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BP-2022-1522 595 COLES MEADOW RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 03-027-001 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-2022-1522 PERMISSION IS HEREBY GRANTED TO: Project# RELINE CHIMNEY Contractor: License: Est. Cost: 9316 FIRESAFE CHIMNEY SERVICES INC 105507 Const.Class: Exp.Date: 01/19/2024 Use Group: Owner: G DENHART BRETT C&DEBORAH Lot Size (sq.ft.) Zoning: WSP Applicant: FIRESAFE CHIMNEY SERVICES INC Applicant Address Phone: Insurance: 277 PALMER RD (413)436-7946 7pjub06033546 WARE, MA 01082 ISSUED ON: 12/05/2022 TO PERFORM THE FOLLOWING WORK: RE-LINE CHIMNEY FOR WOOD STOVE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 1611a1' . >LR' . 94,7 Fees Paid: S105.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts .ter, FOR f e, Board of Building Regulations and Standa"" Massachusetts State Building Code, 780 C ' 2 MUNICIPAL Building Permit Application To Construct, Repair, Renovate Or Detnh a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number: 6ia- 11 I j ?mi. Date Applied: l v10 i /Z- 12-I-ZOZ2 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Addres : 1.2 Assessors Map&Parcel Numbers e 5615 not 11Its,Ooto '2-c: 0'3 '/� 1.1a Is this an accepted street?yes no Map Number Parcel Dumber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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' 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. Owner'o ecor ire- of� cu, nlr' k \AVinn, rIVA Ot zxtC Name(Print) City,State,ZIP 5 Cr►teS r�0 R-�, ezi13),2a�- etoss bcc.‘ s+®p-NO L, cb m No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other iii Specify: Brief Description of Proposed Work': 1 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ q'31 LI, 05 I. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2. Electrical $ 0 0 Total Project Cost3 (Item 6)x multiplier x 3. Plumbing $ ' 2. Other Fees: $ 4. Mechanical (HVAC) $ '3 List: 5. Mechanical (Fire $ Suppression) Total All Fees: , �/� Check No.(G Check Amount'O 6. Cash Amount: 6. Total Project Cost: $ 93 t(1), Do 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) tb Sb 1 'It C `a6 I r 1A -t-1 L L tF50 License Number Expi lion Date Name of CSL Holder �t �,, b \A Lc' S4 List CSL Type(see below) No.and Street Type Description o`.--C` 1r(` I' `&r e c, tM f 6 7��7 L/ U Unrestricted(Buildings up to 35,000 Cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP p,, I M Masonry jLrn�(�i'� ,� { l l uo(\ y.r V et& RC Roofing Covering (2� ��-7 / CO�, WS Window and Siding C�-(,�,3)LC 3� 6� —I Q �o, Insulation Solid Fuel��n8 Appliances Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I L!(-1 L d50)a3 re -ckt ► ' - , r`UI l S HIC Registration Number E irati Date H012'7"rhi t..k er v' Runt Name n �� N and Street719 ` G�iN E.il� address Y �� re t fn\ ZSVpq cD (&11, 719zioSef\ .cQsr(_am 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 )4 No .0 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 V �-t . \.)L Co to act on my behalf,in all matters relative to work authorized by this building permit ap ication. eP C \ --1 ll \lsEpa Print Owner's Name(Electronic Signature) 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. ` ,vk..s Loa_1,1 I i 1 r D j a a _ Print Owner's or Authorized Agent's Name(ElectronM Signature) e 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 www.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 `, rrzrjrr . s% t�' , ''; Massachusetts r� 'I-,,` 8'# DEPARTMENT OF BUILDING INSPECTIONS y; � .' 212 Main Street • Municipal Building J ati � Northampton, MA 01060 S'WY''_ `,�Q 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: Location of Facility: 7,-7 al Me ed Oztey a 0, The debris will be transported by: Name of Hauler: r l ee_cC C.h IV \r\ ac ki L CC Signature of Applicant: Date: IA k $ , aR 1 The Commonwealth of Massachusetts ►'-_-- 1 Department of Industrial Accidents it— , 1 Congress Street,Suite 100 Boston,MA 2114-2017 1 www:mass.gov/dia Workers'Compensation Insurance Affidavit Builders/'ootractors/Ekctricians/Plumbers. TO Bi.HEED WITH THE PERMI'iTING AUTHORITY. Annlicant Information Please Print Leeibts Name(Busincss+'organizauon individual): Cif'e�c Q_ Chef it Se'_V-V t (Q S Address:07 7.1 Pak rv\_e_v‘ e_a City/St z;p:C 'e (Y)iH 6 Phone#: I 1 -"19 ! Co Are you a.et.ohoyer?Cheek dm apprwprlate box: Type at project(required): I. .I am a employer web employe%(full and'or part-tsar)-' 7. New cons(action 2.0 I am a sole ptnprietar at partaeihip and luxe nu cniploy cam w uri:iig fur me in $. C]Remodeling a my capacity(_[No winklecamp.insurance required" I am a honuwiier doittt all(watt myself_[Nu wtxkcrs'comp.n oi ourcc irgeired.i" g. ®Dt�,ttolition r I ®Building addition 40 l am a bemoan net and nil be hiring nosiracrnrs to conduct all%tick on my property_ I w mane that all ctmlraion either have%Mike&cxniipcmaI,in inuranca or arc coke I i fJ Electrical rtpetfl or additions proprietors with no employees. 12.0 Plumbing repairs or additum Salt am a geoc al contractor and I ha hired the sub-contractors fisted on[lie attached sheet 130 Roof repairs These sub-contractors have employees and lane workers'comp.insurance:; p� l 6.®We ant a corporation and ita officer.have exit iaed their ngh M t of exemption per GL e_ l4. UM 152.11(4).and we hasc no employees.[No ethos camp_insurance naiu&) r J.v` *Any applicant that c aka Iwo#1 flutist also fill out die section below sbiiwi g tltair workers'na.tpa.srias panty ietsrmati.rr. +Iionionwncrs whir suhinit this off,trait indicating(beg we doing all wont and lbw bite otmiit conbaciora mint mints(a men at alavit nabeating,suds. :Contractors that check this boa MIA au.chc I an additional ellet AIM ing the name of the mtbcoisoc000rsand Maie wlttttitr or nut divot entities bast employees. If the sub-cardraeturs base eniployoea.they num provide their workers'cutup-terry umber_ !am an employer that is providing workers'compensation insurance for my easploaeees. Below is Ike policy and jab site information. Insurance Company Name: ' Fyilt r S -- e ^� 2 — Policy#or Self-ins.Lie.#�PjU W J�c76q�-l� Expiration Date: Ia. 3 lob Site Address: 56i s COl Q 5 MaCtADL,0 i City St-rte.'Zip; Attack a copy of the workers'compensation policy declaration page(showing the policy number and expi tints date).Me Failure to secure coverage as required under MGL c. 152,4125A is a criminal violation punishable by a fine up S1,500.00 and/or one-year imprisonment,as weft as civil penalties in the form of a STOP WORK ORDER and a fine of up c• $250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA (, insurance coverage verification. I do hereby the palms and penalties of perjury that the information provided above is ante and . • Signature: Date: I I `I 5 l a a Phone#: C CI 13)1 3b Official use only' Do awl write in this area.to he completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): I.Board of llealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: CSSL-105507 . fctpires:01(1912024 JAMES J WJ .LING 1 re - 40 HIGH STREET P.O. BOX 40 SOUTH BARRQMA 01074 y? .) ! Commissioner (iu.)tZ • e .-etnzino-zzateald ey,,,Sezeze/&v4e1X1 Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 182449 FIRESAFE CHIMNEY SERVICES INC Expiration: 06/25/2023 277 PALMER RD UNIT 2D WARE,MA 01082 Update Address and Return Card. SCA 20M-011T Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office-of Consumer Affairs and Business Regulation -1B2449 06/25/2023 1000 Washington Street -Suite 710 FIRESAFE CHIMNEY SERVICES INC Boston,MA 02118 JAMES WALLINGJR `% 277 PALMER RD N alid wi signature WARE.MA 01082 fi=; t3ry DATE(MWDD/TYYY) ACCORD® CERTIFICATE OF LIABILITY INSURANCE 11/15/2022 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(ies)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 CONTACT NAME: Jennifer Waldron BRABO INSURANCE ,ate No, ); (508)830-3800 FAX No): E-MAIL SS: iwaldron@braboinsurance.com ADDRE 65 Cordage Park Circle INSURER(S)AFFORDING COVERAGE NAIC# Plymouth MA 02360 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: FIRESAFE CHIMNEY SERVICES INC INSURERC: INSURER 0: 277 PALMER RD INSURER E: WARE MA 01082 INSURER F: COVERAGES CERTIFICATE NUMBER: 835596 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ D CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 7PJUBOG03354622 05/12/2022 05/12/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 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.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 210 MainSt AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • FIRECHI-01 JWALDRON A CORD MM(DATE /OD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1MM/2022 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(ies)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 CONTACT NAME: Brabo Insurance Agency 65 Cordage Park Circle (A/C,No, (508)830-3800 (ac,Ney( 08)746-1540 Plymouth,MA 02360 E-MAIL Info@braboinsurance.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Northfield Insurance Company INSURED INSURER B: Firesafe Chimney Services Inc. INSURERC: 277 Palmer Rd, Unit 2C INSURERD: Ware,MA 01082 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. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXPO LTR INSO WVD IMM/DD/YYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE TO CLAIMS-MADE X I OCCUR WS472568 7/15/2022 7/15/2023 PREMISES(EaENTED occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINEDn SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person)- $ OWNED SCHEDULED AUTOSRE ONLY AUTOS BODILYO INJURYp (Per accident) S AUTOS ONLY _ wets (Perr acclRdent)AGE UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BEI DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main St Northampton,MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Northampton K. .1 Massachusetts w L cf. ; j * ',G Ij. f , -W Li. % (i. ,.'A. DEPARTMENT OF BUILDING INSPECTIONS �. �;` ," 212 Main Street • Municipal Building �,�.. �b ue"" L Northampton, MA 01060 '� :r g6 `�� APPLICATION FOR SOLID FUEL APPLIANCE INSTALLATION Property Information Owners Name: 13Ce-i-+ Onhc. H Address: 5 q S Ccs I " ` mew, cA (No.) (Street Address) Phone6i -lQ Ce1l(tr I; 3:20`1(5 5 Email: bcckn ha c (0 (r ac,co ten Owners Signature: Date: I t i 1) (9oZ Contractor's Information (If Applicable) Name: q r-e3Ck CV) LIN1M r1/ l Ce'-S Phone: ( )Li3 a -7 L/ Construction Supervisor's License #: I (...)650 7 Expiration: ( l I q &Li Home Impr. Contractor License #: igdi uq Expiration: L ape 010?3 Stove Information Type of Fuel (check all that apply): Wood )C Pellet Coal Location: LLv ins rOO+M Freestanding Insert X Manufacturer: 3 O tt > Model: C_Li 5 D • ---- -------------------FOR BUILDING DEPARTMENT USE ONLY--------------------w--------- Permit# Date Applied: Total all Fees: $ Building Official: K��v 55 Date Issued: 12- I-2O z2 (Print) / Signature of Building Official: / !/