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HomeMy WebLinkAboutBuilding Permit #434-14 - 575 WINTER STREET 11/13/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATIO Permit NO: Date Received Date Issued: ' -- IMPORTANT: Applicant must complete all items on this page LOCATION Y /n// �� ��Z-7 Print PROPERTY OWNER C Print 100 Year Old Structure yesn MAP NO: )bq PARCER 11 ZONING DISTRICT: Historic District yes t1o' Machine Shop Village yes n� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial .Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 0 0,0 �, ,vo, A0,9&Z— Identification Ple se Type or Print Clearly) OWNER: Name: , oma✓w� 7iv10 Phone:�� 0 ` ti Address: S-2.5— 4�,Illk,7-74 " CONTRACTOR Name: C���� �'L/!/ Phone: 500-F Address: O' ��vt�2 1 A/0, r Supervisor's Construction License: ��o�/ �3 Exp. Date: Home Improvement License: Exp. Date: ; ti ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST�BAS`ED'ON$125.00 PER S.F. Total Project Cost: $ /�, oO� FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to a arae d rSgaature of AgenUO_caner Signature of contracto Plans Submitted 0 _ Plans Waived ❑ Certified Plot Plan El Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ _ TYPE--OP SEWERAGE:Di5bSAL Public Sewer ❑ Tanning/MassageBodyArt ❑... ..Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc._ ❑ _ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED: DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature& Date Driveway Permit DPW T'odv . Engineer: Signature: -- Located 384 Osgood Street -FIRE-DEP ��. . .. ARTM. T - Temp Dumpster on site yes no . Located-at 124 Mair, Street Fire Departine► tsignature/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 El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fol swing 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 o 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 apw al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application I Doc: Doc.Building Permit Revised 2012 . I Location 2i1 .� 1 No. -1� — Date i • - TOWN OF NORTH ANDOVER . hr Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check ` r 271 Building Inspector I Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 1 0,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 i I 575 Winter Street 434-14 on 11/13/13 Bath Remodel I I i i i ttoRTH Town of 2 E .. I, Andover 431t- �� �` Z ���rh ver' Mass,, 13- Ali LAHf ♦ CO[HIC Hl WICK A°RATEo S l! BOARD OF HEALTH Food/Kitchen PERIT T LD . Septic System UA THIS CERTIFIES THAT - BUILDING INSPECTOR ......... . .NNw..I......................................... ................ ...................... has permission to erect ............... buildings on 51's ......... Foundation Rough to be occupied as rew ..................................................................... Chimney provided that the person accepting this permit shall in every respect conform 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTRPT S 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 a d a r i Donna Lind 575 Winter Street North Andover, MA 01845 (H) 978-687-8922 (C) 978-764-9407 donnalind@comcast.net September 8, 2013 Bathroom Remodel Work to be included includes: • Acquire Building Permit • Demo of existing bathroom. • Complete all required plumbing. • Complete all electrical (lighting,install new Panisonic vent/light unit, install 2 new 5 in. cans, new switches and plugs). • Install vanity and tub. • Install new blueboard and plaster ceiling. • Install DenseShield Tile board on tub walls. • Install tile on tub walls. • Install DenseShield tile board on floor. • Install new tile floor. • Install new baseboard heat cover and baseboard. • Install new toilet paper holder,towel bars. • Removal of all debris. TOTAL LABOR AND MATERIAL $ 7,700.00 Note: This quote does not include any plumbing fixtures,vanity,tiles, grout, granite, or paint. If current vent is not properly vented,we will need to address. Terms: $2,500.00 upon signing of contract(not to exceed 1/3 of contract price) $ $5,200.00 when job complete Submitted By: Chris Rivet MA Lic#CS072173 HIC#139962 207 Winter Street (C)508-265-3115 (H)978-794-1165 North Andover,MA 01845 All Home Improvement Contractors shall be registered.Inquiries about a contractor relating to a registration should be directed to; Registration Division,Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 Tel:617-727-3200 ext.25239 All building permits required will be the obtained by the contractor.Homeowners who obtain their own permits are excluded from access to the Guarantee Fund. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfac - and are hereby accepted. You are authorized to do the work as specified.Payments ill be made as out ned above. Date // a / Homeowner Signature Dat e���� Contractor Signator Cetteac#or Arbiisra#zon The ITome Improvement Contractor L."provides homealterrowners With the right i o initiate an arbitra�on action(as an oo,atr a tor,to wevT,court action)if they have a dispute With a contractor. The same right is not automatically aFfordedto a. contractor,however. The contractor world have to resolve any dispute he/she has with a homeowner.in eotut unless both parties agree to the opi3onaN 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 cc ctor and the ho -owner here conce by mutually agree in advance that in the event the contractor has a dispute g this contrac' e contractor EC � sub ' the dispute to a private arbitration funs which has been approved by the Se el ofthe E ctttive ffice of ismer Affairs and BusinessReto sub 'tato saich aaibati as.providassachusetts General Laws,chap o e cOnsam h be r-quired He vnefs Signa� NO C a=The signatures ofthe patties above a ntra.ctoi' 3. lures to e resolL-tion initiated by the contractor. The homeowner may initiate ai-tmeinative disptent ofthe �it�-resolution even tit alteniative dispute ere this section is not separately signed by the parties. III A homeowaex's rights under the Home .in Contractor Law(iVIGL chapter 142A)and other consumer Protection laws(i.e,ylG�,chapter 93A)may not be waived in any way, even by agreement. However, ne maybe excluded from certain rights i�.the contractor they choose is not properly registeredent� re _s Homeowners who secure their own,building permits are automatically properl from all Gtas Prescribed •ted bylaw. th e Home.improvement Contiaetor-Law: The contractor is responsible for completing elle work�describe ' p �szons of timely and worlCm n life maser, Homeowners maybe entitled to other specific 1e m a guarantees or provides an express warranty for Workmanship �rights if-dje contractor Provided r= g or materials. In addition to guarantees or warranties b5 the contractor, all Dods sold•in Massachusetts cony an addition ofinerchantability and fitness fo a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfull-agree r added to `,he terms ofthe eonact as long as they do not restrict a homeowner's basic consumer ria y maybe ques'dons about your consumer/homeowner rights,Contact the Consumer IufoimationHotlne(listed below dhts. If you have f ec-ation.of Cont•ac;: ) The contract must be executed in du licate and should not be signed until a copy of all exlnibits and refer document have been'attached. Parties are also advised not to sign the document tmtil all blaulc sections referenced Shed m or marked as void,deleted,or not applicable. One original signed copy of the contract wYdi.an ac have been be given to the owner and the other kept by the contractor. Any modification to the. hments i0 and agreed to by both-parities. Contracted work may not begin-until both parties have received a ifull�e e TJ V y``wli�'ng the contract,and the three day rescission period has expired. y xecuted copy of AceelAr2ted Pay,tints A contractor may not demand pets in advance of the dates ecified o homeowner deems him/herseTrto be the insectue. However,in instances where a contractor sP n the payment schedule in cases where the to be financially insecure,the contractor•nxa re 1 deems him/hers, . account as a prerequisite to continuin Y �e that the valance of fluids not yet due be placed in a=oint gibe contracted .c� J escrow signatures of both parties. work. Withdrawal of finds:from ar(x S. said aCC �. _ • Dunt would xequrre she Additional h2 ormadon .If you have general quer dons or need additional iu tornation about the Home rovem e consumer rights,or if you wish to obtain a free copy o f "q V[assachusetts Constpimer Gtud to Hoactor me 7m�oveme other' contact: p nr Consumer In foLmationHo'f ine Office of Consumer Affairs and Business Regulation 6i7-973-8787;888-283-3757 o10 Park rvvisittthe OCADR-webs teL 02116 1i-eL P-:J/v'w•v.mass.eov/o cabr/ If You want to veiifp the registration of a contractor or if you have questions or need addition about;she contractor registration component of the Home Improvement Contractor Law con additional specifically tact: Director of Horne:improvement Contractor Re OgistrationOf-ace of Consumer Affairs aud•Business Regulation 10 PadcPlaza,Room 5170;Boston,- A02116 617-973-8787, 088-29 83-0-3757 oxvisit the HZCwebsite orbit ://tiw,�vxnass.�ov/ocabr/ Go online to view the status of a Home Inaprovemeht Con actor's Regi � 11t 'db,state.ma.us/(�.oineim roveiuent/licettseelist.aso b dation: For assistance with informal mediation of disputes or to register fo xal complatu�s against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Bet[exBttsiness Bureau 508-652-4.800,50&75:5_2548 or 4.13_734-3114. Vesion2l-11M2/010 Massachusetts=Department of Pubtic Safety ., -Board df Bulldin 'Re ulafioris and Sta aril :�`, 9 5 iO ,s� Construction Supervisor License: CS-072173 CHRISTOPHER F-RIVET"' 207 WINTER ST " s N ANDOVER Ma.01815 Expiration. Commissioner 06/02/2014 34 �e�nrTrzn�rareall�af'��otaac�alelt Office of Consumer Affairs&Business Regulation TME IMPROVEMENT CONTRACTOR legistration: 139962 Type: piratio n: 9/8/2015 Individual a CHRISTOPHER F.RIVET CHRISTOPHER RIVET 207 WINTER ST. N.ANDOVER,MA 01845 Undersecretary k OP ID:SHHE CERTIFICATE OF LIABILITY INSURANCE7109130/13 YYY) 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(ies) must be endorsed. If 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(s). CONTACT PRODUCER Phone:978-688-6921 NAME: Macdonald&Pangione Insurance Fax:978-688-5350 PHONE FAX P.O.Box 428 A1C No Ext): AIC,No): 104 Main Street E-MAIL North Andover,MA 01845 PRODUCER Michael Pangione CUSTOMER ID#:CHRIS-5 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Christopher Rivet INSURERA:Preferred Mutual Ins Co 115024 207 Winter St. North Andover, MA 01845 INSURER B INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN RI TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY I MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE I $ 1,000,000 A nXcoMMERCIAL GENERAL LIABILITY CPP 0180 57 01 05 09/26/13 I 09/26/14 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE 17 OCCUR MED EXP(Any one person) ,$ 5,000 PERSONAL&ADV INJURY i$ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X1 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) '$ ALL OWNED AUTOS BODILY INJURY(Per person) !$ BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS I ER ANY PROPRIETORIPARTNER/EXECUTIVEE.L.EACH ACCIDENT '$ OFFICERIMEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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 ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St No Andover, MA 01845 AUTHORIZED REPRESENTA IV Michael Pangion I ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ,� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_e&�/ --r Ute-/f/d l Address:_ 0?O 2 /n///Vi`/Y�' f City/State/Zip:X1. ,"ii,s<_,, ,19 o/X V 4 Phone#: a ,� 3//S, Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction ployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t 7. [remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.ElElectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l l.❑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' comp.insurance required.] 13.0 Other *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 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 Name: Policy#or Self-ins.Lic.#: C leWol go S-q c7/C>s- Expiration Date:_ Job Site Address:_ —a 44 f/�1�t5�- �l City/State/Zip:la 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 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. [do hereby certify u der ze pains and p allies of perjury that the information provided abov is 111ruend correct. Si nature: Date: � �� Phone#: ro;? Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.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 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(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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia