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Home My WebLink AboutMiscellaneous - 75 CHICKERING ROAD 4/30/2018 (3)4 VI t f Date.. .`�..%`f TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that./4.P.. ... !?fry- .... .... �....�-.i1� .. � Sv�sf Mt ............. has permission to perform ....7..F.........,-�..'.:.s=-..K..^...��...a..�,s wiring in- the building of...... /4..!.. �'..�"►��:.. /-., P—.-5............................................................. at ..........��...(..::. Lt.:!�-�.!�'!`!.....��............> North Andover, Mass. Fee../D?.')...—....... Lic. No. 73/.7... ..... �4i-'............................................................ r ELECTRICAL INSPECTOR Check # &067/ - � tnontneOnWeatlh O� //1Q1d4eh�tdatf3 �epartmeni o�..tire sowices BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �y' l ct Occupancy and Fee Checked [Rev. 11071 ]cave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC). 527 CMR 12.00 (PLEASEPRDVTINDVK OR TYPE ALL INFO 170119 Date:loi7&q City or Town oh ' A 9 -MI To the bispector of Wires: By this appUcation the undersigned gives notice of his or her intention to perform the electrical desc "bY;% Location (Street & Number) ,. -- S — Owner or Tenant Telephone No. Owner's Address No. of Receptacle Outlets Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building 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 Ampneity No. of Waste Disposers Location and Nature of Proposed Electrical Work: Installation of temperature and fan controls on walk ins. Installation of vertical LEDs in reach in plass doors. I TonsI KW Completion ofthe follolvintt table may be lvaived by the Insnector of Rres. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Rot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency Lighting Batts Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Num er I TonsI KW No. ofSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ElConnection other No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of o. of Signs Ballasts Data Wiring: No. of Devices or E ulvalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNofDeignWirin No. of Devices or ulvalent OTHER: 01-0 .lttach additional detail ifdesired, or as required by the Inspector of Hires. r Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule I0, 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 x BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjtuy, that the information on this application is trite and complete. FIRM NAME: Wand Resource Mansprwrd, Inm /) .4 LIC. NO.: ini" Licensee: RaWA.Plar"Jr. Signature (P� LIC. NO.: 17314-" (Ifapplicable, enter "erempt " in the license number line.) Bus. Tel. No.• 7131.INGABn a,d 139 Address: 490 Neoonsel5l., aklo 2. Canton MA 02621 Alt. Tel. No.: 'Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S„ License: Lie. 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: $ 1 n. 5 Signature Telephone No. Lelsliq V -t , (:�4 b 1 M41, CY 3 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): National Resource Management, Inc. Address: 480 Neponset St. Bldg 2 City/State/Zip: Enron, mR uLuLi Phone #• (IM) UU-MI I Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 70 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. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' y � �'• = 9. ❑Building addition [No workers' comp. insurance comp. insurance. iequiredL] 5. ❑ We are a corporation and its 10.X Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and slate whether or not those entities have employees. If the subcontractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation Insurance for my employees. Below is the policy and job site Information. Insurance Company Name: CNA Insurance Policy # or Self -ins. Lic. #: NAWC825410 Expiration Date: 10/1/2014 Job Site Address: All locations in City/Statetzip: Nodk Ard ova MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: '1�� A— �A �e•J�7 aoXf-w i`✓ Date: Phone #: 781.8288877 Ofj'icial 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. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: l ' Client#: 36573 NATIORES ACORD. CERTIFICATE OF LIABILITY INSURANCEDATEPINUDONYM 1010412013 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT, If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Hou of such endomement(s). PRODUCER Starkwweather & Shepley Insurance Corp. of MA Pr BOX 549 Providence, RI 02901-0549 RWIT Kathy Osbom P 781320-9660 Ne ; 781320-9901 E41MLAwnwe Kosbo tabs .com INSURERM AFFORDING COVERAGE MAIC 0 ��A; CNA Insurance 03972 INSURED National Resource Management, Inc. 480 Neponset Street, Bldg 02 Canton, MA 02021 mums: Endurance American Specialty In 41718 wsuRERc: Guard Insurance Group INSURER D: E : INSURER F PERSONAL s ADV INJURY $1,000.000 COVERAGES CERTIFICATE NUMBER! REWRICIN NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR I TYPE OF INSURANCEwamm POLICY NUMBER ApaMIAM& LIMITS A GENERAL LIABILITY X COMMMERc1AL GENERAL LIABILITY CLAIMSMaoE%OCCUR 5095758467 1010112013 1010112014 EACH OCCURRENCE S1,000,000 D s 300 000 MED EXPOM one $5,000 PERSONAL s ADV INJURY $1,000.000 GENERAL AGGREGATE s2 000 000 GEN%AGGREGATE LIMIT APPLIES PER:PRODUCTS POLICY FRI M M LOC - COMPICP AGG s OOO 000 $ A A AUTOMOBILE LIABILITY X ANY Aero ALLOANEAUTOS D X SCHEDULED AUTOS X HIREDAUTOS X CEO OS 5096093603 5095162646 1010112013 1010112013 101011201 1010112014 ° r 0110001000 BODILY INJURY leer www $ BODILY INJURY (Persoddom $ PROPERTY°ArMGE s s B XI UMBREIJA LIAS EXCESS UAB x OCCUR CLAIMS4LUX EXCI0004266300 1010112013101011201 Ewm occuRnNcE $6,000,000 AGGREGATE $5,000,000 DED X RETENTIONs10000 $ C 1NORKERS COMPENSATION AND EMPLOYERS' LIABILITY ,, s WE"R E _„ �� YIN Ot?FtCE EMBEt�D�(CLG Q B OW" In N under DESCRIPTION OF OPERATIONS bebw NIA NAWC425410 010112013 10101120147X7 STATU 0TH EL EACH ACCIDENT $1.000,000 E.L DISEASE -EA EMPLOYEE $1000 000 E.L. DISEASE - POLICY LIMB I 111 000 OOO DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Asecb ACORD 101, Addt lmal Rauft Sdwdul% N mars spm is mp wQ Evidence of Insurance For Permit Requirements Only I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 28 (201 WR 1 of 1 The ACORD name and logo are registered marks of ACORD #S50MO M499546 SCS I Vis; COMMONWEALW OF-MASSACHUSE'ITS ; • • • •-• •AM -_l-tSUESnTHE==FOLLOW I'NG> O'CENSE °AS 'A•.: REG.) STEREDk MASTER ,ELECTR I-C"I AN NAT I ONAL'�RESOURCEt MANAGEAiENTi',;"I NC ,s' o "ROGER *.'PLANT JR 480 NEPONfiET 5T ~! 1 U _ :CANTON=:.' >>` `MA<A= 1 A_ 24'2�1N197 33 i Date............/ //y TOWN OF NORTH ANDOVER PERMIT FOR WIRING i V iti, This certifies that �`�.'t-................... has permission to perform ................. � �. .. f''° ........................... IY ............. wiring in the building of...... `l r 1Q x 75- /...............ee........................................................................ at ............ � .. . 2 /[� s2 �6 .................. . orth Andover, Mass. .................................................................. Fee...�d ......'.... Lic. No?Q..... .d .. r-'...... ...... ............. .................. . F ELECTRICAL INSPECTOR Check It ' a Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ) Z ( (-Pl/ Occupancy and Fee Checked [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co C), 527 CMR 12.00 (PLEASE.PRINTWINK OR TYPEALL )NFORMATION) Date: /9, 02- o) y 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 & N Owner or Tenant i Owner's Address 7.5 /%c t A -i / -/ /V0 , lit e:1D Lel xx Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: iulz o [rt k %i % tt!`rw 1P Ce(A K Completion of thefollowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. o meits Lighting rnd. rnd. Batter Units No. of Receptacle Outlets No. of Oil Burners FM ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons """ '".."...1.K................. KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No, of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 9. -BOND ❑ OTHER ❑ (Specify:) I certify, under the ains nd enalt. ofper�7, that the information on this application is�true and complete. FIRM NAME: r'r b .�er l// ✓L l r� LIC. NO.:.9O 9 �0 - A Licensee: Signatu MC. NO.: (If applicable,ter "ex pt" in the license number lineh0,00V-e--- Bus. Tel. No.: 9 `ir%799- Address: 0, t p 1L ( � 5 ill D AAA('� l `i s Alt. Tel. *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 0 Re- Inspection Required ($.) ❑ Inspectors Comments., Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 4j3 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com .A The Commonwealth of Massachusetts Department of IndustriqlAccid&ts Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): A. (S 41. ( /U ,� , Address: P D. City/State/Zip: p U Ag.De) W,— ah Phone it: 751` 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. ❑ New construction employees (full and/or part-time).* 2. 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9 ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.[4 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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' 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 a're doing all work and then hire outside contractors must submit a 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic.M / Expiration Date: Job Site Address: 75 City/State/Zip: A)Q AA 4,9 dW 6 (,f 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 c rider tl �.• s a pen ie (perjury that the information pro vid above is true a•7�nd correct. 7 Q;_af Ira• nate- "'e Phone #• 7� r —?,ft— %9-7 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 employeiis 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 loeal 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 Gaxxazonwealth o1assac?�usPtts Department oflndustrial .Accidents Office ofInvest?gations 600 Washington Street Boston} MA, 02111 Tel, # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia