10 LIGHTNING LN - BUILDING INSPECTION � i 0 4�'' ,nti •(
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DATE:
Citp of 'rbatem, �55AL�U Ett
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building ID L-IQhEni(lcl Lar)(.2
Building Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install S'din Deck, Shed Pool
Addition, Alteratio Repai /Replace, undation 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:
OwnersNameGohn T)(neice' Contractor: Christopher Znrzy
Street 111, Cit6y �AleQV Street 11 5 North Straat City ga1Pm
State. Phone W1g)_76L) off 53 State MA Phone(97,8) 741-0424
Architect: City of Salem Lic# 14 0 5
Street City State Lic#0 5 7 7 3 3 HIP# 101609
Slate Phone ( ) Homeowners Exempt Form_yes_Zno
Structure: (please circle) Single Family, Multi Family# Other)'
Estimated Cost of job $ A'3rJ off,(�
Will building confirm ty law?—)./—yes no
Asbestos? yes •,/ no
Description of work to be done:
SERVICES
Draw' r S bmitted:,_yes no Mail Permit to: 115 NORTH STREET
X �r-EMS 01AgA
X ,
Signature of Application,SIGNED UNDER THE PENALTY OF PERJURY - - - -
CONSTRUCTION TO BE COMPLETED
DD((WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit#�_6Z ning Map/Lot
I
Permit fee$
COMMENTS:
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SDS-7-15-5:7i
F
DIS?OSAL Or DEBRIS AFFIDAVIT
In accordance with the provisions of 14CL c 40 , S54, I acknowledge that as a
condition of Building °er=;t [° all debris resulting from the
construction zcrivity governed by rhis Building Pe"-it shall be disposed ofs
a properly licensed solid waste disposal facility, as defined by MCL c III,
S 150A. I
Salem Transfer Station owned by:
Th d=_bris Fill be dispos=_d of at: Northside Carting
locat_on of fzcz_,ty
5- 1i - o5
.a ?e _ ap iicant Date
Sig. atu._ of - p
Fully co_olete the following inforarion:
(?lease print clearly)
Chbihtfipheicao;iyr_ .
Name of ?ermit Applicant
A & A Services, Inc .
Firm Name, if any
115 North Street , Salem, MA 01970
Address . City 6 State
The above sr.azul:-e 7enuir=5 that debris from the demo91_tion. renovaL=on, reha'.
or other alteration of building or. structure be disposed of in a araperly
licensed solid waste disposal facility as defined by 1EGL cIII. S1SOA and tha
building .resits or license's are to indicate tite' iocarion of the izcility at
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
0/fl000J/Oy0SU80U0aS
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
city - phone#
❑ I 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.
A & A �$ervices Inc. ;.
c�any name , t +.1tr 11r"+
r 1,
address: 115 North Street
city: Salem, "'MA 01970 /ttfiY,wh«t w.ty �,'
phone# 978-741=9424,
insurance co. The Travelers oolievN WC939X1256 �' tbdJf'• 1.,,.'"`•'��`'
❑ 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:
com on name: '
address:
vw;t�ti N
rx,
Y ..
City:
i ,M. Anne q• t Jy
•.1. f.y,,�N .:�'i H h,•/rye + �4
insurance co; olie # "•:isF.S�Q:Jii;,,,. 1;
com an name
address::• ..
k ,r
.r•
city:
+ "hope#: •, ..t.a�ow���`.•5, iu;;
a Div-
insurance co. Polley#
art;a9„�,rila,,
Failure to secure coverage as required under Section 2SA of MCL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'Imprisonment as well as civil penalties In the form of STOP WORK ORDER and a Out ofS100.00 a day against me. I understand that a
copy of this statemen y forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby eer!!fy n r t Pat ysdalties of perjury that the Information provided above Is true and correct.
Signature Dale 5_
Print name Christopher Zorzv, President Phonc#978-741-0424
official use only do not write In this area to be completed by city or town ofticlai
city or town: permit/license# Building Department
cheek if Immediate response Is required QUee tmenBoard
QSelecmen s Ofaa
QHeallb Department
contact person: phone N; nOther
.i BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR 1
.....I'� c Number. CS 057733
'Birthdate: 05/26/1958
Expires:05I26I2005 Tr.no: 12224
Restricted: 00
CHRISTOPHER ZORZY �
115 NORTH ST
SALEM, MA 01970 Administrator
T� ,o'�� / o�✓6/a�rf�
_ Board of Building Regulations and Standards
_LL5 HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2006
Type: Private Corporation.
A&A SERVICES,INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Administrator
CommonwealthVof Massacgusetts
Division of Occupational Safety ~`
Robert J.Prezioso,Commis oner qqq®
Deleader-Contractor
CHRISTOPHER ZORZY
Eff.Date 01/14/05
Exp.Date 01/13/06 O
. . DC000g40
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