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11 CHURCH ST - BUILDING INSPECTION 40 (ten The Cominomtealth of Massachusetts V y Board of I3utlding Repil:uions and Standards t. I\4assachusctts State 13uilding Code. 780 CNIR, 7°' edition tit: I3uildin, Permit Application To Construct. Repair. (Zeno ate Or I)rnxtlish a Rrrurd hootai t r �\ One- or T:ru-Famil), Dit elling 011S' ]vim ---� This Section For Official Use Only — --- � \ Building_ Permit Nt e Date Applied: to Building Cununts,ioned Inspector ut Buildings Date —_ SECTION 1: SITE INFORMATION S operty address: 1.2 Assessors Map & Parcel Numbers _-- ei Farrel Nwnber 1.I❑ Is this an accepted sn"eet?.yes Map no_ P Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq f) Frontage(1i) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard ! Required Provided Required Provided =disfx)sal PI'u Hded 1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: em: Zone: _ Outside Flood Zone'! al system ❑Public❑ Private❑ Check if yes❑SECTION 2: PROPERTY OWNER'S—HL 2.1 Owner[o ecord: i ( Chore[' 1 zitx-eel , Name iP "nit Address for Service: CM00) `zgJA - =0 - signa re Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units 107 Other ❑ Spccily: Brief Description of Proposed Work'': 'rvls+Gl1 tAto (cZ) SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs:rl , Official Use Only Item (Labor and Materia L Building - 5 ng Permit Fee: 5 Indicate how fee is determined: rd City/Town Application Fee 2. Electrical b roject Cosrt (Item 6) z multiplier1. Plumbing 3 Fees: $ 4. Mechanical (HVAC) $ 5. Mechanical (Fire Fees: Sression) . Check :\mount Cash Amount _-_- j t. Total Project Cost: 5 l 55, db ❑ Paid m Full 0 Outstandinr� Balance Dur:- SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) '5-7733 r License Number I[sp(ruu�m D.ud Name of CSL- I Iulder 1_1st C•SI.Tope (See hclae-1 -- T�, e Descri rinat .. \ddn v L L'nrcs(nctrJ nit w 15.000 Cu. H.i I R Res[ricied L@'_ Fan'th Dkrel1(ne S(enat a.onn Uno „8) 7�2 RC Re (Jenual RuuiemC Trlepluutt \1'S 1teIIJ:nu.J " Ild... .wJ Saline __� SP 12c�ideiniul Suhd Fuel liunun,_ \�rlumc: lu.(.illdu,�u ' p Rnidcnual Ucnudmun .. Regi tered Home Improvement Contractor (111C) 1Q�toc) _ � i � `J?J'V ICpS Y1C' Reinsuation Number HIC Contp:tny Nall,e or HICK us ant Name Address _ ^..-.[h$l7NI _D!A - Expiation Date . Sienatur - Telephone SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure or provide this affidavit will result in the denial of the Issuarike 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 I •>2 1„ �h�� l�C �. as Owner of the subject property hereby authorize Lhrl5mppner to act on my behalf. in all matters relative to work authorized by this building permit application. X 4� 1�/l/0 Si ature Owner �— Date SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION I (I i i5+-o 2 a r- Zr-)I' as Owner or Authorized Agent hereby declare that the statements :md information on the foregoing application are true and accurate, to the best of my knowledge and behalf. t rZ /T Print N. e " pa[c Signature of O Au[hrind Agent ,ned under ns an(Si and of er'u ) NOTES: I. An Owner who obtains a building permit to do his/her own work or an owner who hires an unregistered cuntrac(.or (nut registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration - program or guaran(y fund under M.G.L. c. 142.4. Other important information on the 141C Program and Construction Supervisor Licensing (CSL) can be found in 780 C'MR Regulations I IO.RG and I IO.RS, re,peeticcly. ' When substantial work is planned, provide the intormation below: Total floors area (Sq. Ft.) rincluding garage, finished basemenUattics, decks or porehi Grass livintt area (Sq. Ft.) Habitable room count -- Number of fireplaces - .Number of bedroom, _--- Number of bathrooms dumber Ot ecksuths _.--- - fvpe of heating system dumber o(deeks/ p�anc�s -- --_—_-_-- Typcot cooling system Enclosed Open. �--_ _- -- 3. "Total Project Square Footage- may be Substitiued ti(r "Toml Project Cost" - ��_� CITY OF SALEM 3 =� PUBLIC PROPRERTY , �) DEPARTMENT � r .rs o VLyI,`N 12� AC'V�i lid,,t,��A IRI-I-I ♦ 1VI i V, ALA•,A, I lI �h I :, ,1't�� `,Workers' Compensation insurance Aftida�it: Builders/Contractors/Elec ise Print ers Leb ittiv 1 ilicant Information \;II11� tl3ua tic,; t h_antcm,ut. Indts:.htal l: A l� A .\ddress: 1115 Noah Sfre o f City,Sr.1tc,Zip: �n1om MY� Dlq-7G Phone4: L �7 IN ` ©� \r�e/�'uu an employer:' Check the appropriate box: Type of project(required): I.LJ I all,a employer with _ 4. ❑ 1 am a general contractor and 1 6 New construction —elemployees(full and/or part-time).' hate hired e a ached sheet ors ❑ Remodeling - listed on the attached sheet. 