12 HORTON ST - BUILDING INSPECTION Gt� DATE:
itp of
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building lo� 1-6r7lDn
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install S�cl Deck, Shed,Pool
Addition; Alteratio Repair/Replac ,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:
Owners Name: & NOW Vim o/J�4_ ontractor: A eA 5e-rvicp5�(�7115
Street 19, H7)(*)n ,SfYe& City �7 Street I15 dnrlh City_,S(al m
State-{ Phone ��7g) r o -oa h.� State M A Phone, 078)
Architect: City.of Salem Lic# I�ioS
Street City State 1A n 57 HIP a 1 D I to 09
State Phone ( ) Homeowners Exempt Form _yes no
Structure: (please circle in le F ; Multi Family# Other
Estimated Cost of job S SC(aDlo, Do
Will building confirm to law? ✓ yes no
Asbestos?__yes_ / no
Description of work to be done:
/lr) / Vv lC1(�mv.,� GJrhi/ni ��S
A&A SERVICES, INC.
Drawin 7ubmitted:_yes no Mail Permit to: 1 SALEM,MA 01970
X .,.t 10)Z41-0424:
X W W W.A-ASER1Vf�3.'GUM �
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee S
COMMENTS:
I
I
APPLICATION FOR
pPFiMI' To
LOCATION
PEIM.IT GRANTED
19
APP Vp
INSPECT Ofl F BUILDINGS :: _
CERTIFICATE OF OCCUPANCY
YES
NO + -
r v ti
NThe Commonwealth of Massachusetts
;t Department of Industrial Accidents
1 �lr Office of investigations
1jN / 600 Washington Street
t o% Boston, MA 02111
v" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect*ricians/Plumbers
Applicant Information tt Please Print Legibly
Name(Business/Organization/Individual): N A 5e—r yi�S t ,TY-)L+
Address: 1J i o +h r- Sty e e
I .5 +
City/State/Zip: .50,1 y.M , M t*� Df 9 7D Phone #: 19 7 1 2-I ( —OH a N
r22.
ee an employer?Check the appropriate box: Type of project(required):
b I am a employer with 4. ElI am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.[I 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' 13.Q'8ther 1411 n Jk),5
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Ilomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.polity infonnaCon.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:_ _ t r>_e_ Tro vp I rc�,
Policy#or Self-ins. Lic.M L�/(_' q[aq xC 19, �0 Expiration Date: Q
Job Site Address: City/State/Zip: �7� j� D /g 7D
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 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 a fine
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 certi n r the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date:
Phone#: 91 H
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one): -
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: 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 twd or 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,MGI,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 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 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
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 permittlicense 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 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
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 Transfer Station
owned by Northside Carting -
4
Signature of Permit Applicant
Date
Christopher Zorzy
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
Board of Building Regulations and Standards
Construction Supervisor License
.. License: CS 57733
I B, i_tffi3a38_5/26/1958
I • st< tt „fti�of ?g12009 Trll 13739
�• trispon 9
' CHRISTOPHER
115 NORTH ST
SALEM,.MA 01970 Commissioner
3 Commonwealth of Massachusetts
jDivision of Occupational Safety
!' Robert J Prezioso,Commissioner
Deleader-Contractor
I CHRISTOPHER ZORZY
I _ Eff.Date 04/02J07 ^�I
E
Exp.Date OM01/08 n
DCOODW
- Nemberol C 130
.O.N.ES.T. 08
IIII
IIIIIII IIIII IIIII IIIII IIIII III�IIIII uIII IIIII IIII IIII �BOSTON-R NrEWi..
67
Board oGBuiWin' Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration 101609
Ez_piratlon ,:6/26/2008 I
Type. Private Corporation
lil
4 A&A SERVICES INOC
Christopher Zorzy.
115 North Street ,., _.
Salem;-MA 01970 Deputy Administrator
t
1 _ p .x _.
milp/� �+ A & A SERVICES, INC.
VES 115 NORTH STREET,SALEM,MA 01970
E 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
QIG,V_ i-Yl)A2yELL >N Lu p E
Buyers)Street Address,City,State and Zip Code -
Z _
I I-}err--Toth 5 I SA L 6^4 MA 6 197 O
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address -
V K 1'uNtrv`Y ELLiii
?8-7Zo-IIrv3 418 zio ozss-
The Buyerls)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 ravers.of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specificaton
Sheet is a part. ,
WINDOW REPLACEMENT
Remove and dispose of# -7 existing windows. ���rrr---
loi Install # new S✓JL'RJS� windows: pVinyl ❑Wood
(Manufacturer) , V
Options: Style 1/lky✓GUJ4lGA Grid pattern
Color Interior r( ,7u_ Color Exterior Lt/zz J 77- Glass Type Z-1i
Wrap exterior trim with aluminum: Style !T-1J6L Wn4gyp Colon Wh/ ?76r-
n -
All windows will be installed according to the installation procedures in the portfolio. `dNGH (s/tR"/Jf 0-l JNO4p Y ST
Caulk all interior and exterior edges. FULL, LV44dp A;Ro/u.:
Insulate where possible around new units. rA/Jd/y76'YV JIJ6Pm S'll.L CJ9i'
( _ Insulate window weight pockets if exist,and around new window units where possible.
Included in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and out.
!�euiltling permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS -
Create new window opening b cutting through existing home and framing in opening,
- -
P 9 Y 9�/ 9 9 9
X, Remove and dispose of existing L unit(s)in its entirety.
AlA.Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
Install_I_ windows)into opening(s).
Note: If Bayor Bow installation to include cable support system,new roofs stem(matching color as close as possible)
PP Y Y ( 9 P )
L�or tie into existing soffit system. //^�j_ 1/ -
pt; Bay ❑Bow ❑Casement J 1( r wintldw(s)to include new interior style trim and new exterior style trim and head
C flashing as needed. L v
Yifl Note: Painting and staining not included.
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:
6>V5T L-<-n gVV fW//1"fi Av v : Sv t ass �V�,vyc rLn wr n�
• Law E' 99y7e�v 4ASS{ �8 �/&J D Prr77Ln N /an +� T�2.52/Uqi✓
�SLAn✓ IJv_Tziv-C- Mvo C4_1*J,74F_ AX7MJ"0/i D-14 S7`ILc�
/A/S7*-JL Albta/ sN7byZ/0n- T77r/`?aX I # / /Aif>� 2[arr lavt,�J3.v0 -
��^rn.'S7Yf2-t_ I'XJS7%IV 11zS0 1V e4i.16`,O w VAIt7S,
It le agreetl and understood by and between fear pares Mat this Specification Shear,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes '
the entire understanding between Me padtes,and Men en no verbal undersmMings changing or modifying arty of this terms.This contract may not be changed or Its
terms mounted or round in anyway unless,such changes are In writing and signetl by both the Burnam)and the contractor. Buyerls)h y r e rrawiedge Met 6uye(s)
has road Mis Specification Stuart.
Contractor Initials: ' J Date: 8-G-o� Buyer's Initials: ,r Date D Q' b�
1
�
.
A & A SERVICES; INC.
A&ASOMCES 115 NORTH STREET,SALEM,MA 01970
111111111 lorommm am 3XIMMIMTelephone: (978)741-0424 Fax:(978)741-2012 r r
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyers)Name Dale of Contract
Rick- t Mi4aliFL.eitj Le f s S- 9 -off
Buyers)Street Address,City,State and Zip Code
1Z i }orriToref S-r sWLl fen wl(k o1y70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address: n
W K M/F2Y L'L✓
47�'720- t11o3 Qr'a—t IL9 (7 Z10 OZSS
The Buyers)listed above hereby jointly and severally agree to purchase the goods andlor services listed on the accompanying specification sheets,in accordance with
Me prices and terms described on Me front and Me reverse of this agreement and any specification sheets(this'Agreemenn,and Buyers)haws requested that such
goods or services be installed or provided at Buyer's address listed above. A&A Services,Inc.("Contractor,hereby agrees m Install or cause to be installed Me products
or services listed in this Agreement at the Buyers)address written above. This Agreement represents a cash sale of goods anti services. The Buyers)agree to pay,in
cash the cost of Me goods and services urchased as describe�erein,regardless of timing or approval of any financing Buyer(si may seek for their purchase.
I L c = 0[�7�5�8q��
zOw: Q/.SC4YN%PPurchase Pnceal�>�'L'r /g)OUS Z iG 3, Est Staling Data: 1�
flown PaymenC)�L z�s�o SUN -O"f�M ���U 3 r -� Est completion Data all
❑Ca33j�
Amount Due on Start of Job: deck
❑Credit Card
Amount due on of Completion: No.
Amount Due on_of Completion: Expiration Date:
Balance Due an upon Completion: S7 Cl 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.
Buyers)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 farms,on the date that written above. Buyar(s)also
(i)acknowledge that they were orelly informed of their right to cancel this transaction;and(Iq request that they be contained via their
telephone numbers or e-mall,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 AaN V BLANK SPACES.
A&A Services,Inc. Buyers)
Signature U Signat re -
EO Q3v2 rt l C13
Print Name Pr�me^ -
✓/
Sifirfalfire
275: 0 -LiC Lj_PAG =
Print Name
You,the Buyer(s),may cancel this transaction at any time prior to midnight of the third business day after the Sate of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
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e pMam ardtmamn wewlm ammo Its.Been apprneeW na s.m.tery d Me atemwe onx»of 9ucb erMuaHon ea pmvee In M.G.L c.1 GRA. C �W5�/eZ comw.'am Lerit�AW
0.,e ( con: Ha:
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0
NOTfF IF rod I.TON
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by you wrier I»moment amp to dam mllonan9 own w Me salter of your mnwuabn hided. bJyou am de memo vdMm 10 days mlwaNng battle by Me sells of your c mll.rbn nonce,
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in realm the prole to Me sMler N]1.1 to he ad,MM you remain llmM for pa+mmharca M all he of Me panda m Me Seuerand*1mdo W.Men you remain liable M pMorambir M MI
explore under Me comment T.c el Mutrwedlm,mul or Manor a sigmas Wit dated copy odipvnre Made Me Cmtra.t To cancel his emotional mail or dedwer a plead and deal bidder
M Me mnallatlm eta or dry dMM w added,or send a bmgmm mPM m,no 01 me Wboophobn Nun M any other xeutm rand,or wend a mMgrem,ed. Mega,11a
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(Date) tome)
IXEAE9YcANCELTMIsrdANSACTON. canaummgslpneNm Date IHEREM(CANCELTHISTFANSACTION. Wraumaresiomand Dem