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32C-228 (9) 78 HAWLEY ST#2 BP-2017-0760 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:32C-228 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.1144/2�A) D( Category: INSULATION BUILDING 1 ER IIT Permit# BP-2017-0760 Project# JS-2017-001273 Est. Cost: $839.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: POTENTIAL ENERGY LLC 106184 Lot size(59.ft.): 6708.24 Owner: CUOMO MARTHA Zoning:URC(100)/ Applicant: POTENTIAL ENERGY LLC AT: 78 HAWLEY ST#2 Applicant Address: Phone: Insurance: 4D QUEEN TERR (860) 620-4433 WC SOUTHINGTONCT06489 ISSUED ON:12/12/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE KNEE WALL SLOPE, AIR SEALING, PLASTIC GROUND COVER, 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: Oil: 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 12/12/2016 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0760 APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC ADDRESS/PHONE 4D QUEEN TERR SOUTHINGTON (860)620-4433 PROPERTY LOCATION 78 HAWLEY ST#2 MAP 32C PARCEL 228 001 ZONE URC(I00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUTS// Fee Paid ,/[ f� Buildin Permit Filled out W Fee Paid Typeof Construction: INSULATE KNEE WALL SLOPE,AIR SEALING,PLASTIC GROUND COVER WEATHERIZATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106184 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved 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 _Demolition Delay dre Sture of ail.ing Official 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 are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning& Development for more information. D u V L- -. 15 G E 0 Department use only ty of Northampton Status of Permit: wilding Department Curb Cut/Driveway Permit L1 DEC - g 2016 _J 212 Main Street Sewer/Septic Availability Room 100 WaterNVell Availability Nortnampton, MA 01060 Two Sets of Structural Plans °mmyn`'Plumbing d Fax 413-587-1272 PleNSite Plans Northampton,M Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office _ Map Lot Unit Zone Overlay District Huv+lianip to71 /A °I W O Elm SI District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Myth ft ythft, Cucwc 8 -Law let fit 2 O� hmp n � / Name(Print) C r�eIn "sln lhe v 2o�qVA 0 1 CunG - s'nne i\Ud11(;Vl2L oyv -0`V✓\ Telephone Signature 2.2 Authorized AcenL ichclCIS MHstE,V`' eil-hal -LnErcL IDI E'MaIn ,SY. CAM Name(Print) � Current Mailing Address'. 71 . Y IoO-50Io - 42-V6 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) �Q 5.Fire Protection 'L/ // 6. Total= (1 +2+3+4+5) 473"n pI Check Number �I3 cri This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning mit column to be filled in by Building Department Lot Size I ronpge Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage • Open Space Footage (Lot urea minus bldg&pared parking) #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 recorde'at the Registry of Deeds? NO O DON7KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a bfook, body of water or wetlands? NO O DON'T KNOW O YES 0 IF YES, has a permitbeen or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing Q Or Doors D Accessory Bldg. D Demolition ❑ New Signs [0 Decks [m Sidin. [.], Other[A] Brief 'P °aft° ee�ulbIsfcpe, Oirc?01Ivi �Ir.�stiegrc j�cJcCv�v, w Then alc� 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: 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 AGENTII1 OR CONTRACTOR APPLIES FOR BUILDING PERMIT MUv-EVa NMI .as Owner of the subject property p j /� �n �L hereby authorize YO,H vfl 11 �� C ' u to act on my behalf, in all matters relative to workrized by this building permit application. Sed coieV awl fon — Slgnature of Owner ,�J /� Date VC�CMQ, Yt Flown OJ 'EylerLi ,asOwner/Authorized Agent hereby declare that the stateme is and information on the foregoing plication are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Ni cholas Mostk,Y Pnnt Name IRC Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:/1 (- tyNott Applicable ❑p Name of License Holder: NI Ch Cr)CMe toy CSFA 1010 g License Number LI 1) EueeyTara ceSouth Inot r CT 01 )14cqa / z1 �2CIq Address -J Ecpiraaon Date i(f - - , • is(vD -(020"443-3 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable D 17g40I Company Name Registration Number Paentia\ Rer;1A /Nic:Has muster /z8z01 R Address //�/� Expiration Date �� Y ��".f.l �'C.Y11.t 1.e `3ll(Al 11 I kI r ic IV/Telephone 011) 22O L11-iJ5 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 q' No ❑ 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 not 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,oris 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 your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also he advised that with reference to Chapter 152(Workers Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of die 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 Zoning 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: � Cg HG1wIQ9 Sfi '4Z2 NOr+hamr-ov11MA0V0 .9O The debris will be transported by: Poi-evitlg\ ElieYo3 .i The debris will be received by: Rik-war L0t-eyryIsesbris-tot /Cr Building permit number: Name of Permit Applicant NlOr(otas Mosi-av Fot filcti Date Signature of Permit Applicant The Commonwealth of Massachusetts , I Department of Industrial Accidents �` �;;WI (yd Office of Investigations I- 7--?,ifIli 1 Congress Street, Suite 100 – � Boston,MA 02114-2017 www.nmss.govfdia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibiv Name(BusinesslOrganination/Idividual): -/uTf,[ i ti �i EY'f1.19 Li ILL' /1\\,. (I,1�fi(ill S ��' ��1ti Address: 1 E _MCai ( Stireet _ J City/State/Zip: �)r� fj1 T OuDIC) Phone#: =(.-7�: , _— _-- Are •ou an employer?Check the appropriate box: Type of project(required): I. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-conuactors 6. ❑New conslmetion listed on the attached sheet. 7. ❑ Remodeling 2.❑ lam a sole proprietor or partner- ship and have no employees These sub-contractors have g, ❑ Demolition working formc in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance? 9. Ili Building addition required.] 5. I:1We arc a corporation and its 10.0 Electrical repairs or additions 3.❑ l am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [Nn workers' comp. right of exemption per MCI. 12.❑ Roof repairs insurance required.] / c. 152,§1(4),and we have no , employees. [No workers' • i 3N Other )ISS u I Q � o 11 • comp. insurance required.] 'Any applicant that checks box k I must also fill out thesection below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing MI work and then hire outside contractors must submit a new amdavit indicating such. k'ontmetorsthat check this box must attached it additional sheet M,mving 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 proaidtng workers'compensation insurance for my employees. Below Is the policy and job the information. I I +('!^ I T 1� insurance Company Name: 'HON(l Ilii iir-,uYoflc.e & Ie'lAr Policy#or Self-ins, Lie. #. t; �� C '� 7 Expiration Date �5� 2T� i 7 �7 *� — Job Site Address:_U kak,0Ifli SIk L. li City/Slate/Zin:N0141101(T—or) lv'1A Olio Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). O I O W 0 Failure to secure coverage as required under Section 25A of MOT 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 tin 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 enc er the pains and penalties of perjury that the information provided above is true and correct T__-773-te.-r:.-. � Signature: ' Data: IZ/ 1 _ Phone P: RSD�1 S�'1‘.0— 42(o�' Official use only. Do not write in this area,to be completed by city or town official. City or Town:_ PermitR.icense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Owner Authorization Form 1, Martha Cuomo (Owner's Name) Owner of the property located at: 78 Hawley Street-#2 (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) 10-2.1-16 (Date) Client#: 82429 MEISTNIC ACORD. CERTIFICATE OF LIABILITY INSURANCE DA"" D`VW"' 727/2016 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 policytles)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 cenlMcate holder In lieu o1 such ondorseniont(s). PRODUCER NAMFACT Audrey Lamontagne Fradette Cartson Agency PECNE 860 583-0943 - I;uxol., 860.585-0038 PO Box 2458 ADDRESS; atamontagnei@starshep.com Bristol,CT 06011-2456 INSURERLT AFFORDING COVERAGE NAIL* 860 583-0943 INSURER A.Hartford Ins Group 19682 INSURED INSURER B'. Nicholas Meister DBA Potential Energy LLC 4 D Queen Terrace INSURER o: Southington, CT 06489 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSRANCE LASTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTYI9THSTANDNG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 E%CLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - TYPE OF INsuRA NCE AIOLISUBN COM'EEC POLICY KyP umrts LTR WAR W✓D _ POLICY NUMBER _ WINNOIYYWO IMMIDDY TYI — A X COMMERCIAL GENERAL LIAaILRY X 02S8MRB0509 \;8105t2016 08,105/201 EACH 0 A 01-1:13X 12,01;91100 S.>,A<ly X!au,_eE IL TELUHL vrtence 11 000,000 MED Ex I Lnrn $10000 'Ane o.'_i _. .. =CCDmn sror w_aRT 122,000,000 54,000000 X I 17-:- �I�.a cc ..r...,a -E.; m1,000,000 Cn,_; A Bump MILE LIBEIuTY 02SBMRB0509 08/052016 08105/2017=Lsra 6bY'"OLE M fx,000,000 JIB pop,.B&OP•,Fer;e L0311F -EDJLE o p 6 (1133'1-33 nm X 33 tH„s ,)n.i@ Fc . ZC Pe X Ji ny.,n X 02SBMRB05O9 08/052016 0810520 A x UMBRELLA.LIAR X 17 03(333:31:333- 0110005000 EXCESS CAB ,.„V _Meu_ A:,CRFGATE 11 000,000 era XJ E-IrerrtN alOPOO 1 .. .. A xaR«ERs rrMPENSAnrn 02WECCR0745 08105t2016 08/057201Y X .-r tF —rlE i,*`R- ANDEMPLVY£RS LIAB&MY R IEr 'Lnv�rrN 8500,000 JFEI L NH] EO I . NIA IMenCMoryin NHI E.L.asEFEE-E33 CMPLO3E= 15001000 I 133,3,-131P113 nN C.3I'EPA.IC'Th FL 01.SEE.S1.FSI:Cy I INT 1500,000 usscW PnoN OP OPERATIONS/Locanoxs/YOWL EslacoaoWt.Aenmaml Remarks Schedule,may e..aachea if more=P.ce n roman Columbia Gas of Ma is an additional insured on the General Liability and Umbrella Liability Coverage per written contract or agreement CERTIFICATE HOLDER CANCELLATION COU mbia Gas of Ma ammo ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED X 4 Technology Drive Suite 250 ACCORDANCE WITH THE POLICY PROVISIONS. Westborough,MA 01581 AUTHORIZED RLRRSENTATIVE HOry 1968-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) 1 of 1 The/CORD name and logo am registered marks of ACORD 85843449/M843422 ?CAJL (Tile Yr tnlir)irf/1rrrter(/// / r it e.iice4rtie77i 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 14 419291 NICHOLAS MEISTER NICHOLAS MEISTER 4 D QUEEN TERRACE —` - ---' SOUTHINGTON, CT 06489 - - -- - —.......... Update Address and return card.Mark reason for change. ', n t LT: Address i""I Renewal [J Employment n Lost Card Office of Consumer Affairs rs YBa B Business Regniztien License or registration valid for individual use only • - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: I"79401 Type: Office of Consumer Affairs and Business Regulation Expiration: 7/28f2016 Individual 10 Park Plaza-Suitt 5170 Boston.MA 116 NICHOLAS MEISTER / Q} NICHOLAS MEISTER 4D QUEEN TERRACE ._ _ SOOTHING VON CT 06489 Umier.ecretary Not valid without signature itassace duets soa t o r c date: Board of 3 .:clny =ocu at:sns a.a 3:4' ..rds inst.;u n Su en is„ S, 2 FemOs e s CSFA..106184 NICHOLAS MEISTER TB 41)QUEEN TERRACE Southington CT 06489 - J2.w 04/27/2019 Or Columbia Gas. mail save d Massachusetts • rear.. MASS save PRE-WEATHERIZATION BARRIER INCENTIVE 2.014 - -CONTRACTOR EVALUATION REPORTS • • • r CUSTOMER INFORMATION a.,l,r,.,: a 439'69 parr or A.:ess.rrrrt. 10/21/16Ener9Y Snecialrst. Anthony Szilagyi-Potential Energy • ,'.:• web,. Martha Cuomo ['bone Email: Account#. o Ad, e.+ 78 Mawtey Street.eY City: Northampton State. MA Zip: 01060 NetNetwie os,re e t or„cotter K„,,,rhe ne•) Potential Energy nrei..,a,•n.. Lir,ve, tit root t ie Sec case AUle e>s) 61 E.Main Street :,q Bnstol CT . 06010 - 860-506-4266 Statepip: Phone. .'EST . KNOB a Tun WIRING r Cantractor s to evaluate the selrin locations below where weatherizabon recommendationshave been m tl to determine f three is any az4ve knob ft tube wiring: •\I M1. Evc ror Nein J Basement ; Attic Floor Knee Wall Floor I Attic Slopes MECHANICAL SYSTEM,RIGH CARBON MONOXIDE EVALUATIONC m n side ise to evaluate Me selected mechanical sgas to(b)below and provide service if possible,to reduce high carbon monoxide levels as measured in the undiluted flue gas to below 100 ppm: Anal nrr Ss slam Hot Molt',System 01-ere DRYER VENT EVALUATION Conbnc4+r is to evaluate Inc dryer vent and provide service to properly exhaust the vent to the exterior. C. if kr TTu• 1 rrrt4'4.• a,V r. ..I':L^... :•..rl , KNOB a TUBE WIRING r"ifluon completion of my inspection I have found that thereactive knob&tube wiring the area(s)checked off below: no 41 L. Evtenor%Nal _ tifizseine!t 1 I Attic Flooii_ Knee Wall Floor I AtticSlopes _reser _ _. CONTRACTOR INFORMATION t y Name ,41 coot Lag7y - Gnec Ir,e,&A I \tt . (-7_ aCtti_ttcs°4 City 4r/iso, 'An state/15rf} zipL]Oh0 t ontraatoy Name Zit 2:G•7lr/ Gvy License U. C iter Federal ID#. ave readador the rms&Conditions of the Pre-W athe z bon Barre Incentive. /� / Ct mactp �nnecre: 4. (i.9,free—' � _ .._.__ _ _. .__Date:/yl'Y29-/-o MECHANICAL SYSTEM,HIGH CARBON MONOXIDE EVALUATION The stiles ted mechanical system has beenevaluated and serviced. Testing results of carbon monoxide in the undiluted flue gas are as falowv' -._ _—.._.... .__ Weser. nal IP g S}thy') —_ _CO ppm Hof W'a4•r$ys:em CO ppm '. -0tnoc CO pMr .reser-_ PRYER VENT EVALUATION i 11.Lkpv vprdlOS tWel I miliducted[o the extrrrur CONTRACTOR INFORMATION Corryklnv Name A,brns _.. _ Weser_—__ Cny. State: Zip Contras or Name _ license#: Federal ID# . I have read and agree to.the Terms&Conditions of the Pre Wealhenzatio-Ranier Incentive L 0n1P ao IN S9rtnu'e._ Date. CUSTOMER INSTRUCTIONS:Submit signed and completed Copies of this Contractor Evaluation Report and o copy of the paid Contractor Invoice to your H PLApmonce Contract. Sk)naltii o Date:Lq ifr,1/Y/�t/�_� t mu( )—WFC 1 5rame•( yrv—Yeliew Dewey SnecioI,t—Fnk Contractor—Yoh re RM t/ ^"Oka tile