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60 WHALERS LN - BUILDING INSPECTION � The Commonwealth o t s Department of Publ Massachusetts State Building Code(780 CMR) Building Permit Application for any Buildir4 V#t"N34 a Ot4j oi%vo-Family Dwelling (This Section For Official Use Only) , Building Permit Number: Date Applied: Building Official: ' SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) (cb Sa(et� 0070 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK - - Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? I Yes ❑ No W Brief Description of Proposed Work: 1� 54/lia i^ti�✓ kII vtes G"`' 444 cau•fcv {r S u- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR. CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): - - 'SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) - - A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1 11 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ .. SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) - - Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis osal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? j Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY - Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 5td o -ro G, , c. / NLF5,FF M ta,L-->Z-o 0t/ (- "I I SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 5etiv;�e, 1 el-rck (06 whalers t� Batu o19z0 _ Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Tet, Fe-/ /fe'( ",Zk q7V' 8.53_ 8w G ,lNhi fel�elW fr./� ®Luhcgy .�+et Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property 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 permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) if building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control ' �llnrrhe Suva 971 1479_ g0rz wcs 'lvn� k.7i�e h ,e P.�n I(tO l�(� IfLif Name(Registrant) Telephone No. e-mail address Registration Number IZ I-t-o)( " PfAW). MA 019(00 -7-?q-(g Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Nes 6e�eval dto Company Name I "also, Siva CSL CS to 13 'Name of Person Responsible for Construction License No. and Type if Applicable 3Z M�Krae St lft+ver�i l/ MA 0 I830 Street Address City/Town State //11Zip g7T_9iy_ 7064 1178 7Lq_ (,(,61NCS genes=�GO�tra cfi�l & .9�,ad.Cow Telephone No.(business) Telephone No. cellV e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAWT .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 O SECTION 12:CONSTRUCTION COSTS AND PERMITTEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ (IF 0 00 BuildingPermit Fee=Total Construction Cost x_ Insert here ( 2.Electrical $ 4.do appropriate municipal factor)_$ 3.Plumbing $ (.000 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 11,600 (contact municipality)and write check number here " SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. /f t A4a�ew :5;h1r !/yd l <�`y/ Tfeartirra `f 7S C?71 _ 9rT2 5S-3I-J` Please print and sign name itle Telephone No. Date IL Leho,c Rd PC0160�y MA 01060 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: y G Name Date BRIDGEWOOD CUSTOM CABINETRY FLOOR PLAN DETAIL DEALER CITY / P.O.# CUSTOMER �ekkJ(i� l�v( ^eZlc' CITY �° `� STATE 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 4M 4--�- 1-7-+- , __ - J:t 71i 2 L 4L " 3 E � . . .. .. TJ —IT � — _ +it I v, � _ _ - ,'1-7 7 � iavv . -- _ - M77 - I YY tT _ � p 10 — , ^� 12 �� tt 13 14 15 —r 16 17 44- NSC01531 + 18 The am(et Cmdominium Trust August 30,2016 To Whom It May Concern: On behalf of the Trustees at Hamlet Condominium, it is our understanding that Jenny Helmick at 60 Whalers Lane has hired a contractor to install kitchen cabinets, which is approved by the Board. Should you have any questions,please contact this office at 978-532-4800. Si cer ly, Philli Sherman CROWNINSHIELD MANAGEMENT CORP.,As Managing Agent for Hamlet Condominium i i Managed By CromninshieCd91anagement Co1p., 18 CrolvninshieCdStreet, Peabody, MA 01960 Phone (978)532-4800 • Fax(978)532-602.4 � wiviv.crouminshieCdcom. l ��7, I� Massachusetts Department of Public Safety °-r' Board of Building Regulations and Standards License: CS-199368 Construction Supervisor ' t ' NELSON SILVA 32 MUNROE STREET HAVERHILL MA 01830 r (--j.tU CA, Expiration: Commissioner 09/1011019 SILVCAN-01 LCARUSO CERTIFICATE OF LIABILITY INSURANCE DA 616f20116 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 NAME: Salem Five Insurance Services,LLC PHONE F" 445 Ma Street Bud,(781)933-3100 (AIC Nal:(781)933-9048 Woburn,MA 01801 E-MAIL ADDRESS:insurance.services@salemfive.com INSURER(S)AFFORDING COVERAGE NAIC II INSURER A:Safety Insurance Company 39454 INSURED INSURER B: Silva Candido&Ortins Inc INSURERC: Kitchentuneup 12 Lenox Road INSURER D: Peabody,MA 01960 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 CONTRACTOR 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. ISM TYPE OF INSURANCE INSD WVD POLICY NUMBER MPMCY EFF MWD EXP UMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,QOO CLAIMS-MADE T OCCUR BMA0017213 0411312016 04113/2017 OAMA-GETO-RENTED100,000 PREMISES(Ea ocwnence $ MED EXP(Any one person) $ 5,006 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,060 X POLICY ] PRO ECT LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E Ea accident A ANY AUTO 6217900 0411312016 04/13/2017 BODILY INJURY(Per person) $ 250,000 ALL OWNEDAUTOS �( SCHEDULED AUTOS BODILY INJURY(Per acadeM) $ 800,000 XHIRED AUTOS rd AUTOS rN-OWNED PPReOPPEERTY DAMAGE $ 100,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ TI WORKERS COMPENSAON PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER MY OFFICERIMEMBER EXCLUDED?ETORMARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT 8 .