HomeMy WebLinkAboutBuilding Permit #412-14 - 52 HIGHLAND VIEW AVENUE 11/6/2013 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received N
Date Issued:
11 I TANT:Applicant must complete all items on this page
LOCATION J
Print
PROPERTY OWNER
Print
MAP NO: PARCEL:ZONING DISTRICT: Historic District yes o
Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building D(One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
,Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
3'®iSept�0 Wel `f ®Flood lam ®Wetlands '��E a r is
z p - D Waterashed Data
DESCRIPTION OF WORK TO BE PERFORMED.
�� e,rooF
(Identification Please pe or Print Cie r1y)
OWNER: Name:
Phone:
Address: Jr a % n cQ ( I I/ /-CT's E_
CONTRACTOR Name: �eor out�5 ��'I�SI ZAC , Phone:
V p�
Address: 'Ad C,
Supervisor's Construction License: bS(r yid' Exp. Date: A)
Home Improvement License: 1/7,r7a Exp. Date: `Y .
ARCHITECT/ENGINEER Phone: .,
Address: Reg. No.
FEE SCHEDULE;BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Coat: It 4 P?n h� FEE: $
Check No.: i1 aO t Receipt No.: ��
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature o 'ent%Ovvnerx _ am Si�nafiure ofcont�actom -
a
a
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
# ❑ Swimming Pools ElPublic Sewer Tanning/Massage/Body Art ❑
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
l
i
i
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/Signature& Date Driveway Permit
' DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no j
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
Ij ed for pickup - Date
i
Doc:.Building Permit Revised 2008mi
I
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
C;� Building Permit Application
�' Workers Comp Affidavit
;d 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
t
❑ Building Permit Application }
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o 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 1
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
I
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 orspecial 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
I
I
Doc: Doc.Building Permit Revised 2008mi
MLocation 4- f W �(
No. — Date
r'
7
o - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
0 ®0 Building/Frame Permit Fee $
fi. 17 Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
27080
" Building Inspector
RTH
Town of n over
® to
No. I , I
-
O h , ver, Mass, n® 3
coc"KHEW1CK y1'
A04ATED P .(5
S U
BOARD OF HEALTH
PERMIT Food/Kitchen
T . LD Septic System
w
BUILDING INSPECTOR
THIS CERTIFIES THAT ................. .. . �i�,........�4l.lg. ........... .......................................
..�.........
/, Foundation
has permission to erect .......................... buildings on ......�......J..ksh.�Ajd...ivIew.......
Rough
to be occupied as ....... ... ... ..............��.r�� ...................................................... Chimney
provided that the person accep this permit shall in every respect form to the terms of the application Final
on file in 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MO S ELECTRICAL INSPECTOR
O ' UNLESS CONSTRUCTION Rough
Service
...................... .................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises - Do Not Remove Final
No Lathing or Dry Wall To Be. Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
Office of Consumer Affairs and B siness Regulation
a` 10 Park Plaza- Suite 5170
Boston, Massachusetts 02,116
Home Improvement Contractor Registration
Registration: 117870
rType: Private Corporation
L) J Expiration: 12/12/2014 Tr# 234343
GEORGOULIS CONSTRUCTION, INC
SCOTT GEORGOULIS };
96 ARLINGTON AVE F ;V
Q
*
DRACUT, MA 01826
WA
Update Address and return card.Mark reason for change.
w ;?
-._-1 E] Address Renewal Employment Lost Card.
SCA 1 e. 20M-05/11
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-058498
SCOTT C GEORGbULIS'
96 ARLINGTON [VE
DRACUT MA 0126 (04j)/
1- \
Expiration
Commissioner 10/21/2015
ISEI1010-6955849
�UCSanD ! American
� �OlExtenslon
• � Safety Council
INTERNATIONAL SAFETY EDUCATION INSTITUTE(ISEI) =_"�
ikThis'caCrd cerbflesthat.
SCOTT�GEORGOU-LIs '
has completed a�FVHour OSHA Hazard Recognition Training
11
for-the Constructlon,industry.
08/23/20131
Director:Scott MacKay Trainer:Taylor Sikes Grad.Date:
WYYYY
Ac R CERTIFICATE OF LIABILITY INSURANCE DATE Imo23120132013 '
09/
THIS CERTIFICATE IS ISSUED AS A MATTER OF.INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be andorsed. N SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(a).
PRODUCER Phone: (978)263-3500 Fax (978)263-1438 CAT.cT Gallant Insurance Agency,Inc. -
GALLANT INSURANCE AGENCY,INC. PHONE (978)2833500 g �' FAX t,o (978)263-1438
199 GREAT ROAD/P O BOX 975 �,a
ACTON MA 01720 :
PRODUCER 36702
cuaroee
INSURERS)AFFORDING COVERAGE NAIC 9
IND INSURER" Seneca Specialty Ins Co
GEORGOULIS CONSTRUCTION INC.
CIO SCOTT GEORGOULIS INSURERS : Chards Insurance Company
96 ARLINGTON AVENUE INSURER C
DRACUT MA 01828 INSURER D:
W43URER E
INSURER
COVERAGES CERTIFICATE NUMBER: 36324 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
INGR LTR TYPE OF INSURANCE' ADMINSIR VAID POLICY NUMBER PDIJCYEFF POLICY EXP LIMITS
_...
A ° R"` LIABILITY 13AG4001034 03/05113 03106M4 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAOE TO RENTED 100,000
PREIyUS S urence $
CLAIMS-MADE I�OCCUR MED.EXP(Any one person) $ 5,000
PERSONAL 8 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,0001000
KEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY PRO LOC
$
AUTOMOBILE LIABaJTY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
BODILY INJURY(Per person) $
ALL OWNED AUTOS
BODILY INJURY(Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE
HIRED AUTOS $
(Per accderd)
NON-OWNED AUTOS $
$
UMBRELLA A LUV; OCCUR EACH OCCURRENCE $
EXCESS LMB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE
S
RETENTION $ $
B wowmw COMPENSATION W0009774M 09/25/13 09125/14X '"0 "n' OT" s
AND EMPLOYERS' LIABILITY YIN a
ANY PROPRETORfPARTrEwEXECImYE E.L.EACH ACCIDENT100,000
OFFICERAIENBER EXCLUDED? I� NIA $ _ _.
(aNnOarory ro NN) E.L.DISEASE-EA EMPLOYEE $ 100,000
It yes,desaSbe under _._.. ..
OESORIPrION OF OPERATIONS below E.L.DISEASE-POLICY LIMB
$ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Addiaonal Remarks Schedule it more apace Is negtdrad)
i
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
i
120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
Andover,MA 01845 AUTHORIZED REPResENTATWE
Attention: � .Ga:tlrr�'
Ray Gallant,President
ACORD 25(20 109) ®1988-2009 CO CORPORATION. A I rights reserved.
The ACORD name and logo are registered marks of ACORD
GEORGOULIS ROOFING & CONSTRUCTION, INC.
'
r000�,96 Arlington Ave.
Dracut,MA 01826
Al Greene-Estimator
1-978-453-4242 Office
1-978-888-1700 Cell
georgoulisl4l(c aol.com
CONTRACT
John Weir 10/01/13
Re: 52 Highland View Ave.
N. Andover,MA _
1-978-852-9727
1 flyingf5@yahoo.eom Job Location:52 Highland View Ave.N.Andover,MA
iY
Scope of Work:
Remove all layers of roofing down to wood deck on entire shingled house roofs,protecting the grounds and house body with
heavy duty tarps as stripping-is being done.
Remove all existing siding from all sides of the dormers,Remove upper facial board the meets the dormer roofline.
Install 6'GAF Weatherwatch ice/water shield underlayment across all eaves,3'up all rakes at all roof to wall
locations,curbing up onto sides of dormer walls,and around all roof protrusions.
fInstall new step flashing at all roof to wall locations of dormers.
i Install GAF Shinglemate felt paper on remaining exposed roof deck surfaces.
Install 8".025 gauge heavy duty white aluminum drip edge on entire roof perimeters.
Install GAF Pro.Start starter.strips across all eaves and up all rakes.
Install GAF Timberline HD Lifetime Architectural shingles with Timbertex hip/ridge caps on roof.
Install new Coravent V-400 ridge vent on main ridges.
Install new stack pipe boot on existing plumbing pipe.
Contractor John Weir will be responsible for installing new trim and siding there removed.
Thoroughly clean and magnet grounds and remove all job related debris-from property on a daily basis and at jobs completion.
$55.00 Per SheetExtca Cost to replace any damaged plywood decking(if needed)or
$2.50 Per Lineal Foot Extra Cost to replace any damaged plank board decking(if needed).
Entire job includes GAF Systems Plus Warranty. First 50 yrs.Is non-prorated,full labor and material
coverage from GAF,against any material defect cause.
WE PROPOSE hereby to furnish material and labor complete in accordance with above specifications,
for the sum of.
Det, L d• s lllaxo cK It 138308
Five Thousand Eight Hundred Ninety Dollars
$5,890.00 +0llg'i3
PAYMENT TO BE MADE AS FOLLOWS:
$1,890.00 PAID IN ADVANCE FOR MATERIAL COSTS $4,000.00 PAID IN FULL WHEN JOB IS
COMPLETELY FINISHED ACCORDING TO THE ABOVE LISTED PROPOSAL.
All material is guaranteed to be as specified.All work to be completed in a substantial workman like manner according
to specifications submitted per standard practices.Any alteration or deviation from above.specifications involving
extra costs will he executed only upon written orders,and will becomean extra charge over and above the estimate.
Alt agreements contingent upon strikes,accidents or delays beyond our control.;Owner to,carry fire;tornado and other
necessary insurance.Our workers are fully covered by workers compensation'
Georgoulis Authorized Signature
This proposal may be withdrawn by us if not accepted within0 Lyl
Acceptance Of Proposal-The above prices,specifications are satisfactory and are hereby accepted. You are authorized to do the work as specified.
Payment will be P
made as outlined Ym timed above.
Rivnatnre Sirsnatnre bate of nreentance. io 14?t E
I
The following is part of this contract:
Contractor Registration
All home improvement contractors must be registered with the Commonwealth of Massachusetts.
Contractor Registration#117870 and Construction Supervisor License#058498.Inquires about
registration should be made to: Director,erector Home Improvement Contractor Registration,One Ashburton
P g
Place Room 1301 Boston MA 02108 617 727-8598.Better Business Bureau Inc. r
, ( ) c Georgoulis
Construction,Inc.member ID#35522. Contact the Better Business Bureau
(508)652-4888 or at memberservices@bosbbb.orz.
General
All outside work areas will be left rake clean.Roofing may result in dust or debris falling into the attic.
This contract does not include clean up or protection of the contents in the attic.In the event a satellite
dish should have to be removed to complete.project,Georgoulis Construction,Inc.will not be responsible
for repositioningafter re-installation, should it be necessary.In addition the Roofing contractor will not
arY g
be liable for any damage,whether incidental or accidental,that may occur to any A/C,electrical or
plumbing equipment that is installed or located in a place that interferes with the roofing or re-roofing
process within normal standards&practices of a typical and reasonable roofing or re-roofing installation.
Payments
The maximum down payment or advanced deposit allowed by Massachusetts law is limited to whichever
is larger: (A)One third of the total contract or(B)the entire cost of any special order materials.Final
payment is required within 15-days of the invoice date or a late fee charge in the amount of five(5)
percent of the said payment shall be assessed for every 30-day period for said payment outstanding.If
non-payment becomes a legal matter,the Homeowner will be responsible for all legal fees incurred by
both parties.All Credit Card Sales over$1,000.00 are Subject to a 2.0% Convenience Fee.
Work Schedule
The owner agrees the scheduling date is approximate.The contractor agrees to show good faith in
meeting deadlines,but are not responsible for delays caused by weather. Suppliers, subcontractors,
building officials.asbestos abatement,hidden damages or conditions,accidents,acts of God or anything
beyond our control.
Change Orders
The owner is aware that the work may contain hidden damage,defects,or conditions such as decay,insect
damage,or substandard construction practices,that may require additional work not included in this
contract.In this case,Georgoulis Construction,Inc.will contact the owner and agree on an additional
charge to the original contract price.In the event the owner can not be contacted,and it is crucial that
work continue to protect the residence from the elements,(rain, snow,ect.)photographs will be taken to
document the necessity of the additional work. The owner understands that any additional work will delay
the completion of the project.
Warranty
The contractor,Georgoulis Construction,Inc. agrees to correct any work that fails to conform to the
contract or workmanship that is defective within TEN(10)years from the substantial completion date of
the project at NO CHARGE to the homeowner.The homeowner agrees to notify Georgoulis
Construction,Inc. specifying the nature of any workmanship defect,immediately.No warranty is
provided for ordinary wear and tear,fading,abuse,neglect or casualty,or minor cracking/shrinking of
concrete or caulking.No warranty is provided for materials not directly supplied by Georgoulis
Construction,Inc.or for used,re-installed materials,(including skylights not installed by Georgoulis
Construction Inc)or work done by others.This warranty excluded consequential and incidental damages.
Contract Acceptance
Upon acceptance of the authorized parties at Georgoulis Construction,Inc.this contract and all work
described herein will constitute the entire agreement between Georgoulis Construction,Inc.and the
Homeowner.
' The Commonwealth of Massachusetts
.Department oflndustrial Accidents
�y- Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Vlorkers' Compensation insurance Atridavit:Builders/Contractor•s/FIectricians/Piumbers
APPHeant Information . Please Print IJe 'bl
Name(Business/Organization/Individual): 6'•CO(" yv�� �/�jT `�
!/ 5
Address-AL
City/State/Zip: +LJC-G i U,�; �v[�, a!d'd�� Phone i#: '79dp` �T3—l o-l��
Are you an employer?Check the appropriate box: Type of project(required): f
1.4 I am a employer with/0 4. ❑ 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 # 7. Remodeling
p p attached sheet. ❑
P het. g
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance, g, ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 ain a homeowner doing all work right of exemption per MGL - 11.0 Plumbing repairs or additions
myself'[No workers'comp, c. 1,52,§1(4),and we have no 12.❑Roofrepairs "
insurance required.]t employees.[No workers'
.comp.insurance required.] 13,El Other
*Any applicant that checks box 41 must also fi11 out the sectiorl below showing their workers'compensation policy information.
fi Homeowners who submit this affidavit indicating they ace doing all work and glen hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors aiid their Workers'comp.policy information.
X am an employer that is pro viding workers'compensation insurance for myemploy
information. � ees. Below is tdie policy and job site
.
Insurance Company Name: C4
Policy#or Self-ins.Lie.#: (,JGOO c/`7 r7 !U J> 3 Expiration Date:
Job Site Address: s,�2, �¢��C
��/ �e City/State/Zip^ � aC�/•/��Q,
Attach a copy of the worker compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Sedtion 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 maybe forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
X do hereby certrf under the pains and penalties ofpesjury that the information provided above is true and correct.'
Signature: Q p U Date: //L
Phone#:
Of use only. Do not write in.this area,to be completed by city or town offrciad.
City or Town: Permit/License#
r Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions .
Massachusetts General Laws chapter,152 requires all employers to provide workers'compensation for the'
_ p Yr 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
ofthe foregoing engaged in a joint enterprise,and including the legal representatives of deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of 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 lie'
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 subdi isio
hs shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
b8 returned to the city or town that the application for the ermit or license is
P 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
PIease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottoin
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 pennit/lieense number which will be used as a reference number. Irl 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 pen-nit not related to any business or commercial venture
(i.e.a dog license or permit to burn Ieaves 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 Qf Massachusetts
Depar inmt of Industrial Aeeidents
Office of Investigations
600 Washington Sheet
Boston,ltd 02111
Tel.#617-727-4900 e406 or 1-877—M. ASSAFE .
Revised 5-26-05 Fax#617-727-7749
Www mass.gov/dia