HomeMy WebLinkAboutBuilding Permit #578 - 148 MAIN STREET 3/6/2007 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: J Date Received r J� -�� � 4
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Date Issued: s�gClMls�
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IMPORTANT:Applicant must complete all items on this page
LOCATION �4A,A✓ S7- Usv rT J -/0/ 4 2;W *1vD o ye7,L MA- of v4S
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PROPERTY OWNER AJ4A t 77P
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MAP NO.: PARCEL: ZONING DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑New Building ❑One family
❑ Addition XTwo or more'family 0 Industrial
Alteration No. of units:
❑ Repair, replacement ❑Assessory Bldg ❑Commercial
❑ Demolition
❑ Moving relocation 0 Other ❑ Others:
❑ Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
mAS-Tw- 9A--r4 TWO StXnvVP -14Z iL0- i 4,hMG WA � Pe,w s rbt l.Sr�vlt� VA, V/n1tC,
!�[.11n` r`falC „SDot( vT,Lt< c,�/f fi ✓l9a�i 1-Y/Gp—7V
Identification Please Type or Print Clearly)
OWNER: Name: AIA'nIGY J-.P-,A-rp Phone:/q76-&J51-.t*'?7
Address: 14;,3 Ad a,a1 Sr lj v tT 0 e fa I 4,1,x-79 4N`PO✓M &,bA 0/ &�S
M 2— Me r,-,, e T..d,C,1 t-LC-
CONTRACTOR Name: y,G&rotFru cK -DovcErTy-' Phone: 17gj -37t--1004-
Address: <47Z 5 CM AJCs A ✓Mu4t 1 0 y 3 Z `~
Supervisor's Construction License: 65 0 0 50S'S Exp. Date: 6 -2-(6- 2407
Home Improvement License: 15-15F;o Exp. Date:
ARCHITECT/ENGINEER Name: Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PEgUIT,•x12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER SF.
Total Project Cost :$ y,6200 FEES C6
Check No.: Receipt No.:
Page I of 4
TYPE OF SEWERAGE DISPOSAL
Public Sewer 1z
Swimming ❑
Tanning/Massage/Body Art E] g
Pools
Well ElTobacco Sales F1Food Packaging/Sales 11
❑ Permanent Dumpster on Site El '
Private(septic tank,etc. Electric Meter location to
project
NOTE: Persons contractin ith un eg' ed co tractors do not have access to the gu my fun
If A
Signature of Agent/Own Signature of contrac
Plans Submitted ❑ Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
i
COMMENTS
i
i
DATE REJECTED DATE APPROVED
CONSERVATION ❑ ❑
COMMENTS
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
FIRE DEPARTMENT -Temp Dumpster on site yes no
Fire Department signature/date
COMMENTS
Zoning Board of Appeals:Variance,Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water& Sewer ConnectioNSignature&Date Driveway Permit
i
4
Building Setback ft.)
Front Yazd Side Yard Rear Yard
Required Provided Required Provides Required Provided
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
NOTES and DATA— For department use
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORMOS
Created JMC.Jan.2006
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
a Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Addition Or Decks
❑ Building Permit Application
a Surveyed Plot Plan
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
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
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
Dec:INSPECTIONAL SERVICES DEPARTMENT:81'FORM05
I
Page 4 of 4
,I.)ev.7'D
Location
X/--
No. 7� Date
NCRTh TOWN OF NORTH ANDOVER
Ot� .ao 4,
Certificate of Occupancy $ _
�ssncwusEt Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ {
TOTAL $
Check #
2D (; ,. )
Building Inspector
_�___ -� _ ✓ TIONS
-DING REGER ISOR
gOARO STRUCTION SUP
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License: CON 085055
Numb CS I.
0612611969 85055
no:
Expi '0612OW7 t
Restricted 00p
DpUCETTE
r RICK A.
FREDEAdministrator
NA RHILL, MA 0832
Board of Building Regulations and Standards !
HOME IMPROVEMENT CONTRACTOR
}
Registration:'.151580
Expiraeffioa: 6/12/2008 !
log TV* Ltd Liability Corporation
M2 MEASURE TWICE,LLC;
FREDERICK DOUCETTE
5 PETERS.LANE
HAVERHILL,MA 01832 Deputy Administrator
I
i
�I Electrician to add wall sconce Electrician to add wall sconce
Nancy DeVito
Sink/Vanity 148 Main Street Unit 0-101
Plumber to remove (Sutton Pond Condo's)
sink, install new.
Contractor install North Andover, MA 01845
New Vanity (60")
Pocket Door
Bath Vent
7,_311
Water Closet
2 Plumber to remove
Proposed wall for shower surround install new
IE
a
W o L W
t c
c'c ; Tub
3 3 To stay in place
,L°F cv Contractor to remove wall the/sheetrock Plumber to relocate spout/mix valve(Proposed)
c --a `- replace w/ Durock and re-tile
C 4-
V
N d t H `
Existing spout/mix valve f
Scale: V = V-0"
311
_ %-
v8 0 1
NORTH
own Of
LA E over, Mass.,
O COCHICNEWICK y
7� 0
RA T E O P'P5
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
THIS CERTIFIES THATFoundation
...W/4W .. ..............4".r.....4.).......... ..�. ..�...w BUILDING INSPECTOR
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has permission to erect................... .................... buildings on ... ......�........�j�....�i..�i............................... Rough
Ch' e
tobe occupied as—...��. . .. ........... ��.�.......................................................� ................... u'nn y
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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRU T
Rough
Service
BUILDING INSPER
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.
CONTRACT
This CONTRACT satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL C.142A),but does
not preclude parties from adding language to protect their specific interests.Seek legal advice if necessary.Before agreeing to
any home improvement work on your residence you should obtain a free copy"A Consumer Guide to Home Improvement
Contractor Law"by calling the Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787.
Homeowner Information Contractor Information
Name Company Name
Nancy DeVito M2-Measure Twice.LLC
Street Address(Not Post Office Box) Contractor/Owner Name
148 Main Street Unit 0-101 Frederic A Doucette H
City/Town State Zip Code Business Street Address
North Andover AM 01845 5 Peters Lane
Daytime Phone Evening Phone City/Town State Zip Code
617-241-1305 978-681-0697 MA 0
Mailing Address(If Different From Above) Business Phone Federal Employer ID
Salesperson(s): Frederick A Doucette H Contractor Registration#: 151580 Exp.Date:6/12/2008
WORD TO BE PERFORMED AND MATERIALS TO BE USED
Contractor Agrees To Do The Following Work For Homeowner: Master bath
Demo shower surround walls and install Permabase cement board%2",tile surround walls. Demo old vanity/counter,install new,demo existing vinyl
Floor,Install new tile floor.Demo 21"02"x20"high box at tub,Frame wall fur shower surround,install utility cab at framed wall. Paint walls/trim/
ceiling.Install medicine cab, Electrician to install 2 new wall sconces at sink,install new bath vent fixture.Plumber to remove toilet,sink and
install new ones,relocate tub spout/mix valve.
Materials Expected To Be Used:
See Attachment`B"
The following schedule will be adhered to unless circumstances beyond the contractor's control arise:
Work Scheduled To Begin:03/19/2007 Expected Date Of Completion:03/30/2007
(Date Contractor will begin contractee)work) (Date when contracted work will be substantially completed)
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
The Contractor agrees to perform the work,furnish the material and labor specified above for the SUM of.:$3230.65(*Includeaufinance
charges in this amount*)
Payments will be made according to the following SCHEDULE:
$670.65 upon signing contract(*Not to exceed IB of the total contract price OR the cost of special order items,whichever is
greater*).
$500.00 by 03/23/2007 or upon completion of
$500.00 by 03/30/2007 or upon completion of
$1560.00 upon completion of the contract(*Law forbids demanding futipayment until contract is completed to both parties'satisfaction*)In
order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins
(*Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of
the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet
the completion schedule*):$to be paid for
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Identical copies of the contract should&o to the ho a contractor.
Hom ees Signature/7 Co5WOs Signature
D to ate
You may ncel this agre meat if it has been signed by a party thereto at a place of er than an address of the seller,which
may be his main office or branch thereof,provided you notify the seller in writing at his main office or branch by ordinary
mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of the
agreement.
See attached notice of cancellation for an explanation of this right.
REQUIRED PERMITS
The following building permits are required.It is the obligation of the contractor to secure such permits as the homeowner's agent:
List any and all necessary construction-related permits.Building Permit Town of North Andover MA
NOTE:Owners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund
provisions of MGL c. 142A
WARRANTY INFORMATION
The Contractor guarantees that the work will be undertaken and carried out in accordance with accepted home improvement
practices in the Commonwealth of Massachusetts. This warranty DOES NOT cover materials provided by the homeowner
and DOES NOT cover damage or defects;which are the results of characteristics common to the materials used,or conditions
resulting from condensation,expansion,or contraction of such materials or any other condition not within the control of the
contractor,including but not limited to,unforeseeable circumstances,normal wear&tear or neglect.
NOTE:All home improvement contractors and subcontractors shall be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Director,Home Improvement Contractor Registration
One Ashburton Place,Room 1301
Boston,MA 02108
617-727-8598
Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been
placed on the residence.
