17 MESSERVY ST - BUILDING INSPECTION (5) DATE: /a- a D 67
Df 'AG'Datem, x �L U Eft
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 1? M e5S(_r V(. SIT e_e_+
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, stall idin onstruct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation 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: npv-)tcP, Il ,rr taftP. Contractor: c n r 1 s r n n n p r 7.n r 7.3z _�__
Street_ I] /i 1PSgP_I Jt City SolPrr� Street 11 5 North Straar City_ga l am
State, MPc Phone 307_agH17 State MA Phone(978) 741-0424
Architect: City of Salem Lic# 14 0 5
Street ,City State Lic#0 5 7 7 3 3 HII'# 101609
State Phone ( ) Homeowners Exempt Form_yes__.,/ no
Structure: (please circle Single Famil}, Multi Family# Other
Estimated Cost of job $_&0,H I o0, OC7
Will building confirm to law? ✓ yes no
Asbestos? es v1 no
Description of work to be done:
Zv1SfGtII -Fo -fhrP_° C�i31 S� i IrzYo� o� t/iv�ia l Srnr r,
DrawinSERAVICES
bmitted:_yes no Mail Permit to: 115 g�Tra NORTH STREET
X
MI TREE&
Signature of Appl' stion,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
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Permit fee$
cOmims: a
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(bat flatr_i 6r"n -
5us-7-35-9:55 Ext. 3HD
DIS?OSAL OF D'c331S AFFIDAVIT
In accordance with the provisions of MCL c 40 , 554, 1 acknowledge that as a
condition of Building ?erm L « all debris resulting from the
construction activity $
ov_rned by this Building Permit shall be disposed o1 is
a properly licensed solid waste disposal facility, as defined by KCL c III,
S 150A. Salem Transfer Station owned by:
The d=_bris will be disposed of at: Northside Carting
location of IaC'_S1ty
Si$n t re of ? = litZAL
Date
sully cocplete the following -information:
(?lease print clearly)
ChkiAt0phei'cSo;iyc.
Name of Permit ADDS-;cant
A & A Services, Inc .
Firm Name. if any
115 North Street , Salem, MA 01970
Address. City 6 State
The above st..,-CLte -e7uirc5 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 MCL cIII. 5150A and tha
building permits or license's are to indicate the' iocation of the fzc_lity at
The Commonwealth of Massachusetts
Department of Industrial Accidents
- OIIIceO/%resU0sd0as
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city nhone#
❑ 1 am a homeowner performing all work myself.
❑ 1 am a sole proprietor and have no one working in any capacity
❑ 1 am an employer providing workers' compensation for my employees working on this job.
A &, A •Services
comoanv name• � , Inc. •, k s , t, 2y�
address: 115 : North Street ., I,;� .�?9����•�,rs'tr.,'�
city- Salem, MA 01970 Phone#. 978-741=9424, ra x
3`Yl/g,w. v yry/•}� �.
insurance co. The Travelers oollev# WC939X1256
❑ 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: f ' ..
address:
rj�
.01
city: hone#•
insurance co; olio N A"...
sat 8 0:
company name
x `
address:
,
eft : 444
"hone#.:.
insurance co.
h 1 ? y
Failure Insecure coverage as required under Section 25A of MCL 152 can lead to the imposition orcriminal penalties of a fine up to$1,500.00 and/or
one years'Imprisonment as well as civil penalties In the form ors STOP WORK ORDER and a floe 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 terrify and t e pa sand penalties of perjury that the information provided above is true and correct.
Signature Date ��'• Ol ���5
Print name Christopher orzv. President Phone# 978-741-0424
('contact
fficial use only do not write In this area to be completed by city or town official
ity or town: permitAicense# flBuilding Department
❑check it immediate response ❑Licensing aoard
is required ❑selectmen's Office
❑Health Department
person: phone#; - flOther
. � .,..----T-- r��_ �iTiGe '�nma�r.�azlD£ o�✓�,oanar/uaelA � ..
BOARD OF BUILDING REGULATIONS
License: -CONSTRUCTION SUPERVISOR - -
II Number,,S 057733
i� Birthtiat
iderA_ -958
7 Tr.no: 12633
'Re
CHRISTOPHER
115 NORTH ST " /!
.E
SALEM, MA 01970 commissioner
r .
?-
i
9 . ✓� IDO�lfMr09r o�aJlI[de�d .
J (� Board of Building Regulations and Standards '
{ HOME IMPROVEMENT CONTRACTOR
i .
Registration: 101609 '
Expiration: 6126/2006
., Type: Private Corporation.
A&A SERVICES, INC
i
Christopher Zorzy
115 North Street ,.,,
i.
Salem,MA 01970 Administrator
t.
;i
Comm
onwea/th�of Massachusetts
DNIS%on of Occupational Safety
RoW J.Frezoso,Commissioner
Deleader-Contractor p�¢
CHRISTOPHER ZORZy Ut
`..: EB.Date 01/14/05
Date 01/13/O6
DC0 0
-. DC000440
Abmbvof C.O.N.E.S.T.
6
80 IIIppI''� NNIIIIIII II IIII ( -
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