11 CHURCH ST - BUILDING INSPECTION 501 i
No `
APPLICATION FOR _
TO . •.��
LOCATION
1
PE MIT GRANTED
APPROVFD
CTOR OF 8 DINGS
CERTIFICATE OF OCCUPANCY .
YES
NO
I •
:+ i
t DATE:
I
I
� itp of
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building I I ChUi M ,5f. 501
Building Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install Sidin onstruct Deck, Shed, Pool
Addition, Alteration, epair/Replace, oundadon Only, Wrecking
Other: 4
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications: nn L�
OwnersName:_JQ�n , Inydnn Contractor: A eA S�rVICeSjv7►15 tjr7
Street I l okuic�y) SF -* 512 Cicy,Sil0M Street .115 Nnr4h 5�, _City lc
State, Phone State Mfl Phone• 01%) 7 1 - 0�1021
Architect: City of Salem Lic# 1,44D5
Street City State Lic 057 HIP 4 1 D((o D9
State Phone ( ) Homeowners Exempt Form_yes_.Ll no
Structure: (please circle) Single Family, Multi Family# Other T}� F�jSEx 1aV��bul Icltnq
•
Estimated Cost of job S 73 70— Hut Unlf j_
Will building confirm to law? ,yes no
Asbestos? yesL_no
Description of work to be done:
Zn III ,Six �l6\ Vinill r-4�, tQ1n( pmPk-)E lAjtrylotrlS
A&A SERVICES, INC.
115 R
Drawings Submitted:_yes no Mail Permit to: SALEM,MA 01970
X WRi a1a1-040 -- -
X , www.A-A-sERVTM-r,()m
Signature of AplWication,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(u7 MONTHS OF PERMIT ISSUED DATE
i
The Commonwealth of Massachusetts
t Department of Industrial Accidents
8. ir a OfceofInvestigations
jp tV t
t�tiP / 600 Washington Street
W6 Boston, MA 02i
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A A `j&.l•'yi 6g S Ty-)o—
Address: I I rl o r+h moire e+ `
City/State/Zip: f50A 1 nA M pl 019-70 Phone M 21-I 1 — DII
A,re.�°u an employer?Check the appropriate box: Type of project(required):
1.1�1 I am a employer with�� 4. 0 I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no.employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp.insurance. g, Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.�OtherWl nVl/S
comp. insurance required.]
*Any applicant that checks box#1 must also fill outthe section below showing their workers'.compensation policy information. --
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site
information. —f I
Insurance Company Name: T Vp
Policy#.or Self-ins.Lic. Q " q X 191 (p Expiration DateC (1 113I Cl:9
Job Site Address: d ho rrh Stye ,, Unit ,Srpi City/State/Zip: �( _lam m� (�197 0
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration e).
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 ttp 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 er h pain and penahes ofperjttry that the information provided above is true and correct
Si mature y
Date t
Phone#: 12 i- ;k 1 j
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: PermitUcense#
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#•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two of more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall 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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have'been presented to the contracting adthority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phonenumber(s)along with their certificate(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 permit/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 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office 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.
The 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 1-877-MASSAFE
Revised 5-26-05 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 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, Sea
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northside Carting -
Signature of Permit Applicant
Date
Christopher Zorzy
Name of Permit Applicant
A & A Services. Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
✓sae TOammsooxuse¢�a o�,/��aaaa�mrelA
Board of Building Regulations and Standards
Construction Supervisor License
.. License: CS 57733 I f
- BirtS'd�a3e:�r/26/1958
'+ -Ifon�f2512009 Tr# 13739
CHRISTOPHER ZDF
115 NORTH ST
SALEM,MA 01970 Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.R&cso,Commissioner
Deleader-Contractor 11
CHRISTOPHER ZORZY �u
Eff.Date 04/02/07
Exp.Date 04/01/08
Member of C.O.N.ES.T. -
- BOB
I�IIIIIIIIII�OIIIIIIIIIIIIIIIIII IIIIIIIIIIIII,I �BOSTOENEW�•
Board ofBuilding Regulations and Standards
. HOME IMPROVEMENT CONTRACTOR'
Registration _]01809
Ei:ptrallon 6%26/2008
Type: .Phvate Corporation
A&A SERVJCES INC
Christopher Zorzy_
115 North Street
aalem_MA 01970 Deputy Adminis r foi'
tOPIN RGN< • • I Q��
A & A SERVICES, INC.
