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HomeMy WebLinkAboutBuilding Permit #47 - 174 CANDLESTICK ROAD 7/9/2010OWNER: N Address: ARCHITECT/ENGINEER BUILDING PERMIT TOWN OF NORTH ANpp APPLICATION FOR PLAN EXAM ATIpN Date Received TQ BE PREFp 12, 5n 1 r RMEr) Plle•�aassefj - YPe' or Print Clearly) Address: Phone: FEE SCHEDULE: BULDING PERMIT, $12.00 PER $1000.00 OF THE TOTAL ESTIMARegTE p' No, Total Project Cost: $ CoSTIR ` I FEE: $ ^SED ON $125.00 PER S.F. Check No.: `j J NOTE: Persons contractingwith unregistered contractors do ne1Pt No.: -- -- -� S'nature of_A�ent/Owne .SPS TC����+;=.__ ,.t -ave access to the /pORT#j 6 I�S--tx-36 - - e Location c C L No. Date TOWN OF NORTH ANDOVER L w R Certificate of Occupancy $ b CHU e�Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #_ 230c uo 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 Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM Or W DATE REJECTED DATE AP.PROVED PANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on 0 Si nature COMMENTS 00' 7 � C(" -).N =ac OL HEALTH Reviewed on Signature COMMENTS I 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: Signatu're: Located 384 Os.qood Street 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 - Date j Doc.Building Permit Revised 2010 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 ❑ 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) o 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 submitted with the building application Doc: Building Permit Revised 2008 ui Om O CO L O v o o. O � H � . cm C C c O y CaL) [ co � i ac y.r o w° u Un Z. A as -� ..� w° P U cz w a x cd w a � u0 Un w J 'Q x rL co w w. a a v m o Un Q v Un ui Om CD F. Fels CO O CO L O v G V O o. O � H � . cm C C c O y CaL) � co � i ac y.r ® c s o O tv 0 L Ci m CL oMa �Ea � CD L m C J 'Q � 0 c Z C V h o c �Ey C C c L o o '`r # 0 o c cm N W c �3pp J mc O � y y A Eo LaV m O Baa vy O Q•FZ V=oo c. Q y m C = � m o o D. H CO) �O► C y O �+=•+•Ot cU. •H � F• oc •E dt C v •o v Q* d mflo:p _ mm =4 0 h O -CL 0m CD F. Fels CO O CO L O v Z o. O � CO) C cm C ca W y m m � co � i y.r O tv O O0. 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V y � c + ■C C m �o ca ts cm d. p H co CD � rm�3pp N cm �• J C C � _ m Em co � y m m cm -ac N d C t /! m C • ceZ � :coo a = m mo :CL— H W N m O •CA �O.t O L N •E G V Cl N LU ® cmC V m C.2:2 coo m � O .O = co a.m E N cm O i N C O m 12 C" c _ m 0 cm C �C N CD Z O Z CD 8 IIg 1n CD O O■ �+ O vv Z a O p h c � � vs o c C p 'a ■E CO m C 0 CD ~ Z O� CD CD p O O O d CL CMa co c o c C� ■d O D ♦ ca C Z � V y O C ■C C m 0. ca p W LU U) 19 W LU 19 LUW N �� �� r . aworruurnwl nnuvncl.com I o:C;erlmcate of Insurance (180334711400) 03:47 01/29110GM7-12 Pg 03-04 Client#: 53642 FAMILYPOOL1 ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MIDD/YYYY) 1 PRODUCER HUB International New England 299 Ballardvale St Wilmington, MA 01887 112912010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE. POLICIES BELOW. 978 657-5100 INSUREDINSURERS Family Pools & Patios Inc. AFFORDING COVERAGE NAIC # INSURER .A Nautilus Ins Co ,NSURER B: Technology Insurance Co 70 S. Broadway INSURER C. Safety Insurance Co INSURER D --- ---� Lawrence, MA 01843 tiSURER E: COVERAGES THE ANY MAY POLICIES. POLICIES REQUIREMENT, PERTAIN. OF INSURANCE LISTED BELOIA TERM OR CONDITION THE INSURANCE AFFORDED AGGREGATE LIMITS SHOWN MAY HAVE BEENISSUED TO THE INSLRED NAMED ABOVE FOR THE POLICY OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS HAVE BEEN REDUCED BY PAID CLAIMS. PERICO INDICATED. NOTWITHSTANDING CERTIFICATE MAY BE ISSUED OR AND CONDITIONS OF SUCH LIMITS EACH OCCURRENCE $1 000 000 LTR Q 15Rc TYPE OF INSURANCE GENERAL LIABILITY X CCMhIERCIAL GENERAL LIABILITY CLAIMS MADE x OCCUR X $2500 POLICY NUMBER NC939713 POLICY EFFECTIVE DATE MM! D!Yl'Yl' 09;1912009 POLICY EXPIRATION OAT Mid'pplYYYY 09/19/2010 DAiAAGE T^. RENTED PREp,1ISE� f a occ « co, 5100 000 MED EV(Anyone p?rsor) $5.000 PEPS004AL R .ADV INJLRY S1 000 000 X cu XCU incl CI — GENERAL AGGREGATE $2.000 000 GEN'L AGGREGATE OMIT .APPLIES PER: PRODUCTS - COMP!CPAGG s2.000,000 PRO- POLICY f7 JFCT 7 LOC COMBINED SINGLE LR41 +Eaacadentj $1,000,000 C AUTOMOBILE LIABILITY A14YkfiD 3947232 12131/2009 12/31/2010 ALL 04NEDAUTCS X X SCHEDULED AUTOS HIREC AUTOS BODILY IN URY iFe-Dersalli $ Nxv-UBdNEDA11T05 BODILY INJURY I.PeracodanU $ PROPERTY DAMAGE $ We auadantl GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT S OTHER THAN EA ACC $ AUTO ONLY: AGG S ESS / UMBRELLA LIABILITY OCCUR CLAIMS MADE IAETEN-IOSJ EACH OCCURRENCE $ AGGREGA-E $ DEOUCifBLE $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY AN`! PROPR!ETOR,PARTNER!EXECUTIVE ppFFICERRJEMgER EXCLUYD7 IMa�datory in NNI N TWC3229154 Binkt Subro 12!3112009 Waiver 12/31/2010 Included , f �( :NL'. STATL'- 0? #_ E L. EACH i.CCIDENT $100 000 ` L DISEASE - EA EMPLOYEE $100,000 If yes. dssc66e under SPECIAL PROVISIONS Deice. E.L. DISEASE POLICYLIMI' $500,000 OTHER DESCRIPTION OF OPERATIONS ! LOCATIONS WEH!CLES ! EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 10 Das for Non -Payment EVIDENCE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WH_i ENDEAVOR TO MkIL I_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT: BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORESENrATiVE ACORD 25 (2009101)1 of 2 #S3473961M341043 O 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD WRO01 ZA ' A I � p .�e m p OQ d LA yLz'� p� .,moo `Atm 05 @002 70 South Broadway 0 Lawrence, MA 01843 Tel: 978-688-8307 1 C Fax: 978-488-1949 srNcµ�EE 1978 providing a full line of services and supplies fully licensed and insured www1amilypoolsonline.com Name I) min tie 4- Address l% q (A,,, J z4- f c City Home Phone q) Work Phone Cross Street/Directions o f ,�► %� au" - Sa �~ 45 Route 125 Kingston, NH 03848 Tel: 603-642-9909 Fax: 603-642-9906 q 0 C 0(0 Date Z ? 6441 Za ry '4' `I State 8 A Zip 01 bly d' Cell 7 g' $3-V'_ 3672- Add'I # h IS Estimated Start Date Estimated Completion Date We propose to furnish and install one Cgunite F swimming pool for the sum of $ rn1 THIS PRICE INCLUDES: • Normal Excavation up to 8 hours on day of dig • Ball and Sub -Grade up to 3 hours • Underwater White LigkdR& : • Steel Reinforcing per Engineered Plans for gunite • Steel Structure per Engineered Plans for vinyl • Over -Flo Line for added protection • Pressure testing of plumbing during construction • Ten Year Plumbing Guarantee (see specifications) • Transferable Lifetime Structural Warranty • Manual vacuum cleaner kit •,�,Step.staintessfatfder Rope and floats • IAitial balancing chemicals • 8 to 12 Wk supply of maintenance chemicals (supply depends on pool size) • Leaf net • Wall brush • Extension pole • Waterline Tile (6') • Liner Choice c ( - Test Kit •Surface slimmer (s) • Dual Main Drains • Coping _ _ Z _ q T-,4 IJ • Steps ra"hsce ^ ,A Vl e (- L J6' c.6e • Handrails e��1 O •Y -e. • Filter %0,- D9 C A-t-7*1 (plumbed no more than 25ft from pod) • Pump & motor / THIS PRICE DOES NOT INCLUDE: I, - Any Any plumbing over 25ft from pool. Additional runs are not recommended but would be at a cost of $ _ Z per foot per line. • Machine time in excess of that specified above. Additional machine time to be billed at $ + 6 including machine, operator, and laborer, due with second pod payment • All hours of trucking will be charged at $ �7 r per hour per truck due with second pool payment • Any dumping costs incurred for disposal of ledge, large rocks, garbage, stumps buried or otherwise, building materials, unsuitable or nonstructural soils, or any unforeseen material that must be removed. • Removal of ledge or large rocks by way of a Starr bit, chipper, or blasting. • Additional fill, if necessary, for proper backfill or reshaping of hole, supply or spreading of loam, reseeding of grass. • Patio, fence, retaining wall, or any accessory items other than noted on contract. • Electrical wiring, fuel connections, heater venting, fuel storage tanks or permits. • Repair or replacement of sprinkler systems or any buried items such as well lines, drywells, leach fields, electrical lines, cables, etc. that are damaged during construction,,. //'' '' • Costs due to water or soil conditions (ex. clay, peat, live sand, excessive rock, etc.) requiring a stone pack of the hole. The stone pack will be at an extra charge of $ � minimum to $ _�60 maximum and at the discretion of the job supervisor. Additional machine time and/or materials necessary to rectify such a condition will be at a cost over and above the stone pack and will be quoted by the job supervisor. • Water to fill pool. Initials CUSTOMERS MUST SUPPLY: • Access for all trucks and equipment • Building and Electrical Permits or assume the costs necessary to obtain such permits. • Water and electric necessary for construction of pool • Customer mustwater cure Gunite shell for 1 to 10 days If applicable. • Water to fill pool immediately upon interior finish f a NOTES: �,/ 1 I r /.;"�/ 1 •tt� � 1 _RT _J OPTIONS: TOTALS: Diving Board Solar Cover ) Basic Pod Price $ Additional Pool Lighting S ( Ce,� /'J eyvus Options $ HeateriA C1 Environpool Plus, 8 hd+2 surface SUBTOTAL $ t!� cry Additional Floor Heads ( ) "" L•Z� ' Polaris Vac -Sweep .b96 t Lt -7 ( ) s Sales Tax �3�L. � $ I q Polaris retrofit only ( ) "' TOTAL $ `3 7 S SwimoutBench e removea. removal of ledge or large rocks by way of a Starr bit, chipper, or blasting. dditional fill, if necessary, for proper backfill or reshaping of hole, supply or spreading of loam, reseeding of grass. 'atio, fence, retaining wall, or any accessory items other than noted on contract lectrical wirinc, fuel corections, heater venting, fuel storage tanks or permits. k repair or replacement of sprinkler systems or any buried Items such as well lines, drywells, leach fields, electrical lines, cables, etc. that are damaged during construction,.," :osts due to water or soil conditions (ex. clay, peat, live sand, excessive rock, etc.) requiring a stone pack of the hole. The stone pack will be at an extra charge of $ minimum to maximum and at the discretion of the job supervisor. Additional machine time and/or materials necessary to rectify such a condition will be at a cost over and above the stone ack and will be quoted by the job supervisor. Vater to fill pool. _ Initials JSTOMERS MUST SUPPLY: ccess for all trucks and equipment • Building and Electrical Permits or assume the costs necessary to obtain such permits. Vater and electric necessary for construction of pool • Customer must water cure Gunite shell for 7 to 10 days if applicable. Vater to fill pool immediately upon interior finish { ii a )TES: L ` �� C /� ,/1 4 e � 1 �-i -.1, 41 41 e 3TIONS: ,ing Board ( ) lar Cover ) —' ditional Pool Lighting S t,4 Ce; ater Jrj'rA-�t– CA A, Q ( ) 713 SD vironpool Plus, 8 hd+2 surface ditional Floor Heads laris Vac-SweepC— laris retrofit only ( ) ^ imoutlBench ( } nor Finish ( ) a ( ) tomated Control System It Chlorine Generator W"DI ) IL11W ler W tv Co�►'p� ( Q(coqw o v r VIALA– �rtDPl — 1 TOTALS: Basic Pool Price Options SUBTOTAL $ -7 OV .b% Sales Tax f $ f Lf -7 TOTAL �w� $ 3 : L1 '% Less 10% Deposit $ / Balance of Contrac01AA-f $ I �� PAYMENTS: 113 EXCAVATION 113 BACKFILL + EXTRAS 113 SYSTEM START-UP ie buyer hereby agrees to pay, in full, the total amount of this transaction upon start-up of the installed pool. Your salesman or job supervisor will meet with u prior to excavation at which time all decisions including pool size, shape, elevation, liner print, and all options must be final. Changes after this date will be bject to extra charges, where applicable, and will result in unavoidable delays. You, the Buyer, may cancel this transaction at any time prior to midnight of the rd business day after the date of this transaction. Credit card payments not accepteftl-contrast mount. ��7(�prc,,t� BUYER � date Zi 2010 ILER K dates V 16 CO -BUYER date 0 i .0 • 11, �• , ze ar.,nauJr,✓,�rF✓,zLl.y o,G ; %,i✓yrxcJ�u✓ _ Board of Building Regulations and Standards i� 1_9 HOME IMPROVEMENT CONTRACTOR ,_ �rl �' Registration: 118204 Expiration: 2/13/2011 Tr# 280313 Type: Private Corporation FAMILY POOLS & PATIOS INC WILLIAM GIANOPOULUS 70 S. BROADWAY LAWRENCE, MA 01843 Administrator License or registration valid for individ"ul use only before the expiration date. 1f found return to: Board of Building Regulations and Standards One Ashburton Place Ren 1301 Boston, M2.02108 ® - ot valid wi o na \ \ -01 _ § ? 9 \ 9 ± z 2 { \ © m ( \ / \ \ \ / < 5 / \ \ \ O. 2 ® 3 7 =f= \\} m f 3 3 \ S ..,»� / - m = e, The CommonweQlth of Al assachusetts Department o f Industrial Accidents Office of fnvesiioations 600 YPashinpon Street Boston, MA 02111 Workers' Compensation Insurance Affidnvigra s/Conic licant Informafion actors/Electricians/Plumbers _ r.t I I ..aa�e j"I1IIt plyfltr Name (Business/OrganizationMdiviidual): "wlllr+1 J—e+S-Za .. .. .. Address: YT A o3 W City/State/Zip: r.S 0--'--1- c.e M A o (S'�FT Phone #:A ? S - Are you an employer? Check the appropriate box: L I am a employer with p _ 4. ❑ I am a general contractor and I 2. ❑employees (full and/or part-time).* have hired the sub -contractors I am a sole proprietor or partner- listed on the attached sheet r ship and have no employees These sub -contractors have working forme in any capacity, workers' comp insurance. [No workers' comp; insurance 5. ❑ We are a c required] 3. ❑ .I am a homeowner doing all work Myself [No workers' comp. insurance required.] t orporaiaon and its officers have exercised their right of exemption per MGL c. 152, § I (4), and we have no employees. [No workers' comp. insuran Type of project (required): 6. New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions l L❑ Plumbing repairs or additions 17.❑ Roof repairs ce required ] I3.❑ Other VSuN P & -ny piicant that checks b0];.#1 must Plst+ iul o_f fnc �ectia Fume affidavit indicating c=rov' hov --g f� A or ms' COmY- s oc Y c� . owners who submit fids affida rating they a . aL wart and *Contractor; that check- this box must attached an addi'onal sheet showine the hire outside eontractarF must submit a new a�aavit indicating such. the same of the sub -contractors and their,. T __ ` ---" "" C;Mplfly u+at is providing workers' compensation information. insurance for my employees Insurance Company Name: ---r• r• -w -y uuurmanon. Below is the policy and job site Policy # or Self -ins. Lic. Expiration Date: l Z— (� ?-0 l 0 Sob Site Address: � � � � � �( � S.� GL I City/State/Zip: iJ i �(p 0 V a lei �•S Attach a copy of the workers' compensation policy declaration page (shovi* the policy number and expiration date). Failure to secure coverage as required under Section 25A ofM ) fine up to $1,500.00 and/or one-year imprisonment, as well as Grc. 152 can lead to the imposition of criminal penalties of a of up to $250.00 a day against the violator. Be advised that a co Civil of m the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. Py of statement may be forwarded to the Office of wJ,r, "U"Ur nie pains and penalties ofPerjurl, thast the informationprovided above is true and correct t0 Official use only. Do not write in this area, to be completed hJ, citj, or town off ial City or Town: Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Tom 6. Other Contact Person: Permit/License # Clerk 4. Electrical inspector 5. Plumbing inspector Phone # Information an- d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute; an employee is defined as "...every person in the service of another under any contract of hue, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association o$ other legal entity, employing employees. However the owner of a dwelling house having not more than three apart mx cuts and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintt--mance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be cause of such. employment be deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state or 10.ca1 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 coYmpliance 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 un. -0 acceptable evidence of compliance with the insur=e 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 certificates) 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 stire to sign and date the affidavit. The affidavit should be returned to the „qty or tovrn that the application far the permit or license LLS being requested, not the .Depariar ent. of Industrial Accidents. Should you have any questions regardirl<g 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 pennit/lic=- se number which will be used as a -reference member. In addition, an applicant that must submit multiple permit/licensc applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under `.`Job Sit: 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 ince to the 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,f m—number_....- . The Commonwealth of Massachusetts Department of Industrial Accidents Office of larest igat ons 600 W ashmg on Street Boston, MA 0.2111 Tel. # 617-72.7-4900 m t 406 or 1-977-MASSAFF Revised 5-26-05 Fax # 617-72.7-7749 vrv, v,.mass.. aov/din