41 LIBERTY HILL AVENUE - B-13-175 t
\� The Commonwealth of Massachusetts
JJJ ,e Board of Building Regulations and Standards CITY OF
l} IJ1 ALEM
Massachusetts State Building Code, 780 CMR SdMar
I I Revised Mar 2011
Building Permit Application To Construct; Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Oirry
Building Permit Number: - Date Applie .
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION -
1.1 Poe ddres : 1.2 Assessors Ma & Parcel Numbers
��p i r�F�ll �,. P
l.la is this an accepted et?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property
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.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
-Lone: Outside Flood Zone?
Public El Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1, Iner'orR oeF rd �1 n cC .�- ) � b
_ oLtX��ll J
Na ne(Pi int) City,State.71P
q 918�� -55 1 Pr
No.and Street Telephone Email ddress
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Altera[ion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: _
Brief Description of o osed Work': ( I I _. . _-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials) ________
1. Building $ Q7 I. 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) $ -
5.Mechanical (Fire $ - -
Suppression) Total All Fees:
q Check No. Check Amount: Cash Amount:_
6.Total Project Cost: $ Doo 0 paid in Pull ❑Outstanding Balance Due: _
-- SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) F`7
f J h_Q_f l J J 1 zo License INumber x iraotion ale -
Name of CSL Wilder
WO r I ,� � n R , List CSL Type(see below)
NO No.and Street
l� �f� Type- : Description
S P I I M1 l U Unrestricted(Buildings u el ing cu. ft.)
R Restricted 1&2 Family Dwelling
City/rown,Stat ,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
go7�alay2� n� /IcP( � SF Solid Fuel Burning Appliances
g t71 "'�< td`'4J S_N'� J I Insulation
Telephone mE dress D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 D 1 (ti„)9
) , V ' t X.� II 0 HIC Registration vNumber =zpira[i n ate
I C p y Nam IC R 's rant ame Q-23YAAZ r
d tr e Q I J 1 Email address 1\—YCNII
Ci /Town,State, IP Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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
I,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
. kh n �t n( n _ 8
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
ris o )a _
Print Owner's or AuthorizedAgent's Name(Electronic Signature) ate
.. .: " 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 can be found at
wvnv.mass.got. v`!oca Information on the Construction Supervisor License can be found at_wtivw mas nov;'dns
2. When substantial work is planned,provide the information below:
Total floor 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
to t
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ny� ( Please Print Legibly
Natrie (Business/Organization/Individual): y'�(, [ L�f T spa wk s
Address: "J T MOM S Q
City/State/Zip: ( l m m 0 Q 19]O Phone #: 9 9 S � � ( '
Are�u an employer?Check the appropriate box: Type of project(required):
1.LL/1 I am a employer with_a 5 _ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
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.t
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 1 (r cof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box 91 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 hire outside contractors must submit anew affidavit indicating such.
:Contractors 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 an:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
infor
Insurance Company Name: IN I/Iy���QI�Q u,il J 1
Policy#or Self-ins.�Lie.4: I �p I I I U " ) 1 Expiration Date:A 11,5 1 zU I
Q �] n
Job Site Address: ^ I I F I I 1 ��a . I I � —City/State/Zip:( 11 1 "
Attach a copy of the workers'com ns ion 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 hrlposition 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 insuranc coverage verification.
I do hereby certify d r t e pains nd penalties of perjury that the information provided above is true and correct.
Signature: �} c, ( Date:
Phone# t I
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
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 ajoint 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 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 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 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:
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
Fax# 617-727-7749
Revised 4-24-07
www.mass.govfdia
DISPOSAL OF DEBRIS AFFID YET
In accordance Mith the provisions ®f M. G. L c. 40, Sec. 64, a con '®it6on of
Building Permit Number
beP is that the debris resulting from this Work shall
be diSpDS9d ®f ln a properly Iicm�s®�
ISO&
e
t ie debris %rill be disposed at sal�m Trans e Stafoon
owned by N*Fn, Lido CaFa g
Signs' e off e�ltApplicant
Date C� 0V lawa
Rams of Permit Applicant
A &A SaFt4ca-s, Me
• �i rP�r f���P—Ir®.
15 NOef grralt- Salem. MA 001970
Address, C14r, Stag, tip Code
THE COMMONWEALTH OF MASSACHUSETTS
_ EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT -
s DEPARTMENT OF LABOR STANDARDS
19 STANIFORD STREET,BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A&A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Friday,May 10,2013
IN ACCORDANCE WITH M.G.L. CH. 111, § 19713(b)AND 454 CMR 22.03, THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS 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. I I I § 19713(b)(2)AND 454 CMR 22.03,
HEATHER E.ROWE,DIRECTOR
Massachusetts- Departnienr of Public Safeth
C-Cons upo�,Affairs&Bu o-��a Matt n p Board of Buildim_ Re ulations and Standards i
Office of Consumer Affairs&Busihess Regulation
,I10ME IMPROVEMENT CONTRACTOR Construction Supervisor License
eglstrion: 101609 TypeCorpo
xptratlon -6126/2014, Private Corporatio License: CS 57733
A&A SERVICES INC
CHRISTOPHER ZORZY r
Christopher Zorzy I 115 NORTH ST
1 t SALEM, MA 01970
15 North Street _
g —
Salem,MA 01970 Undersecretary -
r. Expiration: 5/26/2013
__ ti' , Conuaiasionrr Try: 15935
BUILDING..PERFORMANCE INSTITUTE, INC:
107 Hermes Road, Suite 1.10
Malta, NY 12020 Advanced Training
,}
(871) 274-1274 j 1
www,bpi.org
ChlistopherZorzy #20120426000940
i''•�`� w y A&A Services Inc Exp 4/262017
n"3 CHRIS ZORLY 115 North St
Salem, MA 01970
CANDIDA, tD=:CANe76a9
Matthew JtGibson
---�;•, .�{ I- 2 1 n ti♦ r r.�caiaa«amv+,.s
ti ZaPz___
,, /�
5 /✓�// C` A & A SERVICES, INC.
uA sER` 1CW' 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
b -
Buyer(s)Name
Data of Co tract
Buyers)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
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 Buyer(s)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 Qi 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 Daternn
Down Payment Est.Completion Date:
/J
❑Cash
Amount Due on Stan of Job: O Check
❑Orlidit Card
Amount due on of Completion: I
p Amount Due on of Completion: Expiration Date:
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. Buyer(s)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 e-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 ENDS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services,Inc. Buyer(s)
By:
Signature Signatu � & O'� -
S�s1
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.
ARanaanON:The wbt'.1 and me homeowner hereby mutually agree m nirvana nand me e+am euner parrhas dlsp Idemanding this abroad.either M er pa may submit sum dispute to ,
a private arim ration spawn whim has Been approved P/me secretary of free Executive office of consumer Axao-s and apostolic s and the order paM shall be reguiree to submit o
such eANmion we moved in M G.L.c.M2A.
Crichaterimmuld Byeiilvin,
Oar: ante
NOTICE OF CANCEI I aTON NOTICE OF CANCELaTION
Data of Tmnsecom yYou may canrel thin transazlbn,wNmut any penalty or Oate o1 Transaction y You may cancel Nis mansection,without arty peaty or
oblicpaim Mhlnthrea tlaysfmmtheaWve dome,ll you rararm,any property Varied In, ohligation,wMln throdbuserfeas days from the mourn date.If you cadent any thereby tailed In.
my pdi mond made by you under for conch at or sea and any negotiable treatment mandated am•payments made by roe under he Comae or sale,and any negotiable Instrument exewM
by you will M re allows wttn 10 days following ra'.eipf by the Seller of your macerated rMlce, by you will be refumed within 10 days fmlmving conduct by Na Seller ed your candegui en cards,
and any semdry inmresf Arleta out at the tanssmion will be cancelled. It or eel,you mum am any--it,heard men,outvl the troderatedwill he anal... Hyau bi you hod
make smiabk a the Seller at your hardware.in mostantimy as good w.rl as Arm armed, make brains to the Seller at your conceded,in substantia as good aMHbn es when nusied,
airy prods delvered to you under mis Contract or Sale or your may,if you xis,comply with the any goods rebound to you under this Conrad or sale:or you may if you Ash,rangy vnm Be
inslmNms of the Seller come ng the hefum shipment of to goods at me Belles expense and insWtlions of Vie Seller regal the mourn shipment of the gootls m the$¢Ilea expense aM
risk it you do make the goods available to the Seller and me Seller does Tel pick them up ner, If you do make the goods available to to Better eM the Seller it.nod pick rem up
within M days of me data of your Notice of Cancellation,you may stein ar dtamm of the goods within 2n days of Me data of your Notice of Cmlcellefion,you may retain or tllsgwe N me goods
without arty NMer obligation.Ilyoufailtomakethega savailffilatome Belleaoritwuepae without any fuller oblll It you tail to make the goods available Nome sellea or it you agree
to return the prods b the Seller arM 1NI to do so,ten you remain liable far performance of all ch return to goods w me Seller and fail M do so,than you remain fable for performance of col
obligations uMe,me Comact To cancel mi.Vansoatioo coal or delNer a signed and dated copy who$ions under me Lanham.To cancel the formal real or del'os a big net and demed copy
of the mnWllmon notice or rtry other worm nWkb,or send a telegram,to ASA Sa 'cos,its of em cancellation notice w any ether xmlaen eace of Sand a lele9ham,b A6A 8s—e�rv�'iceys,/1)j1�5
North Street Select.Massadtusetts 01970,NOT LATER TURD MIDNIGHT OF No.Street,Salem,Maseschusetb 01970. Or LATER THAN MIDNIGHT OF G Z
(oate) (Date)
I HEREBY CANCEL THIS TRANSACTION. Consumers Sgrome Date I HEREBY CANCELTHIS TRANSACTION. Consumers SignaNre Date
a_ A A SERVICES, INC.
o e
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
ROOFING SPECIFICATION SHEET
Date of Contract
Buyers)Name
Buyer(s)Street Address,City,State and Zip Code
Lf � �
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 below,in Accordance with the 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 can.
ROOFING SPECIFICATION
04Cr+ CO /
Strip Roof of#_ // layers of shingles
it Install 6'of ice and water shield at base of roof where t Install 15.b felt paper to roof.
possible. Install 18-24"of ice and water shield in valleys.
F Flash chimney as needed (no repointing included). t Instal perimeter drip edge to rakes and fascia areas.
t stall vent pipe boots and sealer X. t Flash valleys as needed -g"-x
$ I stall-pai type ridge vent. I t anks/plywood replacement under 32 SO FT included,
tiI l Op- U���' eAPP'Qd -f 'If more is needed there will be an extra charge effr
"/�� pfor labor plus the cost of materials.
/Disposal Included: _t�t ,Ofi tCk' IOther: � y7�( F��/ /cti?+"A1 4E2l-
Location: N 440( G 42 -
Install new roof: Manufacturer pfl Syr Styleftype aTA P_
I luded in this proposal are thorough cleanup,building permit,and company/manufacturer arranties
RUBBER ROOFING SPECIFICATION
t Strip Roof t Not Strip Roof
t Install 1/2"High Density Fiberboard to existing roof using t Flash obstacles as needed.
screws and plates.
t Install .060 membrane EPDM(Black)rubber roofing to t Install 3x3 aluminum drip edge to perimeter of roof with
fiberboard.s seam tape.
t Flash up sidewall as needed.
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
SPECIAL I TRUCTIONS:
It Is agreed and understood by and between the parties that this Specification 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 Buyers)and the Contractor. anyone)hereby acknowledge that Buyers)
has read this Specification Sheet. y
Contractor Initials_ -L Date: /Z- Buyer's Initials:f Date: