25C-142 (2) BP-2021-2059
45 ORCHARD ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
25C-142-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2059 PERMISSION IS HEREBY GRANTED TO:
2021 INSULATION 45 ORCHARD
Project# ST Contractor: License:
Est. Cost: 9000 ENERGY PROTECTORS INC 172960101143
Const.Class: Exp.Date:08/19/202206/16/2022
Use Group: Owner: SHARNOFF ELENA H&LANCE R WILLIAMS
Lot Size (sq.ft.)
Zoning: URB Applicant: ENERGY PROTECTORS INC
Applicant Address Phone: Insurance:
64 PAXTON RD (774)253-0277 65621JB0G29826021
Spencer, MA 01562
ISSUED ON:10/22/2021
TO PERFORM THE FOLLOWING WORK:
45 ORCHARD ST- INSULATE EXTERIOR WALLS & ATTIC
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.
Signature:
,2 Ti .
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
r ( Board of Building Regulations and Standards FOR
IT, Massachusetts State Building Code, 780 CMR MUNIUISPEAI ITY
Built'n_4 Permit Application To Construct,Repair,Renovate Or Demolish a Revised May.2011
One-or Two-Family Dwelling This Section For Official Use Only
itildin FefriiiL umber: I3P--2021—20 Date Ap lied: 10/2(1ZO2-
�Cv,/J� 55 / J4 Zbz j
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address': - 1.2 Assessors Map&Parcel Numbe,rs
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
en c1 S haCfl o`er K)01A-31c,vv PP ivel ,/vx ,�- a "9 6°
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2 (check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other B.SPecity: (vt S t u"
Brief Description of Proposed Work`: On 5 v k.Ct.ie P 1C``reA L(At • la—ec k .S ec.ti
0 c_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ C1 1 000 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No 33)2 Check Amountte Fj= Cash Amount:
6. Total Project Cost: $ C I 0 0 0 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 6/16/22
CS-101143
Joshua Dada License Number Expiration Date
Name of CSL Holder iJ
64 Paxton Rd List CSL Type(see below)
No.and Street Type Description
Spencer,MA 01562 U Unrestricted(Buildings up to 35,000 Cu.ft.)
R Restricted l&2 FamilyDwelling
City Town.State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
774-253-0277 SF Solid Fuel Burning Appliances
jdada79@hotrnail.com _ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 172960 8/19/22
Energy Protectors Inc. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
64 Paxton Rd jdada79@hotmail.com
hotmail.com
No.and Street 774-253-0277 Email address
Spencer,MA 01562
City/Town,State,ZIP Telephone
SECTION 6: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 ti, No Cl
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Oi'ner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
_ c _\ w 1 i LA
Print Ottner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
ww w.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
City of Northampton
' Massachusetts A.(v._
' 4, DEPARTMENT OF BUILDING INSPECTIONS a
l' r; 4' 212 Main Street • Municipal Building til c�/
,,." Northampton, MA 01060 Sf' ''
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
C. LA A c-00-0 rl f-ck
Location of Facility: S 0 �`n c e e , ,M G(y� 4
The debris will be transported by:
Name of Hauler: c"$.Ner--51 00) -u W & C.—
Signature of Applicant: A `a'`t �Ge- `" Date: VO( l 3 h-I
_
►w The Commonwealth of Massachusetts
,c, � 1 Department of Industrial Accidents
?�]_ 1 Congress Street,Suite 100
l" Boston,MA 02114-2017w' www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):Energy Protectors Inc
Address:64 Paxton Rd
City/State/Zip:Spencer,MA 01562 Phone#:774-253-0277
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with 1 1 employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]
9. ❑Demolition
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.0 other Insulation
152,§1(4),and we have no employees.[No workers'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. 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:Ace American Insurance Co
Policy#or Self-ins.Lic.#:6S62UB0G29826021 Expiration Date:9/01/22
Job Site Address: u S V(LAvA iA C. City/State/Zip: +N of µ`C' M 1—ts/1l iM 606d
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and_4/ correct
Signature: Date: V.0 I() ( `
Phone#: 71 e-S 3 —O a-7
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#:
ACC R� n DATE(MM DDrvvyY)
CERTIFICATE OF LIABILITY INSURANCE 08/30/21
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 policy(les)must have ADDITIONAL INSURED provisions or 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 NAME: Nina Arroyo
PHONE FX
Coonan Insurance Agency,Inc. Q-Exit 508-987.7122 iAAic No); 508-987-7152
267 Main Street ADDRESS. Nina@coonaninsurance.com
Oxford,MA 01540
INSURER(S)AFFORDING COVERAGE NAIL a
INSURER A' AIX Specialty
INSURED INSURER B: Safety
Energy Protectors,Inc. INSURER c: Century Surety insurance
64 Paxton Road INSURER D
Spencer,MA 01562
INSURER E: ,
INSURER F.
COVERAGES CERTIFICATE NUMBER: 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.
1NSR ADDLSUBR POLICY EFF POLICYTYP
LTR TYPE OF INSURANCE JNSD VNO POLICY NUMBER (MMJODIYYYY) (MM/DD'YYYYL LMUTS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
D
CLA1NS-MADE X OCCUR
PREMISES Ea occurrence, $ 100,000
MED EXP;Any one person) S 5,000
a y L1N•H714840.00 08/31/21 08/31/22 PERSONAL aADVINJURY S 1,000,000
GENt AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000
X POLIC PRO I L�I LOC PRODUCTS-COMP/OP AGG S 2,000,000
JECT
S
OTHER
AUTOMOBILE LIABILITY EOMBBIINEDISINGLE LIMIT s 1,000,000
ANY AUTO BODILY INJURY(Per person) S
—~ OWNED SCHEDULED
B AUTOS ONLY X AUTOS y 6236519 12/23/20 12/23/21 BODILY INJURY(Per accident) S
XHIRED X NON-OWNED PROPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY ;Per accigenu
S
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 3,000,000
c �— EXCESS LIAB CLAIMS-MADE y CCP1005749 08/31/21 08/31/22 AGGREGATE s 3,000,000
DED I RETENTIONS H
WORKERS COMPENSATION STATUTE ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNERJEXECUTI/E Yn N/A E.L.EACH ACCIDENT $
OFFICER/ME/ABER EXCLUDED?(Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS belon ,_E.L.DISEASE•POLICY LIMIT S
DESCRIPTION OF OPERATIONS;LOCATIONS r VEHICLES (ACORD 101.Addnional Remarks Schedule,may be attached if more space Is required)
Workers Compensation insurance certificate to follow under seperate cover. Action Inc.and National Grid USA Its direct and indirect parents
subsidiaries and affiliates shall be named as additional Insured on Commercial General Liability and Automobile Liability policies
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Worcester Community Action
Council -.
484 Main St.ste.200 AUTHORIZED REPRESENTATIVE .
Worcester,MA 01608 -" `' t
I )
�� ,,t�C °` `' _ ., ._.4•~�~--- , ',.
'"f 1988.2015 ACORD CORPORATION. All rights t Prved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
ii......---- OW31/2021
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 pollcy(les)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
.NAME:_ Nina Arrc_iy0 ---_. ______
COONAN INSURANCE AGENCY HONE
(A/C tio,mot; (508)987-7122 1 �_ -__-__ ___
ADDRESS;IL Nina(Cooneninsurance,com
267 MAIN ST INSURER(S)AFFORDING COVERAGE NAIL F
OXFORD MA 01540 INSURER A: ACE AMERICAN INSURANCE CO 22867
INSURED
INSURER B
ENERGY PROTECTOR INC INSURER C:
INSURER D:
84 PAXTON RD INSURER E
SPENCER MA 01562 INSURER F:
COVERAGES CERTIFICATE NUMBER: 690758 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.
