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31B-108 (6)
BP-2023-1017 19 BRIGHT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-108-001 CITY OF NORTHAMVIPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-1017 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 10000 SUPERIOR INSULA ION 106237 Const.Class: Exp.Date: 06/15/202. KATZ MICHAEL D&CATHERINE I&J A KATZ- Use Group: Owner: BR• .•LINI &J D KATZ Lot Size (sq.ft.) KATZ ICHAEL D& CATHERINE I&J A KATZ- Zoning: URC Applicant: BR I'LINT &J D KATZ Applicant Address Phone: Insurance: 19 BRIGHT ST NORTHAMPTON, MA 01060 ISSUED ON: 08/01/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI ON POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. I Building Inspector Underground: Sere ice: 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 NO HAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: i • r It 52 - (INT Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax (413)587-1272 Office of the Building Commissi ner 5c#ri EtlAm.. 6-1 �� q.A l �• 0 0�i u'� N.�G v1LT 19Cn The Commonwealth of Massachusetts 9 ? '.. Board of Building Regulations and Standar'LEA �ts)O Q ••R Massachusetts State Building Code, 780 MR2sq C 'ALITY _ 9 Building Permit Application To Construct,Repair,Ren ate Or N 's• . R' '.ed Mar 2011 One-or Two-Family Dwelling 2s This Section For Official Use Only Building Permit Number: t 71' d 3 t /0/7 Date Alied: Kr &oss ,2P 8 3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1,l�ro�p�rty Mess;. t 1.2 Assessors Map&Parcel Numbers GG��. ��("�lrYr 3113 lot l 1.la Is thistai accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: IraJ Zoning District Proposed�se Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) h 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 Informationna 1.8 Sewage Disposal System:Vl Public❑ Private 0 Zone: _ Outside Flood Zo Municipal❑ On site disposal systtte 1Im' ❑ �1 Checkdif yes❑ 1 SECTION 2: PROPERTY OWNERSHIP' fe0 d. ^ klor Mitt Name Print) Ci ,State,ZIP-�� No.and Str Telep one 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 Specifygt+lu Brief DescdWTA tion of Proposed Work2: Mt IS —1cXS w1en ( . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building • $ l O O� 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 1 ' ❑Standard City/Town Application Fee ❑Total Project Cost3i(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: q Check No.� ( . ck Amount: L 6.Total Project Cost: $ ID I DO u 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I O -12+ 5 �,,,_� A� License IN(umber Ex ration ate Nam o L Holder rl I n �rit �� I ,^ List CSL Type(see below) l!o�and �tre�et(� r 1 Type Description r i 4 dd �Q [ Olg U Unrestricted(Buildings up to 35,000 cu.ft.) ity/Town,l (Stal Ite,1ZCIP/` [�� R i Restricted 1&2 Family Dwelling M Masonry Cra3@ S( �pelci Yry 1ck . M RC Roofing Covering vt�lit V ,I 'l1lfJ >•w WS Window and Siding rr�' ) SF Solid Fuel Burning Appliances 01-515— ' 5Zu I i Insulation Telephone Email address D I Demolition Registered Home Impro vement Contractor(HIC) p � I� I 1 E�f-t 5 lc\ 5�`�� S HIC Registration Exp ationto 4an ame or H 'RgraLt Name ` ,� apeeTI� u °Z � Email address 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 �J No .❑ 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 SC . a-+Qa1 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 con ' ed in this a lication is true and accurate to the best of my knowledge and understanding. �/ z�iz3 PrinWI or thorized Agent's Name(Electronic Signature) / Da 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 a-MAMY, 4 " ._ sic a Massachusetts _ '<< ,r 4--. , y *.k t d�.I..I ; •• Si DEPARTMENT OF BUILDING INSPECTIONS s f .. r'+ 212 Main Street to Municipal Building Jti O� j Yr Northampton, MA 01060 �SHn, 3,0�^p 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: Hi?) EnterpOs-c___, Ln d �j / 4 The debris will be transported by: Name of Hauler: r laii. n Signature of Applicant: Date: `f l2 Zj The Commonwealth of Massachusetts Department of Industrial Accidents c ii.=. 1�= l Office of Investigations _7111— 600 Washington Street ,.: Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/C 1 ntractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Superior Insulation, LL Address: 140 Point Judith Rd,A7 City/State/Zip: Narragansett, RI 02882 Phone #: 401-515-4524 Are you an employer?Check the appropriate box: Type of project(required): 1.© I am a employer with 12 4. ❑ I am a general contractor. d I employees(full and/or part-time).* have hired the sub-contrac,ors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached shee 1 7. ❑ Remodeling ship and have no employees These sub-contractors hay. 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance.: required.] 5. ❑ We are a corporation and i s 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised the 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per M I 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other Insulate comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'coin -nation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside c•ntractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-co •actors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy umber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Beacon Mutual Policy#or Self-ins.Lic.#: 67872 Expiration Date: 8/2/23 Job Site Address: IQ j S -ri*' City/State/Zip: No r�1' p+b( , KA 6 Attach a copy of the worke ' ompensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can 1 ad to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties ' 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 state ent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify underi the pains and penalties of perjury that the information provided above is true and correct. Signature: /1G 1� � `C2, � Date: 5l 2 J 777777 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#: �.....41 SUPEINS-01 MLONGOLUCCO A�� CERTIFICATE OF LIABILITY INSURANCE Wr DATE(MM/DDIYYYY) 7/14/2023 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: Mansfield Insurance Agency Inc. PHONE FAx 115 High Street (ac,No,Est):(401)596-2096 1 vvc,No(401)348-2060 Westerly,RI02891 E-MAIL ADDRESS: l:info/,,�mansfieldins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Employers Mutual Casualty(EMC)Company 21415 INSURED INSURER B:Beacon Mutual Insurance Co. 30325 Superior Insulation LLC INSURER C:Evanston Insurance Company Michael O'Connor 140 Point Judith Road,Unit A7 INSURER D: Narragansett,RI 02882 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYYI IMMIDDIYYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X X 6D23763 8/2/2023 8/2/2024 °REMISES(OEa occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC 2,000,000 JECT PRODUCTS-COMP/OP AGG $ OTHER:General Aggregate A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO X X 6B23763 8/2/2023 8/2/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTEO�S ONLY - AUTOS SSWN BODILYO INJURYp (Per accident) $ AUTOS ONLY _ AUUTOS ONLY (Per accident)AMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE X X 6N23763 8/2/2023 8/2/2024 AGGREGATE $ DED X RETENTION$ 10,000 $ 5,000,000 B AND ERKMPLOYERS'LIABILIITY X STATUTE EER H ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N X 67872 8/2/2023 8/2/2024 500,000 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Pollution Liability x x CPLMOL118083 7/6/2023 7/6/2024 Per Occurrence 250,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101 Additional Remarks Schedule,may be attached if more space is required) Residential Insulation Contractor-14B Enterprise Lane,Smithfield,RI 02917 Pollution Liability Aggregate Limit$500,000 National Grid and all divisions are named as additional insured per written contract or agreement.Waiver of subrogation is provided in favor of National Grid and all divisions per written contract or agreement. Pollution Liability includes mold CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Rd Waltham,MA 02451 AUTHORIZED REPRESENTATIVE 'kart lit. 4ea45 I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts ® Division of Occupational Licensure Board of Building Regulations and Standards Constructio upel r Specialty CSSL-106237 _. 15itpires:06/15/2025 KYLE L LEDI C 3750 DIAMONb HILL RD CUMBERLANO RI 02E64 Commissioner dia i . Construction Supervisor Specialty Restricted to: CSSL-IC-Insulation Contractor Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govldpl THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affair and Business Regulation 1000 Washing�wt - Suite 710 Boston, Massachusetts 02118 Home Improvement s';• • ctor Re istration III air=47---.1 ,-. i MIME `..'' Type: Supplement Card (.." aslr tw SUPERIOR INSULATION LLC. '"" 1,1 egistration: 175445 140 POINT JUDITH RD UNIT A7 :+ , a � E piration. 05/12/2025 NARRAGANSETT, RI 02882ipp , w .ram �� \Q iii 1.1 I at ;-V \\ +v r -� Z / f1Ai '-- � '��e Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs & Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE;_SAllin elitCard Office of Consumer Affairs and Business Regulation Reg istration+ Expiration 1000 Washington Street -Suite 710 175445 05/1212025 Boston, MA 02118 SUPERIOR INSULATION LLC. _ - 4 .. --'//(/) ) KYLE LEDUC w Y ��R;--� 140 POINT JUDITH RD kiNIT a. 'L L. NARRAGANSETT, RI 02882ti,, � Undersecretary Not valid without signature WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT N WORK ORDER Catherine Katz (413)559-9551 07/11/2023 542563 10302 SERVICE STREET BILLING STREET PROPOSED BY: 19 Bright Street 19 Bright Street Seth Main SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP 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°/0 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. KNOB&TUBE WIRING SIGN-OFF(FSC) 1 $250.00 $250.00 The wiring in the areas weatherization work is proposed will be reviewed by a licensed electrician to determine if there is any existing live knob&tube wiring. HOME AIR SEALING 10 $1,065.90 $1,065.90 Seal areas of your home against wasteful,excessive air leakage. 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.) WEATHERSTRIP DOOR 3 $108.96 $108.96 Provide labor and materials to install Q-Ion weatherstripping to door(s)to restrict air leakage. DOOR SWEEP 3 $88.98 $88.98 Provide labor and materials to install a doorsweep to restrict air leakage. ATTIC DAMMING 30 $83.40 $62.55 $20.85 Provide labor and materials to install an approved damming material in the attic ATTIC FLAT-10"OPEN R-37 CELLULOSE 720 $1,699.20 $1,274.40 $424.80 Provide labor and materials to install a 10"layer of R-37 Class I Cellulose to open attic space. SLOPE-6" DENSE R-19 CELLULOSE 164 $500.20 $375.15 $125.05 Provide labor and materials to install a 6"layer of R-19 Class I Cellulose to sloped ceiling area. HATCH-INSULATE RIGID BOARD 1 $53.96 $40.47 $13.49 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 $103.05 $77.29 $25.76 Provide labor and materials to insulate the back of a door with 2"rigid insulation board. Document Ref:ZZZFG-EDT2T-ZLS2X-SP9OC Page 2 of 4 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENTS WORK ORDER Catherine Katz (413) 559-9551 07/11/2023 542563 10302 SERVICE STREET BILLING STREET PROPOSED BY: 19 Bright Street 19 Bright Street Seth Main SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, Ma 01060 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL WALLS-VINYL SIDED 4" 1,848 $5,636.40 $4,227.30 $1,409.10 Furnish and install blown in Class I Cellulose to vinyl-sided exterior walls. 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 104 $317.20 $237.90 $79.30 Provide labor and materials to install R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. ASBESTOS PRECAUTION A blower door diagnostic test will not be conducted at your home, as a precaution for the presense of steam heating (past or present)that was most likely insulated with asbestos. Total: $9,907.25 Program Incentive: $7,808.90 Client Total: $2,098.35 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 incre se or decrease the size of the Program Incentive Share. �a CailIllie Kate RISE Representative Client Signature Seth Main 07-11 2o23 Printed Name Date of Acceptance Document Ref:ZZZFG-EDT2T-ZLS2X-SP9OC Page 3 of 4 r mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Catherine Katz owner of the property located at: (Owner's Name) 19 Bright 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. Ca/4oiice Kale Owner's Signature 07-11-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor t he above referenced project: SVI I o� Partici ting Contractor Date Document Ref:ZZZFG-EDT2T-ZLS2X-SP9OC Page 1 of 4 , . City of Northampton . t ,-4 ''t Massachusetts `: DEPARTMENT OF BUILDING INSPECTIONS y ��`+ 212 Main Street • Municipal Building9 ; \` . Northampton, MA 01060 kilt i'"% Property Address: \ q Bnr "e.(:)..± Contractor K ,� Name: `1L Address: cr'()rn 2ft Ln 1 1 ir0 City, State: __L ''ktri \60 �} 1 Phone: Li 0 1 �,) 1 5 i 5 2_- 4 Property Name: Owner rtri VIC <t x 1 Address: I q gram- y City, State: , W\ xv1f '-n i1 / tA n I, .C. \---€34-AC, (contractor)attest and affirm that the building I intend to insulat es not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provide he property owner with a copy of this affidavit. Contractor signature /4, Date I 25