211 LORING AVE - BUILDING INSPECTION " DATE: a- a -o2
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERAUT BEING GRANTED
Location of Building a21 1 �-D rl na lqw,%-1//P
Building Permit Application For-
'(Circle whichever applies) Roof,Rero nstall Sidin onstruct Deck, Shed,Pool
Addition, Alteration, Repair/Replace,Foundation Only, Wrecking
Other.
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the hispector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications: n Owners Name: f tPI)I U .�P.h b?-ro Contractor: A � A Seryiu 5,01q d r
Street s korli"iCl !1P City Cr street ll 6 Mnr4h SI. _eity�Laa
State H 0 Phone (9'76. `7/J4- j q State M A Phone. 079) -
Architect: City of Salem Lic# IL-105
Street City State Lic 657 HIP t, 1 D 110 09
State Phone ( ) Homeowners Exempt Form_yes./no
Structure: (please circle Single Family, ulti Family# Other
Estimated Cost of job S o2�1 DD0 OO
Will building confirm t law? yes no
Asbestos?__yes ✓ .no
Description of work to be done:
yen o -e-1 al-4
f vint�l sIr�lr\
A&A SERVICES, INC.
Drawin ub ritted:_yes no Mail Permit to: t fS
SALEM. MA 01970
X VN!^lWU.4-A
Signature of Applic 'on,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Niapp/Lot
Permit fee S
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The Commonwealth of Massachusetts.
WDepartmentoflndustrialAccidentsOffice of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber Applicant Information umbers Please Print v
Name(Business/Organization/Individual):--A Q A SLr yl a0 ,Tye 0
f
Address:
City/State/Zip: 5I L 9 M Mn Q070 Phone #:
Arre_,�°u an employer?Check the appropriate box:
1.Q I am a employer with 4. I amjr
eral contractor and 1 Ty pe°f pE
equired):
employees(full and/or part-time)! have the sub-contractors 6 ❑Nection
2.❑ I am a sole proprietor or partner- listede attached sheet. t 7. O Re
ship and have no employees Thescontractors have 8. O De
working for me in any capacity. workomp. insurance.
[No workers'comp. insurance 5. 9• ❑Builition
P ❑ We aorporation and its
required.] officeve exercised their 10.0 Elecairs or additions
3.❑ 1 am a homeowner doing all work right mption per MGL 11. Plumbing
myself. airs or additions
y [No workers'comp. C. 152 ),and we have no 12, oo epairs
insurance required.] t emplo [No workers'
comp. rance required.) 13•2 0thesl di
x#I must
the section below Showing their workers-
f I lomeownerstwho submit that checks his affidavit indicaltingtthey am doing g all work and then hire outside contractors must submsa-tion--policy it na oew affidavit indicating such:
tComrsetors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy information.
lam an employer that is providing workers'compensation insurance for my employees:',Below is the Policy andJob site
Information.
Insurance Company Name: t r 1e__ Try /O
Policy#or Self-ins.Lic.#:_ �At C C]aq X 12 ti/n
Expiration Date:_ q I1ZhO'-]
Job Site Address: L� [ k Drl yZ
city/state7ip: 1 LM 111 f7 U'1 70
Attach a copy of the workers'compens tion policy declaration page(showing the policy number a .
nd expiration date)Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties te
f a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of 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.
/do hereby cert u r t e pains and penalties ofperJery that the information provided above is true and comet
S`'n re: Date: —Q
P o e# (q1 J4 Ha
OJJ9cia!use only. Do not write in this area,to be completed by city or town oJ�ciaL
City or Town Permft/License#
Issuing Authority(circle one):
1.Board of HBuilding ealth 2. Department 3.City/Tow Clerk 4.Electrical 6.Ot Other
Inspector 5.Plumbing Inspector
Contact Person
Phone#:
'f
DISPOSAL OF 61EBRIS AFFIDAVIT
1
In accordance with the provisions of SSSSSS, L C. 40, Sec. 54, a condition of
Building Permit Number is t the debris resulting from this work shall
be disposed of in a properly licensed
ity as defined.by M. G. L. c. 111, Sec.
150a.
?. i,
The debris will be disposed at: Sale Transfer Statlon
own by Northside Carting
?j
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Y
Sign of Pe it Appicant
Date,qA,�r,
f�
:.r
Christouher Zornr
Name of Permit Applicant tl'i
A &A Services Inc. d
Finn Name.
116 North Street Salem iw► 01970
Address, C State
�Y� , ZIP Code
Y Il r,
� �rooerrrralu
I BOARD OF BUILDING RE TI
i- License: CONSTRUCTION SUPERVISOR
i
Number. CS 057733
BIrt1�laM05/ZS/1958 I
a >�pl OS/26 Op`I:4 Tr.no: 12633
i
Re
CHRISTOI 1�
115 NORTH ST
SALEM, MA 01970
- Commissioner � ,
i i I
✓�,r �omrnonirrnl!/r. o�,//Tiawc/:uoek'a
Ip Board or Building Regulations and StaadarJs
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/26/2008 -
Tipe: Private Corporation
• ASA SERVICES, INC
Christopher Zorzy
115 North Street
Salem,MA 01970 �--
Urpuly AJmialatntor
Commonwealth of Massachusetts
Division of Occupational Safety t
Robert J Prerioso,Comaussiow
Deleader-Contractor
CHRISTOPHER ZORZY
EB.Date 02/09/O6
Date 02/OB/07 DC 0
' DC000440
.. Alemberd C.O.N.E.S.T.
17
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