B-19-883 - 0056 BELLEVIEW AVENUE - Building Permit The Commonwealth of Massachusetts
CITY OF
Board of Building Regulations and Standards r� �}
?RLEM
Massachusetts State Building Code,780 CMR ..f Rev d Mar 2011
Building Permit Application To Construct,Repair,Renovate Or12mofta
One-or Two-Family Dwelling !,
This Section For Official Use Only
1
Building Permit Number: Da pplied
A
1 :Building Official(Print Name) Signature Date
�"
SECTION-1.SITE"INFORMATION'..
1.1 Property Address 1.2 Assessors'Map&Parcel Numbers
�l.1 a 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 Iuilding 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:
.1 st lca >f
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3i DESCRIPTION-OF PROPOSED WORKZ(check all that apply)' "
_ _
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)� Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Worle: inShxtj ane 41 r? Q CQ-M"(_h
Jfl, 00;"— dv Q I SLOT d6
SECTION 4c ESTIMATED CONSTRUCTION.COSTS ;,,>'
Estimated Costs: _ "
Item Official Use.Only
Labor and Materials
ehwfs.dter 71.Building $ 1 Building Permit Fee Indicat mited O
2.Electrical $ ❑Standard'City/Tow i Application Fee
❑Total Project Costa(Itedi 6)x multiplier x
3.Plumbing $ 2 Otlier Fees:;$ �
4.MechanicalList,(HVAC) $
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7 ( 00-
0 Paid in Full ,❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ,, p
5.1 Construction Supervisor License(CSL) Dltj' l� f�3
^ 6 r
Y ` r- 1(LZ License Number Expiration Dal
Name of CSZ Hold ., ,
1 List CSL Type(see below)
Type Description
o.and treet U Unrestricted(BuildiE s up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,Z M Masonry
RC Roofing Covering
WS Window and Siding
Construction Supervisor Sign or(Electronic Signature) SF Solid Fuel Burning Appliances
�^y�]�---�1�_/G•.1 aC/ 1 Insulation
-Telephone SI Email address D Demolition
5.2 Re istered Home Improvement Contractor(HIC)
��►�y �p HIC Regis tra' n ber E irati Date
HI CC p y Name or HIC s ant Name
.- Pj. - `
No. treet gis Signature
HIC e trant-
hon
ti P. Tele e
SECTION 6:WORI-ERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§.25C(t7)
Workers Compensation Insurance affidavit must be comp] ted and submitted with this application. Failure to provide
this affidavit' result in the denial of the Issuance o e 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,as Owner of the subject property,hereby authorize a to act on
my behalf,in all matters relative to work authorized by this building permh application.
Owner's Signature or(Electronic Signature) ate
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 contained in this
application is true and accurate to the best of my knowledge and understanding.
b9 .
r� oriz _.gnt's Zai�me �Eature)Owners oraua
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(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.eov/o.
Information on the Construction Supervisor License can be found at www.tnass.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.) t 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 O en
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
BUILDING PLANNING HEALTH ELECTRICAL GAS PLUMBING MAINTENANCE
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/pp A & A SERVICES;-.INC.
• �' ' 1 Above
115 NORTH STREET,SALEM,MA 01970
A&A SERVICES 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
7,b/1,7
Buyer(s)Street Address,City,State and Zip Code,
�� Ave
v t1 e A A /\ t �9
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
°71/S'S-?-7 g
The Buyer(s)listed above herebyjointly 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 aW the reverse of this Agreement and any specification sheets(this"Agreement"),and Buyer(s)have requested
that such goods 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 Buyer(s)address written above.This Agreement represents a cash sale of goods and services.
The Buyer(s)agree to pay in cash the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyer(s)
may seek for their purchase.
i ii.
