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HomeMy WebLinkAboutBuilding Permit #728-13 - 1511 GREAT POND ROAD 5/3/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit NO: �� Date Received ( / Date Issued,-- IMPORTANT: ssued: MPORTANT:Applicant must complete all items on this page LOCATION (5 d I (30ecS�_ Dnd l PROPERTY OWNER N Print 100 Year Old Structure yesOno MAP NO:WLI PARCELO)ZO ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building L?One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District m Water/Sewer ,I SCIIPT19N OF Wq K TO BE R ORMED: AA Identification Please Ty a or P int Clearl OWNER: Name: one: Phone Address: I`j( ( � �c`Z� %4j CONTRACTOR Name: ` b 1'l Phonei7� 5257 000 Address: 2� t V �C� �� A5 l � Supervisor's Construction License: c -`1 J Exp. Date: Q { ' Home Improvement License: jo5�� Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ r.)A , bid GU FEE: $_� Check No.: 7?D<�Sb Receipt No.: 3J� NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund Signature of Agent/Owner Signature of contract r Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans El Building Department The foliowing 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 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 subm;tted with the building application Doc: Doc.Building Permit Revised 2012 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 a ® Notified for pickup - Date Doc.Building Permit Revised 2010 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 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 DPW Towp. Fngineer: Signature: Located 384 Osgood Street FIRE-DEPARTMENT - Temp Dumpster on site yes no Located at'124 Mair Street Fire Departinent signature/date y.. COMMENTS -ocation l b t' P a7r f ',J M. No. 12 �� Date r • - TOWN OF NORTH ANDOVER • r Certificate of Occupancy $ Building/Frame Permit Fee $ 3y Foundation Permit Fee $ Tf* Other Permit Fee $ ° TOTAL $ Check# 3��Y 26350 �B �--- uiiding inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 31 ,000.00 m $ - $ 372.00 Plumbing Fee $ 46.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 46.50 Total fees collected $ 565.00 1511 Great Pond Road 728-13 on 5/3/2013 Finish off a 16x21 section of basement NORTH Town of E 1, ndover o h ver, Mass o� > > 3 COCHICMIWICK`�� J� 0,4ATED S U BOARD OF HEALTH Food/Kitchen . PERMIT T L D Septic System /� THIS CERTIFIES THAT .,&��4...Y.GSG.r. �t...................../........................................................... BUILDING INSPECTOR + ���� 't✓r��f�i�� ` Foundation has permission to erect .......................... buildings on ................................................1............................ ............... Rough to be occupied as �'"Iii C'�� �'. 4SF ;ti,�n.�. Chimney provided that the person accepting this permit shall in every respect conform to the terms of he application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service .............. ..... .u:f.::v :`.' :::`........................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Page_1 of I— RODDEN CONSTRUCTION License#28538 47 Prescott St. Expires:09/05/2013 N.Andover, Ma.01845 -- -- 978 687 2934 PROPOSAL TODAY'S DATE JOB NAME 3/13/13 Alison Marton and Baddu Vasanth DATE OF PLANS/PAGE#'S JOB LOCATION 1511 Great Pond Rd. , North Andover, Ma. 01845 We propose hereby to furnish material and labor necessary for the completion of: Supply materials and labor to finish off a 16'x 21'section of the existing basement.The floor area will be 2x4 p.t.sleepers with 3/4" plywood and prefinished engineered flooring supplied by owner.Walls will be 2x4 framework with r-15 fiberglass insulation and 1/2"blueboard with plaster skim coat.The ceiling will be suspended type with 2x2 recessed tiles,supplied by owner,and r-19 fiberglass insulation. Electrical will include all rough and finish according to code,and lighting,to be chosen by owners. Run wiring and make connections for an electric fireplace,supplied by owner. Heating to be electric with soft heat units supplied by owner. Plumbing will include supplying and hooking up a sump pump unit. If possible ,the foundation height will be raised where entering the new room. Painting will include one coat primer and two coats finish on all walls and woodwork. Work will be done for a fixed fee of 2,000.00 plus time and materials.All materials and all subcontractors will be billed at cost with no markup. Carpentry rates are 49.00 per hour.Any additional labor will be billed accordingly.All building permits and job debris cleanup are included in this agreement. i We propose hereby to furnish material and labor-complete in accordance with above specifications for the sum of: I Estimated thirty one thousand dollars ( $31,000.00 ) Payment as follows: 2,000.00 fee payment at job startall other invoices payable upon receipt All material is guaranteed to be as specified. All work to be completed in a substantial workmanlike manner according to specifications submitted,per 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,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance.If either party commences legal action to enforce its rights pursuant to this agreement,the prevailing party in said legal action shall be entitled to recover its reasonable attorney's fees and costs of litigation relating to said legal action,as determined byOT7:� n. Authorized Note: this propo I may be withdrawn by us Signature if not accepted wi i days. ACCEPTANCE OF PROPOSAL The above prices, Signature specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature_ Payment will be made as outlined above. Date of Acceptance 3 9VCANJHECO'4TRACTORSGROGP CO' - - - - •- - - [:' - . L j Massae nsetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contactor Law(MGL chapter 142A),but does not include standard language to protect homeowners(Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A Massachusetts Consumer Guide toy Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and BLiness Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.. Homeowner N rmation Contractor Information Marge k,c r� �`pi� � � �` CoKl� (AJ �`'� 3' N n -Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner e Ill �V�� b 1C,3 a I City/Town State I Zip Code / Business Address(mt;sLinclude a street address) Daytime one_ Evening Phone City/Town State Zip Cod 60 2T5 11b 61 Mailing Address(It different from above) Business Phone _P_eTeral Employer ID or S.S.Number • Home Improvement Contractor Reg Number Epppimtion date imprequires tont most bomo l 1a t�q e, improvemcntcontractorat", /U ,/ V n valid registration number The Contractor agrees to do the following 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 necessary.) Required Permits-The followinglbuilding 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 odyn permits will be excluded from the Guaranty Fund provisions of Date when contractor will begin contracted work j MGL chapter 142A.) Date when contracted work will be substantially completed. . i Total Contract Price and Paymelit!Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: O Payments will be made according tothe following schedule: upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ by / / or upon completion of $ by / / i ; or upon completion of $ upon completion o. pars satthe contract. (Law forbids demanding full payment until contract is completed to both party's , The following material/equipment must be special $ to be paid for ordered before the contracted vSork begins in order to meet the completion schedule('k*) $ to be paid for i NOTES:M Including all finance charges(**)Law requires that any deposit or dawn-payment required by the contractor before work begins may not exceed the greater of I(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. Express Warranty-Is an express warranty being provided by the contractor? ❑No❑Yes(111 terms of the wirranty must )be attached to the contract Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this arzrreement 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 and notices carefully before signing this contract.1 I � on't pressured into si ° Dbe P going the contract.Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has alvalid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registerediwith the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage,or ask to see a copy of a`roof of insurance"document. • Know 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 Improvemeni 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. See the attached notice of cancellation form for an explanation of this right. DO NOT SIq' T THIS CONTRACT IF THERE ARE A�� r►► Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. oo Lop SPACES ept by the contractor. Homeowner's ignature j Contr ctor signature Date . Date AcoR" CERTIFICATE OF LIABILITY INSURANCE FDATE (/2 13 05/02/2013 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 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). PRODUCERCONT CT OB NAME: _ _ NORTH ANDOVER INSURANCE AGENCY, INC. jpC"11, Eli: (978) 686-2266 (ac, No):(978) 686-6410 M.J. FOSTER INSURANCE SERVICES ADDRESS; cfernandez@nafins.com PRODUCER 163 MAIN STREET CUSTOMER ID gRODDEN CARPENTRY NORTH_ ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A IAERCHA 4TS INSURANCE GROUP 23329 RODDEN CARPENTRY INSURER B :TECHNOLOGY INSURANCE CO 47 PRESCOTT ST INSURER C INSURER D INSURER E NORTH ANDOVER MA 01845- INSURER F 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. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (POLICY (MMIDDIYYYYi LIMITS A GENERAL LIABILITY Y BOPI054995 2/01/2013 2/01/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / DAMAGE T PREMISES Ea occurrence) $ 500,000 CLAIMS-MADE LJ OCCUR / / / / MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY_ $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PROT- LOC / / / / Is A AUTOMOBILE LIABILITY 111CA7015515 7/16/2012 7/16/2013 COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident)__--___--- -__--- ---- BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS / / / / PROPERTY DAMAGE $ X HIRED AUTOS / / / / (Per accident) X NON-OWNED AUTOS / / / / $ UMBRELLA LIAB OCCUR / / / / EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE / / / / AGGREGATE $ DEDUCTIBLE / / / / $ ElRETENTION $ / / / / $ _� WORKERS COMPENSATION 3341295 1/01/2013 1/01/2014 WC STATU- OTH- AND EMPLOYERS' LIABILITY Y/N X T RY LIMITS _ .ER_ _____ ANY PROPRIETORIPARTNERIEXECUTIVE / / / / E.L.EACH ACCIDENT $ 100100 0 OFFICERIMEMBER EXCLUDED? ❑ N/A ----- (Mandatory in NH) / / / / E.L.DISEASE-EA EMPLOYE $ 100,_Q_00 If yes,describe under DESCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 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 120 MAIN STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER MA 01845- ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/Zia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information p Please Print Legibly Name(Business/Organization/Individual): Address: ' ss,� City/State/Zip-� Phone -7 6� iF,am u an employer?Check the appropriate box: Type of project(required): a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors �,,� ❑ I am a sole proprietor or partner- listed on the attached sheet.1 7. EJ remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions ❑ 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' 1311 Other comp.insurance required.] iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. omeowners Nvho submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. rn hn employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site brmation. urance Company Name: .icy#or Self-ins.Lid.#: �( (LSe '�-t) i-k-1 a'�S Expiration Date: f 1 Site Address: 1( � c� - City/State/Zip:L�• ��1 1 d�a j S :ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tp to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. r hereby certi under t:e enaldes ofperjury that the information provided above is true and correct. nature: Date: ine#: )fficial use only. Do not write in this area,to be completed by city or town official. �ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �.Other 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-contractors)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 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. ,he Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Off-ice of Investigations 600 Washington Street Boston,MA 02111 Tel. 0 617-7274900 ext 406 or 1.877-MASSAFE i CD Xll 01 4 t V./Al L W 1"r H n OPEN St4eLVES FLACOPEN _S4ELVC.S � Tj�c� I�N , t C3 �P - -- j A � v