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HomeMy WebLinkAboutBuilding Permit #869-15 - Nutmeg Ln 50 Lot 6 5/1/20154� � I.. 11 dl BUILDING PERMIT �_eD'°1�° TOWN OF NORTH ANDOVER _ : APPLICATION FOR PLAN EXAMINATIO n � b Permit NO: U ` Date Received Date Issued: t 9SSACHU IMPORTANT: Applicant must complete all items on this page LOCATION �,J L­0,r-3�F- - �� MtZS Print PROPERTY OWNER M J g � Print MAPNO:��� PARCELP-.1 ZONINGDIST RICT: Historic District yesrn Machine Shop Villaqe ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building vOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial i12epair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ___F Septic L Well Ll Floodplain L Wetlands Watershed District Water/Sewer Vko ME \ C-\ `K-0 yeG2yA:�> Q-=- ) �v6 Identification Please Type or Print Clearly) OWNER: Name: H 4 Phone: '::>1%& Address CONTRACTOR Name: Phone: ? ^1 r2� Z Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Nc� ���y,� Phone:_ Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ 16o2 Check No.: tz 6 3 Receipt No.: 2 eg %J NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor F Permit No#: BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNE A ' o�SLED 16 � E r •y C IL p_ c«roceawK , �• Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: 0 Demolition ❑ Other ❑lSeptic ElWell _ ❑ Floodplain El Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification - Please Type or Print Clearly OWNER: Name: Phone: AHriracc- Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: ARCHITECT/ENGINEER Address: Exp. Date Phone: Reg. No._ FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ EE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fend Plans Sub r tted'❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ;'FIREDEPARATiMENT-'TemDurnpsteontste 4�Located at51:24 I --in, Sheet r - ;Fti re_ ;{epa±ments ig natu re/date _-- Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits * Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan �. Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Locatic 6U \rQ LA No.—&�—(S- Check #,,?- 0 3 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $- Ev TOTAL $ A�- Building Inspector v. 0 O n Z N OCLCD -v CL D cam. c=n � O � vCD < '� O Q Cr _CD O ca CD CD C o N. �. C � v Cl) 0 0 O O 70 CD a O N < O o RE WT � --I MU , a7 O 04 S = -h < r v, Z O I z-0 CD C s CD M C p0 Z 6l T fl! (7 =1 m It T = Q v O :3 mrn VI n to < m 3 O z o y - cxi ' O M Z Q � 55 C Cl) �• 0— Z O —� Z cn Z, Cl) W Z , z a < O o RE WT � --I MU , a7 O 04 S = -h < r v, 0 O I r m D CD C s CD M C p0 Z 6l T fl! (7 =1 m r Q T = Q v O :3 07 C 2 C r m m VI n to < m 3 O z o y' �+ cxi ' v, a; �• -n O O CLm CD a) rt Cl) W�• to O -� CD CD x c U) �' o Zy3Zy CD CD 0 Cc z CD o�, a D `Dy - = C7 = ?Q co0 CL :�.. 0 O RL CD Cn ID C < : O CD Q `� tD r � U) 0 O C') O o :c co O c } CD CD �CD OCD y C'1 O �+ D CD o 0' su O CL :qL V) 3 O (p � V) r -F rD — Z WT � 7G v M z 5. N a7 O 04 S N Z cn 0 T 5. N Vf N0 n m Z7 d0 S r m D T N :;a m S M C p0 Z 6l T fl! (7 =1 m Z7 m S T = Q v O :3 07 C 2 C r m m VI n to < m 3 T Q. \ n S WO 0 O D r r SALEM PLUMBING / DESIGNER BATH 97 RIVER ST P.O. BOX 510 BEVERLY MA 01915 978-921-1200 Fax 978-921-1556 QUOTE TO: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01.845 Quotation `i�lUQ::�l1s;TE:�:: .�: : :'�' A?i�li��:NU:6f6�R�•.T.t.�.. 04/27/15 52108165 ORDER T0: ........_......... P.O. BOX 510 SALEM PLIIN�ING f DESIGNER BATH - •"-- 97 RIVER ST 1 BEVERLY NA 01915 SHIP TO: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 110860 BATHS HOUSE SALES ACCOUNT ...... S:<;:•:::: ::• •::•t4; rNo Michelle Ritchie OT OUR TRUCK Cash On Delivery 04/27/15 .r_,��tr ••......,� - t , �,,� � __ _� _ _ ,- .. ,« , t ........................ ;•:::: ...............::•. • :• :•:...::.-.. iZES itT�3:iQN::: ::=: ::: :;; i := :::::::::: = ::. !?ntt 4ryc ¢.. :::. _: DRIiER;.QTF:: •:;•::::;-::•:: Ai3.,?kJ........................:........: :•:_•::::.:::.::::::.::::::........... . lea 284409 AMERICAN STD 2461002 011 CAMBRIDGE 524.550 524.55 BATH RIGHT HAND OUTLET 60 X 32 X 17.75 ARCTIC WHITE 284409 * DO NOT USE ANY BEDDING COMPOUND *** P3 - 0806 -22 ** lea 10640 GERBER 41813 TRIP 18 DEEP ROMAN 130.392 130.39 TUB DRAIN POL. CHROME WITH BRASS NUT 10640 lea 318200 TOTO TS220P1#CP VIVIAN PRESSURE 99.280 99.28 BALANCE TRIM (W/ LEVER HANDLE) - POLISHED CHROME 318200 ** Special Order - Nonreturnable ** lea 318253 TOTO TSPTM VALVE PRESSURE BALANCE 106.080 106.08 ROUGH ONLY 318253 ** P1 - 06135-08 ** lea 362104 TOTO TS220XW1#CP VIVIAN DIVERTER 92.480 92.48 TRIM (3 -WAY W/ OUT OFF, LEVER HANDLE) - POLISHED CHROME 362104 ** Special Order - Nonreturnable ** lea 362154 TOTO TSMXW 3 WAY DIVERTER VALVE 127.840 127.84 ROUGH ONLY 362154 lea 229112 HANSGROHE 04186003 SHOWER ARM AND 41.600 41.60 FLANGE 9" POL CHROME 229112 lea 318224 TOTO TS300AL61#CP TRADITIONAL 39.440 39.44 COLLECTION SERIES A SHOWERHEAD (6" SINGLE SPRAY 2.0 GPM) - POLISHED CHROME ** Special Order - Nonreturnable ** lea 318191 TOTO TS220E#CP VIVIAN TUB SPOUT (W/ 99.280 99.28 OUT DIVERTER) - POLISHED CHROME --------- --- ----------------- ------- *** Continued ------ on ----------------------------------- Next Page *** SALEM PLUMBING / DESIGNER BATH 97 RIVER ST P.O. BOX 510 BEVERLY MA 01915 978-921-1200 Fax 978-921-1556 QUOTE TO: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 110860 (BATHS Michelle Ritchie JOT OUR TRUCK Quotation 04/27/15 S2108165 ORDER T0: 'fAE'1f4:: ........_......... SALEM PLUMBING / DESIGNER HATH - 97 RIVER ST _ P.O. BOX 510 2 BEVERLY MA 01915 SHIP T0: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 HOUSE SALES ACCOUNT Cash On DeliveryI04/27/15 I No ** Special Order - Nonreturnable ** lea 318239 TOTO TS300FL41#CP TRADITIONAL 49.640 49.64 COLLECTION SERIES A HANDSHOWER (4" SINGLE SPRAY 2.0 GPM) - POLISHED CHROME lea 318104 TOTO TS101W60#CP SHOWER HOSE 60" 42.840 42.84 POLISHED CHROME 318104 lea 318095 TOTO TS101R#CP WALL OUTLET - 31.960 31.9 POLISHED CHROME lea 119181 JACLO 7006VBC VACUUM BREAKER POL 29.250 29.25 CHROME 119181 lea 318101 TOTO TS101V#CP HANDSHOWER 25.160 25.16 ADJUSTABLE WALL MOUNT HOOK - POL CHROME 318101 lea 106195 MAAX 135630900084 TUB SHIELD 300.300 300.30 DELUXE CLEAR GLASS CHROME FRAME 30" WIDE 56 1/2 STD HEIGHT 106195 ** Special Order - Nonreturnable ** lea 318200 TOTO TS220P1#CP VIVIAN PRESSURE 99.280 99.28 BALANCE TRIM (W/ LEVER HANDLE) - POLISHED CHROME 318200 ** Special Order - Nonreturnable ** lea 318253 TOTO TSPTM VALVE PRESSURE BALANCE 106.080 106.08 ROUGH ONLY 318253 ** Pl - 06135-08 ** lea 362092 TOTO TS220DW1#CP VIVIAN DIVERTER 85.000 85.00 TRIM (2 -WAY W/ OUT OFF, LEVER HANDLE) - POLISHED - ---------- -------------------- ------- *** Continued ---------- on --CHROME ------------------------------------ Next Page *** ,F SALEM PLUMBING / DESIGNER BATH 97 RIVER ST P.O. BOX 510 BEVERLY MA 01915 978-921-1200 Fax 978-921-1556 QUOTE TO: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 110860 (BATHS Michelle Ritchie JOT OUR TRUCK Quotation IllQiERA_Tf_:__QL?33%Nl?916ER' , .f •T. 04/27/15 S2108165 ORDER TO: ........_....._.... ................. SALEM PLVNIDING / D&SIGNER BATA 97 RIVER ST P.O. BOX 510 3 BEVERLY MA 01915 SHIP TO: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 HOUSE SALES ACCOUNT Cash On Deliverv104/27/15 I No *** Continued on Next Paqe *** 362092 ** Special Order - Nonreturnable ** lea 362152 TOTO TSMVW TWO WAY DIVERTER VALVE 127.840 127.84 ROUGH ONLY 362152 362152 lea 229112 HANSGROHE 04186003 SHOWER ARM AND 41.600 41.60 FLANGE 9" POL CHROME 229112 lea 318224 TOTO TS300AL61#CP TRADITIONAL 39.440 39.44 COLLECTION SERIES A SHOWERHEAD (6" SINGLE SPRAY 2.0 GPM) - POLISHED CHROME ** Special Order - Nonreturnable ** lea 318239 TOTO TS300FL41#CP TRADITIONAL 49.640 49.64 COLLECTION SERIES A HANDSHOWER (4" SINGLE SPRAY 2.0 GPM) - POLISHED CHROME lea 318104 TOTO TS101W604CP SHOWER HOSE 60" 42.840 42.84 POLISHED CHROME 318104 lea 318095 TOTO TS101R#CP WALL OUTLET - 31.960 31.96 POLISHED CHROME lea 318101 TOTO TS101V#CP HANDSHOWER 25.160 25.16 ADJUSTABLE WALL MOUNT HOOK - POL CHROME 318101 lea 119181 JACLO 7006VBC VACUUM BREAKER POL 29.250 29.25 CHROME 119181 lea 351994 MAAX 136671900084 REVEAL PIVOT 617.500 617.50 44-47 SILVER WITH CLEAR GLASS 71.5"HT, 3/4" ADJUSTMENT FOR OUT OF SQUARE WALLS 351994 ** Special Order - Nonreturnable ** 4ea 213930 GINGER 554DGPC POLISHED CHROME 78.400 313.60 *** Continued on Next Paqe *** SALEM PLUMBING / DESIGNER BATH 97 RIVER ST P.O. BOX 510 BEVERLY MA 01915 978-921-1200 Fax 978-921-1556 QUOTE TO: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 110860 (BATHS Quotation :r` fiUQiE:^AT€_T,':::� 'Q?1±3TH!?41EEk' f: 04/27/15 52108165 ORDER TO: ------- ............ :-Al SALEM PLONIDING / DESIGNER BATH 97 RIVER ST P.G. SOX 510 4 BEVERLY MA 01915 SHIP T0: SARAH TUCKER 50 NUTMEG LANE NORTH ANDOVER, MA 01845 Michelle Ritchie JOT OUR TRUCK lCash On Delive :4RI3Ek r ........... . :_: _ =: := =;_: RTF. g?. ......................... .. ........ = _ DEEP CORNER BASKET ** Special Order - Nonreturnable ** lea 103078 GINGER MOTIV 550-26 HOTELIER SOAP BASKET POLISHED CHROME 103078 lea 134875 ELCOMA 012116STA 16" GRAB BAR 1 1/4" SMOOTH W/ TWIST CONCEALED FLANGE POL CHROME ** Special Order - Nonreturnable ** This is a Quotation. Price are film for 30 days, subject to change without notice after 30 days. HOUSE SALES ACCOUNT 04/27/15 1 No 39.900 39.90 77.196 77.20 Subtotal 3466.38 S&H CHGS 0.00 -Sales Tax 216.65 Amount Due 3683.03 Gerald A. Brown Inspector of Buildings Pleaseprint TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20, Suite 2-36 North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION ,DATE: k, 15 \2o-) S; - JOB LOCATION: �S� W �' '�A L_�;F_ Telephone (978) 688-9545 Fax (978)688-9542 Number Street Address Map/Lot HOMEOWNER S NQ�N + Shu"1�C-� �-r� �7� 1!5DG -7 S� 2 - Name Name Home Phone Work Phone PRESENT MAILING ADDRESS !Sb 4'� 3� SEG t-- � City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts twiDepartment oflndustrialAceidents X Congress Street, Suite 100 Boston, MA 0211¢2017 - www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avylicant Information Please Print Let=_ibly Name (Business/Organization/Individual): Address: 7:!� " `�— � C- � City/State/Zip: d,-Xr<ZT* M A Phone #: Are you an employer? Check the appropriate box: Type of project (required)' 1.0 I am a employer with employees (full and/or part-time).* 7. ❑ New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in $, emodeling any capacity. [No workers' comp. insurance required] 9. El Demolition 3_❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10E] Building addition 4&6. a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. F1 Electrical repairs or additions proprietors with no employees. 12. E] Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet 13. Q Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also 511 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #• l `� �5 &©G �? S;,,� Z r Official use only. Do not write in this area, to be completed by city or toren official City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone M 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 -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/lieense 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia