HomeMy WebLinkAboutMiscellaneous - 1820 TURNPIKE STREET 4/30/2018 (13)LIM
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Location
No. C� 2 O Z— Date-3Aj
Check #Z;K /
25087
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee /
TOTAL ;51& v
Building Inspector
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Date....1j.' 2-.'°1.....�.�
;•,�``° "�,� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING,
This certifies that...........�..!'.1.&�....!-".f. ��-�ll��...............
has permission to perform .........t'/ ! P S�L� �v
wiring in the building of .... t l ... Z-/ .............. .................
at
....................... ' North Andover, Mass.
Fee ... 2-"Lic. No. .32541?E........fill�...4......
07/ ELECTRICALINSPECTOR
Check # _ _ _._
10505
N
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.��
Occupancy and Fee Checked
[Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: vi- N— �\
City or Town of: 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 &
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building S 0.1 h Utility Authorization No. C�
Existing Service Amps / Volts
New Service _C) 00 Amps I 'IQ/ k% Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
4 w'► ty-
No. of Meters
No. of Meters
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed LuminairesNo.
4
of CeiL-Susp. (Paddle) Fans
No. of Tota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool rnd. ❑ rnd. 11
No
o. o Emergency Lighting
Units
No. of Receptacle Outlets 5
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches 1p
No. of Gas Burners
o. of etection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices a
No. of Waste Disposers
Heat Pump
Totals:
I NuTt!eE.J
I
Tons. .
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
-Security ystems:
No. of Devices. or Equivalent
No. of WaterKW
Heaters
o. 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 1
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 6%00. t3 0 (When required by municipal policy.)
Work to Start: V 1 y\ 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 cov ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Eff BOND ❑ OTHER ❑ (Specify:)
I certify, under thepainsand penalties of perjury, that the information on this application is true and complete.
FIRM NAME: \` \ Y �. f. ' ` Q. LIC. NO.: 7ja5y� E
Licensee: N\b,:a, L M�\\ 6.,C— Signature LIC. NO.:
(If applicable, enter "exempt" in the li ense number line.) Bus. Tel. No.;Ll'1- ti SO 1Jtsy
Address: n �- \ Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-51, security work 1equiTes Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
ke"11,4 e5� 12,-9-11 //J,
®r
WILL C��� �. O�C 4A2 v
I
f
t
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): (j�{�l `NZ
Address: 60 G
City/State/Zip:
M
Phone #: (9 0_ 9 50 - 315J
Are you an employer? Check the appropriate box:
1.❑ I a a employer with
4. E]I am a general contractor and I
ployees (full and/or part-time).*
have hired the sub -contractors
2. 1 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
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
12.0 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 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:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
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 certif under the pain and penalties of perjury that the information provided above is true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
NW -111
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 #:
9253 Date. J/!. � t4..
TOWN OF NORTH ANDOVER
AL
PERMIT FOR PLUMBING
This certifies that
.........................
has permission to perform .............
plumbing in the buildings of
at. . le,?4?-X7,�V- !A.-5� ........ North Andover, Mass.
Fee Lic.
PLUMBING INSPECTOR
Check # //a -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Print)
NORTH ANDOVER, MASSACHUSETTS
Building Location /�fa?D �i/rn T�i�. c /Z
Owner
New Renovation
Replacement
IVYVV Vrm-Inn
Permit #
Amount
Plans Submitted Yes n No
(Print or type) Check one:
Installing Company Name �� ,.�� ,,/ Corp. Certificate
Address z
El Partner.
r
Business Telephone
Firm/Co.
Name of Licensed plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy ❑ Other type of indemnity ❑ Bond
Inspmpcthree insueranmae:�I, the undersigned, made aware that the licensee of this application does not have any one of the above
ignatur�, OwnerF1Agent
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 un er Permit Issued for this application will be in
compliance with all pertinent provisions of the Ivlas efts S top in de and
i� _ ) e of the General Laws.
own
ZOVED (OFFICE USE ONLY
- W-4/4 �/
Type of Plumbing License
icense INum er Master �...6
JoumeymanA
s
I
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): G
Address: 46
City/State/Zip:
Phone #:g ftV 7 L�
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. [1 Roof repairs
13.❑ Other
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 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
7
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 CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Are you 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
I am a sole proprietor or partner-
`ship
listed on the attached sheet. t
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.]
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.]
* Sny applicant that checks box rl must also rill out the section below sL-e L i__ +xa. -
t
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. [1 Roof repairs
13.❑ Other
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 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
7
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 CIerk 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 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. #1 617-72.7-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
w%,w.mass..govfdia
Date ...I K. I .I T........ .
TOWN OF NORTH ANDOVER
iWy� 9
PERMIT FOR GAS INSTALLATION
.q. .,s
This certifies that . ��' �� � � . ...../ ...
has permission for gas installation
in the buildings of .. 44:mo . "Coz r!"' ....................
at .. /BZ -P.. xtge!11e..: ........ Northndover, Mass.
Fee. !94'. . Lic. No.: ��Sl �/ . 17 !e14V a�r. . .. .
GASINSPECTOR
Check #
7996
V
GIYT, ID=42
W
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
"
CityRown:_ _ , / iy�%� MA. Date: / I/— o%D/� Permit#
Plumber
Building Location:_ / .)o Owners Name: X,--,fZn
Title
Type of Occupancy: Commercial„ Educational ❑ Industrial ❑ Institutional ❑ Residential ❑
Signature of Licensed Plum�Fitte
New:,o Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑
GIYT, ID=42
W
Type of License:
"
By
Plumber
Title
Gas Fitter El Master
Signature of Licensed Plum�Fitte
City/Town
®.lourneyman
ZP
License Number:
y
Installer
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SUB BSMT.
BASEMENT
15T FLOOR
/
2 FLOOR
3 FLOOR
4 FLOOR
9W -FLOOR
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6 -FLOOR
7 FLOOR
8 FLOOR
Check One Only Certificate #
Installing Company Name: —����G��ra�st��"r
_/J�
El Corporation
Address: -7//n /�
City/Town:
State:
❑ Partnership
Business Tel:
Fax:
❑Firm/Company
Name of Licensed Plumber/Gas Fitter:
i
IZ
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A 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
Massachusetts General Laws, and that mignature on this permit application waives this requirement.
Check One Only
Owner U2-' Agent ElSignature o Owner or Owner's Aaent
checking this box VU hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true
... 1..0..cam. V1 lily rnnuwieuge anu inat au plumning worK ana Installations performed underthe permit Issued forthis application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
s
Type of License:
"
By
Plumber
Title
Gas Fitter El Master
Signature of Licensed Plum�Fitte
City/Town
®.lourneyman
ZP
License Number:
APPROVED OFF CE US ONLY
Installer
1,41;.Ijw
-49
s
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
anlirant lilfnrmafinn
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone#:
Are you 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.
[No workers' comp. insurance
workers' comp, insurance.
5. El We are a corporation and its
required.]
3. ❑ I 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'
*A.ny
comp. insurance required.]
a�licant that cheers box #1 must also fill out thebelow Owin v .
7 section b _.. �vu
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.❑ Roof repairs
13.❑ Other
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
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 andel pe altiessoo ff perjury that the information provided above is true and correct
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):
L Board of Health 2. Building Department 3. City/Town CIerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
Phone #:
K
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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with.no employees other than the
members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date -the affidavit. The affidavit should
be returned to the city or town that the application- for the peril o 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, IIIA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSARE
Fax # 617-727-7749
Revised 5 -26 -OS www.rnass.gov/dia