14 MALL ST - BUILDING INSPECTION (5) N4` -�
APPLICATION FOR ^
Lti I'm OUT
s;
LOCATION
a - -
PE
MTGRANTED
APP OVfD
S ECT OF 6 LID
INGS
CERTIFICATE OF OCCUPANCY .
YES
NO k
The Commonwealth of Massachusetts
I Department of Industrial Accidents
i 'If 11 Office ofInvestigations
i' N 600 Washington Street
�tse� Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Ai�. A Cje r yi ea s Tn o—
Address: 1 1,r i Q o r+ ) Sine e+
City/State/Zip:5(21 2,W1 , M 1q 019"70 Phone #: l 01?3 1 '71-I 1 — DPI 9,H
F
pu an employer?Check the appropriate box: Type of project(required):
J I am a employer with 4. El I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
I 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 10.0 Electrical repairs or additions
3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.dOther V V j t/Y' o
comp, insurance required.
*Any applicant that checks box#] 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 anew 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 our an employer that is providing workers'compensation insurance for my employees..Below is the policy and job site
information. —f�-
Insurance Company Name: _ r`e__ Tro yO I is
Policy#or Self-ins.Lic. #: WC_' Cl 3P X r /1 1 l L I a [0 Expiration Dater 13 Doi?
Job Site Address:-IN, rk l.I I Sh'pel r City/State/Zip: R 0070
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 tip 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 cert u deer rhp pains and penalties ofperjuty that the information provided above is true and correct
Sicnature: / [// Date- Z&,Z2.3 AD 7
Phone#: 0-18) 7H 1 D H a lA
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#
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 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,§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 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 Carting -
t4l
Signature of P rmit Applicant
Date
Christopher Zorzv
Name of Permit Applicant
A& A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
�/ee '�oarrvnxanafe¢�/ o�./flainor/eueelg
' Board of Building Regulations and Standards
Construction Supervisor License
License: CS 57733
BidFi57a_t'e sr�6/1958
'.� 7EtCEkmisrt�—. 4.� /2009 Tr# 13739
CHRISTOPHER ZQfm_— V
115 NORTH STv } �i
- SALEM,MA 01970 Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prezioso,Commissioner aqA.
Deleader-Contractor d
CHRISTOPHER ZORZY �a
Eff.Date 04/02/07
Exp.Date 04/01/08 ._
DC000440
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Board�\ Board opolding Regulations and Standards
. HOME IMPROVEMENT CONTRACTOR
Registration 101809
Ezptration 6/26/2008
Type. Pnvate Corporation
. I A&ASERVICES,'INC
Christopher Zorcy:'
115 North Street
i Salem;-MA 01970 Deputy Admims r ,lcr ; .
. =SUNRISE Look for the
AiRWINDOWS.,
The Difference is Clear!, NFRC Label
The National Fenestration Rating MM
hdovvs
Council's (NFRC) Energy Performance Nyalluuded.DDual Gw ,drH1l
'u,u M..Warm Edge spacer
_ JHWYMPGlabel is designed to help consumers ma-= Mudua Type:V.rdca1511da
[CITY MPG PG Frodua Number 0003)
�� measure and compare the energy ENERGY PERFORMANCE RATINGS
19 performance of different window IYFaMrNSA:F) 5DIrHea[GWn CoeflidMbrands. Just as the EPA sticker on a 0.31 0.37
new car will ive ou a uideline to the AODRIONitiam ORMANCERATINGS
AGueI Milerada;oal .ftd.`scoptloonudde 9 Y g VlsaakTranvnittance Air Leakage N.ur71lbllq M1adb eM vehlGa!cOMHlopoRbd 0.54 0. 1
toERalddl�ethatt.ma,be,athe calls fuel economy, the NFRC label on
n iM1edhaddbann.en28andaamMa, a window gives consistent ratings that c���aResura�The higher Ne gas mileagr.
can help consumers determine both 54
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Inter and Summer performance
R.�eM„Mla♦,mb.1 W nbY.FmPbs/Ib®3,
characteristics.
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row
I
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e> „ The Ditterence is Clears. d .-
I te1 NFRC rsummer Z '
FQ� Sunrise Windows Solar Heat Gain
a
Vinyl Extruded, Dual Glaze, Argon Fill ,°CoeffiClent "
NenorwFenestrati
lnthewlNTER,the on Ultra U Plus, Warm Edge Spacer
lower a window's overall Rating CouncilSHGC
U-value,the less heat MEMO= Product Type: Vertical Slider -
youwilllosethrough Product Number 00037 in the 4l iNINIER,a R'
that window. toyver S G means less
xLe' ENERGY PERFORMANCE RATINGS solar radiation is }
va tie�@ yg: admitted throii
use Tess ea" - r . Y°ur
- actor(U.5✓I- Sr'a6( 2atGainCoe icf �t window Your home
ur o saving you will remain cooler and
more,since your furnace our air conditioner will
isn't running as much. O 3 1 Qo 3 7 not have to work as hard.
ADDITIONAL PERFORMANCE RATINGS
Visible Air'
isible Transmittance eakage (U.S - 0
Transmittance :Leakage
Visible Transmittance O . 0 ■ E��&n.
older t e number,
(VT)measures how ranch h t°braesCondensation Resistancegh The lowest
through a product. The number the government
higher the visible assigns is a.I and
transmittance,the less Sunrise Windows
tint there will be to the 54 actually are even lower.
glass. A higher VT
piece rate Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole Windows with an air
ensures a clearer product performance.NFRC ratings are determined fora fixed set of environmental conditions and a leakage number
of glass. specific product sae.Consult manufacturers literature for other product performance information. above.3 fail this test.
www.nfm.org
Actual test sample .03 air leakage.
f041107 SS7-V3
da"r ao A & A SERVICES, INC.
A�kAsamcES 115 NORTH STREET,SALEM,MA 01970
B• 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)yName Date of Contract
NttwL s ' ,�- IQ o -'
Buyer(s)Street Address,City,State and Zip Code
14 ft 1) 54, u vi a Z c) rg7,6
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
61"7 8 2, ZLF a
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.
WINDOW REPLACEMENT
Q/Remove and dispose of# 2— existing windows. /-klA5ft7, V f111��
�
rd Install # 12, new Sir ar1 B F- windows: BVinyl ❑Wood
(Manufacturer)
Options: Style Vkn�lutd Serial Df F Gridpattem o r c Aa
Color Interior W1 6�?_ Color Exterior G2 Glass Type V OTA —
Zrap exterior into with aluminum: Style Color
—
Ailwindows will be installed according to the installation procedures in the portfolio.
Ca I interior and exterior edges.
n e where possible around new units.
Ins ate window weight pockets if exist,and around new window units where possible.
wInc uded in this proposal are set up,clean up,Hepa vacuum and cleaning windows inside and out.
Iding 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 units)in its entirely.
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: It 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
flare: a needed.
V_Y Nlots: Painting and staining not included.
STORM PRODUCTS
❑ Remove and dispose of It existing storm window(s).
❑ Install new storm windows It Manufacturer
a
Style Color Option
❑ Remove and dispose of# existing storm door(s).
❑ Install new storm doors# Manufacturer
Style Color Type: ❑Aluminum ❑Solid Core '
SPECIAL INSTRUCTIONS:
k¢ 11 A6" Riwie- inferior der g &-4v-1.—Q4
'TAl 9 If Neal aritndn d ptkl? Pk+e� Icnr 14121faellir' y }cv�ls t/5�9s N�zderl,
C-,Uk1l K&� hey s// So lift rfIi I --A21rC a 'I1 Aiii 13e &1cker
uOdQf 5;11 on/ Krtclwy"win�vvy Wifl1 /(stc� -
It Is agreed and understood by and between the pardes that this SpacNlcation Sheet,along wife CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the entire understanding between the planes,and there are no ranged understandings changing or modifying any or the term& This contract may not W changed or he
terms modified or varied in any way unless such changes ere In writing and signed by both the ethernet and the Contractor adjoins)hereby acknowledge that Buyar(s)
has reed this Specification Sh st. / l
Contractor Initials:__. -�� Date: /d/�-/p� Buyer's Initials: Dater&.
dwN
W� y n / AD,.. <J samends A & A SERVICES, INC.
&ASERMCE-3 115 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.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer(s)Name Date of Contract
'IkI- $A fiN Iv o
Buyer(s)Street Address,City,State and Zip Code
fi� f ,
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
- - sa
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed an 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-AgreemenC),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 Me products
or services listed in this Agreement at the euyans)address written above. This Agreement represents a cash sale of goods and services. The Buyer(s)agree to pay in
an the cost of the goods and services purchased as de/scribed herein,regardless of timing or approval of any financing Buyer(s)may seek for their purchase.
Aall E G
Purchase Pric Est.Starting Date: Alov 16
Down Payment! Est.Completion Date:
O Cash
Amount Dun on Stan of Job: O Check
Credit Card
Amount due an of Completion: O.
O
Amount Due on of Completion: O Expiration Date:
1
Balance Due on upon Completion: �P 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 Mere 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
(I)acknowledge that they were orally Informed of their right to cancel this trensactlon;and(II)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 TIIIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
as A Service, A / B s ��—
y Signat��urLhStOtN� y S�gngjj I ,r
' Print Name Pratt Nama -
Signature -
Print Name
You,the Buyer(s),may cancel this transaction at any time pdor 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. -
M
ARIMINATON:rim pempeopor and Me tmmeownme heron,muuellY aprm in aaaope main ter event either prom,has a manse mnpem119 Mia wnaazt,outer petty,may submB audit aspuo m
a c aromatic
nor e aeMte wN ma neon apPrwen nY tM SevTery M Me ExeoArve 011ke OI COrvwmm Flleln aW Bu9ress Regulmbna antl the OMer pact ehyl foe 90uirea b sunmil t0
ouchh aromaticnitremappnnor WOvea In MG L c 1npA. Cenovcm Wtielc���''11�� ery.'e Mitiab'.�'— Q<d
oar: Deer: 'tG
ON
rraoaaar,o ode a Towanda . ou may mu may anal Mi.�renanclan.wmtpw v�y newly m wOn y N ow d -1.,a pr nfordel ,wuwul am put.,or
a Ore..,wiMln Mreen days term Me sew.led.Il Youramm.an/plppeHybaeeelm rdb...witn o lame bosons my.from Me above hate.If yoummr.dry plupeM bored in,
ne,carmal made,many.,me contract.1 Safe,awe my ooved..Iralmmole exedMee any paymedd mere ay You under the eomod or seta,and my repoaame remember mandane
err you will be mama.MMm 10 dye Mlmrme o<em Iry me seller a year dadcermuon name. Iry you eau de odmed adon 10 Man®r Roden rmeim by to Sewer of your wwnlabon policy,
and are ssmrria III airing our of Me tmradner will be remained, a you anal,You mum and any aemdro Interest alder,out of Me mammon yal be otcelled, a You—1.you mum
maw,resume tots seam m your r.uemr.In subsa as pore mmlnon as aver rspeivoe. make aysmme to me Dauer.year raaeerad,in mrmmnnsry as poor mmlmn m ohm rmaivee,
my gWa4 derMred to you War Mia Doomed of Selo:or you may,it you Mah,domprywlth Me arty gCWa delivered m you under time Compord,or Sale or You mey,If yea veer,dompof Me
extromms Of Me Seller mg.Ii,the mum Miee.OI to nA]a.Me Smbm ofi—and Irlabu T era of Me B.Ib,reammed IM mum minew.W 1M not at He Sellers eagerla act
hsk. II you do make the prcQe doolenla m me Sells antl me Sell..not fork Mein up hake If you m make the from aaalable to Me Seller and Me Seller Wit not qG them up
warm M day W Me d.901 year Name of prncelMtlon,you may mein do diypa of Me gWaa upin 10 do,of Me drop Ol yWr Nold.on.—Itla..n,you dry releln or Map,ae Ol the D.
eimON any droner obYgalOrt It you fail l make Me gmde OmIf b Me Salim.or if you n y agl wasual any NlMar assaon,If you fail to maw and
gE Baker
s available to Me Bar or it you agree
to mum Me tpma to the$elms um fyl m do a0,hied}ma—am.a or pNmmarco of sl 10 ommonthe gaH.e to the Seller and or to m m,Men you mmvn rede lea performance of al
pmyamnamaermecommMl ommarinialrenaxmn.mats oramiv.r.signed anaaereompr omgeuons under ire calton.To Copped his tmnambon,mat or down a spits and dared spy
of Me compliance mum a any after wMon nits,or cone a bondsman,to ABA 11s W Me-monsoon mtic m a any pope wriflen rati orh m to A it o. sear a are . Sunni s
m from Stand,SBIB .MaeBMaM 1AT u 01970.NOT ER TIAN MIDNIGHT of �1��7 Na-Saw/Baum,Meammumds.1 and,NOT IATER THAN MIONICM OF _
(ode) / / (oast
I HEREBY CANCEL THIS TRANSACTION. Cantu r'a Dgmlure Date I HEREBY CANCEL THIS TRANSACTION. COnwmmff SgmMe Dare
DATE: /D�o73�D7
Citp Df �YQTTC, � �LUEtt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building /Y 1117Q/�SQef
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install ct Deck, Shed,Pool
Addition, Alteratio , e air/Replace, 7oundation Only, Wrecking
Other:
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: Pal)! BGiomrllrld Contractor: A e A 5e-rviu5'�t I
�n5 61-
Street Citv&btn Street .li5 f-nr4h -2, City--.E T�
State Phone (b17) gq 5A State M A Phone,
Architect: City of Salem Lic# Li Q5
Street City State Lic 0`J1 HIP f, I D i to 09
State Phone ( ) Homeowners Exempt Forrm_yes__J,/no
Structure: (please circle) Single Family, Multi Family ,LOther �000IO S
Estimated Cost of job S
Will building confirm to law? yes no
Asbestos?_yes J no
Description of work to be done:
kg5 011 hA Jeer? ( 12) y` Y a�Q'01tckmgm ► irdow'6
A&A SERVICES, INC.
Drawiu Submitted:_des no Mail Permit to:R 1 SA.LEM, MA 01970
v ro�ai 741-042d:
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE