Loading...
HomeMy WebLinkAboutBuilding Permit #113-13 - 17 EMPIRE DRIVE 8/8/2012 40RTH BUILDING PERMIT °� TOWN OF NORTH ANDOVER F APPLICATION FOR PLAN EXAMINATION * ; 1 Date Received Permit NO: ACF1�1s�� Date Issued: IMPORTANT Applicant must complete all items on this page �� rr� �r a y�_� J-^ rz?'� �_�•Tr,F"° 4 s �4�,� .� � '"�- �.sr,�.y "a� I'.+��._ v A c �'�1 .,�:...�r far ', "Ile- . � v u L®CAT�101 k :e y r r"' `� r RPn t + rLr rys ;} t -ssi r Y 2 - PROPERtY�®WaNEF,,f r " .K-�c s,� �`t"e �qv •yam--" � 'YF. r �n� �.'k.n+nr 4`.ry �, ,�,: �r MAPN® �PARCELsJ ®N1NG'DlSTR7CT His#©ric DistY= tom' yesesno� ; t {�' ha �Vtllage yes noF r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ew Building � ne family ❑ Industrial El Addition ❑Two or more family ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg [I Others: ❑ Demolition ❑ Other fl 1N.atershedDiStrict, � §t] ep#Eck fl'Welt r t7 Floodplain ,6t an 4 , xs wa y d .> ,t yf6 lJd"d a h Ax �? - DESCRIPTION OF WORK TO BE PREFORMED: we LL lVG bGeoan�S A S ecU e D'i Identification ease Type or Print Clearly) o^ OWNER: Name: C 1—L G Phone. O Address -7EFI-31 Y6 1� ei Z-A ONTR�1GTrOR� r < .r� �".�+. s �' � 1 � ? � s 4^+ �a �.�,5. �- � �4.✓�I� �� a y r �� � v r-� l ;,Address d w�"�i'x �� s [V' t 'mea x h$ �i>• T ,xt-�^' ' ySupervisbr;s Construction a t+r. r � f t'.{ �,«4 �'y �� ^L 7•.. � t.,3'..w� 'i`a,�"^t ; r i^- ;r<"� '�}. �'v �.7 ��` ��s ;'*sr � ,r..y-^f^k.t��r. � (�`�� ry.� . „3 EHoie Irnprouement`Licrise �� 4= = :Exp WDate;:� 'y.. er r ARCHITECT/ENGINEERQPhone:L7'�-3 Address P� eg. No. -'0?,7 65 FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. � -_ c U� O�rL FEE: $ Total Project Cost: $Lk� Check No.: Receipt No.: S NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund m--. ^-s.—.n+.�s--^ Si nature of A ent/Owner '. f SI nature�of contractor tt_ Location I�--t �'J ©T No. 13"' Date 1 --� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $. Foundation Permit Fee $ Other Permit Fee TOTAL $ Checkl—_ ' "~ 25596 Building Inspector C L / 8 41 r,r Date..... .....1,!...... NORTH TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING �SsACHU This certifies that r .............. ............................. has permission to perform `"I S '° -Zz wiring in the building of....... .vS S . ..q.........../ j../....'.................. :.� '.sa .:.. ,North Andover,Mass. at ..................................................�7 /c6 s� it fC I ............... Fee...............�.`. Lic. ...................../�/t �........... . � ELECTRICAL INSPECTOR Check /1 �Z z y�� r Plans Submitted V Plans Waived ❑ Certified Plot Plan L1J Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer V 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 DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ T &a 7- 7A COMMENTS IV- DATE REJECTED DATE APPROVED HEALTH ❑ ❑ I COMMENTS a Zol g 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 Located at 384 Osgood Street FIRExDEPART,INENT r Temp{Dumpster`oh site yes` x fr � nog a', i Located at 124 Mam Stree�4 s � •' r % S'� -. �_"., `... � H �r� � }. ---� la ��a f� ,,r.,,�i 1r`�,-� ti f✓�_. L, ,.��-t �:� r r f.. Fire w epart - 9 9ture/da#e F J- ment COMMENTS ten; Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. I Total land area, sq. ft.: j 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) se I ❑ Notified for pickup - Date h_ 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, 9 Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit a Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products 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 o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 r1 NORTH W. . w: .: : : t . .. c . . ve' '* No. - I � ti � h ver, Mass, C OC NIC Nl WICK A04ATED S u BOARD OF HEALTH Food/Kitchen PERMI:� T T LD Septic System THIS CERTIFIES THAT 6,k, BUILDING INSPECTOR ........... .......... ..................................0. .......... . Foundation has permission to erect ......... .............. buildings on .. ....1 +..... ,.. � ...... ... • � Rough 4000 to be occupied as .......... ......�sj* ..sqT. Pv..... .... .... ...k.. ............................................ Chimney provided that the person accepting this.permit shall in every re pect 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 IMMONTOS ELECTRICAL INSPECTOR IDO - UNLESS CONSTRU Rough Final TTL=== Service ... ........... BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REUVGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMR 12.00 (PLEASE PRINTININKORTYPEALLINFORMATION) Date: City or Town of: NORTH ANDOVER To theIn pec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) v Z Owner or Tenant f e /_ Tele one No. Owner's Address Is this permit in conjunction with a building permit? Yes ED] No (Check Appropriate Box) Purpose of Building �-+ f �/� . Utility Authorization No. 7 S'y 9"r3 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service le�6' Amps �Zv /gyp Volts Overhead❑ Undgrd [�3�No.of Meters l Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)FansNo.