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Engineering Dept. (3rd floor) Map _ Parcel 4/19wPermit#
House# yDate' Issued q
Board of He<h(3rd floor)(8:15 -9:30/1:00-4:30) S-9q (�uf,%2!? p�a��ee o �=
Conservation Office(4th floor)(8:30-9:30/ 1:00-2:00) 9 I
'KKE rq
19
BARNSTABLE•
MASS _.
TOWN OF BAIRNSTAt� LLED i, °'{'
Building Permit Applicatioi pty6Gti06��Aa�HTAL C0
Project Street Address
Village (, ram~
Owner G'c a,ram g 11A T40 MA.< Address 1, +
Telephone g e�- .3
Permit Request io e r. U�/f" /7�.�/Yc�i ,� !9 b R yy► JJ 56- , /-19/A S
First Floor square feet Second Floor square feet
Construction Type piQc s 51)P v_- tge,,g /C/-e yMr/V,4 d,9 AD Ale,y Derkiilp
Estimated Project Cost $ 4, 000. 60
Zoning District - Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No. of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
Builder Information
Name , (�I-Z(9-'"7UP�Z_ Telephone Number _
Address License#
r Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
j PROPOSED STRUCTURES ON THE LOT.
` ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE AV DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO. 47
DATE ISSUED ' Y
MAP/PARCE O„
F
ADDRESS VILLAGE
OWNER
,
DATE OF INSPECTION:
FOUNDATION r
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
c�
w�
. The Town of Barnstab e
ntal Services
LEM
Department of Health Safety and Environme
a .• Building Division
E0 � 367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227
Building Commissioner
Fax: 508-790-6230
For office use,only ,
Permit no.------,' '
Date — AFFIDAVIT
HOME IMPROVEMENTTN�CONTRACTOR
SUPPLEMENT
wires that the "reconstruction, alterations, renovation, repair, modernization,
MGL c. 14ZA requires y re-existing
conversion, improvement, removal, demolition,one but construction
than four dwelling units or.{h
owner occupied building contaln1°g registered contractors, rv�
structures which are adjacent to such residence or building be done by regis
certain exceptions,along with other requirements.
Est.
Type of Work.
0 8
Address of Work:
�
Owner's Name �
Date of Permit Application:----,-' !G� — 9 G
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under SI,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that: OWN PERNIIT OR DEALING WrM UNREGISTERED
OWNERS PULLING THEIR WORK DO NOT HAVE
CONTRACTORS FOR APPLICABR GRAM OR IMPROVEMENT
DER MGL c. 14ZA
ACCESS TO THE ARBITRATION
~ SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Registration No.
Contractor Name
Date
OR.
Owner's Name
Harp .
The Conuttonn-calth of.4fassachusettti
. . .
Department nt njl�tdustrial.9cciJ�nts
Y
` Off/ceolifivestiyalioas
600 H•ashiai;ton Street
�"��'�-��:�'`• Bustotr.A1uss. OZIII --
�' Workers' Compensation Insurance Affidavit
& l an nfor�mna/ti�on• �q ,/� Please PRINT"le_•ibly � --
/1'! /TS
loci ion-,
cit%, Rhone f+ -77/ ' 6 9 6
1 am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
•. .7w.:►....•.�".•ey-.'�+w..-?.r--r."-» .s•-�w.e;+•'sw !.'.,..7�.* ^!,•.,.. .•.'r'r�r'.'""�{"""..�re-.,.�.
I am an employer providing workers' compensation for my employees working on this job.
comlian•name:
address:
city phone#:
insurance co. policy#
II am a sole proprietor, general contractor, or homeowtur(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
companv n•tme•
address:
nhonc#•
incur-ince co nolicv#
�' - � .•.. - - _... K�,r ..„�o'4�c•�'r,l.' .-�'•ITrfrr*_Rt"`._ +�.^Aef•'�'n�C��"TJ':!J^��iRf�::ii�+M.'!�sRq�'7•:rRa+.!�••�!;.�j arC;+.'�^�.
_._w�-...r.+L�.-wr.�r...�....:J'.' - _ _ ram• _ - - __ ♦ � -_i.a�. LL•.iii
cnmnan•name:
address-
phone#•
incur•tnce co nolicv# _
:Attach additional sheet if necessa � �-- "^�fi,*f ._ %•a:.�.r1 .....,,rr..v.r..r:�a�..:�....a -'
Failure to secure cuwcrnge as required under Section 35A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andiur
one Wars'imprisonment as%well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that n
copy of this statement may be forwarded to the OMCC of Investigations of the D1A for coverage verification. '
Z1d ercht'ccrrij tinder thepains and penalties ojpedun•that the information provided above is true and correct.tgnatur� Date
Print name Phone# 7 v J
official use only do not write in this area to be completed by city or town official �
city or town: permit/license# r111uilding Department
Licensing Board
check irimmcdiate response is required ❑selectmen's Office
LJ [31ie21th Department
contact person: phone#t nOther
IMised 3:9s rnAi
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers'-cnm,P"ei satiott for-tile
employees. As quoted from the "law", an empli{t�ee is defined as every person in the service of another under an•
contract of hire, express or implied, oral or written.
An eynplt rear is defined as an individual, partnership, association, corporation or other legal entity, or ally two or nor
the foregoing enga�- 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
dw lli6a, house of another who employs persons to do maintenance, construction or repair work on such dwelling ho
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employe:
MGL chapter 152 section 'S also states that even state or local licensing ngency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonvealth 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 contrast for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter 1-:
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 as all affidavits 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.
-77
Cin• or'roivns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o:
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plez
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t;
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any question_
please do not hesitate to give us a call.
r-a..,r..w..--,•..,......�........rvr..... ....-.-,,.n..,Y...oe:+r.�..v+-rs'tr•-.. - �tC7r' -
Tile Department's address. telephone and fax number.
The Commonwealth Of:Massachusetts
Department of Industrial Accidents '
Office of Investigations
600 Washington Street
Boston,Ma. 02111
fax #: (617) 727-7749
nhone #: (617) 727-4900 ext. 406. 409 or 375
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print. =
DATE 2 I
JOB LOCATION
-Number Street address Section of town
"HOMEOWNER" ie
N aWe Home phone Work phone
PRESENT MAILING ADDRESS / -1/9 /`r�!}V,-
. .
City town State Zip codE
The current exemption for "homeowners" was extended to include owner-occupi
dwellings of six units or less and to allow such homeowners to engage an ir•
dividual for hire who does not possess a license, provided that the owner
acts as supervisor
DEFINITION OF HOMEOWNER:
Person(sT who owns a parcel of land on which he/she resides or intends to r
side, on which there is, or is intended to be, a one to six family dwellinc
attached or detached structures accessory to such use and/or farm structure
-
A person who constructs more than one home in a two-year period shall not b
considered a homeowner. Such "homeowner"• shall submit to the Building Offi
on a form acceptable to the Building Official, that he/she shall be respons
for all such work performed under the building permit. . (Section 109.1.1)
The undersigned "homeowner" assumes ..responsibility for compliance with the
Building Code -a-nd other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requiremen,
and that he/she will comply with said procedures d requirements.
HOMEOWNER'S SIGNATURE YA
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be requiree.
to comply with State Building Code Section 127. 01 Construction Control.
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner performing work for which a- buildi
permit is. required shall be exempt from the provisions of this section
(Section 109. 1.1 - Licensing of Construction Supervisors) ; provided that
Home Owner engages a persons) for hire to do such work, that such Home
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assumi
the responsibilities of a supervisor (see Appendix Q. Rules and Regulati
for . licensing Construction* Supervisors, Section 2.15) . This lack of awa
often results in serious problems, particularly when the Home Owner hire.
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home"Owner*
as supervisor is ultimately responsible. �. .,.
