17 MESSERVY ST - BUILDING INSPECTION (2) DATE:
Citp Df E)afem, JRaE;!5arbU5ettE;
O-� PLANS MUST BE FILED AND APPROVED BY THE
"I INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 1`l MP.5S a ✓j'
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Si • ct Deck, Shed, Pool
Addition, Alteration, epair/Repla oundation 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:
OwnersName---DQn)SP, —f( Iy-r.afP, Contractor: Christnnhar 7.nr7V
Street17 ML4&.ry J City Street_11 5 North StrPPt City_Sa7Pm
State Phone (Al ) 3D7 -9&40 State MA Phone(97g) 741 -0424
Architect: City of Salem Lic# 1405
Street City State LicC 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form__yes._,/ no
Structure: (please circle Single Famil}, Multi Family# Other
Estimated Cost of job
Will building confirm to law? yes no
Asbestos?_yes V/ no
Description of work to be done:
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Drawings Submitted: SERVICES
g _yes�L no Mail Permit to: 1.15 NORTH STREET
X ATt.MMA A=B7v---
X
Signature of Application,VIGRED UNDER THE PENALTY OF PERJURY --- • -�� --
CONSTRUCTION TO BE-COMPLETED WITHIN SIX (6) MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee S
COMMENTS:
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SDH-e-35-3=75 rs1. 39D
DI5?05AL 0; D=BRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S54, I acknowledge that as a
condition of Building Permit V all debris resulting iron the
construction activity governed by this Building Perm r shall be disposed of _'
a properly licensed solid waste disposal facility, as defined by MGL c III,
S 150A. Salem Transfer Station owned by:
The debris will be disposed of at: Northside Carting
locatson of fac; " ;r y
Signature of ? rat Applicant Date
Fully co=plete the following information:
(?lease print clearly)
ChriAt6pheicZo;iyc.
Name of Permit Applicant
A & A Services , Inc.
Firm dame, if any
115 North Street , Salem, MA 01970
Address. City 6 State
The above statLj:e 7equires that debris from the demolition. renovation, reha'
or other alteration of building or structure be disposed of in a properly
licensed solid waste disposal facility as defined by MGL cIII. S150A and tha
building permits o- license's are to indicate rhe' iocation of the facility a.r
The Commonwealth of Massachusetts
Department of Industrial Accidents
ONC80//60SU08000S
600 Washington Street
• y
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city phone#
❑ 1 am a homeowner performing all work myself.
❑ 1 am a sole proprietor and have no one working in any capacity
❑ I am an employer providing workers' compensation for my employees working on this job.
company name: A & , A Services , Inc. 5 z v{y i t
address: 115- North Street Olin
city: Salem, M9 01970
phone#• 978-741
insurance co. The Travelers policy# WC939X1256 a " b" 'e S
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers'compensation polices:
company name
address
r ;t'{
city: r' hone#
Insurance co;
policy q
company name AY
addrar ,t, f,R 1�Y+fy::: _
,
tr�'�) tAA }Ilyi
city: ;.: none a:.
insurance co. oolliev q
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up to SI,SOO.00 and/or
one years'Imprisonment as well as civil penalties to the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cord y er th pains and pe allies of perjury that the information provided above is true and correct.
Signature Date �� '•O�(D—f�5�
Printname Christopher Zorzv. President phone# 978-741-0424
official use only do not write in this area to be completed by city or town official
city or town: permit/llcense# I"1Building Department
❑Licensing Board
❑check if Immediate response is required ❑Selectmen's Office
❑health Department
contact person: phone#; f-10ther
T 1
•: .r, �iie 7Oavnmww.EazlQ6 ✓� lLc�tIWBQa .
?� BOARD OF BUILDIN REGULATIONS
License: CONSTRUCTION SUPERVISOR
' '• Number 057733 -
' ' s .i BI ! = 958
�! 8- 7 Tr.no: 12633
—_
Re
CHRISTOPHER p - -
�' 115 NORTH ST
g SALEM, MA 01970
Commissioner uj
/, _._ ____ ✓/fe lJa/nntaau�/val/�ea�✓�.ouJe�d
Board of Building Regulations and Standards
�i HOME IMPROVEMENT CONTRACTOR - -
Registration 101609 i
Expiration,-fih6/2006
qL
'a' ;Type: Private Corporation.
i ABA SERVICESINC j
Christopher Zorry �t
4'
1 115 NortFi Street
Salem;lttA 01970
f Administrator
Commonwealth of Massachusetts
Division of Occupational Safety p�tl14
Robert J.Prozoso.Commissioner
Deleader-Contfatr
CHRISTOPHER ZORZY
Eft.Date OVI' 05
EC.Date 01I13106 06 -
.
DC000440
Muoter of C.O.N E.S.3
BO npI' rr1rr1iiI aaI'tt1
IIM�YIN MN AI��II e1�Wl,IN�III�'YI O,I BOSTON-RENMV