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HomeMy WebLinkAboutBuilding Permit #211-2017 - 2163 TURNPIKE STREET 8/29/2016 TOWN OF NORTH ANDOVER ' APPLICATION FOR PLAN EXAMINATION Permit NO:a/ Date Received Date Issued: J& IMPORTANT: Applicant must complete all items on this page LOCATION .1 U,e'Al"Pjl 4:LL.6-7� -- - PROPER-iy,OWNER a Print. M` y Print T 100+Year Old Structure ono j is-tri e. MAP NO:.` PARCEL:- ZONING DISTRICT MachineDS`,ho tVilla e e s no' tI TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ` ❑ Demolition ❑ Other _ 0 Septic.. ❑1Nell A- ❑ Flootlplaih� O Wetlb' ❑ 'Watershed'Distric1.t' a ❑ at We DESCRIPTION OF WORK TO BE PERFORMED: �dL tF,40 A9 e' SW C- 4 r-3 t2& 6" 4zG 1 A,rz�-� t OT 76- fS� 190-MOT, -mss 77 Aa-l£ %-- vr�Tl�rz 3-�'?1 r�G A W Q r T e4 iMl g ASya�A r'£2L Hir�r�-P�; 4'/a-ZG ,1 a rn P{i a-S,41t" SGS �r�1r2 2�J 1/y t7J art2C g, An-cry o��2 coca- R��s+v,o'K, © cs� oTrcS'1 Identification Please Type or Print Clearly) � OWNER: Name: 19--A-1110 &-n N-Jvt 9 Phone: .1- 4gul- 98� Address: 11 4 3 %r 2aVp11,"c S 1tV-d2rV2 "knA . CONTRACTOR Name /, " _ 1�Gj►- _f�7f v2 -YYz Phone: Add.i Ess: rn� . SuP.ervisor's�Construction Licens - -Exp; Dte: 4/-:7 Fe 0,h mprovement License. e _' _ _ - Exp. Date: `3 _-lCxr- � ARCHITECT/ENGINEER Phone: I Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ � �0 FEE: $ Check No.: y 3 .3 Receipt No.: NOTE: .Persons contracting with unregistered contractors do not have access to the guaranty fund '-- Signature,of AgentLQvvne _ Sig �afure of.contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 11 Stamped ans ❑ - c Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ _ TYPE_OF-SEWERAGEDISPOSAL 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 s' INTERDEPARTMENTAL SIGN OFF - U FORM ..: ..DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS s .CONSERVATION Reviewed on Siqnature 1 COMMENTS 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 Tow;! Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTME=NT -Temp Dumpster on site yes v no Located-at 124 Mair Street 'Fir e De'partmeritfsighatia"re%date COMMENTS= �� i -Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: II ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER Z®NE`LITERATURE: Yes No MGL Chapter 166 Section 21A=F and G min.$100-$1000.fine NOTES and DATA— (For department use El Notified for pickup - Date f - Doc.Building Permit Revised 2010 Building Department `rhe fol swing is a-list of the required forms to be filled out for the appropriate.permit to be obtained. RoofirA,g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application Li Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o 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 Li Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit ` New Construction (Single and Two Family) o Building Permit Application 1 ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-tted with the building application Doc: Doc.Buhding Permit Revised 2012 k. Location �xY No. �Z(1 —'ZO/ n . Date 49 / I • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# / Building Inspector NORTH Town o _ s ndover O M. No. V.app * - 1 Zh ver' Mass A-O�A COCMIC[WKw`y1' ' 79 04ATED NP��.(5 S U BOARD OF HEALTH PER IT ' LD Food/Kitchen Septic System THIS CERTIFIES THAT .... .. ........ BUILDING INSPECTORA �............. ................................. ow has permission to erect ........ Foundation .................. buildings on ..�..�..�...� .f��l.1�p��fir..... .... .... Rough to be occupied as .... � .........0 �•I• ,. ,f• •, •, It•• Chimney . . Ch' ey provided that the person accep ing this permit shall in every respect conform the terms of the appllCatIon 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 CONST N S Rough Service ..... .. ......... .... ..... Final BUILDING IN EC R GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place onthePremises — Do Not Remove Final YY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. t Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - TYPE-OF-:SEWERAGEDiSPOSAL - - Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc... ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM _: ..DATE REJECTED- DATEAPPROVED PLANNING & DEVELOPMENT ❑ [� COMMENTS -CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/signature ®ate Driveway Permit DPW Tows. Engineer: Signature: Located 384 Os ood Street 'FIRE DEP,�1RTf LNT Temp Dumpster on site yes L, no Located-at 124.Mair Street - Fire ®epartmer!fsignature/date`` �� COMMENTS NEW ENGLAND CUSTOM DESIGN, INC. 226 LOWELL STREET WILMINGTON,MA 01887 #978-658-0881 Home Improvement Contract Registration No. 102467 ROOFING AND SIDING AGREEMENT This is a legally binding contract.Make sure you read this Agreement and understand it before signing it.Do not sign this contract if'there are any blank spaces. NOTICE:All home improvement contractors and subcontractors,unless specifically exempted by Massachusetts law,must be registered with the Commonwealth of Massachusetts.All inquiries about registration should be directed to: DIRECTOR-HOME IMPROVEMENT CONTRACTOR REGISTRATION One Ashburton Place,Room 1301 Boston,Massachusetts 02108 �y Telephone:#617 727-8598 his Agreement s made on /S 20�,by and between New England Custom Design,Inc.(hereinafter,"Contractor") 1d owner X VI: l2 M/I9� (hereinafter,"Owner"),of ity/'Town 17111,1061✓r/Z State Zipl�/JVJ (H)Phone%2C_-6ef6 V5/8ro b Address("The Premises") __ �U�i�J/��e :S/ (W)Phone ew England Custom Design,Inc.Salesperson c v Roofing will be applied only on slope roof surfaces below,over present roofing shingles unless specified under REMARKS. rW MATERIAL � �U �/�IYL��iLc� ��� Color O Main Roof_vim. Bav Windows�YrS Extensions ye- / tii� lL2/9 c Porches:Front_ Side Rear Other Roofs fie ilvcl",-Irtl NOTE:Roof board replacement cost -_���� per foot OR C/.21 cY` per a'x 8'sheet of inch CDl plywood. EMARKS//EXTRAS:Missing or defective lumber is not included in any category of work unless specified here. �ye-le c1;= H / j` I-O( // C Lt t 7(e,,¢%r"i AIF �•K/ O/ _� C7 Lv�c '7v �'i�o �cxS�•� r c tic,F r?-•i i��' . A%I ��z��r�C1 r/: tvo ��) �=J-srn.f �i)/)rT•vn-� los l E''z/� >S- cc �,,// 6r-/t0/)r/� ��j G ✓t✓� '6/i%1�.,/ c'l-//r ��/i�m�'v�l/ The Contractor�es to perform in agood and workmanlike mannerall work detailed atom gt% C CASH PRICE$ a L�t DOWN PAYMENT'S Note:All Roofing Customers: �!.�l� c 6 ✓' New England Custom Design,Inc.will not be PAYABLE ON START OF WORK$ )�I S held responsible for dust and debris falling in PAYABLE S attic areas during roofing installation.Please PAYABLE ON COMJ LETION S r�?C>5. °` /r✓/7r C j //P� _ remove or cover valuables. DATE: RZ25 --20 -2 RIGHT TO CANCEL ie Owner may cancel this agreement if it has been signed by the Owner at a place other than the address of the Contractor,which may be his main office or branch thereof,provided that the Owner nifies the Contractor in writing at his main office or branch by or mail posted.by telegram sent or by delivery,not later than midnight of the third business day following the signing of this Agree- ent.See attached Notice of Cancellation.A cancellation fee representing 30%of the contract price will be in effect if cancellation is requested alter the legally allotted tune has elapsed. r ac Owner hereby certifies that he has read this.Agreement.that the terms and conditions and the meaning thereof have been explained to him.and that he fully understands them and that there is no tderstanding between the parties,verbal or otherwise,than that which is contained in this Agreement,and agrees that the said Contractor is not responsible nor bound by any representations not con- ined in this Agreement,made by any of its agents,unless the same be reduced to writing and signed by the Con �) TIF. HOMEOWNER NOT SIGN THIS CONT IF TIME ARE ANY B1.AJVK.SPACC6 S 1 /G, /�/-- -1 tier's S azure - a�te -�— Ne England Custom Design.Inc. Date Date owner"s Signature '�.- v - Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-008828 Construction Supervisorr VAI. J LANZA 34 BIXBY ST REVERE MA 02151 ► <:•.': in:r;: r ..ommiss loner Expiration: 04/20/2018 � U12,-P- C2�?Q�???i222�a2iL4�P(.�iL��l2 f- _ O Lice of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration -- Registration: 102467 - Type: Private Corporation Expiration: 7/2/2018 Tr# 419291 NEW ENGLAND CUSTOM DESIGN,-,INC-.-." Val Lanza = 226 LOWELL ST. WILMINGTON, MA 01887 Update Address and return card.Mark reason for change. 3ca 1 05 20M-05/11 � Address [j Renewal F—] Employment [] Lost Card ACCORD� CERTIFICATE Ot= LIA DAT'EIMM10 YYYY) �- _ BILITY :INSURANCE 3/19/16 THIS CERTIFICATE IS ISSUEDAS 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 INSUREMS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the c9MtIcats holder is an ADDITIONAL. ItVSURED, the Policy(ies) must be endorsed. If SUBROGA710 IS WAIVED, subject to the terms and conditions ofthe polity, rimy,certain policies my require an endorsement. A statement on this certificate does not confer rights t0 the certificate holder in lieu of Such endorsemengs). PRODUCER CONTACT Kilgore Tnsurance Agent-y PHONE — 5 Centennial Drive 978 531-6550 Rax N (97B)-531-9441 Peabody, MA 01960 ADss: INSURER(S)AFFORDING_COVERAGE NAIC/ ---- INSURER A;Western World Tneurance INSURED — _.-._.._ .....--.-. IfasuRERs:Travelers Insurance Company Now England Custom Design ---- Ran Weinberg I NSU RER C — ___....._............. ... 226 Lowell Street / Unit B4 INSURER D-A ___.....,..- ...____..._. INS�jtEA e Wilmington, MA 01887 -- --- INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SE.OV11 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 ANDCONOITIONS OF SUCH POUCIES.LMrTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUaR . ... --- --.__... .... _.. LTR TYPE OF INSURANCE PODGY NUMBER POLKY EFF POLICY EXP " MIMN MMIDO! North Andover MIMAP August 29, 2016 108�C 0142; J125�TURNPIKE SlT 108:Cx0053' ,I `1�08888Q010'k 4j 1;08'C=::0009! I3..4 108''C 0054? �2535$�TORNPIRE STS "SO, ,.•..:�.[u.•-::::.. .- 114 `7 $. x - 21s4TURNPIKE ST` 108 C.0008 108�C-0055) 2170 TURNPIKE S - :-., '�j, ,� �2i1!55 TURNP_IKE�ST 1e Tj �lo ,c o032� J f los c�000;; '100, Aw / 2177''�TURNPKESrT X308�Cp004 ` e. RA • &;,y 2^1189�tT_,URNPIKE;ST} ° U C,0067} 105'C 0060' d&. ...- ---- .-._ 2nf63(T�yU RN PI KE 5TH sk rj ••-•' 108'C'"O_059'r `�•rr =' 108"C=.005 , a 108'C-003.8 ":11 �lr t' �ttr 108 C-0042# _ 5alu z t108�C=0043.. 9108�C�,0039� , f—.:.�u:.`--.: lc MVPC Bo Zoning Overlay Zoning 0 Municipal Boundary ©Adult Entertainment Distric 0 Businei s 1 District 0 Machine Shop Village Ove 13 Busine s 2 Di del Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Rail Line Watershed Protection Dist O Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Interstates Historic Mill Area 0 Busine s 4 District HORTil Valley Planning Commission(MVPC)using data provided by the Town of —I Medical Marijuana 0 Gene Business District Of sae q� North Andover.Additional data provided by the Executive Office of —SR ©Downtown Overlay District O Planne Commercial Dev <<? 'aye O Environmental AHaim/MassGIS.The information depicted on this map is Roads 0 Historic District 0 Corrido Development Dist 3. e - O( for planning purposes only.It may not be adequate for legal boundary 0 Osgood Smart Growth(40 it Corrido Development Dist O .— "`- P definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER i r Easements Ct Hydrographic Features 0 Corrido Development Dist f p MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING C`.❑ Industri I 1 Distrix 4t y _ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Parcels --Streams Q Industri 12 District 4t ii ^ OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT Wetlands 0 Industri A3 District ♦ e j ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Exempt Lands Reside ce 1 District 0 Resid d I S District 940 _^^`• ' THIS INFORMATION O Cl Reside ce 2 District SSwCMUSE 0 Reside ce 3 District de ca4 District 1"=144ft deceSDisbct ede ce 6 District age esidential District ' The'Commonwealth of Massachusetts G4 Department:of Industrial Accidents a � a Office of Investigations 660 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'.Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): N l kl 5MCt.A "d CUs /G•r► jOkSiGi.jV !`address: -2--Z 6� 1-6WlL LL 9 I 144 L� 1 ova Illi+/ Ci iy/State/Zip: .W L AlipV,<j o" M4, O/Vj Phone #: _79- il, d 6 0 Are you an employer? Check the appropriate box: Type of project(required): 1.[FI-am -, 1am a employer with�_ 4. ❑ I am a general contractor and I. employees(full and/or part-time).* have hired the sub-contractors 6. F1 New construction 12.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9 E] Building addition irequired.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [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 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 anadditional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ane an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: l� /Z A Vl5 L&a S Poiicy#or Self-ins. Lie.#: 7 oP 6;5O'1)41 Qg -7®`z Expiration Date: -3 / Y-17 Job Site Address: TU r, A/ (f/ k4 City/State/Zip: N, A-" n,� 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 under the pains andpenalties ofperjury that the information provided above is true and correct: Si nature: Date: Phone#: ® nq 1 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 sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pen-nit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in -(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 Revised 11-22-06 www.mass.gov/dia