304 Spring St KTProperty Address:
Contractor
City of Northampton
Massachusetts
DEPARTM TT OF BUILDING rxsPECTXONs
212 Main Street • Municipal Building
Northampton, MA 01050
Name: •;
Address: at+
City, State: '
Phone: LY 1
Property Owner
Name:
Address:
City, Stater -��� , r A
I, fYIL Sie!- LL&.r,ad-icontractor) attest and affirm that to the hest of my knowledge
the building I intend to insulate does norhave 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{
Date