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23B-023 (8) BP-2023-0938 29 HATFIELD ST COMMONWEALTH OF M SSACHUSETTS Map:Block:Lot: 23B-023-001 CITY OF NORTHA PTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2023-0938 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 10200 ENERGY PROTECT RS INC Const.Class: Exp.Date: Use Group: Owner: MCCO MICK THOMAS J& ALICE L HEARST Lot Size (sq.ft.) Zoning: URB Applicant: ENERG PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6S62UB0G29826021 Spencer, MA 01562 ISSUED ON: 07/20/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERIZATION 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: ( +� � 3-1 Lqi• '1 •L Fees Paid: $71.50 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Li-.,�t -, —7-lC ik,i r"�. )' (Ot�ti.r 18g2 /14 The Commonwealth of Massa, uset . Jo �✓, Board of Building Regulations . d Sta'dards 4 1� � sR Massachusetts State Building C 4e, AQT k. R . ICI ALITY� <9p� E /14 Building Permit Application To Construct,Repair, ' ,.-,, a 1emolisfra 'ei'is' Mar 20/1 One-or Two-Family Dwelling 4''"r'o 7i4,� T ss ion For Official Use Onl+ 10 C7i,,� Building Permit Number: 417 DZ 3-13 0 Date Applied: I EVI/J 71Z /12 7-161-ZoZ3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATI)N 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.1a 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 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'Lone? Municipal 0 On site disposal system 0 Check it'yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 16rfx 01 tr[0roN t CR. Jor-v_vv_ow otW1 t s'1 A 010 6a Name(Print) City,State,ZIP 140t 1-4-ct-4:eta' Si- 403 - 3 ao-i1V7 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 l Specify: LP C'4Y-Ke..r'‘7...41-►M Brief Description of Proposed Work2: at c e2e'ct I i t'n Sv tC.,, v-e.- cL i-k‘,(...- AD V1.-4{4 C(vl4Q t /.SL.)l4 i--mac_ eK ke c-ion ‘A.. c.,11 S SECTION 4:ESTIMATED CONSTRUCifION COSTS Estimated Costs: Item (Labor and Materials) Official Use Only I.Building $''V I k p 0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/TownApplication Fee ❑Total Project Cost-1(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ 61 Suppression Total All Fee ) Check No. eck Amount: ��i Cash Amount: 6.Total Project Cost: $ I 0 1,od J 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-101143 6:16/24 Joshua Dada License Number Expiration Date Name of CSL Holder List CSL Type(see below)u 64 Paxton Rd No.and Street Type Description tJ Unrestricted(Buildings up to 35,000 cu.11.) Spencer,MA 01562 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 774-253-0277 jdada79@hotmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 172960 8/19/24 Energy Protectors Inc HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 64 Paxton Rd jdade79@hotmell.com No.and Street Email address Spencer,MA 01562 774-253-0277 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 Issuanc of the building permit. Signed Affidavit Attached? Yes 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner'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. It39CI — 71131 Z3 Print Owner'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 IIIC Program can be found at www.mass.t;ov/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" The Commonwealth of Massachusetts F:_'= 1, Department of Industrial Accidents �T , _;;�_ 1 Congress Street, Suite 100 ; _ Boston, MA 02114-2017 a:;�",Y /r 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 f City/State/Zip:Spencer, MA 01562 Phone#:774153-0277 Are you an employer?Check the appropriate box: Type of project(required): 10 I am a employer with1 I 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. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance require] 9. 