2 HARRISON RD - BUILDING INSPECTION (3) t >,
\ I
�b
� The Commonwealth of Massachusetts
r Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb r. Date pplied:
v77
Building fficial(Print Name Signature e
CTION 1:SITE INFORMATION
1.1 ro7p�e�ty Address: 1.2 Assessors Map&Parcel Numbers
pC 'r iZ-t Wt SU✓l g Cj
Lla Is'this an accepted street?yes no I 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: PROPERTY OWNERSHIP[
2.1 Owne 1 of Record:
MC k�,� ro..1 Al,, lam �IaJe,t �2 -01976
Name(Print) City,State,ZIP
Oar,-rsen k4 R
No.and Street -Telephone Email Address
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 Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 89 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 $
Suppression) Total All Fees: $
C� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Sa l 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ()��-1 3 -3 _.5�o
cA✓I S CIy/2Y License Number Expiration Date
Name of CSL Holder i
1 / NO✓ S• - List CSL'fype(see below) l�(
lo.and Street •, _ Type Description
C A� Vy\ �p ,/L 0 19 -7 O U Unrestricted(Buildings s u el ing cu.ft.)
CJ I�lrf -1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
p' SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) , _- - ,,q
+- A , {�' L-�5 �/t C - HIC kegi tr�ation Number Expiration Date
f6/��rttan}/ p or HIS�2egistrant Name
No nd treet -�� Email address
0- k vv\- DA A- 019-7 d
City/Town,State,ZIP Telephone
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 Issua4 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,as Owner of the subject property,hereby authorize .✓• S 2 yr -z
to act on my behalf,in all matters relative to work authorized by this building permiC application.
QIL aGLh eA. CJ�✓t0.L1 1 - l 5'-�1 3
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
conta' i this a lie a lion is true and accurate to the best of my knowledge and understanding.
Pnnt caner' or Autho 4 ed Agent's Name(Electronic Signature) Date
NOTES:
l. 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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,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"
t
CITY OF S.UY-Als &L1SSACHUSETTS
BUULDLNG DEPART%1&NT
• t 120 WASHLNGTON STREET,Sao FLOOR
A f TEL. (978) 745-9595
FAX(978)740-9846
KI,,,(BRRr EY OPISCOL
i�1AYOR Tlaoatas ST.PIEItRE
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG cO%z:%QSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /t- Please Print Leafbly
Name(Businw,OrganizatioNlndividual): PI;- R t/t C.2S (t'\C•
Address: I tf NOo' t, S�F-
City/State/Zip: <m (,e, M M r0-O 19 70 Phone#: `7 7 Fr= "]yf- QY
Are on an employer?Check he appropriate box: Type of project(required):
I. 1 am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ElNew construction
2.❑ 1 am a sole proprietor or partner. listed on the attached sheet.I 7• F3 Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, Q Building addition
[No workers'comp. insurance 5. Q We are a corporation and its
officers have exercised their IO.Q Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13.❑Other
comp. insurance required.]
•Any applicant that checks box FI must also rill out the section below showing their workers'compenaarion policy infurmuion_
}IL>.neownets who submit this affidavit indicating they am doing all work and then hire outside eonnoctots must submit a new affidavit indicating such
=(7citume .rut cheek this box must attached an xlditi.nal cheer showing the name of to sub-contnaeb0 and their workero'comp.policy infmmntion.
1 um an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
h1formadon.
Insurance Company Name: ��,r-aV142 ) e ✓_S
Policy#or Self-ins.Lie.#:- 2, "/` � M.,�, -1 � Expiration Date: C)l
- -
Job Site Address: d, a-C�✓k r So, h.Gl. City/State/Zip:_"/c7L�VY, 19 7
Aftach 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 S 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 S250.00 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.
1 do hereby certify fill er to pains and pettahles of perjury that the information provided above is true and correct
Sign t tre Date:
Phone#: EE2 0' -7 —d
Ojjcial use only. Donor write in this area,to be completed by city or Iowa oJrc-iaL
City or Town: Permit/f.icense#
Issuing Authority(circle one):
1.Board of lieallh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
DISPOSAL OF DE IIS AFFIDAVIT ..
In accordance with the provisions of K G. L c, 40, Seca 54, a condition of
Building Permit Number is that the debris resultang trom this Work s(i�19
be disposed of in a properly.iicdns®d'faoffitr as defined,by F4 G. L oo 111, era
150a.
The debris will be disposed at Salem `ransfae StaLflon
Owed bV Nor s&do Care
ignafure ®'Pe r, �a®pficang
Date
Warne of Pet�ff Applicant .
A &A SwAaeso Inn.
