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165 NORTH ST - BUILDING INSPECTION 10� ' �. The C-umntumcralth of Massarhuutts Boat) of R)Kt BuIlJing IZcgulatwm wJ Standards \II \Il ll' \III 1 ,NlaSsachLISCUS State 13uJdin!, Code. 780 CNIR. 7" edition I til, "Il /lu n.il li,nwrn\\l Building Penna Appllc,ttiun To Cunwtut. Rrp air. IZeno�.tte Or I)emulish a ne- or Tit o-Funtih• Doi e lin,y --I This Section For Official Use Only ^ Building Permit Ngnhe . i` Date Applied: --- ---- _� Slglta Wle: • , 28 O Buil g Con mu,iuner In a or ut Buildings Dale \J\ SECTION I: SITE INFORMATION LDty (� LC'� /Om 1.2 assessors :'11ap & Parcel Numbers ---- d '? no klap Number P:oecl \'umber I.la Is this anaccepted streety es_ — 1.3 Zoning Information: 1.4 Property Dimensions: Lot Area(sq li) Frontage ,lit Zoning District Proposed Use 1.5 Building Setbacks(ft) Front Yard Side Yards - Rear Yard Required Provided Required Provided Required Proaidcd 1.6 Water Supply: (M.G.L c. J0. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'! biunieipal ❑ Onsite disposal system ❑ Public❑ Private❑ Check if'yes❑ SECTION 2: PROPERTY OWNERSHIP' .1 Yw er'ofRecor Namb i Print) Address For SService: Y ni In vt� t Pkh 478 s9y S�s2� Si � ore Telephone 6 SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory.Bldg. ❑ Number of Units— I Other ❑ Specily: BriefGescriplion of Prop -ed W xk'- C L SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item . (Labor and Materials) - I. Building $ I. Building Permit Fee: S Indicate how tee is deternuned: ❑ Standard Cit /Town .Application Fee City /Town Electrical ❑Total Project Costj(Item 6) x multiplier x 1. Plumbingt. Other Fees: 4. Mechanical List:5. Mechanical Total :\II Fees: SSu, resswitlCheck Nu. Check :\m,ntt:V. Tolal ProjePaid in Full 0 UutsninJing Balance Due:__ ...-_- i SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) v� 55�73� _ ' rnlDploer License .N'umhet F\pir:l on Dalt . Name of C'S L- I folder 1� Ll,t C'SI.I'cpe(see helow) l'v e De,c�n�uon tt(L'3" y7L l. . CnrcstlR � Rcst(eted I�@_' F: (I�J 4 \1 RLN,JL"IUniv 'D RC RoWenual Routing Cmenn„ Telephone \\'S R[,IdenIIJi \Vindu(�,and Suhne - SF Re,tdcmial Sola) Fowl flunung \,ih:mrr lint.il lauuu jj D Re,i11em wl Urmulwun 5,� Regiaa'tered home Improvement Contractor (IIIC) L 11 IC Company ny Name or 1-IIC Registrant Name Reglstrauun Numher -L P )( 4-h s P P- I r m 0 Addrea ZA,t 67-M\ /'11'6422 .xp(ratii(n Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached'? Yes .......... 0 No........... 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I�Qf� leu U� CL /{ i ' - as Owner of the subject property hereby authori'e rl`J'f'Df7lr1P.I' Z��ZLh to act on my behalf. in all matters relative to work authorized by this building permit application. x Signalgre of Owne Date SECTION 7b: OWN,EW OR AUTHORIZED AGENT DECLARATION I, r Irl S t ynVlO J� Zb�ZL� as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. C`�flS� Y tC� t�Z�1 • _- Signature of Own��Authorized.Agent Date a d (Signed under the pains and penalties of er'u ) NOTES: L An Owner who obtains a building permit to do his/her own work, or an owner who hires an tinregisteied contractor (nut registered in the Home Improvement Contractor (HIC) Program), will not have access to.the at program or guaranty fund under M.O.L. c. f-l'_A. Other important infointation on the 141C Progr:nn and Construction Supervisor Licensing (CSL) can be found in 750 CMR Regulations I I0.R6 and 1 10.115, respectively. '. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.I ' (including garage, finished hasement/:ttics,decks or porch) j I Gross living area )Sq. Ft.) Habitable room count _ Number of fireplaces Number of bedroom, Not tberofhathrooms Number othalf/hash, rope of heating system Number ut deck,/ p,aches rypeotcoohngs}stem Enclosed Open 3. "Total Project Square Footage" may he substituted fi(r 'Total Project Cost' _J ,r s CITY OF SALEM 3. PUBLIC PROPRERTY � ' ; it •1 DEPARTMENT \L,„,K I_':: \\'.,;Ir�t,:,,�i;:crit • ti.�lr�l. \L,,,.ui�,i ,ri :, :Ir� ['I I: 9'8-4;.9;e; • F Workers' Compensation Insurance :Uiidacit: Builders/Contractors/Electricians/Plumbers Please Print � r th(ant Information Legibly .`;Iitli t nu.mc>; t h_anttau,nt Inde I'll la A e s Q Y1/l C,25t l�C Address: ' Nor+h Sino of City,State.Zip: CA]fffl Phone #: ( 97S) 7�A I - ©HR .\re you an employer? Check the appropriate bus: Type of project(required): I. I am a employer with_A5__ . ❑ a 6. ❑4 I m a general contractor and 1 New construction Lx_! employees (full and/or part-time).` have hired the sub-contractors 7. E] Remodeling _.❑ I ant a sole proprietor partner- un the attached sheet. t ,hip and have nu emploo yees These sub-contractors have R. ❑ Demolition working for nae in any capacity. workers' comp. insurance. '9 ❑ Building addition [No workers' rump. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions reyuired.l officers have exercised their - ri>ht of exemption p er MGL 11.❑ Plumbing repairs or additions 3.Fl I am a homeowner doing all work S p myself [No workers' comp. c. 152. $1(4),and we have no 12..KRoof repairs insurance required.] t employees. (No workers' 13.0 Other comp. insurance required.] •:1ny applicant that checks box All must also till out the section below showing their workers'compensation policy information. r I lonteowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new um iidavil indicating such. '(-ontractors that check this hox must attached an additional sheet shu"In g the name of the sub-cuntractors and their workers'comp.policy information. I urn an ennployer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. —rl / 1 rL Insurance Company Name: 11'1rt -mik 6c 1 tip Policy #or Self-ins. Lic. #: r DUU M 5� U 13Ex Piration Date:—r= �`zA) ib (S�'fJfz� Ciry/State/Zip:• 1976 Job Site Address - .knach 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%IGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 an(Vor tine-year imprisonment,as well as civil penalties In the firm of a STOP WORK ORDER and a fine of up to S20,00 a day against the violator, lie advised that a copy of this statement may be forwarded to the Office of It:,rstiu;uions of the DIA for insurance coverage verification. L Jo hereby cerci under the p/ains mid penalties of perjury that the inJiirmution provide)above A true and correct. Date: `J-Y/ '2�d _-_— Phone 9 ollicial ace wily. Do not write in this area, to be raniple•ted by city or town of LiaL City ur l'own: __-- Permiti License #-----_—_ Issuirt Authority (circle one): 1. Board of Health 2. 13uilding Department 3. city rown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contac[ Person:____—_—. _.— Phone #:__ Information and Instructions \Lis..ichuseus (rcneral Lanes chapter I5' requucsall cmplo%crs to pros ide workers' con Ill ensaIion for dncir ennpIoyces. I'ursu.utt to this statute, an Colplgree is defined is ".. e�er% person in the set-\ice of.mother under Inv contract of(tire. cvpress or implied. ural or urines.., \n empl✓t'er is defined as •':m indis dual, p,utncrship, .issoaation, corporation or other legal entity, or enc two or more ,.I [lie foregoing engaged in a joint cmetprise, and jUlWhn_g (fie legal representati%cs oI a deceased employer. or rhe rcceis er or trustee of,in individual, p;trmership. .issoci.uion or other legal entity, enplov ing cmplovees. However the u•.s ncr of a dwelling house haat mg not inure than three;spartincnts and a ho resides therein, or rhe occupant of the ,lu ening house of another svho employs persons to do nnaintc•n;mrc, construction or repair work on Such dwelling house ,rr on the grounds or building appurtenant ihcrcto Shall not because of such employ nient be deemed to be an employer." NIGL chapter IS?, �s2S1-(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, .,%I(jL chapter 152, ss2i(-(7)states "Neither the cunmmonwealth nor any of its politicalsubdivisions shall enter into anv contract for the performance of public cork until acceptable es idence 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 dues 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 pennivlicense 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. it dog license or permit to burn leaves etc.)Said person is NOT required to complete this affidavit. The (M-Ice of Investigations would like to thank you in advance for your cooperation and should you have any questions, ple;ue do not Hesitate to give its a call. the DVI-mitincnt's address. telephone and tax 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 le,.iscd ;-'o-u5 Fax If 617-727-7749 www.mass.gov/dia 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 Mmit Applicant 02 8 Date _Christopher Zorzy Name of Permit Applicant A &A Services, Inc. Firm Name 115 North Street, Salem MA 01570 Address, City, State, Zip Code f� y Massachusetts - Department of Public Safetc Board of Buildin,, Regulations and Standards Construction Supervisor License License: CS- 57733 Restricted to: 00 CHRISTOPHER ZORZY 115 NORTH ST SALEM, MA 01970 Expiration: 5/26/2011 ('onunissiimc'' - Tr#: 14751 - ... ✓ udo vz R�or'Fc .✓�aec darruuar Board pC Building ain a ulatlons and Stan HOME IMPROVEMENT CON TRACTOR Registration: 101609 Expiration: 6/26/2010 Tr;k 267870 --,-Type: Private Corporafion A&A SERVICES,iNCr=:- =_ �• Christopher Zor yy. - - 115 North Street , Salem,MA 01970 -' Administrator Commonwealth of Massachusetts Division of Occupational Safety A& Laura M.Marlin,Commissioner Deleader-Contractor CHRISTOPHER ZORZY Eff.Date 0401/09 AML Exp.Date 0406/10 a '? Member of CO N.E.S.T. BO Illllilllllllll llll1111111111 loll 11111111111111 lill BOSTON-RENEW