A&A VICES 115 NORTH STREET,SALEM,MA 01970
Kzff1T6 T Telephone:(978)741-0424 Fax:(978)741-2012
�lOb /�Cjc(('255. GJ.I ttrcN - Contractor Registration No. 101609
_ Federal_EIN:.04-30901.62 - —SRL N?yR+• -41770 Construction-Supervisor-No.CS057733 -- - --- "-
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyegs)Name Date of Contract
n 5o�d D 3d o -
Buy//ens)Street Address,City,State and Zip Code
/ c ,
� if_lqurc �h � Gel+ A( 0
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
zl R7562l -�
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/Or services listed below,In accordance with the probe 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.
a. WINDOW REPLACEMENT
❑ Remove and dispose�off# I'1's �� existing windows.
❑ Install # -
aia�� new ff�}YYQV(�; iC_)R4 /T)YE10le kfWa�windows: i®'Vnyl ❑Wood yr
r �t-.Jl._ ufacture) 6 3 con eM' _rfeiC Sla S6 d-15
Options: Style -and 68C-
Color Interior IADc Color Exterior W le,I hy— Glass Type LD
. ❑ Wrap exterior trim with aluminum: Style Color
Cows will be installed according to the installation procedures in the portfolio.
rt�sulk all interior and exterior edges. 1 SCI.`eGA7S 1�
W-1[ngulate where possible around new units.
❑ Insulate window weight pockets if exist,and around new window units where possible.
nclu In this proposal are set up,clean up,Helps vacuum and cleaning windows inside and out.
uildmg permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
❑ Create new window opening by cutting through existing home and framing in opening.
❑ Remove and dispose of existing unit(s)in its entirety.
Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
❑ Install windows)into opening(s).
Note: If Bay or Bow installation to include cable support system,new roof system(matching Color as close as possible)
or tie into existing soffit system.
❑ Bay ❑Bow ❑Casement ❑Other windowls)to include new interior style trim and new exterior style trim and head
flashing as needed.
❑ Note: Painting and staining not included.
STORM PRODUCTS
❑ Remove and dispose of# existing storm window(s).
❑ Install new stone windows# Manufacturer
P '
Style Color Option
❑ Remove and dispose of# existing storm debris).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
SPECIAL INSTRUCTIONS: -
(Y1S It I&Y ?,t4fe_l'hre*w t 'thzyinr .ch*c 74-S/U�2&
� 1 c�cr fl
It is ailment and understood by and between the pertles that this Specification Shi along with CUSTOM REMODELING AND IMPROVEMENT AGREEMEM combinable
Me entire understandlag between Me parses,and more are no verbal understandings changing or modifying any of Me terms.The contract may not be changed or bb
terms modmed or varied In any way unity such changes are In writing and signed by both Me Batist a)and Me Connector.SWerMs hereby acknowledge Met Buyega)
hea reed Mne Specmceden Sheet.
� I0/30/ 0-7
Contractor Initials: S t-- Date: �_ (�jQ�d7 Buyer's Initia Date:
pg zaF z
A & A SERVICES, INC.
IC 115 NORTH STREET,SALEM,MA 01970
�� Tetephorl(978)741-0424 Fac:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 -. - - - -- Construction-Supervisor No.-CS057733 -- ---- --- - - -- - `_ '
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyerls)Name
e ,p Date of Contract
V Na`DNA/ JAAA✓I,
Buyer(s)Street Address,City,State and Zip Code
I1 CbrurCh nit 'r 5'A lei 414 o 7d ,
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
all q7$- (Pal 7X7,5
me Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance win
me prices and terms described On the front and the reverse of this agreement and any specification sheets(this"Agreement),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 the 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 eek far their purchase.
♦♦1 f f.S4&I o Ilk :GF o A*xya���f�D;K'g 4�'N
Purchase Pdce`:rpA�Q-i Est.Starting Date:_y��
Down Payment:TZ 157n 4 0 Est.Completion Date:
qA� uu[��, ❑Cash
Amount Due on Start of Job: — O Check
O Credit Card
Amount due on of Completion: No,
Amount Due on of Completion: Expiration Date: -
Balance Due on Upon Completion: X CVC Code:
It is agreed and understood by and between the parties thuill 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.
Buyerls)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 We 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(II)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.
A&A Services, Buy Inc.
By: �� G��-
Signature / .y S�natur
1] Jt
Print Name f Prin N�e—
'j C aor del
Signature
Print Name
You,the Buyer(s),may cancel this transaction at any time prior to midnight of the third business day after Me date of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
a '
AnanPAnorv:Tne arma«or aria Ne nomBowner rivalry mulualn ayes ln.Cvarce M«Ir,lire ev 1elMer pea nav aai¢pNo 2ncemine Ibis conOht.eiln«Var1Y^sY submtl SUCK CispuleW li
e p,n'a19 aA'«edon servlm 1Mltli nu peen app'or9e ter 1ne sN/Hery of Na Ea NNe o111te of Cenaamer saw elk Business Haauhmens and the other pays ahal Ee reaumal m bvbmn b
such appro on as pored in M.a L c14]A.
C'Marmentre,,mdas Our ll,tin+6: "
o.t.. o.m ! .
NOTICE ofF I CANf.E1 I ATON NOTICE OF CARGO IATON
Dtle at Tn:'Mc on-IYou may ad.Nu o-ansoclmr,wi hand any amaM« Date of TraLL .0 .You may cancel mia trenmcllon.tinier any paruln or
between.wiNin three bW ys norm you:
Nme oats,a you.1.any pope,..in. aNgalgn.mod three bumbut days them Ne aGrva dam.ll you arc1,any undooy trace]In.
a,prymenm Mete by you under Me eoMM or sad.and any na9ddN insWmm anneals] any payments made by You under,he eonbem or Fale,and mry nobtleole ameWment osenutnd
by you will be retumed epithet 10 days mllowirg mealy By Me salkr of your candalmdon neeks, by ran wul he heWmed whin 10 days havens reeeipl by the senor of your m9 lle nnalee,
and env aeanfy lmem5l edvng aft of M.lmsC4Te wui be CenCeuM.11,Lrenral,youmusl and ury mom,Import Mang ant of me transaction will Me outdated.B you rascal,You mua .
nadefuaileble to Me wile of your penal In wba 1.1 as 9uN tondbba as an—a.. make.waMbmm Me s.n«sl purmsLderca,MerEslendeln as good midien as damn metered,
any goods widened to WU wom his comment Or sae;or you may,It you wlah.comedy walk Me any goads delivered to you under any e«bYY or sale;or you may,if you whin,mmpN wlM the
Irtsmrtlmns W the error dompro p Me mmm smannenl of the gouts al Me Salim importer and Inca omen.r Me Swer mgading his room shimmed of Me g.a el Me Sell apiaries oM
milk. It wall do make Me goods availmW m the Seller and Me Sella dries MI FEE Mom up nak. H you do make they acts avyMbb to the Srlm and Me Selpr don not pof Mom up
worth M days of Me data of der Notre of Cancellation,you may rain or didembe Dt Me goods Near M days of Me dam of your Noel,of clummu ba'pu may mmn or diamew of Me areas
...an,..orabNet..Il you as he.1.Me gAde av 1.1.to Me SNln.omit you agme xiym,any NMer oblpatlon.ll you wl to make Me Makes awerande milk sells,or M am eyes
to mum MB game M be Sellm and.1 to do ad Mn you..In Imb1e fa pedomamm of all to mMm Me game W MB SolereN m0 m do W.then you remain fears for dermmmakn of
wgtl ns under the Conrad.TO CBrceI me denmcdon,mrl or deMer a agretl and dated am, obllg m under Me Centeno To Fuded one Pad on,Mom or maker a signed and mr body
of the mnmlBoon more or any a ammo real oh sew a anseam,W A&A se Ile of the Canal Nkm month d any a1M..M noire,or ways a Mesram.to A&A someone.115
NOM Strum Maim.MCE9BChUeM9 01910.NOT(Area IAN MIDNIGHT OF North Bu de(your.Mn u3 01910.NOT LATER THAN MIn NI101
loam) (MI.)
I HEREBY CANCEL Its TRANSACTION. C mumery84ma m Date HEREBYCANCEt-IIMTRANSACTION. ConsumaA sgvNme Dem