirm(s) ❑ Addition ❑❑ Accessory Bldg. ❑ Number or Units_ Other ❑ Specify: Brief DZ ption of Propos-d Work--: l 60 0 SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials) I. Building S &)o L r Building Permit Fee: S Indicate hole fee is deter ❑ Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost' (Item 6) x multiplier .x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (HVAC) S List: — S. Mechanical (Fire S 'total A11 Fees: S_ --- Su? re<Ni0n) � Check .. o. Check :\muunC (',hh :\nxwm:__.___ 16. notal Project Cost: S " '9 9 OO ❑ Paid m Full ❑ Outstanding Balance Due:_ 11 ! SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSLI 5—7-733 r�2/_ ' I `— License Nunihat li\Puanon Date NamC of C'SL. I Iulder I_ui C'SL'1'cPC(See beltm) %ddress Tv c Ihscn num C t'nresuirtrd ui r to 3;.OU0 Cu. 1-i. R RCStnrted L@_ F:um ) Do�clhne $Igit01ILi e s7 I a,aars OTI 12C Rnidcnual Routing t'm can„ Telephone \I'S Kcsidnwal Windo" .md Sidinc SF Reeidenii;d Sohn fuA Burma,- \0(Neuer hi.i.il l,mun D Re,ldenual Denuohn,m 5.77 Regi tered Home lrnprovement Contractor(IIIc) 1©11009 ftp SPJ VL�DS nc. -- HIC Company.:Name or HIC Revistrmu Name Revismmum Number IIS KJOGA-h 1 Address (9'i3l'7�11-D>a�� xpirauorf 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 n, prueide 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 I, c £ r PO we IS as Owner of the subject property hereby authorize_i Yahe—r Zo zl� to act on my behalf, in all maners relative to work author by this building permit application. - x s/d 7/o --Sienature•ot=Oaa Date SECTION 7b: OWN,EaR' OR AUTHORIZED AGENT DECLARATION kt I, [ hrl5hopher ZOCZ— l , 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. t Ir Z Print Va z Signature of Owncr or Authorized .Agent Dale (Signed under the .gins and "nal" of er'u ) NOTES: I. An Owner who obtains a building permit to du his/her own work or an oumer who hires an unregistered contractor (nut registered in the Home Improvement Contractor (HIC) Program), will not have access to,the :ubilraliun 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 I IO.R6 and I IO.RS. respectively. ' When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished hasemenl/attics. decks or porch I Gross living area (Sq. Ft.) Habitable room count tiumber of tueplaces Number W hedroom, tiumber of bathrooms Numberot hail[/hash, rope of healin! System Nmnher of Jecke/ perches ---_____-- Type of cooling ss stem Enclosed Opsit 3. "Tool Project Square Fowage" may be Substituted fool Total Project Cost' � _J r- CITY OF SALEM 3 1�tr 1 PUBLIC PROPRERTY DEPARTMENT n.Va4 H;I 1 .1K Nt x'11 VLvI 'b I'JAC' ;iti�t,l„�iiltrri ♦ S.v1�N1, Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers k t ylicant Information Piettse Print I evihly Name t nu.ntcs t hgantzaoont Indl% dual): A T. A S ery(IJc5 --Tf�� ddress: 1115 Nor+h S+r e+ \ City,State.'Zip:�l6�. M� (�I° C�— Phone #: Are you an employer:' Check the appropriate box: Type of project (required): i. I am a employer with J. ❑ 1 am a general contractor and 1 6. New construction u �_ ❑ employees (full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or pertner- listed on the attached sheet. Remodeling ;hip and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. Insurance. 'y, EJ Building addition f No workers' comp, insurance 5. El We are a corporation and its 1().o Electrical repairs or additions required.] officers have exercised their right of per N1GL 11.0 Plumbing repairs or additions I 6 exemption ❑ 1 am a homeowner doing all work Pon p l, Roof repairs myself. f No workers' comp. c. 152. e I(a), and or have no insurance required.] f employees. nc workers' 13.❑ ther comp. insurance required.) •,\,,y applicant that cheeks boa NI must also till out the section below showing their worked compensation policy information. / s who submit this affidavit indicating they ore doing all work and then hire outside contractors most submit a new affidavit indicating such. I lunuuwner '('untraUUrs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I out an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Ilefar/il aflOn. , / 1 ted., Insurance Company Name: v Tr�kV Policy #or Self-ins. Lic. #: t //O y�'/1��C(� -'��/ u�j Expiration Date: "Yr bpi X' q .lob Site Address: �1 � I Il ".� ) '�.1City/State/Zip:,Ci U)q :\ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failtue to secure coverage as required under Section 2:A of%IGL c. 152 can lead to the imposition of criminal penalties of a line up to S 1,500.00 and,/or one-year imprisonment. as well as civil penalties ,n the frim of a STOP WORK ORDER and a tine Of op to )_'50.00 a day against the violator. Be advised that a copy of this statement may be lirwarded to the office of Ime>,ic;uions of the DIA for insurance coserage verification. I I/o hereby certify it er to pains and penalties of perjury that the infor/nution provided above is true mrd correct. / Due. ,0 ri: n official tae only. Do not write in this area, to he completed by city or const official City or horn: - -_...--------- _..._—_ Permil/License ___-- Issuing \ulhorily (circle one): I. Board of lleallh 2. Building Department 3. city/rown Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other Contac[ Persmi: —___----- -- Phone tt:-- Information and Instructions \la,,ac l it acus General L a%%y chapter I�' regmresa I cmplo%el, to prnryi de workers' c,'I fix their employees. ['!.usu.uu to this .tatute, an etnploree is domed as ", c%ern person "' file sen ice of,mother under an% contract of hire. c\prc,s or implied, ural or written." An enrly/urrr is defined as "an indi%;dual. p.trtncr,hip, .issuctation, corporation or other legal entity. or any two or more ,,f the IOlQgotng engaged in a joint enterprise, and inc!udine the legal representati%es o(a deceased employer. or the rccei%cr or trustee of do individual, p:nrner>Itip,association or other Irgal entity, employ Ing ernplo\'CCs. I lowY\er the w mer of a dwelling house hak ne not more than three apartnents and who resides therein, or die occupant of the ,hk elling house of another who entploss persons to do maintenance, construction or repair work on such dwelling house ,?I )if the grounds or huilding appurtenain thereto Shull not because of,uch employment be deemed to be an employee" \I(iL chapter I52, X254-(6) also rates that -every state or local licensing agency shalt 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, %K;L chapter 152, §25(1(7) ,tares"Neither the eonunonweal th:nor any of its political subdivisions ,hall enter into any contract for die performance otpublic .pork until acceptable e%idence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractors) name(s), address(es) and phone number(s) along with their certificates) 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till 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 pen-nit/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 thara valid affidavit is on file for future permits or licenses. A new affidavit must be tilled 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 ()tfice of Investigations would like to thank you in advance fix your cooperation and should you have;my questions, please do not hesitate to give its a call. flie Dcp:uvnent', address, telephone and tax 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 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 Cartino Signature of PermA Applicant Date Christopher Zorzy Name of Permit Applicant A &A Services, Inc. Firm Name 115 Forth Street, Salem MA 019, 0 Address, City, State, Zip Code '� '= �lassachusetu - Dc t:uvne . —nLtrtPuhliPublic r c _,d'ctj I VBoat d of Suildin�� Rc��ulations and Standard. 1 Construction Supervisor License j License: CS 57733 _ ' Restricted to: 00 I CHRISTOPHER ZORZY 115 NORTH ST SALEM, MA 01970 Expiration: 5/262011 . i ('onuuissionrr -- — Tr#: 14751 -- . .. -: � - .... _ .._.- .. ..,. r. -.-, -. - ✓die 7oomvmoauuea� '7`� � efaa Board of Building Regulations and Standards HOME IMPROVEMENT CON TRACTOR Registration: 101609 E::piration 6/26/2010 Tr# 267870 -Type:_Private Corporation A&A SERVICES,[NC✓• Christopher Zorzy:��i 115 North Street Salem,MA 01970 -'- Administrator Commonwealth of Massachusetts Division of Occupational Safety Laura M.Martin,Commissioner Deleader-Contractor CHRISTOPHER ZORZY Eff. Date 04/01/09 Exp. Date 04/08/10 - Member of C.O.N.E.S.T. i Bo s IIIIIII�II�IIIIIIIIIIIIIIIIloll II1111lllllllll BOSTON-RENEW' 1 ' =�ethg A & A SERVICES, INC. f SS ICES 115 NORTH STREET,SALEM,MA 01970 a • s - 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 Buyer(s)Name - Date of Contract C1241e 5-Z/ Buyers)Street Address,City,State and Zip Code 73 i 12AIVO-/Selb S7 teWt f" 0/970 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address: - The Buyers)listed above hereby jointly and severally agree to purchase the goods andlor 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(Nis'Agreement'),and Buyer(s)have requested that such goods or services be installed or provided at Buyer's address listed above. ASIA Services,Ina('Contraction,hereby agrees to install or cause to be installed Ne products or services listed in this Agreement at Ne Buyers)address written above. The Agreement represents a cash sale of goods and services. The Buyers)agree to pay in cash the cost of the goods and services purchased dbed herq! regardless of timing or approval of any financing Buyers)may seek for their purchase. Purchase Price Est.Starting Date: r0 2117-IC Dawn Gyms t: r Est.Completion Date: ❑Cash vv/ Amount Due on Start of Job: heck ❑Credit Card Amount due an_of Completion: No. ' Amount Due on_of Completion: p Expiration Date: Balance Due on Upon Completion `�r CVC Code: 11 Is agreed and understood by and between the parties that this Agreement,front sort 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. Buyers)hereby acknowledge that Buyers)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 (0 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 Buyer(s)would be interested in any additional quality products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES. r A&A Services,Inc. � Buyer(s) By: ZZ k L lljl)`tn^ Signature w ff. 'Signaturl� O''GwBfs Print Name rint Names�(.,r� Signature//� 1p ' x `•tti}t� y�ats=eJ`1 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 mnbecbr and the bmmapwner thereby muently agrees,aMante Net in Me event either parry has a dispute mneeming into mmmeL wither pact may submit such amputa M e pct ahiha m sery o which has been approved by Ne Sacmtary of Ne Exacutive Off m pt Coesumrt Attain act a sl a Regulations and Me other perry shell be regulntl 1p submit tip su d omitrom m aeprwe]in M.G.1-c.14M. }O C-brove i BuyvYlnitu6: a �^ N(1lOF CANCEI I ATIMN NOTIC.F OF CINCFI I fall Oats M Transatlor✓- -�S'.You may mal Nis Manuel without any penalty br pate of Traneaccui/-C .you may dent this Uensectian,without arty penalty 0, obligafbn,waste hove business days fmm Me above data.If you cancel,any prppeM traded in, Obligation.within three buanemdaystmmtheabwedata,IlyouwnmLanypropery Vededln, any payments made by you under Ne Comrador Safe.and any negotiable Instrument executed any payments made by you under Ne Contract or Sale,and any negotiadle Hospital exec by you will be mWmed within 10 days tolbvMg receipt"a Seller of your cancellefbn notice, by you will be reamed within le days relaxing receipt by me Sinter of your mnmilafan made, and any¢evvlily interest ansms out of me nensMon will be Cardelled. If you Cancel you must end any sentaty interest wising out of the Inexact all be consu d.If you CeMBI,you must make movable to the Sauer at your razMs..in wbslanMIiy as sant cndNon as ween—em, make avaleble to the Seger at your residence,in euwtenaelry as Me mMibon as whan,acelved, any goods delivarad to you under this Contract or Sala;or you may,It who wish comply with Ne any gwda delivered to you under Nu como-ad or sale;Oryou may,it you wish,comply HN Ne InsiNNons Of Ne Seller regarding Ne ream shipment Of the goods ar the Sellers expense and msWNons of Ne Seller regarding the mture di ipme r of Ne goods at Me Sallee expense and moo If you do make Ne goods troubles of Ne Seller and Ne Seller does hot pick them up nick. If you do make Ne goods avulabls to Ne Seller and Ne affair does not p'rk Nem up Within Sh days of Ne date of your Notice of Cancellation,you may retan or disease of the goods within SO days of Ne dale of your NNam of Cancellation.you may Main or dispose of Ne goods without anyinner obligation.Ilyou fail to make He goads avvleble to the Seller ler ifyou agree witMNawfumberoblgaticn.ltpU iltomakethegmds.v.lalero Na Selbawilyou to rolum the do to Na Seller and fail b do m,Nen ao Wt gm you remain IIBEIs Int ed and date al all N comm s i gcotls b the Seller and tail d od w,Nffn yw remun liable ler pMomlanCa fall do metionsundarNemn dranyM. ot rwnnnn m,on,mail albacorenflarer INmdenddaredropy of the oeration ConUr mr, woman naactipn.m.materaeren,1.A Shortener r let Ne CanrellSWS .M Or any ofMr written NOT or 9TH a tMIDNIG,T ABA Servkea.115 m the SVWal,operation mdce air any other written mike,m 9TH a MIDNIGHT T FW :722.115 Norte Street,salem.Mavechusetla 019]0,NOT tgTER THAN MIDNIGHT 01- NOM$User,Salem,MessachusetN 019]0.NOT LATER THAN MIDNIGHT OF - - (Deal _ ._ Inial .. 1 ERE5Y CANCEL THIS TRANSACTION. Consumw's Sgnarum Co. I HEREBY CANCEL THIS TRANSACTION, Consumere SlgnaN9 pate. AGnxi oat A & A SERVICES, INC. A&ASERVICES 115 NORTH STREET,SALEM,MA 01970 o • • Telephone:(978)741-0424 Fax:(978)741-2012 Contractor Registration No. 101609 Federal.EIN:04-3090162 Construction Supervisor No.CS057733 ROOFING SPECIFICATION SHEET Buyer(s)Name Date of Contract C,eA/ Torn Powers 1 S-Z/ -0� Buyers)Street Address,City,State and Zip Code 23 CRAAICIS .20 s:9ten1 11419 61970 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number. E-Mail Address 9�8-v23-/3ob q�s-7y�- /�sy 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 part. ROOFING SPECIFICATION. Strip Roof of# L-L— layers of shingles Df nstall W of ice and water shield at base of roof where Install 15.b felt paper to roof. possible. Install 18-24"of ice and water shield in valleys. Flash chimney-dwrtoeded-fno repointing included). f Install B"perimeter drip edge to rakes and fascia areas. (JiInstall vent pipe boots and seal as needed. IWIash valleys as needed f Install rollout type ridge vent. Planks/plywood replacement under 32 SO FT included, 'If more is needed there will be an extra charge of$ per hour for labor plus the cost of materials. Du pste isposal Included: f Other: Cr01-CYL ;. aLf9-C/G. L /��•Y[_ Loco ton: Z)2tLff2GA-ra Install new roof: Manufacturer. COnIVini 71'149 Z_5�yr Style/type -7 %?}Q Included in this proposal are thorough cleanup, building permit,and company/manufacturer warranties. -- RUBBER ROOFING SPECIFICATION f Strip Roof f Not Strip Roof It Install 1/2"High Density Fiberboard to existing roof using f Flash obstacles as needed. screws and plates. f Install.060 membrane EPDM(Black)rubber roofing to f Install 3x3 aluminum drip edge to perimeter of roof with fiberboard.s - seam tape. f Flash up sidewall as needed. Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. SPECIAL INSTRUCTIONS: a 487K0V6- - 0,;j X4-aK_ aX (2 ) fZ'W&')C 1NwT. S N is agreed and understood by and between the parties Mat this Specifiratlon Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes the entire understanding between no parties,and Mere are no verbal understandings changing or modifying any of Me to...This contract may not be changed or Its terms modlfled or varied in any way unless such changes are to writing and signed by both Me Buyeha)and the Contractor. Buyer(e)hereby acla owledge that Buyer(s) has read ale Specification She-eettJt L/ +- ^ I-^ a Contractor Initials: r/ *Date: s z�—D� Buyer's Initials: F}� ZIA Date: