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DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 35-3'74&12-OCff. hasf
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Install Sidin nstruct Deck, Shed, Pool
Addition, Alteratiocamair la e, 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 L&z6/ iJ 4/7'? 1 jQ(�iC/+'"IC( Contractor: Q h r; s t n n n a r Z.a r z`�
Street,�54�ZOL " J/, a City &-kIe%'J't Street 115 Nnrth SfrPPtCity Ra1Pm
StateMiq Phone (Q7�) 7qq-,3-197/ State MA Phone(978) 741-0424
Architect: City of Salem Lic4 14 0 5
Street City State Lic#0577-33 HIP# 101609
State Phone [ / Homeowners Exempt Form
Structure:Structure: (please circle) Single Family, Multi Family Other
Estimated Cost of job $ 19, rYYM to
Will building confirm to law?_ yes no
Asbestos?_yes V/ no
Description of work to be done: Vy molm ar?G( oil 5P Q� C X I sh r GYK
f�11 7/J)DL Ole-C-6 14)lA-I ror -r- lem
ERVICE3
Drawings bmitted:_des no Mail Permit to: 1.15 NORTH STREET
X r3AL?r1,1 ARA, ei eae--
Signs re o Applica n, SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE
Department use only: Penni t# Zoning Map/Lot
Permit fee /
COHMENTS:
L
The Commonwealth of Massachusetts
Department of Industrial Accidents
oxceofAWAVS91sl/eos
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
name:
location:
city Phone#
❑ I 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 thisjob.
comoanvname: A & , A .Services , Inc.
address: 115 North Street
city: Salem, ''MA 01970 ohoneN• 978=741=9424,°Kt#Yl"`
insurance co. The 'Travelers ooltcvM WC939X1256
❑ 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:
y` Gt
coin an name: , -, r jR .
address, ,
city: phone q
insurance co: noliev N •r:"F IY'dlry, ' ��'
company name ."•td f.
city:
hone#:
insurance co. nalliv N
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of crimleal penalties of a flee up to$1,500.00 and/or
out years'imprisonment as well as civil penalties In the form of a STOP WORK ORDER and a floe of SI00.00 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.
l do hereby cerflJyj ftye paaiiin�nss`�and p Wallies of perjury that the Information provided above Is true and correct.
Signature bs'=(L� "7 Date 71�,-) csL/
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
r
city or town: permitflicense N rlBuildlog Department
❑check if immediate response is require) ❑ueensleg Roard
Qseleetmen's office
QHealth Department
contact person: phone a; nother
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 by Northside Cartina -
Signature of Permit Applicant
Date
Christopher Zorzy
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
Board al Building Itcgulations and Standards
u HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2006
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street-r—���✓
Salem,MA 01970
Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Pfevaeo,Deputy Dlrader
Deleader-Contractor
CHRISTOPHER ZORZY
En.Date 12/19/03 'r
Date 1220/04
DC
' DC000410 r'
Member d C O.N.E.S.T.
g0 1
�pf
IIIIII IIIII IIIII IIIII III IIIII IIIII III IIIII IIIIIIII aOSTONRENEW
. .., ✓die l�oanrneasuiaa�i o�✓�nduu�udeaa c.
i BOARD OF BUILDING REGULATIONS
r+ License: CONSTRUCTION SUPERVISOR {
Number: CS 057733
Birthdate: 05/26/1958
Expires: 05/26/2005 Tr.no: 12224
Restricted: 00
CHRISTOPHER ZORZY -
115 NORTH STD
SALEM. MA 01970 Administrator