009B FILLMORE RD - B-09-233 VINYL REPLACE. DOOR The Commonwealth of Massachusetts t
t Board of 131.111ding Regulations and SWnJ;uIJs \II NIl'll'.�I.I'll
l. '� Massachusetts State Building Code. 7SO CNIR. 7 edition I'SIP
J r Building 1'ennit ,-Application To Construct. Repair. Reno%ate OI Demolish a Rrn,r,/Jrmm,r,
One- or Tiro-Family Dwel ilw. 1. fo N
T s Sect on 'or Official Use Only
- 1it
Building Penn umber: Date Applied:
Si_nature:
Building Conun esioned Inspec or of ings Date ,_--
-J TION 1: SITE INFORMATION
L1 Prop"" :Address: 1.2 :Assessors Map & Parcel Numbers
q 1 m epJ Rrx�t� -----
Ma Number Panel Number
I.la Is this accepted street? yes no_ Map
L3 Zoning Information: LJ Property Dimensions:
Zoning District Proposed lhr Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards =DisposalSystem:
rd
I Required Provided Required ProvidedProvided
1.6 Water Supply: (M.G L c. 40, §54) 1.7 Flood Zone Information: ystem:Zone: Outside Flood Zone:' osal system ❑Public❑ Private❑ Check if yes❑SECTION 2: PROPERTY OWNERSH
I Owners of Record:
82OrpP�t)on W i I RYA Fi I m P C 1
Ntn—
Sigme i Pr� - Address for Service:
-7 )—M 2519
• ore ,. Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ 1 Owner-Occupied ❑ 1 Repairs)s) 1❑ Al teration(s) ❑ :Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other 16 spedly:JbiAin hoi Ise,
Brief Description of Proposed Work'-:
Tvys+�l1 ono ( I) N/inyl l2rntrQrrurnf 51`dIr)C3 C-Annr
SECTION A: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
i Item (Labor and Materials)
L Building $ I. Building Permit Fee: $ Indicate how (cz is Jcicrnuncd:
❑ Standard City/Town ;Application Fee
2. Electrical $ ❑Total Project Cost (Item 6) x in
x
3. Plumbing 3 2. Other Fees: $
4. Mechanical iHVAC) 5 � List: --
5. Mechanical (Fire S 'total All Fees: S Suppression)
Check No. Check Amoune Ca,h Anioune__.__
j b. Tidal Project Cost:. S �1/)(]a. n ❑ Paid in Full ❑ Outatundiog Balance Due:
J I I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI_)
3,55
_(` hri -i-r�nh�r Litensc Nt i�1non hate
Name of CS L- I folder List CSI_Tvpe(see helow) --
G
Type Uaticri a to
\ddreNs C - ['[itcsuicied,Lill to1j.000 Cln. Ft.
R Restricted 1.@2 Fanuh D�kellmc
(�enatn_e \1 \fasonn Onh .
RC Residential Roolin❑Co�erme
Telephone \SS Itesidenual \\'indwk .and Sidinp __�
tiP, Resideiti:d Solid Fuel 8urnmg \�ilianrr finial Luwu
p Residential Demohu.m
5i't Regered Home lmprovemenl Contractor(HIC) 101 t oo9
/r T � JPXV I f OS Reensuatiun Number
HIC Compan Nome ur HIC Registrant Name
-7`, f� (nldCal�D
Address _U�O�y Fspuatmn Date
Signature - - Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. S 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. F:ulure to provide
this affidavit will result in the denial of the Issuance of the building permit.
. - Signed-Affidavit Attached? - Yes ....-.:. _._"----No .- _r.•� -:. _......
-
SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I e o r , as Owner of the subject property hereby
to act unmy behalf. in all mauer
authorizes
relative to work authorized by this building per application. _
X
Shmatureol'Own r Date
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
mil" , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print N- n,c
Signature of Ow er or Au orized Agent - Date
(Signed under the Cains and Derialties 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 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. 1424. Other important infin m:uion on the HIC Program and
Construction Supervisor Licensing(CSL) can be fiw Cnd in 750 NIR Regulations I IO.R6 and I IO.RS, respectively.
' When substantial work is planned, provide the information below:
Total flours area Isy. Ft.i (including guraee, finished hasemenuattics, decks ur porchl
Gross living area iSq. Ft.) �4abitable room count
Number of fieplaces Number of bedrooms
r ---
Number of buthroums Number of
Number of decks/ p�trchcs
rvpe of heating system ( elf .
. . ... . Type of cooling system Enclosed- p ___—
3. "Total Project Square Footage" may be Substituted for 'Tolal Project Coot" _�
American Properties Team, Inc. �
TO: 9B Fillmore Road
FROM: Jennifer Pappas, Property Manager
RE: Slider Replacement
DATE: July 15, 2008
Please be advised that the Board of Trustees for Pickman Park has approved a
replacement slider for the above referenced unit. This approval is contingent upon it
matching the existing slider and that it fits in the existing opening. It must be the same in
appearance from the exterior (including with the installation of French doors). The Board
will not allow grids, eta - -�-"
We also require that permits be pulled in advance (regardless of what your contractor
may tell you), and then a copy of the final approved permit once completed must be sent
to APT for the unit file as well. We also recommend that owners obtain a certificate of
insurance from the licensed contractor.
You will need to bring a copy of this letter to the Salem Building Department in order to
receive your permit.
Should you have any questions or require additional information, please feel free to call
me directly at(781)932-9229 x675.
cc: Unit File
500 WEST CUMMINGS PARK • SUITE 6050 WOBURN MA • 01801 781-932-9229 • FAX 781-935-4289
CITY OF SALEM
01,
PUBLIC PROPRERTY
DEPARTMENT
1_': \C'\�lii>'t•1'���cllt l I I S.U; xI• \l.+•.Ar
11.1: 9-$--4i-4;,) ♦ 1' 9.'4=-1)84p
Workers' Compensation Insurance Afftdafit: Builders/Contractors/Electricians/Plumbers
Please Print Le2ibIy
k 3 ilt\.tnt Information �y
Name l)r_.m izauon.I IIdn;Jun l.): Ae A
kddress: ' Nor±h S-IYe a
Citysrtterzip: cnlpm M13 0I°-70 Phone:
.\rree(vuu an employer:' y
Check the appropriate box: -
Tpe of project (required):
I.LJ I am a employer with.525— _ 4. ❑ 1 ant a general contractor and 1 6 New construction
employees(full andror part-time).` have-hired the sub-contractors 7.
Remodeling
,hip and have no employees
listed on the attached sheet.
❑ I :un a soli proprietor partner- These sub-contractors have 8. ❑ Demolition
yees
_ ,-working_forme_inany,capac-tryµ. workers' comp insurance. 9. Building addition`_- - -
�......�.,.e -- ..
- -- - -- [No wcfikers- coin insurance- o. . _off pre a corporation exercised
d.t its - "' "` 10.0 Electrical repairs-or_additio-ns, T
P
rcyuired.] officers have exercised their -right of exemption per MGL I L❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work c 5152 $1(4) and we have no I LQ Roof rep1airst ���,'
myself. [No workers' comp. �,L.IUIY3q U
insurance required.] f employees. nc workers' 13.g Other�—
.comp. insurance required.]
'Any applicant that checks box#I must also till out the section below showing their workers'compensation policy infortnation.
t I lomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
K-onmaoore that check this box must attached an additional sheet showing the name of the sub-cumracturs and their workers'comp. policy information.
/our an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _ /
Insurance Company ,'Jame: 4lcfy L
Policy #or Self-ins.