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o mergency ig ting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number.•.Tons•.........KW No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Heaters KW Si ns Ballasts as Data Wiring: ts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: y-/2. Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insuran .ncluding"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covers ' in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties o perjury,that the information on this application is true and coYrtplete. FIRM NAME: �- C� s,. l� z h � - IC.NO.: Licensee: �'txempt" �' - / SignatureI a licab e, in the license number line.) LIC.NO.: �fPP � Address: Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departme of Public Safety,"S"License: Alt.Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ^ v� 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-contractor(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 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 Revised 5-26-05 Fax# 61.7-727-7749 www.mass.gov/dia "Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.— BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMR12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To theIn p ce or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Z ,S/ - ry rr G Owner or Tenant t f ,-17 e /_ Tele one No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ NoCheck A ( ppropriate Box) Purpose of Building tr,/` Utility Authorization No. 7 Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service fl�O' Amps !LG Volts Overhead❑ Undgrd [�J�No.of Meters f Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: - � � t/de •e Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o mergency ig tingrnd. rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. TotaTons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number .Tons...,._.. KW.......... No.of Self-Contained Totals: Detection/Alertin iF Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No.of Dryers Heating Appliances KW Security Systems:* No. of Water No.of Devices or E uivalent No.of No.of Heaters KW Si ns Ballasts Data Wiring: ` No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: kl-/2 -// Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee prbvides proof of liability insuran including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera ' in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penaltieso perjury,that the information on this application is true and complete. FIRM NAME: �. f z - IC.NO.: Licensee: �� a Signature LIC.NO.: (If apphcab e, a er "exempt"in the license number line.) Address: Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departme of Public Safety"S"License: Alt Lic.No. No.� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ j 5 jL i ELECTRICAL PERMIT NO. e ELECTRICAL INSPECTOR-DOUG.SCMALL TIoNRFPORT: I.ROUGH INSPECTION: Passed—[ ] Failed—[ ] Re-inspection require(y($50.00)-[ ] Inspectors'comments: (Inspectors"Signature-no initials) Date 2.FINAL INSPECTION; Passed—[ ] Failed—[ .] Re-inspection required($50.00)-[ ] Inspectors'comments: (InspectorsSignature-no initials) Date 3.UNDERGROUND INSPECTION: " I Passed—[ ] Failed—[ j Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 4.IN —SERVICE: - DATE CALLED NATIONAL GRID: NAME: Passed—M Failed—[ j Re-inspection required($50.00)-[ I Inspectors'comments: (Inspectors'Signature-no initials) V Date 5.INSPECTION-OTHER: _ Passed—'[ ] Failed—[ ] Re-inspection required($50.00)-[ ] [nspectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE)F THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A REINSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 sY www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone #: 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ' 2.❑ I am a soleP or ro rietor partner- listed on the attached sh et. t 7. ❑ Remodeling P P g 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 10.❑Electrical repairs or additions 3.❑ 1 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 Investigations of the DIA for insurance coverage verification. I do hereby certyyunder the pains and penalties of perjury that the information provided above is true and correct. Sienature: 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 M 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-contractor(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 r' 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 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 Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia