464 LAFAYETTE ST - BUILDING INSPECTION DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Buildiug 'q&'q k0-A0L .P7�P. S�reP
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof, Instal ct Deck, Shed, Pool
Addition, Alteratio Repair/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: Sohn rJl(1Q I P ✓��l Contractor: C ,r; R t n n n a r
Street ti/D)4 JAfa11P1fP. City i Street 11 5 North 4traat City Salem
State•Mi Phone 0'6 State MA Phone(978)741-0424
Architect: City of Salem Lic# 14 0 5
Street Cin' State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form_yes_y-"*no
Structure: (please circle) Ingle Famil , Multi Family# Other
Estimated Cost of job$ :2 (o5-;g /tT)
Will building confirm to law? yes no
Asbestos?_yes✓no
Description of work to be done:
I'�Pn Q� Px�S}rr n l. livr�lt i JCL�jrrl� PIoran—� r J a
Its) n�IU �Prvv�I �nli� h �PC Therr-nn Pone
V✓I r'dD V /S.
Drawings mitted: es no ERVIi;ES
g Mail Permit to: 1'I6 N ORTH STREET �
z Asr.Fnr A� e;Es�e
X .
Signature of Applicatio ,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$
COMMENTS:
No.
APPLICA� ION FOR
' PPH Tn
AtAL4u— �akGkf u7�a b n rJ
LOCATION
PE MIT GRANTED
APP VpD
CTO(� OF B ILDINGS
CERTIFICATE OF OCCUPANCY .
YES
NO
i
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 Northslde Cardna . .
Signature of Perm 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office Ot/Oresgissems
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city nhonea
❑ I am a homeowner performing all work myself.
❑ I 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.
A & • A=Services , Inc .comoanrname t
t Sti
address: 115 North Street k krs�kesire+
city: Salem; - MA 01970 ,a
insurance F'raats,
nhonea 978-741 0424 ', y a� i
insurance co. The Travelers oolievq WC939X1256
❑ 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:
C0m an name:
address:
f city-Phone a• iL+ ,
r" }
insurance co: . oolicv a
company name. "..t
address.'
hone a: h'rAa� ,a J pt
insurance co. '=r
ell a
Failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penaltiei of a Rne up.to;1,500.00 and/or
one years'imprisonment o well a elvli penalties in the form eta STOP WORK ORDER and a fine of$100.00 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.
I do hereby certify s err epains and p nalties ofper)ury that the Information provided above is true and correct.
Signature Date
Printname Christopher Zorzv President Phonea978-741-0424
official use only do not write in this area to be completed by city or town official
city or town: permit/license a flBuilding D7Board
nt
❑Licensing check irimmediate response is required QSelectmen
QHealth Department
contact person: phone N; flOther
BOARD OF BUILDIN REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 057733
Birthdate:.05/26/1958
Expliesa05/26/2007 Tr.no: 12633
Restricted;,00:
CHRISTOPHER ZORZ_Y.,
115 NORTH ST0 - G-�
SALEM, MA 01970
Commissioner
' :��e '�ryuxiaanuealC�i o�,.�>iiurzc�uraelG
Board of Building Regulations and Standards
1
i HOME IMPROVEMENT CONTRACTOR
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.Prezioso,Commissioner
Deleader-Contractor
CHRISTOPHER ZORZY
Elf.Date 02/09/06
Exp.Date 02JOB107
DC000440
Rlemierof C.O.NES.T. 07
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II BOSTON-RENEW
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