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Home My WebLink AboutBuilding Permit #624 - 23 COBBLESTONE CIRCLE 3/27/2007BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 2 0 IMPORTANT: Avvlicant must complete all items on this page TYPE OF IMPROVEMENT PROPOSED USE ' Residential Non- Residential ❑ New Building I`One family ❑ Addition 0 Two or more family ❑ Industrial eAlteration No. of units: 0 Commercial ❑ Repair, replacement ❑ Assessory Bldg 0 Others: 0 Demolition ❑ Other Public CJ Sewer t: D Water . : ° flood lam ;:0::Wetlands ❑ Watershed'District. OWNER: Nam DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Txve or Print Clearly) V9 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. 512.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost $ t , �� FEE: $ Check No.: -71 7,fl Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location No. 6,2 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 21C 70 SACHUS Foundation Permit Fee $ Other Permit Fee TOTAL Check# ? 200 3' Building Inspector Plans Submitted ❑ Plans Waived ❑_... _ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM r PLANNING & DEVELOPMENT ❑ COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ WI 'rell E]Tobacco Sales ❑ - S `'I .. Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ Planning Board Decision:Comments Conservation Decision: Comments Water & Sewer Con nection/si nature & Date Driveway Permit Located at '384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no _ Located at 124 Main Street Fire Department signatureldate COMMENTS ` 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 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 r' Addition Or Decks 14 ❑ 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 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 Engineeredproducts 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 'CO) m m �o m m m (A v m 2 H C � COD CM) go 0 CD a y CLO '0 FS, C � � C d. y a� o cmj O C2 CD QQ O rF Q =r d W CD o C O co) avCDy —• o co CCD v CO) O 1CD Z O CD■ CD ri 0 Lo Fj Im-" cn V I \ / O cn O RM ro m m cn o� 0 _ n Z o� m �0 m m 0 y N N Q?m: m S > >mw m a Q ZS. eC2°; 1 Q fA m C iry�i CL \ > C m CID m CL COD `- IL N w to 5b y ate. T �m aQ mc COD co CA 0 V7 CD I : T Fid- :o N � O s CD cn C o ? CD dd CL O C O ~•: El TF zql p O O Orb n O O � r G. x 7d 7d G, qN, H 0 0 c FROM : KIMBLY FAX NO. : 6033629679 Mar. 27 2007 09:51AM P6 HOME IMPROVFMEN1 CONTRACT It .. Sold, Funflshcd and InMalled h Branch Name 7�'', , ;a / Date, k' 11111 AFHanie Services. Inc, dth. a The; 140111C Pepbl At -Homo Servic es 1 345A Greenwood Strut. Worcester, MA 01607 Branch Numher: Job #. %�, Q� Toll Free ($00) 657.5182; Fax: 508-7511-2859 tedir d lT1 >t 75-20M 14F. Lic u C 02439 Rl CWit. U09 1642.1 %� i � t1 i'r f.ic n 1 33 MA rmpnrovenrnt Cw11maM IIcg. 8l'_Ofi93 Installation Address: • ) ( �_+, } op 1. f 1 J� f s �t_ozi City Sp Home Address: (If dift'crent fromlastatlation Addtes6) City Stare Zip - 0. E•msfl Address (to reotive updates and prornotions:finffi The Roma Pro3eCt inf scion: 11WelYau (PtntiltAsei"), tbt owocrs'of f6e ptapofty'lacaterl xt tho'above instdltsdon tirddiess,'offcr to contract catch }come Depmt U.S.A., Inc. ("$ome 0gpor9 to Nish, dcliver•and ezangr fm the installation aall'mstim" as doscrilml on the sttachod Spec Sheet A , wompomted herein byraferatce and made a Pam hernof. Horfle Depot receives the I t ht In,: ancel this bontrect if, Upon. re:foapeetjox $f iht ;}Tema Depot•deberu&es that It Cannot Iicrforin It, -oblllpttiom'dva to a stRimrgi Peitbie7li Whh the berm% prlcing roan or. becsnse'*ork required to complete the lab carts net included hi the 6pec Shaer bi• Ccatiad. -_.:`:DEPOSIT PAYMENT.0PTION6 • .. _ .. •• ' �tibjeet to fAi1d 1RfIf ciliao,mNoi cte&t epplDVOf:) ., . . CONTIIACI AMt)ONT , g i. ' Cbtck, Oshien Cbe* or LiS Posta sermon Mmoy Orifer @trade po&.eih The leoax il"4, *LESS DEPOSrr ,; J I �. , 2. t]sitie iced' an8lornther MM9M oatk+m-(.'irde Ow edaw " vas kUz1vCz4 Piemyar Ameriaaa £d 13ALAiYCrDUE ,• Homc.IkpoitIometmpmwma '[ixSlao,eYwcYoditCard - • ;"�,eiA�.ii ' '''r;�idtr�Aisuoi 'tiltt.�?toc)c.tmIIXl . :*1�iaimriiit3$`1'0 of Coatrnti Ameaat dee aped - 4Y?CtlNii�A9tt}Ilsr9atrAt = Ayaa�t1le,tkedih:.S_ (1RGA.3�OIVGY) indleaie' Pa;`ent Me, tbad For ' ' . w,1 B31L�tNCF:,#]Utr.tflY GwONII!L7ait0 ; :.` :•; _ fes i •t :..my/our ::.beFo rtildw . i j. .. •. •,'c�rg'a`!lu>'e •chit ottheid`epastf...ca4c+d'..: .. •. ` .. : Ddc '• *' 2y' be subject to Credit Apptevat, liutd . .' HIL or1iDCC AUlhoh sate' : `Vt'tiBtaltioh And/or Credit Caed Andtai zit do . t 1Phheiti Pi at Wiwi oY the work, Pmrhaser wilt execute a Completion Cefli6cate and paY �Y PlimUser.ageea that, immediately Pay Purchaser also resew tuband se o111iRsted sad liable deuade ! irt01ellner!. •I�Ygceentent aeae 1s1eh1dtng achy egrecmcni contain the cor ode.agrecment ..lih Oven the ps "and Can amundcd or:in d Writ a ....kneilby •.. /�'ti�Q�37 41�LZ t'1:,�"(>� :: ;�.:" ' ' .;•':- �ali��`��-. •-.,>,�t7r • �,�•',� ��r , SIG! sign this t"riact 6df rs you t�ad'it" Yoit rre e'atiited ep'a'campIe�e� ftiledaii eupy of lite•coatritettet the ohne Sap ICegp It -to protect your rim,, vie oot.slgn Co,'mpktian L`c Cffte'befbre, this pieject fa'camptete. Taw plobibria'bgrta repair CbntmcWrc from• pasgt pr acCept}np Q:Gomple' On Certi6t Rte _bp rhe' owner prier t0 iiffke cite actual Coin eipn o[ the wor4 to'tie.ph.lPas eii U>ir .'You fWkr..rancA this trahtcaction SO tbni prter,tq mfda hr of. the lthird 6usium day after the dgte.of this centrist. See Netice of Canceiletiun fur as ezplaontion of tbls Tight. •. rhere be •a servlet Charge aqua) to 10% of the act, Set t .will ttitiunnt if jrtb is -Cancelled by Pdrebasei AFTER rite thfr• i basiaess day, bOt BEFORE nMteriala arc oryieof There trill lie tt'aeiviec charge surae to 25% of'the coalraet2r 1d ht ffjCb•in csncette+tt by'PurchmerAFTER materials arc ordered. W-MYMUR 9IGNAIUX BELOW,. I1WH AGREE TO E!E EbUND .BY. 111E TERM'S OF rHis. CONTRACT. .ilWB ACIGI OWLEbt,E RECEIPT OF A COPY O.F TiM CONTRAG•T ANA TWt! COMPLETED COPIES C!F THE NOTICE .UF:C.A'NCBLLATl0N. -- : .UNDE�MAND a DY MY/OVR SIC3NURE BELOW, IIWE THAT THE AGREEM6f.IS `:•RiVIEYC/OUR CRED STORY -AND TIWE AUTiORE HOME AO SUBJECT TO iLVIEW OF. 27 IMY/OUR �f !(T.- CREDTTRMORTWGENCY ORD 14 AOO .AND RELEASE THEM FROM ALL L1A131LrrY Ii+ GCtItRED FROM }NAlltlE NS OR ERRORS. ,-— � L BUBlwirr b BY: C Bate: f �okxGmeuiwn j i ! Hom'aowner Date: H, Date: NOTICE; ADDMONAL TERMS AND CONDITIONS ARE STATED ON THE REVEL: 5IUk AND ARE PART Op THIS CONTRACT 10-24-06 C -SG White - BfArKh Filo Yellow _ Cugomar Pink — pales Consultant e _.......... flee t a�sz•�n<.•r,.rr,<:ret%. ref =lru7.sr_cvi�i•1Pt/S rF \ Board of Building Regulations and Standards t u, License or registration valid for individul use only LC HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: `4 Board of Building Regulations and Standards k%/ ... 9 126893 ..... .. _ _ _ . Re istration Expiration:8/3/2008 One Ashburton Place Rm 1301 --:= . Type:. Supplement Card Boston, Ma. 02108 THE Home Depot At -Home Servic AT1NROEUN CHHOUY 3200 COBB GALLERIA PKWY #20 AtIANTA, GA 30339 Administrator Not valid without signature Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor. 345 Greenwood St. Unit 2 • Worcester, MA 01607 • 508-756-6686 • Fax 508-756-2859 • Toll Free 800-657-5182 cz q AT-HOME installed 15 E7 Siding and Windows a, e _.......... flee t a�sz•�n<.•r,.rr,<:ret%. ref =lru7.sr_cvi�i•1Pt/S rF \ Board of Building Regulations and Standards t u, License or registration valid for individul use only LC HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: `4 Board of Building Regulations and Standards k%/ ... 9 126893 ..... .. _ _ _ . Re istration Expiration:8/3/2008 One Ashburton Place Rm 1301 --:= . Type:. Supplement Card Boston, Ma. 02108 THE Home Depot At -Home Servic AT1NROEUN CHHOUY 3200 COBB GALLERIA PKWY #20 AtIANTA, GA 30339 Administrator Not valid without signature Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor. 345 Greenwood St. Unit 2 • Worcester, MA 01607 • 508-756-6686 • Fax 508-756-2859 • Toll Free 800-657-5182 FOR EVIDENCE ONLY 4HNt.tLLA I IVN`, SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE (HEREOF. THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL '10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS CERTIFICATE. Mary Radaszewski I(3IO2) VALID AS OF: 02/28/07 MARSH CERTIFICATE NUMBER CERTIFICATEOF 'V7lRANCE .... _.. ...,... ATL-001234410 01w PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA, INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE homedepot.certrequest@marsh.com POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE FAX (212)948-0902 AFFORDED BY THE POLICIES DESCRIBED HEREIN, 3475 PIEDMONT ROAD, SUITE 1200 ATLANTA, GA 30305 COMPANIES AFFORDING COVERAGE COMPANY 100492-THD-IPUSA-07-08 IPUSA A STEADFAST INSURANCE COMPANY INSURED COMPANY HOME DEPOT USA, INC. B ZURICH AMERICAN INSURANCE COMPANY 2455 PACES FERRY ROAD NW COMPANY BUILDING C-8 ATLANTA, GA 30339 C AMERICAN HOME ASSURANCE COMPANY I COMPANY D NEW HAMPSHIRE INS COMPANY COVERAGES This certlficate'Supersedes and replaces any p eviousiy issued certificAte,for the.policy period noted tielow,;..-,. �. THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDIYY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/07 03/01/08 GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS' CLAIMS MADE a OCCUR 'OF SIR: $1,000,000 PER OCC PERSONAL 8 ADV INJURY $ 4,000,000 EACH OCCURRENCE $ 4,000,000 OWNER'S & CONTRACTOR'S PROT FIRE DAMAGE (Any one fire) $ 1,000,000 MED EXP (Any oneperson) $ EXCLUDED B AUTOMOBILE LIABILITY BAP 2938863-04 03/01/07 03/01/08 COMBINED SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) I $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ X ELF -INSURED AUTO HYSICAL DAMAGE GARAGE LIABILITY AUTO ONLY.- EA ACCIDENT $ OTHER THAN AUTO ONLY: ANY AUTO EACHACCIDENT $ AGGREGATE $ A EXCESS LIABILITY IPR 3757 608-02 03/01/07 03/01/08 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 X UMBRELLA'FORM $ OTHER THAN UMBRELLA FORM C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 2921209 (CA) 03/01/07 03/01/08 WC STATU- TH X I TORY LIMITS ER EL EACH ACCIDENT $ 1,000,000 E 2921210(FL) 03/01/07 03/01/08 EL DISEASE -POLICY LIMIT $ 1,000,000 F D THE PROPRIETOR/ X INCL PARTNERS/EXECUTIVE OFFICERS ARE: EXCL 2921211 (AZ, ID, MD, VA) 2921208AOS ( ) 03/01/07 // 030107 03/01/08 03/01/08 EL DISEASE -EACH EMPLOYEE $ 1,000,000 C OTHER 2921213 (QSI) 03/01/07 03/01/08 E WORKERS'COMPENSATION 2921212 (KY, MO, NY, WI) 03/01/07 03/01/08 G TEXAS EMPLOYERS TNS-C44642086(TX) 03/01/07 03/01/08 EACH OCCURENCE 25,000,000 EXCESS LIABILITY SIR 2,000,000 DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLESISPECIAL ITEMS FOR EVIDENCE ONLY 4HNt.tLLA I IVN`, SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE (HEREOF. THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL '10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS CERTIFICATE. Mary Radaszewski I(3IO2) VALID AS OF: 02/28/07 FOR EVIDENCE ONLY MARSH USA INC. BY Mary Radaszewski'' �.\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 �,�`�.•I , www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors'Electricians/Plumbers Applicant Information _ _ Please Print Leeiblvv Name (Business/Orzanizationllndividual): Address: C�r City/State,/Zip: Phone I `� lob Are you an employer' Check the appropriate box: 1. I am a employer ,,N•ith 4. ❑ I am a general contractor and I employees !(full and/or part-time).* have hired the sub -contractors f—I .,- T aT a Sole pr0p--:.�- 1, or rar=er - listed on the attached sheet. + ship and have no employees These sub -contractors have ,vorking for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152. § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ® Remodeling S. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11.❑ Plumbing repairs or additions' 12.❑ Roof repairs 13. ❑ Other 'Any applicant that checks box ..# I must also fill out the section below showing their workers' compensation police infomtation. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidaNit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' tomo. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the polic}! and; job.siie w r information. Insurance Company Name: Policy = or Self -ins. Lic. #: Expiration Date:- �L, —rte Job Site Address: 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify -under the pains and penalties of perjury that the information provided above is true and correct r Si2mature:�,g � e4 Date: Oficial 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 #: Massachusetts General Laws chapter 152 requires all employers to provide workers" compensation for their employees. J �. 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 indiN idual, 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 ernplo�rrient 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." 10 Applicants t Please fill outtheworkers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees. a policy is required. 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 Indus I ation policy, please call the Department at the number listed below. Self-insured trial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' cotricompanies should enter their self-insurance license number on the appropriate line. Citv 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 affida%it 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 permit/license applications in any given year, need only submit one affidavit indicating current that must submit multiple pe app " applicant should write "all locations in (city or Site Address the (if and under "Job policy information (it necessary) town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the 2nnhcant as proof that a valid affidavit is on file for future peruts or licenses. A new affidavit must be filled out each tr vear. Where a homeowner 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 I1 v.estigations 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 Deparnnent 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.eov/dia