HomeMy WebLinkAboutBuilding Permit #576 - 122 FOREST STREET 1/31/2012 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION 6 i
Print ( /
PROPERTY OWNER Unit#
Print
MAP NO/- 4!PPARCEL:ZONING DISTRICT: Historic District yes n�
Machine Shop Village yes
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building Wbne family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition _ ❑ Other
K--t tic ❑Well] F of odpl 0 W 1'ands WatershedDistrict p
O�Water/Sewers
�i DESCRIPTION OF WORK TO BE PERFORMED:
,fr-\Wr 5%z%(--G6 Tt-tsr/at-�-, yY�1Nl�(. 'S 1►� ir'�,
(Identificat�'on Please Type oZDint Clearly)
OWNER: Name:-5&5 At-k \S 1�TI�ZS Phone:
Address: Nom. &-)I%
CONTRACTOR Name: Phone: clq 5-5 -'r'1
Address: ao �V`�1�-t W�K 5 5 ,�J`� 1�`�� CS��rL 0
Supervisor's Construction License: Q5 - Oc1,aQ�p5Exp. Date: \Vo-Ilam_
Home Improvement License: `(o`� 1 X15 Exp. Date: I°l 12
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.-$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ , FEE: $ Z
Check No.: �f Receipt No.: k-7
NOTE: Persons contracting with unregistered contractors do not have access to the g aranty fund
Signature,ofA�gent/Qwrer' ,,. °_ y: Signatiare;of(cogtractor __ t j
Location 4fi,�a /Is/1T
No. 5 Date
NORTp TOWN OF NORTH ANDOVER
OL
0 R
9
Certificate of Occupancy $
s�CNUSE<�' Building/Frame Permit Fee $ Z
Foundation Permit Fee $
Other Permit Fee Fi/t-e- $ r
TOTAL $ _
Check #
AU
C \�
2 4 9 U 9 Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
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
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
9
i
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
i
DPW Town Engineer: Signature:
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.
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.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
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
❑ Copy of Contract �I, + �
❑ 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
❑ 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 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
Doc: Doc.Building Permit Revised 2008mi
F
R ARSENAULT AND SONS Page No. 1
Q CONTRACTING INC PROPOSAL
M of Pales
DATE
PROPOSAL SUBMITTED TO: 1/04/2012
NAME OB ME
CURLS LEBLANC �
STREET STREET
FORREST ST_
CITY CITY STATE
NO.ANDOVER MA
STATE PHONE
We hereby submit specifications and estimate for:
1)INSTALL 7"CEDERBOARD INSULATED VINYL SIDING NATURAL CLAY
2)INSTALL VINYL SOFFITS SILVER ASH
3)WRAP ALL FASCIAS AND RAKE TRIM
4)PRICE INCLUDES THE REMOVAL AND REINSTALL OF ELECTRICAL METER,LIGHTS AND OUTLETS
v-, t-t e a
We hereby propose to furnish tabor and materials—complete in accordance with the above specifications,for the sum of TWELVE
THOUSAND.FIVE HUNDRED
Dollars($12 500:00)with payments to be made as follows:
WHERE AS SIDING IS A SPECIAL ORDER AND NON RETURNABLE A DEPOSIT OF$6800 IS REQUIRED 2ND PAYMENT
$2850 3RD PAYMENT$2850
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above
specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent
upon strikes,accident or delays beyond our control.This proposal subject to acceptance within 3 days and it is void thereafter at the option of the undersigned.
Authorized Signature
ACCEPTANCE OF PROPOS
The above prices,specifications and conditions are hereby accepted.You are authorized to do th v specif ayment will b made as outlined above-
ACCEPTED:.
bove.ACCEPTED:
Signature r _!
f
DATE ' f Signature
0 E-Z CONTRACTORS FORMS FORM NO.PROP23
V iC
/ 5 �; <f
'
MassaeIusefts Home Improvement Sample Contract
This form satisfies all basic requirements of the state's HomeImp
language to prorovement Contractor Law(MGL chapter 142A),but does not include standard '
tect homeowners(Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A
Massachusetts Consumer Guide to�lRome Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the
Office of Consumer Affairs and B17siness Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website..
Homeowner Formation Contractor Information
Name ,
Comp e y
zd
Street Address(do not use a Post Office o address) Contractor/Sal%espersorf/�Own—Name
�0��SVI 5�
City/Town State I Zip Code Business Address a str etaddress)
ev
Daytime hone Evening Phone
� � Ciiy/To State
� Zip Code
M 170
ing Address(It different from aboSe) Business Phone
Tederal Employer ID or S.S.Number
Lmv mqair
es
Home improvement Contractor Reg.Number E iration d to
that most home
Improvcmcntwniractotshave
a valid registration number•
The Contractor agrees to do the fo!lIowing work for the Homeowner:
(Describe in detail the work to completed,specifying the type,brand,and grade of materials to be used,use additional sheets if necessarv,)
7W Vlo,,el�)
I
Required Permits-The followingltiuilding permits are required Proposed Start and Completion Schedule-The following schedule will
and will be secured by the contractor:as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(Owners who secure their ownn permits will be
excluded from the Guaranty]Fund provisions of /j bate when contractor will begin contracted work
MGL chapter 142A.)
: i
/Z Date when contracted work will be substantially completed.
Total Contract Price and PaymeriISchedule X
The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of.
Payments will be made according to;the following schedule:
upon signing c0u�act(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater)
$ �a by /_ or upon completion of
$ $ d by / i or upon completion of
! i
$ upon completion i i the contract• (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special $ 0 to be paid for ��K ,-•
ordered before the contracted work begins in order
to meet the completion schedule i(k*) $ to be paid for '~
NOTES:(*)Including all finance charges(**)Law requires that any depositor down-payment required by the contractor before work be may'
not exceed the greater oF.(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material
which must be special or3ired in advance to meet the completion schedule.
Express warran v-Ts an ex rens warrlantv being rovided b the contractor? !s 11ill terms of the warran No
Subcontractors-The contractor agrees to be solely responsible for completion of he work'd scribed regardless of the actions of any thirdontract
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 agreelblent
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 lienor other security interest has been placed on the residence. Review the following cautions anti
carefully before signing this contract d no
li
Don't be pressured into si I
fining the contract Take time to read and fully understand it. Ask questions if something is unclear.
Make sure the contractor has alvaiid Home Im rovement Contractor Re 'stration. The law requires most home improvement contractors and
subcontractors to be g to teredlwith 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.
o Does the contractor have insurance? Ask the Contractor forhis insnran
ce company information so that you can confirm coverage,or ask to
see a copy of a`�iroof of insurance"document.
• I{now your rights and responsibilities. Read the Important 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 maim 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 Seethe attached notice of cancellation form for an explanation of this right.
DO NOT SIGN TS,[S CONTRACT IF THERE ARF•ANY BLANK !i r
4Two identical copies ofthe contract must be completed and signed. One copy should go to the h ppp���eowner.The other copy sh sjept by the ACES ontracton
� n •
gnature j
/ Contrac or's gnature
Date ��J'
Date
NORTH -
z over
0 of _
.r,M..�w.fl^i r�F•.
In
No. a'
o , '� dover, Mass., �
O = LAKE
COC MICHE W ICK\y
7 ORATED PPS �Cl
�S BOARD OF HEALTH
Food/Kitchen
Septic System
PERMIT T D
S BUILDING INSPECTOR
THIS CERTIFIES THAT............ .. r!'! ....... ...................................... ................................ ....................... Foundation
•.......... Rough
has permission to erect ....................................... buildings on ...1 T�►....... ..... r.T................ ........... g
Chimney
to be occupied as .��......1..... ikl�A� A� .. .... I.��.......�L!!l..
.
provided that the person accepting this permit shall in every respect conform to the terms of the plication on file in 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
3 a PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR.
UNLESS CONSTRU TS Rough -
�iS f
Service
BUIL 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.
Smoke Det.
SEE REVERSE SIDE
01-30-'12 14:44 FROM-Phil Richard Ins, 1-978-774-1318 T-799 P0001/0001 F-872
V, RTIFICATE
CERTIFICATE OF LIABILITY INSURANCE DAT 0113DDIYYYY)
01/30/12
IS ISSUED AS A• MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
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(ias) must be endorsed. If SUBROGATION IS WAIVED, 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),
CONTACT
PRODUCER 978-774-4338 N Mei
AX
Phil Richard Insurance,Inc g78-774-1318 aONfi Ext: I FA C No:
27 Garden Street Unit 18
Danvers,MA 01923 ADDRESS:
Philip W.Richard PR ARSEN-1
c aT M'R ID#:
INSURERS AFFORDING COVERAOE NAIC q
IN3UR5D Arsenault&Sons Contracting, INSURERA:Travelers AIR I
20 Howard Street INSURER 5:
S. Hamilton, MA 01982 INSURER C:
INSURER D:
INSURER E:
INSURER P
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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
IN SR POLICY EFF POLICY UP
LLIMITS
TR TYPE OP INSURANCE POLICY NUMBER MMIDD/YYYY MM/DD/yy,
GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RERTE I
COMMERCIAL GENERAL LIABILITY I PREMISES'Ea occurrence $
I
CLAIMS-MADE 17 OCCUR MED EXP(Arty one parson)S
PERSONAL&AOV INJURY $
GENERAL AGGREGATE $
PGEL AGGREGATE LIMIT APPLIES PER ' PRODUCTS.COMP/OP AGG $
POLICY 7 PRO• LOC $
AUTOMOSILE LIABILITY COMBINEO SINGLE LIMIT $
(Ea a0cident)
ANY AUTO i BODILY INJURY(Per person) $
i ALL OWNED AUTOS l
� BODILY INJURY(Per accident)I$
SCHEDULED AUTOS PROPERTY DAMAGE $
HIRED AUTOS I (Per accldent)
NON-OWNED AUTOS $
I $
UMBRELLA LIAR HOCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE S
DEDUCTIBLE $
RETENTION S 1 $
WORKERS COMPENSATION X WC STATLIMIT OTH-
AND EMPLOYERS'LIABILITY
YD
A ANY PROPRIFTORIPARTNER/EXECUTIVE 6KUB0314M96010 09/23/11 09/23/12 E.L.EACH ACCIDENT S 100,000
OFFICERMIEMaER EXCLUDED? N/A
(Mandatory In NN) E.L.DISEASE-EA EMPLOYEE 5 100,000
IfYes,dewioe unpar i , 500 000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S t
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Romarks Sohodulo,If mora space Is roqulrod)
Evidence of Insurance
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.
Town of North Andover
Building Department AUTHORIZED REPREEENTATNE
Brian Leaf
120
120 Main St.
(North Andover MA 01846
01988-2009 ACORD CORPORATION. All rights reserved,
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
The Commonwealth ofMassachusetts
Department of IndustrialAccidents
Ofj:rce of Investigations
600 Washington S'tr`eet
_ Boston,MA 021-11
www.ma_ssgov/dia
Workers' Compensation Insurance Affidavit:guilders/Contlractors/FIectricians/PIumbers
A licant Information
please Print Legibly
Na111e(Business/Organization/Individual):_
Address:
.City/State/Zip: ( -%-_ r-)\-c
Phone#:
[Ell
an employer?Check the appropriate b :
a employer with 4. I am a general contractor and I �'e of project(required):
loyees(full and/or part time).* have hired the sub-contractors 6 ❑New construction
a sole proprietor or partner- listed on the attached shgget.t 7. ❑Remodeling
and haveno employees These sub-contractors haveing forme in any capacity, workers'comp,insurance. 8. ❑Demolition
workers'comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition
ired.] officers have exercised their 10❑Electrical repairs or additions
a homeowner doing all work right of exemption per 1VIGL 11.❑Plumbing repairs or odditions
lf.[No workers'comp. c.152, §1(4),and we have noance re uired.
12-E Roofrepairs
q ] employees.[No workers
comp,insurance required.] 13•❑Other
!Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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.
lam an employer that isproviding workers'compensation insurance for my employees Below is thepolicy and job site
information.
.insurance Company Name:
Policy#or Self-ins.Lie.#: '#�1�.�.� �3\�-��v�0�L,0 ' [Expiration Date: f Z�
Job Site Address:
City/State/Zip--
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 maybe forwarded to the Office of
Investigations.of the DIA for insurance coverage verification.
I do hereby cer ify under to ains and enalties o
-p P (perjury that tlse information provided hove' true and correct.
Signature: L
Date: 3 d /2—
I�
?hone#: r) _8�`� l cl a
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitUcense#
Issuing Authority(circle one): ,
I.Board of Health 2.Building Department 3.City/Towu Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other -
Contact Person:
' Phone#:
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 locdl 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 nny
applicant who has not produced acceptable evidence of compliance with the insurancd 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 certificates)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 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 thein`
,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 peimit/license number which will be used as a referened 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(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 marled 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 Coninaormc-alth of 1�assacht�setrs
Depari ent of ladustrial Accidents
Ofte OfInVestiigations
_ 600 Washhoon fteet
Boston;M1-A,02111
Tod#617-727-4.900 ext 406 ox 1-877-MAssA.Fj3
Revised 5-26-05 FU#617-727.7749
'c t? -maSs.l;Ovfdia