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HomeMy WebLinkAboutBuilding Permit #571 - 5 WALKER ROAD 3/26/2010 il BUILDING PERMIT °� NORTI q t LlO 6* �O TOWN OF NORTH ANDOVER .° !"J ° APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received y rEP SgACHUSfc Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION r Qa )��,ld W1 11 '7 Print PROPERTY OWNER N�gt j4cg)W -e colter 4"56 t Print MAP 210 PARCEL: ZONING DISTRICT: Historic District yesn Machine Shop Village yes n 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 PREFORMED: RE-'PA 1+2 ()r IAV 0#.J G U►L..L�r h G W:7 , &JeCA 3 10 C--Ck(41 1 G n 4 E rCA vh I wv\ Q A_t Ot L K , Identification Please Type or Print Clearly) OWNER: Name: HL-AtomJ'I-rO (b&iof) Phone: 60" ) W'i 3M Address: 5 v--11 004A - Qc> �J . AND0J-Cr fAe . 01 bi CONTRACTOR .Name: tiAY5�-', Phone; - Address: r Supervisor's Construction License; t2�} VU Exp. Date: (i 1 G(o E t) Home Improvement:License: Exp. Date: ! ( 1-2,u 110 ARCHITECT/ENGINEER t) 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. PAL �— Total Project Cost: $ /, �°I FEE: $ go Check No.: Receipt No.: NOTE: Pel°so s contracting wi unregistered contractors do not have access t the guaranty fund Signature of Agent/Owner � - nature 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 i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS 'i 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 -Temp Dumpster on site yes no Located at 124'Main-Street Fire Department 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 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 - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. I 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) 4 ❑ 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 Location No. _ Date NpRTk TOWN OF NORTH ANDOVER A Certificate of Occupancy $ �,SSACHUs t� Building/Frame Permit Fee $ D '~ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2207 Building Inspector i Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"a , Massachusetts consumer guide to(tome improvement"before agreeing to any work on your residence.You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8767 or 1=888-283-3757. Homeowner Information Contractor Information Name ompany Name 3. 6 0C13 Street Address(do not use a Post Office Box address) Contractor/Salesperson/Owner Name S Ui A, 'c'1 . bl Al 13th (3Z Cityfrown State Zip Code usiness Address(must include a street address) Daytime Phone Evening Phone .itylTown State Zip Code 9n SO 9&& Mailing Address(lt different from above) Business Phone ederal Employer ID or S.S.Number Law requires that mon home ha- Rome 11131proverancat Contractor Reg.Number Expiration date pmvtmat contractors have a olid registration number The Contractor agrees to do the following work for the Homeo ner: etall the wotK to compiptea,specl"gme type, e 7 -o e t Ce Z GPA i Oeai� ba-CVS e Ui 14b, rmMts 1 Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits will be excluded from.the Guaranty Fund provisions of to Date when contractor will begin contracted work. MGL chapter 142A.) V Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of: (.) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) a� by ;/_/i or upon completionof by /_/_ or upon completion of d a upon completion the contract (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following milkatl qulpment must be special S O_to be paid for ordered before the contracted work begins in order S�_to be paid for to meet the completion schedule.(**) NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an exoress warrapty barna provided by the contractor? No Yes (all terms of the warranty must be attached to the contract) Subcontractors-The-contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement Contract Acceptance-Upon signing,this document becomes a binding contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by:writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. •' Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a co of the Consumer Guide to the Home Improvement Contractor Law. py You may cancel this agreement if it has been signed at a place other than the contractor's.normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following.the signing of this agreement See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM coo identical copies of the-contract must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. omeown. n lure Contr etor' Signature to Date Date \i Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an . alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree.in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved.by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall.be required to submit to such arbitration as provided In Massachusetts General Laws,chapter 142A. Homeowner's Signature Contractor's Signature NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way, even by agreement. However;homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. "Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The.contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced docments have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner'�and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hindherself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work., Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or'tf you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law,"contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston, MA 02116 (617)973-8787 or 1-(888)2833757 If ydu want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301,Boston,NLk 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General ' (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 NORTH 01" , 0 1 � Andover . No. 07/ A K E = dover, Mass., • o !D COC MICME WICK V" AORATE0 �C `r BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR .THIS CERTIFIES THAT "d"......��1i1�...... 1�............... � .............. ... .. ..... .... ........ . .. .. .. .. ..... Foundation ... . ... . ..... ....... .. """' oun ' has permission to erect....... ....................... buildings on ....�....0. k/w....�.... ......... Rough to be occupied as.............. ...........041.r........ Chimney . .. .............................................................................. provided that the person acceptin this permit sh m every respect conform to the 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 �j PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRU= T Rough ...................................................... Service BUILDING INSPECTOR w. 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 BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. CER "I ` j©' `E;( F 11tANC � ISSUE DATE 11/30/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND MTM Insurance Associates LLC CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE 575 Chickering Road DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover,MA 01845 COMPANIES AFFORDING COVERAGE INSURED North Andover Building Corp 70 Pillon Road COMPANY A A.I.M.Mutual Insurance Co Milton,MA 02186 LETTER E. 6 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. CO TYPE OF INSURANCE POLICYNUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MMIDD/YY) GENERAL LIABILITY GENERAL AGGREGATE PRODUCTS-COMP/OP AGG. =COMMERCIAL GENERAL LIABILITY PERSONAL&ADV.INJURY CLAIMS MADE=OCCUR EACH OCCURRENCE OWNER'S&CONTRACTOR'S PROT, FIRE DAMAGE(Anyone tire) JI - MED.EXPENSE(Anyone person) AUTOMOBILE LIABILITY COMBINED SINGLE _ LIMIT ANY AUTO BODILY INJURY ALL OWNED AUTOS (Per person) SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS BODILY INJURY GARAGE LIABILITY (Per accident) PROPERTY DAMAGE EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM a ' WORKERS COMPENSATION AND STAT LIMITS STATE OTHER EMPLOYERS LIABILITY X MA rHEAR EL EACH ACCIDENT PROPRIETOR/ A ARNERS�EXECUTIVE 100,000 FFICIERS ARE: 7023267012009 11/11/2009 11/11/2010 EL DISEASE--POLICY LIMIT EXCL 500,000 . INCL � EL DISEASE--EACH 100,000 EMPLOYEE COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: CERTII CA IIS IIOY UDR _ :. 'CANCELAIIUNa } SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE SHEN HSIAO THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 WRITTEN NOTICE TO THE CERTIFICATE OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL,SUCH NOTICE SHALL IMPOSE NO OBLIGATION R LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. 4 JOSEPH STREET ANDOVER,MA 01810 UTHORIZED REPRESENTATIVE 2009.10-0107:25 Joan McLaughlin 6172984342» 5083580066 P 6112 n �l.r•,..,,hn,►•II. Ih•p;nrnn•nl ..I I'nhlii '�.Ilrl�+ Iln;u•II ul' Ilnil�li►►l; Ifc•!ul;uinr►�.unl '�r,lilil�lrrl� CollAf1wrbni :.inl xvi;ilr Lr,. rn.;r. I,icunru�: 1:5 07.1116 Itu'1�!i11,i, 00 1. JOHN 11 LF:F.MAN JK , /0 PILLON NOAO MILTON, MA 02190 �.�y..:'.C_. ...:�...:. tr.�lru,�►errc tl1101'L010 i .•.... 2WA7 i 2009-10-010725 Joan McLaughlin 6172984342» 5083580066 P 9112 ;3irtr(..I ul'131lildinl! l�i�l�i► 1'�Itiuhs anti•Siaittlard� I ! ) One Atil I)LI11 nl }'kICT _ .Rt1ur�� 1301 -.. LSc►s►tm. '��las�>a�.•h�.►:,Iats (1:'!UX I l��rr►�: 1�211�)t�uNi.n1�►1� t� :r�tr;,i�ltra' It C,L'islr�ttit,ir htmt;hahun• I'fiS:a rpr,�• i'•rrVC.INf I:UI'1>rx;11q�'r '.�UpirUrdl II/16120li1 UJUILDIW6 CORP ,.;,I� ► k.r:rAi�� i 3OX '1:57. "'OVER. mik 0 11145 ! pdaH' 1;I014'r»and ir�ur'n i:ud. tlui�lv!mm rrrr Omw.,,r.. ldrhrf+ Ilr�h�.;d f.rulrb•.uu id 1 0131 1.IIIA I The Commonwealth of Massachusetts Department o f Industrial Accidents Office oflnvestigations 600 ff"ashington Street Boston, MA 02111 wwK-mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apolicailit Information Please Print L.e�ibl Name(Business/Organization/Individual): /l.)A t3 Address: Pd 6OX 13Z City/State/Zip: K' A-4iw -+r M-1 ® l bj fhhone#: Armee you an employer?Check the appropriate box: 1.LV✓1 am a employer with � 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• emodeling ship and have no employees These sub-contractors have 8.working for me in any capacity. workers' comp.insurance. . ❑Demolition n [No workers' comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition required.] officers have exercised their 10-[1 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 insurance ] employees. [No workers' required.] t 12.❑Roof repairs aFalicant that checks comp.insurance required.] 13.7 Other S' rs box ut mus:also fill out the section below shoi irg5 their w ,orrers compensa,; ,,,..,...,...L.., fo:r nation. I3omeowners who submit this affidavit indicating theyare 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 isproviding workers'compensation insurance for my employees; Below is the policy and job site information. Insurance Company Name: A I""A MUl M(„4 Policy#or Self-ins. Lie.#: -7(�Z�,Z -7 V 12 Dal Expiration Date: l� � tl 110 Job Site Address: 5 JJA 1&rAb IV. Av-okay- A41i City/State/Zip: 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 ofMGL 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 th ains and ties of perjury that the information provided above is true and correct Si ature: Phone#: [0ther only. Do not write in this area, to be completed by city or town official wn: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Piumbing Inspector son 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 pesrson 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 maintexiance,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 be 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-cruet 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 permit/license 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 bum 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 11 Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-OS v,,ww,-mass.--gov/dia