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HomeMy WebLinkAboutBuilding Permit #136-13 - 101 GREAT POND ROAD 8/13/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION /Q/ a tC`.97 _PPA-10 - Print PROPERTY OWNER fe-C,44102 Print 100 Year Old Structure yes no MAP NO: PARCEL:n; ZONING DISTRICT: Historic District yes no Machine Shop Village yes no_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Jmr Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District- El Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: S7R�B rQavo, .e�' eoar' Identification Please Type or Print Clearly) OWNER: Name: fCC4-W2 Phone: ??S-669- 30 _2 Address: /0/ C,8��7_ l-9a4,�/J 2/�4 CONTRACTOR Name: ,0,90/0 -7- y Phone: Address: /60 AA,-1,00z1C, /WA 11CC£f-1<A' , /"I4_ Supervisor's Construction License:C55(_—0299 p;2, Exp. Date: /�/,-7o/`/ Home Improvement License: /yG o26 z Exp. Date: o/ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ l:;�, 000 FEE: $ Check No.: �� Receipt No.: �'7i� NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/OwnerJ ___ 0 C i -ature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OF`.SEWERAGE DiSP.OSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . .Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS I I CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature I COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_ -. I Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit IC 'DPW Tow;; Engineer: Signature: Located 384 Osgood Street i FIRE-DEPARTMENT Temp Dumpster on site yes no Located at 124 Mair, Street Fire DeP gartment si natureldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$10041000 fine NOTES and DATA— (For department use B Notified for pickup - Date Doc.Building Permit Revised 2010 I i Building Department The foli-owing is-a list of the required forms to be filled out for the appropriate permit to be obtained. Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. yLicenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks I ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cascs if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Buhding Permit Revised 2012 . Location 9(19 04 PVY-\ No. 11� Date . - TOWN OF NORTH ANDOVER . Certificate of Occupancy $ Building/Frame Permit Fee $ L-2-U xJ Foundation Permit Fee $ f ejFr ' ` 1^ Other Permit Fee ATED 1 $ i TOTAL $ _ Check# -- ` 202 ` Building Inspector { NORT!/ Town of t EAndover As- h , ver, Mass, 201 coc"Ic"t-1c %,1 S IJ BOARD OF HEALTH Food/Kitchen PERMIT T LD c Septic System THIS CERTIFIES THAT .....Eltf*00............... BUILDING INSPECTOR ....................................... has permission to erect buildings on IN... -t .A . Foundation Rough tobe occupied as ......1 ..... ......Re.. , ................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 M1QhVHSA ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO A Rough Service ..................... ... ................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE i TR.Mv RO'Box 1124 " PHONE DATE c i fes. 7'81 s4 Q' 0 a✓ �� &J e'Sa.:� 9s w»7`��<� �s{�IS"r w4 fax J` .�"'_� ,..! s51�� !w f�.7 l i JOB NAME/LOCATION TQ f"o �1 '.lG. i iR / �'''3 L✓''lro. `orf d*�.r"I. 4 JOB DESCRIPTION: Lj .... '/ .rI i .ry .t' &;�d i .:.],.{„ �i; t'"` "` °' s -' -71 ,,;•* � fe.,. t.."--rr/' �r's s (-,-' 'Af': "'" ..�...F f .............C 'Ci :C r .........4- �6''..s° � '' i's ,.% '-.�..f � S"3..�'J .? e � I ............................•.............................._.._.__................_.._...._.._......._..................................._................. ...a'/= �a,1 4... F Faso'fe»✓'' d..._sa°'r./ .l...... .,R°2 F.wl�`Ys 1.l .._...__._..__..._.a:..........._.........................__...___..-......................................................._............__._ .. �. , r. ..................................._.._.. - --....._..................._..................................................._......_.._.-...._.............................................._.........._....._..._................................................._._......................................._....... ............................................_. ........................................................................................................................................._................................__.............._.............__........__--._.....................................................................__._............................................................................................._..................... .........................................--........................................................._............................._..........................I...............................-.........................................................._........__.._..---...................._.._.....--_.................-................._......................I........... .. ........... .................... ".................................. ...... ....................... .._----- .---- ................... ................. .......................... ......................------------ ............"..........-.._......._............ ......... _........... ......._............................ ................... ........... ............................ .................................. ... . .................................................................................................---_....................._.._.. ...-............................_......_.........................................................................................._..................._......._................................................................................................ THIS ESTIMATE IS FOR COMPLETING THE JOB AS DESCRIBED ABOVE. ESTIMATED ` IT IS BASED ON OUR EVALUATION AND DOES NOT INCLUDE MATERIAL JOB COST PRICE INCREASES OR ADDITIONAL LABOR AND MATERIALS WHICH MAY BE REQUIRED SHOULD UNFORESEEN PROBLEMS OR ADVERSE ESTIMATED �� A WEATHER CONDITIONS ARISE AFTER THE WORK HAS STARTED. BY 3 THIS/CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TMS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY.AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions ofthe policy,certain policies may require an endorsement A statement on this certificate does not confer rights to ti,e certificate holder in lieu of such endorsemengs). PRODUCER CONTACT NAME: l John F. McBride, Jr. Insurance PHONE FAX No: One Treble Cove Road E-MAIL North.Billerica, MA 01862 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL= INSURERA:Arbella Protection INSURED INSURERB: Morey General Contracting Inc. P O Boz '124 INsuRERc: INSURER D: Billerica, MA 01821 INSURER E: r INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER! INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERr.,� EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. \ISR ADDLU POLICY EFF POUCY EXP - .TR TYPE OF INSURANCE IN POLICY NUMBER M/OD MMM)D/YYYY UMTS A GENERALLIMUTY 8500025060 6/16/13 6/16/14 EACH OCCURRENCE s 1 000 o'no X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PIR EMI nc S _ CLAIMS-MADE D OCCUR MED EXP(Anyone person) s 5 or,-J.— PERSONAL&ADV INJURY $ 1100010C, GENERAL AGGREGATE s 2 000 00 1 GEN'LAGGREGATE LPMITAPPUESPER PRODUCTS-COMPIOPAGG s 2,000,000 POLICY PRO LOC g AUTOMOBILE LIABILITY COMBINED SIN LE LIMIT(Ea accident) s ANYAUTO i BODILY INJURY(Per person) s ALLOWNED SCHEDULED ! BODILY INJURY(Per accident) s AUTOS AUTOS NON-OWNED PROPERTY DAVAGE $ HIRED AUTOS _AUTOS (Peracciderd) 5 UMBRELLAL1AB OCCUR EACH OCCURRENCE is EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I RS' WC STATU- OTH- AND EMPLOYELIABILITY ANY PROPRIETORIPARTNERIEXECUTiVE NIA I E.L.EACH ACCIDENT Is OFFICERMIEMBER EXCLUDED? (Mandabry In NH) EL.DISEASE-EA EMPLOYEE s H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ )ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Renaft Schedule,if more space is requi red) ^.ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 8EF0RE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED :ti ACCORDANCE WITH THE POLICY PROVISIONS. ~` AUTHORIZED REPRESENTATIVE - - John McBride _ ©1988 2010 ACORD CORPORATION. All rights reserveG. 4CORD 25(2010105) The ACORD name and logo are registered marks of ACORD (lone: Fax: (603) 329-7026 E-Mail: !SN YYYV C.ERTIFICA`�E OF LIABILITY INSURANCE ICATE 1S ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICQT O 5ITRE E DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO'ICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSURER(S),RUTHOR2ED ATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the po)icy(ies)must be endorsed.-If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT i NAME: JOHN F MCBRIDE JR INS PHONE FAX PO BOX 173 (AIC,No,Ext): (A1C,No): N BILLERICA,MA 01862 E-MAIL ADDRESS: 72RJG INSURER(S)AFFORDING COVERAGE Nk,a INSURED INSURER A: TR 44 £RS PROPERTY CASJALTY COMPANY OF AMERICA MOREY GENERAL CONTRACTING INC INSURER B: INSURER C: INSURER D: PO BOX 124 INSURER E: BILLERICA,MA 01821 .INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TRIS 19 T15 CWFYTHAT THE POU", 3 5 INS CE 05TIM 52=0=PREEN ISSUED TO THE INSURED HAM M ABOVE FOR THE POLICY PER10D INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAM CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMSODtYYYY) (MM OIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE I S COMMERCIAL GENERAL LIABILITY 1 DAMAGE TO RENTED is ",LAMINS MADE M OCCUR. EMISES(Ea occuRence) ED EXP(Aryl one person) S 1 :IERSONAL&ADV INJURY Is f GEN'L AGGREGATE LIMIT APPLIES PER: '=ENERAL AGGREGATE S POLICY PROJECT LOC RODUCTS-COMPIOP AGG IS AUTOMOBILELIABIUTY COMBINED SINGLE S ANY AUTO LIMIT(Ea accident) ALL OWNED AU TOS BODILY INJURY S i SCHEDULE AUTOS (Per person} j HIRED AUTOS BODILY INJURY IS (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE S (Per accident) i UMBRELLA LIAR JOCCUR EACH OCCURRENCE S EXCESS LIAB. CLAIMS-MADE AGGREGATE S DEDUCTIBLE $ RETENTION S S WORKER'S COMPENSATION AND IAC STATUTORY OTHeP l A EMPLOYER'S LIABILITY YIN UB-4210P605-13 04130r201,3 041:+3012014 LIMITS ANY PROPERM 3RIPARTNERIEXECUTiVE NIA E L EACH ACCIDENT Is 100,00", OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1C^u,000 (yes•describe under E.LDISEASE-POLICY LIMIT S 500,00", DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSf MICLESIRESIMCTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS CONI P 1-04_7P AGE. THE POLICY DESIGNATED ABOVE IS CANCELED EFFECTIYB-0513M I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, - AUTHORIZED REPRESENT Al 2 3. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. Office of Co suumert9ff ii &t 3-ine`ss egniaiion HOME IMPROVEMENT CONTRACTOR = _ Registration: 140267 Type: Expiration: 9/25/2093 Individual D�J MOREY DAVID MORE Y 160 ANDOVER RDS BILLERICA,MA 01821 `'— Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signattt — IS Jar Y 4n4'svaPy t hGe: CSSL-499882 - DAVID J MORAY PO BOX 124 Z BILLERICAjMA OT821 e s t - sicz:aer 0112=014 i ' 1 The Commonwealth of Massachusetts - Department ofIndustriglAccidents Office o fInvestigations 1 600 Washington Street Boston,MA 02111 www-mass gov/dia Workers' Compensations Insurance Affidavit:Builders/Contractors/Electricians/Plumbers .A.p?licant Information Please Print Legibly Name(Business/Organization/tn.dividual): /`102 E y C C!VGe9 L co'C,TA-1c tAW-/C Address:_ /CSG r9ti,0o cJE,< /ZoQ_ City/State/Zip:&k, 00C4, /)P, Phone#: 9 7t- 3 7 you an employer?Check the appropriate box: Type of proj ect(required): [Are .® I am a em to ex with / ¢. ❑ T am a general contractor and I ' p y 6. ❑New construction employees(full and/orpart-time).* have hired the sub-contractors .❑ I am a sole proprietor or partner- listed on the attached sheet.x 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. F1 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.J]Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.4Roofrepairs insurance required.] employees.[No workers' comp.imurancerequired.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. T Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'camp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. T/L9 UC>' S /�JSUsLi9 i1/C� Policy#or Self-ins.Lic.#: -x/9/0 P &OG --/3 Expiration Date: !�I/ZQIA0/500, Job Site Address:- 14/ CZEAT R6'4/0- /Z0, City/State/Zip: 4J4. RA/�� 11,74. Attach a.copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requirodunder Section 25A ofMGL 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 up to$250.0 0 a day against the vi olator. 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 cert'under the pains andpenadfies ofperjury that the information provided above is true and correct. - Si ature: Date: AZ31d 1 Phone#: 7,S—' -33 Official 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 Inspector 6.Other - - - Contact Person: Phone#: 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 ofhire,• express or implied,oral or.written." An employeY 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 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 chapterhave been presented to the contracting authority." Applicants Please fill out the workers'compensationaffidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)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 LL C or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 he. City or Town Officials -Please be sure that-the affidavit is-complete-and rinted legiblY: The"De aitm erit lias rovidecl a s ace at the"boffom p p- p--"-- 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 permit/license number which-win be used as a reference number. In addition,an applicant that must submit multiple permit/license 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 burn 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 Department's address,telephone and fax number: Tho CoznMonmali ofmfmarhwet - Dep.axtmeiit df adustdal Accidents oface of 1"eNtigatia.s 600 WasWiagtoa Stzeet Boston?MA,02111. TA,#617-727-4900 axt406-oz 1:-877-MASSMF Revised 5-26-05 Fay, '4617- '727-7749