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32A-090 BP-2024-0264 11 GRAVES AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-090-001 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-2024-0264 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 19446 STEVEN COLLINS 106221 Const.Class: Exp.Date: 06/30/2025 Use Group: Owner: TRUSTEE DAVIES, DIANA JO Lot Size (sq.ft.) Zoning: URC Applicant: J&L ENERGY INC Applicant Address Phone: Insurance: 42 SARGENT ST (617)259-4825 WC 9098987 WINTHROP, MA 02152 ISSUED ON: 03/13/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERI ZATI 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: 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 NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $130.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 3- Z. AC r` �UIL T atl� The Commonwealth of M sachusetts 4) \< . ,:uto Board of Building Regulatio anctStandards // FOR Massachusetts State Building Code, 786• Mtt c0c,„ MUNICIPALITY ' USE Building Permit Application To Construct, Repair, Renovate O Demolish,a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: �%73 - Gib`! ! Date Applied: 4U(1.4Zs // 3-1 3-ZOzy Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 11 & 13 Graves Ave. Northampton, MA 01060 1.1 a Is this an accepted street?yes x 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 El Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Diana Davies Northampton, MA 01060 Name(Print) City, State,ZIP 11 & 13 Graves Ave. 508-237-1654 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 l Specify:Weatherization Brief Description of Proposed Work2: Mass Save insulation and air sealing. No structural changes. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 19446.90 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) Total All Fee :$ Check No.t{N Check Amou: { Cash Amount: 6.Total Project Cost: $ 19446.90 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 06/30/2025 CSSL-106221 Steven Collins-J & L Energy License Number Expiration Date Name of CSL Holder 42 Sargent Street List CSL Type(see below) I No.and Street Type Description Winthrop,MA 02152 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 617-259-4825 Permits.jandlenergy@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 202555 07/13/2025 Steven Collins-J&L Energy HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 42 Sargent Street Permits.jandlenergy@gmail.com No.and Street Email address Winthrop.MA 02152 617-259.4825 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 ® 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 Steven Collins to act on my behalf,in all matters relative to work authorized by this building permit application. Diana Davies 'Lw— cf.„36,v!h 3/6/2024 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. Steven Collins L. ���IJ�"� 3/6/2024 Print Owner'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 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<N�' > , Massachusetts << c. d -1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building '•� Northampton, MA 01060 ssNry 3;-j`,�o 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: 15 Marshall St.Ste.N,Canton,MA 02021 The debris will be transported by: Name of Hauler: J&L Energy Signature of Applicant: Steven Collins bj(L Date: 3/6/2024 Fr WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT Y WORK ORDER Diana Davies (508)237-1654 11/07/2023 551272 10302 SERVICE STREET BILLING STREET PROPOSED BY 11 Graves Avenue 13 Graves Ave Ray Dickson SERVICE CRY,STATE,ZP BILUNG CITY,STATE,ZP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 1 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE: RENTERS For eligible measures,the Mass Save Program offers a renters incentive of 100%off insulation,air sealing,and duct sealing measures.To be eligible for the renter incentive,the unit must be rented year-round,seasonal rentals are not eligible. KNOB&TUBE WIRING We have identified the potential existence of knob&tube wiring in your D.D. (initials) home.The following contract is not valid unless accompanied by the Weatherization Barrier Incentive form,signed by your licensed electrician.Work will not proceed until we receive a copy of this form. VERMICULITE HAZARD MUST MITIGATE We have noted there is vermiculite insulation in your home which D.D. (initials) might contain asbestos fibers,a known carcinogen.Weatherization work cannot proceed until the vermiculite is properly mitigated. HOME AIR SEALING 6 $639.54 $639.54 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 FLAT-5"FLOORED R-16 DENSE CELLULOSE 1,600 $4,256.00 $4,256.00 Provide labor and materials to install a 5"layer of R-16 Class I Cellulose to floored attic space. DOOR-INSULATE RIGID BOARD 1 $103.05 $103.05 Provide labor and materials to insulate the back of a door with 2"rigid insulation board. SHEATHING ACCESS 3 $138.72 $138.72 Provide labor and materials to make an access opening from one attic area to another by cutting a passage through sheathing. This access will be left open as it is between two common unheated non firewalled attic areas. Document Ref:XTX88-8J40G-8M2JA-FCQYR Page 2 of 5 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT I WORK ORDER Diana Davies (508)237-1654 11/07/2023 551272 10302 SERVICE STREET BILLING STREET PROPOSED BY: 11 Graves Avenue 13 Graves Ave Ray Dickson SERVICE CITY,STATE,ZP BILLING CITY,STATE,ZIP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL COMMON WALL-DRILL AND PLUG 4" 100 $298.00 $298.00 Provide labor and materials to install blown in Class I Cellulose to exterior walls through an interior surface drill and plug method. Plugs will be spackled and left with a rough finish.Finish sanding and touch- up priming/painting will be the customers responsibility. 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 acknowedgement of receipt and agreement to proceed. BASEMENT SILLS-RIGID BOARD INSULATION 171 $943.92 $943.92 Provide labor and materials to install rigid board insulation to the perimeter of the basement ceiling at the house sill. BASEMENT CEILING-6"FIBERGLASS 944 $2,511.04 $2,511.04 Provide labor and materials to install R-19 faced fiberglass batt D.D. (initials) insulation to the basement ceiling.This will be installed with the paper backing up against the floor above.The un-papered fiberglass side will be facing the basement,and these exposed fiberglass fibers will be the visible side when standing in the basement. Your initials are your agreement and understanding of this measure Total: $9,088.21 Program Incentive: $9,088.21 Client Total: $0.00 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 increase or decrease the size of the Program Incentive Share. RISE Representative Client Signature Ralean Dickson 11-07-2023 Printed MUM Date of Acceptance Document Ref:XTX88.8J40G-8M2JA-FCQYR Page 3 of 5 mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM I, Diana Davies owner of the property located at: (Owner's Name) 11 Graves Avenue 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. Ov..)014 _.,.. 11-07-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Document Ref:XTX88-8J40G-8M2JA-FCQYR Page 1 of 5 -----------.------•-•-•-•-•-•••••••••:-•-•:-;-:.-•-•-•-•-•••;;;;;;;;;;;;;:i.;••;•;::. ,;'=-;-i,,%.;',;,i,';iV:.;;Piii.:i;;: Vqi;i:;zV;i,i;';iVVVN'ii : ;i.;V; V&I:'dg.kg;!gk;tg;!g;t';'dg;:•:,,:.,:,,::cg•:,4:,,,N.,,!.,!,4:.!.,!A,,m,„1,,e,m,!.:,!,t,,t.1„t,.t.t,Nt...,04,; ,,,,:t`ttyt.XtelyfYY....,t-t-t.4-...........-t-t-1....?....t-t-t-t-t-t.."..t44.4....t..1..-Nt-tt-t-t-t-t-t-t.4.-1:-...........-.....-.-_-_-_-_..........-....,....-...-_-_-_ _ _ -• - - - - - - •- - .,.4,,...4 A I r••*4.0: 10'.0...1' .::•:. , ,,„....,,, , ••••:$1' . ,. -. ........ •••... 3-- ...1...orirr.:-._ •.,,-,-.. - -0......ege •-•il.---t,7-zic-i-7.1,--4--e.1--)!-?;;;%754>,..-• .-,-.---.,_-_---•,........:.,_ _. - - •••• .... - ,'-'' . ."-- - ----- •••••• .••••.:..:,.. .4,1-.0-,-<-4---' -04,,,..e.........------ -e-„-- , -.....,,,„....„,...-__. .----. .:•:•:• ••:...., ...!i:'-`-c- .,---_- .-- --rwr- 0..'.--- -----:,-,•;.-3-".5. '---- Signature Certificate ,„,,..,,„+„ .ii,... ..,..;,,,.____. , ,-2,.. _ ...,, 6.4..4.• .•••...••:•:. • , '''''' tel*"* .0111001t.- --:- ...:-" -" ---"..--''. ' :•,-,•;.: •••:. ,:..3.,,,..V' Reference numb c XTX88-8J40G-8M2JA-FCQYR ..,J _• :.4.:,.1. "0,-4.-..... .......1.. .._ ..... ,..._........ - - . , . 4: ., . - ,_. -... - - t...a.4,- ,, --,_ --"r4."."--- --___,' --..- - . - -..--- - `"--. -1Z,;`,..:1, ::•••;.: *****" • - ' - ''-- ''-- --_,_ ' ' ----_ - - 4;-.4..". .,... ...7),./: „e4,,,....„.-- - -- .,-;--_, ..,;: --„-,.< ..Y.. , ,1.- ..V.• F.. ' --1C- -"4",t:--- .,„-- --' 1., •'''''. •: . • - .--,i.- -- J _..,- •- - - ---,,,,-----4 -.!-±tm.,,,..,_--_, ..- .7- '04: 4"'-- ' - ' '••• .:$:,:: Signer-4 - - _ -;,...-10S.&,-;-p:F;:‘ Timestamp' ,,,,>-:-..r.a, _5-• , -4- ,_ , Signature •4‘....---„,,,---'''''.. ,--%.. :_„_'-•?....„--')", ....., _ ._. — ••• 4-••• .••. Ralean Dickson . :v..: ,....., ,...... ,V16.1. Email:rdickson@riseengineering.com , ,••••• ,•••,, •t•:••• "....4, V:k Sent: 07 gned Nov 2023 22:59:03 UTC •griz,,r,--OZCLOG , .. '••••••:40: Si : 07 Nov 2023 22:59:03 UTC ' .4- V•4e I ,./P*4 ••••••• '444. .•.04. :6..0.i •••••, ,..;•;;•: ,..4,•••• .•••••, ,.....4041.• IP address:71.192.20.71 •*.•:•:. ••••••••' Location:Springfield,United States '•••••• •......., :•:•:': .•• ..*•::,' Diana Davies VV.. 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Ap!wt '••' •••••• --•L L - ..- 't-t't...'-'.'....'t't-t-•'...-..ibt;.;t4-ot.iitititit;t;';'4iin;.."';;4ZONi;;;',.!;.' ;:.;;;,:::,;;;;:,-,:,,,..440,04,......4,.4„ ....464...".'"..;.;...;.';74'..;.;:tiV":;;;;;;;;;41K;:;;;;;;;;;;;Vi;;;;-;-47•-•;*41....*:.••••••••••••:•:•:•:•:•;:44:4:•:•:••••••••••••••••••••••••••,..t...0:...t.44.,!..44.4.4....x.....:.!..1,4,4:.42.........,...,......,1,...t.„...,...,..t.t.1.,.....",.t.,,..,..t.t.,.., 'Yttt-ttlt?..1...:!:•-tt!:4-t44Y.Y:!tit•IV.t4tttof..!.t.'t•!•- •',...-t.f.ttt?....N,!.!..ttt-44t.t..t.t.t•-t-,-....-4........t............'.....-t-t-t-t. . — - . - - - . - - - Client: Diana Davies RISEwt Address: 11 Graves Avenue AN EMPLOYEE-OWNED COMPANY Northampton, MA 01060 Energy Specialist: Ray Dickson Phone: (508)237-1654 Program: EGMA-HES Client# 551272 Work Order# 10302 Work Scope DESCRIPTION Qty Notes 1 KNOB&TUBE WIRING 1 2 VERMICULITE HAZARD MUST MITIGATE 1 3 HOME AIR SEALING 6 4 WEATHERSTRIP DOOR 3 5 DOOR SWEEP 3 6 ATTIC FLAT-5"FLOORED R-16 DENSE CELLULOSE 1,600 7 DOOR-INSULATE RIGID BOARD 1 8 SHEATHING ACCESS 3 9 COMMON WALL-DRILL AND PLUG 4" 100 10 BASEMENT SILLS-RIGID BOARD INSULATION 171 11 BASEMENT CEILING-6"FIBERGLASS 944 Diagram ri 12 16 I' 12 c 4 10 B 10 .. 4 AF5" DPC L-13 1 to 3 10 3� F 6 10 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CUENT N WORK ORDER Diana Davies (508)237-1654 11/07/2023 551274 10302 SERVICE STREET BILLING STREET PROPOSED BY: 13 Graves Avenue 13 Graves Avenue Ray Dickson SERVICE CITY,STATE,ZP SLUNG CITY,STATE,DP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 1 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE: RENTERS For eligible measures,the Mass Save Program offers a renters incentive of 100%off insulation,air sealing,and duct sealing measures.To be eligible for the renter incentive,the unit must be rented year-round,seasonal rentals are not eligible. KNOB&TUBE WIRING We have identified the potential existence of knob&tube wiring in your D.D. (initials) home.The following contract is not valid unless accompanied by the Weatherization Barrier Incentive form,signed by your licensed electrician.Work will not proceed until we receive a copy of this form. VERMICULITE HAZARD MUST MITIGATE We have noted there is vermiculite insulation in your home which D.D. (initials) might contain asbestos fibers,a known carcinogen.Weatherization work cannot proceed until the vermiculite is properly mitigated. HOME AIR SEALING 6 $639.54 $639.54 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-lon 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. DOOR-INSULATE RIGID BOARD 1 $103.05 $103.05 Provide labor and materials to insulate the back of a door with 2"rigid insulation board. WALLS-CLAPBOARD SIDED 4" 2,248 $6,609.12 $6,609.12 Install blown in Class I Cellulose to clapboard sided exterior walls. Touch-up painting, if needed,will be the customer's responsibility. 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 acknowedgement of receipt and agreement to proceed. Document Ref:Y4YKP-WF6U-BAMXI-V7UPP Page 2 of 5 WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CLIENT* WORK ORDER Diana Davies (508)237-1654 11/07/2023 551274 10302 SERVICE STREET &LUNG STREET PROPOSED BY: 13 Graves Avenue 13 Graves Avenue Ray Dickson SERVICE CITY,STATE,ZIP &LUNG CITY,STATE,nP Program Northampton, MA 01060 Northampton, MA 01060 EGMA-HES Page 2 DESCRIPTION OTY COST INCENTIVE TOTAL COMMON WALL-DRILL AND PLUG 4" 100 $298.00 $298.00 Provide labor and materials to install blown in Class I Cellulose to exterior walls through an interior surface drill and plug method. Plugs will be spackled and left with a rough finish. Finish sanding and touch- up priming/painting will be the customer's responsibility. 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 acknowedgement of receipt and agreement to proceed. BASEMENT CEILING-6"FIBERGLASS 944 $2,511.04 $2,511.04 Provide labor and materials to install R-19 faced fiberglass batt D.D. (initials) insulation to the basement ceiling.This will be installed with the paper backing up against the floor above.The un-papered fiberglass side will be facing the basement,and these exposed fiberglass fibers will be the visible side when standing in the basement. Your initials are your agreement and understanding of this measure Total: $10,358.69 Program Incentive: $10,358.69 Client Total: $0.00 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(NCI 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 increase or decrease the size of the Program Incentive Share. RISE Representative Client Signature Ralean Dickson 11-07-2023 Printed Name Date of Acceptance Document Ref:Y4YKP-YYF6U-BAMXI-V7UPP Page 3 of 5 40‘ii mass save Savings through Pnergy efficiency PERMIT AUTHORIZATION FORM I, Diana Davies owner of the property located at: (Owner's Name) 13 Graves Avenue 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. _ ?a>� paN i!-ef Ow, a oiyIIai is 11-07-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Document Ref:Y4YKP-YYF6U-BAMXI-V7UPP Page 1 of 5 ,��;•_•.•et o •_• .••...❖.e • • .....�•..o• o,.e e _..•�e.o•....•.•_•._oo•. .4.!••..•_o.o•.r._•_....•;..•: •❖.' •• . a�° "y `� > q , � � .0 ,y,, .,7"1,, : , Signature Certificate r =• :%: Reference number:Y4YKP-YYF6U-BAMXI-V7UPP ,y r `4 ��+ `� 5. :�%' r • s ;•�.�. Signer Timestamp Signature— t " y ;.�.� Ralean Dickson ;11...,. Email:rdickson@riseengineering.com ;���•; .-..-•; Sent: 07 Nov 2023 22:53:43 UTC /�G[Z ./ •7.400ri '••••' ;.;�: Signed: 07 Nov 2023 22:53:43 UTC l ••::. ••••'.• IP address:71.192.20.71 ;•;; {O•: Location:Springfield,United States �••;• :;:••.;: Diana Davies {; �;l;; Email:andrewricotta@gmail.com ::i:�. .;:�«� Sent: 07 Nov 2023 22:53:43 UTC )0Yt4, _1-0, ti•v. 1 —( :•:.:•••: Viewed: 08 Nov 2023 03:45:22 UTC // ✓ •••••� �•,-•; Signed: 08 Nov 2023 03:49:06 UTC ;,.:•; A*: Recipient Verification: IP address:73.38.120.255 •••• :•: ✓Email verified 08 Nov 2023 03:45:22 UTC Location:Holyoke,United States $•::; •�•:••, :••❖. •i i f`�,;?.,F•w's..._ �''• �' F -. .�".n. ..°T^ K 4 .w' .t .>�;, ""--ram ..tom - �•�••' �r; 9... C?OCUmer't completed by all parties on::.r i n, ' .r J 7C a,,, .. .,,, • ~.: f' !,,•: ::: ; dr• ° ..., `- zX • , j nm►o` - • ,■."' •::••;. w �• w-dr 'yam Y. ,,,,, .. .• aw, -• Y tt , ��"• "k"4- ' a•. •i' „ ✓ ,,, . y : a .� .,r . 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Client: Andrea Schmid RISE Address: 13 Graves Avenue AN EMPLOYEE-OWNED COMPANY Northampton, MA 01060 Energy Specialist: Ray Dickson Phone: (508)237-1654 Program: EGMA-HES Client# 551274 Work Order# 10302 Work Scope DESCRIPTION Qty Notes 1 KNOB&TUBE WIRING 1 2 VERMICULITE HAZARD MUST MITIGATE 1 3 HOME AIR SEALING 6 4 WEATHERSTRIP DOOR 3 5 DOOR SWEEP 3 6 DOOR-INSULATE RIGID BOARD 1 7 WALLS-CLAPBOARD SIDED 4" 2,248 8 COMMON WALL-DRILL AND PLUG 4" 100 9 BASEMENT CEILING-6"FIBERGLASS 944 Diagram 5 16 6 F 12 D 2 1 6 4T _ 4 10 C 10 4 AF5" DPC } [ 3 3 10 3 test hole The Commonwealth of Massachusetts h Department of Industrial Accidents , �t = Office of Investigations = Si . Si = Lafayette City Center t� 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): J and L Energy Inc Address:42 Sargent St City/State/Zip:Winthrop, MA 02152 Phone #: (617)259-4825 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 7 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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. ❑Demolition workingfor me in anycapacity. employees and have workers' P tY 9. ❑ Building addition [No workers' comp. insurance comp.insurance.: required.] 