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Miscellaneous - 163 FARNUM STREET 4/30/2018
163 FARNUM STREET - 210l107.A-0037-0000.0 r y `ice a Old( � �!^! '������ BLL xO� `Q 'c� ���� � �� ���a�a� ��� . . � . , � .. �����/ -�� ��� ��o mss.-�.� s Pamela,DelleChiaie • Health Department Assistant Health Department Town of North Andover 1600 Osgood Street I Bldg 20 Suite 2-36 North Andover,MA o1845 — ph 978-688-9540 fax: 978-688-8476 pdellechiaie@townofnorthandover.com r North Andover Board of Assessors Public Access Page 1 of 1 tN,pTti1 North! Andover Board of Assessors, IBM 'SSACHU - roperty Record Card Click Seal To Return Parcel ID :210/107.A-0037-0000.0 FY:2009 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels Search for Sales Summary Residence Detached Structure ,. t Condo . 163 FARNUM STREET w Commercial Location: 163 FARNUM STREET Owner Name: ANDERSON,ROBERT E LOUELLA M ANDERSON Owner Address: 163 FARNUM STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 1.84 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1581 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 402,800 402,800 Building Value: 199,100 199,100 Land Value: 203,700 203,700 Market and Value: 203,700 Chapter Land Value: LATEST SALE Sale Price: 0 Sale Date: 12/31/1956 Arms Length Sale Code: N-NO-OTHER Grantor: Cert Doc: Book: 00851 Page: 0024 http://csc-ma.us/PROPAPP/display.do?linkId=1465669&town=NandoverPubAcc 4/9/2009 I I h 9303 Date. .z Naar TOWN OF NORTH ANDOVER } PERMIT FOR PLUMBING ,sSwcmusE` This certifies that r has permission to perform . . h . . � JG? . . . . . . . . . .`. . . plumbing in the buil, Ings of . w !.4. . . . . . . . . . . . . . . . . . . . . . . Mass. Fee Lic. No..� . . . . . . . . . . . / PLUMBING IN PECTOR Check # /Q i= •.W,, .,tom MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 53CITY j t/'T MA DATE. 2�/� PERMIT# -- JOBSITE ADDRESS /�3R �ris9*-tom 3 _ OWNER'S NAME �"f q-it�C .S`vfi�Kft � ' OWNER ADDRESS �G3��.r +i TEL %7,8 30Z-,(oZ7_ FAX .__ .. TYPE OR OCCUPANCYTYPE COMMERCIAL J,.' EDUCATIONAL RES,LDENTIAL PRINT _ CLEARLY NEW:C:. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES'`„ NOJ_ FIXi'URES Z FLOOR BSU 11 2 3 4 5 6 1 7 a 1 s to It 112 i3 114 BATHTUB CROSS CONNECTION DEVICE I I u ' DEDICATED SPECIALWASTE'SYSTEM _^.I a I DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEt;I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER - FLOORlAREADRAIN u_ INTERCEPTOR INTERIOR .'_.= _, 1—�„d_ _R,,,I _ I' _ e •f KITCHEN SINK / :k _. r LAVATORY. ROOF DRAIN a _ SHOWER STALL SERVICE/MOP"SINK TOILETELI URINAL WASHING MACHINE CONNECTION — WATER HEATER ALL TYPES WATER PIPING I I I . _ I ?' ' I OTHER ] r i ._yl I.rrN..u.a►..w..+ :>:.+wru.r..e_s:` .+,.s,t ac:�..., -. _ -- .-1 --3�:.- -- ..m.Y�..jji ---- INSURANCE COVERAGE: have a current fiabilit lisurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO j IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY(a BOND OWNER'S INSURANCE WAIVER:I ant aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature oil this perGnit application t.��aives this regtiireittetti. CHECK ONEONL. : OWNER 171 AGENT F- SIGNATURE OF OWNER OR AGENT I hereby cedify that all of the details and information I have submitted or entered regarding 1his.a I lion are true a a rate to the best of my tcno�vtedge and that all:pCuFnbing work and Installations performed under the permit issued for this application�Nlt be in comg6a � all Pertinent provision of the Massactmetls State Plumbing Cade and Chapter 1142 of the General Laws: PLUMBER'S NAMEf vEvV LICENSED /;'34Gw SIGNATURE r -- MP�x JP _ r CORPOl2ATfON � iTj 4..x 1PARTNERSHIPf .1111LLC COMPANY NAME' J ADDRESS I/Z ('adv a<t r� t.sT• �%E /�iE ,. />"o _ C CITY /��T�f.e,E ._ ` .. STATEZIP �D�It`1�� �1 TEL FAX CELL ��S' i31 EMAIL J/'G P�/ ria_(��P 2 oy✓,�v T — - _ _ ROUGH PLUMBIN INSPECT ION NOTES BELOW Eop,OEC&FCL us ®NL$t FINA&.YNSIPLCIITON NOTES Yes No THIS APPLICATION SRVES AS THE`PERMIT. `[]. 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L'ittsaarif failtlsstafirfr rtnes }oyig rtefiitedas"., �eiypersoef fne6eriiic$ofanotticitindertrcon[raCtofliite,, �spc�s oriiii Gad'gral .tit�i p ax` Etei><. crttpl03erist#ei,Ie$as"gig rtrclevkly paitiietsliip:assuiatioha cAk�pDrtron cz otherlggerlfrCytoir€tpy hV�oiii t;lore +u€ilia,foixgo engage(Tntaotnfenterprise,antrt iuclircl€ntlte eg�l eprescittaliis.oa fleceasedeniptojs ori leceen r�orfirtstz ®fetfGtcicr 'iiad�tal;lziletterslrip�,asSacistionorotirer.Legal`entit� o �o}ti emplayces: ilat�rete tFtic otenes o€a�i'elHhg-honsc hwvh1g nothtbfz frau resicfmdiavch..oc ilia owipant or-tite, cltvelfiitgflottseotnnotiter vlroennalo syersoastodartiaattenauc constntctionorreliairitou:onsuch divillffighoilft You'ttigromtdso�[trtilitiogoJirrrtenanf tltereto•halGnot beearrse ositcit_einploynientb deentecl"tt►I�e empla}•art' IktGL cf��pict 152 25C(6)also'slates iltat'`•`escl tsitatc or l ocnl ftee»sing ngertc<<s1irt�FtvltlitrolcT'flte ssgauceoi^ i cr►et�dl.01 a 1rccllsC o�pernritfo operal'e a Gusnressoi fo ecttsFrticf biilldings in tile conntto{ttYealth Loi ratty rtppltesnf�t)i4!►as riot pr rtccelttgbleei?I�leltce of ccnt1lITattceirithtfire4iistiriinceteavetirgerecyuirecl Ac�ditiotiaTt};I�GI:c#�p1 er]32,fi25C(�states"bleitlrorih 1 10 1vealtit.Horan}-ofi[spolitical.su5rlivision eot ruttoany coitlracl ortttcpet•ForntaCtco fpuUligCvOrkualJlaccepRb.eevicieitceofcompliAncervitlitiieinsrtrrinee retiiirementsoFtlriseltaptet%,a�eenpres.otecitothe'eontr-C&ma u11►ority�:' ltls � - •-. . .. _ . Pleas eilllout 311eitio -6r§,-C f'tctORtoritplctdl�tD),4ieck;ttgfile boxesih rapiili't4yoiusilrtatidninid,if ns:ces9't3,s11pplysttb-confrae#or(s)11atue(s),ttdcTress(cr)nrtdpltottenrniibe s�along wilhtheirceili6eaie(s)pf jneirartce:LintitedLiabiiitS CompaGies(GI;C)orLitnited .aBifitj/ dtneiships(L P)lvitltiioentptoyeesotlter'tliaii:tite Itieritbersorparftters tcrenolreauitedtaeanjrtvorkFfs`cortipensat'' insurance. IfanLLCorLLPdoeshave eriiployees,tipolicy is iecyuired..B advised tltaf this>it`ticlavif inag be sitbnzitted to theDepartntentof Industrial Accidents forconfirntatrort ofittsttrance:coverage. Also besnce fo slgta nitd alnte 11te rtffidavit: Ttre rifticlavi€should be returnec to the ciV or tots°n that 1110 application for the pemrlt or license is being requested,Plot.Iite Deparintent o ' Fneitasit ial�l ccidents. Sltotilrl you flava a tty'�tresliQus rsgerd'utg.ilte laty @t ifyctr are t-equired to nbfaht n workers' {iipeti fiartpolicytpleaiecalltheD,-01fine;t tjttiienunrber;listed.helots.'self-lnsureiicomp des_sltoptdenter Blair t; If Miltance-license number-ottthe t+llpropriate�line. City;or Toltiit Ofticlals - i PJeas�o b&isnretiiat.tlzaetfidacontlets;atictprintetT.iegibly 7liel?eptlTtieiltltasltroxislecinspaccttttlthottglit oitlig,zfttcixvit fory�oirto fiflbtifin lleeevznf.tlleOftice pflnvestigations ltas fo cotititsEy�curegat iR-Oheflpplicant. Bteasebesure tofiltirNthe penttif/Ijcense.ttnnt rigl?ichtviil.be.used:tsa.refereuceaii�iltTiet hnadciiiion,anapplicaut that�n�s[su8ttritntitItiplepsmllJlicenset<pplicatiol s its anygieeh year,,ueetl:onty sabnlitoneaff davit lndicalingctm4nt )tolicYint`onttation(if ncmwary�ana. rider,,jobSi€aAcidress"theappltcantshouiciwrite"tflocaiionsIn (cls=©i l i Ibtitiff}.:�-Acppyofihea[[tdgtitfliafLas6eenofficiaTCyslantpeclorntarkedU;fitedtyorfntt�tntsgbeprovidedtoitte iiPplicantasproofthatatralidaf[rdavitisorileforfitturepertitfso[licenses.Ariewal3idavitmust'befilled outeach ' exi�:�T�7terettJtonte ottnet of citizen is tibtantiitg:a se,orpertnit not related to anybushiess orcotmnerciaiva�tttrie F (i:e.a clog:license itto burn leaves etc.)said person is N.orroquiread to conTlefe flus FF'ficiavit_ . 'rretl)1'tee-afIilice�Ei�ationsZiontti2iE;efolita`stl }iotririailvancel'oey�otucu��,tafioit,titcY sriaiilcT'y'otilta3'�altygttasti4ns, t Iiteassciartoflt0sttalcla-git+at<rs#tc:fll: - T�tc Ikp��tn�-rtt'sacicir�ss,feteplrone anrT fax uurnTser: �'!ie e`outtrtn�itre�1:i11�►�?�'�as$zelit�setls - ' .T3e�ia€fivento�It�dttsir�I:�iieoict;,lits _ .� �1'fice of<Irtt'e�t%g�toltir 600-xVashitigt6h Street Ros[011,n�A.021 I1 Td.#617-W-.4 00 eXE 406-of 1477 MASSAvg Itetitsti 2G-�5 GI7.727.7749 1tni�vriiass,goE+iclta }' Date....... ...................... a TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHus� This certifies that ... ....... .......... ....,./............ .................... . ........................... has permission to perform_ f` wiring in the building of.................:J.v.T-if .w......................................... C fj rpt .1 ,North Andover,Mass. at... ...... ................. o Fee...�-�—.... Lic.No.�446zij........... . ..... ...Yz. � E Ecrx[cni.Itvs���crox ..... Check # 7 Z 1 0661 Commonwealth of Massachusetts . Official Use Only Permit No. . /06(o l Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS .[Rev. 11/991 leave blank ' � APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Towle of-. AMMSBURY To the Inspector of Wires: By this application the undersigned gives notice of his or her intentio��topeperform the electrical work described below. Location (Street&Number) / b 3 Owner or Tenant Telephone No. Owner's Address �� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. x1,46 Existing Service Da Amps /Zo /ZYo olts Overhead LAS Undgrd❑ No.of Meters New Service Amps / Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com leticn o''theollcwin table maybe waived by the Ins ector of Wires. No.oRecessed Fixtures o.oCe .-Susp,(Paddle)Fans No.of Total � f FiNof PdlF � Transformers KVA No:of Lighting Outlets No.of Hot Tubs Generators KVA tmergen hove ocy Lighting of Lighting Fixtures Swimming Pool Betrnd. nrnd, te Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiating Devices No.of Ran cons g Ranges No.of Aur Cond. No,of Alerting Devices g Tons No.of!'Neste Disposers Heat Pump Number Tons KW No.o -e ontained Totals: L Detection/Alerting Devices No.of DishwashersSpace/Area Heating KW Local ❑ Municipal [I Other Connection No.of Dryers Beating Appliances KW SecuritySystems: No.of Devices or E uivalent No.6f Water KW i o.o No.o Data Wiring: Heaters Si ns Ballasts I No.of Devices or Equivalent No.Hydromassage Bathtubs I No.of Motors Total HP Prelecommunications wing: No.of Devices or Eguivalent OTHER: + Aaacl.additional detail f desired,or as required icy the Inspector offres. INSURANCE COVERAGE: Unless waived by the owner,no permit d:or the performance o`electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The t undersigned certifies that such cov age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSL vCEBOND ❑ OTHER ❑ (Specify.) (Expiration Date) Estimated Value of Electrical Work:-&f 57O O (When required by municipal policy.) Work to Start: — 13 -iZ- Inspections to be requested in accordance with MEC Rule 10,and upon completion. d certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: _ LIC.NO.: Licensee:_C = - Signatun,_�,��� 1AC.NO.: (/Z 3 (If applicable, enter "exempt"in,the license nu nber line.) Bus.Tei.No.• d y r AddressX. r�.v�ve,,,R, /1'1 4 O/F 15 Alt.Tel.MI.: 7 OWNER'S INSURANCE W IIVVER: I am aware that the Lic msee doe,not have the liability insurance coy gage normally required by law. By my signature below,I hereby waive this requirement. 1 am the(check one)❑ owner L owner's a ent. Owner/Agent Signature _Telephone No. PERMIT FEE: S� (� To: 19786870253 Fm:. 21:45 11/14/05 PG 001 Pot � Y J r EQUITY LINE INTE NATIONAL PA TNERS Novemeber 2005 Global Beverage Solutions, Inc. (OTCBB:GBVS) Volume 1, Issue 50 INITIATES COVERAGE ON: GLOBAL BEVERAGE SOLUTIONS (GBVS) CURRENT PRICE: $0.7 0 TWO-WEEK TARGET: $1 . SO 12-].!MONTH TARGET: $5 . 95 Global Beverage Solutions (GBVS) has really opened the eyes larger ones. In fact, growing the value of the company for of individual investors. Now it's set to make its mark at WaII,Streefs investors is why GBVS focuses on manufacturing, distribu- highest level. That's because on Nov. 11 it said it will acquired 80% tion and sales of unique beverages globally. of Rudy Beverages Inc. IBeverage making, branding and beverage distribution That means, by our metria, GBVS is set for a long, steady and is what GBVS management excels in. That's why investors satisfying climb. should be impressed by the huge profit potential of Global But the street is a lumbering giant and individuals are not. Beverage Solution's EON structured water. The way EON is So individual'sigains should continue to outpace institutional influxes formulated means that the human body can absorb up to for another six to nine days. 95%of the water. Tiffs increases the potential to hydrate Individual investors are favoring GBVS because of its associa- the body at a rate that is four times more efficient than tion with such trustworthy man (and brand) as ^udy Ruettiger. Few standard water. EON will form the base of Rudy Bever- will ever forget Rudy's inspiring story... his legendary 27 seconds in age drinks too. the shadow of touchdown Jesus on the hallowed football field at Besides the huge upside GBVS offers investors, its Notre Dame University. primary goal is to create a portfolio of new market leaders } What a tackle... what an inspiration... It starts with a dream and by investing capital in those companies so they can grove. it's always too soon to quit! GBVS management will mentor those companies to enable That's why it's likely that the big guns are set to power up on them to realize a highly profitable exit strategy through sale Global Beverage Solutions. THEY DON'T WANT TO MISS OUT ON or public stock offerings. PROFITS HOOKED TO THE FAMOUS RUDY CONNECTION. This is where the GBVS strategy pays off. Because We also suspect that there's a fine chance that the heavy after a portfolio company goes public GBVS owns a ton of hitters at the big mutual funds and hedge funds already know shares. Some of those shares will be sold to generate im- Rudy personally... they've met him at corporate events and out- mediate profits and a portion will be retained so the value of ings...so they II want to please him and buy shares. the investments will grow. But,as our analysts now know, as you do too, GBVS is so much With a BDC investors usually win two ways: by profits more than the famous Rudy Beverage brand.., though that's not a spun out of the companies such as Rudy Ulster and EON bad wayto et investors throu h the door. and with free shares in those companies which are aid as 9 g p p Global Beverage Solutions is a farsighted 215!century company dividends to early believers when the companies go public. that operates as a business development company. The most fa- Our conclusion then is that a solid stake in Global Bev- mous BDC is Warren Buffe-T5 Berkshire Hathaway Corp... though erage Solutions (GBVS) allows the astute investor two op- like you, we think references to the incomparable Buffett are over- portunities to develop a steady stream of profits on a com- used and often deceptive. pany that is hooked to a famous brand as well as cutting Ir Still, as a business development corporation, Global Beverage edge products. Solutions was founded as a vehicle to nurture small companies into To request not to receive future faxes from Equity Line International Partners, please call 800-958-1769 Equi Line International Partners which is published b Panther Marketing Inc provides financial and,general public relations ser- vices for small and micro-cap companies. Information concerning the subjects of this report was gathered from sources generally deemed reliable, and may include information publicly disclosed by the subjebt or information provided by shareholders, consult- ants and others,some of which they may have obtained directly from the subject by reason of their relationship therewith. Panther Marketing Inc was paid $150,000 for gathering information, preparing this report and arranging distribution. These fees were paid by Gemini Market News Inc, who paid the fee on behalf of certain non-affiliated shareholders of the Company. This is not solicita- tion to buy or sell stocks, this text is for informational purpose only and you should seek professional advice from registered finan- cial advisor before you do anything related with buying or selling stocks. Readers are cautioned not to place full reliance on forward looking statements, based on certain assumptions and expectations involving various risks and uncertainties, that could cause ex- pectations to differ materially from those set forth in the forward looking statements. Im r --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): Address: City/State/Zip: Phone#: �7 9 o y4-3 Are u an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 2 4. ❑ I am a general contractor and I 6. Ve wconstruction 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 7modeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *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 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:. C�Cf 1 Policy#or Self-ins.Lic.#: Expiration Date: lO ` / l -z— Job Job Site Address: ./�f' City/State/Zip: 4 OAo&if, /MF 6 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 and the p lties of perjury that the information provided above is true and correct. Signature: Date: Phone#: / 7 E— G y 3 Official use only. Do not write in this area to be completed b city or town official .f.1+ Y P Y tJ' .f.F 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