23 FRANCIS RD - BUILDING INSPECTION (7) DATE: /0 - /D -D 6
(Eitp Df �arrrr, � a�juEtt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building � f�-analS T lonr
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Sidin ct Deck, Shed,Pool
Addition, Alteration(Repair la ,Foundation 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:
Owners Name:�Dan Aoh c )r)f-1 Contractor: A Se"ic s /ChrIS r f
Street o2'3 fnVY'a.S Rpp(j Cin u�dJCry l street !L5- City_sj�
State Phone ( -7/{) . )05r{ State MA Phone, L-C 14 a'l N
Architect: City of Salem Lick— I hD r5
Street City State Lir a HIP# 101 co D9
State Phone ( ) _ Homeowners Exempt Form_yes✓ no
Structure: (please circleCSingle:F:anily) Multi Family# Other
Estimated Cost of job S 3 D, nQ
Will building confirm to law? yes no
Asbestos?_yesVno
Description of work to be done::
\/I n .1 1 IMP I nC D w P�
J '
Drawings b itted: yes� no Mail Permit to: 115 NORTH STREET
X
Signature of Applic '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 S
CONMENTS:
i
i _ III
No. 7
APPLICAYION FOH
' PI=H TO
LOCATION
PEIdMIT GRANTED
3 4� s
APP VPp
INSPECTO�j O BUILDINGS i
CERTIFICATE OF OCCUPANCY
YES
NO • ,
• Y,
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 bv Northside Carting -
Signature of PermA Applicant
/0-/D-OCp
Date
Christopher Zorzv
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
Office of Investigations
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name:
location,
city: state: zip: phone#•
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑ Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
I am an employer providing workers'compensation for my employees working on this job.
companyname: A � A Se-roCeS, -TnG
address: I I c5 IJD(4-h cYh'ee+
city: Sn I rn phone#• 1 T7 4 r7H t vN aH
insurance co. 'ThL TfGtVPIG ILGy# WCg3gx) 9 610
❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who
have the following workers'compensation policies:
company name:
address:
city: phone#•
insurance co. Policy#•
company name:
address:
city: phone#:
insurance co. policy M
Failum to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one 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. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verifications.
/do hereby certify and th p as and penaides ofperjury that the information provided above is true and correct
Signature Date
Print Name hone# 6�g 7H 1 -o N a�
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑ Building Deplrnnent
❑ check if immediate response is required Licensing—Hoard required ❑ Selectmen's Office
❑ Health Department
contact person: phone#: ❑ Other
(re dead Sept.2003) -
BOARD OF BUILDIN�REGULATIONS � '
License. CONSTRUCTION SUPERVISOR
1 Number CS 057733
Birthrate 0526/1956
Ex Ims i0526/2007 -
. P � Tr.no: 12633
r:;y
Restricted 0o
CHRISTOPHER ZORZY
115 NORTH ST ` / -
SALEM, MA 01970�
Commissioner
Board or Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR -
Registration: 101609
Expiratlon: 626/2006
- - Type: Private Corporation,
A&A SERVICES,INC -
Christopher Zorzy
115 North Street 2`
. .. Salem,MA 01970 Administrator
commonwealth of Massachusetts -
Division of Occupational Safety
RoDeJe adders, ntractor
Deleatler-Contractor
CHRISTOPHER ZORZY
ER.Date 02/09/06
DEXP CODate 07/O6/07 0 •.a
DCOOOgAO
Iteamvd c ONes T.
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