(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ fm describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddtOonal Remarks Sdhedule,may be attached If more apace Ia n uirsd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof Of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1 Finish Acceptance Form Page I of 2 FINISH ACCEPTANCE FORM f following finish: Your kitchen will consist o t the fo o g Q UNFINISHED: Cabinetry could be exposed to high levels of temperature or humidity fluctuations, poor handling, etc. Exposure to these or other harmful contlaions can result in splitting panels,as well as warp,bow or twist of other hardwood components.We call this to your attention so that should you choose to sell unfinished cabinetry,you,as well as your customer,understand that once Bridgewood Custom Cabinetry inspects this product for shipment,its liability for this product ends. Q NATURAL: Because there is no staining done to balance the color and uniformity of the wood,variations will occur on adjacent cabinets, between pairs of drawers and or doors,and even within the same panel.We call your attention to these characteristics because we cannot be held responsible for the type of or degree of variation you will experience in real wood.Unusual graining will not be cause for replacement. 0 SOLID COLOR AND PICKLE FINISHES:Solid and pickle finishes are very attractive,but they will display characteristics not usually associated with some other finishes you may be more familiar with.After a period of lime,some yellowing may appear.The pigmented finishes that Bridgewood Custom Cabinetry uses are very high quality, high solids, catalyzed varnish.When white,pickled and other solid colors are applied to wood, peaks and valleys will form in cracks and crevasses.All woods expand and contract due to changes in humidity.Wood also expands and contracts at different rates across the grain versus along the grain. When two pieces of wood are joined together a visible seam may occur due to expansion and contraction. Maintaining proper temperature and humidity in the home can help avoid this.It is beyond the control of Bridgewood Custom Cabinetry to guarantee that visible seams will not occur. Q PICKLE FINISHES:Pickle finishes have an overall translucent tone and will allow the color to vary with the wood species. Some stain build up will occur in open grain as well as difficult to wipe areas.Pickle finishes will display more noticable variations between solid woods and veneers since the translucent finish only lightly masks the full range of color and grain varaition, including mineral streaks and spots. Another characteristic of pickling white is its inability to hide the changes that occur in hardwood during nature's aging process as the wood mellows to its final patina.When normal wood movement occurs some compression and separation will occur at the joints. When pickle finishes are used,this movement will result in cracks at the joints.These cracks are acceptable on pickle finishes. QX MAPLE FINISHES:Maple in its natural form is a light colored wood.Maple wood grain patterns are subtle but win display intricate detail such as flecking, burling and small mineral streaks.This wood accepts stains in the light to medium color range but begins to blotch significantly when darker stains are applied. Maple is a very hard and durable wood,and tends to yellow when exposed to U.V.lighting. Q ARTISTIC FINISHES:Cabinetry with these finishes are subject to slight differences due to the craftsman's individual technique.Several steps are taken to produce a final product that is as consistent as possible,however,no two orders will be exactly the same.The sample is representation of what you can expect. We cannot guarantee the cabinetry you will receive will be exactly like the sample. Slight differences should be expected. As Artistic Finishes are solid color finishes as well,the conditions of a Solid Color Finish shall apply. WALNUT WOOD:Walnut is a very stable hard wood with a rich appearance.Generally straight and moderately coarse grained wood with rich dark brown eartwood and nearly white sap wood. In its natural form the difference between the heart and sap wood can be quite dramatic. Walnut finishes well in color ranges darker than the natural color of the wood and can minimize the color variations you we in Is natural state. U.V.photo-aging will cause Walnut to yellow over time,this being more prevalent in natural or lighter stains. Q HICKORY WOOD:Hickory is a very hard fight grained wood.Because of extreme color variations between heart and sap wood,ranging from white to brown, black or green,hickory in its natural form looks very rusfic.The color variation in this can be tamed significantly with darker stain applications,or artistic finishes. The degree and speed of photo aging due to exposure to U.V.lighting is less with Hickory than woods like Cherry and Maple. RKNOTTY HICKORY WOOD:Hickory is a very hard tight grained wood.Because of extreme color variationsbehveen heart and sap mod,ranging from white town,black or green,hickory in Ws natural forth looks very rustic.The color variation in this can be tamed significantly with darker stain applications,or artistic finishes.The degree and speed of photo aging due to exposure to U.V. lighting is moderate and gradual. Knotty Hickory will have a random number of knots ranging from very small to several inches in diameter.Doors and drawer fronts will have at least one knot per piece but could have several knots.Face frames and moldings will be Gear or have only modest knots.Open knots will be filled to assure integrity. CHERRY WOOD: Natural Cherry is a very tight grained wood with fairly subtle and uniform grain characteristics. Because of extreme color differences tween the heart and sap woods,cherry will show shades of pink, red,white or even green to a lesser extent. Staining and photo-aging minimize these color variations, but natural cherry will exhibit these characteristic.Cherry is also prone to darkening with exposure to natural light or even intense artificial light.This change Is almost immediate upon exposure.Cherry is another wood which will mellow significantly with stain application.Cherry has natural defects such as small knots and sap wood streaks that adds to the natural beauty of this wood.Cherry is moderately hard making it prone to minor dents. KNOTTY CHERRY: Natural Knotty Cherry is a very tight grained wood with fairy subtle And uniform grain characteristics. Because of extreme color i erences between the heart and sap woods, knotty cherry will show shades of pink, red, white or even green to a lesser extent. Staining and photo-aging minimize these color variations,but natural cherry will exhibit these charecteristiw.Knotty Cherry is also prone to darkening with exposure to natural light or even intense artificial light.This change is almost immediate upon exposure.Knotty Cherry is another wood which will mellow significantly with stain application.Knotty Cherry has natural defects such as small knots and sap wood streaks that adds to the natural beauty of this wood. Knotty Chert will have random knots ranging from very small to several inches in diameter with as least one knot in the door or drawer front.Open knots will be filled with a matching putty to assure integrity. Knotty Cherry is moderately hard making it prone to minor dents. Q OAK:Natural red oak is a medium to light colored wood with a naturally occurring reddish hue.Oak wood is a very open and highly defined grain wood that accepts stain in all color ranges from light to dark in a very uniform manner.Areas of open grain such as panel and edge profiles may accept the stain more readily for a darker appearance as they are more open and accept color more readily.Oak is very hard and durable and will slowly darken or yellow as the wood reaches with long term exposure to uftm violet lighting. ®KNOTTY ALDER:Knotty alder is a straight grained even textured wood.Pale yellow to reddish brown in color with indistinct boundary between heartwood and sapwood.Knotty alder accepts finish uniformly in ranges from light to dark.Knotty alder is a fairly soft wood that is easily dented and dinged.As long as the finish . is not broken this will not be considered a defect.Alder does not machine as uniformly as harder woods leaving a rougher texture in open grain areas like panel about:blank 8/31/2016 The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia w.rkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Applicant Information J Please Print Leathly Name(Business/Organintion/Individual): Kt'1/Lt^.Ect Address: l7 tec.ayc, 9-A City/State/Zip: P"-" �v) /t Phone M %n c� Are you an employer"Check the appropriate box: Type of project(required): 1.01 an a employer with employees(full and/or part-time).• 7. 0 New construction 20 1 am a sole pmprioDr or partnership and have on employees working for me in S. ©'Remodeling any capacity.[No workers'comp.insurance required.] 9. 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance requv1 ed.J t 10 Demolition Buildinldi [� g addition 4.0 1 am a homeowner and will be hiring emuractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.0 I an a general contractor and I have hired the subcontractors listed on the attached sheet. 13.0 Roof repairs These suh-contractors have employees and have workers'comp.insurancet 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.) *Any applicant that checks box#7 must also fill out the section below showing their workers'compsosation 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 time of the sub-contractors and stare whether m not those entities have employees. If the sub-contactors have employees,they most provide their workers'comp.policy number. I am an employer that is providing workers'eampensation insurance for my employees. Below is the policy and job site information. ( / Insurance Company Name: ` t r'J L a,sW 4 c 1 t Policy#or Self-ins.Lic.#: Expiration Date: 4 a �u r �h S¢1tw, 1Q,,4 oto Z o Job Site Address: City/State/Zp: 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 under the pains aannd penalties ofperjury that the information provided above is true and correct. Sienamre• Date- Phone Official use only. Do not write in this area,to he completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants '— Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town),"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia