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38B-156 (7) BP-2022-001 0 4 MADISON AVE / COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38B-156-001 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-2022-0010 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 8000 ENERGY PROTECTORS INC 101143 Const.Class: Exp.Date:06/16/2022 Use Group: Owner: ROTH, ADAM E &YUKA TAKEHARA ROTH Lot Size (sq.ft.) Zoning: URB Applicant: ENERGY PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6562UB0G29826021 Spencer, MA 01562 ISSUED ON:01/04/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/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: trough: 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: idh• T''. • Fees Paid: $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RECEIV h€ J AN - 3 2022 �� j & The Commonwealth of Massachusetts 1 FOR lT nc r,:,ii,7lNsprcT:ONt' Board of Building Regulations and Standards MUNICIPALITY - ._ Massachusetts State Building Code, 780 CMR USE Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only BuildingPermit Number. '1(1 a 0Date A lied: Dui Qo5 / 1 3 ZOZZ5 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers L 1'v‘ct cX 1 So t1. f J Q 3 3 6 i &0 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 0 lone: — Outside Flood'Lone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owiler1 of Reco A c .c tvyy Ai 6 ill of 1-w vvJtZ)fl t /h 14- 0 t.0 6 0 Name(Print) City, State,ZIP `A YVlc 4 tSOrl A v`P.�- Lit 3f uo 4 —a-$65" No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed W ork2: 1 tr\Si- 'tom. ` -Ar l e__. !2 ,�.C 0 r-_.► (-L\ t'S ChcA A-hc_ Ct1 -- t-C.... Al, VZ—` k`l SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. BuildingI. Building Permit Fee:$ Indicate how fee is determined: $ �� ❑Standard City/Town Application Fce 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: Sr? Suppression) Check No.3306Check Amount: Cash Amount: 6.Total Project Cost: $ ` WO 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 Name of CSL Holder U 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.) Restricted 1&2 Family Dwelling City Town.State,ZIP M Masonry RC Roofing Covering — — ---- WS Window and Siding SF Solid Fuel Burning Appliances 774-253-0277 jdada79@hotmail.com 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@hotrnail.com hotmail.com No.and Street 774-253-0277 Email address Spencer,MA 01562 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 Issuan of the building permit. Signed Affidavit Attached? Yes ! 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 O+'ner'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 O+%ner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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. I42A. Other important information on the HIC Program can be found at wwsw.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. R.) (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 he substituted for"Total Project Cost" The Commonwealth of Massachusetts ► w. , ��!/. Department of Industrial Accidents ?�1= I Congress Street,Suite 100 if=itil—1 Boston,MA 02114-2017 ,,� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly 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): 1.0 I am a employer with 4 1 employees(full and/or part-time).* 7. El New construction I am a sole proprietor or partnership and have no employees working for me in 2.0 8. E3 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 30 I am a homeowner doing all work myself.[No workers'comp.insurance required.) 10 D Building addition 4.❑I 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.[l Plumbing repairs or additions 5.1::]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� repairs re airs 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 TIGL c. 14.G✓ Otherinsulation 152,§I(4).and we have no 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. 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:Ace American Insurance Co Policy #or Self-ins.Lie. #: 4 6S62UBOG29826021 Expiration Date:9/01/22 Job Site Address: k Mcixit% (1 '1`e- City/State/Zip: k)ork" •e"I04 11'1'i DLO 6 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 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: O /)�► �dz 1 C _ Date: f�L 7 Phone#: '',7 4' S 3-O a -) 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#: City of Northampton 9,W4 A klji ) / Massachusetts ��. : N. , iI A,. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Straat • Municipal Building s .D 1(,"!t Northampton, MA 01060 rst-,y .a_��\' 'imi 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: �p c e(` ri/ G`5-6`L" The debris will be transported by: Name of Hauler: En e r63 0 (a ,c-Gc e5 . 4.► �f Signature of Applicant: ` `�"`" Date: --( 1--) Ac' ?RLJ DATE(MMIDDM/YY) �, : CERTIFICATE OF LIABILITY INSURANCE 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 ADDITI&IAL INSURED,the policy(Ns)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 CN arT'CT Nina Arroyo Coonan Insurance Agency,Inc. 4.1.„„, 608-987-7122 1 „; 508.987-7152 287 Main Street ge; Nina©coonaninsurance.com Oxford,MA 01540 INSURERM AFFORDING COVERAGE NAIL I INSURER A: AIX Specialty INSURED INSURER a: Safety Energy Protectors,Inc. NlsuRsR c: Century Surety Insurance 84 Paxton Road INSURER 0: 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 FFPAID�PCCpLLL�AIMS, IN TYPE OF INSURANCE OW wm POLICY NUMBER 1�T17,(SWJD /Y ,, LENTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f 1,000,000 r DAMAGE TO RENTED CLAIMS•MADE Q OCCUR PREMISES(Ea occurrence) ,s 100,000 MED EXP(wry one penonl S 5,000 — a y L1 N-H714840-00 08/31/21 08/31/22 PERSONAL a ADV INJURY $ 1,000,000 _ I�ENt ADORE TE LIMIT ES PER GENERAL AGGREGATE $ 2,000,000 X Policy11 JECT LOC PRODUCTS-COMP/OP AGO 3 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED S SINGLE LIMIT $ 1,000,000 Ea L ANY AUTO BODILYY INJURY(Per person) 3 8 pwNEp X BCTEO9OULED y 8238519 12/23/20 12/23/21 BODILY INJUR ecd Y(Per denl) $ `� AUTOS ONLY �,� PROPERTY DAMAGE _f AURETOS ONLY X A OS ONED IPet wddrnll S S X UlleRILLA LIAR X OCCUR EACH OCCURRENCE S 3,000,000 c EXCESS LIAAR CLAJMS•MADE y CCP100S749 08/31/21 08/31/22 AGGREGATEp p $ 3,000,000 WORKERS COMPENSATION S I STATUTE I 1 ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVED NIA E.L.EACH ACCIDENT $ OFFI �M NH) EXCLUDED?(Mand DISEASE•EA EMPLOYEE1$ Dya describe uncle(DEl.DISEASE•POLICY LIMIT ESCRIPTION OP OPERATIONS below DESCRIPTION OP OPERATIONS r LOCATIONS/VEHICLES (ACORO 101.Add bona►Remarks Schedule.may be attached It more spew N requited/ Workers Compensation Insurance certificate to follow under separate 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 LiltAlAtit. 1988.2015 ACORD CORPORATION. All rights ed. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ACc® CERTIFICATE OF LIABILITY INSURANCE oATE(MMIoanYYY) ika.../ 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: If the certificate holder Is an ADDITIONAL INSURED, the poiicy(tes)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 PHONE _tAic tio.e t). (508)987-7122 fAX.No): ,Amiss; Nina@coonaninsuranco.com 267 MAIN ST INSURER(0))AFFORDING COVERAGE __ _NAIL I_— OXFORD MA 01540 INSURER A: ACE AMERICAN INSURANCE CO 22687 INSURED INSURER B ENERGY PROTECTOR INC INSURER C: INSURER D: —_.---- 84 PAXTON RD INSURER I: SPENCER MA 01562 INSURER F: COVERAGES CERTIFICATE NUMBER: 690758 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. NS 1 TYPE Of INSURANCE 'ADOL SUER 1 POLICY OF ; P&icv EXP LIRINRO IeND POLICY NUMBER DIY D/YYYY) IMMIDDMIYY OUTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 8 1 CLAIMS-MADE OCCUR DAMAGE TO RENTEDPREMISES iEa a y renca) 8 — I MEO EXP(Any on*person) 8 —..