iiiiP7 Asors POLICY EFF POLLICr�Y OW
io LTR TYPE OF INSURANCE ;1NBD W POLICY NUMBER IMMIDDIYYYY)I'IMM/DD/YYYYI LIMITS
COMMERCIAL GENERAL LIABILITY • EACH OCCURRENCE S
CLAIMS MADE OCCUR PREMISES lEa oocurrsnce) S
MED EXP(Anton,Person) f
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $
POLICY[ JPERCT l ._:IOC PRODUCTS•COMP/OP AGG `S
OTHER ) S
AUTOMOe1LELU►BSJTY ! COMBINED SINGLE LIMIT S
___-.____--__-------------
--� BODILY INJURY(Per person) $
ANY AUTO
TALL OWNED SCHEDULED N/A-AUTOS j BODILY INJURY(Per accident) $
AUTOS ---NOH.OWNED . PROPERTY DAMAGE S
i HIRED AUTOS AUTOS (Par accident)
t
j UMBRELLA LIAO 1--' OCCUR I EACH OCCURRENCE S
EXCESS LY1B !CLAIMS MADE N/A I• AGGREGATE S
nE� RETENTION S , }
WORKERS COMPENSATION X STARTIJTE • ER"_
AND EMPLOYERS'LIABILITY Y/N - !
ANYPROPRIETOR/PARTNER EXECUTIVE E.L.EACH ACCIDENT $ 500,000
A OFFICER/MEMBEREXCLUDED? N/A NIA N/A' 6S62UB0G29826021 09/01/2021 09/01/2022------------------•(Mandatory ill NN) E.L.DISEASE_EA EMPLOYEES 500,000__-_
It yyes,describe under
I DESCRIPTION OF OPERATIONS below i E.L.DISEASE•POLICY LIMIT $ 500,000
NIA
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Addhfonal Remarks Schedule,may W attached I more space Is re0ulred)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 08 B,no authorization Is given to pay claims for benefits to
employees in states other than Massachusetts If the Insured hires.or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the Issue date of this
certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at
www.mass.govilwd/workers-compensation/investigations/.
Sole proprietor has not elected coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Eversource National Grid ClearResult ACCORDANCE WITH THE POLICY PROVISIONS.
120 Turnpike Rd Suite 200 AUTHORIZED REPRESENTATIVE
Southborough MA 01772 Daniel M.Crawley.CPCU,Vice President-Residual Market-WCRIBMA
®1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs and Bus ness Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home improvement Contractor Registration
Type: Corporation
Registration: 172960
ENERGY PROTECTORS INC. Expiration: 08/1912022
64 PAXTON RD.
SPENCER, MA 01562
Update Address and Return Card.
Office of Consumer Affairs&Businas,Regulation
HOME NAPROVEMENT CONTRACTOR . Registration valid for Individual use only
TYPE:Corporation before the expiration dabs. If found return to:
81110108181211 Expiation Mee of Consumer Affairs and Business Regulation
172960 08/19/2022 1000 Washing Street •Suits 710
ENERGY PROTECTORS INC. Boston,MA 02118
JO PHAUA ADADA lL• �� ""4 14-n
RD. valid without signature
SPENCER,MA 01582 Undersecrvtwy
DocuSign Envelope l0 F0936A80-F78F-4E98-AE8C-302F75193280
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
1, Elena Sharnoff
(Owner's Name)
owner of the property located at:
45 Orchard Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize
Subcontractor(to be filled in by office)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The permit will be secured by the subcontractor, at no additional cost.
It is the homeowner's responsibility to close out this permit by contacting their municipality at
the completion of this work.
-UUo�c Ju�S,mnedCbyLoft/toff
Lu,2 J
O`w`iTdP Sklid'W ire
9/20/2021 1 2:25 PM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
H�M City of Northampton
r,
.,°a °4. SAS .��^
'`- Massachusetts �4, `<,
A. 4; 'i, ii.
' I * t. `,r DEPARTMENT OF BUILDING INSPECTIONS y e�
212 Main Street • Municipal Building A.nr 4
Northampton, MA 01060 rn' 'w'>‘�
Property Address: 95 .nrc 1c"', S/-
Contractor
Name: Ent-rill Pr- lrc 74 r)
Address: CI( R.4„,_ ! 4
City, State: *N,,t e( AAA,
Phone: .77L-I- 753-33 -7..)
Property Owner (r'
Name: Cr(�c' c,hcr In ot-e
Address: Lis -c icrt( 5+"
City, State: NJr r►,i p Ikik
I, CAcr`'l )cc-ic k (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 /
7
Date /0/7/2