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19 NORTH ST - BUILDING INSPECTION (2)
DATE: 4 , Df a49)aUl ' JT1AE;5ALbU5ett5 PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Building Location of Building 19 No t9-h Sire& Permit Ap plication For:A ppl '(Circle whichever applies) Roof, Reroof, Install S• ' ct Deck, Shed, Pool Addition, Alteratio Repair/Replac 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: s i Owners Name: 1-0(q E. Po m IanQp2 Contractor: C n r i R r n n n a r 7 n r.}v Street A)l WoI CpJ4 Rnl City Street 17 5 Nnrrh RrrPar City gp7oro State HA Phone lq'193ULP _noon State MA Phone(978)_741-042.4 Architect: City of Salem Lic# 1405 Street Cih' State Lic#0 5 7 7____3 3 ffiP# 101609 State Phone ( ) Homeowners Exempt Form_yes.�no Structure: (please circle) Single Family, ulti Famil # y Other Estimated Cost of job S- 411to 7 p Will building confirm o law? es_ t no Asbestos?_des V no Description of work to be done: RP la Siu 1 �Innr-1 WinrjoLAie, to I-4-h Six (LA n W�tx� wtr,r-inW� -Fri rnu � x t 41,na Drawing b tt d:_yes no Mail Permit to: 136 NORT STREET - � asr..rer ARA-A�8�6 X � Signature of ApplicUtion,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX(6) MONTHS OF PERMIT ISSUED DATE Department use only: Permit# Zoning Ivtap/Lot Permit fee$ COMMENTS: No. d ©7 APPLICA ION FOR ' PER TO LOCATION PE MIT GRANTED APP OVPp P CTOM OF CERTIFICATE OF OCCUPANCY YES ' NO .: m 4. _ r• ? e The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors name: location: city: state: zip: phone#• work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑ Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition I am an employer providing workers'compensation for my employees working on this job. eompanvname: A Q A SeroceS, T✓ c- address: ll y fJD(Fh �Yf✓Pr l city: 13rt I e—nn phone#• 1 —0JJ RH insurance co —rhL Tra i f S policy# WC q 3Q X 1 ak 6J10 ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers'compensation policies: company name, address: city: phone#- insurance co. policy#• company name: address: cc: phone#: insurance co. policy#• Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement in , be forwarded to the Office of Investigations of the DIA for coverage verifications. I do hereby certify and r h pains and penatdes ofperjury that the information provided above is true and correct Signature Date 9' `06 Print Name hone# 6-7219) 211 -ON ai-1 official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑ Building Deplttnnent ❑ check if immediate Licensing'Hoarde response is required - ❑ Selectmwos Office ❑ Health Department contact person: phone#: ❑ Other (revised Sept.2003) 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, Sea 150a. The debris will be disposed at: Salem Transfer Station owned by No side CarNna - Sig ature ofPefmlt 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 BOARD O� BU N&(EGULATIONS ,1 Lioense: CONSTRUCTION SUPERVISOR Number.'CS 057733 j Sirihtlata 05126tl956 ExPlres-052613007 Tr.no: 12633 I - 'ResWFtetl1 CHRISTOPHER ZORZY - HSNORTHST / t SALEM, MA 01970 i Commissloner I r _i— ✓die i0omk o�✓sI.adlac�iiEe((d Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR - Registration: 101609 Expiration: 6/262006 Type: Private Corporation. A&A SERVICES,INC Christopher Zorzy 115 Nonh Street Salem,MA01970 Administrator Commonwealth Of Massachusetts - Division of Occupational Safety Robert J Pro Oeo,Commksiwm p� Deleader-Contractor mpVf[fY► CHRISTOPHER ZORZY ER.Date 02D9/OB O � Exp.Date 02/08t07 DCOOO4Q Naa bod C O.N E.SA 130 loll 111111111111n'fI11IIW W 1 - &L^rOµaENEWI