242 LORING AVE - BUILDING INSPECTION DATE:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building cAQ Lt'in AU N It✓
Building Permit Application For:
'(Circle whichever applies) Roof, Reroof• Install Sidin nshuct Deck, Shed Pool
Addition, Alteration, eparr/Replac Foundation Only, Wrecking
Other: r
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:
Owners Name:AV-44qur^ �,TPGnlpp FT-arCIS Contractor: Chri stnnnar 7.nrz,z _
Street 'AWE &/Pl1Ur✓City,�a(6M Street 11 5 North Straat City_Calam
State 1HA Phone MS) WV4 - 5 tea, State MA Phone(97g) 741 -0424
Architect: City of Salem Lic#( 14 0 5
Street City State Lic#0 5 7 7 3 3 HIP# 101609
State Phone ( ) Homeowners Exempt Form_yes- no
Structure: (please circle mgle Family, ulli Family# Other
Estimated Cost of job$_ add J-tRSI (YD
Will building confirm to law?des no
Asbestos?_yes i/no
Description of work to be done:
Sr�s+all etahFeer� tl�� �ares rjf vinul �Ica �nG •
SERVICES
Drawin bmitted:_yes no Mail Permit to:g 115 NORTH STREET
lit IrM nt.4
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SignatuA ot Appli lion,SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BE COMPLETED WITHIN SIX (6) MONTHS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning Map/Lot
Permit fee$
COMMENTS:
t y
No. ,7
APPLICATION FOR
PEAW TO
LOCATION
PE MIT GRANTED
AP OV p
t, _
INS ECTOP OF BUILDINGS
CERTIFICATE OF OCCUPANCY
YES
NO ,
The Commonwealth of Massachusetts
r Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name:
location:
city: state: zip: phone M
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑ Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
I am an employer providing workers'compensation for my employees working on this job.
company name: A Q A Ge-r-w e s,, Sr1 G
address: 115 tJD(Ih 5iF ee-+
city: I-sn Iem phone#• 19 d) 'ZAA i -0N aN
insurance co. T17L TrQI/P_jGfS policy#• WCq% X125To
❑ I am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who
have the following workers'compensation policies:
company name:
address:
ci►': phone#•
insurance co. policy#•
company name:
address:
city: phone#-
insurance co. policy#:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement m forwarded to the Office of Investigations of the DIA for coverage verifications.
I do hereby cerdjy we�rlp as and nahies ofperjury that the informadon provided above is true and correct
Signature Date - 7' qJ-6(10
Print Name Phone# (`1178) 7H I -OH ;; -J
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑ BuDbiphM=t❑ Ll❑ check if immediate response is required ❑ Sel❑ Hecontact person: phone#: ❑ Om
(revised Sept.2003)
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 bv Northside Cardn fA. Az
Signature of Pe it Applicant
9- ai-
Date
Christopher Zorzv
Name of Permit Applicant
A &A Services, Inc.
Firm Name
115 North Street, Salem, MA 01970
Address, City, State, Zip Code
�7rr000a
BOARD OF BUILDIN REGULATIONS
License: CONSTRUCTION SUPERVISOR
? NNmber:"GAS 057733 -
Blrthdatey05/26/1958 I
plres 05/26/2.007 Tr. no: 12633
' •.. Rettrf tTsd
d0 1
CHRISTOPHER 26A0101�
i 115 NORTH ST
SALEM, MA 01970\1— c /f
.. - Commissioner
. .—�_.,r\._ ___..__✓�����minam�aeall� ol.yffruru�ute(fa
Board of Building Regulations and Standards
iD
HOME IMPROVEMENT CONTRACTOR
Registration: 101609
Expiration: 6/2 612 0 0 8
Type: Private Corporation
A&A SERVICES, INC
Christopher Zorzy
115 North Street
Salem, MA 01970 Deputy Administrator
Commonwealth of Massachusetts
Division of Occupational Safety
Robert J.Prevoso,Commissioner q�,
Deleader-Contractor (UVh�ptT
CHRISTOPHER ZORZY
Eff.Date 02/09/06
Date 02/08/07 DC O r,
- DC000440
Member ofC.O.N.E.S.T. -
. 7
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