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22 LARCHMONT RD - BUILDING INSPECTION N0. APpI ICATTION FORPERMTr TO _ LOCATION Z2 PEqMIT GRANTED APPR Vp TOR OF B WINGS CERTIFICATE OF OCCUPANCY . YES N0 r DATE: Citp of '4§aJ TY, r PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED �LC�C�IYnbj�f l Building Permit Application For: Location of Building OU '(Circle whichever applies) Roof, Reroof, Install Si " truot Deck, Shed, Pool Addition, Alteratio epair/Replac Foundation Only, Wrecking Other: PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Buildings: The undersigned hereby applies for permit to build gn Y PP Pe according to the following. g g Owners Name:_ �21i'+ � l-l-7--4O5h1(1S Contractor. A eA St'rVIG25hi4Yl_�br'7,t, Street a2 LQ1�'IVYu I Ed C4 5� Street II Q(4h �f"" City I>°m State (` Al Phone (lq@ 7�/oD State M A Phone- NIS) 79 L.-_D-'i A�A Architect: City of Salem Lic#,- I DS Street City State Lk 057 HIP# I©I(a D9 State Phone ( ) Homeowners Exempt Form_yes _,no Structure: (please circle Single Famil , Multi Family# Other Estimated Cost of job S� a 5, Q C) Will building confirm to law? yes no Asbestos?_yes /no Description of work to be done: 61 .Zv> Sfirll �-en ��v) l/�nul rP,plac�n�vn� r.Jir�la ., 5_ A&A SERVICES, INC. 115 Drawin u itted:_yes no Mail Permit to: SALEM, MA 01970 % rg7al 41-0d2d :-' xAz vw A Assn ala-- Siguature of Appikyation,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE i IN The Commonwealth of Massachusetts { 6 Department of Industrial Accidents 1•- + I Office of Investigations l� t 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business(Organization/individual): A e� A Sit"yl a TY-) t Address: I I.ri I I Sjye ` City/State/Zip: N iq OI R-7D Phone#: / °I7$ 1 7L{I —pq a 1 Fship mployer?Check the appropriate box: r Type of project(required): mployer with ail— 4. ❑ 1 am a general contractor and I es(full and/or part-time).* have hired the sub-contractors 6. ❑New construction le proprietor or partner- listed on the attached sheet. t ?• ❑Remodeling have no employees These sub-contractors have 8. ❑Demolition for me in any capacity. workers' comp.insurance. 9. ❑Building additionkers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions . 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' �/ / comp.insurance required.] 13•t_J Other yp ji3aQtl/j *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. t(Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site Information. Insurance Company Name: t r lt? Policy#or Self-ins.Lic.#:/_ �C Q 3Q X 1 'a Expiration Date: 9 113) 0-7 Job Site Address:22 L O Yrhm uri� AnaxiCity/State/Zip:_Ej 2=Le ) , /)9# Q (9 /0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and eexxpiration 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 a STOP WORK ORDER and a fine Of tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and a sins and penalties ofperjuty that the information provided above is true and correct Si mature: Date Phone#: cl"I$ L{ a .14 Official use only. Do not write in this area,to be completed by city or town LInspector City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.ElectPlumbing Inspector6 OOtherCon 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 hire, 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,§25C(7)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-contractor(s)name(s),address(es)and phone numbers)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 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' 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be.sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pemnt/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 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. The.Department's address,telephone and fax 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 Revised 5-26-05 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 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 Cartina Al Signature of Permit Applicant Date Christopher Zorzy Name of Permit Applicant A & A Services, Inc. Firm Name 115 North Street. Salem, MA 01970 Address, City, State, Zip Code i Board of Building Regulations and Standards Construction Supervisor License License: CS 57733 Bi_rtld, =5/26/1958 Expiration—5'2612009 Tr# 13739 J `Resstt i'i6&--0 ram; i CHRISTOPHER I is NORTH ST SALEM,MA 01970 Commissioner Commonwealth of Massachusetts Division of Occupational Safety Robert J.Premoso,Commissioner Deleader-Contractor CHRISTOPHER ZORZY ER.Date 04/02/07 Exp.Date 0M01/08 O a DC000440 '*' Wmoer of C.O.N.E S.T. 8 BO IIIIII IIIII IIIII IIIII IIIII III I IIIII IIIII�IIl II II BOS ON RENE . � ✓li¢ l9airylltOiu!/e¢WL o�✓�aadac>zube%(a Board of Building Regulations and Standards 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