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HomeMy WebLinkAboutBuilding Permit #79 - 145 BARKER STREET 7/31/2007 BUILDING PERMIT Noer" q 4.t,lO 6 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 7q Date Received Date Issued: �VS CHUSS� I PORTANT:Applicant must complete all items on this page 10CATI614r% —Kier� PROPERTY OWNER tmb t .=NA .C . Prat MAP NO. :PARCEL/o Zfl:NING LQISTRICT His#acic 13istrict des M 4 oh ine Shop WiIIa9e yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Iteration No. of units: _ Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic WTeIV foodpaira /e#lands Watershed 0stric# 1 lateir/Sewe DESCRIPTI N OF WORK TO BE PREFORMED: eL ho v '�- C( osr✓4- �Q--ZAcve vJ 0eJ 5 e`— Identification Plea Type or Print Clearly) OWNER: Name:-7- L C�` W�° C P e:C( 9^ RI -6go 1 Address: e r—'St— CO.NTRACTaR Name: #"�' ;�, Phon, Adress:.. ` ISI - ln A j 1 Supervisor`is.Cons#ruct�onA'License Exp-, Dai.- Horne Irnpr rnent Lt nse: 4Fyn Date:, GVSE Che 4-C.y-10 267 -1-13 - 7Y O . AR "'TE-(,'T/ENGINEER Oen Wyc Phone: , - - - --�,�a Address: Go by r u'n-� M a Reg. No. Oq @ 8'_$' FEE SCHEDULE.,BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ,aG ;CdA FEE: $ l0 g-,100 r Check No.: ��a� Receipt No.: .?.6 </ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �gnatq _c!Agent/Owner=_ _=- S gnatdre �f contractor - E _- - Location No. 74 Date 7/ G 7 NORTIy TOWN OF NORTH ANDOVER F + ; , Certificate of Occupancy $ CMUs Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 204 Bu in Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL �ublicSew Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT I COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS IIS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments C Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT4- :Ternp Dwmpsteron.site yes no Located.at 124 Main-Street Fire Pep artrn�x�A!gnatureJdate _ s COMMENTS a 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 2007 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 ❑ 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 ed 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 i ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 TfNORTH own o ` Andover No. 17? - _ _ �o L dover Mass., zz COCMICMEWICK ' RATED P �S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System c� - BUILDING INSPECTOR THIS CERTIFIES THAT............. ..'02.......�S�. �Z1.�-.l q................................................................................... Foundation has permission to erect........................................ buildings on .. ..... Rough to be occupied as (, fie'. ......../....l.l s,� . :. cf' /' F .S'. Chimney ..... �r' �......�, d.S . ./ ........:-........................ provided that the person accepting this permit shall in every respect conform to the terms of the application 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 PERMIT EXPIRES IN 6 MONTHS Final ` ELECTRICAL INSPECTOR UNLESS CONSTRUCTIOSTART Rough XiBUa_1L­D1 ............................... Service N SO PECTOR 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 SIDE Smoke Det. i I p a . � ; ✓fie �oy��nonurea/�/�REGULATIO`NS' �i, �xrczc, . ;;. BOARD OF BUILDIN �y+ u cense: CONSTRUCTION SUPERVISOR` (umber: CS 044498 lrt45e °09/16/1960 Expires: 09116607 Tr.no: 19033 1 _ stricteii .00 NI � � tlTl_ER 29 GRE�tN ST j S-4—Ekk kA 01970' Commissioner ✓fie v!omvnzonusea�l� o�✓v�aaaac�zt�aela Board of Building Regulations and Standards License or registration valid for indlvetul use only ret HOME IMPROVEMENT CONTRACTOR before the expiration date. If found urn to: Board of Building Regulations and Standards Registratin:; 147359 One Ashburton Place Rm 1301 Expiratwn fi729/2009 Tr# 132233 Boston,Ma.02108 ,Type---DBA' JOHN BUTLER INTERESTS- I i 1` i The ssachusetts - Depa araanf of Fire Services a. Office of the State Fire M -p o BOX a25%S to Marshal Road Stow,MA 01775 North And PERMIT" (City of To �eX IDItj0 Date: / 3—Q In accordance with the (LPApplicable provisions of M G.L 1 8 Ghagter ) big Safi-.Num e1 Thisper"Utisgranw to: -�-� Provided in sectio 3 D1 w t' 4 - Start Date Percussion to locate d u m Pull name Ofperson,Firm or Co ps.ter for eonstructonratton /renovation �oRirnents:.: - /demolition o.f buildin.g, f Res[xictzons' dumpster must . be clearance dum 2S t from structure if pster must unable to lace w ' at �— be covered with with re uired ��. 