23 FRANCIS RD - BUILDING INSPECTION (2) DATE: IRl —'O� "D7
(Eitp of 'rR)aIM, ;ffla55arbU!5ttt5
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building A3 [`—a'1(U 6 �nnrV
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alteration pair , Foundation Only, Wrecking
Other: F
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:
Name:( J'QICI �Mn1 ITJIoe(, Contractor: tkf '4 6 e " 1US `0V)n r -zL
Street o rYar)ojS AMrj Citytddjefn. Sheet . (1.6-A// A 6f.' _City.LL 1&YYl:-�`--
State. r/P Phone i97�)-1f,9 3-/3D IP State Ida_ Phone
Architect: City of Salem Lic# �� 5
Street City State Lic L 'J� HIP ar 10 J(o O 9
State Phone ( ) _ Homeowners Exempt Formes/no
Structure: (please circle Single Faint y, ulti Family# Other
Estimated Cost of job S -�t osl)l, 8 p
Will building confirm to law? V/ yes no
Asbestos?--- yes/no
Description of work to be done:
2�✓�yl-
Drawin Sub fitted:_yes no Mail Permit to: 115_NORTH STREET
4 RAI EM.FAA 01970-
X W1NW(978) IC2W
Signature of Appli ation,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
.;--67
f
j APPLICATION FOp
11 ' PEAW TO
7 '
LOCATION
23ac�S
PEgMIT GRANTED
APPROVfD
P TON OF BUI INGS
CERTIFICATE OF OCCUPANCY "
YES
No- 0
J.
rx; ,
r� The Commonwealth of Massachusetts
6 Department of Industrial Accidents s
Office of Investigations
[( 600 Washington Street
k Boston, MA 02111
f www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ably
Name(Business/Organization/Individual):. 6 Q A Sor via 5 Xn t- '
f
Address:_ I�I I o r+h
City/State/Zip: . ( D VVl M 11 tilt[-70 Phone#: 2,4 eN _Q�J q L�J
Areu an employer?Check the appropriate box:
I.UV i am a employer with 4. 0 1 am a general contractor and iJP
roject(required);
employees(full and/or part-time)." have hired the sub-contractorsw construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. _ modeling
ship and have no employees These sub-contractors have molitionworking for me in any capacity. workers'comp.insurance.[No workers'com insurance 5. ilding additionP• ❑ We are a corporation and itsrequired.] officers have exercised their ctrical repairs or additionsI am a homeowner doing all work right of exemption per MGL mbinm self. 8 repairs or additionsy [No workers'comp. c. 152, §1(4),and we have no f
insurance required.) t employees. (No workers' Cepa�insurance required.) er�✓�/ )��(i✓5
Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
t I lonicowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContracton that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy infom adon. .
I am an employer that is providing workers'compensation insurance for my entploye,c;..Below Js the poUcy andJob slte
Information.
Insurance Company Name: The e Tr0 !D 1 f
Policy#or Self-ins.Lic. Q q- X 12 ti l 1
Expiration Date:-- q Imo!O-7
Job Site Address: 3 F/)nCj S &0 0 `e 'Q 1970
City/State2 /
ip:-Lx(
Attach a copy of the workers'compensation policy declaration page(showing the polity 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 cets'Ijy er t e pains nd penalties of perjury that the information provided above is true and correct
Sinature: .: ... . .,....,
Date:
Phone#: (q1 �4 — H a
Official use only. Do not write in this area,to be completed by city or town o�ciaL
City or Town: Permit/License#
EInspector
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector
6.Other
Contact Person:
Phone#:
DISPOSAL OF DEBRIS AFFIDAVIT
S�b'r�i i
In accordance with the provisions of § . L. 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 `.''Iity as defined by M. G. L. c. 111, Sec.
150a.
{ }Y
F
The debris will be disposed at: Sale Transfer Station
owned;bv Northside Carting _
a 14y
j
r ,
Sign a of Pe it Applicant
�w � a a47
Date 1'
z
si6al�
Christocher Zorzvr`
Name of Permit Applicant
A &A Services, Inc. " wl' '
Firm Name '
115 North Street, Salem MA 01970
Address, City, State, Zip Code
1�+fig,
I414 ' ,I
Y r.
IBOARD OF BUILDINaG e REO �
License: CONSTRUCTION SUPERVISOR
I Number. bs 057733
!I •' BlrthdsEe•.05/$6/7958 I
05/260,0`/ Tr.no: 12633 -(
R / `f // ..
' CHRISTOPHER
115 NORTH ST i
SALEM, MA 01970
Commissioner f
t
;� ✓� �mrnarur.ea(!� o�-1r�ir.Wos/uaella
Board of Building Regulations andStandards
HOME IMPROVEMENT CONTRACTOR
ACTORR
Registration: 101609
Expiration: 6/26/2008
Type: Private Corporation
• ABA SERVICES, INC '
Christopher Zorzy
115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational safety f
Robert J Prerioso,Commissaw
Delearter-Contractor
CHRISTOPHER ZORZY
Eff.Date 02/09/06
Date 02lOB/07
DC O
DC000440
Mm6erd C.O.N.E.S.T.
7
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90STOM ENEW t .
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