11 HARROD ST - BUILDING INSPECTION (2) DATE: 2 - cZ 7
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building /I / {CtrrD(X li)1 re f
Building Permit Application )ror:
'(Circle whichever applies) Roof, Reroof, Install S�ict Deck, Shed,Pool
Addition, Alteration, oundation Only, Wrecking
Other. :t
PLEASE FILL OUT LEGDILY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings;
The undersigned herebyapplies for a permit to build according to the following specifications:
Owners Name: AQU:e P rkv3r/7 l lrain,k4 Contractor: A � A 5e-iyICa5Mhn5 bLL,
Street city� Street- i 5 IJ nf4h 3 City—,,EQ(gym
State M/� Phone (4�$)Jq5-- agi5 7 State rA fl phone. (q78)
Architect: City of Salem Lic# I AJ05
Street City State Lit b HIP* I O I(o 09
State Phone ( ) Homeowners Exempt Form_yes t/no
Structure: (please circle) in le Family, Multi Family# Other
Estimated Cost of job S 7-1-/ 93, D D
Will building confirm to law?__yes no
Asbestos?_,_'es ✓ no
Description of work to be done:
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A&A SERVICES, INC.
Drawings bmitted: yes no Mail Permit to: SALEM. M_A 01970
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Signature of Appii 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
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The Commonwealth of Massachusetts
f WDepartment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibiv
Name(Business/Organimtion/Individual): 6 Q or via S ,=•y)C
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Address: I I.ri KI 0I�-+h e�+
City/State/Zip:5W o M M 19 012-70 Phone #: 4
A
reployer?Check the appropriate box:
employer with _ 4. Type of project(required):
❑ I am a general contractor and I
s(full and/or part-time)." have hired the sub-contractors 6. 0 New construction
le proprietor or partner- listed on the attached sheet. t 7. 0 Remodeling
ave no employees These sub-contractors have 8. 0 Demolition
for me in any capacity, workers'comp.insurance.
No workers' coin insurance 5. 9. ❑Building addition
[ p. ' ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12,0 oof repairs
insurance required.)t employees. [No workers'
comp. insurance required.) 13. Other_JdL t2aLj, S
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
IComractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp Polic
y infomaton
t am an employer that!s providing workers'compensation insurance for my employees: Below is the policy and Job site
information. —f�
r f
Insurance Company Name:_ t e— Tro VP I p
Policy#or Self-ins.Lic. 01 Cl sp X 12 ti l n
Expiration Date:
�q I I-3 1 O'7
Job Site Address:_1'l U12tzJQ Q/ Stre e'-F City/State/Zip: �C 4 �/�, m6 0 /970
Attach a copy of the workers'compensation policy declaration page(showing the policy 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$I,500.00 and/or one imprisonment penalties in the form of a STOP WORK ORDER and a fine
,as well as civil
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.
l do hereby certl n r t e pains and penaltie70fperjury that the information provided above is true and correct
Si,nature: Date: KU Q J
Phone#: �1 LI a
OJrcia!use only. Do not write in this area,to be completed by city or town ofrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Pl 6.Other umbing Inspector
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partrership;association of other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .
Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their.
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof thit a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Departments address, telephone and fax number:
The Commonwealth of Massachusetts .
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 62111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
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DISPOSAL OF i lEBRISAFFIDAVIT
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 ity as defined,by M. G.L c. 111, Sec.
1508. {
The debris will be disposed at: Sale 'd?ransfer Station
_. own " 'b Northside t;artin _ .: .
Sign
�r of ermlit Applicant
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Name of Permit APP iican '
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A&A Services Inc. '
Firm Name '
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11S North Street. Salem MA 01970, i
Address, Crty, State, Zip Code "
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.. .._IOARD�OF g�p NCi RE TI1013
i'- License: CONSTRUCTION SUPERVISOR
Numbs r'tS
057733
rtt 1p,`. ,1958
0& Tr.no: 12633
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CHRISTOPHER
115 NORTH ST '•`' I .
SALEM, MA 01970'`� i I
Commissioner ,�
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Board of Building Rrgul CO and s
HOME IMPROVEMENT
CONTRACTOR
Registration:. 101609
ExPiratlon: 6/26/2008
Type: Private Corporation
• A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Urputy A— d,n— In tar
Commonwealth of if
Division of Occupational Safety
Robert J%zioso,Commissioner +
Deleader-Contractor
CHRISTOPHER ZORZY-
EN.Date 0209/06
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Exp.Date OZDW07
02I0&07
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