23C-075 (2) 31 WILLOW ST BP-2017-0647
GIS#: COMMONWEALTH OF MASSACHUSETTS
MwiSlock: 23C-075 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-0647
Project# JS-2017-001056
Est.Cost: $725.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group: THE ENERGY STORE 106024
Lot Size(sq.ft.): 4312.44 Owner ASHER KIRAN&ROBERT V S REDICK
Zoning: URAp0OVwsP(l00)/ Applicant: THE ENERGY STORE
AT: 31 WILLOW ST
Applicant Address: Phone: Insurance:
31 OLD ROUTE 7 SUITE 200 (888)840-6641 WC
BROOKFIELDCT06804 ISSUED ON:HI/8/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.:AI R SEALING INSTALL 6MM VAPOR BARRIER
ON CRAWLSPACE INSULATE RIM JOIST WITH 2' THERMAX
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/4 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 11/8/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0647
APPLICANT/CONTACT PERSON THE ENERGY STORE
ADDRESS/PHONE 31 OLD ROUTE 7 SUITE 200 BROOKFIELD (888)840-6641
PROPERTY LOCATION 31 WILLOW ST
MAP 23C PARCEL 075 001 ZONE URA(I001/WSP(100)'
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT /
Fee Paid 06 nf�
Building Permit Filled out �V
Fee Paid
Typeof Construction: AIR S ,LING " ALL 6MM VAPOR BARRIER ON CRAWLSPACE INSULATE RIM
JOIST WITH 2'THERMAX
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
_ Owner/Statement or License 106024
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
6.41proved 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
_ Demolition Del., J
Signa . sm di g ffcial 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.
+ Department use only
� City of Northampton Status of Permit:
Building Department curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Weil Availabdify
Y% d ! Northampton, MA 01060 Two Sets of Structural Plans
/ pne 413-587-1240 Fax 413-587-1272 Piot/She Plans
Other Specify
A -.' •TION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:'/�fl� I./ '/'jIIL. This section to be completed by office
3) ll/0W ✓ ' Lot
Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K1Irot, Ashes 3) 4illow S+ flovence (1$ 042
Name(Print) 1 L 1 - \\ Current Mailing Address:
(seca+l cld)
Signature Telephone 1_ 113 58LI 01 6 8,
2.2 Authorized Agent:
III .,.t- •F b Po c ISI SherVieldI mft 01257
Na .-(- -np Current ling Address:
i� l]u75 2oL, - c S
Signa ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection (
6. Total= (1 +2+3+4+5) $72-S. f' Check Number 33 c 744
This Section For Official Use Only
Date
Budding Permit Number: Issued:
Signature:
Building CommissionerMspector of Buildings Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg Square Footage
Open Space Footage 'Y
(Loi arca minus bldg&paved
narking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. D Demolition ❑ New Signs [0] Decks I❑ Siding ICI] Other([Q
Brief Description of Proposed 11 / Tn Sul0.it r"in` \or wl-k-h 1I2" �hcnlnA
work: Air SeG].noy Ins-kg town Japel, J FIC/ on crnw`CNite . /
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housing, complete the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT
1 1OR CONTRACTOR 1A�PPUES FOR BUILDING PERMIT
I, K 1 row/ 5/�uES ,as Owner of the subject
propertyft //`fa7/7--��..rr--��
hereby authorize C.krlsetr \
to act on my behalf, i all matters relative tbbbbb work authorized by this building permit application.
r> A ll I SI Ile
Signature of Owner _ ,., (/^ Date
I, Cjr LS l 4�ef ♦ S , as Owner/Authorized
Agent hereby declare that the statem is and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the poi and penalties of perjury.
j Lth-SIS
Print Na / -.sem—
Signature•Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction�Su'pe1r_visor: /� Not Applicable ❑
Name of License Holder: �f 1rt fur cI_Fn 41S 1060 2`'I
License Number
PCS 3,c 181 &4 \d Mtn O[ZS7 g I l I I K
Ad. .-. / ' i Expiration Date
' 175- 2-at -11S3S
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Theme E-nero y �re� 1-1%39
Company Name �/ Registration Number
s Old +Pch7 `/ /o/ 17
Address (� ,y/ (/pp pI/ Expiration to
'ECCOl IP101 \ �� oboULl Telephone nOp 11_IO -6101iI
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affda must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ' g permit.
Signed Affidavit Attached Yes No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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.CUR 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 nut 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 he required from time to lime,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,von 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
C
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: 3 ) 1/1)1/h R) 1
The debris will be transported by: I V D pe hY i C
The debris will be received by:
Building permit number:
Name of Permit Applicant J is
/ -
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
'2=at—
t. Office of Investigations
�
s 1 Congress Street,Suite 100
•
1. 4 Boston, MA 0211 4-2 01 7
t'•4>.z. • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): _
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I
employees (full anchor part-time).* have hired the sub-contractors 6. ❑-New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have g_ 0 Demolition
workingfor me in anycapacity. employees and have workers'
P X t 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their II.❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152,§1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc 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.
1 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. Lie. #: 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 57,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
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.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
./ Department of Industrial Accidents
R --t - Office of Investigalons
,/ I; I Congress Street,Suite 100
'F. ,—,-313'--. ...,
_ .3Boston,MA 02114-2017
� www.massgov/dict
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busiinneess/Organization/Individ1ual): Tne Er trey S-1 o e_ _
Address: ;7I Old. R- 7 `.J
City/State/Zip: I/,S / 0 r UL Phone#: , fT N0 — IP r Li
Are ou an employer?Check the ap.ropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. 9 New construction
employees (full and/or part-time).` have hired the sub-contractors
listed on the attached sheet. 7. 9 Remodeling
2.❑ i am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. 9 Demolition
working for me in any capacity. employees and have workers'
cora insurance.:
9. ❑ Building addition
[No workers' comp.insurance p
required.] 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.9 P bing repairs or additions
myself. [No workers' camp. right of exemption per MGL 12. oof rrr�eeppp rrs
insurance required.] ' c. 152, §1(4),and we have no I1
employees. [No workers' 13. Other 171n 70(1
comp. insurance required.]
'Any applicant that checks box in must also fill out the su.uon below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether rant those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
f an:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Br ,. I.. OA . ' . .1 sI
Policy#or Self-ins. /Lie.#:EN UVJ( 13 37I y Expiration Date: I I lc) Zo[7
lob Site Address: 3 J V[t I IIow S City/State/Zip:(Jj['?TJLQ01'0 0 IO vl2
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.
t do hereby certify u+ a he poi an penalties of perjury that the information provided above is true and correct.
Signature: Date: 11l5-j40
Phone 4: '1S Z° — LAS-VS—
Official
"( SKSOfficial 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#:
AC RO O CERTIFICATE OF LIABILITY INSURANCE DAT(MM/OWYYYYI
6.....----- 4/12/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyfies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Brian Gallagher
BNC Insurance Agency, Inc. NUCPHO E 2 .p: (914)937-1230 FAX N ) (914)9 37-112&
111 south Ridge Street iAO4Eu.bgallagher@bncagency.com
INSURER'S)AFFORDING COVERAGE NAIL
Rye Brook NY 10573 A:Selective ins Co of South Carolina 19259
INSURED INSURERS StarN t Insurance Company 40045
ENERGY PRE LLC InsuRERcaandmark American Insurance Co. 33138
dba THE ENERGY STORE INSURER 0:
31 OLD ROUTE 7
INSURERE:
-
BAOOKFIELD CT 06804-1711 INSURER F:
COVERAGES CERTIFICATE NUMSER:CL1641170511 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR Anal SUER POLICY EFF POLICY EXP - ---
LTR TYPE OF INSURANCE 114S0 wvo POLICY NUMBER IMMmDryYYY) IMMDOPYYYI LIMITS
I X COMMERCIAL GENERAL UABILItt
_ - . EALH OCCOR $ 1,000,000
A CWMSMADE X OCCUR DAMAGE TO RENTEENTE D 100,000
PREMISESga onwnen2l _ S
X Contractual Liability 52153542 3/27/2016 3/27/2011 MED EXR iAnymle Person) 5 5,000
PERSONAL BADV INJURY $ 1,000,000
GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE a 2,000,000
POLICY X PRO. PRODUCTS
ODUC. _ . _.
_ JECT LOC PgODUCT$AOA1P/OP AGO S 2,000,000
-_.
OTHER'. 5
AUTOMOBILE LIABILITY I COMBINED SINGLE UMI 5 1,000,000
.-_ FLEa accident)
A I % ANY AUTO BODILY INJURY(Per person) S
ALL.OWNED SCHEDULEDI
- - -------
AUTOS AUTOS 52153592 3/27/2016 3/27/2017 BODILY INJURY(Per accident) 5
BRED AUTOS
NON-OWNED PROPERTY DAMAGE
Auras /Ear accident)
X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 5,000,000
EXCESS LIAR CLAIMS-MADE•
.
A AGGREGATE 5 5.000,000
I DEO RETENTIONS 52153592 3/27/2016 3/27/2017 5
WORKERS OOMPENSATON "•• PER 0Th-
AND EMPLOYERS LIABILITY YIN 4 X STATUTE ER
ANY PROPRIETORIPARTNEGE%ECUTNE EL EACH ACCIDENT S 1,000,000
OFFiCEidridB (Mandatory iEXCLUDED, XIA
nn tan EXCLUDED, BNOwCD131379 4/15/2016 &/15/2017
EL DISEASE-EA EMPLOYEE 1,000,000
DESsResuON under --- - E- --
DESCRIPTION OF OPERATIONS beiov, ELDISEASE-POLICY LIMIT S 1,000,000
C Professional Liability LBR756563 3/27/2016 3/27/2017 LIMIT 2,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (AGGRO 101,Additional Remarks Schedule,may be attached if more space is required)
Proof of insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PROOF OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WFTN THE POLICY PROVISIONS.
AUTHORIZED REPRESFIITATNE
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®1988-2014ACORD
CORPORATION. All rights reserved.
ACORD 25(2014(01) The ACORD name and logo are registered marks of ACORD
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mass save Form -
PARTICIPATING •
CONTRACTOR
Site ID: 500050157752 Customer: Kiran Asher
Kiran Asher owner of the property located at:
(owners Name,printed)
31 Willow Street Florence
(Property Street AdeTess) (Ciryl
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and o a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature: 4,c
Date: 1— 2g-- Z0C6
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
•
•
Participating Contractor Date
•
For Office Use Only
•
Cm_ervatioe Services Group • 50 Washinglnn Street.Suite 30W • WeRboruugh,WA 01581 • 1800-080-7473
Rev.062015
eo City of Northampton
Massachusetts h�
.A t
F . E p DEPARTMENT OF BUILDING INSPECTIONS 111\\\
212 Main Street • Municipal Building
' Northampton, MA 01060 �sEM t'1l
Property Address: QDI VJ�\ i I I6 v( (-71--:E.
Contractor //�' ��
Name: TjL/rll'tS p ri. Sos
Address: Y 01 _ �(^-X 1 YYY11I U I y�,p
City, State: S�'12tt1P.JG I 1I 1' 012Si
Phone: LI-2F) 2c4- t-IS'55-
Property Owner As—tr...
"�� e �"
Name: 11.1 rr - 7 \s (
Address: 31 V IIIoVV 6
City, State:St "Florence--GQ� ‘ I�k 01 o G22--
I, ` Sr ,r\ �1hF(contractor) attest and affirm that the building I intend to
insulate does no h ve ny open ar(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 signature /
—A.• 4- 41111L" ----....\
Date III ,//i /