23 LINDEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of 131,111ding Regulations and Standards \Il'Nll l.l'.\I.I Il
N9assaehusctts State 13uikling Code. 780 ('MR. 7 ' edition til'
Building Permit application To Construct. Repair. IZenosate Or Demolish a
KcrurJ li,nu ,n
One'- or T ro-Family Dwelling / -rfl6S
---�
This Seciiun For Official Use Only ------- I
Building Permit N h r. Date Applied:
\ Sl analu'e
Build g Conuniesioned Inspector of Buildings Daic
--1
SECTION 1: SITE INFORMATION
1moperty :address: 1.2 Assessors Map & Parcel Numbers
l ii= 4frPP�
1.1 a 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 It) Frontage(li)
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. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'!
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
1 Owner of.Record:
Narrinn - W Address for S�u�
�Sienature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repuirs(s) ❑ Alteratien(s) Addition ❑
Demolition ❑ 1 Accessory.Bldg. ❑ 1 Number of Units--I - Other ❑ Specify:
Brief D scription of Proposed Work-:
V
06 S Y'!
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building $ L, 60 I. Building Permit Fee: $ Indicate hum fee is determined:
❑ Standard City/Town Application Fee
3. Electrical $ ❑ Total Project Cost' (Item 6) x multiplier x
i
3. Plumbing S 2. Other Fees: $
4. Mechanical IHVAC $ - List: —
i
5. Mechanical (Fire S Total All Fees: S ---
Su . ression) -
Check No. Check Amount: Cash
' 0. Total Project Cost: $ �9 yC1o. --
- J " ❑ Paid m Full ❑ Uutsrmding Balance Uue:___.____
SECTION 5: CONSTRUCTION
�2SERVICES
5.1 Licensed Construction Supervisor (CSL) 5-77J _ — - _ � 1P�0/p
Uccn,e Number I.s Pirauun Dale
tart P_t'
Name of cSI - I]older 1_ut C'SI. I's Pe (,cc below)
ID
I ih DcsCri'(lon
lid re. l t'nresincled of t m IjMOO Cu. R.i
R Restricted I&'_ Farad, D,kellllig
Si cnatu e .O M \I: iJenl OnIN
RC ReslJenual R oullne('osenne
Trlrphonc N'S Rc,ldrnlial \Vmdo" .ind SLJinc
5F Rc,licitiul Solid Fucl liunon❑ \ Thaucc lu.l.ilLui��u
. p Re,iJenuul Urnndw.m
5.y� Rei�t gered m Iloe Improvem
ent Contractor (HIC) 1 u 10CP _-
ft f'� rJ lUr ` Ti1r Registration Number
li IC Company Name or 111C R• isnant Nnne
Add •s fq-181741—Dl4a-J E.cptratiun Dane -
Sienature ! Telephone -
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
- — Signed Affidavit Attached? — Yes .::.-. . ------ No '.......
13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN'.
_
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 e/ - , as Owner of the subject property hereby
authorize f 151mTUI`1Pl" zO(-ZfJ1
to act on my behalf, in all mattei:s
relative tom+`vork authorized b�this buff ing permit application. l
Date
Signature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
7�r7 as Owner or Authorized Agent hereby declare
[,
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge an
behalf. pp.
Print Nme r
Dale
Signature of Owner or AullhoriLCU Agent
ISiened under the 2ains and enalties of er'u ) NOTES:
1. 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 Home Improvement Contractor (HIC) Prollram), will Prat have access to,the mbitranun
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 C•MR Regulations I IO.R6 and I IO.R5. respectively
' When substantial work is planned, provide the information below:
(including garage, finished hasement/attics, decks or porch=
Total floors area (Sq. Ft.)
Habitable room count
I Gross living area i Sq. Ft.)
Number of tiieplaces Numbe Numberof half%ha:hs
r tit bedrooms
_ - -
Number of bathrooms
_— -
rvpe �:f healing system Number of Jeeks/ porches ---_-----
TvEnclosed
pe of cooling S)'stem -
3. "Total Project Square Footage" may be substituted for "Total Project Cost" J
The Commonwealth of Massachusetts
Department of Industrial Accidents
~�A a Office of Investigations
4 ll II, t 600 Washington Street
Boston, MA 02111
t' 7s www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual): A Q. A SorV1(Q S Tr-)
Address:_ I I S rJ r+h .SL e F \
City/State/Zip:�}n ICI 11 Df 970 Phone #: J °I�$ 1 r/1 I I — Did a JA
Are an employer?Check the appropriate box: Type of project{required):
1•LJ I am a employer with�� 4. I am a general contractor and 1 6• New construction
employees(full and/or part-time).* have hired the sub-contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp. insurance 5. We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3;I] lama.homeownerdoing.all-work-• right of exemption.perMGL------ - 1.1..0.Plumbing-repairs or additions - - - - -
_ . Myself P § O -
y [No workers'.comp. - - _: c. 152, 1 4 ,and-we have no- 12.� Roof repairs -
insurance required.] t employees. [No workers' 13.�Other
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 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: 1 v>e__ Tro Ve I.p 1•-c)
Policy#or Self-ins. Lic.#:_ �/(�' q�Q X 1 o Expiration Date: q '1'' ) C R
Job Site Address:_ 3 I mil ) �'�} P P City/State/Zip: iS�/�P/ f})j� /�jC�7O
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
tine up to$1,500.00 and/or one-year.imprisonment,as well as civil penalties in the form o 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 de the ins fid penalties of perjury that the information provided above is true and correct
Signature: Date S>// logl
Phone �"f8) ''//-II - DHa14
F
use only. Do not write in this area,to be completed by city or town official
Town: Permit/License#
uthority(circle one):o f Health 2,Building Department 3.City/Town Clerk -4.Electrical Inspector-5. Plumbing InspectoYPerson:
Phone#:
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'conracting 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-Gompanies(LLC)or Limited-Liability-Partnerships-(I LP)-with-no-emptoyees other dl& the
members.or partners,are not required too carry workers'compensation insurance. If an LEC or UP 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 bum 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 ext406 or-1-877-MASSAFE - -
Revised 5-26-05 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 Number is that the debris resulting from this work shall be disposed of in a properly licensed facility as defined.by M. G. L. c. 111, Seca
150a.
The debris will be disposed at: Salem Transfer Station
owned by Northside Carting -
Signature of Pe it Applicant
gli lob
Date
Christopher Zorn+
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street. Salem, MA 01970
Address, City, State, Zip Code
✓- ��cr� ✓l2Qaaaa ! ,
Board of Building Regulations and Standards
Construction Supervisor License
i
- License: CS 57733
Birthdate__5/26/1958
Expiration 5l25/2009 Tr# 13739 1�
Restnction 00.- � �I
CHRISTOPHER ZORZY a y
115 NORTH ST �';,.•`` % "�— �� ��
SALEM, MA 01970 -` Commissioner
✓/e 1�ioanrnanareaC!!ri o�./G1cr�aaclzuaetto
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2010 Tr# 267870
Type:. Private Corporation
A&A SERVICES, INC
Christopher Zorzy,` ,I `
115 North Streets
Salem,MA 01970 " " Administrator
Commonwealth of Massachusetts
.. Division of Occupational Safety
Laura M Marlin,Commissioner �u
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 04/09/08
Date OM08/09 DC0 �
DC000440
Wmherof C.0 N.E.S.T. 09
130
(IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII BOSTON RENEW
• l
vv :ram M A & A SERVICES, INC.
SVIOFS 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
SPECIFICATION SHEET
Buyer(s)Name Data of Contract _
WMIe& 2Z
Buyerts)Street Address,City,State and Zip Code
L� AXIS S4Wiisi 48A , nt9-70
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address -
C 7S8S7 R• 97Ff-74S 4
The Buyens)listed above hereby joingy and severely agree to pureness the goods and/or services listed below,In accordance with the press and terms descrMadI on
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is apart.
Cdl72A}-� SPECIAL INSTRUCTIONS
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It la agreed and understood by and belwesn the"Idea Mat this Specification Sheet,along wBh CUSTOM REMODELING AND IMPROVEMENT AOREEMEfQ epnetlMtae
Me entire understanding between Me pardes,and More am no wrbel understandings changing at modltylog arty of Me terns.This contract may not Ee changed or be
set a modified or Varied In any way unless soon changes are In walling and stereo by been Me Buyerho and Me Contractor. Buin r(s)hereby acknowledge that Musette)
hew rased this specifiratlon Sheet.
Contractor Initials: SL+ Date: � Y� - Buyer's Initials: Dater -
^ �zofZ
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A & A SERVICES, INC.
Aare SUM 115 NORTH STREET,SALEM,MA 01970
a Telephone:(978)741-0424 Fax:(978)741-2012 '
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.GS057733 - -
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(s)Name Data of Contract -
b_CA - (6K-A- 7 zz o
Buyer(s)Street Address,City,State and Zip Cade -
a3 L�,deal 5- . S 1 4III
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
c S 6 ,q
The Buyerys)listed above hereby jointly and severally agree to purchase the goods andlor services listed on to accompanying specification sheet,In accordance with
Me prices and terms described on to front and the reverse of this agreement and any specification sheets(this'Agreement),and Buyer(s)have requestetl tat such
goods or services be installed or provided at Buyer's address listed Boone.A&A Services,Inc.('CoMreclpr7,hereby agrees to install or cause to be installed the product
or services listed in this Agreement at to Buyer(s)address mean above. This Agreement represent a cash sale of goods and services.The Buyers)agree to pay in
cash to cast of to goods and servic s purchased as described herein,regardless of liming or approval of any andng Buyons) a seek for tAr purchase.
-cE_ roNa1; + . xn-1- a R73"
Purchase Price: Ltqo Est.Starting Data: xs
11
Down Payment: Est.Completion Date: "�
O Cash
Anne uM Due on Stan of Job: ❑Check
O Credit Card
Amount due on of Completion: No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion: CVC Code:
it Is agreed and understood by and between the parties that this Agreement,front and back and any addendum,constitute the entire
understanding between the parties,and there are no verbal understandings changing or modifying any of the terms of this Agreement
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 that written above. Buyer(s)also
(1)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-mall,as listed above, In the event Contractor believes Buyer($)would be Interested In any additional quality
products or services of Contractor. DO NOT SIGN TETS CONTRACT IT IT CONTARNS ANY BLANK SPACES. _
A&A Services,In IB,zr��)\\
Vim^U / _
_ 6y. Signature Si mat - --
Print Name n'n�t 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
transacgon. See Me following Notes of Cancellation form for an explanation of his right
ARBITRATION:The convenernt FT a Me nenner ree tnMel,e0ma In cenem'e Men In Me were dNer Nutty
res a deb m m rceN mgatl,g Pb seer ever MY &MY event sconce to
apense arElEaWn once enrich has teeen approved b,Me Secretary 0 He E—Ave Men N Cortaumv AHers ant Melne»ReOUMtlma aq tln atl,v PenY aeon W n eulRd Is eerie b -
mMaestrelenupmae]InMoIc.fa]A.
GOW[Imiwteb:1' Ue4:Men,
NOTI- n�F FR'ANcs I Al. Nr1T L'F O a1� r
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b rtWm MapWeblee$ellvu IMN,o»,NB .m1Maln v.,»HNoMxj le4 to mNm Hb gene Hneres. ant letbd,m,Men yW,amen lbWe br PedomurB»of all
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MIDNIGH]OF /`°r.f
(D.) (D.)
I HEREBY CANCEL THIS TRANSAmION. e1e I HEREBY CANGELTHISTRAH$ACTON. Co�SS mans bete
I