23 FLINT ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY
NU
Board of Building Regulations and Standards OFSALEM
Massachusetts State Building Code, 780 CMR, 7 edition RevisedJanuary
Building Permit Application To Const Repair,Renovate Or Demolish a 1, 2008
One-or Two amil Dwelling
This Se, tion For Wicial Use Only
Building Permit Numb D e plied:
Signature: 4V4.,
Building Commissioner/I ec r of B ilding Date
SECTI ITE INFORMATION
1.1 Pro erTy Address: 1.2 Assessors Map&Parcel Numbers
7� /i/�7 S1Y
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:r F10o PROPERTY OWNERSHIP'
y 2.1 Ownef Record: SE L 2
L J Ft!1 /U / �65�/
Na int) Address for Service:
9Z Sys=
gnature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
goc,P;17 Se Q-IlaC,4 Conti t P-0Z2 diffZ/2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 5 ❑Paid in Full ❑ Outstanding Balance Due:
J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) )—7 ) 53 —
r2 License N/umber Ex iration ate
Name f SL- old-
List CSL Type(see below)
Addres l Tye Description
U Unrestricted(up to 35,000 Cu.Ft.
tu[ R Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 Re stered Home Im vementpro Contractor(HIC)tnyy.
HIC Company Name or C Re strant Na e _(' Registration Number
cS —
Addre /
if
Ex ration Date
SignatureTelephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssua_unpCof the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'rrS//AGGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Ell G/V SS ALL as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relativ . work au ' ed y this building permit app: ation.
'gnaturc of Owner e
SSEECTIION 7b: OWNER' ORAgUTHORI D GEN ECLARATION
I, � � %�Jke
/ l- 257
= / 1 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoin plication are true and accurate,to the best of my knowledge and
behal
Print Name
Signatur(T of Owner or Autho ed Agent Date /
Si ed under the pains and enalties ofperjury)
NOTES:
1. 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. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
x Department of Industrial Accidents
Office of Investigations
600 Washington Street
r, f, Boston, MA 02111
,._ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgmization/Individual): aca
Address: 1 1 "J N lMh S-JfQ p+
City/State/Zip: Mh 619 0 Phone #: 9 q S a U
Areu an employer?Check the appropriate box: Type of project(required):
I.
L�/I I am a employer with 4. ❑ 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. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have.workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its ME Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑Pl bing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required.]t C. 152, §1(4),and we have no employees. [No workers' 13.❑ Other
comp. insurance required.]
*My applicant that checks box Rl must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit anew affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �'n T /1 /� t1 (' C
Insurance Company Name: I! 'Q' f 1/�y(�,! ��l' Y jf l�/�
Policy#or Self-ins.Lic. #: t I 1 I t >°R 7 Expiration Date: 3
Job Site Address: aint Islf-u City/State/Zip /9 70
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 up 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 un r he ins and penal ' s ofperjury that the information provided above is true and correct.
Si nature: ' I Date:
Phone#:
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#:
i
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 aparhnems 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 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 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
DISOPSAL 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 property 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
, P k�'
Signature o Permit Applicant
/7-/fir-//
Date
Christopher Zorzy
Name of Permit Applicant
A&A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
q (•�
Control No: 7` 5 1 9 3
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
DIVISION OF OCCUPATIONAL SAFETY
,. ,. 19 STANIFORD STREET, HOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A &A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Wednesday, April 11, 2012
IN ACCORDANCE WITH M.G.L. CH. 11 I, § 197B(b)AND 454 CMR 22.03, THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR,DIVISION OF OCCUPATIONAL SAFETY TO THE CONTRACTOR
ABOVE FOR THE PURPOSE OF ENTERING INTO OR ENGAGING IN DELEADING WORK.
THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L. CH. 1 l 1 § 19713(b)(2)AND 454 CMR 22.03.
HEATHER E. ltowE,ACTING CO[vllussi0NER
�i
Printed on Recycled Paper -
.. . _. ..✓� �>�ac�� a�✓Lloe. u4e�u >`.. Massachusetts - DepalKment of Public $;d'ch
Office of Consumer Atfairs&Bdsiness Regulation 'tip,• ']I Board of Building Regulations and Standards
Ir, HOME IMPROVEMENT CONTRACTOR ♦ 1` Construction Supervisor License
Registration 101609 Type License: CS 57733
_ Expiration 6/26/2012 Private Corporatio'
at
1 SERVICES,!fNC - .ipry,
� r CHRISTOPHER ZORZY
115 NORTH ST
Christopher Zorzy SALEM, MA 01970 m-r.
,115 North Street _
Salem,MA:0�1970 - - Undersecretary .
Expiration: 5/26/2013
t'onnuissiuuer Tr#: 15935
Aa d
/� gyp`/ = 901 A & A SERVICES, INC.
A&A SERVICES M ICES 115 NORTH STREET,SALEM,MA 01970
•VITA I W11 I A I amb] 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
Buyers)Name Date of Contract
�Z�EtI /2vsS�Lt� —7-7Z-1/
Buyers)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
9?8-7yS-la7S2 9,7S-Z/0/1-9tgi YNEEn1Z438�Gfall
.1°o
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with
the prices and terms described on the front and the reverse of this agreement and any specification sheets(this"Agreement'),and Buyers)have requested that such
goods or services be installed or provided at Buyer's address listed above. A&A Services,Inc.("Contractor"),hereby agrees to install or cause he be installed the products
or services listed in this Agreement at the Buyer(S)address written above. This Agreement represents a cash sale of goods and Services. The Buyer(S)agree to pay in
cash the cost of the goods antl services purchased as described herein,regardless of timing or approval of any financing Buyerts)may seek for their purchase.
,L eE = (ZS`1 C"� nn
Purchase Price: Qo Est.Starting Date: Z—t�>>
Down Payment' 70, Est.Completion Date: O
❑.,,Cash
Amount Due on Start of Job: yynl✓eck
- ❑Credit Card
Amount due on of Completion No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion 033 37, be 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 there are no verbal understandings changing or modifying any of the terms of this Agreement.
Buyers)hereby acknowledge that Buyerts)has read the front 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 date first written above. Buyer(s)also
(i)acknowledge that they were orally informed of their right to cancel this transaction;and(it)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///CCono///nntracton DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services,Inc. � Huyer � C�LUJCAC�r--
By. G/ L
Signature Sigrta re
/31/��ij fi ktLt� v 53� L
Print Name Print Name
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
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION:Theoretical and the homeowner bects,muffirdw agree In advance that in the event either pvty has a dispute concerning this Contract,either party may Submit such shopule to
a pmela a20ralionervice s which has been approved by to Secretary of the gathered Office of Consumer Affairs and Busine Regulations antl the other parry shall be woulred to submit to
such arbitration as proved L.In M.G c.102A. 't a+�
Commeteriffitals: oared•miaal.:
as. ��/2^(-) Dale:T
NOTICE OF QANCEI I ATIC `J �'J NONCE OE CANCELLATCN
Dale of Therms bit . I2_ cal I I.You may ca This transaction,without any penalty Or Unto of Trait ac 77-1 You may F®rward this transaction,without any among,o
Obligator.witch three business days lam the above dale.llyouc cedarepropeMtrabebin, obligatnio ormin three business days from Me above date.llydu wl.anypmpeMtradedinr
any payments made by you under the 0ommult or Sale,and any negotiable instrument executed any payments made by you under the Contract or Safe,aM any negotiable instrument executed
by you will be returned within 10 days lollowfng receipt by the Seller of your caredidern notice, by you will be returned within 10 days following receipt by the Seller of your cancellation notice,
and any security interest arising out of me transaction will be cancelled. It you cancel,you most eM any secant,interest arising out of the transaction will be cancelled yo II you cancel. u most
make available to the Seller st your mairence,in modulmially as good condition So when anneved, make avalable to the Seller at your maidens,In subMwtlallly ss good cormaon as whenreceived.
any goods delivered to you under this Contract or Sale;or you may,if you wish,nearly Win to mry goods delivered to you under this Contract or Sale;or you may,if you wish,marry wit the
inslmctions of the Seller regarding the return shipment of the Sows at the sellers expense and In4ucclans of the Seller regarding the return shipment of the goods at the Sellers expense and
Oak, If you do make Pe goods available to the Smler and to seller does not pick Them up me. II You do make the gootls available to the Seller am to Seller dean net pick them up
within 20 days olthe date of your Notice of Cancellation,you may retain or dispose of the gootls within So days of the date of your Notice of Cancellation,you may retain or dispose of the goods
without any further obligation If you fail to make the goods available to the Seller or ll you agree without any fuMerobligation.IfyoulailNmake Nege sav licabletote Selleoor ilyouame
to return to goods to the Seller am fail P do so,then you remain liable for performance of all to reform the goods to the Seller and tall to do so,then you remain liable for performance of all
obligations under the Conran.To cancel this anchavrmn,mail or deliver a signed and dated copy obligations under the Contract.To cymdddmISHMnsamcn,mail ordellver a signed and dated may
of Pe cancellation notice m any dih¢r adiden nation,or send a telegram,F AaA Services,115 of the accounting notice or any other written notice,or send a telegram,to A&A Servke2 115
North street,seem,Massachusetts 01970.NOT"TER THAN MIDNIGHT OF J-1 —I/. Node Strom,
Sam.Massachusetts 01970,NOT LATER THAN MIDNIGHT OF 1
(Date) (Dote)
I HEREBY CANCELTHIS TRANSACTION. Co reasons Si1mmdm D. I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Data
A^ A A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
• Telepbone:(978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No. CS057733
MISCELLANEOUS SPECIFICATION SHEET
Buyer(s)Name Date of Contract
�LLEN ku552ci 77-17--//
Buyer(s)Street Address,City,State and Zip Code
73 F-LitvT Sr .5,4LP),fA yi?q 0/9.70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
%76-7vS-1�75z qTB-y91-9(�7
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices 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.
SPECIAL INSTRUCTIONS
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it is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This contract may not be changed or Its
terms modified or varied in any way unless such changes are In writing and signed by both the Buyer(s)and the Contractor. Buyers)hereby acknowledge that Buyers)
has read this Specification Sheet.
p
Contractor Initials: {'"J Date: Tit'—// Buyer's Initials: Date: