HomeMy WebLinkAboutBuilding Permit #549 - 46 MARBLEHEAD STREET 3/16/2010TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: / Date Received
/
Date Issued: �1 % 'l
IMPORTANT: Applicant must complete all items on this page
LOCA
PROPERTY
Print u
MAP NO:_kPARCEL:. /),, ZONING DISTRICT: Historic District yes o
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 PERFORMED:
15i gy e2?j
Please Tvne or Print Clearly)
OWNER: Name:
ARCHITECT/ENGINEER Phone:
I n
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: $ _5p4a� d15- FEE: $
Check No.: ��3 �f Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
er
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
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: Doc.Building Permit Revised 2008
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
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 yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Siclnature & Date Driveway Permit
DPW Town Engineer: Signature:
ocated 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no _
Located at 124 Main Street
Fire Department signature/date *' f
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
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
IM
Doc:.Building Permit Revised 2008
Location Y No. Date
Date
NORTH TOWN OF NORTH ANDOVER
Certificate of Occupancy $
��s''•° ^ Eta Building/Frame Permit Fee $
swcmus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 9B
22652
Building Inspector
O
F=4
w
_
c,, �> 1
z
0.4
W
�Q
aUw.
r£ Q
A
o
PQ
O
O
F=4
w
z
0.4
U
6-0
aUw.
A
o
PQ
0
U
Co
w
cn
w
7G
w
a
�
z
cn
v
o
O
cn
CD W
O N
i.+ C
O
Com, CJ
CLC
CO O Q
m O
L a
CAN�
y E a
rLm.. C � v
m •„—O
V i
� O a
:.. N Z H
O� z
CD
��
m c E
ti
CL. -
CD m a
O m 3 �
N
Cm N
m C�
�z
N O C
O O
N
E CD
v
'aCD� o C/)
C/)
: = t -05
O c= W
L co
nom m �
v •h O C
Z
o ao c
a o Co •o
= m ia'L"� N
H $ Nmol m
ti ev r m
WU WCo�LU mm m � C
V� a m 'D O :0
O
�- s
CLO.. Cc :m -
fill
0
O
v
Z
co
CL
O CO)
� C
0 �C
C o�
E- co cc
CL ~
CL-)
�
0
0
M O d
iii C Q
h
� = C
cc
V 00
CL C3 m
CO2 Z s
Cl CL
U) y
c C
C =
C
c
CL
_IO
0
LU
U)
W
W
19
,,Www
Y/
The C® on ea1th of Massachusetts
Departmeh.t of Fire Services
Office of the State Fire Marshal
P. 0. Bax 1025 St<ite Road, Stow, M4 0I775
PERMIT Date:
North Andover 1'erntitNo
(Cityof Town) ( If Applicable) Dig
In accordancV with the provisions of M G -L 14 $ .Chapters (Z as provided in sectio" 5 7 7 f'iKg 34
Start Date
This Permit is granted to: . T C� ea � -
Full name ofperson, Fum or Co"tion
Permission to locate dumpster for construction/renovation/demolition
of building.
Comments:' dumpster must be.25' from structure if unable to glace with re uired
clearance du/mpsster must�be covered with l wood or tar end of work -day
at 4 tJ l%"O_%/tel/® Xi ),(,/
( Give location by street and no. -or describe to such manner as to provied adequate identification of ibcation )
Fee P aid $ 50-00
'
Fire
Chief
Ties Permit tinll expu�e. (S t 1 ttng pe t) Ofrical granting permit (Title )
ilk •
T
Ein # 51-05033313
ii...fing
rMA Reg. Hit # 149221 "k
MA Lic. # UCS 078130 Single -ply Lic. # 1711932'
265 Winter Street, Haverhill, MA 01630
We are: ✓ Licensed ✓ Insured ✓ Factory Trained ✓
Estimate for: BE•><(< l 00-A1 K i NG Date: / d /w/le.G
Telephone 1: 978 681--77A-7 E -Mail /Alt:
Billing Address: City/Town:
Job Location: L/6 P1/7Q.Bi EJ4C-AD City/Town:
-y Certified Installers
ZU t r.7
State: Zip:
State: Zip:
0RN MMgSr
BBB
T
MEMBER
L.R.C. agrees to commence described work on / or about %-, j W -V and described work will I a completed in about 1'2 working days.
L.R.C. shall not be held liable for delays due to circumstances beyond our control. L.R.C. shall not be lic ble for any damage to landscape, attics, interior
walls or ceilings and/or fixtures due to circumstances beyond our control. L.R.C. can not and will not b held liable for any damage to the surface that the
disposal container is placed on. L.R.C. shall not be held liable for ice dam development or damage cau ed by ice dams. L.R.C. shall not be held liable for
pre-existing conditions including but not limited to mold and/or wood rot, defective, faulty, rotted or wi irn building counterparts such as but not limited to
siding, gutters, masonry, plumbing, and windows that jeopardize the watertight integrity of the building and are not covered under roofing warranty.
The following work includes all permits, labor and materials needed to complete your job in a professional workmanship like manner.
7p slope Quick -quote proposal to furnish and install the following: Approximate roof area -
T. ew Roof ❑ Re -roof C3 Gutter Ll Repair ❑Ventilation
,frrepare for re -roofing by ensuring all safety measures are taken in accordance to OSHA standard regulations and landscape is properly protected.
15 Remove existing layers of shingles down to roof deck andAispose of in a legal fashion from the job site. Inspect wood deck, if we discover
any rotted wood, replacement will be performed at $X :5_ *per LF for roof deck boards. If substantial deck rot is discovered,
re -sheathing of roof deck can be performed at $�55 *per SF. If individual sheets are found o be rotted and/or delaminated removal, disposal
and replacement will be performed of *per sheet. If any trim boards are rotted, replacement will be performed at $qd�) * per LF for
new pre -primed pine. Inspect siding at roof line and all flashing behind siding, if we discover any damaged lashing or siding at the roofline, replacement will be
,performed at $r-rM * If wood deck, siding, and flashing is sound, we will re -nail any loose wood to rafters, sweep deck, and prepare for roofing.
V( stall 8" Drip edge to all rakes and eaves. ❑ Install Hug edge (Re -roofs only) to all rakes an eaves. Color
(�pply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or
it Apply premium (UNDERLAYMENT) to the balance of the exposed wood deck.
1,R flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof I ractice to ensure watertightness.
, upon inspection, we discover chimney lead to be warn or deteriorated, replacement will be perfor ed at $
Cg Install a new Year C) Traditional MZnhitectural style shingle roof system ❑ Designer
Color <:869<�AL 8(.A c_. Monf. <: WW0&cA?
❑ Furnish and Install a new shingle over style ridge vent system.
❑ it vent system $
All debris generated by Lambert Roofing Co., Inc. will he cleaned up and disposed of from the job ite in a legal fashion. Under no circumstances
will the watertight integrity of the building be compromised.
Special Notes:
Warranty options: Ztandard LRC ❑ Manufacturers Upgrade $
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 '36 YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER.
This document can serve as a contract, however if a more elaborate contract is desired we will issue it at the owners request.
Please sign and return one copy upon acceptance. NOTf.• if this contract is not accepted in days, it may be withdrawn by LRC.
Denotes potential additional costs above the total estimated price.
Financing is available
A finance charge of 1.5% per month (18% per year) will be charged on past due act unts over 30 days.
Total Estimate Price: $ (j2 Date of Acceptance 12— 01 A(L.c_N
I
Payment to be made as follows: /.7 sti i—I Gtr (Home/Business owner) =motet
,' 5ignature
a%
(LRC)
/V 6f"l -Signature =
Haverhill MA 978.374.9224 • Lawrence M . 8.16BZ nmpctead NH 603.329.8200 • 1. 88.SOS.ROOF (767.7663) • Fax: 978.521.5791
"Our Proof is on Your Roof'
www.lamberfroofing.com
IFRe'Massachusetts - Della dent o
Board of Building
a atiOns
Construction. Sup ri isor
License- CS 78130
Restricted to: 00
RICHARD J LAMBERT
95 MAPLE AVE
ATKINSON, NH 03811
( �,iumi..iuncr
lic Safet-,
Standards
!Expirati >n 6/2/2010
rlt, 27762
I
i
Off, e` of
LAMBERT ROOFIP
RICHARD LAMBE
265 WINTER STRI
HAVERHILL, MA 0
'S-CA1 Co 5OM-04/04-G101216
COI
I
sumer Affairs and business Regulation
0 Park Plaza - Suite 5170
ston, Masskek:usetts 02116
)rovement ,iQ=actor Registration
-• _-:_= Reqistration: 149221
==_�•-. __= = Type: Private Corporation
Expiration: 12/6/2011 Tr# 290268
Update Address and return card. Nark reason for change -
Address F] Renewal [] Employment ❑ Lost Card
VhU-U2-2UUU WED 11 ! Ub Aft ALLAN INS AUNUY HA NU, U lb+ l4btb4U� F. Ul
AG- Os&DR f1" ��i1�1
M'fAB f�1 1. '�NSURANCE .. 12/02/2009
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERT AGATE GOES NOT AMENI EXTEND OR
ALLAN INSUP-ANCd AGENCY INC-
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
63 1/2 J'etferson Avenue 2nd S
COMPANIES AFFORDING COVERAGE _.__.,.. ..
P.O. BOX 511
SALEM ABA 01970-0511
COMPANY
Seneca Iasuranca Company
A
INSURED ----- ---_•• -
COMPANY Safety Insurance GYOLTB
TGLRC INC dba Lambert Roofing
265 WINTER STREET'
COMPANY Landmark Insuranca Company
_
RAVERHILL Mil 01830-
COMPANY AIG
BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED
OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM
MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE
AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,,--
EXCLUSIONS
POLICY EFFECTIV POLICY ExPIAATtO LMIITS
CO TYPE OF INSURANCE
POLICY NUMBER
DATE {NMlDDfYY} DATE (NIlIND/YYI .
TR
BODILY INJURY OCC _ 6 - 1� 001) , 000
GENERAL LIAL�I TTY
XT comPEHEN-TTY FORM
GL3000422
_
/ / / / BODILY INJURY AGG $ „•- - 21 oOD `00
�._
PROPERL Y DAMAGE OCC $ 21000 000
X PREMISESIOPERATIONS
_
11/12/2009 11/12/2010 pROPER_rr_DaAAGEACA $.. ?,000 OUb
A—UNDERGROUND
ExPLOSION A COLLAPSE HAWD
_
BI & PD COMBINED OCC
X PRODUCT3ICOMPLETED OPER
/ / / / SI A PD COMBINED AGG__
X coNTRACTUAL
1 000 , 000
PERSONAL INJURY AGG $ _
INDEPENDENT CONTRACTORS
/ / / Medical.
X BROAD FORM PROPERTY DAMAGE/
X PER60NALINJURY
AUTOMOBILRUABILITY
BODILY INJVRY
iP.xpersal) $ ----
5
X
ANY AUTO
ALL OWNED AUTOS (Private Parrs)
203819
.—_. •--•...... S _._... ... _�_
/ / 8P901L INJURY
r xddetA)
X.1
ppL{,`` 01NNFD RUTOB
(01hw then Private Paesen -)--
_.. _ .__—.. _._....
HIRED
07/16/2009 07/16/2010 PROPERTY DAMAGE S
.X
X
I NON -OWNED AUTOS
--- -- _ —� -- -
BODILY INJURY IL
GARAGFLLABIUTY
PROPERTY DAMAGE $ 1,000,000
• COMBINED
EACH OCCURRENCE _.- $ ._ ..._000 r 000
C
t:XCES$ LIABILITY
I X IL4VBRELLAFORM
LWW46005
11/12/2009
11/12/2010
_
AGGREGATE _ $ 5.0001000
rl OTHER THAN UMBRFJ•IA FORM
$
STATU. x OT
D
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
09934145
/ /
/ /
MRY MRS— OR -
EL EAC C�EF1T $ Y 1, 000, 000
__ _
THE PROPRIETOR/ X
INCL
08/28/2009EL
08/28/2010
DISEASE• -•POLICY LIMIT $ 1,000,000
EL DISEASE -EA EMPLOYEE E 1 OQQ 000
O IC RSMECUTIVE
ACL
OTKER
DESCRIPTION OF OPERATior4WLOCATIONSNWICLESISPECWL ITEMS
CERTIFICATE tiOLDER .
78) 521-5791 I SHOULD ANY OF THE ABOVE DeWRII&ED POLICIES BE CANCELLED GWORE THE
(I�
'j'GLIiC dba Lambert Roofing (9 9MRATION DATE THERON INK ISSUING COMPANY VNLL ENDEAVOR TO MAIL
30 DAYSWRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
265 Winter St BUT FAILURE TONAL $UCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF AWIFND UPON THE COMPANY, ITS AGENTSIM REPRESENTATIVES,
aavarhiil NA 01830- AUTW7 EPR9 A x
I.
CQ�~gip Gott tiN .1.�$a .
AQOt4D'.26:N Ml9�
tnE (.ommoezweajik ofMassachllsef`t,S'
Depart w Of Industrial Accidents
D.f `ice of InresfFig afions .
600 ffrirshk-ton Street
Bo"ata, MA 62111
'+'>w>`U r�zassgov/din ,
Workers' Compensation insurance .A-ffidaviL, RmIders/Contractors/Eiectric%aas/Pittmbers
3iicant Idorma ion .
Narni (fir orpnizafion/Individual).
Addmss:
I'll, -�
city/staff/zip: Gf� SGC mi F�
Phone P.
M
Are you as empioyer? Cheett�e appmpriate-bo=
I • ► I, an, a employer with 4 ❑
employees (fun and/or *
part-time).
2. ❑ I am.a.sole..proprietor or
I am a general contractor and I
havo hired the suis-contractors
pier-
ship and neve no em 1
3isted on the attached sheet. 3
working for me in p oytes
may' capacity.
Th`se subcontractors have
workers' comp, insurance.
[No workers' comp. ins4rWce .
S. Q 'We ar-e a cmrporstion and its
required')
3. ❑ I am a homeowner doing
officers have exercised t ic.ir
all work
comp,
� srancelt e o -work=' ui
right of exemption per MQL
c 1S2, § 1(4)x' and- we have no
required.] t
d.1
-empicr[No wor3o '
:�Z2
Type of Project ("aired):
6. []Now. construction .
7 Q Rernodeiing
8. Q Demolition
9. (] BW7ding addition
10•Q Electrical repairs oradditions
plumbing repairs or additions
12.0 Raof repairs
`Amyappiitxmpa;t —P• n;zsurancera}un�ed..] I 13.].Other I
checks boZ t; l must also i;v our th:; rection below showing &,irworkaat' a°mp m jinn poiuy mfomtetrott
Fiomemvtter¢ Mrho sehtnit this affitiavif indiceung pray, are doing gi won:�k . Caathan hire outside connectors nnisi
nactors that check this box rnmA tsehtd an addhioasl sheaPttiro
Wing• the none of tL- m submit a naw aftidnvit indicating such
b-t:mttraGiots end t3mir r;_,
a an emp oyer fAW hnsavtr�atrtg:rvrrr&e. '..ter; `� , srinnmton.
infarrrx�o� ���'� rnsru-anrefort�'�Iove�: W.ts.*,rie .,r'
site
Ins Ince Com '� ' Ojos
parry Name:.*
Policy # or Set =ins. Lie. #: �.
Expiration Data:
Job Site fi ddrms;
Attach a copy of the workers' com Crh'��telLip: l%
peQsaiio>n policy deC�ration page (showing the policy number and e
Fafhac m seNra a caverage as required under Section 25A of MCiL C. 152 can lead to the ir=tpositian Of criminal irptioo date}. .
fine up to $1,500.00 and/or one-year impr•isonmMt; as well as civic penalties les in the form of a S71iP Ofcrim
of up to $250.00 a Penatti:s of a
invesfi agar. the violator. Be advised thax a copy of this statement ORDER and a fine
gations of the DIA for insurance coverage venin"Nation; may be forwarded to the Office of
r .t t:. --z. _
wry Cr aims arsd penalties of par�my J*ar the infnrnsalion Provided above atrQ' Correa
MI.. � - a mce
Official use oily. Do not write us fftrs area; bo bt co I
wed by aky or towtt. of ,.w
City or Town:
Issuirro AutbO ' Permit/License #
b rriy (circle one):
1. Board of Sealtb L Sulfding Department 3. Cit�/
6. Otber 7-oR,n Clerk
!� Contact
4. Electric,! Inspector 3. Pfumbtog
Inspector
Phone #:
lillUi"Ination it IIQ MsTrUCUORS
Massachusetts General Laws chapter I S2 mquiros all emp Joy= to provide workers' compensation for thoir employees.