•3Lic. #: V�1C.C1 ,30x ] � 5i a Expiration Date:
Job Site Address: qih h Ir)nDre 12)('nrl City/State/Zip: 5ll jfM M o 0-7v
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 tNIGL c. 152 can lead to the imposition of criminal penalties of a
tine op to S 1,51)0.00 and/or one-year imprisonment. as well as civil penalties in the torm of a STOP WORK ORDER and a fine
f up to 5250.Oq a day against the violator. Be advised that a copy of this statement may be 6orwarded to the Office of
Imesliealions oflhe DIA for insurance co+erage cerificalion.
/Jo ha•rrh}'rem/{• a der he p in.+ rird penuhies of perjury that the information provided uho+•e i.+'true wrJ correct.
Date: 9 0 iL
Cien,u urr:
ll'
U/Jirial use roof}•. Do not write in rho:+area, to he rornple•ra•d bycirt' hv or rou a rciuL
.. City or Tub>n: - —_--_.--_- _ Permit/License ..- -------------
Iscuim� \uthority (circle one):
1 Board of Ilealth Z. Building,Department 3. Cits'/town C'Icrk 1. Electrical Inspector 5. Plumbing Inspector
.
6. other
Phone #:
Information and Instructions
\LI:..t.husetis (kneraI Laws chapter I tequres all cmplosers io pro%ide workers' conipcnsation Ior I lie ir employees.
I'i.rsoani to this statute. ill emphiree is defined as - Ci cry person in the sect ice of,mother under:uiv contract of hire,
:\p:css or implied. oral or %%I iten...
.\n emplurer is defined as '':ui indii idual. parmcrship. .i,sociation, Corporation or other legal ciin"'. or:uiy two or more
,.I the liire_omg engaged in a joint cmeiprise, and including the legal icpresentatis cs of a deceased employer, or the
rcceI%Cr or trustee of an indictdual, partnership. association or other Irgal entity, employing cniployces. tlowcier the
nw ner ofa dwelling house has ing nut inure than three apartments and who resides therein, or the occupant of the
d,iclling house of another who employs persons to do mainten:mce, construction or repair work on Such dwelling house
or oil the grounds or building appurtenant thereto shall not litean5e of such eniploynlCnl be deenied to be an employee"
\i(iL chapter 152, �N2S06) 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 commooweaith for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.\dditionally, \IGL chirpier.152, ¢2S(.(7) crates"Neither the coniniunw-calth nor any of its political subdivisions shall
enter into any contract for the perfiirniance of public cork until acceptable ei idence of compliance with the insurance
- requnenients 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)-natne(ti),-L4dretis(gs)_mo,phoilefnuniber(s).along.with their certificate(s) of—.
_ --_--. '.-- insurance. .Limited-Liability Companies (LUC) or Limited LiabilityPartnerships{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 ille affidavit for you to fill out in the event the Ottice of Investigations has to contact you regarding the applicant.
Please be sure,to fill in the per-miu'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.c. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
Tllc 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.
Pie Department's address. telephone and tax number
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
- - - --- Tel. If-617-727-4900 ext406 or 1-877-MASSAFE
Ite'.tsed :-'n-tic 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, Seca
150a.
The debris will be disposed at. Salem Transfer Station
owned by Northside Carting
Signa ur of P�ermllt 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
cl� P�,,o,r«alr� ✓!�/��odu
- Board of Building Regulatio'ns and Standards
i
Construction Supervisor License
Licinse: CS 57733 `
Bi rtha".te_:=:5/2 611 9 5 8
Expiration 5126/2009 TrR 13739 tl
Rektnctlon OOj'
�I
CHRISTOPHER Z,01,
115 NORTH ST -
SALEM,MA 01970- Commissioner
I
Board of Building Regulations andStandards �
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2010 Tr# 267870
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy ,
115 North Street
Salem, MA O1970 Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Martin,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 04/09/08
Date 04/08/09 DC O
' DC000440
Member of C.O.N.E.S.T.
IIIIIIIIIIIIIIIIIIIIII IIIIIIIIII IIIIIIIIII IIIIIIIIIIIII BOSTON-RENEW
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