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HomeMy WebLinkAboutBuilding Permit #1142-2016 - 128 DALE STREET 5/3/2016 "/61M l p up TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: `� Date Received Date Issued: T011� all items on this age I ORTANT:A licant must com Tete LOGATI©N ,ER -ER 10�O ear;OI Struc'ure T yes, no, MAP�NO _PARC.EL. Z®NING'DISTRICxT; Histonc,Distnct yes no - MechmeShop�Vill'age y"est no, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial RAlteration No. of units: ❑ Commercial ❑ Repair, replacement ElAssessory Bldg 11 Others: ❑ Demolition ❑ Other ❑;Septic, ❑1Nelli ❑ Floodplain: O',1Netland's Watershed District D 1Nater/,S;evv_er ff: DESCRIPTION OF WORK TO BEP !TFRM iw0 � A ,oAo �at.� �D cJ ntification Please Type or Print Clearly) (�� b21•�8 OWNER: Name: �� S Phone: Address: Af ) 2 CONTRACTOR? Name::: n. - Adtl'ress Superyisor,-s;C:onstrucfion}License_: / US 3 Expo; Daterf1 �_ - Homei Lmproveroent License: I h c7 L� 3 Exp ®ate O D ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /0 , Soa FEE: $ Check No.: Receipt No.: ccess to the uaran and NOTE: Persons contracting wi h unre istered contractors do not have a g h'f + !sig-fi-atUre of Agent/Ow .Sig atur&of contractor:: Plans Submitted ❑ Plans Waived ElCertified Plot Plan El Plans TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued, on this page I ORTANT:Applicant must complete all items VO_RTANT.Applicar 7 U 0 bA, "PrAtV 1(P.R0P,E_RT�Y„&kNff-RiC 7 OU&rr rS f,v H,` , ;, T-R� C,! _J§toric -ag y -7 x 4-.- ' -7- TYPE OF IMPROVEMENT_ PROPOSED USE Residential Non- Residential ❑ New Building El One family El Addition 0 Two or more family 0 Industrial Alteration No. of units- [I Commercial 0 Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other qptic' EWel . I 2 . 6d Um &. Wetlands 0 .Watershed.Distnct bWatdflaewer Y DESCRIPTION OF WORK TO BE PERFORM 1 � J,4 % A ".1 t `7 t + 14) dentificatiop Please Type or Print Clearly) Phone: 78,62,1 * OWNER: Name: Llr\ r.q Address:X, A 4 ' Phone-:... ,CONTRACTOR Name: m_� Maress”" :- o icense: _Exp: "Date:' �A Supervi§&!s Constr Exp:. Dbtb:- mprove.ment'L se' Hombl License. '9 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ILA" FEE: Check No.: Receipt No.: tyfund NOTE: Persons contracting with unregistered contractors do not have access to the gu raniyjunt� '..'Sig.naty r*e'o'f Ag6riti0whe Signature of'b6htractor P1 .. Plans Submitted D Plans Waived F__J Certified Plot Plan ❑ Stamped Plans Location No. , 4 Date I . - TOWN OF NORTH ANDOVER Certificate of Occupancy $►, Building/Frame Permit Fee $E 1 A Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r. Check#1 - Building Inspector �` 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE.DISPOSAL Public Sewer R.- Tanning/Massage/BodyArt ❑. . 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 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes-.. Planning Board Decision: Comments 0onservation Decision: Comments Water & Sewer Connection Driveway Permit DPW Toivz Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMFf T - Temp Dumpster on site yes no Located at'124 Maira`Street Fire DeparrieEt signature/date COMMENTS 4 �I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ _. Swimming Pools ❑ WeII ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF a U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH 'Reviewed on Signature g ature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceiptsubrnitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/S1 nature Date Driveway Permit DPW Town ]Engineer: Signature: Located 384 Osgood Street ' FIRE DEPARTME=NT - Temp Dumpster on site yeas no Located at'124 Main'! h Fire ®epa`grner)t signatureldate COMMENT'S 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 i' NOTES and DATA— (For department use I� I I ® Notified for pickup - Date Doc-Building Permit Revised 2010 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 i 0 Notified for pickup - Date i t I f )oc.Building Permit Revised 2010 I i �I Building Department The folowing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing Siding,, Interior Rehabilitation Permits ❑ Brailding Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work o- Engineering Affidavits for Engineered products gOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application Li Certified Surveyed Plot Plan o Workers Comp.Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered produclis COTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) L3 Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ -Mass check Energy Compliance Report o Engineering Affidavits for Engineered products qOTE: 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 subm' ted with the building application Doc: Doc.Building Permit Revised 2012 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 o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract { o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products DOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition'Or Decks Li Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract Li Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: 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 app.al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording mist be submitted with the building application Doc: Doc.Bui!;fiing Permit Revised 2012 I Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 14,000.00 m $ - $ 168.00 Plumbing Fee $ 21.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 21.00 Total fees collected $ 310.00 128 Dale Street 1142-2016 on 5/3/2016 Master and Common Bathroom Remodel I NORTH T - wn ) ic . ,. ver o , ..�:: 1 No. i IL h , ver, Mass, coc"Ic"Im'N y1' 4ArED V BOARD OF HEALTH Food/Kitchen PERM LD Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ��ul ........... . .................... ...........A .....................................�... . Foundation has permis ' n o rect .......................... buildings on .. ... .... ... -ece-F.................. Rough to be occupied icPA �,..Mft�..... .. .. � J �i�. . #.%t .1 Chimney provided that the erson'acce tin this permit shall in eve res 1 ct conform to the terms of the application p p accepting p every pe n pp 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION Rough Service ........ Final BUILDI INS CTOR 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. V r o p o ga t Page# of pages 1 I John Morrissey Remodeling 57 Concord St. No. Andover, MA 01845 c1 vA �k \c, " I PROPOSAL SUBMITTED TO: JOB NAME JOB# f ADDRESS JOB LOCATION DATE DATE OF PLANS �( PHONE# FAX# ARCHITECT Zxye hereby submit specifications and estimates for: .................... ................. ........___.__ _.._.._. ......................... .......... ....................-------------- _._.. .74 ...........----,j--. j T �'[ _ - l► P JA!� v -40 . A Ar 'K . .. __ ................ .... ......... ..................................... ...._............... ..._.._......... ------ .------ ....... Ve propose hereby to furnish Taterial and laborr–complete in accordance/�0,1h the above specifications for the sum of: $ �r G? ,i �+ e h� �. r`c' ��jl Dollars with payments to be made as follows: `.Oy`�- ®/t-4 d�1t/l Any alteration or deviation from above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. acceptance of Proposal 9 The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature Date of Acceptance a ` Signature p I A-NC381 9/T-3850 09-11 `{ L I �- i { Tl- -- j I _ -VVd4\ i DATE(MMIDDNYYY) A�R" CERTIFICATE OF LIABILITY INSURANCE 5/3/2016 THIS CERTIFICATE 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to rights the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer g is to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Paul MacDonald NAME: MTM Insurance AssociatesPUHCO w . (978)681-5700 TFAX.I(AIC No:(978)681-5777 1320 Osgood Street q� :certificates@mtminsure.com INSURERS AFFORDING COVERAGE MAIC# North Andover MA 01845 INSURERA:Travelers Casualty Ins Co of 19046 INSURED INSURER 8: John Morrissey INSURER C: 57 Concord St INSURER D INSURER E: North Andover MA 01845 INSURER F: COVERAGES - COVERAGES CERTIFICATE NUMBER:15-16 Master 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. INSR ADDL SUBR POLICY EFF POLICY EXP i LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MIDDIYYYY1 (MMIDDIYYM LIMITS X COMMERCIAL GENERAL LIABILFTY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE F OCCUR DAMAGE RENTED $ 300,000 6802DS957331542 6/18/2015 6/18/2016 MED EXP(Any one person) $ 5 r 000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- FACT F LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: AIOI $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraaadent UMBRELLA L.IAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTiVEE.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? ❑ NIA (Mandatory in NH) E-L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-P01-ICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 109,Additional Remarks Schedule,may be attached H more space is required) This certificate of insurance represents coverage currently in effect and may or may not be in compliance with any written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. Bldg. 20 Suite 2-36 N Andover, MA 01845 AUTHORIZED REPRESENTATIVE P MacDonald CPCU, CIC JO W&4--— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD IN S025 rgn'l4m i C�%1r�`(Gnrotjitnrrrae+rlffr r f�.'�4frJ.1<uclrricfft 4 Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR �Registration: 169543 Type: Expiration: 70201 ,, DBA JOHN MORRISSEY REMODELING' wi JOHN MORRISSEY 57 CONCORD STS , NORTH ANDOVER,MA 01845 r Undersecretary i Massachusetts Department of Public Safety Wj Board of Building Regulations and Standards License: CS-105236 Construction Supervisor 't JOHN MORRISSEY � 67 CONCORD STREETFr,,01 NORTH ANDOVER MA 01$45 CA-- Expiration: Commissioner 11/26/2017 The Commonwealth ofMassachusetts - Department of IndustriglAccidents 02 Office of Investigations 600 Washington. Street Boston,MA.02111 www mass govIdia ns Worker' Compensation Insurance Affidavit:Builders/Contractors/Electrltclia /Plumbers Applicant Information Please Print Legibly Name(Business/Organi'zation/lndividual): �� 1/�t�d�� ��� �`t •�M e ��I✓L 5' Address: r i-�- -^ City/State/Zip: Phone#: 7 , . Are you an employer?Check the appropriate box: Typo of project(required): L❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑New construction employees(full and/orpatt-time)* have hired the sub-contractors 2.#I am a sole proprietor or partner- listed on the attached sheet.+ �• E]Remodeling / ship and'have no employees These sub-contractors have 8. [J Demolition working for me in any capacity. workers'comp.insurance. g• E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner.doing allwork right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and wehave no 12.QRoofrepairs insurance required.] employees.[No workers' q ]- 13.0 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are 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'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: /, yd ecI �X . Policy#or S elf-ins.Lic.#: 3 L 5-17(o Expiration Date: (� Job Site Address: �� �e s City/State/Zip: A / AIj tler ��� 618-1iS' Attach a copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 certlo under the pains and penalties ofperjury that the information provided above is true and correct. f �1 sign 0: Date: Phone#• !�2 7 E _ V:) 0 6Y--7 Z-/ � 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 s.Plumbing Inspector 6.Other - - _ ph nn".ff• M 1 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 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 employe." 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 ofits 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 our situation and,if necessary,supply su 1 sub-contractors)name(s),addresses)and phonenumber(s)along with their certificate(s)e(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation insurance. If anLLC 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 p eimit/licens o 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. Anew affidavit must be filled out each year.Where a homeowner 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 Depaximeut of.ZudusWa.1 Acoldeuts Office of Investigatio.m 600 Waftpa S#xeet BostQn? 02111 Tel,#617-727-4900 ext 406 ox 1-877MASSAFIF, Revised 5-26-05 Fax#617-727-7749