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Augerton Building Permit Application_Final
City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ● Municipal Building Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW 1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES, FENCES, GROUND MOUNTED SOLAR, ETC. l. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work. (Digital and hard copy) 3. Site plan with location of proposed structure(s) and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new / replacement windows). 8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable). 9. Note any Conservation and/or special permit requirements (if applicable). 10. Driveway Permit (if applicable). 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit - public land by DPW / private land by Building Dept. 13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit application before issuance of permit. 14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Dwelling FOR MUNICIPALITY USE Revised Mar 2011 This Section For Official Use Only Building Permit Number: _____________________ Date Applied: ______________________________ ___________________________________ ____________________________________________ ___________ Building Official (Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: ____________________________________________ 1.1a Is this an accepted street? yes_____ no_____ 1.2 Assessors Map & Parcel Numbers _____________________ ____________________ Map Number Parcel Number 1.3 Zoning Information: _______________ ___________________ Zoning District Proposed Use 1.4 Property Dimensions: _____________________ ____________________ 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) Public Private 1.7 Flood Zone Information: Zone: ___ Outside Flood Zone? Check if yes 1.8 Sewage Disposal System: Municipal On site disposal system SECTION 2: PROPERTY OWNERSHIP1 2.1 Owner1 of Record: ________________________________________ _________________________________________________ Name (Print) City, State, ZIP _____________________________________________ _________________ ___________________________________ No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition Demolition Accessory Bldg. Number of Units_____ Other Specify:________________________ Brief Description of Proposed Work2:_________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee: $_______ Indicate how fee is determined: Standard City/Town Application Fee Total Project Cost3 (Item 6) x multiplier _______ x _______ 2. Other Fees: $_________ List:_________________________________________________ ____________________________________________________ Total All Fees: $_______________ Check No. ______Check Amount: _______Cash Amount:______ Paid in Full Outstanding Balance Due:__________ 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ 5. Mechanical (Fire Suppression) $ 6. Total Project Cost: $ January 08, 2022 x 253 Crescent Street Northampton MA 01060 Mark Augarten Northampton, MA, 01060 253 Crescent Street 413-320-7310 maugarten@gmail.com x Solar 4000 14000 18000 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) ________________________________________________________ Name of CSL Holder _________________________________________________________ No. and Street _________________________________________________________ City/Town, State, ZIP _________________________________________________________ __________________ ______________________________________ Telephone Email address _____________________ ______________ License Number Expiration Date List CSL Type (see below) _______________ Type Description U Unrestricted (Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation D Demolition 5.2 Registered Home Improvement Contractor (HIC) ______________________________________________________________ HIC Company Name or HIC Registrant Name ______________________________________________________________ No. and Street ________________________________________ ____________________ City/Town, State, ZIP Telephone _____________________ ______________ HIC Registration Number Expiration Date _______________________________________ Email address 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 I, 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: OWNER1 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: 1. 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 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” Lando Bates CS-109944 12/01/2023 51 Assabet Drive Northborough, MA, 01532 774-249-1687 Lando.B@empowerenergy.co Empower Energy Solutions Inc 198351 04/05/2022 39 Fernwood Dr Rocky Hill, CT, 06067 (475) 221-2356 operations@empowerenergy.co x January 08, 2022 CITY OF NORTHAMPTON SETBACK PLAN MAP:_______ LOT:________ LOT SIZE:____________ REAR LOT DIMENSION:_____________________________ FRONTAGE_____________________ REAR YARD _____________ SIDE YARD______________ SIDE YARD______________ FRONT SETBACK_______________ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ● Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number ________________ is that all 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 disposed of in: Location of Facility: ___________________________________________________ The debris will be transported by: Name of Hauler: ______________________________________________________ Signature of Applicant: __________________________________Date: ___________ Empower Energy Solutions Inc 720 S Washington street North Attleboro, MA 02760 January 08, 2022 City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ● Municipal Building Northampton, MA 01060 HOMEOWNERS’ EXEMPTION ELIGIBILITY AFFIDAVIT I, ________________________________________________________ (insert full legal name), born ___ (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners’ exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners’ exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code’s definition of “homeowner” as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code’s requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this _____ day of _______________, 20___. ___________________________________________ (Signature) 76 North Meadowbrook Drive Scott E. Wyssling, PE Alpine, UT 84004 Jon P. Ward, SE, PE office (201) 874-3483 Gregory T. Elvestad, PE swyssling@wysslingconsulting.com January 7, 2022 Empower Energy Solution Inc 15 June Street, Suite 2a Woodbridge, CT 06525 Re: Engineering Services Augarten Residence 253 Crescent Street, North Hampton, MA 5.600kW System To Whom It May Concern: We have received information regarding solar panel installation on the roof of the above referenced structure. Our evaluation of the structure is to verify the existing capacity of the roof system and its ability to support the additional loads imposed by the proposed solar system. A. Site Assessment Information 1. Site visit documentation identifying attic information including size and spacing of framing members for the existing roof structure. 