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39-041 (10) 15 ATWOOD DR BP-2019-1205 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-jMock: 39-041 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Categorv' ALTERATION BUILDING PERMIT Permit# BP-2019-1205 Proiect# JS-2019-001956 Est.Gosh $72500.00 Fee: $508.0: PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: G NICHOLAS WOHLERS 053982 Lot Size(sa.fQ: 217800.00 Owner: NOR'rHWOOD DEVELOPMENT LLC Zorn=GB Applicant. G NICHOLAS WOHLERS AT. 15 ATWOOD DR Applicant Address: Phone: Insurance: 388 EAST STATE ST (413) 467-1540 GRANBYMA01033 ISSUED ON:4/29/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:ENCLOSE PARKING SPACES WITH MOTORIZED GATE FOR JUDGES, ADD PRIVATE ENTRY DOOR INTO BUILDING 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: Brh,swav Final: Final: Final: Rough Frame: Gas: Fire Deoarimen[ Fireplace/Chimney: Rough: 011: 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 si n t re: FccTvve: Date Paid: Amount: Building 4/29/2019 0:00:00 5508.00 212 Main Street,Phone(413)587.1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Veisionl.7 Commercial Building Permit May t5,2000 Department use only p ( - I ' i_:L) City of Northampton Status of Permit: Building Department Curb CutlDmmanty,Permit APR 2 9 2019 212 Main Street Sewenseptic AvailabiMy Room 100 Water/Well Availability orthampton, MA 01060 Two Sets of St uctuml Plano FuDm,iaisPem4 3-587-1240 Fax 413-587-1272 Pkabalte.Plans -ryq" oll NA0l ,o 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 Preoertv Address: �nThis section to be comp,by oTNtx /S '4f1.r� o e' / �Cf Map 3q Lot O N( Una NO�/�ArIoj0l�J '9 Zone Overlay District Elm St.Dlsmot CB Dl~ SECTION 2-PROPERTY OWNERSH�I�PJ(/AUTHOLIZEID AGENT 2.1 Owner of Ret;cird: p. U � V � W.r . SJ1 'Z ✓I Name(Pnntl �(1 � Curent Mailing Address: L10 - pry 3721a Signature p S Jl...! (r OWW'r Telephone 2.2 Authorized Anent: G' /V/ao/qs Name(Pant) Current Mailing Address: 3W CAST -ITE SI- 33 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only core leted b rmit applicant 1. Building 70 006, (a)Building Permit Fee 2. Eleclneal (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 This Section For Official Use Only Building Permit Number Date Issued Signature Building Commissioner/Ins `1pectorof Buildings Date / 29 ( 1 Versionl.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[3 Repairs Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign E3 New Signs[3 Roofing❑ Change of Use Other Brief Description Enter a brief description here. ,✓GCSE TO Of Proposed Work: ,tgor O/Ci Z.f.D St/;g �� 5�C�21�/�-anJGi�✓C ,RC2 S��J` 'ES• Zyovh- 57Vr"a^ SECTION 5-USE GROUP AND CONSTRUCTION TYPE 2>1216/2 USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 1:1A-2 11A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ I-2 ❑ 1-3 ❑ 3B M Mercantile ❑ 4 ❑ R Residential ❑ R-1 11R-2 [IR-3 11SA ❑ 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 5 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Flom(so 1s im 2n0 2n° 3,0 3' 4e 4e Total Area(s0 Total Proposed New Construction(so Total Height(R) Total Height it 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Publi Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system[] Versionl.7 Commercial Building Permit May IS,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No SECTION II -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, herebyauthonze IGNa�^� !�'pq�/r.J2.S to actmy b relative to wo an ed by this building permit application. ]OS/ifs• l u/ 01✓/L4f/ Y/6 6// Signat of Owner Date Y I, t1w Q rG ,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 underDains and o pe ' (Y1 yo Print Name Signature of OwnedAgent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction 1S1lu'oemIleor: , / Not Applicable ❑ Nameof License Folder: �' Nl�'rol/15 V✓ ti(k,/ZS License Number 329 fl,7s Srrrh Sr. Coq why /4n- oio33 Atltlress ` ' Expiration Date /1 y/3 3 15� � � Signature Telephone SECTION 13-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 Ye No O 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: i.3 '41—->01-1/ /�� The debris will be transported by: ;', c/ons The debris will be received by: Building permit number: Name of Permit Applicant L.2 &G9 Date Signature of Permit Applicant 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 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: "Er/w Z),-L _. _..... _ _. _.. . Not Applicable ❑ GREgoR� S o 'c�F,h,o2 Name(Registrant): Registration Number ra Expiration Date Signature Telephone 9.2 Registered Prolesslonal Engineer(e): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor 0, N/C/ ,, AS WC17144S Not Applicable Company Name: Niue V✓o(11fiX�s ��S�i �vi (olrt.2s Responsible In Charge of Consirudion N(cls z4?- Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning Thiscolumntob fi11Minby Building Departmem I a Size Frontage Setbacks Front Side L:—R: L:_IR— Rear Building Height Bldg.Square Footage % Open Space Footage % (Int area minus bldg ffi pavW arkin #of Parking Spaces FII: volume&I ad.) A. Has a Special Permit/Variance/Finding ever been issu for/on the site? NO O DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO A) DONT 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: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO.�QS IF YES, describe size, type and location: !`L E. Will the construction activity disturb(Gearing,grading,y&vabon,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO tX IF YES,then a Northampton Storm Water Management Permit from the DPW is required. In itial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the ninth edition of the Massachusetts State Building Code, 780 CMR,Section 107 Project Title:Atwood IQ Court Entry Date: April 19,2019 Property Address: 23 Atwood Drive,Northampton,MA Project: Check(x)one or both as applicable: New construction X Eldsting Construction Project description Create judges gated parking area with judges private building entrance I, Gregory J. O'Connor, MA Registration Number. 7914 Expiration date: 8/31/19 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: X Architectural Structural Mechanical Fire Protection Electrical Other•. for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project I understand and agree that I (or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed m a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports (see item 3.) together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a'Final Construction CAAR me. lr��Gy Enter in the space to the right a"wet"or electronic signature and seal: Nq rete MRCESTER 1NBS Phone number.508-757-137/ Email::greg.aconnor�@gj sociates.com rMq Buildl q Offidal use 0.ly Building OfB<ial Name Permit Na: Date: Version 01 Of 2018 nc Ro a CERTIFICATE OF LIABILITY INSURANCE DA03rzv2019 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: R the certRieate holder Is an ADDITIONAL INSURED,the polky(im) must INS endorsed. If SUBROGATION IS WAIVED, subject to the lama:and conditions of the polity,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certillcate holder in lieu of such erMursement(s). PRODUCER Mwe Cindy MIIeWakl WHITE-JUBINVILLE INSURANCE AGENCY INC PA0,`NEa. _ (413)538-8293 1FAX xo: POO�REn. cintl nn 'ubinville.wm 39 LAMB ST INSURERS AFFORDING CONCRAGE III SOUTH HADLEY MA 01075 I.WRERA: LM INS CORP 33600 INSURED INSURER B: G NICHOLAS WOHLERS INSURER C: _ DBA NICK WOHLERS DESIGN BUILDERS mwREn o: 388 FAST STATE ST INSURER E: GRANBY MA 01033 INSURER F: COVERAGES CERTIFICATE NUMBER: 381295 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. IMSR TYPE OFINSUMXCE ADDL Be POLICY EFF POOCYEFP LTa POLICYNUMBER MWD MNN umm COMMERCNLGENERALLMBILT' EACH OCCVRRENCE S CNIMBJMDE �� OCCUR PREMISES Eecmrtenm $ MED EXP(An,a a Parton) S N/A PERSONAL.ADVINJURY S GEN'L AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE s POLICY.PRO LOC 1ROOVCTS-COMP/OPAGG $ ECT OTHER $ AUTOMOBILE WNIJIY (T.—IN.$INGLE LIMIT $ ANY AUTO BODILY INJURY i erperwn) $ uL OWNEDSCHEDUI20 j WA BODILYINJURY IPeramaino S AUTOS AUTOS HIRED AUTOS NON-0VRIED PROPERTYDAMAGE $ AUTOS fpff e¢tlmt UMBRELLA WB OCCUR EACH OCCURRENCE E E[CESS LAB CIAIMS#1ADE N/A AGGREGATE $ DED I I RETENTWN$ $ WORKEMCOMPENSATON IA EMPLOYERS' X GTATUTE OR A AOFRCEWME-TEREXCLUDEmEcunvE wA SA wA WC531S620650019 02J0412019 02/04/2020 EL.EACPERN AccIOEm $ 100,000 '!B....".Nm EL DISEASE-FA EMPLOYCE1$ 100.000 Xy6 NernN-00 DESCRIPTION OF OPERATIONS Eebu EL.OIGEASE-POLICY LNIIT 1 IS 500,000 NIA OESCRIPTONOFOPEM ONS/LOCATIONS/VEMCL (ACORO101,AE4111wuIRmv S d%mrybem WffmOrPap i&MuIW) WORexsCompensation benefits will be paid to Massachusetts employees only.Pumuan(to End..nr.nt WC 2C 0306 B,rw aulM1onration is given to pay Gaims for benefits to employees In states otM1erthan MassecM1useEs M IM1e inwretl M1ims,Or M1es M1iretl(hose employees oufsitle of MassacM1useRs. This Certificate of Insurance shows the polity in force on the Dole that this ceNficate was ISSUED(unless the expiration Eats on the above policy precedes Me issue Este of this certificate of insurance). The s Ws of this avemge can be moniloretl daily by aaessing the Proof of Covemge-Covemge Vehfication Search tool at avvw.mass.gov/IwClwoilem-compensation4nvestigationsl. Sole proprietor las not elected!average. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Homes by Leblanc ACCORDANCE WBN ME POLICY PROVISIONS. PO Bos 307 AU$HORQEDREPRESENTATIVE 1 L South Hadley MA 01075 "� Daniel M.Crow y,DPCD,Vice PresHen[—Resitlual Markel—VJCRIBMA ®1988-2014 AC0RD CORPORATION. All tights reserved. ACORD 26(2014,01) The ACORD name and logo are registered marks of ACORD r CommonweaNh of MaSS3Ch45etl5 Board of Bf Swuildinidin Professional Licensure g Regulations and Stantlartls COnStrLLCE161t SOQ2NI50( CS 053982 _. + £spires: 04/16/2020 GLEN N WONLERS MEASTSTATEST itl i GRANBY MA AM yd � Commissioner �/"" The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, e14A 02114-20177 www.mass gov/dia U,krkers'Compensation Insurance Affidavit: BuiklerstContmetors/Electriciaos/Plumbem TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /. Please Print Lmiblv Neale (Business/OrganimtioNlodividual): Address: 3 k S71 )k.. City/State/Zip-4ON A• 6)oPhone Are you an employcO Cheek the appropriate but: Type of project(required): I.❑I am a employer with employees(full and/or pwt-time)' 7. ffNew construction 2.❑l not a sole pmpnetor or parlarship and have no employces working for me in g. C]Remodeling any capacity.[No workers'comp.insurance required] 3.Lj I sm a hoer doing all work myself poo workers'comp.insurance required]' 1 ❑Demolition homeowner 4.�1 am a homeowner and will be hiring contractors to Condon all work on my property. I will 10 Building addition ensure that all contractors either have workers''compensanon ins mance maresnle 11.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5 1 an a general contractor and 1 have hired the sub-conambus listed on Me numbed shed. 13.[:]Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6We are,a corpnmtimn and its offerers have exercised their right of exemption per MGL c. 14. Other 152,§I(4),and we have no employees.poo workers'comp.insurance requited.] 'Any applicant that checks box qt must also fill out the section below showing Meir workers'compensation polity 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. =Contractors that check this box most attached an additional sheet showing Me name of the subcontractors and state whether or not those entities have employeeslithe sub-contractors have employees,they most provide thew workers'com,policy r mober. I am an employer that is providing workers'compensalion insurance for my employees. Below is the policy and job site infnrmatiot4 � InsuranceCompany Name: ,3_111&NV,114 -7;:i5 ( p Policy#or Self-ins.Lic.#: 4 PV`5 l(,/Y7 / Expiration Date: O Job Site Address: Z�r TG✓ooc� City/State/Zip: oh ,dr( rD, � Attach a copy of the workers'compensation policy declaration page(showing the policy number oath expiration date). Failure to secure coverage as required under MGL a 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 star==may be forwarded to the Office o£Investigations of the DIA for insurance coverage verification. I do hereby certify under t�he panJs andpenalues of perjury that the information provided ahove is true true andconect S'g tue' Dat .f e' rr06 9 Phone 4: �13— -3 f�—,`d &oC+ Official use only. Do not write in this area,to be completed by city or town ojf¢iai City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/To"Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thew 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 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 w 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 numbers)along with their certificates)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 anLLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 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, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 vv w.mass.gov/dia