11A LINCOLN RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards OFSALEM
CITY
Massachusetts State Building Code,780 CMR, 76 edition Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Famil we ing
This Section or Offi ' I Use Only
Building Permit Number: �/ Da Applied:
Signature: ` r?"i �/�y
Building Commissioner/Inspector of Buil Date
SECTI 1: SITE INFORMATION
1.1 Property Address:n / / 1.2 Assessors Map&Parcel Numbers
1LLg Lihroln / 7W
I.Ia 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(
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: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Ina'- liezi/e d FR Neil
Nam (Print) Address for Service:
r1 ti 9�'P,7y/-06,3 0
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed/Wtork2: / - Enf aal7r`A?&cf lwe
QliCc_if1-o�__LKd/ hI� gidit)
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I.Building $ 0 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 ❑ Outstanding Balance Due:
h C� � >� b a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 33- y /
�✓ Z License Number Expiration ate
Name f SL- old
114 List CSL Type(see below)
Add re S�� f Tye Description
F
U Unrestricted u to 35,000 Cu.Ft.
bra R Restricted 1&2 Family Dwelling
tut O ,�/zz M Masonry Only
RC Residential Roofing Covering
Telephone WS, Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 Registered Home Improvement Contractor(HIC)
HIC Compan Narme or C lstrant N e _(' Registration Number
Ad re
- '� Ex ration ate
Signat reTelephone
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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR"PLIES FOR BUILDING PERMIT
I, wa � U GAG is M.klliire as Owner of the subject property hereby
authori to act on my behalf,in all matters
relative to work authorized by this building permit app ' ation.
Signature of Owner Date
SECTION 7b: OWNER'' OR AUTHORIZED AGENT DECLARATION
�I, � / � - 2J7 zm , as Owner or Authorized Agent hereby declare
that the statements andlinformation on the foregoin plication are true and accurate,to the best of my knowledge and
behal
Print m
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 l IO.R6 and 1 IO.RS,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
F� Boston, MA 02111
?J www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information p �/ 1� /� Please Print Legibly
Name (Business/Organization/Individual): Aca 0)�'.1 V I l Q Ina
Address: I I b N10 Si L Q f-
City/State/Zip: 1 m1 1O O I I O Phone #: 9 r)U k
Are u an employer?Check the appropriate box: Type of project(required):
1. " I am a employer with 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
o workers' comp. insurance comp. insurance.:required.] 5. ❑ 10.❑ Electrical repairs or additions We are a corporation and its P
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.] : 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 hive outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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. � T
Insurance Company Name: I I f Q I ���
Policy#or Self-ins.Lic.#:/ /Oay I I U �l�1 J Expiration Date: I
Job Site Address: Md ,(/ D/� ��� City/State/Zip: &A 1 270
T
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 der,thee jp.,ainssaandpenalties ofperjury that the information provided above is true and correct.
Signature n (WAG � ll Date: D �iY� �z
Phone#: 0g10 � UI 0UaY
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#:
f
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 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
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
DISOPSAL 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 property 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
FNW -
Signature of P rmit 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
Control No: '� 5 1 93
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
DYVISION OF OCCUPATIONAL SAFETY
19 STAWFORD STREET,BOSTON,MASSACHUSETTs 02114
DELEADER CONTRACTOR LICENSE
A & A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Wednesday, April 11, 2012
IN ACCORDANCE WITH M.G.L. CH. 111, § 197B(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. I I I § 197B(b)(2) AND 454 CMR 22.03.
HEATHER E. ROWE,ACTING COMMISSIONER
e
Printed on Recc
ycled Paper
✓ p > .. ��1 lti+uhusetts De r uKment of Public S.tret.
fie '(oarrvnxaottueae a�✓tac/weeCG 1
\ Office of Consumer Affairs&B smessRegulation Board or Builllln� Re�uLltiuns.loll SLU7ll.U'(Is
HOME IMPROVEMENT CONTRACTOR Construction Supervisor License
Registration 101609 Type:
e Expiration 6/26/2012 Private Corporation License: CS 57733
,I SERVICESOINC
y CHRISTOPHER ZORZY .,•�:
> 115 NORTH ST r
Christopher Zorzy ` SALEM, MA 01970
115 North Street -
Salem, MA•,01970 - Undersecretary
Expiration: 5/26/2013
('unuuiss inner Tr#: 15935
R + no a
Sir., A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
2.01TWOFEW 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
FP—A-Nf-IS fMRa-(Ia INJA La.KCs-P—
Buyerls)Street Address,City,State and Zip Code
11A (_1rJCOLA1 2D r144 0197C
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
978-7z//-003 a
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 dad 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. ABA 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 cast of the gootls antl services purc setl 7described�rein,regardless of timing or approval of any financing Buyerls)may seek for their purchase.
kpnn
Purchase Price: 2�95 Est.Starting Date: -3 7�1
Q kp
Down Payment: •0/ Est.Completion Date:
❑Cash
Amount Due on Start of Job: Check
❑Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: m Expiration Date:
Balance Due on Upon Completion: OOS, 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. Buyerls)also
(i)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,Inc. Buyer(s)
By, ,,A K 77,1r QL fQ & Qa//OIri
Signature 6 6i12 - � �clgm r�R�n L.L{Jl/1`� Z.,),,fLK?
Print Name C! 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.
ARBITRATION:Tha-...,and the hameawner hereby mutually ru
egrea a advance that in the event either par,has a dispute concerning this contract,either party may submit such dispute to
s private arbitration service which has been aroved by Me Secretary of e Sassafras Chase of consumer AHelre aRE Business Regulations and Na other parry shall be repulred to submit to
such uncommon me mweb In M.G.L.c.142A. x
Contractor initials Dat, nilialf.
/��.q NOTICE OF CANCELLATION /a NOT - Of FF AN FIATON
.are of Trbrobaclop V 3-I/ .You may cancel this manna son,Adrom any penalty or Dale o1 T of aegion�o-s'-7/ You may cancel this formation,without any penalty o
obligation within three business days from the above date.It you camel,any property traded In. oblyalgn,within three business days from the Name date. It you cancel,any proper,traded in,
any payments made by you under the ranched or Sale,and any negotiable instrument macNed any payments made by you antler the Colombo or Sala,and any Marcos Instrument executed
by you will be returned within 10 days allowing receipt by the Seller of your cancellation rouse, by you will be returned within 10 days following receipt by the Seller of your cancellation notice,
and any sr:cufiy interest arising our of rue transaction will be cancelled. If you canwl,you must and any security Interest arising out of the transaction mitt be cancelled If you cancel,you must
make av&able to the Seller at your becJerre.In suMtanderly as good mnaiticn or when received, make available to the Seller at your reardence,in substantially asgw]condition as Aren received,
any goods delivered M you under this Contract or Bale;or you may,if you wish,comply with the any goods dellvereb to you under this caused or SHE:or you may.it you wish.comply with the
aria ions of the Seller,act,the return shipment of Me goods at the Sellers expense antl nslmctions of the Salle(rayeading the(arum shipment of the goods at the Sellers expencre and
risk. If you do make the goods available b the Seller and rue Seller does not pick them up risk. If you do make the goods available To Me Seller and Ma seller does not pick Nam on
After 20 days of the date of your Notice ofCancellation,you may retain or dispose of the goods wM'm 20 days of the tea a your Notice of concelation.you may retain or dispose of the goods
wilhost any further obligation. It you fail to make the Were available to Me Seller,or if you agree without any tether obllgetbn.if you fail to make the goods available a the Seller or if you egrea
to return Me goods to the Seller and all to do m,than yae swish liable for perceived of all he return Me goods To Na Seller and fail to do an then you remain liable for pedormence of all
obligations under MeCommon.To cancel this transaction,mail or deliver a signed and tlateticopy obligations under Me Oommes,To card this transaction,mail or deliver a signed and dated copy
of Me cancellation notice or any other written notice,or send a telegram to
, A Sa oses,115 of the cancellation notice or any other Argon notice,or send a telegram,to A&A Service
s.1115
North Sailer.Salem,Massachusetts 01970,NOT LATER THAN MIONIGHT OF&(p-71/ Nonh Street,Selem.Me55achuaeds 019]0,NOT LATER THAN MIDNIGHT OF
(Date) (Data)
I HEREBY CANCEL THIS TRANSACTION. consumersissa ass Date I HEREBY CANCEL THIS TRANSACTION. Consumers Slyness Data
�! a 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
ENTRY DOOR SPECIFICATION SHEET
Buyers)Name Date of Contract
Buyers)Street Address,City,State and Zip Code
114 LUNCOLAJ RD S,41_ On"i 11-19 01?7o
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
1 78-7L11-0030
The Buyers)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
Remove and dispose of# existing entry door units.
'/Install new entry doors# 1 Manufacturer -7-MV72yl - �U
Location
Type: O teel moothStar O Fiberclassic ElClassicCraff O Sliding Patio Door ElFrench Hinged Patio Door
Model# Sidelight(s)# Sidelight(s)type/model#
OPTIONS:
XAdjustable threshold for ThermaTru Door ❑Grids for patio doors: Style:
0 Stain Kit: Supplied to owner
Expand or shrink the size of the opening Details
Cover exterior trim with aluminum coil stock: Style Color
Hardware: 'ti6andelset 'X,beadbolt O,,Football ❑Mail Slot ❑Peepsite
Instal k tflp at floor as needed. L�r�+•1>'�
Caulk interiors and exterior edges.
Insulate around new door unit where possible.
Painting is not included.
Included in this proposal are set up and clean up.
STORM DOOR
Remove and dispose of# existing storm door(s).
Install new storm doors# f Manufacturer bkl//13&J
Style 0019✓c!L Color bos,& 7_1;�_ Type: ❑Aluminum X-f-Solid Core
Location: 15ZP -7
SPECIAL INSTRUCTIONS: r
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 partles,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 Buyemn and the Contractor. Buyer(s)hereby acknowledge that
Buyers)has read this Specification Sheet.
Contractor Initials: a- J Date: l0'3 1 Buyer's Initials: }r .7 z1/- Dater `