12 TREMONT ST - BUILDING INSPECTION -. tip.-•
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building Q 7_964prU7' ST,CE ET
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, install Sidin Co ¢t Deck, Shed, Pool
Addition, Alteratio epair/Replace oundation Only, Wrecking
Other: M� Zlo l-p l 12,
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING 1
To the Inspector of Buildings: 1 S�-4 (,VN'1-)
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name:KIC00-D Sic vEe Contractor: Christnnhar 7.nr7.y
Street Q TPIF-Mad,Fr SW__e T citvS,4toyj Street 11 5 Nnrth Straat Clty_ Salam
State.tMf} Phone (QR) State
MA Phone(97g) 741 -0424
Architect: City of Salem Lic# 1405
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form_yes no
Structure: (please circle) ingle Family, Multi Family# Other
Estimated Cost of job S. I� 930, Q(�
Will building confirm to law?— yes no
Asbestos? yes no
Description of work to be done: .0 ACC A0 SQL)A&S O�-_ U I./UyL S!D/X6-
Drawings bmitted: es no Mail Permit t A&ASERVICES
_y o. 115 NOATTi STREET`
% rter.rrM MA-A=848 Ja
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Signature of Appucao6n, SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# gZoning Map/Lot -'
Permit fee S 1 l'�� (AL (o b 2A
CONMENTS: _
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The Commonwealth of Massachusetts
Department of Industrial Accidents
0/t/ce nt/nsest/,Dst/ens
i 600 Washington Street
Boston, Mass. 02111
�4
Workers' Compensation Insurance Affidavit
name:
location:
city phone#
❑ 1 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.%'S eryices , Inc .
address: 115- .North Streets +; §, N * ?:_
city: Salem, AMA 01970 phone# 978-741-0424' r
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insurance co. The Travelers policy# 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:
company name: ti#
,sd t v -r.
address: .a "t`
ate.°
. �N -r• ,
city phonek•
insurance co;, policy
company name.
s Mr'
:e
address: e i
city: a vu�5lr ?z
phone#:
insurance,co ��». N.
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 S1,500.00 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 verification.
I do hereby certify u d r the sins anJ ena es of perjury that the information provided above is true aan�d7 correct.
Signature Date
Print name Ch r_i_s tophi Zorzv, President Phone# 978-741-0424
official use only do not write in this area to be completed by city or town official
city or town: permittlicense# FIBuilding Department
[]Licensing Board
❑check if immediate response is required ❑Selectmen's Office
(]Health Department
contact person: phone#; f-IOther
(wind 9N5 PIA)
0. Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association,corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if
you are required to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
( Office of Invesupaueaa
600 Washington Street
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406
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jrS-745-5555 c`s:. 3313
DIS?OSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40 , 554 , I ackno::ledge that as a
condition of Build-ing Perm- L E all debris resulting from the
Construction aCLSVlty gOverned by this Building Pert shall be disposed of --
a properly licensed solid waste disposal facility, as defined by MGL c III,
S 150A. Salem Transfer Station owned by:
The debris will be disposed of at : Northside Carting
loczuon of izc__zty
Signature of ?er-- - Date
�_ Appiicznt .
Fully complete the following information:
(?lease print clearly)
Chki6.t6pheicZe;iye.
Name of Perrit Appiicant
A & A Services , Inc .
Firm Name, if any
115 North Street , Salem, MA 01970
Address . City d State
The above SLntL'te 7Equ;_=5 that debris -ironthe demolition. renovation, rent
or other alteration of building or structure be disposed of in z properly
licensed solid wasre disposal facility as defined by MCL cI11 . S150A and tha
building peralt5 Or liCen5e5 are LO .Rd.Ca Le the, location of the facility at
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. '••..�/li¢ U/dNVdGON/IICQIUL a�✓ L(fd8�d f.
rte BOARD OF BUILDING REGULATIONS
icense: CONSTRUCTION SUPERVISOR f
Number: CS 057733
Birthdate: 05/26/1958
Expires:05/26/2005 Tr.no: 12224
Restricted: 00
CHRISTOPHER ZORZY
115 NORTH ST
SALEM, MA 01970 Administrator
Commonwealth of Massachusetts
Division of occupational Safety
Robert J Preiioso,Deputy Daedor
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 11/21/02
Date 11l20/03 DC O
DC000440
Member of GORES T.
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HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2004
_ - Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street l.G.
Salem, MA 01970
Administrator