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BP-77193 Permit No. BP-77193 . BUILDING PERMIT GIS#: 3345.00 CommOnweatth of Massachusetts Map: 0066 TOWNOFDARTIWO1)TH Lot 0002 400 SlocumRoad,Dartmouth,MA 02747 Sub-Lot- 0131 Phone:(508)910-1820 • Far(508)910-1838 Category: DECK Project# 7S-2015-002683 PERMISSION IS HEREBY GRANTED TO: Est.Cost 36800.00 Contractor: License. Phone# Fee: $75.00 VIRGIL M MIRANDA G-5 I6331 (774)263-2175 Coast.Class: - Engineer License: Phone#. Use Group: R3 Lot Size(sq.ft.) 41000 Applicant: - Phone# Zoning: : SRB - CHRISTOPHER BOGIE (508)542-0280 Aquifer Zone: N/A OwrvL.R: Flood Zone: ZONE% BOGIE CHRISTOPHER I) _ New Coast.: 2425q.ft. 1 Alt.Coast:: - N/A DATE ISSUED: s.:J 15 Date Typed: 05-06-2015 TO PERFORM THE FOLLOWING WORK. Construct new deck attached to existing decks PER PLAN P, ect Location: 3 WREN LN , Approved/Issued By: t LLB 11.(J2®� ,[ F,1_+ /3 -'r4 DAVID BRUNETTE,L'UCAL BUILDING INSPECT T All work shall comply with 780 CMR Sr"Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion,final inspection is required. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK.if items under their jurisdiction are not met; not withstanding the issuance of this Building/Zoning Signature of Owner/Agent: ) • "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service II: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross ConnectionFinal: Final: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET tiin, O 9 oH8- U LDINFAX: 5G$DEoPAR$TMENT RECEIPT 77133 NamL �t3! L. ( ropertyOwner: Date:J�(�� Job Location: 3 /� '.t ‘Le �� Map: `-1(/' Lot:i / / Description ,o' 54 edger#'s el.# Amount Building& Building sc. k0'010(110- 4105 fi' - 75 '6 Electrical ` y r 0 6 ak000-44106 Plumbing & Gas -off s 01000.44107 Trench Safety aCOt:ECT'J :10-44129" Other Department Revenue 01000-42420 7�_White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By/ V / THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS RESIDENTIAL . . ❑ Phased Approval(R106.3.3) S25.00 APPLICATION FEE IS NON IHE-FUNDABLE ET NONmTBANSFEICABLE urH. DATERECEIVED o!�;-' ,.. DARTMOUTH BUILDING DEPAI�TME,^NT • .o ri 400 Slocum Road ;- j • z fir 7.% Dartmouth, MA 02747 _ . • ? „' Phone: 508-910-1820 Fax: 508-910-1838 26 1fi44 --' www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING NTHistEATION F©RoEFICIAL USE ONLY 3 RECEIVER-BY BUILDING PERMIT NU BER i7ATE1SSUED: . Sttit}ATtJRR 3 � a Q 1�� � �1 DATE: ;SAY €3 a �615 �� Building Commissioner/Inspector of r - C.-gs ZantngDisfrieli �«{S , •Proposed Use ,Zope .J ❑B ❑A D V AquiferZone: _) - ,—.�- THE FOLLOWI;NG'AG LIES SHOULb SE NOTIFIED ' DPW D Boarcof and of ❑Cons -0 Planning• ❑Address 0 Engineering El Cross Appeals ealth Conmission Card ` Connection Conn 0 fire. : .p Gas - ❑Electric ,CI Other :o Water Card ❑Sewer Card .Chief;: : '. Cat •Off . cut'OH : Cot Off - Cut Off" r ` '�:! DEPARTM TAL'APP,ROVAL'tS) " - - - Board of Health: Signature: Q � /( Date: ✓/ LG'/� Conservation Commission: Signature: Date: D.P.W: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: ,/ Brief escription of work being performed: In 1! Mthf nCry pc Ch c'i i,eh,ri y ? , ' . * `+ 5EL`TtON1 S{TE CNFQRAdAT1P.N _-'. 1.1 Property Address: 3 wrt vt. 444,A- 1.2 Assessors �Mj/app&Lot Number: / Contact Person: C Ill`1.1 /3a<5i< Map `f Cd ` Lot - /1/ Phone Number i f a s42 -0 Zfo 1.3 Historical District D Yes 0 No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ MunicipalMu! 0 Municipal 0 Altering more than 25% per side of building 5:1-P ivate Well 1� Site Disposal System Has application been submitted to the Historic Commission? ❑Yes ❑ No Date: Revised 5/13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT 1 RESIDENTIAL 7/::PC,--c-21:'.':;-'"r--••11-;:::PiH-:, .-,,,-:.11],fij•,t4IPPTION1;PROP:gRTYVWlinS10101110.kgEp,40tNt::.::::: : ::::.7.,. .-::-ff:45.?;%, : . t---- 2.1 Owne Record: Lfte\s-roPlica_ -730GIE- . anue___ sog-sti -oarPo , Name (print) - Contact Address Phone Number 2.2 Authorized Agent:, Name (print) Contact Address Phone Number L of f 31 Licensed Construction;upervIfo d'S' pLl±:EL:Ter:ifCiffilt-01131731CriNICEaLciclent:::::;11-CT l'-?-1 ;;1;177-71frT , .. Company Name/Contractor Name: (f)rbj. I A sr 4,,b Liktf-try Lit:14 (Ohdiruz1/4 itirnipP 4.•fetltv Address: ca 0 7 rogns fan it /VII MA 0 214f Expiration Date. , ignature: kr._ .1---...--------.... Telephone: 77cfr,,Z 6 ) ..„.2)zif (212 4/I1 3 2 Homeowner Exemption-One&Two Family Only Section 110.R5,1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land en which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures: A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applying under this sectiorcsign below: Signature: r*:::***12. 4";:g.a.K$X-aLkt.44*-01,11.latti3OlfteNtWa.00,11A.ent-trfattAM.OtSatigik40;aliage Wacker's 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: 0 Yes 0 No :,t:'3f.1.:Cil*NNNt.;53;5.1ValitalWrnbt$111010NOntt.10#44.0.:a0(0.-46.0104400174{ErgatierrnaTSA Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove 0 New Construction* 0 Accessory Bldg. .0 Addition 0 Roofing/Siding 0 Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No.of windows Doors ( IJ 0 DEMOLITION (specify): Location of debris removal (per MGL C.40 Sec 54): 0 Dumpster on site 0 Dumpster On Street Facility Name: Location: *If new construction, please complete the following: Single Family: No. of Bedrooms No. of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 0 Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): 0 Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): 0 HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify): 0 Air conditioning-(separate unit) 0 None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other SeCTfON 6_ESTQNATt[-0g7N5Tj;UFfiFFtkFAST. Item j Estimated Cost($)to be completed by permit applicant 1. Building rad. au 2. Electrical 3. Plumbing ' 4 Mechanical (HVAC) 5 Total=(1 +2 +3+4) r) fSEGTIQN a O NERAU�H,QR(? TI H ,';to Be cowpleted wheriowne s agenF o_r oiFfraetoC_`app(Ies fi*buiIdutg=permit) (Please Print), A „Y u''v f & ,( e ,as Owner of the subject property hereby authorize /vir f A !r^z��rdf to act on my behalf, in all matters relative to work authorized by this building permit application. S/e Signature of Owner Date rn` (, SECTION,'76 -OWNEItIAUTRORIZfi19 A;GGRRt DECLQRATfON..;. V `, t� N(Z1 S V 061E ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. CDC - S1e1/ - Signature of Owner/Authorizes Agent Date r SECT[ON$ `OFFiGEfl3aPEGT02SNOTES Less Application Fee: $25.00 Remaining Balance: $ 'PO Total Permit Fee: $ 75 Other$Amount$ Gross Area-New Construction total sq.ft. 2'-(Z Gross Area-Alteration n/total sq.ft. / I / Permit Issued to: r' G�';11.77''L‘c°�/�.1[(z� rJs2_4- .. a .j`'f cteti.,ci Y'a /7/4G/3 .G1�'e- ��d.h _ • r _ it ea.l£ :_';:.°'u e.{„Y _SEG7'IQnabtl tills,: 1 t1 tatan -,.'_..r ffitI.ak ;a „,W,4! tqs 614- ie C2( Ifi-1%is De611 ,5,///r P/6c.. (9/A f Permit No. BP-77193 Project Location: 3 WREN LN Commonwealth of Massachusetts TOWN OF D�RTM©UTH GIs# 334500' Mag r 0066 ,, 400 Slo o d,Dartmouth,MA 0274'1 " , �" Ph ne (5 9101520 • FU (508) 1018i8 "Eat"µ 0002 u Bu � DING PER a x' DECK 4` .Li l P � -201t.5-002� �+ � ( �r� /� '1 Chi $6800 00 , FIELD IN►JPL' li�1 ION Fee: $7500 229 j Gons`Y Glass 11 Use Group R3 Contractor.' License: Phone#: Iat ze q 41000 VIRGIL M MIRANDA (774)263 23$ • Zoning SRB Engineer License phone#. -- Aquifer one: .f N/A Applicant. Phone #: ZONE)C w . CHRISTOPTR BOGIES �` (508) 542-0280 Go 242'sq" £Cu °' OWNER: y- a.. Alt nsf N/A BOGIE CHRISTOPHEI �D,&' -< j DATE ISSUED: 6//3//n TO PERFORM THE FOLLOWING WORK: Construct new deck attached to existing decks PER PLAN DATE TIME I TYPE OF INSPECTION &REMARKS INITIAL 12i A W 6�z/,-,1' L LIC Permit No. BP-77193 . BUILDING PERMIT: Say' 51 Z"° GIS#: 3345.00 Commonwealth of Massachusetts Map: 0066 TOWN OFDAR MOUTH Lot: 0002 400 Slocum Road,Dartmouth,MA 02747 Sub-Lot: 0131 : Phone:(508)910-1820 • Fax:(508)910-1838 Category: DECK Project# JS-2015-002683 PERMISSION IS HEREBY GRANTED TO: Est.Cost S6800.00 Contractor. License: Phone#- Fee: $75.00 VIRGIL M MIRANDA (774)263-2175 Const.Class: - - - Engineer. License. Phone#: Use Group: R3 Lot Size(sq.IL) 41000 Applicant Phone#: Zoning: SRB - CHRISTOPHER BOGIE (508)542-0280 Aquifer Zone: N/A - OWNER: Flood Zone: ZONE X BOGIE CHRISTOPHER➢ New Coast.: 242 q.ft. Mt.Const: N/A - DATE ISSUED: C /3' /„�_ ` , Date Typed: 05-06-2015 TO PERFORM THE FOLLOWING WORK Construct new deck attached to existing decks PER PLAN nec?t L�ocati n: 3 WREN LN Approved/Issued By: DAVID BRUNETTE, CAL B DING INSPE All work shall comply with 780 CMR 8'si Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion,final inspection is required. I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building/Zoning 4-7/140 Signature of Owner/Agent: "Persons contracting with unrdgistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: 3.`z 0---/,S ^ Underground: Oil: Underground: Service: 13t�/J Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: oral: Final: Final: ry 1 Cross Connection Final: Final: 6/d1, r {W 1-Apel l Board of Health E-911 V Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPSS) Mass.Gov Home State Agencies • ensee Details O� ullit,mographic InformatJ9J2MMIRANDA ender: IW.ner Name: 'cense Address Information r ddress: •ddress 2: ity: NEW BEDFORD •tate: MA Vipcode: 02745 ojntry: United tates Ire_�se In or n icense tdo: 1b 330 License Type: Construction Supervisor i•rofession: Building Licenses Date of Last Renewal: 2/27/2015 Issue Date: Expiration Date: 2/24/2017 icense Status: Active Today's Date: 5/7/2015 econdary License: Doing Business As: atus Change: License Renewal. rerequisite Informaon o rrerequisite Information Discipline No Discipline Information ocumentum Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us c http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license id=292268& 5/7/2015 T., S' ' IPOOtm` Litre — --- FEevCr -� S ' Ul 9.3 o Iss m abrraiti a /ci a f i Simeime J -Qs, 1 Cc- o _a o c f Lis Cs • era * `ti MIN N -� _� G MINIM— ' O *, by t ) kti i:` m R -. Z c C r t J 1- //PAWY 6,•.1 -- • �^�� A S t -t- tcAl ------1; I /7/7"-------- - ilic C i v V U -j . Z 1 -{- cp -bc Q cm It, O ' 1 U C1 W ;s 1 o f . �� ispv _ 2 pi f� et.Ci it r a:.. • RESIDENTIAL ' . . ❑ Phased Approval(R106.3.3) S25.00 APPLICATION FEE IS NON BE-FUNDABLE &NON-TRANSFERABLE r_______; DATE RECEIVED i is uU H DARTMOUTH BUILDING DEPARTMENT 19,y ''' 400 Slocum Road z = Ett Dartmouth, MA 02747 • <, ,s, Phone: 508-910-1820 Fax: 508-910-1838 fi„ i �""" www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i5 015S#'40N P„©V F1014.: E O ti$ NLY . f 3 -t '^\ . _ .: 74 r i.[ y RECEIVED BY BUILDING,PERMIT NUMBER DATE 1SSUEb. S(GNATITRg, DATE: Suifding Comm(ssionerllnspecforoTBu1dmgs • Zontrtg liffirtc){r ,PropdsedUse "`Zope O J4 cO B rf A D V , Aquiferzone ,.- �Fi( F�LtO[ 1l GAG CP S 58tdI�L�I NEt�OTf E� * ' DPW C Boardof {If and of ❑Cobs b P1adrNng - ❑74dress _ ❑Engineering ' ElCross_ i s,Appeals Heath _totnmiissmn Gard Connection €;: ,D,Eire` -D ag - ❑Electnc :. d Other - fp Water-Card. p Sewer Gard ' ;;; -�.,O,blef Cutoff ,Out Off _Cut off - .-:.Cut Off '` /' D ARh EN T i APPR©VAL1S) / r— 1 Board of Health: Signature. (6%IL4 Z. Date: 6/l -�/�J Conservation Commission: Signature: Date: • D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: • Brief escription of work being performed: In i{1 i hJ nay Dc 4..6 CA f>e h✓/v-1 2 r ..., ,::: ::f ._; ._sa.. � :. $EoiON v S}'ftsig@R1NA7J�N sz-rit.. r„>t'; . .r.._'- - : , 1.1 Property Address: 3 i'✓rc"t. 1.44�- 1.2 Assessors Map&Lot Number: Contact Person: ciii`1.( I3??,Si'e Map Lot - i Phone Number: Od� - t 1 B2?o 1.3 Historical District ❑Yes 0 No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal 0 Municipal ❑Altering more than 25%per side of building "Private Well 61'6 Site Disposal System Has application been submitted to the Historic Commission? ❑Yes ❑ No Date: Revised 5/13 r it 1,OrJ T I / ,/ x 1 il_ i is 0 1 c If Z. s: ;` C . — { a -11 sc tit? Vk w tta 1--- fir 3 CI 1 The Commonwealth of Massachusetts Department of Industrial Accidents -' 1,= Office of Investigations 1 Congress Street, Suite I00E.�t_ _ ti Boston,MA 02114-2017 ,��� www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ant Information // Please Print Legibly /yicers, me(Business/Organization/Individual): V 1ih1I Mlrynd5 COrIJfrt.Gfr ii Address: a (I j^'r//i4s Jua If /178 MA Uz 7 Ys City/State/Zip: Phone#: 7 74/ - a. 6 7-2.27 5 Are you an employer? Check the appropriate box: Type of project(required): 1. G2 am a employer with L - 4. ElI am a general contractor and I employees(full and/or part-time). + have hired the sub-contractors 6. ❑New construction 2.�I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.t 9. ❑Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions ' myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.® Other DeGc comp. insurance required.] EnTSN S i o r) *Any applicant that chec sjoz4l Must'also fill out the section below showing their workers'compensation policy information. t Homeowneis who-sabmit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. n Insurance Company Name: Sovd-L f tif�tM //vf, 7 the//q /if / n• P licy#or Self-ins. Lic. #: n S l7(� 4.41 3Expiration Date: n `/1ry/2 U/L ob Site Address: �/ t� �5� C City/State/Zip: D4irI/navrlL fr"9 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I o hereby certify'under the pains and penalties of perjury that the information provided above is true and correct afore: `!� Date: ✓ I 2di hone#: 17 c( `oj. 7- 92,27.f Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Dent of Industrial Accidents Mike of InvestIptions 1 Comma Street,Suite 100 Roston,MA 02114-2017 Tel.#617-727-4900 ext 7406 of t-877-MASS Revised 7-2013 Fax#617-727 7749 1�v1d a