Untitled 244-246 NORTH ST BP-2017-0704
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 145 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category:INSULATION BUILDING PERMIT
Permit# BP-2017-0704
Project# JS-2017-001159
Est.Cost:$7977.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sq.ft.): 17206.20 Owner: Marta P Martinez
Zoning:URB(100)/ Applicant: POTENTIAL ENERGY LLC
AT: 244 -246 NORTH ST
Applicant Address: Phone: Insurance:
4D QUEEN TERR (860) 620-4433 WC
SOUTHINGTONCT06489 ISSUED ON:11/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:EXT WALL INSULATION, AIR SEALING,
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: O1: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 11/22/20160:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0704
APPLICANT/CONTACT PERSON POTENTIAL ENERGY ILC
ADDRESS/PHONE 4D QUEEN TEAR SOUTHINGTON M0)6204433
PROPERTY LOCATION 244-246 NORTH ST
MAP 25A PARCEL 145 001 ZONE URB(1001/
'PHIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT \
Fee Paid
Building Permit Filled outVANI
Fee Paid
TypedConstruction: EXT WALL INS 1QN,AIR SEALING, WEATHERIZATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Awned Statement or License 106184
3 sets of Plans/Plot Plan
THE POLL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR TION PRESENTED:
pproved_ Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §_
Finding Special Permit Variance'
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
.aelay
/ //; A7
Si••. eofBml.r L{ ffi "7" Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances arc granted only to those applicants who meet the strict standards of MGL 40A.Contact Office-of
Planning&Development for more information,
25 — 416r
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
1 SOU 212 Main Street Sewer/Septic Availability
1B� Room 100 Water/Well Availability
(,„o
pton, MA
Sets of
pr�.OFBfP Pr"'''�nrea phone 413-587-12401Fax 413-587- 1272 Pl0 ot/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:' 1This section to be completed by office
2 LI LI to Z y kn H C kJ F'1 St . Map Lot Unit
Y V>>ro1 r / NA A MOO Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MaVte\ Mckrt-in 24L Nt;vth ,St ., N6vHVamptcir ,
Name(Print) Cu�Lrgl t �b - y32Z ilin d�r s. MA Di
i D(G )se atFft)✓ nnTelephone
Signature
2.2 Authorized Agent:
NIChn1as Meister 4o G; L-Dn SGUdhcto . CT
Name(Print) Current Mailing Address: ( -,9
C
\i)() -
1,`W j t iII
Signature i I y-_r+-�' li)( J4.2AL;( )
Telephone 1L
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building
$1) /11 (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 vy //'
6. Total= (1 +2+3+4+5) $7) C 17 -- Check Number 7/!O r�((O
This Section For Official Use Only
Budding Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Cate
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 fillal in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage ro
Open Space Footage .�
(Lot area minus bldg&paved
parking)
h of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document N
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW a YES O
IF YES, has a permit been or need to he obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO C
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and Location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES (3 NO srsizz
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 1 1
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs SDI Decks ID Siding[D] Other i
Brief wok: --bat.6ion 1. 1 Proposed
Work: al ea V nc� 11iQCO'YiCr IOtth
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing, complete the following: BVI%4
a. Use of building One Family Two Family Other
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
1. , as Owner of the subject
property Cchk (f "nA+h
. -iu v1 /thereby authorize
to act on my behaI(,jn all matters relative to work authorized by this building permit application.
Signature of Owner Dale
r
I, NIOneiCk \A Qicter/ PeRint (,l �1��YD�; LLC asOwner/Authorized
Agent hereby declare that the statement and information on the foregoing app cAj9n Are true and accurate,to the best of my knowledge
and belief
Signed under the pains and penalties of perjury.
NichnIm MP, -;Y
Print Name
C II / IV/i �
Signature of Owner/Agent D to
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su(pervis�or:/� p U �/ Not Applicable
Name of License Holder: N iChtI RS MaH € CSC - kcAc
License Number
14 -) 6UeeVI )YY. ) SUythl11(3-D(11QT OiPl-iBq 142-72_01gq
Address Expiration Date
0 -9CM 421010
Signature _ --_. Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Po�P�tyc l 'Iraq y ( NichoLIS Mefs± t) 1q � 01
Company Name Registration Number
— SR V11 C& CSL- x/ 2-82012
AddressExpiration Date
nn
Telephone /lAtr
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 ❑ No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does nut possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling.attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor sour presence on the job site will he required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated.you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Amine Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature _ _ _
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 2LIq 24� Nu'rih Sty Ncyi Yomr or1MAcion
The debris will be transported by: FCttVTI CU ntVT,i
The debris will be received by: F'TH+,YSD'Yl _Y;t€yryISeS 5YI`t)IlCT
Building permit number: �"
Name of Permit Applicant N \Ch(`\C6 Mic I it (or Vf I/1A Of N r-a_
IV'1 (' Hi
Date Signature of Permit Applicant
The Commonwealth of Massachusetts-
"
assachusetts
t
.� - Department of Industrial Accidents
_/ Office of Investigations._� 1 Congress Street, Suite 100
_ ` Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leuibly
g ): POT a� 1�4rwi LLC /'
Name Busincas%Or ani>ffiIoMndividual �,1- ��� L�I��I��� �'�L'_J I
•
Address: y 1 E MG I yi, Ctveet
---- -- — -
Ci /State/Zi : > i �LT_' 1, _(Ui Phone #: BUJ--iIi 1��1_,fl---
Are ou an employer?Check the appropriate box:
1. I am a employer with
4. ❑ I am a general contractor and I of project(required):
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. I❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance.:
9, ❑ Building addition
[No workers' comp, insurance
required.] 5. ❑ We arca corporation and its 10,0 Electrical repairs 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.A Other ]I l�a (�-h (,'{rl
comp. insurance required.]
'Any applicant that checks box 41 must also fill out de section below showing their workers'compensation policy information.
I Homeowner.who submit this affidavit indicating they are doing all work and then himoutside contractors must submit a new affidavit indicating such.
k tontmelors that check this box tours attached an additional sheet shoving the marc of the wb<ontracton and shoe whether or not those entities have
employees, lithe sub-contractors have employees,they must provide their workers comp.policy number.
I am an employer that is providing workers'compensation Insurancefor my employees. Below is the policy andjob site
infornmlion.
Insurance Company Name: -�oaroCIA 12(6u]'Rr toe GVCur __.
Policy 4 or Self-ins. die..LI
Z.I ,�1 /L 0jvC-_,<77 , f Expiration Date: Qw77� r2r.v i I t,s /�
Job Site Address_%`I Ll dt 21Wt (vCllb St-. City/Slate/Zip: " ' 4 en or11y 1A
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). C' CI IC C
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. Re advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cenijjr uncljr the pains and penalties of perjury that the information provided above is true and correct
C c==.- i _cc:
-1
Signature: -=- --' Date'
Shunt: U(C)— L3Ot-42042
Official use only. Do not write In This area,to he completed by city or town official,
City or Town: - Permit/License ii
Issuing Authority(circle one):
1.Board of Health 2.BuildingDepartment 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone a:
Owner Authorization Form
Marta Martinez fr
(Owner's Name)
Owner of the property located at:
244 &246 North Street
(Property Address)
Northampton. MA 01060
(Property Address)
hereby authorize Potential Energy, LLC , a certified Mass Save Home
Performance Contractor, to act on my behalf to obtain a building permit and to
perform work on my property.
/
(Owner's Signature)
10-11-16
(Date)
ClienUt 82429 MEISTNIC
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE IMMODNYYYI
7/27/2076
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT FICATE 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 policylies)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement.A statement onthis certificate does not confer rights to the
certln cafe holder in lieu of such endorsementlsl.
PRODUCER NAMEAOf Audrey Lamontagne
Fradette Carlson Agency E860583-0943 �FnR 860-585-0038
San
A
PG Box 2456 E-MAao, a tA<,not
ooR m alamontagne6starshep.com
Bristol,CT 06011-2456
INSURER(S)AFFORDING COVERAGE NAIL*
860 583-0943
INSURER A:Hartford Ins Group 19682
INSURED —� '--
Nicholas Meister DBA WSURm e:
Potential Energy LLC INSURER c:
4 D Queen Terrace INSURER :
Southington,CT 06489 INSURER E:
INSURE: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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSJED 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.
MSR ADDL SUER POLICY EFF POLICY EXP
R - - -
TYPEOFINSURPNCE INSR VNO POLICY NUMBER IMMmORYVVI LMMIODflYYVI nurs
A X COMMERCIAL GENERAL aewTv X 02SBMRB0509 08/052016 08/05/2017 r-33.ciio F E .E $2,000,000
ILAIMS MALE FX1 rvL .N P r1 reecer 13000,000
Ye re ER recA $10,000
Pe.
