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48A LAFAYETTE PL - BUILDING INSPECTION DATE: d/ , PI D 7 �itp ]if afar*Tni a#g;arbU!�ettE; PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A .PE:'NUT BEMGY GRA1Ni F D Location of Building _A Building Permit Application For: '(Circle whichever applies) Roof, Reroof, lnstall ' . 2onsgyt Deck, Shed,Pool Addition, Alteratio Repair/Replace, undation Only, Wrecking Other: PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING To.the Inspector ofBtrildings. The undersigned hereby applies for a permit to build according to the following specifications:Owned Name' or: ajYVICS/n 7Y5 l � P Df street �i8� Ira nieaiiv: �� tit. �PV11 street 115 Marl 51 City_,C�a� State-- F i� Phone (C{�g) q 6 —�573 State M fl Phone• 078) 7-9 1 Architect: City of Salcm Lic'J N05 Street City State Lir b 57 " HD?f, 1 t)I to og State Phone ( ) _ Homeowners Exempt Form_yes, L-_�no Structure: (please circle) Single Family, Multi Family# Other r imt� �'�irft� Estimated Cost of job S D-7_ , Will building confirm to law?—Lies no . Asbestos2._yes-_ono_. Description of work to be done: 0" _ boc trr 11QuJ oirrb2� _ A&A SERVICES, INC. Drawin b Wed: ves� no Mail Permit to 1 5 " SgLEM,MA 01970 X W W W.A-ASERV LEE. Signature of Appli 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 CDlIlS WS: ,t { f I� 'A" •• tv r LL LU LU o . n Q n ac a_ a- Z. �_. CL < The Commonwealth of Massachusetts WDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrIut Leetbiv Name(Business/Organization/Individual): i� A 5orvia,6S'h t Address: 115 Q o r+h �rhrc e� City/State/Zip:__5a1 y rye M 11 01970 Phone#: l q 74i 7H -OH Fam ployer?Check the appropriate box: Type of project(required): ployer with�� 4. � I am a general contractor and 1 s(full and/or part-time).' have hired the sub-contractors 6. ❑New construction proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ave no employees These sub-contractors have 8. Demolition or 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 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions i myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0'Other E D- *Any applicant that checks box#! must also fill out the section below showing their workers'compensation policy information.t I loma:owners who submit this affidavit indicating they are doing all work and then hire outside c (Contractors that check this box must attached an additional sheet showi ontractors must submit a new affidavit indicating such: ng the name of the subcontractors and their workers'com p.policy infotmaton am an employer that is providing workers comp ensatnon information. insurance for my employee&;Below Ls the poticy and fob sift Insurance Company Name: —t�f" _ 1 r le TrQV 0 I Qr-S Policy#or Self-ins. Lic. #: W C q R4 X I a n Expiration Date: q '��p-7 Job Site Address: -h 2 LA ( Ifs M('e City/State/Zip:.�2_I fl t HP( Q 1g70 Attach a copy of the workers'compens.tion 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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /do hereby certljy d r the sin and penalties ofperlury that the information provided above is true and correct Si nature: a 0 Date: Phone#: q�i$) 7� — Hof [6. cial use only. Do not write in this area,to be completed by city or town ofctaL y or Town - Permit/License# uing Authority(circle one): I. oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ther tact 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 hint, 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,partnership,association or 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, §25CM 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-contractors)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 maybe 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'r compensation policy,please call the Department at the number listed below. Self-insured companies should enter their' self-insurance license number on the appropriate lire. 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 permittlicense 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 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 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. r ne Department's 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 >' it 4 ql DISPOSAL OF EBRIS AFFIDAVIT t�s n� In accordance with the provisions of . L. C. 40, Sec. 54, a condition of Building Permit Number.. is the debris resulting from this work shall be disposed of in a properly licensed .� a ity as defined.by M. G. L. a 111, Sec. 150a. 9�4am The debris will be disposed at: , .- Sale (.Transfer 3tatlon ' own b No side Cartln F- • .r ' ... '. I � qq a ,./� � _ r Sign " F of permit Applicant � k : c9 A Date 'Z--- Christooher Zorzv _��,.. Name of Permit Applicant A &A Services Inc. Finn Name , . 115 North Street. Salem MA 01970 ^ Address, Cdy, State, Zip Code . , _ r F va ✓M .._ _70011D OF NllOBUILDING Rfrtca�(II{ o"�. I BOAREO ONS a- License: CONSTRUCTION� SUPERVISOR 1 i Number,'CS 057733 ' BI � 958 j 9�16 "05/2 �00y Tr.no: 12633 1 e CHRISTOPHER #,�� 115 NORTH ST i SALEM,.MA 01970' Commisalonar I � ;� ✓/re �ricrnaninersll/ o�.//,`riJrtq/�pre/{Q Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101609 Expiration: 6/26,2008 - Type: Private Corporation A8A SERVICES,INC ' Christopher Zorzy 115 North Street Salem,IAA 01970 Ueputy A� drain—btrator Commonwealth of Massachusetfs���" Division of Occupational Safety Robed J Rezoso,Cwmnsiow Deleader-Contractor CHRISTOPHER ZORZY' EB.Date o2/og= O Exp.Data O7JO=7 Bl07 DC000440 - namard CO.N.E.ST. 7 ,���aaaatt�aaea� rlrl1�ppaalI 11p1aaaelI aaaaa.rr''r• r'��'ryarylI BOSTON-RENEW i .