10B-017 (4) 48 RIVER RD BP-2021-0724
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-017 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2021-0724
Project# JS-2021-001218
Est.Cost: $573.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sq.ft.): 17075.52 Owner: DOLLARD CATHERINE
Zoning: URA(100)/ Applicant: POTENTIAL ENERGY LLC
AT: 48 RIVER RD
Applicant Address: Phone: Insurance:
1 HARTFORD SQ BOX 2E (413) 798-0273 () WC
NEW BRITAINCT06052 ISSUED ON:3/3/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION
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 UP N VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
i ` ,r • •
+
Certificate of Occupancy Signature:I
FeeType: Date Paid: Amount:
Building 3/3/2021 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
,�oti,µ.►;�o 2 ity of Northampton Status of Permit:
b
•:Iding Department Curb Cut/Driveway Permit
I , .-kk` 1_ " C`sQFo�, 212 Main Street Sewer/Septic Availability
«; o‘�,T" \P Room 100 Water/Well Availability
\)\\PAD Northampton, MA 01060 Two Sets of Structural Plans
`� ✓� '�� one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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 office
A% VEc Map �' ! Lot C ` Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
is o 7.r rA _ASC 1VL.v42 - Q—�•�•� hi G: eltsT-4n rnA- c_ 13 'I
Name Print) � Current Mailing Address:
f/0 Telephone
ignature
2.2 Authorized Agent:
Name(Print) J Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5-)3 (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) 5-73 0 Check Number 497�
�
This Section For Official Use Only
/
. /
Building Permit Numb r: d•LI Date
Issued:
Signature: '- /1-/'2(JZO
Building Commissioner/Inspector of Buildings Date
((1 . � : 1 C h('N 1/ 1 . . C v i`N1
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors l]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[O] Other[4olf..04+;
Brief Description of Proposed
Work: (',C Ck Ll tscacO. Cp:.:V, c9
I i( ` 'Th O 1 `lkcn'Q-f �� nty j S
Alteration of existing bedroom Yes No Adding new bedroom Yes / No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other N
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 stories?
f. 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, C 0.�hp�.s‘e.. .T)O\\C , as Owner of the subject
properly
hereby authorize ` C pA-ec \-i cA ?...np_cc‘ki , 1 tr
to ac n my behalf, in all matters relative to wortkauthorized by this building permit application.
J
Sign ture of Owner Date j —
I, TO .QANA-;G C Q t , as Owner/Authorized
Agent hereby declare fhat`the stMtefment and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
C\nc,\c 3 Vnt:z SIt'P.!
Print Name
I0.-i-ZaZ;0
Signature of en Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage _
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO (Y DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regis of Deeds?
NO Q DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Qf DONT KNOW Q YES Q
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 Q NO V
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO ®'
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex ation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �bdHOLJ1 S' 'e73Tn !
. License Number
141-1 ,A116t .sS 53-c-eAZAr �c�-rn C iy t.q V 12 7 f�.1
Address J 7 Expiration Date
/3 7980273
Sig r Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
` t'OTCNTIli-t-(i &-? * /9225 V
Company Name Registration Number
11- rcoeo ortPc- KC. 26 ,04w 6KI/Ftw, e -060€- 6/20.2
Address / Expiratio Date
/>4;)$' Telephone /�2 O273
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 denial of the issuance of the building permit.
Signed Affidavit Attached Yes 111 No 0
City of Northampton
Massachusetts l�
` G
+ DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building v� cs:b
Northampton, MA 01060 rJlryyj��`�
Debris 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.
The debris from construction work being performed at:
c;' -er ct :s.:st
(Please print house number and street name)
Is to be disposed of at:
kock-
(Please print n me and locatio off ity)
Or will be disposed of in a dumpster onsite rented or leased from:
9
(Company Name and Addres'sj
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
0.H M
!C
Massachusetts �'•-'t�
° L'
DEPARTMENT OF BUILDING INSPECTIONS .11
.fir , J 212 Main Street • Municipal Building �J6 �''
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: C ASQgc,,,2_ Est.Cost: SS 1340
Address of Work: 4 �, �L-oc_ j u o A rN 0 i o l":3
Date of Permit Application: r .—i
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
it-1--z 2f') 0 14-:0.\ ���� .Lce_— I 71 k1
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
taPr City of Northampton
ti z� c
Massachusetts �� �`�
1s * G'
,i
:it t
Ad x
t e'! DEPARTMENT OF BUILDING INSPECTIONS y; '' ti
212 Main Street • Municipal Building vI- ��'`�
Northampton, MA 01060 Y
Property Address: A% R:ae.c QLoad MocckiramoArr, O A C irss'3
Contractor Name: `/�c c*--ltd Cave 1 y, t_t_&_
Address: I 1-tCL n-et SGLAth..e— Sv. 'Zit,' ''a)�� CaS JVe L! ;+si:h,t i oc::Ms-
City, State: f te.ci Sr,. \a:c‘ C. I o(n IDS-
Phone: (.(1S - /CV - O2 71
Property Owner
Name: (\.,cAka, _ -TNa\W
Address: AY Ci4er Le,c(11
City, State: Afc„-A-1na,..011„ irt4. n t riS 3
I, kJ ,(r GALS rg.e;s-her 4f1kll contractor) attest and affirm that the building I intend to
insulate does not have 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 signature
.// ,...„5:0!! ;›,_
Date
I7---1-1z2Z
Qom, C62042?/122042W-eaagdi
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
POTENTIAL ENERGY LLC Registration: 192284
1 HARTFORD SQUARE Expiration: 06/21/2022
BOX 2-E
NEW BRITAIN,CT 06052
Update Address and Return Card.
SCA 1 C 20M-05/17
'/4r ;,.in,Imnu'err///r/ llir.;.indii.:r>//:
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
192284> . 06/21/2022 1000 Washington Street -Suite 710
POTENTIAL ENERGY LLC Boston,MA 02118
NICHOLAS MEISTER
1 HARTFORD SQUARE nut 4.
DOOR 65 SUITE 216 Undersecretary Not valid without signature
NEW BRITAIN,CT 06052
Commonwealth of Massachusetts
Division of Professional Licensure
and Standards
Board of Building Regulations
ConstructionSuperVisor 1 & 2 Family
CSFA-106184 Expires:04/27/2021
NICHOLAS ALEXARDETRI MEISTER;
344 ANDREWS ST
SOUTHINGTOMI CT 06489
Commissioner q�.•« '��1
DocuSign Envelope ID:F6438592-DC20-43DE-8D9B-FB819247A076
Permit Authorization
mass Save Form
r .=a+ otwrgy
Site ID: 4031017 Customer: CATHERINE DOLLARD
Catherine Dollard ,owner of the property located at:
(Owner's Name,printed)
48 River Rd Northampton, MA 01053
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
DocuSigned by:
Owner's Signatur : �krila t Uoa(4ri
72ADFC 1E8E614BB...
Date:8/27/2020 14:21 PM EDT
sassasswats!!•siasasass.sassassasassasassesasi#iliiii•slssasseasassess
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Potential Energy, LLC 12/7/2020
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Only
Rev.102015
DocuSign Envelope ID:F6438592-DC20-43DE-8D9B-FB819247A076
CLEAResult" CONTRACT
CLEAResult
50 Washington Street, Customer Name:CATHERINE DOLLARD
Westborough,MA,01581 Email:cadollard@gmail.com
Phone:413-588-1472
Premise Address:48 River Rd,Northampton.MA 01053
Mailing Address:48 RIVER RD,Leeds.MA 01053
Project ID:4031017
Date:July 20.2020
Applicable Customer Required Actions: Notes:
• Other Customer must confirm no active knob&tube wiring in
house and all vermiculite is being removed before
insulation contract can be issued.
Job Description
Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance
with the terms of this Contract, including the attached recommendations/work order describing the work in detail(the"Work")which are
incorporated herein by reference.
Measure Description Location Quantity Unit Total Cost Customer Cost
Air Sealing at Estimated 62.5 CFM50 Per Hour 1 hr $92.58 $0.00
Door Sweep(with AS hrs) 2 each $50.62 $0.00
Exterior Door Weather Stripping(with AS hrs) 2 each $60.14 $0.00
Crawlspace Ceiling-2"Thermal Barrier Polyiso 120 SF $573.60 $0.00
Total: $776.94
Program Incentive: -$776.94
Weatherization Barrier Incentive: -$100.00
Customer Total: $-100.00
Payment
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows: Payment#1:=I as a Deposit
payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs). Mail check&contract to CLEAResult, 50
Washington Street, ,Westborough,MA,01581. Final Payment:_as the final payment for the Work shall be payable to the
Home Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work. Customer
Page 1 of 4
DocuSign Envelope ID:F6438592-DC20-43DE-8D9B-FB819247A076
understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of 11.1111.Changes
to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share.
Dispute Resolution
The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contract,the IIC may submit such
dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be
required to submit to such arbitration as provided in M.G.L.c 142A.
