Loading...
HomeMy WebLinkAboutMiscellaneous - 10 CIDERPRESS WAY 4/30/2018 (2)1-4 U U Uc-+ U O U � 0 0 3 U cd -d U o bUA � U Q GOO o c 0 , O cn �, CdU to U cn O cn cn ' j U O cd Ste" �. D1 rU+ cd 4"' O U � M Cd �" U U p cn Cd to J:L 7� COcn bA Ln Cd to Q�°3 � in. U U O O U M > cn cn o Ln � O 4� cn ZU 'C N N 3 � d c° .� L cn . cn U cn cd ^cb O cn 4-4 N N Cd cd O cn Uo OCIO -cn O �, Cn ��U U co Nto rLn -i �p C,� m Q ,bA N (JIN SM T i -I U^ j 1 co" n aai ca Q N c w E Ln h p En cd U s m 1— U D ti U 4� bbb + U C O C U CA LLV vi V 1-4 U U Uc-+ U O U � 0 0 O U o bUA � o 1-4 ft Date., - TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ............ ......... AC-.U4.q . .............................. ........... .... ........ ....... ..... ......... ...... has permission to perform .... . VP j plumbli in the buildings of ��.e /7 . ...... ... ................ ...... ........... 1-12:1 .. ....... , North Andover, Mass. Fee,7.,�.' 4.7. Lic. No. .... ..... �;. ...... w ............................................................. PLUMBING INSPECTOR Check " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I MA DATE ( PERMIT # JOBSITE ADDRESS OWNER'S NAME U P OWNER ADDRESS _ TEL 11FAX TYPE OR OCCUPANCY PE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Mf PLANS SUBMITTED: YES 0 NOM FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _( t _ i (___ DEDICATED WATER RECYCLE SYSTEMl.�- DISHWASHER— DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN I t 1 J l (` __) INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY i _ _.J. _-. _J 1 __—I 1 I ___J __.___I .-_-.__l J _I ROOF DRAIN SHOWER STALL___.I _..___1 ____j ---I I SERVICE/MOP SINK TOILET URINAL ..._...... j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _l ( _ - i l i I I -_ J -_ _ - _ I ' - WATER PIPING I . i I i OTHER 1 f __. _ __.._._J __..___I ____.1 ( _._.-� J _.._...1 ..._.... III I ..._.._. III.._. -_._I ! �i INSURANCE COVERAGE: 9, ` have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ,. , NO Di IF YOU CHECKED YES, PLEASE INDICATE THE T OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW E t N LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ( BOND _t OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the S S Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 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 plumbing work and installations performed under the permit issued for this application will be in compliance with 1 Pe ' ent p i ' of the Massachusetts State Plumbing Code and Chap f the General Laws. PLUMBER'S NAME _ { LICENSE # % /� (—� SIGNATURE (sn. IMP [9�' JP I CORPORATION 0#PARTNERSHIPM# ( LLC COMPANY NAME _ ADDRESS —J1 CITY �p�fjf� � STATE ZIP _� �� �� T L FAX( CELL/� :� EMAIL L/,� I W F O z 0 F U W W o D z N O t- v1 W O W a z 0 = o a W cninW a p z w� as � J C. d Q cf) LLI EE w I.- LL. rA W F °z z F U a rA ap' ' N • The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 021.11 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers City/State/Zip: Areyouan employer? Check the appropriate box: 1. 037, am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet, # ship and' have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they a?e doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date:, Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required -under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un er the ains nd penaIde ' ry that the information provided abo77� d correct Signature: _ _ Date: �� g3-%3/ Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 Industrial Accidents for confirmation of insurance coverage. AIso 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us.a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial ,Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel. # 617-727-4900 ext 406 or 1-877,7MASS.AFF Revised 5-26-05 Fax # 617-727-7749 wwwmass.gov1dia Date... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifi es that .......................................................... -- .................. has permission for gas inytalla �-* on .... ...... A. ........................ A�P,o 17 6VLdV— ( i �K in the buildings of ................................ -.1 ........................ at ................................... I�r. .. ............ North Andover, Mass. Fee!�6 . ..... Lic. No. ....................................................... ............. Check # GASINSPECTOR //,7 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ,ytUOri _� MA DATE / PERMIT # ' JOBSITE ADDRESS ice. _ NAMErst0�r 'G _OWNER'S OWNER ADDRESS _.P.- TE _ _ FAX TYPE OR OCCUPANCY E COMMERCIAL [jEDUCATIONAL RESIDENTIAL �^ PRINT CLEARLY NEW: _. RENOVATION: E] REPLACEMENT: El PLANS SUBMITTED: YES 0 NO APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER) BOOSTER CONVERSION BURNER _.,. ------ COOK STOVE (-- COOK DIRECT VENT HEATER DRYER FIREPLACE J.I I FRYOLATOR FURNACE- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �- OVEN- POOL HEATER _ 1 ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER 1 ( l WATER HEATER OTHER — —^ — INSURANCE COVERAGE its the MGL. Ch.142 YES 1 10 E have a current liability insurance policy or substantial equivalent which meets requirements of 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 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 AGENT 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 plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti nt pro 'sl f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'I V PLUMBER- SFITTER NAME ``�� LICENSE # ( SIGNATURE MP MGF [A JP El JGF Q LPGI ©' []# = PARTNERSHIP 0I#[ LLC i# `CORPORATION COMPANY NAME: _ � _ w(,�_����G���---Lam__~-----ADDRESS CITY_ _ STATE�ZIP TEL FAX CELL EMAIL _ _ z 0 H U W a Con C o gC)l z W } � � W E -4a Z U w �* W : 7Q w W a co w 0 w w CO a ocn a a U J H °- a co Y w F— LL M H 0 z o H Y U W a a r ZOMMONIN ALTH` OF A C USE�I'75 PLUP1l13ERS AND CASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: vl!cH'AEL W KELLEK cd 20 KENNEDY DR N PE'LHAM N!!, U30 i6-:2605 1515% 05/+JI!14" r e i r ZOMMONIN ALTH` OF A C USE�I'75 PLUP1l13ERS AND CASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: vl!cH'AEL W KELLEK cd 20 KENNEDY DR N PE'LHAM N!!, U30 i6-:2605 1515% 05/+JI!14" -4-1�� �&<% L ( L-C� This certifies that .... ........................... has permission to perform . %1�]W7t 174��P5 j!7- 7 . . . . . . . . . . . . . . . wiring in the building of �et ..... (70,� ....... at . ..... North Andover Mass. Fee. ...... Lic. No. 5-/� MA ..... ELECTRICAL INSPE'CTORj Check # ((2j,7-6 M 3� ,. Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS eexl ' Official Use Only Permit No. //,5- 7 Occupancy and Fee Checked Lev. 1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT RV INK OR TYPE ALL INFORMATION) Date: r o I 0 6 12-, City or Town oh NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ;W C"� E-�t pi't CSS Telephone No. 6g- 7—Z.` 3� Owner or Tenant .M Cfa 1 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building L—S iZJ .�—'C 4 A4— Overhead ❑ Overhead ❑ - Existing Service New Service Amps / Volts Amps / Volts Number of Feeders and Ampacity .Np Ate.- Jy—k� M A No ❑ (Check Appropriate Box) Utility Authorization No. Undgrd ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: W" t4 45 C-D.^:b D No. of Meters No. of Meters Comnletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection andInitiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Dis osers p Heat Pump Totals: Number ' ' Tons J.KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, oras required by the Inspector offires. Estimated Value of Tectrical Work: t l` pcep.`p (When required by municipal policy.) Work to Start: (© (A L Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 Covera is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: _L Licensee: , AALCAt ,?'T lignature LIC. NO.: Z ^ (If applicable, ent "exempt" m the liceif a number line.) Bus. Tel. No.: —20 ?`1 Address: 3�-�—S�J r "`fig l� �-Ls W� Vim�.tJE Alt. Tel. No.: `ifs 7 *Per M.G.L c. 147, s. 57-61, sectirity work requires Department of Public Safety "S" Lich: 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 PERMIT FEE: $ Signature Telephone No. ... •.+JJU1L•(CM''MFt•�.('LJ/CyjJ�.�.I�►J/i"-'•�.�T'j.'�.`�®•�� j�i�j'� �.'-�.)1.7J. J:1`UJt.RV...l ®.�••�l.i d..C4OT)►,y�"•. 1=1�Gi=lC,f,eLO.IQ! �• •• - - . �'�ssei�•-� �_ _ " �+'aile�-� j � �e-xuspeciZou xes�uzxec�($�DAU) ~ � � 3ns�ectpx exits: - ghgeefoxsy z atuz - ato nit aTs) Slate U �- 3'asseaL r I 1 to ns ectzo� xee�tzixe ( 4.OD)w j. �StS�iectax�' commextts: (MspectoxsO gignature-)to Wfials) safe P. TTNDI+E: OrJND WSRACUON. 'asse��Z � �+'ailecl•-j � T2.e��s�eefzo�a'e0uixet�(��D.00)~[ � • aspBofors, comn.ents: Ci.�nspeetoxs',15ignafare •-m iaitzals) pate CAM, TIONMI. `�,C-R1� ; NAME:. sse�.--[) T+'aiie�.•-j � �e-�.nspecfionxequixe�{�50A0)-� � ' vectoxe9 P-Owneits: gasp actors, fta�iux'e-ho �Uifials) Date Oe—[ I )TaIlerl—Z )- 7 - actoxe coxam.erifs: - I '04SP edoxsMinatue - dao IU* flals) - - date dl'P �A' A Q� S d 'i �7f'�1 R �i' l7 .f'i it d1fiPi' d rpt El i T� 7T d DYa7 �'7�i '7i 7k 'F�d3�'i APV. d TCT R'P.. MqPRP'A' b T.�q vnry PC The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): V- L.1/t_�}- Address: R P V- -S Biu ,,4 -0,4-e,1� City/State/Zip: n,ra�� r -t A-4 03Yti5rPhone #: Are ypu an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I .employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have ,working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. [q'ew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �,-kAAIOSJtn� L AJ5 Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: ZkG tti e;,S Ci /State/Zi ty p 0-0- .A/Ik r4 Attach a copy of the workers' compensation policy declarati n page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. F do hereby certi�,under the pains and penalties of perjury that the information provided above is trite and correct. Fd i Official ttse only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and'should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia