The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #249-2017 - 16 WOODBERRY LANE 9/8/2016 oRTfj BUILDING PERMIT ` SLED LED TOWN OF NORTH ANDOVER 10 32 5 ,.`• APPLICATION FOR PLAN EXAMINATION h Permit No#: -( / Date Received �QADRATED�PP`'(� Z �SSgCHUS Date Issued: 0 IMPORTANT: Applicant must complete all items on this page LOCATION V 0 PROPERTY OWNERG�C P ` �/ 4::E& J Print 100 Year Structure yes no MAP 46 PARCEL: / 3 ZONING DISTRICT:_ Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residenti Non- Residential ❑ New Building - ne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑,,Septic ❑1Ne.11 J} ❑ FlootlplamWetl`ands ❑ Waterst%edDistncf, T ❑,1Nate /Sewer D CRIPTION OF WORK TO BEP RFOR D: Identification- Please Type or Prigt Clearly OWNER: Name: 1!t5/ q?✓j g!!�e44z Phone: gV�- C�;`J` t5 Address: /4� ® ,� �-I � D mmrse zNf Contractor Name: �eT Gg� is Phone: `' Email: Address: a5,29::- LV 1"1234p,, M Supervisor's Construction License: �� Exp. Date: Home Improvement License: A Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING P fRMIT.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSTBASEDON$125.00 PER S.F. Total Project Cost: $ 'a� FEE: $ ` b � Check No.: 4D 4-,6 Receipt No.: 366B NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �io , 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 Duimpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS 4z CQNSERVA.TION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS q 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 Town Engineer: Signature: Located 8 food Street FIRE�DEPARdTMENT�xT;�emp Dumpster on"site :,yes�., .:� ' '' ` V �n Located a_t 124�Main�Street :' . ..€3_ - �� .s.�''t nl •tt"t4 '�a'S':"+ Re �rla' ,4 � t��'�.h`1.�"� y `•`: i. Fire Departmdn#4sig atu*r a �. nature/daler ;s.• ,r. t' :"wt �. '1�. 3 �a =t,� � •,. �. b ;�� t«i�� .gt� '�� l' �y,. Try's �`�.��' �� ro "s � �ti�'�. '�at�+.�� ;t it��R`"•` e,�F"j stFFs "".:....�T^*rp'r';�;""",�'ti�.�.wa"�`""rk . `-�,rt Rys.�i#3x�jt��r }�, tpt'` T's , t'» k:!" �.,' .t �•,r a:��?r��°Xc. "'�'�Sp .�x5`f4w`r .t{1 ?rs. �t ' �� 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 4. 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 g g OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks I 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/Cross Section/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 . 9 g OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4- 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: 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:Building Permit Revised 2014 Location /r No. Cil �'� Dated' • TOWN OF NORTH ANDOVER �d� ,:: ,fid� • Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check IM ! � f Building Inspector NORTly Town of t .. s ndover No. * _ ver, Mass i o�h coc«1c«[w1cw y1' A�R�TEO PIN, S U BOARD OF HEALTH Food/Kitchen PERMIT 'T LD Septic System � � .� THIS CERTIFIES THAT ,,,,,,,,,,,,,,,,, ,,,,,,,,,,,,,,, BUILDING INSPECTOR .. . .... ..... AlowhaFoundation has permission to erect .......................... buildings on ..,i ...... 44 Lei. Rough to be occupied as ........� ....... ... d ............................................................... Chimney . ..... .. ........ provided that the person accepting this permit shall in every respect conform to the terms of the 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 CONST TION Rough Service .... ....... . . ........ ................ ... ..... Final BUILDING IN EC OR 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. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE A.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 26158 POLICY NO. AWC-400-7014648-2015A PRIOR NO. I AWC-400-7014648-2014AI ITEM 1. The Insured: Arthur Walsh DBA: A J Walsh&Sons Mailing address: 159A Waverly Road FEIN:**-***6792 North Andover, MA 01845 Legal Entity Type: Sole Proprietor Other workplaces not shown above: See Location 2. The policy period is from 11/14/2015 to 11/14/2016 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code I Estimated Per$100 Estimated i No. Total Annual Of Annual 1 Remuneration Remuneration Premium INTRA 40579 1 i INTER SEE CLASS CODE SCHEDU E 1 Total Estimated Annual Premium &' GOV GOV Deposit Premium STATEiCLASS, MA ! 5403 j State Assessments/Surcharges ' $.00 x 5.7500% $ This policy, including all endorsements, is hereby countersigned by 11/05/2015 Authorized Signature Date Service Office: Durso&Jankowski Insurance Agency LLC 54 Third Avenue 11 Saunders Street Burlington MA 01803 North Andover,MA 01845 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with Its permission. Page# of pages CS # 022680 j. 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 159A WaverlyRoad 1-978-912-2853 North Andover, MA 01845 Pr sat Submitted To: Job Name Job# Address "" _ Job Location Date � � � Date of Plans Phone# V Fax# Anitect We hereby submit specifications and edimates for. ff�� 7. 1 ' V r_ 1,4,1 � We propose h eby to furnish material and labor—c mplete in acro dance with the above specificationsor the sum of: $ ay 1 � U Lywy 4 � Dollars with payments to be made as follows: l—�t r U Any alteration or deviation from above specifications involving extra costs wUl be Respectfully executed only'upon written order,and win become an extra urge over and above the estimate.AN agreements contingent upon states,accidents,or delays submitted ' beyond our cohtrol. Note—this proposal may be withdrawn by us if not accepted within days. The above prices,specifications and conditions are satisfactory and are �."S gnature hereby accepted.You are authorized to do the work as specified. Payments will be made as outlined above. U Date of Acceptance_ Signature MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form:satisfies all basic r"ufrements of the state's Home improvemeo Contractor Law(1!? �,Gbutdoes not include standard . chapter 142A language to protectbomeownem Seek legal advice if necessary."Any person•planning home.,L rho quPmvements should first obtain a copy of"a Massachusettsteonsumer guide to homeimprevement"before agreeing to any work on yourresidence;You may-obtain-a free co Office of Consumer.Affairs and Business Rt Y copy by colli°g the Regulation!.j Consumer Information Hotline at6t7-973'�8787'or 1.:6'8W.83-375.7.- Homeowner Information -Contractor Information r . ams .. � Pavy ams'' �Cl, lS So .. Street Address(do not use.aPoatOffice Box address): tractor/ al G"C;e Name fSty/fown state Z' Coda usiness Address(must include a strut AID �,aoUelZ �eG) Daytime Phone - Evening Phone. it tp Code Mailing Address(It different from above) us'ness Pboue lderal Employer ID or S.S.Number ' las require autmon 6emeim• Acme 1Cr•artleraep5lhmHc .#�atiaad�b' ,- pmvm�eot oontrmon Wws �y . msiseatiw number I I ,33- The Contractor agrees to do the following,wcal me wQrX Id adinpunce, ork for the Homeo nei Required'Permits-The-following building pemrits are required Proposed Start andCompletion Sehedale-The following schedule will and will besecured:by the contractof as the'horneowner's agent; be adhered to unless circumstances beyond:the contractor's control arise (Owners who secure their own permits will be excluded from:the:Gnaranty Fnad'provisions of 6Dt.wired contractor will begin contracted work MGL chapter 142A-) �= �Date when contracuid .work :.besubstantially:c0mpleted.. Total Contract Price and Payment Schedule The Coatraetot.agrees to perform the work,furnish the material and labor specified above for the total sumof Payments will be made according to the following schedule: Ss l/s�upon.signing contract(not•to exceed 1/3 of the total contract price.gr the costmf special order items,whichever is.gteater) $ by 7:=./ or upon completion of — - $ by_T or upon completion of - $ 4V. C�yytt,,bd . (� upon completion of the contract (taw forbids demanding full payment until.contract is completed to both party!s satisfaction_) The following matcrial/equipment must be special S to be paid for ordered before the contracted work'begins in order to be paid for to meet the..completion schedule.('*) / NOTES:(•)lnclu*all finance Charges(••)Law requires that any depositor down-payment required by thecontractor before work begins may not exceed the greater of(a)onetbird of the total contract price or(b)the actual cost of any special equipment m mistom made material which must be special ordered in advance to mat the completion schedule Express Warranty Isere exert ase warranty barna provided try the contractull No Yes (09 terms of the wit o mast be attached to the eontnNl Subcontractors-The contractor agrees to be solely responsible for completion of the work descnbed regardless of the actions'ofany third Party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to an attaronnactors for MA=Wsandlabor under thi aereernot Contract Acceptance-Upon signing,this document becomes a bindingcontract under-low. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract Take time to read and fully understand it Ask'questioris ifsonfethins is unclear. • Make sure the contractor has a valid Home Improvem cat Contractor Re2istratio The few requires most home improvement contractors and. subcontractors to be registered with.the Director ofHome Improvement Contractor Registration You may inquire ebout.connactor registration by writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 orby.calling 617-727-3200.or 1400.223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured • Know your rights and responsibilities. Read the Important Information on the reverse side of"form and get a copy of the Consumer Guide to the Home Improvement contractor Law. You may cancel this agreement if it has been signed at a place other.than the contractor's'normal place of business,provided you notify the contractor in writing ochre/her main office or branch office by ordinary mail posted,by telegram sent or delivery, Witt business day following signing of(iris a by erY.not later than midnight of the. g agreement..See the attached notice of cancellation form for an explanation of.this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical Copia of the eennaet must be completed and si1,ed.Ooe eapyahould so to the he adw ,,,ryryry ` Copy should be kept by the contractor. �yaOIDCOWnCr'a SI la1L '�, .: Contractor's Signa Date ,Date Contractor Arbitration The Home Improvement Contractor Law rovideshomeowners with.the nght-to-initiate•an arbitration action(as an alteniative to court action)if they have a dispute with.e contractor. Tlie same rightis no4 automatically afforded to a . contractor,however-The:contractor would have;tp resolve any,dispute lidshe.ltas.with a homeowner in court unless ..•. both parties agree to the optional clause provided below..This clause would give the.contractor the.same.right to , arbitration as is afforded to the homeowner.by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute conceming this contract,the contractor may submit the dispute to a.private arbitration firm which has:.been.approved by s the Secietary of the Executive Office of Consumer Affairs and Business Regulation andthe consumer shall be required it to such a�tration as provided In-Massachusetts General Laws,chapt 142A. ' L % 7�e t ,ii 2 � omeowner+s Signitture / Contractor's Signature f OTICE:`The signatures of the parties above apply only to the agreement of the parties to alternative dispute'resolution initiated by the contractor The homeowner inay initiate altemative::dispute resolution even where this section is not g s stately signedbythe pattiesr::. ` Homeowner's Rights A homeowner's tights unde•tho.Honie'Improvement Contractor Law(MGL chapter'142A)and other consumer protection laws(Lt.MGL chapter 93A)may not be waived in any way,even by agreement: However,homeowner$ may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. •The contractor is responsible for completing the work as described,in a timely and,workmanlike:manner. Homeowners.may be entitled to.other specific legal.rights if the;contractor guarantees or provides.an.express warranty for:workmanship of materials. In addition to.guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability:andtitness_fora particular purpose. An enumeration of other matters on which.the homeowner and contractor lawfully agree may odded to the. terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights;contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all'exhibits and referenced documents have been attached Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by.the contractor. Any modification.to the Iriginal'c6n6et must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day recission period has expired Accelerated Payments A contractor may not demand payments inadvance.of the dates specified on the payment schedule in cases where the homeowner deems bim/herself to be financially insecure. However,in instances where,a.contractor deems him/herself to be financially insecure,the contractor may require thatthe,balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general.questions or.need additional information about the Home Improvement-Contractor Law or other consumer rights;or if.you wish tb..o ndin a.free copy of"A Consumer.Guide to the Home Improvement Contractor Law,"contact . Cgnsuaier Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)283.3757 If you want to verify the registration of a contractor or if you have questions or need:additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 s (617)727-3200 or1-800-223-0933 For assistance with informal zfrediatron'o'fdisputes or to register formal complaints against abuss,call: C66iri iet'Coimplaint'Sebtion Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 The Commonwealth of Massqchusefts M Department oflndustrialAccldents . 1 Congress Street,Suite 100 V. Boston,MA.02114-2017 • �^•. . -SY.Y�t www mass.govIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE F1LED WITH THE PERMITTTING AUTHORITY. Applicant Information • Please Print Legibly Name(Business/Organizationlfndividual): � � S,�=SGs Address: City/State/Zip: --dP -Phone#: 7�'� Areyouan employer?Checktiie appropriate box: Type of project(requirod): 1.e'f am/a employerwith_employees(full and/or part-time).* 'J.- Q N(-w construction 2.E]I am a sole proprietor or partnership and have no employees working for mein 8. []Remo debug any capacity.[No workers'comp.insurance required.] 9, Demolition 3-Q I am a homeowner doing all work myself[No workers'comp..iusuranee required.]f 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.1 ]Electrical repairs or additions proprietors withno employees. ` 12:[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. R�airs These sub-contractors have employees and have workers'comp.msurance.t ' 14.[]Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4).and we have no.,einployees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fdl 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 lContractors that check this box must•attacJied an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contracfors have employees,ley'must provide their workers'comp.policy number. X am an employer that is pioviding workers'compensation insurance for my employees.'Beloiv is the policy acid job site information. /►h /"/c�J ,1/TLS / � (� Insurance Company Name: ' �/J Policy#orSelf-ins.Lir.#: 7 `7Expiration Date: Job Site Address:_7 ®� City/State/Zip: AO Attach a copy of the workers' compensation policy d claration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cer ' under thepains and enalfliesofpefjury Haat the information provided above i srue and correct. Si ature: wa,47!w� - Date: Phone#: 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 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 common'Tealth 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. lie advised that this affidavit maybe submitted to the Department of-Industrial Accidents foi-confirmation of insurance coverage. Also be sure to sign and date the a-Mdavit. The affidavit should be retained 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 ox 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Deparbnent of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext.7406 or 1-877-MA.SSAFE Fax#617•-727-7749 Revised 02-23-15 www.mass.gov/dia �— (�Fxl Ntassachusefts Department ofPublic Sufefx iOffice of Consumer Affairs&Business Regulation �0N Board of Building Regulations and Standards "O"='M'R" MENT CONTRACTOR License: C8-022880 � � ) '~-='~~~~~^' '''~' Construction Supervisor | � exp|rau Private Corporation � } &JVVALGM& ARTHUR JVVALm*JR . J. ""' 159AVVAVERLYRD ^ , � NANDOVER MAn184s' ' Arthur Walsh 55 Pleasant S8 | NAndover,MA 01845 mnuomocrxmry Expiration: . _ Commissioner 06109/2018 � ' � � � � ' � � . � ' ^