17 HEMENWAY RD - BUILDING INSPECTION '�� t li
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DATE: /O -3D-
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PLANS MUST BE FILED AND APPROVED BY THE
_ INSPECTOR PRIOR TO A PERMIT BEING GRANTED pp
Location of Building 17 k//p717fiynad(.VJ/ l Xd
Building Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install Siding ct Deck, Shad, Pool
Addition, Alteration, pau/Replace 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-.-T U Po., ri y(nl,r, Contractor: Chri stophar Znr7.g
Street C7 4o rnm j L)h x In i E �i/ �.�Ci'q�' on— Street 1 1 5 North S t r a a t City_sa.'=
State Phone Rl ) 74T-,Q4iAH State MA Phone(978) 741-0424
Architect: City of Salem Lic# 1405
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) _ Homeowners Exempt Form_yes no
Structure: (please circl qiIniiFamil • ulti Family# Other
Estimated Cost of job SJ(o. /` & /)D
Will building confirm to law?- yes no
Aibestos?_yes iZno
Description of work to be done: _-J:i� -k Jl fhlYfe>°n 13 ) ;Jrz/P n
Drawin ubmitted:_yes no Mail Permit to: 1.15 NORTH STREET
% IIAr.EN yl�e1 9=84v"—=
Signature of ApillicafXon,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE CO`MPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit#q 2q-2001iZoning Map/Lot 11
Permit fee$ -QZ=9 C4 -
C0104ms:
c.
The Commonwealth of Massachusetts
Department of Industrial Accidents
{ 0/I n811tlyesdoof oss
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city phone#
❑ 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.
companvname• A & , A-Services , Inc . le ti
address: 115- North Street
city: Salem, �'MA 01970 phone#• 978-741-0424 `'Nr a #'..
r � ,��ra�r
insurance ca. 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:
t t 3,
company name
address:
city: hone#•
insurance ca. Policy#
company name.
address:.
4.
city: hop!#: +.?fir,a•t +`
inauranco-co.- off # s a" S.daiva
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 s ulfor
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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 uncle e p ns and enallies of perjury that the information provided above is true and correct.
�
Signature , Date
Print name—Chris tODher Zorzv, President Phone#978-741-0424
official use only do not write in this area to be completed by city or town official
('contact
ity or town: permittlicense# nBuilding Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑health Department
person: phone#; 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 Cardna
A/
Signature of Pe it Applicant
Date
Christopher Zorzv
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
BOARD OF BUILDING REGULATIONS
.icense: CONSTRUCTION SUPERVISOR
C
Number: CS 057733
Blrthdate: 05/26/1958
Expires:05/26/2005 Tr.no: 12224
Restricted: 00
CHRISTOPHER ZORZY
115 NORTH ST (_
SALEM, MA 01970 Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
. Robed J.Pmmso,Deputy Director
Deleader-Contractor
CHRISTOPHER ZORZY
Efl.Date 11/21/02
Date 112 DC 0/03 O
DC000440
salter of C.O.N.E.S.T.
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Board or Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
. Registration: 101609
Expiration: 6/26/2004
Type: Private Corporation
A&A SERVICES,INC
Christopher Zorzy
115 North Street
Salem,MA 01970 �✓►
Administrator