Purchase Price: 760 � / �7�` Est.Starting Date. R
Down Paymentf- �DLt ![���� Est.Completion DV9 ,5'
❑Cash
Amount Due on Start of Job: c . 1 j ❑Check
❑Credit Card
Amount Due on of Completion: N0. '
Amount Due on of Completion: Expiration Date:
Balance Due Upon Completion: ' A� o(dL CVC Code:
It is agreed and understood by and between the parties that this Agreement,fronts back and any addendum,constitute the entire understanding
between the parties,an(I there are no verbal understandings changing or modifying anybf the terms of this Agreement. Buyer(s)hereby acknowl-
edge that Buyer(s)has read the front and reverse of this Agreement and has received a completed,signed and dated copy of this Agreement,in-
cluding the two attacheel 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 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.
A&A Services, . Buyer(s)
r
By g—P
Si
9 the Signature
S• Lu X loma 69 �-.LL
Print Name Print Name
Signature
• '`Print Name ' is
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 the Homeowner hereby mutually agree in advance that in the event either parry has a dispute concerning this contract,either party may submit such dispute to
a private arbitration service which has been approved by the Secretary of the.Executive Office of Consumer Affairs and Business Regulations and the other parry shall be required to submit to such
arbitration as proved by M.G.L.c.142A. _�q
Contra gor Initials. Buyer's Initials:p__��'�'l��
Date:
I10TICE OF CANCELLATION
Date of Transaction You may cancel this transaction,without penalty or Date of Transaction0mad.
ou may cancel this bansaction,without penalty or
obligation,within thre� sil ss days from the above dale. It you cancel,any property obligation,within thre from the above date. If you cancel,any property _
traded in,any payments made by you under the Contract or Sale,and any negotiable traded in,any payme you under the Contract or.Sale,.and any negotiable
instrument executed by you will be returned within 10 days following receipt by the Seller instrument executed by you will be returned within 10 days following receipt by the Seller
of your cancellation notice,and any security interest arising out of the transaction will be. of your cancellation notice,and any security interest arising out of the transaction will be
cancelled. If you cancel,you must make available to the Seller at your residence,and cancelled. If you cancel,you must make available to the Seller at your residence,and - -
substantially in as good condition as when received,any goods delivered to you under this substantially in as.good condition as when received,any goods delivered to you under this
Contract or Sale;or you may,if you wish,comply with the instructions of the Seller regarding Contract or Sale;or you may,if you wish,comply with the instructions of the Seller regarding
the return shipment of the goods at the Seller's expense and risk.If you do make the goods the return shipment of the goods at the Seller's expense and risk.If you do make the goods
available to the Seller,and the Seller does not pick them up within 20 days of the date of your available to the Seller and the Seller does not pick them up within 20 days of the date of your
Notice of Cancellation,you may retain or dispose of the goods without any further obligation. Notice of Cancellation,you may retain or dispose of the goods without any further obligation.
If you fail to make the goods available to the Seller,or if you agree to return the goods to the If you fail to make the'goods available to the Seller,or if you agree to return the goods to the
Seller and fail to do so,then you remain liable for performance of all obligations under the Seller and fail to do so,then you remain liable for performance of all obligations under the
Contract.To cancel this transaction,mail or deliver a signed and dated copy of the cancella- Contract.To cancel this transaction,mail or deliver a signed and ated copy of the cancella-
tion notice or any other written notice,or send a telegra',,1,'+,,;��'�f�S,9�,y"17,115 North Street, � tion notice or any other written notice,or send a telegram,o A8 /i 115 North Street,
Salem,MA 01970,NOT LATER THAN MIDNIGHT OFF[/% Salem,MA 01970,NOT LATER THAN MIDNIGHT OF . .e) /'
at)
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION
Consumer's Signature _ Date: Consumer's Signature Date:
The Commonwealth ofMassaehusetts
Department of Industrwi Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual):_ y� y �CAS rh tr
Address: / 1,6—MO"f{1n
c�
City/State/Zip: G IK � Md(97U Phone#:��
Are you an employer?Check the appropriate boa:
Type of project(required):
[2.