0 Demolition l0 0 Building addition 4.0 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 1 LE]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. insulation 14.0 Other 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant that checks box/l must also fill out the section below showing their workers'compensation policy intormation. 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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:National Liability& Fire Insurance Company Policy#or Self-ins.Lic.#:V9WC383933 Expiration Date:9/1/23 Job Site Address: Z Ck h Q.� act C`t S+— City/State/Zip: 11/4) 0(t ric4.,AA..0 ViM t ri A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). C9l06 0 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 S250.00 a day against the violator.A copy of this statement may be forwarded to the Offf4 of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pal s and penaltiesof perjury that the information provided above is true and correct. Signature: (") - 4 "-C.-�. Date: l� ( 3 I Z3 Phone#:774-253-0277 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#: City of Northampton t"AM •p'Y\ �S • SAC A, • Massachusetts • < fit t- 't • # V , a:: + DEPARTMENT OF BUILDING INSPECTIONS 2 ' ,... 212 Main Street • Municipal Building 4r Northampton, MA 01060 sSNh 100' CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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 MGM?c 111, S 150A. The debris will be disposed of in: Co(4 Pc i-�-" 3Qecle C' ( PAP 0cj6,2 Location of Facility: The debris will be transported by: Name of Hauler: Ear � '� Oco-\-C-CVDIS Signature of Applicant: � Date: '�1 I I /-3 �®AC DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 8/31/2022 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 Coonan Insurance Agency, Inc. PHONE Nina Arroyo FAX 267 Main Street (A/C.No.Eat):508-987-7122 WC.**508-987-7152 Oxford MA 01540 ADE DREsa: nine@Lioonaninsurance.com INSURER(S)AFFORDING COVERAGE NAIC y t icsnse#:1782985. INSURER A:AIX Specialty Insurance Co INSURED ENERPRO-01 INSURER a:Safely Insurance Company Energy Protectors, Inc. INSURER Capitol Specialty Insurance Corporation 64 Paxton Road --- Spencer MA 01562 INSURERo:National Liability&Fire Insurance Company INSURER E: Philadelphia Ins Companies INSURER F: COVERAGES CERTIFICATE NUMBER:2132532233 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. IN ADDL'IS.-0-I_ - . -. (MM/DPOLICY OF POLICY EXP--_ LTR TYPE OF INSURANCE INSD IAA/� POLICY NUMBER (MMIDD/YYYY) ( M/DD/YYYY) LIN/T8 A X COMMERCIAL GENERAL LIABILITY Y L1N-H714840-01 8/31/2022 8/31/2023 EACHOCCURRENCE 61,000,000 CLAIMS-MADE X OCCUR OAMAG(TO RENTED PRE..MiSE$.1E4 rrenctl- $50,000-- _ MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENt.AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $2,000,000 X I POLICY PRO JECT I I LOC PRODUCTS-COMP/OP AGG 51,000,000 OTHER: E B AUTOMOBILE UABILITY N 6236519 12/23/2021 12/23/2022 (t`FA�ha18MEVINGLE LIMIT $1 000,000 ANY AUTO BODILY INJURY(Per person) $ AU NED OS ONLY X AUTOSULED BODILY INJURY(Per accident) $ X HIRED y NON-OWNED PROPERTY DAMAGE $ r— AUTOS ONLY AUTOS ONLY itPeraccident) _. C X UMBRELLA LIAB X OCCUR Y CCP1070518 8/31/2022 8/31/2023 EACH OCCURRENCE $1,000,000 _ EXCESS UAB CLAIMS-MADE AGGREGATE s DED X RETENTIONS in fvtnOTH- f o AND EMP WORKERSOVOERSENABILOITY YIN V9WC383933 9/1/2022 9/1/2023 X - ER ANYPROPRIETOR/PARTNER EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBEREXCLUDED? n N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under 'DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $500,000 E Pollution Liability PPK2368760 1/6/2022 1/6/2023 Each Occurence 1,000,000 General Aggregate 2,000,000 Products-Completed 2,000,000 DESCRIPTION OF OPERATIONS/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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Eversource 247 Station Drive AUTHORIZED REPRESENTATIVE Westwood MA 02090 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure 1 It Board of Building Regulations and Standards Cofr ns�ciww S visor CS-101143 * , pires:06/16/2024 JOSHUA S DOIDA I — 64 PAXTON RD 4 SPENCER MO 01 11 ` % ,_ • r•., truss. p i V THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affaitt a Business Regulation 1000 Washing #- Suite 710 Boston, Massachusetts 02118 Home ImRro et t • _:cloy istration : !zi 'IPS MOM .41 7....„ IIIM iv/ ._,.Regatwn: 172960 ENERGY PROTECTORS NC. "6 sirt t 64 PN}(TLMI-ice. -"N Ii E> On: 08/19i2024 SPENCER.MA 01562 _-- It,_ Nr.i... tide Address and Return Cara_ THE COMMONWEALTH OF MASSACHLSETTS Office of Consumer Affairs&Business Regulation Registrauo i valid for individual use only before the HOME IMPROVEMENT CON rt2AC TOR expiration date. If found return to: TYPE Cisrparatio Office of Consumer Affairs and Business Regulation RegiWitttert. ClitiQn 1000 Washington Street •Suite 710 '72900 08'19/20 4 Boston.MA 02118 ENERGY PROTECTORS INC. JOSHt1A DADA __ c� 1 st t 64 PAXTON RD. t. = v.;.-x-1._ ;1 «L-' 1, SPENCER.MA 01562 Un 1Nbt valid without signature WEATHERIZATION CONTRACT EVERSSURCE CUSTOMER PHONE DATE CLIENT M WORN ORDER Tom Mccormick (413)320-178 05/25/2023 455029 10304 SERVICE STREET BILLING STREET PROPOSED BY 29 Hatfield Street 29 Hatfield Street Ray Dickson SERVICE CITY.STATE.ZIP BILLING CITY.STATE,DP Program Northampton. MA 01060 Northampton, MA 01060 EGMA-HES Page 1 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE 75% For eligible weatherization measures, Eversource is offering an incentive of 75%for insulation measures and 100%for the air sealing measures, both with no limit. You are eligible to apply for the 0%Heat Loan to finance your co-pay, applications must be submitted before the weatherization work begins. HOME AIR SEALING 8 $754.64 $754.64 Seal areas of your home against wasteful, excessive air leakage. I? Materials to be used to seal your home can include caulks, foams • and other products. Primary areas for sealing include air leakage to attics, basements, attached garages and other unheated areas (windows are not generally addressed.) TRANSITION AIR SEALING 33 $214.17 $214.17 Provide labor and materials to air seal the open kneewall transitions of your home against wasteful, excess air leakage. WEATHERSTRIP DOOR 4 $127.24 $127.24 Provide labor and materials to install Q-Ion weatherstripping to door(s)to restrict air leakage. DOOR SWEEP 1 $26.11 $26.11 Provide labor and materials to install a doorsweep to restrict air leakage. ATTIC DAMMING 18 $44.10 $33.08 $11.02 Provide labor and materials to install an approved damming material in the attic ATTIC FLAT-8"OPEN R-30 CELLULOSE 675 $1,282.50 $961.88 $320.62 Provide labor and materials to install an 8"layer of R-30 Class I Cellulose to open attic space. ATTIC FLAT-7"FLOORED R-22 DENSE CELLULOSE 351 $933.66 $700.25 5233.41 Provide labor and materials to install a 7"layer of R-22 Class I Cellulose to floored attic space. KNEEWALL GABLE WALL-2" RIGID BOARD INSULATION 60 $291.60 $218.70 $72.90 Provide labor and materials to install 2"rigid insulation hoard to the open gable wall in a kneewall attic region. KNEEWALL SLOPE -2"RIGID BOARD 166 $805.10 $603.83 $201.27 Provide labor and materials to install rigid board at R-10 or greater with the required fire rating to the sloped rafter area behind a kneewall. WEATHERIZATION CONTRACT EVERScURCE CUSTOMER PHONE DATE CLIENT WORK ORDER Tom Mccormick (413)320-1787 05/25/2023 455029 10304 SERVICE STREET BILLING STREET PROPOSED BY: 29 Hatfield Street 29 Hatfield Street Ray Dickson SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL HATCH-INSULATE RIGID BOARD 1 $47.37 $35.53 $11.84 Provide labor and materials to insulate the back of an attic hatch with 2"rigid insulation board at R-10. DOOR-INSULATE RIGID BOARD 1 $90.61 $67.96 $22.65 Provide labor and materials to insulate the back of a door with 2"rigid insulation board. WALLS-WOOD SHINGLE SIDED 6" 1,664 $4,675.84 S3,506.88 $1,168.96 Furnish and install blown in Class I Cellulose to Wood shingle exterior walls.The butt of the upper course of your wood siding is cut to drill holes into the wall sheathing behind.The holes are then plugged and the wood siding is reinstalled using exterior grade nails. Touch-up painting, if needed,will be the customer's responsibility. Homeowner has received a copy of the EPA's Renovate Right Lead- Safe information guide explaining the potential risk of the lead hazard exposure from the weatherization work to be performed.Your signature is your acknowledgement of receipt and agreement to proceed. BASEMENT SILLS-6" FIBERGLASS 112 $301.28 $225.96 $75.32 Provide labor and materials to install R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. CRAWLSPACE-6 MIL POLY GROUND COVER 80 $81.60 $81.60 Provide labor and materials to install 10 ml polyethylene over open ground in designated crawlspaceiearthen basement areas. CRAWLSPACE WALL-2"RIGID BOARD 100 $485.00 $363.75 $121.25 Provide labor and materials to install 2"rigid insulation board to the open wall. Document Ref:XAXTY-CX#CKQ-CPWQF-DDZCD Page 2 of 6 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENTS WORK ORDER Tom Mccormick (413)320-1787 05/25/2023 455029 10304 SERVICE STREET BILLING STREET PROPOSED BY: 29 Hatfield Street 29 Hatfield Street Ray Dickson SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 3 DESCRIPTION QTY COST INCENTIVE TOTAL INSULATED BATH EXHAUST HOSE 1 $28.00 $21.00 $7.00 Provide labor and materials to install an insulated 4"exhaust hose to existing bathroom fan(s). Total: $10,188.82 Program Incentive: $7,942.58 Client Total: $2,246.24 I.DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the above work at the Client's Address in a professional manner and in accordance with the terms of this Contract II.PAYMENT Client agrees to pay the Contractor for the Work,the Client Share of the Contract Cost is payable to the Independent Installation Contractor(IIC)upon satisfactory completion of the Work.Client understands that they will not be required to pay the Program Incentive Share of the Contract cost.Changes to the individual line items and/or previous incentives may increase ordecrease the size of the Program Incentive Share. /�:eZkie, rd/ row Mccoxuick RISE Representative Client Signature Ralean Dickson 06-23-2023 Printed Name Date of Acceptance Document Ref:XAXTY-CXKKQ-CPWQF-DDZCD Page 3 of 6 Alft mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM Tom Mccormick owner of the property located at: (Owner's Name) 29 Hatfield Street Northampton (Property Street Address) (City) hereby authorize the Mass Save® Home Energy Services Program assigned Participating Contractor to act on my behalf and obtain a building permit to perform insulation and/or weatherization 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. rota Nlccorrucck Owner's Signature 06-23-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: c>"1 r)(I 2-7 Participating Contractor Date Document Ref:XAXTY-CXKKQ-CPWQF-DDZCD Page 4 of 6 ,, City of Northampton 4._ Nit` 3i.. µ Massachusetts x, r ;I DEPARTMENT OF BUILDING INSPECTIONS a ,. 212 Main Street • Municipal 'Building 'sf ;^ ,. ,a s Northampton, MA 01060 lY irs) Property Address: 10 .11re,(C4 Sf Contractor Name: t A rq1 P►'a i. o Address: 6M P ,. 1.. Roc City, State: ciyeKccr MG.. Phone: /~711_l .. "" Op " '7 Property Owner ,- Name: _o Y - (c- -vvv,4. IC Address: 2 7 ,k4 f-rzet 4 City, State: /VJ` 4 t,G 0 -DI,-. 6-" i, ri)S,,,.04,1C` (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 1 ,41 Date