Loading...
HomeMy WebLinkAboutMiscellaneous - 358 DALE STREET 4/30/2018 (3)Date. �� ,Z�. • .. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r.` This certifies that ... .�-��?�-..! t,, y� . 1.� . . has permission for gas installation ?.--.................. . U ,G. C... in the buildings of ......G�.�....... .................... at ............ `? , �- .�?T; , ort An v r, S. Fee. )15z�.... Lic. No.i1.5�8.... GAS INSPECTOR Check # 4(,0(01 i • i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A/0. _ /4t Ve LC.-( MA DATE E:��� - J HI PERMIT # ol JOBSITE ADDRESS �JL� S" OWNER'S NAME$ 7—t= �/�,►'��¢ GOWNER ADDRESSTE1 '50�3� i do-1 FAX _ _ - TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL CLEARLY NEW: Pr 0.11 RENOVATION: REPLACEMENT:[--i] PLANS SUBMITTED: YES EJ NO APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE_,- DIRECT VENT HEATERA I�- DRYER FIREPLACE FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATERS ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATERI WATER HEATER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NOn-_I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY [] BOND E] 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in COMAnce with rtinent prov'si n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ®,G PLUM BER-GASF ITTE R NAME e!S ICENSE# SIGNATURE MP 0000MGF JP [D JGF LPGI © CORPORATION __� # �__ [�] PARTNERSHIP D# _._.. _.. LLC i# COMPANY NAME: ev�a�, Q _ _ ADDRESS CITY -- - - — - -- STATE ZIP � �TEI-Ft t? FAX ^ CEL j3 %6 TJ MAIL k if L'; d� W a ui w U- ' The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Invesfigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): AA3W_lo 1.4--(,J /7 Lice. Address: PCA City/State/Zip:A/euJ a,,-eJ V, /� 6 3 7 W Phone #: 6 6 3 J P,;� 7 Pa Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I _ Wployees (full and/or part-time).* have hired the sub -contractors 2. II 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. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] umbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic. #: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certi under thepAs andpenalties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -7 -.7—) f —N.— 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 Instrncti®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their 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 CommoRwealth of Massachusetts Department of ladustrial .Accidents Office of Investigations 600 Washington Street Boston, M.A, 02111 Tel, # 617-7274900 ext 406 or 1-877,7MASSAaFB Revised 5-26-05 Fax # 617-727-7749 __WWW-mass,gov/dla 9505 Date. r!. �. I I -I-- 9505 I-- TOWN OF NORTH ANDOVER .a PERMIT FOR PLUMBING r. _SAV �)� This certifies that . `!`' has permission to perform `,�.P?... `!\t'"- ................. plumbing in the buildings oft. Syn C.A. V. ......... . ...... . at .......... ` . , .... ort Ove ass. Fee .5d�.��.... Lic. NO. 11��.. M .. ..... . PLUMBING INSP OR Check ." I% Y, •'fig MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 0 MA DATEPERMIT # JOBSITE ADDRESS OWNER'S NAME .' ; e fie— 6^0 Cf4 POWNER ADDRESS ( TELr9 7 3(.d o a!_ 11FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL PRINT CLEARLY �/ NEW: R1 RENOVATION: El REPLACEMENT: 0 PLANS SUBMITTED: YES ® NOD FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBI __ I ._I .____ ��I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM.__E DEDICATED GREASE SYSTEM _ ..........._.._-...._.f =j DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER I .----...J _.....__-( .-_--�� _._____! _ I I l .--_---(( .__-- _------J FLOOR/AREA DRAIN —..___I __�1 INTERCEPTOR (INTERIOR) -.._.I .__ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET I ._..__( _• f _.--- _l _ ._ 3 _.___! ____ E .._..___I ..___ ..1 .__ __._! __! _.__..._ _.__. URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES t WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES[]NO �! IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Oer OTHER TYPE OF INDEMNITY D BOND 0 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc ate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pliance we II Pertinent pro 'ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q PLUMBER'SNAME __,_4 6eA? AJ 4 LICENSE# // SIGNATURE MPR�r—JPR CORPORATIONEI# _i PARTNERSHIP #=LLC COMPANY NAME ,?X Cg qc. / ADDRESS CITY w--jM ....___..__1 STATE ZIP 3 TEL FAX _.___.._- CELL 7(QSia?._. MAIL_teG.`'.---.__...l�S_(.._.._eT_......_........_-------.._._...-__--__--.__I r- F °z 0 H U W a w to oo yEl COD `a W O u z W o W a LU LLJ co p z a a H W � � U J a a � a LU = w rA H O H U a rAO a a a a ' The Commonwealth ofMassachusetts Department of lndustrigl Accidents Office of Investigations kvi 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): Ait°1{'e�/��! Address: /.J- City/State/Zip:A,1ez. J 6<) n /� 63 �7S? Phone #: 663 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. F1 New construction ` loyees (full and/or part-time).* have lured the sub -contractors �• F1 Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p tY• workers' comp. insurance. 5. ElWe are a corporation and its 9. E] Building addition [No workers' comp. insurance required.] officers have exercised their 10. El Electrical repairs or additions 11.�umbing 3. ❑ I am a homeowner doing all work right of exemption per MGL repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *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 aie doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fire of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer4tAunder the p,*s and penalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License -7 ,np- > - f ,X, 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 9uestions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The GorrmonwoaithofM-assachusotts Department ofZndustdai Accidents Office of Iavestigations 600 Was ingtoo Street Boston, MA 02111. Tel. # 61.7-727_4900 at 406 or 1.-877:MASSAFB Revised 5-26-05 Fax # 61.7-727-7749 vrwwanass.gov/dia This certifies that .. !a . s !C)-- has permission to perform e--? ...[,*UN- ^.R-- ............... . wiring in. the building of .. II � - . �? e........... . atP......'-�..................... , h Andover, Mass. q. Fee �.�... Lic. No�h��i .. M�� . i ELECTRICAL INSPECTOR Check # - ' (p2_ 11002 I Commonwealth of Massachusetts Official Use Only Department of Fire services Permit No. _ V ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co e (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 19 —(0 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned give's notice of his or her intention to perform the electrical work described below. Location (Street & Number) 35t ()an Sal Owner or Tenant Owner's Address 7L,`Z-- Telephone No. Is this permit in conjunction with a building permit? Yes U No U (Check Appropriate Box) Purpose of Building Utility Authorization No. 12-) ,�_ j 8 - Existing Service Amps / Volts OverheaUndgrd ❑ No. of Meters New Service 2(9(!) Amps 0 /240Volts Overhead �Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ('mmnletinn nfthe fnllnwinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus addle p �) Fans s Total of TransKVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- 1:10. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis osers p Totals: .......... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal 0 Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Ea uivalent OTHER: Attach additional detail f desired, or as required by the Inspector of wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cove e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the ains andpenalties ofperjuty, that the information on this application is true and complete. FIRM NAME: d h! LIC. NO.: F Licensee: Signat LIC. NO.: (If applicable enter "exempt" in the license number line.)%Zoi Bus. Tel. No.: /� �` 7 Address: Alt. Tel. No. • *Per M.G.L c. 147, s. 7-61, security wor requires Department of Public Safety --5-- License: Lie. No.• t� •% 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. A ' 1 J y • EJI.JJuC.LiaeL'VF�.LJ/c'.*J.r.�.lfJf-�r.�.*..eyJ..� O.•[.�^ �'(�j f'�-('� .'.•�• 7RJ:J`U.K.R�+.f.7 J.'CJ✓JG VRT. r 3wm sPa�XOX. _ . 72�sset�•-, __ _ • �+'aiiefl-'C J �e-uzspeei�onx'equ�.tet�($�'O.DD) � j � 3usPectpxs e)Its: (nspeeoxsyzgizatuze� o fnitiaTs) Slate 3.'asse$-- � �te�ns,�ectzox�xe�txixe� {��O.OD)-• j � ' JCtts�iectaz co e�xfs• ps�actors'ggna re � to fstz aTs) date 'asseci--j � �`azIet�..0 � �te��ns�eetzo�xe[�uixet�(�sD.QO)�j ] aspectoXs' Comments: 7 J�+'aileti-- I', �,pectoxs' Co�anm.eptfs: { ttspectongl8zgaature to znspectiox�xc BCtOx�g CDL1747,I;T1tS: _ � e • 5 ' 5n'RTA0—sA'R*P,TWA ,Ii1f1�r1YOTT`ifAM)T,','RTW.�T`�'i+`.'i1t`'dpi;.ARVA_'zOBEI"SPACT-RD.M.NoT e 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): U L A lam/ 5L o A. Address: 4Y4a�k_, iii t iz nR- �T-Kih.Sd)o City/State/Zip: O SAC 1 Phone #: / - �G3 � Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. VI am a sole proprietor or partner- listed on.the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its t required.] officers have exercised their r-,�y, 3. LI 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. El 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. J Insurance Company Name: Policy # q4r Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce tzfy under the p ns and penalties of perjury that the information provideb v is true and correct. 4� Mr�AI Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall 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 0\ 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 ZO 0 W F v Z WO c��SETTS b� '��� O N "�1 ¢ OR O J 3 Q�'� Z Us m O F - LL -w co Q u_ i w ?- (n to ww w Upm UJ m w 0 U ;' 0 w cn o c� �i �0 N N N NZZ� ci oZ �S V U Q o V N F-- w z N o II o W O O n �WW00 Q� �S Q Q p N .. Y }Q Q �wWa N W m z O `� ,°�°o Ki o < z } Qo�� °� g `9 r _ m z w Mz J N w �NNz a w W C/1 0 Q 44 U 0 Z U0w O J p (n N — U to F- a r, 9 w PE YCo Co W 0` -d CL z z Q 2�9T0t9- '`+. J1 ' . � W �r ^ v 1 r `E V 1 \ CIO N 0 OCr-cr- II II W 2�9T0t9- O Z W W F r, v Z 00 0 c�AS�ZTI N ('� 00 c�P . 0 Q O 3 Q�, d�j rr,�I 4L Q �.I cif U: ��� v_ r,, W 0 v 1 W W �% z0 m ` Q J N �" Tom, 1 � Lo Z r� ;aa m `� 1 w O O `44 4 �0 v N N cnzz�W rjb� � �� ��,� o� U Q co U ^I > S O W }- W zz N p II o W o N o ���WW00 QR�� t Q O `, J Q �% � o� N Y< X Q �ww< N� w 0 a-rw�, m Z 0 K)z J "' N 0 0 0 W~O0 CL Z Q Ga �J �1 O g Wx U-x0o Q 0 rO F w U F O< p OJ 0 V) ON M—UV)F- a Q W 9 Ld Q Z s Z Z Z Date.. ?� L ......... Z., ) TOWN OF NORTH ANDOVER s PERMIT FOR GAS INSTALLATION �9 , This certifies that . .... ti.P_ -s_ . _ . _ .. �S _ -� ., has permission for gas installation in the buildings of . .-,,ci ........................... at..� ..41��. `5 T . . . . . . . . , North /Andover, Mass Fee 3f Lic. No../�//.-�y x7! rfar. fr. /a Trl GASINSPECTOR Check # 9 8319 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE - / PERMIT# JOBSITE ADDRESS - -_, __- OWNER'S NAME p ) o�,q GOWNER _S/ ADDRESS T r _ , TE9110 FAX TYPE OR PRINT TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL OCCUrRENOVATION: CLEARLY NEW:__) REPLACEMENT: 01 PLANS SUBMITTED: YES—01NOD APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATERW DRYER FIREPLACE -------- —_- .. j1= FRYOLATOR FURNACEr GENERATOR E_Q GRILLE INFRARED HEATER LABORATORY COCKS C: _ �I (u_1 j — J --,—=1 =,j 1.— __( _1 MAKEUP AIR UNIT. OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER l1 --i _ _ WATER HEATER OTHER .................. . INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equ' lent which meets the requirements of MGL. Ch. 142 YES NO J 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _1 OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0-1 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia ce ith all inept provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ___-__-__ PLUMBER-GASFITTER NAME _ f LICENSE # 30I IGNATURE MPI MGF 01 JP r Jf JGF LPG] CORPORATION D# _ PARTNER I #_—,� LLC [#� COMPANY NAME: �aJ]ADDRESS._ CITY STATE I!,w1r,11ZIP� TEL FAX CELLW EMAIL 1 z w a ui w LL The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): City/State/Zip:. Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11. [1 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. 7 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA, for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: 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. EIectrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Y, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Goxmx�onwealth of Mfossachu.setts Department of ladustdaf .Accidents Office of Investigations 604 Washington Street Boston, MA 02111 TQL ## 61.7-727-4900 ext4Q6 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 www mass,govldia Date .g..— .13..-1 Z..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........Y........ Z ... w.t-.! ,54 .0 Ca..? .......................... has permission to perform l� ���1« .................................................-................. wiring in the building of - sf� .... r. gLE ...5..7 ................ North Andover, Mass. Fee .. �`�:'�':... Lic. No..`: ---:5 1 .... ....... ELECTRICALINSPEC OIt Check # 3413. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (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: G ° f - I `Z City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Owner or Tenant Owner's Address Is this permit in cc Purpose of Building Existing Service _ New Service Utility Authorization No./ 507 �A 77 Amps / Volts Overhead ❑ Undgrd ❑ Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- Elo. rnd. rnd. o Emergency Lighting Batte 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. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .Tons KW ................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security 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 Equivalent OTHER: 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: 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 covera&a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. —. LIC. NO.: 5d`j' Licensee: Signatu LIC. NO.: (If applicable enter "exempt" in the license number line) Bus. Tel. No.: - r Address: L JAlt. Tel. No.• *Per M.G.L c. 147, s. 57-61, security work requir6sbepartmm—f ofIyublic Safety "S" icense: 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. G r ' _ �jl e r n'�, d.C�-£.i,.t3 v_► IJ.gF9JC SL'iY�,l, �U'� -+� .'. _ _ r ��ssec�--•[ � �+a3IeQ-�� � �e-xnspecizoa.xequiz'ecT($�O.OD)�X � 3ns,pectuxs' co7oanzexts: ' (rnspectore skmatuxe -mo kPAIRIs) plate ?�'asse�-- [ � • �'ailec�--� � � �c-ins�eetiohxec�uixed (��0.00}-- [ � . 7nspeetox-s' co�n.enfs: (I'n4ectors' gignature -- m i nffials) plate �asseci�-� � �'afIe�—j � �texns�ectZon�'et�uiret�(�50.00)�j ] • �ns�eciozs' co7mme�.ts: , (Luspectoxs'ignaiure -ao ?vitals) ]ate asset-- 'VaRed--j xze-5nspeedonrequired ($50.00) [ is�ectors' a xnmep�fs: . _f (7Cn ecto7rs' zg oure rio nitialsa date ;Sed ---r [- 'litenspeciionze�uized (56.OD) • [ �ecto?'s' cobianerifsa _ , asp eeioxs' ,�zgnatuxe uo i�nitias} date D)Off. TA(9,5 .ASE'`O )3F+ gBi LED P-OTAM UFT ONRITENTREAM TO BE INET TUD Xg NOT 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 Legiblv Name (Business/Organization/Individual): -TOE L �j _�1,1 L 6t.,-) Address: City/State/Zip:_A1</, S -ON Phone #: ��4 -Z/ 23-'` (/ 7 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I loyees (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. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. F do hereby ce tify under the pains and peyAlUeE_o erjury that the information provided above is true and correct. Si nature: Date: r j 2 WITM %LIE Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #: 11 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 Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia