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HomeMy WebLinkAboutBuilding Permit #598-2017 - 20-22 Robinson Court 12/5/2016 Z�i, AJ �U Lr' BUILDING PERMIT o� ' oRrC� .(.SLED TOWN OF NORTH ANDOVER 02 yy':`- `_�'•'6 APPLICATION FOR.PLAN EXAMINATION K x Permit No#: Date Received 0 1 DRQOcx""`: A.y R'tiTED/•4 �SSACHU Date Issued: IMPORTANT:Applicant must complete all items on this page riS ..oj. ��-. _^.. •_+i.:'�..f►�—1�'` [._-^-r.—�7}c"'^^�r� �' y��+ �° . :^i107Print PROPERiTY�)WNERA `"t vFL:..Im� . ., .F�, k i -� -•' "'' n YearS�tructure.• �'`�"°`y s-� no 'MAP' �PARCELz: ZONING DISTRICT=}=r "' ' pt`� ,., , �'Htstonc.®i"strict= no _ = = , . Mac} ine Shop:Village _yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition rvo or more family ❑ Industrial �(teration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other p Septic Well ❑ Ploodplairi Wetlands .-VVafershetl District- O.Water/Sewer . _._... DESCRIPTION OF WORK TO BE PERFORMED: S l cT �` ift o) -M\),3 `n , r v tel. i Identification- Please Type or Print Clearly' OWNER: Narne: p tA ' Rp�1.1 Phone: -0 Address: �� �� Q 1 \ L—L e_ IWD��2� Ids Contactor hone: Address: �-j Supervisor's ConstructioriLicense:.,... �� � ,�._ _ _Exp. (q- -. . Home Imp�oveent •� L-icense eu. b ARCHITECT/ENGINEER Phone: Address: Reg. No.. ,: FEE o. <- FEE SCHEDULE:BULDING PERMIT. $92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PE F. �.; otal Project Cost: $ � U "v � FEE: $ y Check No.: 1 Receipt No:: 3 NOTE: PeYsons contracting witli unregisteFed c n a d n ave.access to the guaranty fund Si"�natu�e:of.A e : nt/Owner I nre of atucontractor; ` ` g _w. . .... ._. ._._._.. Plans Submitted ❑ Plans Waived El. Certified Plot Plan ❑ Stamped Plans ❑ tw'rp'r'F 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS C HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes r Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Du mpster on site yes no Located at 124.Main Street Fire Department signature/date COMMENTS limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of Electrical Inspector Yes Ido DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email ate Time Contact Name Doc.Building Permit Revised 2014 _. . Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. r 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/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 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 40TE: 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 I Location a U 0 ' No. Sc/ �"�i? Date . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ —y i Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# I C Building Inspector .� � 230 '� � NORTIy own of '� , ? _E ndover O �+ No. 1� - o h ver, Mass, o .r 9? ®/4 CO[NICtSe WICK 1' Q.o ��. DRATED P4p��5 S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System T THIS CERTIFIES THA k .. BUILDING INSPECTOR ..... .... p g .. .... � ��.��. • Rough Foundation has permission to erect .......................... buildings ......... ..� to be occupied as ....fr#.�e.....f.......XC&rtjo!�......... .�. .r....s s-x.. 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 CONSTRUCTIOT RTA4=-�-; 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. Contract Vinny s Construction Phone 617-669-7952 TERM : CASH DATE: NOVEMBER 21, 2016 To: Giao M Tran 10 shaker hill lane CONTRACTOR: VINH TRAC Woburn Ma 01801 CONSTRUCTION SUPERVISOR LICENSE # : 094891 HOME IMPROVEMENT LICENSE # : 156593 INSURED BY: PENN AMERICA INSURANCE COMPANY ]obsite address : 20-22 Robinson ct, North Andover, Ma : strip and re-Roof, install vinyl Siding QUANTITY DESCRIPTION UNIT TOTAL PRICE Roof Complete strip all existing roof materials on roof Check for loose board , rotten board , add nails for loosing boards on roof, replace rotten boards if needed ( up to 2'x 8' boards free) Install ice and water shield 3 feet up from roof edges, install roof paper for the rest 8300 of the roof floor( 15 lbs) Install new drip edges(white, 8 inches) all around edges, new pipe booth and all new flashing . Install new architecture shingles (owner choice of color) , install rig vent on top for 27000 ventilation Siding Install 3/8"foam insulation all around the house , 17500 Install new 4"type vinyl siding (owner choice of color) Complete cover all windows trim and fascial boards with white aluminum , install white soffit for roof soffit Gutter Install seamless gutter around the house 1200 30 yards dumpster will be onsite for debris, all permit fees included Payment: $1000 upon the day contract is signed to apply for permit (non-refundable) SUBTOTAL 27000 $16,000 once permit is issued $10,000 once the job is completely done DISCOUNT AMOUNT PAID TOTAL DUE 27000 Owner 1-1 Contractor AC RO O CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) `- 11/30/2016 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 an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Vincent Pad BROADWAY INSURANCE AGENCY P",CN; . (617)387-8600FAx AIC No ADDRESS: vincent@broadwayins.com 810 BROADWAY INSURERS AFFORDING COVERAGE NAIC# EVERETT MA 02149 INSURERA: AIM MUTUAL INS CO 33758 INSURED -INSURERS: VINH TRAC INSURERC: VINNYS CONSTRUCTION INSURERD: 680 BURNCOAT ST INSURER E: WORCESTER MA 01608 INSURER F: COVERAGES CERTIFICATE NUMBER: 107313 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 ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDIYYYY MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMA E ENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- JECT l LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO _ BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE ' N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N X STATUTE EERH ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? NIA NIA N/A VWC10060218132016A 11/23/2016 11/23/2017 --- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I I I E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensation/investigationst. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 120 main st AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.CrowlEy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11-21-2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. 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. L IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 7—TSURB-OGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer right to th certificate holder in lieu of such endorsement(s). PRODUCER ,ZEVincent Paci Broadway Insurance Agency PHONE (AIC,No,Ext): (617) 387 - 8600 810 Broadway (ac,No):(617) 389 - 0814 ADDRESS: Everett, MA 02149, INSURER(S)AFFORDING COVERAGE NAICA INSURERA:Penn America Insurance Company INSURED Vinny's Construction Company INSURER B: INSURER C: 680 Burncoat St INSURER D: Worcester, NIA 01606 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE INSR VIVO POLICY NUMBER POLICYEFF PO CY X IMM/DD1YY1'Y) (MMIDD/Y1'YY) LIMITS x GENERALLIABILITY PAV0035224 10/27/16 10/27/17 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) S 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E 2,000,000 POLICY jE 0. LOC $ AUTOMOBILE LIABILITY COMBINtUSINUU:LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Par person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) S S' UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE E DED RETENTION S $ WORKERS COMPENSATION WSTATU AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' ❑ NIA (Mandatoryin NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,Hmore space Is required) Carpentry NOC CERTIFICATE HOLDER CANCELLATION Town of Noth Andover 120 main st .SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Office of Consumer."7fairs&Business Regu.atim: . a- —(AOME IMPROVEMENT CONTRACTOR egistration: 1 6x93 Type: �... •- Expiratigwi--7%171201:7: DBA ViN STRUCTION r- 'V1NH TRAC i 630 BURUWAT ST ' ORCESTER, MA 01606 Uodeisecretary Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-094891 Construction Supervisor VINH C TRAC 680 BURNCOAT STREP WORCESTER MA 07606' Expiration: Commissioner, 07/19/2018 •.The Commonwealth of Massaehusetts _ Department of lna'ustrial Aecidents M ='~ I congress Street,S !M 100 02114 2017 Boston,MA i www mass gov/dia ODM 5�1ti -Wa kers'Compensation bsurance Affitdavit:Builders/Connractors/ lectrzcians/'lumbers. TO BB TILEI)WITH THE)ERA TT'NG AUTRORM. .)please,Print Le ' 1 A �licant Information Name(Business/Orgat&ation&cliviauual): Address: 6 v �`� (� Phone#: ( � 65 D q City/State/Zip: d Areyon an employer?ChecktIie appropriate box: Type of project(reeluixed); 1.VI am a employer with / employees(full.and/or part-time,).' 7. [1NeVd6nstr66tion 2.❑I am a sole proprietor or partnership andhaveno employees Working forme in 8. El RemodcE ig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.E]I am ahomeowner doing allworkmyself[No workers'comp.insurance required,] 10[]Building addition 4.r]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Elecixical re airs or additions P: ensue that all.contractbrs either have workers'compensation insurance or are sole Plumbiri repairs or additions E:. 12Q g p propriefnrswithno emglbyees. 5.F]I am ageneral coniractorand Ihave hiredthe sub-contlisEed onthe attached sheet. 13.[]Roof repairs These sub-contractors-&v6 employees and have workers'comp.insnrance.t 14.n Other 6.FJ We area corporation and ifi,officers,have exercised their right ofexemption per MGL c. 152,§1(4),and.We have no empidydes.[No workers'comp.insurance required.] *Any applicant that checks bbx#1 must also fill outthe section below showingtheir workers'compensation policy information I Homeowners who submit•this.4fl.BVI aIiched an additional-ft- c�atiiigthoy am sheet showing the all-work name of the sub contractoan hire outside rs and rs must ewhether or affidavit Othose ntih�esnhaveeb t,ontractors that check b 'do their workers'comp.policy number. employees. If the sub-contractors have employees,they Must prov f am an e�nployet that isptovidingworkeils'compensation insurancefor my ernployees. .Below is thepolicy and)0h site information. Insurance Company Name: ExpirationDate• Policy#or Self-ins.Lie.#:. �� ,L1 A �K S City/State/Zip: AJ. Job Site Address: the otic number and expiration date). Attach a copy Oftbhe-workers' compensation policy declaration page(showing p y to$1,500-00 Failuxe to secure coverage as required under MGL ennalties2in tthe f m o f OP WORK 6BD�land a fi e of up to $250.00 a and/or one-year imprisonment,as well st civil p day against the violator.A copy of tbis statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby erlify der tliepains andpenalties ofperjury that the information provided ab ve is tru�aud c�ct - Date: Si ature: ( f- Phone#: official use only. Do notwrite In this area,to be completed by city or town offzcia Permit/License# City or Town- Issuing.A,uthority(circle one): ector 1.Board of Stealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Insp 6.Other _ Phone#• ContactPerson' 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 defuied 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 recei0for ttnstee 6f 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 b6 deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or to cal 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 applicaAtwho lfas 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 certiEcate(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 as LLC or LLP docs have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affadavit 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-Accidenis. Should you have any questions regarding the law or if you are required to obtain a w' orkers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate lino. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space atthe bottom of the affidavit for you to Ell out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to Ell in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pmmit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"lob 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. Anew affidavit must be.filled out each. year.Where a home owner or citizen is obtaining a license or permit nat 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 7ndustrialAccidents 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 wwwmass.gov/dia