18 WALTER ST - BUILDING INSPECTION c DATE: i1910 7
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 'C, W .r J`--h�e-e-+
Building Pe it Application For:
'(Circle whichever applies) Roof,$��r}s�f Install Siding,Construct Deck, Shed,Pool
Addition, Alteration, Repair/Replace,Foundation Only, Wrecking
Other.
PLEASE FELL 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: A � A ServICA5�t^hn5 ors
Street_L06 VVO l+pr LS"IYP e+ City Snlen Street 115 110rih ` _City—� l�m
State.Mi Phone ( $)-7H 5- 313 7 State Mfl Phone•N78) 714-11-_m A H
Architect: City of Salem Lic# I 1 05
Street City State Lic 1)57 HIP# I D I(o D9
State Phone ( ) _ Homeowners Exempt Form_ yes—k/no
Structure: (please circle) le Famil • Multi Family# Other
Estimated Cost of job S3 , `3q ; DD
Will building confirm to law? ✓_yes no
Asbestos?_yes✓no
Description of work to be done:
hippince " (9 x a5 rcJhhPr �� Lt I-II , neu) !0 Y.
A&A SERVICES, INC.
Dmwin u�'bmitted:_yes no Mail Permit to: 1 SALEM,MA 01970
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Signature of Appl' ation,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning lvlap/Lot
Permit fee S
C01 KENTS:
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The Commonwealth of Massachusetts
WDepartment oflndustrial AccidentsOffice of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leetbly
Name(Business/organization/Individual):. 6 Q A j&-r'yi
Address: I i 5 IJ o r-I-h
City/State/Zip: rLyt M p 01970 Phone #:__I c[�7$1 7H I
Fam
ployer?Check the appropriate box:
ployer with�_ 4. ❑ I am a general contractor and I Type of project(required):
s(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
le proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
have no employees These sub-contractors have 8. ❑ Demolitionforme in any capacity, workers' comp.insurance.
[No workers' comp. 5. 9. ❑Building addition
p ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.] t employees. [No workers' r
comn.insurance required.] 13.UOther ADD�I'
May applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. _
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a new affidavit indicating such. _
tContmctom that check this box must attached an additional sheet showing the name of the subcontractor and their workem'comp,policy information.
!am an employer that is providing workers'compensation insurance for my employees;.
information. Below is the policy and Job site Insurance Company Name:. t-r
r e— Tiro VO I r I�n
Policy#or Self-ins. Lic. #: _W O Oj 39 X I of ti /
Expiration Date: q 113'07
Job Site Address: I c/i Wri I+P r 5h-e e_+ City/State/Zip: SQ��YI/l (ill}
� 9 7D
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby cert de the sins and penalties ofperjury that the information provided above is true and correct
Signature Date d210 7
Phone#: (9y ' ,H I - D J-I 1 H
Official use only. Do not write in this area,to be completed by city or town offichiL
City or Town:
'Permit/License#
Issuing Authority(circle one):
I.Board
Ot of Health 2.BuildingDepartment
men t 3.City/Town Clerk 4.Electrical
Inspector 5.Plumb
ing Ins
pector
Contact Person
Phone#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,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,§25C(6)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,MGL chapter 152,§25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture.
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. .
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,�?
please do not hesitate to give us a call.
The Departments address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial"Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia ; iI
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 Northslde Carting _
Signature of P nnit Applicant
il9/o 7
Date �—
Mato her Zorzv
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street. Salem MA 01970
Address, City, State, Zip Code
` i
r
J , � �rraem
. . BOARD OF BUILDIN2(REGULATIONS �
License: CONSTRUCTION SUPERVISOR
Numlxr•'t S, 057733
BlgpRhdaEs OS/28/]958
_'� a5P18/211607 Tr.no: 12633
Re
CHRISTOPHER -I.t
115 NORTH ST .
SALEM, MA 01970
i. Commissioner � ••
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i
✓axe �iio>u.onmu�w.al/�. �f�,�tii�elile(td
-�- 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.Prezwo,Commissilw All
Deleader-Contractor
CHRISTOPHER ZORZY
Eft.Date 02109M
Ems. 02/0&07 0 7
DCOOD44D44 0
Mnrbmd C.O,NE.S.T.
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