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Miscellaneous - 1 LACY STREET 4/30/2018 (2)
N O Location No. D a t e , 1�1411 TOWN OF NORTH ANDOVER 90 -1 0 Certificate Occupancy of $ C14U Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # '17656 Building Inspector r 'TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING � v .. ; � '. g R,.a >> � -: ,4k£ Fi. ✓5�.'3^ i`C i.F �a�e�' `�'- l ''' �°R �'� ( .� "x S � � ' 'j Y BUE DING PERMIT NUMBER: DATE ISSUED: 99 07 l `��`Q SIGNATURE: '1 Building Colnmissionerfintor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number v V C I v Nk 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area s Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Reqtfired Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 111's -7,11c; astrict: Ycs No 2.1 Owner of Record �N/ Z>ULO- ZGlc S Name (Print) 7 Address for Service: Signature Telephone 2.2 Owner of Record: ow Name Print% ✓y y� �- Address for Service: / b / r Signature Telephone "-- SEETION3 - CONSTRUCT16N SE CES 3.1 Licensed Construction Supervilott. Licensed Construction Supervisor: ' / Ll 6�. �, Address 2, f/ Signature Telephone Not Applicable ❑ License Number � 0 �/ / Expiration Date %// ff 7/��I 3.2 Registered Home Improvement Contractor DIV ; AI -Us Not Applicable ❑ Company Name Registration Number /7/ Address i Expiration Date 7 r J S ,�2 Signature Telephone M M z R� c S' �1 0 ic aZ z G) SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check aII applicable New Construction 0 Existing Building ❑ Repair(s) Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 0 SECTION 6 - ESTTMATEn rnNCTR1irTTnN rncTc Item Estimated Cost (Dollar) to be CompJeted by permit applicant OFFICIAL USE ONLY .. . 1. Building j ; G' l (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing p/--- Building Permit fee (a) X tb> % D 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 f v© 0 Check Number Or,a.><iviINis vwi"z]K Av inulu,LAllViv 1 V HE UUMPLETED WHEN OWNERS AGENT OR CONTRACTO APPLIES FOR BUILDING PERMIT Vill C,-tIfe I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si attire of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I' 2' 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GM DERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE J ,f Town of North Andover o� 4`;� ` Building Department 27 Charles Street North Andover, MA. 01845 S';�u,t D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax Please print. DATE JOB LOCATION l /_ C9 Number HOMEOWNER LICENSE EXEMPTION Street Address Map "HOMEOWNER %") �UI I.1 ( Y1iJ ��(1 r/n //�i �� l i Y 0 Name Horne Phone Work Phone PRESENT MAILING ADDRESS A9? City Town State The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: 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 ac- cessory 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. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she ui Building Department minimum inspection procedures comply with said procedures and requirements. / HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING tands the Town of No. Andover requirements and that he/she will Zip Code The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 , Workers' Compensation Insurance Affidavit I Name Please Print Name: Location: City Phone # F -1 I am a homeowner performing all work myself. F-1 I am a sole proprietor and have no one working in any capacity I am an employer providing workeis' compensation for my employees working on this job Comoanv name: Address City: Phone #. Insurance Co. Policy # Company name: Address City: Phone * Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment.as .well.as.civil.penatties in -the fern of a_STOP .WORK_ORDER..and..a fine .of.(.$100.00) a stay against .me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. .Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town PermitlLicensina Building Dept []Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other z LLJ am c c O L3 N C V r x w A x w ca o o X u a x a w o cG a w" a w w o w g ia. w. a o c�4 w Z is W v) cn LLJ am 0 w a I ccm O•— h Q � di — h OO •� m m LIL- 3� O O Q i E: O a �a o � c cc V c Z CD 0 CL u W O C C ■ C c CLy Q J 0 c c O L3 O N C V r •d C C +O+ O � O Ea Z is •• MIL It E5 s o -- M 7 cm o �cr E Q zip C CM.1m; C No,% N p mzip o ♦r cv CM c : � Q4WD C CL Go C C • O r.. COD LLJLL. W=w m ■N C +�+ *&= C !- •N Z O 93 CO2 d •0% O= s N a� N = a0m� O 0 w a I ccm O•— h Q � di — h OO •� m m LIL- 3� O O Q i E: O a �a o � c cc V c Z CD 0 CL u W O C C ■ C c CLy Q J 0 Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ 41 4L Building/Frame Permit Fee $ Foundation Permit Fee $ .1 CHUS b Other Permit Fee5l"--c $ Sewer Connection Fee $ Water Connection Fee $ $ TOTAL IAI 02000 9 Building Inspector 03/09/99 12:10 2-,j, 0o PAID Div. Public Works a LW 71 z .J i4 'R L-A ©W 9 G IY �I z I ] oir 1 T II -A N G 7 W j C W z i li r Z 1 � U � Z I f � � J — z ~ Y A N s rel r — � ^ a a LW 71 z .J i4 'R L-A ©W v z G 7 W L C W z i V V V %J LJ Q 1 %J V G 111%_j I H L. L- IAA I tiJ I `ll IkI41Y11 Permit A building permit is required for the installation of,any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove /r A. New V Used B. Type/radiant 0 Circulating C. Manufacturer hid/ . P Lab. No. Name/Model No. ZiA� P 0%:'(7 17' Collar size Dimensions/ Height Length Width Chimneyr A1C l l-jLOQ' A. New P Pk Existing G. Size (flue area) Co" C. Other appliances attached to flue (Number and flue size) . O 0. "Prefab (Manufacturer—name and type) E. Masonry/Lined Flue liner Unlined type 6 manwacturerr F. Height (refer to diagrams) cap CHIMNEY HEIGHT Hearth (non-comoustible) . a A. Materials tir'r `Q B. Sub -floor construction 6,,�r)SN C. Minimum dimensions (refer to diagram) Clearances and Wall Protection (see stcve installaecn clearances chart) A. Type of wall protection provided r'% B. Clearances (refer to diagrams) FiREFLACE CORNER HEARTH WALL CENTER 13 REGULATIONS After obtaining the permit, there are three consider. First, the stove; second, the chimney; First: All new woodburning stoves inst, approved to U.L. 1482 -and/or U.L. 737 as appy; building department or the fire department. Eve permanent and legible factory -applied label con 1. Manufacturer's name and trademark 2. Model and/or identification number c. 3. Type of fuel(s) approved 4. Testing laboratorys name or tradema. 5. Date tested 6. Clearance to combustibles a. Side b. Rear 7. Teststandard a 8. Label serial number Second: Existing chimneys should be. c ? general structural condition. A smoke test may t the flue is without obstruction and if there is a: chimney is needed to check for creosote deposi is in good working order. The following two a( inspect. The area where the chimney penetrate checked to be sure that there is at least two inc! and the chimney. Third: Chimneys and chimney connector: (see installation clearance table). The connectc ney and the connections overlapped upwards i ance shall be maintained where insulated pipe p and approved for lesser clearances. A non-combustible hearth must be provic: below; if the legs are not present, an air spac provided. Clearances vary with circulating and shield should be installed with ventilation behinc clearances, and if the wall is a concrete foundat; The following systems have been approv, Permaflue, Air Krete, Smi Exterior Insulation an IsoKaern. The code requirement for two inch because of its high insulating and refractory q s in the stove installation process to ie actual installation. 3ssachusetts must be tested and ,d stoves may be approved by the :I -burning room heater shall bear a ',,st the following information: rce on r the presence of a flue liner and J,termine if the draft is adequate, if eakage. A visual inspection of the racks or breaks, and if the damper to the chimney are important to .ie floor of ceiling joists should be ice between combustible materials -�:alled with the required clearances sloped upwards toward the chim- �osote leakage. A two inch clear - combustible wall, unless it is tested -ves have legs and allow air to pass non-combustible hearth must be :s. In general, a non-combustible :learances, no protection for large nimum distance may be allowed. istruction Material Safety Board: ::em, Supaflu, Thermo Crete, and exempted from this type of lining 5 2 3/4'- (70mm) VERMONT CASTINGS WOOD STOVES 21" "— (533mm) — 30" —1-- I (762mm) 281/4" pd (718mm)Wil Lill! - —y �] 19 1/2" 33" _ (495mm) ��� (838mm) f ---25-1/2"(650mm) — R � 27-1/2" ° II (700mm) f 26" (660mm) I 1 6, 150 mm) j f-- 25" (640 mm) —► -- 21-1 /2" (550 mm) -► I ! llll 25" I (640 mm) �- 19" (480 mm) 221/2'---1 21/2"—tel I I 21-1/4" (540 mm) M W MAJPEpSTIPC - _- ----- 475 Admiral Blvd. 1000 East Market Street, I-� 21-1 /4" (540 mm) 251/4" Tel: (905) 670-7777 Tel: (219) 356-8000 �- 27" Fax: (219) 356-1039 www.majesticproducts.com I 60 (4mm For the location of the nearest dealer call 1-800-227-8683 f ---25-1/2"(650mm) — R � 27-1/2" ° II (700mm) f 26" (660mm) I 1 6, 150 mm) j f-- 25" (640 mm) —► -- 21-1 /2" (550 mm) -► I ! llll 25" I (640 mm) �- 19" (480 mm) 221/2'---1 21/2"—tel 21-1/4" (540 mm) M W MAJPEpSTIPC - _- ----- 475 Admiral Blvd. 1000 East Market Street, I-� 21-1 /4" (540 mm) �_ 18" Tel: (905) 670-7777 Tel: (219) 356-8000 Fax: (905) 670-4676 Fax: (219) 356-1039 www.majesticproducts.com I 60 (4mm For the location of the nearest dealer call 1-800-227-8683 I� 25-1 /4.. i 23 5/8" f ®®®® 1 I� _ (640 mm) 24 I I % I II � 'III To exit fluecdlar height I F' 7-0 1/8" (18mm) \ J f � �� Imo- 15" --+� -� 21-1/2" (545 mm) L— 13-3/4" - (350 mm) s -%17f * a�n + �17- -1% �' t �-s� °'tr 4�IllisslCSR�nrl`���'�15��Ik�����1a(I]Sjit`xtr�$%�1f` s u s�m.Y .sn '* €�; ^+��� ..� a ?may", �`•' 'L•y� �,a� � Sr hY'- 2w +7CztU rffi r '�Q jo^? 4r [k;<s 3 e 9tE rz s a 'a .,,ta- &tit a e .. zV Jgi1t T'k ti � m«� e mow.. 3(14 2- µ *fir *'`�' § "� '".°, ° :2,. �' r- b �,4 .c;� �� ? #h, Www $ � a * r.r�4 �'*'l� � 4 �'�7S 5 e,-rl ,d.. " �.c; ,i$,.a '+- �: -i4"- 1`�" 42✓w a 'Y t it+,4 +y jlgm It 'T'''�'i to is 3 -1-1/4" (31 mm) —i G 22" In the interest of constant product improvements, we reserve the right to ��pjo'E741 change specifications without notice. Before installations, please read -P - Installation Instructions and check all local Building Codes and Gas 7 Regulations. MDQ YOUR VERMONT CASTINGS DEALER 1000-0340 7/98 M CFM W MAJESTIC M W MAJPEpSTIPC 475 Admiral Blvd. 1000 East Market Street, Mississauga, Ont. L5T 2N1 Huntington, Indiana 46750 Tel: (905) 670-7777 Tel: (219) 356-8000 Fax: (905) 670-4676 Fax: (219) 356-1039 www.majesticproducts.com www.vermontcastings.com For the location of the nearest dealer call 1-800-227-8683 -1-1/4" (31 mm) —i G 22" In the interest of constant product improvements, we reserve the right to ��pjo'E741 change specifications without notice. Before installations, please read -P - Installation Instructions and check all local Building Codes and Gas 7 Regulations. MDQ YOUR VERMONT CASTINGS DEALER 1000-0340 7/98 O z 0� x w Qn' p-u v \ LE E U a4 z ,.a � W a b w° -aa C4 v U co w a c�° co w OE -4 U w W� U V)w —co0 x o W r-. C7 .-C Wit � w E� z w A CG w G M o z C/)cn v 0 O 8 CMF. 0 Cf? C) bli f6 VAL,o* Mw4th� 0 CO c CD c � ; o � O c O N O V C.3 CO) d C :cam �1! U �E CD C L O O O co CL_� O � v N cX Ea CD CE Q� f►''1'�/1 CD ® Q L � OJ o a C E E Mm :,o m Z `c :ft**4 Q o 0 COD C u CM m c N R CDm cm � m •_ m ' _O 'O N O N m m o y m m .) �• c O Q a C L ..O N O C,z C H h tL CO �_... .0 OL NR ca •ds H N C W E q.0 cc ca C.3 m O m! C ca C m� O� c aim 8 CMF. 0 Cf? C) bli f6 VAL,o* Mw4th� LLJ0 CD LLJ U) W W W Lij U) CD L O Co* CO) ®Z�3 �1! U �E = O O co CL_� O CD +�+ v r.• 0 Q� f►''1'�/1 CD C.� ® Q L � OJ y C Mm CO2 Z CDCL Q COD C � D LLJ0 CD LLJ U) W W W Lij U) �cq BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION I Permit No#: ®�, r 1 / '7161 Date ,<eceived 7 ` to - 1 Date Issued: I I b l V ANT: ADDlicant must complete all items on this LOCATION DT' T_� Print PROPERTY OWNER AA.", r e d -,V - Print 100 Year Str cture yes MAP 165 PARCEL: ZONING DISTRICT: Historic District ye Machine Shop Village yes /V��Z LED ,6 •y 1 �,n A�R�reo �PP�4y no no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement - ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other El Septic o Well ❑ Floodplain ❑t Wetlands ❑ 'Watershed District 0 Water/Sewer _ OWNER: Name:_ f It Address DESCRIPTION OF WORK TO BE PEKFORMEU: Identification r. ease Type or Print learly &_AJ I`e� - Phone: Contractor Name: I Address: Supervisor's Construction License: C S O % Exp. Date: 21 -1? Home Improvement License: (\�o .Z n -' Exp. Date: l 20 • 2-v 17 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: $ .Z d 3 5'C> FEE: $ �- Check No.: � // -7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund w � w r 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 e U FORM PLANNING & DEVELOPMENT Reviewed On Signature COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes A Planning Board Decision: Comments v -Conservation Decision: Comments 6. Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: ..� -,• Located 384 Osgood Street ,,FIREDEPARTMN� Temp® r� to yeses" ated T umpste onisi {fLo�c �af124IVlain Street ,: - - _ _ _ rFere art_� h - dpi Dep .�ment�sigtue`�e �,fa _, . e' C®MMENTS: fi. 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 drops requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine 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 4, Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4, 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 TE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products IOTE: 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 Location U No. C 17 Date 7 A�/Av Check# :�Q; 117 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee A TOTAL $ 3 0 5 7 Building In6pector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 203350.00 m $ - $ 244.20 Plumbing Fee $ 30.53 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 30.53 Total fees collected $ 405.25 1 Lacy STREET 013-2017 on 7/8/16 remodel master bath F- 2 LL. O O O m J6L N u \ a O O LL v N U O. v N OF- V tail Z Z co c O "6 7 O LL t O O K C s U - c LL 0 W (A Z C7 Z m J a L :3 O d' M O LL 0 u W (A Z J V W t 7 O K U N ID O LL a O U W CL fA in t m O O f0 C LL F- Z W F - Q w C oWC C i O m O z v (% Y _N 0 y N w ui LU c� 2 F- E CD CL cn U) _ �a m O _ ._ 0 N d s 0 z 0 J A, z O Z W w CL w H W CL 0 : V W :a t� z m O U cn z U W Z ti N v c� O w AGREEMENT FOR SERVICES This CONTRACT satisfies all basic requirements of the State's Home Improvement Contractor Law (M.G.L.c. 142A), but does not preclude parties from adding language to protect their specific interests. Seek legal advice if necessary. Before agreeing to any home improvement work on your residence you should obtain a free copy of "Consumer Guide to Home Improvement Contractor Law" by calling the Office of Consumer Affairs and Business Regulation's Information Hotline at 617-973-8787. You may cancel this Agreement if is has been signed by a party thereto at a place other than an address of K & R Contractors, Inc., which may be its main office or branch thereof, provided you notify K & R Contractors, Inc., in writing at its main office or branch by ordinary mail posted, by Telegram sent or by delivery, not later than midnight of the third business day following the signing of the Agreement. See Attached Notice Of Cancellation For An Explanation Of This Right. Homeowner Information Contractor/Owner Name: Kevin and Maureen Carney Kenneth Roy, President 1 Lacy St. Business Street Address North Andover, Ma 01845 K & R Contractors, Inc. 1 Campbell Road North Andover, MA 01845 Business Phone: 978. 726.5062 Federal Employer ID: 000961723 Salesperson(s): Kenneth Roy, President Contractor Registration: 80721 Exp. Date: 4/29/17 MA Sup. License: 137557 WORK TO BE PERFORMED AND MATERIALS TO BE USED Contractor Agrees To Do The Following Work For Homeowner: Renovate Master Bath Work to include: Demolition of all existing fixtures, walls ceiling and flooring. Reframe shower to the left more and make as wide as possible without moving door and keep 60" long. Also frame %2 wall to right of shower (near toilet). Update electrical and add 2 light in shower, 3 recessed over sinks, 2 wall lights around mirrors and add a Panasonic vent/light combo centered in bath. Plumb in new custom copper pan for shower and move toilet to the left, replumb new bath sinks and fixtures and new base heat. Tile floor of bath, cement floor of shower, durock walls of shower, tile and add niche. (tiler will need to see final selections of tile to verify tile labor) Repair broken joist under bath floor. New plastered walls and ceiling. Replace discarded trim. Paint bathroom. Custom glass shower door and upper half of/Z wall (priced in clear glass and chrome hardware) Includes permits Customer purchases cabinetry and hardware, tile, grout, toilet, faucets, shower valve, countertop and sinks, stone thresholds and shelves. Deduct $450 for acrylic shower pan, add $600 to move bath entry door The following schedule will be adhered to unless circumstances beyond the contractor's control arise* Work Scheduled To Begin: 7/6/16 Expected Date Of Completion: 8/17/16 TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to perform the work, furnish the material and labor specified above for the SUM OF $20350 Payments will be made to the following SCHEDULE: $5000 due upon signing this contract $7000 due upon completion of electrical rough inspection and plumbing rough inspection $5000 due upon completion of tile $3350 at completion of project Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of: (a) one-third of the total contract price or (b.) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule* ) No final payment shall be demanded until the contract is completed to the satisfaction of the parties thereto. OTHER IMPORTANT PROVISIONS You are dealing with a Registered Home Improvement Contractor and are entitled to certain rights under the provisions of 780 CMR R6 and M.G.L.c. 142A. Payments: If payment is not received as per the Contract, then the Owner shall be responsible for all attorneys' fees, court costs, and other costs incurred by the Contractor and enforcing Contractor's rights hereunder. Pets: Homeowner agrees to keep all pets out of the work area and take whatever steps are necessary to safeguard them from any harm that may come to them as a result of the work being performed under this Contract, including but not limited to injury on or outside the Premises or ingestion or inhalation of, or contact with, hazardous substances. Company assumes no responsibility for any harm to the pets as a result of the work performed under this Contract. Further, Homeowner shall take all steps necessary to protect Contractor, its agents, servants, contractors and employees, from any harm as a result of contact with said pets. Characteristics of wood: Wood is a hygroscopic material. Wood swells and/or shrinks in relation to the humidity, temperature and environmental conditions of its surrounding. Generally, wood flooring is expected to shrink in any conditions and expand when exposed to moist conditions. Natural wood also contains variations of graining, texture, hardness and/or knots, depending on the wood chosen. Contractor cannot be responsible for the natural features of the wood chosen. Contractor is not responsible for shrinkage, checking, swelling, or other conditions which are the normal condition of wood or the result of household or environmental humidity, heat, cold, or other conditions. Colors: You may choose colors and finishes for the parts being used in your remodeling project. It is important to remember that a color or finish you see at the store or in a showroom may not look the same in your home, especially after all of the different colors and finishes are brought together upon the completion of a project. In addition, one manufacturer's named color is not the same as another manufacturer's named color. The Contractor cannot be responsible for the appearance or lack of coverage from Homeowner/chosen paints and/or stains and finishes. Building Officials: Any additional costs incurred by Contractor as a result of decisions made by Building Officials will be the responsibility of the Homeowner. The costs of additional work will be calculated as follows: cost of materials plus an hourly rate of $45 per man hour. Liens: In the event of non justifiable non-payment, Homeowner's residence or property may be subject to a Mechanic's Lien as a consequence of signing this Contract. Utilities: The Contractor will use reasonable efforts to notify the Homeowner in advance of any interruption of utility services. However, there may be instances where the Contractor must shut down these services without advanced notice. Homeowner must arrange for emergency backup service for any utility critical equipment such as medical devices and computers. The Homeowner must also notify the Contractor at the start of the work day if you will be engaged in any utility critical activities in that the Contractor makes a notification in writing in the daily log book or otherwise. Additional work: Any additional work requested by the Homeowner which is beyond the scope of the work to be performed as set forth in this Agreement, shall be the subject of a separate agreement, and/or if not, subject to the same terms and conditions as set forth in this Agreement and billed on a time plus cost of materials basis at Contractor's normal hourly rate. Contractor's normal hourly rate per man hour is $45. In the event that additional work is to be performed on an hourly plus cost of materials basis, the Homeowner shall be required to execute a Change Order which shall include Contractor's best estimate as to the time required, together with the cost of labor as well as the type and cost of materials necessary. Delays: Contractor is not responsible for delays attributable to Homeowner initiated modifications or additions, or for delays incurred due to the actions or inactions of city/town officials, strikes, acts of God, unfulfilled customer obligations, vendor delays, interference by other tradespersons, customer supplied items or other delays beyond Contractor's reasonable control. Contractor will use reasonable efforts to stay on each job until substantial completion by allotting specific time periods to each Homeowner to complete each job in as timely a manner as possible. In the event that Homeowner does not allow Contractor and/or his employees or sub -contractors access to the residence or property so as to allow Contractor to perform his obligations and/or to complete the scope of work in as timely a manner as possible, other than for reasons of safety or other reasons mutually agreed to between Homeowner and Contractor, then the Homeowner shall be responsible to pay Contractor the sum of $500.00 per day, on a pro rata basis, to cover the costs of delay. Contractor reserves the right to suspend work and/or delivery of materials in the event of unjustified non-payment. In such event, the Contractor shall have no liability to the Homeowner for alleged delays or damages due to said suspension. Punch -list Items: The Homeowner agrees that routine "punch -list" or repair items after substantial completion are outside the agreed scope of services, and covered by Contractor's warranty obligation and will be completed as soon as practicable and according to Contractor's and Homeowner's mutual availability. Homeowner agrees that it shall use his/her best efforts to make himself/herself available to observe and/or sign off on the completion of any such punch -list Items, and that the approval of one Homeowner regarding the completion of any such punch -list items, as well as change orders shall be binding upon all Homeowners. Unforeseen Conditions/Circumstances: Contractor shall not be responsible for any changes at the request of the Building Inspector. Contractor shall also not be responsible for any unforeseen bedrock/ledge or latent defects such as structural and/or dry rot or insect damage to the existing structure, or for preexisting faulty or inadequate wiring or plumbing. Contractor shall also not be responsible for any pre-existing code violations or responsible for correcting contiguous work completed by others not under the Contractor's authority. Insurance: Homeowner agrees to carry fire, theft, vandalism, liability and all other necessary insurances to protect their personal property while construction is in progress. Contractor will carry all required and necessary insurances including worker's compensation insurance. Contractor will ensure that all personnel including sub -contractors will be covered by all required and necessary insurance including worker's compensation insurance. Homeowner's Cancellation Rights: In addition to the rights the Homeowner has, as set forth in the attached Notice of Cancellation, the Homeowner may have rights under other Massachusetts Statutes, including M.G.L. c. 93 § 48, M.G.L. c. 140D, § 10 and M.G.L. c. 255D § 14. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the contract should go to the ho owner and thecontr r. Homeowner's Signature Contractor' Signature K Contractors, Inc.: Date: - fJ By: Kenneth Roy Its: President You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of the agreement. See attached notice of cancellation for an explanation of this right. NO WORK WILL BEGIN UNTIL BOTH PARTIES SIGN THE CONTRACT AND THE OWNER RECEIVES A COPY REQUIRED PERMITS The following building permits are required. It is the obligation of the contractor to secure such as the homeowners agent: Electrical rough and finish Plumbing rough and finish Insulation Framing insp. Finish and occupancy NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL c. 142A. EXPRESS WARRANTY All workmanship and materials to be free of material defect for a period of one (1) year. During the Warranty period, the Company may, at its option, either repair or replace products or workmanship which prove to be defective. This Warranty shall not apply to defects or damage arising from improper or inadequate maintenance by the customer, customer's applied products, unauthorized modification or misuse, damage incurred as a result of acts of God or civil strife, or normal characteristics of the materials such as wood shrinking, expanding and otherwise reacting to moisture or environmental conditions. The Company's liability is limited to the repair or replacement, at its option, set forth herein and Company shall not be liable for any consequential, sequential, incidental or other damages not set forth herein. The Warranty set forth herein is exclusive, and no other Warranty, whether written or oral, is expressed or implied. Company specifically disclaims the implied Warranties of Merchantability and Fitness for a Particular Purpose. NOTE: All home improvement contractors and subcontractors shall be registered and any inquires about a contractor subcontractor relating to a registration should he directed to: Director, Home Improvement Contractor Registration One Ashburton Place, Room 1301 Boston, MA 02108 617-727-8598 Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence, ARBITRATION The contractor and the homeowner hereby mutually agree in advance that in the even the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and thetonsumer s}oalLheTequired to submit to such arbitration as provided in M,G,L. c. 142A. Contractor: Date: !? - 7 - I Homeowner• Date: t �O NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE SETFLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOTSEPARATELY SIGNED BY THE PARTIES. ACCELERATION OF PAYMENT Homeowner's Financial Insecurity -A Contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hint/herself to be financially insecure. Contractor's Financial Insecurity- In instances where a contractor deems himself/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal from said account would require the signatures of both parties. Homeowner agrees to allow reasonable access to allow Contractor to reasonably attempt to remedy any outstanding uncompleted, disputed or non -satisfactory item. If you have general questions or need additional information about The Home Improvement Contractor Law, contact: Consumer Information Hotline Commonwealth of Massachusetts Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170 Boston, MA 02116 617-973-8787 If you have questions about Contractor Registration, contact: Director of Home Improvement Contractor Registration Board of Building Regulations and Standards One Ashburton Place, Room 1301 Boston, MA 02108 617-727-3700, x25205 NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT PENALTY OR OBLIGATION, WITHIN THREE (3) BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS FOLLOWING RECEIPT BY THE CONTRACTOR OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE CONTRACTOR AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE CONTRACTOR REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE CONTRACTOR AND THE CONTRACTOR DOES NOT PICK THEM UP WITHIN TWENTY (20) DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, OR IF YOU AGREE TO RETURN THE GOODS TO THE CONTRACTOR AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO K & R Contractors, Inc. 1 Campbell Road, North Andover, MA 01845 NOT LATER THAN MIDNIGHT OF TBD. I HEREBY CANCEL THIS TRANSACTION. Date: Buyer's Signature: Received: : The Commonwealth of Massachusetts z Department oflndustnialAccidents T! E a X Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: /V . r-) N & u -&f (V f 1 Phone #: �7(z --�z(,,- Sb6,2. Are you an employer? Check the appropriate box: Type of project (required): 1. Q I am.a employer with employees (full and/or part-time).* 7. [] New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ DemoIition 3. ❑ I am a homeowner doing all work myself. [No workers' compAnsurance required.] t �] 4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ 13.E] Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6.We are a corporation and its officers have exercised their right of 'exemption per MGL c. 14. [j Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit #his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-contiactors have employees, ley 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. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: ) Xob Site Address: C y �f = _ City/State/Zip: Attach a copy of the workers' Com ensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. Ido hereby certify kl,,- und thepainsandpe altie f perjury that the information providedabove is true andcorrect. Risrnafrrre- _ A _�� late- / !o - O INIM Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone OP ID: PS A� RE'� CERTIFICATE OF LIABILITY INSURANCE DA07/06/201 Y) 07/06/2016 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 Foster Sullivan Insurance 163 Main St. North Andover, MA 01845 Stephen Sullivan CONTACT NAME: Pete Sullivan a/CDNNo, Ell: 978-686'2266 rnAic No : 9?8-686-6410 a DRESS: psullivan@fostersullivangroup.com PRODUCER K8RC0-1 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED K & R Contractors, Inc. Ken Roy 1 Campbell Road INSURER A: MERCHANTS INSURANCE GROUP 12775 INSURER B: North Andover, MA 01845 INSURER C: INSURER D: INSURER E: BOP1062559 INSURER F: 12109/2016 GUvtKAGt5 CFRTIFICATF NIIMRFR• DCVI¢InKI IUI IRADCD• 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 LTR TYPE OF INSURANCE D L SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR BOP1062559 12109/2015 12109/2016 PREMISES Ea occurrence) $ 500,000 _ MED EXP (Any one person) $ 15,000 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X1 POLICY PROT L1 LOC $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE (PER ACCIDENT) $ HIRED AUTOS NON -OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? F-1 NIAE.L. WC STATU-OTH- TORY LIMITS ER EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) mdeems@northandoverma.gov ** INSURANCE EVIDENCE ** l.eK 1 IrII.A I t hULUtK /`AIJ!`CI 1 ATUI/AI U 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. fax # 978-688-9542 AUTHORIZED REPRESENTATIVE MAURA DEEMS 1600 OSGOOD STREET NORTH ANDOVER, MA 01845 U 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD r C&ation J4 B�nessReg � Consumer Affair CTOR Office of ENT CONTE Type: HOME IMPROVE 62123 Corporatio, Registration: •� private 112012017 Exp►ration CTORS;sINC y 1% K"& s CONT Undersecretary 1 CAMPBELL MA X1845 N. ANDOVER, JIML Massachusetts - Department of Public Safety Board of Building Reguiations and Standards construction'OupeiviNor ; License: CS -080721 KENNETH R ROS- 1 CAMPBELL RID( �E7 0 ¢ s North Andover Na 0f �i ✓..�... ,11.""' Expiration Commissioner 04/29/2017 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 -contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees -other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Ifidustrial Accidents fok confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia