34 UPHAM ST - BUILDING INSPECTION (2) DATE: /'
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building_'Pq ODI�Vn S�YPP
Building Permit Application For:
(Circle whichever applies) Roof,Reroof, nsta11 Siding, onstrtrct Deck, Shed Pool
Addition Alteration, /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:�k L1M C)DnV1Q LO KO Contractor: Chri stonhar Znrz
e
Street ,3H I City,58 Jron Streetl15 North .9irPPt City Salam
State,LL, Phone State MA Phone (978)_741-0424
Architect: City of Salem Lic# 14 0 5
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form
_yes LZno
Structure: (please ci Single Famil Multi Family# Other
Estimated Cost of job$_a$� I#M , Dp
Will building confirm t law?
/ es no
Asbestos?_yes no
Description of work to be done:
,
8 s
Drawing, b fitted: es no Mail Permit to: 1.1fi NORM TREE?'
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Signature of Application,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 i
Permit fee$
COMMMS: ;
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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 Cartina -
Signature of ermit 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
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
0//%oI/aresUOsuoas
600 Washington Street
Boston,Mass. 02111
Workers'Compensation Insurance Affidavit
name:
location:
city phone a
❑ I 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.
com si name: A &, A •Services Inc.
address: 115 North Street
city: Salem, 'MA 01970 ohonea• 978=741=Q424 tK1��""``'t"'I �.'':
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Insurance co. The Travelers Polity# WC939X1256
1 am a sole proprietor,general contractor,or homeowner(circle one and have hir
ed the contractors listed below who
°
the following workers'compensation polices:
company name very "
n
address:
ci .r;, .;
one M. tr+
insurance co;
Doliev p
comonny name
address::
city:
'hone p: ,.rl'rda.�'ad',.•.t. s:
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a Roe up to$I,SOO.00 aatVor
one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Rae of 5100.00 a day against me. 1 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 un a he alns and penalties of perjury that the Information provided above Is true and correct.
Signature Date
Printname Christopher orzv 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: permit/license a flBuilding Department
❑check if immediate response Is required ❑6leensing Board
❑selectmen's Office
❑Health Department
(contact person: phone a; flother
��"r � GT,fe >°oancnw�uiealo4 ��aaa��eQ3 �, ,
BOARD OF BUILDING REGULATIONS
E u License CONSTRUCTION SUPERVISOR '
Number ',CS 057733 �
Birt \QSf26E 958 Ik 111
r r �5/26.007 Tr,no: 12633
u CHRISTOPHERr
-.� 115 NORTH ST
f
SALEM, MA 01970 ; s /f
f r Commissioner r
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Board of BuilJing Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration:, 101609
Expiration: 6/26/2006
Type: Private Corporation-
A&A SERVICES INC ?
i Christopher Zorzy
115 North Street
)(, Salem,MA 01970
i Administrator
Commonwealth of Massachusetts
Division o/Occu Occupational Safety
h
Robert J.Preziaao,Commissioner
Deleader-Contractor
CHRISTOPHERZORZY
Etl.Date 01/14M
Date 01113/O6 DC O _
DC000440 '
bomner of C.O.N.E.S.T.
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