8 LINDEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7a' edition Ois SALEM
Revised January
Building Permit Application To Construct,Repai novate Or Demolish a 1, 2008
One-or Two-Family D Ilin
This Section For O cial Us Only
Building Permit Number: D e pli
Signature:
Building Commissioner/Inspector oPffuGildlings to
SECTION 1: SITE I ORMATION
1.1 roperty Address: 1.2 Assessors Map&Parcel Numbers
rSf-k
1.1a 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: PROPERTY OWNERSHIP'
2.1 Owner of Record:
NmintiF G,hosscz clf m
Name(Print) Address for Service: J
Si nature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief DescrintjoonoffPxoposl Wprl2:
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: $ G cj/L �� 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 6"7 J 7'�_ G /�
�✓Z License Number Ex ;ration ate t
Name f SL- old -
List CSL Type(see below)
Addr f Tye Description
f�tU Unrestricted(up to 35,000 Cu.Ft.
tur R Restricted 1&2 FamilyDwelling
// 0( 2 l M Mason Only
h' j RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 Re stered Home Improvement Contractor(HIC) Ai( q
la
HIC.Company Name or C strant N e _(' Registration Number+��,
(f
Addre / f-
�� Ex ration Nate
Signature elephone
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, 00MIJO F lS r as Owner of the subject property hereby
authorize r to act on my behalf,in all matters
relative to work authorized by this building permit appplation.
Signature o Owner Date
SE-CCTIION, 7b: OWNEW OR�AgUTHORIZED AGENT DECLARATION
M , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoink plication are true and accurate,to the best of my knowledge and
behal
Print me
Signs re of Twnbr or Autligrized 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 I0.R6 and 1 I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"
=."'=v The Commonwealth of Massachusetts
�i� Department of Industrial Accidents
i . '
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Orgmization/Individual): 1
Address: 1 I b Mo Nhl sM an �r t �1
City/State/Zip: MH O I I O Phone #: ' I 0 - I' O r-I Or q
A,rree,7y,_6u an employer?Check the appropriate box: Type of project(required):
1.L!/J 1 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
[No workers' comp. insurance comp. insurance?
required.] 5. El We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
per MGL right of exemption p
myself. [No workers' comp. rig 12J Roof 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 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 hire outside contractors must submit a new 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 an:an employer that is providing workers'compensation insurance for nzy employees. Below is the policy and job site
Information. ---�'��t/�(� T'/ J t1 '
Insurance Company Name: ]' 1K 1 1 �4 ��Q�Y
Policy#or Self-ins.
GGLic. #: ) n 615 n�1 R) Expiration Date: },� �., /l
Job Site Address:n��Olt 1 !n lS-,,X f l� City/State/Zip:�� n
M f (A( q �V
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 u r!le;pains and penalties ofperjury that the information provided above isltrue and correct.
Signature �" / —//
Phone# v1 1 I LA I ll LA a
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 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
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance t ith the provisions of M. G. L. c. 40, Sec. 54, a condition®f
Building Permit Number is that the debris resulting from this wo, shall
be disposed of.ln a properly ficmnsed facility as defined,by M. G. L co 11
t ie debris will be disposed at, Salem `pansfae StEgcn
owned by N10fthaide Caging
Signature of p=,milt Applicant
Date
Barns ®f Permit Applicant .
�irr�n Iv�ar�l®
115 N01th kFaet, Sales M-A 01970
�o�ress, ail, State, Zip Code
Control No 7 , 1 J 5
THE COMMONWEALTH OF MASSACHUSETTS
i
DEPARTMENT OF LABOR
DIVISION OF OCCUPATIONAL SAFETY
.. ., 19 STANIFORD 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, § 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. 111 § 197B(b)(2)AND 454 CMR 22.03.
w
HEATHER E. OWE,ACTING CoNsfissIONER
�
Printed on Rece
ycled Paper '
_. ✓/ .� - - -- �oedaclu a *- 111sti 1(husetts Department of Public Safet}
ze mnmzo�rau�ea a :/
Office of Consumer Affairs&B siness Regulation s Board o1 Buildin Regulations.11l(I Stlln(1Jrdb
HOME IMPROVEMENT CONTRACTOR Construction Supervisor License
. Registration 101609 Type:
Expiration 6/26/2012 Private Corporatio' License: CS 57733
SERVICES INC _ -
!� CHRISTOPHER ZORZY :
Christopher Zorzy-'. 115 NORTH ST +
A 15 North Street SALEM, MA 01970 `
4 Sk
Salem,MA-01970
\� Undersecretary
Expiration: 5Y26/2013
("mulissimler Tr#: 15935
NOV-06-2010 16:19 Sunrise Windows AA P.02
vanguard 1 N ® @ ® e ® e o e
A view that works e
Vanguard Windows are tested and certified to National Fenestration Rating Council (NFRC)
standards. These are the numbers ENERGY STAR® uses to determine how fenestration products comply
with their standards, and to categorize the products for the appropriate climate zone(s).
Window Glass U-Factor SHGC I
Type Package
VG Plus 0.28 0.28
Double VG 12 0-28 0.21
Hung VG3Ar 0.22 0.22 x
VG Plus 0-29 0.28
Slider VG 12 0.28 0.21
VG3Ar 0.22 0.22
VG Plus 0.28 0.28
Tilt•ln Slider VG 12 0.28 0.21 r:e®' (( NorNcrn
t lrn Iny
VG3Ar 0.22 0.22 I ❑ NOnh,Cenlral
VG Plus 0.28 0.30
Picture VG 12 w 0.27 0.22
- ❑ SouthlCentral
VG3Ar 0.21 022 �
.-.-.----- `"'•�....!_-;,.,.. .. :. .. ® Southern
VG Plus 0.26 0.24 ,
Casement VG 12 0.25 0.18
�� - �� �=+ !A Alternative
VG'Arw 0.21 0.19 Critarta Allowed
VG Plus 0.26 -� 024
Awning VG 12 0,26 0.18
VG'Ar 0.21 0.19
VG Plus 0.26 0.28
Casement VG 12 0.25 0.21
Picture
_V_G'Ar 0.20 0.22
VG Plus 0.30 0.27 PRO
_.
Sliding boor VG 12 0.29 _0.20
VG3Ar N/A L NIA I N/A
www.vanguardwindows.com
This data is accurate as of February 25,2009.Due to ongoing product changes,updated test results,or new industry standards or requirements,this data may change over
time.Ratings are for sizes speciped by NFRC for testing and certification.Ratings may vary depending an use of tempered glass,different grid or decorative glass options,glass
for high altitudes,coastal applications,etc.
9 6
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TOTAL P.02
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A�,,,, //�� I al sn2 A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
e • 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
Ng7HAN fCfll�/SSIE 61zAGKETr —26— I
Buyer(s)Street Address,City,State and Zip Code
9 Ll"DET1 S7- 019.70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
alf-li F Clylifi f"A RAe1G6t1
978-98S-371 Yvty a CDN l
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 antl 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:7—Z6 It0—/�
as
Down Payment 2 2 00a Est.Completion Date: /0-10—/1
❑ as
Amount Due on Start of Job: ❑Check
d'
Amount due on of Completion:
Amount Due on of Completion: Expiration D
Balance Due on Upon Completion �7's2• CVC Cade:
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
(i)acknowledge that they were orally informed of their right to cancel this transaction;and(II)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. � �Boye (s I )
By:
Signature Fv e> n ,- Signature
Print Name Print Name
K
Signature -
x
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:The contract-1 the homeowner hereby mearially agree in aMance mat in the evem elttier pant has a disputedenchadecithereachred,enter party may submif s..h c leer lw to
a proud untration serv'ce whim has been approved by the Secondary of the Executive Office of Consumer AMalrs end Bushy Regulations and the other party shall be repuiretl to submit b
sum arbilreYon as proved In M G.L,c.1G2A. )/ }d/ka0
Lots m rills: deal Initials:
Oa¢, e
$��������__N�OTCE OF CANCELLATON 'j(NOTICE OF�CGN F AEON
Data of Tra ca rider�����.You may cancel this trensanion,wilrout any penalty or Date of Transaction 8 z6-fr.You may camxl Mls transaction,without any panels or
obligation.within Mree business days from the above dab.If you cancel,any mr,smy tadetln. obligation,within three business days from the above dead.If you carcel,any Pal traded in.
any payments made by you under the Contrea or sale,ant any negoiddlesnceument executed any payments made b✓you under the Central or safe.ant any negordes instrument execlned
by you woo be reamed such 1g do,Ialowmg hadeps by Saw Senn of your arcmencon nogm, Iry you fell us ahead will to days reliance receipt by the sever of your vane moan mare,
and any smris interest arising out of the trareaccon will No ctrxenod. If you abet,you must and any real Interest arising out of the banuction will bs sentence, II you cancel,you must
more consame b me seller at your nowearlce.Inw y as gmp mMitun as when receNM, make avlabfe to tMSBYer at youreskmce.in mhelxnery as gent.,clan es when ruchirei,
any goods desered to you under this eomrecl or we;or you may.it you With,comps with the any goods delivered to you came me Contract or Babe or you may,it you Wall,comps with the
accordance a Low Seller return shipment the shipment of the goods at the Sellers girder m Site,
s and In ss ctio of the Ser re mains the realm shipment of the traced;M Ne Sellers expanse and
vs If you or make the .We available to Pa Sa ar ant the Seller deals not pick them up risk. If you do make the goods available to the Seller and the Seller does not pick them up
vetch 20 days of me time of your Notice of eancellMbn.you may redid or disease of the gaAs within M days of to data of your Nonw of Cancellation,you may town or dispose of the gootls
without any beffer obligation.it you fall to makn(M earls available to alb Seller,or it you agree warypNeryfudherabligenon.IfwulailtomaketegcWa Wlablebthe Sener,orilyouagreB
to return the goods to the Seller and far to tlo Ad,then you remain Male 1,perlmlmrce of all b realm the goads to Me Sella,and tail to do al dere you reman liable far performence M all li
obligations under Pe octaletl.To sarrandTo transaction.mail or deliver d dented and dated cop/ obligations under me Conrad,To cancel this mechanism,mail or deliver a signed and dated corn,
of the carrearsu r notice or any other whimin nice,or send a mother,as As Servi 1a5 of the cancellation notice or any a-u welled deice,or send a talegrem,to A Services,f s
NOM Street Sell Massechustt Onme,NOT LATERTWIN MIDNIGWOF 2e_I NOMSfinea,Baer,Masaachueeda upon,NOT LATER TWW MIDNIGHT Of�O_I�.
(Duel (Dare)
I HEREBY CANCEL TIIS TRANSACTION. Consumer's Speree Data I HEREBY CANCEL THIS TRANSACTION, Conmoral Signal pofe
A & A SERVICES, INC.
A&A SMICES 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
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyer(s)Name Date of Contract
IVA-i447V -, Wjet5S1E Ae, Ck&T
Buyer(s)Street Address,City,State and Zip Code
S LitiDeN 5 i SALOM MA Ol9"]-0
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
78-905-371a
The Buyerud 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 hoot and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a part
WINDOW REPLACEMENT
Remove and dispose of# U existing�y indows.
Install # 8 new windows: )(Irnyl ❑Wood
(Manufacturer)
Options: style D�-} Grid pattern
Color Interior CVtfI 7Ls Color Exterior f yR I Tg� Glass Type 1>003f.Y&I-9 Law—E
a f1(y(ylb1�
�IWrap exterior trim with aluminum: Style Color
All windows will be installed according to the installation procedures in the portfolio. '
Caulk all interior and exterior edges.
>p�t7 Insulate where possible around new units. '
!qJ Insulate— ^'^� ^g...-p , ^'around new window units where possible.
Included in this proposal are set up,clean up,Hope vacuum and cleaning windows inside and out.
Building permit included.
BAY/BOWS/CASEMENT UNITS/ANY FULL CONSTRUCTION WINDOWS
❑ Create new window opening by cutting through existing home and framing in opening.
❑ Remove and dispose of existing unit(s)in its entirety.
Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
❑ Install window(s)into opening(s).
Note: If Bay or Bow installation to include cable support system,new root system(matching color as close as possible)
or tie into existing sett it system.
❑ Bay ❑Bow ❑Casement ❑Other window(s)to include new interior style trim and new exterior style trim and head
flashing as needed.
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:
lArS aL4- X ejki / /a') F/16--09U"F705 9 &�>C7F3Y1- 07Z_ S S'
Gyl"ova S.
/X5 -/;`11 /V9W # If Pines An/76" OYL- STreS
It is agreed and understand by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
me entire understanding between the parties,and there are no verbal understandings changing or modifying any of the forms. This contract may not be changed or its
terms modified or varied in any way unless such changes are in writing and signed by bath the Buyerfs)and the Contractor.Buyers)hereby acknowledge that BuyeNa)
has read this Specification Sheet. A Ic 6
Contractor Initials: l/yJ Date: 6-2�—H Buyer's Initials: � / �1 Date.v�— O �G J3 Il
r
J
y The Commonwealth of Massachusetts
Department of Industrial Accidents
g2 Office of Investigations
`k 600 Washington Street
1 Boston,MA 02111
? www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):_nF-ia oJX,I yins II let
Address: II /� �1
Ot
City/State/Zip: 0 6 19 M Phone #: 996 f� q ( ' l! U "1
AVu an employer?Check the appropriate box: Type of project(required):
1.Ll/J 1 am a employer with n 4. ❑ I am a general contractor and 1 6. -1 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
workingfor me in an capacity. employees and have.workers' 9
y p ty. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.]
5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
right of exemption per MGL
myself. [No workers' comp. 12.��/Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.U Uther
employees. [No workers'
ilypiw—
comp. insurance required.]
*Any applicant that checks box#1 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 hue 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 ant an employer that is providing workers'compensation insurance for nzy employees. Below is the policy and job site
information. T� ` p ,'
Insurance Company Name: �Q'' ff 1 y�Q I�Q f is t�
Policy#or Self-ins.lLiic.#: 1 I I U� Q l l Expiration Date:�y }/3y� �/y�
Job Site Address:/ / f -C� ��[ City/State/Zip: Y l ti 1/ 1 l I I a /97V
Attach a copy of the workers'compensation policy declaration page(showing the policy number and eipiration 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 acopy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification. -
I do hereby certt ily anddhe p ms nd penalties of perjury that the information provided above is true and correct.
Signature 1 (1�1G//�/ j I ' Date: L <�
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 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 cant'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 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
DISPOSAL OF DEBRES AFFID""A 7T
In accordance twith the provisions ®f M. G. L. c. 40, Sec. 54, a conditicn of
Building Permit it(cmbeP is that the debris resulting iron this iwo, shall
be disposed cf.ln e properlylicecsed facility as defined.by M. G. L. co 119, Sec."
95@s.
The debris will be disposed at Mam `ransfev'Statocn
owned by NoFftide CaFting
. Sig��t�re ®f Pee its,®piic�nt
Date
Wem® ®f Per—M t Appffcarit .
�irri� fv��n®
���'eess, 6ity, Mtete, 3(p Salem. e
Control No: '7 5 1 9 3
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR
DIVISION OF OCCUPATIONAL SAFETY
19 STAMFORD STREET,BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A & A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
LICENSE: DC000440 EXPIRES: Wednesday, April 11, 2012
1N 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. 1 I 1 § 19713(b)(2)AND 454 CMR 22.03.
HEATHER E. ItowE,ACTING COMMISSIONER
PnntrA an Recycled Pepe
✓2 N � � *=" :N :ssachusetts - Department of Public Snfch
1C dIYNr Affairs 6�
Office of Consumer Affairs&Basiness Regulation Board of Building Regulations and Staodan'Is
HOME IMPROVEMENT CONTRACTOR ir, Construction Supervisor License
Registration 101609 Type license: CS 57733
Expiration 6/26/2012 _ Private Corporatio''110 F
.1 SERVICES, INC
CHRISTOPHER ZORZY s .k
115 NORTH ST
Christopher Zo¢y - SALEM, MA 01970
115 North Street
Salem, MA,01970 —�
r Undersecretary
--I-am Expiration:Expiration: 5/26/2013
('ommissioucr Trlt: 15935
Bnre'9g2 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
a9 A,/
Buyers)Street Address,City,State and Zip Code
t—7 1 .5� lf.,u-r
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
q 7io4, O,
The Buyers)listed above hereby jointly and severally agree to purchase the goods and/or services listed on me 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 If sin,r bull of timing or approval of any financing Buyer(s)may seek for their purchase.
Purchase price: / /��n Est.Starting Date: e
Down Payment Est.Completion Date:
❑Cash
Amount Due on Stan of Job: �z4�ra- ❑Check
❑Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: A4ACU' 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
understantling 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 react 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
(i)acknowledge that they were orally informed of their right to cancel this transaction;and(11)request that they be contacted via their
telephone numbers or a-mail,as listed above, in the event Contractor believes Buyers)would be interested in any additional quality
products or services of Contractor. D i T SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services,Inc Buyer(s)
Signature v Signature fp')h,�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 ezpianation of this right.
ARBITRATION:The wrbactor and the Msommner he"mutually agree in reverse that in me event offer party has a dispute wncerning this mmmkf,either parry may submit such dispute to
e Orivate erGtretien serviw wllicn has hen approveU hY Ne Secretary of Ne Executive Olflce of Consumer Abood and Buenas RegulaWm antl Ne outer party shall be raluiretl b submit N
such afbiVetion az proved In M.G.L c.102A
Cddtracwrmoss Be , loidnh
Da¢: OYs:
v // NOTCE OF -ANC. IATION
Date of Transazmer O �rou may`anal this transaction,without Any penalty or Oaten W Tral woo f Yeu may cancel tars er...mr,wi0oul any penalty or
obligalbn,wiNln Ores business days lmm Me a[ove Eaten.hyoucalcetanyteropeMlratlMle, off,me,
su i vi O�ary from the above date,it you cancel,any property trades in,
any payments made by yen under Me Data.or Saw,aW any negohble instrument executes any payments made by you unite,the Conrad or Sam aM any negotiable instrument executed
by you will be hetumed wholn 10 tlay,following rea opt by Me Seller of Your cancellation no0ee, by you will be mounded withm 10 days following receipt by the Seller of your carcellatlon notice,
aM any sewrity Interest worm,out M me transaction will be cancelled.If you camel,You must and any xwdty Interest arising out of to bansallon will the cancelled.If you cancel,you must
t eavalade to the Seller at your reslden:e,in substantially as good cenfiton as when awared, make availaale to Oe Sells,re or rMNentt,In suMslanh y ae gad exceeded is xTen txeiveE,
Any goes,delivered N you under this central or Sale;or you rag II you wish,mmpy wM Me any Sends generated,to you under me contract or salt;or you may if you wism comply Mth Me
InseruNons of the Seller regaMing Me rekm shipment of Me goes,at Me Sellers expense And matmNons of the seller regarding the return shipment of the goods at Me Sellers expense and
risk. If your do,made'the Seeds evvlable k Me Seller and Me Seller does art pies Oem em risk. If you do make the goods available to Me Seller and the Seller does not but Oem up
world 20 days of the data of Your Nofe of Cerebral you may heard or dispose of to goods whin 20 bays of Me data of your Nodce el Cancellation,you may moan or modern of the goods
wiltloW any factor oblgadon.Ifyher fail to make the gootls awmabb to'Me Seller or if you agree without any further obligation.Hynes fall to make re goods available to the Seller or lfyou agree
r rekm Me goods to Ne Seller and fall O do so.Men you remain liable for performance of all k return re goods to the Seller and fall to do so,Men you remain fable for performance^�
obligations under Me Contrast Memel Membranes,mail erdelivera signed aM food copy obitmetArmonder Necontrzet Tocancelthisnansadon,menloodeaverar" '
d the cancellation token m any other written notice, a or,ad telegram O, A&A Som 115 of to foreordain action or any other wheat wets,or send a telegram.
Noes Street Sell Masioneveers MET,NOT LATER ZN MIDNIGHT OF North Sheet,Salem,Mommenumus 01910,NOT LATER THAN MIDNICHI
R
(Datel (Date)
I HEREBY CANCEL THIS TRANSACTION. consumer's Signakry Dale I HEREBY CANCEL THIS TRANSACTION, Consumer's Signature
A(stldt W
�.� A �p A & A SERVICES, INC. �9
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
ZMNe Telephone:(978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No. CS057733
MISCELLANEOUS SPECWICATIONSHEET
Buyer(s)Name Date of Contract
Frg k 4- wt I
Buyers)Street Address,City,State and Zip Gods
/7 y
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mal Address
79 7u0- 57
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
Shoat is a part.
SPECIAL INSTRUCTIONS
S fro 2 fM 5 0'
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It Is agreed and understood by and between the sirtles 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 as
teems 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 Slnuficatian Sheet. (//(/,'
Contractor Initials: Date: O p a-01 Buyer's Initials:�J�{A7 Date: ,J-2f-I)
/ + ;�
vV ., /� �p /1�`� A & A SERVICES, INC. 6
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
MISCELLANEOUS SPECIFICATION SHEET
Buyers)Name Date of Cc tract
h + T f? ANC)
Buyer(s)Street Address,City,State and Zip Code
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
c(78 3 dos+er4r `,�P fl�rr�
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.
SPECIAL INSTRUCTIONS
t �`+�-4.1ou"2 ���ccv}S�d� fYyf6��A,h•�L`�-��S toniT--h i-ro�T F�ITS•�Ph �5S
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c ,sve j di� r� �4ef ( brzf3s sw ��f�1nn 4 na 'L
It Is agreed and understand by and between the Parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the share understanding between the partlee,and there are no verbal understandings changing or modifying any of the terms. This contract may not be changed or its
score modified or vaned In any way unless such changes ere In writing and signed by both the Muscle)and the Contractor.Buyarts)hereby acknowledge that Buyers)
has read this Specificatlon Sheet.��heee
Contractor Initials:—J__r_�` Date: Oq/t Buyer's Initials: Date: _(�� �'�l