Loading...
HomeMy WebLinkAboutBuilding Permit #157-11 - 42 Water Street 8/24/2010 BUILDING PERMIT "ORT"�ti U TOWN OF NOR TH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0 Date Received 4A°��� -K• °' Date Issued: gcHus IMPORTANT Applicant must complete all items on this page Y''a. `2'S, ..Y-qc'''M C,'"y r"f, r ['*£ �L'Y � ✓�.d a. F s :.;� r F �+t 7 k+`�d' 3'a ENEMA-� � d p 7 'i 'TR d`7 •'1�S ?r•' '!} 1 ?l-. .1R *"e+- .d 3 ^5u� y{.1^ �, _ it { 1 ay.l 2 Y 4yP fid''!••-. T 51 75, i�'&"r; „� '{�'!S`• z r^-r-,r� div ° SrW,'St� 3 j��a: `"' F,'' J�' .I °i3��,+PJ�ll.l `!'+--''' .... `�..rt t M f ���1� ©W�'.�-=�Ln- r .. h�� �`c r' .s� '.- fi•""'�z*�`ssa'� '�,...s'�c ��1.Y tom.' ^4.t i }c 3S T ''� ate-- 4'&.>}`s -+a''. e'.--•�.�"` -�.�� ...xa..:.nxn� k�R,„s. 'L'"'y> 5 a,. . � ,�'�tf'„'''�vdr��} •,{y°���, n�; w r r'7;5`x' {�tr5 -f�+�F•`�-aI7 f"�� 44,•'4-r' �'-va: 4'a -tlsrr�'t,: -5 L�'.Y a1 r.-v.� y,_c s;-, e�� „�g e.c ..au �`re;� rx��'e'y�� T 1�t�yLS�4Y'ry fi •���,�+�"�J VA t-T .''P1i ri�5 Y.rS nY".�i?„ ,1 R.4a;.yt S`IO .. - L ,� � .� �� '1� � '� y:.,,+�-� �, ?.e 7 tcl A��7$ �„ 1,a�kR'y.��r ��3.�Lr� LrtnF�Er�,"'xg _"-tr.�t�Y�-�'[�r�� 'S',.SJIrP �r YjY-�`�"�'h �rr✓,�''i 'f..�����r`ti.M t-„ _3L a'YraF��t18 c4rd� -'�"�---.'.lYi- -i-.. •.r1f-�11•�r-"�1 ..T,Y�:S$;:'�S J-•t! -s�-N,f},!I �'"^ s:sis�iJ216� �^HY�H�����"tf����t1��Y' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building _ One family _ Addition `wo or more amil� Industrial Alteration No. of units: _ Commercial - - Repair, replacement Assessory Bldg Others: Demolition 'I ��� '�'�E �r�� -F �c5�f-�x",�F�*.r `ten -�� .a#- 'T�' ...�a��' �'�•���> �� r �.�� r����--_�+,z�.. • DESCRIPTION OF WORK TO BE PREFORMED: eae.� 4 8 4 fo 6v ��otllS w� r ✓Lb�i Y�Cs^i or �7��ls e✓i ���/rtfl>sE 41 .e—AC. Ad-,, L, e&o lye �i r�/G.6�! � �Pew7-t�Of�t^rCfy G fir• AJ�T�w �/ti w✓�i� S�tc 1�(/O/�S ` Identification Please Type or Print Clearly) OWNER: Name:_-.J��d�'{-� �hrr•,-1- Phones n 2A'l-4:%wO Address: yy-yZ �qr, ha- .d�-�¢� ca:ta{ �- L t.�£ ���ti�ir �.��.�'�a t���i'�.t'f�ui 'r•Nf�S�� `�-c`�^`y''""':� 4r� ! `�i -.5,� 2'-'?§4�-:." .�so '}� 1P+s r`''�� `�t»�r�?!. -,{3,esL-,�us��d 7 :�m� �",�'-y+,,t�"tr-,'�+G- �nzs jt93r,:.-+>v,.-• �.:.: s .� 3 I 9 1154, 5� e •a �'3u. -s #�' "y ,r"'1-- eA 'ri9rrf `�,-0N; r� 4F--i ;a ,sNTVi,i ,� ..;r'rrY '-wr,* •�..?�, '.3�...z'�- ..' 'Yr.t ,i'-t' MIN �'z K r s�..'' 4� t^+-«iY�, #'-i;r.1*,3`a�- ,..h•.3�' �'r'ie�y. ,{;y} 3• :j�r�:.r yS"Y jJQ sr'�°'� $' cr77 ,.a%`•- e 7r ,Pm� r - v `Y f yk �" 1'•I � �`� _i I. rCL�1ll �1I �' � n�ztaI 'or� W ��Yr �, '�.�,�"P�°k7 "f-+X�,�'�.F' �y;�� .,key vet-4'fii '�� eye A`hsl��9"araa-�' '-� +.y *mss i^ "amu%-�ea.���� � �+ �}�-�•a�Fi ,3 ,-•iY -ixst - .• 'Ep.. Y-,r+r +r.,..'_ yyur"',3x "�'.7 a ••, r4 e a`t'"*a i+5 .!K ,.,yam ?3.La1y'm Tt c `t�an"' J .'i... 7=a4 �Yd1i1��----- ----- ARCHITECT/ENGINEER -_ I - ARCHITECT/ENGINEER Phone: I Address: Reg. No. FEE SCHEDULE:BULDING� / PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Tota! Project Cost: $ "/ FEE: $ Check No.:._�_._��O Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acess to the ar n fund �_ 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 Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY I " INTERDEPARTMENTAL SIGWOFF'- U FORM" DATE REJECTED -DATE APPROVED PLANNING & DEVELOPMENT COMMENTS- --`- r: , CONSERVATION Reviewed on Signature HEALTH Reviewed on ' f ,- Signature ry d :y r COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments 'Conservation Decision: Comments Water & Sewer Connection/Sictnature& Date Driveway Permit DPW Town Engineer: Signature: f. o Located 384 Osgood d Street A� ';1111 1NTlo,".Dyte � e `� ri �{ ray 4 _ a; 4 ?Locatetl at"lvlain Sfree# r 77 r r i 4 5 # "Fere3aeparrDen r � e a _ e .. r - 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 i NOTES and DATA— (For department use) it 1� j iT - i ❑ Notified for pickup - Date L '_ 1 Doc.Building Permit Revised 2010 Irk -- 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 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:Building Permit Revised 2008 'S Location No. Date 0NORT" TOWN OF NORTH ANDOVER . 3? �,,`•O °,hO O F w A + ; ; Certificate of Occupancy $ / Building/Frame Permit Fee $ �•.� J�cMus Foundation Permit Fee $ ' Other Permit Fee $ TOTAL $ Check # 2334 Building Inspector NOIy T0VM Of RTAndo ve r No. ^ o dover, Mass., Q - IAKE COCMICMEWICK V %S RD ATEC� BOARD OF HEALTH In Food/Kitchen 'PE �RMIT T U Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ . .... . �!1.C.. ..... ...... ...................................................................................... Foundation has permission to erect..............:......................... buildings on o...... ( ..K�rGI........ .4 �...-.............................. Rough to be occupied as..... !�. ......J. ......... .. .. .......... Chimney �'fi�— provided that the person accepting this permit shall in a e� ry respect conform to a 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 TS 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. 1 Ivassaclrrr. Bo.rrd of Buil -Derrirtment dint= of Ptihlic Safety Const:uctidrr S e"`u""ions and Standards ¢ License: CS Rervisor License R?4tricted to:. 00 RICHARD a 54 ECHO STREET f EET 'y MAIDEPd, MA 02148It (�,r,,miscirrner Expiration: 121. office of Consulner � a; t, � � HOME IMPRoyEMENT CO Business RegopafioA Registration- NTRACTOR Expiration 64893 -11 11!30/2011 TYPe Gvrporat�on Tr# 292.1& y. ADVANCED ENERGY SpL RICHARD BORGES N7 iONS LLC. 28 HAMILTON RD r PEABODY.MA 0198U Undersecr�t�ry: _ m m m o C 4 s 8 � sssss ss � � s $ BI ss s sad d c3 O M r O O M M g O 0 0 0 0 0 0 T 0 0 0 0 0 0 0 O O O O O O O O q g m � 1 Door Rep]brtedw so6W am 283r 0 0.00 Door Red pre hurl 32-W wood" 0 0.00 EnewSlar R-4 RW VW Fee to T3'U1. 0 O ao I Energy Starr R-4 MO Vegt Red 74-W ML 0 000 c ErmW Star R-4f&gid%W Red 84W U.1_ Q 0.00 Energtr Star R-4 Rftcl vmSA Reid 94-101 U.l. 0 0.00 Page 3 = i AUDffOR NOTES Basement Wiirrdow Rept.AwnmW Hopper 0 0.00 k Basenmt WmWow Rep.Vft a 1110me 0 0A0 Permits I Few(Wap MW 0 0.«) SUBTOTALS U48.00 i 6d7.E.C.MATi:RiALA ABOR 5227.56 ! S& HEAL f H&SAFETY AUDITOR NOTES Ved Bath/Kfthen Fan 1 85.00 1#Root ba8voom Dryer vent w/admud dud Heartwnd 0 0.00 Dryer Tmmdtion Durt oniy 0 0.00 Blower Door Test Pre Paste`. 0 0.00 I i SUBTOTALS 85.E 8b.REPAgt MATERIAULABOR AUDITOR NOTES Un s d(door)Sdte or equal 1 70-00 Front door i Repair/Refit Door 0 Q00 Rem Side Stop 0 0.00 RedaosCaslM 40 161.20 C Relent to 64 u.L 1 42.00 roan 12v2DA drVe Pane Gloms Replace nest per ul over 64 0 0.400 Sash Sidelock/rop Replacenwnt 0 MOD ThmaWd(Wood) 0 0.00 Tt (Alu rftm> O ono Slide Botts 0 O.OD i Plug Pits Cover 0 O.OD Crit/finish altickmeewa9 aeoess 0 MOD Cut/dose atSodm wamil access 0 0.00 Labor Rate Hours 4.5 270.00 Repair waa be m bks 1 arat ar rtaid TOTAL REPAIR+HEALTH&SArM 20 [[ i fdRAND TOTAL WORK ORDER# (A) 3535 9855 T6 t t k Any aster ftw or&VMWW from the above spedfWafts involving i F t e)dra assts mud be cleared in writing before uniallation. i The Work Order must be complete vallm 15 world g days from date sem+: i CONTRACTORADOMPANY: { ZZ I a o � —--------- ....................... ................. ............... ......... ...... � s � � g 0 0 a 0 0 a a a 0 0 0 0 0 �. � � � � � . area is dc dt a0 a g I P8 P8 I .....�_.,...o,_ N I D o b a n o o n a a 0 0 0 0 0 b o a a o 0 0 0 0 o 0 0 0 a 0 a b a o 0 0 o N �15 lit � a vv _ ,. 07/06/2010 TUE 9:49 FAX 6174231789 -•-•- Advanced Energy Solution 2001/001 ALCM CERTIFICATE OF LIABILITY INSURANCE =7/6/10 THS CERTIFICATE IS ISSUED AS A MATTER OF IWORMATION 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. THS 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 temps 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 CONTACT NAME: Paul T. Murphy Insurance Agenc PHONE FAX 16 Lebanon St -MAI ss: AC Malden, MA 02148 PRODUCER 7064 RMM S AFFORDING COVERAGE NAIL# INSURED INSURERA:Scottsdale Ins Advanced Energy Solutions LLC INSURERS:Peerless Ins 28 Hamilton Rd. INSURERC:AIG Peabody, MA 01960 INSIRERD: INSURER E• INSURER F: COVERAGES CERTIFICATE NUMBER: 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. I TYPE OFINSURAMCE POLICY EFF POLICY EXP L POLICY NUMBER M MMlDCrYYYY UNITS GENERALLIABILITY EACHOCCURRENCE $ 1,000,000 A X COMNERCIALGENERALLIABILITY CPS1014919 5/7/10 5/7/11 DANAGETORENTEO $ 100,000 CtAMS-MADE Fx—]OOCUR MED E XP(A one Parson) $ 5,000 PERSONAL&ADVINJURY $ 2.000.000 GENERAL AGGREGATE $ 2,000,000 GEMLAGGREaATELMITAPPUESPER PRODUCTS-ODMP'OPAGG $ 2.000.000 POLICY PRO- LOC $ AUTOMOINIELIA81UTY COMBINEDSINGLELIMR ANYAUiD gaaccident) $ 11000,000 BODILY INJURY(Per person) $ B ALLOWMDAUTOS 8633314 3/19/10 3/19/11 BODILY INJURY(Per accident) $ X SCHEDULEDAuros PROPERTY DAMAGE $ X HIREDAUTOS (Peraacldert) X NOKOWNEDAUTOS $ S UMBRELLA LUIB OCCUR EACH OCCURRENCE f FXCESSLIAB CLAIMSA%DE AGGREGATE S DEDUCTIBLE S RETENTION $ $ VORKESCOMPENSATION 006789459 5/14/10 5/14/11 WCSTATU- OTH- AND EMPLOYERS LIABILITY Y I N C ANYPROPRIETORIPARTNERIEXECUTNEEL.EACH ACCIDENT $ 500,000 OFFICER&TMBEREXCLUDED? � N!A QNandalory id NHj EL DISEASE-EA EMPLOYEE $ 500,000 Nyyeess,,desariba under DESCRIPTIONOFOPERATIONSbstow EL_DISEASE-POLICY LIMIT $ 500,000 13ESCRIPTIONOFOPERATtONS!LOCATIONS/VEIOCLES(AtiachACORD 101,AdditiondRenuftSdwdute.Ifnwespace Isregdred) Insulation- Coverage subject to polios terms conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Lawrence ACCORDANCE WITH THE POLICY PROVISIONS. AU MrD REPRESE1FTATNE f0 0 9882009 ACOIRD CORPORATION. All rights reserved. ACORD 25(2009109) The AC ORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations 600 Washington Street FI f�l l w=, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / / Please Print Legibly Name (Business/Organization/Individual): !`✓limen et*c w �So 4"'Irbis...c. Address: ZY A&ff1f;6fig,G,D City/State/Zip: Ami�e 0 /g "�fjf" Phone #: 7ow/, V7,jC—,ZOf,t� Are you an employer?Check the appropriate box: Type of project(required): I I am a with employer 4. El am a general contractor and I _sib* have hired the sub-contractors 6. r-1 New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 131-1 Other comp. insurance required.] *Any applicant that checks box#I 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. Contractors 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. Lic. Expiration Date: ,� /4/4 p Job Site Address:T— ,� �.�SCr*� City/State/Zip: .,,(��/f�0/�/, 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 the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided ab ve is true and correct. Si nature: Date: ?-r/1O Je Phone#: 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 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 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.t6-'do1maintenance;`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 1iCens'orper permit to•operate a business or to construefbuildifigs in thecommonwealthfor 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 cavy workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confinnation 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 o , Please be sure that the affidavit is complete and printed legibly. The Depart vent has provided a space at the bottom of the affidavit:,for you to fill out in the event the Office of]ri�estigati6As"has.to.cd'ntact you regarding the applicant. Pleasebe sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant ."",` that must subm;t•multiple pen that applications in any given yeaf,'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 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: ti.. c.4 t 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