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14 MALL ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Department of Industrial Accidents Xp t I Office of Investigations 600 Washington Street Boston, MA 02111 r ,r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A A S&-rVI a 7 Tyra Address: I I S 1J 0 r+h 5hrr e+ ` City/State/Zip:_15nJ_L.rA M r) 01970 Phone #: j 9713 1 eN I —Ql I a J-4 ,Aree u an employer?Check the appropriate box: Type of project(required): 1.L�/J 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 parser- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have $. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' 13.u]Otber y I n y\f comp,insurance required.] *Any applicant that checks box#1 must also fill out.the section below showing their workers'.compmsation 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. tContmctors 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. —r insurance Company Name: _ t r 1e__ Tm Vp I P Policy#.or Self-ins.Lic. #: W C q%q X 12 510 Expiration Date:—��1111-13 OQ Job Site Address: P9 "01 I J IY -I-e City/State/Zip: 19i'K2, ILIA O M 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 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 np 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 ceR' der the aims and penalties of perjury that the information provided above is true and correct _Signature:. Date: Phone#: cl"IS) �H1 D- I,; ',H 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 G.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employee's: 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 of 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, §25g7)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 numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other thaw 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 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, Sec. 150a. The debris will be disposed at: Salem Transfer Station owned by Northside Cartina - Signature of Permit Applicant 1/E9Z05�' Date Christoolier Zorzy Name of Permit Applicant A & A Services, Inc. Firm Name 115 North Street, Salem, MA 01970 Address, City, State, Zip Code Board of Building Regulations and Standards Construction Supervisor License LI ense: CS 57733 i Aia"fb /26/1958 l s r tc—fi/Z: I2009 7rq 13739 [ i CHRISTOPHER ZO dI I IS NORTH ST Y Z 7 - SALEM,MA 01970 Commissioner Commonwealth of Massachusetts Division of Occupational Safety Robert J.Preaoso,Commissioner Deleader-Contractor CHRISTOPHER ZORZY Efr.Date 04/02/07 Exp.Date 04101/08 DCOOD440 a Nemberof C.O.N.ES.T. BO I0111 III IN111111111111111111111111 Basro EW 12 74 Board orRailding Regulations and Standards I.' . HOME IMPROVEMENT CONTRACTOR Regsstration 101509 %: Ezprration :6/26/2008 . . . J . . Type _Private Ccryora4on A&A SERVICES,INC '.,i. Christopher Zorzy.. .11.5 North Street i Salem;.MA 01970 Deputy Administ' Y' 'JAbae ,an, A & A SERVICES, INC. CEoa`^i 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 - Buyerls)Name Date of Contract EMMA LVADe /-/y—OS Buyer(s)Street Address,City,State and Zip Cade /y ~tj, ST S)¢Gi M/9 of97o Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address 97B-7YS-S1I3 y 5'�8-�oz-! -893/ 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 SpecificaUm sheet end the front 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# Z existing windows. Install # Z_ new .SilN2/S I windows: 'Vinyl ❑Wood (Manufacturer) Options: Style _VA'V4V Grid pattern Color Interior W/f t 7V— Color Exterior Ls Y 7V Glass Type kA -90 Tn/pl,Gs Wrap exterior trim with aluminum: Style Color `It All windows will be installed according to the installation procedures in the portfolio. Caulk all interior and exterior edges. Insulate where possible around new units. X) Insulate window weight pockets if exist,and around new window units where possible. 