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32A-124 (8) c214 r /;I NOTICE z NOTICE T W 0 O a TO EMPLOYEES W� EMPLOYEES �W / V OEM S'I6 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (GSGOUB-9998L40-9-1 3) 11 -02-13 TO 11-02-14 POLICY NUMBER EFFECTIVE DATES ENCHARTER INSURANCE LLC 25 UNIVERSITY DRIVE AMHERST MA 01002 NAME OF INSURANCE AGENT ADDRESS PHONE # ° CODY, DAVID DBA CODY 79 GULF ROAD CONSTRUCTION _ BELCHERTOWN MA 01007 ° EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE �- MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the ° provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.. The reasonable cost of the services a provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 003995 W20PIG02 TO BE POSTED BY EMPLOYER (feARTNUNT OF PUBLIC S FETY Elevator Division New Construction / Modernization / Repair / Decommission Permit Maintenance Company: Owner or User: 101 Mobility Jack&Priscilla Finn 289 Elm Street 57 King Street I Marlborough, MA 01752 Northampton, MA 01060 j Type Class Tag Number Permit No Type Fee Date Order t Located at: i EL R 214-R-326 0 0 1 340.00 05/06/2014 0 Finn Residence Equipment or devices subject to the provisions of 524 CMR shall not be constructed, Finn Residence i Installed,relocated or altered unless a permit has been obtained from the 57 King Street a Commonwealth of Massachusetts,Elevator Division,before the work is commenced. Northampton, MA 01060 4 A copy of such permit shall be kept at the site while the work is in progress. f Decommissioned Date DPS Inspector Thomas G.Gafzunis Commissioner 15- V\-KY 57 KING ST BP-2014-0215 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 32A- 124 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2014-0215 Proiect# JS-2013-001524 Est. Cost: $240000.00 Fee: $938.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: Homeowner as Contractor Lot Size(sq. ft.): Owner: FINN JACK V&PRISCILLA R TRUSTEES Zoning: CB(100)/ Applicant: FINN JACK V & PRISCILLA R TRUSTEES AT: 57 KING ST Applicant Address: Phone: Insurance: 57 KING ST NORTHAMPTONMA01060 ISSUED ON: TO PERFORM THE FOLLOWING WORK: CONSTRUCT ADDITION & INSTALL ELEVATOR & SPRINKLER SYSTEM: NFPA 13D system per BBRS Appeal 7/16/13 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: lJ '/0 Rough: `1f 1�R House# Foundations 0 ^ a^ -�� -� Driveway Final: s S Srt-i Y < ,YS t 0 c Final: g�f Final: ��- � ` ,�,✓l, 11 'a i( Ots Rough Frame: I�~' �j J (mot' Gas: Department Fireplace/Chimney: Rough: Oil: Insulation: '/'G ©A� t�. f Smoke: �-� Final: I �� Final: % THIS PERMIT MAY BE REVOKED Y THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE IO Certificate of Occupancy Signature: FeeType: Date Paid: Amount: - Building 9/23/2013 0:00:00 $938.00 212 Main Street,Phone(413)587-1240,Fax: (4 13))587-1272 Louis Hasbrouck—Building Conunissioner