17 FORRESTER ST - BUILDING INSPECTION xr The Commonwealth ofMassachusefts.
Department oflndustrial Accidents
Office of Investigations
Iltt 600 Washington Street
VVVVYYYY Boston, MA 02111
f www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Business/Organization/Individual):
--A A Q A Se Y'via,s ,Z'y�!'+
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Address: I I S o r+h SFre e�
City/State/Zip:_5 ,e rA M 11 DI R7p Phone#:_1 q�$1 rJL 0H a W
F
,Y°u an employer?ChjCl�
k the appropriate box:
I am a employer with _ 4. El I am a general contractor and I Ty�of project(required):mployees(full and/oime)." have hired the sub-contractors 6 ❑New construction 1 am a sole proprietor paner- listed on the attached sheet. t .7. ❑Remodelingship and have no empyees These sub-contractors have 8. 0 Demolition
working forme in any capacity, workers' comp.insurance.
[No workers'comp. 5. 9• ❑Building addition
P ❑ We are a corporation and its
required.] its
have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no i2, Roof insurance required.] t employees. [No workers' ��/ a� /�
comp. insurance required.] 13•�vier �OD7—
'Any applicant that checks box#I must also fill out the section below showing their worker:'compensation policy information.
t I lomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lComractors that check this box must attached an additional sheet showing the name of the subc rac onttors and their workers'comp policy information.
!am an employer that is providing workers'compensation insurance for my employees;'.Below Is the policy andlob site
Information. -1�- .
Insurance Company Name:- ' r`e TM 1/D It r-�)
Policy#or Self-ins.Lic. #:_w C q�4 X I a 1
Expiration Date:�� 0-7
Job Site Address:
City/State/Zip: 019 7b
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.
if do hereby cerfljy er he pains:andpenalries ofperJury that the information provided above is true and correctSi natnre: Date:Pho e#
=Other
only. Do not write in this area,to be completed by city or town official,
n' Permit/License# l
hority(circle one):
I.
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
son'
Phone#•
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It'
DISPOSAL OF EBRIS AFFIDAVIT
In accordance with the provisions of !.. c. 40, Sec. 54, a condition of
Building Permit Number is t the debris resulting from this work shall
be disposed of In a properly licensed
ity as defined.by M. G. L. c. 111, Sec.
1508. ,!
The debris will be disposed at. Sale ,Transfer Station
own ` b Northside Caron
Sign Permit picant
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Dater;,+,w,
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Chrlstooher Zomr a
Name of Pennit Applicant
A &A Services Inc.
Firm Name ; -
+rr�.p
116 North Strest Saiem RRA 01970
Address, City, State, Zip Code ,
. ....... . .
BOARD OF BUILDIN REGULATIONS '
4 License: CONSTRUCTION SUPERVISOR
i Number'CS 057733
Blrttldeea
1,1 :�/ZB/19s8 I
flpl 105/2 66 Tr.no: 12633
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CHRISTOPHER 1 i�
115 NORTH ST -
SALEM, MA 01970 ' i •�
Commisalonar � -
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Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2008
Type: Private Corporation
A&A SERVICES, INC
_ Christopher Zorzy .
115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Diyiaion of Occupational Safety F
Robed J Frozlaso,Commissway
Deleader-Contractor
CHRISTOPHER ZORZY
EH.Date 02/09/06
Date 02/08/07 DC O
DC000440
MK(barol CO.N.E.S.T.
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IIMI����MBAII OIIW���I���IA4 BOSTON-RENEW ` '•-^
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building �OrrP.S f C SP�
Building Permit Application For-
JCircle whichever applies) Rod , eroo , stall Siding, Construct Deck, Shed, Pool
A eration, Repair/Replace, Foundation Only, Wrecking
Other.
PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of:Buildings
The undersigned hereby-appltes`for a permit to build according to the following sp6cifications:
Owners Name-.1nh/r p Oask- Contractor. A A Serviii5104g5 b r7
street I7�i7'�S�er S'f cit♦', Streef�ll5 I�n(�h S�". City .�1I m
State,h Phone ft)_24M - 35607 State M A Phone, 078) 7tJ I z D)J A/J
Architect: City of Salem Lic# 1 H 05
Street city I State Lic 057 HIP# I o i �9
State Phone ( ) Homeowners Exempt Form —yes t/no
Structure: (please circle) Single Family, Multi F lyOther
Estimated Cost of job S db
Will building confirm to taw?J yes no
Asbestos?=_ yes..: ..uo "._ , /
Description of work to be done: [L1LL(�r O i l a oryJ Q ho 1 T ( l I/2
n Shloales oe-) )bwee' r Or 0 'rfrn�l
_rat fi�or�l��� �hv ? ai z n h� l� /�'la I 6Q-r�2rP
r�hf�e rrv�� �h Upped- ry r mn�
A&A SERVICES, INC.
D(awin�Y n fitted: 115 _
_yes no Mali Permit to: SALEM,MH-01a70
�41-0424 - -
Siguatur ,of Appliciition,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
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