24B-079 (42) 73 BARRETT ST UNIT 4128 BP-2019-1103
GIs#: COMMONWEALTH OF MASSACHUSETTS
.Block: 24B-079 CITY OF NORTHAMPTON
ov-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Deck BUILDING PERMIT
Permit# BP-2019-1103
Project# JS-2019-001789
Est Cost, $1600.00
Fee, $100.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: JONATHAN DEVINS 083221
Lot Size(sp. ft.): 785822.40 Owner: HATHAWAY FARMS TOWNHOMES LIMITED PARTNERSHIP C/O SPEAR
MANAGEMENT
Zoning:URC(IOOVWP(7)/ Apolicant: JONATHAN DEVINS
AT. 73 BARRETT ST UNIT 4128
Applicant Address: Phone: Insurance:
73 BARRETT ST SUITE 2000 (413) 586-1405 (5) WC
NORTHAMPTONMA01060 ISSUED ON.4/5/2079 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/Chimncy:
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 signature:
Fee•IWpe: Date Paid: Amount:
Building 4/5@0190:00:00 5100.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Corrunissioner
File#BP-2019-1103
APPLICANT/CONTACT PERSON JONATHAN DEVINS
ADDRESS/PHONE 73 BARRETT ST SUITE 2000 NORTHAMPTON (413)586-1405 (5)
PROPERTY LOCATION 73 BARRETT ST UNIT 4128
MAP24B PARCEL 079 001 ZONE URCU0OVWP(71/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: 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 Site 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
q-5 -zoic(
Signature of Ouilding 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.
r 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 Building Permit Mav, 152000
Department use only
City of Northampton Status of Permm:
Building Department Curb Cut/Ddveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets or Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloVSite 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 I -SITE INFORMATION
1.1 Prooerty Address: This section to be completed by office
73 Bore+h S# At$411401/ Y/fid Map ay3 Lot Ol f Unit
Z
NOrI#14MP#ON MA Oto 6o one Overlay District
Elm SL Dlsldd CS Dialnet
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
H41i%w-q T7M(M3 -Fc—homes L,P 73 $4rreit 54ree# S,+[ 07000 t.kr{1w..p6wMM1
Name(Print) Current Mailing Address:
413 -Str 1,1405
signature Telephone
2.2 Authorized Allard:
T
�4m/ ye✓i w'r f],tire/r•+F M4N�J<r 79 b<rre{}
Name(Print) l/ Durran Mailing Addreer.
413 -586 -/Yas
signaWa Tebphone
SECTIO&.ESTIMATED coNsTgucnofii COSTS
Item Estimated Coat(Dollars)to be Oficial Use Only
completed bpermit applicant
1. Building �G00.Oo (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
S.Fire Protection
6. Total=(i +2+3+4+5) Check Number Q �'
This Section For Official the Only
Building Permit Number Date
Issued
Signature 11F
Building Commiaal«rornpapactor of Buildings Date —GD��
Vemion).7 Commercial Building Permit May 15,2000
SECTION 4.CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition El Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other ED
Brief Description Enter a brief description here. J'j,.ulA;,�3 , 0 y 15 deck off eF f1.e b,ck of
Of Proposed Work: jk' cq 4't—"+ for res.d<�i ✓.Se
SECTION 6.USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
AA ❑ A-5 ❑ IS ❑
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 ❑ 5q ❑
S Storage ❑ S-1 ❑ S-2 ❑ 58 ❑
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(s()
is
2^a 2m
3d 3p
4
4. e
Total Area (so Total Proposed New Construction(at)
Total Height(it)
Total Height it
7.Water Supply(M.G.L.c.40,§64) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private El Zone Outside Flood 2one❑ Municipal ❑ On site disposal system[]
Version1.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
Existine Proposed Required by Zoning
Cs column to be filled in b)
lding UWnmum
Lot Size
Frontage
Setbacks Front
Side L: R: L R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(ta area minus bldg A Wvcd
elkin )
4o Parking Spaces
Fill:
(volume d:Lontian
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW O YES O
IF YES, date issued.
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW O YES O
IF YES: 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 0 NO O
IF YES, describe size, type and location: {„t, a,.(ra,re tltmd cn t .,rrM st idw6�y;e3 Iwl°°_,y
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO
IF YES, describe size, type and location.
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 sae or is K pan of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
V ersionl.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 illi(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant).
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registation Number
Slgnalure Telephone Expiration Dale
Name Area of Responaibilfty
Atltlrass Registration Number
Signa ure Telephone Expiration Dale
Name Area of Responsibility
Address Registration Number
Signature TNephora Expiiatbn Data
Name Area of R lsponstiliy
Address Regisbetion Number
Signature Telephone Expiation Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Change of Construction
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
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .a� �O�`
1. ✓E+@f).f—P��4t96W5 Aksl UC55 I M'1b�R �C� {(��(�j/^1 r'�✓YS'bwner of the subject property
herebyauthonze t: dz, ../ CVirKS to
act on my beh�Q atter;;r to work authorized by this building permit application.
Signatureo </ Date
I, `/ON4 <i✓ �<✓i�Lt ,as Owner/Aulhonzed
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signetl��un��der th��e//pains!a�nd penalties of perjury.
f/ONG//fGr !/C✓_il+J
Print Name
S' ure MOw�r/Agent Data
CTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: CS -O83,2 (
License Number
73 'B<arre-ff- Sfree{ csw}e a000 Q 90 t!o
Address Expiration Dare
-_� Y/3-586 -/yAscKit .S
S' re Telephone
SECTION 19-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavil will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ® No O
The Commonwealth of Massachusetts
Department of Industrial Accidents
OffCongress
ss Strest Suite 1
I Congress Street,Suite 100
Boston,MA 02114-2017
wtpw.mass.gay/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Aoolicaut Information Please Print Legibly
Name(BusinessrOrganixatioNlMvidu1): iGLt= �"�.1/MffaMet LIQ
Address: 13 A-,rrefl- 97e f
Ci /State/Zi : Nogqymofia, lq4 01060 Phone 4:
Are yyh an employer?Check the appropriate box: Type of project(required):
1.Lin I am a employer with_g_ 4. ❑ I am a general connector and I
employees(full and/or pert-time).• have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor m partner- listed on the attached sheer. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have wmk.' 9. ❑Building addition
[No workers' comp.insurance compmsmance.
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions
myself. (No workers'wrap. right of exemption per MGL 12.0 Roof repairs
insurance required.)t c. 152,11(4),and we have no
employees. [No workers' 13.2'OIher -0a.K
camp.insurance required.]
•AVY rpphcmt Wuchcckebox»I svatal.nn at rha section below,ebow,ieg Neaswdms'ampmraoa,x Uryndfwaxd..
t Romeownas who submirmu emdrvitindiativafeet are doing all wwk aW tbrnhia outride cabaaorsmustabuuta raw eaidm,mduatinesuch.
k'ontndon Natcheckno,W.wtmmadsed a eddmare a slwrvm{the arae ofNesubcatrectaeeMsun wheNcorum Nose ames law
anekres. If Ne subaavemn has aoployca,Nry mastlmrsidethcv wwkm'camp.igliry cumber.
lam an empbyer that it providing workers'compemaann Imur w fm my amplayers. Bduw h the policy andlob ske
Information.
Insurance Company Name: ATM f,4 u},ta I _
Policy#or Self-ins. Lic.#: WMZ - 8O0 - &006160- BotIA Expiration Date:_ 719 r.1.9
Job Site Address: 17.3 rfarreit 54-ree+ CitytSmtdZip: A/orAg art AM 07066
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 MCL c. 152 can lead to the imposition ofcriminal 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 fm insurance coverage verification.
l do hereby cer/cify ander thhe/palm andpenddn ofpepjwy thatthe information provided above is hue and eorz t
c'oaemre -L-.. CE_.!O Date:
Ph 1//?- SPc - 1'165'
Okla/use only. Do not write In this area,to be completed by city or roam ofcid.
City or Town: Permif/Liceme#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone M.
Aa CERTIFICATE OF LIABILITY INSURANCE
DAYS'"MI """
8/16/2018
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,Me policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of M°Policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such andorsement(s).
PRODUCER NAMEp Michael BOnacoreo
BOnacorso Insurance Agency, Inc. PHONEIII (TB e
1I 99T-9200 No:ITe119na.m
SO Cedar SG[aat A1NL micheelMbovaccreoiv .com
ADDRESS.
Unit X 92 INSURERS AFFORDING COVERAGE N.C.
Woburn MA 91801 _ _ INSURER AIM Mutual _
INSURED
Hathaway Farina Townhc0e", IF I SURERC:
C/O Spear Management Group INSURER D:
595 Southbridge Street INSURER E: _
Auburn MA 01501 1 INSURER F:
COVERAGES CERTIFICATE NUMBER:2018 Maater 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.
MEN
LTRTYPE OF INSURANCE POLICY NUMBER PWCY EFF PMUCY SW LIMITS
COMMERCIAL GENERAL LIA&l1TY EACH OCCURRENCE_ $
D._ CWMSM4DE CCCUP PREMISES EB OCCunMCS
MED EXP(My We euCn) S
PERSONAL&AP/INIURY S _
GEN'L AGGREGATE LIMIT AFPLIES PEW. GENERAL AGGREGATE $
POLICY[::]JXoi 1:1 LOC PROOUCTS OUMPNPAGG $
OTHEN: S
AUTOMOBILE LIABILITY N L UNITS
Ea accdaU
µV ATO DDILY INJURY IPA Ib-) S
ALL OVMD - ALTOSSLHEWIED GODLY INJURY IPA nNA&,Q $
ALYCE
HIRED AUTOS ---ED Pw PERTVOPAUCE $
AUT°B PA acceBm _
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CWMSINOEAGGREGATE $
OED RETEMION $
NORNERS COMPENSATION X PER X
AND EMPLOYERS'LASIUTY YIN STATVTE ER _
ANY PROPIETOWPARTNERIEXEO UTIVE ❑ NIA EL EACH ACCIDENT E 500.000
A OFFICERMEMBER EXCLUCECI EAEMI E 500.000
(Maxamn,In NN) 5-800-800630]-]OIaA 7/36/3018 7/26/2019 EL.DISEASE-
Nyes 4mmEBunOB,
CE ScwPfION OF OFER410NS Ww EL DISEASE.POLICY UNIT E 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES UCDRD MI.Ad&Moml W„u,Yt ScIwWW1 ewch.Nm.B No—IB nyuOM)
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 REPRESENTATIVE
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(701am)
athaway Farm
iONN11p A16� \ORiHAMPiOY
Commissioner Hasbrouck
Subject: Request for Waiver
I request that you grant a modification to waive the requirement for control construction for the
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 Barrett Street.#210),Northampton.MA 111116111 T.1 411586 14115 Fax 4135808038 TRS SM.439.0183 11 Email leaduvay6Tienr -rrniynecom Q
City of Northampton 212 Main Street,Northampton,MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, 1 acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Pennit 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 LT41reof Mpf
The debris will be transported by: C Sc ll n Jos+e
The debris will be received by:
Building permit number:
Name of Permit Applicant
Y �r
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 hire,
express or implied,oral or written.-
An
ritten"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 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 your 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 dale the affidavit. The affidavit should be resumed 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 permitflicense 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). A copy of the affidavit that has been officially stamped or marked by the city or town
maybe 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
I Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Form avrvimd 02-23-15
Jonathan Devins
From: vztpositivenotification@verizon.com
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.
I
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