24A-138 (2) 40 ROE AVE BP-2017-0095
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 138 CITY OF NORTHAMPTON
Lot: -OW PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2017-0095
Project# JS-2017-000162
Est.Cost:$80000.00
Fee:$520.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HENRY WHITLOCK 061355
Lot Size(sq.ft.): 7710.12 Owner: KUENY TUCKER&MELISSA
Zonine: URAIIOOV Applicant: HENRY WHITLOCK
AT: 40 ROE AVE
Applicant Address: Phone: Insurance:
191 NORTH ST (413) 253-2235
B E L C H E RTO W N MA 01007 ISSUED ON:7/26/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT KITCH CABINETS, 2
WINDOWS, DOOR & FLOOR
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 7/26/2016 0:00:00 $520.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File It BP-2017-0095
APPLICANT/CONTACT PERSON HENRY WHITLOCK
ADDRESS/PHONE 191 NORTH ST BELCHERTOWN01007(413)253-2235
PROPERTY LOCATION 40 ROE AVE
MAP 24A PARCEL 138 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid 0OLCO20
Building Permit Filled out
Fee Paid
Tvpeof Construction: INSTALL REPLACEMENT KITCH CABINETS.2 WINDOWS, DOOR&FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 061355
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
la e'
Si44. Oreo Be'Idi OO ficial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
RECc I v p �+� ; - DepartmenCuseonly
_ • No iharnOon Status of Permn
Build) ! D. partment Curb CuUDnvewayPermlt
AL 2 5 2'2 ai Straei Sewer/SepticAvatlabdlbj
P.OM 00 Water/VVell Availability
�, -1(
?-- ; on, lA 01060 Two Sets of Structural Plans
- • ax 413-587-1272 PloUste Plans
l v Other Speedy
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address This section to be completed by ice
. - off
- - - -
.4fro £ce. Map
Zone Overlay OtstrrcY
Q1 coo
Elm St.District ,CS District -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Invia bit (vex✓ 4t gee A-tie ✓Ibrtltai4pi- n rapt 0104+0
Name(Print) J
ICurrent Mailing Address-
i^:y1 LISj
Section A. ZONING AIL Information Must Be Completed. Permit Can Be Denied Due de complete InryffDmgg�rrmation
red •y anI •
d• to beHee inby `
Lot Size Ad
Frontage
Setbacks Front
Side LR L R _
Rear
Building Height .
Bldg.Square Footage
Open Space Footage %
(Lor area onus blag&paced
parking) -+t,
#of Parking Spaces a , "-
(volume&Location) —_— ----- n ._ _
A. Has a Special Permit/Variance/Finding ever been issue° for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 _YES 0
IF YES: enter Book Page , and/or Document II
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES CD NO 0
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading ovation, or filling)over f acre or is it pad or a common plan
that will disturb over 1 acre? YES 0 NO
1F YES,then a Northampton Storm Water Management Permit from the DPW is required• .
r
maw &t cit/.cam-rC � � � A� �
• SECTION 3-DESCRIPTION OF PROPOSED WORK(check all aeplicable) (1-43 44 0041"11 /� aliC a W1M '�
IC Pta IL
• New House ❑ I Addition ❑ Repiacement�Nryrmdows Alteration(s) Roofing
Or Doors 'i`4
Accessory eidg. ❑ Demolition R` New Signs [CO Decks [CI Siding(DI Other[DI
Brief Description of Propo ed �/. g,
Work: �A✓t LNIp /l1➢n.0 / .IA ..�4 .^ i been_
Alteration of existing bedroom Yes / No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. If New house and or additipn to existing housing,.complete the following:
a. Use of building : One Family `J Two Family Other _q4
Ty
b. Number of rooms in each famunit: O
Number of Bathrooms 3'41-
c. Is there a garage attached? L Si
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction �tn�
i. Is construction within 100 ft.of wetlands? Yes / No. Is constmetion within 100 yr, floodplain Yes No
j, Depth of basement or caner floor below finished grade.
k. Will building conform to the Building and Zoning regulations? V. Yes No
I. Septic Tank City Sewer- Private well / City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, antY. e I( ss R KRer , as Owner of the subject
property 11
hereby authorize 7tepic wrh,}10c c.
to act act on
fl y 'ht behalf, in atter elative to work authorized bythis building permit lication.