a+LN Ir.I 2,000,000
Ty_TE EAT :Ir5PFF NE .... ._._!4,000,000
EDLIC1 a ,AE,..-,r,_ $4,000,000
OTHER
A AUTOMOBILE LIABILITY 02SBMRBOSO908/0512016 08/05/2017 a�jer>, -FLIM!: $2,000,000
INTER,(Per:Risen 1 f
jotyII 1 I
+aper asuem
_ ..o A TJti
I$
A X UMBRELLA LIAB X oc::.a X 02SBMRB0509 08/051201608105/2017- Hoc�PNEr�E x$1,000000____
EXCESS LAE elbee.,.ADE TELPECATF 161,000,000
Ierr r X FriENTr_ry 670,000 ,s
A ANOWORKERS C LI anon 02WECCRO745 08/05/2016 08I05Y2017 X '
AND EMPLOYERS'OLIABILITY ylar T Y IFF
OFrCER rT R R UCP gum= 4500.000
(Mandatory
R n NHI WCEO"+ �� NIA
IMasdw.y ire NHI a clsE- E-_,ErnFLo,EE s500A00
ires.Lee L Jr
.n HAL PA:lo.l_twee aHIAFEEF ,. Jr•n 6500$000
DESCRIPTION OF OPERA-ROHS(LOCATIONS IVEHCLES(ACORN.mt Additional Remarks Sche&,le,may be attached if more space is required)
Columbia Gas of Ma is an additional insured on the General Liability and Umbrella Liability Coverage per
written contract or agreement.
CERTIFICATE HOLDER CANCELLATION
Columbia Gas of Ma SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
4 Technology Drive Su Re 250 ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough,MA 01581
AUTHORIZED REPRESENTATIVE /��
/� Ce-C�
®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 2512014/01) 1 of The ACORD name and logo are registered marks of ACORD
#S843449/M843422 FCAJL
t , ci11C' oJI1pro ll t[/P17��>l C /7�fl.iJ(Y('flflJP��.i
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 179401
Type: Individual
Expiration: 7/28/2018 TN* 419291
NICHOLAS MEISTER
NICHOLAS MEISTER
4 D QUEEN TERRACE -
SOUTHINGTON, CT 06489 - --- - -
Update Address and return card.Mark reason for change.
imams r' Renewal ❑ Employment = Lost Card
SCA 1 to
�,
t //A /- /L -.,%re.,n;
Office of Consumer Affairs&Rosiness Regulation License or registration valid for individual use only
- :-;' before the expirationdate. If found return to:
' ap -1 HOME IMPROVEMENT
TYpo CONTRACTOR
I.rzRegistration: 179401Office of Consumer Affairs and Business Regulation
"
- Expiration: 7/28/2018 IndividualB Park Plaxa-Suite 5170
.:'.' Boston,MA 116
NICHOLAS MEISTER
NICHOLAS MEISTER
4D QUEEN TERRACE \_ -_—
SOUTHINGTON,CT 06489 U� r -- _- ---
uJersecrcbry Not valid without signature
..Massae''users - eaar e _.,,,
3oara of 3L ug .egu a.s,s aro 3:a.-dards
('maven SupezRip'. 1 ; 1
_CL CSFA-106184
NICHOLAS MEISTER ■
4D QUEEN TERRACE
Southington CT 06489
%.G..JI,bC¢.. _ _ ._
.. e- 04/27/2019
Customer ID 423241 fp 44t479 Customer Name Luis Pizha Lok * Address)-44 /yry(i £ . /vlfJryiJya�r,
Logan Vincent-Sutherland
KNOB & TUBE WIRING
During the Energy Assessment of your home,indications of knob and tube"wiring were found.This old style
of wiring involves individual wires that are run through walls and ceilings in a house, with ceramic"knobs"and
"tubes"to prevent contact with wood framing.The knob and tube wiring that has been noted may or may not
a/giear to be attire. Even if the observed wiring appears to be inactive, there may still be active knob and tube
circuits hidden inside walls or other inaccessible areas of the house.
Program guidelines require that you have the home checked by a licensed electrician and certified as being free
of all active knob& tube wiring,beforeinsulation and/or air sealing work can be done.Your electrician should
fill out and submit a copy of this document to Honeywell in order to verify the absence or inactivity of the knob
and tube wiring in the areas of your home where we are proposing insulation to be installed.Due to the
liability involved in signing such a form,we suggest you show or describe this form to your electrician
before hiring him to inspect your home to be sure he/she is willing to sign it.
Your home could benefit from insulation andtor air sealing in the:
X Attic X Walls X Basement
**Only after this certification is received by Itoneywell can a
Job be released to a contractor,for energy saving insulation and/or air sealing work. **
Electrician's Certification
(This form is invalid when any qualifications or alterations are added.)
Company Name&Address &CI
4S Linstec �{ , I e 1 t .�( SIA ( ma&
Electrician's Name 1a Alt , u _ ,/ ' License ft c`�O3I t1 " !-t
I have performed an inspection of the wiring at the home of:
,Uaitct MQ(+II tt at r , IY }t „}1l inil /7
(Owner's Name) (Street Address) (City)
Upon completion of my inspection I have found that there is no active knob and tube wiring in the area(s)
noted below. // �,,,/�'�/� ,�
c'2� JWalls `:"Iflasement ^r'
Electrician's Signature , ddi Date
7 _