50 FREEDOM HOLLOW - BUILDING INSPECTION (8) v -
1
DATE: 7- 28-04a
CItp ]of `49)ate T, JEA!�!Mrbu!5EttE;
PLANS MUST
S BE FILED AND APPROVE
D BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building � 6Ye jt)O {+DI Inter qD1
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alteration epair/Replace, dation 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:
OwuersName: (- &be, 0' I+Grr1e_+ FneQn-On Contractor: Cnri stnnhar- 7.nr7
StreetSD ffi&tJfyn Hbi lmA MIDI City Street l 1 5 Nn r t h R t r a a t City_S a l Pm
State__ M� Phone (178)7HI - I15qq State MA Phone(97g) 741-0424
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__L/no
Structure: (please circle) Single Family, Multi Family#_
Estimated Cost of job $I((oH,
Will building confirm to law? yes no
Asbestos?_yes v1 no
Description of work to be done:
ZV1Sf(]ll 1fc>D 21 v nw) r001n Pyyl A IA)IVV'uy
Drawin IES
u mitted:_yes no Mail Permit to: Il6 NORT STREET
Signature of Applicofion,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (17 MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee$
COI4fE1!ITS
�T
I
No. � .
ArPLICATION FOR
Ao' PPRMIT7d .' •��
Ace 2 '`1A(
LOCATION E. _
PE MIT GRANTED
APPR VFp
!�OPIiETOP OF-BUIL15INGS
CEBTIFICATE,OF OCCUPANCY " .
YES
NO ,
a ' ,l
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 lic
ensed facility as defined by M. G. L. c. 111, Sec.
150a
The debris will be disposed at: Sal
em lem Transfer Station •
owned by Northside Cardinn -
Signature of Permit Applicant
7- o28rO(O
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
Isom
oxceO/100soJ affoss
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city nhone#
1 am a homeowner performing all work myself.
1 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.
s
comanrname: A & , A ?Services , Inc .
115 North Street
address:
01970 city: Sal , .
insurance co. The Travelers policy 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:
v ggpl{ ?stEt
comoanv name: t: a
lip
address:
city:
hone#: t�itq
insuranceco: policyp "f+,�,Pd v tr'�, _� •,,
companyname• +� i.
address..'
city: : .': : 'hope#:
insuranceeo: ......
policy# .+v .Fa$,r,,is t- _ .�•''
Failure 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 verification.
do hereby certify n r e pa/I and penalties of perjury that the Information provided above Is true and correct.
Signature-�� /N--- - - - -- Date -7- '2Z0- 0(J
Printname Christopher 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: permit/license# riBuilding Department
❑Licensing Board
check if immediate response is required oseleetmen's O�Dce
QHealth Department
contact person: phone#; 710ther
REGULATIONS
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
•'�- Number: CS 057733
` Birthdate:,05/26/1958
.'r Expires:05/26/2007 Tr.no: 12633
Restricted: 00
CHRISTOPHER ZORZY
115 NORTH ST
SALEM, MA 01970
Commissloner
-
--�` - Board of Building Regulations and Standards
TUF
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expl ration: 6/26/2008
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J prez/oso,Commissioner »
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 02JO9106
Exp. Date 0210&07
DC000440
Member of GO.N.E 5 T. 07
so
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