5. ❑ We are a 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 13.0 Other Weatherization employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Policy#or Self-ins. Lic. #:WC9098987 Expiration Date:08/06/2024 Job Site Address: 11 & 13 Graves Ave. City/State/Zip:Northampton MA 01060 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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. Be 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Steven Collins Digitally signed by Steven CoNins 09/20/2023 Signature: Steven 2023.04.10 18:41:06-04'00' Date: Phone#: (617)259-4825 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 11:1Board of Health 20 Building Department 3EICity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Ac o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 8/2/2023 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 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 McSweeney&Ricci Insurance Agency, Inc. PHONE FAX 420 Washington Street (A/c.No,Extb 7814348-8600 (a/c,No):7814343-8807 IL Braintree MA 02184 ADDRESS: mrireception@mcsweeneyricci.com INSURER(S)AFFORDING COVERAGE NAIC t INSURER A:Selective Insurance Group 12572 INSURED J&LENER-02 INSURER B:Westchester Fire Ins. 10030 J&L Energy, Inc. 42 Sargent Street INSURER C: Winthrop MA 02152 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1471965881 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 EFF POLICY EXP LIMITS LTR INSR VD POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY S 2516438 8/6/2023 86/2024 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 PRO- -1 POLICY LOC _ $ JFCT A AUTOMOBILE LIABILITY A 9109411 8/6/2023 8/6/2024 COMBINED SINGLE LIMIT (Ea accident) $1.000.009 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per ecddent) $ AUTOS X N N-OWNED PROPEERTT YDAMAGE X $ HIRED AUTOS $ A X UMBRELLA LIAB X OCCUR S 2516438 8162023 8/82024 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED X RETENTION$0 _ $ A WORKERS COMPENSATION WC 9098987 8/6/2023 8/62024 x WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? n N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Pollution Liability G7426962A 002 8/6/2023 8/6/2024 Each Occurance $1,000,000 Aggregate $1,000,000 Deductible $2,500 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Northampton ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • 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)7273200 or visit www.mass.gov/dpl Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Reg lations and Standards ConstructidaigupeMe9T Specialty . CSSL-106221 V E�pires:06/30/2025 STEVEN M CpLLI 42 SARGENT/STRE WINTHROP I 0215 • 5� Commissioner c °j . api. nr THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affai and Business Regulation 1000 Washingt4p Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration "" At t Type: Corporation 'e =w =*--: 'StYation: 202555 J&L ENERGY INC. °'4 a Expiration: 07/13/2025 42 SARGENT STREET + • WINTHROP,MA 02152 — —••».. --- ,.": ...= y l�j1itf .r S`�ti: Update Address and Return Card. 1 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the I HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: I TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street •Suite 710 202555 x- �. 07113/2025 Boston,MA 02118 J&L ENERGY INC ;; .: .1i- .tr 3 44/--4-11'ot STEVEN M.COLLINS sC.Asig) 42 SARGENT STREET � �a 4.4"WINTHROP,MA 02152 ,1.R As, Undersecretary lid out signature Renter Pre-Weatherization incentive mass save Knob & Tube and Vermiculite Mitigation u � •«. incentive Amount: Up to $5,000 per rental unit m,..� ..,.�... ,::v s,'1a�y ..�_6� i�a Y3�, ..aa,`...S w>,wok;.' .»rz� °,�< .w.....