12 HAWTHORNE BLVD - BUILDING INSPECTION (2) The Comnwm%c:fJill of A1asSuehusetts t)R
�\ r Guard of Budding RCULflatiunS and Standards All NI( II, \I.I'I 1
li\I:ISSaChLISCIIS State Building ('ode. 7S(1 C`\IR. 711i edition tilt
13ifiIdin_ Permit Application To Construct. Repair. Reno%ate Or I)einoIish a Rrru,d hmio,
One- or Tit o-Fmnil r Du ellin,q
/1 This Section For Official Use Only
'Buildine Permit Nw her. Date Applied:
6 I
13uildiu onvni,sioller/ Inspector of Buildings Date
—1
SECTION I: SITE INFORMATION _
L1 6 per y kddres' r 1.2 Assessors Map & Parcel Numbers
f �c
l.la Is this an accepted sweet? yes_ no— hlap Number P:uerl \'un,hrr
1.3 Zoning Information: 1.4 Property Dimensions:
k. Zoning District Proposed Use Lot Area(sy it) Frontage if[) .
1.5 Building Setbacks (fq
Front Yard Side Yards Rear.Y'arJ
ReyuircJ Provided RcyuireJ Pnrvided Reyuirrd Pro,idcd
t1.6NVater Supply: (M.G.L c.-40. §54) 1.7 Flood Zone Information: I.S Sewage Disposal System:
Zone: _ Outside Flood Zone? - Municipals❑ On site disposal system ❑
Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 caner'of,Reco d: I
Wm 5 M
Name(Prim) Address ror Service:n 9 - 17yq _ j/ 3
S ma[ure - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK" (cheek all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ :\Jdinon ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Speedy:
Brief Descript' n of Pr[puled Work':
LT
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
t. Building S I. Building Permit Fee: S Indicate hum fee is dclermined:
❑ Standard City/Town Application Fee -
2. Electrical b ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing 3 2. Other Fees: S
1. Mechanical (H\'AC) S List: —
5. Mechanical (Fire S Total All Fees: 5_ ---
Su. ression)
Check No. Cheer :lmounr. ('ash :\m unr.
j b. Total Project Cost: 5 5a7 5 ❑ Paid in Full ❑ Outstanding I3ahuxe Due
A,4
SECTION 5: CONsrRUcr1ON SERVICES
5.1 Licensed Construction Supervisor (CS1.) - 7 ���//
License Number I[apu,ruon Dal
Name of CSL- I It I •r -
/ Lnl CSI.l'cpc (see hrinw)
\dd .s / 7 v c Drscri riven
L- l.'nrc lriclyd ui r lu?i.000 Cu. EI.i
R Restricted I.@_' F:muh D%%elline
Sn 't _ /� S1 \lauonn Only
elgl,� RC Rcnidenual Roof-111C('ut irm_
Telephone , \1'S Re,idcuual Will'I'm ind Sidin_
SF Re,ldcnlial Snhd Fuel liurnulm \ chance hn(all,na 7n
D Readeuual Denwlwun
5.2 e ist• ed ome Im we2,en "o7t • o (I110 ,J
HIC C m any Name or UIV Re r it Nall ^ Re�slsuauun Numhcr _
Fs Ira[ion 4ae
SignAure 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 prutide
this affidavit will result in the denial of the Issuance of the building permit.
Siened Affidavit Attached'? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf. in all matters
relative to work authorized by t Is building permitapplication. _
Owl 20 1 c
i�nature ul'Owner
n SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION '
as Owner or Authorized Agent hereby declare
that the statements:md nformat[on on the foregoing appli- (ion are true and accurate, to the best of my knowledge and
behalf.
Pn tW
Sig ature of Owner or A uthorized Agent .\ Date -
(Siened under thepains andpenalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered cuntractor
(nut 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.HlC program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5. respectively.
?. When substantial work is planned, provide the information below: -
Total floors area(Sq. Ft.I rincluding garage, finished basemen Uattics, decks nr pinrhl
1 Gross livins area (Sq. Ft.) - Habitable room count _
Nwnber of tueplaces :Number of hedrnntn,
Number of bathrooms Number or halt/hauh,
rope of heatin✓system - Number,it decks/ perches. __-- 1.
T}'PC of cooling system Enclosed Open --_-- _ --
1, "Total Project Square FunCtge- may be substituted tot 'Total Project Cost' J
CITY OF SALEM
a } ,#) PUBLIC PROPRERTY
DEPARTMENT
,,%I;li 0 IINh1 011
\L\! IR 12:WA,11i\I,11I\ti;ghl 1 •
I't:1: 9-8,4;.9;95
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information G (�� / Please Print Le�ihlV
Namin e lf3u.un•sllr�dnllJ(Iun I11d111dlNLl: "L " ' Se � V=51 �✓��
Address;`5 )J(Jf4h fd f e e—
C'iry,State.'Zip: C—Yq I fm Mp 0I9-70 Phone #:`17S) 7N I - 0!� 2)4
rre,/t uu an employer?Check the appropriate box: F7. []
roject (required):
I.L�J 1 ain a employer with�5 I• ❑ I am a general contractor and 1 construction
employees(full and/or part-time).' have hired the sub-contractors 1
'.Q I :ran a sole proprietor or partner-
listed on the attached sheet. : modeling
ship and have no employees thesesub-contractors have molition
working for me n any capacity. workers' comp. insurance. ilding addition
No workers' cum insurance 5. ❑ We are a corporation and its
L P• 10.0 Electrical repairs or additions
required] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I,❑ Plumbing repairs or additions
myself. [No workers' comp.. c. 152, §1(4),and we have no 12.❑ Roof rep irs
insurance required.) t employees. [No workers'red.1
i I
r Other
com . insurance re1 u
\ray applicant that checks box#1 most also till out the section below showing their worken'compensation policy information,
r I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such.
Tuntrucmrs that check this box mustbattached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
am an employer that is providing workers'c•oatpensation insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name: -n^� rFAV ��r J ppyy
Policy#or Self ins. Lic. #: H51 5 ()8 Expiration Date: gL _ / w
Job Site Address: City/State/Zip: F� �` �w
Attach a copy of the workers' 52
to nsation policy declaration page (showing the policy number and ex .iration date).
Failure to secure coverage as required under Section 25A of bfGL c. 152 can lead to the imposition of criminal penalties of a
line up to 51,500.Ot)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
Inl atatu of the• IA for insurance coverage verification.
ie Ions o � U . r
l do hereby cer•ri y d r the p ins'and penulrie•.c oJ'perjury that the injarrnurion provided above is true and c•orrec2
q'Ci Illife'
Date' 7- ZrJ b
Pholic
Uljirial use only. Do not write in this area. to be ron,plete•d by city or town oJi c•iaL
City or Tltsx n; - -----,------__..--- PerrnitiLicense #---..---'----
Issuin4 Authuriti. (circle one):
1. Board of Health 2. Building Department J. Cit}ir(mn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and Instructions
\I.1z1.tchuseus General Laws chapter I;_ regwres all Cmplu}ers to pro%ide �%orkcrs' compensation for their employees.
Pllrsuanl to this .tatute. .in enrph{ree is dclined.is".. ct en person in the scn ice of.tnwher under any contract ofhire,
c\prc.s nr implied,oral or a ritten."
An :nyrfr! er is delined as "an indit tdual, pdrmership..taOCIation,corporation or other legal entity. or:my two or more
,,I tile ti legoing engaged in ajuint enterprise,and induding the legal represcntatisrs of a deceased uniployer, or the
rccci%cr or trtt,tee of an individual, partnership, association or other legal enuly, employ ing employees. 110%C%er the
u•.t ner of a dwelling house having not more than three apartments and a ho resides therein, or the occupant of the
dkt elling house of another who employs persons to do maintenance, construction or repair Murk on such dwelling house
or ,it the _rounds or building appurtenant thereto shall not because of such employment be deemed to-fie-an-employer." -
\I(iL chapter 152, �N25C(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, SIGL chapter 152, s'25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfumtance ufpublic cork until acceptable es 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 ceriticate(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 entry 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 affidaviL 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
wif-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"lob 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
your. Where a hone 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 of-ice 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
rhe I)eparument's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ol'Tiee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Ire%ised>-]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."
