21 SURREY RD - BUILDING INSPECTION DATE: 10- q-Do
Citp Of q)af'em, ae3�arbuE;PttE;
�r
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 1 .SIJI ro r/ f�DCJ
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Si • ct Deck, Shed, Pool
Addition, Alteratio epair/Replace oundation 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 spermcations:
Owners Name: M r5, R I66rd W�,I �) Contractor: ACM `crdiu-5, j tr jc
Street al Surreu Rpa-1 City SC
lem sveet ►f nlo(+h Sf • _city_ ilcm
State HA Phone 618) 7{M -5�-I 8a StateL A Phone•C178- 7H I_,IQ�4 olq
Architect: City of Salem Lic# I� 5
Street City State Lic saaaa—HIP# l Ol(n 09
State Phone ( ) _ Homeowners Exempt Form yes_ ✓ no
Structure: (please circle) i gle Famii Multi Family# Other
Estimated Cost of job$ 4+ $q 0
Will building confirm to law? yes no
Asbestos?—__yes�/ no
Description of work to be done:
Tr)4aI r any C t ) Le4IOUMea4 v ri A CIOD-K la &nl- �atn
Drawings Submi d: es no Mail Permit to: 115 NORTH STREET
g _ 3AIrEM Mel"01970
Signature of Applrca ' n,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee$
COMONTS:
N0.
AITLICATTION FOR I
' t'BRMi TO "
I
_ 1
LOCATION 4
PEl Mff GRANTED
. • .. . . • .. _ it
APPR �p
INSPECTOR 0 BUILDINGS _ - _ � - <:� :
CERTIFICATE OF OCCUPANCY " ("
YES
NO
• S
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.
company name: A Q fk Se_ryi c e S, Tr1 G
address: HE IJ6121h 5fY-eef+
city: Sn IP_rn phone#• 19TO Vi i -oM aN
insurance co -(hL -rra y e--A GrS policy# WCQ'Q X I a'�S(o
❑ 1 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 M
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 nA bg fbmard9d to the Office of Investigations of the DIA for coverage verifications.
i do hereby certify u er h p ' a d penahtes ofperjury that the information provided above is true and correct
Signature Date /Q - 9-d
Print Name hone# &2716> 7HI -DHaH
official use only do not write in this area to be completed by city or town official
city or town: permittlicense# ❑ Building Dephrtment
❑ check if immediate response is required ❑ Limnsing'Eoard❑ Selectmen's office
❑ Health Department
contact person: phone#: ❑ Omer
(redaed Sept.2003)
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 Pekmit Applicant
Date
Christopher Zorzy
Name of Permit Applicant
A & A Services, Inc.
Firm Name
115 North Street, Salem MA 01970
Address, City, State, Zip Code
BOARD OF BUILDIN REGULATIONS 'I
License: CONSTRUCTION SUPERVISOR i
Number-Its 057733 - -
I Blrthdate 0&%6/1958
Ems: � •'
@xplres 05/26/2007 Tr. no: 12
a633
1 b
` RestricteH;„00
CHRISTOPHER ZO�RZYi( t i
115 NORTH ST
SALEM, MA 0197(1
Commissioner
^•.—_•.._��.._ vl�e V�amviitooureral� pj;;(/r1RtJp,Cl
Board or Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
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
Robert J.Prewso,Commissioner V1
Deleader-Contractor
CHRISTOPHER ZORZY
Ex Date 02/08/ O
Exp. Date 02/OB/07
07
OCOOD440
Niember Or C 0,N.E.S.T.
7
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