HomeMy WebLinkAboutMiscellaneous - 98 MIDDLESEX STREET 4/30/201810667
Date ....r%!J./...T.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... Ul.......y`..............................................
has permission to perform ....f,�4.. r..a+........ ..............
plumbingin t/he,buildings of.............................................................................................
at..? ..................................... N rth ndover, Mass.
.�
Fee..r�!Sv.. Lic. No. C.
% P UMBING INSPECTOR
Check # (�
NJ\
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- _
CITY il/�7N--- U✓MA DATE .._ _ PERMIT #
JOBSITE ADDRESS . OWNER'S NAME .�
---� --�
OWNER ADDRESS _....�-- +'a u. _ _ ._-- ____-_----.-__---_.___._ _.______
. _.. _ TEL __.�.u_.�--�.-------_FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL Q EDUCATIONALF-11 RESIDENTIAL (�
PRINT
CLEARLY
NEW. 0 RENOVATION: Ej REPLACEMENT: PLANS SUBMITTED: YES[] NO[]
FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM '
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM J ._.._.._. t .7-1
DEDICATED GRAY WATER SYSTEM ._'_.
DEDICATED WATER RECYCLE SYSTEM-:
DISHWASHER
DRINKINGFOUNTAIN _ .___. _. _-._---.--._._ _.___._ .._..__-. _. ____J __._----.._...-- •---_._. _.__._1 ....__..._......_... J _.....__` .._. __
FOOD DISPOSER _ ..... -------
_----_FLOOR/AREA
FLOOR/ AREADRAIN
INTERCEPTOR INTERIOR f .:._.-I
KITCHEN SINK
LAVATORY
ROOF DRAIN .__( __
El
SHOWER STALL I t
SERVICE l MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES _.-..------ 1
WATER PIPING
OTHER
__........ 1 _.w..._._J _ ...___! ._— I .__-- I .._.._.J . __...__J ___i ____- . --.-- _ I ._.. _ 1 J ._..__J
INSURANCE COVERAGE:
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO F]
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ---J OTHER TYPE OF INDEMNITY 0 BOND 0
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 0 AGENT []
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information 1 have submitted or entered regarding this application are t ue and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b co pllanc th a erllnent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME--.._..,_-,�S�q%P•G _....__._._.-_i LICENSE # _.. a3.6SIGNATURE---�
MP EI JP ._ i CORPORATION# 3 - }/ -' PARTNERSHIPEI#= LLCEj#
COMPANY NAME..5. �R14- ...- P. - ADDRESS p O.... -
CITY -- Od2t'.y n_,_, /p7/�-_._STATE 21P Of $_...___ II TEL
FAX .5412a ] CELL _0 S- �3�_ EMAIL
NJ\
F�
a
0
Date ....... .` & — 14111.............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
...........................................................................................................................
has permission to perform ..............(...d-7---? Wvp.(
..........................................................
wiringin the building of...................................................................................
IF .M/ ..
at ............................. p/>:.............................. ....... ,North Andover, Mass.
Fee...... ................ Lic. No. 2. [...%
�.......................... �.......................
! —7 ELECTRICAL INSPECTOR
Check # ! � j �� '
TIC)
_"eFarcmeru Of ✓cre ,ervwe:r
Occupancy and Fee Checked t 2_1
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (ieaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE TION) Date:
- LL IF RMA
City or Town of 1f
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) 7t' Z7)�JoJe5 Z,2 Sy.
Owner or Tenant /',. �, Telephone No.
Owner's Address ��rr,-2•
Is this permit in conjunction with a building permit? Yes ,N No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number.. of_Eeeders.and_Ampacity_
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completion of the following 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. -ofLuminaireOutlets �
No. of -Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool rnd. bove ❑ - ❑
o. ond. BatteryUnits cy ighting
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Coni; Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
TonsNo.
of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KWLocal
❑ Municipal 11 Other Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Nater
No. --of No.. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total UP
a ecommumcationswiring:
No. of Devices or Ectuivalent
OTHER:
Attach additional detail if desired,, or as required by the Inspector of Wires.
Estimated Value of le trical Work: yai (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 ❑ BOND ❑ OTHER ❑ (Specify:)
I cert, under the pains �and penaltie/sof, erjury tit to information on this application is true and complete.
FIRM NAME: : �` % 7 i_ �/ c �� c. Y Al- dra o 0�'JS GLC LIC. NO.: �l %OS
Licensee: U jyr�% Signature / LIC. NO.: 2) 9Oj
(If applicable, enter "exempt" ip the h ense number line. Bus. Tel. No.:
Address: 2 PJ41wly 7�,> , /�/or-J'.�nr t %�D, alm Alt. Tel. No.:
*Per MG.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
Signature Telephone No. PERMIT FEE: $
n i
�C��
� r
�,
9331 Date.
has permission to perform .... kwzr
plumbing in the buildings of ........................
at ... ........ N rth Andievet, Mass.
g, 1-4)0
Fee—.!.�".'$�U . Lic. No. 11414. . ./. 1. -.-. . . . *
PLUMBING NSPECTOR
Check #
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SS
US
This certifies that
...........
has permission to perform .... kwzr
plumbing in the buildings of ........................
at ... ........ N rth Andievet, Mass.
g, 1-4)0
Fee—.!.�".'$�U . Lic. No. 11414. . ./. 1. -.-. . . . *
PLUMBING NSPECTOR
Check #
• . t
P
TYPEOit
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY j MA DATE] Z�Zit J PERMIT tl
JOBSITEADDRESSSNAME S - OWNER`l'VlIfe
rt i 1 Y �
OWNERADDRESSi 9f K � TEL JFAXI I
OCCUPANCYTYPE COMMERCIAL] J EDUCATIONAL RESIDENTIAL)
NEW: { R RENOVATION: (REPLACEMENT: I I PLANS SUBMITTED: YES I I NO.(&�-
FIXTURES FLOOR-
BSM
1
2
3
4
5
ti
1 7
fi
9
10.It
12
13
14
BATHTUB
_
. , .._
.......
:..
�,
_....
..
-
CROSSCONNECTION DEVICE
.
� .
_ ....
_ .....:.
_.'
.., :
...
f
_ ..
DEDICATED SPECIALWASTESYSTEM
DEDICATED GAS/OIUSAND SYSTEM
_
j.
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
_ _j
.... _
.:-.._ _.:.,_....�
......_....
. ,
'
. .. -. I
.. .._.
;..::....,
__.:._I
. :.:.!
....... i
.._.. ,.....,.
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
-
_
: • --
FOOD DISPOSER
i
.. ,
I
!
.
i._t
-
.: ..
'
... i
:-:....
FLOOR /AREA DRAIN
f
-
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
I
_.. _.
_ 4,
_ .....:._
.
.. _...:
ROOF DRAIN
j
_ _ .._�
SHOWER STALL
I
I
i
SERVICE/MOP SINK
TOILET
i
i
I
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
.OTHER
4
INSURANCE COVERAGE:
1 have a ctirrent liabilit iitstlrmice policy.or its substantial equivalentwhich meets the requirements of MGI -Ch. 142. YES J,-I'NO J i
IF YOU CHECKED YES, PLEASE INDICATE THE TYEOFCOVERAGE.BYCHECKINGTHE APPROPRIATEBOX BELOW
LIABILITY INSURANCE POLICY I OTHER TYPE OF INDEMNITY J BOND (,
OWNER'S INSURANCE:WAIVER: I am aware that the licensee.dbes not have the insurance coverage required by Chapterl,12 of the
Massachusetts General taws, and that,nty signature on this permit application waives this requireinent.
_ CHECK-ONEONLY: OWNER ( AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify lhal all of the details and information I havasubniitled of entered regardiog lOis application aid. nd accurate to t st of my knovAddge,
and that all plumbing work and installations perfornied under the permit issued for this application Will be in iplia tall n provision of the
Massachusetts State P 6iIng �Ckde and C i+s�r11142 of Hie General Laws.
PLUMBER'S NAME -KZ' ' I � `°� � 1LICENSE fl 1 I3 g SIGNATURE
MPS I ,1PJ I CORPOI2ATIONJ .JM 1PARTNERSHIPI Iffy ILLGJ J#I)
COMPANY NAME �QWJy12/M��"�/�l�/ Si 'A -j ADDRESS ( 1p 4kNk Sf }
CITY r I STATE (/%G ZIP 16'/ E? TELL 107if- JY� AZO%
FAX CELL EMAIL f /S
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- aviti,
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-din, the aplllfcaitt,
PleilsabeisllrO to fill io th6pmifffice'
lilaf must strbtitit' atillfiple penlliilticeilse applica[iolis itt nnysgiveit year; ueetl'oniy� "submit one �ffidaxif indicating ctnrenl
(city-or
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7- . 6 77.:MApAr.F-
Date .. ?/*/Z ........
TOWN OF NORTH ANDOVER
n
• PERMIT FOR GAS INSTALLATION
This certifies that .................. t`
has permission for gas installation
in the buildings of . fivq<9.............................. .
at ...,lam . A!' .le-FW2 /. .. ! ..... North Andover, Mass.
Fee.?b.•.�V . Lic. No./?�l�G.. .41 -k
GAS INSPECTOR
Check # 1,6 3
•
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: /�d�r�1 /Y�✓7 MA. Date:Z Permit#
Building Location: b Owners Name: lh& i�
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: � Replacement: ❑ Plans Submitted: Yes ❑ Nom
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SUB BSMT.
BASEMENT
151 FLOOR
2 FLOOR
3Ku FLOOR
4 FLOOR
5 FLOOR
'
6 FLOOR
-ff
FLOOR
6 FLOOR
Check One Only Certificate #
Installing Company Name: dv'rv1r't
,V&�I'
Address: 4( /`pier•/ City/Town:
/ ,�
44401? /J4c State: /0/+
❑ Corporation
Qui
Business Tel: 97t I /` �i
Fax:
❑Partnership
❑ Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yeg-�'No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 9--r
Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner El Agent El
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) repardina this aoDlication are true and
db{JuldtV w ine Desi or my r�nowleage ana that an 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 Co nd ter 142 of th neral Laws.
Type of License:
By [�' lumber
Title
El Gas Fitterture of Licensed umber/Gas Fitter
r
ourne man License Number: 3
APPROVED (OFFICE USE ) ❑ LP Installer
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
..600 Washington Street
.Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
MiCant Infnrmaiinn
Name (Business/Organization/Individual):
City/State/Zip
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. 13I am a general contractor and I
employees (full and/or part-time).*,
2. [° Imam 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.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We
are a corporation and its
required.]
3. [1.1 am a homeowner doing
officers have exercised their
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.]
.-
ny a.:g:icant that checks bas *l must also fill cut the .
t section beloi�
�y�zd7
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8..❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
hey Homeowners who submit this affidavit indicating they are doing all work and then lure outside contractorsside contrsctors 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
Policy # or Self -ins. Lie. #:
Job Site Address:
Expiration Date:
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 er t and penalties pe ' "✓J that the information provided above is true and correct
Sienature:
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 #:
U
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 15.2, §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 umtil 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 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
be. rs tamr -e_ to the city or town. that' app'Noa �o• or the pc :Alt or license s being e ee n
'� e 4 f F n e r eg g requ stec, not the Der$Tt�r:ent or
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 cumber. 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 0211.1
Tel. # 617-727-4900 ext 406 or 1-8.77 I IASSAFE
Fax # 6.17-72.7-7749
Revised 5 -26 -OS
www- mass-gov/dia
7741 Date . 7 ..— !. � . -.1. ! .....
` TOWN OF NORTH ANDOVER
-,z PERMIT FOR GAS INSTALLATION
This certifies that . t�. ? �- a �Ni. Y?�.... ! .......? ..... .
has permission for gas installation.:0-GC.a!!C E.
in the buildings of . . v, :�l ...6 !r�'^.H ...................
at North Ando er, Mass.
Fee.a. :c. v.. Lic. No.,3 .. V. ...A&�.
_ GAS INSPECTOR
Check # O 7 65
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
-Nf3LIA ANOMPL , Mass. Date12-PI Permit #
Building Location Owner's Name N UZ DA A
MO'i A AMIXI ER.. HA Type of Occupancy SII►iixz.E FAM ILSI
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
k
Installing Company Name COLLMBIA (AS GF MASSACHU56TTS Check one: Certificate #
Address 55 MARSTON STREET XD Corporation 1862
LAWRENCE, MA 0118 41 - 2312 El Partnership
Business Telephone q 7 ei" 66 1" 64'06 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have aY usrrenntt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy K 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner[] Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application will bQn mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/
By Te of License:
Plumber Signature of Licensed Plumber or Gas
Cov—
Title Gasfitter
Master License Number x3%4.5
City/Town Journeyman
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Installing Company Name COLLMBIA (AS GF MASSACHU56TTS Check one: Certificate #
Address 55 MARSTON STREET XD Corporation 1862
LAWRENCE, MA 0118 41 - 2312 El Partnership
Business Telephone q 7 ei" 66 1" 64'06 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
INSURANCE COVERAGE:
I have aY usrrenntt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy K 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner[] Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application will bQn mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/
By Te of License:
Plumber Signature of Licensed Plumber or Gas
Cov—
Title Gasfitter
Master License Number x3%4.5
City/Town Journeyman
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
AMDAOVE,R Mass. Date
I)Ul j Permit #
Building Location 48 M I DDALESEX ST. Owner's Name !'1k&1 Z DEQ 116
MA Type of Occupancy S lucyr— FAM ILS
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑
Sol,
Installing Company Name COLDKBIA SAS r,F MASSACHUSETf5 Check one: Certificate #
Address 55 MARSTON STREET X] Corporation 1862
LAWRENCE , MA 018 41 - Z3 12 ❑ Partnership
Business Telephone 7 e' 691- 64 06 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery _.
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked Yes, please Indicate the type coverage by checking the appropriate box.
4 liability insurance policy K Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
1hapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
signature of Owner or Owner's Agent Owner[-] Agent [I
hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurgie to the best of my
;nowiedge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all
m' 'ent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. .0 (/
3y Type of lJcense:
Plumber Signature of Licensed Plumber or Gas
me RGasfitter _3745
Master License Number
;iiy/Town Journeyman
1PPFZOVED O FICE SE ONLY
NONE
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Installing Company Name COLDKBIA SAS r,F MASSACHUSETf5 Check one: Certificate #
Address 55 MARSTON STREET X] Corporation 1862
LAWRENCE , MA 018 41 - Z3 12 ❑ Partnership
Business Telephone 7 e' 691- 64 06 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter Francis X. Corkery _.
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked Yes, please Indicate the type coverage by checking the appropriate box.
4 liability insurance policy K Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
1hapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
signature of Owner or Owner's Agent Owner[-] Agent [I
hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurgie to the best of my
;nowiedge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all
m' 'ent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. .0 (/
3y Type of lJcense:
Plumber Signature of Licensed Plumber or Gas
me RGasfitter _3745
Master License Number
;iiy/Town Journeyman
1PPFZOVED O FICE SE ONLY
Date. //9./.! Z.........
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TOWN OF NORTH ANDOVER
-'PERMIT FOR GAS INSTALLATION
This certifies that..!� .. .. {., artJ! / Avmin
has permission for gas installation �5.'�?��.:.......
in the buildings of/ .A,!'. ..4zf q ......................
at . 1. /G? �?. S�!/^ .... ,North overt ass.
Fee. A, � Lic. NO.. Y .. .
��// GAS INSPECTO
Check # 7�
.r
M
G
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY �r T -c[. _ /� MA DATE t . yPERMIT # --�
JOBSITE ADDRESS ji�`r. _ OWNER'S NAME
OWNERADDRESS
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL [G�
NEW: [—RENOVATION: 0 REPLACEMENT: Ej PLANS SUBMITTED: YES ( ] NO
APPLIANCES -1 FLOORS— I BSM I 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 13 14
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
MMMMMMMM
mm
INSURANCE COVERAGE
I have a current liabili` insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES r - NO 11
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � 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 Generale Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [- AGENT
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 a d 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 com ane IIZ!Xe2rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. )/
PLUMBER-GASFITTER NAME ` _ j .. LICENSE #f� 3 SIGNATURE
MP I_ _-, MGF L1 JP {� JGF �r LPGI [ CORPORATION [,—,]# � u PARTNERSHIP #[ — - LLC
COMPANY NAME: �;� qq/_®! Secs�ADDRESS[��,��,._ s
u,y _
CITY ry4z�� STATE Jh� ZIP ()r tt3j TEL _17 l - �ZO �
FAX T4MAIL
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Deparbizeitt qfhdushih[Acd(Tej&,
600 Washinglair SYred
Roston, MA 02111
'Work eW Caminmadou Insti,ralme Atfidivit.-
gigge Plint
P 7f -
Are you alt empIGyer? Meek the appropriate bor.
Type of PrQj0d (rCqdM'dy
LD I#rn.uerupt%,w%vfth
4. 1 arn a general cantmelormcl I
6. Ne
w WiTSIMCCion
employees (fall andWpaLt-thrid).' -
2.01 mu a sold proprietor or lmtw-
Im [tired dro st& cmitractors
listed, an the at ulted sheet. I
I. El Remodeling
Ship and 1-mve no employees
'"Me S-Ilb-confiftiom havo
& El DtutoMim
Working for M in vily Capadw.
Ok %WftM' 0.0111P...113SUMCC:
workeW cGuip. itmirat=
S. D We are a corporation and Its
i 0. 0 RniMing addition
r 00MCILI,
of f kers havV uvrebed their
10D Electricd rqairs oradditions
3. D I am a ftouteowner doing off %voik
411f of exemption Baer MOL
ph or additions
tilyself L [No Workere comp.
:c. 152D §1(4)" arid Iva have 110
12-[] RIDGrMFft
t
Conip. inutrauce regained I
[fluamunulcyare GOMMU IwIN (MG into FjIfC0UISt4ffi6C0JdrMCt0TS rdttSjSVtVRjj atMVV8Wt(%%jj hWCjjjn�.SWjL
%w tka e caivp. rCwv LA, 1 n imfo i L
I BID am emplaivritranspmatraW rvoa-ea' compenvadair huwaricefirutiremplojrms. Defowlsilrepoft-mdJubske
I nsuran= Company MM..-
policy got Sdf-fix&'. ff.-
job SF
Attack a copy of Cine w.otL,&s' contpensation policy decratation lyage (showing tire pottey numbCrni'd eXPrMfWId'a(q).
FRITare to securecovTMpAs required, under- S;etfi4t 25A of 14GL.c. 152 cavi kad to, the ftapositian oftridiff W PM&M Of a
f -me up to SIM'xo' auffor of tt—year unprisoninent, as well as, civril prAtaldes in the. fdnn: of a STOP. VI ORK QRDM ad a fam
Be adirised (flat acopy of this StatenIMA way be fonvarded to, tim Office or
tavestkatiousefthe DIA for,
awkinfew'011f - DO, nor WdLIC hr M."ear to he CURIfted. Itv do? or(Ovlr aft'
Cify orTbt h:
-Murnfouceumeg
CM01.
Issuing Aft(hadir (elmhe oney,
1. * Mud of Health I pa
Building Dertment 3. Cilyfrowit CkSi rk 4. Cledricat Inspector -PlInubta inspect be
'g
6. Offier
COW
Information andInstrue'tions
hrfassachrrsetts General Latus chapter 152 requires al0 empIVas to gocride-w(wkers' compeasagon for their employee&
l'tratxt to this statute:, an enrploee.is defined as ",; er y person rr the side cif anotltaierarty contract ceftcire,
or ineplied, oral or written.'°
Am eratpfvper is defined as "an individual Partners lri N assoc i 60% cMwafion or other W entity,; or any two, or more
Of tine foregoing engaged in a Joint enterprise, and inelw iII the
g W uepreserttatives of a deceased eintptoj�er, or the
v� or truAee of an individual, parirnerslrip, asmciat or other legal! entity, emgloymg However the
owner of a dwelling house having not more draft &W apartments and, who resides the
r&% or the occupant of the
del K09 house of another who employs Persons to do i aaittfenantce, construction.
or on the grounds or building appurtenant thereto shalt no, because of such, employ get b1 deemed bdwelling,
employer'
MOL chapter 152, :§25C(6) also states that" every state or local licensing, agertey shall withhold the issuance or
t menval of a license or permit to operate a busitness or to consfrtcct buildfngs in the commonwealth for any
applk"t tubo hass not produced acceptable evidence of comphanee lvitih fire rusrirrenre +rove age. regrtr'tted"
enter nto, anty, MGI: chapter 1'52, p5gj) states "Neither the co a, onwealfh nor any of its political subdivisions shall
enter rata any contra for the performance ofpublic ul arh uniiI acceptable evidence of tntpliance Withthe instrrattaae
requirements of this chapter have been presented to the contracting authorit�n."
Applicants
Please fill out the Workers' compensation affidaavit cOmpletely, by checking the boxes that ap* fo yoursituat on and, if
rrecessMY. supply sub-eontractor(s) rutrtre(s), addresses) attd phone awiiber(s) along with their certificates) of
ntsurauce. Limited Liability Companies (LLt✓) or Limited Liability Partnerships (LLl') UritInno employees outer than the
tinernbers or partners, are not required to carry -,vorkers' compensation insurance If air LLC or e p does have
employe, a policy is required .Be advised that this 'affdavit may, be submitted to the Department of Industrial.
Accidents for confirmation of insurance coverage. Also be sure f0sig" and bate the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, rtot the Department of
Industrial Accidents. Should you have any cyuesttons regarding the l'nv or if y®�r are required to obtain a workers'
couspensatiOn policy, please call the Department at thenurnber.listed beloly. _Self -it red compatnies should enter their
self=insurance licttse ntrntber on
the.appropriate line.
City or Tojvn Officials
Please be sure that the affidavit is complete and printed legibly. 'die Department has,providled a space at the bottom.
of the affidavit. for you to fell out'b the event the ofrrce of fnvr stigations has to contact you regarding the applicant.
Blease be sure to fell in the pertttithicense number which, will be used as a reference i umber. Jn addition, an applicant
that must submit multiple permit/license applications in any, given jwr, need only submit one affidavit indicating current
policy{ information (if necessary) and under "Job Site address" the applimnt should wite "atl I'o�rteorrs #n (cit} or
to in '2 copy of tine atfrdav�it that has heart officially stamped or marked by the city, or town may lac provided, to the
applicant as proof that a valid affidavit is on file for future permits or liceuses, tl new affidavit must be filled out each
year dog
a home otc�tter or citizern is obtaining a license orpertmftmot related to any business or commercial venture
(i e. a dog license or permit to barrel leaves etc-), said, persons is NOT rc q*ed to clomplefe this affidavit.
The Office. of htvestigations avould bike to th6nk Yotr in advance for yourf cooperation aztd should 5rcttn have any questions,
pled do not hesitate to give is a call.
The 13Cpartment's address, telephone and fax number.
The Comsnanxv tl>! of_Mamchuseft
Department oflttdttslr a� Accidents
'flee of IrrlRest gaf an
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4000 ext 406 of 1.-$7"7 MASSAFF
Revised 5-26-05 lax 4 617-727-77,49
NVVIRV mass.govIdia.
Date ..... �- 2 -7--. ./Z.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............. CSj j`.%ti...... ... .... ..�.........................
has permission to perform?:�'�
... ...... .
wiring in the building of ....................................... .........................
Andover Mass.
Fee�.... Lic. No....l.. ..�......... 21orth
........ ..ELEL INSPECTOR`
Check a 123 7
10623
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. iib 9
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (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
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �7cw uc.s-�-J ac, Q
City or Town of. NORTH ANDOVER To the Inspector of Wi s:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) Off 11-A JJ
_Sex G4
Owner or Tenant
Owner's Address
M
Is this permit in conjunction with a building permit? Yes ❑
Purpose of Building c,�CJ Erre— p I4 c - e
Telephone No. q 7g? L irS' )N/S'
No LX (Check Appropriate Box)
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 Dire
Electrical Work:
F re D l4 c -P
Cmmnlotinn nftho fnllnwina inhlo mnv ho —A-4 h„ ilio rticnant— ..f!V,'
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- E]
"_n d. grnd.
No. of -Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
.."'...""....
Tons
"'
KW
"""""""""'
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KWLocal
❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water,
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
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: ) - —X12 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.
,�am,
CHECK ONE: INSURANCE JBOND ❑ OTHER ❑ (Specify:)
I cert, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAM, E: Drst' 0,/er— 4r1`c LIC. NO.:
Licensee: rc C /—� /Dsa-Signature LIC. NO.:
(If applicable, enter "exemp 11 in the license numbIr line.) s. Tel. No.• 7y e/ cl
Address: I S u h= �oc�� Rc{ A41Jdyt-V- N A o f k/d lt. Tel. No.: ct 7 8 7 d 3
*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'sa ent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
ELECTRICAL P i'PUM No.
_ ELECTMCAL INSPECTOR
Z. ROUG,XN_ SPCTO �2:
Passed -- [ ] Va.Ued-- [ j Re-impection requ i�recl ($50.00) - j j
Inspectors' comme�ats:
t.Y • •
(inspectors' Signature -no initials) Date
)Passed — railed - [ j Re -inspection required ($50.00) •- [ �
Inspectors' comments:
(Cuspectors' Signature -• no initials) Date
I UNDER GRODND INSPECTION:
Passed— [ ] Failed-- j l Re -inspection required ($60.00). [ ]
Inspectors' comments:
(Inspectors' Signature- no initials) Date
D ® OR TAGS .ARE TO BE FILLED OBT AND LEFT ON SITE IF THE AREAS TO BE INSPECTED is NOT
.ACCESSIBLE AND A. RE NSPECTION OF L50.00 IS TO BE CHARGED.
The Commonwealth of Massachusetts -
Department of Industrial Accidents
Office of Investigations
Uf 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: 1 S u n.S
City/State/Zip: r-ryk
L Z t\aC,C
Phone #: '? `7 i�— 7 V r; 9 S-v�l
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).* have hired the sub -contractors
2. Pq I am a sole proprietor or partner- listed on the attached sheet. I
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
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ 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. Lic. #:
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 he'—pert fy under the pains and penalties pf perjury tjuft4iq information provided above is true and correct.
Phone # 179- 7 Y(9 (SS r4y
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
�K aC< 20 Q,
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
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 1-877-MASSAFE
Revised 5-26-05 Fax # 61.7-727-7749
www.mass.gov/dia