9 BELLEVIEW AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7`h edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2108
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: - Date Applied:
Signature:
Building Commissioner/Inspec of Buildings Date
SECTION 1: SITE INFORMATION
1.1�gopefjy AyltJr �% �j 1.2 Assessors Map&Parcel Numbers
1.1a 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 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:
s\ Public❑ Private ❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
t
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reco d:
lrmGOr� �)Orre2 t &MP1JeeA f 1er�,csP
ame P iQjo for Service:
Signature V Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration( Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Desc iptionofProp sed WorkZ: (Sf
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:
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 $ Total All Fees: $
Suppression)
,(� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ / a ❑ Paid in Full ❑ Outstanding Balance Due:
1
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 577� 3 �i�
/ License Number E piratio ate CJ
Na e f C L- olde List CSL Type(see below)
A?r s Type Description
l/�' U Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
7// J�/O �� M Mason Only
"/ RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
er o e m ovetyent Cqn for(HIC) /D�ly D l
HIC C an me r CC fir'JJ Registration Number
A r
PKpiration bate
Sign ture Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be c mpI ted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc 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 z to act on my behalf, in all matters
relativ7r,
ork authorized by this building permit application.
e? 3 - A o / O
Si nature of Owner U Date
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I,� �� � 7� as Owner or Authorized Agent hereby declare
that the statements and�on on the foregoing#ication are true and accurate,to the best of my knowledge and
behalf
Print Name
Signature-670wrief or Autho ized Agent Date
(Signed under the pains and penalties of perjury
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halffbaths
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"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�.V:Ih!Y I l l rK ISt r t I
\L\l i iK I_':WA I IINI•11IN ti l llhh l • S.%I h
I'fa: ')"S-7a5-•IjeS • F\x: '1"$•"l7-'IS•In
Workers' Compensation Insurance Affidalit: Builders/Contractors/Electricians/Plumbers
rmlicant Information //� � Please Print LeviblY
`�[lmeifhi,mcss llr_amtaor in lndnldua ll: A L� A 6e-✓ V�( U51, Intl
Address:_LI5 tgr)K+h 5+-e of
C'ity,State"Zip: c;nJfm hIq D19-7D Phone #: L "37 >� VJ )A
Are you an employer:'Check the appropriate box: Type of project (required):
1.E�1 am a employer with A5 4• ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors
'.Q I am a sole proprietor or partner-
listed on the attached sheet. ; �• ❑ Remodeling
ship and have no employees rhese.sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp, insurance. q• of
addition
No workers' cum insurance 5. ❑ We are a corporation and its
[• P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4), and we have no Roof repairs
insurance required.) t employees. [No workers' 13.
comp. insurance required.]
'Airy appficani Ihat checks box 101 most also tilt out the section below showing their workers'compensation policy information.
'I fumeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
ICuntraciors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
f am an employer that is providing workers'c•onlpensation insurance far my employees. Below is the policy and joh site
information. •1
htsurance Company Name: —1fY 1CL �rFAV t�
Policy#or Self-inss. Lic. #: f �Q,2/4/ ,�.Ml 3l S U 13 � �p Expiration Date: ' / /l
Job Sitr Address: / �Ll V/ &A �/e /!.(/ e City/State/Zip: tZ
O/ 97 0
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;VIOL 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 in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
In\esti_ations of the DIA fur insurance coverage verification.
l d«herehy c•c•rtif t de t/tepuins and penalties of parjur}'thus the information provided above is true and c•«rrec•L
tii �r uurr
Phone a / /l
t 1jicial use only. Do nut Iorite in this urea, to he completed by city' it nrrt•tr ojfic•iaL
City or
lssuint; Authority (circle one):
1. Board of!Health 2. Building Department 3. C'itytTuwn Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Information and Instructions
\las.achusctts Cicnoral I..aws chapter 15' requues all cntplo\ers to prat ide workers' compensation for their employees.