2.❑ 1 an, a sole proprietor or partner- -fhese sub-contractors have S. ❑ Demolition ;hip and have no employees i workers comp. insurance. y, Building addition working for me in any capacity, [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers'have exercised their ri ght of exemption per NIGL 11.0 repairs Plumbing patrs or additions {.❑ I am a homeowner doing all work b myself. C. 152, $1(4), and we have no 1_1[] Roof repairs r workers' comp. insurance required.] r employees. [No-workers 5e 13.�V Other 1Ahr_ Q!0Le7 comp. insurance required.] -:\uy applicant that checks box 01 must also till cut the section below showing their workers'compensation policy information. t I lontcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �('onvucntrs that check this hox must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information. /ant an employer that is providing workers'coutpen.salion insurance far my employees. Below is the policy and job site in,Jartaation' _ Insurance Company Name: i Policy #or Self-ins. Lic. #: W C 9��1 5�/) Expiration DatzG:�,,.'"i�?- / 7 11 Ch ��.i^h 4siYP.�-I' 4 �jQ� City/State/Zip:�_r rJR Ng70 Job Site .\ddress: t _ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure cm crage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up m S 1.500.00 an&or one-year imprisonment. as well as civil penalties in the firm of a STOP WORK ORDER and a fine ,tf tip to S'_50,00 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 111\Q>tlaalltlns of the DI for insurance coserage scritication. / Ju hereby terns j• u u ul r it,1) it s an penalties of perjury that the iliprmution provided above is true and correct. Date: 11_'Iyll ill e: t 2l J U(Jiciat Ilse oa(I:J Do not it-rite in th is area, to he completed by city or town ofJiriat Perntitil"icense #_.__—.—. .__ —.._..------------ ksuin,� i othority (circle one): 1. Board of Health 2. Building Department J. cih4rown Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other --_ -- -- Phone #:__ - Information and Instructions \I,i...tchu..eus (;cncIaI I-aws chapter I�I requires :IH cntplo�crs to pet)%ide %%orkers' corrtpcnsation I-or theirentplo}-ces. I'ttrsu.utt ro this >(At lie. an rotploree is detincd as ", every pct:son in the sen ice of.mother under my contract )fit Ire. c\press or impl icd. oral or ri II Co.". , \n .nrld,rrer is defined as "un I dit iduaI. pal morship, .tssucIaIioil. corporal ion or other legal entity. or atp ttivo or more ,I the foregoing cn:;aeed in ajoint emcrprise. and including the Irgal rcprescriames of a deceased employer, or the recCit er or trustee of an individual, partnership,association or otter legal entity, employ in_ entplt)yees. I t)weycr the ,P..t ncr of a dwelling house h:n ing nut more than three ❑parttnents and who resides therein, or the occupant of the Ihk elling house of another who eutplo\s persons to do ntuinten:mre, construction or repair work on such dwelling house ,a on the grounds or building ;ippurtClant thereto shall not because of such emplo%ntent be deemed to be in cmplo}er" \I(d.. chapter I i2, s25CI6) list) 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, \IGL chapter 152, §2 C(7) states"Neither the commonwealth nor arty of its political subdivisions shall eumr into any contract for the perlbrm:mce Of public cork until acceptable e%idence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." - - - Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) nante(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 dues 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 Ile 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitilicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiulicense 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 the for future permits or licenses. A new affidavit must be filled out each year. \Vhere 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 Otficc of Investigations would like to thank you in advance for your cooperation and should you have any questions, plensc do not hesitate to give us a Cull. fhe Ocpurtment's address. telephone and tax 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 RC% :cd ,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 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 Northside Carting Signature of Pe it Applicant s1� log Date Christopher Zorzy Name of Permit Applicant A &A Services, Inc. Firm Name. 115 North Street, Salem, MA 01970 Address, City, State, Zip Code P U-VALUES AND R-VALUES AT Harvey Manufactured ENERGY STAR 5 � HARVF_v/NOCISTRIES PARTNER . . - Windows and Doors WHOLESALE PRICING i • 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 Harvey vinyl