6 RIVERBANK RD - BUILDING INSPECTION DATE: (y- 27-07.o
�itp Df `9)a1P' 7, �S AL U�Ptt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building Permit Application For: Location of Building to Anne -F)anK Rrnri
YCircle whichever applies) Roof, er Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, epair/Repla 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. Contractor: C h r i R r r,n h P r z Q}r,,7 V_�__
Street_65 Rnl 1 mrT �a City n :int Street l 1 5 North S t r P P t Cif
State Phone (qq8) 7HN - 0314FjiA5' State MA Phone(978) 741-0424
Architect: City of Salem Lick 14 0 5
Street City State Lic#0 5 7 7 3 3 H1P# 101609
State Phone ( ) Homeowners Exempt Form_yes__.,//no
Structure: (please circle) Single Famil - Multi Family# Other
Estimated Cost of job S _ 1 !5, j}Q
Will building confirm to law?-z—yes no
Asbestos?_yest/no
Description of work to be done:
Zil�ifQ(I 61K ( 4 wail (rPnlote neH Wl(i lfl �
pi"Wce_ eui,�Lq VrzDF u)ifh &u& r iLTM- Arci)4eciura.l
SERVICES
Drawin s S in ed _yes no Mail Permit to: 1.15 NORTH STREET
% eT.E.M"A-AE8�9
X
Signature of Applic Non,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:
No. / U,�_,�G ;
APPLICATION FOR
' PPpMM Tn
6-7XI P d le�oe&v
LOCATION f: _
PE MIT GRANTED
APP VP
G ..
P CTOP OF 6UIL INGS
t
CERTIFICATE OF OCCUPANCY
YES
NO
v
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the r p ovisions o. 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 Cartina
;ignatreu'of P rmit Applicant
lD 17 -OZo
Date
Christoeher 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
Now Department of Industrial Accidents
Off/CO 0//OYOsUpB//00s
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city nhone#
❑ I 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#• 9 7 8-7 4 1 0424 ,• v .� ���` •f�sxti "�`r
insurance co. The Travelers oolievN WC939X1256
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers'compensation polices:
J,Cir�h+11 •v,'MGC
company name: - �tit�� ,t '�✓ y�
O 4 '
e ± w tt
address: i`i P.sSst�sn :v!
i ,f �•M
city: ,.:. hone#• 1 i-.1
insurance co: . Doliev,N
Company name:
tl address`:' .`� ^7" Ile,
1 A
lit, p
- city: tG , : : "hone N•
insuranceco.-. ''` olf 44
N c9� arb ahiw�A..
Failure to secure coverage w required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up.to SIA00.00 aad/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 may be forwarded to the Office or Investigations of the DIA for coverage verification.
l do hereby eeritry de the pains and pen a It's of perjury that the Information provided above Is true and correct.
Signature AA i Date
Print name Christopher Zo Zv, President Phone#978-741-0424
F
do not write in this area to be completed by city or town omcial permit/licenseN riBuilding Department
❑I.iceasing Board
edfate response is required ❑Seleetmena Offitt❑Health Department
phone N; —Other
. . � ITS ���alo� �✓11���
BOARD OF BUILDIN REGULATIONS
License: CONSTRUCTION SUPERVISOR
'^ Number: CS 057733
B i rthdate:.05/26/1958
Expires: 05/26/2007 Tr.no: 12633
-� Restricted: 00
CHRISTOPHER ZORZ_Y
115 NORTH ST G-
' SALEM, MA 01970
Commissioner
... Al. 61oirzvrunrzrea&' o/,,
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/20 08
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 02/09/06
Exp.Date 02/08/07
DC000440 11
Wmlxa of C.O.NE.S.T. 07 ' 1
80
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