38 HAZEL ST - BUILDING INSPECTION y
✓\ The ('onununwralth of %1asSaChnsettS
r Bouid of Building RcgulationS and Standards \I('NIl'111A tl 1
Massachusetts State Building Code, 780 CNIR, 7' edition 51`
Building Permit application To('unsu'uct. Repair. RenoS ate Or I)emulish a Rr
'unS
Onc'- or Tit r 'I' ilt' LJne lli,,,ti
(<� This Section For Ot'ticial Use Only
\\ Building Permit Numh . -Date Applied:1"11
Jut
Building Conunissionar/ Inspector of Buildings Date
SECTION 1: SITE INFORMATi0N
I. P P•rt ' :�ddres': 1.2 :Assessors Map & Parcel Numbers
Ma Nunrher Farrel Number
I.la Is this an accepted street? yes_ m(_ P
1.3 Zoning Information: 1.4 Property Dimensions: —
Lot Area(s ti) Frontage(ti)
Zoning District Proposed Use 4
1WRqcord
5 Building Setbacks (f )
Yard Side Yards Rear Yard
Provided - Required PruvideJ Required Pn(e iJeJ
(M.G L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' - Municipals❑ On Site disposal system ❑
❑ Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
rd q G �„
Name rim) Addres for Service:
'
'•�,S mat e Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (cheek all that apply)
New Construnion ❑ Existing: Building ❑ Owner-Occupied ❑ Repairslsl ❑ Alteration(s) ❑ Addition Cl
Demolition _ ❑ Accessory Bldg. ❑ Number of Units_- Other ❑ Specify:
Brief Descri of Proposed Work-:
t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
~ i hem (Labor and Materials)
1. Building $ [l 6-0 I. Building Permit Fee: $ Indicate haw fee is determined:
❑ Standard City/Town :\pplication Fee
2. Electrical S ❑Total Project Cost' (item 6) x multiplier x
i. Plumbing 5 2. Other Fees: $
a. Mechanica) HVAC) .S List: - —
5. Mechanical (Fire S
Total All Fees: S
-
Suppression)
i Check No. —Check :\m,n(nt Ca,h :\nn,un(:---_-
b Tidal Project Cost: S 9 �yy, Cl Paid in Full O Outstanding Balance
SECTION 5: CONSTRUCTION SERVICES � /-
5.1 Licensed
Construction
Con[s
tru ction_Supervisor
upervisor eI CSLI T�t`
5774 Ltiense Numher F\)itauon ):see
N meofCSL- IIu1 er " CSL'fNpc tsca huspescnriion
kddreu -
//
L l'nresu)ctcJ u t w?i.000 Co. Ft.
R Rc>ttincJ L@_' F:muh Mkc1line
Ile,
e D N1 Nlasonrt OnlY
RC ResiJenual ltuulSnc Cot eruct
Telephone N'S ItcsiJrnudl \Vindutt ,mJ SiJnie
SF Rcsideiuial Solid Fuel liurnme 1 )tlnmerin.i,illauui�
. D Rcsidentml Demolition
5,2 e ist •red home Improvement Contractor IC)
/ t
li l� 't�npm Name u l IC Regi3tr t Nat IZegtstratiun tiun ber
Address S i 6 Z 6 e)
61 E. piratiun bate _ ..
Signature .-.. Telephone - - - -
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fadure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
j L as Owner of the subject property hereby
authorize r /^ G to act on my behalf. in all matter:~
relative to work authorized by this building permit application. .
Si re ol'Owner Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
r
1, r-Ac/s tz z)h ar r i — as Owner or Authorized Agent hereby declare
that the statements and infer ation on the foregoing applicati are true and accurate, to the best of my knowledge and
behalf. ,
r
Print Name
Signature of Owner or Authors e .Agent Date
ISiened under the pains andpenalties of er u ) "
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contraetur-
(nut registered in the Home Improvement Contractor (HiC) Prog_ram), will not halve access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important intltrmauon on the HIC Program and
Construction Supervisor Licensing(CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5. respectively.
'. When substantial work is planned, provide the infircmation below:
Ttnal fiUors area(Sq. FL i [including enrage, finished hasement/atties, decks or porch)
I (";rocs livins area (Sq. Ft.) Habitable room count _
Number of fireplaces - Number of hednnims
Number of bathrooms Number of halt/hash. _.
rope of heatinv system Number of decks/ p, ichcs I
Type of cooling system Enclosed _Open
i. "Total Project Square Footage- may be substituted for "TolA Project C0,1"
CITY OF SALEM
, PUBLIC PROPRERTY
'? "
DEPARTMENT
%I.UI 'K 12:\S'.\ilNNt,IlINSl It)11 • S.\I \f, \L\,,.\tIII ,f :I'f
Il:l:9-8•,45.9j45 ♦ F\%:'1.7g•-l:-'/h'ao
Workers' Compensation Insurance Afffdaiit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Levibly
Name I f3u., tic,s I h_anitauon Indn Iduul.t: A L A S C.' V [ CAS In c-
ALItiress;1(5 Nor 5+re -+
City,State,Zip: so f M Mq 0197D Phone 4: L il7SS> 2� 1 - WA �
1re,/%'On an employer:'Check the appropriate box: Type of project (required):
I [j l aln a employer with�K 4 ❑ 1 ain a ,encral contractor and 1 6. ❑ New construction
employees(full and+or part-tiine).' have hirrd the sub arntraeuirs r
listed on the artached sheet. % 7• ❑ Remodeling
�.❑ I am a sole propriety or partner- - ✓
ship and have no employees rhese sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q. Building addition
LNo workers' comp. insurance 5. ❑ We pre a corporation and its
10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof re irs
insurance required.) t employees. [No workers l Other
comp. insurance required.] lam"
-Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. a
t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such ,.
lContmcmrs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
f urn an employer that is providing workers'compensation insurance for try employees. Below is the policy and job site
information.
Insurance Company Name: le,
Policy#or Self-ins. Lice. #: [ 0, 2.0 M $I_5_(-1 Expiration Date: yam_
Inb Site Address: n p )t t Q Q Ciry/State/Zip: R O )q'16
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 1\iGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up ht S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
In\estigations off he DIA for insurance coI,era,e verification.
l do hereby versify under the iris and tenulties of perjury that the information provided above is true and rurrecL -
\i Lv' nure7 C-4 / ' /� - Date'Phtn • � `7 N 9 - / / - 0L/ 429
U(jiciul use onlj'. Do oat write in this area, to be completed by city or rown ojjiciaL
City I r ['uan: - ---------__—..--- f criniULiccnse #---.----------
lssuing.kuthority (circle une):
1. Huard of ifealth 2. Building, Department 3. C'f fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and Instructions
\I.tssachuscus 6encral L;O%s chapter I5_ requues:Ill cmplovers to pro\ide workers' compensation lift their emplo)ees.
I'!Irsa.Inl 10 ill is st;lnite, .Ill enijph ree is defined as c%eR person In ill SCr\lie of .I II011ler ul Lie r ally contract of hire.
i\prc<s Or 1111pled.Ural or w ripen."
\m :mphi"1-er is dclmed as "an imJivdual,partnership, association, corporation or oilier legal entity. or any Iwo or more
oI the tivegoing engaged in ajoint enterprise,and including the legal representatives ul'a deceased employer,or the
roved cr or trustee of an ititiMdual, partnership,association or other legal entity,employ in; employees. llowcver the
wa ncr of a dwelling house hay mg not more than three aparnncnts and who resides therein, or the occupantOf the
d\\elling house oranuther who employs persons to Jo maintenance,construction or repair work on such dwelling house
or on the grounds Or building appurtenant thereto shall not bCC:Wsd of such employment he deemed to-be-an-employer." --
0 t. chapter M, �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, SIGL chapter 15 2, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public cork until acceptable ev idence of complisncewith the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors) natne(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 amdaviL The affidavit should
be retumed 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to ftll,in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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(narked by the city or town may be provided to the
:Ipplicant as proof that 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The t fttice 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 Department's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Ire.iscJ :-'tl-tl5 Fax # 617-727-7749
www.mass.gov/dia
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 Wort:shall
be disposed of in a properly licensed facility as def►ned•by M. G. L. C. 111, Seca
15Qa.
The debris will be disposed at Salem Transfei Sttion
owned by Northside Carting
i
eL A
Signature of PahlypHaant
Aj l0
Data
Christopher Zorzv
Name of Perrnit,4ppiicant .
A &A Services. Inc.
Firm t lame
"S North Street, Salem► MA 019,70
Address, City, State, Zip Code
NLlssachusetts Department of Public SafetN
Board of Buildiri Regulations and St ndardsd
Construction Supervisor License. "
License: CS 57733
E Restricted to: 00 -
CHRISTOPHER ZORZY .
115 NORTH ST
SALEM, MA 01970 S
Expiration: 5/26/2011
('ununisiuncr Trlf: 14751
v'. fee -Po:m�nzomuieaCC�i �canaac/uuelta-'.
Board of Building Regulations and Standa di .
HOME IMPROVEMENT CONTRACTOR
'i Registration:, 101609
Expiration -6/26/2010 Tr# -267870
� - Type Pri'tate Corporation
I! A&' SERVICES, INCH - -
fChristopher Zo¢y --
I 15 North Street
)Salem',MA 01970 - AdministratorqL
Commonwealth of Massachusetts
Division of Occupational Safety
Laura M Marlin,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Eff. Date 04/14/10
Exp. Date 04/13/11
DC000440 -
Memherof C.O.N.E.S.T.
- - BO
IIIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII BO 0WRENEW