windows with Low-E/Argon and all Majesty double hung windows with .4n F. Low-E/Krypton qualify for the ENERGY STAR®.program throughout the U.S.' !so�eool Clear Insulated Low-E* Low-E/Argon* U-Value R-Value U-Value R-Value U-Value R-Value VINYL WINDOWS Classic Double Hung (Mechanical) 0.50 2.00 0.37 2.70 0.34 2.94 Classic Double Hung (Welded Sash) 0.50 2.00 0:36 2.78 0.33 3.03 Classic Double Hung (Welded Sash & Frame) 0.49 2.04 0.36 2.78 0.33 3.03 Classic Acoustical Double Hung STC40 0.23 4.35 0.18 5.56 0.17 5.88 Signature Double Hung (Mechanical) 0.50 2.00 0.37 2.70 0.34 2.94 Signature Double Hung (Welded Sash) 0.50 2.00 0.37 2.70 0.34 2.94 Slimline Double Hung (Welded Sash) 0.51 1.96 0.38 2.63 0.34 2.94 Slimline Double Hung (Welded Sash & Frame) 0.50 2.00 0.38 2.63 0.35 2.86 Slimline Single Hung (Welded Sash & Frame) 0.50 2.00 0.38 2.63 0.35 2.86 Vinyl Casement/Awning 0.47 2.13 0.34 2.94 0.31 3.23 Vinyl Casement/Awning and Thermal Panel 0.31 3.23 0.25 4.00 0.24 4.17 Vinyl Designer Shapes 0.49 2.04 0.34 2.94 0.30 3.33 Vinyl Hopper 0.47 2.13 0.35 2.86 0.32 3.13 Vinyl Picture Window 0.46 2.17 0.31 3.23 0.28 3.57 Vinyl Welded Deadlite 0.50 2.00 0.34 2.94 0.31 3.23 Vinyl Roller - 2 Lite and 3 Lite 0.50 2.00 0.36 2.78 0.33 3.03 Clear Insulated Low-E* Low-E/Argon* VINYL NEW CONSTRUCTION WINDOWS(pg190-231) U-Value R-Value U-value R-Value U-Value R-value Vicon Double Hung (Welded Sash & Frame) 0.50 2.00 0.37 2.70 0.34 2.94 Vicon Single Hung (Welded Sash & Frame) 0.50 2.00 0.37 2.70 0.34 2.94 Vicon Classic Double Hung (Welded Sash&Frame) 0.49 2.04 0.36 2.78 0.33 3.03 Vicon Casemept/Awning 0.47 2.13 0.34 2.94 0.31 3.23 Vicon Picture Window 0.47 2.13 0.32 3.13 0.28 3.57 b Vicon Designer Shapes 0.48 2.08 0.32 3.13 0.29 3.45 Temp.Clear Temp Low-E Temp.Argon PATIO DOOR (pg 257-260) U-Value R-Value U-Value R-Value U-Value R-Value Harvey Solid Vinyl Patio Door 0.49 2.04 0.40 2.50 0.37 2.70 Low-E/Argon* Low-E/Krypton* WOOD WINDOWS (pg 261-270) U-Value R-Value U-Value R-Value Majesty Double Hung N/A N/A 0.35 2.90 Majesty Fixed Casement (PW) 0.37 2.70 N/A N/A Majesty Casement/Awning 0.42 2.38 N/A N/A Majesty Picture Window (DH) 0.34 2.94 N/A N/A 'The use of tempered Low-E glass may effect ENERGY STAR®qualification in your region. U- and R-Values are subject to change without notice. Not all products stocked at all locations. Call your local branch foravailability. Pricing and information are subject to change Without notice& may vary from region to region. For current pricing, call your local branch or visit www.harveyind.com. Effective 3/t 7/03 256 Sly: r PI[OPOSAL « A & A SERVICES, INC. 9 115 North Street Salem,MA 01970 '- Tel.:(978)741-0424 Fax:(978)741-2012 ' MA Home Improvement Contractors License No.101609/MA Construction Supervisor License No.CS057733 Submitted to: Work to be performed at: Street: G k Street: City: .. Ci tv State: Zip: State: Zip: Home Telephone: �$— — ,5a Work Telephone: We hereby submit specifications W r.estimates INDOW REPLACEMENT WINDOWS: - Stone Windows:# Carefree: Tru-Channel: Color: }(wr4 Vmyl Windows:# Slimline: Comfort Plus: Majesty: ! - _I Color: Other: Options for windows:/� Grid Pattern yj_l Low E/Argon Gas: Foam Fil -lin lg Wrap Exterior Trim with Aluminum Coil Stock:El Other.Ir I DOORS: Storm Doors:# Aluminum: Solid Core: ❑ Style Name: Brass Hardware: Beveled Glass: "'o, SPECIAL INSTRUCTIONS: L ocyf;oA/'A.u4Sfrzf o w' �advs e (3 o f Q d U C� C A.l e eX 0 b s s i /ACtU� 6 All aterial is guaranteed to be as specified, and the above work to be performedinaccordance with the s ecfiwtionssubmitted for bove.work and mpleted in a substantial workmanlike nner for the aum of. _ Ftf+} 13 R/a!1nnJYollarsT wrath payments be made/as follows 7 -7 `I,O© _ PlArlce4�,aJ((bNtrPov (l3Q Any alteration or deviation'from above specifications imolving Respectfully submitted Sales Representative extra costs,will be executed only upon written orders,and Agent for A 8 A Services no. will become an extra charge over and above the estimate. All + lag'saments contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary NOTE: This proposal my be withdrawn by us if not accepted insurance upon above work. workmen's Compensation and within ninety(90)days. Public Liability Insurance on above work to be taken out by A S A Services,Inc. ACCEPTANCE OF PROPOSAL The above prices specifications,and conditions are satisfactory and are hereby accepted. You are auth d to do[the /work as specified. Payment will be made as outlined above. 7/2 Signature Date Signature Date —You may cancel this transaction,without any penalty or obligation,within grove business days from the signing of _ this proposal."'