NUM &Wait Salem. INA 01970
Address, Ciao, Sfafq, j7p Code
"sr A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET, SALEM, MA 01970
• ''• Telephone:(978) 741-0424 Fax: (978) 741-2012
Contractor Registration No. 101609
Construction Supervisor No.C3057733
Federal EN: 04-3090162
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Date of Contract Bu er s Name
Bu r s Set w tha ,City,State and ZipCode
2treRafsoly 20 M14 019-70
Da 'me Tele hone Number Evm Tele hone Number Mobile Telephone Number E-Mail Address
2 —9S3o 978_;,phone
g'- aq-9�� 6t Ai�Naz7nv r cv+ u
c
The Buyers)listed above hereby jointly antl severally agree to purchase the goods and services listed on the accompanying specification sheets,in accordance
with the prices and terns described on the front and the reverse of this agreement and any specification sheets(this"Agreement"),and Buyers)have requested
that such goods or servicesed installed tl re provided vital Buyers address listed above.above.
Services,Inc.("Contractor"a hereby agrees to install se races to be installed
the products or services listed f this Agreement rvihe Buyers)edaddress rewritten above.This Agreement represents o cash sale n goods and services.The Buyers)
agree to pay in casM1 the cost Of Me goods and services purchased as described herein,regardless of timing Or approval of any financing Buyer(s)may seek for their
purchase. p
Purchase Price: I2 S8/a Est.Starting DatrI 2 -�
q O
Down Payment: Est.Completion Oate:o"-�a-�
ryj�1j Cash
Amount Due on Start of Job: Check
El Credit Card
Amount Due on of Completion: No.
Amount Due on of Completion: > Expiration Date'
Balance Due on Upon Completion: 3`l�' 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.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 email,as fisted 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.
A&A Ser ices,Inc. Buyers / ��
By:7�
Signature Signature
Print Name Print Name
y
Signature
X
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 night.
ARBITRATION:The mntanm and the homeowner hereby muwally acre¢in advance mat M Me event mMerpadr best a dispure aYaming this mnwact.eimerpam may satinet sum,disam M a
pned.ardtramn span ire werr bus bran ammeed by the seQemrymme E.emuve INfiaof eonsurre5raire and Sweet—Hagdationst and the ova parry shml be required m submit to main
morrraum as proved in such cAfeoa
camr.emtmbmlst 126 aur<ro tmrhls.
Date: -1st-1st Dnra. x 'z�i3-�3
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
sa Odle of Tranction r''a—, -73.You they cancel Nis generation,winds any penalty o Data of Transaction—��—��.You may ca col this transaction.Mmods any penalty or
obligation,within three business do,from the move date.IT you rarest,any pmpettyt2tied it. obliga5an.wimin MaebusinessdayshommeaMve te.If ymanW,enypmpenytredrdm,
any vmnI trade by you under me Contract or Sale,and any negmardl,insburrent ewcured any paytrank made by you under me Contrail a Sala,and any negotiable insburrem emmted
by you will to rewired wain 10 days mllaw ing receipt lay Me serer of your ranrauatiw mass, by you will be resumed sewn 10 days knowing reraps by the seller myour ranceoamn mute,
and any uordty im¢met arising out of me Y mchon wit the sanrellas N You cancel,You must and any security Interim maing out N me comment,will be dowelled.If you mine.you trust
crake avanable to the seller at your re9dence,and substantialry in as head condition as when make decease to Me Seller at your readerre,and eubmandony in as cord condom as when
received any goods recorded M you under this Solaro or Sale;or you may.if your Wish.xmlJy weverred,any goods delivered to you order MLS ConYap or Saw or You mug if your wilt.conply
.In me instmtims of me uglar regarrm,me reNm shipment a me goods at me Seller's uflh Me mearch ns of the Seller regarding was realm shpment or Me goods at me color
depense and ask.It yW do cake Me gems assailable to Me Seller antl Me Seller does not pid, pyenm and risk.If you do make me goods wavicale to Me doidr and Me Seller does not pick
them up within 20 days of the date of Your Notice of Cancellation,you may retain or disposer 0 me them up wihin 20 days of Me date of part Notice of Wnmllmon,you may retain or Liepose of
from embeut any WMer obligation.It you fail to make Me goods avemde to Me Schead do It you me goods words any future,obligation If you fati to make Me goods reashle to Me Seller,or it
m.to realm Me goods b the Sella and Mil to do an Men you arawnliime for perfamanm 0 you agree to retum the goods to me Seller and fail to do so.Men you certain liable for pedwnanci
all obligadms under the Carrown To saner His transaction,roil or deliver a signed and dated of all obligations under Me concert To camel this baneayon.coal or deliver a agree and dated
copy of Me constitute notice or any other written notice,or serd a telecom,to Aot Se oa may of me ancelletion nods or any over notice,or send a program,yJ'to Ask
115 North Sweet,Salem MA01970,NOT LATER THAN MIDNIGHT OF7-1 ie-1 � s 115NoMStr Laalem MA019T0,NOTLATERT MMIDNIGHTOF La
roan, mow"
1 HEREBY CANCELTHIS TRANSACTION I HEREBY OANCELTHIS TRANSACTION
Cmsurrer's SgnaWre a.., Consumers Signature Date:
+ AGcd
rya, A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
• • Telephone:(978)741-0424 Fax:(978)741-2012
y1;
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
ROOFING SPECIFICATION SHEET
Buyer(s)Name Date of Contract
ru�r/7 * WIL /Vm-7aW 7 — i3 —r3
Buyers)Street Address,City,State and Zip Code -
°� «2 f S mV yQD �742�r I Yrr1✓�- Ol�i`70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
The Buyers)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 pad. if %/
P92T/q-L— ROOFING SPECIFICATION
Strip Roof of# layers of shingles M may"' RvTs� nW�yr p r.,ra.>t.t dX.S Nc^�
C
nstall 6+•ebice and water shield ahbliae ah root where 'AInstall 15.b felt paper to roof.
possible. 'ek#in-valleys:
$�Flash chimney as needed (no repointing included). nstall W perimeter drip edge to rakes and fascia areas.
Install vent pipe boots and seal as needed. )k Flash valleys as needed `
*Install rollout type ridge vent. lanks/plywood replacement under 32 SO FT included,
'If more is needed there will be an extra charge of$
per hour for labor plus the cost of materials.
Dumpster/Disposal Included: Other.
Location: ✓MO 'r"n-vim
Install new roof: Manufacturer CraD2--il1W79dd9 3U yr Stylettype gRc�{t TLsC '(---
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
RUBBER ROOFING SPECIFICATION
it Strip Roof t Not Strip Roof
I? Install 1/2"'High Density Fiberboard to existing roof using `A Flash obstacles as needed.
screws and plates.
f Install.060-membrane EPDM(Black)rubber roofing to $ Install 3x3 aluminum drip edge to perimeter of roof with
fiberboard.s seam tape.
r
T Flash up sidewall as needed.
Included in this proposal are thorough cleanup, building permit,and company/manufacturer warranties.
SPECIAL INSTRUCTIONS:
keM&VI - -r 01-s 77" CC-nl1y`Z- -S;ois
11-2 Oct.- s/®e3 r air r��vzn S
//US T/-),L 7-t�,�a>1. Si o G�3 Ix' D-Tu ra
8 —rti. /wl� � �
I Iii� �//�-� A,7y.1 Lr dWyL /2 e� T Gl--
Af 82(J A LV ie-i mI I"
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 ere 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 Buyens)and the Contractor. Butterfat hereby acknowledge that Bothnia)
has read this Specification Sheet. IV
Contractor Initials: y,J Date: 7'13 -/3 Buyer's Initials:A' 1'T Dater'' \
� µ+ AGratle n
01970
�g� ', 1 Ale.- A & A SERVICES, INC.
A&A SBMICES Telepho115 ne::(978)74RTH �1-0 24 Fa�cE 978)MA
41 2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
MISCELLANEOUS SPECIFICATION SHEET
Buyer(s)Name Date of Contract
7 - 13 -) _
Buyer(s)Sheet Address,CM.State and Zip Code
2 144-QlL;Smv III n 1 A 01970
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
7e-7yS-S11o'7
The Buyers)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
PL7MM /29 -IAS_7V ✓I- 0Crs 77A/ � I:a'}/L /W4 Sys
6Z�r�e,.ts �y ) b'Kls -n+v5 00-0617_ P6S-7- , Per°g;2 9*St7--
POSE IA;I T74 fit/Ew Y y1 C004-It- Pos i.
��P4 Tit. A"Ll tZoTT /6 7- 64S f_ aF PO-S /e65 T LA 1
•- I C L3
/YL S i_ LVM; Vv f2iqSffir✓c, �g>ur� 45t5W c,tv-
rip-i .�v, ��rya OXI/ Mkf1^1 /ZcoF,
//V S771—&1 A-1aDA/ A-g -pa-f-klo C"f37J/fin— :—Xfmz� uF OYU
��-�ySl/JL� � (7YLWLl��i_ �S1GJ�3 f�i+/✓> �tsw T— �1//s'%Z_S
,Sh`,.vc Z 7- Al or- e-ox A �
c<+uL, A- Ayi-rO Sa&-*1_ AFL- F\,CWnrO'Z-
O l� %�S 7-✓f"LfiL��
AIL 64ND CGt3y/N -�� //vGLvOis�
— plmn t If T- //L G LyD(F_�
E1A: 1SW P/ffiwT/N /✓fi�/� //li!' LuD��
It Is agreed and understood by and between Me parties the this Speclacation Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,careaurtes
Me entire understanding between Me parties,and Mere are no verbal understandings changing or modifying any of the terms.Thls 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 Buyers)and Me Contractor.Buyers)hereby acknowledge that Buyer(e)
has read this Specification Sheet. K —�
1
Contractor Initials: � Date: 7�13 -1� Buyer's Initials: x >n't !� Date: 43- \