211 LORING AVE - BUILDING INSPECTION (2) , y
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' DATE: o[- 2 - D 7
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PLANS MUST BE FILED AND APPROVED BY THE
.. • INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building
kori/2'4Buildin Permit Application For:
'(Circle whichever applies) Roof,Reroof, Install Sidi ct Deck, Shed,Pool
Addition Alteralio Repair/Replace oundation Only, Wrecking
Other. t
PLEASE FELL 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:
Owuer•s Name:
en
Contractor
. A hP.YY,I A �A Service5Mbn5 bra
Sheet, 2ll LDYII ra h1/enue City sale Street l� Mnrl 5f, City ,
State- M` Phone 070 714 44 -a t State MA Phone, MS) 7til a lA
Architect: City of Salem Lic# NQ5
Street City StateUc b57 • HIP# IDI1009
State Phone ( ) Homeowners Exempt Form�es�no
Structure: (please circl ingle Family, ulti Family# Other
Estimated Cost of job S_/(n, -/,? b Z�
Will building confirm to,I�W?,; yes no
Asbestos?__yes✓oo
Description of work to be done:
TES ll au/�ir/Za- se lien La'7 yn cam! r2�lCrC�iri_P, rf
win d�l-tjs,
A&A SERVICES,INC.
Drawin ub itted:_yes no Mail Permit to: �.SgLLEM,MA 01970
Signature of Appli ation,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(t)MONTFIS OF PERMIT ISSUED DATE
Department use only: Permit'# Zoning Map/Lot
Permit fee S `'1
COMMENTS: ;
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The Commonwealth of Massachusetts.
WI
Department oflndirstrial Accidents'
Office Of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers en
Applicant Information Please Print L
Name(Business/Organization/Individual):. A SO r via S t ,Tye 0—
Address: l 1,r, jKl O rz- h
City/State/Zip: Mit 21e170 Phone#: I ci7$ 1 rl�II —OL 1
Arree�°u an employer?Check the appropriate box:
I. v�.._j i l m a employer with_�� 4. 0 1 am a general contractor and 1 Type of project(required):
employees(full and/or part-time)." have hired the sub contractors t l New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑RemL
ship and have no employees These sub-contractors have 8. Dem
working for me in any capacity. workers'comp.insurance.
[No workers'comp. insurance 5. 9• ❑Builn
❑ We are a corporation and its -
required.] officers have exercised their 10.❑Elecs or additions
3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plums or additions
myself. [No workers'comp. c. 152, §1(4),and we have no
insurance required.] t employees. [No workers' l2.❑Roof
comp. insurance required.] 13•f0ther Wt ?•
*Any applicant that checks box#1_must also fill out the section below showing their workers'compensation polity information.
t ontraowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
Elam n e that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy inforration•
I fo as employer than is providing workers'compensation insurance for my employees:'.Below is the poAcy and Job site
Information.
Insurance Company Name _F�Ae- Tro e l e Iz-c,
Policy#or Self-ins.Lic.#.- )LAIC C1,
4 X I a h l
Expiration Date: 4 1 ,0-7
Job Site Address: ty p_ �PiYli �� (�/t/'f(�
Ci /State2i :�a2
Attach a copy of the workers'comp nsation policy declaration page(showing the policy number and expiration data).
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 aeretry certo u Q r i e pains and penalties of perjury that the information provided true and co
above is rrect Signature,
oy
Date
Phone M (Cl AA a
OJJ9cial use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
Issuing Authority(circle one _
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Ins
ti.Other g Inspector
Contact Person• ..., ,
Phone#:
,i
1
9
1 4M
DISPOSAL OF DEBRIS AFFIDAVIT
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In accordance with the provisions of L. c. 40, Sec. 54, a condition of
Building Permit Number is tf the debris resulting from this work shall
be disposed of in a properly licensed f iity as defined by M. G. L. c. 111, Sec.
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150a. 1
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The debris will be disposed at: Sale Transfer Station
own 1_ Northstde Cardnst . .
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Sign a pA of P it Applicant
y��y
-a - 67
Date
Christopher Zorzv l z1
Name of Permit Applicant 1N ix
A &A Services. Inc. i Sl
Firm Namen
_115 North Street, Salem MA 01970uh�
Address, City, State, Zip Code
IBOARD OF REGULATIONS
c- License: CONSTRUCTION SUPERVISOR
Number.'bS 057733
I BI
rtt�la0s.=.AS/�/1958
��{f1AIr�4�65.iia 2i0 Tr,no: 12633
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CHRISTOPHER .II
115 NORTH ST
SALEM, MA 01976 . C
Commissioner
` X. "�ovwrnanarrzll� o�.��iilv¢c•/uote!!'s
.� Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6t26/2008
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 Ueputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety a
Ro6erf J.a FYeziaC ntractor q „
Deleader-Contractor
CHRISTOPHER ZORZY
EN.Date o210 M
Exp.Date 02lOflr07 O
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