11 HARROD ST - BUILDING INSPECTION (3) The ('ulnnwnncalth of MJSSs IchLISCUS
Board of 13ullding Regulations and S1JnJa1JS
'. y \II NI( II'.\I.II1
t. iVI:ISSJChUSCIIS SLI(C Mlilding Code. 7So CMR. 7"' cJition ( ll,
U
I Building Permit ,Application ToConsuuct. Repair. Renovate Or Ihnutlish a Rrru ,I.Luui n
Once- or Tiro-Family Dtrc'llinq /. 'u(i,e I
This Section FAr Official Use Only
W Building Permit Number:
WW Si_nature: a 3 /, /w.. --- --
Building Commissioner/ Inspecu of Blllhhngy ale
—1
1i r SECTION l: S T 11 FORMATION
11.1 J PQ�I"Y 1rtY Aclor{Sy O� 1.2 Assessors Map & Parcel Numbers ---
L la Is this.an accepted street? yes_ ❑o_ Map Nuniher Panel Number
Is.
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Fronmge ih) .
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
1 Required Provided Required Provided Required Proeidcd
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' municipal On site disposal system ❑
Public❑ Private El Zone:
if yes
SECTION 2: PROPERTY OWNERSHIP'
Own E Rec rd:
Name 'nl) Address for Service:
t Sig at e Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Rei irsls) ❑ \lteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief escn ion o Pr tp sed Work':
V) l s �n �x MA rDn�e� l 91n <� _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item [Labor and Materials)
I. Buildim, S GJ2 6O 1. Building Permit Fee: S Indicate how I've is deiernuned:
- - - ❑ Standard City/Town Application Fee -
2. Electrical
❑Total Project Cost (Item 6) x multiplier x
3.Plumbing S 2. Other Fees: S
J. Mechanical IHVAC) 5 - -. List-
5
. Mechanical (Fire S
Suppression)chi Total All Fees: $
Check No. Check :\mount ('ash Amomn:_—_,..
j b. Total Project Cost: 5u52,00 0 Paid m Full 0 outstanding Bal:mre Due:___..____
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI
7�3 —_ to
YS O r' untbar liyjnr;wonl)a�•.
�' III•of CS I.- I lu Je - _. 'I'e e lsce helot%) -
r -
Desnl u. f
ki� - (*IIICSI I'I CIt'J i II t IU??.00I)( U I
- .. Rc [riueJ INc'_ F:unih Dw e.11ln_•.___.,.
�,i t �_ — Nlasonr\ Only
J
/ "/� Re.+IJenual Ro"hin:(•I)\ern .._._._
Trlrphunc Rc,lacimal winJot\ .uiJ SidingRestdeniwl .Solid Fuel liunung \ tthann• 6nl.ill.ui�n>I
:"IJeuuul Drnnlhuon
styd�r ' Y�yp 'emeWtractor(1110
r
IC 'u t ; '' n or H c pis ant �� tt Registrmiun Numhrr
A rc s n // N �/n)
2(o 01
I. l./`7 L� _.vpiratiun Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 9 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 Issuance 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, as Owner of the subject property.hereby
authorize 6 to act on my behalf, in all matters
relatiy o work auth wize4by1hi itdYng groin application.
( -
G61, 3 �-3-1d
Si naturr of Owner I Date
SECTION 7b: OWNEW ORAUTHORIZED AGENT DECLARATION
1, IC
jn p h ),r ZV I- Zr--- as Owner or Authorized Agent hereby declare
that the statements and�ation on the foregoing applicaBifn are true and accurate, to the best of my knowledge and
behalf.
5 6
.. Print Nam
S � /'
� ��G/
SignutureofOwnerorAut rized .Agent Dale
(Signed under the pains and penalties of 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) Prozram), will not have access to,the:ubitration
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 I l0.R6 and 110.115. respectively.
_'. W-hen'substaritial work is planned, provide tfle-infiirmation below - -
Total floors area ISq. Ft.i )including garage• finished base men Uattic+ decks ur poichi
Gross living area I Sq. Ft.) Habitable room count
YuinLi�rluflireplac•es .._ -._ .- . ._ —NUrnberothedroran;...
