35A FIRST ST - BUILDING INSPECTION DATE: /�aO�O(P
�itp D� `a��YE1U, a �LJU �tt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 3,5H t' S>L SfrP e;f
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install S' Deck, Shed, Pool
Addition, Alteration Repair/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 to build according to the following specifications:
OwnersName---Mor-Oin )`1!11fYl r) Contractor: chriarnnhPr 7.nr7y "
streetIbrA Fir-,yr- 61fe " Cln' ? , Street 115 North RrrPPr City_Sa1Pm
State_h1� Phone -y�)_�t�j-ln;�l l a? State MA Phone(9 7 8) 7 41-04 24
Architect: City of Salem Lic# 14 0 5
Street City State Lic#057733 HII'# 101609
State Phone ( ) _ Homeowners Exempt Form __yes no '
Structure: (please circle) Single Family, Multi Family# Oche (P jjj w
Estimated Cost of job$_110, W9100
Will building confirm to law? yes no
Asbestos?_yes/no \
Description of work to be done: _- p'54911 �P t!� � 7 1 V'IYI U I Lt.n IQU M P.r4
1AJ)nd0W,5 ClI)61
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'` Drawin S mitted:_des no Mail Permit to: IX8 NOItTg gTEItEER'
X ISAr.F r► e� 7e
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Signature of#Appl* on,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6) MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
I -
Permit fee$ a
M
COMMENTS:
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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 -
ignature of PeVmit 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
omceollonsuoodess
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name: r
.1
location:
city nhone#
❑ 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.
comoanrname• A & , A :Services, Inc.
address: 115 North Street ;zcktfyr ', 3p,
city: Salem, M4 01970 5{31 �<"wwR� 118Yi'rc
phonem 978-741=Q424 , e i�7� w,0kxts � '•
insurance co. The Travelers oon¢ya WC939X1256
❑ 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:
vzr#
company name
address
^..
city: hone#:
insurance eo : noliev#
company name
address. ,
city:
insurance co: noHimit#'.
air•A .Yt
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 51400.00 and/or
out years'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understood that a
copy of this statement may be forwarded to the Omer of Investigations of the DIA for coverage verification.
i do hereby certDuner, e p its and penalties of perjury that the information provided above is true and correct.
Signature Date ���0/91q
Printname Christopher zorzv. President Phone#978-741-0424
O
fficial use only do not write In this area to be completed by city or town official
ity or town: permitAlcense# flBuilding Department
❑Ucensing Board
❑check irimmediste response is required ❑Seleetmea's Office
❑Health Department
person: phone#; nOther
�. «G,v�aa '
BOARD OF BUILDIN REGULATIONS
(? a' License: CONSTRUCTION SUPERVISOR
P
NumberOs 057733
Birt 0122 958 p
/ 05/26P{00y Tr.no: 12633
Re
�j
:o CHRISTOPHER NE J _
115 NORTH ST ' _—'1,�� r
r; SALEM, MA 01970 r
Commissioner er
( S
.... 71w lJmPrONOXrrPea o�./C�reegc�ertJe((y .�.. .
Board of Building Regulations and Standards -
- HOME IMPROVEMENT CONTRACTOR
Registration:, 101609
Expiration. 6/26/2006
Type: .Private Corporation!
� A&A SERVICESJNC
Christopher Zorzy I
;- 115 North Street
1 Salem
, A
M 0
Administrator
Commonwealth of Massachusetts j
Division of Occupational Safety
Robed J.ftnoso,Commtssforw
pleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 01/14/05 _
Exp.Date 01A3tt16 O
. . . DC000440
Member M C.O.N.I:.S.T. 6
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