23 LINDEN ST - BUILDING INSPECTION (3) i
The C'onurtonwealth Of Massachusetts I:()R
t Board of 13uIIdi11g RCgtlIittlpns and Standards III Nlt II' I fl 1
t. Massachusetts State Building Code. 780 C NIR, 7° edition tit(
41- l Y
Building Permit Application To Construct, Repair. Renos ate Or Demolish a Rrri ,l / rmm�t
One- or Tit o-Famih' Dtt c1iin,q
This Section For Official Use Only
Building Permit Nut er: -Date Applied: --------
��VJJ SI_Hnatul'e:
Building Cununis.sioner/ Inspector at Buildings Date
SECTION I: SITE INFOR.NIA,riON
L1Pn_rper[} ^ / 1.2 :\ssessurs Slup & Parcel Numbers
�
S7"re e
NIa Numher Parcel Number
I.la Is this an accepted street? yes_ net— P
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sy li) Fromage(ll) .
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Reyuired Provided - Reyuired Provided Reyuired Prueided
1,6 Water Supply: IM.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: — Outside Flood Zone" - Municipal On site disposal system ❑
Public ❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 wne lof Record: e, n / 'n �y{ o o �—
Name i Address for Service: —
��� -75�5- 9775 _
Si_enature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description uR5)QUsed 7W/ / I.
Ile
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
L Building S [j� I. Building Permit Fee: S Indicate haw ice is determined:
❑ Standard City/Town ;\pplication Fee
2. Electrical S ❑Total Project Costa (Item 6) x multiplier x
i
3. Plumbing - S 2. Other Fees: .S I
J. Mechanical (HVAC) 5 List:
5. Mechanical (Fire
S � Total :\II Fees: S
Su. ression))
Cheek No. Check :\mounr. (':uh :\mount:-----
j b. Total Project Cost: S �� iT ❑ Paid inFull ❑ OutsrmJing Balance Due:___..
(VJ
� r
SECTION 5: CONSTRUCTION SERVICES
5.1_ Licensed Construction Supervisor 1CSLI2-03--
S _ License NumberIN in li�piraw�u )aii
-"1 `der I ql CSI_ I\pe tsre hclawl
kiJr c Descrh i, on _ ..
._ - L L'in cst need i uvw-:�� 1100< u..Gli ..-_. _.
_._..
_. _ _ R Restricted I L1k'_ F:unih+D„ell ine -
. .. .
Ova y.. - ,1 >I:u�,nr, ()nl,. - _-- — — ---
-- RC Rnidenual . u)aruta
Ti lrphune 1PS RC]nlem Lll \Vindu 1, .md Siding
sl- Re.iJelmal Solid Fowl Burmnu 1 ,thanre In.l.illdw nt�
D Re>identtal Demuhu.m
5.2 F e tste d flume Ini rovement Contra to IIC) /D/�O
AM ,sue j��.p s t , . 9. --
MC Cm airy NI nu or F I R• t nt Nan u
Regisuaun Number
.Adires
i iraflull :IIC
Sig cure Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE.AFFIDAVIT(M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prucide
this affidavit will result in the denial of the Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... IV No ........... ❑ -
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
;as:Ownecof the subject property hereby
- - - /� - .., 'ti, act on my behalf in ail matters
_relativp/ ' work iuthor d by is -ilding permittpplicanon. ^7 ('j
(oft
Signature of Owner Dale
�/•� SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the the statements and in(ormation on the foregoing app 41�- tion are true and accurate. to the best of my knowledge and
behalf.
Print N
Signature of Owner or Auttickized Agent Date -
(Siened under the pains and penahieS of .erju )
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor (HIC) Program),.will trot have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Pntgr:mr and
Construction Supervisor Licensing (CSL) can be f6und in 750 CMR Regulations I IO.R6 and I IO.R5."i"espectively.
_'. When substantial work is planned, provide the information below:
._, „ (including gar,tee, finished hasemenUattics. Jerks (�r ),mrhi -
Totalfluars.are.rlSq:.Fr.) I
�Habitableroomi
iNumber of riieplaces - Number Ot hedroom.s
Nbrubei of hathna,ms Number Ot hall/hath,
L3r�:Totheaiing s�'slem-- -._._ ." _ --- Number"(,I decks/ li,,icnes it ioOling systemal Project Square Fourage- may he substituted fLr '"Total Project Cost"
t
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,.trnlclt nkla , 11
%1AIIIK 12.'W.1111;NAd,INS1HII'1 0S.\1 1 %1,NI
rla:'11,4;,);,A # Ft%: '1.78--4:-984n
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le_ibly
Nat IIeIBu..mc.ithgamiauonlodnIduul.l: At A 6Q-r\1( U5,, SnC-
Address:l5— 1�nr- h 15frf T
City,State•Zip:�If M;� D19-7o Phone #: `17 ,H
Are cuu au cmplu}'er:'Check the appropriate box: Type of project (required):
I. I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
:.❑ 1 am a sole proprietor or partner- _. .'
,hip and have no employees rhesesub-contractors have 8. ❑ Demolition
uurking for me in any capacity. workers'comp. insurance. q, ❑ Building addition
[No workers' comp, insurance 5. ❑ We are a corporation and its -
reyuired.J officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) employees. (No workers' Other
comp. insurance required.)
•,%ny applicant that checks box#1 most also till out the section below showing their workers'compensation policy information.
'I lumcuwnem who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. _
:('ontmctors that check this box most attached an additional sheet showing the name orthe sub-contractors and their workers'comp, policy information.
l mn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
irtfonnution.
Insurance Company 'Jame: �_
Policy#or Self-ins. Lic.#: '. 0-,2 qz b�l U 13 / Expiration Date: qJLq tr jg��t Q
Job Site Addressz� (�f- Ciry/State/Zip: V� / 70
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 biGL c. 152 can lead to the imposition of criminal penalties of a
inc up to S 1.500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up nt S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Imestigations oflhe DIA fur insurance coverage verification.
It do hereby ver:r ff er herains fnd penalties of perjury that the information provided above is true arid correct
<i runic' //// Date- "o Phone V. �- r/— y
Official use only. Du not n•rile in this area, to be completed by city or town officiaL
City or ('nw n; _ ------.---------- Permit/License #_._—..----'.—_--
Issuing .luthority (circle one):
I. Board of Health 2. Building Department 3. citr,ronvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and instructions
\Lt.:..i huscus General L;ms chapter I rogtureS Al emplo%ers it,pro%ide %%orkcrs' compensation l'nr their eniplo)ees.
Pursuant W this aatute, .lit emrR{ree is defined Is ".. et en person in the Scrt lie of another Wider anv contract of hire,
ctptoNs or implied.oral or ttrinen."
.\n :mpL).rer is defined as •'an indit!dual, partnership, association,corporation or other legal entity, or any two or more
of the ti,ngoing engaged in a joint enterprise,and including the legal represcn tat it es ul'a deceased employer. or the
receiter or trustee of an individual, partnership•association or other legal entity,employing employees. Iluwcter the
ner ot'a duelling house hwmg not more than three apartments and ttho resides therein, or the occupant of the
du clling house of another who employs persons to do maintenance,construction or repair stork on such dwelling house
or,nt the grounds or building appurtenant thereto shall not because of such employment he deemed to-to-an-employer.— --
%It 1- chapter 152, 025C(6)also states that "every state or local licensing agency shalt withhold the issuance or
renewal of a license or permit to operated 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, SIGL chapter 152, t25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfumtance of public at ork until acceptable et idence 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 retumed 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 Deparnment 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 rifled 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 Uflice 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
OITIee of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext406 or 1-877-MASSAFE
Ise•,tied >-'0-05 . Fax # 617-727-7749.
www.mass.gov/dia
DISPOSAL OF DEBRIS AFF[QAV'iT
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 work,shall
be disposed of.in a properly:licensed facility as defined,by M. G. Lc. 111, Sec.
15Ba.
die debris swill be disposed at Salem Transfer Stytion
owned by Nor hside Cardno
Signature of Pern'e t Applicant
Elate
christooher Zort►
Name of Permit Applicant .
