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HomeMy WebLinkAboutMiscellaneous - 92 LISA LANE 4/30/2018t� 1 N_ O O b aN O O O O' Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director (978) 688-9531 March 24, 2000 Ms. Patricia Barbera 92 Lisa Lane No. Andover, MA 01845 Re: Sewer Tie-in Dear Ms. Barbera: :.. . 0 A �9SSACHUS���y Fax(978)688-9542 The Health Department has been supplied with a list of all residences, currently on septic, which have access to the municipal sewer system. As previously published at a Public Hearing on March 17, 1994, the Board of Health has adopted regulations concerning the required sewer tie-in. The following timetable concerning your property status was adopted: 4.1 All establishments that currently do not have municipal sewer available to them must connect to the sewer as soon as it becomes available, with a maximum time limit of sig months. The purpose of these regulations is to safeguard North Andover's drinking water, surface waters, groundwater and surrounding environment. Sanitary sewer is believed to be the most effective form of wastewater treatment. A copy of the entire regulation can be obtained at our office. Your property is in violation of this Board of Health regulation. Please contact the Health Department regarding this matter immediately. If we do not hear from you by May 10, 2000 your name will be placed on the regularly scheduled Board of Health meeting agenda and placed on public notice. The meeting will be held on May 25, 2000 for discussion of legal action including court hearings. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Sewer Tie -In 92 Lisa Lane Page 2 Any questions concerning this regulation should be directed to the Board of Health at (978) 688-9540. Additional inquiries regarding the physical tie-in and permitting process should be directed to the Department of Public Works at (978) 685-0950. Please be advised this Board intends to persevere in this regulation. Yours truly, Gayer Osgood, Chairman J Francis P. MacMillan, M.D., Member r\. S. Rizzi, D.M.D., Member SF/smc SEPTIC SYSTEM INSPECTION FORM ADDRESS 5Z L u& n - DATE INSPECTED O - qg` PROPERLY FUNCTIONING? 6) N WEATHER CONDITIONS COMMENTS: WA ER 4t3ALt i Y. TESTEb ? JZESULTS� DYE TEST PERFORMED? Y N DATE? SKETCH: T Location �� VISA �AIU e -- No. i a D Date 81 -?003 MORTM TOWN OF NORTH ANDOVER AL •. • O 9 ' Certificate of Occupancy $ 300 ,SSA�MUSESt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ x Check # 33cf.3 i `16655 C�- 1 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / D DATE ISSUED: , SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION L F LI Property Address: < 9-2- A15.,q 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimenyions: �+ 2"3 ?�)• 3 �zW 133 Zoning District Pr used Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone.Infoation: Public Private ❑ Zone Information: Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO 2.1 Owner of Record 2- Name Print) Address for Service: Signature Telephone 2.2 Owner of Record: VlauSiJlLaec. Nam Prin Address for Service: SignatVre Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 'cen Construction Supervisor- Not Applicable ❑ icensed Construction Supervisor: License Number 33 ��/� 5.�.- / . �f��/�� ��• �1�� Address Expiration Date Sig re Telephone doe Z 3.2 Regist ed Home Improvement Contractor Not Applicable ❑ Company Name 5 - '� // ��%% 33 Nl � ,-,-V S-;7- /1'U • le,, �/ (/ Registration Number Address Expiration Date Si re Telephone T rn X z O c rn 11 W O z rn 90 O mn3 r r zz Y♦ SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 DescHi tion of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ ` Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: /Ue 461 1413- �(v 1 e C K s c e e e v C) SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant (iFFICIAL ELSE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) — 4 Mechanical (HVAC)�0© 5 Fire Protection _ 6 Total- 1+2+3+4+5) ;' Dt0 00 t' Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT ORCONTRACTORAPPLIES FOR BUILDING PERMIT I, �/9"' /` �''� - as Owner/Authorized Agent of subject property Hereby authorize cJ(�/%`J�� �o Vim. �� .y�'s� to act on My behalf, in all matters relative to work authorized by this building permit application. 