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HomeMy WebLinkAboutBuilding Permit #754 - 480 REA STREET 5/25/2010BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: RTANT: Annlicant must LOCATION PROPERTY OWNER \ C Date Received 9--16) ISN b Print MAP 210 3 PARCEL: 6,2 ZONING DISTRICT: all items on this page Historic District !Machine Shop Vilh v' �t`eD 16j•~O\ °� 9_ yes no ves 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 DEscRIPTIUN OF WORK TO BE PREFORMED: re - T \T ANp'� . l entification P e Type or Print Clearly) OWNER: Name: L.hye�a Phone: �#• CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: 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: $ 3�op FEE: $ 3F Co Check No.: Receipt No.: Q2.2 o S� NOTE: Persons contracting,04h unr gis red contractors do not have access to the guaranty fund Signature of Agent/Owne f Signature of contractor 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 INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on COMMENTS HEALTH COMMENTS Reviewed o �. 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: FIRE 'DEPARTMENT - Temp Dumpster on site yes, Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no Dimension Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 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 NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 No 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 ,a—Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit .= n . Licenses j Copy Of Contract ❑ ° F-1 Croses#iapl_Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Ca cuIf A li_pcable) ❑M i rgnergy Compliance Report (If Applicable) ❑..- E Ing idavits for n neered 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 Location Ill or'G No. Date U Check # 2gr2U4 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $= Foundation Permit Fee $ Other Permit Fee TOTAL wilding Inspector m m m m m v m v ra C � Ci CA CD 0 Z y a0r. � ? o CL =• y n� -v O C.) o v CD CD o CL cS "CCD CD o CD W ao C CD CO) �. CD Q CD O y CD C3 CO) O 'O Z O O O CD 0 CD C 0 to �- O =r -to to Nl C CT cos m�'aC.) O 01 M � N =CL. .,d O O O N O 'p IE�mCD _-0 O : n O Z �• COy O N C2 O O H a 0 C,tc o s_s m O N CD N .�• d N S. d C � v. �C.CD co HCD N C3 CD 1 \ CD x CD CD -moo O ^• : J CD: ;w NCD 0 : Co C, CD p� 0 aIO C, � W CnC� O K, C77 D mzCD H 71 w- jJ G O � 'T7 w (nIx O H O w O � 0 ` P:j zG III G 0* H � b C/) (D p O 'J W v c z 0 v, 0=3 0 9 0 c paO H N-0 l Q4 0 6 -4)9� o d �$16 g9: °. 1 �j w� 4 BUILDING PERMIT AORT6 TOWN OF NORTH ANDOVERb _ 6 c APPLICATION FOR PLAN EXAMINATION GJ �0 Permit N0: Date Received_ R,T.o'�" cy / Date Issued: —0/ IMPORTANT: Applicant must complete all items on this page LOCATION 4 � 0 RM 3_/ - Wo. A,, J-Y-eK , MA D /06 - PROPERTY S PROPERTY OWNER Ki'ch a ki d at !( }�7�D Y11 Gi t?y Print MAP NO:PARCEL: 06'9 ZONING DISTRICT: Historic District Machine Shop 1 yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer 1JtbUK1F i 1UN Ur VIIUKK t0 BE PREFORMED: �x �6 " PV lxc Identification Please Type or Print Clearly) OWNER: Name: '21 c� Qyij (Tal /Romaho Phone: 973-.79q t/0� Address: TY0 9 -ea, SL2 ao 4�idoye-�, /uA 01PIs CONTRACTOR Name: - v (, Phone: to 0 / J Address: 16 L)9- 6 Supervisor's Construction License: (- S8J- Exp. Date: � to Home Improvement Licenser �Q, (10 dl O Exp. Date: 10116 1 3W3 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: $ � (i0 FEE: $ 169- Check No.: Receipt No.: Q NOTE: Persons contractink with. unregistered contractors do not have acce o uara and Si nature of A ent/Owner g_ �g_ _ Signature of contractor 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 INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on AIIO Si nature COMMENTS � � `^� s 0 AjC') b�V cid-fi�ci�u (�a� HEALTH Reviewed on Signature COMMENTS y ibning 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: uocatea 384 USgood Street FIRE DEPARTMENT Temp Dumpster on site yes -no Located at 124 Main Street Fire Department signatureldate 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 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use 0 Notified for pickup - Date Doc.Building Permit Revised 2008 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 o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o 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 o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o 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 Location 7 0 41-4— �.,. j _.cc No. •� _ Date TOWN OF NORTH ANDOVER n Certificate of Occupancy $ r Building/Frame Permit Fee $ A;1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # J 3 r 2 1 , 86 Building Inspector a: a - r,� footing plan x 10' Elevation 46 post Arch 31 /2" 480 rea st N.Andover MA Rich romano DECK FLOOR SYSTEM 31 31 I 31/2 a c be m 2x10 able T 16' triple 2x10 noble I Idobli I SII i;l f { I 2x'l floor system WO I 210 It All 2x 0 joices x w a p CC u �G w � cn cn U' z A ra wG :: G w x w v U x A t z a a: w a O W a abo w x n' cn x U a w w z W x w A w w a v c0 CO z cn cn D J Q : 0 m oQ' `NG y C Ol cm�p \ m c E O N CD 0 N cm a L�ca E N w m CD 0 aC) m N 0 404 cz ocm C cO Q C N � /4 ♦: 1� � C Z p F�- 0 p f m C >Z o `� o •� cm cao. �o o c Q m�Lmc o = o : o� 0 N :d O ~ r N 0+'~ CD Z W cCA m H .N C l0 C Z U •E v o c03 E •� • O o cC cj V� 0' 0 ' O zCL -coj f- r .p. 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C O d O ♦0., C G3 CL V to O C C c CL CO) Q ACORD CERTIFICATE OF LIABILITY INSURANCE ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR DATE(MM/DD/YYYY) TM NSR LTR INSRD ADVIL 105/16/2008 PRODUCER TODAY'S INSURANCE AGENCY THIS CERTIFICATE IS ISSUED AS A ONLY AND CONFERS NO RIGHTS MATTER OF INFORMATION UPON THE CERTIFICATE LIMITS HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 771 CAMBRIDGE ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CAMBRIDGE, MA 02141 EACH OCCURRENCE $ 1,000,000 617-547-6212 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: SCOTTSDALE INSURANCE COMPANY BEAVER BUILDERS INSURER B: TBA MED EXP (Any one person) 16 BEACH STREET INSURER C: INSURER D: REVERE, MA 02151 INSURER E: PERSONAL &ADV INJURY $ 1,000,000 COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR LTR INSRD ADVIL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DDNY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY CLS1491103 04/18/2008 04/18/2009 EACH OCCURRENCE $ 1,000,000 DA A PREMISES (Ea OCCurence) $50,000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $ 5,000 CLAIMS MADE X❑ OCCUR PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1,000,000 POLICY RC LOC JPECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ rl GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ THAN EA ACC $ ANY AUTOOTHER $ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR ❑ CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND TBA 05/01/2008 05/01/2009 TORYLIMITS ER E.L. EACH ACCIDENT $100,000 EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 200,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 100,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CARPENTRY SERVICES CERTIFICATE HOLDER CANCELLATION RICHIE ROMANO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 480 REA STREET NOTICE TO THETIFICATE HOLDER NAMED TO THE FT, BUT FAILURE TO DO SO SHALL NORTH ANDOVER MA 01845 IMPOSE NO OR LIABILITY OF ANY KI UPON THE INSURER, ITS AGENTS OR OB'eATION REPRESEN A. AUTHOR PRESENTATIVE �) - 1 ACORD 25 (2001/08) O ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations 600 Washington Street Boston, MA 02111 5 y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): y�0 City/State/Zip: [e�lW �� Oe 1 �, Phone.#: �g/ S g.2 Type of project (required):* 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10..❑ Electrical repairs or additions HE Plumbing repairs or additions 12.0 Roof repairs 13.[:]Other D6CSC *Any applicant that checks box #1 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 state whether or not those entities have employees. If the sub -contractors have 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 NMD.,: V� 4, ��IM t- �� [,� �,¢A\ 11/ E—j e n Policy # or Self -ins. Lic. #:'�77� Expiration Date: 057/0 oGl.(�/ Job Site Address: ^iY10 12&4U�/©® l�A)OW 6— L/ City/State/Zip: ' �r 0a dj� Attach a copy of the workers' Failure to secure Covera' regt: fine up to $1,500.00 an or ne-y of up to $250.00 a day a a' t the I do hereby certify under the msation policy declaration page (showing the policy number and expiration date). under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a nprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ator. Be advised that a copy of this statement may be forwarded to the Office of perjury that the information provided above,is true gnd correct 0SW610 fa .use only. Do not w)ite in this area, to completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact .Person: Phone #: Are you an employer? Check the appropriate box: 1. I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5• ❑ We are a corporation and its I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reauired.l Type of project (required):* 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10..❑ Electrical repairs or additions HE Plumbing repairs or additions 12.0 Roof repairs 13.[:]Other D6CSC *Any applicant that checks box #1 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 state whether or not those entities have employees. If the sub -contractors have 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 NMD.,: V� 4, ��IM t- �� [,� �,¢A\ 11/ E—j e n Policy # or Self -ins. Lic. #:'�77� Expiration Date: 057/0 oGl.(�/ Job Site Address: ^iY10 12&4U�/©® l�A)OW 6— L/ City/State/Zip: ' �r 0a dj� Attach a copy of the workers' Failure to secure Covera' regt: fine up to $1,500.00 an or ne-y of up to $250.00 a day a a' t the I do hereby certify under the msation policy declaration page (showing the policy number and expiration date). under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a nprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ator. Be advised that a copy of this statement may be forwarded to the Office of perjury that the information provided above,is true gnd correct 0SW610 fa .use only. Do not w)ite in this area, to completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. 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' ndividual, 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-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 (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 submitted to the Department of Industrial Accidents for.confirmation 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 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 permittlicense 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 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.2111 Tel. # 617--727-4900 ext.406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia 4" PVC INV. J. 00 LIMIT OF 14A )TA <1 jo, LOT 52, 750 S. F. SEPTIC VFAI T "�z m f 1 a' LU. ✓!ze -Po.,.,,e� o�✓G�,�oac/u�aetita Board of Building Regulations and Standards Construction Supervisor License License.: CS 96581 Birthdate: 7/22/1974 Ettpkation: `-7- 22%2010 Tr# 96581 Restnctian:' 10: REGINALDO CORRF:A 42 SYLVIA ROAD C7, MEDFORD, MA 02155 Commissioner rpm fie �o7nmw�,aurea�i a�✓�aaoac�iu�e�a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:, 157563 ` Expiration -10/16/2009 Tr# 260106 TYPe DBA SYMON CONSTRUCTRUCTION REGINALDO CORREA . 42 SYLVIA RD. MEDFORD, MA 021554 Administrator