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller,provided you notify the
seller in writing by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the
signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
r—OocuSgned by: DS
r y 8/27/2020 14:21 PM EDT
`-tti§iftfrkirr6Slijnature Date Indicate your selected IIC here,if applicable Ini la ere if you
want the Program
to assign a
Participating
KtviG 9-4-2020
Kevi n Cote Contractor
kv
CLEAResult Signature Date Name of CLEAResult Representative
Page 2 of 4
NI
RCS PLANVIEW DIAGRAM
Customer: k.04t6 e-Osc.I Home Phone. ( )-
. Address Work Phone: ( )- �Yr " A�7
ut V v - t44 I,
Qpcfy .Town: Cell Phone` ( 413
Any limitations for access by large truck, N�' •r+� yes if yes,describe_.___._-.._._ .,._..__....._._,.-..--
t --
Any spec f c directrons or landmarks? ra<. ��� yes il yes.describe _._ .
-.
. .... ......
tk Site ID: Energy Specialist Reviewed by.
t:
k-tv Lt fir,-.. _ 51155� -
r c " t, L -- ?�u t Eva" -cr�6 u A POI ,S k-x j ()
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4 U \ a ra4-
F 0 _`0
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F-- cs —� --'--�
& / \ ,t•P oc. 40 0 PS;
):3 iN) (k.,,) \
02)
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orb
For Office Use Only
Bushes Ladder _ 4 1 Neighbor Proximity Pocket Doors insert Radiators Fence(s)
Existing Conditions X=Access 0=Vents Note Inside Square R=Roof S=Soffit G=Gable
RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Drip Edge T=Triangle
Install 0=New Access Note in Circle C=Ceiling W=Wall S=Sheathing Temp Unless Noted Otherwise
A=Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For Access
1-1t.9PP0HTttUG MATH
A t a x�•L
LiC�-,J V ( is.T is` , .d) - ( cots s r i7 (?rtd)J '` c'_vent $f . , r
dvvv..eyNis roil
� ate
P�rc0CS /lay (ut�` -7Y
r�' i7 _ - _
f ._ ___ . (act
7TIT * Hl
i
,
aq_ck _✓
Recommended _
Ventilation Calculation
Recommended
ventilation Calculation r fo (300 - 6 , e l CSV Qn A '�.a, Jf,Dsp "
Air Sealing Work Hour
Calculation rA4 - (Qv
Work Hours 4 i O 8 10 12 14 16 (+2)
Attic Sq.Footage <500 f 501 -800 801 -1100 I 1101- 1400 1401- 1700 1 1701-2000 2001-2300 I Every 300'
Exceptional AFL Hours Primarily Floored Attics ! Chimney or BF=1 Hour Multiple Chimney/BF=2 Hours
Prefab/Modular Hours No Chimney=4 HoursT Chimney=6 Hours
—
Exceptional KW Hours X<20 feet=1 Hour T 20 ft<X<40 ft=2 Hours J X >40 ft=4 Hours
Rim Joist Only Hours RJ< 150 ft= 1 Hour ____RJ_>150 ft=2 Hours
E,,IT Ceiling Only Hours Ceiling Area<2,000 sq ft =1 Hour Ceiling Area>2.000 Sq ft=2 Hours
"'NOTE:You MUST be INSULATINQ RJ or Basement Ceiling to specify RJ or BMT Ceiling ONLY Air Sealing Hours•"
0 >6"Loose Insulation Cross Batt Insulation
Multipliers ---_.___—___._ �__.___. __ _ ._�.._..______ _-_�.—_
>_6"Mix Batt&Loose Insulation Truss Construction
Ogre
For Office Use Only
r '�y The Commonwealth of Massachusetts
Department of Industrial Accidents
lit.=• Office of Investigations
`r
-7.�i600 Washington Street
"1 = Boston,MA 02111
"'• www.mass.gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Pluinbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ,`} Ace--ANCa.k Er,t�
Address: �„t a St.,.,4-e....'l il� ' c tr 1� ;: �c ,,t�_Si u�t"
City/State/Zip: , s3- c:e1, t c c c Phone.#: y t 3 - -7 C$ —i✓.,
Are you an employer?Cheek the appropriate bor: Type of project(required):
1.El I am a employer with_Ai 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance comp.insurance. . repairs 5. ❑ We are a corporation and its 10❑Electrical or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.0 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 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. lithe subcontractors have employees,they must provide their workers'tongs.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: rs; eti ei� `c t� 't;j1t Sec a;
Policy#or Self-ins.Lic.#:. tat q�R � 3 Expiration Date: 8't'2'. I„c,c..
Job Site address:-48 River Road City/State/Zip: Northampton MA
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
Investi motions of the DIA for insurance coverage verification.
Xdo hereby certify un thevp rr es of perjury that the information provided above is true'and correct
Signature. _._ Date; 3/3/2021
_ es
phone#: `'t i''3 --'?G Sk --C _y,
Official use only. Da 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 S.Plumbing Inspector
6.Other
Contact Person:,, Phone#:
- t