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21 GREEN ST - BUILDING INSPECTION (2) The Commol wcalth of MassaChusettS \ Board of 13wlding Regulations and Standards MI'NJ('IP.\H I Y Massachusetts State Building Code. 780 CN•1R. 7°i edition tit'. Rrr�+rJ.l,ow.,rt 13uilding Permit Application To Construct. Repair. Reno%ale Or Dcnu,lish a _tn)•4 One- or Tnn-Fumilt- Duelling This Section For Official Use Only -- -- Building Permit Number Date .Applied: $I_anaiale: �� -- --- Building connniesiuner/ Insl or of Buildings Dale SECTION 1: SITE INFORMATION L1 Property address: / 1.2 Assessors Nlap & Parcel Numbers kla Number Pariel ,Numhcr I.l a Is this an accepted street? yes_ no—. P 1.3 Zoning Information: Lit Property Dimensions: Zonine District Proposed Use Lot Area(sq f) Froniaee(li) . 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard ! Required Provided Required Provided Required Prodded 1.6 Water Supply: (M.O.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone" Nfunicipal El On site disposal system ❑ Public❑ Private❑ Check if yes❑ 5n SECTION 2: PROPERTY OWNERSHIP[ .address for Service: �aN (Pri SiOn—wure Telephone - SECTION 3: DESCRIPTION OF PROPOSED WORK'"(check all that apply) New Cunstructiun ❑ Existing Building ❑ Owner-Occupied ❑ Repairsls) ❑ ' Alterations) Addition ❑ Demolition ❑ 1 Accessary Bldg. ❑ I Number of Units_ Other ❑ SpecilY: Brief DescriptioryofSG or 7 _ w IOU dQ! JS f r ' SECTION d: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials) I. Building $ Q Qd I. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x 3. Plumbing S d. Other Fees: $ J. Mechanical (HVAC) $ List: j 5. Mechanical (Fire S -- Total :\II Fees: S Su. ression) - Check No. Check Amount: (•;uh :\mount:,--- j b. Total Project Cock $�Q y/�'/, d ❑ Paid to Full ❑ Outn[anJin�� Balance Due:___...___ SECTION 5: CONsrRUCTION SI,:R1'IC•FS 5.1 Licensed Construction Supervisor (CSL) . II f License/\'u✓nhttl livpu�:rnnn I)�.ue pan• rfC 'I - lul e Llel C'Sl.l'vpe(sn•halnw) Ti. c Drscri note \d r ss C C'niesincicd,u i[it 1i.(J00 Cu. 1:1.1 j y JF} 0`IGL R Restricted I&_ F:mnl� M-11ine v1 ,t:q RCRrmdenial Roulhe Cor crure Telephone \1's Rcnidcutial Wnidua .ind SiJin_ SF Relldenlial Solid FI)cl Burnun! \ r rllanc� hntallduun D RC jenlyd Uemoliuun i 5.7 Re ' teryCd home lm ruliennentlLu trrte[or (IIIC) 16l 6 o l Ci -- H ' nnp:n m c r II• ei tr t Name - - Registiauon Number Ad • , �7 Crio�ay _xpiruti rn U:ue SI at e Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. I52. § 25C(6)) Workers Compensation Insurance affidavit must be •ompleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan- 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 1, G as Owner of the subject property hereby authorize to act on my behalf. in all matters relaZA o work authorized y this building permit appli � Ion. �V , Si of Owner Date /SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION —7[�I as Owner ur Authorized Agent hereby Declare that the statement information on the fo going application:u a true and accurate, to the best of my knowledge and behalf.' Print Nam 9 A- oSignatu o wAut rind Ag ent Date (Sim, the pain enaltiesof perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to.the arbitratinn 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 750 CMR Regulations I IO.R6 and I IO.RS. respectively. 2. When substantial work is planned, provide the information below: Total flours area(Sq. Ft.) .tincluding garage, finished basemendattics• decks or purcht - - Gross living area (Sq. Ft.) Habitable rtwm count _ Number of fireplaces - Number of bedroom. —_ Number of bathrooms Number of halt/h:uh. fvpe of heating system Number ntJecks/ pitches __-- Type of cooling system I:nclu.ed Open __-- _- -- 1. "Total Project Square Footage" may be substituted firr "Total Project Guf• J CITY OF SALEM a lip PUBLIC PROPRERTY DEPARTMENT %l.\l�-K. fla; 9-8-'a9.9g3; � Flz: '/-g.'a:'183n Workers' Cumpensation Insurance Afftdacit: Builders/Contractors/Electricians/Plumbers imlieant Int'ormation bly ��±± Please Print Leei Name If3u,lnr,s ttr_amm tam ludo IJua1.1: A L ALldress: 115 ]Jr)04-) f�h,° e.+ City,Stale,Zip: S61fM, Miq 12I970 Phone #: ( '37S)7)J1 - DJJ )A Are you an employer:'Check the appropriate box: [7. ype of project (required): I.tJ I am a employer with _ 1 ❑ I am a general contractor and I . ❑ New constriction employees(full and/or part-time)•+ have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : ❑ Rem ode ling ship and have no employees rhese sub-contractors have . ❑ Demolition working for me in any capacity. workers' comp. insurance. ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its required.] oBicers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L[3 Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no 12.❑ Roof repairs / insurance required.] t employees. [No workers' Other comp. insurance required.] %ny applicant that checks boa Kt must also till out the section below showing their workers'compensation policy information. 'Homeowners;who submit this atrrdavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. �('uniraciors that check this box must attachedan additional sheet showing the name of the sub.contractors and their workers'camp. policy information. f mn an employer that is providing workers'c'ontpensorion insurunc'e for try employees. Below is the policy and job site information. Insurance Company Name: TrrzV Policy#or Self-ins. Lic. #: f- (,(� Expiration Date: Job SiteAddresJ/ / # A City/State/Zip:l�//Am 6/ 970 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,NfGL c. 152 can lead to the imposition of criminal penalties of line up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine of up to S250.00 a Clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Inl csti_ations of the DIA for insurance co.erage verification. /do hereby re•rtif3•ut •r t e pains t id penulties of perjury that the informution provided above its true and correct. 11_�II.IItirC: Date: �I J /`� Pholte = (1 - . Official use only Do not write in this area, to be c'oniplete•d by cloy or ion•n official . Cin• or Fine n: - -----..-----_-._-- PermitiLicense #—___---.----- lauing .Authority (circle one): 1. Board of Ifealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Information and Instructions \I.r...r.huseus General L.:nvx chapter 152 rcquiresall enmplosers to pro%ide %corkers' compensation Ihnheir entplo)ees. Pursuant to this astute, .m enrph{ree is defined is ".. cc cry person in the scrc ice of another under any contract ofhtre. cycress or implied. oral or cc riven." \n :urplurer is defined as "an indic tdual,partnerShlp, aSSOCILItion,corporation or other le gal entity, or any two or more III the tiurgoing ongaged in a joint enterprise.and including the legal representatic es of a deceased employer, or the rcccicer or tru.stee of in individual, partnership, association or other Iegal enuty,employ in,employces..11ouccer the ucc ner of a dwelling house haying not more than three apartments and a ho resides therein, or the occupant of the dmc oiling house oranot her who employs persons to do maintenance,construction or repair x ork on such dwelling house or on the grounds or building appurtenant thereto shall not because of such emplo)ment be deeuted to-be,rn-entploger." -- \1(iL 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 cvho has not produced acceptable evidence of compliance with Elie insurance coveragerequired..' Additionally, MGL Chapter 152, $25C(7i states"Neither the cornnwnvvealth nor any of its political subdivisions shall enter into any contract for,the performance of public%cork until acceptable ec idence of compliance with the insurance requirements of this chapter have been presented to the Contracting authority." Y Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractors) 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 confutation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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 till 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 or 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 bum leases etc.)said person is NOT required to complete this affidavit. The ()(fist 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 OMce of Investigations_ 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Rcctscd 5-_6-05 Fax # 617-727-7749 - www.mass.gov/dia DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of M. G. L a 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 defied.by M. G. L c. 111, Sec. 150a. 4.. The debris Will be disposed at Salem Transfer Station owned by hlorthside Carting as ,P ft nature of Pee it�.ppEicant Daek Christoohar z®cry Dame of Permit Applicant A &A Services. Inc. Firm h�ame . 115Morth Street, Salem MA 01970 Address, City, State, Zip Code -- • I• • � 11 1 I. I" "1 I •• • YJF "t...P or l l �x 'a,nu.= zt.*u+��"��s 111. 111 .» ,e•II IIB 1 III 111 1• IIB IIBI ask `@� a r o "" " p m @ 7 >NWI'1C r�y,r ;�t,'•-€g2.tt�` 'lu e , H nSW�i1 rii��c�'�s kr ��y. P Pt��{�jCli zp���,�`s�� pP�^"�,'�a°! ''B . yam- B . 5 C .o -B � B .• 8 ® 111 111• IIB 1111 IBI 1 IIB 111 1 `� 4'g� y��'t�.{✓.cxR ,�, � p �.�l i. B a x' @ rl1 .f ;N a b,. � N g�, B �� c o , ® B11 114//• 111� 111 �5 111 1IB 111 I/11 y+r mI s. F N av ERRxs�'✓} f�'Y6 afPf t rt� � P �'..?kl ts..z"'S �`v � .,c �a, _er�_'-_' .h. �y"lei � '� Z : J* Ems§. •�. a.�5. ,w. � �€-�'.,•� • •9 111 . I11 1 101 B11 IIB III III• II11 • 1 3rr'' , t�" Y . : .! l�u'�y aT. " �'4�.>s.. /�+ Ei . B •t 1��,,! *�`�, pply,� + C° ":� Piz-R y�4vFsl.BliM Y:RA�I 4wtYi.. }l N9a, S I14 1lli'. � P i Y, k^a ,w sit s.'-3. 'c_ 'F�?.a+;.r=''nal�t�^1 .. ' - Y.. Y 4� � a° •� Fe;. .@ . m"+ see .:ke^. R. �'` ' :- s. �W�.�+`tt t , } n+ AGratle ' 5�N2 A & A SERVICES, INC. I SERVICES 115 NORTH STREET,SALEM,MA 01976 • 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 Buyers)Street Address,City,Slate and Zip Code Daytime Telephone Number Evening Telephone Number Mobile Telephone Number - E-Mail Address: The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed an 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. ABTA Services,Inc.("Contractor'),hereby agrees to install or cause to be installed the products or services listed in this Agreement at the Buyers)address written above. This Agreement represents a cash sale of goods and services. The Buyer(e)agree to pay in cash the cost of the gootls and services purchased AS describe tl herein,regardless of timing or approval of any financing Buyers)may seek for their purchase. AegmC - 0 Z 5Z3, Purchase Price: z©� �8. Est.Starting Dale: :7 7-3o W Down Paymi �x Est.Completion Date: 7-30 ❑Cash Amount Due on Start of Jab: Z�a ❑Check Credit Card Amount due on of Completion: No. Amount Due on of Completion: o Expiration Date: . Balance Due on Upon Completion Chili Cade: It is agreed and understood by and between the parties that this Agreement,front aB9 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. Buyer(s)hereby acknowledge that Buyer(s)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. Buyers)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 Buyers)would be interested In any additional quality products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES. By: Servture Inc. ,0 _a nature ^u � n Il//\ .d) �L rwy Signature ///2 - � Signature '/ G � rx' �GVt t) y 17 f.4)i'YICo 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:The contractor and Ne homeowner hereby mutually agree in amerce 0.In hie event either paM has a dispute conksming Nis contract,either party may submit such dispute to a pMale erbivalbn seMco which has been approved by the Secretary at the ExecNNe ice of Consumer Affairs Mtl Buslner�spauauona and the other party shall be reaulred to submit to such arbitreton e5 proved In M G L C l,OA. ry'/�'ffy�--JJ//(r Connector initials: o•— auyv's Initials: NOTICEOFANl ,- NOTICEOE��FANf ATION Dole of Transallon 40'/0.You may cancelrar this t aadion,without any penalty or Data of Transaction -/O.You may cancel this asnsme ,without any penalty or obligation.within three business days tram the above date.It you cancel,any pmpsM Mice im atogation,within three business days from the aMva da .If you cancel,any propeM traded In, any payments made by you under the co ttr cc or Sale,and any rregatiable Insdumem executed any payments made by you under Me Contract or Sale,and any reasonable Instmment mmMetl by you will be cetumed within 10 days bllovdrg receipt by the Seller M your core ration mice, by you will be reNmed wifte 10 days following mcelort by hie Seller of your cancelaorch narks, and any security interest ansing out or Me transaction will be dart d, It you cancel,you must and any security Interest arising out of the transaction will be canceled. If rou wncet you must n ark IIeblatomesenarmpurmis nca,insubstanualyazg mMltionaswmremivetl, ma oea llablstallw Selkrmwurmsdence,insuMientlelyas mrxlitionaswhenrecerved, any goods delivered to you under this common m sale;or you may,if you wish,comply wuh she any 9aMs delivered to you under thb Centred Or Sale;or you may,it you wish,comply with me Instructions of the Seller regartling Me rmum Shipment of the goods art Me Sellers Overnu am Iprommons of Me Seller agree,the raNm shipment at the goods st Me sellers expense and reek, II you do make hie goods rentable to hie Seller and to Seller does net pick them up rook. If you do make me goods available to the Seller mod the Seller lows not pkk them up within Se days of the Onto of your Nptiw M Candarkmon,you may resin or dispose N Me goods within 20 days of the date 0 yarr Notice of Cancellation,you may retain or capose of the goods without any Further obligation.It you fail m make the goods available ro the Salley or it you Agree without any luMercbugallm, Ifyou lellbmake Ne gm]sevalableta the Seler,orltyau agree to mum hie gams io Inc Seem and all to do m, an you remain liable be me.—M all to Mum the goods to the Seller and fall to do m.Men you remain liable Far performance of all Obligations under the Contract.Tocanwl NlstrenseNoR mall ordef ra signed am datedcopy obligations under Na Comraa To cancel his Mercer on,mail or dark a signed and dated copy of the cancellation notice or any other written nodes,or Send a bagmen,to A"Services,115 of the cxnhillatun notice or any other when ounce,or send a telegram,b"A Services,115 North Street.Seem,Marawasures 01970,NOT LATER THAN MIDNIGHT OF —/4/Q NOM saw.,said.,MassaNusells 01970.NOT LATER THAN MIDNIGHT OFfO /yam/0 foetal (Date) I HEREBY CANCEL THIS TRANSACTION, Consumer's Signature Data 1 HEREBY CANCEL THIS TRANSACTION, Consumer's5gnmers Date epA, p, {, �m A & A SERVICES, INC. A&A SERVICES 115 NORTH STREET,SALEM,MA 01970 OEM SiM FIN MOT271111Telephone: (978)741-0424 Fax: (978)741-2012 Contractor Registration No. 101609 Federal EIN:04-3 0901 6 2 Construction Supervisor No. GS057733 WINDOWS AND STORM PRODUCT SPECIFICATION SHEET Buyer(s)Name Date of Contract DAVI lJ C�eWN4C-a (o -10— GO Buyer(s)Street Address,City,State and Zip Code -at ST. ;6� Z Ail if O/ ?7-0 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address ' 781—Vow—W0co 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. r� WINDOW REPLACEMENT ,!Remove and dispose of# 2 / existing windows. X Install # 2Y new S111V 26Se-T-- windows:Xvinyl ❑Wood 21 D}I VANr�Va<R.<, (Manufacturer) Options: Style O}} Sv«t-4S Grid pattern /l/ONJI�-- ,n �Color Interior Lt/� -i yZr Color Exterior 1,-Ab � Glass Type VLA-C/ L9-Vr9w*rc(6' ��-Wrap exterior trim with aluminum: Style Color All windows will be installed according to the installation procedures in the portfolio. J Caulk all interior and exterior edges. Insulate where possible around new units. /1110 Insulate window weight pockets if exist,and around new window units where possible. l~ Included in this proposal are set up,clean up,Hope vacuum and cleaning windows inside and out. Building permit included. BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS ❑ Create new window opening by cutting through existing home and framing in opening. ❑ Remove and dispose of existing units)in its entirety. Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with. ❑ Install window(s)into opening(s). - Note: If Bay or Bow installation to include cable support system,new roof system(matching color as close as possible) or tie into existing soffit system. ❑ Bay ❑Bow ❑Casement ❑Other window(s)to include new interior style trim and new exterior style trim and head flashing as needed. �7 Note: Painting and staining not included. r Y STORM PRODUCTS ❑ Remove and dispose of# existing storm window(s). ❑ Install new storm windows# Manufacturer Style Color Option ❑ Remove and dispose of# existing storm door(s). ❑ Install new storm doors# Manufacturer Style Color Type: ❑Aluminum ❑Solid Core SPECIAL INSTRUCTIONS: SG✓YL-t� �j Li9-3'S /w ,�dT}� �19�' G�s' 6fYL It is agreed and understood by and between the partlea that thin Specification Sheet along with CUSTOM REMODELING AND IMPROVEMENT AGREEMEN[constitutes the entire understanding between the Ponies,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 Buyerts)and the Contractor. Buyer(S)hereby acknowledge that Buyers) has mad this Specification Sheet. ? / Contractor Initials: (/c' Date: -/O -10 Buyer's Initials: Date: 6 0 /v