80 MOFFATT RD - BUILDING INSPECTION (4) Yo The Commonwealth of Massachusetts
t Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-FamilyDwelling
S
VI This Section For Official Use Only
CCC Building Permit Number: Date Applied:
mt, V.t _ ��t 122YltcwSlG / 'L ��
Building Official(Print Name) lgn ure Date
SECTION 1: SITE INFORMATION
1.1 Prspe e;,s a_y 7
L Ia I (/r,je� 1.2 Assessors Map&Parcel Numbers
f s this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ER/ Private❑ Zone: _ Outside Flood Zone? Municipal Von site disposal system" ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
24 wnvr'of Record:
Name(Riot) 1 T q 'ty State 0 i`!q 1P 5
(n/Y M� C)-FfG
No.and Sneet Telephone Email Address
SE TION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building V Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description ofPropos Work 2: ( eC C 6 Z c6c�u
Y c i 5 r ),,1 ,r4reE Ewa,
r 1 'eq
rep
Z
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Yo, xd. pQ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ OG 0 O ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
1 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ yQl Fi 10- 0(' ❑Paid in Full ❑Outstanding Balance Due:
/ r
II
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) `7 a Zs 4 l//
hQ n dQ!l C w m e4 f License Number Expiration Date
Name of CSL Holder
49 :Z(J(�
�'wahu� �d
List CSL Type(see below) U
�
No.and Street Type Description
'6 )h �jal D12 � R Unrestricted(Buildings u el ing cu.ft.
(J 'U C( J b R Restricted 1&2 FamilyDwelling
City/fown,Statd,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
5 SF Solid Fuel Burning Appliances
II I Insulation
Telephone Email address D Demolition
5.2 Registered
ppHome
Improve Improvement Contractor(HIC) I q0 1 q r( 6/�z
��e t �r�er I J(� IC Registration/Number Expiration Date
H I o y Name r HIC Re strant N e
� ic� rn � �w d Corn(r4ane@c6mC#6fvre
No. nd Street + _ �� ;l � 2I, / 2nC� Email address
�[A _ fior f A (/ O J `l ✓UJ
City/Town, Sfate,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.-1LE;�1, 'i%L1S&A CHUSETTS
• BUILDING DEPARTSIEi-r
120 WASHINGTON STREET, Yea FLOOR
\ f TEL (978) 745-9595
FAX(978) 740-9846
KI,%iBERLEY DRISCOLL
MAYORI�tobtAS ST.PrERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%5aSSIONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ' I /j Please Print Legibly
rI� / /
Vatnt (BusitlessOrgattizatiotvindividuaq:�LG 1 O1/7e�77//!lee4 /l�Q�j M�� mfi(�e LLe
Address: H"I �Urn GJG')Y� lJ Pd ' n' /
City/State/Zip:E . IL Phone #: ( IX 3l Y SUSS
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1
mployees(full and/or part-time).* have hired the subcontractors 6. ❑flew construction
2.Cy le
a sole proprietor or partner- listed on the attached sheet. 7 Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑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 chocks box ii I muss alw fill out the section below showing their worker'compensation policy infutmuioa
r I Inmeownt n who submit this affidavit indicting they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
=Contractors that check this box most amached an additiorxtl sheet showing the name of the aubcontncton and their workers'comp,policy infomatioo.
I um an employer that is provid►ng workers'competisation 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 S 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 S250.00 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 ofperjury 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 i
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cilylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other,
Contact Person' _ Phone#:
CITY OF S. .E:LI, N-WSACHLSETTS
a
BUILDING DEPARTMENT 120 WASHLYGTON STREET, 3� FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIJiBE u-EY DRISCOLL
MAYOR THoetAs ST.PIFRRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
av� St )eevle
(name of hauler)
The debris will be disposed
gg'�of in
Q I I I K D Lt/G tJ°R-
(name of facility)
30-0 s+ P r'�' 6006 0-4
(address of facility)
signature of permit applicant
date
dcbrivirdm
Nlassachusclts- Department of Public Safety
Board of Building Regulations anti Standards
ConstructomSupervisor License
License: CS 72225
Restricted toe. 00
RANDALLyK- EMMETT h Fa
49 BURNTSWAMP RD
E KINGSTON,NH 03827'
Expiration: 12I 2011
('ommis4ioncr Tr#: 14542
>� The Commonwealth of Massachusetts
� I
1�r Department of Public Safety
j Nlassachusrtts State lSuilJinf;Qnle(7411CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwel i g
(ThLv Section For Official Use Only)
Building Permit dumber: _ _ Dale Applied: _ _ Building Official -
SECTION 1: LOCAL ION(Please indicate Block N and Lot N for locations for which a street addr .s is not available)
---
No, and Street City/Torun /if,Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NIA Slate C+xle used"_-- - If New Construction check here❑or check all that apple in the hvo nn+:s bvlow --
Existing BIIilding❑ Repair❑ Alteration ❑ 1 A,dilam❑ Deniol tion ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other.4-Specify; _ _
Are building plans,and/or construction drxvnrents being supplied as part of this permit application? Yes ❑ No;R- __
Is an htdependent Struchval Engineering Pee Review reyulred? Yes ❑ Nolk
Brief D,y�rriptiy11 of Proposed Work:.__ t' ltir.d✓'�-. /)C1 - S <<?}— C ' -
SECTION 3:CONIPLETE'THIS SECTION IF EXISTIiIN'G BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an @listing Building Investigation and Evaluation is enclosed(See 780 CNIR 11) ❑
Existing Use Group(s): _._ Proposed Use Group(s): .
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Total Area(sq.ft)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-I ❑ A-2❑ NighlClmb ❑ A-1 ❑ A4❑ A-3❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ !1: Ili h Ilanvd H-1 ❑ H-2❑ 11-1 ❑ H-4❑ li-i❑
1: Institutional 1-1 ❑ 1.2❑ I-3❑ 1-4❑ �Yt: I\lercantile❑ R: Residential R-113 R-2❑ R-.3❑ R-1❑
S: Storage S-1 ❑ S-2❑ I U: Utility❑ Special Use❑and please describe below:
Special Use .
SECTION 6:CONSTRUCTION IYPE(Check as applicable)
IA ❑ IB ❑ IL\ ❑ IIB ❑ IIIA ❑ IIIB ❑ iv VA ❑ vli ❑
S ECnON 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if Outside Ilu,+d Zone❑ Indicate numicipal ❑ A oVIICh +rill not be I-icvnseJ Dkposa l Site❑
Privale❑ or indenlik Zoim: or On vile scstem ❑ rryuirod ❑or trench Or vpec lky _ _
- permit is enclosed ❑ __
Railroad right-of-way: Hazards to Air Navigation:
Not Applicable❑ Is Slrnlclurr within airport appru,irh en•e' Is their rn•cww completed'
Or C onscml hi Butt eiieloved ❑ )rs❑ or.No❑ I - 1\•s❑ No ❑
SEC I ION 4:(-ONTI-NI'OF CI?It"n II(A,\I F OF OCCUI':\NCY
li d I It,.n,,1 Code: ... . -_ L'so Group(s): . ._ _ Ic pe of Condon lwn: Ur.upant Lased per Boor
I toeslhr[Ill ild int;cIll lain.m Sprinkler St s tom': tipeci.1 Sl1P❑Ial it)IIs
J/
r
i
SISCIION 9: PR011i7fi l'Y O1VNI:R AU'I'11URIZA IION
Neu,e.md Address of +path Ow ner
u
Nance(Print) No. and Street City/Town Zip
Property Owner Contact Information:
Title ---- --- telephone No. (business) Telephone No. (cull) a-mail address
If applicable, the properly owner hereby authorizes
---- Name _--- - Street Address _--- City/Town --- State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building +ennit., ,lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f buildings is less than 35,00(1 cu.ft.of enclosed s+am and or not under Construction Control then check here O and ski+Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address - -- --- City/Town - -- — - -State Zip- - Discipline - - -- Expiration D;ite" —'
10.2 General Contractor
Ca i 1)r %L4t G'f1Gr(t�
co ,,any Name-
A-00 0 rVt o ��r - r S' led
N7 of Pylon esponsibly fur Crn,struction Licen- se No. and Type if r\pp iblu
Street Address City/Town State Zip
Tole +hone No. business Telephone No. cell c-naafl address --
SECTION 11:\t,n:F.l.1ih, I v n ',I.N,111RA c'I'.v to-,\vi l M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes O No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =S_
1. Building 5 /' - 7�d - -1 building Permit Fca:-Total Constn,ction Cost x_(Insert here
1. Electrical $ appropriate municipal factor) =5
3. Plumbing $
I. .Mechanical (11VAC) y Note: Minimum fee=S (contact municipality)
S. ,Micihanicel Other S
Fnduse ihttik payable to
'2 (contact munwipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERIv11T APPLICANT
Be entering illy n,ume bolow•, I hereby ,utcst under the pains and penalties of perjury that Al of the information contained in this
aI+I+Iication is true and accurate to the best of nny knowledge and understanding.
I'Ieaso r tl ,n,d sifpl i arm' title Telephone No Date
1-114' r
- -J (�LLlCi - -, - - - - - - -- - .f��. -- -
ititnal :address G /T lyown State /ip
Municipal Inspector to fill out this section upon application approval:
Name -- - I tale..
CITY OF Sou-E•«, jAkss.ICHL'SETTS
BUILDLNG OEPAATt&N-r
120 WASHLVGTON STRW. 7'O FZOOII
Tt+L (97� 141-9S9S
KMSERI LEY DA=OLL FAX(978) 710.9&M
.tiL1Y01t 7140.% uST.PMXU
O"Ecroa or PLSLICPIIOPEATY/BIpDOjGCOSL%IISSIO.EA
Construction Debris Disposal At17davit
(required for alldemolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 780 CMR section 111.S
Debris, and the provisions of MOL a 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
I, S ISOA.
this work shall be disposed of in a property licensed waste disposal facility as defined by MOL c
11
The debris will be transported by; 1
C/71r �'T1L�� c17iFKJ
(n.une of hauler)
The debris will be disposed of in ;
(name of facilily)
(Jddreai of fJcihty)
tynJnue o(permrt applicant
JJte
I
CITY OF SALEM
e ar
PUBLIC PRUPRERTY
DEPARTMENT
'rrr.• III1 Y n1141'l1
1 i� 49A It N/A jCrrkl' • j,111•N, 111,ht 4.l ll IA I I+yl'17�
s I'+.t 77N•74C-I14
wurkurx' Cumpensarion )murun ca UOduvih. IlulldcryCuntracwrs/!(ectr(e(anyYlurnben
%U1111cilltIn artnrllo
PI Int a 'hi
VdIT1C 111utn+v.ril)r;lAnlrninrvinJr r,duull: /
City,srtrc•%ip Phone
I .eroynu au vmployar7 Chock ihe:glprllprldte box:
1 ❑ I:loll a vmpluycr with 4, ❑ I :loll A�cnaral contractor and I 1)Po iorpr")eet(roqulred):
Linymit.
ycvs(cull Antyur part-lino).• huvu hirvJ(hu suh•cimirmors 6. ❑New cunsituctiun
told prnpriertw or punnet- lisud on rho Inached.+hcat 7• ❑RamdJefind
nd have no elnpluyvas These subcontractors have
d tiff Ina In Any capacity. tvorktro'comp, Insurance. �' Demoliridn
orkers'awnp. insurance J. ❑ We are a ern 9. ❑ Ouildind aJdiriun
d) pontinn And iqatlleers huvu utvmi.4a their 10.QElectrical repair or aJditiane
homYtl+rnvt Juind all work right dresmnptiart put M1IQ6 I IQ I•lumbind mpuiraur atWitinry
(Ro+vnrkcrs'comp, c. IJ2,I}I(s),and we hnva necu rcyuirrd.) unPluyecs. (No worker 12'0 Ruu1'mPuirs
crntlp,'insurancu myuimd.J I J.0 Uthor
•+n)•,q+hcae rhr ahvahs 0"el mum low tin low I
'Ilumy,rr M W+'lion klYw,Mwrne rtrl/ir rwtllte'aulllrrrlryrnYp/1{,11Cr rnlirr111YlilY►
mrt rho uAin't#'his or NW#iQiulint ill"at ylip 41.rare and Ih,4 h
im'r'.urU.NnN+IIIm tha're Ihle boostmIW j"Whll�ae uldlliuyt.h,q/thuwtnx IM rnNM he ids their rntren mnr/.ulwle a net nOJe•il InJl+ueme re:ft.
Xh1re,+nd their%UAW$'ra",IrnI1Cy.A1b n ah,s,
who an urrlployer thud IF prur/dlnr IvurAey'rumpatrn//ea hL1Y/N/ral�flr/Ny e/N!/lYyeao Bdmr/s/hepu/fey and ulr esle
br�ururullnrt •�.
InxlrunwC'umpany .Wme• , .1 / '� - -
Vlilicy Y or 3vlr•ins. Cic.Hr • _--_
Eepirutun Data:
lids 5iu �\ddrels;_. _
C'Ity'slutaZlp:;Jllufv d copy of the worltere required tille
pulley Jueluratlun polio(thawing rho Polley nun/bur and vcplrmulr date),
P,Ilury w +ccure cweru qe as reyulreJ wlJar Scgiun 1JA lot' c. 132 eau lead tin•'+ql 1-1 " faOJM,ndlur mle•yesr imprimnlonont, at %%ell to nu imposition ol'eriminAl Wnalriy of a
as vial pcnultlu in the form ut'a STOP W
i up rn i1f0 N1 a Jay ryuin,l the vt'Altor Ile sdvl.IQd that A copy nrihr+ .lutemam may by turwardeq to the U110icuu t, a Rne Ln..aly,nrrns ul';hv 1)
1'1 ;or m+ur.u'cc al+cra;c 1a ui.aaun. -
/du hprrAy l.rn%(•nnJ¢r`r prrint,alJ /rnn/ 'a u
Il/rrplry//IY//III illlallNY//ON yNYll/ed YbYYI ix bYe Arid laTt•CL 11//$iu/rnI urdy, /)v nor Irrire iN/hit arru. lu Ar rwny/crel/by ciq ur/Otte•r/�lciuL
( lrror Iblrn: _
I,.uiny \ulhurity (circl0 nnv): Vvnnit/Llccme e
I IL,.r YJ r(Ile.lhll 1. IhuLhlo•�
'Ut p.lr llr h'nt 1. (.i11.
I 6. Ulher - lur+n C'Icrk /. O'Icctric.11 hnp.cNr ;. rhnnWny I�I+ycaar
�I 1 --it.ICI I'trrwl:
Phunv I.
i
information and instructions All their eln loyee�. '
eve ean in the scrvt:e ul another un,ler Illy tu
, nfrn
ct of hire.
V.u>.r:hweua licnrrAl Lawa:hApter I i2 Ieyuttey cngalu)rn Io Provide ,wrhen' wmpenauu„n tot
I'ur.u.uU w uus ,astute,an amplurae Is Jetined Ae n' P'tc
vprcaa or unp6cJ, oral or arntcn•" or AIi two or mull
An :mplupar is dctincd L"a" Mdividual, puttnanhip..t+wetutlu^. :oryurauon or other legal ennry, Y
asmenhtp, ssoetatwa or other legal¢nary,employing employees. However tilt
t the t;,requmg engal;eJ to a Joint enterprise. And uacluding the legal raprcriety,i m Iu a deenlpI0 ccs- Ho r, or t t
ecmver ter uuatre of.of indivldual, p en fthill ilirts house
to • nons to dolnQtnbecausa of such�unsuranion of rent be wormpair work ed tucbei naampluyer."
owner of a dwelling house having not Mort than three Apatcnents and who resides therein,or Ihg occupant o
,I,vrlhng house of anaahar who c Appurtenant thereto shall
or on the.rounds or building shag widlhotd Iht Issuance or
�IGL chapter 132, �13C(6) also states that"every Ilan or local construct
bo Agency I ulnd.'
lowltifo
ovidoace of cump0saes wlds tut Insuranet subdivisions shall
renewal of a license ter p+res g tg upaals a husineu ar to coutruet b 11h l gs In Iht eotnm ors%# tY or nay
;applicant who has not pradue+d acceptable ofiuPolitical
lwdilionully.�IGL e11upter 151, i-'SCt 71 atatas"Neither the common1-1131 nut my
enter into any contract for the parfomwnce ul'public work until acecpabls cviJanct of cwuSli;uwe with the insuranea
reyuiremenu of Ihis chapter w ha been lal"MOnted to the contracting uwhoriry." - - -
ApSllcugs checking file bases that apply to your situation and.if
addrales)and phone number(sl along with'heir' of
plea.+e rill out
the workers, compensation atl7davit completely,by s LLP)with no employees other than the
neccs+ary,supply sub-contractor(s)puma( )' have
insurance. Limited Liability Companies(LLCworker'at tcampe O°uuuroner.(If an LLC or LLP doe+ 14
member or Pannell,are not required to carry o submitted w the Depart'
of industrial
employees,a Policy is required f!t advised that Ihie alTldavit array devil thou
of
�ccidanu for contlrmation of insurance coverege Also be sun to sl{ro had dung the u seed, n The aUldsvit shoo
ha returned to the city or town that Ihg application for the Sonnet tx licenIf is being requested, not the l)aP
Industrial Accidents. Should You hsva any questions regarding the law ter if you erg myuired to obuin u workers'
industriCompenal
Aveion policy,Sloan call the Department st the numbs listed below. Solr•insured companies should enter their
sclf•insuranct licenses number a"tilt aporapriald line.
ary er'rows Offlclals
'its•Department ilia provided u sDw:rh�tao Leant
ttom
please he sure that the affidavit is complete ;old printed legibly. W hcam
,II die Affiduvit for you to till out in the event the 0111ce of Investigation refer contact you regarding DP
of fil a be cur' ro fill in the porrnit/licmasa nwnbor which will be uaed as a reference numbat, In addition,an aDD eft ter
indicalinj
he LIPP laant.ihauld write"all lot:a6uns in l' Y
than moat subanit Multiple Sennitllicelute applicrtions in any given year, need only submit aria at11 boa to the
policy iuformatiun(if necaasary)and under"Job Seto Address" or marked by the city or row" nay provided
rolicy..,�copy of Ihg offidaavit that has been officially sump'
Applicant as proof that a valid affidavit is ten file for ftio uto permits or licenses. A now a111Javit must leg filled out cash
)car. µher+hwne owner ter citizen is ubuinin{a liunso or Dennis not related to any business or commareial venture
u. .a wog licen.at or permit w burn leaves ate.) said person is NOT required to complete this alfldsvit. unuuns.
I IIc )I Ike „I Iuvr.Iiyatiuns ,vuuld hoe to Blank)'w in AJvancu fur your:oopmtion and Should you have.urY 4
dea.e wu nut hcsasare to gave us a¢All.
fhe Ucp•Irnncnt's Ad tress, telephone And fix number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Iavtadisdons
600 W6&hi08tOn Street
Boston, MA 02111
ref. 4517.727- 6117
00 ext 02 a114971-MASSAFE
Ali mass.jov/dis