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HomeMy WebLinkAboutBuilding Permit #057-15 - 64 SUGARCANE LANE 7/16/2014 BUILDING PERMIT of "°erH06.1 E TOWN OF NORTH ANDOVER �� �: °� o APPLICATION FOR PLAN EXAMINATION h 04 4 1 �i Permit No#: Date Received �s OOR�TEo'Pa`�g CHUS Date Issued: IIJV1111� IMPORTANT: Applicant must complete all items on this page 'L,-OCATION, ' --- PF20PERTY 0111/NER._�n_r.£_i: �1_ _w.�tic�al��'__/'ia -►1_�-�-Y- _�_ cord �:�IJ�Lt�--.�.'�.3 nno Print 100 Year Structure yes!MAP V_ __PARCELb ZONING DISTRICT _Historic District yes_ Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 9 One family ❑Addition ❑ Two or more family ❑ Industrial ikAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑'Floodplain 0 Wetlands 1Natershedibistrict- ElWater/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: iw/14 04' ',l mo S At e4 Ansem r/0 zilmq - Tv, i4ncn L-P&- *4 � � f Identification- Please Type or Print Clearly OWNER: Name: c i e e,T—1 �e • o a 1z Phone: -)3 do <,1-7 Address: 4 ContractorNamelnhf ,4X,-- Rhone .___5* 322 '?835. Addres8: �O .in t rl K _ _�,h+,-it eoveo ° /'1`I. _ e�-td rJ Supervisor's-Construction License: Home 1m, provement'Licens.0-1 .1 q`7 QG_`. _.__: _Exp. Date: i ARCHITECT/ENGINEER Phone: Address: Reg. No. ' r I I e FEE SCHEDULE.BULDING PLfRMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COS BASED ON$12,6.00 PER S.F. Total Project Cost: $ FEE: $_ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have JaCcesAto the gijqrantyfiund S nature of Agent/Ovvner ____ Signature o .-cont Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ _T_Y-P_E_OESE_WERA.GE DI.SPOSA.L— Public Sewer ® Tanning/Massage/Body Art ❑ Swinuning Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS i CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS d Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments f Water & Sewer Con nection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT 7Temp Dumpster on site yes no `Located�at 124Wairi:Street I ;Fire iDepartment signature/date tQMMENTS__ ---Dimension Number of Stories: M 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 Di Building Permit Application w Workers Comp Affidavit zi Photo Copy Of H.I.C. And/Or C.S.L. Licenses w Copy of Contract s Floor Plan Or Proposed Interior Work Aa ❑ 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) Li 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 o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract Li Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 t Location No. "' Date ! I P o - TOWN OF NORTH ANDOVER ' I e , _ Certificate of Occupancy324'� $ Y: Building/Frame Permit Fe2�p $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# ..Y 27 '784 Building Wpector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 126,000.00 m $ - $ 1,512.00 Plumbing Fee $ 189.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 189.00 Total fees collected $ 1,990.00 64 Sugarcane Lane 057-15 on 7/16/14 Basement Remodel t%O R T1i Town of t ndover h ver Mass 1. 612b,q T O LANA COCHIC nI WICK A04ATS S U BOARD OF HEALTH Food/Kitchen PERMIT T LD �! l Septic System •`6Q� ��1 l�T BUILDING INSPECTOR THIS CERTIFIES THAT ........ Gr� ............................................. .. ................ .............................. has permission to ere ............ buildings on 1 • Foundation Rough to be occupied as ....... ....!1.� .'.'.. .........�.... •....... ... . .a ... � .�.... Chimney provided that the person accepting this permit shall in every respec 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 CONSTRUCTION STARTS 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. Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 126_ ,000.00 m 2 $ - $ 1,512.00 Plumbing Fee $ : 189.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 189.00 Total fees collected $ 1,990.00 64 SUGARCAIN a Fay Construction Estimate 20 Beresford street Date Estimate# Lawrence, MA 01843 7/15/2014 166 E-mail fayconl@comcast.net Name/Address Job location Weichert workforce mobility 64 Sugarcane Lane Susan Kaijala North Andover 1625 State Route 1.0 Morris Plains NJ 07950 Customer Phone Terms Description Qty Rate Total Basement area finished off without permits: Work with the building department for permitting and inspections for all trades involved.Cost will be determined after the building dept.has completed a walk through. Permits must be in place before building dept will get involved.I estimate permits cost for all trades to be 1200.00 750 sq.ft.basement area finished off: The area is divided into three areas. Foyer entered from garage or stairway from 1 st floor. Rec/TV area with wet bar and built in cabinet area. Original 6 ft slider to back yard. Bathroom, shower--toilet--vanity and sink. There is an unfinished area with hvac--water heater--ejector pump. I have inspected the area and found the following: Framing wood 2x4 studs on PT plate Electrical: 60 amp sub panel for.new area--8 circuits,Romex,combination of 15 and 20 amp. recessed lighting thought out--switches and outlets as required--smoke and co detectors Plumbing: 30 gal. 1/2 hp ejector pump picking up 3/4 bath--bar sink--utility sink--2" discharge and vent. Insulation is original r-19 faced on original 2x6 outside walls. Blue board and plaster finish on all walls and ceilings. Total Page 1 s. Fay Construction Estimate 20 Beresford street Date Estimate# Lawrence, MA 01843 7/15/2014 1 166 E-mail faycon1@comcast.net Name/Address Job location Weichert workforce mobility 64 Sugarcane Lane Susan Kaijala North Andover 1.625 State Route 10 Morris Plains NJ 07950 Customer Phone Terms Description Qty Rate Total Doors,trim, cabinets: wood good quality Flooring: mixture of the and engineered wood flooring. Walls and ceilings have paint finish. I estimate the cost of the basement area finished to be between $ 55.000.The work completed for all trades.is good quality. Fay construction------------- Weichert workforce--------- Total $0.00 Page 2 G W AUG AVA4C Lhj 'BACA. YA R J ARICA YAJ �iMlShce� ARES cLos�� �e�partvrmararuea���i _per/�� Massachusetts -Department of Public Safety Office of Consumer Affairs&Business RegulationBoard of Building Regulations and Standards OME IMPROVEMENT CONTRACTOR Construction Supervisor egistration: 147062 Type: License: CS-058683 Expiration 6/81201-5 Individual CHARLES A FAY AR CHARLES A FAY JR` y 20 BERESFORD 5'T 'I,, 2111 3 " Lawrence MA 01843 3r CHARLES FAY 20 BERESFORD ST Qac,• .,�—o �'"+ i �` LAWRENCE,MA 01843 1 ,..� Expiration Undersecretary 0511112014 � Commissioner - 8Q#S `. V- -OURNEYMA' lull Fay Construction Estimate 20 Beresford street Date Estimate# Lawrence, MA 01843 7/15/2014 166 E-mail fayconl@comcast.net Name/Address Job location Weichert workforce mobility 64 Sugarcane Lane Susan Kaijala North Andover 1625 State Route 10 Morris Plains NJ 07950 Customer Phone Terms Description Qty Rate Total Basement area finished off without permits: Work with the building department for permitting and inspections for all trades involved.Cost will be determined after the building dept.has completed a walk through. Permits must be in place before building dept will get involved.I estimate permits cost for all trades to be 1200.00 750 sq. ft.basement area finished off: The area is divided into three areas. Foyer entered from garage or stairway from 1 st floor. Rec/TV area with wet bar and built in cabinet area.Original 6 ft slider to back yard. Bathroom, shower--toilet--vanity and sink. There is an unfinished area with hvac--water heater--ejector pump. I have inspected the area and found the following: Framing wood 2x4 studs on PT plate Electrical: 60 amp sub panel for new area--8 circuits,Romex,combination of 15 and 20 amp. recessed lighting thought out--switches and outlets as required--smoke and co detectors Plumbing: 30 gal. 1/2 hp ejector pump picking up 3/4 bath--bar sink--utility sink--2" discharge and vent. Insulation is original r-19 faced on original 2x6 outside walls. Blue board and plaster finish on all walls and ceilings. Total Page 1 Fay Construction Estimate Date Estimate# 20 Beresford street Lawrence, IIIA 01843 7/15/2014 