11 CHURCH ST - BUILDING INSPECTION 520 DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building
Building Permit Application For:
Circle whichever applies) Roof,Reroof, Install S'_'_ en truct Deck, Shed, Pool
Addition, Mteratio Repair/Repl e,Foundation Only, Wrecking
Other
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:
Owners Name., Contractor: A j� tq e;P.t
Street It O,huaU ,hh city hem Street I(,c5 K) n(h--)L5+. _City Ct(eM
State_ Phone O%JM—ALDI State Phone (Qq ��(::2 aH
Architect: City of Salem Lic# 05
Street City State Lic D ' ' HD?# ' I D I (p 0Q
State Phone ( ) Homeowners Exempt Formes /no _._..
Structure: (please circle) Single Family, Other
Estimated Cost of job s`3 A(o Q. 00
WiU building confirm to law? —yes no
Asbestos?_yes/no
Description of work to be done:
1t��rlrill FI�Ut / �1 Vlv�ul (- )QcPMDf� I.0In n7A>4,
Drawi g u m'ied:_yes no Mail Permit to: A&A SERVICES, INC.
115 NORTFYSTREET-
X . (979)i41-0424
Signature of Application,SIGNED UNDER THE PENALTY OFI'W&WRACES.COM
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee s
COIIlfMS:
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APPLICATION FOR
' PERMi TO 1�
LOCATION
✓� C��r S� Un1f3ZD _ i
PEr MIT GRANTED
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APPROVfD
*ECTOM OF4B �-DIWS
CERTIFICATE OF OCCUPANCY
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YES
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The Commonwealth of Massachusetts
' I Department of Industrial Accidents
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Office of Investigations
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600 Washington Street
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Boston, MA 01111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/OrganizatioNlndividual): Q A Se,r Ul Le
1
Address: 1 15 Q O r+h Stye e+
City/State/Zip: .5a( D,rA M K1 DI ct-7O Phone #: Old 9,H
[2.
re u an employer?Check the appropriate box:
Type of project(required):
I am a employer with� 4. ❑ I am a general contractor and 1employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
❑ 1 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. 9• ❑ Building addition
[No workers' comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions .
myself. [No workers'comp, c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.] f employees. [No workers'
comp. insurance required.] 13•[XOther 2d10dQtOJ
'Any applicant that checks box#] must also fill out the section below showing their wk 'compensation policy information.
t Homeowners workers'who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConuactors 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. —�t-
Insurance Company Name:_ ' y`e__ Tro V12 1 f
Policy#or Self-ins. Lic. C a q X 12 CO Expiration Date: q [3 p
J � hlJrr^ �pP+ )oI(k 520 Ci
Job Site Address: L ty/State/Zi p:L J p YYl " Dt9 7D
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 tip to$250.00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do hereby cerN nd r the ains and penalties of perjury that the information provided above is true and correct.
Si�naNre: Date: — Q�
Phone# (918) -7,q I - D H a H
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
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 M
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 or 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 authority."
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 phone number(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 resumed 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 permittlicense 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 Investigations4 ,
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, Sec.
150a.
The debris will be disposed at: Salem Transfer Station '
owned by Northslde Cortina _
Signature f Perm Applicant `
Date
ChNstooher Zorzy
Name of Permit Applicant
A &A Services. Inc.
Finn Name
115 North Street. Salem MA 01970
Address, City, State, Zip Code
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- BOARD OF BUILDING REG��p� I
License: CONSTRUCTION SUPERVISOR
Number: CS. 057733
i BirtFidate r0$/2b/1956
kp1r OS/Z6/2007 Tr. no: 12633
CHRISTOPHER
115 NORTH 0
SALEM, MA 1970�'C I j
Commissioner
�f�./�r,Unr�iroalTe
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2008 -
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety &,
Robert J.Prezioso,Commissioner >
Deleader-Contractor
CHRISTOPHER ZORZY
ER. Date OV09/06
- Exp.Date 02/0B/07
DC000440 0 7
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HARVEY INDUSTRIES
U-Value and R-Value Test Results
• U-Values in accordance with NFRC-100 • Based on residential sizes
• U- and R-Values are subject to change without notice •Whole window values
All windows with a U-Value of.35 or less qualify for the Energy Star program REV 511/00
HARVEY MANUFACTUREDWINDOWS AND DOORS
Clear Insulated Low-E AdvantEdge
WINDOWS U-Value R-Value U-Value R-Value U-Value R Value
•Classic Double Hung(Mechanical) 0.51 1.96 0.40 2.50 0.35 2.86
•Classic Double Hung(Welded Sash) 0.51 1.96 0.39 2.56 0.35 2.86
•Classic Double Hung(w/ProWeld Technology) 0.49 2.04 0.38 2.63 0.34 2.94
•Classic Plus DH W/CFW 0.33 3.03 0.28 3.57 0.27 3.70
•Signature Double Hung 0.51 1.96 0.39 2.56 0.35 2.86
•Signature Double Hung(Welded Sash) 0.50 2.00 0.39 2.56 0.35 2.86
•Slimline Double Hung(Welded Sash) 0.52 1.92 0.40 2.50 0.36 2.86
•Slimline Double Hung(w/ProWeld Technology) 0.50 2.00 0.38 2.63 0.35 2.86
•Thermal One Single Hung 0.53 1.89 0.40 2.50 0.36 2.78
•Majesty Double Hung 0.54 1.85 0.44 2.27 0.40 2.50
•Majesty Fixed Casement(PW) 0.53 1.89 0.40 2.50 0.37 2.70
•Majesty CasementAwning 0.86 1.16 0.45 2.22 0.42 2.38
•Majesty Picture Window(DH) 0.53 1.89 0.43 2.33 0.38 2.63
•Vinyl Casement/Awning 0.47 2.13 0.36 2.78 0.33 3.03
•Vinyl Casement/Awning&Thermal Panel 0.32 3.13 0.26 3.85 0.25 4.00
•Vinyl Designer Shapes 0.49 2.04 0.34 2.94 0.30 3.33
•Vinyl Hopper 0.47 2.13 0.36 2.78 0.33 3.03
•Vinyl Picture Window 0.46 2.17 0.33 3.03 0.30 3.33
•Vinyl Picture Window Deadlite 0.51 1.96 0.37 2.70 0.33 3.03
•Vinyl Roller-2 Lite&3 Lite 0.50 2.00 0.38 2.63 0.35 2.86
VICON SERIES
New Construction Vinyl Window
•Vicon Casement/Awning 0.47 2.13 0.36 2.78 0.33 3.03
•Voon Picture Window 0.46 2.17 0.33 3.03 0.30 3.33
•Voon 1000 Single Hung 0.53 1.89 0.41 2.44 0.37 2.70
•Voon 2000 Double Hung (w/ProWeld Technology) 0.50 2.00 0.38 2.63 0.35 2.86
•Vicon Classic Double Hung 0.51 1.96 0.40 2.50 0.35 2.86
•Vicon Designer Shapes 1 0.49 2.04 0.34 2.94 0.30 3.33
Temp.Clear Temp Low-E Temp.Argon
HARVEY PATIO DOOR U-Value R-Value U-Value R-Value U-Value R-Value
•Solid Vinyl Patio Door 0.50 2.00 0.41 2.44 0.38 2.63