11C-063 (2) pM City of Northampton I (C
[ Oil 3
1 rt Massachusetts `
or'sr• �, DEPARTMENT OF BUILDING INSPECTIONS
�%.08 212 Main Street • Municipal Building rrV`
Northampton, MA 01060
Property Address: 7,S— Asc Sf Lcc 33, AiA p (e 53
Contractor
Name: The Fnargy SpOWASIH is
Address: 212 Ann.Rd.
Ffempdun,MA 01036
City. State:
Phone: 49/3 5-6
Property Owner
Name: /'n<.., r;.l ,S<,J rc ,.,r1
Address: 7Y A✓ci 571 Gpr ./S, ,K4 0 /e J'3
City, State: Lrrd S, /y4 n/o y 3
I, r Su?J 77 1,1roe J/S (contractor)attest and affirm that the building I intend to
insulate does not ha?e any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signat /iC _lam
Date
• ECEIVED
MAY 3 I ?els