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Home My WebLink AboutMiscellaneous - 25 CEDAR LANE 4/30/2018N i �IiO � � D �' o v 0 g m 0 This certifies that ..... !. 141. AA) . .............. . as permission to perform ....�. .. � . .... L''J ............ wiring in the building of .. �. �)' Y-� ................... � ........... .... NorthAndover Mass. Fee . 5= .... Lic. No. 3 ! � ... ......... ... ELECTRICAL INSPE` TOR' OR ` Check # 11309 J Commonwealth of Massachusetts Official Use Only Permit No. ? a Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank 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 ININK OR TYPE ALL INFORMATION) Date: ')? C, I q - 2C)12 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 & Number) ?—S CEDU LA Owner or Tenant TA SMUts\ Telephone No.9 8 (OS3 Owner's Address S 1A VVI Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters . Number of Feeders and Ampacity No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans s Total of Trsformers KVA Tran No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. pf Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number Tons " ' 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 Heating Appliances KW SecuritNo. o Systems:* evi es or Equivalent No. of Water I(W No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Adach additional detail if desired, or as required by the Inspector of #fres. (When required by municipal policy.) Work to Start: 12_ -JL4 -12. 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Xcertify, under tliepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Licensee:M W n e— Signature (If applicable, enter "exempt" in he license nzimber line.)I fl 3 LIC. NO.: LTC. NO.: 31 (nm Bus. Tel. No.• ' 1:022) Alt. Tel. No.: I; *Per M.G.c. 147, s-.57-61, security work requires 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 agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: t Inspectors Signature: Date: ROUGH INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass ? Failed Re- Inspection Required ($.) ❑ Inspectors Comments: 1,7-2-1- f2 - Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 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): ::�71 IM UJ � 1 M Address: City/State/Zip:, A O t g�j 2, Phone #: 9 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I If employees (full and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. 3 fJ ship and have no employees These sub -contractors have ;working for me in any capacity. workers' comp. insurance. Vo 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.] 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.❑ Roof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Iformation., isurance Company olicy # or Self -ins. Lic. #: Expiration Date: )b Site Address:2,6!r=F_0l4P�– N o %q-tl E Q ti DO1/�6?ty/State/Zip: J y JA ©l S 45 Atach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Cup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ►vestigations of the DIA for insurance coverage verification. do hereby certif y under the pains and penalties of perjury that the information provided above is true and correct i nature: vvvl LTJ Date: 1 —1 � 12– Official itse 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. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 evised 5 -26 -OS www mace vnv/dia Date ..q•��./7— This certifies that .......7D /3/�L .. .......... has permission to perform ... aeW ................ wiring in the building of ... /J� -5 / ., 4 ............... at 0/ ............. North Andover, Mass. �-r ..... Lic. No. ELECTRICAL INSf*-CTOR Check # 070 / a 72�) ConunonweA. o� Mad.,=I m.th Official Use Only cc /�� Permit No.?� .1JeparEntenf ol,}cc77 ire �ervice� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC}"6- 27 r/7— 13.00 (PLEASE PRINT IN INK OR TYPE INF MTION) Date: City or Town of: �D2 / d O U e- r, To the InspedoP ofWires: By this application the undersigned gives notice of his or her intentiPMAK form the elec ical work described below. Location (Street & Number) �� Owneror Tenant S ATelephone No. Owner's Address 54mp Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building �7L,4 �� Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters No. of Recessed Luminaires -- :2 •• No. of Ceil: Susp. (Paddle) Fans ,"",u OR( VC ivul VW U), [Ile ins ecror o Wires. No. °f Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] rnd. grnd. No. 01 Emergency Lighting Battery Units No. of Receptacle Outlets" No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches iNo. of Gas Burners o. of Detection an InitiatingTotaDevices No. of Ranges No. of Air Cond. Tons l -Pump No. of Alerting Devices No. of Waste Disposers Heat Totals: um er JTons o. of e - ontaine Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal❑Other Connection No. of Dryers No. of Water KW Heaters Heating Appliances KWSectio o. o No, of Si ns Ballasts of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommunications Wiring: No. of Devices or Equivalent OTHER: f_ 12- i✓ �c,V Sv (p attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �^ (When required by municipal policy.) Work to Start: 0- 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 Iicensee 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 s e to the pe it issuing 70ce CHECK ONE: INSURANCEBOND ❑ OTHER ❑(Specify:)i�applb �� 1 certify, under the ants a td pen�{i' of erjury, l/ t thein rtnation on t ttt is true andFIRM NAME: v s G iC � LIC. Licensee:,Signature LIC. NO.: (Ifapplicable, ant "erem t" in tlie license number li} / �j ` y� Bus. Tel. No.• Address: v�i� �A tC /i�rzl M � �- AA Ac%Cpa Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security wQj',lf requires Departnient 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 agent Owner/Agent Signature Telephone No. PERMIT FEE: $ 1 I► 0�-7,PYV /�"' /-0/9- 1 P- /,?- r-�4 0-,t( 2, Z i It, i 9564 Date. . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that S,�Z� .�.� � 411 - has t has permission to performs plumbing in the buildings of .A A .............. at ..2 .......... , ort ndover, Mass. Z............ PL M81NG INSPECTOR Check ." � 3/ rf MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Blimp fflj CITY �;io< CA.,, _�-'L-� —� MA DATE� !1-) PERMIT# JOBSITE ADDRESS L v✓ OWNER'S NAME POWNER ADDRESS TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES[] NO FIXTURES'l 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 GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM (_ ..-__ ._I f _ _. _{ �_._._ 1 _ _ . I _ f I I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _f ! .__.._.__ ..__ f (I ( ._._.._( ._...____! ( .._.___..E -. J _ r 1 FLOOR /AREA DRAIN i I (_ 1 I ___.._-...I _.__.. 1 1 .__..--._ INTERCEPTOR (INTERIOR) _ P _I __._.._f i ...__ i i _----_1 KITCHEN SINK LAVATORY ROOF DRAIN ___I ___.J __l ______j ._-.._J SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i t ! . OTHER I —I -------I -I 99�_ L_ A31 __._ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R' NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ®1 BOND �l 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 M AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicatio are tru an ccurate to the best f my kno dge and that all plumbing work and installations performed under the permit issued for this application will be in comp ' n e ith all P rtinent p vision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME.+ .rt. Gvk_- G_- LICENSE # ( GNATURE MP [T JP [j CORPORATION [j?# - o► I PARTNERSHIP 0# r LLC U COMPANY NAME ,�, �esn �, ►- Ir/ ;ADDRESS _S Y CITY �l u. �h.. I STATE � /1) ZIP o ! �Y,� TEL FAX CEa��iS 7�� MAIL c� o� Z W CL ui w LL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 swww mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Q Address: y K City/State/Zip: ")"W , 4W,1© 0 - Phone #: Q'? (Sz�- -Z� Are you an employer? Check the appropriate box: 1. ERII-am a employer with `1'- 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. ❑ 1 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.] f 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. ❑ 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. F am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy # or Self -ins. Lic. #: Expiration Date: fob Site Address: 9 �_ C_e d4—/Z �y,__ City/State/Zip:tij 4 e4� P"* d i !F`fj� attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ?ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ane 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 if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby rtify nd the pains an penalties perjicry at the information provided above is true and correct. Ii nature: //) 5�, -211-0 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): I. 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 'O Sox 55098 3oston, MA 02205-5098 H7-951-0600.. Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall N ANDOVER, MA 01845 N ANDOVER, MA 01845 RE: Insured: DAVID A PASHAYAN and ELIZABETH PASHAYAN Property Address: 25 CEDAR LANE, N ANDOVER, MA Policy Number: HMA 0132057 Claim Number: BOS00049640 Date of Loss: 2/18/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000:00 or cause. Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Connor Donovan Claim Examiner 2/19/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5362 Fax: (617) 603-4926 Email: Connorponovan@Safetylnsurance.com