�_— N/A PERSONAL a ADV INJURY $ OENL AGGREGATE LIMIT APPLES PER: (( pp�� r GENERAL AGGREGATE 8 POLICY t__ JECT El LOC i 1 — -- — — PRODUCTS•COMP/OP A00 8 OTHER: — —_ — -- AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $ a amdent ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED SCHEDULED "�------ i____ AUTOS AUTOS N/A BODILY INJURY(Per accident) 8 HIRED AUTOS +NON-0WNED PROPERTY DAMAGE _AUTOS (Per accident! 8 I — $ UMBRELLA LIAO ` OCCUR ' EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE N/A AGGREGATE _ DEO RETENTIONS 8 i WORKERS COMPENSATION t fix pER (pJH. ANO EMPLOYERS'UABILITY Y/N I STATUTE I E ANYPROPRIETORIPARTNEREXECUTIVE 09/01/2021 O9IO112O22 I E1.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? I N/Al NIA NIA 6S62UBOG2982602 --- -- (Mandatory In NH) LI E.L.DISEASE•EA EMPLOYEE 8 500,000 Es, rn ee D bNunder : E.L.DISEASE•POUCYLIMIT 8 500,000 DESCRIPTION OF OPERATIONS beivv N/A . I DEBCRIPT1ON OF OPERATIONS/LOCATIONS/VEHICLES IACORD 1St,Additional Remarks Schedule,may be attached N more spec•le 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 date on the above policy precedes the issue date 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.mass.govilwd/workers-compensationlinvestigationsi. Sole proprietor has not 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 ` ce Southborough MA 01772 Daniel M.Crowley,CPCU.Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD c f- - .0"."."...."........"..."'''.""""...... . . , .. ....-1—. 1. ill. 0 V. i . . • .1, a --:. • . t=> % .- . — • . .., .._ tx. - k..., ,... 0 0 . ts.....' I Cs 3.15 1 :' 1 '"::-- lIt a.0 a me I 0 0 41 ,... Mce of Consumer Affairs and Business &vitiation 1000 WashIngbm WNW- Suite 710 Boston, Mesesdi sew 02118 Home Improvement Conb otor Registration M ?won 04 PAN AM 01 Upellis Miriam ad Nation out otriassoorsomeiverriarwtalho tairsolVa Mom Ow XISHUA DMA VeV --b._ , ,(4 04 W ma arfAsiorit44q PENC R,MA aliMa Undymeafwltri Not void without signa#u DocuSign Envelope ID:853BEB61-9CCC-4Al2-B5F4-F07A828F659E \Wit RISE ENGINEERING OWNER AUTHORIZATION FORM I Adam Roth (Owner's Name) owner of the property located at: 4 Madison Avenue (Property Address) Northampton, MA 01060 (Property Address) hereby authorize En ( 'j PvU Te - T At 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. p —D�occu.S.pneed by n rogt 8/12/2021 110:39 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com 41004( mass save 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 CUSTOMER INFORMATION Customer Name Adam Roth client p,, „ 324811 _ Site Address 4 Madison Avenue city Northampton state MA ZIP 01060 Pi•c.nn N,mnber 413-404-2865 Email adameroth@gmail.com_,_ Customer/H ` 5 • Kerr, '< . .... Att+c Floor Attic Wall le Attic Slope Exterior Wall V Basement Q Other 0 Other -inummastmmusimasarnammanmaminumammume Aim= 1 Ames adonis Q Other ___Q Other. ..A Ctimph`;•, Contractor / r'. • ,hn c con+' • r -. r rformed m spection of the electrical systems listed above and have corrected any barriers as •-d My sion firms that I have read and agree to the Terms and Conditions outlined on the back of this form MECHn' STEM Aa, 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(ppm) Draft Failure:Contractor is to correct the draft in the selected flues) Refer to table on reverse for acceptable draft ranges n Monoxide Draft Failure Revised CO•pm 1 Existing Draft Pa Revised Draft Pa 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 0 Heating System Q Hot Water Heater 0 Other Contractor Name Address City State ZIP Company Name: License Number Contractor Signature: Date: 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