214 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards OFSALEM
CITY
Massachusetts State Building Code, 780 CMR, 7 h edition RevvisedJanuary
d Building Permit Application To Construct, ir, Renovate Or Demolish a 1, 2008
One-or Two-Fa r y Dw !ling
440
ic' 1 Use Only
Building Permit Number ed:
Signature: Building CommissDate
SECTION 1: FORMATION
1.1 Pro er Address: 1.2 Assessors Ma &Parcel Numbers
P p
�Ly �Ji� f%draur ��P�
1.1 a Is this an accepted street?yes_ no 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: PROPERTYOWNERSHIPr
2.1 Owner of�tecord:
lurnes ' Uon/Ja
Name rint) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all"that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
fr r/ 000,- - .see r clered C!miy-act o/' to_;Xf
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ El 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 $ Total All Fees: $
Su ression
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due_
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
ZLicense Number Ex iration ate
Name f SL- old
List CSL Type(see below)
Add f Tye Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
M Masonry Only
V LJ RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 Registered Home Improvement Contractor(HIC)
16)9 -2wV/rya AMC, . //1/6 0
HIC%mpan Name or ReQ'strant N e _(' Registration Number
(J
Ad r s / �qy�
(/L Ex ration to
Signa re 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 Issuan 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, KY ' 001717a /jt/b as Owner of the subject property hereby
authorize Z, to act on my behalf,in all matters
relati to we authmprizd IIy this building permit app ' ation.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
261ZZ4 , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing plication are true and accurate,to the best of my knowledge and
behal
Print am
Signalirre of Owner or Au prized Agent Date
(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
(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
?, 600 Washington Street
Boston,MA 02111
ry} ;
.'
wwtv.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n �/ /� c �1 Please Print Legibly
Name(Business/Orgmization/Individual): C aca o2X_.1 yi l'Qs i ne,
Address: /�
City/State/Zip: m m0 o 19]0 Phone #: 9 (� �' ll L1 a vl
AVu an employer?Check the appropriate box: Type of project(required):
1.Ll/J I am a employer with i� 5 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance?
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no l.p ,Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. -h T(y�{5�/iI X
Insurance Company Name: —
Policy#or Self-ins. Lie.#: ! I I U " Lf Expiration Date: J q
City/State/Zip: .
Job Site Addres ��/�� �L1 � Q�/ 7�
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 certify er ze paind penalties of perjury that the information provided above is true and correct.
Si nature Date /
Phone#
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#:
i
i
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 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 licensingagency shall withhold the issuance g Y 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 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/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 pernits 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 burn 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: i 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 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
DISPOSAL OF DE R[S AFFIDAVIT
In accordance e ith the provisions of M. G. L. c. 40, Sec. 54, s condition of
Building Permit Number is that the debris resulting from this Work shall
be disposed of In e properly licensed facility as defined.by M. G. L, co 111,
�e�o
1002.
E he debris will be disposed at Seem `ransfep'Stmbon
owned by NoFftide Carting
Signature of PeffnitApplicant
Date
Banjo ®f Permit Applicant .
firm �r�®
115 NDgh Strad Salem. MA 001976
Address, City, Mete, Zip code
f `�
Control No: Z j f
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
WIISIION OF OCCUPATIONAL SAFETY
.. ,. 19.STAwoRD .STREET,BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A &A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Wednesday, April 11, 2012
W ACCORDANCE WITH M.G.L. CH. 111, § 19713(b) AND 454 CMR 22.03,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR, DIVISION OF OCCUPATIONAL SAFETY TO THE CONTRACTOR
ABOVE FOR THE PURPOSE OF ENTERING INTO OR ENGAGING IN DELEADING WORK.
THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L. CH. 11 I § 19713(b)(2) AND 45�4�CMR 22.03.
HEATHER E. ROWE,ACTING COMMISSIONER
66
Printed on Recycled Paper '
Massachusetts - Department of Public Safeh
' Office ot Consumer Affairs&B sinessRegulation Board of Building Reulations and Standards
` HOME IMPROVEMENT CONTRACTOR Construction Supervisor .License
Registration 101609 Type:
• Expiration 6/26/2012 Private Corporatio• License: CS 57733
,SERVICES
fNC
CHRISTOPHER ZORZY !3
Christopher Zorzy" 115 NORTH ST
•115 North Street SALEM, MA 01970 '
g �
Salem,MA 01970 d-
\� -" Undersecretary
I Expiration: 5/26/2013
<'ommissionrr Tr#: 15935
NO Z
aG e
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
Federal EIN:04-3090162 Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(S)Name Date of Contract
S1" Al"i I t a 3
Buyer(S)Street Address,City,State and Zip Code
z 1 y 3e ecSC:vu AVl S,*�11 All ,0 l 70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
' ` 4
The Buyers)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 and 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 goods and services. The Buyers)agree to pay in
cash the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyers)may seek for their purchase.
Purchase Price: Est.Starting Date: swi
Down Payment: 65b Est.Completion Date:
❑Cash
Amount Due on Stan of Job: ❑Check
O Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: Expiration Date:
11� rr
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.
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 forms,on the date first written above. Buyers)also
(1)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 a-mall, as listed above, in the event Contractor believes Buyer(s)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 Services,10. Buyer(s
By: r--� F
Signature; Signature
Print Name Print Name
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. See the following Notice of Cancellation form for an explanation of this right.
ARBITROTION:The wnlraMr antl Me homeowner hereby mutually agree In advance Net In me event either party has a dispute Concerning Did modes '1 rpaM1y may SUEmpsucbithe to
a private arrilatim service which has Loran approved by the Secretary of the Exed"Yo Cked of Consumer Altars add Bus Regulations end modest shell M requlree Wasn't
la
such aNilatern as proved in M.G.L utOY. �/
Con w 1 � BuynilaidaL,: ^ (� )���
De¢: a— _ 5—
god'..OF CANCEL I ATON NOTICE OFCAN f Arms!
Bale of Transectien You may mncel tube beneacdon,wiow.any penegy or OaPo OI Transaclbn You may Cancel tltts vensaNan.witMN any penally or
Mfgatoq within Oreeb sin rays from Ne aWve date.Il you cancel,er,propeM tratlee in. Obligatbn.wlWnthrea sine tleys lmmtM1eaWva Bate.IlyeuaroblimeyemaMbadMin,
troy"Memo made by you under the Contract or Sale,ana any negoludd.instrument overNrd any paymam made by you under the Colonel or See and any ne9otabla norms enl executed
by you will be natural with 10 data bllowlng her by the Seller of your ransellatim nonce, by you will he alumeb within to days removing receipt by Me seller of your cencalleYon notice,
and any security interest adding out of Me transaction will be centered,It you canal,you must and any study imposer arising out of the deer aclbn will be cancelled If you cancel,you must
make marchle to the Seller at your insurance,in subslantialy az good rondNon es when hwived, make available to Me Seller et your newlenw,in substantiely as gouts mMitunss when acervid,
My added delivered to you under cola Central or Sale:or you may,it You wiern.campy wits the any goods delivered to you under I Contract or Sale,or der may,if you wish.mmpy with the
instructors at the Seller regarding the return shipment of the gooks at the Sellers eyreres and Instmdiws of the Seller regeMire the return shipment Of Me goods at are Sellers expense and
dsk. II you do make the goods available b the Seller and the Seller does not pick them up risk. If you do make the goods morable 10 the Seller and the Seller does not pick tam up
Whin SO data of the data of your Notice of Castellated you may retain or disprse of the goods spur 20 days of to date of your Notice of Cancellation,you may relain or social of the goods
w thoutanyfuhherobllgam,Ilvoumito makethegoNsevailable tome Seller,or,fynu agree wiNoulade NhheroWigaYon.llyoufailbmakelheg savallffiISO,gSelleporltyouagree
to return the goods W the Seller and fall m do so,Men you remain liable far performance of all to reNm the goods to the Seller add fail to do so,then you remain note for pertormaere of air
obladers under Me Conlratt To ranwl this transaction,mail or deliver a based eM tlatetl ropy oblgarlons under the Cooper.Towncelthistmnsa ion,mailordeliverasigneear d..py
of Me cancellation nonce or any other wdtlen bonds.Or send a telegram,b AaA S 5 Of the cancellation notice or any other written make,or send a telegram,0 A"Se Ices,115
North Street Salem.Ma55achuseas 01970,NOT LATER THAN MIDNIGHT of W, North Steel,Salem,Massachusetts 01970,NOT LATER THAN MIDNIGHT OF
(Dow) (Data)
I HEREBY CANCEL THIS TRANSACTION, Consumer's Signature Data I HEREBY CPNCELTHIS TRANSACTION. Consumber's,nature Orate
A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
JUT • Telephone: (978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No. CS057733
MISCELLANEOUS SPECIFICATION SHEET
Buyer(s)Name Date of C ntract
Q` r g 23 11
Buyer(s)Street Address,City,State and Zip Code C
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
G-70 -71 t 4 1 r
The Ruyeds)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 Specifcation 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
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It Is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMEW,,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 Buyer(s)and the Contractor. Buyer(s)hereby acknowledge that Buyer(s)
has read this Specification Sheet �r /
Contractor Initials: S Date: 0 3 r( Buyer's Initials: Date;(,