2. Design drawings of the proposed system including a site plan, roof plan and connection details for the solar panels. This information will be utilized for approval and construction of the proposed system. B. Description of Structure: Roof Framing: 2x6 Dimensional Lumber Framing members 20” on center. Roof Material: Composite Asphalt Shingles Roof Slopes: 8 & 12 degrees Attic Access: Accessible Lumber type: Assumed Spruce Pine Fir, No. 2 Foundation: Permanent C. Loading Criteria Used • Dead Load o Existing Roofing and framing = 7 psf o New Solar Panels and Racking = 3 psf o TOTAL = 10 PSF • Dead Load o Existing Roofing and framing = 7 psf o New Solar Panels and Racking = 3 psf o TOTAL = 10 psf • Live Load = 20 psf (reducible) – 0 psf at locations of solar panels • Ground Snow Load = 40 psf • Wind Load based on ASCE 7-10 o Ultimate Wind Speed = 125 mph (based on Risk Category II) o Exposure Category C Analysis performed of the existing roof structure utilizing the above loading criteria is in accordance with the 2015 International Residential Code, including provisions allowing existing structures to not require strengthening if the new loads do not exceed existing design loads by 105% for gravity elements and 110% for seismic elements. This analysis indicates that the existing framing members will support the additional panel loading without damage, if installed correctly. Page 2 of 2 D. Solar Panel Anchorage 1. The solar panels shall be mounted in accordance with the most recent Ironridge installation manual. If during solar panel installation, the roof framing members appear unstable or deflect non-uniformly, our office should be notified before proceeding with the installation. 2. The maximum allowable withdrawal force for a 5/16” lag screw is 235 lbs per inch of penetration as identified in the National Design Standards (NDS) of timber construction specifications. Based on a minimum penetration depth of 2½”, the allowable capacity per connection is greater than the design withdrawal force (demand). Considering the variable factors for the existing roof framing and installation tolerances, the connection using one 5/16” diameter lag screw with a minimum of 2½” embedment will be adequate and will include a sufficient factor of safety. 3. Considering the wind speed, roof slopes, size and spacing of framing members, and condition of the roof, the panel supports shall be placed no greater than 40” on centers. 4. Panel supports connections shall be staggered to distribute load to adjacent framing members. Based on the above evaluation, this office certifies that with the racking and mounting specified, the existing roof system will adequately support the additional loading imposed by the solar system. This evaluation is in conformance with the 2015 IRC, current industry standards and practice, and is based on information supplied to us at the time of this report. Should you have any questions regarding the above or if you require further information do not hesitate to contact me. Very truly yours, Scott E. Wyssling, PE MA License No. 50507 FOHDRIVEWAY CRESCENT STM INV AC MSP B μ AC LEGEND M INV AC MSP B D LC μ UTILITY METER INVERTER AC DISCONNECT MAIN SERVICE PANEL DC JUNCTION BOX MONITORING UNIT DISTRIBUTION PANEL LOAD CENTER CONDUIT FENCE SCALE: 1" = 15' N S EW ATS AUTOMATIC TRANSFER SWITCH AUGARTEN, MARK AUGARTEN RESIDENCE 253 CRESCENT ST NORTHAMPTON, MA,01060 413-320-7315 RACKING: IRONRIDGE XR-100 JOB NUMBER: 1122 UTILITY: NG OWNER:DESCRIPTION:DESIGNED BY: REV:DATE: 1/7/2022 PAGE NAME: PAGE: MS INVERTER: (1) SOLAREDGE INVERTER SE3800H-US (3.80 KW) 3.80 kW AC SITE PLAN PV2REVIEW BY:5.60 kW DC ROOF SOLAR SYSTEMUTILITY ACCT #:15966-60008 HAMODULES: (14) HANWHA Q.PEAK DUO BLK ML-G10 400 Signed 1/7/2022 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N/A SUBR WVD ADDL INSD 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 THISCERTIFICATE 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS AUTOSAUTOSNON-OWNEDHIRED AUTOS SCHEDULEDALL OWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD N/A N/A 12/03/2021 R S GILMORE INSURANCE AGENCY INC PO Box 126 MA 02761 Ann-Marie Kahanowitx (508) 699-7511 amkahanowitz@rsgilmore.com NORTH ATTLEBORO EMPOWER ENERGY SOLUTIONS INC MA 06067 LM INS CORP 33600 10 RAMBLEWOOD DRIVE ROCKY HILL 722376 N/A N/A N/A A WC533SB2191Q011 11/03/2021 11/03/2022 500,000 500,000 500,000 N/A Workers’ Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires, or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued (unless the expiration date on the above policy precedes theissue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage - Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. Empower Energy Solutions Inc 10 Ramblewood Drive Rocky Hill CT 06067 Daniel M. Crowley, CPCU, Vice President – Residual Market – WCRIBMA The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Name (Business/Organization/Individual): Please Print Legibly Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1.0 Jam a employer with employees (full and/or part-time).* am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself, [No workers' comp. insurance required.] 4.fl Jam 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 proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers' comp. insurance.t 6.fl We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. fi New construction 8. fi Remodeling 9. 0 Demolition 10 El Building addition 11.0 Electrical repairs or additions 12. fi Plumbing repairs or additions 13. fi Roof repairs 14. fi Other *Any applicant that checks box #1 must 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 sub-contractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: 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 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 and penalties of perjury that the information provided above is true and correct. Signature: 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 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date: Empower Energy Solutions Inc 39 Fernwood Dr Rocky Hill CT 06067 (475) 221-2356 RS Gilmore Insurance Agency Inc WC533SB2191Q011 11/03/2022 5 Old Coach Rd Canton, MA 02021 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia