HomeMy WebLinkAboutBuilding Permit #631 - 71 OLYMPIC LANE 4/28/2008L
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION
/Q`�TLID 16''ryO\
0 t �
Print
G DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family ✓
Addition
Two or more family
Industrial
Alteration ✓
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition ✓
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTIUN Ur VVUKK J U tat: rrccruF% r -u
Please Type or Print Clearly)
OWNER: Name:
CONTRACTOR Name:
Address:
Supervisor's Construction License: D -` 19!:>' Exp. Date:
Home Improvement License: ld r ?'03Exp. Date: '7L d
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3�, 5 Ud. e,(. FEE: $� d
Check No.: Receipt No.: C� 11(
NOTE: Persons contracting with unregistered contractors do not have access to the uaranty fund
Signature of Agent/Owne_ �-�" Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan . Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - IJ�F(2M
DATE REJECTED 'DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on q/2, la -
COMMENTS
IQ lN�avv�S W,, (V c" too � O'G"
HEALTH
M
,t
Reviewed on �1 `� '
J
Zoning10oard of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
ti
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
i Located 384 Os ood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street '
Fire Department signature/date
COMMENTS
n
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)
Ed V\ 1dV 0��n A k
❑ Notified for pickup - Date
................... __..__.......... .................................................................................................. _.._-.................... ........ __.......................................................................................... _._._.__._.......... _...................................._....................... ....................... ...... ............................................................................. _............
Doc.Building Permit Revised 2008
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
L3 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)
L3 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 2.2008
Location -7 / cMv:!,,ai lee�
No. Date
Check # 6-7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
1111�
21 1 13 6-e:::=
Building Inspector
11-� � f:g
ate. . . .
TOWN OF NORTH ANDOVER
#0
PERMIT FOR GAS INSTALLATION
7' ":
This certifies that .............
has permission for gas installation ...........
in the buildings of ........ 1-.,c ........................
at ..... North Andover, Mass.
Fee. '-54. rTo7—Lic. No.. . 11�3�41 . .................
GASINSPECTOR
Check# C;2
6497
I
Name of Licensed Plumber'or Gas Fitter <
MASSACHUSETTS UNIFORM APPUCATON FOR PERNIIT TO DO GAS F rr1NG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Lggations
Owner's Name
New D Renovation D Replacement D
G
UB-BASEM ENT
ASEMENT
ST.
FLOOR
ND.
RD.
TH.
FLOOR
FLOOR
FLOOR
TH.
FLOOR
T H.
F L O O R
TH.
TH.
FLOOR
FLOOR
Permit # ./97
Amount $
Jy4r-j
e
Plans Submitted
11
Check one: Certificate Installing Company
0 Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes
If you have checked es please indicate the type coverage by checking the appropriate box. No
Liability insurance policy Other type of indemnity 13 Bond 1
Owner's Insurance Waiver: I am aware that the licensee does_ not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
.�Check one:
Signature of Owner or Owner's Agent Owner 13 Agent
I hereby certify that all of the details and informati n I have submitted 13
r entered) in aboAapiion true and accurate to the
best of my knowledge and that all plumbing work installations perf rmed ema lication will be in
compliance with all pertinent provisions of the lktassachu at �) p�ppd ha teeneral Laws.
By:
Title
City/Town,
OVED (OFFICE USE ONLY)
Signature of Li
.� Plumber
Gas Fitter
..Master
Journeyman
sed Plumber Or Gas Fitter
V. /dir 3c
License Numoer
a
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Check one: Certificate Installing Company
0 Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes
If you have checked es please indicate the type coverage by checking the appropriate box. No
Liability insurance policy Other type of indemnity 13 Bond 1
Owner's Insurance Waiver: I am aware that the licensee does_ not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
.�Check one:
Signature of Owner or Owner's Agent Owner 13 Agent
I hereby certify that all of the details and informati n I have submitted 13
r entered) in aboAapiion true and accurate to the
best of my knowledge and that all plumbing work installations perf rmed ema lication will be in
compliance with all pertinent provisions of the lktassachu at �) p�ppd ha teeneral Laws.
By:
Title
City/Town,
OVED (OFFICE USE ONLY)
Signature of Li
.� Plumber
Gas Fitter
..Master
Journeyman
sed Plumber Or Gas Fitter
V. /dir 3c
License Numoer
A07
AOR
SA U5
This certifies that
L
Elate X" ........
\-7
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
..................... b ....................
0 -
has permission to perform
plumbing in the buildings of .......
7
at .............. y
North Andover, Mass.
Fee. . �'.77". . Lie. No../03'�V* . ............................