Pursuant to this statute, an entpieyee is defined as "..:every person in the service of another under airy contract ofbirf,-
express or implied, oral or written."
An einplaper is defined w "an individual partnership, amc:%diatioN corporation or other Iogal entity, or any two ormore,
of tie foregoing engagod in a joint enterprise, and includi"g the legal represciitativos of a dcc=Bd employer, brihe
receiver ort mstm-of an individual, partnership, associatiazn or outer legal erntity, employing mnployees. 'Howeverthe
owrzer-of a dwelling house having not more than three apaLrlments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maizitmiatee, oonstmc6c n or repair wcirlc on such dwellinghouse
or on tate grounds or building appur(nrraat thereto shaU nate because of such an3pioyiment be deemed to be an employer."
MGL chapter I 5 §25C(6) also states thmi "every state o•s- local ficensing agency sbaD withhold the issuance, or
renewal of a license or permit to operate a bus' or ito construct boiidmp m the commonwealth for any
applicant who has not produced accepiabk rsvideece.oir compliance with tlie.iusarance covemge mquimd."
Additionally, MOL chapter 152, §25C(7) states "Neither t3he carnmonwealth nor any of it political subdivisions shall
enter into any corrtract for the pmfnrnnance of public wart-- uoffacceptzbla evidence of compliance with the instironce
r equir mnon s .of this chapter have been pre=ftd to.thc curttr-acting authority."
Applicants
Please fill out the workers' compensation. affidavit completely, by checking the boxes that appiy to your situation and, if
necessary. supply zub-c�or(s) name(A address(es): aitd phone numb=#) along with their eerdficate(s) of
insmzarce. Limited'Liability Companies (LLC) or Limited Liability. Partnerships (LLP) with no -=ploy= otherthan the
members or partners, are not regi d to tiny workflrs' cc3.,ynp=safiW insolence. Ifan LLC or'LLP does -have
employees, a policy is required. Be advised brat this affidavit may be submitted to the Departzam t of industrial
Acciderris for confirmation of insi=nce cov=ne. Also Ewe sore to sign and date the affidavit The affidavit should
be rewmed to the city or town that the application for the peirnit ,or license is being mgaested, not`the Department of
Industrial Accidents. Should you have any questions regas-d mg the law or if you are required to obtain a workers'
ooMpenmf ion pof icy, please -call the Department at tate-nmr. ober listed below, Selfinsured wnipanies sireuld enter their
self insi mncieli=isc number on dta appropiiste iirzr.
City or Town Ot%cinis
Please be sure that the. affidavit is complete and printed IeWbiy. The Depai trnerit has provided a space at the bottam
of the affidavit for you to fill out in the event the Office of Investigations has to cont you regarding die appri=l
Please be sum to fill in the permit/license nrmrber which %&-M be used as a reference number. In addition, an applicant
that must submit multiple pea•mit/ficins-- applications in any gives y, need only submit one: -affidavit indicatingcmimi
policy •information (if necessary) and under "Job Site Address" the appiiciint should write "all locations in (city or
town) " A copy ofthe afi&vit that has be:=.officia{ly staimped 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 licenser'or p=mitnot related to arty business or commercial vsihac
(i.e. a dog license or permit to bum leaves etz.) said poison is NOT.requirod to-complctz this afndaviL
The Office of invesfigstions would lite-- to thank you in advance for your cooperation and should you have any questions,
please do not. hesitate to give us a tail.
The Deprm ment's address, telephone and fax number:.
The Common ve$1th of Massachusetts
Depar"Iment of FMdust ial Accidents
Office of Envestigafions
600 W nhing-ton Street
Basfon, MA 02111
TeL # 617-727- .900 i= 406 or 1-9.77=MASSAFE
Fax # 61 7-727-774Q
Revised 5-2ti-QS VVWW --;mq gov/dia