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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