�• This off is to assist landlords of rented properties with the cost of knob and tube and/or vermiculite abatement where it prevents the installation of Mass Saver insulation or air sealing work.A maximum of up to$5,000 of eligible costs per rental unit will be available before abatement work begins in the form of a twomparty check made out to the contractor and the customer Please refer to the bpek of this form for a full list of Terms and Conditions. ENERGY SPECIALIST TO COMPLETE-BARRil Ps C!t r''iE'C) A Mass Save weatherixation work scope has been developed,but knob and tube wiring and/or vermiculite has been observed in the following work area(s)and wit need to be removed before the work can be completed(check ail that appiyi Knob&Tube Wiring: , i Attic Exterior Walls ({Basement Ceiling (.,)Crawlspece 0 Other ;Other .-—.....-... — Vermiculite: Attic Knee Walt Stsace i/'Other Exterior wails ,-Other. PONr Residential Electric Provider Cape Light Compact Eversource National Grid Until Residential Gas Provider Berkshire Gas • Eversource liberty National Grid Until Electric Account Number Natural Gas Account klumnbo (Confirm this unit is occupied by an owner or renter Owner ti i Renter Assessment Site SOT 5512 74 Tenant Account Holder �....... Cate: My signature confirms that I am the tenant occupying this address and that I have read and agree to the Terms and Corxdttions outlined on the back of the form. RENTAL PROPERT o Check Payable To: Phone Number installation Address City' I State Rental Property Owner. __.__ W_...m_ Dana: My signature confirms that I have reed and agree to the Terms and Conditions outlined on the back of this form KNOB AND Tt EE CONTRArtOPOWMPLETE AFTER ABATEMENT Co any Name j' o(r n !cC Y i d L L E octric€ants License Nurnbe Z Z U I Z A.............. PhKone Number_ 1 then Email Addr.�l,. C.cxatzrctPerson (��}" ��,� H3 �S" - I Hiding Address'3 O Monk12,4.... Cfty i l l ri:+ State: A 7IP 37)-- nave performed my inspection and determined there is no active knob and tube wiring in the areas selected book, Knob I Tube Wiring: _ =Attic f✓Exterior Walls d,,,kftasement Ceiling Crawlapace 0 Other: :?tier: Contractor signature _$ .. __ __ ___ _ Date: 1/10/2024 My signature confirms that I have performed my inspection of the electrical systems in the areas above and have remediated knob and tube wiring as; indicated My signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this form 1CompanyName WC 5 ,f`i De, '4( ;:;,4. Contact PersonD' frkifrrine Numbr r t ire r,s t.MaiiirgAifeiress S..G?.54(r ili1Z061( act, .1+ '_. s -F"efo I,stag ztP22 .8 01. 3 eve performed rely inspection arid determined there is no remaining vermiculite in the areas selected below. Vermiculite: ,,attic i,..,r knee Wall Space I)Mee Contra r Si9naU r ; Fats._.l L�.�-- tt My signature confirms t I have performed my inspection and have remediated the vermiculite in the areas identified above My signature also confirrris that I have read agree to the Terms and Conditions outlined on the back of this form • 3 �-Vn40 3i�<n"ta' . sS, ,u»`b... <:.....,.: s�as,,a,r;ae�.v.•`+/a;<.. ..e.+rwc89 3t n.r, .,..r, ...,:. ., . .. , 2 }22-23 Weatherization Barrier incentives Based on your Energy Specialist's recommendations,your home can benefit from program-eligible insulation and/or air sealing improvements,Before moving forward,please follow all the instructions below to remediate your weatherization barriers. CUSTOMER INSTRUCTIONS t.Hire a qualified,licensed contractor to evaluate and/or remediate the weathenzation barrier(s). 2.Submit signed and completed copies of this form and a copy of the paid contractor invoice(s)within 60 days of your Home Energy Assessment to:RISE Englneering,765 Attucits Lane,Hyannis,MA 62601 or email to MassSave•" RISEengineerang,coin. 3.The weatherization incentive will be deducted from the customer co-payment amount of the weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount. i.Complete the recommended weatherization improvements, Customer t Name, Andrea Schmid client#or site lD' 551274 i. Add,css 13 Graves Avenue City Northampton State: MA ZIP: 01060 Phone Number: 508-237-1654 Email: andrewricotta@gmail.com grnaiI.com Customer/Homeowner Signature: Date: .._ To determine if there is any active knob and tube wiring,the contractor will evaluate the following areas where eligible Mess Teve' weathenzation recommendations have been made: 0 Attic Floor 0 Attic Wall Attic Slope Vi Exterior Wall 0 Basement i,,.Other: • :Other, ;r slave ossetiadneo my inspe.:wn and determined there as oo active knob and tube wiring.n the areas selected behove, E Attic Floor 0 Attic Wail °Attic Slope i;i xter io°Wall 0 Basement 0 Other: _.e..._0 Other; < Contractor Name: 1311121` Jcii d Address:.' 1O /4II/ra cif /g(t' City:_S7 /if/rt14' state:,, :'t .ZIP: G 'Ji,� Company Name- M"I i7 Eke r c_ License Number: 2i�/2 A Contractor Signature: ktiiee, iel Date:__ 7_21e72e," My signature confirms that I have performed my inspection of the electrical systems listed above and have corrected any barriers as indicated.my signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this to'a-i inttgatanatannEeMPWRIERS:;o f .. High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and recl.ice the i., bed;r•:rzi:oside level, as measured in the undiluted flue gas,to below 100 parts per million(ppm). Draft Failure:Contractor is to correct the draft in the selected flues),Refer to table on reen°tree for aci ep;,atik'draft ranges, g�mnrr r ;are . ,. ..gerittart k t?t zidg. ''AI tt Existing CO ppm _ Revised CQpptn Existing Draft Pa ..- Revised Draft>e Heating System Hot Water Heater Other Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation, (.,.>Heating System 0 Hot Water Heater 0 Other: Contractor Name: Address: _ City: Sty: ZIP: Company Name' -.� License Number Contractor Signature: My signature confirms that I have performed my inspection of the mechanical systems listed above and have corrected any barriers as indicated,My signature also confirms that I have read and agree to the Terms arid Conditions outlined on the back of this form, Renter Pre-Weatherization Incentive mass save Knob & Tube and Vermiculite Mitigation NsIVIM,11 thrtX0141 41108gV 4°,1.-,,,..v Incentive Amount: Up to $5,000 per rental unit This offer Is to assist landlords of rented propel:OK with the cost of knob and tube and/or vermiculite abatement where it prevents the installation of Mass Save insulation ot air sealrhg work A maximum of up to SiS,000 of eligible costs per rental unit will be available before abatement work begins in the form of a two-party check made out to the contractor and the customer Please refer to the back of this form for a full list of Terms end Conditions ENERGY SPECiii LIST TC COMPi r TE - . A Mass Save weatherizabon work scope has been developed but knob and tube wiring and/or vermiculite has been observed in the fonowing work stea(s)and wit need to be removed before the work can be completed(check an that apply)i .., Knob&Tube Wiring: 0 Attic ,r Exterior Wails itt Basement Ceiling 0 Crawispace ()Other„, Other Vermiculite: ( ,Attic (7') (rice Wall Space '7, Other Exterlfix wells 0 Other ,.,l i Ltiaiser ACCOUNT HOLOEP itirocimAT oN Residential Electric Provider Cape Light Compam Eversource 0 National Grid Until Residential Gas Provider Berkshire Gas • Eversource Liberty National Grid . Until --t , Electric Aecount Number .(56 ... ci.so 3 5, :Natural Gas Account Number; 1LOO5 Li 0 till _ _ „. i Confirm this unit is occupied by an owner or renter (:,)Owner **Renter Assessment Site ID.* 551274 unant meow*iiakur. RA.&/4 .501mt ii,-:•''''''''' , ,, ,':''tP ,,-;,'il'''''' '-',-" i iitC1 7 .C\-.6) .-7; My signahrre confirms that I am the tenant occripying this address and that i hex*read and agree to the Terms and Conditions outlined on the back of this torn i orN TA W:,i,S.',PF d,Y ."..,%.,,,,L :PO(.14M ATION LCheck Payable Toi i Advil lykvig,a iphone Nurni2e5:1 -t),71/-tig 5 ,, _.,... installation AddieFit n1 C--Ci'r A v il.L., AVE., .!..ottr, Wa lai+40vt Psi°, ,,,. ,,,ate' rill J ZIP. , . t.., , ..,' Rental PforrertY°Woe': I)iCAV't 1„, C''''111'l'''') rAll'e t 3,,tirirgit<tt774 Dew t• i ..i' i -"":!,,o .,-. ',,, -t, My signature confirms that i have read arid agree to the Terms and C-i-iii: i i i alined on the back of t Ns form KNOP AND TuriE, CONTRACTOR TO COMPLETE Ai- ::a ri:iATEIMENET i K,_ 'rCompany Name. !AO Tiii. .t.Lcif,\IC,4 Electrician's License NumberZ2.6 i„ . ., _.„. .„ Contact Person .e>ts FA/I- A4t1f,,,Iiii 1 phoaa hiumbac tii 5 Anzio it IEmAddessrtjs4_ ailogAd di ess t ii Co4 tiggy cl., i City,S.."44.4,1_ tit.e0,4 to Lek State NIA ' ! 71P 0J513 ()I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below Knob&Tube Wiring: ''',::',Attic Exterior Walls PS/Baser/sent Ceiling sc,.'l Crawl L,7‘)Other C Other — Contractor Elgriatunsi , Dater ,._,........ My signature confirms that I have performed my inspection of the electrical systems in the areas at:rove and have rerriediated knob arid tube wiring as indicated,My signature also confirms that I have read and agree to the Terms arid Conditions outlined on the back of this form Afri:ii7F';-OS CON;;:0;"'7::ri TO ,7:'y,i-.L,17,7L- iir,c7co ET,q,'0,4T Company Name: Contact Person, Phone Number- Email Address: LMailing_Address, _____ City State ZIP ... . I have performed my inspection arid dietemyried there is no remaining vermiculite in the areas selected bestow ,.. Vermiculite: 7)Attic 0 knee Wall Space ,Other , r.,,,,,„'Other Contractor Signature; Dam .,....„ . My SI9Iliittlie confirms that I have performed my inspection and have remedrated the vermiculite in the areas identified above My signature also confirms that I have read and agree to the Terms and Ccincithoris outlined on the back of this form mass save 2022-23 Weatherization Barrier incentives Based on your Energy specialist's recommendations,your home can benefit from program-eligible insulation and/or air sealing improvements.Before moving forward,please follow all the instructions below to remediate your weatherization barriers, CUSTOMER INSTRUCTIONS 1.Hire a qualified,licensed contractor to evaluate and/or remediate the weatherization berrier(s). 2.Submit signed and completed copies of this form and a copy of the paid contractor invoices)within 50 days of your Home Energy Assessment to;RISE Englnaering,7ES Attacks Lane,Hyannis,MA 026tH or email to Mass SEengliseertng.com. S.The weatherization incentive will be deducted from the customer co-payment amount of the weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount. 4.Complete the recommended weatherization improvements, Customer ame, Diana Davies 551272 Client#or Site ID: slue, ddr .zs: 11 Graves Avenue city. Northampton State: MA zip, 01060 5D8=237-16s4 Phone L,giber. Email: andrewriootta cvgmaiLoom Ctistorner/Homeowner Signature: Date: To determine re if there is any active knob and tube wiring,the contractor will evaluate the following areas where eligible Mass Save' weathenzation recommendations havebeen made: +C) ` Attic Floor Attic Wall Attic Slope F191 Exterior Wall e Basement 0 Other: J Other • ►*Att r rr' e inspectionAttiinthere no active knob and tube Tiring ors the,areasspins-ton' low. rind t or Ct-- Slope �tericu Wet Baser€t F Other Other. Contractor Namo: r €g fl ?4t'rr r7 Address: 'PK Hen/4'TC at; ;es city:-5idat /_ coc state;. ZIP: 013 7 Company Name: frie(r/) f l irt-6 C License Number: 7 Z.L#f 2 4 . Contractor Signature:��02... Date: ( 2etVi My signature confirms that I have performed my inspection of the electrical systems listed above and have corrected any barriers as indicated.My signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this form, :e.c.HANI At,SYST M'ESARRlER$,,, f a v ,..1 _; E:&t =_t as • High Carbon Monoxide;Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level, as measured in the undiluted flue gas.to below 100 parts per million(porn), Draft Failure:Contractor is to correct the draft in the selected fleets).Refer to table on reverse for acceptable drr,ft, r # � 'W` -` - s•�e • graft " Existing CO Prim Revised CO ppm Existing I s#in�t�� ..w PIt Revised Draft Pe Heating System Hot Water Heater m. ' tether .... ...__...__. Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation, 0 Heating System CJ Hot Water Heater 0 Other: Contractor Name: Address' City:- ..w ._ State: ZIP: Company Name: License Number Contractor Signature: My signature confirms that I have performed my inspection of the mechanical systems listed above and have corrected any barriers as indicated.My signature also confirms that i have read and agree to the Terms and Conditions outlined on the back of this form,