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17 LAURENT RD - BUILDING INSPECTION (2) DATE:_ t/ -6fo �ifp of a��YETTr, aaLUEff PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Location of Building 7 �QU re-n+ Fcod Building Permit Application. '(Circle whichever applies) Roof Reroof, Install Siding Construct Deck, Shed, Pool Addition, Alterati 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 a permit to build according to the following specifications: OwnersNamej�ir!hord AryinM n Contractor:A E A 6C �� Chri Street 11 i-&)rer ,{ 200 .I. City 501er1 Street Jl5 rJnr-th 5free4 City_Lr I,P� State H to Phone loll$) 7/-I1 -337 h State h1i4 Phone• (9781 -W-i1 Architect: City of Salem Lick IH 05 Street City State Lic HIP# IOI (o Cq State Phone ( ) Homeowners Exempt Form_yes_..V/ no Structure: (please circle) Single Famil , Multi Family# Other Estimated Cost of job S �i 313, OCR Will building confirm to law? ✓ Yes no Asbestos?_yes f no Description of work to be done: T0-6 I I nnQ Drawing b itt d:_yes no Mail Permit to: 116am LIN LF N013IH S7l1RLIr$ X 1 Signature of App cation,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$ cole- NTS: i No. � APPLICATION FOR PERWIT TO LOCATION PERMIT GRANTED APPROVFD CTO� OF BUIL INGS CERTIFICATE OF OCCUPANCY . YES . NO q' The Commonwealth of Massachusetts WDepartment of Industrial AccidentsOffice of Investigations 600 Washin ton Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leefbly Name(Business/Organization/Individual): __A Q A jir VI a t Address: 115 t I 0 r+h ,3}YC�+ City/State/Zip:_5nALM M 3 DIG1-70 Phone#: A re u an employer?Check the appropriate box: I am a employer with � 4. ❑ 1 am a general contractor and 1 Typeof project(required): employees(full and/or part-time).* have hired the sub contractors 6' ❑hrew constmction I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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.EfOther ECJZy -Door — *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation polity information.t Ilomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContmctors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'com p.polity informaton - . I am an employer that is providing workers compensation insurance jor my employee>ti`.Below is the Polley and Job site information. Insurance Company Name:_ t r le Tr-1 /D I IDS Policy#or Self-ins. Lie.#: �/(_' Q 39 X 12 Expiration Date, 113 O7 Job Site Address: City/State/Zip: t°j Y11 ja (�IC7 71D Attach a copy of the workers'compensation 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 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 n er the pains and penalties of perjury that the information provided above is true and correct Si111 nature: �� jy ©( Date Phone#: (9-15) r"M I - D JA a 11 01W,Cial use only. Do not write in this area,to be completed by city or town official, City or Town: 'Permit/License ense# Issuing AF ity(circle one): 1.Boardalth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact 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" , e 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 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 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense 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 Departments address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents pi Ri 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 • ij,, _ , 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, Sea 150a. - - The debris will be disposed at: Salem Transfer Station owned by Northside Carting Signature gnature of Pennit Applicant Date Christoph er her Zo D Tr Na me me of Permit Applicant nt A &A Services. Inc. Firm Name 115 North Street. Salem MA 01970 Address, City, State, Zip Code i ' 1 _ k '�o�srmraaerrrert�llc o� . BOARD OF BUILDING ' q�7 p NS License: CONSTRUCTION SUPERVISOR � Number: CS 057733 • I Btrthdate r05J26/1958 , I E'kpires OS/261 607 Tr.no: 12633 ^I Re9�'t�rf��t�ei0 Bb CHRISTOPHER 115 NORTH ST SALEM, MA 01970' ComMlssloner i ^ ✓fie Go�xsnrvarnen//� o�..•�✓,riuor�avvlld r� ---_ 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 Adminisir:dor Commonwealth of Massachusetts Division of Occupational Safety Robert J.Prevoso,Commissioner Deleader-Contractor CHRISTOPHER ZORZY EH.Date 02/09/06 EC. Date 02/OB/07 0 . DC000440 Member of CONES T, 80 IIN11111111IN111111IN1111111111111111111111 BOSTON.RENE