Number,Ifh:uhrooms Nuntberothalt/hash,
rope of heating systern Number tit Jerks/ pllrches ----____--
Type of cooling s)stem Enclosed Open
3. "Total Project Square Footage•' stay be substituted tier "Total Project Cost••
CITY OF SALEM
PUBLIC PROPRERTY
�Mf DEPARTMENT
%IA'! 'H
I..'1V.\il liNW'tI\tit RhFl a \\I i\I,M.\++.\t Ill +hl :+.1'1�=
rla:'1'd-'i;.y;yi # F\x: 'J75--4:-'184n
Workers' Compensation Insurance Affida%'it: Builders/Contractors/Electricians/Plumbers
applicant Information ^^ Please Print Leeihly
Name (Bu.mnessurganlcanonludolduul.t: A L'' A Sery[ ua �I�C
Address: Not h S -e f_+City,Stai :Zip: ,Jfjn. MP D19-70 Phone #: LTZSS)\
7llAI - 0� �4
Are %no an employer:'Check the appropriate box: Type of project(required):
I.E I am a employer with 4. ❑ 1 am a general contractor and 1 6. New construction
employees(full and/or pan-tihnc).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
,hip andhav'e'no employees . Thesesub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. q, ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their l0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEJ Plumbing repairs or additions
myself. [No workers' comp, c. 152, §10),and we have no 12.❑ Roof re airs
insurance required.] t employees. [No workers' 13.0 Other WinijoW,
comp. insurance required.]
'Any applicant Ihar cheeks bux#1 must also till out the section below showing their workers'compensation policy information.
r I lunicuwnen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Cumracmrs that cheek this box must attached an additional sheet showing the name of the sub-cuntraefon and their workers'comp.policy information.
l ain tin employer that is providing workers'compensation insurance for my eriiployees. Below is the policy and job site
inforatation.
Insurance Company Name:
Policy a or Self-ins. Lic. #: '. 0,24161 LS "U 1j
(j Expiration Date: _
Job Site Address: I I Ll � f n� �7 {2� City/State/Zip: 6 I D
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 I1MGL c. 152 can lead to the imposition of criminal penalties of a
line 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 tip it) 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
In\esti_ations of the DIA for insurance cc%erage verification.
I do hereby reriij}• ter re pains end enulties of perjury that the inforination provided above if true and correct
\I'!ll,lf ll re:` Data:
O fieial use only. Du not Ivriie in this area, to be completed by city or town afficiaL
Cit• or Town: _ —.—_—_.------ ..--- Permit/License #—._--.----.----
Issuing Aulhurity(circle one):
I. Board of Health 2. Building Department 3. Cihvrown Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and Instructions
\las,achuseos G encraI Laws chapter 15' requtresall cmplutcis it)pro%ide uorkcrs' compensation IUrtheir employees.
I'.rrsu.uu ro this statute,.m ensphg•ee is delined as-.. et en person in the sen ice of xioiher under any contract of hire.
ctprc.s or implied.oral or ttritten.-
\n :mplgrer is del inod as-an indit dual,parutcrship•association,corporation or other leg al entity. or a I I Iwo or inure
,d the tim_oing engaged in ajoint enterprise•and including the legal representatites ofa deceased employer, or the
reccitcr or tru,tce of an individual,partnership, association or other legal enuty,employing employees. l lower cr the
n•.t tier of a dwelling house hwmg nut more than three apartments and a ho resides therein,or the occupant ofthe
dtt olling house of anorher who employs persons to do maintenance•construction or repair tt ark on such dwelling house
or on the grounds or building appurtenant thereto shall nut because of such employment be deemed to—to-an-employer." -
\I(iL chapter 152, �Q5C(0)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 sr'ho has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, %IGL chapter 152, j25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract fur the performance of public .cork until acceptable et idence 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 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 ubtain 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 regardingthe 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 tilled 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 01-ice of investigations would like to thank you in advance for your cooperation and should you have any questions,
pica-se 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
itet isod 5-,6-05 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, Sec."
150a.
The debris will be disposed at Salem TmnsferStation
owned by Northside Carting
f
SO
ignature'of Perm' Applicant
Elate
Clsristager Zo—
Name of Permit Applicant
A &A Services Inc.
