HomeMy WebLinkAboutMiscellaneous - 29 GRANVILLE LANE 4/30/2018 (3)x
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Commerce
INSURANCE -
April 15, 2015
The Commerce Insurance Company'm
Citation Insurance Companyw
11 Gore Road, Webster, Massachusetts 01570
508.949.15001 www.com merceinsu ran ce.corn
BUILDING COMMISSIONER or
INSPECTOR OF BUILDINGS
TOVv1N/CITY HALL
NORTHANDOVER MA 01845
Board of Health or
Board of Selectmen
Town/City Hall
RE: Our Insured: ROBERT LANIGAN / MAUREEN LANIGAN
Property Address: 29 GRANVILLE LN
Policy#: BCQKSL
Date of Loss: 02/12/2015
File#: JVVVR57-HNPCR3
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
MEGANFINACOM
CLAIM REP 1, PROPERTY
Telephone: (508)949-1500 Ext: 15847
Toll Free: 1-800-221-1605, Ext: 15847
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
April 15, 2015
INTERIOR WATER DAMAGE DUE TO ICE DAMS
CIC 254 (Rev. 4/95) MAIL 786
Location
17 -
No. Date
TOWN OF NORTH ANDOVER
07 - .
Certificate of Occupancy $
Building/Frame Permit Fee V
CHUS
$ z
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check,t-Z
'14"" 4 Building Insp'e"ctor
0, i_/�.
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
A/Indsne6ctor of Buildings Date c) 4
BuilcA
I arlt-ILIVA i -NUE M14UKMAI1UT4 I
1.1 Property Address:
gn -
i I
zq Cc rce V-\ oz-_ I_r4
1.2 Assessors Map and Parcel Number:
/0G
Map Number Parcel
ro
00,51
Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (st Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard , Side Yard
Rear Yard
Required Provide Required
Provided
Required
Provided
1.7 Water Supply M.G.LC.40.154) 1.5. Flood Zone Infonnation:
Public 0 Private 0 Zone — Outside Flood Zone 0
1.8 Sewerage Disposal System
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSE"JAUTHORIZED AGENT
2.1 Owner of Record
]&,G
Name (Print)
Address for Service
Signature Telephone
2.2 Owner of Record:
k
Name Print
Address for Service:
Signature__ Telephone
bEU I ]LOIN 3 - CONSTRUCTION SERVICES I
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
0
Signature
16
Telephone
3.2 Registered Home Improvement Contractor
. - . 1E A\16"p— ee-_�Vkl:
�ompany Namk
Qg,� U -v
Not Applicable 0
License Number
Expiration Date
Not Applicable 0
7�
Registration Number
0 3J,31 /0(�-j
Expiration bate '
0
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0
low
94
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0
AV
SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit %vill result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg- 0 Demolition 0 Other Specify
Brief Description of Proposed Work:
Or-oc-
I SECTION 6 - FSTIMATRn CnNRT121TVT1rn1V t-nQT4Z I
Item
Estimated Cost (Dollar) to 'be
Completed by permit applicant
W a
(a) Building Permit Fee
Multiplier
'n -
V
I Building
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
--.— 1. �VVIIMX"'Mv JLV nr, 4-urnrJUE]LE" WIM4
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAUT
1, , as O.wner/Authorized Agent of subject property
Hereby authorize to act on I
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
property
Hereby declare that the statements and information on
and belief
as Owner/Authorized Agent of subject
I
foregoing application are true.and accurate, to the best of my knowledge
of Owner/Agent Date/
NO. OF STORIES SIZE
BASENMNT OR SLAB
SIZE OF FLOOR TlIvIBERS s'r 2 ND 3 RD
SPAN
DMENSIONS OF SILLS
D114ENSIONS OF POSTS
DRVENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERTA I. OF CHININEY
IS BUILDING ON SOLID OR FILLED LA�R
IS BUILDING CONNECTED TO NAnJIZAL GAS LINE
0
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0 70
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IMPROVEMENT CO�KTRACTOR
0 0] 3/31
3/31/?2002
br-Wtt Roo4hr,-Ia----
UR nahoney
4WAWST.
READING
MA 01864
or, r --
Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax o
� (978) 688-9542
DEBRIS DISPOSAL FORM
0 2 0 '6 A13
01
0
04 A'rfa P.?
S.A.—"§ i4:%
In accordance with the provisions. of MGL c 40 s 54, and a condition of
Building per-znit.# the debris resulting froin the work shall.be disposed
of in a properly licensed solid waste disposal facility as defined by A4GL c I'l, s I 56a.
The debris will be disposed of in /at:
Facility location
Signature of Ap7p]"icant�
zTZ --------- — ---
D ate,
NO . TE.- A demolition permit from the Town of.North Andover must be obtained for tfii'
project through the Office of the Building Inspector. his
0
?�j r \ NL TOWN OF NORTH ANDOVER
(0
PERMIT FOR GAS INSTALLATION
This certifies that . r� -!� .........................
has permission for gas installation ... ....................
in the buildings of kf. .........................
at North Andover, Mass.
Fee.,.. ) ..... Lic. No ........... 0; n- . ........
Check # 610-1) GASINSPECTOR
4733
on
MASSACHUSETISUNIFORMAPPUCATONFOR
(Type or print)
NORTH ANDOVERY MASSACHUSETTS
Building Locations
z; 1Y,4 // /, / /_ /-, Z //,
B46' 1,411N/61411 -Owner's Name
TO DO GAS FfFMG
� I
New Renovation Replacement Plans Submitted
Date
Permit # 4 -'?-1o7
Amount $ 2j--
(Print or type) Check one: Certificate Installing Company
Name 114� i1,!f7721__F Corp.
Address 4/ 13 ld6ll ke- Partner.
7W, 4� li,$r� 61 /1 IV
Business Telep-Mon—e X 3 E]Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes e- No
lf you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy [M-, Other type of indemnity M Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all ot the detaiis ana iniormaucon j nave sumutteu kOr UIRUICU) M alwvc; aFF11"Livu mu uuu anu auumaLu LL) LIM
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Sionature of Licensed Plumber Or Gas Fitter
b
Plumber
Gas Fitter License Number
0 Master
[D_Joumeyman
Cn
W
Ln
C4
E�
z
z
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g
0
44
z
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cn
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4
0
0
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-13 A SEM ENT
SSUB
BASEMENT
IST. F L 0 0 R
2 . ND. F L 0 0 R
3RD. F L 0 0 R
4TH. FLOOR
STH. F L 0 0 R
-W—T H . F L 0 O'R
7TH. F L 0 0 R
Ell
8TH. FLOOR
(Print or type) Check one: Certificate Installing Company
Name 114� i1,!f7721__F Corp.
Address 4/ 13 ld6ll ke- Partner.
7W, 4� li,$r� 61 /1 IV
Business Telep-Mon—e X 3 E]Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes e- No
lf you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy [M-, Other type of indemnity M Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all ot the detaiis ana iniormaucon j nave sumutteu kOr UIRUICU) M alwvc; aFF11"Livu mu uuu anu auumaLu LL) LIM
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Sionature of Licensed Plumber Or Gas Fitter
b
Plumber
Gas Fitter License Number
0 Master
[D_Joumeyman
Date .......
............. ......................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Th is certifies that ........ ....... e .......
............................................................................
has permission to perform ... / �, , /-- ". ,
.....................................................................................
wiring in the building of do?
..................................................... ..........................................
at
4' -7 V, // X 40
............................................................................. . North Andover, Mass.
Fee ��7
....... ............. Lic. No.
TRICAL INSPECTOR
Check#
2 5 4 q
4d
M-
.1
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Of ri c i al Us e Only
Permit No. 2—
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 (NEC), 527 CMR 12.00
(PLE, 4 SE PR IWT IN INK OR TYPE A LL I NFOR A M TION) Date: 9'- 171-1,:�
City or Town oh 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) :Z, Z (-/, // ,< 1,41 --
Owner or Tenant 5- 1-7 Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes n No [I (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service 2 &-d Amps
New Service Amps
Volts Overhead [I -(JndgrdF]
Volts Overhead Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completionofthefollo-win table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In-
Swimming Pool grnd. grnd. El
0. 0 �mergency Lighting
Ag!��its
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
lNo. of Zones
No. of Switches
No. of Gns Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
HeatPump
Totals: �
Number
...........................
ITons
I .........................
IKW
I .......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Lor-alEl Municipal E] other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. 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 Eauivalent
OTHER:
A dach additional detail ifdesired, or as required by the Inspector of 07res.
Estimated Value of ElectricapIlGrk: (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 licensee provides proof of liability insurance including "completed operation7' coverage or its substantial equivalent. The
undersigned certifies that such covera 4S-iff-force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE [9 BOND n OTBEREI (Specify:)
Icerfify, underthepains andpenalties ofperjury, thattheinforniation on this application is true andcom
plete
FIRMNAME, LIC. NO.:
Licensee: LTC. NO.:—
Bus. Tel. No.
Address: Alt. Tel. No.:
(Ifapplicable, enterlexempt" in the license number line.)
*Per M.G.L 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 (che one) El owner El owner's agent.
Owner/Agent
Signature Telephone No. FEE.- $
0 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 20 10 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.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit D
El Permit Extension Act — Permit/Date Closed:
Trench Inspe i n
Pass M �,Z
Failed
Re- Inspection Required ($.) El
Inspectors Comments:
Inspectors Signature:
Date: /,s
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) El
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass F?1
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
V*.
W
The Commonwealth ofHassachusetts
Department ofIndustrialAccidents
. . . . . . . . . . . . . . . . . . . . 1 Congress Street, Suite 100
Boston, MA 02114-2017
WMmass.9ovIdia
. . . . . . . ctorsiqectricians/PhImbers.
VVorkersq Compensation Insurance Affidavit: Builders Contra
I TO BE MED WIT]a TM FFRMn-�NG AUTjE(ORITY.
NaMo (Busin,,ss[Oigathationfindividual):,
Address:
Oyer? Ch. eck the aVpropriate box:
Phone#:
I -ElI am . employer with . art-tim,0.*
__�11100YGe3 (" andlor p
2.F] I am a sole proprietor or partnership and have no employees workiryg for me in
any capacity. [No workers, comp. insurance required-]
myse
'If. [No workers, r
3.E] i am a homeowner doing all work omp. insurance required.] t
I am a homeowner and will be, hiring contractors to conduct all work on MY Property- I will
4-0 ensure that all contractors either have workers' compensation insuratirc or are sole
n' � 6.�6 W
proprietors with o Gf�l I' e*s.
and I have hired the sub -contractors listed on the attached shGet-
5.FJ I am a general conti-40tPr 1, � - �
These sub-contractor�'&�� w�aployees and have w0lker�' con"P. "s-r-ce"
6.FJ We are a corporatiq# and its ' oMc6rs.have exercised their right oflexemPti(M Per MGL 0 -
comp. insurance required.]
av no �mpll ' s. [No workers'
1,�,7 RJM andWeh 6 oyep
Type of project (vequired)*
8. Remodeling
9. Demolition
10 E] Building addition
ll.E] F d , As
,lec4ical rpppirs or a ditio
,2 7 bing repai,rs or additions
13-.E]Ro6f re�air§
14.n Other�—
I I . .. .- . -
-A,y applicant that ch dck§bbk41 0�6�;t I �Is 0% ffll out the section below showing their workers' compensation POlicyinformat'on" in in G
all work arid then hire outside contractors must submit anew affidavit dicat 9sub-
nij,�h� 8M�avjt indicating theY are doing
t Homeowners who sub] d �n additional sheet showing the name of the sub -contractors and statq whqther or pot those� Pntiges� have
tcontractors that checkthis b6k ' Must attache ide their workeq comp. policy nurnber-
have employees, they must prov
employees. If the sub -contractors d)ob sit�
I am an employer that isprOvidingworkers, compensation insurancefOr my emplbyees. Pelow is thepolicy an
information.
Insurance Company
Policy # or Self -ins- Lic.
Expiration 1)4te;
City/State/Zip*
fob Site Address: conipepsation Policy declaration page (showing the policy number and expiration date).
Attach a copy of the workers' ixed under MOL c. 152, §25A is a criminal violation punishable by a Elie up to $1,500-00
Failure to secure coverage as requ enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as well as civil p be forwarded to the Office of lilvestigdtiOns of the DIA for insurance
day against the violator. A copy of this statement may
coverage verification. re and correct.
he�rehy ce�rtjfy under thepains andpena ties ofperjurY t iat th e information provided above is tru
Date:
Signature:
in this area, to be completed by c1Y or town official,
0fJ7c1al use only. Do not write
Permit/License
City or Town:
issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical inspector 5. plumbing inspector
6. Other
Phone ff:
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide, workers' compensation for their em' I" '
P, 0 ees.
y
Pursuant to this statute, an employee is defmcd as "...every person in the service of another under any contract of
express or implied, oral or written."
An employer is'defin6d as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint ent6rprise, and including the legal representatives of a deceased employer, or the
receiv&'& trustdd o; fan individual, partnership, association or other legal entity, employing empl6ypes� - However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occu�- anti*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 appuftenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or locallicensing 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(l) 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 thi's chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
riece�sary, supply sub'contractor(s) name(s), address(es) and phone number(s) along with their certi:ffcate�s) Of
insurance. Limited -Liability Companies (LLQ 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 confmation 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 requ�steq, not the D -artmentof
ep
IndustrialAccidents. Should you have an y* questions regarding the law or if you are req*ed to obtain aw'o'rkers'
compensaticui policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insuraric'e 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
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "fob 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 fature permits or licenses. A now 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Departrnent of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia