45 BELLEVIEW AVE - BUILDING INSPECTION 1 ,
No.
Apt ICATTION FOR _
' pERMiT TO
LOCATION // E
PEqMIT GRANTED
APPR VFD
AC:MnOF 6UIL NGS
CERTIFICATE OF OCCUPANCY .
YES
NO
DATE: 14
Citp of .45aYEm, 1EaE;!5arbU5Ett5
�z
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building �I 5 fit?I IeVI t:w Nent to
Building Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install Sidin C truct Deck, Shed, Pool
Addition, Alteration, a a r/Replace 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 tto build according to the following specifications: n
Owners Name, IIChP/1I f ��tIfu1P. I)IY fro Contractor: A e,A Se- viCp5'lhnt>Z17t 7,l
Street_Ncj Vv )eviZW kenU City SaLorn Streer .il5 f-nr4h 5�. City_LaLcm_
State Phone - Q -
--H� (�`18> 7Hti 'i1•l�I State MA Phone� � 78) 7y��.,M a 1-i
Architect: City of Salem LicC N 05
Street City State Lic Q57733 HIP# I D((o O9
State Phone ( ) Homeowners Exempt Form_yes__.,,/no
Structure: (please circl Single FamiDMulti Family# Other
Estimated Cost of job S 3R�$,Do
Will building confirm to law? yes no
Asbestos?_yes/no
Description of work to be done: Yt•15 i a I me (I) KP k) o vy)o e0 �YL{
rADDr.
A&A SERVICES, INC.
Drawin U fitted: es no Mail Permit to: SALEM_,MA 01970
41-Od2d,,
X WWW.A ASE VtC .
Signature o Appii ation,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX MONTHS OF PERMIT ISSUED DATE
Qzr� The Commonwealth of Massachusetts
1 Department bf Industrial Accidents
Office of Investigations
600 Washington Street
/ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): A Q A Sol^VI 6gs Tn
Address: I I.S r I o r+h Sive e+
City/State/Zip: ��D.rye Mn Df R7D Phone #: 92$ 71 I I —DH a N
r2. 1
u an employer?Check the appropriate box: ' Type of project(required):
am a employer with_� 4. ❑ I am a general contractor and 1 6. ❑New construction
mployees(full and/or part-time).* have hired the sub-contractors
m a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling
ip and have no employees These sub-contractors have 8. ❑ Demolition
orking for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers' comp. insurance 5. We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LF1 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.F] Roof repairs
insurance required.) t employees. [No workers' 13.0 Cther
Ortn
comp, insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'.compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'wrap.policy information.
I am air employer that is providing workers'compensation insurance for my employees,Below is the policy and job site
information.
insurance Company Name: jhe__ Tra vp yn
Policy#or Self-ins.Lic. #: \A,(C 9 Sq X I of 5—(0 Expiration Date: q '13 CQ
Job Site Address: _W 5 F�el l eV 1 eyy A1)e_-4G P City/State/Zip: ON70
Attach 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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year,imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certi n r the pains and penalties ofperjuty that the information provided above is true and correct.
Si•nature:
Date
Phone#: (975�
[-ty
ficial use only. Do not write in this area, to he completed by city or town official
or Town: Pertnit/License# Elnspector
uing Authority(circle one):oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plu
therntact Person: Phone#
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hue,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two of more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(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, MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence 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-contractor(s)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 does 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 pemmitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 peanits 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.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call:
The Department's address,telephone and fax 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
Revised 5-26-05 Fax # 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 Carting -
Signature of Permit 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
�/ie Taom mta�w e¢ a oe4�aar/ueelA
' Board of Building Regulations and Standards
Construction Supervisor License
Llceitse: CS 57733
' Eic�d'aYe,�/26/1958
�ratt1 6/2009 Tr# 13739
rfetii7�001
CHRISTOPHER Zpy ��•
115 NORTH ST
?.-
SALEM,MA 01970 Commissioner
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Pmzioso,Commisstor
Deleader-Contractor
CHRISTOPHER ZORZY tl
Eff.Date 04/02/07
Exp.Date 04/01/08 _
DC000440 r '?
Member of C.O.RES.T. 08
BOBB IIIIIIII - _ '�
u�III IIIII II�II�II IIIII IIII IIIII II IIuU IIII III BOSTON-RENEW
Board of Building Regulatigps and Standards
HOME IMPROVEMENT CONTRACTOR
Registration _101B09
Ezptrat]on
Type. Private Corporation
ABA SERVICES INC
Christopher Zorzy -
115 North Street-
Salem, MA 01970 Deputy Adncrostr;Lur` ;
The Commonwedt6 of M tlietb
State loud ofBuildiog Rasubdoua, Jon#: 1"�i sanl 0►0 7
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Massachusetts State BBuildinS Code. _Sent to Owner:
780 Cl�IIt Bldng Dept: Mailed: �----
Fee: �—
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7l//97(Stleotive]J L" 790 CMR-sl3ah Edition