1 wood or tar end of 'work day _ (`Give location by street and sY Fee paid S 50_0,0 0..or descr,'be 1115 i Slvs Permit will eipire 7—� �n"�er tn;;;;*location) ignature of o�cal antin F'ire>P gperrnit) Chief grantng.permi[ (Title) 1 I� JOHN BUTLER INTERESTS JBI 4 Draper Street, Unit C I Woburn, MA 01801 P: 781-932-1330 F: 866-690-9477 MA Lie# 044495 HIC # 147359 DATE: June 29,2007 CONTRACT: This agreement is between JBI and Tim&Mary Lou Medlock 145 Barker Road N.Andover,MA The owner agrees to hire the contractor to perform the following: INCLUSIONS: PERMITS&FEES $2100.00 j DEMOLITION: $8526.00 Outside Wall/Kitchen Cabinets and Tile Floors Siding/Windows Dining Room Floor&Wall Decks Master bathroom Closet Master Bathroom-Including floors/shower/vanity Removal of Bedroom window , Mud Room Floor &old laundry hook-up Misc.Selective Demo Includes Dum sters EXCAVATION: $7350.00 Removal of excess materials from site Stock pile loom Back fill foundation Rough Grade Finish grade by others Includes Perimeter Drain to dry well FOUNDATION: $ 16065.00 Footings/walls/3-windows and floor BULKHEAD&DOORS $4200.00 FOUNDATION SEALANT&INSULATION: $ 1050.00 I C 2 FRAMING: $ 19005.00 Install beams kitchen&dining room(waiting on design and approval) Frame floor/walls/roof/ceiling/doors&windows Frame kneewall at kitchen island Frame stove wall in family room Re-frame pocket doors at mud room/laundry/half bath/office Master bathroom—re-frame closet Re-framing 1 bedroom window $2047.00 Frame and install I bedroom window EXTERIOR TREWSIDING: $5901.00 Frame small deck&landing Frame two stairs at new doors Outside trim Fascia Soffit Window/doors Install primed cedar clapboard Manufacture&Install Quoines to match ELECTRICAL: $14826.00 Kitchen/Dining Room Family Room Mud Room/Bathroom Office Master Bedroom Move Service/Move Disconnects Master Bathroom—Fan light/Scones and sealed beam in shower Per Drawings Recessed lighting/Panasonic Fan/Light and devices by contractor Allpendants/deco lights and fans by others HVAC: $5512.00 Move units&reconnect Reconfigure kitchen ducts New A/C family room only Split(1 -1/2 ton)system by Goodman Ext.compressor unit int.fan coil unit including wiring &non-programmable thermostat PLUMBING/HEATING: $13890.00 Kitchen/Dining/Mudroom/Laundry/Master Bathroom&Family Room Install toe kick heater/slant fin baseboard heat were needed Move and increase gas line to new stove and zero clearance fireplace(add supply for grill—No Charge) Rough and install kitchen sink/bar sink/2 faucets/ice maker New laundry hook-up Half Bath install new toilet and sink in existing locations Master Bathroom Rough and install vanity/single bowl sink&faucet Rough and install copper pan&stainless drain/shower valve and shower head Suspended Ceiling: $ 525.00 Partial removal and replacement for access as needed i i a 3 INSULATION: $ 1838.00 All exterior floors/walls&ceilings Sound batt between Bathroom and laundry wall at Dining Room wall PLASTER: $5355.00 Addition/kitchen/bath/laundry/island/office/master bath&master bedroom closets Any patches necessary due to construction PAINT: Exterior -New work areas only(two sides) $3675.00 Interior—New work—Paint or stain to match (no faux or decorative paint carried) $ 5250.00 GUTTERS: $ 525.00 White gutters and downspouts on new addition TRIM: $4988.00 Build and install columns in arches in kitchen Trim all new windows and doors int.and ext. New base board in all new areas Patch in existing baseboard ADDED ITEMS: Build 2 master bedroom closets—approx.5 feet each $ 1365.00 Buy and install—Brazilian Oak Flooring in Family Room $3360.00 New 3 zone 169K boiler including wiring and thermostat for Family Room $8820.00 STOCK: $37655.00 Framing/Roofing/Sliding/Decking Int.Doors and Finish Misc. 7-New Andersen Wood Wright Windows 2—New Andersen—3 panel French wood hinged doors SUB-TOTAL: $173829.00 O&P: $34766.00 16 New—Andersen Wood Wright Insert Windows:(No Mark-Up) $ 13890.00 CONTRACT TOTAL: $222485.00 The price for the above outlined work$222,485.00 The payment schedule for the above outlined work is as follows: The ls'payment will be:$31,314.16 (Window payment$21,314.16 and Gen.Conditions of $10,000.00.) Remaining Balance:$191,170.84 The remaining payments will be drawn by requisition weekly.These payments will be potions of line items drawn before,during and after commencement of work per line item,till project is complete. Any work above and beyond contract or industry standard orspecial/custom items requested by owner, I performed by contractor or sub-contractors will be billed with a 20%mark up on labor and materials. 'lease make all checks payable to: John E. Butler i 4 I Permit notice:That it shall be the obligation of the contractor to obtain such permits as the owner's agent. The owner shall be responsible to obtain the permits for any work he has performed. Owner's that obtain their own permits or hire unregistered contractors shall be exempt from access to the Guaranty Fund. All home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or his subcontractors relating to a registration should be directed to;Director,Home Improvement Contractor Registration,P.O.Box 871 Taunton,MA 02780-0871 (508)821-9375. ARBITRATION:The contractor and owner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit such a dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the owner/consumer shall be required to submit such arbitration as provided by Massachusetts General Law MGL C.142A JBI Date: G 7 Timothy Medlock Date: Mary Lou Medlock Date: ( REQUIRED SIGNATURE LINE(for arbitration clause only) NOTICE:The signatures of the parties above agree only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately the parties. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of this contract. As a homeowner you have a three-day right of rescission to rescind this contract under MGL c93 sec.48: MGL c 140D sec.10 or MGL C255D sec.14 as may apply. No work will commence nor materials ordered prior to three days from the signing of this agreement. DO NOT SIGN THIS CONTRAC j11FT1HERE BLANK SPACES JBI Date: Timothy Medlock Date: Mary Lou Medlock Date: (!W3 d E E ACOS,,, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) PRODUCER 7/20 2007 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Yarjan Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 271 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES Stoneham, MA 02180 BELOW. 781 438-5577 INSURERS AFFORDING COVERAGE NAIC# INSURED John Butler Interests INSURER A: PENN AMERICA INS CO INSURER B: AMERICAN ZURICN INS CO 4 Draper Street, Unit C INSURER C: Woburn, MA 01801 INSURER D: 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. INSR DD'L LTR INSRD TYPE OF IN URANCE POLICY NUMBER POLICY EFFECTIVE POLICYEXPIRATION GENERAL LIABILITY DATE MM/DD DATE MM/DDIYY LIMITS EACH OCCURRENCE $ 1-10-0-0,000 X COMMERCIAL GENERAL LIABILITY DAMAGE CLAIMSMADE [i]OCCUR PREMISES Ea occurence $ MED EXP(Any one person) $ A PAC 6612806 7/28/07 7/28/08 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2 000 0 GET AGGREGATE 00 NEGATE LIMIT APPLIES PER: ; X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2 ,000 ,000 AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT $ (Ea accident) ALL 0 WNED AUTOS SCHEDULED AUTOS BODILYINJURY $ (Per person) HIRED AUTOS NON-OWNEDAUTOS BODILYINJURY $ (Peraccident) PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTO ONLY ACCIDENT $ ANYAUTO i OTHER THAN EAACC $ AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �ICLAIMSMADE AGGREGATE DEDUCTIBLE RETENTION $ ' WORKERS COMPENSATION AND $ WCSTATU- TH- EMPLOYERS'LIABILITY TORYLIMIUS X ER ANY PROPRIETORIPXCLUDE/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B Oyes,describe R EXCLUDED? 6ZZUB-0290L55-6 1�24�07 1�24�08 E.L.DISEASE-EA EMPLOYE $ IPECIesPROVnder 500 000 SPECIAL PROVISIONS below OTHER E.L.DISEASE-POLICY LIMIT $ 100,000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS k i 145 BARKER ROAD ` N ANDOVER MA CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Building Department DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town Hall NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL North Andover, Mass. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ` AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents U� Office of Investigations 600 Washington Street N p Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/lndividual):�, Address: L `fi Ci City/State/Zip:U G C R) rA& C)1 $0 l Phone#: '761 — q732— 123O Are an employer?Check the appropriate ox: Type of project(required): 1. I am a employer with_ 4. I am a general contractor and I 6. ❑N construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y P tY• 9. E] Building addition [No workers' comp.insurance 5. ❑ We are 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' 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. Homeowners who submit this affidavit indicating they aredoing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors 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: M c C t c Q n t J C• 1 C R I rl S C Q Policy#or Self-ins. Lic.#: Expiration Date:(,Q Job Site Address: I Ltd :7 cL 4l,E �b A) City/State/Zip: M Ct O $y 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 certify un er the pains and peg alties of perjury that the information provided above is true and correct Signature: Date: -7/2, 310 7 Phone#: C 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#• 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 g g en ggJ 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of PP Y insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 pen-nits 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 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.govldia