19 NORTH ST - BUILDING INSPECTION DATE: Bf 30/0(0
�itp Df ar , 1Ra'e5arfju'qPttE; �.
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
1 - Location of Building 13 M D rlh 5haa L
Building Permit Application For:
JCircle whichever applies) Roof, Reroof, Instal ct Deck, Shed, Pool
Addition, Alteration, Repair/Re 1 Foundation Only, Wrecking
Other.
PLEASE FELL OUT LEGD3LY & 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: ," (0p pp- Contractor: C n r; 4 t n n il P r 7.n r 7 yr
Streetd`A V\)OCclt Ed City Street 115 Nnrth StrPat City Salam
State Phone -APU - O nQb State MA Phone(978) 741-049.4
ti
Architect: City of Salem Lic# 14 0 5
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) _ Homeowners Exempt Form_yes_�,/no '
Structure: (please circle) Single Family, ulti l` I 1{ Other
Estimated Cost of job S 18, OCo, co
Will building confirm to law? yes no
Asbestos? es_ / no
Description,of work to be done:
400g QX 1`ifiCQ A= A citC�'.�IM on
- n \IJ _
4k0 .5a VIO
Drawl s witted: ES
es no Mail Permit to: 136 NORTH STREET
X
Signature of Applic 'on,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
Permit fee S /
COMMENTS:
APPLICATION FOR
pA' PERW TO
LOCATION
PE MIT GRANTED
44 19
APP V D
INSPECTO BUILDINGS -
CERTIFICATE OF OCCUPANCY "
YES
NO q'
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 b r Northside Camino _
Signature of Pe it 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
0///COO//�IrOStl08tl09S
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city
phone N
❑ 1 am a homeowner performing all work myself.
❑ i 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 .
address: 115 North Street
city: Salem. 'MA 01970
phone N:. 978-741=Q424 „-4r t�"�•t<'t• r
insurance co. The Travelers oollevN WC939XI256
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
v} + °
company name: a2?a'
address 'l4 :Ut
city:_ hone p•
insurance e : olio N '•FSf!d. -"1 ��'
�y .I]; v
company name.
city: : 'hone N:
insurance co. .
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 51,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statem may be forwar ed to the Office of Investigations of the DIA for coverage verification.
1 do hereby ee jy u r the alrts nd penalties of perjury that the Information provided above Is true and correct.
Signature Date
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/license N 1718ullding Department
❑uceoaing Bard
check if Immediate response is required QSeleetmen's Ocoee
Health Department
contact person: phone N• f-10ther
� ✓6a to„e,,:aMum/N o�,illo„aa�n,,,m. _
eOARD OF eUiLDIN REGULATIONS �
License: CONSTRUCTION SUPERVISOR
Number CS 057733 j
eirthdate 0 512 6/1 958
I Expires{05/28/2I 07 Tr.no: 12633 ; -
ResMctedi, -7 i)
CHRISTOPHER ZORZY f! ,f l$"
115 NORTH 01
SALEM, TH 01970' 1 -
commissloner i
i
'I -7i{eonowr�eal//o�✓�naw.aFaee(�d_.
0onrd of Building Regulations and Mandnnis
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/262006
Type: Private Corporation
ABA SERVICES,INC .
Christopher Zomy
115 North Street 2:;,—J
.. - Salem,NIA 01970 AJministm[or
Ommonwealth of Massachusetts
Division of Occupational Safety
Roberti FYezia' .CO'ho wgxr
Deleader-Contractor
CHRISTOPHER ZORZY
'EB.Date DZD9106
OCO Dale 02/OSr07
DCW O .a
OMO
Wp c[C.ONE.ST.
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