ARBITRATION
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 such dispute to a private arbitration service which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to
submit to such arbitration as provided in M.G.L.c.142A.
Contractor: Homeowner:
Date: Date:
NOTICE:THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO
ALTERNATIVE DISPUTE SETTLEMENT INITIATED BY THE CONTRACTOR THE OWNER MAY INITIATE
ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES.
ACCELERATION OF PAYMENT
Homeowner's Financial Insecurity-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.
Contractor's Financial Insecurity-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 from said account would require the signatures of both parties.
THE CONTRACT MUST ALSO CONTAIN:
1)A Complete Description of any other documents which are part of the agreement;
2)A List and Description of other matters upon which the contractor and homeowner lawfully agree;
3)Any Other Provisions otherwise required by applicable laws of the Commonwealth-
Remember,
ommonwealthRemember,the Contract must be the Complete Agreement between the contractor and the homeowner.
If you have general questions or need additional information about
The Home Improvement Contractor Law,contact:
Consumer Information Hotline
Commonwealth of Massachusetts
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170
Boston,MA 02116
617-973-8787
If you have questions about Contractor Registration,contact:
Director of Home Improvement Contractor Registration
Board of Building Regulations and Standards
One Ashburton Place,Room 1301
Boston,MA 02108
617-727-3200,x25205
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 T AT Y
O THE SELLER OUR 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
,AT
NOT LATER THAN MIDNIGHT OF (date).
I HEREBY CANCEL THIS TRANSACTION.
Date: Buyer's Signature:
Attachment `B"
Materials Expected To Be Used:
Permabase,151b Felt Paper,cement screws,screws/nails,2x4/2x3/lx2/1x4,Paint supplies/primer,Versabond thinset,mesh
tape(Cement/regular),Durabond setting type joint compound,lightweight compound,insidetoutside corner bead, 1/8"
tempered board,
Homeowner to provide the following;
• Wall tile for shower surround,grout,color match caulk
• Floor tile,grout,color match caulk
• Wall and Trim paint
• Toilet
• Vanity(Utility and 60"wide for sink)
• Faucet j
• Sink and Countertop
• Light fixtures and bath vent fixture
• Misc fixtures,mirror,medicine cab,towel bar,paper bar etc....
r
i
Electrician to add wall sconce Electrician to add wall sconce
Nancy Devito
Sink/Vanity 148 Main Street Unit 0-101
Plumber to remove (Sutton Pond Condo's)
sink, install new.
Contractor install North Andover, MA 01845
New Vanity(60")
i
I
Pocket Door
Bath Vent
7 -32° "
Enew
Proposed wall for shower surround
rL
y
D
4-
0 b
C L d
+ 4- c
3 Tub
3 To stay in place
a
v X C Plumber to relocate spout/mix valve(Proposed)
CM N UContractor to remove wall the/sheetrock
X `o replace w/ Durock and re-tile
o o c 0 }
t
v
N
N L H
Existing spout/mix valve
Scale: 1" = 1'-0"
-8a 0 1
8
SUTTON POND
February 23, 2007
To Whom It May Concern:
As the managing agent for Sutton Pond Condominium, please allow Rick
Doucette to pull a permit for a bathroom renovation at 148 Main Street 0 10 1.
Rick has assured me that this work is only cosmetic and does not involve
structural elements.
If you have any questions regarding this, please feel free to call me in the Sutton
Pond management office at 978 - 681 - 4567.
Sincerely,
Ch�D�ke an
Property Manager - Sutton Pond Condominium
CC: Unit file
Condominium
Homes
148 Main Street
North Andover
MA 01845
(978) 681-4567
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
6 P-,�,il
kv
00 Washington Street
Boston,MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):_M 2- 446ASUX4F
Address: S" peTe<_5 E'
City/State/Zip: Y,4y&xs*c MSF 6 i 9 3 Z Phone.#: 17 S 372- /Oo 4-
Are you an employer?Check the appropriate box: Type of project(required):.
1.❑ I am a employer with 4. [] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction
2 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have
8. C]Demolition
working for me in any capacity. employees and have workers'
insurance. 9• E]Building addition
[No workers'comp.insurance comp.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
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 may be forwarded to the Office of
Investijzations of the D e coverage verification.
I do hereby c u der tpains an ties of perjury that the information provided above is true and correct
Signafore:
Phone#: X17 8 37 2 /Oo4-
Official use only. Do not write in this area,to be completed by city or town of•f�ciaL
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
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-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under`Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum 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 11-22-06
www.mass.gov/din