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HomeMy WebLinkAboutBuilding Permit #88-12 - 29 MABLIN AVENUE 5/1/2018 l AORT11 BUILDING PERMIT O�,1t�°o "b TOWN OF NORTH ANDOVER ..''.- *° APPLICATION FOR PLAN EXAMINATION * ,� V i ^p Permit NO: !� Date Received �9"°R,T.o cti �SSACHUS�� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION A Print PROPERTY OWNER,,, ` 7i , i;eco Print MAP NO: PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Village yes rno 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: a Identification Please Type or Print Clearly) OWNER: Name: Phone: } Address: CONTRACTOR Name: . � ..- f Phone: w Address: Supervisor's Construction License: w_� . 4?/. ?JExp. Date:: / -t1/ G Home Improvement License: r ` Exp. _Date. ' ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ CSD D FEE: $ ,6 Check No.: / 3 Receipt No.: 01 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty and Signature of Agent/Owner Signature of contractor Building Department The followingis a list of the required forms to be filled out for theappropriate ermit to be obtained. qP Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑. Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o 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 DEPARTMENT:BPFORM07 Revised 2.2008 I Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public SewerTanning/MassageBody 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance Petition No: Zoning Decision/receipt submitted d 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 Eire Departmentsignature/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 2 1 A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) i ❑ Notified for pickup - Date L.............__..........................._....._....................._......_..................._....._..._......................................................_..................... Doc.Building Pennit-Revised 2008 AORTH TONM Of ,to o0 dover, Mass., GO C HIC KE WICK \1 ORAT E D p'P�,��� BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 00 BUILDING INSPECTOR THIS CERTIFIES THAT........ ......... .. ! ................................ ........................................ Foundation has permission to erect...........:.:........ ................ buildings on ...Q �......... .«.. . r............ . ......... Rough to be occupied as.............6.....: .. +S. ... 'i'..... . ........ .. 4}.. Chimney provid8d that the person accepts this permit sh in every respect conform t terms of the application on file in Final 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 CONSTRUC STARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. EIN#51-050-3313 Haverhill MA 978.374.9224 MA Reg.HIC#149221 amber Lawrence MA 978.687.7339, MA Lic.UCS#78130 Hampton NH 603.929.9224 offing BBB. Single-Ply License#1711 Hampstead NH 603.329.8200 S%vic�Pi19.320, Toll Free 1.888.SOS.ROOF 265 Winter Street Haverhill MA 01830 t/� �rLicensed *Insured *Factory Trained" *Factory Certified Name: 11 1' C� Date: Telephone: ( r 9 6 1;0(1 1! Alt.Telephone: E-Mail: Billing Address: r� 1S1l+. n r�� *.,�0. CA_A)f It Job Address: eScope`of Work O,St p and Re-roof ❑Re-roof Approximate Roof Area:" C.0 '2 epare-force-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. 1�5Reiil6e existing layers of shingles down to roof deck and dispose of in a legal fashion from the job site. dAf�spect wood deck,if we discover any rotted wood,replacement will will performed at*$ S. 9.f per LF for roof deck boards.If substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$ per SF.If individual sheets are found to be rotted/or de-laminated,removal, disposal and replacement will be performed at*$ /rte--aper sheet.If any trim boards are rotted; .replacement will be performed at*$ " per LF for new pre-primed pine. Inspect siding at roof line and allflashing behind siding,if we discover any damaged flashing or siding at the roof line,replacement will be performed at*$ Z --- .If wood deck,siding,and flashing iis•sso�und,we will re-nail any loose wood to rafters, sweep deck, and prepare for roofing. �,lnstall,8"drip edge to all rakes and eaves. Color G.-4-41, pp y ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or X15%74 1-ile ®Apply premium(UNDERLAYMENT)to the balance of the exposed wood deck. 24e-flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness. fI'ff upon inspection,we discover chimney lead to be worn or deteriorated,replacement will be performed at*$ nstall anew: Year ❑ Traditional ❑ Architectural ❑ Designer i'�7;Fu fish and Install a new shingle over style ridge vent system ❑Soffit vent system*$ Z,Alfdebris generated by Lambert Roofing Co.,Inc.will be cleaned up and disposed of from the job site in a legal fashion.Under no circumstances will the watertight integrity of the building be compromised. Spleciafl Notes 1a' i Y � � �o- U �" 1/1.Ct CL �. ��� - I �i C' t •'te c'K t= 1/ , UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND..>' YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. � TOTAL CONTRACT PRICE AND PAYME'1\ CHEDUlfLE The Contractor agrees to perform the work,furnish the material"and labor specified above for the total sum of:,$_:�Z, (Dollars) Payment will be made according to the following work schedule: $ _, deposit upon signing contract � � f � $ by_/_/_or upon completion of $ �, �/. upon completion of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. I it DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES i Acceptance of the Contract Proposal Home Owners Signature(s): 1! k C-A C___ Date• Contractor's Signature: Date: / / EIN#51-050-3313 Haverhill MA 978.374.9224 MA Reg.HIC#149221 ambe Lawrence MA 978.687.7339 T MA Lic.UCS#7813d ' Hampton NH 603.929.9224 BBB. Single-Ply License#1711 '" offing Hampstead NH 603.329.8200 -'SivLAcA-_i19.32Cp, Toll Free 1:888.SOS.ROOF 265 Winter Street Haverhill MA 01830 (� *Licensed *Insured *Factory Trained *Factory Certified / 1 Name: 1 F �, t�.. Date: e5 / Telephone: f G�GG bf Alt.Telephone: �( E-Mail: Billing Address: ck-1 i l� f Job Address: S ope'/f Work 68t it p and Re-roof ❑Re-roof Approximate Roof Area: (©C _Z P-epare-for.re-roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is p7operly protected. emove existing layers of shingles down to roof deck and dispose of in a legal fashion from the lob site. E6,41 spect wood deck,if we discover any rotted wood,replacement will will performed at*$ 9 5- per LF for roof deck boards.If substantial deck rot is discovered,re-sheathing of roof deck can be performed at*$ /'. G per SF.If individual sheets are found to be rotted/or de-laminated,removal,disposal and replacement will be performed at sheet.If any trim boards are rotted, .replacement will be performed at*$ — per LF for new pre-primed pine. Inspect siding at roof line and all flashing behind siding,if we discover any damaged flashing or siding at the roof line,replacement will be performed at*$ 19— . If wood deck, siding,and fla is sound,we will re-nail any loose wood to rafters,sweep deck,and prepare for roofing. VT-­InstalL8"drip edge to all rakes and eaves. Color G., /;, ,C ,pp yy ice&water shield(UNDERLAYMENT)as per manufacturers'specifications and/or � Tf" ® Appl�remium(UNDERLAYMENT)to the balance of the exposed wood deck. ®%'Re-flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensure water tightness. ,,k-!,f upon inspection,we discover chimney lead to be worn or deteriorated,replacement will be performed at*$ Install a new.: Year ❑ Traditional ❑ Architectural ❑ Designer �'T`Jur is and Install a new shingle over style ridge vent system ❑Soffit vent system *$ debris generated by Lambert Roofing Co., Inc.will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstances will the watertight integrity of the building be compromised. SP ial Notes\ �� ye .���"o /�' c; yr/ 1- C UPON COMPLETION AND PAYMENT IN FULL,ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF— YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY ANDJ�t5YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. ��, TOTAL CONTRACT PRICE AND PAYME' ' CHEDULE The Contractor agrees to perform the work,furnish the materia.19 and labor specified above for the total sum of:�$� _n�' / f_. �'L%'' /�C/G/-.•{�' i' /. "///� fr' (Dollars) Payment will be made according to the following work schedule: $ -deposit upon signing contractC�,f28.� $ by_/_/_or upon completion of YY�/ $ iCJ. upon completion of contract. / 1 (Law forbids demanding full payment until contract is i ompleted to both party's satisfaction) You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached niotice of cancellation for for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Acceptance of the Contract Proposal I , Home Owner(s)Signature(s): cjk t _ r, `-'t. ..�� Date: Contractor's Signature: Date: I � �ce of�:80sumer Affairs and usmess Regulation 10 Park Plaza.m Suite 5170 Boston, Mass psetts 02116 H01-11e Improvement et®r Registration - r-= Registration:, 149221 9�{ w r^ Type: Private Corporation. .�� ,. ={ Expiration: 1 2/612 01 1 Tr4 290268 IRs' ROOFING CO rte,� RiCHAIRD LAMBERT 265 W NTE-R SI-REET HAVERHILLI INA�- 01830 Upd :Address and.return card.!mark reason for shaaaga cis ce l �o soW04(0 G191216 Addams [] Renewal Employment Lost Ca Massachusetts- Department o,Public S.at'et-, !-ON Board of Building Regrulrations and Standards Construction Supervisor License License: CS 78130 RICHARD.J LAMBERT 94 PICADILLY RD ' HAMPSTEAD, NH 03841 Expiraf;om 61212012 f :HaSii?Asd:➢i'i +: 30062 ::. S . DATE0ORDCERTIFC' 'fOL � ► RNa�f�0/2a11F ' � � A - PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTED OF INFORMATION ALLAN �iSURANCT AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA7E HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 63 1/2 Jefferson Avenue 2nd F ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. SOX 511 COMPANIES AFFORDING COVERAGF SALEM IBA 01970-0511 _. — COMPANY A senas~a irisuraaca Company tCOMPANY . Safety Irssurance Group TGLRC INC dba La 1,%art ttoofinq .._. ---.. , _.._ 265 WINTER STREET COMPANY C Landmark Insurance Company HA'VSRSILL MA: 01830- _ . .._._.__. _._.. ....... COMPANY National Union Fire Insurance R THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY P59100 INDICATED,NOTWITHSTANDINGANY REQUIREMENT,TERM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENTWTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTC ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY FFFRCTIVE POLICY EXPIRATIONLIMITS L DATE(000M) DATE(MMIDOIYY) OENERALUANUTY BODILYINJURYOCC y1,00O,OOD X COMFMHENSIVEFORM GL3000422 11/12/2010 11/12/2011 BODILY INJURYAG_G $ 2 OOO,OOO PREMISESIOPERATIONS PROPERTY DAMAGE QCC $ ?'A00'000 A UNDERGROUND €. _, PROPERTYPAMAGEAGG $ _ 2,OOQ,.000 EXPLOSION&COLLAPSE HAZARD X PRODUCTS/COMPLETEDOPER ISI&PD COMBINED DOC $ X CONTRACTUAL / / / BI a PO COMBINED AGG $ INDEPENDENT CONTRACTORS PERSONAL INJURY AGG R BROAD FORM PROPERTY DAMAGE / / / / Medical Payment-, _ 5,000. :e--.PERSONAL INJURY AUTOMOFILE LLARILITY BODILY INJURY ANY AUTO (Per per—) _ S B R ALL OWNEDAUTOS(PrivatePass} 5203619 07/16/2010 07/16/2011 BODILYINJLIRY $ - R (gar than Prwe assenaer) (Per axtids X HtR=_DAUTOs / / / / PROPERTY DAMAGE $ R NON-0WNEDAUTOS GARAGE LIABILITY BODILY INJURY& -- PROPERTY DAMAGE $ 1,000,000 CAMFINED EXCESSLIABiLrIY EACH OCCURP,E_NCE $ 51000 QQO C xIUMBRELLA FORM LBA054597 11/12/2010 11/12/2011 AGGREGATE— S _ 5r000 000 OTHER THAN UMSRL:LLA FOMt $ WORKERS C011PENSATION AND Y fC STATU• V. 0TH C EMPIAYFRS'LIAE147Y 09934145 0$/29/2010 08/26/2011 IMITS.. FjL THE PROPRIETOR/ INCL EL DISEASE_POLICY LIMIT $ 1,000,000 PARTNERSIMGUTIVE , NK - OFFICERS ARE: EXOL / 1 EL DISEASE-EkLMPLOYEE $ 1,000 OD0 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLMSPPCKL ITEMS -—_-- ,''_r-TiFiCATE.ti�IDE�•.. •: , , .. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEROF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 NAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TD THE LEFT, FLIT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE ND OBLIGATION OR LIABILITY 01= KMIGtUpON THE COMPANY,ITS A EN19OUPPRESENTATIVES. A REP THE . AC ORl CpRPORATION•1988 The Commonwealth of Massachusetts Departmento f Industrial Accidents Office ofInvest,-adons 600 Washin,.on Street Boston, M4 02111 www-rn Ao�licant Information gBuilders/Contra diaWorkers' Compensation insurance oda it: Builders /Contra ctors/Electricians/Plumbe rs Name (Business/Organization/IndivPlease Print Legibly01 idual): ✓�. . Address: City/State/Zip: Phone#: e you an employer?Check the appropriate boa: 1 a employer with Type of r 4' ❑ I ave a general contractor and I project(required): 2•❑ employees(full and/or ptirt-time).* have hired the sub-contractors 6' ❑New construction I am a sole proprietor or partner_ listed onthe attached sheet # 7• F7Remodeling ship and have no employees Ttlese sub-contractors have working for me in any capacity. workers' c g E]Demolition [No workers' comp. . omp.insurance. p insurance 5. ❑ We are a corporation and,its 9' [1 Building addition 3. required.) officers have exercised their IO•❑Electrical r ❑ I am a homeowner doing all work right of ex eP or additions myself. [No workers'comp. c. 152 14mptldn e MGL I1.❑Plumbing repairs or additions ees. insurance required.] t employees., m loy [ and we have no P Y [No workers 12•7 Roof repairs comp.msu'ance required.] 13•❑ Other Romeo t that c heakE�,�i �wst also uu cu:the seam h--low e:^.eaW,. q Wnefs who submit affidavit iodinating tht�,a=dciu^aL'wo � -ork--rs"camps--5—mm Y••:�,^•J •u'�a:ZS�.^.a. +Coniiactota that hWl;this bor.must at-ched an additional sheet shows r ann then hire o decontra^-tor L4•Wa.submit a new alhdavit indicating such. the name of the sub-contractors and their workers'comp"pommy infonaaiion. j I am an empbiyer that is providing workers'compensation insurance for my employees Below is the • , information. ` polio and job site Insurance Company Name: Policy#or Self-ins.Lic.#:_ ��.��' Expiration Date:��a��`� Job Site Address: - Attach acopy of the workers' compensation policy declaration pave(sho 'Ci,h/e /Z� {� Failure to secure coverage as required und„or Section 25A of M wing Policy number"and expiration date). fine up to$1,500.00 and/or one-year imprisonment;as well as Ge• 152 can lead to the imposition of criminal penalties of a Of up to$250.00 a day against the violator. Be advised that a civil Penalties m the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. Py of this statement maybe forwarded to the Office of I do hereby certify under the pains and penalties o er' ,th rP Signature: !m'J rri the information provided above is true and correct Phone#: Official use only. Do not write i this area, to be completed by city or town offz-ciaL City or Town: Issuing Autbori" A : Permit/License# ry(circle one) 1:Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S. PIumbinrt 6. Other b Inspector Contact Person: Phone n: Information an- d 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 Peon 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 t1ae legal representatives of a deceased employer, or the receiver or trustee of an inaiviaual,partnership, association o>r other legal entity,employing employees. However the owner of a dwelling house having not more than three apartnz encs 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 appurtzi a thereto shall not because of such,employment be deemed to bean 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 comp ce 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 un-Cil 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-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 W)with no employees other than the members or parhners,.are not required to carry workers' comp ensation inau_,-a„re. 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 store to sign and date the affidavit. The affidavit should be mtura d to the city or town tlia,the application for the permait or license is being requies*�d,not F:ne Depar�:e tt.of Industrial Accidents. Should you have.any questioms regardi^g the law or if you are r.M fired to obtain a workers' compensation policy,please call the Department at the.numbe;r listed below. Self-insured companies should enter their self-inset-ance 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/lic:=se number which will be used as a reference number. In addition,an applicant that must submit multiple permit/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 than you in ach-mce for your cooperation and should you have any questions, please do not hesitate to give us a call. The Depar=ent'.s address,telephone and.,iax number..__ The Commonwealth of Massachusetts Departmem Of Imustrial Accidents Office of lnvestic ations 640 Washington Street Boston,M-A 02111 Tel. # 617-72.7-4900 ext 406 or 1-87/7-NLkSS-AFE Revised 5-26-05 Fos #617-72.7-7 749 V'VrV7.1nass..gov/d i2