129 HIGHLAND AVE - BUILDING INSPECTION A�— DATE: 7-a S-O Cam_
& 02 dry
Citp of gbal'em, a!YE;arbu5EttE
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building 1 a q 1- Qb l Hyen
Building Permit Application For:
JCircle whichever applies) Roof, Reroof, Install Siding, ct Deck, Shed, Pool
Addition, Alteration, Repa' /Replace, oundation Only, Wrecking
Other:
1
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: r)LLj P)Urlo2 Contractor: C h r i s t n p"r
Street JaC] Lhghlpnd Ave-. City j Street 115 Nnrrh Srraat City_Satam
State` Phone (q78) '7,q LI --75 a State MA Phone(9 7 g) 7 41-0 4 2 4
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__V/no
Structure: (please circle) Single Family, Multi Family#
Estimated Cost of job$_a1 DI b , DO
Will building confirm to law? /_yes no ti
Asbestos?_yes_ / no
Description of work to be done:
Tv)a+r 11 ran b1 yll� l r �iC��mmenl ndr�t ��P
L0lnr-1n . � .
DrawinZ
itted:_yes_ no Mail Permit to: A N SERVICES
RTH STR
EET
�--� _ % lidr.F.M K4 E�
Fxz_
Signature of Appli lion,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee$
CONHEns:.
No. D�APPLICATION FORPEnW TO
_
LOCATION t
rE MIT GRANTED
APP v D
INSpECTOn OF BUILDINGS
CERTIFICATE OF OCCUPANCY .
YES
NO'
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 Carting
Sig ature of Perm' Applicant
--as--I)co
Date
Chrlstocher 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
IBM Department of Industrial Accidents
- Ol//COO{/OYOS//yBUO�S
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
❑ 1 am an employer providing workers' compensation for my employees working on this job.
companvname: A & , A•Seryices , Inc .
address: 115 North Street
city: Salem; kA 01970 - phone#• 978-741=9424
t {
insuranceeo. The Travelers policy# WC939X1256Mill
'+ S•`' " '`
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
com sn name VeF� '"
H.. .,t..0 W' ,
address: .
eit hone a:
4 1
insurance co: Policy a
company name: }�M„2•
address. .,:... . ,
city: "hone#•
insurance co. policyp•� .,6r'.,�e5
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties ors flat up.to 51,500.00 and/or
one years'Imprisonment w well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify un the sins and penalties of perjury that the Information provided above is true and correct./
Signature T - _-_ Date /—25 —Q&
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: permittlicense a flBuilding Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑health Department
contact person: phone a; FlOther
• BOARD OF BUILDING REGULATIONS '
s. License: CONSTRUCTION SUPERVISOR
_t Number: CS 057733
Birthdate:-,05/26/1958
Expires:05/26/2007 Tr. no: 12633
-' Restricted: 00 -
CHRISTOPHER ZORZY,
115 NORTH ST G--/
SALEM, MA 01970
Commissioner
F it s Board of Building Regulations and Standards
[y HOME IMPROVEMENT CONTRACTOR
t71d{�3F Registration: 101609
°\ Expiration: 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.Remo,CommissiOuer
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 02/09/06
Exp.Date 02/08/07
DC000440
Wember of C.O.N.E S.T. 07
80 _
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII oil III BOSTON-RENEW
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