15 FREEDOM HOLLOW - BUILDING INSPECTION (2) DATE:.
�itp of a�A�PTTi, A �ALJtiPtt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 15 Ef�rlDfn hbI 112141.
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Sidin nswct Deck, Shed, Pool
Addition, Alteration, epau/Replac 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, y Vivrtnv� l Contractor: Chrigtnnhar 7.nrzy
Street lr, Street 11 5 Nnrrh Straat CitySa gm
State,ram Phone Fj7$) 7J41 379-7 State MA Phone(978) 741 -049.4
Architect: City of Salem Lic$ 14 0 5
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) _ Homeowners Exempt Form_yes__�./no
Structure: (please circle) Single Family, Multi Family# Othe Tnt.)nhp(iSt?,
Estimated Cost of job$a'71 on , Q
12
Will building confirm to law?_yes no
Asbestos?_yes ✓no
Description of work to be done:
1nS-1n11 -Pc x M H) )LIiL I 1 nlnf aMer\+ II IYYlu kA&A1�
Drawin b itted: es no Mail Permit to: 1.15 NORM STREET
% rsAT-EA9 94 0309M
X
Signature of A pl• 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 feeJ��
coffl4 Ts:
No
APPLICATION FOR
' PERMIii' Tn
LOCATION
PE MIT GRANTED.
APPR D .
INSPECTOM OF BUILDINGS
CERTIFICATE OF OCCUPANCY .
YES
NO +
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
owne.d by Nortlig de Carting _
Signature of P rmit Applicant
B3bd
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 ofMassachusetts
Department of Industrial Accidents
off/to of/crgsal R&ORs
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city phone#
❑ 1 am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
❑ I am an employer providing workers' compensation for my employees working on this job.
companvname: A & , A-Services , Inc .
address: 115. North Street ;xi321 +r "kzraiN�.
city: Salem, IfA 01970 phone# 9 7 8-7 4 1 0424,�� 'jrt' a+rif'Agstr
insurance co. The -TraVe lers oolicv# WC939XI256
❑ 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:
tA.
address
city:
hone#•
y,
� t
insurance co: olic #
company name. tip' .-
cif ,�+�i an 'F. "'i•>i'.. "hone#: ..^.'jai • t
msurancecoi Valley#
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$19500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. 1 understand that a
copy of this stateme may be forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby certi d the s a d penalties of perjury that the information provided above is ostee and correct.
Signature Date l3D�DCo
Print namc_Christooher Zorzv, President Phone#978-741-0424
official use only do not write in this area to be completed by city or town official
city or town: permittlicense#_ nBullding Department
❑cheek if Immediate response is require) - Ql.iceosing Board
Qselectmeo s Office
QHealth Department
contact person: phone#; f—lother
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e+$if�'i1y n
on various factors—like the R "` �'
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g Y p
Ln%1.5r. ..i .2.1'.�41 6�p. T. � .�. ^r it..: {o' ?>.. Sri LVr ♦ .M . .
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Use the chart to the ri ht to .
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+ B
BOARD OF BUILDIN�REGULATIONS �
License. CONSTRUCTION SUPERVISOR
NumberCS 057733 j-
Blrthdate 05/26/.1956
I . Expire a;405/26/2007 Tr.no, 12633
'Restrictedr
CHRISTOPHER ZORZ +I
I ISNORTHST
SALEM, MA 01970 C—1
' _ Commlulonar �
_. CT �'—mox—ukvlGf o�✓ .oan�rzee!!e
BoaN of BuilJiog Regulsrinns mrJ SmnJards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration[ 6/26/2006
Type: Private Corporation
A&A SERVICES,INC
Christopher Zomy
115 North Street
Salem,AAA 01970 AJminisrrntor
~`Commonwealth of Massachusetts
Division of Occupation/Safety
RderlJ Aozoso,Commissions
Deleader-Contractor
CHRISTOPHER ZORZY
ER.Date D2/00/O6 O
Exp.Date 02/06/07
DCOOD440
Moolod CO.N E S.T.
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