1 AURORA LN - BUILDING INSPECTION DATE:
Citp �far�rrr, aatu �tt
PLANS MUST BE FILED AND APPROVED BY THE v
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building I AUr�c rC� t--nn P
Building Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install SidingConstruct Deck, Shed,Pool
Addition, Alteration, epatr/Replac , 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: pbe r4- E 1p4nnP.0r)l I i rl5 Contractor:A �.�Servs c g6 1 Cbirl�h„�orq
Street 1 A)rnrr. �nn _ City 501ein Street 1.15 klo(4h 5tre + _City_LrA,lern
State Phone (Q78) 7/iH -32D(o State HA Phone q-1S--7,'41,— Q/- AN
Architect: City of Salem Lic#(__I
Street City State Lic 05'7 33 HIP 9 10I
State Phone ( ) I Homeowners Exempt Form__yes. ✓ no
t /l
Structure: (please circle) Single Family, Multi Family# Other l Lrrin"-)
Estimated Cost of job$ 1 I# S(oo) , D p_`
Will building confirm to law? yes no
Asbestos?_yesv,no
Description of work to be done:
-Tns+olI -Fcxur 041 r blarpmef SII Ira �nt�r� �mr�
Drawings Submitted:_yes_ no Mail Permit to: _
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
COMMENTS:
f
APPLICATION FOR
PMW TO1
pu,,�� i
LOCATION k
PEqMIT GRANTED
19
APP p
INSPECTOn OF BUILDINGS
CERTIFICATE OF OCCUPANCY .
YES
NO
_ A ,
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractots
name:
location:
city: state: zip: phone M
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑ Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
G2rI am an employer providing workers'compensation for my employees working on this job.
companyname: A2 A Se—SeTnG
address: 11 ri tJD(I� �YfYPP {
city: Sn Irrn phone#• 19'I`6) '7,41 n14 RH
ins iso 'rhe-- Tr'a /Par rs policy# WCc13R XI a.S(o
❑ I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who
have the following workers'compensation policies:
company name:
address:
city: phone#-
insurance co. policy#•
company name,
address:
cty: phone M
insurance co. policy 9:
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
one years'imprisonment w 11 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 -forwarded to the Office of Investigations of the DIA for coverage verifications.
I do hereby cerdfy an er a. nd penahies ofperjury that the injormadon provided above is true and correct
Signature Date
Print Name hone# (1�g) 211 —QH vii-{
official use only do not write in this area to be completed by city or town official
city or town: permittlicense# ❑ Bulldi*4 t
❑ check if immediate response is required 11 Licensing❑ Selectmen's Office
❑ Health Department
contact person: phone M ❑ Other
(raviaed Sept.2003)
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 P it Applicant
4- a�'-oma i
Date
Christopher Zorzy
Name of Permit Applicant
A iii A Services. Inc.
Firm Name
115 North Street. Salem IIIA 01970
Address, City, State, Zip Code
BOARD OF BUILDINd REGULATIONS
License: CONSTRUCTION SUPERVISOR
� r
j Numberfcs 057733
Birthdate�05/26/l958
j x Ex res 5/28/2007 Tr. no: 12633
Restrfctetl db ��
-` CHRISTOPHER Zbf +��
115 NORTH ST
SALEM, MA 01970 '%>{ /y
commissioner `
__..._.-_.._..-___--------------
�
✓ice Go „tet, Vii/ of"l/,, /,.«c�
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2008
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorcy
115 North Street
Salem, MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J Proboso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
ER.Date 02J09106
Exp. Date 02108/07 07ofCONES
DC000440Member . . . T.
BO
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