30 BALCOMB ST - BPA-2007-82 REPLACE FRONT PORCH DATE: 7• ag - oo
Citp of '4&aY'Pm, JRaq5arbU5Ett5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 30 -P)OICom b
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Siding( Dec , Shed, Pool
Addition, Alteration, Repair/Rep ace, oundation Only, Wrecking
i 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: Mn LW e)110 Contractor: C h r; a m nn a r Z n r z
Street, MMJCI t01h� a��_Citycz Street_115 North Straat City_:Salam
State.MP Phone ('198241-4 _ -7gI 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__V/ no
Structure: (please circle) Single Family, �9-uIti amily Other
Estimated Cost of job $ LO, Lo q C), M
i
Will building confirm t law? yes no
Asbestos?__,yes no
Description of work to be done:
I�iP�«a c� p x i`5h r;ra -Frn,�l- �nrct-, t a �ith �P��� -�r�✓�-I- �rrf,
(-k 4y _ '4)rnro ( I r s I MS
Drawi s ub itted:_yes no Mail Permit to: 1.16 NORTH STREET
�aer.Fyl A�4 A:B?
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$
COMMENTS:
APPLICATION FOR
' PERW TO
LOCATION
PE MITT GRANTED
_- !l/ 9 -
1APP OVfD
INSPECTO OF BUILDINGS
CERTIFICATE OF OCCUPANCY
YES -
NO 1
i _
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 property licensed kciiity 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 Pe it Applicant
Date
Christopher Zorzy
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
Office OI NOVSUy81I08S
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city phone#
❑ I 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.
A & , A�'Services Inc .
comoanv-name: , r a ::,t t t•ti:,
address: 115 North Street
city: Salem, 1IA 01970 'tt)rr'%Yaxtx v�D.
ohoneq• 978-741=0424
insurance co. The Travelers policy# 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:
comoanv name
address fr.e P>¢xf5 .`
city: ,;;.. hone q• te�`Df ?,if
1 '/A tJy Yt�
insurance eo: policy#
company name,
address'.
f •a y fA'+1 gsq
city: ,i `hone a:
insurance co: "- policy NKx' 'y
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition orertmiesi 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 rice 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.
l do hereby cettify u d pains and p trollies of perjury that the information provided above is true and correct.
r� ��,-/+y,�q+
Signature — - , Date �' `I V
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: permittliceme# rlBuilding Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
(`contact person: phone a; !lather
• BOARD OF BUILDIN REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number:'CS 057733
;. Birthdate: 05/26/1958
Expires:05/26/2007 Tr. no: 12633
Restricted: 00
CHRISTOPHER ZORZY
115 NORTH ST
G-SALEM, MA 01970
Commissioner
Board of Building Regulations and Standards
_ HOME IMPROVEMENT CONTRACTOR
-r Registration: 101609
Expiration: 6/26/2008
Type: Private Corporation
A&A SERVICES, INC _
Christopher Zo¢y
115 North Street ��,•„Gy,e,,,`
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prevoso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Elf.Date 02/09/06
Exp. Date 02JO8107
DCOOD440 07
t&mberof C.O.N ES T.
BO 1pI
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