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25C-004 $ 100.00 One Hundred and 00/100** **** *****************************`***** DOLLARS 'F-e•» NOT VALID OVER$1000.00 ' NON-NEGOTIABLE Customer Copy DRAWER/REMITTER ADDRESS ADDRESS - --------------------- - ----- - - - No. 211706 %.53-716812118. Florence Savings Bank DATE March 03, 2014 85 Main St., Florence MA 01062 MONEY ORDER PAY O i ORDER O F IL-jj "7+.���1 U�` � �a� 1c �t�4t': $ 100.00 One Hundred and 00/100* ********************************* ******* DOLLARS + j NOT VALID OVER$1000.00 MEMO � `t'(��i:��tlr1 I�'L. + r;f � DR WE . EMITTER ADDRESS ADDRESS 11' 2 11 ?OE311' 11: 2 1 18 7 16881': L98005675911' DATE March 03, MONEY ORDER PAY TO THE ORDER OF $ 100.00 One Hundred and 00/100******************************************* DOLLARS MEMO ( --( , -a,.�G� NOT VALID OVER$1000.00 �+ NON-NEGOTIABLE Customer Copy DRAWER/REMITTER ADDRESS ADDRESS l _ -- No. 211705 �t c D,, 53-716812118 Florence Savings Bank DATE March 03, 2014 _ 85 Main St., Florence MA 01062 4, MONEY ORDER PAY TO THE ORDER OF C :�►rvl4w ���) � s�f $ 100.00 One Hundred and 00/100******************************************* DOLLARS MEMO NOT VALID OVER$1000.00 C_.1"t/i-[.t..�N..Yi�v+ �uE�t G� cf•r" DR�.IN;S/�ER -- - f�U No. 211707 Florence Savings Bank 53-716812118 85 Main St., Florence MA 01062 DATE March 03, 2014 MONEY ORDER PAY TO ORDER OFE $ 150.00 One Hundred Fifty and 001100 DOLLARS MEMO f� L NOT VALID OVER$1000.00 NON-NEGOTIABLE Customer Copy DRAWER7REMITTER ADDRESS ADDRESS .. -------- ----------------- ----------------------- -_. ----' No. 211707 Bank 53-716812118 - Florence SaNings DATE March 03, 2014 85 Main St.,Florence MA 01062 MONEY ORDER `PAY TO THE 6 ilk t'`. $ 150.00' ORDER OF t� Y1►rt�J� 1 i1i3' G��r� ! y/ One Hundred Fifty and 00/100 ************** DOLLARS NOT VALID OVER$1000.00 MEMO �� ' ��/� DRAW .REMITTER s ` AD ES5 l31Cc/C AAbDRESS 11' 21170711' 1: 21187 L6881: 1918005675911' The Commonwealth of Massachusetts Department of Industrial Accidents v Office of Investigations d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Lezibly Business/Organization Name: 0,orq 3 M&601 ov1G_L1 i)!1.41e e ,/,' Address: tn/�►� P� f3D,��o���'� City/State/Zip: Phone #: y(7j --57,57 - '7S-97 Are you an employer? Check the appr priate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• F-1 Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.Fl We are a non-profit organization, staffed by volunteers, �" , with no employees. [No workers' comp. insurance req.] 12.p Other Ytt /VL Ve *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **if the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy# or Self-ins. Lic. # Expiration Date: 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 MGL c. 152 can lead to the imposition of criminal 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 for insurance coverage verification. I do hereby cert' , under the pains and penalties of perjury that the information provided above is true and correct. 3 1 Si ature: Date Phone#• td (--k — 57 — 6I 5 7 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia -_� City of Northampton rq Massachusetts AV, DEPARTMENT OF BUILDING INSPECTIONS n 212 Main Street • Municipal Building � - `' Northampton, MA 01060rRX ,�1 .may SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS Permit Fee: $25.00 Check # PLEASE TYPE/OR PRINT ALL INFORMATION 1. Name of Applicant: G &, I Address: v e /i'/lr'q y . 6 444- P/C11 losq TelephoK : . 14/3' J'7S`T,5-T 7 2. Owner of P/rope�rt�(y, Address: 1�"1 I'�' �V i J 1 t c rt (ti�,°J +.c�tdr t1�&g4Telephone: 3. Status of Applicant: Owner Contractor 7 4. Type or Brand of Stove: 6� L If applicant is not the homeowner: Construction Supervisor's License Number Expiration Date Home Improvement Contractor Registration Number Expiration Date All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit 5. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE:-3 L31 APPLICANT'S SIGNATUREr '1 DATE: �' ( 4 HOMEOWNER'S SIGNATURE i�r- --- APPROVED DATE: BUILDING OFFICIAL 124 NORTH ST BP-2014-0933 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-004 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2014-0933 Project# JS-2014-001614 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CORY J MCGILL Lot Size(sq. ft.): 27965.52 Owner: SPEYER SVETLANA Zoning:URB(100)/ Applicant: CORY J MCGILL AT: 124 NORTH ST Applicant Address: Phone: Insurance: P O BOX 1054 (413) 575-4SS7 WILLIAMSBURGMA01096 ISSUED ON:31712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL PACIFIC ENERGY ALDERLEA WOODSTOVE 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 Signature: FeeType• Date Paid: Amount: Building 3/7/2014 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner