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HomeMy WebLinkAboutBuilding Permit #204-2017 - 39 MAIN STREET 8/26/2016` BUILDING PERMIT of NORTH " TOWN OF NORTH ANDOVER J �CAN� APPLICATION FOR PLAN EXAMINATION _ " w 1 Permit No#: . Date Received �y QUA tTEO Pp�4`� © SSAC HU`�� Date Issued: �J zz�J cI�MPORTANT: Applicant must complete all items on this page LOCATION / 444LI J S Print PROPERTY OWNER !,,, &Zlc C;a E-LSd-✓ Print 100 Year Structure yes no MAP 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: S-Gemrnrrcial Q4e'pair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain o Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: j`f..,✓ cam, , Identification- Please Type or Print Clearly OWNER: Name: G-e ,6 c c"4;-C Phone:l.,,) 3 .2 3(5"- 7 C 2 g Address: In6 i AJ _q 7— a_ Contractor Name: ra, S,sc �. Phone: G a 3 a S'1 3 g, Email- Address: �vN fZA e��CJ ,U I•t rJ d 7 C/ Supervisor's Construction License: c= S 7 1 "3 Exp. Date: C Home Improvement License: 7'/ 7 7 Exp. Date: a Z2 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. Total Project Cost: $ � S C� FEE: $ K� "— Check No.: K7 �/ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund J Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dempster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On /u'�I� Signature_ Ate(' COMMENTS_ /��/P 611l Z,6� s-1 J,),f- oi� t9 tdq I&AS CONSERVATION Reviewed on 1 Si nature COMMENTS HEALTH Reviewed on Siqnature COMMENTS 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 - TempDumpster o,n;site ;rioa Locate didt`�124yIVlainrStreet - _ - Fire,Depat ttment signature/date COMMENTS i 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 Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 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 ,r 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 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 I ECC Energy code � 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& Z.046 • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $A6�2� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# r v Building Inspector y x,10 RTF/ Town of 1. 6 ndover O - 0 No. ad — 261 * - y 1 ° h ver, Mass, 2fa 2*f6 COCNICNl WIC" y1. S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT............. .IF. 'r .............. BUILDING INSPECTOR . . . ....... Foundation has permission to erect ................R .. buildings on .......... ..... ���........e�.�.. .................. Rough tobe occupied as ....� %..... A . ...................................................................................... Chimney provided that the person accepting permit s all 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 and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST.. .. . N S Rough Service . . ...... ... .. ............... "" Fina BUILDING INSPE OR 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. Plans Submitted ❑ Plans Wai'bd. ❑ Certified Plot Plan ❑ Stamped Plans ❑ [Public YPE OF SEWERAGE DISPOSAL Sewer ❑ Tanuing/1VlassageBody Art ❑ Swimm.ing Poolsell ❑ Tobacco Sales ElFood Packaging/Sales EJPrivate(septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF e U FORM PLANNING & DEVELOPMENT Reviewed On �lZbf I Signature_ COMMENTS ILUA6- -'D �.✓. 6K dee- CONSERVATION Reviewed on I Si nature r COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIREP4R+TIVIENT. - Temf Dusit"" ,1 �y ",F ocafecllafp12;4tM e :, p► �mpste on airS:Stre FirelDepartment>signature/date ',1 i .. •' • .5 ~.' 1.s`t s�_r i � _ ..� ... c _. ...m .- ---..- COMMENTS 028'0(Rif 0280'J[ C j 1 -- iY ,0-001.1 C — Jam.•-''-T , . � � s ,���. .I y wi 1c(71' A �I 32800013 , OIL .. 'c 18 a i}Olns 017''-0 1.3, a� 019 0 1K)11, ,z, ' ► 02a.0-001, r o29 1 y A x; 017 0-002 3 029 0-000 1 y, 0 zki- -r w- s: y ,: �CJO: e1 09c. . � C29oia cc J3 ( C[1:• � IF 014u.)0121 i' 02� M f I ll • yr ^13 0 C'n1.102911005. O-vO10 \21 is �IG�wr n�� •ri?L��u3 ii. `r_-� , i1 � , u i�18l' rl,lc J-Ou3� tea:�� Clh 0 „31 —1 . J18.0 116 s 0036 J184 '` y !¢018 4- ii / Y# , L 8 u 0034 - f 018 0 0037 r°+ ko • i *� OF NOPTH 9H 2 �o Property Information Property 210/018.0-0001-0000.0 Location 39-41 MAIN STREET O ID 5 Owner L. CARLSON9SSA CHUSf,� MAP FOR REFERENCE ONLY validityNOT A LEGAL DOCUMENT Town of North Andover, MA makes no claims and no warranties, expressed or implied,concerning the or data presented on �471121-� Propagal ur-H ULE CCNSTrUCTICN D"CLITICN Decks Remodeling All Professional Carpentry Sun Rooms Richard J. Morrison • 603-898-0984 Kitchens • Finish Work 84 Lake St.,Salem,NH 03079 PROPOSAL SUBMITTED TO PHONE DATE 8,tl — 4-2-7 sli§ rIAJ jU4 STREET 7 �i71 JOB NAME w3 /h! /7 J/ i CITY.STATE and ZIP JOB LOCATION Sal)?e ARCHITECT DATE OF PLANS J08 PHONE We hereby submit specifications and estimates for. ......