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23A-020 (2) BP-2021-2298 13 PARK ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-020-001 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-2021-2298 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 11000 ENERGY PROTECTORS INC 101143 Const.Class: Exp.Date:06/16/2022 Use Group: Owner: LY, VANESSA & ANTONIA MAKOSKY Lot Size (sq.ft.) Zoning: URB Applicant: ENERGY PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6S62UB0G29826021 Spencer, MA 01562 ISSUED ON:12/1 5/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERIZATI ON 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: QcIrdiAra Fees Paid: $71.50 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner / .\ i' 'Z''- - - s / The Commonwealth of Massachusetts ocC 1 A 7 7! Board of Building Regulations and Standa; 2021 ! FOR/ Mt)lTCIPALTTY �'Y. Massachusetts State Building Code, 780 Cl4 [�r,, ! Building Permit Application To Construct,Repair,Renovate Orbinm�Ji . r ♦rived/liar 2011 4 n ., Q1ic • • One-or Two-Family Dwelling �ir,,,,� 0 This Sectio For Official Use Only Buildin Permit Nu ber: 6/9-A1.-� .A...22(11Date A plied: fi C-vNJ s5 it ili ZOZ I Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pr'perty�Address: 1.2 Assessors Map& Parcel Numbers �� icr d l.la 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❑ Zone: _ CheckOutsie fyesOFlood _one? Municipal 0 On site disposal system ❑ if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 'wah s s Ly Roce(vce, i MA- 0106a- Name(Print) City.State.ZIP t3 Pc SA- �S l -35v -at(4, 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 19'ecity: ft"S"1 1. f. _ Brief Description of Proposed W rk2: l vl S 0 i Cl i'e... P )C (S t C(' `" k I 1 i SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 1. ( 0 OD 1. Building Permit Fee:$ Indicate how fee is determined: i 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: j r61) Check N Check Amount:"�I' Cash Amount: 6. Total Project Cost: $L;t i 0"01) 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-101143 6/16/22 Joshua Dada License Number Expiration Date Nance of CSL Holder jJ List CSL Type(see below) 64 Paxton Rd No.and Street Type Description Spencer,MA 01562 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling Cite Town.State,ZIP M Masonn• RC Roofing Covering --- — — -- WS Window and Siding 774-253-0277 SF Solid Fuel Burning Appliances jdada79@hotmail.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 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 Issuance of the building permit. Signed Affidavit Attached? Yes kl,r 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. Print Ouner'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 gqi have access to the arbitration program or guaranty fund under M.U.L.c. 142A. Other important information on the HIC Program can be found at w1 .mass.s ov'oca Information on the Construction Supervisor License can be found at vvwyw.mass.eov-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 4'•' 0+c). Massachusetts -4+' '4,„ 1,.;> ( „ _ DEPARTMENT OF BUILDING INSPECTIONS !! 17) T �/ 212 Main Street • Municipal Building yi. -�pRR Northampton, MA 01060 '3't�y ;,<��` 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: o„ Li P cock-on (Lc Location of Facility: S Ipe\,C_e(` c J`".,Ae c) (-5-6 _ The debris will be transported by: Name of Hauler: hercjI 0 ry -Cf,..Y'S aAiC Signature of Applicant: 6_ Date: LZral Z( The Commonwealth of Massachusetts it il Department of Industrial Accidents _ i_ 1 Congress Street,Suite 100 =I:tf_ Boston,MA 02114-2017 . >'tnvw mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le tibiv 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): 1.1=1 I am a employer with �� employees(full and/or part-time).* 7. 0 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.] 9. 0 Demolition ?.01 am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 0 Building addition 4.01 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 11.0 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. 13.0ROOf 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.©Other Insulation 152,§1(4).and we have no employees.[No workers'comp.insurance required.] *An)applicant that checks box=1 must also fill out the section below showing their workers'compensation police information. '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. 1 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: % 3 Pci r k' c t City/State/Zip: P IUf e vv C C- I /44, 0106 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 Ivell 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 correct. Signature: 21-14/1-\--1 Cl-A---- Date: t '- --.1 'f " t Phone#: r-nti' a.5-3, -0a-77 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#: AC'C7Rtis CERTIFICATE OF LIABILITY INSURANCE GATE(MM1D0lYYYY) bek,...,,, 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 Coonan Insurance Agency,Inc. PHONe Exit, 508-987.7122 I A,I44); 508-87-7152 ADD �eaa: 267 Main Street Nina@coonanlnsurance.com Oxford,MA 01540 INSURERS AFFORDING COVERAGE NAIL 0 INSURER A: AIX Specialty INSURED INSURER B: Safety Energy Protectors,Inc. INSURER C: Century Surety Insurance 64 Paxton Road INSURER D: Spencer,MA 01582 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 CLAIMSS..ItIR rp� TYPE OF INSURANCE ~ OWIR o aD WVD POLICY NUMBIR AMNYI ( 1 /YYYYYI LEMTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TOTrENTbD 100,000 CLAIMS-MADE 0OCCUR PREMISES/Ea aarrenoo) $ MED EXP(Any on.person) $ 5,000 a —_ y LIN-H714840-00 08/31/21 08/31/22 PERSONAL a ADV INJURY i 1,000,000 LOC GENERAL AGGREGATE $ 2,000,000 X POLICY(�iEN L AGCRE TE LIMIT AP(PL�ES PER PRODUCTS-COMP/OP AGO $ 2,000,000 JECDT ►_1 OTHER: S AUTOMGBIIa LIABILITY (Ea sockien ICOMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per parson) $ B — AUTOS ONLY OWNED SCHEDULED 6236519 12/23/20 12/23121 BODILY INJURY(Per accident) $ X AUTOS y HIUTO BpOROPERTY DAMAGE REDS ONLY X AUTOS ONLY IPer soddentl i A i X UMBRELLA LIAI X OCCUR EACH OCCURRENCE i 3,000,000 — C EXCESS LIAR CLAIMS-MADE y CCP100S749 08/31/21 08/31/22 AGGREGATE $ 3,000,000 DED i RETENTION S 7 p i WORKERS COMPENSATION 1 S N- ATUTE I ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEri N 1 A E.L.EACH ACCIDENT , $ (Mandatory Mandl to y O In FFICER/MEMBER EXCLUDED? I ' E.L.DISEASE•EA EMPLOYEE $ M y s describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached N more space Is required) Workers Compensation Insurance certificate to follow under'operate 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.sta.200 AUTHORIZED REPRESENTATIVE Worcester,MA 01808 I (" 'j'Ie015ACOD COR RA ON. All rgghts ed. ACORD 25(2018/03) The ACORD name and logo are registered marks of ACORD ACO D CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD/YYYY) ‘41..-.-'- 08/31/2021 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: ff the certificate holder Is an ADDITIONAL INSURED, the policy(Ies) 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 Arroyo COONAN INSURANCE AGENCY A L�ek,c o_ _ (5081,987-7122 • ,pis): Amens Nina@coonaninsurance.com 267 MAIN ST IN 8URERIS)AFFOROIN(COVERAGE NAIC/ OXFORD MA 01540 INSURER A: ACE AMERICAN INSURANCE CO 22687 INSURED INSURER B: ENERGY PROTECTOR INC INSURER C: ----- -- -.._..-- ------------------- INSURER 0: 64 PAXTON RD INSURER E SPENCER MA 01562 INSURER F: COVERAGES CERTIFICATE NUMBER: 890758 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 INSURANCE — `Xt56C"SO13fF- -_--- POLI1CY EFF POL Y EXP --- 1TRMID WVD POLICY NUMBER IMM/DD/YYYY) (MM/DDITYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I S 'B70AGE-TO RENTED -- I 'CLAIMS-MADE OCCUR .P_RELq$E_4S€@.Mut10041) $ ___-- MED EXP(Any one Eason) S-- N/A PERSONAL 6 ADV INJURY $ GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY — —. _. J JECT LOC PRODUCTS•COMP/OP AGO S OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE Lit.'JT 1 ANY AUTO BODILY INJURY(Par person) S A OWNED i SCHEDULED BODILY INJURY(Per accident) $ AUTOS 1-7TOS F_ AUTOS N/A _ —_ NON-OWNED PROPERTY DAMAGE S ^' HIRED AUTOS ` AUTOS (_Per accidenli ( $ UMBRELLA LIAR OCCUR : EACH OCCURRENCE $ EXCESS LIAR ~ i .CLAIMS-MADE' N/A AGGREGATE $ 1 ' DED ,ftETENTIOp S $ WORKERS COMPENSATION } X PER I 1 E R•'AND EMPLOYERS'LIABILITY Y 1 N ,. ANYPROPRIETORrPARTNER EXECUTIVE E.L.EACH ACCIDENT S 500,000 A OFFICERrMEMBEREXCLUDEDy NIA N/A NIA 6S62UBOG29826021 09/01/2021 09/01/2022 '----' ------ - —_, (Mandatory k1 NH) E.L.DISEASE•EA EMPLOYEE $ 500,000 If yes.describe under ._..------------------------.—_ ..._._ DESCRIPTION OF OPERATIONS below I E.L.DISEASE•POLICY LIMIT $ 500,000 I NiA DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddRlonai 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 dale on the above policy precedes the issue dale 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.rnass.gov4wd/vvorkers-cornpensationlinvestigations/. Sole proprietor has no:elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 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.Crowley,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 • f j 1. k ..IA. 'Q ;`'�es-iy LY , ., • • Office of Consumer Affaf's and Buses Regtdetkn 1000 Weehington eilmet M Suite 710 Boston, Massachusetts 02118 Hors Improvement Contractor Registration Wan MA O1 Update Adams and Ibtam Oat oft domsemalailliser ape HIM • =1"1102111:Ittri* rein ION Warldmells!NW NM TO INISO Y PRoTSCIORS uro., rem NM mil JOSHUA MA ItaWVA%titi2 iframetigAine Holt vMid*thole•ram DocuSgn Envelope ID:3CE0109A-1 EE3-4889.9FEA-73481 F4CCOC8 RISE ENGINIFRING OWNER AUTHORIZATION FORM I _ Vanessa Ly (Owner's Name) owner of the property located at: 13 Park Street (Property Address) Florence, MA 01062 (Property Address) Zi5 hereby authorize �� �, �?"✓�r,c 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. r—poeuSpned by .JM& Y.a. (11 Oiitr'e 'Slgn�ibre 11/2/2021 I 2:44 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 Canton, MA 02021 1339-502-6335 www.RlSEengineering.com City of Northampton o, ; Y,, ..: ' 1' Massachusetts �w *" `e. A i. A w ; 0 �: 1G �;,r DEPARTMENT OF BUILDING INSPECTIONS S �' S 7' y ;0'1'ft,-, 212 Main Street • Municipal Building tid `''. Northampton, MA 01060 �W ��� Property Address: i3 \-a,k 'if- Contractor (� Name: be q Yc..) r o c Address: CH Y,,c.1.,ti CO City, State: pt .�<r, Mr.. Di :, l Phone: 1-jti-- s`2-- JD f) — --Property Owner t ) I Name: VC rs f,:`1-A-- h0-i Address. 13 \ Cr _ 5 - City, State: { kc-e y,,,L. I, C.r(('jj ),,,L,•.,r (contractor)attest and affirm that the building I intend to insulate does ndt 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 r 0, �, ' Date PI q-/.. !