Pavyer �t1� 1I
SiI, fiVi e If$S A Kcte n``{{ as Owner/Authorized
Agent hereby declare that the sitements and information on the foregoing application are true and accurate,to the best of my knowledge
and hale
Signed under the pains and penalties of perjury,
the II'5S' kue411y
Print Name
Iets5 5 .1 la,-2.41-----
Signature
5ignatOwner/Agent ...�
Date
SECTION 8-CONSTRUCTION SERVICES 4 , 4,/F " ,
SA Licensed Construction Su/nerviser: /,' /// ,/— Not Applicable E
Name of License Holder. .7tity] g%(dJH-N _ r
✓ License Number
�i 37 o� C5 ora
Address Expiration Date
Signature Telephone 724/
147
fri-7-1. f- ---- °/l3 - C93- 18y
9. Registered Home Improvement Contractor ', Not Applicable f
Company Name Registration Number
Address Expiration Dare
Telephone
SECTION 10-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 dental of the issuance of the puilding permit
Signed Affidavit Attached Yes../... E No...... f
11. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner'.Person(s)who own a parcel of land on which he/she resides or intends to reside, on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
6 The Commonwealth oflWPesa^.Cla.Hsetts
LetDepartment ofIndisstrial Accidents
„___I"
11'4ll oI t, l-r Office of Investigations
t �f 600 Washington Street
`k, ,gLor e� Bosun, MA 02111
t ; l ' www.moxss.gov/¢fear
Workers' Counpensatnon I[nsarance Alftellawit: lBnillders/Contractcars/IElecttwetumns/Pbu hers
Applicant Information JJ�� �` / Lr u ]Please Print (Legibly
Name (Business/Organizationilndividual): �1Z""J- / id�L' K. I'Oh T h 0�/I I
Address: '3 7 //( o „.ta
City/State/Zip: Q/yt-n + t ina_ 6)0a )__Phone 4: fJ 3j— 53,-786-(
Are you an employer? Check the appropriate box:
Type of project(required):
I. I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time)."
have hired the sub-contractors 6. ❑New construction
2.V,. am a sole proprietor orpartner- listed on the attached sheet. 7. [Remodeling
ship and have no employees These sub-contractors have g- ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance? 9. ❑ Building addition
required.] 5. E We are a corporation and its 10. f Electrical repairs or additions
3.❑ lam a homeowner doing all work officers have exercised their 11.1 Plumbing repairs or additions
myself [No workers' right of exemption per MOL
Y comp. 12.0 Roof repairs
insurance required.] t c. 152, §I(4), and we have no
employees. [No workers' 13.E Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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 must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 cern under the paainsaand penalties of perjury that the information provided above is true and correct.
Signature: AZt (/"yW' d� Date: 7 /uJ/ (e
Phone#: L(1 3 - 7 c �y i - '7 8 U`(
Oficial 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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
City of Northampton
'�� � ^saeaachuaetts r ,.
if;
�i
DEPLETED-NT OF BUILDING INSPECTIONS , / fI
h�f� 212 Main 54e=[ o Municipal 010 Building r,
.
Northampton, MA O1n60 `rg � � •
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Ferson(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill). sonotube holes (before pour), a rough building insoection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
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: y ) eat ij
The debris will be transported by: LfX////ta /62,ccc.7 s
7- Yo
/
The debris will be received by:
Building permit number:
Name of Permit Applicant L a''t
7/14/4
Date Signature of Permit Applicant
THE COMMONWEALTH OF MASSACHUSETTS For OCABR Use Only.
OFFICE OF CONSUMER AFFAIRS AND
BUSINESS REGULATION Registration No:
10 Park Plaza, Suite 5170 Effective Date:
Boston, MA 02116
•' Application for Registration as a Home Imorovemeut Expiration Date:
Contractor or Sub-Contractor Reference:
(MGL c.142A;201 CMR 18.00)
ONLY CERTIFIED CHECKS OR MONEY ORDERS CAN BE ACCEPTED.ANY OTHER FORM OF PAYMENT,
INCLUDING BUT NOTiIJILEvUTED TO PERSONAL OR BUSINESS CHECKS,WILL BE RETURNED AS INELIGIBLE.
1. NAME OF APPLICANT: y;�[l� E'I IA�`1 1+1 CR
(MUST BE A LEGAL ENTITY INDIVIDUA ORPORATEON,LLC,PARTNERSHIP,LLP,TRUST,ETC)
2. APPLICANT TYPE: INDIVIDUAL(X6 CORPORATION/LLC( ) PARTNERSHIP/LLP( ) TRUST(
(MUST BE THE SAME LEGAL ENTITY IDENTIFIED IN#1—FOR BRA APPLICANTS,ALSO SEE#9)
3. NUMBER OF EMPLOYEES: C.J _
(NOT INCLUDINGAPPLICANT) 3
4. APPLICANT SOCIAL SECURITY#: 011 83081 FEDERAL TAXID#:
(� �j- /�j p (� (IF APPLICABLE;PLEASE SEE ATTACHEDINSSTTRUCTIIONS) _ �J
5. APPLICANT PHONE 86: /3 ,JDA -7n 1 APPLICANT EMAIL ADDRESS: //lie Triddl rot,
ek
6. MAILING ADDRESS: 7 itt i.. aL.T. I %Ib.�. 1* • . e 01 o C�
STREETTR _� � CITY (� STATE ZIP
7. PERMANENT ADDRESS: a��/ f 6-0044. 5d- 6el(k,ertq p.N- 4' Q/667
STREET CITY STATE ZIP
(PLEASE NOTE THAT A P.O.BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS YOU MUST LIST A STREET ADDRESS.)
S. IF THE APPPLICANT IS A CORPORATION,LLC,PARTNERSHIP,LLP,OR TRUST,PLEASE PROVIDE THE NAME,
ADDRESS, SOCIAL SECURITY#,AND TITLE OF THE INDIVIDUAL WHO WIT.T BE RESPONSIBLE FOR ITS WORK
(PLEASE SFP ATTACHED INSTRUCDONS;ADDHIONAL DOCUIMENTATIONREQUISFD):
LAST FIRST SOCIAL SECURITY# TITLE
9. IF APPLICANT IS DOINGBUSINESS UNDER A D/B/A,PLEASE PROVIDE ITS NAME IF LOCATED IN MASSACHUSETTS,
ATTACH A COPY OF THE FICTICIOUSNCERIINICATE FILED WITH THE CITY OR TOWN CLERK
DEA NAME:
10. (a)DOES THE APPLICANT OR RESPONSIBLE INDIVIDUHOLD ANY OTHER CONSTRUCHON-RELATED STATE,
CITY OR TOWN LICENSES OR REGISTRATIONS?f YES No
(b)IF YES,PLEASE FILL IN INFORMATION BELOW.ATTACH ADDITIONAL SHEETS IF NECESSARY.
LICENSE TYPE ISSUED BY LICENSE/REG.# EXP.DATE LICENSEE NAME
�5 ¢£if'
V6. tom. OG)355" /))? /i7 Patif t c1
U. LIST ALL PARTNERS,TRUSTEES,OFFICERS,DIRECTORS,AND MAJOR OWNERS(10%OR GREATER OF
OWNERSHIP)OF AN APPLICANT PARTNERSHIP OR CORPORATION,BELOW.USE ADDITIONAL PAPER IF
NECESSARY AND INCLUDE NEEDED PAPERWORK(SEE INSTRUCTIONS).PLEASE INDICATE BY AN"X"IN THE
LAST COLUMN THOSE INDIVIDUALS WHO REQUIRE AN APPLICATION FOR ADDITIONAL REGISTRATION LD.
CARDS.USE ADDITIONAL SHEETS IF NECESSARY.
FULL NAME TITLE % OWNER ADDRESS SUPP.CARD
146lriy calclloclu 33? rneadawyr
12. (a)HAVE YOU BEEN REGISTERED PREVIOUSLY AS A HOME IMPROVEMENT CONTRACTOR? V YES NO
(b) IF YES,PLEASE PROVIDE THE NAME AND REGISTRATION NUMBER UNDER WHICH YOU WERE PREVIOUSLY
REGISTERED: 2// `'3//)
W
NAME: H � IJ✓ GN GHIC REGISTRATION#: 7/5057 l
13. (a) ARE YOU CURRENTLY OR HAVE YOU EVER BEEN AN OFFICER,PARTNER,OR CO-VENTURER OF AN
APPLICANT WHO PREVIOUSLY APPLIED FOR OR HELD A HOME IMPROVEMENT CONTRACTOR
REGISTRATION? J YES NO
(b) IF YES,PLEASE
�PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND THE REGISTRATION NUMBER:
NAME: PEiV l O�` rF
j W✓I L2C yl HIC REGISTRATION#:
14. (a)ARE YOU CURRENTLY OR HAVE YOU PREVIOUSLY BEEN EMPLOYED BY A REGISTRANT OR APPLICANT
FOR REGISTRATION AGAINST WHICH DISCIPLINARY ACTION WAS TAKEN?
YES ki,No
(b) IF YES,PLEASE PROVIDE THE NAME OF THE APPLICANT/REGISTRANT AND TUE REGISTRATION NUMBER:
NAME: HIC REGISTRATION#:
15. (a)HAVE THERE EVER BEEN ANY FORMAL COMPLAINTS AGAINST YOU WHERE DISCIPLINARY ACTION WAS
TAKEN BY THE DEPT.OF PUBLIC SAFETY OR CONSUMER AFFAIRS,OR ANY COURT JUDGMENTS OR
ARBITRAT N AWARDS ISSUED AGAINST YOU?
_YES NO
(b)DO YOU O��1��/rEE MONEY TO THE GUARANTY FUND?
YES No
IF YES TO EITHER,PLEASE IDENTIFY BY DATE,CASE NUMBER,OR DOCKET NUMBER:
ALL CONTRACTORS. INCLUDING CSL's WHO ARE APPLYING FOR A TUC REGISTRATION MUST
PAY A REGISTRATION FEE OF$150.00,AND A GUARANTY FUND FEE. (See instructions for Guaranty
Fund fee schedule.) TT
16. REGISTRATION FEE ENCLOSED:$ Ci/a° GUARANTY FUND FEE ENCLOSED: /6O' Ci
O
PLEASE INCLUDE TWO(2)SEPARATE CERT IVIED CHECKS OR MONEY ORDERS,ONE MARKED
'REGISTRATION FEE"AND ONE MARKED"GUARANTY FUND."ONLY CERTIFIED CHECKS OR MONEY
ORDERS CAN BE ACCEPTED.ANY OTHER FORM OF PAYMENT,INCLUDING BUT NOT LIMITED TO
PERSONAL OR BUSINESS CHECKS,WIT I BE RETURNED AS INELIGIBLE MAKE BOTH CHECKS PAYABLE
TO"COMMONWEALTH OF MASSACHUSETTS."
I hereby swear, under the pains and penalties of perjury, that all information set forth on this
application and submitted in support hereof is true and accurate to the best of my knowledge.
Further,I certify under G.L. c. 62C,§49A, that I am in compliance with all laws of the
Commonwealth relating to taxes, reporting of employees and contractors, and withholding
and remitting of child support.
Si a ure Applicant If a corporation or partnership,position held. D e a /
--'^ ^^•�"'�""� TMISOOCOMENTCONTgINSgTPOE WgTEPMLgx-XOLUTO LIGNi TO VIEW -
423508
GREENFIELD SAVINGS BANK Since /869
SS-70792M
400 Main Street•P.O.Box 1537•Greenfield,MA 01302 July 25, 2016
DATE
PAYTOTHE - -,CONNONWEALTH OF MASSACHUSETTS'* 100. 00
ORDER OF
""9100 DOLLARS AND CO CENTS`* DOLLARS
_uaa.�.Nzr FUND FEE
CASHIERS CHECK �
EP
AUTXORIZED SIGNATURE
11.42350811• t: 2LL8707991: OL 80 00118311•
10 GREENFIELD SAVINGS BANK Siwe mew 423508
400 Main Street•P.O.Box 1537•Greenfield,MA 01302
DATE PAYEE AMOUNT
- .
25,ZiQ6 ` °`COMMONWEAL TH CF MASSACHUSETTS* lOO . CJ
REFERENCE
SUAItAN'P'Y FUND FEE
211870799 01 80 007183
CASHIERS CHECK
CUSTOMER COPY
423507
►� GREENFIELD SAVINGS BANK Shue 1868 S3ID792118
400 Main Street•PO.Box 1537•Greenfield,MA 01302 July 25, 201E
DATE
PAYTOTHE '*'COPESONWEALTH CF MASSACHUSETTS" $ 150. UC
ORDER OF V
**S150 DOLLARS AND 00 CENTS*
DOLLARS
HIC LICENSE CASHIERS CHECK //
AUTHORIZED SIGNATURE
•
el. 23507n' 1: 2Li8707991: OL 80 00LL830
GREENFIELD SAVINGS BANK Since 1864 423507
400 Main Street•P.O.Box 1537•Greenfield,MA 01302
DATE PAYEE AMOUNT
“o/ -'COPLMONWE<H OF MASSACHUSETTS ••
REFERENCE
HIC LICENSE
211870799 01 80 001183
CASHIERS CHECK
CUSTOMER COPY