59 FEDERAL ST - BUILDING INSPECTION (2) t t
A]'Y�LE A 9IQ ti F�➢i2-PLAN f� S� A dit� A' 4�d€➢ Iflrk�tBS Vf f'a t$ai�
STRUCTURES FPLC, PT 1 9AD 2_F iv fl Y D `es§'__
[IvYY'OK 7 41_t":Applicants eu V>i tomt>Is(t.all rtcmv On tiers p aCe
Location Name �1�_kfG(r 13ui!< n
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.....—................_.....»_� Use Groups
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Tfi ypc of improvement Revt;eni ,({hot..linw vi k
(oheck Ora) - fisscnt6h=(churches) :k
New Building...... 1 _ Aisernbt�•(nightclubs etc) r:.2
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AItc atino_� Husines
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I Telephone 0-18 7,q/4 -6350
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CONTRACTOR INFORMIATION'
Name A ,- A SeryiuSa L-)P 4
Address, ll ! Nu(r S{YyP+j 4;nhv» MA- D1117b
Telephone
Construction Supervisor's Lic#
Home linproVement Conu-actor#_ J D
ARCHITECT/ENGLN`EERIz FORMATION
Name
1 Address
Telephone
Mass. RelgiSLrat.ion #
PEinarILE CALCULA1iON
Residential est. cost x $761.,000+$5.00
Commercial est. cost x Si I/SL000 +$5.00=
CONTMENIS
The undersigned does hereby attest that all Information stater!above is true to the best
of my kno Wedge under the penalties aft3eijnly
Signerl�
Date /D- - 091�
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1IaI If I • S.\I i \t- -"\"\' I p "l- I :' :1'I-:
['I 1: 9-8 4;-')Sgi ♦ f:\x:
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ala litant Information Please Print Le Ia'bly
N;1111e t Huanc.; l k_dntcw.nt InJt\,dua1.0 A F A ServlC�S� S��
Address: 11 '5 ►�Qr+h fifyef+
City,State,Zip: ,;0rJ j n Mj� Ui q-7a Phone
\re eou an employer'.'Check the appropriate box: "Cype of project (required):
3. ❑ 1 am a general contractor and 1 6. New construction
I.I"J I am a employer with� ❑
employees(full andlor part-time).* have hired the sub-contractors 7. ❑ Remodeling
'.❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no emplovees These sub-contractors have S. ❑ Demolition
_.._.-Work i rig-forme-m_anXeAllweItY._.... __ workers' comp insurance. 9, ❑ Building addition
5. ❑_We pre a ct.rpuratiorf its
_ No'workers'-comp;- insurence. :._. 10. -Electrical repairs ora�ldnions - -IN
- officers have exercised their ❑ - P --
exemption right of per MGL I LE Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work S P
myself. [No workers' comp. c. 152, }1(4), and we have no l?,y❑,y{{ Roof re�pxiyrs,, �
insurance required.] i employees. [No workers' 13171 Other t_ _Lt��__Idl�
comp. Insurance required.] J
•:\uy applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
I funmuwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�('untracturs that check this box must attached an Aditional sheet showing the name of the sub-contractors and their workers'comp. policy information.
l out an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: -/-
in 1 n 9 ' Expiration Date:Name:-
Policy #or Self-ins. Lic. #: �hC 1 � �i(o P _
Job Site Address: 6-0 T�Orxdl S-IYPP-F City/State/Zip: 01g7D
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coccrage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,50(L00 an(L'or one-year imprisonment- as well its civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S2i0.()0 a Jav against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Imcslicalions of Ilse DIA for insurance co\erage \'crificalion. -
/do he•rehy certi under rite pains urtd penalties of perjury that the information provided above is true and correct.
_. _.�.... -_ `/
Phont
011h ial use oily. Do not write in this area, to he.umpleted by cit-v or tortes offrciaL
PermitiLicense #___._-.-.
I\iuim{ Authority (circle one):
1. Board of Ilealth 2. Building,Department 3. Citp town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:____- — .Phone #:__
Information and Instructions
\Lix..ichusrtis (ieneIaI Laws Chapter I5' requites all emplo�crs to proN ide workers' compensation for their employees.
I':.inu.un to this .tatute. .in empLo.hre is dctuted -is '-.. e%en person in the set%ire of.unalmr under unv contract of hire.
cy,rC,s or implied. gral or wrinen...
.\n e nrplerer is defined as ":m indi%u.lual.paru:Crsltip, .ussoCuation, Corporation or other legal entity. or :uty two or more
,,I the lioreuoing engaged in ajoint entriprise, and including the Icgal rcpresentati�es of a decc:ued cnhploocr, or the
reCci�cr or(ru,tce of:n indiN idual, partnership, association or other legal entity, ctnplo)ing employees. Ilowc�cr the
o A nor of a dwelling house It:n ing not more than three apartments and who resides therein, or the occupant of the
d Clling house of another who eutploys persons to do maintenance, Construction or repair work on such dwelling house
or on the grounds or huildittg appunenaru thereto Shull not heCatlse of such employ man[ be deemed to he in employer." -
\16L chuprer 152, @25C(6) also ;(ates that "every state ur 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 taho 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
riucr into any contract for the perliantanCe of public pork until acceptable evidence of compliance with the insurance
rcquirantents 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_wntractgr(s) n;pme(s),-address(gs).and.phone number(s).along with their ceriiticate(s)_of -- --- - ---
-_ _msurance._Limited-Liability Companies (LLC) or Limited-Liability-Partnerships (LLP) with-no employees sother 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
,.f the affidavit for you to till out in the event the Office of Investigations has to contact youregarding the applicant.
Please be sure to till in the permiu'license 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 file for future permits or licenses. A new affidavit must be filled out each
Your. 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.
Tile t Mice 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 faux 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'
Ito'.i:Cd '0-0i Fax # 617-727-7749
www,inass.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 P rmit Applicant
Date
Christopher Zorzv
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
✓rre 'Pomimmz<rreal!/c o�✓�.tuow'�is<aedd '
- Board of Building Regulations and Standards
Construction Supervisor License
License: CS 57733
Birtlide te-_-5/26/1958
Expiration 5_/26/2009 Tr# 13739
R25ttictlort. _ I- .
_ I
CHRISTOPHER ZORZY -
115 NORTH ST
' SALEM,MA 01970 Commissioner
�I
- --- - - �— - - - _ - --- -- --- `�\ - —Board of Building Regulations and Standards - —
--
HOMEIMPROVEMENTCONTRACTOR +
Registration: 101609
Expiration: 6/26/2010 Tr# 267870
---,Type: -Private Corporation
A&A SERVICES,INC ,
Christopher Zorzy: ..-==
115 North Street
Salem, MA 01970 Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Marlin,Commissioner r
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/09/08
• Exp.Date 04l08/09 '0 9
DC0004,Q a,1
- Omher of C.OLINLIES.T.
IIIIIIIIIIIIIIO rl11111111u11III IIIIIIIIIIIIIIIII BOSTON-RENEW'
* avaee
A & A SERVICES, INC.
AaA-SERVI Telephone:NORTH
:(9 8)74R�E-0424 LEax:978A41 20g12
Contractor Registration No. 101609 III
Federal EIN:04-3090162 Construction Supervisor No.CS057733 -
ENTRY DOOR SPECIFICATION SHEET
Buyer(s)Name Date of Contract
koNA/I! S&-CjAG ANO #,qZ IN 7M/
Buyer(s)Street Address,City,State and Zip Code
59 Z�E065XIL- Sr- M4 0/970
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
978-7Y�!-03S-0
The Buyer(s)listed above hereby jointly end severally agree to purchase the goods mWor services listed below,In accordance with the prices and terms described!on
this SpedAcation shoat and the front and Me reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which MIs Specification
Sheet is a part.
/ ENTRY DOOR
Remove and dispose of# S existing entry door units. /
Install new entry doors# l Manufacturer -SLN/1/SC/ (///N�j D7T2/Y]
YYY---
Location
Type: ❑Steel ❑SmoothStar ❑Fiberclassic ❑ClassicCraft d$liding Patio Door ❑French Hinged Patio Door
Model# Sidelight(s)# Sidelight(s)type/model#
N'P PTIONS:
Adjustable threshold for ThennaTm Door /(/Grids for patio doom: Style:
Stain Kit: Supplied to owner
Expand or shrink the size of the opening Details
Cover exterior trim with aluminum coil stock: Style Color
Hardware: Ddelset `❑DeadbDlt kFootbolt ❑Mail Slot ❑Peepsite
[Zt.Ira--S
Install oak rip at f oor aSsx)
needed.
Caulk interior and exterior edges. -
XInsulate around new door unit where possible.
El Painting is not included. // P-I saw)
Included in this proposal are set up and clean up.
STORM DOOR
❑ Remove and dispose of# existing stone door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
❑ Location:
SPECIAL INSTRUCTIONS: 6��
y S ! GF7&vZ10fL 772
OP770AI To 1012Ne P11-1AILf CaArIJ
R 4 agreed and understand by and between the"Mm Mat this Specification eheeL along with Me CUSTOM REMODELING AMID IMPROVEMENT AGREEMENT,eonall-
mee Me anthe understanding between Me portent,and Mom am no verbal undermoulings changing or modifying any of Me tame.Thin contract a"n t as changed
or Its Lama mmlaad or varied!In any way unless such changes ale M wrMW and signed by bah the Barons)and the contractor. Buyar(e)hereby acknowledge Ma
Buyers)hoe need this epeciffismo SSheeL p _
Contractor Initials: U7 Date: 9—/0'OC, Buyer's Initials k-g( Date: 7Q1V
i
Asada
Smal mor A & A SERVICES, INC.
115 NORTH STREET,SALEK MA 01970
• 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 ,.
/0AJAA1, rSCy41— AWO /74RR/A/ 7277V 9— /V -D$
Buyer(s)Street Address,City,State and 9p Code
-'7 —ST SALeam AM 0/970
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address: -
y78-7qq-03S0
The Buyer(a)usual above hereby jointly and severalty agree W purchase the goods and/or services listed on rife accompanying specificafon sheets,in acmrdenm with -
me prices and terms described on me front and me reverse of this agreement and any specifcafon shesta loss'Ageeament),and Bu,w(s)have requested that such
goods or services be installed or provided at Buyer 9 address listed above.A&A Services,Inc,1'COntrador7,hereby agrees W Install Or cause to be installed the prOducB
or services listed in this Agreement at the euyer(s)address written above. This Agreement represents a seem sale of goads and services. The Buyer(s)agree to pay in
cash the cost of the goods and services purch az described herein,regardless of timing or approval of any retracing Buyers)may seek far their purchase.
S3 O.-'� w AA'nAvrrvj
(, DIS44vu�I Purchaas Price: �/' V/ L.5�./� J�o OBj!i Est.SafeniinDate:
L
Down Payment: 30. /NTlwlj T/Z/YV/ — ✓/ Est.Completion Date: /Z D 19
❑Cash
Amount Due on Stan of Job: heck
O Credit Cam
Amour[tlua on of Completion: No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion' 2 87y' 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 more are no verbal understandings changing or modifying any of the terms of this Agreemerd.
Buyer(s)hereby acknowledge that Buyers)has read the hem 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 time 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 e-mail,as listed above,In the event Connector believes Buyer(s)would be Interested In any additional quality
products or services of Connector. DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services,Inc,� �/ BBurye
By; / /_S __ter e _
Signature a S, -
Print Name 4,Z.—e
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
"reaction. See the following Notice of Cancellation form for an explanation of this right a
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