115 NORTH ST - BUILDING INSPECTION (5)f
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RECENQ
The Commonwealth of'lrvfARAMe s.
Department of Public Safety, e
t Massachusetts State Building(;oMfp f1A A it' 32
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1.::LOCATION(Please indicate Block#and Lot#pfor locations for which a ssttrreeet�-a4dress is not available)
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No.and Street City/Town Zip Code Name of Building(if applicable)
r.(1 SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration d I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review req, red? Y/es ClNo ❑
Brief Description of Proposed Work: l i1 S la'I I r��S 54,- yi rt-Y/ $i �.-VyG '�a 'r7a✓lf
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑ and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB Cl IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required ❑ or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Comnussion Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street ity/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
[f building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.132.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ dc)- /
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5.-Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereb attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to be t of m wledge and understanding.
Ch✓;5 Zor;r_y ✓�7 aQtn C
Please rfnt and sign name Title ,�n , Telephone No. ate
Street Address City/Town - State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
1
The Commonwealth of Massachusetts
Department Of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information //� Please Pnnt Le tbly
Name(Business/Organization/individual): ry'T' Vl �lr\/ �S /n C
Address: 1 (S N"o.<{ S:+
City/State/Zip: �C�(e—vvl M t 1 )(q�G'
A
re you employer?Check the appropriate boa:
employer with 4. TyPe of project(required):
�_ ❑ I am a general contractor and I
yees(full and/or part-time).* have hired the sub-contractors [10.0
6. ❑New constm-tion
sole proprietor or partner- listed on the attached sheet.1 7. Remodelingnd have no employees 'These sub-contractors have g. ❑Demolitiong for me in any capacity. workers' comp.insurance.orkers'con .insurance 5. 9. ❑Building additionp ❑ We are a corporation and its
d] officers have exercised their Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12. Roof r
insurance required.]t employees, ❑ �rs
[No workers'
comp.insurance required.] 13.0 Other
•Any applicant that checks box#I must also fill out the section below showing thcir workers eampenaadon policy information.
r Homrnwncm who submit this affidavit indicating they are doing all work and then hire onside wntractors most submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy Wommume.
am an employer that is providing workers'compensation insurance for my employees. Belo
nfor w is the policy and job site
imation.
Insurance Company Name:�V�U U Q.� S
Policy#or Self-ins.Lie.#: C)0-4"� Kg (
` � / / Expiration Date:'( �) pL�
Job Site Address: 11 _Ahb- /_f1�t c 5 - City/State/Zip:_Sa lern1 M4 D/ [ 0
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 up 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 certify er he pains and penal8es ofperjury that the information provided above is true and correct
i ature:
Date:
Phone#:
F
ial use only. Do nor write in this area,to be completed by city or town official
or Town: Permit/License#
ng Authority(circle one):
ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
heract Person: Phone#:
` Phone: 978-741-0424
az-zoiz Fax 978-741-2012
A lAl SERVICE
\/ .6(`\V/ ■V_ r 115 North Street
WOMI® U. ® Salem, MA 01970
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 property licensed facility as defined by M.G.L.c. 111, Sec. 150a.
The debris will be disposed at: Waste Management 877-515-2845
c/o Melrose Transfer Station
740 Broadway
Melrose, MA 02176
or
Waste Management, Dumpster Service
at
115 North Street
Salem, MA 01970
� U (V V
Signature of P rmit Applicant
Christopher Zorzy, President
Name of Permit Applicant
FEB 2 6 2016
Date
Certificate No: A044298
_\ THE COMMONWEALTH OF MASSACHUSETTS
.0 EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT
Ir— fI
L� isi DEPARTMENT OF LABOR STANDARDS
v
! 19 STANIFORD STREET, BOSTON,MASSACHUSETTS 02114
DELEADER CONTRACTOR LICENSE
A &A SERVICES, INC.
115 NORTH STREET
SALEM MA 01970
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LICENSE: DC000440 EXPIRES: Saturday,June 25, 2016
IN ACCORDANCE WITH M.G.L. CH. I 11, § 197B(b)AND 454 CMR 22.03,THIS LICENSE IS ISSUED BY
THE DEPARTMENT OF LABOR STANDARDS TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF
ENTERING INTO OR ENGAGING IN DELEADING WORK.
i
THIS LICENSE IS VALID FOR A PERIOD OF ONE YEAR.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR WHEN ENGAGED IN DELEADING
WORK IN ACCORDANCE WITH M.G.L. CH. 1 I I § 1976(b)(2)AND 454 CMR 22.03.
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WILLIAM D.MCKINNEy,DIRECTOR
................/U // /�<.-✓/, Massachusetts - Department of Public Safety I
.�� / � � Board of Building Regulations and Standards
Office of Consumer Affairs&Business Regulation 1
HOME IMPROVEMENT CONTRACTOR + """"""`' ' '•'"�r '
r�!Registration: 101609 Type; License: CS-057733
L1� a
;Expiration: 6/26/2016 Private Corporatio X12
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CMUSTOPHER 2;0
P/e A&A SERVICES, INC t/f 115 NORTH ST ; § ¢ c
f a Salem MA 01970%
Christopher Zorzy
115 North Street
Salem, MA 01970 Undersecretary " i��7� t1 Expiration
i Commissioner OS/26/2017
A&A SERVICES, INC.
115 NORTH STREET
;SALEM, MA 01970
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