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HomeMy WebLinkAbout0137 PLEASANT STREET )o ,� �� SENDER: I also wish to receive the o ■Complete items 1 and/or 2 for additional services. following services(for an y ■Complete items 3,4a,and 4b. N ■Print your name and address on the reverse of this form so that we can return this extra fee): 20 card to yo4. 4ii d ■Attach this Corm to the front of the mailpiece,or on the back if space does not 1.❑ Addressee's Address permit. 2.❑ Restricted Delivery m � ■Write"Return Receipt Requested"on the mailpiece below the article number. ry N L ■The Return Receipt will show to whom the article was delivered and the date Consult'postmaster for fee. delivered. P a 0 3.Article Addressed to: 4a.Article Number z 02/5 6� �'/� cc a a 4b.Service Type 3 ouf u 11 �`�fS -t—'St ❑ Registered Certified p� i N ❑ Express Mail El Insured � 2 i"tg'� YY�111 ['Return Receipt for Merchandis ❑ COD i G 7. Date o Deliv ry ,o ®0 o' cc 5.Received By: (Print Name) 8.Add ssee's Address(Only if r uested Y and fee is paid) t �6. ig at e: (Addr�rgent) ~ X 2 PS Form 3811 December 1994 102e95-98-B-0229 Domestic Return Receipt UNITED STATES POSTAL SERVICE Postage & Mall Postaage&Fees Paid USPS Permit No.G-10 O Print your name, address, and ZIP Code in this box O g Town of Barnstable Building Division 367 Main St. Hyannis, MA 02601 Z 368 667 518 US Postal Service Receipt for Certified,M,,, all No Insurance Coverage Provided. Do not use for International Mail See reverse ntto Street&Nu P i ,S te,&ZIP Code Postag $ Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered n Return Receipt Showing to Whom, Q Date,&Addressee's Address CDTOTAL Postage&Fees $ c"3 Postmark or Date 0 0 LL Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front).'y 1. If you want this receipt postmarked,stick the gumm4b�to•thE ght of the return address leaving the receipt attached, and present the faficre"41 a f»st office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the;gjirfted stub,t0 the rightlof the return address of the article,date,detach,and retain the r2oeipt,aM majrthe article. Cr , P LO 3. If you want a return receipt,write the certified mail number an our Keene and address � on a return receipt card,Form 3811,and attach it to the front of the article by means of the _ gummed ends if space permits. Otherwise,affix to back 614article Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number J �,+ a 4. If you want delivery restricted to the addressee, onto an Oiithokq.zed agent of the C addressee,endorse RESTRICTED DELIVERY on the fropyof the article!!.'ir' M 5. Enter fees for the services requested in the aprropl92te sprites a the front of this E receipt. If return receipt is requested,check the applicablh.%locks in iterA,1 of Form 3811. ti y 6. Save this receipt and present it if you make an inquiry. °-102595-97-B-0145 a i °F IME A The Town of Barnstable :.snxxsznai.E. 9° MAM d Environmental Services ,�$ Department of Health Safety an f Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner July 59 2000 Carolann Huckemeyer 137 Pleasant Street Hyannis,MA 02601 Regarding: Helen H Dear Ms Huckemeyer: We have asked you on several occasions to file a Site Plan Review application for the operation of the Helen H on Pleasant Street. We have not heard from you on this point for a long time. At this time,I must inform you that,unless you file for Site Plan Review within 30 days,we will be forced to issue a Cease and Desist order for your operation. Sincerely,. Ralph M.Crossen Building Commissioner RMC/lan CERTIFIED MAIL Z 368 667 519 R.R.R. g000705b 08/23112006 14:08 5087900062 RECORDS PAGE 01 -ICAP . b jLown of L a yble : M DARANa%.A 1 , Poll 17 Ern Main: (508)775.0387 John J.Finnegan Adudn- (508)775.0920 Chief of Police ; Records: (508)775.5466 dais,. 026 Fax: (508)790.6317 www,barnsstablepolice.com F'A COVER SHEET DATE:_ � 0 � TIME: TO: , FAX:Rob FROM: NUMBER F PAGES INCLUDING COVER SHE T:_ NOTE/MESSAGE: This fax is intended only for the use of the individual or entity to which it is addressed,and may contain information,which is privileged,confidential and exempt from disclosure under applicable law. If the reader of this message is not responsible for delivering the message to the intended recipient,you are.hereby notified that any copying, dissemination or.distribution of this communication is strictly prohibited. If you have received this communication in error,please notify us by telephone and return the original to us at the above address via US postal Service. The villages of Bamstb.ie,Centerville,Cotuit,Hyannis,Marstons Mills, ®stervillc,West Barnstable Serving the Villages of Barnstable, CeUterville, Cotuit, Hyannis, Marstons Mills, Osterville and West.Barnstable 08/23/200-0 14:08 5087900062 RECORDS PAGE 02 Barnstable Police Department Page: � Call Number. Printed: 08/23/2006 For Date; 09/12/2006 - Saturday call Dumber Time Call Reaaan Action Priority Duplicate 06-25029 2302 Phana - DISTURSANC8, NOISE UNFOUNDED 3 Ca11. Taker: 763 - Dispatcher TINA LEHANE Call closed By: 218 - ?T,L MATTHEW J LOUNSS'URY Location/Address: CHYA) PLEASANT ST Party Entered By: 08/12/7006 2303 763 - Dispatcher TINA, LEHANE Calling Party: ROBINSON, KATRY w 125 PLEASANT ST - HYANNIS, NIA 02601 508-534-9407 Unit, 16 PTL. STEPHEN O'BRIEN Disp-23:05:16 Arvd-23:14:09 Clyd-23:14:19 Arrived By: 218 - PTL MATTHEW J LOUN9EMY cleared By: 218 - PTL MATTHEW J LOUNSBUI�Y Narrative: 09/12/2006 2303 Dispatcher TINA LBILAn noise disturbance-loud music A Message Page 1 of 1 Giangregorio, Robin To: Hinckley, Kathy Subject: Copy of police report Hi Kathy, I am working on a zoning complaint regarding 137 Pleasant Street. This is the departure site for the HelenH. A neighbor, Kathy Robinson from 125 Pleasant Street informs us that she called the police regarding a large noisy crowd congregated at 137 Pleasant upon return from a fishing trip. I need to confirm that the incident was in fact at 137 Pleasant Street. I am not sure of the date but the complaint came into us on 8/14. The Building Commissioner asked if you send over a copy to us. Can this be arranged? Thanks for your help!!! 196in Roh.i n C. Gi angre-Or.°o Zoning Larforeemeni: Officer 1`c}wn at' f3are�s t,�fil e 200 .11a.in St.t-ee t. gvann.i s, AM 02601 508-862-4027 8/23/2006 t ITT 106 +r - ?4 •�°... 'nF-h1"".°'�, ., per. r � w/� t � r jF t�3 i — r •wW r - j+ a ' M1 Z' wry - u__„w y IRS > Fw Mr, 6 8 d µ' r p fi v l 137`Pleasant St. , Hyannis 8/23/06 r h . h•M M ��..j �yr. t' ��• JW 4 ab a 4. y 14 IL 'F? t Vim- audi�J. 11.�,� r�srs� [. '� r e II a/ -^• a is _-� Vy .,j •a. / . � .. k � ft �*" .,yam � a�,r:u. ye . per/f ,¢ �v .. a �:� �" ..3r � �d t pY �.,��>E�•��'. x x �E x m • OF1 • r , f� G 9� 3 _ t Ll 44 ,�{�°�3 r � ,. ar„'�k xt • `�,., s .,fis � I �'°. t S f '� r P 4'r •"#^ '6 1; w`$:.�,.;.�`'��, �. �; ,_.'Y;_l��.r*�S*t����.'.�^ #. ;� �'».fjS� .M:+'�� '?'.�,:`� ����#�r�•�`.,f, 'f �.- rs >,�"'�yti Sl'+;� ��.,�;a e'f �r#.` �,�. � sa.t �x♦ .,.�+f « �'t� jny`.s.. ,s ¢' - ,,,.t4 q.. 'd� � '' r,,r�� �y#'t .{ .'air.�' ram,—•.,.. i' '°`y -'�.i _ �: � r. r r f ^�;, 137 Pleasant St. , Hyannis 8/23/06 . " afs4 - ,�,' ! i -o '�.' ` +e'y ice, �.1 � r9� yys� `°'r.»�P�.�t,i�,i'M;• _. •.�tl. d,� y� 'a�• � '�`q�4,� a - ,'�, � ,ems ,Y.° - �,,w�5� • � r i y� aRI :. Old ,• ,5Y4,w;„ Ta ITL- .M.af�' In�y in ,. �P�i*w. � �. � � �a aye .,.sir{�jJ'•"�,yC �a ' �... r � "-fir " W � •,V .,,. ,,. ,. .,- . lb .n t a . � ;`. .. ,, •,f fir-..