11 Included in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and out. Building permit included. - BAV/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 units)in its entirety. Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with. u Install window(s)into opening(s). Note: If Bay or Bow installation to include cable support system,new roof system(matching color as close as possible) - or tie into existing soffit system. ❑ Bay ❑Bow ❑Casement ❑Other window(s)to include new interior style trim and new exterior style trim and head flashing as needed. IN Note: Painting and staining not included. STORM PRODUCTS Cl Remove and dispose of# existing storm window(s). , Install news torm windows# 3 Manufacturer 11`14W&VV iientn-ems E L/N�-.o a Style _(��i t„ /Igr-vrtJ Color (.1/ i 7.6 Option Le-µ, CCW ❑ Remove and dispose of# existing storm pearls). ❑ Install new storm doors IF Manufacturer Style Color Type: ❑Aluminum ❑Solid Core SPECIAL INSTRUCTIONS: CYL DH Nip it is agreed and understood by and between Me parties that this Specification Sheet along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,committees Me entire understanding between the Rertles,and there are no verbal understandings changing or mdditylog any of the terms.TNs compact may not be changed or Its terms modified or varied in any way unless such changes are In writing and signed by bath the signals)and Me contractor. Buyeds)hereby acknowledge Mat Buyerm) has read this Specification Sheet. Contractor Initials: Date: Buyer's Initials: ( `� � Date: A & A SERVICES, INC. , A,MES 115 NORTH STREET,SALEM,MA 01970 Telephone:(978)74I-0424 Fax:(978)741-2012 Contractor Registration No. 101609 Federal EIN:04-30911162 Construction Supervisor No.CS057733 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT - Buyers)Name Date of Contrail cMMA WADE /- /Y -OB - Buyers)Street Address,City,State and Zip Code " I y twill4 L ST Y4L'& r M/9 0(970 Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address: 9?8-7vs--sysy 1 1978-67-1-el The Buyers)listed above hereby jointly and severally agree to purchase the goods andlor services listed on the accompanying sp st iflcaflon sheets,in accordance with ' the prices and temps described on the front and the reverse of this agreement and any specification sheets(this"Agreem ill and Buyerts)have requested that such good.or services be installed or provided at Buyer's address listed above.ABA Services,Inc.("Conhailor"),hereby agrees to install or muse to be Installed the products or services listed in this Agreement at the Suyar(s)address written above. This Agreement represents a cash sale of goods and services. The Buyer(s)agree to pay in msh the rest of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyer(s)may seek for their purchase. 2�Car = 2Z 0e '— Purchase Price' 337(�r Est.Starting Date: c Down Payment: 1 d 0 r Est.Completion Date: ❑CEO Amount Due on Start of Job: eck ❑Credit Card Amount due on of Completion: No. Amount Due on of Completion: Expiration Date: Balance Due on Upon Completion: Z 7f 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 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 (0 acknowledge that they were orally Informed of their night 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. DO NOT SIGN THIS CONTRACT Or IT CONTAINS ANY BLANK SPAC By: Services,Inc ip BqK(Sl �� >// !� By: - Signature b. �� nv�E Signature �� � Print Name L� tint 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. a ARBITRATION:no mnVe rarA Me homeaxner herein mUpory aarae in a&..that in theinmewer party has a shourec0xforro9 this mn✓atl,vul party may driall such seems( a pMehe eblhetlon xnew—filch has been approvm Ey Ne Secretary sure,Exec OMm of Conwmer Aaalm and per, Rugulanons ag lno oMar pain hoo nth mpul ed er m l w Man aNlhallan as,.In M G.L c.1I3A. X Crours:'la: V 6ayv91vitialr:` - Uue: ��� I —QQ Ua ���y�r NOTES p NOTr.F nF r'AN aTON x Est of Transaction/-/YV A .rod may camel this tmnse uw,worout any pantry or Dow 0 Transaction/—Hi .you may mrcal Nis moral without any penally or oblgeM1M, Into area business data has Na a.dale,x you Canal,arty propeMtraEeO In, oblaration.within those eusmeas darn from me ahover time.if You canal.am pmpeM dated in, any peymmm made by sounder the cantrura ore e,eho am negoeablehdbumeme.ecuAd any peymeme three M You Under Me Comma or Be.,end any negodebm inalamem ea—,. by you will as reamed within 10 days WIomme dund by Me Sell,of you, msolumn rmuea In You win be mNmm vitnin 1.des mllwiemNipt by Me Sells,M your a.I.- eM any aocrdly lnleraL aivuy uulW Ne tranea.ticn will be COncallad. llyoumnaetyoumusl oho any coCUMy IntIXKI VISIhg out of lna trahsection will bB carcellM. p orde Cnawl Mn som my p wtilabbmer WYou L}ssthis arcsiin,or siddrNa%m 9m ifYou ends ere Me mygrowidblsk Ne Senn at under an,Earmuff or$as,orYym pay mMNm uxfiM r mpsy worMe InygaNnsid..eSal,OuuNer this mrsonsmaele:11.rysy,i11ouwlsione-M - nd anyeass,0 thmPt to r no under NIBrear.s05ek;myoumad Ion t wLsh,w notiormor Instructions I you of Ma ne M mends assume teem shipment of Me the S mrd es sh Pxkfir a antl Mrs. ifMs OI Ma Seller regarding MB let cnie saypment of MB Wads ar d ysllsn ok the and MO, tl you Oo meld Me i you mflo N nw Seller and the Seller dada o bf Mere up nsk. II you do make IM gaW9 evalable to Me Shcar and Na$elbr Ooas not plcF Nam u0 wmartiodapol ihedateotyourufailwlaothegnr weylete tftolcroseblwuaghe wIMIn R00ays 01Na Date Wywr WucdMCanWIIWpn,ypu they retain br dispose of ihegm]s 0 noNeny NdMr bbli Me eeybume dot MBor gCMserNMnkbMaar Perorllyou a ode MMoN any luMmoo Me cSeetnutailr to dos NO gJaYou heiman toefor Per.pnyWaoRe excremental crem lQv b om$ells ca lal to M w.Men yw remain nark ur pBdmmencd o1 ell to dNm NB erd b Ne Se11IX ak tell t ido so,ken you remain IIffile Mr pmtor"edof ell fthe Me Conveys.Totarsalademe o,or uns a reaver to A& senhend edmp5 or MedonsuMer Meeks or mr,o me., a..a delipwn,.A.S,/atedwpr of ins meet S on ,pro or arty to 0 97an refire,Br sand a lele9tam,to ABA$ervke5,115 0l NB Short,Seem, ,a e or any other wrlden mhce,or THAN a Alegre(,b F $e 115 NpN Street Sam,Ma55azhused501g]O,NOT LATER THAN MIBNIGMT OF/—/R—� NOM$trml,$ekm,Messacnu%tA 019]e.NOT LATEfl THAN MIDNIGHr OF ' fide.) loam) I HEREBY CANCEL THIS TRANSACTION. Conaume,'95geturs OaA I HEREBY CANCEL THIS TRANSACTION, Consumer's Signal Date DATE: �itp Df a�a&> TC, a aL U Ptt �a PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED c} Location of Building lj� W a I l VI ► C'�� Building Permit Application For: '(Circle whichever applies) Roof,Reroof, Ins tng t Deck, Shed, Pool Addition, Alteratt n, Repair/Replace,° oundation Only, Wrecking Other: 4 PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Buildings: The undersigned hereby applies for a permit to build according to the following specifications: Owners Name: Cr/110 Wade_ Contractor: AP, A Srrvic;5/C4n > bra Street IH HnI I + City Street W5 ILL-1 5L CityL Icy-, State,'Y) Phone ft) 25 --54M State M A Phone 76, -_O-j A H Architect: City of Salem Lic# 1 H D5 Street City State Li( f)57 HIP I©I(o09 State Phone ( ) Homeowners Exempt Form_yes no Structure: (please circle) Single Family, Multi Family L_Other Estimated Cost of job S �-J%(p. Will building confirm to law? yes no Asbestos?_yes_v no \ Description of work to be done:- -1n51Q11 -hA1 �a 1 VI0(ji YP4I<YC TnSknG 4hvpip 1 QIC U'P ' tSVX M U)IrrjtYal� _ A&A SERVICES, INC. Drawin u mitted:_yes no Mail Permit to: 115 NOR IMA TKL'- �j41-0424: X WW070 1V.A-A ERVR.tS." Signature 6f Ap lication,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX MONT$S OF PERMIT ISSUED DATE No. <O APPLICATION FOR ' PEpMr TO LOCATION ' /j< Y007774 EMT PEIMIT GRANTED APPROVfD c IN8 ECTO�j OF 6UILOINGS _ CERTIFICATE OF OCCUPANCY . YES NO A