166 E-mail fayconl@comcast.net Name I Address Job location Weichert workforce mobility 64 Sugarcane Lane Susan Kaijala North Andover 1625 State Route 10 Morris Plains NJ 07950 Customer Phone Terms Description Qty Rate Total Doors,trim,cabinets: wood good quality Flooring: mixture of tile and engineered wood flooring. Walls and ceilings have paint finish. I estimate the cost of the basement area finished to be bat $ 55.000. The work completed for all trades is good quality. Fay construction---------- - �� Weichert workforce- - -- -- Total $0.00 Page 2 131? �3?1� pa�s1 N —elan p Prr°ti qDlot' �� � Iql -3 vfj9n,57> /-7? �e�parnnna�zcuea z o�6 crc,luroe�i'a iltassach-usetts -Department of Public Safety Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards OME IMPROVEMENT CONTRACTOR Construction Supervisor egistration 147062 Type: License: CS-058663 s Expiration 6M12Q'15 Individual �`r} i�� s� CHARLES A FAY,-YR r•� �� CHARLES A FAY JR: 20 BERESFORD ST 1 Lawrence MA 01$43 CHARLES FAY 20 BERESFORD ST. Gs _ ��� Expiration LAWRENCE,MA 01843 Undersecretary" OS 111?014 Commissioner . Qmmo1W H OFIIRI 1s iI�S Vl- .- N1E»1:S ;A F AY 20 :BERGS"'d 0 ,STRE LkWREN�CE 7 KLA 0184324�1 � r � y • ---� OP ID: SS ,d►�CORn' CERTIFICATE OF LIABILITY INSURANCE 7OTE(MMIDD/Y7/16/20144 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). PRODUCER CONTACT NAME: Durso&Jankowski Ins Agcy LLC PHONE FAX 198 Massachusetts Avenue A/c No Ext): AIC,No): North Andover,MA 01845 E-MAIL ADDRESS: Durso&Jankowski Ins.Agcy. PRODUCER FAYCO-1 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Fay Construction Co. INSURER A:Main Street America Assurance 14788 Charles A. Fay,Jr. INSURER B:NGM Insurance Co 14788 20 Beresford Street Lawrence, MA 01843 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDIYYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY MPP48861 06/07/2014 06/07/2015 DAMAGE ( RENTED PREMISESS Ea occurrence) $ 500,000 CLAIMS-MADE Fx_1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICYLI PRO- F LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ B ANY AUTO M1T9239C 12/18/2013 12/18/2014 (Ea accident) BODILY INJURY(Per person) $ 100,00 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 300,000 X SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) $ 100,00 NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONWC STATUTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMIT- OER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Bldg Dept 384 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 4631L ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD I I The Commonwealth of Massachusetts - Department oflnclustriglAcculents Office o,f'Investigations 600 Washington Street .Boston,.M 02111 wtvw.massgov/ctia Wo rkexs'�Compengaton.imurance Affidavit:BuilderslContrac ox>y/Eiec XczanslZ'lrznaber A.ppXican ol.aiaatZon Please Print Ledbh 'Namo(Business/Oro nization&di.vidual): �i/l�CE'•r �/� Address.—,2c &nerLl s ff City/Stade/dip: t,L'aCaL!' /'9�I �1 �t3 Phone#:_ �l' g 2 F `�d?3S� 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 f employees(M and/or parE time)•* have hired the sub-contractors 2.�( I am a sole proprietor or partner listed on the attached sheet I 7• Remodeling These sub-contractors have 8. [(Demolition ship and`havena.employees woxli g forme in any capacity. workers'comp,insurance, 9. U Building addition [No workers'comp.insurance S. ❑We are a corporation and its 10[]Electrical repairs or additions required.] officers have exercisedtheir Tight of exemption per MOL 11.❑Plumbing.repairs or additions 3.[I Z am a homeowner doing all worst c�52 14 anal w have no myself[No workers comp. a§ ( )� 12.p Roofrepairs insurancerequired.a i" employees.[No workers' 13.[]Othex comp.insurance required.] Any applicaffithat checks box#I must also fill outthe section below shovtingificir workers'compensationpolicy information. 7•Homeowners who sabn itihis affidavit kdlcatingthey 9doing allworKandtheilRe outside contractors must.submit anew affidavit indicating such. TContractors that cherkthis box must attached an additional sheet showing the name of the sub-contractors andtheir workers'comp.policy information. Tainan exnpToyeNt/tatisprovidingworkeYs'compe�asationinsz�rar�ce forM employees Be W isthepolie ancijoh site information. Insurance Company Name Policy#or Sem ins.Lic.M. Expiration Date: Tob Site A.dchess;,�11 S�Sj)&C1&£ '�/I/ d MdOVVY, Pity/State/Zip: .Attach a copy of tete workers'comp ensatloxtpolley declaration page(showing the Polley number and e irationc crate). R'ailure to secure coverage as reguixedunder Section 25A ofMGL 0.152 can lead to the imposition,of criminal penalties of a fn e up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a tme ofup to$250.00 a day against the violator. Be advised that a copy of this statem.entmay be forwarded to the Office o£ Investigations of the DTA.for insurance coverage verification. X do hereby cert&under the pains and penalties ofpe#ury Mat trie infarrnatiox�ppovidecl alcove is true and correct - _ Sxenatare � Date: Phone Oficial use o'nly. .DO not write in this area,to he completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board oMealth 2.Building Department 3.01yMovm Clerk 4.Electrical Inspector 5.PXumbiug Lispector 6.Other - - - •or, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuaz t to this statute,an employee is dei:J.tted as"...every p exson k the service of another under any contract oXhire,• express or h pRA oral or written.." An emproydis defined as"an individual,partnership,association,coxporation or other regal entity,Or anytwo ox moxe of the Foregoing engaged in a joint enterprise,and including the legal representatives of a:da eased em to er.or.the receiver or-Mistee of an individual partnership,association.or other legal entity,employingem o ee s ' ty, ply . However the owner of a dwelling house having not more than three a ar-tments and whoresides e e` dweller h PtIr r zu,or the occupantofthe g house of another who employs poisons to do maintenance construction nsttuction orrepair work on such dwelling house or on the,grounds orbuildin a g �' appurtenant thereto e g h x to shallnotbecause o s, . pp f 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 buiidiugs in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the iusurance coverage required." Additionally,MCL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have,b a On pros ented to the cQatractingauthority..,, Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and;ii necessary,supply sub-contractors)name(s),addresses)andphotenumber(s)alongwith their cettiflcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notre,quired to carry workers'compensation insurance. ff an LLC or LLP does have employees,apolicyisxeq*ed. Baadvised thatthisaffidavit may besubmitted tothe,Department of ludustrial. 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 peamit or license is being requested,xtot 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. Selfiustrred companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavitforyou to fill out in-the event the Office of Investigations has to contact youregarding the applicant. Please be-sure to fdl in the POnu t/license number which will be used as a reference number, hr addition,an applicant that must submitrxtultiple.permit/license applications is any givenyear,need only submit one affidavit indicaft current Policy information(if necessary)and under"Job Site Address"the applicant shouldwxite"all locations in (city or towir)".A copy oi'the affidavit that has been officially stamped or marked by the city or town,maybe provided tote, applicant aspzoofthat 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 p ermit not related to auy business or commercial venture (i.e.a dog license orpermit 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 youx cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone a9rd fax number: ThaCQ towelalthol'lilbMact-WetlI - Depattment dlUdwWal Acoldenta QfcedZn. stigAama 6,Q0W@s gran 8�reGt La.9Qn,Ste.42111 T01, RM-27,4900 W- 406 Qx-1-8WMASRop, Revised 5-26-05 FRX#6177 727 7749 v�w4v.�Rass,gQ�l�clza