HomeMy WebLinkAboutBuilding Permit #726 - 23 STACY DRIVE 6/9/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
-?a(
Permit NO: . I/
Date Issued: - �!
IMPORTANT:
LOCATION o? 3 STI, ee
Date Received
must complete all items on this
_ Print
PROPERTY OWNER -7D2 'R,/l d1,11 e
Print'
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
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
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION ,OF WORK TO BE PREFORMED: r.
Identification Please Type or Print Clearly)
OWNER: Name: J-O5e/W 11oUL f Phone:
Address: d-� s7;0vee V 90/2
/7/1# 0/94 ,�
CONTRACTOR Name: ,7�C>S'el''1 Phone: 9 2if' Y.?
Address: /G d!T& %7% 6T 'Th �Q ei2' /99 /�L 491 e��-
Supervisor's Construction License: 1 Exp. Date:_62 QC -0
Home Improvement License: /400 9' ' Exp. Date: � SfdO/D
ARCHITECT/ENGINEER Phone:
Addre
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: $ �� OD® FEE: $ 0701—
Check
701"
Check No.: 6-301 � Receipt No.J D a a a—
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWER/AGE 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
COMMENTS
CONSERVATION
COMMENTS
DATE REJECTED DATE APPROVED
Reviewed on Signature
HEALTH Reviewed on Signature
COMMENTS
r
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department: signature/date
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
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
o 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENTMFORM07
Revised 2.2008
Location ir,
No. Date • b
TOWN OF NORTH ANDOVER
A P
Certificate of Occupancy $
M�s <�• Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Z�9Check #
2.222 ? Building Inspector
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CONTRACTORSCOPY
RESIDENTIAL CONTRACTING AGREEMENT
Read this agreement and make sure you understand it before signing it. This Agreement has legal
force and effect binds those who sign it.
Notice:
All home improvement / general contractors and subcontractors engaged in home improvement
contracting, unless specifically exempt from registration by provisions of Chapter 142a of the
general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about
registration and status should be made to the Director, Home Improvement Contract Registration,
One Ashburton, Place, Room 1301, Boston, MA 02108.
Designated Registrant's Name: Roger J. Ratte', Inc.
Salesperson's Name: Joseph R. Ratte'
Registration Number: 100294
License Number: 015004
This agreement is made on June 6, 2008 between Roger. J. Ratte', Inc.
DBA R. Joseph Ratte', Inc. of 10 Main Street North Andover, MA 01845 Ph. (978)-688-8839
hereinafter called "Contractor" and Joseph Houle of 23 Stacey Drive North Andover, MA 01845
(978)687-1044 hereinafter called "Owner".
I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED
Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such
work consists of the following: Remove and replace kitchen cabinets & countertops. Remove and
replace bathroom vanity and tops, tile kitchen floor. Install pocket door.
DETAILED DESCRIPTION OF MATERIALS TO BE USED
Materials to be used in performing the above described work consist of the following:
Supplied by owner.
II. PRICE
Contractor agrees to do all work described in Section I for the total price of : $20,000.00
Twenty thousand dollars.
HIDDEN CONDITIONS AND NECESSARY ADDITIONAL WORK:
Hidden conditions or additional work may require adjustment in the overall price for the necessary
work related to this contract. In such case the Contractor shall inform the Homeowner of such
conditions forthwith and where necessary a written amendment of this Contract will be negotiated
and executed by the Parties. Additional work beyond the scope of this contract will be billed at an
hourly rate of $60.00 per man hour for carpentry and $80.00 per man hour for plumbing.
Additional material and subcontract work will be billed at direct cost plus a 25% General
Contracting fee.
III. PAYMENT
Payment will be made as follows:
$5,000.00 Deposit with signed contract
$2,000.00 At start of job.
$5,000.00 Completion of cabinet installation.
$8,000.00 Completion of job as per specifications.
Optional work will be billed separately.
Payments as provided above shall be made when due. Any payments that are delayed shall be
subject to a finance charge of I% per month.
Notice: No agreement for home improvement contracting work shall require a down payment
(advance deposit) of more than one-third of the total contract price or the total amount of all
deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain
delivery of special order materials and equipment, whichever amount is greater.
IV. COMMENCEMENT AND COMPLETION OF WORK
Contractor will not begin the work or order the materials before the third day following the signing
of this Agreement, unless specified here in writing. Contractor will begin the
work on or about June 9, 2008. Barring delay caused by circumstances beyond Contractor's
control, the work will be completed on or about June 30, 2008. The Owner hereby acknowledges
and agrees that the scheduling dates are approximate and that such delays that are not avoidable by
the Contractor shall not be considered as violations of this Agreement.
V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED
The Contractor may not require payments to be made in advance of the time specified in Section
III (Payment) above for the reason that he deems himself or the payments to be insecure.
If, however, he deems himself to be insecure, he may require, as a prerequisite to continuing the
work described herein, that the balance of the payments under this contract that are in the control
of the Owner, shall be placed in a joint escrow account that requires the signature of both the
Contractor and the Owner for withdrawal.
VI. INSURANCE
Contractor will be responsible to Owner or any third party for any property damage or bodily
injury caused by himself, his employees or his subcontractors in the performance of, or as a
result of, the work under this Agreement. Contractor agrees to carry insurance to cover such
damage or injury.
VII SUBCONTRACTING
Contractor agrees that, notwithstanding any agreement for materials and/or labor between
Contractor and a third party, Contractor is responsible to Owner for completion of all work
described in a timely and workmanlike manner.
VIII CONSTRUCTION -RELATED PERMITS
The following construction related permits will be necessary in order to complete the scope of
work included in this contract and are the responsibility of the Contractor:
(mark X where applicable)
Building X Demolition
Plumbing X Electrical X
The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and
obtain all construction related permits. Home improvement work (i.e.. additions, garages, porches,
etc.) may require other permits including but not limited to Variances and Special Permits under
Zoning by-laws through the Board of Appeals, Board of Health Permits for expansion of sewage
disposal systems, Conservation Commission for an Order of Conditions, etc. Such permits which
may require non -construction related, engineering, technical or legal representation of the
Homeowner, shall be the responsibility of the Homeowner.
Notice:
If the homeowner obtains his own construction -related permits for the work described under this
agreement, the homeowner is hereby advised that in the event of a dispute, judgment and
nonpayment of the Contractor, the homeowner will not be entitled to make a claim to or
collect from the guarantee fund established by Chapter 142A, M.G.L.
IX. MODIFICATION
This Agreement, including the provisions relating to price and payment schedule cannot be
changed except by a written statement signed by both Contractor and Owner. However,
cancellation by Owner is allowed in accordance with the Notice of Cancellation (annexed).
X. WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from defects in materials
and workmanship for a period of one year following completion and shall comply with the
requirements of this Agreement. In the event any defect in workmanship or materials, or damage
caused by Contractor, his subcontractors, employees or agents, is discovered within one year after
completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith
remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or
such defect in materials or workmanship. The foregoing warranties shall survive any inspection
performed in connection with the agreed-upon work.
All warranties for equipment supplied by the Contractor under this Agreement shall be those
given by the manufacturers of such equipment, which shall be and are hereby passed through
directly to the Owner. Under such manufacturers' warranties, the Owner may be required to
register or mail in a warranty card or other evidence of ownership and use of such equipment in
order to activate such warranties. The Owner's failure to mail in or register such documentation,
which failure voids the manufacturer's warranty, shall not create any responsibility for the
Contractor to warranty such equipment.
XI. COMPLETENESS OF AGREEMENT FOR EXECUTION
The Owner is hereby advised that he should not sign this Agreement unless and until all blank
sections have been filled in or marked as void, deleted or not applicable, and until all exhibits and
related or referenced documents that are incorporated herein are attached hereto.
XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER
This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate, and
an original signed copy hereof given to the Owner at the time of execution. No work
under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner
of a copy thereof.
RIGHTS TO CANCEL
The owner may cancel this agreement if it has been signed by the owner at a place other than
an address of the contractor which may be his main office or branch thereof, provided that
the owner notifies the contractor in writing at his main office or branch by ordinary mail posted
by telegram sent or by delivery, not later than midnight of the third business day following the
signing of this agreement. See attached Notice of Cancellation.
HOMEOWNER DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner's Signature Date Signed Co actoWsDate Signed
t.;
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registrati w.. 100294
ExPiratlO: 6115/2010 Tr# 268002
TypePrivate Corporation
ROGER J. RATTE INC.
Joseph Ratte
340 Mt. Vernon Std,,,.`
Lawrence, MA 01843 Administrator
19WMn09u1Aeae!Qi 0-Aaaaac/uu a
3osrd of RWbfwm sad Staedards
Corm Stapervisor License
LIC040 CS 15004
"—Im-012
JOSEPH R RATTE'' r v
340 MT VERNON ST
i
LAWRENCE, MA 01843 Commissioner
04/30/2008 14:52 FAX 9785572130 Michaud Rowe Ruscak Ins 10 001
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID
RATTE-1
DATE(MWDDNYYY)
04/30/08
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. T - ITWITHSTANOING
THIS CERTIFICATE IS ISSUED ki A MATTER OF INFORMATION
TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY E ISSUED OR
PRODu�
ANY, REQUIREMENT,
AFFORDED BY YHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONU-1TION3 OF SUCH
ONLY AND CONFERS NO RIGHT -1 UPON THE CERTIFICATE
Michaud, Rowe And Ruseak Ins.
"HOLDER. THIS CERTIFICATE We$ NOT AMEND, EXTEND OR
M,WwcLTRR TYPE OF INSURANCE POS NUMBER
DATE MMIO P M LIMITS
ALTER THE COVERAGE AFFOK ED BY THE POLICIES BELOW.
198 Massachusetts Ave
EA: •I OCCURRENCE
$1000000
North Andover MR 01845
Phone: 978 688 8829 Fax: 978 557 2130
PR; 'AIH US (Ea eaurenoe)
INSURERS AFFORDING COVERAGE NAIC #
NLSURED
MEI: EXP (Any ana pereon)
INSURER A' DXpLorrad Mutual Yneur. AC* Co. 15024
A X Business Owers
03/28/08 03/28/09 PE SONALaAOVINJURY
MSURERB Safety Insurance COmpan_y 12808
GEI,ERALAGGREGATE
INSURER C: American International COS
Roger J. Ratte I Inc.
PRi'DUCTS-CONIPIOPAGG
_
10 Main Street
INSURER D:
North Andover MA 01845
CC'•IBINED SINGLE LIMIT
b
1500030
01/16/08 01/16/09 (E''''mIder1)
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. T - ITWITHSTANOING
TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY E ISSUED OR
ANY, REQUIREMENT,
AFFORDED BY YHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONU-1TION3 OF SUCH
MAY PERTAIN, THE INSURANCE
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
M,WwcLTRR TYPE OF INSURANCE POS NUMBER
DATE MMIO P M LIMITS
EA: •I OCCURRENCE
$1000000
GENERAL LIABILITY
$ COMMERCIAL GENERAL LIABILITY BI
PR; 'AIH US (Ea eaurenoe)
$50000
CLAIMS MADE X❑ OCCUR
MEI: EXP (Any ana pereon)
$
A X Business Owers
03/28/08 03/28/09 PE SONALaAOVINJURY
$1000000
GEI,ERALAGGREGATE
32000000
GEN'LAGGREGATE LIMIT APPLIES PER
PRi'DUCTS-CONIPIOPAGG
32000000
POLICY JEa LOC
AUTOMOBILE UAPKJTY
CC'•IBINED SINGLE LIMIT
b
1500030
01/16/08 01/16/09 (E''''mIder1)
B ANY AUTO
ALL OWNED AUTOS
BCI.ILY INJURY
s250000
(Pin Person)
X SCHEDULED AUTOS
X MIREOAUTOS
BC ALY INJURY
$500000
(Pu actideM)
X NON -OWNED AUTOS
—
PR, PERTY DAMAGE
$100000
_
(Ph: a=jdmd)
AL 0ONLY -EAACCIDENT
$
GARAGE LIOJNLIIY
ANY AUTO
ANY
EA
01 ER THAN
S
AL 0 ONLY: AGO
$
EXCESSAIMBRELLA LIABILITY
EP H OCCURRENCE
S
OCCUR CLAIMS MADE
AG. AEGATE
$
•
5
DEDUCTIBLE
RETENTION $
WC STATUS
ER
WORKS COMPENSATION AND
IC
TORY LIMBS ER
EMPLOYERS'LIABILITY NC8944334
04/23/08 04/23/09 E.1 EACMACCIDENT
$100000
C ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICERIMEMBEREXCLUDED9
E.I. DISEASE - EA EMPLOYE
$100000
Ify6B d6ecflbeund9f
E.I. DISEASE - POLICY LIMIT
$500000
SPECIAL PROVISIONS below
OTHER
pE$CRIPTION OE OPERATIONS I LOCATIONS I VEHICLES I EXCLUSKINS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Trustees of Phillips Academy are named as Additional Insureds with rf!:;Pect
to liability arising from the operations of
the Named Insured.
CERTIFICATE: HOLDER CANCELLATION
' SHOULD ANY OF THE ABOVE DESM11101 POLICIES BE CANCELLED BEFORE THE EXPIRATION
PBILLT 1
DATE THEREOF, THE ISSUING INSURER VL LL ENDEAVOR TO NAIL
DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER N6MED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY O; ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATPJES,
ACORD 26 (2001108)
The Commonwealth of Massachusetts
Department of Industrial Accidents
MI Office of Investigations .
d 600 Washington Street
Boston, MA 02111
www.mass:gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluamtlbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):V
Address: /�
City/State/Zip: I%% 1,Yp1/��ye�2 Phone #:
Are u an employer? Check the appropriate box:
I. I am a employer with 3 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $
ship and have no employees
working for me in any capacity. E
[No workers.' comp. insurance 5 El
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
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
lo.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ 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_
LContractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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. Lie. #:�il/�� 8� 6 7 -23 z Expiration Date:
Job Site Address: 9?3 City/State/ZipM-
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 fihe violator:- Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA.for insuzance cover.g verification.
I do hereby cei ' under the pains a ei al.' .s of perjury t�t the information provided above is true and correct
Tate:
Official use only. Do not write in this area, to be coMpleted by city or town official.
City or Town:
Perruit/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 legalentity, 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 employei_"
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 cone ionwealth 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 Parnrerships (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.. ae 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 permighcense number which will be used as a reference number. In addition, an applicant
that must submit multiple perrnit/licensc 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 pem►it to bum 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.gov/dia