Loading...
HomeMy WebLinkAboutBuilding Permit #962-16 - 117 NUTMEG LANE 3/10/2016 L BUILDING PERMIT o�"°DT 6;��0 44"'�"�,��no I TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION'- Permit No#: 4 k Date Receiveda *A " 7,9 A�RAreo�P .(5 SSACHU5� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 11-1 a, LoL G PROPERTY OWNER ) Print 100 Year Structure yes <EE7 MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes io TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building iZOne family ❑Addition ❑Two or more family ❑ Industrial S'Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other f79 epti c 0 Well ❑ Floodplain ❑ Wetlands ❑ Watershed District. Wates/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 00 4-1 ppd 7 ^ � eve ©r l,) A �r��r",-Cry i��er'+CN< 'S'-%r,e�i ,roti Identification- Please Type or Print Clearly OWNER: Name: �'�,° 9'; Phone: Address: Contractor Name: �o-y.v ��S W Phone: `�^?$ - �S .� "D- O D Email: Mf 54 A$CsJ2 C-0•-r,Cg �- Address: Supervisor's Construction License: C- 5 0 5(4:2 1<g Exp. Date: f b Home Improvement License: k Exp. Date--- ARCH ITECT/ENGINEER ate--ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSR ASED ON$125.00 PER S.F. Total Project Cost: $ 31, $ 0 FEE: $ �$. Check No.: Receipt No: C �J/� NOTE: Persons contracting with unregistered contractors do not-have acres �66 the guaranty fund �. — - - - ,_._,� Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tannuing/Massage/Sody 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS I HEALTH Reviewed on Signature COMMENTS ® J Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted .yes Planning Board Decision: Comments Conservation Decision: Comments j Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street j ,� .+�...,.,.-.:_-«....-min- ,t"r.•---y -4ts-�. ' za •- .:: �;.• �.4 �•r t�yq :..��,�-.�...�--. ,_ �1 y FIRE 00��1RdTENtT <wTempD,umpsfer;_on►site ��yes � , ;' ,,. o - � �iLocated�af�i124iMain�Street •� ,; Y�� ;�FDepartment�.s gfnatur�e/date..,.,_-�_-.�,-_ - _ _� • � P��¢-_i,,� ���_�_�.m,. 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: lies No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA.-- (For department use) Ll Notified for pickup Call Email jDate Time Contact Name - Doc.Building Permit Revised 2014 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 4, Copy of Contract 4. Floor Plan Or Proposed Interior Work 4. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks � Building Permit Application a. Certified Surveyed Plot Plan 4. Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 4, Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4� Mass check Energy Compliance Report (If Applicable) � Engineering Affidavits for Engineered products . OTE: 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 4. Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract � 2012 IECC Energy code a. Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance ors special permit was required the Town Clerks office must stamp the decision from the Board of Appeals P P 9 P PP that thea appeal period is over. The applicant mut then e pp p pp s get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. 6`/14r4 f� V Date l v A TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ �, Check# Building Inspector ��1P� 7�� �i � NORTH own of EAndover h ver, Mass cochic"tw's K 1. 7,y °RATED 0"PR��cy s U BOARD OF HEALTH Food/Kitchen PERM LD Septic SystemsT T 0 BUILDING INSPVCT THIS CERTIFIES THAT ..................... �.......... .x.. ................................................................ C+Rz Foundation has permission to er t .......................... buildings on ..�. `.�.....Aw.#W .....*.......................... Rough to be occupied as .. !� .... .�, •. A ...... . ........... `Chimney " ... .. provided that the person accepting this permit shall in eve6+ry res ect conform to the terms of the application Final p ' G 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final � /& PERMIT PERMIT EXPIRES IN 6 MO TH ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ough r Service ..................... ... .....................BUILDING............................INSPECTOR.. Final Ok, 3 6,1 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. a Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 3%840.00 m $ - $ 478.08 Plumbing Fee $ 59.76 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 59.76 Total fees collected $ 697.60 117 Nutmeg Lane 962-2016 on 3/10/2016 Remodel Existing Basement FNORTH own of y-: 0 No. * t - a- a, ver, Mass y � > > as)/'D T O 4 C OC NIC1C Nl wICN V Ano ►'Pp��5 1 S u BOARD OF HEALTH i I Food/Kitchen PERMIT T LD Septic System VTHIS CERTIFIES THAT �..........KoAt-L BUILDING INSPECTOR ..�. . � Foundation has permission to er t .......................... buildings on .... a.......................... 6 0 Rough to be occupied as . .... r � ........L' .�I ...... ....A ..... . ........... ...... 0 Chimney provided that the person accepting this permit shall in every res ect 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 MO TH ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO 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. TES TA Building and Remodeling Start date 3/14/2016 5 APPLETON STREET Finish date 5/14/2016 NORTH ANDOVER , MA 01845 HIC Lic. 120296 Expires 11/19/17 (978) 682 2023 CSL Lic. CS 54718 Expires 6/8116 Proposal Proposal Submitted To: March 8, 2016 Eli Kalil Home Phone: (978) 117 Nut Meg Lane North Andover, MA 01845 Job: Remodel Finish Basement Job Description: Obtain building permit Complete removal of all demolition and construction materials Generated by Testa Building and Remodeling and its subcontractors. Main Basement CONSTRUCTION: Re frame parts of the basement. But Basement is already framed. Remove paneling. Leave insulation where possible. Create a utility room and a coat closet coming into the basement. ELECTRICAL: Outlets, switches and lights as listed by code off of existing to include Rework the electrical that is already in place where needed. • NOTE All recessed fixtures supplied by electrician. • NOTE All other fixtures supplied by owner installed by electrician. PLUMBING: Jack up the concrete and install a stand up shower unit. HEAT: Zone off the existing hot air furnace. PLASTER: All walls and ceiling will be hung with'/s blue board and skim coat plaster. PAINTING: Paint all walls and ceiling in the basement. Paint all new trim in the basement. FINISH: All doors will be solid Masonite doors casing and baseboard will match existing. A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications, for the sum of.- $39,840 f:$39,840 Thirty Nine Thousand Eight Hundred Forty Dollars One-third to start,one-third after rough inspection,one-third upon completion. Authorized signature L I reserve the right to cancel this contract if not accepted in 30_days Signature Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES i I This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners.Seek legal advice if necessary.Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of ConsumerAffairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work MGL chapter 142A.) Express Warranty-Is an express warranty being provided by the contractor? No Yes(all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor:The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. •Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. •Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. •Does the contractor have insurance?Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a"proof of insurance"document. •Know your rights and responsibilities.Read the hnportant Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. DO NOT N THIS ONTRACT IF THERE ARE ANY BLANK SPACESIII TWO identical pi f the ntract be leted and signed.One copy should go to the homeo r e other copy should be kept by the contractor. • Hom er's S ntractor's Si ature Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor.The same right is not automatically afforded to a contractor,however.The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below.This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be ed submi such arbitration as provided In husetts General Laws,chapter 142A. t v Homeowner's tore is Si re NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor.The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93A)may not be waived in any way,even by agreement.However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law.The contractor is responsible for completing the work as described,in a timely and workmanlike manner.Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose.An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require thesignatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the OCABR website at http://www.mass.gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http://db.state.ma.us/homeimprovement/ficenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/201 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOU CANCELLATION NOTICE,AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION,YOU MAY RETAIN OR DESPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO [Name of Seller],AT [Address of Seller's Place of Business]NOT LATER THAN MIDNIGHT OF (date). I HEREBY AN EL THIS TRANSACTION. Date: Buyer's Signature: The Commonwealth of Massachusetts _ Department of industrial Aceldents -64 M X Congress street,Suite 100 tl02114 2017 ' Boston,MA www mass.gov/dza �7M Sy.v Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plnmbers. TO BE PILED WITH THE PERMITJING,A.UTHORTT Y. Please Print Lepribly A '•licant Information • Name(Busine8sl0r`gauization/Individual): �� � g�• , Address: tj A� '� A v1`6��� Phone#: `�71—lo�sa�� o� 3 City/State/Zip: • ,. .:. .. , ._.zx�.: n,: . . .• ? appropriatebox: Type of pxojeet(i eq& dd), Are you an employer. Check the ein to ees(fiill and/or part-time). 7. F1NGW construction L[]I am a employer with P y 2.0 I am a sole proprietor or partnership and have no employees Working forme in 8. Rexnodeliiig any capacity.[No workers'comp.insurance required] 9. F!Demolition 3.Q Tam a homeowner doing all work myself.(No workers'comp.insurance required.]t ]0❑Building addition 4.F11 am a homeowner and will.be hiring contractors to conduct all work on my property. I will ll.[]Electrical'repavCs or additions ensure that all contractors either have workers'compensation insurance or are sole 'p]urnbiilg repairs Or additions R proprietorswithn(' R oyees. 5.❑l am a general contracfo,and I have hiredthe sub-contractors listed on the attached sheet 13; goof repairs These sub-contractors have employees and have workers'comp.insurance. 14.Q Other 6.Q We are a corporation and;ifs,officers have exercised their right of exemption per MGL c. 152,§1(4),and'yve have�no employees:[No workers'comp.insurance required.] *Any applicant that checks bbxl must also fill out the section below showing their workers'compensation policy information i Homeowners who subc10,'b:W of 61.it indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. tu+r #Contractors that checktbis box fnust attached to additional sheet showing the name of the sub-contractors and state whether of not(hose,entities ave employees. if the sub-contractors have employees,they must provide thea workers'comp.policy number. X am an employer that is providingworkers'compensation insurance for my errrployees' !Wow is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address- number and expiration date). Attach a copy of the'evorkers' compensation policy declaration page(sho ung the po/Z y Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 of a STOP 0 O and/or one-year imprisonment,as well as civpenalties in the form forwarded to the Offi e o£Invesga 0 a ER of the DIA for insuxanc day against the violator.A copy of this statement may coverage verification. --i—do hereby the pains cer ' nder and penalties of perjury that the information provided above is true and correct. Date: 3 l O /b Signature: Phone#: — Oq2- >aa Official use only. Do not write in this area,to he 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 Phone#• Contact Person: Information and. Instructions Massachusetts General Laws chapter 152 requires all empl6yers 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,luxe, express or implied,oral or written." An employer is d'efuied as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver'&trustee of an in 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 occupani df 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,wh&has'not produced-acceptable evidence of compliance with the insurance coverage re44red." 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 ofthis 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.contractors)name(s),address(es)and phone number(s)along with their certiflcate(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 thatthis 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 of dAvit should be returned to the city or town that the application for the permit or license is being requested,not the Department of IudustrialAccidents. 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 Had. 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 thaf must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)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 Department's address,telephone and flax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1877-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia I Sti 4o bW 1�3 alsN AOQNV-N b1S3.1 SdbS ' Opw�H :adfL b80 ekoe16L/C1 t '9Nro,rns yls3t 1 aOl3bal1VO 96,10 luo!�e�/dx3 �27�rtr ��as ssaorsng srrg3W anOad�►/�31Nas s nsuo30 Jo a O uo� 0 a� .`` -- 9018�k90 4411 c))!SSJ"44,03 -'shim- TO O Y 10 :k �r8�.r. ISO eJLI ar qn Sua°!�e/nga j SUO,3 l eon i f