14 HEMENWAY RD - BUILDING INSPECTION (2) DATE:
i tp of a�dYE1TT, a'e!5aLbU5Ptt5
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building lq d p Y>7Y1&U Ancri
Building Permit Applicati r:
YCircle whichever applies( Roof Reroof, Install Siding, Construct Deck, Shed, Pool
'A3dition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
OwnersName:Te S LQf1r) Hnar4b-0 Contractor: A A Serviu5l�hn5 ?�r�tj
.- _.
Street �+P V10YlUAW Fcal Cit}•,5�km Street -115 Nnf4h 5f. City-�,�,
State Phone ( `1 S) 7W� -57lo State M A Phone- (a79)
Architect: City of Salem LiclJ6iQ5
Street City State Lit 057 7 HIP# D 1 1'0 09
State Phone ( ) Homeowners Exempt Form _yes,. I//no -
Structure: (please circl Single Famil , Multi Family# Other
Estimated Cost of job S_(a t II CU Q
Will building confirm to law? ✓ yes no
Asbestos?__yes✓no
Description of work to be done:
f) f -en
DF 3o r. r it
A&A SERVICES, INC.
Drawl ubmrtt d:_yes no Mail Permit to: SA.LEM,MA 01970
% . lo7gi 41-0424
}( � VWWW.A-AT"TS�RV E'.�aYvT—�
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
No. 7b/ ��
APpLICA ION FOR _
pFRW TO
LOCATION
� Tl e�'V�-eVIGv
PE MIT GRANTED
A4rCTonVfD
CAJ
IN OF 9U1 INGS
CERTIFICATE OF OCCUPANCY .
YES
NO
NThe Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ilN 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legribly
Nagle(Business/Organization/Individual): 6 9� A jor\/I e S'n o
Address: I I S LI n rEp( 5 Kr
I, City/State/Zip:-5 evV , M h DI97p Phone # 01 �� 7ti —
CH 9, J` 1
Fam
an employer?Check the appropriate box: Type of project required):
a employer with 4. El I am a general contractor and 1 6. ❑New construction loyees(full and/or part-time).* have hired the sub contractors
a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
and have no employees These sub-contractors have 8. Demolition
C ing for me in any capacity. workers' comp.insurance. 9. Building addition
workers'comp. insurance 5. ❑ We are a corporation and its
ired.] officers have exercised their 10.❑ Electrical repairs or additions
a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
lf. [No workers' comp. c. 152, §1(4),and we have no 12.❑ oofrepairs
ance required.]t employees. [No workers'
comp.insurance required.] 13.6ZOther
ik •Any applicant that checks box#I must also fill out-the section below showing their workers'.compensation policy information.
E t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indi
'( :Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and their workers'comp.polity informato
c
n.
information. catng such.
I an employer that is providing workers'compensation insurance for my employees..Below is the policy and job site
i —r�k Insurance Company Name:_ t y Le— Tm Vp
Policy#.or Self-ins.Lic. #: W o Gt 3q X 12 6zp Expiration Date:_g'l�' .) O�
i� lob Site Address: Ci /State/Zi ���,�,
ty P SQl(fll._MR L970
Attach a copy of the workers'compensa n policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required trader 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 afine
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 certifi er tithe,p ins and penalties ofperiury that the information provided above is true and correct
Sip, amre• lil/Y '/1� Date
�I
Phone#: (9-75) r M I — n H 21-I
FID
only. Do not write in this area to be completed by city or Town official
n: Permit/License#ority(circle one):ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#
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 of 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 apartments 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 chaptei have been presented-to the 6biitracting authority." - -
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 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 thew -
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 penniUlicense 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"ail 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 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 5-26-05 Fax # 617-727-7749 q.
www.mass.gov/dia
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M. G. L. c. 40 Sec. 54 a condition of
Buildin
g mg Permit Number is that the debris resulting from this work shall
f be disposed of in a properly licensed facility as defined_by M. G. L. c. 111, See.
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northsid e Carting
Signature of Flbrmit Applicant
yzg/a'r
Date
i
I '
Christopher Zorzv
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
sex
A & A SERVICES, INC.
A&A SERVIICES - 115 NORTH STREET,SALEM,MA 01970
q• Telephone:(978)741-0424 Fax:(978)741-2012 -
Contractor Registration No. 101609
Federal EIN:04-3090162 - Construction Supervisor No.CS057733 -
ROOFING SPECIFICATION SHEET
Buyer(s)Name Date of Contract _
Buyers)Street Address,City,State and Zip Code u
nD /yry� /70 -
N� %
III y ,
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address -
978-7qy-si G 9' 979-7073
The Buyer(.)listed above hereby jointly and severally agree to purchase me goods andlor services listed below,in accordance with me 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.
ROOFING SPECIFICATION
Strip Roof of# AL'i layers of shingles
Install 6'of ice and water shield at base of roof where - 10Install 15.b felt paper to roof.
possible. Install 18-24"of ice and water shield in valleys.
Flash chimney as needed(no repointing included).C2� �ilnstall 6"perimeter drip edge to rakes anr
fasc d ia areas.
1 Xmitall vent pipe boots and seal as needed. '*lash valleys as needed
! A Install rollout type ridge vent. Tanks/plywood replacement under 32 SO FT included, -
'If more is needed there will be an extra charge of$311
per hour for labor plus the cost of materials.
gDumpster/Disposal Included ❑Other: (,`OLOYt,` 70 QL-r /iN�1int't�j -
Location: Q21VLTL );L/ - -
Install new roof: Manufacturer Cd12T!}iN'1LWO 3-0- yr StyleAype 4712CA77
G
ncluded in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. -
RUBBER ROOFING SPECIFICATION
❑Strip Roof ❑ Not Strip Roof
❑Install 1/2"High Density Fiberboard to existing roof using ❑ Flash obstacles as needed. -
screws and plates.
- ❑ Install.060 membrane EPDM(Black)rubber roofing to ❑ Install 3x3 aluminum drip edge to perimeter of roof with
fiberboards seam tape.
❑ Flash up sidewall as needed.
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties. -
O
SPECIAL INSTRUCTIONS:
III -
it n agreed and understood by and between the padles Mat this Specification Sheet along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,conateutea -
Me entire understanding between the parties,and there are no verbal understandings changing or modifying any of the forma. Thla contract may not be changed or ib
forma modified inverses in anyway unless such changes are Meshing and signed by ham Me Suyerta)end Me Contractor. Buyedin hereby acknowledge that Buyers)
has read Mls Specification Sheet.
�j/Y�
Contractor Initials: V Date: 3—ZV-08 Buyer's lnitials: X� 1A Date.
Simulate,
A & A SERVICES, INC.
A&ASEWICES 115 NORTH STREET,SALEM,MA 01970
Telephone:(978)741-0424 Fax: (978)741-2012
Contractor Registration No. 101609
Federal 1 04-3090162 - Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyers)Name Date of Contract
Tip I-YAW MAIi-<F1CLD 3 - ze- o8
Buyers)Street Address,City,State and Zip Code -
/5� of"170
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
978-7tiy-5-/7(0 '97
978-479- 7073
The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,In accomance with -
the prices and tonne described on the from and me 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 ro install or cause to be insWled the products .
or sernces listed in this Agreement at the Buyer(s)address written above. This Agreement represents a cash sale of goods and services. The Buyers)agree to pay in
cash the Cost of the goods and services p rchesed as described herein,regardless of timing or approval of any financing Buyer(s)may seek for their purchase. -
L PQICIT r .S 2It0, _-
Purchase Price: T2 Za - Est.Starting Date:
'��O�. s-s-
Dawn Payment. � Est.Completion Date. 08
. U ci
9'E Amount Due on Start of Job: - heck
O Credit Card
Amount due on of Completion: No. -
Amount Due on of Completion: n Expiration Date:
8 ��`' - _
Balance Due on Upon Completion 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 Buyers)has read the front and the reverse of this Agreement and has received a completed,signed
n f this Agreement,Including the two attached Notice of Cancellation form n the r w' v and dated copy o g g o cs,o a date first written above. Buyer(s)also
(i)acknowledge that they were orally informed of their right to cancel this transaction;and(li)request that they be contacted via their
telephone numbers or a-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 TBIS CONTRACT NIT CONTA4Y5 ANY BLANK SPACES.
A&A Services In Bu erS
, Y O
By: Cr '�---ram -
Signature 'IaVn at/&+i Sign r
Print Name .-7 Print Name
Signature
Print Name -
4 You,the Buyer(s),may cancel this transaction at any time prior to midnight of the third business day after the date of this
ii trnnsRNinn Sep the following Notice of CanrallRfine them far an explanafinn of this right.
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IHEREBYCANCELTiTRANSACTION. Unsmrere Syna m pate I HEREBY CANCEL THIS TRANSACTION. Canavmereffenadd dab