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HomeMy WebLinkAboutBuilding Permit #25-12 - 112 FOXHILL ROAD 7/12/2011 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: s7 k Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION t J / (L Print PROPERTY OWNER PV 5C..6 --teekC,�,,�,ko— Print MAP NO: L1.a_PARCEL: 00l0 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial ❑ New Building One family Non- Residential 4 ❑Addition ❑Two or more family ❑ Industrial ❑Alt ation No. of units: " ❑ Commercial N1fepair, replacement ElAssessory Bldg ElOthers: ❑ D Demolition ❑ Other Se tic t ` Well ❑Flood � ,p ❑ Wetlands "` ; t 0, Watershed Districts ' . .. DESCRIPTION OF WORK TO BE PERFORMED: � ear,� e (Identification Please Type or Print Clearly) OWNER: Naive:_ ���A• �Q�b �- Phone: v Address: - -to �c CONTRACTOR Name: �. ,. Phone: "7- �. ,.� Address: 7 ,y-. v /�Jot .w LV f . r � Supervisor's Construction License: DOW— Exp. Date: Home Improvement License:76 r to 342- {t,, e (' M xp. Date: ' � � ,. '? I ARCHITECT/ENGINEER Phone: I-- Address:— - Reg. No. FEE SCHEDULE:BULDING PERMIT.•$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_ FEE: $ 37' y Check No.: L� �� -- Receipt No.: ) 43 C2_ NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fu ,.Signatur f Flgent/Owner -` 4 1� - gnature ofcont�a / - nl� �. Locatio / No. s~—�2.- Date 0wr), TOWN OF NORTH ANDOVER F?'• • LA i Certificate of Occupancy $ C14US Building/Frame/Frame Permit Fee $ s�cnusE 9 , t Foundation Permit Fee $ y. Other Permit Fee $ TOTAL $ Check # 24562 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Swimmin Pools ❑ Public Sewer ElTanning/Massage/Body Art .,.,.❑y; g Well ❑ - �Tobac"co 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS a Zoning Beard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wates' & Sewer Connection/Signature& Date Driveway Permit t DPW Town Engineer: Signature: - n Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street ' Fire Department signature/date - COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions.—L.-9 00 Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No i p DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine i NOTES and DATA— For department use i ® Notified for pickup - Date - - Doc:.Building Permit Revised 2008mi - .. F=' Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed.Interior Work ❑ Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ 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 (VOTE: 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 Li 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 cases if a variance or special permit was required the Town clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application i Doo: Doc.Building Permit Revised 2008mi ORTH TO" ofO Andover 5,.. to O a L`, • .. , 1... 0 Zp L A K E O dower, 1Vlass.,_, � L Il COC HICHEWICK 7�AORATE0 P'Pa,��y SS BOARD OF HEALTH PER T T D Food/Kitchen Septic System BUILDING INSPECTOR �� ��.i'� THIS CERTIFIES THAT .......... �. � 1 C m dLy �w►........................................... Foundation � u n has permission to erect ............:..:...................... buildings on .1.11L.......Taw.k,"A. ............. .....C. ..................... Rough to be occupied as........... h' ' ..... s Chimney 4......�. . ............�. . ./...... �..� '��1il4r.... provided that the person accepting this permit shall in ev res ect conform to the terms of thea lication on file in P P P g P r P PP Final 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 MONTHS UNLESS CONSTRUC T TS ELECTRICAL INSPECTOR Rough .......... ........... .... .............. ... ......... Service .... BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SOD E Smoke Det. 06/15/2011 11:31 9786822572 HERITAGE PKG PAGE 01/01 JUN-10-2011 (FRI) 14: 02 Office (FAX)978 887' 5875 P. 002/002 HI #167367 Dcrusco Irrcvaemblt:Trust �,�, BIN#56-2618812 441 Market St. (f"'-� Job#: Lawrcnce,MAO 134.1 (973)686.6127 Job Location: 112 FOX Hill Rd—'tprth Andover,MA _D,O � �. Cl 8 January 1&2011 . Dear Stephen, '�""'' Revised; April 25,2011 I have prcpute,d the fullowing estimate,for the installation of the vinyl siding at the above location. This will bo a full euvcrage,iob with no maintenanQ9 required wad lifctlmc tvumnly. All work Will be performed to the manufacturer's spechications to ensure a llttitimc warranty. Below is o briefdcscription orthc iivrk that%qlI be performed. Vinyl Siding([Nr--0 ll: • Remove exi0ing masonite siding from the entire house • Irimll We&water shield:uvund all windows and doors(tear-ot1'only) • Install CcrtainTecd Monogram vinyl siding Is AO LCr Install 3"outslde corner(white) C. e Install aluminum coverage on 411 ftula and rake boards • Install white center vented soffit • NOTC: J-channel around all existing winduw trinro will be r ced when new windows aro installed • Replace any damaged or rotted fascia or rake boards tt7)$10 • You may choose t0 have us install vin}9 shutters(this i option mid is not included in estimate) • Job will be:carted and compIcted without any int piton • !+•nts�tuu muAt be obtaine a licensed electriclAn COLOR. tnitl l ! nc nu erre rlransln'helut►a Cost for La bur&Material for Vinyl Siding eer-Of 511.000.00 Cost for Electrical Permlt& Building Permit: S 500.00 PAvtRent Tgt= 00 1/3 deposit due upon signing contract: $ � �'�" 61 1p�i )p'�3 1/3 payment due upon start of job: S r T 113 payment due upon completion of job: S Remit to Turnpike Genera/Contracting lna-P.O.BarJ65,Topsftcld,MA 0198.E Total Amount Agreed To Be Pald; S The following schedule will be adhered to unless circumstances beyond Turnpike's control mise: Work Scheduled to Begin; TBD_ Cxpected I1ate Of Completion: TBD Warranty: Turnpike General Contracting Inc.Euarantem all work performed for a period of one year. If any problems occur we will cover the e03t of all labor and material to correct the prublctn mid meet the 6ustomer•s satlalbacdon. Do not sign this contract If there are any blank suaces, (addWonal provlslons jopnw and are IncorporQted herrin by thla relem"ee) Robert Winters.Project Manager StephenIN ••e•Turnpike General Contracting Inc. p Delt wen Irrevaca 'frust JJUN 7 i 0 FAYD 1 �- `iassachus:tls - Deparintcnt of Public Saict•. ? Board of 3uiltlin'l Regulations and Stand wtl� �--�' Construction Supervisor Specialty License License: CS SL 100902 Restricted to: RF,WS JOHN WINTERS ;. :' . 6 RIVERSIDE DRIVE NORTH READING, MA 01864 ;. �Y Ex.piratior: 9/23/2011 nnii..i nu•r Tr-,: 100902 GTS ��, �✓�a�uo�a Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Registration:,.'m,'.16.7567 Type: Expirat ori A j 12012 Supplementlug C TURNPIKE GENERAL CONTRACTING INC. ROBERT 239 BOSTON STREET-BOX-366 TOPSFIELD,MA 01983:`' Undersecretary txl'^'htFax C3-1 11/10/2010 8:39:28 AM PAGE 3/003 Fax Server I c +a :, .' :•y, 'd .. 'f hf'hF A f _ .• s • ISSUE DATE : w :i S�,i l��J; •Jx.N .�r`' tiwf a `f? F ad' mrir,x, Ay$ Nr:s ,_l ht:�.t. 2010 THIS THIS CERTIFICATE IS ISSIIED AS A MATTE&OF INFORMATION ONLY AND CONFERS NO RIGHTS IIPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFU MATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.TIM CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sh AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policypes)must be endorsed.If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT CHASE&LUNT,LLC NAME: 47 STATE STREET PHONEPAX No Est: AIC No: POB 590 EMIL NEWBURYPORT,MA 01950 ADDRESS: PRODUCER CUSTOMER D t INSURED AFFORDING COVERAGE NAIC# TURNPIKE GENERAL CONTRACTING INSURERA TRAVELERS PROPERTY CAS CO OF INC AM 239 BOSTON STREET INSURERB TOPSFIELD,MA 01983 INSURERC INSURERD INSURERE INSURERF COVERAGES CERTIFICATE NUMBI*R: REVISION NUMBER: THIS IS TO CER77FY THATTBE PO1 XIPSS OF DdSURANCE USTED BELOW HAVEBEEN ISSUED TO THE DJSURED NAM M ABOVE FOR TBE POLICY PERIOD INDICATED. NOTWITESTANDDNOANY REQUIRMIENT,TERM OR CONDITION OF ANY CON72ACT OR OTBERDOCUMFNT WrM RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAYPERTAIN,TIM INSURANCE AFFORDED BY TER POUCD?S DESCRIBED BMW IS SDBWr TO AIL MM TERMS,EXCIASIONS AND CONDITIONS OF SUCH POLICIES,LWISSHOWNMAYHAVEBEENPMUCMBYPAIDCLA 0 IIQSR TYPE OF INSURANCE ADDL SIIBR POLICYNUII®F.R POLTCYEFF POLICYEXP LROUTS LTR MR WVD GENERAL LIABILTIy EACHOCCGRRFSICE S OCOMMRCIAI,OENFAA LIABUM DAMAGETORENIm S PRM,113Es oeaoraocc 0 CLAIM9MADE Q OCCUR MED.EXPENSE(kvanperss 0 PERSON&&ADV, S DMT 0 OENERALAGGBEOXIE S OEM AOGREG=L=APPM PER: D POLICY 0PROJEC1' 0 LOC PEODUCI9•COMPPoP S AW AUTOII<OBILE LTABH 1TY COMBNNID MN= S Imo' acid D ANYAVRO BODWROURY S cPesc D ALLOWNIDAUT09 BODDY11GURY S c Accid 0 scHEomEDAIIIOS PBOPERTYDAMACM S 0 BIItFDAVTOS ermid S 0 NON4MMAUM S 0 0 UA®REUALU3 0 CCCUR EACHOCCORRENCE S O EXCESS LM a C[AWWADE AGOMATE S 0 DIDDC'lIDLE . S 0 RE4MUONS S WORIM'COMPENSATION wC dnBSIJSV[ORY A AND EMPLOYERS LIABILYIY YIN NFA Ia ANY PBOPAD TOR/PARTNER/ EIG.C[rIIVEOFFI EXCIADID9 marA62d8IA y N/A 7PIUB-4419PO94 10/22!1() 10/2LI1 �AOCIDE' $1000000 PIANDATORYMNM D15EhM—EA 61000000 byes,dam3e�deDESCRWnONOF Y� OPERATIONS below DI6FJf9E-POIdCY $1000000 DESCMnoNOFOPEBAUONMOCAIIONSNERMES04uhACORD101,A"tloml8o�kaSdrcdtdgUmorospaeelsrequire0 THIS REPLACES ANY PRIOR CER!1IFICATEMSUIDTOTHE CERTMCMROLDERAFFEC13NGVVOP4 MCOMPCOVERAGE .f , .. .... .. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EYPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AOIRORMIM SEMEWi[OM 0 � , , RhOrtdov Outer ACORD CERTIFICATE OF LIABILITY INSURANCE OPID MSDATE(MMI)DNYYY) PRODUCER TURNP-3 10 29 10 "hale & Lunt LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION P O Box 590 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 47 State Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newburyport MA 01950 Phone: 978-462-4434 Fax:97B-465-6204 INSURERS AFFORDING COVERAGE NAIC INSURED INSURER A: Northaand ansur a Companies Turnpike General Contracting INSURER B: George Vasiliades INSURER C: 239 Boston Street INSURER D, Topsfield MA 01983 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 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 IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NW LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE M" DATE M D LIMITS GENERAL LIABILITY EACH OCCURRENCE $11000,000 A X COMMERCIAL GENERAL LIABILITY WS084566 10/20/10 10/20/11 PREMISES Eaoccurenee $100,000 CLAIMS MADE OCCUR MED EXP(Arty one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GERL AGGREGATE LIMIT APPU ES PER: PRODUCTS-t:OMPIOPAGG $2,000,000 X POLICY1-1 JET El LOC AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT ANY AUTO $ (Ee ea9dent) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON-OWNED ILY INJURY WNED AUTOS (Per accIdent) $ PROPERTY DAMAGE $ (Per sadden) GARAGE LtABRM AUTO ONLY-EA ACCIDENT $ RANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR m CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND $ EMPLOYERS LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNERID(ECUIIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? IT yyes desalbe under E.L.DISEASE-EAEMPLAYE $ SPEGtIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMR $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS For Information Purposes CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 • DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REP SFUJ TATIV AUT R RES E ACORD 25(2001/08) ©ACORD CORPORATION 1988 i The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name(Business/Organization/Individual): 63 r-o )P Address: ca 15�L, -D City/State/Zip: .S.L.Q) Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.( jI am a employer with 4. ❑ I am a general contractor and I i employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheget. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We ate a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.. [No workers' comp. c. 152, §1(4),and we have no . 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.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: �% `�2i L c ,, Ll Policy#or Self-ins.Lic.#: J -QST�ti ��p _ Expiration Date: Job Site Address: E, 1 ELL 12 City/State/Zip: ® ��►moi/�. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 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 up 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 hereby c117 ,nder the a* s nd penalties of perjury that the information provided above is true and correct. Si nature: Date: ! Phone#: 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#: I Information and Instructions 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 of hire, express or implied,oral or written." An employer 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 chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)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 LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be 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 line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom 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 will 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-87.7-MASSAFE Revised 5-26-05 Fax#617--727-7749 www.mass.gov/dia i � NORBERTO BOSA Electrical Service O(D '. O � F Residential Commercial Insured License: #11930.6 161M19-4601 w