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HomeMy WebLinkAboutBuilding Permit #168-2016 - 29 Riverview Street 8/6/2015 NORTH C�\ BUILDING PERMIT J TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION * ,� Permit No#: Date Received 5� / sSgcHuse Date Issued: U IMPORTANT: Applicant must complete all items on this page LOCATION 3 iS 'I' Print PROPERTY OWNER gy' G s cc•y- Print 100 Year Structure yes no MAP Q 7 a PARCEL: 00, 1)ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building XOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement 0 Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain 0 Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: =7n,s se I a{s 4A//e 2- S/2 6-1 b to"., I , 1, r a G/, &LSA ,eX �Gr,�,. c oo rS ✓erg + b �(,. �. _., �� �� s���,-. •e ivy 40 e'Lt r Identification- Please Type or Print Clearly OWNER: Name: l=IG.he /?ra �s� Phone: Address: 31 J)o r cL v-c.- t t44 A o 17 qs- Contractor Name: Awa-iceef ��fvo �«Phone: ��! yes• Email: 0. 0 wee�. wie• c o --, Address: rLo 6-)•e.r� L o 4 t� v9 0/ 9 Supervisor's Construction License: /1�o ���,,,. 1 Exp. Date: Home Improvement License: .,lva e2S Exp. Date: s ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. bD Total Project Cost: $ `�.� a� •�7 y FEE: $ Check No.: �— Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to thear ty u d Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Taming/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 7,.r;ig Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments i Water& Sewer Connection/Sicinature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FI�REsDEPARQ MENT Temp;Dumpster,on-site. eyes _ noa, Located of 124 MainStreet ,t r Fire De paft, t 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 DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) I � ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pernvit Revised 2014 i 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 I 4, 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan �. Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) � Building Permit Application 4 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 2012 IECC Energy code 4� Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location ��?? No. Date d �� _ 1 • • TOWN OF NORTH ANDOVER e Certificate of Occupancy $�_ Building/Frame Permit Fee $ + Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �— 2 J 1 70 Building Inspector NORTH own of E ndover No. � was 1 ver, Mass, Ul$� COC NIG"I WIC.I y1' 7.9 A�R^rEo P-'? S U BOARD OF HEALTH DFood/Kitchen '\ PER Septic System THIS CERTIFIES THAT M[' l N 6 .......r�.�s g..L�... r BUILDING INSPECTOR .................................................. ........................ ................ ......` , ..... 3 ��I ee A# 5 ��� Foundation has permission to erect .......................... buildings on ......... ......................................... ....................... � 1`� h 1 I.. .. " Rough tobe occupied as ..... ................................ . .... �.......�.w t�....................f..................�.�... .. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration Q; J 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 CONSTRUCTIO ARTS Rough Service .......... ......... .. .. ....... .................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Client Elaine Brasseur(978)685-5453 address 31 Riverview St city I town North Andover, MA 01845 contractor Advanced Energy Solutions 1.WEATHERSTRIPPING/CAULKING QUANTITY TOTAL AUDITOR NOTES Door Kits Q-Lan or Equiv. 1 51.00 ._._. Door Sweeps(Regular) 1 17.84 _ Door Sweeps(Automatic) 0.00 Reglaze Windows 11n.inch 0.00 Window.WeathstrSchlegal per side 0.00 Recessed light cover per SWS.Not a tenmat cover 0.00 attic sealing 2 part foam 0.00 attic sealing 1 part foam 0.5 35.00 Chimney basement and living space air sealing 1 part 1 70.00 Chimney kitchen and bath sinks SUBTOTALS 173.64 2A.INFILTRATION 1 INSULATION AUDITOR NOTES Domestic pipe Hot-Water Tank 1st.6' 1 17.70 Sill Two Part Foam w/Fiberglass Batt 0.00 1"T-max only foam boardPerimeter per IECC&SWS sq.ft. 0.00 2"T-max only foam boardPerimeter per IECC&SWS sq.ft. 0.00 Drape DOOR R-5 or T-max only 1 57.00 Tape Joints(Alums Grip only)per hr. 0.00 Duct Ins w/Tape sq.ft.R-5 conditioned space 0.00 Duct Ins w/Tape sq.ft.R-8 unconditioned crawl/garage/attic 0.00 Hydronic pipe insulation to 1"R-5 0.00 Hydronic pipe ins.1.25"-2"R-5 0.00 Steampipe Ins. 1.25"-2"iron pipe R-5 0.00 Steampipe Ins.2.5"-3"iron pipe R-5 0.00 Air Conditioner Meeting Rail 0.00 Air Conditioner Cover 1 43.00 Air Conditioner Cover Special Order 0.00 SUBTOTALS 117.70 2B.INSULATION AUDITOR NOTES Open Unrestricted R 49 0.00 _ Open Unrestricted R 38 300 495.00 De ends on what is up there Open Unrestricted R 30 0.00 Open Unrestricted R 20 0.00 Open Unrestricted R 10 0.00 Restrict FUSloped R 38 0.00 Restrict FL/Sloped R 30 0.00 Restricted FL/Sloped R 20 48 74.40 Restrict FL/Sloped R 10 0.00 R-19 FGB open rafters/walls/kneewalls 0.00 R-11 FGB open rafters/walls/kneewalls 0.00 Attic Stairs(stairwell&common wall) 0.00 Cover Pull Down Stairs Thermadome up to R49 per SWS 0.00 Site built pull down stairs 2"foam box 0.00 8a. HEALTH&SAFETY AUDITOR NOTES CO detector 0.00 Vent Bath/Kitchen Fan 1 100.00 Dryer vent w/exhaust duct Heartland 0.00 Dryer Transition Duct only 0.00 Bath fan 50 CFM(replace exsisitng)fan only 0.00 Bath fan 50 CFM(new install)with timer 1 750.00 Bath fan Smart timer 0.00 Blower Door Test Pre _ Post 1 45.00 Must twice a and post reading ics If fire are no pjgs contractor wIli need to go back to set up tostwlth GLCA sdsif# are SUBTOTALS 695.00 8b.REPAIR MATERIALILABOR, AUDITOR NOTES Basement outside door solild core inc all hardware 0;00 Basement outside door w/jambs Inc all hardware 0.00 Basement outside door site built per SWS Inc-all hardware 0.00 _ Door Repl pre hung 32-36"Steel's w I Lite 0.00 Door Repl interior solid core 28-32" 0.00 Door Repl pre hung 32-36"wood**w/Lite 0.00 Window Replacement wt SIR less than 1 0.00 Basement Window Rept Awning/Hopper 0.00 Basement Window Repl.With a frame 0.00 Lockset(door)Schlage or equal 0.00 Repair/Refit Door 0.00 Replace Side Stop 0.00 Replace Casing 0.00 Glass Replacement to 64 u.i. 0,00 Glass Replacement per u.l.over 64 0.00 Thermo pane Glass replacement 0.00 Sash Sidelock/Top Replacement 0.00 Threshold(Wood) 0.00 Threshold(Aluminum) 0.00 Slide Bolts/pull handle W10 Cut/finish attic-kneewall access 0.00 Cut/close attic-kneewall access 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Permits/Fees(Wap only) SUBTOTALS 0.00 TOTAL REPAIR+HEALTH&SAFETY 895.00 GRAND TOTAL WORK ORDER# (A) 4526.74 Any alterations or deviations from the above specifications involving extra costs must be cleared In writing before installation, The Work Order must be complete within 15 working days from acceptance date below: CONTRACTORICOMPANY: Advanced Energy Solutions ACCEPTANCE:Company/Contractor AUTHORIZED SIGNATURE: Date AGENCY APPROVALS: CTI Authorized Signature: Date____ GLCAC Authorized Signature: Date Attic/Kneewal Floor Transition. Dense pack cellulose 0,00 W.S.Hatch Q-Lon or equal 0.00 W.S.&bat Hatch,dam around etc.complete to attic 1 67.00 Kneewall R-12 cell behind Per.Memb 0.00 - Open Rafter R-20 Cell,/w poly Q.00 Open Rafter R-30 Cell./w poly 0100 Basement Overhead R-19 fiberglass 0.00 Basement Overhead R-30 fiberglass 0.00 Crawipace Overhead<4'high R19 0.00 Crawlpace Overhead<4'high R30 0.00 Garage Ceiling cavity filled wl cellulose 0.00 Wood,Shake,Ciapboard,Shingles Vinyl 1352 2704.00 Asbestos(single nail)J Asphalt 0:00 Asbestos(doub.Nail)/Aluminum 0.00 Brick/Stucco 2 hole 0:00 Vinyl over Asbestos 0.00 - Multi-layered 3 or more layers DAD - Drill rough plaster or finish wood plug 0.00 Drill finish plaster 0.00 Test Drill Walls(all 4) 0.00 SUBTOTALS 3340.40 2.INSULATION TOTAL 2A.+2B. 3458.10 3.STORM WINDOWS/DEADLITES AUDITOR NOTES-_ Plexiglass up to 88 u,i. 0.00 - Additional.per UI over 881, 0,00 Dead light 0.00 SUBTOTALS 0.00 S.OTHER MATERIAL AUDITOR NOTES Ridge vent In ft. 0,00 Gable Vent rectangular 0.00 Varipltch Vent 0.00 - Roof Vent 135(1 sq ft NFV)Large 0.00 - Roof Vent 865(A sq ft NFV)Small 0.00 Soffit Vent Rectangular 0.00 - - - Turbine Vents All 0.00 - - Stack Vent 0.00 - Acuvent proper(Must be this product)available( HomeDepot 0.00 - Permable House Wrap 0.00 - 6 mil poly on ground 0,00 Energy Star R-4 Rigid Vinyl Repi 94-101 UI, 0.00 SUBTOTALS 000 6./7.E.C.MATERIALILABOR 3631.74 AC40RO® CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DD/YYYY) 6/9/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Select Dept Eastern Insurance Group LLC PHONE 800 333-7234 x66807 233 West Central St ( ) FAX .781-586-8244 E-MAIL selectwork@easterninsurance.com ADDRESS: NatickINSURERS AFFORDING COVERAGE NAIC A MA 01760 INSURED INSURERA:Guard Insurance Group Advanced Energy Solutions Llc INSURER B C/o Richard Borges INSURER C 28 Hamilton Rd INSURER D: [iNSURER F: SURER E PeabodyMA 01960 COVERAGES CERTIFICATE NUMBER:15-16 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN RI T TYPE OF INSURANCE D L U POLICY NUMBER POLICY EF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGEREN FED PREMISES(Ea occurrence) $ , CLAIMS-MADE 0OCCUR MED EXP(Any one person) $ PERSONAL 6 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS-COMP/OP AGG $ POLICY LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accidentl g I ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDLA LED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOSNED PROPERTY DAMAGE $ Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION A WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY x WC STATU-MTS 'ER PROPRIETOR/EXCLU R/EXECUTIVE Y/N $ 11000,000 (MandatoryOFFICEMMIn H)EXCLUDED? N/A E.L.EACH ACCIDENT (Mandatory In NH) WC691424 /14/2015 /14/2016 If yes,describe under E.L.DISEASE-EA EMPLOYE $ 1 000 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 10+ AAAffinnal Remarks Schedule.If more space Is required) i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE tXPiRA T IUN UA 1 E THEREOF, NOTICE WILL BE UELIVEREU IN Town of Reading ACCORDANCE WITH THE POLICY PROVISIONS. 16 Lowell Street Reading, MA 01867 AUTHORIZED REPRESENTATIVE I I John Koeael/PKG ACORD 25(2010105) I IIY 1 ©1988-2010 ACORD CORPORATION. All rights reserved. 1�%�1 111 111 r11I'I SAO Vr�Iifl II/I OfAY if n/;IM/1 OrY r0/\IQTprp1;TO►MQ Iii!lf�IMI I �po�n�zzonrrzeal/�oC�jf� (t Office of Consumer Affairs& Je Business Regulation `�,i DOME IMPROVEMENT CONTRACTOR ` egistration: 164893 T Expiration: Type: =11/30/2015 � --. Corporation ADVANCED ENERGY SOLUTIONS LLC, RICHARD BORGES . 28 HAMILTON RD i , PEABODY,MA 01960 Undersecretary Massachusetts -pe —'"----- partment of Public Safety Board of Building Regulations and Standards Construction Supen:isor. r—,-- License: CS-09.0 02 RICHARD B BORES 28 HANUTON ROAD ' Peabody MA 019E0 1..' Commissioner Expiration 1,1/01/2016 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA. 02. 14--2017 www massgov/dia sy' Workers'Compensation.Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aplilicant Information / Please Print Ledbly Name(Business/Organization&dividual): � ip•H��.o f .�� lo�S [rG G Address: 28 %orb A40 City/State/Zip: va', o 9 Go Phone#: 7/> - I/2.f- 20 S Are you an employer?Check the appropriate box: Type of project(required): 1. lamaemployer with_employees(full and/or part-time).* 'I. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required] I Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12..Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[_] 152,§1(4),andwe have no 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. 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 an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-con6cf6rs fiave employees,'they must provide their workers'comp.policy number.' I am an employer that is providing workers'compensation insurance for my employees'Below is the policy and job site information. Insurance Company Name: 6 Policy#or Self-ins,Lie.#: fro W C y Z Lt Expiration Date: 5_ e V i Job Site Address: 3 Q r-t✓'V I r-w S City/State/Zip: A). /.ju�o,.e/� 4.4 6 Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby cert under Ile p ' s andpenalties ofperjury that the information provided above is true and correct. Signafore: Date: • G Phone#: 71I• q 7 S-L dq $r 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 1.52 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 foi•confirmation of insurance coverage. Also be sure to sign and date the ahiiidavit. The affidavit should be retained 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' compensatioii 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 permit/license applications in any given year,need only submit one affidavit indicating cuzxent 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia