2 NURSERY ST - BUILDING INSPECTION DATE:
Cftp of �aYin, aatjuEt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building_:9 /IJV r S PY7 StrP P -f-
Building Permit Application For-
'(Circle whichever applies) Roof, ero , Install Siding, Construct 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 rn nSnrYYJ Contractor: A A S2ryi Us /0-hrin 7DrLLJ
Street oZ nlurSPn 1 �4�7P?� cit♦ 0 JaM Street 1.5 f�(tillln S{r2Q� city_ ��'ilew>
States Phone (8)7�-1J-,59% State MA Phone. q� - q)J [; , d. A
Architect: City of Salem Lic# R)6
Street City State Lic flfj HIP# 10 f LD 0 9
State Phone ( ) _ Homeowners Exempt Form_yes__L// no
Structure: (please circle Single Fami •, Multi Family# Other
Estimated Cost of job S o203J, DU
Will building confirm to law? ✓ yes no
Asbestos? _yes ✓ no
Description of work to be done:
_�r�lncjp- -Lc )O "auares r}F
Drawings Submitted: yes_ no Mail Permit to:
X
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED ."IT:Iu:SL`' (6^1 MONTHS OI<PERt+iIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee S
COPff+lMS:
•M
y .
No.
APPLICA :ION FOR _
' PEAWTn
LOCATION
i .
pu
PE MIT GRANTED -
CV 19
AP ROV�p -.
INSPECTO OF BUILDINGS -
CERTIFICATE OF OCCUPANCY .
YES
NO -
, t
t
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 by Northside Carting _
Signature of Permit 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 oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
klip 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.
companvname• A � A Ge_rOCC5, TnC_
address: tI C5 -44-) 5f'YPr }
city: Sn letr phone#• 19?4 7Ed l yN 2H
inauranceco -The_ —FraklojGf S n^lisy# WCq' Xi 'd.s(p
❑ 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:
city: 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 S 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 maA forwarded to the Office of Investigations of the DIA for coverage verifications.
I do hereby certify and p ins and penaties ofperjury that the information provided above is true and correct
Signature Date 9- /—D(o
Print Name hone# (`,7z 7H I -o H a y
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑ Building I)eptranent
❑ Liareing'13oard
❑ check if immediate response is required ❑ Seie2ing Office
❑ Health Department
contact person: phone#: ❑ Other
(revised Sept 20(13)
BOARD OF BUILDING REGULATIONS
License:, CONSTRUCTION SUPERVISOR
i
i Y Number:*CS 057733
Blrthdate-05/26/1958 I
_ 129004E OS/26/2007 Tr. no: 12633
Restrrct �
CHRISTOPHER 2t§RZYjL 1 i.
115 NORTH ST
SALEM, MA 01970�''<' `
Commlaeloner
'�-' --✓/ee �ommmtovall/z o�.1',oa�ac/uaelta
a�
Board or Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2008
Type: Private Corporation
ABA SERVICES, INC -
Christopher Zorzy '
,115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Rob rl J.P-ezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Ei1. Date 02t09/06O
Exp. Date 02/O8/07
07 y`
DC000440
Member of GO.N.E.S.T. .�
7
n0
IIIN�IIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII BOSTON-RENEW