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HomeMy WebLinkAboutBuilding Permit #502-2017 - Exception 11/14/2016� ��,� Sere �►✓� � NORrH BUILDING PERMIT c TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit No#:oz ZOAL Date Received sgcNus% Date Issued: // Pr IMPORTANT: Applicant must complete all items on this LOCATION Pnot PRORE:RTY OWNER_ AV—". "_ Print 1 D0'Y&Ir structure if MAP __PARCEL.. _-_ �- ZONINO DISTRICT`His onc Distnct9 yes 11 en V,inc Chiari VilinhP VPS TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ©'One family ❑ Addition ❑ Two or more family ❑ Industrial CKAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition _ - ---- E Septic 1] Well El Other Floodplain ❑fWetland's _ __ L1 1Natershed District [; 1Water/SeVver _ _- DESCRIP] IONN L& VVVL)MM 10 BE r`ERFuniviEu. / � / � �� /oc� T°l tF :C.J +J�'7'� !� t-�/�ovK /,�'ji•�7%it GJ�, IIS r -'L 5 C lcsa,,.T. S Identification - Please Type or Print Clearly OWNER: Name: Ake C2r�s.so Phone: Address /-e Contractor'NamePhone:_ X76 -3o a yyS�. Email'V, la', s d s. Addfess:. Supervisors Constfuction1Jcense LS-lo�P?oy __-_ _ Exp' Date. /a%7/.l e Improvement License:/.�� 3�3.: _ Expw ®.afe:. �7 �� ARCHITECT/ENGINEER AM Phone; Address Reg. No. FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ W c oo 0 FEE: $''- Check No.: /0 ��� Receipt No.: NOT Persons contacting with un�egisteYed contracto do not liave access to the guaranty fund ure of contractor re of Agent/O,wner _ i at Location 1-7, 1�✓,�! L./� No. !W7,Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL Check # �� Q :i v Building inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSSA/L Public Sewer u Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature, Reviewed on Signature Reviewed on Signature Zoning Burd of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature &Date Drivewav Permit DPW Town Engineer: Signature: _ 38 FIRE' DEPART r _ 4 0 _ .. MENT" = TempgDum z Aster.on site yes• Located Located at 124 -; - - --- .� --- ree _,�MaintStreet Fire Departinent,signature/date j COMMENTS.. - - Enter construction cost for fee cal - North Andover Fee Cakulat on Construction Cost $ 203000.00 m $ - $ 240.00 Plumbing Fee $ 30.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 30.00 Total fees collected $ 400.00 12 Bonny Lane finish basement 502-2017 on 11/14/2016 v C � Cn 0 '0 O CD 0 Z CO) CD O CL r - CL �- N (O .a O vCD CD CLcr O CD - m CCD O w Im CD CL O N• CO CD � v 0 0 o O CCD 0 CD c� c� in - Z m cn 0 cn m X To z 0 Vr < C70 19 $ _ N <CD N cT m Co, rn �Q Z��c y -IL CD. -- o rt n = m N N WCD D y CD 2 CD. .•z cN CD / c� o CD <D CD -0 MEMO o_ C �• O < co p oZ0,CD a rt N np < Q. Q _ N <CL CD CD �, o W� N Ifto ' CD C # � O v, 0 ti 0 1 7Nt a° f Er 0 p ,-. m 21), I CD Cep •, C ro� ' CD ••i' I CD s' p 0 r 0 rt n� CD O � _ 0)o CL V7N pC 77,�•CL tD 'O" OZ W T .Z7 T d N �• Z7 O S T N A C S T p3j (7 ;] C ? T C Q ID O N "a n N T O n z m -ZI G1 N mZ -1 r m A H v m 00 r C W Z v m 0 3 W\ C3 2 Z to v m 0 rr N S N O y O 2 m D 2 Donald Belanger Inspector of Buildings Please print DATE: , f O 11SI/ G TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Telephone (978) 688-9545 Fax (978) 688-9542 JOB LOCATION: /.Z 9_0/In � 'ril? R__ NumberStreet A dress Map/Lot HOMEOWNER rVc,,-i 61-e_s-Sn f7�_ Name Home Phone Work Phone PRESENT MAILING City Town State Zip Code The current exemption for "homeowners" was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one -or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO R5.1.2) The undersigned "homeowner" assumes responsibility for compliance with State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. -� HOMEOWNERS SIGNATURE APPROVAL OF BUILDING 01 Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 _ I. ►--I -► .I _ --_ _ --_-Y._ -I_-L_ __-- - _I-L-I-_��_- LIS The Commonwealth of Massachusetts Y ..F Department of lndastrialAccidents 1 Congress Sheet, Suite 100 Boston, MA 02114-2017 • ,..: -': �.` www mass.gov/dia o�M 5yy ygo3:kere Compensation Insurance Affidavits Suildexs/Coni:racioxs/Electricians/l'lumbexs. TO BE FILED WITH THE PERMITI�G AUTHORI7 S'. ,ora , �o Print 1 Name (Business/Organization/Individual): /l Address: City/State/Zip: AZ Are you an employer? Check the appropriate box: Phone #: 1. ❑ I am a employer with employees (full and/or part-time)-* 2.a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t rz(�I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑I am a general con"ctor and Ihave hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. QWe are a corporation and its, of kers have exercised their right of exemption per MGL c. 152 1(4) and'we have no empldydes. [No workers' comp. insurance required.] t-.3 vol -7 Type of project (required) 7. ❑ Nd 'c6nstr6ction g, �emodeling 9. ❑ Demolition 10 [] Building addition I1.❑ Electrical repays or additions 1.2,[] -Plumbing repairs or additions 11 [] Rbof repairs 14.M Other *Any applicant that checks b6k,# 1 must also fill out the section below showing their workers' compensation policy information. rs must submit a t Homeowners who submit, afff artkac dic ti dhe nal shegshowing the all work andWarne of the sub contren hire outside a to�s and state whether or renow pot thoseindicating n ties have Contractors that P• policy employees. If the sub -contractors have employees, they must provide their workers' com olic number. X am an employer that is pr0v1d1n9w0rkers' compensation insurance for my employees..8elow is the policy aradyob site information. Insurance Company policy # or Self -ins. Lie. Expiration Date_ City/State/Zip: • Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requweellasd ivMGL alties?in the form of criminal25A is a 'OPiolation WORK ORDER and. a fine of p to $250.00 a and/or one-year imprisonment, day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do hereby certify under thepains andpenalties ofperjury that the information provided shave is true and correct. in this area, to be completed by city or town officia Official use only. Da not write l. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #l: Contact 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 enferprise, and including the legal representatives of a deceased employer, or the receiver'or trustee ofan 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 b6 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=contractors) name(s), address(es) and phone number(s) along with their certificates) 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 IndustrialAccidenis. 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 Iuvestigations 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 thai 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAYE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine No 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 ❑ 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe: Building Permit Revised 2014 Location A) - No. Date 2 Check # " �7) TOWN OF NORTH ANDOVER Certificate of OccupaMy con $ Building/Frame Permit Fee $-' ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector Y Commonwealth of Massachusetts Y Sheet Metal Permit Date: l' 62 q-16 Estimated Job Cost: Plans Submitted: YES NO Business License # Business Information: Name: f�f✓L�Ps f f �V �� Street: City/Town: �4^ 1 Telephone: Permit # a M Permit Fee: $!5v— Plans / — Plans Reviewed: YES NO Applicant License # ld ld Q Property Owner / Job Location Information: Name: 9 Street: Z) yah ny City/Town: l�%n mei Photo I.D. required / Copy of Photo I.D. attached: YEI' Building Type: Residential: 1-2 family Multi -family — Commercial: Office Retail Industrial Building Cubic Footage: under 35,000 cu. ft. /— Sheet metal work to be completed: New Work: HVAC Metal Roofing Kitchen Exh Provide brief description of work to be done: :7-n INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes El/No ❑ If you have checked Yes, indicate a type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxD, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Progress Inspections Comments Final Insuection Date Comments Type of icense: By Master Title ❑ Master -Restricted City/Town ❑Journeyperson Signature of Licensee Permit # ❑Journeyperson-Restricted License Number: / 61900 Fee $ El Check at www.mass.gov/dpi Inspector Signature of Permit Approval Commonwealth of Massachusetts Sheet Metal Permit Date. l' i / Permit #- � 7() Estimated Job Cost: Permit Fee: $ �� Plans Submitted: YES NO Business License # Business Information: Name: —�;f Street:i` City/Town: T74/'` i Telephone: dda�-S 08��C Photo I.D. required / Copy of Photo I.D. attached: Plans Reviewed: YES NO Applicant License # Id W Q Property Owner / Job Location Information: Name: Street: City/Town: Telephone: ��� 3d� _ 7r-9 YES NO Building Type: Residential: 1-2 family Multi -family _ Commercial: Office Retail Industrial /— Building Cubic Footage: under 35,000 cu. ft. V j Sheet metal work to be completed: HVAC Metal Roofmg — New Work: Condo / Townhouses Educational over 35,000 cu. ft. Institutional Renovation: t, Kitchen -Exhaust System Chimney / Vents Provide brief /description of work to be done: I isA 4�oc r. . INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes E� No ❑ If you have checked Yes, indicate a type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[], I hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Progress Inspections Comments Date Comments Type of icense: By Master Title ❑ Master -Restricted CitylTown ❑Journeyperson Signature of Licensee Permit # Elio urn eyperson-Restricted I�nna License Number: Fee $ Check at www.mass.gov/dpi Inspector Signature of Permit Approval Sheet Metal Commercial Guidelines / Life Safety / Critical System_ s Inspection Checklist Yes No N/A„ Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided .All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampens with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper 616'31ances, fire rated enclosures and pressure testing required: �­.ia'.'Int'b installFi'4' -offi rctegplred 011 eg1111lment and d?? A..,o .� Duct penetrations in firer& tvall-3 and floors sealed' Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nins installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean -properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -oft) b t Sheet Metal Residential Guidelines / Inspection Checklist Yes No NIA. Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metalwork being performed with proper journeyperson-to- apprentice ratios Equipment sized per heating/ cooling load calculations Duct work sized per manual "D" calculations Bath/ shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) SPEEDY'S HVAC Heating • AIC • Refrigeration Tina Avenue, Pelham, NH 03076 603-508.0856 SPEEDDEE@aol.com www.SpeedysHVAC.com BILL TO HVAC SERVICE ORDER INVOICE THIS WORK IS TO BE ❑ C.O.D. ❑ CHARGE ❑ NO CHARGE MAKE MAKE MODEL MODEL SERIAL NUMBER SERIAL NUMBER NAME STREET Uhn ,dam DAT � ENVIRONMENTAL CHECK LIST - WORK PERFORMED CITY f !! PROMISED wow PEwORMEO QTY TYPEJDGSPOSmON CONDENSING UNIT COND'SATE DRAINS ❑ RECOVERED LEVELED CLEANED MAIN DRAIN PHONE CALL BEFORE ElA M ❑ P.M. ❑ RECYCLED CLEANED COIL REPAIRED MAIN DRAIN TECHNI AUTHORIZED BY ❑ RECLAIMED CHECKED CHARGE CLEANED PAN DRAIN ❑ RETURNED REPAIRED LEAK IN COIL REPAIRED PAN DRAIN WORK TO BE PERFO�EL�, f / f n t f vC /f l G!'�1+' C- "� ( ❑ DISPOSAL REPAIRED LEAK IN COPPER FURN. OR FAN COIL ❑ DISMANTLED ❑ CHANGED OUTIREPLACED TOTAL $ A REF. REPLACED BELT CHECKED MOTOR ADJUSTED BELT QTY. MATERIALS & SERVICES _. UNIT PRICE AMOUNT .. ...... .__._ ... DESCRIPTION OF WORK PERFORMED CHANGED MOTOR REPLACED PULLEY / .....................!.......e...l....A......' ,,. .... ......... ............... .................._�L..G.....�._�..........�,�!444.KKK....._�..1t._��!.1:./ ......... ............................................................._...._....._..........__..............................._.. ..............................................................._..................._....._................................ .._....................................._............................._...................................._............._........._........�............. �................FILTERS........_. REFRIGERANT R LBS ......... .. ......_ _ _._._ � .....Y..L......_V(/!r/`......_...fs.�......................... t1i..f!..f .._ _........... ?,:(............................. 6✓ .,., ..............................................................................................._... .......... ........... ......................................../ r .........__..... ....._...........__............. _......................... _........ FILTERS X X X X ....................................._............................_._ BELTS I _ I._.__. .� . _ ._. ._.._...... I ...._._ .r_._. _.._......_ I ..._......... I _._.........._........�_....... __..._._.1.......... _..........__.................._..........._.._....... ._....... _........ ....... ......... I I 1 .._...._._...........L........................................1......_... I .____..._ _.�_.._... ...._...._......_.. I✓ `� I .. ._. . I �_._...._..... _. I ...._ .I............ ._._....._.:.............�......................._......._........:....................,................................................................._.................... ... ._............ ..........I............. 1VALVE _ T.....................................................>.;............................................................................................ ._.......... ...... _........... I _................_._....�. _.._.................._. I t ......__. �� ._.... _ ...._ItL `L./ 1�.�. , .._..._. .-.. _— ... ..... ............ _l'.�_ � ........_.!! .I7ds ...G ...._ .._..................... F.�.�%'Y/ JTp �'�y N' ......%...`._ /_I _. ._. !_. ..... ........ - .._.._................._..._. ��rJL// � ...... .......//................._......::..V..._.... /{/HEAT J..`::.. ._..'j....:S.Sr.+...,.rJ4✓.... ... ......................................... ..........,..........._......................... .............. _......................... ... ...... ........... .._......................................... _.......................................................................... ` - RECOMMENDATIONS REPLACED BELT ADJUSTED ULLEY ADJUST ED BELT LEAN CLEANED BLOWER REPLACED CONTACTOR RELAY START. REPLACED BEARI E OILED MOTOR REPL START. CAPACITOR OILED BEARINGS REPLACED RUN CAPACITOR CLEANEDOR ACTOR CLEANED HEAT ED REPLACED EXCH. REPAIRED WIRING C EANED OR AJ. PILOT REPLACEDFUSE REPLACED COMPRESSOR REPLACED THERMOCOUPLE OCOUPLE REPAIRED VALVE EVAPORATOR COIL REPLA ED REPLACED E7(P. VALVE ADJUSTED EXP VALVE CLEANED BURNERS DUCT REPLACED CAP. TUBE REPAIRED CLEARED CAP. TUBE AIRED COIL LEAK AJUSTED THERMOSTAT REPAIRED COPPER CONN. REPLACED " CLEANED COIL ADJUSTED TOTAL MATERIALS ................................ --.................................... _.................. ._....._............................... ...' LEVELED COIL ELECT. HTR. CLG TOWER HRS' LABOR RATE AMOUNT REPLACED LINK CLEANED ....._................................................ .... ............... ._......... ......_........................ ....... I .............. ..........I............. I I .................... ._.....I............. I .............................. .................. ........................................................ ................................ REPLACED KLIX. REPAIRED WIRE PUMPS i 1 REPLACED CONT. GREASED REPAIRED FILTERS ❑ CLEANED ❑ REPLACED MATERIAL$ ALABOR MAY B cormNDEDonoTH ABOR I I LIMITED WARRANTY: All materials, parts and a Iii ment are warranted b the 4 P y manufacturers' or suppliers' written warranty only. All labor performed by the above named company is warranted for 30 days or as otherwise indicated in writing. The above named company makes no other warranties, express or implied, and its agents or technicians are not authorized to make any SUCK warranties on behalf of above named company. TOTAL SUMMARY TERMS rrrl11 ,(�� (� TOTAL MATERIALS I TOTAL LABOR I have uthodty to order the work outlined above whi been Seller re . to ui menUmated until final payment as agreed, seller can remove sal equipmenVmatedals at Sellers said removal shall not be the responsibility of Seller. - satisfactorily completed. is made. If expense. Any damage I agree that payment is not made Vesulting from aG TRAVEL01 CHARGE I ElREGULAR ElWARRANTY ❑ SERVICE CONTRACT TAX (yew TOTAL O CUSTOMER ATURE DATE I n 5 SHEET:,AETAL -IKAI IUN PP Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 CLCAT@CL-NA.COM Facsimile (214) 488-6766 ***********************AUTO**3-DIGIT 018 772 T3 P1 95000058962 Building Commissioner or Inspector of Buildings 120 MAIN STREET HO N Andover, MA 01845 ME Claim Number: Policy Number: co Company Name: N a) Cause of Loss: co LO C) Date of Loss: Insured: 0 Property Location: Cunnin ham Va Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B NA 2642262 05 BAY STATE INSURANCE COMPANY ICE DAM 3/11/2015 Ryan & Sara Grasso 12 Bonny Lane Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 38. No insurer shall pay any claims (1) covering the loss, damage, or destructions, to a. building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 d Date.... .....................G�.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..... ............................................................................... has permission to perform .... ........../7,OU$'...................................... wiring in the building of ..........`.�. ��.............................................. D � at .... 12:../J,D ti. 4%iif�lam....................ALECrRliCAL Nor�NS�PE��'r� h Adover, Mass. 2 Fee.�/..�>.�..... Lic. No..�..2... 1...........� Check # 8966 r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 923 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 MR 12.00 (PLEASE PRINT INIIVK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To .the Inspect r o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) lcZ Ie Owner or Tenant A J (ZhN 102— A Std Telephone No. Owner's Address Is this permit in conjunction with a building permit? YesNo Purpose of Building ' El (Check Appropriate Box) G e Utility Authorization No. Existing Service Amps / olts Overhead ❑ Und rd g ❑ No. of Meters New Service (�L O u Amps /cR_) / ay GNolts Overhead ❑ Undgrd No. of Meters J Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires 5 0 No. of Luminaire Outlets No. of Luminaires -- . No. of Receptacle Outlets /00 No. of Switches (� No. of Ranges No. of Waste Disposers No. of Dishwashers ' No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs Completion o the olh No. of CeiL-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool �d e ❑ In" tyrnd No. of Oil Burners No. of Gas Burners 1 No. of Air Cond. Total S Tons Space/Area Heating KW Heating Appliances KW No. of o. of Signs Ballasts of Motors Total HP vin table may be waived by the Inspector No. of Total Transformers KVA Generators KVA ❑ o gency Lighting Batte Units „FIRE AI,ARtyIS ,No, of Zones jNo. of Alerting Devices Wires. IILoeai ElCnnneefinn ❑ Other �I No. of Devices or Equivalent Data -Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of ctrical Work: ,2, 900 (When required by municipal policy.) Work to Start—SLIJ 0 e( Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (0 BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties f perth 'u ,at the info FIRM NAME: rmation on this application is true and complete � e � Licensee: LIC. NO.: I a a2 f } Signature LIC. NO.: (If applicable�,+enter '�empt " in the license number line ) Address: Bus. Tel. No.:"G3 tM 130 e7 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. elc I n 1tie l �1l ,;� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nrashington Street Boston, MA 02111 C j www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Pinmbers Applicant Information Please Print Legibly Name (Businessiorganization/Individual):_ k n .� AtltirPee• /� �.d� . �_ City/State/Zip:_v(//i1�./�.41 Phone #: . Are you an employer? Check -the appropriate box: I . ❑ I am a employer with 4. 11I am a general contractor and I Type of project (required): employees {full and/or part-time),* 2: I am a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 6• ❑ New construction �• ❑Remodeling ship and have no employees These suis -contractors have 8. ❑ Demolition working for ire .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition required.] 3. ❑ I am a homeowner doing officers have exercised their 10.❑ Electrical repairs or additions all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No -workers' comp. insurance c. 152, § 1(4), and we have no 12. Roof ❑ repairs required.] t req ] employees. [No workers' 13,7 Other comp. insurance required.] *Any applicant that checks bo)t # l must also fill out the section below showing their worker;' compensation policy information. r Homeowners who submit this afiiilavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. tCotnrsctors that check this box mustattached an additional sheet showing the time df the sub -contactors and their workers' comp_ i ib cW - I ant an employer that is.providcng:workers' compensation insurancefor my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration datej. 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 cert ty under the pains and penalties of perjury that the information provided Official use only. Do not write in this area, to be completed by city or town ofcial City or Town: Permit/License # and correct Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plum 6. Other bing Inspector Contact Person: Phone #: Information a nd 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 bmstee 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 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 coriiracting authority."_ Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to ypur 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 cant' 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 *fbe 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, notthe 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 nurnberlisted 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 permitflicense number which will be used as a reference number. In addition, an applicant that must submit multiple permiMicense 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 of1he affidavit that has been officially starnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture �. (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington ngt on Street Boston, MA 02111 Tel. # 617-727-4900 text 406 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia Date .. F//", IA -1.' ........ 01 TOWN OF NORTH ANDOVER 41 PERMIT FOR GAS INSTALLATION This certifies that ... �4. a�/..-! �4 .. � ............. has permission for gas installation ...�� ..../��!`.`�........ . in the buildings of .... .. S. .......................... at ...... A(4...l���.lt�.�.... `"E... ., North Andover, Mass. Fee.. �:. `... Lic. No.) $ ./ �..l. Check # I 6>ul c� % "S INSPECTOR MASSAMUSE.M UNIFORM APPLICA r0N FOR PUZWr TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Loqations / h Imo, A-,.# Owner's Name New Renovation ❑ Replacement IG SLB-BASEM ENT BA—SE M ENT_ 1N D. FLOOR 3RD• FLOOR 4TH. FLOOR TH. ` FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR. (Print or type) Name Addressb Permit # G' Fd / Amount$ lam Plans Submitted ❑ ---- -• --av- r,umoer or Uas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE 1 have a current liability Insurance, policy or it's substantial equivalent Check on If you have checked Yes • please in ' e the type coverage by checlLin Yes Liability insurance poli g the appro ria+ b No[:] Other type of indemnity i 3 p e ox �-+ Bond ❑ Owner's Insurance Waiver 1 am aware that the licensee does n_ o�$ve the insurance coverage required by Chapter Mass. General Laws, and that my signature on this Permit application waives this Insurance coventerage ap 142 of the Signature of Owner or Owner's Agent Check one: i hereby' cert' fy that all Of the details and information 1 have submitted 13 Agent ❑ fest of my knowledge and that all plumbing work and instal}subm a (or entered) in above application are compliance with all pertinent provisions of the Massachusetts State Performed under Permit Issued for true and accurate to the Co a and Ch this application will be in hter4,?1bf the General Laws. Title City/Town, APPROVED (OFFICE USEONLI7 Signature of Licensed Plumber Or Gas Fitter ❑ Plumber LLS 7 WMas asFitter License um er ter ❑ Journeyman a w m � Occ v. a a p v.. m � x cc l z z e ---- -• --av- r,umoer or Uas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE 1 have a current liability Insurance, policy or it's substantial equivalent Check on If you have checked Yes • please in ' e the type coverage by checlLin Yes Liability insurance poli g the appro ria+ b No[:] Other type of indemnity i 3 p e ox �-+ Bond ❑ Owner's Insurance Waiver 1 am aware that the licensee does n_ o�$ve the insurance coverage required by Chapter Mass. General Laws, and that my signature on this Permit application waives this Insurance coventerage ap 142 of the Signature of Owner or Owner's Agent Check one: i hereby' cert' fy that all Of the details and information 1 have submitted 13 Agent ❑ fest of my knowledge and that all plumbing work and instal}subm a (or entered) in above application are compliance with all pertinent provisions of the Massachusetts State Performed under Permit Issued for true and accurate to the Co a and Ch this application will be in hter4,?1bf the General Laws. Title City/Town, APPROVED (OFFICE USEONLI7 Signature of Licensed Plumber Or Gas Fitter ❑ Plumber LLS 7 WMas asFitter License um er ter ❑ Journeyman ! r f� ? k, . UMc, -�.�.,�•r-Cacrn o� Afanachuretiy Department of Industrial Accidents . Office of Investigations 600 W¢shinoton Street L'astorz, M,4 62111 Workers' Compeasatiou Iasurance A'M'L -&v -it: �' ct 3Iicant Information ans/Piumbers Namt(8usmess/Organization/in dividual): Address: City/State/Zip: Phone #: Are you au employer? Check the appropriate box; 1. ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole 4- ❑ I am a have hired the sub-conotractorsr and l proprietor or partner- ship and have no employees Listed the attached sheet t e sthe These wooing for me in any c capacity. NO workers' comp. insurance have workers' comp. insurance. 5. ❑ workers, are .a Corporation required.] 3. ❑ I an a homeowner doingall and its officers have exercised.their work myself. [No. workers' cm p. rilt of exemption Per MGL c. 152 insurance required] t ° § 1(4), and we have no mploye:es, [No workers' cam Type of project (required): .6. ❑ New consiruciian 7• ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addifion 10"13 E}eCthal repairs or additions I1.0 Phznbing repairs'oradditions 12,L] Roof repairs I- trtsLrrance required.] I 13 ❑ Other ny appli=n ,fhwWho checks box # 1 .must also.f"l out the section blow showing tleeir workers' t Homeowners who suUmit.f]tis affidavit indicaiu4 the"r are doir,, <`u�t'r - , compensation po1:c}, mmrtnahon. 100nDuctors that chest: this bm .must attached an additional sfieet showing trite Dire outside contrscione must submii a new atntiav the name oft?:- sttb ccr, ii indietinF o ch. I eZmrt an. employer tha< is proviD2W wore�ers' coo-�pep�a i� ' tractots and tndrr workers' comp. pol io informnt,,,,, igformation, uSurance for ng, employees. Insurance Company Name: Policy # or Self -.ins- Litt. #: Below is the poficy' and job sfze Expiration Date: Sob Site Address; Attach a copy of the workers' rompensafinn Cit'/5�lZip:_ .Failure to =Mr coverage as required under Section 25A of L,ou Fate (showiQ; the policy number and expiration date). fine up to 51,500.00 and/or one -Y prisonment ear itn MGL c. 152 can lead to the imposition Ofcriminal of up to .S250.00 a da g • as well as civil penalties in the form ORDER an' ofd a fine y against the violator. $e advised that a copy of a STOP WORK Investigations of.the DIA for insurance coverage verification, of thisstatementmay be forwarded to the (D ER of .." —v c—ij, unaer the pains aced penalties of perjurf' rjzat the inforrnatton provided above is true Signature: and correct U ciaL use nnfp. De not write in this area, to be completed b3' cio, or town off CiaL Cite or Towtt: Issuing Authority Permit/License # e rite (circle one): I. Board of Health 2. Building /T Department 3. C' , 6. Other ' wn Clerk 4. Electrical inspector 5. piumbiag Inspector Contact Person: Phone#: .iLLL1V1 LL"LLIVU r_:.jj'U ;1115LI UC_U1UitS Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined. as "...evmry person in the service of another under any contract of h ire, 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 inclutieiri.g the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associate on or other legal entity empioying employees. However the owner of a dwelling house.having not more than .tf►ree a¢ artrnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do mintenance, construction or repair work on such dweiling house or on the grounds or building appurtenant thereto shall not because of such employment be dem-med to be an employer." MGL chapter 152, §25C(6) also states that "every state yr r focal licensing agency shall withhold the issuance or renewal of a license or perTnit,to operate a business or- ut:o construct buiidings in the commonwealth for -any applicant who has not produced acceptable evidence of compliance with the insurance covera;e required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall error into any contract for the performance of public wor% until acceptable evidence of compliance with the inwitnce requirements of this chapter have been presented to the r-X�ntra.cting authority." . kpplicauts Please fill out the workers' compensation affidavit compi•eetely, by checking the bores that apply to yoga siivatim and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their c- rdficate(s).af insurance. Limited Liability Companies (LLC) or Limhe;a 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 j employees, a policy is required Be advised that this afacLavit may submitted to the Department of. Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and .date the affidavit:. Theaffidavitshould b , 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 arry questions regi iing the -lata, or. if you are mquimd to obtain a workers' compensation policy, please call the Department at the nrurnber:Iisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officisis Please be sure that the afrida-k :is complete and printedlegibly. 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 appiicant Please be. sure to fill in the permitAicease number which will be used as a reference number. In addition, an applicant that must submit multiple permit4icame applications in ar-:y given y=, need only submit one affidavit indicating current policy information (if necessary) and undcr "Job Site Addx-ess" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially sia rrrped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is- on file for f rftme perms ar Iicenses. A new affidavit must be filled out each year. Where, a home owner or citizen is obtaining a Iicens� or permit not related to any business or commercial venture (i.e. a. dog license or permit to burn leaves etc.) said persoin 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 fay, number The Commonwealth of 1VIassachuse1t Department ofImidustial Accidents. atHee of ravestigatiEow 600 Washdngton Street Boston, MA (12111 T51. # 617-727-4900 == 406 or 1-8 7 7 MASS,4FE Revised 5-2645 Fax 4 617-72.7-7749 ww'.mass.g.ov/d is