HomeMy WebLinkAboutMiscellaneous - 4 HIGH STREET 4/30/2018 (5)°o O
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This certifies that,,--., i 9�11 .........................................
has permission to perform..S..�J� ... 1� .. ..........................................
plumbing in the buildings of .... .... (.�� . ........ " C_'.. TJ ....................
..... .. ........ ....... . .
at ........ ....... .............. 1.q..T10-w",1-North Andover, Mass.
Feej�.L.51. Lic. No. ........... I ....................................................
PLUMBING INSPECTOR
Date.:j.)..11.1� ..........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Check # 17 NC9
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY �. � � V �.� MA DATE � � PERMIT
JOBSITE ADDRESS 14a-4 5f I s D*/ NER'S NAME Z [ r
P
OWNER ADDRESS 1 '�" l -V k L UD SI S6/�I TEL I ipt 7 % ZS c FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY
�/
NEW: IB RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
_
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
dWATER PIPING
OTHER
It
INSURANCE COVERAGE:
I have a current liabili 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 V OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ 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 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Q
PLUMBER' NAME l /KL60 q `-)' -4-14 LIC NSE # 1 S� � / SIGNATURE
MP JP F-1Ir CORPORATION # K ZQj PARTNERSHIP# LLC ❑ #
�❑
COMPANY NAME _6�' � ; V— �l ✓►G► ADDRESS /C2 D)t6 2a 6;7-4-7-T,/
CITY ��% r7 �i' ! STATEL' ✓�' ZIP a TEL ?D-3 - 0/ 77
FAX CELIj6 235- SVI 0 EMAIL v � ® � CO I
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The Commonwealth ofHassachasetts , . -
- ae�r� € nex2 of &dUSftitirAccz &fS!
• . Offlee ofluvesfigafeoa,s
6#0 Washington Street
Roston, MA 0.211
-WWW Mass govId a .
'[ orkexgl Compewaflon bsurance, xc-adt: UP
AppR cant Wornaayon Please.PrintLedh104
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' �a�Cle(Busiti.essFdrganiaaiionLfnd�tidual}: _ _
%dtl-re;;s: /0
02,
�01=npllolyav
yer? Cheek the ap ro ' to hox: Type of project (required):
�, X am a general coniract°x and I
1. a with 5 6. []New c6nsirizetioll
employees (tallaad(orparttixne): havehixedthesuh-confractors
+listed on. tfte attached sheef � 7' n liem°deltng
2. Q 1 art a sole propxzetor orpariner
SNP a-anaveno.employees These sub- confractow have, 8. (Remo •tion
worlang forme in any capacity. woxkexs' comp, insmauco. g, ' j g addition
!No wor7�exs' comla. insmanco 5• ❑ We axe a corporation and its 1011 Electricalxepaixs ox additions
xegakad.] officers have exercised.fheir
or MOL
11.[] 'lumbingxepairs or addiiious
3. [l x am. a homeowner doing right of exemption all wont 13 p
anyseL �(oworkers' comp. c. 152, §1(4}, andwehaveno 12.�]Raoizepais
insuranc�re ed. employees. [Noworkexs' 1g,[] Ofliex
comp. inswancarecluired,]
Pham 4: 7g " 'S' AC O / ��
Anyapplicanithaiclieoksbox Imus alsodilianfthesectionbelowgowingiMrworkers'compensatioupolicyinfoimatiom
Homeownersvsa
W110 sabmittivtftdagituadfcatingi[tey 're doingaITworkaudthenRaoutsidecontraotorsmusesubmitanewaflxdagitindieatiugsuch.
?Conicacforstba elxeckthisho 3vnstatfachedanadditionalsheetshov,�ingtheuameofthesuh-eonfraeforsandthekworked comp. polioyinformafion,
.ram imemployertiiaiisp�oviding17o.-fers'corPtjlelasat�onins�liancefoPYrtJ�e�2�royee9. 13E�o1d�%�i�2��lalie anifJoh9t'e
infumadon. l / L _ �-- _ it N
1�5i]xan.Ce CO2Ttparl�i.l�laJbe;- / [ � � ,
Policy # ole"-ins.ic. #' % �D W �� 7� �� - ExpiratxonDate:
Job�ite.A,ddxess` 7 1-17-/- �''— lCiiyfSiate/Zip:
Attach a cope o t tewoxirers' coxnpensatiowpolicy ileela-rafion page (nowing•the policy mmber and expiration trate),
'ailuxe to secuxo coverage as recfurxed uudex;�eciion 25E� ofIV1G1, c. 152 can lead to the imposition of criminal penalties of a
fneupto$1,500,00and/orones-yeaximpxiso�neni,aswellascigiipenaltzesinE6efoamofa TOPWORE£OPbEItandafare
ofup to $250.00 a day against the -WONa r. Be, advised that a copy ofthis statementmay be, foxwardedto the OfUce of•
7nvesfigations of fhe DfA. fox insurance coverage verification.
do lie eby eel c e t%2e tains �enaXiies of jraxy tXiat tfie informtion vi ovidect at ove is true and eo rect,
Simature: . Z7 Date:
�r
- d/-77
OffXMI Use 61.9ly. vo not write in Mis area, to be eoyqreteci by cit, or town off1claf
Cale' or Town, PexmtMUccuse 0
Issuing Authority (circle (Ma)
1. Board off(ealth 2. BuildingDepartmeet I Catyl9Cown, Clerk 4. BlectAcal Inspector 5.11mbiugfispector
f. Other - - -
Information an
- d Instructions
Massachusetts General Laws chapter 152xeq#es aft employers toprovideworkers' compensationfor ihei employees.
. Pursuant to thus statute, an ervployee is defined as ° ..every person, hi. the service of another under any coriixact oXhixe;
express orimplied, oxalorwxitten."
.:t eW, o�ye,�N defied as "an.:kd vidual,paxinexsbip, assoclatl�c corpor LID t o� otherLegal entity, or aoyiwo oxmoxe
of the foxegohi engaged in a jokt enterprise, and includingthe 1egalxepxesentative3 of adeceased elnplQye ,.or iTte
receiver orttzistee os au individual, partnership, association or other legal entity, employing employees, however the
Mmor of a dwelianghouse having notmore than three, apartments aud who resides thereto, or the occupant ofthe
dwelling house of anther who employs persons to do maintenance, construction oxx'epair work on such dwelling crouse
OT onthe grounds orbuilding appmtoamtthexefo shallnotbecauseof such employmentbe deemedtaba an employez:"
MGL chapter 152, §25C(6) also states that "every sfate or Ideal Ile-eusfng agency shall withhold the kma' e or,
renewal of a license or permit to op erase a business ox to constrict buildings in. the: Commonwealth .fox arty
applicant who has not produced -acceptable evidence of eompliance with the insurance coverage required:'
Additionally; MGL chapter 152, §25C(7)states"Weitherthe eommonwealthnax any of its political subdivisions sltafl
enter Into any contractfoxtheperfoxmance ofpubiicworkunMacceptable evidenceofcoznpliancewith the insurance
requirements ofthis ehaptexhavebeenpresentedtathecauixaciingautizorziy."
Applicants
Please fill out the workers' comp ensaiion affidavit completely, by checking ilia boxes that apply to your siiaafion and, ii
necessary, supply sub-contractor{s} name(s), addresses) andphonenumber(s) alongwith their cettificate(s) of
insurance. limited MabiliV Companies (LLC) or Limited Liability Partnerships (LTA. )Withno employees of&extbattthe
meembers oxpartuers, arenotmquiredto canyworkers' compensaiioninsurance. Lan LLC oxLLP doeshave
QM ployees, apolleyis xegaired. De advisedthatt is afCxdavitrnaybe submittedto the apartment 7ndustrial
Accidents for confirmation ofinsurance coverago- -Also be sure to .sign and date the affidavit : 1ko am -davit should
b e retcrnedto the city ox town thatthe application fox theperntit or license is being regaested, not tate De�axtment ox
Stxdusiral Accidents.houldyotz have any questions regarding the law ox if you are required to obtain, a Workers'
comp ensationpolfey, please call the Department attbenumber .listedbelow. gelfznsuoacompaniesShould enterthe7x
self insurance incense number on the appropriate line.
'City or Town Off taws
Pleasebasure that th-eafidavitiscomplete andpxiatedlegibly. TkoDeparkmnthaspxovidedaspaceatthoboftom.
ofthe aifzdavitfoxyouto ll outinthe event the Office ofhVesiigailoushas ta contactyouxegardingtlteaplilYcan
Please bo -sure to Bl in tha permit/license number which will be used as a reference number. Iu addition, an applicant
tlzat�,ms submiirmultiplepezmit/ilcenseapplicationsinanygivenyear,needonlysubmitoneofidavitindicatingcurrent
policy information Vnecessmy) and under "Job Site Address" the applicant shouldwxite "alllocaiions in. (city ox
towh)" .A. copy 01mo affidavit thathas been officially stainped or marked by the city ox town may be pxovided to the
applicant as pzoofthat avalid afrzdavitis on file fox fuiuxepermits orlicenms..Anew aftxdavitmtistbeffllgd out each
year Where 3&me owner orcitizen is obtaining allcense oxpennitnotrelatedto anybusiness or commercial veltiuxe
Q.e. a dog license orpexmit to bum leaves etc.) said PUNA is N'OTregahad to complete this affidavit.
The Offfee df InvostigationdwoWd like to thank you in advance for your cooperation and sh.Quld you have any gt�esiions,
please do notho4ta%to give us a call.
The Depatimen-es address, telephone anal faxnumber;
1?P1Pa 0,Td&JU 'zal AccldWa
6.Qalal2"xelc
Revised 5 26-05 Fay,617427"7749
sv
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3=3021,
Date .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. .. P0. - 141 ...... . . ...........................
has permission to pe, rr . ........ P ................................................................
.,wiring in the building of ...... .........
at .......
............... ...................................................... 4 North Andover, Mass.
/ 3 A.7
�Fee ........... ...................... .......
Lic. No.
4 L
Check #
12 7 1 F)
A,
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
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 Code (MEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives otice of his or her intention to perform the electrical work described below.
Location (Street & Number) #wt/ r.
Owner or Tenant
Owner's Address
Is this permit in conjunction with a//b��uiild//i/ng permit? Yes
Purpose of Building �,�/n12b'
j - Existing Service
New Service
Amps / Volts
Amps / Volts
Telephone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Cell: 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-. El
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets �j
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches 3
No. of Gas Burgers
No. of Detection and
Initiating Devices
No. of Ranges
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 Key
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 E uivalent
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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:)
I certify, tinder the pain a penaltieso, f„lie j , that th nformation on this application is true and complete.
FIRM NAME: _ '� LIC. NO.:
jQ 4z
Licensee: Signature LTC. NO.:
(If applicable, ent r "exem t" in the licens num ) Bus. Tel. No.: /
Address: , , �/ /vG Alt. Tel. No. -
*Per M.G.L c. 1 7, s. 57-61, security work requires Dep rtment of Public Safety "S" License: Lic. No.
•
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the q
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass n
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
f-�
Inspectors Signature:
V 7
Date:
FINAL INSP ON:
Pas
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
ei Al
Inspectors Signature:
E s /� frK ¢
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): /u 0,�, g 6 -^ T
Address:
City/State/Zip: %1��0� Phone #: 0
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. F1 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.] i
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
11.0 Plumbing repairs or additions
12.❑ Roofrepairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they ace 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 DIA for insurance coverage verification.
I do hereby cert& under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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
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 anLLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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:
Tho Commonwealth of Mossachmotts
Department of Industrial .A,ccidonts
Office of Investigations
600 Washington Stxeot
Boston., M.A. 02111
TO, # 617-727-4900 ext 406 or 1-877:MASSAFE
Revised 5-26-05 Fax # 61.7-727-7749
www.mass,gov/dia