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12D RUSSELL DR - BUILDING INSPECTION (4) The Commonwealth of Massachusetts CITY OF 9 Board of Building Regulations and StandardECEIVED SALEM Massachusetts State Building Cod ell'WIMP MAL SERVICES Revised Mar2011 Building Permit Application To Construct, Repair, Rellovate Or Demolish a One- or Two-Family Dweffi-ny15 JUL -9 A 8- 3 9 This Section For Official Use Only Building Permit Number: ate Applied:ay� M Building Official(Print Name) Signature Dale SECTION 1: SITE INFORMATION JJ 1., P rQpertXAddress: 1.2 Assessors Map&Parcel Numbers..LDS //�lus�r!L � i^r �✓E 1 1.1 a Is this an accepted street?yes no Map Number Parcel Number f_n 1.3 Zoning Information: 1.4 Property Dimensions: 1 Zoning District Proposed Use Lot Area(sq R) Frontage(R) two(\( 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. Owner'44q¢cord: Name(Print) City,State,ZIP /2 /J /Lvs�tf�c lJ.cr `t7Y-ZS'1-6t G 1 o.and It Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: LrJ1 n//)ow1 (.v L—xsi T?�C_ C.c�,f 7/-� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ d/ 4. Mechanical (HVAC) $ List: c' ) t 5. Mechanical (Fire Su $ Total All Fees: $ ression Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ?Is ❑Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) -7277Z -7"l License Number Expiration Date Name of CSL Holder , / Z� List CSL Type(see below) V No.and Street Type Description ��r✓�� ��/�� - U Unrestricted Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Coverin WS Window and Siding q7yd `y-CM 9 SF Solid Fuel Burning Appliances / y I Insulation Telephone Email address D Demolition 52 Registered Home Imp rovymeat,Contractor(HIC) / ,16Lr i✓Oa✓ !%"P"� ��S%U� HIC Registration Number Expiration Date HIC Company Name or HIC Registrant No.and Street Email address t-✓u�� Are 7Yr- F32-ye6>' Ci /Town,State,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 ........V 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. i 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 thi ation is true and accurate to the best of my knowledge and understanding. /4- 5_rccl —7 7-/ l wner'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.¢ov/oca Information on the Construction Supervisor License can be found at www.mass. ov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,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" American Properties Team, Inc. TO: 12D Russell Drive FROM: Jennifer Pappas, Property Manager RE: Window Replacement DATE: May 27, 2015 xxxxx**xxsxxxxxxxxxxxx*.x+x+xxxxxxxxxxsaxxaxdxxxx�:�z*x�*xxxq�x«rxxwxxxx*a:zx Please be advised that the Board of Trustees for Pickman Park has approved replacement windows for the above referenced unit. This approval is contingent upon them matching the existing windows and that they fit in the existing opening. Installation of rlhe windows must be completed from the interior of the unit and they must be the same in appearance from the exterior. Should the installation be completed from the exterior of the unit,you will be responsible for any damage that your contractor might cause (this includes painting). The Board will not allow windows with grids,crank outs, etc. Should you contractor find any rot or damage during the window installation,please make sure that it is reported to my office immediately. We also require that permits be pulled in advance(regardless of what your contractor may tell you), and then a copy of the final approved permit once completed must be sent to APT for the unit file as well. We also recommend that owners obtain a certificate of insurance from the licensed.contractor. You will need to bring a copy of this letter to the Salem Building Department in order to receive your permit. Should you have any questions or require additional information,please feel free to call me directly at(781)569.2675. cc: Unit File 500 WEST CUMMINGS PARK•SUIT 6050• W090RN •MA •01501-781-932&229 -FAY,78].935m289 ✓% ,° istration valid for individul use only before the expiration date. If found return to: Office of consumer Affairs&Business Regulation License or reg jOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ` Registration: 166026 Type,'. 10 Park Plaza-Suite 5170 Expiration; /12/2016. supplement Card Boston,MA 02116 -4 _ WINDOW WORLD OFBOSTON LLC. _ r JEFF STEELE 24 CUMMINGS PARK=SUITE 15 A WOBURN MA 01801"� Undersecretary Not valid without signature Massachusetts -Department of Public safety ' Board of Building Regulations and Standards Construction Supervisor License: CS-072772 ' JEFFCSTEELE -`s� ' z, 24 SHERWOO19 Danvers MA 01523 s' rs Expiration Commissioner 04/07/2016 WINDO-2 OP ID:J4 CERTIFICATE OF LIABILITY INSURANCE OATATEH 12015Y) o5rt2/2B15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR. NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. PRODUCER CONTACT Senn Dunn-GSO NAME Kathleen Jaques 3625 N.Elm St. AMC.99 Ezq;919-719-9592 INC.Noi 9i 9-719-9572 Greensboro NC27455 ADDfiE85:1<aC ues senndunn.com C.Timothy Ward,CPCU,CIC — ----r-----�-- IN INAIC X INSURERA:Citizens Ins Co of America 31534 INSURED Window World of Boston,LLC INSURERB;Allmerica Financial Benefit 4 118 Shaver Street v _ North Wilkesboro,INC 28659 INSURER c:Hartford Fire Insurance Co. _1_9682 INSURER D r _ INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE.TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. N DL TYPEOFINSURANCE BB - POUCYNUMBER MMIODirouffmYY MMMDNY LT YY LIMITS A COMMERCULL GENERAL LIABILITY EACH OCCURRENCE. § 1,000,00 CLAIMS-MADE, ❑-OCCUR OB67902527 04101/2016 04ID112016 X Business Owners MEDOKI,Voy..pw-on) $ 5,00(r PERSONAL S ADV.INJURY .$ 1,000,00 G_EML.AGGREGATE.LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 'i POLICY 0 PRO-JECT l EJ LOC PRODUCTS-COMP/OP AGG Sm 2,000,00( OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE IJMII $ 1,000,000 �� [Ea mr,r enf B ^_ ZANY AUTO W68767615 06M612014 06/1612015 BODILY INJURY(Per person) § AUTOS NED SCHEDSCEDULED BODILY INJURY(Per ecGdmp $ NON-OWNEQ PAOPERTY.OAMAGE § HIREDAUTOS AUTOS - Per acudont $ X I UMBRELLA UAH X OCCUR EACH OCCURRENCE $ 11000,000 A 1 EXCESS LIAR CLAIMS-MADE D667902527 04101/2016 04/01/2016 AGGREGATE § -- _._ _ ( )ED 1 1 NETENTIDNS I § WORKERS COMPENSATION ER OTH- ANDEMPLOYERS'LWeILnY X sTB?UTE El; _ C ANY PROPBIETORIPARTN'eR/EXECUTIYE YIN 22WECLJ2635 01/27/2015 01127/2016 E.LEACHACCiDENT' § 600,000 OFFICERMFMBREXCLUOED]E NIA — IMAMatorylnNH) E.L.DISEASE-EA EMPLOYEE S 600,00 W Yes. IPTIOe rower — .QESCRIRTIONOPOFERATIONSAoIow E.L.DISEASE-POLICY LIMIT $ 600,00 I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD tbt Additional Remarks SchodWe,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE l rya, „ tJ1.sA{Zt� ©1988-2014 ACORD CORPORATION. All fights reserved. ACORD 26(2014101) The ACORD name and logo areregistered marks of ACORD ° Window World of Boston, LLC MA HIC Registration Offices & Showrooms Number: ❑ 15A Cummings Park ❑ 295 Old Oak Street 166025 Woburn, MA 01801 Pembroke, MA 02359 Federal ID # (781) 932-4805 (781) 826-628.1 27-1481665 "Simply the Best for Less www.WindowWorldof Boston.corn Customer: G 1 hA FC G Or)P— Phone (h) Install Address: I a ) R lA sellI I ) Phone (w) City: Sa Ie m M% State: MA Zip O/ '77O E-mail WINDOW WORLD GLASS OPTIONS _1000 Series Single-hung All-Weld $189 �o SolarZone Elite $79 474 _2000 Series DH Mech/Welded Sash $195 Triple Glazed TG2* $155 & 4000 Series DH All-Weld $2001.200 (*Series 6000 Only) 6000 Series DH All-Weld $235 WINDOW OPTIONS _2 Lite Slider $329 ✓ Glass Breakage Warranty $15 INCLUDED 3 Lite Slider (113,V3,113) (1/4.1/2.1/4) $520 ✓ 1/2 Screens $9 INCLUDED Picture/ Fixed Lite $329 ✓ Foam Insulation on Jambs and Head $11 INCLUDED ✓ Double Strength Glass $15 INCLUDED Awning $255 — ✓ Qnuble_Locks��_2.6'�__—__-$5 JNCLUIlED - �sement Full Screens $22 —2 Lite Casement $ Colonial Grids (Contoured/Flat) $45 —3 Lite Casement (,I3,1l3.1r3) („4.,/z,Va) $855 Prairie Grids $51 —Basement Hopper $329 329 Diamond Grids $69 —Bay Window- Soffit Mount/ INS Seat $2660 Simulated Divided Lite $182 _Bow Window- Soffit Mount/ INS Seat$2785 Tempered DH Sash (BSO) (TSO) $65 _Garden Window $1875 Obscure Glass (BSO) (TSO) $35 —Specialty Window $ Oriel Style (40/60 or 60/40) $30 _Beige/Almond $35 Foam Enhanced Frame $35 _Wood Grain Interior(Series 4000/6000 only)$95 PRE 1978 BUILT HOMES (Federal Lead Containment Law) (Light Oakl Dark Oak/Cherry/ Fox Wood Lead Safe Practices Required $25 Rich Maple/Paintable/Stainable) MY HOME WAS BUILT IN THE YEAR gd Initial —Brown Exterior(Arch. Bronze/American Terra) $95 MISCELLANEOUS —Designer Color Exterior $150 Custom Exterior Aluminum Cladding ❑Textured $75 ❑ Smooth G-8 $75 $ Window Color I / W n I Facing Color Inside Outside Metal Window Removal $50 NON CUSTOM DOORS New Construction Vinyl Removal $175 _Vinyl Rolling Patio Door 5ft. or Eft. $995 Specialty Window Exterior Trim $ _Vinyl Rolling Patio Door 8ft. $1095 Mull to Form Multi Unit $30 Vinyl Rolling Patio Door (Custom) $1150 (p - Install Interior/Exterior Stops $50 .3Q_ French Rail Sliding Patio Door 5ft. or 6ft. $1295 Install Interior Casing Starts At $95 _French Rail Sliding Patio Door 8ft. $1395 Insulate Weight Boxes $20 _French Rail Sliding Patio Door 9ft. $1495 _Custom Exterior Cladding $150 Roof for Bay/Bow Windows $500 _SolarZone Elite or ETC Glass $175 Existing New Const. Ext. Retro Fit $150 _Grids Patio Door $129 Removal of Existing Bay/Bow $250 Woodgrain Interiors $295 Repair Sill or Jamb $50 _Exterior Designer Colors $395 Mullion Removal $30 _Interior Casing 2112 3112 $175 Bay/Bow Conversion Ext. Retro Fit $350 Handleset Options $ (New Siding Will Not Match) $ Building Permit $150 Door Color—/ . . ROUND-UP FOR WINDOW WORLD CARES: Inside Outside V - St.JurleChildren'sResearch Hospital $ IDISCCAIWRi�Cu Somer�is responsible forthe fallowing in connection with this contract:Painting,Staining,Alarm System disconnecUreconnect Building Permit fees in excess of$25 00,Homeowner and or Condo Association Approval Historic District Approval City of Boston parking&sidewalk Permit fees In connection with Installation F'NORARK IF NOT IN WRITING! Customer agrees to the terms of payment as follows: r S Extra Labor& Materials $ 4276X f /,;Fo Site Set Up, Disposal & Delivery Fee $ $195.00 Total Amount $ �ia8�. 00 Custom Order Deposit 50% $� Ck# Balance Paid to Installer upon Completion $ ���//�! -5V Amount Financed $ Window World of Boston anticipates starting this work on 171-6 W I<S and being substantially completed in / days. Security Interest:Yes No Any deposit required in advance of the start of the work SHALL NOT exceed 33 1/3%of the total contract price or the actual cost of any material or equipment of a special order or custom made nature,which must be ordered in advance of the start of the work to assure that the project will proceed on schedule. No final payment shall be demanded until the contract is completed to the satisfaction of both parties. All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170 Boston,MA 02116.Phone:(617)973.8700 No work shall begin prior to the signing at the contract and transmittal to the owner of a copy of such contract. Window World of Boston under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits. Window World of Boston shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting agencies, authorities or individuals. Notice:If the PURCHASER(S)obtains his own construction related permits for the work described under this agreement or deals with unregistered contractors, the PURCHASER(S) is hereby advised that in the event of a dispute,judgement and nonpayment,the PURCHASER(S) will not be entitled to make a claim or collection from the guaranty fund established by chapter 142A,M.G.L. You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Notice of cancellation must be in writing postmarked no later tha n midnight of the followi ng mg third business day. _ THIS IS A CUSTOM O8DER—NOT-FOR-RESALEr-- endently owned and o eratetl b Window World of Boston,LLC.under license from Window World,Inc. 1/5 - / Owner: Do not sign if thelf are any blank spaces. D to Sales o not sign if there are any blan spaces. / Date Owner:Do not sign if there are any blank spaces. Date Boston 04-15 White Cop y-Original Yellow Copy-File Pink Copy-Customer Hayes Printing 888-667-1116 The Commonwealth of Massachusetts Department of lndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia uIpWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Pr' t Le 'bl Name (Business/Orgaruzation/Individual): �7`•✓ G•iUn G,T6^� Address: City/State/Zip: 1'14 G/frlt Phone#: Z — Are you an employer?Check the appropriate box: Type of project(required): I.E41 am a employer with Gf 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 8. ❑Remodeling any capacity.[No workers'comp.insurance required] 3.❑1 am a homeowner doing all work myself.[No workeri comp.insurance required.]t 9. Demolition❑ 10❑Building addition. 4.❑I am 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.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurairm: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] -Any applicant that checks box#I most 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. 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 subcontractors 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: ��✓""� �y�"""' Policy#or Self-ins.Lic.#: 2Ze,/H C L-r26 3 r Expiration Date: Z 7�1� Job Site Address: 2 /) /�-�jft=u- 12AL 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. I do hereby certify u r i ins 1perjury that the information provided above is truet �ue and correct. Sign; Date: 7— 1 -ff— 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 S.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires A 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/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 dqg license or permit to bum 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-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia