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Home My WebLink AboutMiscellaneous - 289 Webster Woods�i v � 1� CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number Date A;2-3c�)- —0 0 THIS CERTIFIES THAT THE BUILDING LOCATED ON /6 O� 02) 812 a)OOC4 zt, MAY BE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO ADDRES'k IQI fb E-�', 0 "IZI\ L� qft% rl 6 z C2 cc cc j C3 lb: co .Jz . 4A, .0 L CD & 3:4 - CD 0 CL E.S 0, 0 CD cm CL La w CD. -4,4. :5 CR CD w Cc -CE to -E Go CD 0 co CLC.2 LZ CD cm S COO 0 <c ca ca ICSDJ - NCAD 0 A cis 0 S. z C, Va , Mcj .0, m ts qk",. NO ) - J./ )U -.4-1 Cf) coo ui cv:5. D lo.. AR *4 m = C2 L= u ce CLM -.— 00 a ca CM ZW C.3 COD CD CD 0 -05 u CD 'A L.. Z C!5 cz ng a .4 Cd to W, u P-4 wo w u 0 z Q) 44 0 :3 50 x 14 0 cf) C/) qft% rl 6 z C2 cc cc j C3 lb: co .Jz . 4A, .0 L CD & 3:4 - CD 0 CL E.S 0, 0 CD cm CL La w CD. -4,4. :5 CR CD w Cc -CE to -E Go CD 0 co CLC.2 LZ CD cm S COO 0 <c ca ca ICSDJ - NCAD 0 A cis 0 S. z C, Va , Mcj .0, m ts qk",. NO ) - J./ )U -.4-1 Cf) GO, it, 44, E z ca 0 Me E CL U .m CL CO) 2) CL CO2 a!� cc 'a CO) L 0 isa) CL CO) .E CD CM co CL 0 CL cmcc CD z t5 co CL COD E f LLI 0 U) w U) T— LU LLJ Ir LU w C/) coo ui cv:5. D lo.. AR *4 m = C2 L= u ce CLM -.— 00 a ca CM Z cl C.3 COD CD CD 0 -05 CD 'A L.. Z C!5 Z. CLtA. CC GO, it, 44, E z ca 0 Me E CL U .m CL CO) 2) CL CO2 a!� cc 'a CO) L 0 isa) CL CO) .E CD CM co CL 0 CL cmcc CD z t5 co CL COD E f LLI 0 U) w U) T— LU LLJ Ir LU w C/) o Town of SAC NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT PERMIT NO.: 0� I 1P — PROJECT:-311jo '�4-111 oJ*(IN@P'E1RM w UNIT NO.: REMARKS: FLOOR: DATE- 5-- 1 X 0 0 -) on WING: BUILDING NO.. Excavation - depth and soil conditions Framing - Other: Date: T1 - Ro - C) 0 — Date: Date: Inspector " (CU, inspector—AA Inspector Footings and foundations and drains - Insulation - Other: Date: q — Date: I Date: AAA( Ad A4 (CCA^— Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: -am Date: Date: Inspector ::I-, Inspector Inspector - Electrical - final Plumbing and/or gas - final Other: Date: 0, 0 (Do Date: I ;z- Date: Inspector 401f Inspector A. Inspector - ,or 1re Dept - A burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: JaAA--boc of 0 # A4 Inspector Inspector- Inspector -,M Form #995 Action Press, 685-7000 I. * 1 -1 .. I I I 0 MI Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 0 1845 (978) 688-9545 Fax (978) 688-9542 0 L APPLICATION FOR CERTIFICATE OF OCCUPANCY / tNSPECTION ADDRESS c2 R -7 We-LSfr_-r Wo 0.�S LOT NUMBER 12 —SUBDIVISION DATE REQUEST FILED DATE READY FOR INSPECTION I & FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION ]�� TWENTY-FIVE ($25.) DOLLARS WILL BE CHARGED IF THE STRUCT�RE DO�S NOT MEET ALL APPLICABLE CODES. SIGNATURE "OFFTC[AL USE ONLY ROUTING CONSERVATION DATE Z,00(-) wt Aa � PLANNING DATE D.P.W. -WATER METER 6Z 'TZLJ —DATE- D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO THE INSPECTION REQUEST DATE. -IL,W4 0 A)1A* SIGNATURE /66PM(/AUTHORIZATION mWded VM "Mo old Oft ShWW, Mesiti Dev Group Fax:978-5578160 Jul 17 2000 13:54 P. 01 TOWN OF NORTH A"OVIER DIVISION OF PUBLIC WORKS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Mr. Kenneth. Grands� President Mesiti Development Group 231 Sutton St. Suite 2 F North Andover, Ma. 0 1845 July 14, 2000 Re: Conditional Operation of the Campbell Forest Sewer Pumping Station. Dear Mr. GrandswT. The Division of Public Works has inspected the sewer collection system and sewer pumping station, and appurtances on Campbell Road related to the construction of the CamOMI Forest and Lyons Way subdivisions. We hereby grant conditional approval for use of thesystem and pumping station subject to the fbIlowing: 1. Completion of items I through 15 as listed on the July 10, 2000 letter to Mr Dennis Bedrosian from Maurice Harpin of Mesiti Development Group, a copy of which is attached. The work will be completed within 45 days of acknowledgement of the receipt of this letter. 2. Satisfactory completion of an as -built plan for the Campbell Road sewerage system. 3. Submittal for our review and approval a copy of the preventive maintenance contract for the pumping station. 4. A performance guarantee shall be provided in the amount of $25,000.00 to insum the proper maintenance and operation of the pumping station. 5. The Division of Public Works will be allowed access to the Pumping Station and will be allowed to reconstruct, repair, replace, add to, service, inspect and operate the pumping station and related equipment and facilities in the event that Mesiti Development or its agents fail to adequately perform maintenance of the pumping station. Mesiti Dev Group Fax:978-5578160 Jul 17 2000 13:54 P.02 6. Mesiti development shall reimburse the Town upon demand for the reasonable' costs of emergency repairs to the Pumping Station. 7. Mesiti Development Group and its successors or assigns shall indenw*, defend, and save harmless the Town of North Andover and its Division of Public Works and their respective employees, officials and agents against all suits, claims, judgments or liability of every name and nature arising at any time out of or in consequence of the acts of the "Towe' or its agents, employees and officials in the performance of the access purposes covered by this grant of conditional use or the fdure of the developer afid its successors orassigns to comply with the terms and conditions of this grant. Very ours, 44r 7T J. HniurcJi.E. Director of Public Works The undersigned acknowledge the receipt of and agrees to the terms and conditions of the above grant of ndlitionall umse. up rl 7iti Oe I/j, -7- KA Qbeth GT:�& M&dent Date: Date. . C'0. .......... N2 4573 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that .......... has permission to perform � .............................. plumbing in the buildings o ............................. at.,:�.7. North Andover, Mass. eel Fee4�?3 ... Lic. No ........... I .............. P L U M81 IZ4�51N S PECTOR Check# WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETrS -�4-4 W rn�q� 11 Building Loq4tion W C - Owners Name / Date 141,90 Permit# Amount Type of Occupancy QP -5 I New Renovation F1 Replacement Plans Submitted Yes No r FIXT11RES" '(Print or type) K Check one: TKt t� 4 Installing Company Name Corp. Address Partner. \J Business Telephone (�)637�18 76q,)o a<Co. Name ofLicensed Plumber. KA- LT L Insurance Coverage: Indicate the type i surance coverage by checking the appropriate box: Liability insurance policy lij Other type of indemnity 11 Bond 0 Certificate Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance 7ignature Owner M Agent r-1 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 Massachusetts State Plumbinee(T��Ahter 1N #� General Laws. -J, � - 'I - APPROVED (OFFICE USE ONLY Type of Plumbing License A;A Q� =inse NumBer Master Journeyman 21-� '(Print or type) K Check one: TKt t� 4 Installing Company Name Corp. Address Partner. \J Business Telephone (�)637�18 76q,)o a<Co. Name ofLicensed Plumber. KA- LT L Insurance Coverage: Indicate the type i surance coverage by checking the appropriate box: Liability insurance policy lij Other type of indemnity 11 Bond 0 Certificate Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance 7ignature Owner M Agent r-1 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 Massachusetts State Plumbinee(T��Ahter 1N #� General Laws. -J, � - 'I - APPROVED (OFFICE USE ONLY Type of Plumbing License A;A Q� =inse NumBer Master Journeyman 21-� Location /d 141< ��, No. 0/00 Date 02-- IJP Check# e) 14014 Buil TOWN OF NORTH ANDOVER Certificate Occupancy of $ CH Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ 13 2 TOTAL s Check# e) 14014 Buil JUL--19-00 WaD 8 : I :a s . r= C -9 fs- :s C3. f-- i CL it P. 02 T-- aiv cERnF1FopLorPLAJV 0-0 S.F. CUUMMOS .4 ASSOCIAMS TCAA)�� Pe-IZZ4 P.O. 80X 1007 PLAISrOW, N.H. 00805 go tve"p marwoNe FAir w0c,#- Cri � 4-10 00" L-27.40' R -JO -00, )A TE: JM Y 17, 2000 3CALE I " = 60' 1'... OF FLAGGED ilL ICTLANDS m-34 I 4ERE8Y CER77FY rO rOWN Or NORrH -�,Moovu, mA gumpwq orpARrueNr �� r mF cxls wo rouwA r1o1v DRA w PN rHIsAAN IS LOCAW AS SHOWN 'AN Im r Ir DOES COMPL Y TO ME D T w1mum 8ulmw serBAcKs ro Ropury mrs, rLOT .I 45,444 S.F, l"a A k CA UPBEL L FORES T NOR774 ANDOVER, MA rAX MAP 210 8L OCK 106. 6 LOT 19 YINImum sk-mAcn- FRolvr - jo FEkr sloe - jo f irr REAR - jo Firr JMASSACHUSETrS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING ype or print) Date TYP� NORTH ANOOVER, MASSACHUSETTS Building Locations 6_�* New Renovation F� U z GW .0 z S U 3 - 8 A S E M E N T B A S E M E N T I ST. F L 0 0 R 2 N D. F L 0 0 R 3 R D. F L 0 0 R 4"F If F L 0 0 R 5'r ii F L 0 0 R 6'r ii F L 0 0 R 7 *r ii F L 0 0 R 13T If F 1, 0 0 R :Print or type) ,kddress iness 16 14ame of Licensed Plumber or Gas Fitter 6 9 es, SS C Date - 19 Of 000" 00% GO P" P f IF011 .Vital P IWIS celf1fies 111stallaflon pevols lot, fol %as 'has dilags of tle Vdl- I mass. qvev 'soft,' o- pjt0k- Is .1 / 17� 1JC eUj%d%09 ,Fee � .,,- OP'S ...�Wll_n �Comp�an 7 NN Partne FirmlCo L-37L— NSURA.'NCE COVERAGE Ched have a current liability Insurance policy or it's substantial equivalprit. Yes f vou have checked ves, please indicate the ty pe coverage by checking the appropriate box. -lability insurance policy Other iv v , pe of indemnir, MW Bond M Dwner�s Insurance Waiver- I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the vlass. General Laws, and that my signature on this permit application waives this requirement. Check one: 3lenarure of Owner or Owner's Aaeni Owner F1 Alzent ZD - hereby certify that all of the details and Intbrmation I have submitted (or entered) in above application are true and accurate to the )est o1my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in -ompliance with all pertinent provisions of the 'iylassachuserts State Gas Code and Clqp�er I I o en fy AvskeNr eNI Ll`�\ By: Title ttv/Town ATPROVED (0FF!CF USE ONLY) Signature of Lic,,nsed Plumber Or Gas Fitter Plumber - Q�q�q, Gas Fitter 717rise INUM157- clumeyman 104 4-X1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING y BUILDING PERM[IT NUMBER: DATE ISSUED: 4 SIGNATURE: Building Commissionedln�22ctor of Buildings Date SECTION I- SITE INFORMATION I 1.1 Property Address: .1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District osedCse Lot Arei (sf) Fr..—t—age(ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided t4m / 3(D / - 301 3- / 30 1.7 Water Supply M.G.L.C.40.5 54) 1.5. Flood Zone Inforniation: 1.8 Sewerage Disposal System IF Public W Private 0 Zone Outside Flood Zone 0 municipal On Site Disposal System 0 SECTION 2 - PROPER - TY OWARSEUPIAUTHORIZED AGENT 2.1 Owner of Record C�2� Z5* -5 74 - Name (Prinl� Address for Service - ��4 6 & 7 o Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor LIS o 6 �' 2 3;�,, License Number Address ,?Z,/ 6 5 7 E�300 Expiration Date Signature Telephone ,S 6�, -7 3..2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone ou M z 0 I M Qj I 0 z M 0 mn M r Z. G) I SECTION 4 - WORRERS COMPENSATION (NLG.L C 152 § 25c(6) I Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ... * J11 No ....... 0 SECTION 5 Description o Proposed Work (check applicable) New Construction Existing Building 0 Repair(s) 0 Alterations(s) 0 I T Addition, 0 AccessoryBIdg. . 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: 67 2-'z $�'e/ Z FIMI L/ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to Completed by permit applicant OFFTCIAL USE ONLY - I . Building /0' --2 2 S- (a) Building Pen -nit Fee Multiplier 0 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Pen -nit fee (a) x (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) 5-0� 0 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERAUT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, /R"s "'o As gmw/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print N A2, =�4 , Signature of Owner/Ajei4Z Date NO. OF STORIES SIZE a��- BASEMENT OR SLAB SIZE OF FLOOR TRABERS Isr $�,VX-7-0,�St—TND�77, 3PLD SPAN 110/C ' DIMENSIONS OF SULS (0 DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS 11EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X 0 MATERIAL OF CHININE Y weg 0 Ci IS BUILDING ON SOLID OR FILLED LAND 5 -06 -TV -1 IS BUILDING CONNECTED TO NATURAL GAS LINE Wr uv t f7 okio vj VI/O vi uq tc CAJ Location 10,41? a,)OA No. CO (9 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee $ TOTAL $ Check # 13C, 8 Building Inspector 4k 4-X1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVA DEMOLISH A ONE OR TWO FAMILY DWELLING WELDING PERM[IT NUMBER: ft) DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION I- SITE INFORMATION = 1.1 Property Address: e -o -r 19 1.2 Assessors Map and Parcel Number: (0 S Map Number Parcel Number r;z% -7 1.3 Zoning hiformation: Zoning District ProposedfJse 1.4 Property Dimensions: Lot Arei (sf) Frontage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide R�red Provided Re �red Provided 3(D,' 301 1 ;260 " 1.7 Water Supp�yM.G.L.C.40. 54) 1.5. Flood Zone Information: Public X? Private 0 zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHONAUTHORIZED AGENT 2.1 Owner of Record Ae-)-e-5 r a Name (PrinK Address for Service 6 & 7 -,S -,?c-> o �?Z, k i� Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: A�� r7l Licensed Construction Supervisor: Address 6�300 Signature Telephone 6-67 7 - 6- 0 Not Applicable 0 06 o 6 �' .2 3,9 - License Number Expiration Date 3,.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone 00 M X z 0 19 M 0 z M 90 0 mn r M z G) SECTION 4 - WORRERS COMTENSATION (rvtG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... )67 No ....... 0 SECTION 5 Descrietion of Proposed Work (check all applicable) New Construction Existing Building 0 1 Repair(s) 0 Alterations(s) 0 Addition 0 AccessoryBIdg. . 0 1 Demolition 0 Other 0 Specify Brief Description of Proposed Work: C'e 511a7k 0010171'5-L '5' 3 lvaws P roa?n�, Y t-/ 7- FIM I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) Mechanical (HVAC) -4 5 Fire Protection -6 Total (1+2+3+4+5) 6VOES�' 6 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMYLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PER�41T I, I as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Qww/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the. best of my knowledge and belief MEMM Print N Sieature of Owner/A le* Date NO. OF STORIES 12 SIZE 01—ct�- -BASEMENT OR SLAB ROW004A-t-t SIZE OF FLOOR TRVMERS sr 2 N '�r �.77, 1,4- 3 R -D SPAN Z DIMENSIONS OF SILLS DIMENSIONS OF POSTS -DfME,NSIONS OF GIRDERS f-lEIGHT OF FOUNDATION THICKNESS .SIZE OF FOOTING Z') Ae X 0 6 .e MATERIAL OF CHDvINEY we) 0 Ct IS BUILDING ON SOLID OR FILLED LAND socid IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify th-at all fiec-essary a ' pprovals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/c %r landowner from compliance with any applicable or requirements. L IC ANT FILLS OUT THIS S,'�.e4tt 6-6-7 APPLICANT C,,W '3 v/ lee PHONE (e,, 7-6-3oO 01 eZ� /G-,,e� . �'e C - LOCATION: Assessor's N12p Number /09.9 PARCEL 183 SUBDIVISION e-;5 71� LOT (S) STREET ST. NUMBEP,_4?&7 RECOMMENDATIONS OF TOWN AGENTS: l(t7– CO ERVATION ADMINISTRATOR COMMENTS USE DATE APPROVED DATE REJECTED co/ -5 fy� f COMMENTS FOOD INSPECTOR -HEALTH SEPTE INSPECTOR -HEALTH COMMENTS DATEAPPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS CRIVEWAY PERMIT— 'Are 3-157-6t�:> FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9\97 im DATE FROM MCKENZIE ENGINEERING GROUP,INC PHONE NO. : 6179412662 Apr. 19 2000 10:08AM P2 C-4 ar 4y SF =4,485 32. . . ........ ........ 33.0' _7 7 a.-O—o -R-60.00, 9. 6k I L=27.40 RM31 40 )c (ts S C-4 ar 4y SF =4,485 32. . . ........ ........ 33.0' _7 7 a.-O—o -R-60.00, 9. 6k I L=27.40 RM31 The Common wealth of Massachusetts Depaitment of Industrial Accidents Offic-a of Inve-stigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit F—Name Please Print Name: Location: city Phone # 7 1 am a homeowner performing all work myself. 7 1 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. ('n�nnn%i Address a� 31 5,) 7)4er7l Ste S� e- City- lt)or4 411clevf4 —Phone #- (2 2 5) 6 7 (D insurance Co. 0zL2-e,11, I -ode" - rl(� _Zns, ia�, Policv # Al W 121 5� Comoanv name: Address City: Phone #,. insurance Co. Policv # Failure to secure coverage as required under Section 25A or IVIGL 152 can lead to the imposition of criminal penalties of a fine up to S1, 500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORCER and a fine of ($100.00) a day against me. I understand that a ccpy of this statern nt may be forwarded to the Office of Investigations of the DIA for coverage verification. .gl_ do hereby certify under e pa' s and pen Ities of pedury that the information provided above is true and ccrrect Signature Date - Print name Phone #_n�17-�;_ _)Cp Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensina 0 Building Dept FICheck d immediate response is required C3 Licensing Board n Selectman's Office Contact perscn: Phone #.* L-1 Health Department 7 Other BUILDING DEPARTNIENIT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: UC 2 S -Y -,e t- 0 /*h tF:? S -i ec,-,�e 012 jy, Location of Facility Sigha� ofPermit Applicant Ji Dke NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Growth Manaclement Bylaw Exemption Stratenient Town of Ncrth-Andover Building Cepartment This form shall be used to assist the Building 0epartment in their determination of exemptions under section 8.7,6 of the Town of,North Andover Growth Management Bylaw. Tile building applicant shall provide all of '�e necessarl information as requested below. Name of Applicant o n Suilding Permit (below) Address of Property 'cr Per7it (below) . z2na/ 0�ff 7 Mao and Parcel Purpose of Application (check below) Phone Number of pplicant Single Family Two Family — 6<'-7-s-:3DO 1 the undersigned applicant for the above property attest that the attached buildincl permit ror which this form is ccimpleted does comply with the E<EMPTION seejon 8.7.6 of the North Andover Growth � Management Bylaw. I also understand providing this form does not absolve me cr any party to this permit from the requirements of obtaining other permits required prior to the issuance of the __'�uflding Permit. Further I understand that my interpretation of the E(E.NiPTION status is subject 'ci review by the Building Department and is only offic!ally accepted when the Building Permit iq issued. Based an section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for an the above lot, in the building permit application and asscc�ated attachments, c--mplies with oneor more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement. restoration, or reconstruction of a dwelling in exiszencs as of the effective date of this by-law, provided that no additional residential unit is Created. J�_ The lot(s) were/was createdpriarto May 5, 1996 are exempt from the provisions of ths ecc Ty—faw. n 8.7 of the Zoning This application is for dwelling units for low and/or moderate income families or individuals, where all of the cancitians of 8.7.6.c,-�re met and/or represents Owelling units for senior residents, where cccupancl of the units is restric:ed to senior persons through a property, executed and recorded deed restriction running with the land. For purposes of this Section 'senior'shall mean persons over the age of 55. t This application is a part of a development project which voluntarily agreed to a minirnum 40% permanent re,ducticri in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental condffians of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open sPac-- and/or farmland. The land to be preserved shall be protected from deve!oPment by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board thatwill ensure its protection. This application represents a tract of land existing and not held by a Oevefoper in c--mmon ownership with an adjacent parcel an the effective date of this Sectian 8.7 shall receive a one-time exemption fram the Planned Growth Rate and (Development Scheduling provisions for the purpose of constructing one single family dwelling unit an the parcel. i his applicaton represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and he Oevelopment Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per (Development until such Ume as the (Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all informafion that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the att2c!-,ed building perrit is allowed an E(EMPTIGN as cited above. Further I understand that the submittal of misleading and or inaccu� .4e i(nfc ticn, the checking off of an above item which does not comply, Whether done to my e Or L n knowle n t, is grcun for refusal by the Building Department to issue a Building Permit. 7igAnature at ' wrLe0`brAttffonz7eCd_Agenr who signed the Attached Building Permit Oat This form must Se attached to the Building Permit upon application for such permiL e 91. &om-owweald 0/,,4/&JJadw-0 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number. Expires: Birthdate., 90214: 0510912000 0510911954 00 Restr ided T ALAN G RUSSELL 400 MAIN ST: GROVELAKD, MA 01834 TOWN OF NORTH ANDOVER DIVISION OF PUBLIC WOFXS 384 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 0 1845 J. William Hmurciak, Director Timot4y J. Willett StaffEngineer Telephone (978) 685-0950 Fax (978) 688-9573 Additional conditions for lots 6. 19, and 22, Campbell Forest March 14, 2000 This Division agrees to sign the Form U, and issue water and sewer permits, for lots 6, 19, and 22 in the Campbell Forest Subdivision subject to the following conditions. We agree to sign the Form U for these lots so that the construction of these three homes can begin at this time. The conditions are as follows. I . No sewer service shall be installed into either residence until all off site sewer facilities are declared "active" by this Division. These off site sewer facilities include sewer lines and a pump station on Campbell Road, as well as sewer lines and two pump stations on Turnpike Street. At this time, the construction of these items has not been completed. 2. No water service shall be installed into either residence until all off site sewer facilities are approved by this office. Any violation of the above conditions will void both water and sewer connection permits. No refunds will be granted. 3ZI �5�2�e� Mesiti DevloVme'n`i�®rp Printed Name Date 7zz�xk k -U, �) 4 M�e -tf 3-1-5-00 Division orl�*orks Printed Name"V Date CC: Bill Hmurciak Jim Rand Mike McGuire Heidi Griffin N2 955 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. Z000> Application by the undersigned is hereby made to connect with the town water main in subject to the rules and regulations of the Division of Public Works. The premises are known as No. Z07 Street or subdivision lot no 6`0 7- '5' :�00 0 Address Owner �71 ddress Contractor Ly A D Ii pplicant's gg-nature "'der E� PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the water main at subject to the rules and regulations of the Division of Public Works. Inspected by Date Board of Public Works By See back for rules and regulations 1490 APPLICATION FOR SEWER SERVICE CONNECTION �&r 64 Z�C;:' North Andover, Mass. 15 4 -9 -- Application by the undersigned is hereby made to connect with the town sewer main in L'4( e stw"— subject to the rules and regulations of the Division of Public Works. The premises are known as No. -Z,37 �Je-L!�4'el Street or subdivision lot no / 1� --- (�a,Azoell LL Owner Ac, �-- 4 Contractor Address Address X7 A'pplicant's SigHeZe PERMIT TO CONNECT WITH SEWER MAIN The Division of Public Works hereby grants permission to IC,�, re -1, 7/-- L Z- (:::- to make a connection with the sewer main at Street subject to the rules and regulations of the Division of Public Works.. inspected by Date Division of Public Works By See back for rules and regulations TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET, 01845 Telephone (508) 685-0950 Fax (508) 688-9573 6 0\ DRIVEWAY PERMIT Date: 0 V "0z' -s Lew e 4_1 LOCATION: -2_�3 7 /,J BUILDER: phone: OWNER: L L C phone: The North Andover Superintendent of Highway Utilities & Operations MUST be notified of the grade and set -back from street established in any driveway entry onto any street or way maintained by the TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval of such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. I Remarks: Approval: FROM : MCKENZIE ENGINEERING GROUP,INC PHONE NO. : 6179412662 Apr. 19 2000 10:08AM P2 tr V af=60.00* ca. 6 44 - —4 If SF 43, 48; 32. 33.0' . . . . . . . . . . .. L=27.40' R=3 W' �.R � MAScheck COMPLIANCE REPORT Massachusetts Energy Code Permit # MAScheck Software Version 2.01 Checked by/Date I CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 4-27-2000 DATE OF PLANS: March 31, 2000 TITLE: Lot 19 Boxborough PROJECT INFORMATION: Campbell Forest Subdivision North Andover, Ma. COMPANY INFORMATION: Campbell Forest, LLC / MeSiti Dev. Corp. 231 Sutton Street Suite 2F North Andover, Ma. 01845 COMPLIANCE: PASSES Required UA = 556 Your Home = 548 Area or Cavity Cont. Glazing/Door Perimeter R -Value R -Value U -Value UA ------------------------------------------------------------------------------- CEILINGS 1534 30.0 0.0 54 WALLS: Wood Frame, 16" O.C. 2268 11.0 0.0 202 GLAZING: Windows or Doors 484 0.350 169 DOORS 96 0.490 47 FLOORS: Over Unconditioned Space 1582 19.0 0.0 75 HVAC EQUIPMENT: Furnace, 92.0 AFUE ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment seler_",,�o heat or cool the building shall be no greater than % of the esi load as specified in Sections 780CMR 131/:0 '�4 Date Builder/Designer be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R -values, glazing U -values, and heating equipment efficiency must be clearly marked on the building plans or specifications. DUCT INSULATION: Ducts shall be insulated per Table J4.4.7.1. DUCT CONSTRUCTION: All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. The HVAC system must provide a means for balancing air and water systems. TEMPERATURE CONTROLS: Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING: Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. SWIMMING POOLS: All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. HVAC PIPING INSULATION: HVAC piping conveying fluids above 120 F or chilled fluids below 55 F must be insulated to the following levels (in.): CIRCULATING HOT WATER SYSTEMS: Insulate circulating hot water pipes to the following levels (in.): PIPE SIZES (in.) NON -CIRCULATING CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F): RUNOUTS 0-1" 0-1.25" 1.5-2.011 2.0+11 170-180 0.5 1.0 1.5 2.0 140-160 0.5 1 0.5 1.0 1.5 PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4" Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 Steam condensate any 1.0 1.0 1.5 2.0 COOLING SYSTEMS: Chilled water or 40-55 0.5 0.5 0.75 1.0 refrigerant below 40 1.0 1.0 1.5 1.5 CIRCULATING HOT WATER SYSTEMS: Insulate circulating hot water pipes to the following levels (in.): PIPE SIZES (in.) NON -CIRCULATING CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F): RUNOUTS 0-1" 0-1.25" 1.5-2.011 2.0+11 170-180 0.5 1.0 1.5 2.0 140-160 0.5 1 0.5 1.0 1.5 ai -H < z in :r 0 Ln m 0 c , 7-r a) 0 :) — --I n CL 0 m m I . z o 0 aj 0 00 I+ -.% =r M aj (D '0 -0 -0 (A m -n N M m 0 0 0 4.0 -1 M C o' c 3 CL P* CIJ 0) 0 rn 0 q. 0 (A n 6' 0 0 M V) 0 rD :3 (D 0 D 0-0 0 -U r > M > m -% (D Q 'N%. 0 0- C: �-t 13 0 CD m 0 (D U3 n r m 03 - -9 ul m C 5 3. CL CL CL 3 c Ln 0 n 0 0 c i3 c ai % c " = $a ';4Z Z -1 0 0 m E o< Z 4 To E :3 CL = In CL CD 3 cr m LO 60 0 m CD M mn >a) CL 0 IV CD m E. CLO �I 1+ 3 :r — CD Ln r* 0 c < LN CD oil CD 0 0 0 ag S (D COD C/) m m M m m m C/) m Cl) 0 m CA CD cl) z E; 0 C2 CD CL cr loc CD 0 re- --N 0 - I E w CD CD 0 0 rA, 10 0 cm) 0 CA Cl) co 0 )-Z CD CD CD 0 z CD a 0 CD n 0 ON 4 0 (j) EL a* CL U2 0 4c CD CD co cc 0 CD: c CL to: CD C3 w CL C L a. : 2� i "Co ::, : %j = "***% CA CD : C92 OMC CA Q co CD ci C=* � co coo 0 = CD CD C3 Ch M3 N't CD . . . w CL C-) C3 c C2. C7 a S" C/) 9 0 C/) " Ix 7� �; 0 C: - -E� Cp z elz 0 In n C/) MC ccl C3 RL C: 0 co cr 0 Co -a 0 co 'cl CA 0 C) CL CIS 0 n m 0 .� :3 --F r) :7, rD z son 5- = — = CL rcL-* La. 0 — =r CD 0 =r M rA CA m CO) C2 CD agrst it ca -4 co co 0: rfl C3 C.3 n 0 ON 4 0 (j) EL a* CL U2 0 4c CD CD co cc 0 CD: c CL to: CD C3 w CL C L a. : 2� i "Co ::, : %j = "***% CA CD : C92 OMC CA Q co CD ci C=* � co coo 0 = CD CD C3 Ch M3 N't CD . . . w CL C-) C3 c C2. C7 a S" C/) 9 0 C/) " Ix 7� �; 0 C: - -E� Cp z elz 0 In n C/) RL C: 0 0 C/) rx C) Z (D r) :7, rD z CA rfl I rA Its ICN omi 0 9 0 41i CD ol Date'. 6 6 Sol TOWN OF NORTH ANDOVER MOO PERMIT FOR GAS INSTALLATION This certifies that . 4� ................... has permission for gas installation in the buildings of ... Aln? v- i ............................ at /,.,-J.,,Nort Andoyer, Mass. Feago, 5V Lic. No..�?.� GASINSPECTOR Check# 11/4 6 �v MYTIMPQ - - - - - - - - - Lu z MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING I City/Town: do v e lv— MA. Qate: 2 Permit# Building Location: 0 - Cs Name: Nt. b ri 1A wrier j4AkWVj-1A1JdS� " IL Type of Occupancy: Commercial El Educational E] Industrial E] Institutional El ResidentialA F -Cd 3: W New: Alteration: Ej Renovation: E] Replacement: Plans Submitted: Yes El No Of MYTIMPQ - - - - - - - - - Lu z C0 Lu F -Cd 3: W M LU X V) W 0 LU C) 0 Lu 0 03 U) 1-- E� F- 3: 0 C0 Uj z 0z 0 0 zc)o� Lu 0 F- C0 w Luwol--=) 0 E LU 0 < W Cl) W Lu > co LU C) Lu Z U) W < W CO a. F- 0 C, UJ Lu 1-- X X [C >WF0-WWz<0-IWi�9(0a:W�- z W W W (0 _j 1-- < F- 0 Z —1 0 <.m W 0 z (0XZLuWW u- 1-- 0 (0 != W I-- W > z 1-- UJ X 0 5% n LL W W > 0 0 0 W z R Z W > F - 0 SUB BSMT. BASEMENT FLOOR f'r—FLOOR 3"u FLOOR eff—F—LOOR 5'" FLOOR 6 1H FLOOR 7T" FLOOR -H 8'ff--FLOOR J I i Installing Company Name:6rJ4'h1T- IL&&I Check One Only Certificate # Address�/r P6 - City/Toww"1114101- State./,Y/-r- 2(corporation El Partnership Business Tel: Fax: El Firm/Company Name of Licensed Plumber/Gas Fitter. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL. Ch. 142 YejK No If you. have checked Yes, please indicate the type of coverage by checking the appropriate box below. Allability insurance policy �iK Other type of indemnity El Bond El 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 Signature of Owner or Owners Agent Owner El Agent El By checking -this box E]; I Eereby certify that all of the details and information I have submitted (or entered) reciardinq this aDt)lication are true and 4641uldie LU Lne oest or my rnowjeage ana tnat an plumbing work and installations pS,*Ted under the permit issued for this application will be in compliance with all Pertinent proyjsIon of the Massachusetts State Plumbing Codo-TrLOChapter 142 of the General Laws. B a/. - Type of License: ylgl�z 1 c4ge� D Plumber Title El Gas Fitter of Licensed mber/Gas Fitter Master I City/Town ourneyman License Number: �0? APPROVED (OFFICE USE ONLYI �JLP Installer The Commonwealth ofMassah,,s,1tS Department ofindustrialAccidents OffIce of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: BuUders/Contractors/Electricians/Plu-mbers Name Address City/State/Zi� - P: /dad Phone #:- 9 11T Are you an employer? Check the appropriate boxi employer with 4. El I am a general contractor and I e ployees (fall and/oi—p �_time). 2. 1 am a sOle or have hired th - e sub -contractors listed proprietor partner, 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. El We are a corporation and its 3.0 required.) J am a homeowner doing Officers have exercised their all work right of exemption per MGL InYself [No workers' comp. C. 152, § 1 (4), and we have no insurance required.] f employees. [No *orkers' cOmP. insurance required.] -��'Y sPlicautit that cheeks box #! mi_ t also a. out tL. e r lecti below -1-4— T'ype of project (required): 6. El New construction 7. Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions .11 - Plumbing repairs or additions 12-EIRoof repairs 13.n Other "Azzzms comp—m alion poljcy inlorm–,tion. — 1' T Homeowners who submit this affidavit indicating they are doing aIl w-rkand then hire outside contractors 'Contractors that check this box must attached an additional sheet showing the must submit 2 'new �ffidavit indicating such. name of the sub -contractors and their workers' comp. policy information, am an employer that isproviding workers'compensation inSurancefor MY emPloyees. Below is thepolicy andjob site informadom Insurance Compiny Name: Policy # or Self -ins. Lie. #. 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 i4GL c. 152 can lead to the imposition of cruninal penalties of a fine up to $1,500-00 and/or one-year imprisonment, as well as civil penalties in the forna of a STOP WORK ORDER and a fine aink of up to $250.00 a day ag i the violator. Be advised that a copy of this §tat m t may be forwarded to the Office of Investigations of the DIA for i s ance coverage verification. I do here�y certf& andpanalfies of -31 !th�a�t�rmation provided above is true and correct Date: -2 -d- 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. Plumbino, 6. Other . Inspector Contact Person: - Phone#: Information aiid Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is de -fined as "...every person in the service of another under any contract of hire, express 6r 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 employe; or the receiver or trustee of an individual, partnership, association or other legal entity, employing e miployees. 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 6rbuilding appurtenant thereto shall not because of such employment be deemed to bean 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 coinpliance 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 fo.r the performance of public work- iantil acceptable evidence of compliance with the insurance requirements of this chapter have ' been presenttd to the contracting authority." Applicants Please fill out the workers' compensation affi&vit 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) witl�.no employees other thn 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 bt!� r ed, -Im O. -C city or town 10-14-t Itue- apphi cation for the p er-r—jait of, license iR being reqtiested, Put the D8,nartment: 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 affidavi ' t 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 officky 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 perruits 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.lea.ves 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 hesitak to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investiggations 600 Washing -ton Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 -wvm,.mass..gov/dia