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HomeMy WebLinkAboutBuilding Permit #492-11 - 190 BERRY STREET 12/20/2010Permit NO: 1 nota Icciiarl• 1�-n1a BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received /2 A \7e 4�R1TED PPP�'L�� I ORTANT: Applicant must complete all items on this page S LOCATION .1 • �� 7- 3 J _ Print PROPERTY OWNER.` ROF,CR TscS LLC_ Print MAP 210 PARCEL:... ZONING'DISTRICT:_ Historic District. yes. o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential j�New Building pd One family El Addition ❑ Two or more family ❑Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic Well ❑Floodplain El Wetlands 0 Watershed District. ❑ Water/Sewer '' i DESCRIPTION OF VVUKK i U Ut rtKrUKMME. �ONSI Ie0C.T �/CLJ SLAG -LE ��4M�Lj� 1foML' Identification Please Type or Print Clearly) OWNER: Name: KrNe-.s ohr. PiZzp6RrsC-s LL -C- - TONY r -K A1N`105 A Phone: Address: r'o YSox t- 14AMt17-01 R-LLs 1vo CONTRACTOR Name: 4, 3 -.9 y11-6 A'> 9 „ -Address: ���X / CQ� If��'-� i-� c �s Supervisor's Construction License: S Exp. Date; Home Improvement License:. Exp. Dater AR'^'xG C. GL Lr��S ARCHITECT/ENGINEER Phone: Address: 5 79 41 v_o S� /.Sdd. �� A Reg. N FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00PERS.F. ,`15z sr x /Zs= 3 y%000 00 Total Project Cost: $ 3Ll '-- Check No.: NOTE: Persons contracting with unregistered Signature of Agent/Owne E: $1�8 ., Receipt No.: 3 'ors.'do not have access to the zuara Signature of contracto Sly fund L Location ed &4� No Avi ate1 v TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Check # a 1 23bb4 ° wilding Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL _ Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools f Q � ❑ Y; 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 ❑ [ILIn & COMMENTS VCONSERVATION Reviewed on 2' 1 D COMMENTS HEALTH Reviewed o COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: . Water & Sewer Connection/signature JDPW Town Engineer: Signature: FFIREPARTMENT --Temp D124 Main Street artment signature/dateTS. Comments Comments 4Q Dr0 m ewa Permit" Lojoated 384 Osaood Street v no �` �OL �d 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 Doc.Building Permit Revised 2010/0ctober 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) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ 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 Doe: Building Permit Revised 2008 0 0 Cd aha � o O Ll. co� a v V)w x OU p to O r2 v U G w x 0 �' O G o W w W O cru y U) `° G O� pm C O G W w G. as z Y cn o cn �I . C � CL) C Cc C N O C A O v c.3 ' C C = o o e`a as Q CF CD co �, co Jo a. co co la o CD urn r �i ren c O.:r E V: ,J N W m N = M C O J CIO Cc ,1Go Cc� y O O cm N eo 'fl O 3: a(..2 m N O CD 12 vi. � 'D C C N �O C \1• : m o� V N O O A ` Z ea C O C H: Q _ � � y O C 'O = eo ® .3: N d CO2 ~ O N �... •rA MD N dt O C Z O ;+ ®LU C.3 •N 0 CM y d m = eya H �O O s seam m 11 U 0 N U) W W W U) O E O � L O O v O Z CL O G CO) C O� pm C CO) CDC CO O �O m CO 3—=13— 0 CD CD O � m O G O o a ocm - CMa co C o -I-- C cCc v J .O •CO3 tsC CL V CO) C C � _c Cl N U) W W W U) U I rA W R;", O z. �¢ x O f� U ° f) cn w w O P-4 A h-1 W 0 ,, j G a2 v U —CdwCd w a O U �W., 'ion a�' w p W U J) w O M c4 r, w w °' as z° cn q o C/) a+c 0� O C A O Ci 8 a c is :Cc ca �c O O W CDQ CE �„ co 0 0. C', .� :E_ 0 CDo Ci 5 rn m c V : to ea m 'CDy N f 3 z c o�' v :EmCD N o ^r N MODv .: m -co, c m :m0'C c CO.i h O G Z c OL cm O c colCL _ ® ® ,C2 N :a CO) o as m J --- C2 tL g :5 .. ca CL �a w H o ca CD 8 C.3 CD CO2 O" m: �._ Z R mi C46 C sa.m O U a 0 CD 0 E 03 L O O v Z CD 0. O � y C — O cm CO2 O ca mm L „ s CD a� O 18 O o cc a CL CMa h C o *- c O to CJ"FL J .0 CD C d /O V C to � Q CO2 ' 0 0 Y♦ ul N W W W W U) 1llassachusetts - Department of Public 5, . Board of Building Regulations and Standards Construction Supervisor License License: CS 59036 �.�� - Restricted to: 00 i ANTHONY W FRANCIOSA 111 PO BOX 166 HAMPTON FALLS, NH 03344 I Expi Stion: 11/17/2011 C o111missi(mer i r#: 1617! Energy Code: Location: Construction Type: Glazing Area Percentage: Heating Degree Days: Climate Zone: Construction Site: Lot 3 - Berry Street North Andover, MA REScheck Software Version 4.4.0 Compliance Certificate 20091ECC North Andover, Massachusetts Single Family 18% 6322 5 Owner/Agent: gi Compliance: 1.5% Better Than Code Maximum UA: 392 Your UA: 386 The % Better or Worse Than Code index reflects how Gose to compliance the house is based on code tradeoff rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum -code home. Designer/Contractor: Ceiling 1: Flat Ceiling or Scissor Truss 1588 38.0 0.0 48 Wall 1: Wood Frame, 16" o.c. 2560 21.0 0.0 117 Window 1: Vinyl Frame:Double Pane with Low -E 404 0.350 141 Door 1: Solid 38 0.190 7 Door 2: Glass 60 0.350 21 Floor 1: All -Wood Joist/Truss:Over Unconditioned Space 1588 30.0 0.0 52 Compliance Statement The proposed building design described here is consistent with the building pians, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 20091ECC requirements in REScheck Version 4.4.0 and to comply with the mandatory requirements listed in the RESchec Inspection Checklist. p�G. D"j-Za�U Name - Title Signature Date Project Title: _ Data filename: Untitled.rck Report date: 12/07/10 Page 1 of 4 REScheck Software Version 4.4.0 Inspection Checklist Ceilings: ❑ Ceiling 1: Flat Ceiling or Scissor Truss, R-38.0 cavity insulation Comments: Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: Windows: ❑ Window 1: Vinyl Frame:Double Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes _ Frame Type Thermal Break? _ Yes _ No Comments: Doors: ❑ Door 1: Solid, 1.1 -factor 0.190 Comments: ❑ Door 2: Glass, U -factor: 0.350 Comments: Floors: Cl Floor 1: All -Wood Joistfrruss:Over Uncondifioned Space, R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints (including rim joist junctions), attic access openings, penetrations, and all other such openings in the building envelope that are sources of air leakage are sealed with caulk, gasketed, weatherstripped or otherwise sealed with an air barrier material, suitable film or solid material. ❑ Air barrier and sealing exists on common walls between dwelling units, on exterior walls behind tubs/showers, and in openings between window/door jambs and framing. Recessed lights in the building thermal envelope are 1) type IC rated and ASTM E283 labeled and 2) sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. ❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated (without insulation compression or damage) to at least the level of insulation on the surrounding surfaces. Where loose fill insulation exists, a baffle or retainer is installed to maintain insulation application. ❑ Wood -burning fireplaces have gasketed doors and outdoor combustion air. Air Sealing and Insulation: ❑ Building envelope air tightness and insulation installation complies by either 1) a post rough -in blower door test result of less than 7 ACH at 33.5 psf OR 2) the following items have been satisfied: (a) Air barriers and thermal barrier: Installed on outside of air -permeable insulation and breaks or joints in the air barrier are filled or repaired. (b) Ceiling/attic: Air barrier in any dropped ceiling/soffit is substantially aligned with insulation and any gaps are sealed. (c) Above -grade walls: Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier. (d) Floors: Air barrier is installed at any exposed edge of insulation. (e) Plumbing and wiring: Insulation is placed between outside and pipes. Batt insulation is cut to fit around wiring and plumbing, or sprayed/blown insulation extends behind piping and wiring. M Comers, headers, narrow framing cavities, and rim joists are insulated. Project Title: Data filename: Untitled.rck Report date: 12/07/10 Page 2 of 4 (g) Shower/tub on exterior wall: Insulation exists between showers/tubs and exterior wall. Sunrooms: F1 Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U -factor of 0.50 and the maximum skylight U -factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Materials Identification and Installation: Ej Materials and equipment are installed in accordance with the manufacturer's installation instructions. 0 Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R -value. LI Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. El Insulation R -values and glazing U -factors are clearly marked on the building plans or specifications. Duct Insulation: Lj Supply ducts in attics are insulated to a minimum of R-8. All other ducts in unconditioned spaces or outside the building envelope are insulated to at least R-6. Duct Construction and Testing: 0 Building framing cavities are not used as supply ducts. Cj All joints and seams of air ducts, air handlers, fitter boxes, and building cavities used as return ducts are substantially airtight by means of tapes, mastics, liquid sealants, gasketing or other approved closure systems. Tapes, mastics, and fasteners are rated UL 181 A or UL 181 B and are labeled according to the duct construction. Metal duct connections with equipment and/or fittings are mechanically fastened. Crimp joints for round metal ducts have a contact lap of at least 1 1/2 inches and are fastened with a minimum of three equally spaced sheet -metal screws. Exceptions: Joint and seams covered with spray polyurethane foam. Where a partially inaccessible duct connection exists, mechanical fasteners can be equally spaced on the exposed portion of the joint so as to prevent a hinge effect. Continuously welded and locking -type longitudinal joints and seams on duds operating at less than 2 in. w.g. (500 Pa). Lj Duct tightness test has been performed and meets one of the following test criteria: (1) Postconstruction leakage to outdoors test: Less than or equal to 223.4 cfm (8 cfm per 100 ft2 of conditioned floor area). (2) Postconstruction total leakage test (including air handler enclosure): Less than or equal to 335.0 cfm (12 cfm per 100 ft2 of conditioned floor area) pressure differential of 0.1 inches w.g. (3) Rough -in total leakage test with air handler installed: Less than or equal to 167.5 cfm (6 cfm per 100 ft2 of conditioned floor area) when tested at a pressure differential of 0.1 inches w.g. (4) Rough -in total leakage test without air handler installed: Less than or equal to 111.7 cfm (4 cfm per 100 ft2 of conditioned floor area). Heating and Cooling Equipment Sizing: Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. C] For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial Building Mechanical and/or Service Water Heating (Sections 503 and 504). Circulating Service Hot Water Systems: L] Circulating service hot water pipes are insulated to R-2. C) Circulating service hot water systems include an automatic or accessible manual switch to tum off the circulating pump when the system is not in use. Heating and Cooling Piping Insulation: Lj HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3. Swimming Pools: L] Heated swimming pools have an on/off heater switch. Pool heaters operating on natural gas or LPG have an electronic pilot light. Timer switches on pool heaters and pumps are present. Exceptions: Where public health standards require continuous pump operation. Where pumps operate within solar- and/or waste -heat -recovery systems. C] Heated swimming pools have a cover on or at the water surface. For pools heated over 90 degrees F (32 degrees C) the cover has a minimum insulation value of R-12. Project Title: _ Report date: 12/07!10 Data filename: Untitied.rck Page 3 of 4 ,r' Exceptions: Covers are not required when 60% of the heating energy is from site -recovered energy or solar energy source. Lighting Requirements: • A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following: (a) Compact fluorescent (b) T-8 or smaller diameter linear fluorescent (c) 40 lumens per watt for lamp wattage <= 15 (d) 50 lumens per watt for lamp wattage > 15 and — 40 (e) 60 lumens per watt for lamp wattage > 40 Other Requirements: • Snow- and ice -melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting off the system when a) the pavement temperature is above 50 degrees F, b) no precipitation is falling, and c) the outdoor temperature is above 40 degrees F (a manual shutoff control is also permitted to satisfy requirement'c'). Certificate: A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R -values; window U -factors; type and efficiency of space -conditioning and water heating equipment. The certificate does not cover or obstruct the visibility of the circuit directory label, service disconnect label or other required labels. NOTES TO FIELD: (Building Department Use Only) Project Title: Report date: 12/07/10 Data filename: Untitled.rck Page 4 of 4 2009 IECC Energy Efficiency Certificate Ceiling / Roof 38.00 Wail 21.00 Floor t Foundation 30.00 Ductwork (unconditioned spaces): MIM . Window 0.35 0.70 Door 0.35 0.70 Heating System: Cooling System: Water Heater: Name: Date: Comments: www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly Name (Business/Organization/Individual): �/��%��� %/t/ �s2�AlC2DS� Address: 17 if �G c,Q�sT O /< City/State/Zip: %� ����'' i%9<<s wll o3oYWhone #: :�o 3 —9,4,� - 4',9-�r_8 Are you an employer? Check the appropriate box: [. ❑ I am a employer with 4. ❑ I ain a general contractor and I employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] i have hired the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ® New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition t0.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. F1 Roof repairs 13.❑ Other *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 acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:, Job Site Address: Expiration Date: 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 certify . der the pains and penalties of pefjury that the information provided above is true and correct. Signature: �^ Date: / z/7 // `3 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 #: The Commonwealth of Massachusetts c I Department of Industrial Accidents i �A 1. Office of Investigations 600 Washington Street e _ Boston, MA 02111 V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly Name (Business/Organization/Individual): �/��%��� %/t/ �s2�AlC2DS� Address: 17 if �G c,Q�sT O /< City/State/Zip: %� ����'' i%9<<s wll o3oYWhone #: :�o 3 —9,4,� - 4',9-�r_8 Are you an employer? Check the appropriate box: [. ❑ I am a employer with 4. ❑ I ain a general contractor and I employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] i have hired the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ® New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition t0.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. F1 Roof repairs 13.❑ Other *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 acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:, Job Site Address: Expiration Date: 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 certify . der the pains and penalties of pefjury that the information provided above is true and correct. Signature: �^ Date: / z/7 // `3 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 commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sur&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 pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pen-nit/license applications in any given year, need only submit one affidavit indicating current policy infonnation (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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pennit 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 Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia