HomeMy WebLinkAboutMiscellaneous - 7 EMPIRE DRIVE 4/30/2018 I � E�y�,�� �a.��
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Date . A +. . . .'.? .
• �.CSliW�iy�a�. .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . . . .4� �:�^� . �"t - . `. . .C - •` 1
has permission for gas installation . . . . . kA0vv---R . . . . . . . •
r
in the buildings of. . . . .Q.< <1!`�J�- ` '�---
at . . . . . .7 . . . . , North A dz1ver, Mass.
Fee's 10U,Q a. Lic. No. . .1
GASINSPECTO
Check# 5
8548
'1AlIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: �4,U AV MA. DATE: . -(0 `(3 PERMIT# (?�V.—
JOBSITE ADDRESS: C.M p TKR__ WT-4— OWNER'S NAME:
GOWNER ADDRESS: TEL: FAX:
TYPE OR
PRINT OCCUPANCY TYPE: COMMERCIAL E) EDUCATIONAL E] RESIDENTIAL[�J
CLEARLY NEW:[!I' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
F
IANCESi FLOOR, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
R
ER
RSION BURNER
STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER ( µ
INSURANCE COVERAGE
I have a current iiabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [7 NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY [J' OTHER TYPE INDEMNITY n BOND El
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ 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 wi be in compl' nce with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER/GAS FITTER NAME: SjfiPHEN C. GALINSKY LICENSE# 1034's SIGNAT
COMPANYNAME: QAL10K'd PLUrAi 1 G -t M1_fi11 & ADDRESS: P.Q. RGX 1701
CITY: OAVE21f I LL- STATE: rn.A• ZIP: 018 31 FAX: q7$ 621-4131
TEL: q79—3714- 17y3 CELL: 5-0g - S A_ 6goq
EMAIL: 'W'W'W m rcD+h EJ O
@ yr
MASTER[/ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION/# 31 qb PARTNERSHIP❑# LLC❑#
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
X10
i _ J
FEE: $ PERMIT#
PLAN REVIEW NOTES
L,t7 h
7r 3
0 11751 9 Date . .1 -� . - . 3
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . . . ±^SV`� \ w.•1�`rt^. `�"�?! . `.
has permission to perform . . . . . . . . . . . . . . . . . . . . .
. y
plumbing in the buildings of. . . . . . . . . . . . . . . . . . . 'L-. . . . . . . . . . .
at . . . . . . P-',R. . . .P".-c .. . . . . . . . . . North Andover, Mass.
Fee . !—('.0 . . Lic. No. . Q. ?LL g . //
PLUMBING INSACTOR
Check# ` S-7 S
MASSACHUSETTS
"wUNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY I_"IJ"YI� VfU� MA. DATE I - l O - f 3 PERMIT#
JOBSITE ADDRESS FVV tnT l+,0" OWNER'S NAME d✓t-L V��C.f�N�
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO ❑
CLEARLY
FIXTURES 1 FLOOR BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
E
ATED GREASE SYS
ATD GRAY WATER SYS
ATED WATER RECYCLE SYS
ING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY of
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET Z
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current iiabiliinsurance policy or its substantial equivalent which,meets the requirements of MGL Ch. 142. Yes(?'No El
YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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 BOX ONLY: OWNER ❑ AGENT ❑
Si nature of Owner or Owner's Agent
I 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
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap r 142 of e G eral Laws.
PLUMBER NAME SrEP1+150 C- GALfOSKY SIGNATURE
LIC# (03413 MP[' JP❑ CORPORATION X# 319(- PARTNERSHIP ❑# LLC ❑#
COMPANYNAME_ &AL4f.15KY Pt,UM01Mb *- RIMT11AG ADDRESS: P-0. 6ax 1709
CITY HAVC(ZRILL STATE M.A• ZI_P 01131 EMAIL h/%.vw• mr lvmbeg1 . co !
TEL q7$'37+1- 17ij 3 CELL 50-50'4-510H FAX q7$-5AI—`413i
1
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
i
FEE: $ PERMIT#
PLAN REVIEW NOTES
Date / —/.3
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . . . . . . . . .w'? R r /
has permission to perform . . /1,/r-. . . .
wiring in the building of . . .!3�./ . . . 1`�r.sr5.,.`r� .�. . . . . . . . . . .
at . . �� . . . .�� . . . . . . . /. '✓�.�;NortfAhdover, Mas
Fee . g23Z.�ic. No. .A,. ? U. . . . . . . . . .
ELECTRICAL INSPECTOR
Check# /3 z a S
11387
commonwealth of Massachusetts Official Use Only
Permit No. // -3 S-`7
Department of Fire Services
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(NEC),527 CMR 12.00
(PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: / ?/— / 3
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&Number) VNo
i i f
Owner or Tenant t S� Telephone No.
Owner's Address Z Is this permit in conjunction with ailding permit? Yes ❑ (Check Appropriate Box)
Purpose of Building �� / �J Utility Authorization No. ��_��
- Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service ZAV Amps 1-4"/ a-f o Volts Overhead❑ Undgrd [�]�No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the ollowin table may be waived by the Ins ector o Wires.
No.of Total
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above o.o Emergency ig mg
In-
No.of Luminaires Swimming Pool rnd. rnd. Batte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Gas Burners No.of etection and
No.of Switches Initiating Devices
No.of Air Cond. Total No.of Alerting Devices
No.of Ranges Tons
Heat Pump Number .Tons KW o.of Self-Contained
No.of Waste Disposers Totals: Detection/Alerting Devices
Municipal Other
No.of Dishwashers Space/Area Heating KW Local❑ Connection
' Heating Appliances ecurity -stems:"
No.of Dryers KW 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 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:/—3/ —/3 Inspections to be requested in accordance with NEC 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 orce,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 pinerjury,that the ormation on this application11
is true and complete.
FIRM NAME: . LIC.NO.:
Licensee: ��. / - �5�„ �� Signature O.: �/y 3
(If applicable,a er "exempt"in the license number line.) Bus:'1'e1.iVo.: ,��7=�
Address: Alt.Tel.No.:
`Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check m2❑owner ❑owner's a ent.
Owner/Agent PERMIT FEE: $
---- Telenhone No.
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR-DOUG SMALL
1.ROUGH INSPECTION:
Passed— Failed—[ j Re-inspection required($50.00)-[ ]
Inspectors' mments:
rilaz
T
(Inspectors'Si natu no initials) Date
2.FINAL INSPECTION:
Passed— ) Failed—[ ] Re-inspection required($50.00)-[ j
Inspectors' mments:
(InspectWs'Signat re-no initials) Date
3.UNDER GROUND INSPECTION:
Passed—[ ] Failed—[ J Re-inspection required($50.00)
Inspectors'comments:
(Inspectors'Signature-no initials) Date
4.INSPECTION—SERVICE: .
DATE CALLED NATIONAL GRID: NAME:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date
5.INSPECTION-OTHER:
Passed—[ j Failed—[ ] Re-inspection required($50.00)
Inspectors' comments:
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
Date.............................................- .
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
10
s�CHugfc
This certifies that .................................... .............................
has permission to perform ...
......................................................................................
wiring in the building of........ ............... .............................
/L L North Andover,Mass.
#t ......................................................................................
................
Fee...,3 ....... Lic.No.1).��-33 .................... ...................
........................................
ELECTRICAL INSPECTOR
Check#433 3 7-
7' 47'
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(NEC),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: S — d — -Z,11/3
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&Number)
Owner or Tenant — - Telephone No.
Owner's Address Z 77 11-7 /,r
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of BuildingS- /�`� - Utility Authorization No.
- 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:
Completion of thefollowing table may be waived by the Inspector o,f Wires.
Trans
No. of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Total
Trsformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ NO,o mergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets 69" No.of Oil Burners FIRE ALARMS I No, of Zones
No.of Switches 3 No.of Gas Burners No.of Detection and
Initiating Devices
Total
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Dis posers Heat Pump Number Tons KW No.of Self-Contained
p Totals: - Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other
p g Connection
No.of Dryers Dr Heating Appliances KW Security Systems:*
3' No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
1 Heaters Signs Ballasts 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: S- — /3 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: . , / / �e��� LIC.NO.: 3�
Licensee: w�� s Signature LIC.NO.:
(If applicable,entp "exempt"in the license number line) Bus.Tel.No.-
Address: Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(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
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 0 Failed IN Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date: '
SERVICE INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INECTION:
Pass K Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
e 611
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
- Department of Industrial Accidents
Office of Investigations
600 Washington Street
i` Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#'
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. E]New construction
employees(full and/or part-time).* have Hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. E]Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
1 ri ht of exem tion er MGL 11.❑Plumbing repairs or additions
3.❑ I am a homeowner doing all work g P p
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:.
Policy#or Self-ins.Lica#: Expiration Date:
Job Site Address: City/State/Zip:
T 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:
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-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 f
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 Coni onwoalthofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA.02111
Tel,#617-727-4900 ext 406 or 1-87T MASSAFB
Revised 5-26-05 Fax#617-727-7749
www.mass.gov/dia