24B-079 (41) 73 BARRETT ST UNIT 4135 BP-2019-1104
GIS#, COMMONWEALTH OF MASSACHUSETTS
YU.Block:24B-079 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateaorv, Deck BUILDING PERMIT
Permit# BP-2019-1104
Protect# JS-2019-001790
Est Cost $1600.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor. License:
Use Group: JONATHAN DEVINS 083221
Lot Size(sa. ft.): 785822.40 Owner: HATHAWAY FARMS TOWNHOMES LIMITED PARTNERSHIP C/O SPEAR
MANAGEMENT
Zonine:URC(100)/WP(7)/ Applicant: JONATHAN DEVINS
AT. 73 BARRETT ST UNIT 4135
Applicant Address: Phone: Insurance:
73 BARRETT ST SUITE 2000 WC
NORTHAMPTONMA01060 ISSUED ON.41512019 0:00:00
TO PERFORM THE FOLLOWING WORK:12X15 DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature•
FeeTYDe: Date Paid: Amount:
Building 4/5/2019 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2019.1104
APPLICANT/CONTACT PERSON JONATHAN DEVINS
ADDRESS/PHONE 73 BARRETT ST SUITE 2000 NORTHAMPTON (413)586-1405 (5)
PROPERTY LOCATION 73 BARRETT ST UNIT 4135
MAP 24B PARCEL 079 001 ZONE URC(l0o)/WP(7)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TypeofConstruction: 12X15DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included,
Owner/Statement or License 083221
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
_Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Sire Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance•
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
_Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
LIZy 5-20 9
Signafire of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
.Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Versionl.7 Commercial Buildin Permit May 15 2000
Department use only
City of Northampton Status or Permit:
Building Department Curb CUVOdveway Permit
212 Main Street Se"dSeplic Availability
Room 100 Water/Well Ava0aM0ry
Northampton, MA 01060 Two Sets of Structural Pians
phone 413-587-1240 Fax 413.587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office 73 B—re+h �Y7 St- AP4rhM c.F 4135 Map 7 �/g Lot 6 /-I unit
0(O6o Zone Overlay District
NdrWr4MPfON MA
am St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHOR12ED AGENT
2.1 Owner of Record:
H4H14w.q 'F�(m z 'row,ultra+,es 1-P 7.3 '4rm f 54ree+ Sw+e a00C Ndrfby,.pkaMA
Name(Prim) Current Ma&rig Address:
413 -SSG-1405
Signewre Telephone
2 2 Authorized Aa
;/G 4My JTI," ✓r A6fie/s'.+F H4—e) 73 114rr+4 S+r[el- 5-.+e pow Ner♦tie,.ple.,MR
Name(Print) Current Mailing Address:
4t3 -586 -IY4S
Signature - Telephone
SECT10a.ESTIMATEDCONSTRUCTION CQATS
Item Fstimaled Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building . yG00.00 (a)Building Permit Fee - - -
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number ao
This Section For Official Use Onl
Building Permit Number Date
Issued
Signature
Building Ca mlasionempapeccr (Buildings Data
Versionl.7 Commercial Building Permit Mav 15,2000
SECTION 4.CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building[:1
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing[] Change of Use Other
Brief Description Enter a brief description here.h AAA;N, c p v a IACY V, .4 va ttie b.'e
Of Proposed Work: ti" 4(aR...<.+i for rsa;ae-+t r e
SECTION 6.USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly11A-1 ElA-21:1A-3 131A ❑
AA ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(at)
IM is
2nd 2.
3- 3.
4a
4"'
Total Area($l) Total Proposed New Construction(at)
Total Height(g)
Total Height It
7.Water Supply(M.G.L.c.40,g 54) 7.1 Flood Zone Information: t7 3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[] Munldpal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON TONING
Exisline Proposed Required by Zoning
This column to be filled in by
Building Uprnme ,
Lot Size
Frontage
Setbacks From
Side L R: L R:__
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(I.a vee minus bldg a pav
pinking)
#of Parking Spaces
Fill:
Ivolume S Lo,won
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW Q YES O
IF YES, date issued:
IF VES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW O YES O -
IFYES: enter Book Page and/or Document#
B. Does the site contain a brook,body of water or wetlands? NO ® DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES NO O
IF YES, describe size, type and location: { a,.)rarre s;tNa cW I .rreit 54 idw ll�y;,,� Iwlti.�•y
D. Are there any proposed changes to or additions of signs intended for the property 7 YES O NO is
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grating,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO 40
IF YES,then a Northampton Storm Water Management Pernik from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 36,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
RegisUaUon Number
Addmss
Expiration Date
Signature Telephone
9.2 Registered Professional Enginear(s):
Name Area of Responsibility
Address Registragon Number
3ignalure Telephone Eptragon Date
Name Area of Raeponsibllay
Address Regisuadon Number
SignaNre Tekphone Exprambon Date
Name Area of Responslbllay
Address Registration Number
Signature Tekphorre Expiration Date
Name Area of Responsibility
Address Registration NumW
Signature Telephone Eviration Data
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Conawcgon
Address
Signature Telephone
Version l.7 Commercial Building Permit May 15,2000
SECTION 10.STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 6"4-f-p -1{t((,aJ�t5 ,,�ge"S .r/c�s IMA.N�R F&f &71lh VW �,,,,r,er of the subject property
herebyauthonze 6,72/7(4. Ddy NS to
actonmybah.(, nail ane r�to work authorized by this building permit application.
Signature of 3ZWr Date
I, ` /ON4�ic iJ �e✓i.Lt ,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��unndder th�e/pains and penalties of perjury.
�/ONAT4! Tei.-,r
Print Name
Wgure of OwnerlAgent Data
CTION 12-CONSTRUCTION SERVICES
10.1 Licensed Constructio
n Supervisor;
� Not Applicable ❑
Name of Lkanae Holder:,. �/pN_4 I4N.KY-!!S_. . . _ [,S 'O p3A8)
Ucense Number
73 Sfree+ t 4 Qo
Address EVIragon Date
_� yra,srrc-�yoi-eAr s
S re Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 162,J 2SC16))
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 0
The Commonwasith of Mossarchaseas
Department of IndustrialAcridenn,
Of in
ns
o gessStret,Suiie1
1 Congress Street Suite 100
Boston,MA 02774-2017
wwwmassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contmctors/Uectric(ansMIumbers
Applicant Inforfnation '/ Please Print Legibly
Name(Business'OrgaoizatioMMividoal): ?416Ys �GYn/Mfianr er L.P
Address:
Ci /State/Zi : q6 &6r o Pbone M 4113
Are y employer?Cheek/t7he appropriate box: Type of project(required);
1. 1 am a employer with I 4. ❑ I am a general contractor and I
employees(full and/or pan-lime)." have hired the sub-contmctors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner. listed on the attached shcet 7. ❑Remodeling
ship and have no employees These sub-contreclors have g. ❑Demolition
working for me in any capacity, employees and have workers' 9. ❑Building addition
[No workers'comp,insurance comp.insurance.t
required.] 5. ❑ Weare a corporation and in 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12❑$cof airs
iinsurance required.]t c.152,§1(4),and we have na 13 VC1 er repDECK
amployees.[No workers'
wrap.insurance required.]
*My applieandatcheAsbox gl amnalxo 9a w,desati®below dnwiegamwukas'wmpmwamplisymasseuse.
t Hommwnea wbo submit Wuatgdavi[indimting they ere doing At comicaMMenhim.tnile camnMmsmun submits Dery affidsvitiMisati, ach,
:Conmctmelw chackthisb.x watemchMan addiu.nd act#ehowmatbe name ofthembamtmsmsaad sea whMmormt Ihose.bi6es bare
employers. If da subconhufanheve eegrlyas.arymM provideaev vvkm'comp.polisymwbm.
law an employerthuisprov/dingworhers'compmadon Isummulormyemployees Bel"is Mepolicyandjob site
inforstadon. "�
Insurance Company Name: Al—f-t M-+,,,1 _
Policy#or Self-iac.Lic.N: W M Z - 800 -kt)e 6169- .1017A Expiration Dalet_ 7 'al6'19
Job Site Address: 23 -Rerreil SFreeh City/Stwc/Zip: AinrAaa ser /" 0To66
Attach a copy of the workers'compensation policy declaration page(showing the policy number and aspiration date).
Failure to secure coverage as required under Section 25A of MCL c. 152 can Ind to the imposition oferiminal 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 ofthe DIA for insurance coverage verification.
I do hereby carander lhe�painsan�dpendaes ojperfury thatthe informadonprosided above is true ondcorrect
Sienature' G-..CJ Date
Phoste Y1?Y1?-.SSG -/Ya6-/r/a✓�
OJJlcial use only. Do not write In this area,to be completed by city or sewn official.
City or Town: Permit/License 0
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/fowm Clerk d.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone at
ATS
A�d CERTIFICATE OF LIABILITY INSURANCE 08/16 2018TI
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: Ifthe ce mM holder Is an ADDITIONAL INSURED,Mile policy(les)must be endorsed. H SUBROGATION 15 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
csrtHlute holder in lieu of such endorsement(s).
PRODUCER g N : Michael HOnacoreo
BOnaCOrso Insurance Agency, Inc. °HSE (7811939-3PW' Ne. 1f6119>f-1]01
10 Ceder Street pESE.michaelabonSE 200 oins.coar
Unit 8 32 INWR s AFFORDING COVFAAOE NUCN
Rob.. MA 01801 INSURER AIN Mutual
INWREO INSURERS:
Hathevay Ferals ToMnbomes, LP INSURER C.
C/O Spear Mirage nt Group INSURER D:
575 Southbridge Street INSUPERE:
Auburn MA 01501 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:2018 Master 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.
Ia90. TYPE Of INSURANCEPMICY Fff PQICYW
Im POLICY NUMBER LIMITS
CONMEMC GENERALLIANL EACH OCCURRENCE E
CWMSIMDE 1:1CCCIAi PREMISES Its ex s,. $
MED EXP(My vw pews) E
*RS0N LL&.I.UR, E
GENL AGGREGATE LIMIT APPUEB PER: GENERAL AGGREGATE E
POLICY�JEEC O LCC PROOVLTB COMP.DPAGG E
OTHER: E
AUTOMOBILE LIABILITY EAIM taIN LE UNIT E
ANYAUTO WNLY IWUNY(Px pslim) E
ALL CANNED SCNEWLED SOULY INIURY IPP x Unn $
MRCS AUTO$
NOH-0WNEO giOPERTY DAMAGE $
HIRED ROTO$ AUTOS
UMBRELLALW OCCUR EACH OCCURRENCE $
EXCESS UAB CLAMS-MADE AGGREWTE $
DFD I I RETENTIONE
WgLNERS COMPENSATION X X
AND EMPLOYERS'LIABILITY
1.)N TA TE ER
A.PROPRIETORmAWNENlE.E LJTIVE E.L EACH ACCIDENT S 500,000
OFFICERMEMBER E%CLUOE C? IIIA
A IMFMNery In NN) Nv.-B00-.006103-0018A 7/16/1010 9/26/2019 E L DISEASE-EA EMFLOYE S 500,000
OMMM LIMBI
OE BLMPTION OF OPERATIONS Wm E.L.DISEASE-POLICY UNIT 1 E 500 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACO0.0101,A641001s1 Rs—is SSMduM.mry Is,MUeHW N—space Is nyulrs0)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Coverage. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESEMATIYE
®1888-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
IN3025(20141)
PIathawa Farm
OWNHOMFS ,IORTHAMOTON
Commissioner Hasbrouck
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction forthe
Entryway roof at Hathaway Farms Townhomes 73 Barrett Street, Building 8,in Northampton because
the work is of a minor nature,will not affect health,accessibility,life and fire safety,or structural
requirements and is impractical in that the cost of control construction is considerable when compared
to the cost of the proposed work.All work will be completed within the prescriptive requirements of
780 CMR.Thank you for your consideration.
"Mass Amendments,sections 107.1 allows for an exclusion from control construction for this project"
Respectfully,
Jonathan Devins
Operations Manager
Hathaway Farms Townhomes
73 Barrett Street
Mass CSL CS-083221
73 Barren Street,#2111x1,Nurthunp,.,MA 01060 A T.1 411586,1405 Fax 4133868038 TRS 81R1.439.0183 A Email hathattayhrnur4>2pearm�m.<om Q
City of Northampton 212 Main Street,Northampton,MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111. S 150A.
Address of the work: 73 .ISGr re++ J+Vee f /lbw •,.pi e N MA
The debris will be transported by: _C^ 5c 1(o. Joe}e
The debris will be received by: f4fe tt•, Jos}c,
Building permit number:
Name of Permit Applicant b/D�✓.r.�l�cr �e✓%�+S
y . -
Date Signature of Permit Applicant
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 hive,
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 ajoint 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 ofpublic 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 yaw insurance company's time,address and phone number along with a certificate 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 petmit/license applications in any given year,need only submit one affidavit indicating current
policy information(ifneeessery). A copy ofthe affidavit that has been officially stamped in marked by the city or town
may be provided to the applicant as proofthat 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
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fora Revised 02-23-15
Jonathan Devins
From: vztpositivenotification@verizoncom
Sent: Thursday, March 21, 2019 10:52 AM
To: Jonathan Devins
Subject: 20191210144
Dear Excavator,
Your request to locate Verizon facilities for the ticket identified above has been reviewed. The extent of work described
in the request noted above has been compared with our facility records. Verizon has determined that the excavation
location and scope of work you have identified does not conflict with our underground facilities. If you have questions or
have additional information where you feel Verizon's underground facilities are in the excavation area,do not hesitate
to contact our National Facility locate Call Center at 800-492-3100.
Thank you and remember to dig safely!
Please do not reply to this email as the account is not monitored.
1