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HomeMy WebLinkAboutMiscellaneous - 178 CORTLAND DRIVE 4/30/2018_ -. 0 C' .Ay N'ORTAI pI zfisadak • 4� .� wj— '�' csa� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number, _ 567(3/23/10 Date: April 29, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON _ 178 Courtland Way MAY BE OCCUPIED AS Sinale Family Dwelling — 40B IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Meetinghouse Commons LLC 115 Carterfield Rd North Andover MA 01845 Building Inspector f 19 V O z • rA W cc K LU QLM E a LIOy 10CIO O A cmm 92 C" c S m 0 CD c C N O t O Z co CD L CD O E O L �+ O v ca z C O y CD CM D � I C C y O O Q O O� 'o O �co 0 CD cc O � a cmQ O � c cv ev _v J .O �= O CO y Z V O a C.a CO) O C C y cm O •m C O C V O � O o C.) CL C R e0 m C :Z O O m f/f Ea •� o �.. m $ cm SCO E. z .r CE C Cc os r: a= CA cc C os CD3 m = C R yCD y E 'o o.C.3 LZ M m ; .LZ O c oQ • CIO dCt O O0 co CM Z �v m y C = m m w O r0+ y 0.2 1 -- COD W C �= C W V d CD cm O . C CIO GO y D C = J- O..- m E a LIOy 10CIO O A cmm 92 C" c S m 0 CD c C N O t O Z co CD L CD O E O L �+ O v ca z C O y CD CM D � I C C y O O Q O O� 'o O �co 0 CD cc O � a cmQ O � c cv ev _v J .O �= O CO y Z V O a C.a CO) O C C y cm Date ...—. ..... 1:P. ..... ....... /11) ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .,/4— ................fes-................................................... has permission to perform ...:...../.) ................................. wiring in the building of ..... .... ........................... .................. .. . I North Andover, ass. North A at ............... 9 , a �ss* ig(Fee3 ............ Lic. No- 2,mp .................... . . ........ .. . . CAL INSPE R Check # 2111 9 3 UO IN IL 'x Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 93" Occupancy and Fee Checked ,ev. 1/07J APPLICATION FOR PERMIT TO PERFORM ELECTRICAL(blank) leave All work to be performed in accordance with the Massachusetts Electrics] CoWORK (PLEASE PRINTW INK OR TYPE ALL NFORM1gTl0 City or Town of NORTH ANDOVERTo the M Date: 3 By this application the undersigned gives notice of his or her intention to per1: to 0Of Location (Street & Number) form the electrical w>ies described below. / / _ 1 / _ i A Owner or Tenant Owner's Address Is this permit in conjunction with ab uilding permit? ` ' �I�L Purpose of Building Existing Service Amps _/ cos New--' Service ,7,f L Amps lo2YVolts Number of Feeders and.Ampacity �4/" Location and Nature of Proposed Electrical Work: Telephone N 170 119� - . No ❑ (Check Appropriate Box) Utility Authorization No._��� Overhead ❑ Undgrd ❑ No. -of Meters _ Overhead, ❑ Undgrd No. of Meters completion o the ollowin table maybe waived b the Ins ector o%Wires. No. of Recessed Luminaires No. of CeiL-Sus , No. of p (Paddle) Fans Transformers KVA No. of Luminaire Outlets KVA No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above❑ o. o mergency No. of Receptacle Outlets No. of Oil Burgers d' d. aftery Units t No. of Switches F`RE ALARMS No. of Zones No. of Gas Burners 0. of Detecfinn a.,a No. of Ranges No. of Waste Disposers No. of Dishwashers ------------- No. of Dryers o. _011W ater Heaters KW vivo. Hydromassage Bathtubs OTHER Of Air Cond. Totals: _ . _ .._��� ._, :e/Area Heating KW Ing Appliances KW AO. Or Ballasts . No. of Motors Total HP o. of Alerting Devices t n/AlertinQ Devices ❑Munmrapal COnnectinn Other No. of De, :a Wiring. No. of Dei of Estimated Value of Electrical Work:/ Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) Inspecti ns to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no time licensee .provides proof of liabili Pmt for the performance of electrical work may issue unless ty insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCFX BOND ❑ OTHER 11 I certify, under the ains and /en'aldes a the (Specify') FIRM NAME: fPm1 ry, that e information on this application is true and complete C .v r �'L _ LIC. NO.: Licensee: /A`r (yfapplica le, enter exempt" to the license number line.) Signature LIC. NO.: 3 f��,6T Address:Vr� us. Tel. No.: *Per M.G.L c 147, s 57-61, security work requires D �AS� ���1 ePartznentofPuety "S" License: Alt. Lici No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiabili ty required by law. Bcheck one my signature below, I hereby waive this requirement I am the insurance coverage normally Owner/Agent ) ❑owner ❑owner's agent Signature Telephone No. PERMIT` 1 E�� -lzel let r 5 v The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 JEashineton Street Boston, MA 02111 Workers' Compensation Insurance Afficiays Sfideerrs/CoUtrac%rs/Eiectrici Lucent Information ans/Plnmbers Name Address: City/State/Zip: Phone A Are you an employer? Check -the. appropriate box: I.9–I. tarn a employer with 4. Type of project �: ❑Ian► 8 gametal contractor and I (°i 2• ❑employees (full and/orpart-torte).* have hired the sub -contractors 6 ❑New constniction I am .a.sole proprietor or partner- Iisted on the attached sheet 2 7. ship and have no employees ❑ Remodeling These sub -contractors have working for me .in any capacity, workers' comp. insurance. 8. Q Demolition [No workers' comp. insurance S. ❑ We are a corporation and its 9• ❑ Building addition 3-Q required.] offic= have exercised their Io•Q Electrical I arrt a homeowner do' repairs or additions mg all work right of exemption per MOL I I -Q Plumbing repairs additions elC insurance. �� o workers comp. Z. 152, § I (4),'and we have no . l ] =Ployees. [No work12 ers' ❑ Roof repairs camp. insumnee.required..] 13.❑ Other *Any eppiicarut Chet t�ueclts bo>;!� l mast silo fuTt out the section below Showing 1 Homeowners who submit this affidavit indicating they aro doing at) g their workeus' oompeuusafion policy infomtetion kVntraat r8 that check this box must r �"'. and then hke outside conua t m must submit a new, af"tudavit indiaatisg �� attached an addttiouu�i sheet showing __ I a m onemployer name of the sub.con .�„ Fti.� . ' �rp. Po in' thltt lS' ro s •• �.••� � Policy mnnaiion. p .>tding:warkers car ensazlion ' information. ' u7sacrance for rrry. employe= Below is the poay. madyoh sfte Insurance Company Name: ' � Policy # or Self -ins. Lic. #: / Expiration Date: l) �� Job Site Address: / % City/State/zip:X—AU) Attach a copy of the workers' contpe°sation policy dtxfaratioo 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 �. fine up to $1;500.00 and/or one-year imprisonment; as well as civil penalties rn the form of a S7Y3P WORKmal penalties of a Of up to 5250.00 a day against violator. Be advised that a copy of this statement may be forwarded to the ffice ORDER f a fine Investigation's of the DIA for insurance coverage verification. I do hereby certify u��r pains and enaltiass o P jperjaary than the in formation provided =bow true and correeL Si talre:. J Date: C7 Offjcial use only. Do not write in this attma, to he complete!fly ci0' or town o cfa( City or Towar Issuing Authority (circle one): Permit/License # I. Board of Health 2. Building Department I City/Town Clerk 4. Electrical Incoe,t.... a ns_ _�• 6. Other Contact Person: Phone #: Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -�ACMUT This certifies that ..../. !! . W.. !`�. /``�?...... /4 ............ has permission to perform ...... :z� .....11-a" S' . plumbing in the buildings of ...... I .... Z4.;.Ue u%...... . at ... l�............... ,North Andover, Mass. Fee l J... Lie. No../. 5� 6*:7. ....: - .................... PLUMBING INSPECTOR Check # 85uu MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location ' 7 Owner New 0---' Renovation n Date m.." / LgL Permit # 7 ` Amount Replacement ® Plans Submitted yes No r, rstmrrn►�� (Print or type) Check one: Certificate Installing Company Name L AW / ❑ Corp. Address❑Partner. G h��►, W G 76 Business Telephone®Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have anyone of the above three insurance Signature Owner ❑ Age ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under permit Issued for this application will be in compliance with all pertinent provisions of the Mw a�ssachusetts State P Bing Cod d 142 of the General Laws. By: 170T1ATtIT Title Type of Plumbing License City/Town % / S 7 APPROVED (OFFICE USE ONLY en rcse NUMDer Master Journeyman The Commonwealth of Massachusetts Department of 1-ndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nniirant Tnfnr..,.4:,.., Name (Business/OrganizationAndividual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with -4.7 I am a general contractor and I employees (full and/or part-time).* 2. ❑ have hired the sub -contractors I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance S. ❑ We are a corporation and its required.] 3. [1.1 am a homeowner doing officers have exercised their 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.] :Any applicant that.checks.box #I must also fill out (he section bel ^w ;n Type of project (required): 6. ❑ New construction 7. Remodeling 8. [] Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.11 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other t Homeowne s 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 information. employees. Belowis the policy and job site Insurance Company Name: 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sip -nature: Date.; Phone #: F i1 al use only. Do not write in this area, to be completed by city or town off ciaL City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: N 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 I 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 numbers) 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 fhe affidavit. The affidavit should be returned to the city or town that the applicafion for the permit or license is being requested, net 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 bice 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 Investibations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 VVVi'VV.IDaSS.. gOV/dla Date. ...... p• „ao ,°.ryC• TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSACHUSEt This certifies that ...e�.. ..... .. j .... ....... has permission for gas installation ... .../.'!!l ........ . i in the buildings of .... ..�.../ I(/ C/ /' I ")............ at .... ........ North Andover, Mass. Fee !' U 0.... Lic. No.. � X. 'O.. ,................... . z,GAS INSPECTOR Check # Ti 90 A MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTIlVG (Type or print) Date I NORTH ANDOVER, MASSACHUSETTo S Building Locations / 2 k �(zr'1�/gym_ '� Permit # Amount $ Owner's Name 1&024400- A New Renovation Replacement Plans Submitted (Print or type) Name Address 0367 Name of Licensed Plumber or Gas Fitter �c, Check one: Certificate Installing Company ❑ Corp. El Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©/ No 1 If you have checked yes, please i ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 —j u=y LIA— a- VL «,� ucLaiLb aiiu u„Unctauurl 1 nave suormt<ea kor entere(j) In above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /S—IS 7 0 ;Master Fitter License Number Journeyman w vi w z W d w W p ��L• a W W v� W z dz a W w Q o > p W q F U d Q F -. E rA z o E. z o F W x 5 0. x w 3 0 a> A a F o SUB -BA SEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. - FLOOR (Print or type) Name Address 0367 Name of Licensed Plumber or Gas Fitter �c, Check one: Certificate Installing Company ❑ Corp. El Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©/ No 1 If you have checked yes, please i ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 0 —j u=y LIA— a- VL «,� ucLaiLb aiiu u„Unctauurl 1 nave suormt<ea kor entere(j) In above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /S—IS 7 0 ;Master Fitter License Number Journeyman The Commonwealth of Massachusetts Department of industrial Accidents Office of investigations ..600 Washington Street Boston, MA 02111 ky www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieians/Plumbers nnlirant T.,f....,.,.,�:,... Name (Business/Organiza6on/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I have hired the sub -contractors 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. [No workers' comp. insurance .. ", workers' comp. insurance. 5. ❑. We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other ciJV 11L VUL LUC section ne.-O � snow' --g :uwr Iti e: �'' 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 isproviding workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: 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 r 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. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the perrritor 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-MASSAFE Revised 5-26-05 Fax # 617-727-7749 vc ww-mass._gov/dia