57 SCHOOL ST - BUILDING INSPECTION DATE:2'D �(p
Cirp of �eattm' ammrbu5EW5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building_5�_50J'100( 5frP0_+
Building Permit Application F
'(Circle whichever applies) Roof Reroof)hstall 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: 6Ap{rl ne, [+ I I Contractor: C h r; g t n n h a r Z n r 7.g '
Street 5'1 City C)OIM Street 1 T 5 North S t r P a t City S a l c m
State hA Phone 078) '7+H-53314 State MA Phone(97g) 741 -0424
Architect: City of Salem Lic# 14 0 5
Street City State LirHO 5 7 7 3 3 HIP# 101609
State Phone ( ) _ Homeowners Exempt Form_yes_yl no
Structure: (please circle) Single Family Multi Family t! Other
Estimated Cost of job $ °'Jqp �,J / 4d
WiU building confirm t law?_ Yes no
Asbestos?_yes7no
Description of work to be done:
� ICtC� FP�.vl ( I ) �Qt)�irPS t1� rn0�
Drawin i d:_yes ERVICE8 no Mail Permit to: I16 NORT7i STREET
z • - z s,er.r�rca-e.e7e
X j
Signature of Appfication,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$
C0144ENTS:
APPLICATION FOR
' pl=pMTI' TO
LOCATION
PE MIT GRANTED
AP POVfD
EC TOM kYV BUILDINGS
CEBTIFICATH OF OCCUPANCY
YES
NO
r
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
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.
comanvname• A 2 A Ge"Ce5, Tnc-
address: 11 ri MOM-) 5rPP+
city: Sn I rm phone#• I'Y?4 rl AA l roN 2H
ins y�t!ra�ce_co -rbe-- Tratiear rS Folicy# WC�39 XI a5�
❑ 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$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$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verifications.
I do hereby certify under rpalks and�penaftier ofperjury that the information provided above is true and correct
Signature�� � / p!'Y , Date
Print Name hone# (TIZ 21I -01-1 aN
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑ 9uild4 DePrunent
❑ check if immediate response is required Licensing-8oerd required ❑ selectmen's Office
❑ Health Department
contact person: phone#: ❑ Otner
(re ted Sept 2003) -
r
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M. G. L. c. 40, Sec. 54, a condition of
Building Permit Number is that the debris resulting from this work shall
be disposed of in a properly licensed facility as defined by M. G. L c. 111, Sea
150a.
The debris will be disposed at: Salem Transfer Stetson
owned by No side Cartina
CA - N
Signature of Permftykpplicant
Date
Christopher Zorzy
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street Salem MA 01970
Address, City, State, Zip Code
L
BOARD OF BUILDING`REGU��LA�pI$v I
License: CONSTRUCTION SUPERVISOR
_ Number.,CS 057733
Birthdata ow16/1958
Explrea 105/26/2007 Tr.no: 12633
4yy
Restricted) 00
CHRISTOPHER ZORZYI(i� /r.
115 NORTH ST
SALEM,NORTH
01970 {
Commissloner
' � goarJ of 6uilJing Regulalium mi0 StavJanls
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6262006
Type: Private Corporation,
A&A SERVICES,INC
Christopher Zomy
115 NOM Street
Salem,MA 01970 Adminislrntur
Commonwealth of Massachusetts
Division of Occupational Safely
Robed J Flez.,,Commieslorer
Deleader-Contractor
CHRISTOPHER ZORZY
Elf.Dale
. .ozD%w
Exp.Date OWOS107
DC000W
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