11A LINCOLN RD - BUILDING INSPECTION (2) Y\ The Coi nnoimealth of %lassachuseltS R
Bouid of Building Regulations and Slandai %it lt'IP.\I I'I1
MaSSHCItUSettS State Building Code, 780 CNIR, 7 edition tiI[
I { r
rJ.hum� �
Building I'crmit Application To Construct, Repair.air. Rends Lite Or I)cnu,lish u li c'ru rn
One- or Tn o-Family Doi elling 'uuS
'Phis Section F Official Use Only
Buildim Permit Number Date AI IF
pplied: — --- _�
Shunalul'e: --
Building Cu ininsiouer/ pecnir of Buildings Dale
1
SECTION I: SITE INFORMATION
L1 Property Address: 1.2 :1ssessors Nlap & Parcel Numbers
� �� 111C01(\ ROG-d
Farrel Number ---_
1.1 a Is this an accepted street? yes_ no_ hIa p Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 1'1) Frontage It 1
1.5 Building Setbacks (ft)
Front Yard Side Yards - Rear Yard
! Required Provided Required Provided Required Prodded
1.6 Water Supply: (M.G L c. i0, §51) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood zone? Municipal On site disposal systcin ❑
Puhlic❑ Private ❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
�1nc\s Mrlrnt.\ �tYe�r 11 h
Name tPrint)
Address For Service:
Signature Telephone
SECTION 3: D SCRIPTION PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ - Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_' Other ❑ Specify:
Brier Descriptionuf ro u W, k'.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building '$ '7 (o 1. Building Permit Fee: $ Indicate how Ice is determined:
❑ Standard City/Town .\pplication Fee
2. Electrical ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List:
5,. Mechanical (Fire
S Total All Fees: S
Su ression)
Check No. Check :\mount Cduh
j b. Total Project Cost $5579, 0 Paid In Full ❑ Out.stnnding Balance Due:___.___
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI_) �7� 7111;1
�� '� 2mzNi License Nunthcruon U.ue
Naon•Tit('SL- I older
Y. Lt,t CSL'I'ype Isce hclotcl
(Jdr l v c Descri +Ilan
L L'nresuiCled rot[u 1�,000(Cu. 1-1.1
R Restricted Lei'_ F:uudt Dttcllurg
Si titre �1 \Luonn Unh
•��- 1 � ' 09 2- t RC Residential Hooling('tit rruPl .
Telephone . 1tis ResldeIIILd Windut, .wJ STU""' _
SF Rc,tdential Solid Fuel liurmn, t tliancr lu,l.ilLn tan
D Re,tdenoal Demohuun
51 Legi re 1 me l t r rtry cont c (►IIC)
< --
IiIC C nn ;my . t C e istrmri n _ �^ Rc�tstrauun tiwnhar
AJJrc - -20
�' `7/Vi' b
Expiration Da r
Sign ore - Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issue ce 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.
Signature ol'Owne Date
SECTION 7b: O ERt OR AU,TTHOR� �EDD AGENT DECLARATION
/ ��/,Y as Owner or Authorized Agent hereby declare
that the statements and inf�ation on the foregoing applicator ,re true and accurate, to the best of my knowledge and
behalf. - --
.. Print. r e b ��
Signature of 00 ner or Authilrized 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 cuntraclor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to.the at
program or guaranty fund under M.G.L. c. 142A. Other important information on the H1C Program and
Construction Supervisor Licensing (CSL) can be found in 7SO CMR Regulations I IO.R6 and 110.115. rcspecti�el.y
' When Substantial work is planned, provide the information below: - -
Total floors area (Sq. Ft.i (including garage, finished basemenUattica, decks or porcht i -
(-,iross living area;Sq. Ft.) Habitable room count
Number of rireplaces .Number of hedroom., -
Number of h:uhrooms - Number of haU7halh,
rvpe rtf heating systern Number of decks/ porches
Type of cooling s)'Stem Lncluaed Open
3. 'Total Project Square Footage• may be substituted for "Total Project Coat'• -
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
ru lu I\ Dent ,[I
•\ ' a 12: \l•,\il li Vt JO\Sllih l'I I $.11 i\I,
fla: 9-8-,4j.9j95 ♦ F\S:
Workers' Compensation Insurance Afftda%it: Builders/Contractors/Electricians/Plumbers
lnplicant Information /? py Please Print Lejib1V
\;!tilt !flu,inc•,s I)ruamLan,in lndl UdIWLI: A Ti r\ 5 e:ry( U5� �nc-
Address; 11,5 Nor+h S-hfe + \
City,State.Zip: �- 0 Phone #:
. Are sou an employer? Check the appropriate box: - F
e of project (required):
1. I am a employer with 4• ❑ 1 am a general contractor and I ❑ New construction
employees(Full and%or part-time).* have hired the sub-contractors -
'❑ 1 am a sole proprietor or partner-
listed on the attached sheet, t ❑ Remodeling
ship and have no employees rhese.sub-contractors have ❑ Demolition
working for me in any capacity, workers' comp. insurance. ❑ E3uilding addi[ion
No workers' comp. insurance . 5. ❑ We are a corporation and its -
[• P• ❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp,. c. 152, §I(4), and we have no 12.❑ Roof repairs )
insurance required.) f employees. [No workers' 13Zkbther (YA7
comp. insurance required.)
'Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
r I lumeowners who submit this affidavit indicating they are doing all work and than him 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. policy information.
l ain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
btfornration' T
Insurance Company Name: d Y , -
Policy#or Self-ins. Lic. #//: '- D M l U 13 Expiration Date: .Jnb Site Address: C ��(1�/ ��/ City/State/Zip: /q
76
:lttach a copy of the workers' compensation policy declaration page (showing the policy number an expiration date).
Failure to secure coverage as required under Section 25A of hiGL c..152 can lead to the imposition of criminal penalties of a
line up to S 1.500.00 andlor one-year imprisonment, as well as civil penalties in the firm ofa STOP WORK ORDER and a fine
of up a) S250.00 a day against the violator. Be advised[hat a copy of this statement may be forwarded to the Office of
Inv emi_ations of'the DIA for insurance coverage verititation.
l do hereby certify ucw r/tthe )uitis curd penaltiev afperjury that the infontration prrrvided ctbogve is/true acid correct
Date:
Phone =
Offleial use only. Do not n-rite in rhiv area, to be completed by city or town oJJic'iaL
City or 7ltw n: _ PermitiLicense
Nuuing Authority (circle ane):
1. Board of Health 2. Building Department 3, Citytfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and Instructions
�las,.ichuseus General Laws chapter 15' retluues all employers to prat ide tsorkcrs' compensation for their emplo)ecs.
Pursu.tnt to this�tafute, all enydol-ee Is defined as".. c%eat person in the scrt lie of amidier under anY contract of hire,
cy*i o�s or inipIicd. oral or n riven." -
An dnlplgrer is delined as "an indit:dual,parnwrnhip,as,ucra6un, eorporaiion or other la�sal entity. or any two or more
,d the liu'cgoing ongaged in ajuint enterprise,and including the legal representatit es of a deceased employer.or the
rccciter or trustee of an inJi%idual,partnership,association or other legal entity, employ in;employees. lfutve%cr the
warier of a dwelling house having not more than three apartments and tt hu resides therein, or the occupant of the
dtt tilling house of another who entpluys persons to Jo maintenance,construction or repair Murk on such dwelling house
or on the_rounds or building appurtenant thereto shall not because of such employment be deemed tu-bean-employer." .--
,I(it. chapter 152. �2506)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, %,IGL chapter 152, $25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public+sork until acceptable et idence of compliance with the insurance
requirenicnts 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)nairi address(es)and phone number(s)along with their certificates)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 pennit/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 fdture 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhe off ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do nor hesitate to give us a call
File Department's address, telephone and tax 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
tet iced >-'t>-u5 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 Dumber is that the debris resulting from this wort,shall
be disposed of in a properly licensed facility as defined.by M. G. L c. 111, Sec.
15Da.
E he debris will be disposed at Salem Transfar Stataon
owned by Northaide Carting
Signature of Permit Applicant
-721
Date
christo:)her Zo=
Dame of Permit Appiicant .
A &A Services. Inc.
Firm Name
11S North Street. Salem. MA 001970
Address, City, State, Zip Code
�> Nhissachusetts- Del)atirnent of Public Safety. .
A�f�y_f Board of Builditi Regulations and StJJKLtrds;
Construction Supervisor License-
License: CS 57733
i Restricted to: 00
r � ,
CHRISTOPHER ZORZY
115 NORTH ST
SALEM, MA 01970
Expiration:.5/26/2011
<'unmiissiuuer Tr#: 14751
J .� 1411 ✓G�
OfSce of Consumer Affairs&B siness Regulation
HOM EIMPROVEMENT CONTRACTOR
Registration 101609 Type:
Expiration 6/26/2012 Private Corporatio:
A&A SERVICES rNC
Christopher Zorzy
115 North Street
Salem, MA 01970 g��
Undersecretary {{
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Marlin,Commissioner ® e
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 04/14/10
Exp.Date 04/13/11
DC000440 j
Wmberof C.O.N.E.&T.
BO
IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII ' BOSTON-RENEW
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ar 0 /. * A red
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sires 1922 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
Buyers)Name Date of Contract
S A i4d LALtm pgIl 1 711311,9
Buyer(s)Street Address,City,State and Zip Code
r rye jpI AM, d l9 d
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
1-0
The Buyer(si 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
goads or services be installed or provided at Buyer's address listed above. A&A Services,Inc.("Contracton,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 goodsn`d services rohaseQ,asJlaecribed herein,regardless of timing r approval of any fina�mg Buyers)� y see r their urchase.
X'Ko
Purchase Pit Est.Est.Starting Date:�7 i4'el
Down Payment Est.Completion Date:
❑Cash
Amount Due on Start of Job: 0 C
rood t Car
Amount due on of Completion:
Amount Due on of Completion: Expiration Dale:
Balance Due on Upon Completion: c+ 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 Buyer(s)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 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,PC. Buyei
By: ze
Signatur Signatur T
tddv
Print Name Print Name
Signature
Print Name
You,the Buyeds),may cancel this transaction at any time prior to midnight of the third business day after the dale of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION:The contractor
and the homeowner hereby mutually agree In advance that in Me assed either parry has a dispute concerning This contract either party may submit such dispute to
e ,.a'a
scatter,service which has base.,—adby In.secretary of the Executive Office of Consumer AHeln and BusinessRegulations and the other partyshall Up required to submit to
such aNHration as proved in M.G.L.a102A. I
Conuecbrini°�'la: SL Buyer's initi.l.:
oem: Itf�(�n o.m. �.
NOTICE OF CANCELUTON NOTICE OF C-ANI I ATH]N
Data of TranseNon Yen may camel this trorwaxo ion,without any penalty or Date of Transaction ,You may Camel this ancesNon,without any penalty or
oEllgallon,within Nrea Ina days lromihe eEwe dare.Hyouw l,anypmp MtredWin, obligation,wMln three business days from the above data.it you wncvt any proper,traded in,
any payments made by you under the contract or Sala,and any negoti is a instrument exerted any payments made by you under the CaMrect or Sale,and any negotiable instrument executed
by you will ba mtumwd within 10 days following receipt by the Seller of your cancellation narks, by you will be mtumw within 10 days got ng remnat by the Seller of your cancellation rw&e,
and any terms,interest them,out of the mareallon will be cencellM. It you cancel,you mull and My secudry immest arising out of the Isms clbn will be cancelled. If you cancel,you must
Make available to the Seller at your mrseemce,in sueffavelry as good mMition as when recelvnd, makes illwo to Ore Soler At your readerlro.In substarstally as good contract as when recevrs,
any goods delenreb to you under Nk Contrast or Bale;or you may,if you w'sh,comply with the any goods delivered to you under this Correct or Sale;or you may,it you wish,comply with the
instructions of the Seller regarding the retam shipment of the goods at the Sellers expense and Imanne io m of the Sella,agent,the return shipment of the goods at Me Sellers expense and
Mr. It you do make the goods available to Me Seller and the Seller tices net pick Nem up risk. II you as make the goods available to the Seller and the Seller does not pole them up
wiMm 20 days of the date of your Notice of Cancellation,you may retain or disease m the goods within 20 days M the data of your Notice of Cancellation.you may retain or disposed of Me g.a
withour any Under obligation. If you fail to make the goods available to the Seller,or it you agree wMoutany Ndlmrobligation.Ifycufailbmake Megmdsavailable Nthe Seller,orilyauagma
to return the goods to the after antl rail to do so,then you remain liable for performance of all 1. to.the gootls to the Seller and hell to do so,then you remain liable for Pod ammuse of all
obligations under the Comwi To cancel this trmention,mail or deliver a signed and dated may obligations under the Composed.To cencel this bansutian,mall or deliver a signed and dated copy
of the wtcellamn norm or any other written secs,or send a telegram,to ABA Serviyyes,1��15 01 the canwllation Arco or any WM1er written notice,or send a telegram,to AAA Servlws,115
Nunn St N,Salem,Maccamseame 01 top,NOT LATER THAN MIDNIGHT OF Near Sam.,Some,MassaMusetl501.70.NOT LATER THAN MIDNIGHT OF
mare) (Date)
I H E R E BY CANCEL TH IS TRAIN SACTION. Consumer's egnature Oat. I HEREBY CANCELTHIB TRANSACTION. Consumers Signal ome
pp,,,, //�� `' I�a 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
ENTRY DOOR SPECIFICATION SHEET
Buyer(s)Name Date of Contract
:2113 io
Buyers)Street Address,City,State and Zip Code
Auro(14 A Ate, O q p
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
y . g f- hklrtFbr V,srfzwh.
The Suyer(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 part.
// ENTRY DOOR "�
t�Y/ 7ot,eemd dispose of rna- existing entry door units. sG jq7 Af �funf�
®' Install new--en7ntry doors# �n(�Lr Manufacturer sN/J fl$� ^f/AoL1Ald 6e r1�5
Location OrdN
Type: O Steel ❑SmoothStar ❑Fiberclassic ❑ClassicCratt ;ding Patio Doors" ❑French Hinged Patio Door
Model# Sidelight(s)# Sidelight(s)type/model#
OPTIONS: ...""_....'.'"".. ,.
❑ Adjustable threshold for ThermaTru Door ❑Grids for patio doors: Style:
❑ Stain Kit: Supplied to owner
❑ Expand or shrink the size of the opening Details
❑ Cover exterior ' with aluminum coil stock: // Style Color
Hardware: and/&et ❑Deadbolt Ii�FOotbolts ❑Mail Slot ❑Peepsite
� Ir1Wall oak stri{pat floor as needed.
i➢'/Caulk interior and exterior edges.
/9sulet's around new door unit where possible.
fa P Ing Is not included.
Included in this proposal are set up and clean up.
1 he 1tC
STORM DOOR
Cl Remove and dispose of# existing storm door(s).
Cl Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
❑ Location:
SPECIAL INSTRUCTIONS:
r/r I6PRflu9 GOWN sr1-I/u5' h0g(AS5
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It Is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,coned.
tutes 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. Buyer(s)hereby acknowledge that
Buyerts)has read this Specification Sheet .�//' / L
Contractor Initials: . Date:-Date ///}//O Buyer's Initials: )L Date: ��/
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