To ensure that the Home Owner is fully aware of his/her responsibilities
communities require, as part of the application, that the Ho.m e Ow:
certifythat understands the 'he/she u responsibilities of a supervisor. 0i
last page of this issue is a form currently used by several towns. You r
care to amend and adopt such a form/certification for use in your commun-:
r
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Assessor's Office(1st floor) Map ' .a/1 Parcel Permit#
Conservation Office(4th floor)(8:30-9:30/1:00 '2:00) ,S' `7 Date Issued
Board of Health
.(3rd floor)(8:15 -9:30/1:00-4:45) �� �'�
Engineering Dept. (3rd floor) House# _ j8 � '� NE
Pinnnina
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TOWN OV BARNSTABL
Building Permit Application r
1 ANNA$LC /moo .�T
Project Str C.�ete s ''e
Village B N7t- R V 1 4 e,
_Owner 00-'n At 0 tf� na a).44 dr- �Q P ,�cv�f'te�' Address , /�i'' 111.4Y eS ReL 6CAA.-I Pt L.4�
Telephone 771 f4l •
II � /
Permit Request 4 C e Gl'D D d ��i iy_�D� . S -� LlJ//✓d a//l S — �D D f �4,
g '57 el 70
First Floor J ' r � square feet N b�
6 CLA y�Second Floor square feet !�
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use Proposed Use
Construction Type
Commercial Residential
Dwelling Type: Single Family Two Family Multi-Family
Age of Existing Structure j Basement Type: Finished
Historic House Unfinished
Old King's Highway �Jd
Number of Baths No.of Bedrooms
Total Room Count(not including baths) Z First Floor
�r Heat Type and Fuel O � entral Air �—J Fireplaces
Garage: Detached Other Detached Structures: Pool
Attached Barn
None �! Sheds
Other
Builder Information
Name ��a/Y �C Telephone Number
Address License# - f
Home Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
X1
,SIGNATURE DATE 3/7�
1 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
a�
E � FOR OFFICIAL USE ONLY
PERMIT'NO.
DATE ISSUED K
MAP/PARCEL NO. _
ADDRESS ' VILLAGE _ y
OWNER x k
DATE OF INSPECTION: r
FOUNDATION " n
FRAME i +
INSULATION
FIREPLACEF
t
ELECTRICAL: ROUGH .R FINAL t -
PLUMBING:,. `ROUGH FINAL t _
GAS: a k,,ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
f
The Town of Barnstable KUS' P Department of Health Safety and Environmental Services
� Building Division
367 Main Street,Hyannis MA 02601
Ralph Crow
Office: 508 790-6227 Building Commis
Face 508-775-3344
For office use only
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,.=ncnal, demolition, or construction of an addition to any pm-
cdsting Omer occupied
building containing at least one but not more than four dwelling units or to smuct=which'v'adjacent
to such residence or building be done by registered eontractom,with certain exceptions, along with other
requirements
1 r
Type of Work: t0 M-e,� G(�r11� ,6 i14 l y ��Fst. Cost A), �7 0
Address of Work: 02 D G// —
Owner.Name:
Date of Permit Application:
I hereby certify that:
Registration is not required for the foiiming rraso:.(S):
Work excluded by law
Job under S1,000
- -Building not owner-ooaipied
—
—:� Owner pulling own pennit
Notice is hereby gi<mn that: CONTRACTORS
OWNERS PULLING TFIEiR OWN PERMIT OR DEALING WrM UNREGIS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE .ACCESS TO THE
ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A
SIGNED UNDER PENALTIES OF PER,TURY
I hereby apply for a permit as the agent of the m Rcr:
Date Contractor name Registration No.
OR
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
_ .'.. :....a'i',
DATE
JOB. LOCATION ti 6 E — LU .
Number Street address Section of town
N1 ��9 . SW lF Cev 'c'1,4 4, —21OWk j 140- uwq 5
"HOMEOWNER J&5EPH 4 X)C-180P-Aws-w 1 :.-+::.'
Name Home phone Work phone
PRESENT MAILING ADDRESS c9_ A-ti)A) A-6k6 IAC)l )-F
ity .town State Zip code
The current exemption for "homeowners" was extended to include owner-occupi
dwellings of six units or less and to allow such homeowners to engage an in-
dividual for hire Who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Person(sj who owns a parcel of land on which he/she resides or intends to r
side, on which there is, or is intended to be, a one to six family dwelling
attached or detached structures accessory to such use and/or farm structure.
A person who constructs more than one home in a two-year period shall not b;
considered a homeowner. Such "homeowner"• shall submit to the Building Offi:
on a form acceptable to the Building Official, that he/she shall be respons:
for all such work performed under the building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the i
Building. Code -and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requiremensl
and that he/she will comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner performing work for which:;.-a-Fuildir.
permit is required shall be exempt from the provisions of this section
(Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that
Home Owner engages a person(s) for hire to do such work, that such Home C
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assumin
the responsibilities of a supervisor (see Appendix Q, Rules and Regulatic
for .licensing Construction* Supervisors, Section 2.15) . This lack of awar
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home"Owner, a.
as ' supervisor is ultimately 'responsible.
To her ensure that the Home Owner is fully aware of his responsibilities,
/ p .
communities require, as part of the permit application, that the Home 'Ownt
certify that he/she understands the responsibilities of a supervisor. On
last page of this issue is a form currently used by several towns. You mz
care to amend and adopt such a' form/certification for use in your communit
.+
�r "` The Coninionwealth of Massachusetts
_. -.. ,r Department of Industrial Accidents
OfBcgsff st/1
a1/oas
600 11 asltinhton Street
-x Boston.A1ass. 02111
Workers' Compensation Insurance.Aliidavit
.Aatsaot tnfot•mation: Please 1'Ri1VT'lew ly T -�''R
name:
location-CQ O r
city (� P,x1/—P:Q 171 P h nhone f!
I am a homeowner performing all work myself.
I am a sole proprietor and have no otie working in any capacity
RIX ..- _
MIT-
0 1 am an emplover providing workers' compensation for my employees working on this job.
comnant name:
address:
cif: nhone#•
insurance co. 120lia#
1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
COMM,name:
address:
city: phone#•
insurn ice co.
j���__ �-_;-:-:-•- _ ,,,cnu=..•er:.:.•araa-=-?y--•--�••ecs;�s. +•�•• �t�!^*4*�+- _ •-'.--sr
i�mn2m•name:
address:
city: nhone#•
insurance co. oR lily#
:Attach additional'sheet if necessary .•:�._ w:� s t s-.+�r+s*ram;- T+►;: �A� ;;,
failure to secure coverage as required under Section 25A of AICL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a
copy of this statement may be forwarded to the Officc of Investigations of the D1A for coverage verification
I do herebt•certif}•under the pains and penalties o perjuty that the information provided above is trae and Coerce
Si_nature ate
Print name Phone#
oi1'Jdal use only do not write in this area to be completed by city or town official
city or town: permit/llcense# rtBuilding Department
Licensing Board `
(7 check if immediate response is required (3Seleetmen's Office
C311eatth Department
contact person: phone#;. rlOther
(wised 3.4)5 P1A)
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 emplitme is defined as every person in the service of another un' cr any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association. corporation or other ;::gal 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 1'S2 section 25 also states that even,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 in 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.
..,,,,,.,.r,r.�+.�„-+.�..�..�......+...�...; �`.y day:. 4�:� ' rC: S..:t'Mc r,!�i�''✓'^ �•��i�.t�...'..-�.
_ _ �... .�y .v:•< �;L+,•T+i:..•\xt lu w^y r. _i•�' I'�� f!!7s: ��S u.:, � .:f-i.
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 as all affidavits 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 tite 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.
77 .+....a'.:l^_r .( '.r S� Lsq. .:�..sca +'+. 'C7 , •3'+!+fYi�!i „•.. ,
On, 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 returned to
the Department by mail or FAX unless other arrangements 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.
..r..�.r�......r.,.+s.—ev.!vat+ -.-.%..-...-�•e�+��'+wr.` .< « ,i l.+e. .r., �: ;:.. ;.,, -r..r,T,•.�......s.....aes.•
The Department's address,telephone and fax number. ,
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
-- Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 7274900 ext. 406, 409 or 375
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