—......—.............--.---...---.........—•-----------------------------------------------------------— _— —_—____.__.--... --•--..................................................................... -° -----..C, s... s-ns L.........® -C0-1;5L.4 a n------ -- - -...........................................................__--------------------------------------------------------------------------------------------------------------------------------------------.--- .........-......-............................-........................._.............................................-.-.---.......----........-....-_...-............................................................................-.....................--__._... ----------------i - :grar` .._._ 1 = `�-b- r, : > �d',��a -` • e -- 4q.)-----•--••--•---------•----•------------••--•----------•-------------------•----------------...--•-----......--------•-----•-----•------------------------------------------•-------•--•-------------------------•---------. .............. ,...... -S............. l-=.........-........-............--- -----------•------•----------------------------••-••.....--•-----•---....----------•---------•--------------•-•--•-------------•-•--...._...---•--.._....-•------.._...--------------•...---•-....------------....---......---•--•.....-_..........-•-------••------••------------- cd .........................•------•-------•-•---•-----•-------•-----•••--•----•-------•••--•-•---•----------•---------.... --------------------------------- ,WS----------t..,:UU0----------------------------- ---------------------------------------------------------------•---------------------------------------------- ¢ - c3zrd ---------.......... ...................................-.......................................................................................-.............- - --....-................-...................--..........................................-.........-..........---•-....... ................N .� � `� .cf. . r.p_..J t �hcd -------------- rs- f � ems- �m .P_-------------------------------------_.----_----------•----------------------------------------------------------------------------.--------------------------------------------------_...._- ¢ propO$e hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: 4 �� 6� ��� ��� dollarsrg Payment to be made as follows: is All material is guaranteed to be as Authorized g specified.All work to vi completed in a workmanlike ^�— manner accordmgtostandaMpractkes.Any aUerationordeviationfrom atxwespeafxatbns Signature involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or Note:This proposal may be delays beyond our control.Owner to carry fire,tomado and other necessary Insurance. Withdrawn by us if not accepted within days 9ctePtanCe Of VrOPOgal - The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to sign,,, do the work as specified.Payment will be made as outlined above. Date of Axeptance: Signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-071037 Construction Supervisor THOMAS A DEFUSCO 23 DUTTON ROAD F,, o PELHAM NH 03076 _/l..n� Expiration: c=ommissioner 06/18/2017 Vlle�amUriza�r.rueat-C�u�� !�cca:;uc�rc�eLtr �L\ Office of Consumer Affairs&Business Regulation �OME IMPROVEMENT CONTRACTOR egistration: 117.756 Type: xpiration: 1-1/1512016 DBA TOM DEFUSCO GENERAL CONTRACTING THOMAS DEFUSCO 23 DUTTON RD PELHAM,NH 03076 Undersecretary 1��17r/` lbQ��ifir$fp TOr1 DMSCO CONTRACTING COEF.- Has successfully completed a training seminar and other requirementts io become a Roo rlrig Products International r Apple.%i tor. :. f' o t rest Date ,Authorized Signature and Title i ACORO0 DATE(MWDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE $/24/2016 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 NCAONTACT William Tarpey Tarpey Insurance Group, Inc. NCNI o ext: (781)665-1034 A No:(781)662-0301 109 West Foster Street ADDRESS:bill@ tarpeyinsurance.com INSURERS AFFORDING COVERAGE NAIC# Melrose MA 02176 INSURERA:Essex Insurance Co an INSURED INSURER B:Liberty Mutual Ins Co Thomas DeFusco, LLC, DBA: Tom DeFusco General INSURERC: Contracting INSURER D: 23 Dutton Street INSURER E Pelham NH 03076 INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 GL / WC 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 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR POLICY NUMBER MM/DD MWDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 GE RNTED A CLAIMS-MADE ❑X OCCUR PREM SES EaEoccurrence $ 50,000 3EG2744 8/3/2016 8/3/2017 MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 1 JET LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Fa accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPER TY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LUU31LrrY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 100,000 OFFICER/MB (Mandatory in H)EXCLUDED? a NC5-31S-604860-016 5/14/2016 5/14/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) General Construction. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE William B. Tarpey ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) 8 Commonwealth of Massachusetts z_ Depaytment ofIndasidalAccidents d 1 Congress Street,,Smite 100 f tr Boston,MA 02114-2017 www alas..govtdia 'Porkers'Compensatio-ahsurance-AffZdavit:Builders/Con.tractors/EIectxicians/Plimbers. TO BE FILED WITH TSE PERNDTTTING AUTHORITY. Applicant Information Please Print Le ' l Name, (Business/Organizationadividual): .1 SCCA Address: � r/ ► O"� '�- Gty/State/Zip: �Ch�`�^ N J'�—. 'hone#: Areyou an employer?Cheek fo ap i opriate box: Type of project )Vequired): 1.Q I am a employer•with employees(full and/or part-time).* 7.• []New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remo deli dg any capacity.No workers'comp.insurance required.] 9. Q Demolition IF]Iamahomeomerdoingallworkmysel£pToworkers,comp.,,,cmrancerequired.]t 10 ❑Building addition 4.QI am a homeowner and will be hiring contractors to conduct all worts on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors withno employees. 12:Q Plumbing repairs or additions 5.�ageneral contractor and Ihave hiredthe sub-contractors listed on the attached sheet. 13.Q Roofrepairs . '-hese sub-coniractors}iave employees andhaveworkers'comp.Tnc�Trance.� 14.El Other XiK11J D f ell 6> 6.Q We are a corporation audits of cprs•havo exereisedthch7rig7at of exemption perMGL c. 152,§1(4),andwehave no eYnployees.jNoworkers'comp.insuranceregnired.] . -• �,�� Any applicautthat checkssbox#i must alsofll outthe sectionbelowshowiugtheirworkers'compensationpolicyhformation. e Homeowners who srilimifitik af5.davit indicating they are doing allwork and then hire outside contractors must suLmit anew affidavit indicating such. ?Contractors that checkthis box must•attached an additional sheat showing the name of the sub-contractors and state whether ornotthose entities have employees..ffithe sub Tuve employees,&y'must proQide their workers'comp.policy number.' I ain an erriployer tlz at is pPovidzngworkers'compensation insurance for my employees.'Beloit/is thepolicy acid job site information. _ Insurance Company Name: L-1 E irationDatePolicy#orSelf-ins.I�ic.#:stir �/� C ��G' �l� � \ City/State/Zip: Job Site Address: !�(i�' /I�i��j Attach a copy of theworkers' compep4ation policy declaration page(showing the policy num. er and expi ratioa 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$2 '0.00 a day against the violator.A,copy of Ibis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ti icr�der tliepains andpenaities ofpet�zcry tlaaithe informationprovided a7�ove is arae and correct: Si afore: Date: Phone#: Official use only. Do not-write in this area to be completed by city or town official. City or Towzr• Permit/License# Issuing Authority(circle one): i 1.Board of Healtla 2.Building Department 3.City/Towo.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions ' Massachusetts General Laws chapter X52 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 bhire, express or implied, oral or written." An employer is defined as"an in:d vidue,partnership,ass ciation,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 to cal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings iu the commonWealtb,for any applicant who lias 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 oftbis chapter have been presented to the contracting authority." Applicants PIease fill-out-the workers' compensation affidavit completely,by checking=he boxes that apply to your situation and,if necessary, supply sub=contractors)name(s),address(es)and•phone numbers)along with their cortif<cate(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. lie advised that this affidavitmay be submitted to the Depaximent of-Industrial Accidents fb confirtnation 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 Accidenis. 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 shouid'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. Pleaso be sure to fill in the permit/license number which will be used as areference 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"rob 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 pezmits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or p ermit not related to any business or commercial venture (i.e.a dog license or p emut to bum 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. # 617-727-4.900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia