64 BROAD STREET - BUILDING JACKET r
- -
y
UPC 10333
No.153L-3 �'ts,�,ss`
HASTINGS. MN
City of Salem, Mass.
.% ELECTRICAL DEPARTMENT
y 44 Lafayette Street
4�
PAUL M. TUTTLE ,CITY ELECTRICIAN
DATE . . . . . . . . . . . . . . . . . . . . . . . .
To: INSPECTOR OF BUILDINGS
Salem, Mass.
-_------------------Electrical Contractor
V� (Signature of Applicant)
----------------------------'-'----'------......................... ------- --------. _.....—" ......
................................................
has signified their intention of performing the required electrical
work, viz: removing and later replacing all electrical wires, fixtures,
receptacles, etc., on outside of building located at:
(•"- k•ACG -� ........ ............Street
in conjunction with a wall siding installation to be made by:
.........._..W.�i l ..,�.......................................' Siding Contractor
ISSUED BYI
................ -----------------------------•-•I------------- ---------------
This is a requirement, preliminary to the issuance of a permit
for the sidewall installation by the Inspector of Buildings.
ORIGINAL-SIDEWALL INSTALLER
PINK COW-BLDG. INSP.
YELLOW COPY-ELEC.FILE
DATE: vZ�a 7�OLn
CItp Df a�aY &' Ji
4N111�
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building (DN &-,000' 6h-eP,f
Building Permit Application For•
Circle whichever applies) Roof Reroof nstall Siding, Constrict Deck, Shed Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies fbi a specifications:
to build according to the following specations:
Owners NameI rion Contractor: C h r i s t n gj,a r Z o r z e
Street U14 A( ' Sl DQ reej- Citl Street 11 5 North Straat City_ Salam
State I q Phone (ft _qJ )J-Irlll 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_,,Ino
Structure: (please circl Single Family, ulti Family# Other
Estimated Cost of job$ 7 J-0701 00
Will building confirm to aw?�yes no
Asbestos?_yes_no
Description of workto be done`
" n,5fd11 -h,, ejye- Clad rmf 6htnates .
SERVICES
Drawing u mi ed: es no Mail Permit to: 115 NORTH STREET
r g CAI.EM X4 9t 879
Signature of Applica •on,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$
C014fENTS
. j
No. Q
APPLICATTION FOR
PIMMq TO
LOCATION
PE MIT GRANTED
y1s
APP V p
INSPECTOP OF BUILDINGS
CERTIFICATE OF OCCUPANCY .
YES
NO,' ,
'
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Ol//CB O//OI�SUy8dO�S
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
name:
location:
city nhone N
❑ 1 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.
company name: A & , A $ErviCOs , Inc .
address: 115 North Street %k +Ta '� �r'i'
t,city: nhoneN• 978-741=9424 ifs'. 'µipw7�e7tYir:
Salem, 'MA 01970 ,1
!+—• Math�i,!�Y:
insuranceco. The Tradelers oolieva WC939X1256
❑ 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:
company name "> ,CW _'?� .
5
address-
city: hones•
insuranceco:
Dollev a
company name .
address:
iy
city: � �v � "hope N: -.l,'d-dp�'tw#�•r.:.
insurance co: ociliiry N, th+�4dpr ` Va
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine up to sI.M.00 and/or
one years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a
copy of this statement may be fo arded to the Office of Investigations of the DIA for coverage verification.
/do hereby eertijy de !h Was an ena Iles ojper/ury that the Information provided above Is true and correct.
Signature _ Y _ '—'-'7 Date _P1a7//)/o
Printname Christopher Zorzv, President Phonea978-741-0424
official use only do not write In this area to be completed by city or town official
city or town: permit/license N_ flBuilding Department
❑Licensing Board
[]cheek if Immediate response is required []Seketmen's Of0ee
[]Health Department
contact person: phone N• flOther
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 rmit Applicant
S197 c�
Dater
Christopher Zorzy
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
�' 7 ,r�„we rlAf �11 �rraaa
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR y' .
A•
Number_ 057733
� A
'�. Birt 05/l6k 958 k
y f
i E_0lQ7 Tr.no: 12633
Re
I .v CHRISTOPHER -
p:: 115NORMA 01
��
i SALEM, MA 0197 r -
Commissioner fY
1
Ak C mmmvu�
Board of Building Regulations and Standards
/ - HOME IMPROVEMENT CONTRACTOR
Registration:, 101609
Expiration: 6/26/2006
4' Type:-Private Corporation.
r
� A8A SERVICES
Christopher Zorzy - -
; 115 North Street
Salem,MA 01970 - "
Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Ptezm Commissioner
Deleader-Contractor
CHRISTOPHERZORZY
� Eft.Date 01114/05 -
Ems.Date 01/13/O6 0
- DC000440 .
KbbNO C.O.N.E.S.T. _
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