Firm Name
115 North Street Salem. MA 0-1970
Address, Cray, State, Zip Code
Nlassachusctts- Depm-iment of Public Safety
Board of Buildnm, Regulations and Jtandards
i Construction Supervisor License
License: CS 57733
_ Restricted to: 00
CHRISTOPHER ZORZY
115 NORTH ST v
SALEM, MA 01970
Expiration: 5/26/2011
('u in issi,mer -- - Tr.#: 14751
. . -. - Boa of Regulations and Standards
— HOME IMPROVEMENT CONTRACTOR
Registration: 101609
E:piratiore 6/25/2010 Tr#0 267870
:.Private Corporation
A&A SERVICES,iN _ ^ _'
Christopher Zorz"i, yi
115NcrthStmet ;`
Salem,MA 01970 Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Martin,Commissiorrer
Deleader-Contractor
CHRISTOPHER ZOM
Eff.Date M01/09
Exp.Date 04l06110
. DC0004Q
Wmber of C.O.N.ES.T. .F
so ,k t
Illlll�lll llilll II III I011 it II BOSTON-RENEW -
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" t~ 7^:' F+?n f m n F r.'•+-�f p � ri n"ns -:sv i S � . vat .+i
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®IffITITIT.T.WSKIT171 off 1• 111 /11.1 111 11/ 1
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ti�aC -ky�pp �e✓kF»� } "�i��x � ° f`oJ`-�a�.:r���"r�� i€L€ �y @''.�f�A�� b'�': 'vy � t'S�9k p�� �[t'S 5' :�``f q i
6 r�',a`wF'1°m�d�..u&US.�a 4N; 4� -k`3 aa„� '� .i{r�� �" �G«f����s Fr—w�s.. t ���_,v.k3�`3`w�-. 5 .�F�'�`�V u�3= S v���'}' •
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• • 11/ 111 1 111 /1/ 111. 111 111 11/1
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�r.'Lk3Lw�
1- . • of • • • �• •- • • .
�` AB rid �zo L
aa2 A & A SERVICES, INC.
� .3tI�w 115 NORTH STREET,SALEM,MA 01970
e a e Telephone:(978)741-0424 Fax: (979)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
nMI F Tab
Buyers)Street Address,City,State and Zip Code
d Ii III a
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 on the accompanying specification sheets,in accordance with
the prices and terms described on the front aad 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 to be installed the products
or services listed in this Agreement at the Buyers)address written above. This Agreement represents a cash sale of goads and services. The Buyers)agree to pay in
cash the cost of the goods and as ices port d as describe tl herein,regardless of timing or approval of any financing Buyers ma seek r their porch
p era d co AAnn,,
Purchase Price'.
Est.Stalling Date: �f
Dawn Payment:rip Est.Completion Date:
Amount Due on Start of Job: / 0 Check
0 Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completionta CVC Code:
It is agreed and understood by and between the parties that this Agreement,front Mind back and any addendum,constitute the entire
understanding between the parties,and there are no verbal understandings changing or moditying any of the terms of this Agreement.
Buyer(s)hereby acknowledge that Buyers)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 -
(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 Contractor believes Buyer(s)would be Interested in any additional quality -
products or services of Contr or. DO NOT SICN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services, c. Buyer(s)
By: ,
Signature Signature„
Print Name Print Nang(
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. Sae the following Notice of Cancellation form for an explanation of this right.
ARenRANOM The o nlractw and the nwneowner f eelry mutuahy al in andante that in me rvenl either paM has a dispute mrcerning this[enter,either party may sulsmu such dispute to
a pmate arandi h service Mien has been approved by"Summary,army Executions OKee q Consumer Atlaira and Butt 4 fle00uulationa end me omsr paM shell Ee requiretl to submit b
such a teragan as proved In M.G.L.c.142A x,
be or
rials auynitividvh
bare: a: o r_,✓� ..iL
NOTIl OF QANCrI I A7QN NOT - OF AN- I ATILVg`
Data of Tre odors- You may senml N mmIs tr tbn,without any penalty or Bate of random. .You may tam-nl Ms i transaction,ageout any pronely or
bullwwlmM1�tirom the endue data It you.1,my prober,tmdad'In, odigadon,wMin urea Wtineu Gaya from iM above aetie.ltymoncel,aMprop tadedin,
any payments made by you under the Central or Bob,and any nsggiade informed exewted any payments made by you under me Convaq or S.W.and any museums irmtilm rf axewled
by you will de reNmrod within ID days following receipt by ma aelkr of your Mulligan home, by ym will be returned Yemen 10 days rollawtng Marie by me seller of your cancellation term, '
and any woody interest attains cut a the mall will be eanmlled If you mnfor you must and any sttvnry interest m6ing oil of the level wit Ee canmlmd.X you mincel,you must
offorelYdethe me Seller at you,exagam In subsMntialy del goal mMNan as when removed, make"Nod to me Better el your Moamar of Somali a good mndi0m as men removed,
any goods darned ro you other this Comm.or sale;of you may,n rou wish, rely wOn me any goods delivered to you under this Combat or Sale:or you may 0 you wish.emgy,him the - -
' hawNons m the seller regarding me Mum shipment M me goads anhe Sahara e:cenm and instruments of seller Mosleg the return shipment dins goods at me Sellers expense are
msk. If you M make rots goods available to the Seller and the seller rims not pick them We risk. If ym do make the goods avalffild to me Seller and Me all tices hi them up
within 20 days of the day,of your Nome of Cancellation,you may retialn o,disease of the goods whin 20 days of Me eau of your Node q Camelmbon,you may rman m liter of the goals
AthoNany NNneroblgation.Il youleil to make the goMaevaileble to me Sellar.m it you spree witiroN any lunher aMigatlon.if you tall to make the gao]s waieble to me Boller.or ilyw agree
to rehire the golds to Me Salbr and fall to do so,men you remain liable far performance of all to return me glass to me Sellm and fell to do so,men you remain liable for mdormanm of all
obligatons under the Context.Tomnml this sanaagion.mall or del'war serum and dated dopy c lliperonsunderthe Centred.To outuel mumat ion,mall or all signal and dared body
W me bandsman node or any other whom miles,or send a diseases,to ABAA of the conablation r or dhn whenAA made,or send a WWII b A S imaim.115
None Slrem same,Mamam hutts 01970, THAN
o,NOT LATER AN MIDNIGHT OF 9er me ASAS eam don,hall
seers,seem,MassaChusal1501970,NOT LATER THAN MIDNIGHT OF
(bay,) cam)
I HEREBY CANCELTHIS TRANSACTION. Consumers airline Dale I HEREBY CANOELTHIS TRANSACTION, Consumehsignature Data
L
+ AGMs
to } A & A SERVICES, INC.
115 NORTH STREET,SALEM,MA 01970
ee e Telephone:(978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyers)Name Date of Contract
I? 'ra
Buyers)Street Address,City,State and Zip Code
I I gcce v_ SNIKA /LAA ,0
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
Z — . C
The Buyeds)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 Specitication sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a pad.
WINDOW REPLACEMENT
❑ Remove and di ose of# �duf existing windows. `` It
❑ Install # ON {—� new t)v11(i St_ `s tAq ytfc� X� c`5 windows: inyl ❑Wood
(Manufac urea)
Options: Style 14
fNi✓t�l Grid pattern +b'd
6bII,I}k �u F
/CD�pr Interior Col r�zterior w>7 i}-g Glass Type �'t h Pvtt
B" Wrap exterior trim with aluminum: Style �2�?5h(/e Color (A/{l f tIS,— Ar y
windows will be i stalled ace r ng to the installation procedures in the portfolio.
era 'pitYrt�✓r
IB C Ik all ge's. Imo.6C4.,in kf Ii FJEvd('oa'l'—S•lyq
e where possible around new units. J
❑ Insulate window weight pockets if exist,and around new window units where possible. R1- I1iyrt IZ7 dQC�w I
a ded in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and out. 1..1 .
❑ Building permit included. " (L 5T4i0I,?i) F bef 9(4jSS
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS l
❑ Create new window opening by cutting through existing home and framing in opening.
❑ Remove and dispose of existing grills)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 windows)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.
❑ Note: Painting and staining not included.
STORM PRODUCTS
❑ Remove and dispose of If 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:
-�i✓.i ( '#/ 2iN2 ' iof S/- c 'L Il s.. dk s v.burr✓'1u, ..
T1✓St4N 'veal kn 2 2�c�c,k �xfer'l sjll , 1�rNorin 9G ors/r<
t C? f vuer x C Ptlt`F < C-4 Gl e
It is agreed and understood by and between the Parties that this Specmcetion 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 Esthete)and the Contractor. Buyers)hereby acknowledge that Suitable)-
has react this Specification Shear.
Conhactor Initials: J Date: e�--F Buyer's Initials" Date:)l"-'1/%-/`1