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Home My WebLink AboutMiscellaneous - 50 SUTTON HILL ROAD 4/30/2018 50 SUTTON HILL ROAD 210/097.0-006-1-0000.0 r i Date...l... a`O. g ..... ... N°RTM °f<<`'°;•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING cNusE� This certifies that .....C!.�� ..... F. <�l'. . !......�. f� .!�.............. has permission to perform .......Yter....... wiring in the building of...../,. "�/.yI at...../a,�.-� Ta!�.. G...�� ....................North Andover,Maass. Fee.. �—.. Lic.No f.S�3...A-52-f'� S5 91.kiRICALINSPECTOR v Check # 7 8550 /I / �/j / Official Usc Only 1 Permit No. �Sp _ �sOrsrVfu�/J• u�r/'•re �Jart.Ca3 Occupancy and Fee Checked BOARD GF FIRE PREVENTION REGULATIONS eV. 1/0 (cave blank) APPLIC.AT�ON FOR PERMIT TO-rPERFORM ELECTRICAL WORK, • All work to be perfo:-mcd in accordance with the MassachuscrCs Elecuicai Cede(,EC) 527 CMR (2;00 (PLEASE PRINTIN;"VK OR TYPE ALL INF'OR 4TIOM• Date: City or Town of: To the Inspector of Wires: LY, is application the undersigned gives node of his or ;er::i:erition tdorm the elect ical work described below. tion (Street& Number) —5—e d7/-,OJ l l � Telephone No. �✓ Cwber or Tenant --L- /� ', -l/� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Utility Authorization No. Pur p�;se of Buildiag I Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No_of Meters Service APs / Volts Overhead F-1Undgrd ❑ :. No.of Meters* PJew ,,prnber of Feeders and Ampacity11� ' cstion and Nature of Proposed Electrical Sxiork: � S4 actG r 0-,-, C)�c�e Com let, no the ollawin table m be waived b• the Inspector of Wires. No_of Total Na.of Reces3ed Luminaires No.of CeiL-Susp_(Paddle)Fans Transfoil— Generators KVA KVA No.of Luminaire Owlets No_of Hot Tubs o_o mergency ig ng Above In- No.of Luminaires Swimming Pool rnd_ ❑ Md. ❑ Bane units *To_of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones o.of Detection and No_of Switches Nti.of Gas Burners Initiating Devices -- Tota1 No_ofAlertin Devices No of Ranges No.er Air Cdad. ;ons g Heat Pump Number Tons if ontsined No_of Waste Disposers Totals: Detection/Alerdng Devices Municipal ❑ Other No.of Dishwashers SpaeelArea Heating KW Local❑ -t�•ae� n ecurity yystems- No.of Dryers Heating A•PPtiances KW No_`ofDevices orE u'valent )f No_of No.of Water • i�tv. Festers KW Signs Ballasts No_of Dev1ces or E uivaleni Telecommunicntions Wiring NQ_Hydromassage Bathtubs No.of Motors 'Total HP ',To_of Devices or.'� 6 valent OTHER: y • v -' .��d Attach additional detail if d-sired or as required by' `Insh pector of Wires ired by municipal policy.) 1 : Estimated Value of Electrical Work.--. `7` ( (When requ Rork to S Inspections to be requested in acc=ordance with MEC Rule 10,and upon completion Of ca.1 work diay issue ormance- y the ow. INSURANCE COVERAGE: Unless' in uding 'coo permit ted operationn�eo g�or its bstantial aluivalc t The unless the licensee provides proof of liability undersigned certifies that such coverage is in force,and has e �bitcd proof of same to the pczaut issuing office. CHECK ONE: INSUR.A.NCE E] BOND [I OTHER ID (Specify-) I certrfy,under thepaimr andpruraLdes ofperjury,that the information on this plication is true and carnplet�r 53 3 -FIRM NAME: LIG NO.: I>iccnscc: Signature (nGZ3 �i'94� 5�1 3 a9 Bus.Tel.No.: -(yapplicable,enter .e ern in the license nsarrbcr fine.) t o Alt TeL No.' Address: : *Per MGL.c. 147,s.57-61,security work requires Lic.No. Department ofPublic Safety"S"License he liability e normall OWNER'S INSURANCE'WAVER: I am aware that the Licensee does noaam the t have ticheck one)❑ owner. C1 owner's a nL required bylaw. By my signa•t=below,I hereby waive this requirement I towner/AQeat 5 O tJt 1raN _rtl -_tr._t c .� V in fel' 9L. 619 4�' tulz71 v9 � ?--04;EC-,T. GOAJCkS.T- ®R �r.nv1_NG _Ex�srI.AJ - 8A-S;r-MFtiT Cr 1 R-D_E.f 14+v p v:�'T .. ® R A c niG 'TSI,e rn pct I T4 A B 1z .ai C TPOS'r T5 O-Gos w'o 0 o PLAT.E `to 6. p?0E-Q 2X 8 PL4T1° X FL VII 000 _ `VAI t p x "319 Vit to,X""3:9 . k AI ZI-- — OF M Ss9c Lav& . IS .► toLAT'�' LAN/RENGE S C o - HARO.LD r� GM 1 t i t t E Z I th PS ofkj .off�� 2 65 O C�4.cJM N 2 _ 0 G, .-re...L CAP T'914(05 `ass/ n of SGP.awS 1*0 y$1 04 Lawrence H. Ogden P.E. 198 East Main St Georgetown, MA 01833 f Date. ` TIy Of NOF ,4, �. o6 6 TOWN OF NORTH ANDOVER ti 9 PERMIT FOR,GAS INSTALION �,SSACHUSE� This certifies that ! ! . . . . . 'P .. .. . . . . . . . has permission for gas installation . . .Ar U U in the buildings of. Z !'A4 h4.�!2 M!t 4!t!. . . . . . . . . . . . . . . . . at (� North Andover, Mass. Fee. Lic. No.. d. �t -e_. . 1!t' �t. . . V GAS INSPECTOR d Check# ( `7 6626 MASSACHUSETTS UNIFORM APPLICA-rON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date h' ?' ) Building Loqations �— — Permit# Owner's Name - Amount$ ,New❑ Renovation . Replacement Plans Submitted ❑ ' � w c� Wa c c F z mrnF e a z z J , C g G ° 4 ° m F W F z z e z a w ° c > w z d w a F F w �' o > W v s ee S s 'o z a C e p Z w p F w SU B -BASEM ENT U m o d° BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . .FLOOR STH . FLOOR. (Print or type) `� Name Y ' Gt Check one: Certificate Installing Company X Corp. ' 61)Address -S-DG .. �'-- Partner. Busine—ss7eFepilulic_ �.D Name of.Licensed Plumber or Gas Fitter INSURANCE COVERAGE ! have a current liability Insurance,policy or it's substantial equivalent. Check one: If you have checked es please indicate the e coverage Yes "NoQ Liability insurance policy typ erage by checking the appropriate box p cy Other type of indemnity D Bond Owner's Insurance Waiver. [Am aware that the licensee doesn_ o�ve the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Signature of owner or Owner's Agent Check one: er t hereby certify that all of the details and information 1 have submitted for entered)in above application ncation�a and accurate best of my knowledge and that all plumbing work and in ions pe ormed under Permit Issued for this application will be in urate to the compliance with all pertinent provisions of the Massac etts tate Code and hapter I of the eneral Laws. itSignature Signature of Licensed umber Or Gas Fitter TilePlumber City/Town,. Cj Gas Fitter icense um r Master _ APPROVED(OFFICE USF ONLY) P Journeyman Date. d'". . .... .. WORTH o� °` TOWN OF NORTH ANDOVER . • PERMIT FOR GAS INSTALLATION . �° 9SSACMUSVEt This certifies that . . �.t !�!< �?�. . �.?�rt has permission for gas installation J.C(J? . . . . . . . . . . . . in the buildings of . . !!??f . . . . . . . . . . . . . . . . . . . . at . . 5 .�?. ?��: .l �. �.L'. E . . . . , North Andover, Mass. Fee, ?. . . Lic. No. o � 7�- Q - hAS INSPECTO ' Check# ` 6601 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: / yG7 �� Date: Permit# J� c / Building Locatic (� G�/�J �/ ��/L- Owners Name:��/ %��C°✓' 9 Type of Occupancy: Commercial Educational Industrial Institutional Residential New: Alteration: Renovation: Replacementx Plans Submitted: Yes No FIXTURES Cn W W Y W O = rn N m X WU' J t) W ~ to * W W 0 lY z z z o � W ° a o F O O O a W W W m Q [L t— W J X Q X U a M W F- a a W w W z a4 = w rn = W rr t>c U W z O J � P O z J U' W H f- W W W W z W } W N J Q Q m W O z O N z F- H H _ v o o LL X i o a �a iW- > > 3 o SUB BSMT. BASEMENT 15T FLOOR • 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 TH FLOOR 7TH-FLOOR 8 FLOOR /� - Check One Only Certificate# Installing Company Name: lVerr//YJae, / Corporation Address: City/Town:.j1,tyhG�� . ... State: MA - Partnership Business Tel:,��1�� L.rt Fax yJ`s-,�O.�'? .-:�7 FirmlCompany _. . �.. . Name of Licensed Plumber/Gas Fitter: f INSURANCE COVERAGE: 11 I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy / 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 Owner's Agent By checking this box❑;1 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 hapter 142 he General Laws. oe ✓Type of License: BY Plumber Gas Fitter Tale Signature f icensed Plumber/Gas Fitter Master Journeyman ; cay/Town LP Installer APPROVED OFFICE USE ONLY Location No. _ Date t N°RTM , TOWN OFNORTHANDOVER 0. gg Certificate offOccupancy $ ` Building/Frame Permit Fee $ Foundation Permit Fee $ sACHUSEt Other.- Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ 6 TOTAL $ Building Inspector { i 10027 Div. Public Works f Location SG7 • v ffiirt ��( �� ` No. -/�-`tG Date TOWN OF NORTH ANDOVER p Certificate of Occupancy $ + Building/Frame Permit Fee $ �ssCMusEt Foundation Permit Fee $ . I Other Permit Fee $ 75. Sewer Connection Fee $ /Oct Water Connection Fee $ TOTAL $ � d Build g Ins ector s € �' 9059 . Div� is Works PERMIT No. APPLICATION FOR PERMIT TO allILD — NORTH ANDOVER, MASS. PAGj- MAP 4-40. 9.7 .LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK :PAGE DIV. LOTNO. LOCATION PURPOSE OF BUIL13ING OWHIR*9 NAME &7/ NO. -1 STORIES SIZE —2— OWNER'S ADDRESS ST BASEMENT OR SLAS ARCHITECT'S NAME CA 19 e>Al S12E dF FLOOR TIMBERS IST'z 'r/e' 2ND 3.R 0 BUILDER'S NAME SPAt,4 im, DISTANCE TO NEAREST BUILDING DIMENSIONS OF BILLS DISTANCE FROM STREET 20 POSTS -1 — _ DISTANCE FROM LOT LIKE 9 SIDES 0 REAR GIRDERS --- --- L AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS — zs' a 15 13UILDlt$G NEW SIZE OF FOCTING x I ?— o IS BUILDING ADDiTIO N MATERIAL OF CHIMNEY 7-A IS BUILDING ALTZRATV:'N 13 BUIL13ING ON SOLID OR FILLED LAND WILL BUILDING CONFOC��!TO' ,!'REQUIREMENTS OF cope 16 BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACT301,4. IF ANY 13 BUILDING CONNECTED TO TOWN $EWER IS BUILDING CONNECTED TO NATURAL GAS LINE ? TY INFORMATION INSTRUCTIONS 3 PROPER LAND COST SEE BOTH SIDES 1212S &ST. BLDG. COST Sy PAGE I FILL OUT GECTIONS F- 3 EST. BLIXI. COST PER 6Q. IrT. - PAGE 2 FILL OUT BZCTIONG 1,- 12 EST. BLD43. COST PER ROOM & 0.0 o SEPTIC PERM T NO. ELECTRIC MKTlPS MUST BE ON OUTSIDE Of BUILDING ATTACHED GARAGES MUIVT,'CONFORM TO STATE FiRE REGULATIONH 4 APPROVED 13Y PLANS MUST BE FILED Atlt��APPROVED AY BUILDING INBPfCTQlA DATE FILED_ 9 -2— 4�r'000e 71 z W oe oe z A e-9900 SUILDING INSP�j SIGt4'ATfJRIE OF O^ER OR AUTHORIZED AGENT 2 F E E NERTELI oT PERMIT GRANTED Lm ;0MR.TEL 1 j�/12 kK� -2— 2 CONTH.LIC.I 9661 H.I.C.I BUILDING RECORD 1 OCCUPANCY 12 hI SINGLE FAMILY STORIES - THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM - MULTI. FAMILY oFFICEs 4 _._ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- ' APARTMENTS IRAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION' 2 FOUNDATION B INI:ERIOR FINISH CONCRETE I _ S. 1 2 JJ CONCRETE Bl K. PINE O ;;�, 6,- BRICK BRICK OR STONE HAROW"6 PIERS PLASTER .DRY V/Alt- UNFIN. 3 BASEMENT AREA FUIt IN, B'M'T' AREA FIN. ATTIC AREA N_O B M T FIRE PLANES _ Z - HEAD ROOM Q MODERN„KITCHEN D - 4 WAILS ( 9 _FLOOR$ �- CLAPBOARDS 9 1 2 J - DROP SIDING CONCRETE �_ w00D SHINGLES EARTH ASPHALT SIDING HARG_'�0_ —j{_ ASBESTOS SIDING COMIAC;N_ ✓I VERT. SIOING ASPH^—LIGE STUCCO ON MASONRY STUCCO ON FRAME ATTIC SIRS...4 FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WILING STONE ON FRAME - SUYERNIJ,R POOR {f_ ADEQUATE I�- NONE I 5 ROOF 10 ►LUMBIHG GABLE HIP BATH 13-F L GAM6REl I MANSARD TOILErR—M"iJI1 FIX.) fLAT SHED WATFflfCLOSET _ ASPHALT SHINGLES LAVA;nRY WOOD SHINGES XITCFE14 SINK SLATE NO PLUMBING _ TAR 6 GRAVEL STALL SHOWER - ROLL ROOFING MODERN FIXTURES TILE F:OCR TILE D`A'DO _ 6 FRAMING i l 't HEATING WOOD JOIST 4Z PIPELESS FURNACE FORCED HOT'AIR FURN. TIMBER BMS. 6 COLS. STEAM . STEEL BMS. 6 COLS. HOT W'T`R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT Hl G UNIT HEATERS GAS 7 NO. OF ROOMS OIL - B'M'T 2�d ELECTRIC 19,d IQ._ NO HEATING NORTH ` R F O Odover No. 31g 0 ^`L 1K " dover, Mass., 7 199 COCWCHEWICK ADRA TED P?�L, � 5 BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D BUILDING INSPECTOR THIS CERTIFIES THAT.............................. .......�`� F..% �.�.�.......��` �.��..... ................ . ....`.................;... Foundation /l� /'/!..!.../....fie..D... Rou h has permission to erect.......... .. ....................... buildings on .......6...................�Ll.�.......... ` g to be occupied as.......................................................... /..150 G..1`! ..............F- ..�...4pp-l-i-catio.n. . . . .. . ............... Chimney provided that the person accepting this permit shall in every respect conform to the terms of on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT FOR FOUNDATION ONLY Rough REGULATED BY PARA. 114.8-S. ,g,C. Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION S GC �� ELECTRICAL INSPECTOR Rough ................................................. ...................... ..... ............................... Service BUIL INSPECTOR Final Occupancy 'Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. (� � Smoke Det. ` k 29 2 0 `r-ROAD 3 1 f ;IN 63°39'2],,E vt♦!� ♦ ® �,. ---- 209.9 �Y ?' !,6W. •♦ ;' -''� _ n .CO 3 Af LTN C) ® _ ♦♦♦i zn ,Mims _ ti 3 i tTrl 5 ' � sT . eon 04tS� 1 ✓ EXISTING No BUILD EAS ! AO - -w F3 C) f s s-r LIQ 0 �6 a0� 0 1 85,00, 4 0'49 S EMENi, , 71 N 72 T1 i FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor's Map Number 17 Parcel - 4 7 Subdivision 1�0 ✓c H-, r�I nn Lot(s) - 3o t3 Street St. Number 5-0 ************************Official Use Only************************ RECOMME AT NS T AGENTS: Date Approved 71212 Conservation A ministrator ' Date Rejected Comments Date Approved Town Planner p Date Rejected Comments _Q '1(,4�Y� C✓�Yl It L OC~ '1�A Q .I LLQU Date Approved Food Inspector-Health Date Rejected ' Date Approved hep-tic Inspector-Health Date Rejected Comments Public Works - sewer/water connections 7J�� - drive permi - 1-e5 -�1 Fire Department Received by Building Inspector Date Growth Management Bylaw Exemption Statement Town of North Andover Building Department r This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit(below) Address of Property for Permit(below) 6,0rrn/e74 Map and Parcel :Vl-o2/ Purpose of Application (check below) Phone Number of Applicant: /�Single Family _Two Family l�/17 6)V�•.2,1 1 the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. 1 also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement,restoration,or reconstruction of a dwelling in VI / as of the effective date of this by-law,provided that no additional residential unit is created. V The lot(s)were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals,where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents,where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section"senior"shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40%permanent reduction in density, (buildable lots),below the density, (buildable lots),permitted under zoning and feasible given the environmental conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland.The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction,dedication to the Town,or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot v:hich is ready for building permits,(i.e.all other permits from all other boards and -- -commissions have been received and the prnj,•ct is in compliancewit:,those-per-mits), nd-the Development Schedule. does not accornmodate issuing a building perinit in that Year,one building permit will be issued per Year per r:evp!cpment until such time as the Development Schedule accommodates issuing building permits.--Aupl.i-tint n ust su,,)piy approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply,whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. 'f'---)- -Pi� Signature of Owner or Authorized Agent who signed the Attached Building Permit Date This form must be attached to the Building Permit upon application for such permit. r � Office Use Only u�� L1� 11n ��1of IttarIIUP�ts Permit No. 13tvartmxnt of Public —%fxtg Occupancy& Fee Checked 3/90 leave blank) �• BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (MI i or Town of NORTH ANn0VER To the In ect r of Wires: The udersigned applies for a permit to perform the�ectrical work described below. ` Location (Street & Number) Owner or Tenant HIF Owner's Address Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building / �� Utility Authorization No. C� ^ ed� Existing Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service 2 Amps /Z/ (y Volts Overhead Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Total No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures I Swimming Pool Above❑ In- In-d. ❑ I Generators KVA grad No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners I Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devices No.of Heat Total Total No. of Disposals Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW DetectionlSounding Devices IMunicipal Other No. of Dryers Heating Devices KW Local ❑ Connection No. of No. of Low Voltage No. of Water Heaters KW I Signs Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws NO _ I I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES have submitted valid proof of same to the Office. YES r NO Z If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 'J� BOND = OTHER :: (Please Specify) (Expiration Date) Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rough Final 4 Signed under the Pe altie f periu LIC. NO. FIRM NAME (9/i Licensee Signature LIC. NO. G DAs. Tel. No. -r-- Address Q� C Alt. Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re b Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owne 9 q Y Jd (Please check one) �� O Telephone No. PERMIT FEE S VVV (Signature of Owner or Agent) x-5565 5 4; Date..... ..... ...��. 854 NOR7M 3j�etr��•°�e��0L TOWN OF NORTH ANDOVER PERMIT FOR WIRING r r This certifies that ......... ...... �- t has permission to perform ...... '4.4fi?.....tiC1yii e......L,! .a.�5.��? (....... wiring in the buildingof.....1A.Q nAy........�T-4.!'.A.('ck..VL.......................... ....... L l;r0 nh (( u4. .: ...............North Andover,Mass. FeAl..l ....... Lic.No. ............ ....... . LECTRICAL INSItCTOR G 04!10/9 7 1 0:40 310.00 PAID ' WHITE:Applicant CANARY: Building Dept. PINK:Treasurer r. -•-....... .VVa�i �.. -si4rur7M ^rrLJVNIaun r%jn t-rnAatY �u uV ri.uw�uu.v (Print or Type) NORTH ANDOVER . Maas. Date r Building Permit * 3` Location .1-,Q Owner's ' Name tln—,N New (a Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No.❑ FIXTURES • a� w }. « tr y J w t' V < w s W. v o at � � ~ M s s r~ as et i e s < it ai r or w A 0 s o & ` or I er s at a ao s o y o Y a Is o $ w x s a s w�e i � s i o sus—�sMT. aAttYtjNT 10T FLOOR f 1NOFLOON 3 1 l LINO FLOOR 4TH FLOOR ITH FLOOR sTH FLOOR STH FL10 aTH FLOOR Check one: Cadlflcate Installing Company Name ❑Corp. AddressAD J 5T ❑Partnership ❑Firm/Co. Business Telephone (0 1-) - QQg- .Name of Ucensed Plumber ('r f P t,, „-�o S INSURANCE COVERAGE: Check one 1 have a current liability Insurance policy or No substantial equivalent. Yes ❑ No ❑ If you have checked j", please Indicate the type coverage by checking the appropriate box A liability Insurance policy lid— . Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner a Owner's Agent Owner ❑ Agent ❑ I=certify that al of the delaf s and inlormaflon I have submftted for entered)In above tion are true and accurate to the best of my ►nowtedpe and that al plumbing wotk and installations performed under the permM Jawed this appll�ibn_ bs In compliance with all pertinent provislons of the Masuchusetts Stale PiumbkV Code and Chapter 112 of int at By This na uteof 13cansed Plumber GtylTovvn License Number b J Type of Plumbing license: Masser A Q� T110NED(OFFICE USE ONLY) Jownsyman 0 -s Date �.�= 3345 L T: A "0°r FI�4, TOWN OF NORTH ANDOVER ° o: P PERMIT FOR PLUMBING S • o�- `a ,SSACNUS� ,,QQ This certifies that . . . . . . . . . . . . . . . { has permission to perform . . . . 1.G. . .^.. . . . . . . . . . . . . . . . . . r� a, plumbing in the buildings of . . .6?1.eeq. .(a � . . . . . . at. i� . . . . . orth Andover, Mass. Fee.3�.U.':.Lic. No..`� ?}.T . . . . . . . . . . . . . . . . . . . . . . . . . . t PLUMBING INSPECTOR WHITE: Applicant . CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINtG (Print or Type) _ c� NORTH ANDOVER Mass. Date tuilding Location ,SI 2-j :t-A lv Permit Owners Name ('')e , ea. ►sem' . Y New renovation II Replacement II Plans Submitted II a a� c m us ai - � to UA UA _ W w — o. w 4 a _ — a_f02 c7 F 1 F' F- to O ? tz t-- U3 Vi ._ SASEMEaT I ST FLOOR --`III FLOOR 1 ! ! I I f �` ! !~ I� ! ! ! f ! ! f ! l •�! ! _f , f. _ ! .._.. :IRM FLOOR 4TH FLOOR ..�_....! _.I .A . I I I. L . I f I � I � � i( I l L..:_:�_.__.► t."�:L_�!_T EA '.1-- S ,K FLOOR ! ( I ! ! ! ! I I ! ! ! ! ! I ! I I f ( ! - I .'"I. HI 6TH FLOOR I I I ( I I I ! ! ! I I I I I I I I I IIIII I TTI{ FLOOR I f I I ! ! I ! ! ! ! I I I I I I I I I f 8TH FLOOR ! (Print or Type) Check one: Certificate Installing Company Name �Je-'j S.—)b-/u Q Corp. - Address O -i/ L1.6AAAA �Sj c Partner. =---Firm/Co.- Business --F-irm/Co.Business Telephone: Name of Licensed Plumber -or-.Cas Fitter Insurance Coverage: lndica;e -- e type o: insurance coverage by checking the appropriate.-.box:. Liability-,insurance policy_ ct^er type of indemnity..=.,.-.Bond. Insurance Waiver: ., [, the ur.dersicned, have been made aware that.:the_licensee.of - this ap.piication.does not have any one or the above three insurance coyerages,__•..-. Signature of owner/agent or property Owner -Agent - I he:ehy ccrtify, that ill oC the details and information I have auhmitted (or entered)in&tore appiication are true and accurate to the best oC my k-la-tedse and that &tI plumbing worst and tnataUatiocs ;criorae,'. urdar'tcrrnit i:=zd for this &pVdC%t_oa w' to eompiiance witty all pertlaet Prorisians of L'G Stu&sarr'tu.&ctts Slate Car Cade snd C!6aptc Is:tf L!:4 C,.%r i LAWS. By TYP= LICENS V1 ,1X TitleSignature of License< City/Town: ster Plumber o�Gasfitter Journevman JOSS( APPROVED (OFFICE USE ONLY3 License Number n,4 .4„Ay7j•,�:;.---s `..-.w -.�;,...,.�.,��.�.,9' fir. .--+.irsGr: ., .r,.._.:! �� 253 Date A a Gf No o'Q,,tio TOWN OF NORTH ANDOVER16 $ : o? . PERMIT FOR GAS INSTALLATION- CH NSTALLATIONCH This certifies that . . . f.t n .,13 A S/1%,-. . . . . . . . . . . . . . . .�. has permission for gas installation . . . -.f . .y�.�Z . e. . . . . . . in the buildings of . . . . . . . . . . . . . . at . .3. .5Yrf.Y 1/: t Pk . , North Andover, Mass. Fee. .7f,.—. . Lic. No.'V.? ` GAS INSPECTISR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File . 0 0 Date... ... ../� ...1..... z) Q0tTft o 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAC U This certifies that �.,1,0 7..... .. .. ........... .......................... has permission to perform ..... ri-e.M........ .................. !.....................) qvt wiring in the building of...... ................................................. at ,...3 ... ................... .North Andover,Mass. cc Fee. 5..f.&... Lic.No.1401 ............................................................1�� ELEc-rmcAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer ' u U The Commonwealth of Massachusetts P.-mitP.-mit N'.. 1! t-St. Lh'tDepartment of Public Sofety Occupancy S fee Checked BOARD OF FIRE PREVENTION REGULATIONS S27 CIdR 1200 3/90 ileave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Macsachusetu E)ectrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL IITFORMATION) Date / - I?_ 9e City or Town of /(/o,erW .4NOd✓E,P To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. ,Location (Street 6 Number)_ 1-'40 .SurMA/ Owner or Tenant 61,?4 zi/Yl� tMA/V Owner's Address ISAME ( 978 97S 2308 Is this permit in conjunction with a building permit: Yes ❑ No ❑x (Check Appropriate Box) Purpose of Building Utility Authorization 140. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation of Alarm System No. of Lighting Outlets No. of Hot Tubs ' No. of Transformers Total KVA No. of Lighting Fixtures Above In- 8 g Swimming Pool grnd. ❑ In- . ❑ Generators KVA No. of Receptacle;0utlets No. of Oil Burners - No. of Emergency Lighting t Battery Units No.. of Switch OuElets -- No. of Gas Burners FIRE ALARMS No. of Zones . No. of Ranges _ No. of Air'Cond: -Total Noof Detection andtons Initiating Devices No. of Disposals No. of Heat Total Total .-Pumps Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal ❑Other Connection No. of Nater Heaters KW Signs Ballasts Wiring tag XZAe No. Hydro Massage Tubs No. of Motors Total HP OTHER: Cl/) 72-5e 7V A- INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO ❑ I have submitted valid proof of same to this office. YES❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work S gra O G C Expiration Date Work to Start /— 7/98 Inspection Date Requested: Rough Final /�_24/9,P Signed under the penalties of perjury: FIRM NAME -A.D.T. SECURITY SYSTEMS NORTHEAST INC. LIC. No. 1231C j Licensee DONALD A BROOKS .Signat aN0; 1231C Address 60 William Street, Wellesley, 8 s• el4o. �413t._32-4400 Alt.-Tel. No. 617-431-5831 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or is sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) DO Telephone No. PERMIT FEE S (Signature of Owner or Agent c/ �� Office Use Only n << �4I' LQritriiDitlU>:# Uf I1ttgoa#jit.l.tg Permit No. 3epartment of Public 35ttfetq Occupancy& Fee Checked C BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 1 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:90 (PLEASE PRINT IN INK.OR TYPE ALL INFORMATION) Date '9 (M* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) -5-0 sV 7719 w ///i// /Z/,?Owner or Tenant _ /C (i � )kI4 f S 10 Z161~,S _ //h Owner's Address Is this permit in conjunction with a: building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building )e-eS i ci-en fl vi Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electripal Work ��; -N a Y No. of Transformers Total No. of Lighting Outlets No. of Hot Tubs KVA Above— In- No. of Lighting Fixtures I Swimming Pool grnd. l grnd. ❑ I Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners . FIRE ALARMS No. of Zones Total No. of Detection and No. of Ranges No. of Air Cond. tons Initiating Devicec No. of Disposals No of Heat Total, Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers I Space/Area Heating KW Detection/Sounding Devices 1 I r � , Mun.ich^! Local - I Other No. of Dry-ts Co n6aUUn _ ' w..-.... .. Low VoltageNo. of Nc-701- No. of Water.Heaters K\N. Signs., Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP OTHER: C-i)YI T A-1 OL rr (4 '4 INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws ^ I have a cunt Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES -R`,NO I have submitted valid proof of same to the Office. YES e NO = If you have checked YES, please indicate the type of coverage by Checking the appropriate box. INSURANCE .� BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of ElicaI Work S --:4000100 Work to Start 'S 2 ec c)-7 Inspection Date Requested: Rough Final Signed under the Penalties of perjury: FIRM NAME s Ai ' `p ^ n A P A/Gt Y#L4 OQ LIC. NO. 2.2 Y-2 0 Licensee _ � er -, Pc/ ty0► r` Signature r LIC. NO. s-G Bus. Tel. No.SO e- 4 V 4-fe 7 / Address 9-7 /e�f�/ y t♦et Y- `� �' / ' ,/ Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit applicavan waives this requirement. Owngr Agent (Please check one) r�(7j/ lel Telephone No. PERMIT FEE S ' (Signature of Owner or Agent) x-6565 _ C � 0 �o — Date....... ... AA.z. o 911 NORTH 0�,.�•� .e,ti TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �SSACHUS This certifies hates �j :t:a. . ci Z .... � .. . _ .. ..................................... has permission to perform .......� ......... ............................... wiring in the building of �.�.L.�tl.x/.....,(E. fc� r�... ....f............................... at... ....................... .North Andover,Mass. Fee... Lic.No.2.9.yv.............................................................. ELECTRICAL INSPECTOR CG >� y 05/05/97 12:08 35.00 ARID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer v Date.. ....... NORTH 0 -_6 0 TOWN OF NORTH ANDOVER AL 10 . % PERMIT FOR WIRING J This certifies that .... .................................................................. has permission to perform ......... ......... i. c ...................... wiring in the building of............ ............. .............................. .North Andover,Mass. Tee.�.:............ Lic.No�Qr .5......................................................... ELECTRICAL INSPECTOR Check ,, J-12"I - . 9,1 13, Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 9//,3 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked }; [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 MR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspe,dor WiYes: By this application the undersigned gives notice of his or her inten 'on to perform the electrical work described below. Location(Street&Number) Owner or Tenant Owner's Address p �] Tele hone No. -'4 G Is this permit in conjunction with a building Yes ermit? J / No ❑ (Check Appropriate Bog) Purpose of Building o��/ Utility Authorization No. Existing Service Amps / olts Overhead 5�r Undgrd❑ No.of Meters f New Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters Number of Feeders and.Ampacity 0 W714/1"-7 Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Ni of Tota! Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above E3in- o.o Emergency T g d. d Batte Units —, No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches O No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Hest Pump I Number Tons Totals: KW Deteetion/Alertin Devices No.of Self-Containe - "�'�"'-��"'- �' No.of Dishwashers . Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances Security Systems: No.of Water No.ofo. No.of Devices or Equivalent Heaters )E Si s Ballasts Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total gp Telecommunications Wiring: OTHER: No.of Devices or E uivalent 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 Iicensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such cove is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Er BOND ❑ OTHER ❑ (Specify:) I certify,under the p 'ns and penalties of perjury, that the information on this a lication is true and P complete- FIRM NAME: '� ✓ l�' /Cf LIC.NO.: Licensee: Signature LIC.NO.: (� (If applicable, ent r"ez mpt"in the license number line.) Address: ( f r ,�� Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: L AIL lc.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ i The Commonwealth of Massachusetts 4. Department ofIndustrial Accidents Office ofInvestigations 600 Washington Street Boston, A"- -02111 www.massgov/dia Workers' Compensation Insurance A-Mdavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/ftanizationflndividual): Address: Si Ie.,?D/ C City/State/Zip:-A &, .,Ij 1 0 Phone#: Are y an employer?Check a appro riate bog: Type of project(required): 1. I am a employer with--4:57 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have ❑ working for8. Demolition me in any capacity. workers'comp. insurance. 8. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers haveexercised their 1011Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §.1(4),and we have no 12.❑Roof repairs insurance required.],t ..,employees. [No workers' COMP.- required.]_ 13T1 Other ; in t Any applicant,that checks box#1 mu&—also:ill out the section below showing their workers compensation olic t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. tContractors 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 isproviding workers'compensation insurance for nzy employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: d'V 2� Expiration Date: Job Site Address: �✓ 41 City/State/Zip: �f�/ y 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. Ido hereby certifyM7! erjury that the information provided above is true correct 1 Signafore: Daze: 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 eriiploys.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 orlocal 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 permittlicense 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 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. j The Department's address,telephone and fax number: The Commonwealth.of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington.Street Boston,MA.0.211.1 Tel. # 617-7274,9E00 ext 406 or 1-8,77-MASSAFE Fax 4 617-727-7749 Revised 5-26-OS u-A-A1.mass.�ov/dia