15Da.
he debris will be disposed at Salem Transfar Sftdon
owned by Nor haide Carona
Signature of Pe i ltappEicant
Date
ChristooherZornr
Name of Permit applicant .
A &A Services. Inc.
Firm Game
115 North Street, Salem MA 01910
Address, City, State, Zip Code
69assachusetts- Department Of Public Safety
Board of 6uilditiW Re rulations and Sta ldards:
C6nstruction'Supervisor License "
. License: CS 57733
L Restricted to: 00
CHRISTOPHER ZORZY ra
115 NORTH ST _
SALEM, MA 01970 _ f,
f� Expiration:.5/2 612 01 1 ,
('ummis.iuncr Tr#: 14751
ZN
✓,lze �iomvrnanrueal!/ a�✓�aoo¢c,<ietoelta
Office of Consumer Affairs&il siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration �101609 Type:
Expiration 6/26/2012 Private Corporaho,
A&A SERVICES INC:
Christopher Zorzy,1,
115 North Street
Salem, MA 01970 {
Undersecretary i
Commonwealth of Massachusetts
Division of Occupational Safety q�
Laura M.Marlin,Commissioner q
Deleader-Contractor Iplu'6�us"
CHRISTOPHER ZORZY
Eff.Date 04/14/10
Exp. Date 04/13/11 �y p
DC000440 II,�IpI
Member of O.O.N,ES...
BO IIII
IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIO IIIII IIII IIII BOSTON-RENEW
A Grade
Above
sloce i 9az Phone: 978-741-0424
SERVICES _ Fax: 97 m
012
www.a-aservices.cices.co
'• , 115 North Street
Salem, MA 01970
July 14, 2010 Page 1 of 2
Women's friend Society
12 Hawthorne Blvd.
Salem, MA 0197 r
Landing/ Steps/Bulkhead Door
Replacement Proposal
• Pull Permit
• Remove and dispose of existing landing steps and bulkhead door including
framework (Existing system is rotted and being eaten by carpenter ants)
• Build new landing/ steps/bulkhead door & frame to code using the following
components:
• PT 2x8 Framework for deck and bulkhead door/wall
• PT 2xO Stringers
c PT 4x4 Supports
• PT 2x4 Railings
• PT 1 '/4" x 1 r/„Balusters
• Fir Tounge & groove Ix4 decking for steps and decking material.
• Knotty pine tounge & groove 1x7 material to build door and to close in
below the landing and the small bulkhead door wall
m Preprimed pine Ix stock as skirtboards, stringer trim and risers and z-bar
supports for'P&'G door
• Install new pull handle, hinges and interior slide bolt to bulkhead door
• Flash the new deck to the body of the home
• Cleanup all job related debris
• Apply 2 coats of sikens oil base solid green stain to the exterior of all the new
components and the interioru[the bulkhead door.
Price: $5 275.00
Payment Schedule:
Deposit: $1,758.00
Balance due upon completion: $3,517.00
-.Pag�frL
P�
Any alteration or deviation from above specifications involving extra costs, will be
executed only upon written orders, and will become an extra charge over and above the
estimate. Any unforeseen wiring that does not conform to the local code ordinance will
be subject to fees proposed by a licensed electrician. Any unforeseen construction costs
that arise beyond the scope of the proposed work will be billed at $84.00 per hour per
man. All agreements are contingent upon strikes, accidents or delays beyond our control.
Owner is to carry fire and other necessary insurance upon above work. A & A Services,
Inc. carries a $1,000,000 General Liability Insurance Policy and Workman's
Compensation. A Certificate of Insurance is available upon request.
If you have any questions, please do not hesitate to contact me at (978) 741-0424.
Thank you for giving me this opportunity to serve you.
RESPECTIVELY SUBMITTED: Sean Luddy
NOTE: This estimate may be withdrawn by us if not accepted within (45) days.
The above prices, specifications, and conditions are satisfactory and are hereby accepted,
you are authorized to do the work as specified. Payment will be made as outlined above.
Authorized Signature Date
-7 O
Sean Luddy Date
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