I'?.trsu.uu m this aatuIe. .lit emph{ree is dcI!ned as".. et en person in the scn ice of another under any contract of It ire.
ctpress or implied, oral or tt rirten.-
.\n employer is dclined as •'an indn ideal,partnership,.issocialion. corporation or other ld_al entity. or any two or more
of the furcgoing engaged in ajoint enterprise,and including the legal representatites of a deceased employer. or the
recciier or trustee of an inJMdual, partnership• association or other IcgJl entity,employing employees. However the
u.t tier Of a dwelling house having not inure than three apartments and who resides therein, or the occupant of the
,ht elling house of another who employs persons to do maintenance,construction or repair w ork im such dwelling house
or"Ti the grounds or building appurtenant thereto shall not because of such employ ment be deemed to-be-an employer. --
NIGL chapter 152, �25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or perrnit to operate a business or to construct buildings in the commomreulth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, j25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public cork until acceptable et idence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
.Applicants
Please fill 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 cenificate(s)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 be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill 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 permitilicense 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 that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
File uflice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
fhe Department's address, telephone and fax 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 I-877-MASSAFE
Re•%iscd 5-'0-05 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 Dumber is that the debris resulting from this work shall
be disposed of.in a properly licensed faci8fy as defined.by M. G. L,C. 111, Sec.
150a. .
The debris will be disposed at Saiem Fransfer'StWon
owned by Northside Carting
Signature of Pd mitApplicant
Date
Christoaher Zorzv
Dame of Permit applicant .
A & A Services. Inc.
Finn Pvame
113 Forth Street. Salerrr MAEI`rgt`€i
Address, City, Stata, Zip Code
'Wassachusetts - Deptkrtment of Public Safety
BoaM of Buildid, Regulations and Statkdards;
.Canstruction Supervisor License "
License: CS 57733
Restricted to: 00
CHRISTOPHER ZORZY `
115 NORTH ST
SALEM, MA 01970
Expiration: 5/26/2011
C'Munissiuncr Tr#: 14751
Office of Consumer Affairs&B siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration 101609 Type:
Expiration 6/26/2012 Private Corporation
Christopher Zorzy ` .
115 North Street 4 0
Salem, MA 01970 --
Undersecretary j
Commonwealth of Massachusetts
Division of Occupational Safety ,
Laura M Marlin,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/14/10
Exp. Date 04/13/11 i Li
DC000440
Memberof C.O.N.E.S.T.
so
�Ilp�ypp 4 _
IIIIII IIIII IIIII I�III IIIII I�III IIIII IIIII�IIII III IIII BOSTON- ENEW
Acted
Wig, A & A SERVICES, INC. 7 ✓( O
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
91 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
Buyers)Name Date of Contract
Buyers)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
�7� 7YS A-Z�l
The Buyers)listed above hereby jointly and severally agree to purchase the goads 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'1,and Buyers)have requested that such
goods or services be installed or provided at Buyer's address listed above. A&A 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 Buyers)agree to pay in
cash the best of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their purchase.
Purchase PRO . 1 L Est.Starting Date:
Down Payment: SE �LU T �iSGo(/.�T�' Est.Completion Date:
0 ❑Cash
Amount Due on Start of Job: O DC eck
_ as ❑Credit Card
Amount due on of Completion: No.
IF
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion: 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.
Buyer(s)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
(i)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 a-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 IT IT CONTAINS ANY BLANK SPACES.
All Sul rest la Buyer(s)
By. Sig—nature
4-a^� Q—T
I nnature Signature
C�ci �ffilGif�lZ � X2F-t��+� L� -2,z&L2,
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 right.
ARBITHATION'.The comment and the homeowner hereby mutually agree in advance[hat In the event either pall has a dispute concerning has contract,either party may submit such assembler
a private arbitration service which has been approved by Me Secombi of the Executive Office M Consumer Affairs on Business Regulations and the other party shall be reauired to submit to
uch arstudarn es proved In M.G.L.c.102A.
C:v_mrinitiela: �C auyefe lniriel
Do, cam: A• "LL�' lC
NOTICF OF QANCEI I ATION NOTICE OF CANCELLATION
Date M Transaction 1 6 U.You may cancel this[researcher,without any penalty or Data of Transaction iU.You may cancel this aansaction,without any penalty or
obligation,within three business days tram the above oats.It you cancel any property traded in, obligation,within three been¢es days from the above date.It you cancel any pmpeM ended in.
any payments made by you under the Contract or Sale,and any negotiable instmmenl executed any payments made by you under the canna[[or Sale,all any negotable Instrument executed
by you will be returned with 10 days mays,receipt by the Seller of your cancellation natice, by you will b s reti med within 10 days standing receipt by Me Seller of your cancellation notice.
and any security interest arising out of the transaction will be cancelled ll you ca cel you must and any security interest arising out of the handsome will be cancelled- Il you cancel,you must
make available W the Seller at your rsidre en ,in subsum Tally as good conarron es when received make available to the Seller at you nce eside ,In whostantially as geed condition as when receved,
any goods delivered to you under this contract or Sale;or you may,it you wish,comply with the any goods delivered to you under this Contact or Sale;or you may,it you wish,comply with the
instructions of the Seller regarding the rNum shipment of the goods at Me Sellers a Tense and inotmRions of the Seller regarding the return shipment of the goWs at the Sellers expense and
mall. If you do make the goods avaiable W the Seller and the Seller does not pick them up risk. If you do make the goods available W the Seller and the Seller does not pick[hem up
whin 20 days of the data of your Nual of Cancellation,you may retain or dispose of Me goods when 20 days of the date of your Notice of CancelIal you may retain or dispose Of the goWs
without any WrlherabligedIon.IfyoulailWmake[hegoWsavailable Wthe Selleporilyouagree without any fuller obligation.If you fail to make the goods avalable In the Sall or if you agree
W return the goods to me Seller and fail to do On then you remain liable for performance W all to return the goods W Me Seller and fail W do so,then you remain liable for performance of all
Obligations under the Contract To cancel this transegbn,mail or deliver a signed and dated copy obligatlOns under the Contract.To cancel this transaction,mail Or mall signed and dated copy
Of the cancellation home or any other written notice,or send a telegram,W ABA Si...
5 of the carwellalen notice or any other written notice Or sand a telegram,W ABA Se I
Noun Street.Serum Maseachounds 01910,NOT LATER THAN MIDNIGHT OF _�[f. North Street Sa
lem,Macintosh W chusetfs 010,NOT LATER THAN MIDNIGHT OF d
(Date) / , (Date)
I HEREBY DANCELTHIS TRANSACTION. Consumers Signature Date I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date
�5 a
. /� .aayZ� siree�.° A & A SERVICES, INC.
A&A SE -VICES 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
ROOFING SPECIFICATION SHEET
Buyer(s)Name Date of Contract
Buyers)Street Address,City,State and Zip Code
� Avz Sfrc-E M,`l �LF7U
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 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 parjw
ROOFING SPECIFICATION
Strip Roof of# /-)-LC- layers of shingles
stall 6'of ice and water shield at base of roof where t Install 15.b felt paper to roof.
possible. Install 18-24"of ice and water shield in valleys.
It Flash chimney as needed(no repointing included). nstall@"perimeter drip edge to rakes and fascia areas.
Install vent pipe boots and seal as needed. t Flash valleys as needed
t 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.
(3,'Dumpster/Disposal Included: Ce�-mP nc2 cK t Other:
Location: 021l2 we9'7
Install new roof: Manufacturer CC.72.77i/ ��U .:!S— yr Style/type SCL}-7r= (;-fL4y
Included in this proposal are thorough cleanup, building permit,and company/manufacturer warranties.
is FfcGM GNf RUBBER ROOFING SPECIFICATION
atrip Roof t Not Strip Roof
&nstall 1/2"High Density Fiberboard to existing roof using .Flash obstacles as needed.
screws and plates.
Dnstall .060 membrane EPDM (Black) rubber roofing to CUnstall 3x3 aluminum drip edge to perimeter of roof with
ffi�ibLerboard.s 13ell/el�s1� /�f.CF GNL seam tape.
Ct_� lash up sidewall as needed.
Included in this proposal are thorough cleanup, building permit, and company/manufacturer warranties.
SPECIAL INSTRUCTIONS:
.S'77'2/P IS7Ne-- SN1ru�cc-� &iN PdtGi-11-T S/OIL r�.vLLl e s/oF
, l
t.ricC,cio/,�� or✓2ME�2 �o� /,fis77:K-L .tie=u: 1n-�amine— 8���
e(-ft-�elc- /—ts4sHiN�f t,vs"7�1-t-<_ it.�-z�� L'rYL77ri-i.�'�2-n 2-� y 'w4Z
3 �rnz syi�acc-s �� s�n�n i3uc��ltcaan 2� F 7)
kn �'�o� ✓ �/o
C-Lc-Ar</ [lyO A-tc ./zJ3 0?/2/s
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 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. Buyer(s)hereby acknowledge that Buyer(s)
has read this Specification Sheet.
Contractor Initials: Date: U�—/E'—(0 Buyer's Initials: 1"0 D. Date: 00 I w•I D