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Home My WebLink AboutBuilding Permit #709 - 50 ROYAL CREST DRIVE 4/5/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building b One family ❑ Addition Two or more family. [I Industrial ❑ Alteration No. of units: Q Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �.�x �z �� - ..i-.�• ��.±±�„�.loo.:�ain;,�,:��:;;D�W��:,.. x i •Yy�Y;� t,..,.. x �__ ❑U1;atershe� D's �iiJt�;':�' �:, ... c - 'SY •j ME .t.�.� �FY""�.i.w�^``=;i! k'%�;�JFaiEt�..FTY^•. �+ �`:�:®�S•e�"tic �'��1�llelt`:yy,-,,�,,.��_;as <:��,�.: .lSx��.��.t ,f. •:.it! -.-'.r:•-1 .�',:: f., tl, zCa:f"''x 5.'.,*.'« c�,,y,.�ix'``-.�'�.. �„�rOr-�"��'��r t j,. y u'.'v?�P <E.R.2hra IZA DESCRIPTION OF WORK TO BE PREFORMED: 4 wos �— e4i ue k Identification Please Type or Print Clearly) OWNER: Name: GZo a k C I Phone: A AA, --n. ARCHITECT/ENGINEER Phone: Address: Reg. No 2'fp `i FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 7i VOO 66 FEE: $ Check No.: 02 - / Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gryarantyu�eft 0 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Seng 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS ❑■ DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Drivewav Permit Located at 384 Osgood Street 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 Nu i is ana UA I A — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location 6y a No. Date Check 25159 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee _ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ G7-Le� �,� Building Inspector For Over 40 Years Alm II !m!N' l 800.736.2706 - cleanerducts.com Estimates 15546 Printed 4/5/2012 Page 1 of 4 Mail to Location: Work Location: Royal Crest Estates C/O Aimco Primary 50 Royal Crest Drive Royal Crest Estates C/O Aimco North Andover, MA 01845 Dan Milinazzo 6 Royal Crest Drive North Andover, MA 01845 Air Duct Repair and Cleanings - Unit 3 Item Description Qty Amount 51TH 10X10 TRUNK 5.00 $218.20 21 16X10 END CAP -trim down to 10" x 10" 1.00 $7.00 5TTH 14X8 TRUNK 1.00 $39.66 21 14X8 END CAP 1.00 $8.16 5 FT 6" 30 GA W/A 10.00 $79.00 10 X 6 WALL REGIS 1/3" - WHITE 4.00 $60.00 62 6" TOP TAKE OFF 2.00 $14.72 24R 6X10 6" 90 DEG REG BOOT 2.00 $47.40 91 6X10 REGISTER BOX 11" HIGH 2.00 $46.08 3" X 100' FOILGRIP IN/OUT TAPE 3.00 $172.50 FLEXGRIP - MASTIC SEALANT IGAL 1.00 $29.32 Permit Fee - Yet to be determined. 1.00 $0.00 Miscellaneous materials for duct reconstruction. 1.00 $75.00 Installation of Modification of Ductwork- Replace fire damaged ductwork like -for -like. $1,200.00 Power Vacuum & Source Removal Cleaning of Remaining Ductwork of 1 Residential HVAC System that was $350.00 not damaged by the fire. See additional pages for explanation(s) Subtotal: $2,347.04 Tax: $49.82 Total: $2,396.86 FINANCING AVAILABLE- NO INTEREST IF PAID /N FULL WITHIN 92 MONTHS* On rc ases opm nteres will a charge to your account from the purchase date if the purc ase ba ance is not NO in ull Namor if ou MaKe a late a men Minim m payments are required Nam www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 For Over 40 Years 800.736.2706 - cleanerducts.com Estimates 15546 Printed 4/5/2012 Page 1 of 4 Mail to Location: Work Location: Royal Crest Estates C/O Aimco Primary 50 Royal Crest Drive Royal Crest Estates C/O Aimco North Andover, MA 01845 Dan Milinazzo 6 Royal rest Drive North Andover, MA 01845 Air Duct Repair and Cleanind - Unit 3 Item Description Qty Amount' TLTH 10X10 TRUNK 5.00 $218.20 21 16X10 END CAP -trim down to 10" x 10" 1.00 $7.00 TLTH 14X8 TRUNK 1.00 $39.66 21 14X8 END CAP 1.00 $8.16 5 FT 6" 30 GA W/A 10.00 $79.00 10 X 6 WALL REGIS 1/3" - WHITE 4.00 $60.00 62 6" TOP TAKE OFF 2.00 $14.72 24R 6X10 6" 90 DEG REG BOOT 2.00 $47.40 91 6X10 REGISTER BOX 11" HIGH 2.00 $46.08 3" X 100' FOILGRIP IN/OUT TAPE 3.00 $172.50 FLEXGRIP - MASTIC SEALANT IGAL 1.00 $29.32 Permit Fee - Yet to be determined. 1.00 $0.00 Miscellaneous materials for duct reconstruction. 1.00 $75.00 Installation of Modification of Ductwork- Replace fire damaged ductwork like -for -like. $1,200.00 Power Vacuum & Source Removal Cleaning of Remaining Ductwork of 1 Residential HVAC System that was $350.00 not damaged by the fire. See additional pages for explanation(s) Subtotal: $2,347.04 Tax: $49.82 Total: $2,396.86 FINANCINGAVAILABLE - NO INTEREST IF PAID IN FULL WITHIN 12 MONTHS* On p rchases of $700 or more n erest will ne charged to your account from the purchase date if the purchase balance s no paid in full within 2 rmonths or iffv—o-uTm—ak-eTallat-eTr-)avmentiaMinimum payments are requ red www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 800.736.2706 - cleanerdiucts.com Estimates 15546 Printed 4/5/2012 Page 2 of 4 NATIONAL CHIMNEY SWEEP 0 L NF PX d MEMBER * With credit approval for qualifying purchases made on the Armstrong credit card at participating stores. APR up to 19.5% APR. Minimum interest charge up to $1.50. See card agreement for details. Offer valid for consumer accounts in good standing; subject to change without notice; see store for details. May not be combined with any other credit promotion or select discounts. www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 800.736.2706 - deanerducts.com Z`oNp�40 Estimates 15546 Printed 4/5/2012 Page 2 of 4 ALq"ICNAL CHIMNEY . n4. GUILD NFPA® MEMBER * With credit approval for qualifying purchases made on the Armstrong credit card at participating stores. APR up to 19.5% APR. Minimum interest charge up to $1.50. See card agreement for details. Offer valid for consumer accounts in good standing; subject to change without notice; see store for details. May not be combined with any other credit promotion or select discounts. www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 =or Over 40 Years 800.736.2706 - deanerducts.com RE: Air Duct Repair and Cleaning - Unit 3 Dear Dan Millinazzo, Estimates 15546 Printed 4/5/2012 Page 3 of 4 Thank you for allowing us the opportunity to offer a quote for reconstructing the fire damaged ductwork in Unit 3. This service will include the cleaning of the ductwork that was not damaged by the fire and removed. We propose to furnish material and labor- complete in accordance with the specifications and the sum stated in this estimate. All material is guaranteed to be as specified. All work to be completed in a workman like manner according to standard practices. Any alteration or deviation from the above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Our employees are fully covered by our Workmen's Compensation and General Liability Insurance. Warranty Work: Warranty work will be provided per product manufactures warranty specifications. Unless noted by manufacture all warranty work will be subject to labor costs. Restocking Fee, Return Information: If items are returned to Armstrong (subject to return conditions, used or burned items will not be accepted) they are subject to a 15% restocking fee. Used, burned, installed items cannot be returned only exchanged if issues arise. Exchanges are at the discretion of Armstrong. Acceptance of Proposal- The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Remaining amount is due when work is completed. We accept mastercard, visa, check and cash. Payment will be made as outlined above. This estimate has been based on our evaluation and will not include additional labor or materials that may be required should unforeseen problems arise that require additional labor or materials after work has been started. This agreement between the Customer and Armstrong shall be construed and governed according to the laws of the State of New Hampshire. Further, the Customer and Armstrong agree that jurisdiction over the parties shall vest in either the Hillsborough County Superior Court or Manchester (New Hampshire) District Court depending on the amount of damages claimed. If Armstrong has to submit this account for collection customer agrees to pay all collection costs and court costs as well as reasonable attorney's fees incurred by Armstrong in the collection of payment due Armstrong for services rendered to customer or their client. Accounts over thirty (30) days old will be charged interest at the maximum rate allowable by law or 1.5% per month, whichever is greater. Signature Date Signature. Date www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 40 Years Estimates 15546 Y Printed 4/5/2012 Page 3 of 4 800.736.2706 - deanerducts.com RE: Air Duct Repair and Cleaning - Unit 3 Dear Dan Millinazzo, Thank you for allowing us the opportunity to offer a quote for reconstructing the fire damaged ductwork in Unit 3. This service will include the cleaning of the ductwork that was not damaged by the fire and removed. We propose to furnish material and labor- complete in accordance with the specifications and the sum stated in this estimate. All material is guaranteed to be as specified. All work to be completed in a workman like manner according to standard practices. Any alteration or deviation from the above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Our employees are fully covered by our Workmen's Compensation and General Liability Insurance. Warranty Work: Warranty work will be provided per product manufactures warranty specifications. Unless noted by manufacture all warranty work will be subject to labor costs. Restocking Fee, Return Information: If items are returned to Armstrong (subject to return conditions, used or burned items will not be accepted) they are subject to a 15% restocking fee. Used, burned, installed items cannot be returned only exchanged if issues arise. Exchanges are at the discretion of Armstrong. Acceptance of Proposal- The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Remaining amount is due when work is completed. We accept mastercard, visa, check and cash. Payment will be made as outlined above. This estimate has been based on our evaluation and will not include additional labor or materials that may be required should unforeseen problems arise that require additional labor or materials after work has been started. This agreement between the Customer and Armstrong shall be construed and governed according to the laws of the State of New Hampshire. Further, the Customer and Armstrong agree that jurisdiction over the parties shall vest in either the Hillsborough County Superior Court or Manchester (New Hampshire) District Court depending on the amount of damages claimed. If Armstrong has to submit this account for collection customer agrees to pay all collection costs and court costs as well as reasonable attorney's fees incurred by Armstrong in the collection of payment due Armstrong for services rendered to customer or their client. Accounts over thirty (30) days old will be charged interest at the maximum rate allowable by law or 1.5% per month, whichever is greater. Signature Date Signature. www.cleanerducts.com 1-800-736-2706 Date Fax: 603-627-7070 1 40 Years i r— Estimates 15546 - Printed 4/5/2012 Page 4 of 4 800.736.2706 - deanerducts.com Please feel free to contact our office if you have any questions or would like to schedule the work. This estimate is valid for thirty (30) days. Sincerely, David M. Monson Operations Manager www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 800.736.2706 - deanerducts.com Estimates 15546 Printed 4/5/2012 Page 4 of 4 Please feel free to contact our office if you have any questions or would like to schedule the work. This estimate is valid for thirty (30) days. Sincerely, David M. Monson Operations Manager www.cleanerducts.com 1-800-736-2706 Fax: 603-627-7070 Armstrong Heatin & Power Vac Inc. Commonwea of M 6111 4Li�^� �es and Perm & Re s MA Sheetmetal Licence 1/3/2012 100.00 Fold, Then Detach Along All Perforations -r COMMONWEALTH OF MASSACHUSETTS SHEET METAL W ORKERS NR TR ii WARD AS :A::. s� a�bvE�1LS�rts��aE� t ;M I TYPE RICHARD P MACDONALD; ARMSTRONG HTG AND PWR N{: Ml 7,2-0 E..:IND PK DR NHNU3109-5614 MANCHESTER 21 126362 • ' `Fold, Then Detach Along All Perforations ) Safety -17 meflt °{Pub dads pepatt1\5 aid star . jMMONWEA�-TH QF MASSACHUSETTS Jae s Reg\at`0 n ISO AS '.. BUSINESS j °aid °t ,cCu�d°a sA3ap�1 Con �Se, G��,t rs r�r:�, ISSUES THE ABOVE LICENSE TO: \ 1►� ' AyU ��'�' MACDONALD� �p eter.b.kelly@state. $10 1`t r CHARD P V I ;, 2012 10:01 AM MSTRONG HEATING: AND_.POWER �C"LVp,1'�p310Z in 0 E INDUSTRIAL PARK DR "'., Board 310 0�1�31201 IT 9` 0000 a — N H 0 310 9 � , ,`'`'if�Q� N C H E S T E R � o�m`Ss ones 176 01%05/13 970062 ,d With the incorrect exf7T' is ,lith it may be confidential, f the he disclsure of recipients to whom ie�e of the intended recipients vended solely for the, use sients you are notified that caking any other action in reliance on tleasen encs the fitly prohibited. In a separate email, p anal email or and delete the orig' ed this e-mail by err Armstrong Heatin & Power Vac Inc. Commonwea of M 6111 �.L[r_— es and Perm & Re s MA Sheetmetal Licence 1/3/2012 100.00 Fold, Then Detach Along All Perforations _a --.a.,-- fey ds ePa�mer< °ia d gtardac I �MVIONWEAI^TH OF MASSACHUSETTS o at�Ors .:� Uses :.S.�IN"T (il(ETAC`fIITORKERS Massa°hg�\\d�n9 r,r,\�oc ASA BUSINESS ; °acd °f rUcvur A3gA1� 1 _ 6 Cone se CS ,A ti s nl""p , ISSUES THE ABOVE LICENSE TO: \G�'O r ...� i@ [petio 90 �ac1Jp1 r, r CHARD P NACDONALD it 201210:01 AM MSTRONG HEATING: AND POWER sYLVQ,1`{�p3�oZ o \` vs at�Or 0 E INDUSTRIAL PARK DR I Board 3Ma�cbestet b� p2'o31201Q IT`9 NH 03109. 0000 `ltt �' N CH ES T E R } �o��}SS`anec 176 l 01/05/13 97D062 „d With the incorrect exp. I I DO ,lith it may be confidential, the disclosure of which is :ended solely for the use othe re recipients tints ed that to whom this ie of the intended recipientsYou are Of caking any other action in rateaemailn othe pleasennotify the tly prohibited. In a separ and delete the original email Pd this e-mail by error t. �1 c ts O y C V V CLC ev � m C S� H r Did C � Y = o ... s fit, a, w CD a. Q r.+ y 1'.,i E 5 V O O aF** 0 O Z 3 :z cm E • m a E y W m m i y �m3 y cm �: y C 0 A .W y P.2 CO G CA O E m .a m 0 � '00 R, w G G O.CL m m y..0 G C = O m w N ~ r N O 1 m L ui C O.s 'N dt C Z 4D C* a o'oo� S cya ...apy� p �- L Sam 1 O M 4-4 2 O IO cm CD C � p '� .y m m L- Hi CL ++ 310 co G3 v 0 cc o a a- Q C H 0_••• C ZCc co CD 0 CL V y � C C CO2 p LLI U) W W 19 W ,w w x a x o w � po C 7 cd w a no �c W bov w w w z cn Q cn c ts O y C V V CLC ev � m C S� H r Did C � Y = o ... s fit, a, w CD a. Q r.+ y 1'.,i E 5 V O O aF** 0 O Z 3 :z cm E • m a E y W m m i y �m3 y cm �: y C 0 A .W y P.2 CO G CA O E m .a m 0 � '00 R, w G G O.CL m m y..0 G C = O m w N ~ r N O 1 m L ui C O.s 'N dt C Z 4D C* a o'oo� S cya ...apy� p �- L Sam 1 O M 4-4 2 O IO cm CD C � p '� .y m m L- Hi CL ++ 310 co G3 v 0 cc o a a- Q C H 0_••• C ZCc co CD 0 CL V y � C C CO2 p LLI U) W W 19 W ,w w The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A/vvls (-ra V�r_ C_ Thl= Address:_- U s i ��%-fry o t�G 9 P_ _ -.14 cl City/State/Zip:_ iti%vtc L&57ZEI-.4 X/W G7/y2 Phone #: $ c)o- 73 6 - a 7o k Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with / a 4. ❑ I am a general contractor and 1 6. ❑ New construction `` employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 10.E1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. F1 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' 13.� Other d ez- r P comp. insurance required.] `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 aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 Policy # or Self -ins. Lic. Job Site Address: Expiration 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 requiredunder 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. X do hereby cert undelteyains andpenfrlides ofperjury that the information provided above is true and correct. Phone #: - 7 .JG - oZ 7 U, Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # `f- Z-- zo 1 2 -- Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Pers 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 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 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 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 permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) 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 Massachuseutts Department of Industrial .Accidents Office of Investigations 6.00 Washington Street Boston, MA, 02111 Tel, # 61.7-727-4900 ext 406 or 1.-877�,MASSAaFE Revised 5-26-05 Fax # 61.7-727-7749 www.mass.gov/dia