KT Sign Off2019 WEATHERIZATION�
mass save BARRIER INCENTIVES
Savings through energy efficiency
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. dire a qualified, licensed contractor to evaluate and/or remediate the weatherization 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: Pre-Wx Barrier Incentive, c/o CLEAResult, 50 Washington St. Suite 3000, Westborough, MA 01581
or email to: prewxoffer@clearesult.com
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.
4. Complete the recommended weatherization improvements.
CUSTOMER•• •
Customer Name: JOANNA SMITH ♦ �' 1 I ��o M►QI�S Client # or Site iD: 4320716
Site Address: 22 Old Wilson Rd city: Northampton State: MA z1P:01062
Date: 60 - Z o • Za zl
To determine if there is any active knob and tube wiring, the contractor will evaluate the following areas where eligible Mass Save
weatherization recommendations have been made:
QXttic Floor IDAttic Wall 046tic Slope I2r6terior Wall 94aasement ❑Other: ❑Other:
P-11h,ve performed my inspection and determined there is no active knob and tube wiring in the areas selected below.
O'Attic Floor MAtic Wall ,[Attic Slope Btxterior Wall CH5a-sement ❑Other: ❑Other:
133'fhave read and agree t e Terms and Conditions on the back of this for . ` -
Contractor Name: � QII�i C (_ Le. — U1AC.L�//y l ,yk
Address:_ (� /� ��� �rt City: f:;;",4)'1A Cs L�i 2 lS State;Na ! ZIP: r,3 l C3 �
Company Name: 14,rj_— C (�%ram[- $�TiC? �C License Number: 4 46 t ( 7
Contractor Signature:
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 flue(s). Refer to table on reverse for acceptable draft ranges.
Existing CO ppm Revised CO ppm: 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
❑ Heating System 0 Hot Water Heater ❑ Other:
❑ I have performed my inspection and have corrected the items noted in the areas selected above.
❑ 1 have read and agree to the Terms and Conditions on the back of this form.
Contractor Name:
Address:
Company Name:
Contractor Signature:
Page 1 of 2
License Number:
State: ZIP:
Date:
Continued on back
enRnP 1 of ?1
Exhaust Fan for Fresh Air. Contractor to install exhaust fan to provide measured, continuous or intermittent whole building ventilation,
The required rate of flow must be capable of providing CFM (measured at fan).
Dryer Vent Evaluation: Contractor to ensure the dryer vent is exhausted to the exterior through hard metal ductwork.
❑ 1 have installed an exhaust fan to the specifications noted above.
❑ 1 have evaluated and/or repaired the dryer vent fan to the specifications noted above.
❑ 1 have read and agree to the Terms and Conditions on this form.
Contractor Name:
Address: City:
Company Name:
Contractor Signature,
TERMS AND CONDITIONS
License Number:
State, ZIP:
Date:
Eligibility Requirements: Applicant must be a residential customer of a participating Mass Save Sponsor, Customer must participate in the Mass Save
Home Energy Services Program (must reside in a 1-4 family home). The qualifying barrier must be identified at the time of the Home Energy Assessment as
a barrier preventing the installation of proposed weatherization improvements. Customer must complete the recommended weatherization improvements
to receive the applicable incentive. Customer must submit the completed Contractor Evaluation Report including a copy of the dated and itemized invoice
from the licensed contractor on company letterhead within 60 days (postmarked) of the Home Energy Assessment. If contractor invoice is not provided
within 60 days, the eligible weatherization barrier incentive may be forfeited. Customer participation does not guarantee the barrier will be cleared. In
submitting this application, the Customer agrees to all Terms and Conditions.
Contractor Responsibilities and Acknowledgement: in performing any work in connection with the Weatherization Barrier Incentive (as set forth in detail
below), the contractor shall: p) abide by all local, state and federal guidelines, applicable laws (including, but not limited to all applicable environmental
laws). building codes. regulations (including, but not lim ted to EPA lead -safe and any and all other applicable environmental regulations) and licensing
requirements: and 00 stop work and immediately notify the customer in any case where existing or possible health and/or safety problems exist. The
licensed contractor must fill in and sign off on the testing results in the appropriate place on this form. Contractor shall remain solely and fully responsible
for their confirmations and notes that they provide on this form and with respect to the Contractor Responsibilities set forth above.
Knob & Tube Wiring Evaluation (up to $250 incentive): The knob and tube wiring that has been noted cannot be determined inactive at the time of the
ome Energy Assessment performed by the Mass Save Home Energy Service Program. Even if the observed wiring appears to be inactive, there might
still be active circuits located in inaccessible areas of the home (i.e. walls, etc.). The Mass Save Home Energy Services Program requires that a licensed
electrician verify the absence or inactivity of the knob and tube wiring in the areas of your home where we are proposing insulation be installed. We advise
YOU to share this form with your electrician before hiring them to inspect your home to ensure they agree to the terms. The Home Energy Services Program
vvill rely on the electrician's certification and will not be liable it inaccurate.
Mechanical System Evaluation (up to $250 Incentive): Combustion safety testing has been conducted on all the heating and hot water systems in this
home_ These tests are conducted with all the exhaust equipment running simultaneously, creating a "worst -case" depressurization of the building. If a
Problem was Identified, repairs to correct the problem must be completed by a qualified HVAC contractor. The problems and corrections are as follows:
1 Carbon monoxide levels exceed 100 ppm in the undiluted flue gases. After a clean and tune, or other applicable service, the measurement(s) of undiluted
f:ue gas of carbon monoxide are to be recorded on the front of this Contractor Evaluation Report where program rules state the maximum allowable
concentration is :00 ppm.
? During your Home Energy Assessment it was discovered that the identified mechanical system(s) was continuously spilling exhaust gases into the home.
This cond.t on is also known as back draft and should end within 60 seconds of system operation in order to be considered acceptable. The contractor
must service the system(s) to correct the spillage problem in the selected flue(s). and certify by signature on the front of this form that the spillage
condition has ceased after 60 seconds of operation.
3 Du+,ng your Home Energy Assessment a was discovered that the identified mechanical system(s) are not creating sufficient DRAFT, TNs condition is
where exhaust gases are not moving through the chimney at a fast enough rate. The contractor must service the system(s) to correct the draft problem
n the selected flue(s). New draft results must be provided on the front of this form and within acceptable draft ranges as described In Table 1.
Outside
c10 -2.5
Table 1 -Acceptable , 10-90 (outside Temp/40) -2.75
Draft Test lunges
>90 -0.5
Exhaust Fan Installation (up to S250 Incentive): The results of the completed blower door test at the time of your Home Energy Assessment or scheduled
.weatherization installation with a Participating Contractor, determined that your home will need an increase in fresh air flow before undertaking any
program eligible weatherization work. Mass Save provides a Weatherization incentive for the installation of an exhaust fan to provide additional fresh air
to the home. Your energy specialist can help determine the necessary flow rate and provide recommendations. This incentive is only available in limited
situations and not all customers will receive a blower door test at the time of the Home Energy Assessment.
BROUGHT TO YOU BY
BL.)CKSTONE \
GAS COMPANY Golumbia Gas,
EVERS_URCE Liberty Utilities nationalgrid � unim
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