PLUMBING INSPECTOR
Check #
78'1 2
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, SSACHUSETTS {—
r� ',1 J `
Building Location V 1�-t t C,/-MwnersName Date o I� Permit # /
Amount
Type of Occupancy I
New ri Renovation 17 Replacement Plans Submitted Yes No
FTXTT TR FC
(Print or type) �� Check one: Certificate
Installing Company Name A4 C /
Corp.
o
Adtress Q Q
❑Partner.
usmess elephone - - Firm/Co.
Name of Licensed Plumb _ Com-•- c #4
Insurance Coverage: Indicate the pe of msurarifecoverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver. L the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Owner Y Agent
I hereby certify that all of the details aninformation I have s5Sta
6P1u
best of my knowledge and that all plumbing wor anstalla
compliance with all pertinent provisions o the �Massachusetts
By: e o rcense um
Title
Type Of Plumbin ice
City/Town rcense um er
APPROVED (OFFICE USE ONLY
on are true and accurate to the
r this application will be in
of the General Laws.
Master Journeyman ❑
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Page No. 1 of
RODDEN CONSTRUCTION
47 Prescott St. North Andover, Ma. 01845
Phone 978 687 2934 Fax 978 687 0293
PROPOSAL
PROPOSAL SUBMITTED TO
Chris and Andrea Hanle
TODAY'S DATE
3?25 08
DATE OF PLANS/PAGE #S
PHONE NUMBER
9782587628
FAX NUMBER
1
JOB NAME
ADDRESS, CITY, STATE, ZIP
.North Andover. Ma. 0184S
JOB LOCATION
We propose hereby to furnish material and labor necessary for the completion of:
Renovate existing sunroom. Remove all existing windows, doors, plaster, flooring and moldings.
New flooring height will either be raised to the existing kitchen floor height or lowered to a full 7.5 in.
step down. The step down is only feasible if the perimeter framing does not have to be altered. New
ceiling to be cathedral type with framing as required. Reframe walls to accept new windows and doors.
Reside exterior as required. Fully insulate all areas with fiberglass batts to meet code. New walls and
ceilings to be blueboard with plaster skim coat. New finished floor to match kitchen as nearly as
possible. New door and window moldings to match existing. Open up wall section between kitchen and
sunroom and support as required. Electrical will include outlets and lighting with allowance to follow.
Plumbing and heating will include some new and some repositioning with allowance to follow. Any gas
fireplace installation is by owner, however, if an exterior dog house needs to be erected, there will be
an additional 600.00 charge. If new perimeter footings are necessary, add 800.00.
Renovate existing kitchen. Remove existing cabinets and counters. Remove existing closet. Install
new cabinets, to be supplied by owner. New counter installation to be by others. Electrical and
plumbing and heating will be as required with allowances to follow. Any necessary venting is by
others. There will be an additional charge if any floor patching is necessary.
Remove existing deck and erect new 10 x 14 deck area with stairwell to ground level. Framing will
be p.t. and railings will be square type posts, railings, and ballusters. Decking will be 5/4 x 6 trex or
equivalent. Area beneath deck and stairs to be left open. Install new footings and posts as required.
For all of the above work, permits are included and job debris will be removed.Any plans or
engineering required by the town would be additional Allowances are as follows:
All electrical materials and labor 1300.00
All plumbing and heating labor and stock 1500.00
Windows and doors, including ext. trim 3000.00
We propose hereby to furnish material and labor - complete in accordance with above specifications for the sum of:
Thirty two thousand five hundred dollars ( $ 32.500.00 )
Payment as follows: _10,000.00 job start. 15.000.00 plaster. 7.500.00 completion.
All material is guaranteed W be as specified. All work to be completed in a substantial workmanlike manner according to specifications submitted, per standard
practices. Any alteration or deviation from 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. Owner to carry fire, tomado and other
necessary Insurance. Our workers are fully covered by Workmen's Compensation Insurance. If either party commences legal action to enforce its rights
pursuant to this agreement, the prevailing party in said legal action shall be entitled to recover its reasonable attorney's fees and costs of litigation relating to
said legal action, as determined by rt of competent jurisdiction.
AuthorizedNote: this proposal may be withdrawn by us
Signature J if not accepted within I dais.
n ee�r—r
ACCEPTANCE OF PROPOSAL The above prices, specifications and Signature
conditions are satisfactory and are hereby accepted. You are authorized
to do the work as specified. Payment will be made as outlined above. Signature
Date of Acceptance
+'„14,12004 12:20 PM FRI:+At FoctQ,- Insurance+ FostQt Insur2n.cr T0: 1-9"i8-6,7-11293 PLZFL- .J::.2 OF 103
ACORD. CERTIFICATE OF LIABILITY' II SURA�ICE DATE
04/14/2008
PRODUCER
NORTH ANDOVER INSURANCE AGENCY, INC
9 WAVERLY ROAD
NORTH ANDOVER Y4A 01845-2415
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURED
Michael Rodden
Rodden Carpentry
47 Prescott Street
North Andouer DIA 01845-
NS"..;RERF; CITIZENS INSURANCE CO
a ISLRER _< HANVOER nNSUMICE
NSURERC: ZRICAN INTERNATIONAL GROUP
INSURER
_
INsuRER E
CnvFRYC:FR
THE POLICIES OF INSURANCE LISTED BELOIN HAVE BEEN ISSUED 70 THE INSURED NALIED .ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAND!NG ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIF!CA'E AY LSE ISSUED OF! MAY PERTAIN,
THE INSURANCE AFFORDED V THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AMC) CONDITIONS OF SUCH PCLICI6S.
AGGREGATE LIRA ITS SHOWN MAY HAVE BEEN REDUCED BY PAID CU11M5.
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
-�
POLICY EFFECTIVE
DATE MMlDCNY
POLICY EXPIRATION
DATE MM2E
LIMITS
A
GENERAL LIABILITY
/ ,�
EACH OCCURRENCE S 1,000,000
FIFE DAMACE a.ry me tire) 5 300, 000
X COrAMER SIAL C ENERrAL LIABILITY
C-AIMSMADE CC,,
3BN 5605683
02/01/200902/01/2009
MEDExp ;ryoneperscn)
PERSONAL&AU;IIVJUG.Y 1,000,000
---10,000
GENERAL AG GFEGATE is 2,000,000
'L AGGREGA-E LIMIT AFFLIE5 PER:
E
FRCCL TS-:;"IutP4�p AG 2,000,000
POLICY PRO- E LOC
B
A.L7I'OMOEILELIABIL17Y
ADN 8336670
07/16/2008
07/16/2009
COl.'4BINEDSINGLE DIA, -
ANY AUTC'
(Eaaccdent) y
ALL O, ZDALITJ3
/ %
/ /
ECDIL.Y IN,"JR'i
X
SCHECJLED,AUTOS
(Perpers)r) 100,000
hIRE;;A,UTO5
/ /�
r
! /
BC'DIL1' INJUR'!
NON-CV�NED AUTOS
(Peraccdent) s 300,000
l
FRCFERTY DAMAGE
[Peraccldert) 100,C00
GARAGE LIABILITY
AUTO ONLY - EA ACC!DENT S
ANI' AUTO
I %
I /
OTHEP, THAN EA ACC 5 _
AUTO ONLI'. �.
Acs
EXCESS LIABILITY
/ %
/ /
EACH OCCURRENCE S
A.6r;REGATE S
OCCUR-.AIM5MADE
DEDUCTIBLE
g
RETENTIO?I $
EN.PLO�S,LIABILITTIGNAND
/ /
/ %
X TG,AYLlk(LS 1 C
E.L. EA:H ACCIDENT S 100,000
C
WC1760133
01/01/2008
01/01/2009
.=_L.D!SE.ASE-EAEIIPL0`rEZS 100,000
I E,L.DISEAcE-FCLICY LIMIT S 500,000
OTHERT
/
/
/ /
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLLSIONS ADDED BY EPIDORSEMENTISPEC:AL PRAVISIO14S
ven n rivn i e nvwen I I AUU11IUNF,L INJURF.U; INUUREKLETTER: %epUlbCLLl1 EI WN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WLL ENDEAVOR TO MAIL
10 DAPS WRITTEN NOTICE TO '-HF. CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
TOWN OF NORTH ANDOVER FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES. _
[AUTHORIZED REPRESENTATIVE
NORTH ANDOVER MR 01845 �►'"� �
ACO RD 25-S (7197) ,t ACORD CORPORATION 1985
• INS025S f:i9319).7! ELECTRONIC LASER FORMS, !N'C. - (-o60)Si.%-0545
T,. Fagg 1 or 2
The Commonwealth of Massachusetts
Department of Industrial Accidents
m
Office of Investigations
600 Washington Street
Boston, MA 02111 ..
5www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip:
mak..
1� Phone .#: i 7
Are ygu an employer? Check the appropriate bog:
1. ETI am a employer with '
4. E]I am a general contractor and I
employees (full an part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.$
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.
Type of project (required):,,
6. ❑ New construction
7. remodeling
8. ❑ Demolition
9. ❑ Building addition
10..❑ Electrical repairs or additions
11 - Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeo)vners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Icontractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. 1
Insurance Company Name:
&161(4z�«
Policy # or Self -ins. Lic. #:' e L 7 ,���� Expiration Date:
Job Site
Attach a copy of the workers'
City/State/Zip:l /- A idUw (mus 61 "
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains an_d`enalties of perjury that the information provided above is true and correct
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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
ct 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 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/heense 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 11,22-06
www.mass.gov/dia