13 LINCOLN RD - BUILDING INSPECTION (2) ASS
The Commonwealth of Massachusetts
F a Board of Building Regulations and Standards CITY OF
SALEM
11s' Massachusetts State Building Code, 780 CMR Revised Lar1,2011
'J Building Permit Application To Construct, Repair, Renovate Or Demolish a m'
t One- or Two-Family Divelling :
n x,
..Y This Section For Official Use Only rn
Building Permit Number: Date Wied.. ri
''
p VT .
Building Official(Print Name) Signature Dak
SECTION 1: SITE INFORNIATION it
11 Property Address- 1.2 Assessors Map& Parcel Numbers
L. n1Ci2JN R00d
L 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 YardSide 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:
MAA L!1CIV &AHM141eJS �a.�v�ln 14 4 ON
a
Name(Print) City, State,P r
13 L'l JAI &ar0 8. 77g yao�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Afteration(s)AJ Addition ❑
Demolition ❑ Accessory Bldg. Number of Units Other ❑ Specify:
Brief Description of Prop sed Work'-:
-SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1. Building $ 113-22 (,' 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ )ZI 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: $
f ��� p Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ S ❑ paid in Full ❑ Outstanding Balance Due:
�1 �IZ. Mnit�� TD EjG.
,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1
r c ayuyk e r 2,z,6,L License U)'Kl Es4tDt 1
Nameame of CSL HoBer
List CSL Type(see below)
cl�
No. and Street Type Description
A OO
i_:i I� {� „ Gt�1 U Unrestricted(Buildings u to 35,000 cu. ft.)
1 Y Ul L ! R Restricted 1&2 Family Dwellina
rCity/Tdwm, State,ZIP M klasonry
RC Rooting Coverina
WS Window and Siding
SF Solid Fuel Burning Appliances
T���� � p - I Insulation
Tzie hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Q I
RIC Registration Number - E. iratPiD
HIC Compv Name or HIC egtstrant Name
l S—�,t��2 k h
Nr. nd�0 M n I�t1_y� q�' =7u1 - o-�d`( Email address
H l�
City/Town, State.ZIP Telephone
SECTION 6:,WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. § 25C(6))
Workers Compensation Insuranceaffidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuancehe 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 k ,4 1 K tie 1
to act on my behalf, in all matters relative to work authorized by this building permit application.
See CC)L 0& 941,4
Print Owner's Name(Electronic Signature) Part
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
0 -I
Print Owner's or Authorized Agent's N e(Electronic Signature) cAtel
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.Pov/oca Information on the Construction Supervisor License can be found at mmm.mass.gov/dns
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"
A&
//�� x+ 30'=A A & A SERVICES, INC.
1 A&A S 115 NORTH STREET, SALEM, MA 01970
rol RA to I in I caremaTelephone:(979) 741-0424 Fax: (979) 741-2012
Contractor Registration No. 101609
Construction Supervisor No.CS057733
Federal EIN: 04-3090162
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Bu s Name Date of Contract
uerJ 1 5-30-!6
Bu er s Street Address. CII State and Zip Code
/3 L//vcoL7v 2 S192C1^-1 /vi 0/970
DBI Telephone Number Evenum Telephone Number Mobile Tele hone Number E-Mail Address
97S rrB-YzoZM2t/_/-y')V1Vri /'tmL C'gi
The Buyerls)listed above hereby jointly and severally agree to purchase the goods and/or services fisted On Ne 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'Agmement'),and Buyerls)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 cause to be installed
tM1e products or services listed in this Agreement at the Buyerls)address written above,This Agreement represents a cash sale of goods and services.The Buyerls)
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
i
Purchase Price: . 53731 eat.Sterling DWI
Down Payment ( 9L , lEEsst.Completion Data: 10_3V_' IP
LgIl Cash
Amount Due on Start of Job: Ul Check
RCredit Card nn �rO I
Amount Due on_of Completion Np y/y7 Z D 2U lS3 I, G
Amount Due On of Completion: 2 �{ Expiration Date: eg /
13
Balance m
Due on Upon Copletion ✓5"� CVC Code: 193
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 Buyers)has read the front and Ne reverse of Nis agreement and has received a completed,signed and dated copy of WE
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 Iii)request that they be contacted via their telephone numbers or email,as listed above,in the event
Contractor believes Buyer(s)would be Interested In any additional quality products or services of Contractor.00 NOT SIGN THIS CONTRACT IF IT
CONTAINS ANY BLANK SPACES.
A&A SerVe l Bu (s)
By:
Signatu�reNy/l"
Print Name IX PTIIINa
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:The contractor and Ole.--a,h by mutually agree in advance that in Me t ditherearryM1 dispute wnwrring this WnoaC191her party appy oUbMt Such dispute baa
phva rti - rNce xTMhas been erq.vt by 11re 5eaetaryolthe Eaecul us ORW NC AfieuSe dB - Regulagom and Me other each shell be rryured to submit to such
metre- p ed in MGL of 42A
c.. 'l.�'f`J anrr 1 1
red R ?o—l l y Dab
�
�NO�TICE OF CANCELLATION NOTICE OF CANCELLATION
Dale ob Transallon6''j1�U.You may Mandel this trarecion,eiNaN any penalty or pale of Transaction you may ra cal this trona on,w Mout any penalty a
obliga0m,villin In..W. .days hon the Move date,Il you cancer ,anypmper,laes
dir. adigabon.vdlhin MteebusimssdayshomMeaWvdtlW 11 you cancel,any properly traded it.
any WYltents Made by you antler the courts or Sea.and any negotiableirearmenl executed any payments made by you under theCarrout a,Sm.Md any negob"e instrument exetaed
by you unit be usur ed achat 10 tlays busting receipt by Me Gell¢of your cenrxllation notice, by you will ba husband wahin 10 day3ldlawirg mmim by Me seller of your mntttiatiM.oust
and any se urity'nleresl caning WI of the hansactian and W wnselled 11 you Mi you trust and any seceny interest arising out of Me hens Mon WI be demand.If ya ra cel,you must
Make ailabla to He$eller a your residence,and substantially in as gat itnd0on as when vailable b the Seller at your reside..,and suc.nrally in as Such mndiuoo as when
appeard,any gots delivered to you under Mls contract or Sale:oryou tray,it you wish,romply ancervand.any,.,prepared to you uter Mis Can...,Sok.or,trey,ty.ki sway
win He instructions of the Serer regarding Ne reach shipment of He gids at Nle seller's xith the indicans of to Baker regaMing Me return shipment of Me goods at the Sellers
s:pema and risk.II you do ask,the goods evalrvid to the Seller and He SHIM does net pick ¢stens and risk.It you do rtake the gats available to the Sell and Me Seller tices not pick
Ihemupwithin 2e days of the dab al your year.of Carnahan,you mry reran.disease ofar. them up winin 20 days of the data of your No4.of Cooduabon,you my hatpin or disease of
goods without any Motor obligation.If you(A to make the goods...hide to Me Sells[oh it Mo goods MMoul anyludhar obllgetion.If you fail to make the .a available to the Sells,p8
apse to relum the Press to the Seller and fail A do sn then you remain factsfor penm
aace nof you agree to rerson Me hats to the Seller and but to do so,Men you remain Badm
Bade for perforance
ell AWHIMMA under He courni TO f9ad.,this Missouri it Or deliver a signed and daLLW of at obligation under the Crnhd.To cancel Mis transaction.me or deliver a signed and dared
on yof thechn.11ation noneor any other whiten nonce,or sends le le rerR to Aseserviess. supyollhecanceliatonuOd o,.-- Me noliCe.Or u rd A8A Services.
115NOMStet.Salem MAO18]O,NOT LATER THAN MIDNIGHT OF�7-/-/y 115 Nonh greet Salem MA 019]0,NOT LATER'HA
MIDNIGHT OF .-/"/L:
maim mare,
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION
Consur.r'c SIB^sure pab; Consumer's Sig^ewre Date:
+ AGM
zUl... A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
Insist a rel mi 0 lim UNSITA witil a 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
M44 t3c�vlvr�2 p 83°-1�o
Buyer(s)Street Address,City,State and Zip Code
l3 LiAICOL" Rb M
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
97£3-778 -gzoz
The Buyer(s)listed some hereby jointly and severally agree to purchase the goods and/or services listed below,In accordance with the prices and terms desenbed 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.
ENTRY DOOR
ARemove and dispose of# existing entry door units.
X Install new entry doors# Manufacturer 77h?,?-M o--77u/ /series sMyD?"f
Location 3,46y t5�rv7wrq �C_ SLOB
Type: ZI Steel ,'Fiberglass ❑Sliding Patio Door O French Hinged Patio Door
Model# -0—& Sidelight(s)# Sidelight(s)type/model#
OPTIONS:
,j Adjustable threshold for door. X Grids tec Patio deers Style: (n 'L 1
Prefinished Ayes Ono color: interior exterior bLK
❑ Expand or shrink the size of the opening Details
❑ Cover exterior trim with aluminum coil stock: Style Color
Hardware: �d Lockseteadbolt ❑ Footbolt Q Mail Slot ❑Peepsite Detail
1<eq,g j �l 1<6
Replace interior trim as Heeded Details!AIS,777LNejj,1 i x� SI?1_L Z.7J_ 1N 1l�YLr u2 77Lr M
)Q Replace exterior trim wa�eow-- Details IAJS-i?9� Nr3Y�( !x� rx�-�2ra•'f�'Y) eX i2�rL.d)L--TILr WI
Ne Install oak strip at floor as needed.
Caulk interior and exterior edges.
Insulate around new door unit where possible.
Painting is not included. Details /NrB✓L Pte— 'I' (.k l��llTfti C/9S/rU�Z
$'1 Included in this proposal are set up and clean up.
STORM DOOR
yam' Remove and dispose of# existing storm door(s).
_
Install new storm doors# Manufacturer 1hil,1 0"y S /series L!/ 2 "K&5L
Style OmF-Lr T15— Calor tOilI A= Type: i]Aluminum &Soiid Core
Location: AA-(K. eY-'7'Ylr"/ C S!G7(5-
/-" Hardware style S7Nrv09n-!J Color
SPECIAL INSTRUCTIONS:
w
3
73 .
wyas i
It Is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,sorest-
base the entire understanding between the parties,and there are no verbal understandings changing or mediating 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 Buyers)and the Contractor. Buyers)hereby acknowledge that
Buyers)has mad this Specification Sheet. ry
Contractor Initials: �Ub� Date: 9-30-1 to Buyer's Initials: _ Date: x. 3� r
CITY OF S�UEM, TNL- sSACHUSETTS
BUILDING DEP.\RT%MNT
130 WASHLNGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KD IBERIEY DRISCOLL
LWYOR T HOB W ST.PTERRE
DIRECTOR OF PUBLIC PROPERTY/BI:ILDLNG CO%L%RSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
Name(Busines&organizatiorvindividwl):
Address: I`.�- N� nku,,� &�
City/State/Zip:_�—ICJ ] Phone #: I n i— /n
&11-0 ya
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet, : ?• 0 Remodeling
ship and have no criployem These sub-contractors have 11. 0 Demolition
working for me in any capacity. workers'comp. insurance,
(No workers'coin 9. Building addition
. insurance 5. 0 We are a corporation its
P rpo
required. officers have ex 10.0 Electrical repairs or
exercised their ep additions
3.0 1 am a homeowner doingall work right of exem tion
per Il.
p pe GL ❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no
2.[]
insurance required.)t employees. (No workers' Roof repairs
comp, insurance required.) 13.0 Other.
•Any applicant that checks box#t most also rill out the seclino below slowing their wmk=.compensation policy miumtatioa
s IFomcownnts who submit this affidavit indicating they ate doing all work and then hire outside commcmm most submit a new anidavit indicating such
:Commcm.that chink this box most attached an additional sheet showing the name or the sub- mur"t,,s and their workers'comp,policy mro motion.
1 am an employer that is providing workers'compensation Insurance for my
information employees Below Is the poltcy and Jab site
)
Insurance Company Mame: =,-57A U
Policy#or Self-ins.Lic.#:_ /�� Expiration Date:__2— /2— �
f
Job Site Address: /
` 'l D46����� Ciry/State2iP. S_ �Qp- 7
—
Attach a copy of the workers' Compensation calfcY 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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
I do hereby certify ui r theyplat and penaldes of perfury that the information provided above s true and correct.
Si gnat ue•&
Date:
Phan #:
F
al use only. Do not write in rhkv area,to be completed by city or town offtciaLr Town- Permit/License#g Authority (circle one):
. rd of Health 2. Building Department 3.City/1 own Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF SA X.M, N`LkSSACHUSETTS
BL u.DL\G DEP.+RT�IE�iT
130 WASHNGTON STREET, 3"°FLOOR
TEL (978) 745-9595
FAX(978) 740-9816
KI,,iBERIEY DRISCOLL
MAYOR THouAs ST.PtERAE
DIRECTOR OF PUBLIC PROPERTY/BUnnNr,COJLMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CbfR section 1 I t.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
111, S 150A.
The debris will
�bee�transported by:
a til a C1 Q I'll e6
(name of hauler)
The debris will be disposed of in
EDC_ � � ��— :
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
A&A SERVICES, INC
Christopher Zorzy "'
115 North Street License: CS-057733
A 01970
Salem, M CMUSTOPHER 71"7y
115 NORTH ST % I WIN}
Salem KA 01470%
SCA 1 ei 211M-05111 � �`
_ n1" Expiration
Yr,nnin,urnrrr/// r"��gWir�u.ro//J �� � W2011
`1°�� Office of Consumer Affairs&Rusi ess Regulation Commissioner 05/26/2017
+ (. HOME IMPROVEMENT CO TRACTOR
Registration 101609 Type
sw �P Expiration 61261201,8 Private Corporation
a
A&A SERVICES, INio
-
i.
Christopher ZOrzy -
n,
115 North Street
Salem,MA MA 01970 Undersecretary