27 WEST AVE - BUILDING INSPECTION DATE:
Cifp of '6W,e TT, �RA!y5arb 5et5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building J 7 Alp 9 Aje n L/P_
Building Permit Application For:
YCircle whichever applies) Roof, Reroof, Install Siding on=wct Dec Shed, Pool
Addition, Alteration epair/Rep ac oundation 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:: /� ( mayjle-r Contractor: C h r i s t n p h a r 7.n r z;z
Street A7 ya,(,Sk AMf)IlL Cit lyrn Street 11 5 North RYraat City Ralam
State, MA Phone 619)_71-M - J/pg State MA Phone(978) 741-0424
Architect: City of Salem Lic# 14 0 5
Street Cit}' State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form_yes_L1 no
Structure: (please circle) Single Family, Multi Famil Other
Estimated Cost of job S ,�3(0,B"p
Will building c nfirm i w? yes no
Ashes tos?1 9r , o
Description of work to be done: ,3Q to ra Pc4
394a 5Q ( afe AD� 4�rdeoul RP 0/0 BYE (I ) vn1rU
SERVICES
Draws g S bmitted: es� no Mail Permit to:g 115 NORTH STREET
_ - . - - t
RM NA a=ego
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 Map/Lot
Permit fee$
COHMENTS:
r
a
No. l-
APPLICATTION FOR
pl=RMff' 7n
LOCATION
PEIMIT GRANTED
nPP Ov�D
-�
INSPECT OF BUILDINGS 3 -
CERTIFICATE OF OCCUPANCY
YES
NO '
is.
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 Northside Carting _
Signature of Pe it Applicant
�///0�o�
Date
Christopher Zorzv
Name of Permit Applicant
A &A Services Inc.
Firm Name
115 North Street, Salem MA 01970
Address, City, State, Zip Code
The Commonwealth of Massachusetts
Department of Industrial Accidents
0//%c//BreStlp8tl0os
600 Washington Street
Boston,Mass. 02111
Y •
Workers' Compensation Insurance Affidavit
name:
location:
city phone p
❑ I 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.
comoanyname: A & . A-.Services , Inc .
address: 115- North Street
city: Salem MA 01970 sKt»� tyrNe+s�
ohoneN• 978=741 0424
insurance co. The Travelers oolicvp WC939X1256 tv, '+
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
y
company name: �;r. ,.' �;f � r•.:
address:
city: hone H: tr"
,arm
insurance co; Dolicv p r r'd• j4
company name: 1
;. �address•.. x 1,
hone i{' .rla .t` JF ;itt
insurance co. oli q k »iyq
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 SI,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofs100.00 it 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.
/des hereby caWyw _
e polo and nallies of perj ly that the Information provided above Is true and correct.
Signature ��_'..� :_. ._ -- - — -� Date
Printname Christopher Zorzv. President Phone#478-741-0424
Fontact
do not write in this area to be completed by city or town official
permit/license H flBuliding Department❑IJcensing Boarddiate response is required ❑Selectmen's Ogee❑Health Department phone N;_ flOther
BOARD OF BUILDIN REG�U�Lq�jpN �
'A License: CONSTRUCTION SUPERVISOR
i NumberfCS 057733
' Birthdals:-O 28/_1958
j Exp es, 05/26/2007
j Tr.no: 12633
Rests t54 Ob
CHRISTOPHER ZORZil'1FF—._
115 NORTH ST
SALEM, MA 01970
Commissioner
I
� ✓�re �nonvnwrzuie¢� 0�✓6,.aa,nT,�:ucefl 1
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���rre✓
Salem,MA 01970 Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J Rez=O,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 02/09/06
Exp.Date 02/08/07I
DC000440 O
Wmter M C O.N.E.S.T. 7
130
IIIIII IIIII IIIII IIIII IIIIIIIIII IIIII IIIII IIIII IIII IIII BOSTON-RENEW
IL
1
i
Al
7-7
t r
ID
4- �'