27 WEBB ST - BUILDING INSPECTION DATE:
I Citp ]of '&aft i, �fflxE;JgarbUE;Ett5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Buildingc� 7 Kebb 5 7"ee
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install g ct Deck, Shed, Pool
Addition, Alteratio 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:MIGiVNI E' eeIIQ 6DM4 Contractor: Chr; Rtonnar 7.nrzg
Street dq ln/Fhh 5We- `(" City/ Street 115 North Seraat City Sa1am
State Phone (q%)_��S9 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 ✓no
Structure: (please circle) Single Family, ulti Family# 02 Other
Estimated Cost of job $_ 7 q$ '% /70
Will building confirm to law?_yes ✓ no
Asbestos?_yes ✓ no
Description of work to be done:
ys15� a i +Wa ( a1 ;"heryalass ranII(Jayn+ Pnb 4
r,L--)Drs
SERVICES
Drawing ub itted:des-4-1no Mail Permit to: 115 NORTH STREET
% rasr.FM K.4 a-
X
Signature of Applic lion,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 S
C0141IMS:
APPLICATION FOR
' PERMf(' 70
LOCATION
PE MIT GRANTED.
19
APPR �D r.
INSPECTOR O BUILDINGS _ 4w
CERTIFICATE OF OCCUPANCY .
YES
NO
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
Signa u e of P rmit Applicant
Date
Christopher Zoriv
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street, Salem. MA 01970
Address, City, State, Zip Code
i
The Commonwealth of Massachusetts
MEMO Department of Industrial Accidents
0///ce o//oresUesdaas
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
name:
location:
city phone#
❑ 1 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.
commnvname: A & , A•Services , Inc.
address: 115 North Street
city: Salem, MA 01970
phone#• 978-741=Q424
insuranceco. The Travelers oouev# WC939XI256
❑ 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:
�5 ♦ V
address: rtt t
city: lir: qr hone#• r
insurance co; vile # "k+,i7di,-Y,; t '�
eom an name.
address
hoveN: .'.o-A`n� wr.*. W
insurance co. . Dolliv N
F ' a 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
oat years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cerfyyD er the pains and penatttes of perjury that the Information provided above is true and correct.
Signature ( Date
Printname Christopher zorzv, President Phone# 978-741-0424
official use only do not write In this area to be completed by city or town official
(contact
ity or town: permit/license# I"1Building Department
. ❑LiteosingBoard
cheek if immediate response is required QSeleetmen's Office
QHealth Department
person: phone#• nOther
r BOARD OF BUILDIN REGULATIONS
Llcense: CONSTRUCTION SUPERVISOR p
Numbe_$ 057733
Bi 05/26. 958 j
5/2 00y Tr.no: 12633
4 CHRISTOPHER -
p,.Vy 115 NORTH
r` 01970
SALEM, MA �r '.
Commisslonar Y
,
r� f
.. r � ✓� U/Oflf f/rrY�W�{[� G�✓(q.O40[u'huJ,B(� �
UVBoard of Building Regulations and Standards -
HOMEIMPROVEMENTCONTRACTOR r
Registration:, 101609
Expiration: 6/2 612 0 0 6
i
Type::Private Corporation.
A&A SERVICES,INC '
Christopher Zorzy, � -
115 North Street
Salem,MA 01970
' Administrator
Commonwealth of Massachusetts 7
Division of Occupational Safety
Robert J.Prezwo,Commis wwr > .
Deleader-Contractor
CHRISTOPHERZORZY
Eft.Date 01/14/05
Date O7/13/06 DC O
. DC000440 .
Msmberol CO.N.E.S.T. ,
6
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