�n'" s�•� a:' �.ra' ,�'�~ .y� c: - ��'`i� � - r �p� �� �`%' a �+..• € �' t � n r: 5�'*r^ �.::. s ,.tea,,. ^,. "" - •_ _. $ ,,,,d,. lR�Arr,.�.,c + a - i.� = y 4 l +V v r i c r s f a s ' r + r QL e ., w. e`7p +fJ., t+Kc F •�' azxE s`"" ay 4r A:. y s 1 x i -,t mx w' .: � t� b _..p.+� J 1,�p "'� ���J ..SR4#4# tT• r��n i�T ���gix r ..�, .4 ' �u. '75 y -*r'EcT..� c Y ^4 e VF 7^ •M� ". �M4E <...r'rM1' L:`. JW PI nt St. H 23/06 13 � easa Hyannis is 8/ 00 UM0 EP 00 . o • We operate the two fastest party t _. � • fish e on the W protected I, boats in New England giving you J ° more fishing time and less riding. , liwaters of Nantucket �., a�. Cape 4 < � 30 yeas ot t ®00aIEC 70©MS ��� d's Largest experience , -. , � P r � • P ` k �OatS uttin eo Cape COMING FROM THE EAST CAPE �ed1 �Q,S� g P� P Route 6 to exit 7,Willow Street south to end of road. Right on Main Street to as Q.d th Cod has t �e� .' nF. M ., Pleasant Street. Left on Pleasant Street- one and one half blocks to office on the most ( right. ,je � ; - roductive a%� Our vessels are p COMING FROM THE WEST/OFF CAPE e = uard Inspected � • ..�' fishin r ,, r -� g grounds i From Cape Cod Canal take the Sagamore Bridge. Go over Bridge and take Route 6 East to exit 6. Make a right onto Route 132 and go about 3 miles to Coast'Guard on the-East`Coast+ . AAA rotary. Take 2nd right in rotary (Barnstable Road). Follow directions below. ' fi.-�- and certified. a 5 � r TO HELEN H You're on Barnstable Road. Go to 4th light and make a left onto South Street. The first right you can make is Pleasant Street-we are I/2 way down on right. *I , 7,77 You're on onl Barnst/ableRoDadAgoGo E4h light and make a left onto South Street. r te The second ri ht you can make is School Street.Take down to end and unload. ♦ N��`P a. g Y A 'v ID ROUTE6MIDlJ1PEHICAIWAY \ Y " art # w. ! ., • w+L� FAIMOIIIH ROAD � t � � A •�r � :.... • •• ,,::- % . <. 57A LES /s ,� -`,'�"1 ,:. a."1y .... "y" "' - 4``. � L7":J �.,. s , w . D 5.. � • �' .� POW ERHORN ` - , _ �. FISH G&TACKLE a r ii i Y ��2 {�'� ]�^1t ,;• MAIN S'fR�T R '„ �.. �' K�`�:`=��j�A�'�• �• big .e � .a �•g-t� ru�K� 6 O wwwrW!I��r"`V• •• • ' ,„4 [ C ^ z7r1G DOCKSIDE MAR I FERRY 01 ` �/W31Y�a..�r . •- • . • :, I •' M0 �/J I ! o n�g� �eE. t �1-. Wr r �• Im i S0�3 7 90 06 r tea 1211% " r0. : o � 6 0 o - xa V � . {7U W WOheoenIfYOc®m K . 137 Pleasant St., Hyannis =SA4 A S , . `> rems.= w 4 r a } I 1 IFISh AMOMM111 CZEDe Cod 309 IFn$Iln Haw1k a®®9 IHIeIleBn IHI aBLUES t 1 Cape Cod's largest 6 man charter boat with a 225 square «. All Aluminum construction with 3 electronic Bluefish are among the fiercest 0 foot cockpit, giving you plenty of room to stretch out. Diesel engines producing 2500 horsepower. . i ' fighting fish in the ocean-great 0 The Fish Hawk also has a clean enclosed restroom for Coast Guard licensed and inspected. Individual action for the whole family. your comfort.Top of the line fishing equipment is included tickets are available for daily trips throughout the 4-20 lbs.July-August �'' with the trip. Offshore Tuna or Cod trips are available summer for Giant Bluefish and Fluke. Sailing daily along with local fishing for Striped Bass, Blues, Seabass, 2-3 trips a day for great action on Nantucket Scup and Fluke. This is the ultimate for private groups up Sound. Fishing equipment is available on board FLUKE D � _ to 6 people. Also ask about our 12 person charters. and all bait is included.Also enjoy our large Fluke are the favorite among sun ec d k on the second level to catch some rays. seasonal fisherman for the good fight and great eating. 8 hour Fluke 3-16 lbs.June-September. Nantucket trip Sam daily. , .. June-October , Call for reservations. `� ;�' � .�:.