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Home My WebLink AboutBuilding Permit #1189-16 - 173 BERKELEY ROAD 5/13/2016 BUILDING PERMIT NORTH O�tT`4D '6A�0 TOWN OF NORTH ANDOVER F - p APPLICATION FOR PLAN EXAMINATION- Permit XAMINATIONPermit No#: 1 " l Date Received �q ADgw7ED AC US Date Issued: IMPORTANT:Applicant must complete all items owthis age LOCATION l73 &d(plrk 'b /", Wed, Print PROPERTY OWNER :r411 Pro& Print 100 Year Structure yes no MAP PARCEL:-/�_1---ZONING DISTRICT: Historic District yes no Machine Shop Village yes. no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑Other Septic ❑Well 0 Floodplain F Wetlands ❑ Watershed District El Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly Phone: O F� f7o �a7�7 OWNER: Name: Cc rr [ fPry r- 1/J� ) �,O Address: )7 J gerAF(ci )?(i ICV , Contractor Name: ,�':cy► �f��'C@i�l C Phone: � `ff. -/ 7 Email: Address �n4;g,R �h �► cc Supervisor's Construction License: Exp. Date: 11,7 _� `7 Home Improvement License: Exp. Date:. ARCHITECT/ENGINEER Phone: Address: Reg. No.. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COSF:BASEU-ON,$125.00 PER S.F. a Total Project Cost: $ FEE: $ Receipt No.: Check No.:3ld) NOTE: Persons contracting with u registered contractors do not have access ta. e gua my fund Location No. Date TOWN OF NORTH ANDOVER 11 Certificate of Occupancy $ Building/Frame Permit Fee $ 7 f ° Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 30370 Building Inspector 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 Dmnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments r ti Conservation Decision: Comments Y Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street EPA =�- � -� � a �-.-.� z�..,.�, , 'FIRED ,R,4�MENJT,!�T�Q,-P U;Iumnpsftevr0on sitek �y0S '' r '"�"�y - J It ocated at t12x4iMain> reet$€, "+ 1 '-� Fire Departs menus gnatu_re/date • r r h C®MMENiTS' L _ a Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq, ft.: ELECTRICAL; Movement of Meter location, mast or service drop requires approval of Electrical Inspector yes No DANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine N®TES and DATA—(For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled ou+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 OTE: 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/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 OTE: 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 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 1 NORTly Town of �2 _ R L n.dover No. Ift-jbife +� h ver, Mass, A- C OCNICHl WICH V 7a ORATED PP�,i�(5 lS u BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ..... . r�f� `'. ... .°..Ue......................................................... ................. BUILDING INSPECTOR has permission to erect ........................... buildings on . �.�1../deF.��/..C. .. ............................. Foundation _ Rough to be occupied-asp. �� Q� ................... 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 CONSTRUCTION STARTS Rough Service ........ ........................ "" 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. Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor 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 to Home Improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office ofConsumer mer Affairs and Business Regulation's Consumer Information Hotline at 617.973-8787 or 1-888.283-3757 or on our website. Homeowner Information Contractor Information N Company Name p c�ld�j ��1/ D Street Address(do t use a Post OfTic x address) Contractor/Sales rson/Owner Name 173 City/r ftate Zip Code Business Address(must include a street address) d a V x > /�f Da time Phone Evening Phone CityrFown ?Stater Zip Code _�972 � Mailing Address(It different from above) Business Phone Federal Employer ID or S.S.Number Home! ixovememcontnetoraeg.Number Expuntion date Law requires that most home Impnvement Cneon have Mad ngttntion 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.) !4rspt I froq Required Permits-The fallowing building 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 own permits will be j excluded from the Guaranty Fund provisions of ! Date when contractor will begin contracted work. MGL chapter 142A.) a4 Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,famish the material and labor specified above for the total sum o. (') Payments will be made according to the following schedule. $ 0 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ P by _/ / or upon completion of $ by_/_/_or upon completion of $-56 upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ ` to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ "" to be paid for NOTES:(•)Including all finance charges(4•)taw 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. Express Warranty-Is an express warranty being provided by the contractor? ❑No LW Yes(all terms of the warranty 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 agreement 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 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 questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration tration. The law requires most home improvement contractors and subcontractors to be registered with 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"proof 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 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 at his/her main 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 SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of the Contact must be completed and signed.One copy should go to the homeowner The olha copy shoal kept by the contractor. Homeowner's Signature Con tor's Signature Date Date Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has 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 concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, ter 142A. � _I xilfw Homeowner's Signature tractor's Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners 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 or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added 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 consumerlhomeowner 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 ail 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 original contract 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 rescission period has expired. Accelerated Payments A contractor may not demand payments:n advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,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 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 Improveine,Lt Contractor Law or other consumer rights,or if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at httv://www.mass.gov/ocabr/ 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 Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at http://www.mass.gov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: htti):Hdb.state.ma.us/homeimprovement/licenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 Version 2.1-11/22/2010 ,a►coR� CERTIFICATE OF LIABILITY INSURANCE DATE`MM,DDNwY) 03/15/2016 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 as ADDITIONAL INSURED;the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. Astatement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). CONTACT PRODUCER NAME_ Cade{Ili D@ nan DEGNAN INSURANCE AGENCY, INC. PHONE 978 6$$-4474 yC No: E-MAIL ADDRESS; cde nan de naninsurance.com 85 SALEM ST, INSURE S AFFORDING COVERAGE NAIC# LAWRENCE MA 01843 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER 8: JAMES DEBRECINI INSURERC: FAMILY ROOFING& PAINTING INSURER D: '?TANAGER WAY INSURER E: LONDONDERRY NH 03053 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 37186 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 - TYPE OF INSURANCE ADOL SUER POLICY EFF POLICY EXP LIMITS TR POLICYNUMBER MMIDD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED a CLAIMS-MADE r_1 OCCUR PREMISES Ea occurrence a MED EXP(Any one person) a N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: a AUTOMOBILE LIABILITYMBINEDSINGLELIMIT a E ecddent ANY AUTO BODILY INJURY(Per person) $ ALL OWN UTOS ED AUTOSULEO N/A BODILY INJURY(Per aocidenQ $ UPROPERTY AGE aHIREDAUTOS AOS �ddet) a UMBRELLA LUIS OCCUR EACH OCCURRENCE a EXCESS LIAR CLAIMS MADE N/A AGGREGATE $ DED I I RETENTIONS $ Wbi KERS COMPENSATION �/ AND EMPLOYERS'LIABILITY Y/N X STATUT ETH ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT a 100,000 A OFFICER/MEMBEREXCLUDED? NIA NIA NIA AWC40070259002015A 05/11/2015 05/11/2016 - (Mandatory In NN) E.L.DISEASE-EA EMPLOYEE a 100,000 I1 yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 500,000 N/A The Commonwealth of Maswchusetty, F Department of IndustrialAccidents X Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): dC,M e=_s-b recejt( Address: City/State/Zip: to, t1 Phone#:��i��.� �� Are yon an employer?Check tlie appropriate box: Type Of ro]eCt(7Ce(�ulred)' l.�am a employerwith �. employees(full and/or part-time).* 7. ❑New construction 2.[]1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3..Q I am ahomeowner doing all work myself[No workers'comp..insurance required.]t 9. F!Demolition [] 4.4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensurethat all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.[�oofrepairs These sub-contractors have employees and have workers'comp.insurance.t 6.F]We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no..employaas.[No workers'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 subnut',us affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCoatractors that check this box must•attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have s have employees,they,must provi c Their workeis'comp.policy number. employees. If the sub-corilracior fain an employer that is providiiig workers'compensation insurance for my employees.'Below is the policy and job site information. �� Insurance Company Name: ` r /' L d _ i l Policy#or Self-ins.Lie.#: /WG do~ 710��fat✓ D�J/T Expiration Date: / / Job Site Address: 17 �/�Cle Od City/State/Zip: N) A)all /V Attach a copy of the workers'compensation policy declaration 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. I do hereby c tify ander t1 zi and penalties ofpejjujy that the information provided above is true and correct. Si ature: 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 ofhire, 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 enferprise,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. S e advised that this affidavit may be submitted to the Department of Iirdustrial Accidents fei•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 roust 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 Department's address,telephone and fax number: .The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.##617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i �I Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-099685 Construction Supervisor Specialty JAMES J DEBRECENI 2 TANAGER WAY LONDONDERRY NH On53 = i J; ...n Expiration: Commissioner 1210612017 i.' 02.�� egistration valid for individul use W11gn,rioouueccll1 o�C aa�ac uagLui + License or r only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: H ME IM2iZOVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Type: ,eg'istration fi2385 10 Park Plaza-Suite 5170 xpiration: 8I2Gb18;.3 DBA Boston,MA 02116 w J-&D WEATHERSEY� �=-� k _ JAMES DEBRECEW- s 2 TANAGER WAY LONWi DONDERRY,NH 03053 Undersecretary Not validwthout signature i'. M.- f is is