3 Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name _ 7 Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB 50N 7a -c e S - SIZE OF FLOOR TIMBERS ZX / 0 1 2 ND 3 PD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I-lEIGIIT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND _ae IS BUILDING CONNECTED TO NATURAL GAS LINE /%./V d Vicky Mikas 8, Daniel Lotman Z\.- -L-zu- e. WIK tCon HortpaFe MORTGAGE INSPECTION PLAN AM -.RS- I- cmwt W= now m-(- _m64MV VvAr LE (FRONT, sloE �cREAiFSETAACK-CttY1 -MftcntMT ACTIMI U*MW=,MA= at. MLf--W-QWIM 400. 5WnW outside i-nwrAm-cmm-!mATim-mwmTyIs 110t--L0cAwD'-W-E5TmUsHmFww ONA cmmuMTrpV4M--N0.--- 25—r09,P- aOQOC-- D*M- - 6-2-91- DEED - ANY UMMIRES-MME-SIMMIM-M W-TAOMM oAw-oF-TWAA7mT-MD OF-RIMOM PAW -W,jENqdER gULDWW AM SmM LMSWM CM FOOT FROM THE PROMTY UNE IT IS ADVM CERT. UM jtdAZA YORE ppMCjSL%AVLY BE MADE M VF7tlfY WEASIMIJIDIM -— TM CERrfrAMM m-8A5EM-*L.jW_L=&T" OF VJRWY UARVM OF KMM PAW I --P"SMBMWY.-NEUMAWN OF -SW&-f-MAMNS -L= W yA BsAC=pl Im max ax M ACUMAN-AGIMPANT SIAM. C E7 -!!O- PLAN-#- DAUM . ISM -FOR MORTGAGE MW - wl- 5J TCSL i� OFFSETS AS-SHOYM-ARE NOT TWK-...BOUW-AWAr,- f USED FOR THE EsTABUSAwn-OF-PROMIT LIN Wv I` I., L -r% A r% r-.-% r% r% WA 0 &I FORM U*- LO T ., s . cjcrnr� �onQ.� RELEASE FORM moq r -- DA-_ -e Q 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 or requirements. ------- ­­ --- " WWWW**"****APPLICANT FILLS OUT THIS APPLICANT_—/ �il CD1i•-G- LOCATION: Assessor's Map Number �p� SUBDIVISION STREET_ / Z1�� o HECOqpENDATIONS 0 - JF TOWN AGENTS: ,A PHONE_ PARCEL_�/2_ LOT (S) ST. NUMBER USE QNLY **** DATE APPROVED _ DATE REJECTED COMMENTS IVED DATE APPROVED % DATE REJECTED VC v NORTH ANDC` --R PLANNING DErAR.';,r,E:Nff FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERAVATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9W jm TE Name 0 �i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Ile- 10C , /YG� . I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity Please Print 7 7S -fo ur -& cc s 1 am an employer providing workers' Compensation for my employees working on this job. Company name. Address City Phone Company nine: , Address city: ; Phone #- Failure to secure coverage as required under Section 25A or MGL 152 can lead to the impmftn of criminal penalties or.a fine *to $1 SM arKVor one yearn imprisonment_ as_VicetLas.cafR4wnalties -theiam-daSTOPYAORK.9ROER and_afim-&A$Imw)ajlaY � understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cerffy under the pains and peva/ties of pequiy that Nae kgbm titian provided above is hve aendcare 0 -# 1 7,f `(e4r G ru, Official use only do not write in this area to be completed by city or town official' City or Town PermMcensi 0 . []Check if immediate response is required - SuifdingDept p Licensing Board Contact person: Phone #: �❑ Selectman's Office Health Department ❑ Other NEW ENGLAND ENGINEERING SERVICES �k INC August 11, 2003 North Andover Planning Board 27 Charles Street North Andover, MA 01845 Re: 92 Lisa Lane, North Andover Dear Sirs: Please accept this letter as certification that New England Engineering Services has inspected the above referenced property and determined that it is located further than 400 feet from any Bordering Vegetated Wetland within the Watershed Protection District. If you have any questions or require additional information please advise. Sincerely, F lyq� 02� RICHARD Rich d C. Tangard, PE. C. c TANGARD 13021 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number Iis that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) Q�d-, OU5�,� "4.,. - Si ure of Permit plicant O Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector TatmanPl _ ^ � �- '---- --�-_-.- -.-_�'---_--___�-� � Con mu PLAN t p l BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR $ _ Number: CS 040870 ' Birthdate: 07/01/1950 Expires: 07/01/2005 Tr. no: 14156 Restricted: 00 JOHN J HASHEM JR 176 KARA DR N ANDOVER, MA 01845 ".c+ Administrator f ✓fie �o�rvaz�vntuea a�✓Y�%aaaarfr�caella - -_ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR f Registration: 116025 Expiration: 5/10/2004 Type: Private Corporation HASHEM CONST INC i JOHN HASHEM JR 133 MAIN ST M� N. READING, MA 01864 Administrator Cf) M m C/) 0 m v, y d c � m CO) CM) CD n Z y CD CL O �• r c CL y �X CD CD CL cr d CD CCD O CCD W W a. c CD Na av y CDC2 H O 'oCD Z CDo 0 CD O -• ca O Q N O. O m M y »pCDS O o C) CD CA 0 CL CD .+ c Z O• ._.► = 10 m C T O a CL d = y O O m N p N 0gr0 m = =my: a -al 0 m o• � _ n Z CIA. " o n. C. N06 X :� f1^^� t0 O VJ = m W N cn mn ot _ -cm,a d C/) N y �Q O tC CD . co �uco Z, ® 0: 0R. C/)z y� C.3 co W ca "� W-0 Z Z CL's CA b cco O o o ro z " n o 0 �g d c� y 0 9 0 c ..e ......... ... ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that............................................................................................. has permission to perform K ./ 00 ........................................... wiring in the building of .... .. P...) " -��A a,, m /�-j .......... ........................................................ at ......... L-,ot�e . ...................... . North Andover, Mass. Fee .�6............ Lic. No .129 ......... 4` A ................. 4 ENSP.ECTOR Check# 10756 :.s ;'T Commonwealth of Massachusetts Official Use Only S Department of Fire Services Permit No. /'C--7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy 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 CMR 12.00 (PLEASEPRINTININKORTYPEALLINFORMATION) Date: VtfIG4 112 - QX or Town of: NORTH ANDOVER To the Inspector of Wires: �,y7this application the undersigV gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address L t s �► tAr-1 - E Telephone No.61 -. W, _ i Li Is this permit in conjunction with a building permit? Yes ❑ No E] (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 Ampacity Location and Nature of Proposed Electrical Work: `tai �� r n G UZS t U No. of Recessed Luminaires v.I v me ulluw{rl No. of Ceil: Susp. (Paddle) Fans cute m ae waivea a meg ector o Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency Lighting rnd, rnd. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices ' No. of Ranges No. of Air Cond. TotaTons l No. of Alerting Devices No. of Waste Disposers Heat Pump Number_ Tons......... INA-- No. of Self -Contained Totals: DetectionaAkrting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:x No. of Water No. of No. of No. of Devices or E uivalent Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs 7JNo. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6-0"Z ^ (When required by municipal policy.) Work to Start: () , Gr 4f I c2 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 con piete. FIRM NAME: M&WtCi1 C 1\„�� 4 LIC. NO.: i Li - Licensee: 1 `Z (�— % Signature- "� LIC. NO.: 1/1-1 %1S (Ifapplicable, nter "exempt" in the license number line.) Bus. Tel. No.: TkS�- i Address: 1 �` L,� \& CtkL—, S:A • Lo "t« vK �A p t�S C� Alt. Tel. No.: QT— ?-S,, *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic 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 Signature Telephone No. PERMIT FEE: $ E),ECMCAL PFRMT NO. WSPECTxON R_ POR ELECTRICAL Re -:inspection requzxecY($50A0) - X j 3:nspectors' comxmJats: - )CnspectoreSignature -xxo WOOS) Pate — I?assedLil Failed—[ l rWbspeetionrequired ($50.00)•-[ � r!! ' eats: (tzi.spectors° signature •- no 'tials Date 3. UNDER INSPECTION- Pa NSPECTION: passed — �jQ S�aiied— [ Re -inspection, required ($50.00) - [ � Inspectors' comments: (Inspectors' Signator no initials) Date 5. ISFECTION •- OMR: Passed—[ ] X+ailed- [ ]. ?te-inspectzon rer�uired ($50.00) [ 7 Inspectors, connments: (luspectorW Signatuxe -• no initials) date x➢O OP, TA.G,5 ARE TO BE P'IGLED OUT AND LEFT ON SITE M THE AREA TO 3E INSPECTED 19 NOT .ACCESSIBLE AND A. R_E JUSPECTION OF _$50.00 IN TOM, CFIARGED. - The Commonwealth of Massachusetts Ln Department of Industrial Accidents Office of Investigations k1i 600 Washington Street 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: (� �` Lt i �'��%, �. CJ �•1-e « Ni `A City/State/Zip: L-0 L, -ft Phone #: Are you an employer? Check the appropriate box: 1.0 I am a employer with 4. El I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2 .�I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3.0 I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.]r employees. [No workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *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 a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. 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 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. Sipmature• Date: 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia