101 WEBB ST - BUILDING INSPECTION (2) S O C7 DATE:
Citp D� a�AY�TIi, aS��LUQttS
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED 1/y e' J-
Location of Building /DI -64) Sh-e6+
Building Permit Application For:
Circle whichever applies) Roof, Reroof, Install Deck, Shed, Pool
Addition, Alteration, epair/Repla , 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.-Vi 'dirt l O kA l' -I ed Ge. Contractor: C h r i s t n n h e r Z n r z;_
Street 1O1 in/P �J1O City CpJpm Street 11 5 North Strppt City__galam
State_ Phone State MA Phone(978) 741 -0424
Architect: City of SalemLic# 1405
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form_yes�o
Structure: (please circle) Single Family, tulti Family# Other
Estimated Cost of job S 0D.. 00
Will building confirm to law? yes no
Asbestos?__yes \17 no
Description of work to be done:- 4-2 nP 0i G�l'L�ii )a,LL i L 41�LP
lkheL a-nl� ILQ hdCA M01211 21 Lh122 /'d 191v7v
>Nt 1 f el'rl a,irl .
Drawi s S bmitte :_yes ES
no Mail Permit to: 2-Ib NORTH STREET
X $AT-IWM 11�8:878
X
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
Permit fee S
COHMENTS:
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The Commonwealth of Massachusetts
Department of Industrial Accidents
o//%o//arestleaUoss
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.
com0aayname• A & , A •Services , Inc.
address: 115- North Street i +f " ,gip•;`
•eili, �1NA 01970 ... •.�'} " `' l >•Yo "'`
city: S a 1
phone 978-741=9424 w �r,�y ��r� r"
insurance co. The Travelers Policy# WC939X1256 >>*rs S
❑ 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:
���Frdi� P
company name: t# .,• •;
address: t t' P?¢
city: hone#: tiro r
insuranceco: olio #
t 2 ti�
company name
t' .. . .
address'-" qF• 'y ;,.
city: iihime#:
insuranceco:
Failure to secure coverage as required under Section 25A of MCI.152 can lead to the imposition of criminal penalties of a flee up to SI,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Bat of sloo.00 a day against me. I understand that■
copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification.
/do hereby eerflj u d the pJa penalties ojperJury 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
city or town: permit/license# nBuiiding Department
❑Llcepdng Board
❑check if Immediate response is required t ❑Selectmen's Office
❑Health Department
(contact person: phone#; fnOther
LiiU IIi SaJEni, 4 aEszjrhusEii_13
`� � �uniit �rngrrtg �su�r,'m�f;
'a,,,�� 2�uitijintz a�rnrrni
(gas &u1r_1 6=n -
SDS-715-3��i r_zt. 39D
DIS?OSAL OF Dc33T_S AFFIDAVIT
in accordance with the provisions of MCL c 40 , S54 , I acknowledge that as a
condition of 3uildirg ?erm= t r: all debris resulting from the
construction zctivity governed by this 3uilding Per--Jr
shall be disposed of
a properly licensed solid waste disposal facility, as defined by MGL c I11,
5 150A. Salem Transfer Station owned by:
The debris Fill be disposed of at: Northside Carting
location of fac_s_ty /
Signature of Per—., c AOpiicznt Date
Fully complete the following information:
(?lease print clearly)
ChkiAt6phekcZe;iyc.
Name of ?ermic Applicant
A & A Services, Inc .
Firm Na=e, if any
115 North Street , Salem, MA 01970
Address. City d State
The above 5t_—zu7:e rea.u'res chat debris -from the demo--L-on. CenOvaLlpn. Teha.
or other alteration of building or structure be disposed of in z properly
licensed solid waste disposal facility as defined by MCL clI1. 5130A and tha
building permits or license's are to indicate the• iocation of the -facility at
. ., .-✓/+e YJomvmonweaw� o�✓t�aaJ , ,
BOARD OF BUILDING REGULATIONS lj
License: CONSTRUCTION SUPERVISOR c„
.i, Number: CS 057733
i
'Birthdate: 05/26/1958
Expires: 05/26/2005 Tr.no: 12224
Restricted: 00
CHRISTOPHER ZORZY -
115 NORTH ST
SALEM, MA 01970 Administrator
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609 ,
Expiration: 6/26/2006
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street� ✓
Salem,NIA 01970 Administrator
commonwealth ofMassachusetts
Division of Occupafional Safety
Roberti.Prezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZy
Eff.Date 01/14/05
Exp.Date 01/13/06 O
. DC00p44p
Member of C.O.N.E.S.T.
6
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