I am a employer with 4. Q I am a general contractor and Iemployees(full and/or part-time).' have hired the sub-contractors 6. rEl New construction Q I am a sole proprietor or partner- listed on the attached sheet.t 7. Lei Remodeling
ship and have no employees These sub-contractors have. 8. Q Demolition
working.for me in any capacity. workers'comp.insurance,
o workers'con 9• Building addition
� p.insurance 5. ❑We are a corporation and its
required.] officers have exercised their 10.Q Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.Q Roof repairs
insurance required.]t employees_[No workers'
cornp.insurance required.] 13.❑Other
;Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
'Contractors that cheek this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information
d am an employer that is providing workers'compensation insurance for my employees. Below is the
information pokey and job site
Insurance Company Name: -rv-a V(?-I-R
Policy#or Self-ins,Lid.#: o"`rt�-q-.�� � � Expiration Date:
Iob Site Address
]�_C,tt<!L: v City/State/Zip:, () �lj`Q�I�,}rn 4-4(g7C
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
fine 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 up 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 r e pains and penalties of perjury that the information provided above is true and correct
�--' Si tur : sa �,
— Date: D
Ptaone#: ��
Offuial use only. Do not write in this area,to he completed by city or town official
City or Town:. PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
JDA Phone: 978-741-0424
1982-2012 Fax: 978-741-2012
www.a-aservices.com
A&A *""hERVW169 115 North Street
■ ■ Salem,MA 01970
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 property licensed facility as defined by M.G.L.c. 111, Sec. 150a.
The debris will be disposed at: Waste Management 877-515-2845
c/o Melrose Transfer Station
740 Broadway
Melrose, MA 02176
or
I
Waste Management, Dumpster Service
at
115 North Street
Salem, MA 01970
Signature of rmit Applicant
Christopher Zorzy, President
Name of Permit Applicant
I
Date
c
cr�c Gernmcale No: AIJ4 •blb
- THE COMMONWEALTH OF MASSACHUSETTS
I ;7A EXECUTl1'E OFFICE OF LABOR ANIn 1-Y`�/ORI(FORCE DEVELOPMENT
r' DEPARTMENT OF LABOR STANDARDS
19 STANirom STREET,BOSTf)N,MASSACHl1SETTS 02114
i
LEAD-SAFE RENOVATION CONTRACTOR LICENSE
i
A &A SERVICES,INC.
115 NORTH STREET ;
SALEM MA 01970
LICENSE: LR002749 EXPIRES: Thursday,August 20,2020
1N ACCORDANCE WITH M.G.L.C. 111,§ 1978(b)AND 454 CMR 22.04,THIS 1-IC_-NSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
i
ENGAGING IN LEAD-SAFE RENOVATION.
I
THIS LICENSE IS VALID FOR A PERIOD OF FIVE(5)YEARS.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE:WITH M.G.L.C. 111.
§ 197B(b)(2)AND 454 CMR 22.04 WHEN ENGAGED IN LEAD-SAFE RENOVATION AND/OR
MODERATE-RISK DELEADING WORK.LEAD SAFE RENOVATION CONTRACTORS MAY NOT
j PERFORM MODERATE RISK DELEADING WORK UNLESS THEY EMPLOY A SUPERVISOR,WHO HAS
TAKEN THE REQUISITE TRAINING AS REQ0IRED BY 454 CMR 22.00,TO OVERSEE.THE,WORK.
IM t1�
WILLIAM D.MCKINNEY,DIRE
ry'k,. inivtoxal3��a ,el�s commonwealth of Massachusetts
Office olConwrimrABaht Bus6weR fNalor► t)ivisiion of Professional:Licensure
HBME IMPROVEMENT COMRACTTOR Board of Building Regulations and Standards
TYPE:Corooretiori I �.,��,
RAWAftoo
EttiQD i Cons tt isor
101609 060 2Q20 •• !j.
ABA SERVICES,INC �ires::0,5126/202i
CS-057733 -
CHRISTOPk4IR
115 NORTH SKr I
CHRISTOPHER ZORZV J C i SALEM MA �C
U r
115 NORTH STREET
SALEM,MA 01970 OISSA 0�a
Undersecretary
Commissioner /
, i