4 OUTLOOK HL - BUILDING INSPECTION + ` DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
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Building Permit Application For: Location of Building
'(Circle whichever applies) Roof, Reroof, Install Siduigf.Qnstruct Deck, Shed, Pool
Addition, Alteratio Repair/Repl 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:—rnm ec-f-a -j l p h Contractor: C h r i c t o n h a r Z o r n y_
Street 14 OLHOfltv) lhll City,�lem Streel115 North Straat Cily—salam
State_H/i Phone 01g)_'7yy- S State MA Phone(978) 741-0424
Architect: City of Salem Lic#L 14 0 5
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ). Homeowners Exempt Form_yes-y/no
Structure: (please circle Single Family, Multi Family# Other
Estimated Cost of job $ , 0'7,�3, 6-0
Will building confirm to aw? ✓ . yes no
Asbestos? es no
Description of work Tobe done:- TnS�/i/1 Dno �/ � YPn/�/D/ytyn� P/7f� 1
Drawio u mitted: es no Mail Permit to: 1•lb NOR.STREES ET'
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X
Sigu re of Applictfion,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$
CON ENTS
�1
No.
APPLICATTION FOR
' PEAW TO
Y
LOCATION
PE MIT GRANTED -
APP Vfp
CTOM OF BU DINGS _
CERTIFICATE OF OCCUPANCY
YES
NO ,
•
DISPOSAL OF DEBRIS AFF
IDAVIT IT
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 Statlon
owned by Northside Cardna _
Signature okPr—m—ifttAppa licant
Date
Christopher Zorzv
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street, Salem MA 01970
Address, City, State, Zip Code
w
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
oxceo/%resagompos
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
name:
location:
cif
Phone q
❑ 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.
comoanv'name• A &, A:,.•Services , Inc.
address: 115 North Street MA .? >P+''-
city: Salem', NA 01970
phone#• 978-741 0424•'> s .ti�� nmr* :r""!i�•
insurance co. The Travelers oolicv# WC939X1256 i
❑ 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: .
company name:
address: � 1t
city: hone#: r .,
insuraneaco: • ' DOliCV# +" z, '`"titsi• t ,
f SP J. IJi
company name:
city: v : t6honeM �,.r,`i�xa;.,.
1:
insurance co:..' oli p is . xa �i
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$1,500.00 and/or
one years'Imprisonment as well as civil penalties in the form ors STOP WORK ORDER and a fine of SI00.00 a day against me. Iunderstand that a
copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification.
t do hereby certify a de j1paints►�and`penalties of perjury that the Information provided above Is Imeand correct. /,,
Signature i Y�1 Date & ,a 10 �0fa
Printname Christopher Zorzv, President Phone# 978-741-0424
oBlcial use only do not write In this area to be completed by city or town official
city or town: permittlicense# rlBuiiding Department
❑cheek if immediate response is require) ❑Liceasing Board
❑Selectmen's Office
❑Health Department
contact person: phone p• f'lOther
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
- '� Number: CS 057733
Birthdate: 05/26/1958
Expires: 05/26/2007 Tr, no: 12633
Restricted: 00 .
CHRISTOPHER ZORZY
115 NORTH S 0 G-
SALEM, MA 1970
Commissioner
,� ;��%K' t/JP4l2we(m.IOia�C�, c�w�/t�A�r[J¢ll4
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
J� Registration: 101609
,-
Expiration: 6/26/2008
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Roberl J.Prezioso.Commissioner f Va
Deleader-Contractor
CHRISTOPHER ZORZY
E Date 02/0 / O
Exx p.Dale 02/08/07
07
DC000440
Wmberof C O.N.E.S T. 7 .. t
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