A &A Services. Inc.
Firm name
115 North Serest. Salem. MA 019,70
Address, City, State, Zip Code
massacbusetts - Department of Public S;ifetc
Board of Building Re,ulations and Sttnil:uds;
Construction Supervisor License "
License: CS 57733
c Restricted to: 00
CHRISTOPHER ZORZY c r
115 NORTH ST
SALEM, MA 01970 S_
Expiration: 5/26/2011
('unmiissiuner Tr#: 14751
�re �ovrrmo�uaealty Be
1T\ Office of Consumer Affairs&BGGsiness Regulafidn
HOME IMPROVEMENT CONTRACTOR
Registration A101609 Type:
Expiration 6/26/2012 Private Corporatio:
A&A SERVICES
Christopher Zorzy,,�,C_;_z>-``-r`_-_;
115 North Street
Salem, MA 01970 fl
Undersecretary
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M.Marlin,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 04/14/10
Exp. Date 04/13/11 g�
DC000440 1'S1J^p Memberof C.O.N.E.S.T,
BO
4 i
IIIIII IIIII IIIIIIIIII IIIII IIIII IIIII IIIII IIIII IIII IIII B=ON-RENEW
�� J�r � Aso,
,, A v/1SinceHad A & A SERVICES, INC.
AAA SERVICES 115 NORTH STREET,SALEM,MA 01970
rITOONA e l 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
iii E\`\bey 710
Buyers)Street Address,City,State and Zip Code
2,?)L t v1AoAja 2A WJ4 AM , BSI q Zd
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
4 78-?1i �5-- 7 °17 C07 7?-e5-7 S-qy d.h
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 hire of the gootls antl serviceumhased as described acorn,regardless of timing or approval of any tin ncing Buyers)may se k for thejr purchase.
✓- O L'Viat^L,S',,f-[l$�"D^-tdGf4ffPiGt-- RQ Nr UM°v'!N/•al oY
Purchase Price: 60 {ru0' "� Est.Starting Date: ��
�{{
Down Payment:3��� ��qNA_UTJ�G{'L't�CiLLkIP( Est,Completion Date:
❑Cash
Amount Due on Start of Job: 111� O Check
❑Credit Card
of Com letion: No.
Amount due on p
Amount Due on_of Completion: �--� Expiration Date:
Balance Due on Upon Completion 1 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 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. Buyers)also
(1)acknowledge that they were orally Informed of their right to cancel this transaction;and(10 request that they be contacted via their
telephone numbers or a-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 ANV BLANK SPACES.
A&A SeR'ICes,IOC./ Buyer s
7
By:
Signature Signet re
/i
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.
ARBITRATION:The contractor and the homeowner hereby mutually agree m advance Main the ahem either party has a dispute benscming this moi either path may submit men dispute to
a priv'a arbitrationservice which has Wen apprw se ry ea by the creta onhe Examined Offersowonsumer Nlalrs en.' ( 0 quslnpss Regulations and Vw Niter path shall be re9uiretl to submit to
such aNlVadon as moved In M.G.L.cA mwA
obscrome„iriila', arers nitieL:
Dow De
{NOTfF OF A(AN F A00 OF CANQ
Date o1 Transaction /IN .Yeu may cancel i,.transazlime.wlremn any probi or DNe el Tramomm, .You mew cancel Mls 4ishome en,will any penalty or
obligation,wiNln three Pl['daysl You ma =eats.If you cancel any proper,hawed in, emission,within three business days from the aWve date.If We memo.any property traded in,
any payments made by you under the Contract or Sale,antl any nummuene Instrument pecomed any payments made by you under the Contract or Sale,and any negotiable Instrument espoused
by you will be reNmed wlNie to do,Iellowlne w acpt by he Seller of your cancellation nptke, by you will be returned within I days following receipt by the Seller of your cancelwast notice,
and any security interest allied out of the transaction win be worries, If you cancel,you must and am mumm,interest armed out of Me transaction will be cancelled. It you cancel,yen must -
makesyibbletomeSellerayourrumanim:insbstantially es good comwer es when received make werampls to me Seller at your entracte.In suhst alry az good wnartbn as when rested.
coy grome delivered b you under this Contract or Sale;or you mad it you wish,comply with Me cry
"dies delivered to you under the Compact or Sam;or you mad n youwish,dimply with the
InsWNshe of the Seller regarding Me earth shipment shipment of Me mous at the sellers a yer end Insttuctlons of me seller horkinding the return shipment of the goods at Me Sellers expense and
risk. If you do make the"dicta eveilable to the Sella eM the Seller does not pick mom up dsk. If you do make the goods available to the seller and the Seller was not pick them up
within 20 days of the date of your Notice N Conscience,you may retain or ensure of the goods within 23 days of Me data of Your Notice of Concelmtioq you may retain or dersoes of the goods
without any Wdberrobligation.Ifyou UlemakalhegmdsaveilabtowMe Selleporifyouame without any further essence, Xyou fall to make Megmtls eveieble to Na Seller.or flourished
to return the goods to the sailer and tail to do be then you remain liable for Performance of all b return the goods to the Seller and fail to do so,Men you remain liable for performance of all
obligaliom under me CoNmR.To cancel this transaction,mail a deliver a signed and dated copy obligations under the Contract.To cancel this transaction,mail or deliver a signed eM dated copy
of the cancellation notice or any of women notice,or send a telegram,to A&A Se 115 of the corrallaton homes or any oNer woman notice,or send a elagram,to A&A Seattle.115
North Street,Salem,Nomechumt6 01970,NOT LATER THAN MIDNIGHT OF North Slrmt Salem,MeuacM1usalls 01970.NOT tATER THAN MIDNIGHT OF
(Dole) lows
I HEREBY CANCELTHIS TRANSACTION, Consumer's Samtue Date I HEREBY CANCEL THIS TRANSACTION. Consumer's Signature Date -
PJ IO Fv
AJx
IT,, /� �p ■/��C�see 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.OS057733
ENTRY DOOR SPECIFICATION SHEET
Buyers)Name Date of Contract
ebr t �� G a
Buyer(s)Street Address,City,State and Zip Code
33 L!P1deU3A _ 01770
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
1 [o `45--(?'—/ — Mk Iq S ,S cI 4`h it kl-F
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 ,^
R�emove and dispose of# [�— existing entry door units. 7
install new entry doors# r Manufacturer 1414c�r` SON
LocationA,Mi�ion IQ
Type: ❑Steel ❑SmoothStar ❑Fiberclassic ❑ClassicCraft Sliding Patio Doo6 0 French Hinged Patio Door of FI C%2
Model# t� Sidelight(s)# Sidelight(s)type/model# V�
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 trim with aluminum coil stock: / Style Color
Hard re: ❑Handelset ❑Deadbolt ®/Footbolt5 ❑Mail Slot ❑Peepsit��/(�6`�5
/Install oak strip at floor as needed. i/ 6 )ASS {/C bE Lew E#' u�• Sf}�
®' CyJk interior and exterior edges. L/ Fel"'dtN /d"�GF�'
0'//In�Iato around new door unit where possible. � y
Q P 'nting is not included.
eluded in this proposal are set up and clean up.+STSP65" I OF I( jc) 6f S
y�Paragt I i.4 cl u dad
STORM DOOR 1-4
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core
❑ Location:
SPECIAL INSTRUCTIONS:
��e t-s Lq-\A-- p V- P>SLIS"A AIiCk�LkAli--AW."l,_M)1f�-
r S R Setu(R 1<1--V 10Ck o, I
om
it
1lAL
hgAtlfelreqs- . �e
o Glean oL(+ ql rdebn`S 'F&-V4 under S+W rOO44 Akd (0
It Is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,coned.
notes 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 he terms modified or varied in any way unless such changes are in writing and signed by both the Botanist,and the Contractor. Buyer(s)hereby acknowledge that
Buyer(s)has mad this Specification Sheet.
Contractor Initials: JL_ Dater Buyer's Initials: Date: y