25C-004 $ 100.00
One Hundred and 00/100** **** *****************************`***** DOLLARS
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' 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
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DATE March 03,
MONEY ORDER
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One Hundred and 00/100*******************************************
DOLLARS
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ADDRESS
ADDRESS
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No. 211705
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Florence Savings Bank DATE March 03, 2014 _
85 Main St., Florence MA 01062 4,
MONEY ORDER
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No. 211707
Florence Savings Bank 53-716812118
85 Main St., Florence MA 01062 DATE March 03, 2014
MONEY ORDER
PAY TO
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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
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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