� 2 m 4,Hourarips Daily Blu s? Fluke'/Porgy aSCUP & .,.' < + Julythr ghAug SEABASS D N Night Blues al available —+ AIlIl iV IEW 9 Angner a F S w ue o times va ila These are the fish �� m, 8 , K• Call for.times YAK of choice for fast, y ,.The East Coast's fastest party boat powered by 3 Diesel and reservations. steady action. 1-5 engines with a total of 2500 horsepower. The Angler's lbs. May-June engines drive 3 Hamilton water jets to a top speed of r over 30 knots. With this speed, the Angler can fish spots on the back side of Nantucket and Martha's Vineyard that COD D i no other boat can reach in a day trip. During the summer Cod are the mainstay of _ the Angler will be running 8 hour giant Fluke and Seabass fishing in New England. They are great eating! Sizes up to trips around Nantucket and Martha's Vineyard. 'y } _ HELEN H _ 60 lbs.January -December. - All of our vessels , have the latest .. _._ _.. - - _ _ _ _ safety & fish-finding w, a ` TUNAequipment. � °- ,.�...�,.- .` Tuna are the giants of the ocean with fish reaching up to 1000 lbs. Most are A school of L Fish Hawk charters , All of our captains"are Coast Guard licensed and among 50-2001bs. Tuna are the ultimate seabass and scup available year-round for battle. August-October. m ,, under the boat 4 and 8 hour trips the most experienced and top producers on the coast. , -, PtiiilMa Parcels 326055 f '" 32605 �9�D V ACCO 002401 Pat' 0000000 5 I'll , . ': M ' HUCKEMEYER,CAROLANN �," �@� 10, A/K/A BROWN,CAROLANN tf�81k 1 ��f ° 0000145 137 PLEASANT ST a Adelz ` 00 ` ,F r HYANNIS MA 02601 sew@�, 00-0000-000 = �DeetlU e ' 100196 lte,' 10415045 �� �3 HUCKEMEYER,CAROLANN »itUiM 1096 @@ e ° 10415045 000118000 tied 000052500 E a res: 0000000000 " !ocalo 137 PLEASANT STREET oad i„ 1283 rt g 0060 i gyp' HY �°In R ' L. t: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Db S '' Parcel 05-5- Permit# �7 ' Health Division Date Issued Conservation Division Fee Tax Collect r Treasurer ' Planning Dept. Date DefinitivWPI1rXAovedPlanning Board Historic-OKPreservation/Hyannis Project Street Address 157 f'1-5/�5�9- T S7 Village &u 4 nA r S Owner 6<W(- AANw H VC,/A- ClheN c'. Address �//1�- BUCA Telephone 52 E3 — 9�7 57 —9 9/S Permit Request S/c% 6"g ,c._ — Wff 7--,- C&019-e .SAly&z,ES Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new -f Estimated Project Cost 69. Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family 0 Multi-Family(#units) Age of Existing Structure Historic House: 4(Yes ❑No On Old King's Highway: ❑Yes tdNo Basement Type: ❑Full Crawl ❑Walkout 0 Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil Electric O Other Central Air: ❑Yes l(No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:0 existing ❑new size Barn:0 existing ❑new size Attached garage:O existing 0 new size Shed:O existing ❑new size Other: Zoning Board of Appeals Authorization 0 Appeal# Recorded 0 Commercial E�Yes 0 No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name w/ 1//17m I C C-/ Telephone Number ( 5-VE? s Address yS (,o-,hhlP 5 7-a,1,y,6_ 2-9/ License# o 94� a Lt3 1h,V1LJ Si tBL-E /V1,4 Home Improvement Contractor# 0 SS f" Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE i ���Y� yt. �_ DATE r r FOR OFFICIAL USE ONLY PERMIT NO. -*� DATE ISSUED f MAP/PARCEL NO. 't ADDRESS '^ VILLAGE ` OWNER + x , r DATE OF INSPECTION: 4 FOUNDATION FRAME INSULATION s FIREPLACE _ ELECTRICAL: ROUGH FINAL - r PLUMBING: ROUGH FINAL ; '4 GAS: ROUGH FINAL FINAL BUILDING' DATE CLOSED OUT - ASSOCIATION PLAN NO. , f Op 1HE Tp� The Town of Barnstable BAMSrA11M MASS. �0� Department of Health Safety and Environmental Services rEn�,,yrA Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date , AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: I P G✓A'<< Estimated Cost O 6 o0 Address of Work: 3 f �� �� I - 5 d`j?�A 15 Owner's Name: 11Vl -I;/+ WN— �� I e C % Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply fora permit as the agent of the owner: Date Contractor Name Registration No. OR ` 'Owners Name Date t q:forms:Affidav The Commonwealth of Massachusetts s ==• ' Department of Industrial Accidents v - ; Olticr of/m�estigatio�s 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance davit name: 1 C C location / 3 r� P��=/9 city� f�,�n K � ��£�.e'S%r�a3 Dhonet - ❑❑ aamI i homeowner performing all work myself. ®:I am a sole etor and have no one worlds in anv capacitV D//� 'i/////%/%i an emplqpr providingworkers compensation for my employees.working.on this job.:: ::::::::::{{{:{:::::::::: : ::: : :: :: }}: an con .main ::......;....:.:::::..........:.::..............................:.:...... address.. :: . Una: .......:::::. :.::: .....:.....: Qh". ... .......:.::. ........:.:..::.:.......:.:;:: :<:>;:rah insurance co . ,..;;::.>::.:::; ..:. .... ... ...:....... :..: /%%/ ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have owin workers' compensation polices: the g mP ..... .:: ::.:. :.:::::.:. :::::.. ::::.:::.............:...::::,..::.: .:.:...:....... :::.::;::.::.::::.;.>;:{::.;:::..{{..:.....:;.......;>;<::;: con anvnam ................ . sa dre ..... ::. ...... ........n......;:.v.............. .........:v�nv w:::::::::::::}::::....... v:::::.v:.w:::+•'^.vf.M'•.'+:.F-.........................`:::::. city ............................................................................................... .......l.... ....... ..........n.}.....+}.v... .::�:v. ...... ..... .........Y ......}..r.n...• ...................................:...::.�::::}}:.......::.{..••{?•..:•:::.:::::::•. .. :.�:::-:•.�•}}+'•::::::::.::!:v:{{{::{.} :•.�}:}}:{::•':•.:vi::•{}.:�:{:•::::.:::^?is}::::.:::: :{.:.;;::;.:;::.::.:..:.. .....::::..,:.:::.:::...:.. ........ oliev FM ::.........::...... ....::::................:...:..:.::::.:..... .......... ..Z. .. »;. one: dta- ....:.. .:.:.................. p ..:..............::.:.:...:::. Faflnre to secure coverage as required under Section 25A of MGL M can had to the imposition of crhnind penalties of a fine up to$1,500-00 and/or one years'imprisonment as well as viva penalties in the form of a srOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. I do hereby certify und�ear the pauu and penalties of perjury that the information provided above is trw•and correct Signature �i✓ GGC 1�(���.'[p/C./C Date Print name �'; 1�ia�n.. a C' i Phone!! official use only do not write in this area to be completed by city or town oiHdal city or town: perrmitAicense# Mudding Department ❑Licensing Board ❑check if immediate response is required ❑Sdectmen's Office ❑$alth Department contact person• phone#, 0 a_ (towed 9195 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any co=r..�. 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 c: 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 section 25 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,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 in the workers compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of irmzance 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. City or Towns 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. The affidavits may be retuned io the Department by mail or FAX unless other anangeme&s have been made. The Office of Investigations would like to thank you in advance for you 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 Department of Industrial Accidents office of lavesduadons 600 Washington Street • Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375