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HomeMy WebLinkAboutMiscellaneous - 73 BUCKINGHAM ROAD 4/30/2018N ^i G W ' O W fT C Q C7 O Z '" G7 i � � ' O p :l1 S D 1Op l _-.�-:. r.�_-_---__~-_~__~.___-`_,_. .�`_ .�_--�_` `` . ! ' `� / ! I]ub: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I� pl/{✓ MA DATE —071W/2015 PERMIT # h5 A JOBSITE ADDRESS �f�etie,_ OWNER'S NAME OWNER ADDRESS Same TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ® EDUCATIONAL RESIDENTIAL f'T Ti A UT V NEW: RENOVATION: ED APPLIANCES 1 FLOORS- BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I -- REPLACEMENT: 11 PLANS SUBMITTED: YES® NO 10 1 11 1 12 1 13 F 14 3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [] NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ED OTHER TYPE 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. SIGNATURE OF OWNER OR AGENT I CHECK ONE ONLY: OWNER [I AGENT Ej 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 co liance with all Pe en provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Robert Josey —] LICENSE # 9185 SIGIVTURE MP (J MGF ® JP[j JGF ® LPGI ® CORPORATION [j#= PARTNERSHIP ®#= LLC ®# COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY Auburn STATE MA ZIP 01501 TEL 508 832-3295 FAX 1 508-926-434=7]CELL 508-245 7431 EMAIL I'Ll ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY 7Iz � is Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE; $ PERMIT# PLAN REVIEW NOTES A �Q FINAL INSPECTION NOTES Division of Professional Licensure: License Search * The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > ..............................................................................................................................................--........... ........... .......................... ...................... .......... Check A Professional License By the Division of Professional Licensure LICENSEE Name: ROBERT A. JOSEY E DOUGLAS, MA NEW SEARCH **This Licensee has additional Licenses, click here to view them.** Licensing Board: PLUMBERS £t GASATTERS License Type: MASTER PLUMBER License Number: 9185 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday, July 15, 2015 at 3:20:42 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma4us/public/pubLicenseQ.asp?board_code=PL&type_class=_M&li... 7/15/2015 Date/...... , % 4-iP01 TOWN OF NORTH ANDOVER. PERMIT FOR PLUMBING This certifies that ....................................................................................................................... has permission to perform ........ ....... ....................................................................................... plumb in the buildings of ... .. . ........ ""' ... ­­­*­*­***' T� —bAQj4-4 �� '� Andover, at ................................................ . .............. .................... ............ North A er, Mass. Fee ..... Lic. No..:. ... MY"k. .......................... PLUMBING INSPECTOR Check # \ 11-V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s _ ' CITY MA DATE PERMIT# JOBSITE ADDRESS �"731 OWNER'S NAME POWNER ADDRESS4A-MA' I TEL FAX Lj TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIALfig PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES ® NO E] FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE�i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM_..__J -- i I DISHWASHER DRINKING FOUNTAIN _ FOOD DISPOSER i I _._.-.-._.1 f _..__.i I-_-__-"--_-__�----.._i i _._..._ [ ....__..I .__._I I FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN. SHOWER STALL f _ _.___I -__J cRVICE / MOP SINK TOILET I t f _ _f _ _. P I _1 WASHING MACHINE CONNECTION f i _._..__.. _' WATER HEATER ALL TYPES WATER PIPING _ i _.___..f _f — I i _....._ _....__I _.._._f f _..._.._ f –J OTHER __l _ i_ ... __i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Q NO _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND Q 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 _i AGENT IQ 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 witb all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ I LICENSE # SIGNATURE IMI JP © CORPORATION 0#PARTNERSHIP D# LLCj COMPANY NAME ADDRESS CITYj STATE I tqA ZIP ^� �' ^� TEL FAX CELL �� EMAIL \ 11-V }3, �J Date ... i�/� 4�� ................ TOWN OF NORTH ANDOVER PERMIT, FOR GAS INSTALLATION J This certifies that ... .............\c -,-A..... .......... .................................................... has permission forS. tall tion.bv7::e.4.Nej ..... ...... in the buildings of ........ ......P... .0- . ... I ......... ............................................. atT5. North Andover, Mass. Fee.. ......... Lic. No. ............................................................... GI qt;riGAS INSPECTOR Check # 9537 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY aiM�9� MA DATE PERMIT # JOBSITE ADDRESS I �'7 �; h. _ ►�n� •� ••- OWNER'S NAME Gil OWNER ADDRESS TELFAX TYPE OR PRINT� OCCUPANCY TYPE COMMERCIAL _ I EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER-- CONVERSION BURNER =. _ _.__ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE —_ (_a1_ L..__....._--I -- - - - =.— �c GENERATOR (� f GRILLE INFRARED HEATER. LABORATORY COCKS MAKEUP AIR UNIT OVEN �� - _ L^ POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST--- `I;'i1IT HEATER LJ �, EN ED ROOM HEATER { _ TER HEATER OTHER_ . r INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES []NO [� I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F-31 OTHER TYPE 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 Q AGENT Elf SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with-all Perti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME. LICENSE # ( SIGNATU E ��,-c-�,� MP6 MGF JP JGF LPGI CORPORATION 0# L�. 1 PARTNERSHIP®#= LLC ®#= COMPANY NAME: _ LGy�i4-`t a-aw ADDRESS _.._.._i: 444 49 - O CITY p �c, STATE ZIP O 2_1 �r TEL FAX CELL EMAIL The Commonwealth of -n2assachusetts Departmentof liidustriglAcculents Office of Investigations 600 Washington. Street .Boston, .NIA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contracl NaMe(Businsss/Organi'zationffnadivviidual): °// 11K ✓ - v Address: City/State/Zi-p: 9i514J-11-1 Phone #: L17 626 —36 Are you an employer? Check the appropriate box: Type of project (required): 1. K1 am a employer with 4. ❑ I am a general contractor and 1 6 [j New construction employees (full and/or part-time).* 2. [] 1 am a sole proprietor or partner have likedthe sub -contractors listed on the attached sheet 7. ❑Remodeling ship and'have no.employees These sub -contractors have 8. 0 Demolition working forme in any capacity. workers' comp. insurance, 5. ❑ We are a corpora�on and its 9. F1 Building addition [No workers' comp. insurance equired.] officers have exercised.their 10,[] Electrical repairs or additions r3. ❑ am a homeowner Going all work right of exemption per MGL ME] Plumbing repairs or additions m seo workers' comp. [N. lf y p c. 152, §1(4), and we have no 12.❑ Roofxepaixs insurancerequired.] t employees. [No workers' 13.0 Other comp. insurance required.] '%ny applicant that checks box #1 must also fill out the section below showing their Workers' compensation policy information. i -Homeowners who submit this affidavit indicatingthey ke doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheAthis box must attached as additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am are employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self ins. Dic. #: l Expiration Date: Job Site. Address: �� C41,1� 6"t g4-1 CityIState/Zip:_ )I% xAt Me,- Attach ce%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 ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or ones -year imprisonment, as well as civilpenalties 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 cert! undeAtYZe pains andpena�ies of perjury that the information provided above is true and correct, Oficial use onfy..Do not write in Mis area, to be completed by city or town official. City or Town: Permif cense # 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 Ins4ructions 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 tri the service of another under'any contract of him, 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 ox trustee of 'au 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 shalinot because of such employment ba deemed to be an employes." 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 riecessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificates) 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. B e advised that this affidavit maybe submitted to the Department of Industrial fir 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 thepermit 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 thatthe affidavit is complete andpHuted 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 whichwill. be used as a reference number. in addition, an applicant thatmust submitmultiple pemit/license applications in anygiven year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "allloeations in (city or town)." A copy of the affidavit that has b eon officially stamped or marked by the city ox town may b e 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 orpermit 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: TN Com mom.e tit oi'Massa ..c 1 wotts Mvar ent o£XndwWal .Accidents Moe dwestiga-am 600 Waftgtom (reel Boston, MA. 021 X Z TQL # 617-7-2.7,4900 ,4900 et 406 Qx Z -877•:W. SAMI Revised 5-26-05 Fax # 617-727-7749 749 w�vw..�tass.govfdia. 5, MENLO tt 02135-2 n O MONWEALTH OF MASSACHUSE., ERIAL MBER LICENSE NUMBER EXPIRATION DATE SNU Date ...47 !..! .�.Z ...... . p` „ro ,ere pL TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r This certifies that ..:�� v:...... ......... ......... has permission for gas install tion .... �'' �` !'..riT in the buildings of ..:-?.P�'!'�� ......................... at ... vC�h A .... , North A dov M'as Fee.0� r. �(). Lic. No.. 3�? ./....... . GAS INSPECTOR Check # /Z s • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE J Z PERMIT # JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS _ rJ1 TEL—��11FAx TP" O" OCCUPANCY TYPE COMMERCIAL]! EDUCATIONAL D CLEARLY NEW: Q RENOVATION:) REPLACEMENT: EZY APPLIANCES 1 -, FLOORS-► BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN (� POOL HEATER ROOM/ SPACE HEATER _ ROOF TOP UNIT (� TEST UNIT HEATER UNVENTED ROOM HEATER _ WATER HEATER RESIDENTIAL [9— PLANS SUBMITTED: YES E] NO E] 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES larw IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © 13OND1 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 E] AGENT F SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc rate' to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp}ia'�ce w all Pertir}�nt prove n of thy/ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / / i I/ PLUMBER-GASFITTER NAMEJ1 LICENSE # MP Q MGF 0 JP El JGF_; LPGI []( CORPORATION [ff# PARTNERSHIP 0--1 #= LLCM# COMPANY NAME:_ 5.1-ywl,it - ,t- 67/ ' ADDRESS�/- CITY Lt �e,=_& j l u v -G STATE�ZIP �_ � I TEL'- 7 6 M ��C3 i� v FAXCEEB TIS 73 EMAIL J,4e L.) -,0'4 ja J ALIN The Commonwealth of Massachusetts Department of-ndustriall4ccidents Office of 1-nves gations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Vlicant Informa.i-inn Name (Business/Organizatio Andividual): - - Address: - - -- --- City/State/Zip: Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).*" 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. t ship and have no employees These sub_contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ am a homeowner doing officers have exercised their _I all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *any appiieant t`at chec:y, box 41 m,_ -t also fill 0111 the section belor; , T Ho eir wa' �- — — Type of project (required): " 6. ❑ New construction 7. ❑ Remodeling 8. "❑ Demolition 9. ❑ Building addition 10.❑ Blectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other meo ors that who submit thibo affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ConTcactors 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 information. insurance for my employees Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of fine up to $1,500.00 and/or one-year imprisonment, as well as criminal penalties of a 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 flusstatement maybe forwarded to the Office of �^ Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjuYy that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town offcial City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. CiVTown CIerk 4. Electrical Inspector 5. PIumbing 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 6r 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 _._dwel inghouse-of another_who.employs.persons to-do.maintenance,.constructioin or -repair work on -such dwelling -house -. ---. - or on the grounds 6r 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), addresses) and phone number(s) along with their certificates) 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 �� that thee v � the res_-a:�'� t7 the city lir t+�Ct� taaa�. taar F�—u��rFeC�' cin for t,:e per,,,�i� OT 1?ctin5e 15 beteg request --d, -no: the D"• arta=ent 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance f6r your cooperation and should you have any questions, please do not -hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8-77-M. ASSARE Revised 5-26-05 fax # 617-72.7-7749 wv7vj.rnass.xovfdia