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11A-007 (7) BP 022-1419 35 CHESTNUT AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 11A-007-001 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-2022-1419 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 2000 HOMEWORKS ENERGY INC 106148 Const.Class: Exp.Date: 07/30/2024 Use Group: Owner: GRAVEL LESLIE CHALMERS Lot Size (sq.ft.) Zoning: URA Applicant: HOMEWORKS ENERGY INC Applicant Address Phone: Insurance: 59 TOSCA DR 781-205-4484 ECC-600-400 1 0 1 7-2022 STOUGHTON, MA 02072 ISSUED ON:11/02/2022 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: 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: i 7-1,8 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner FEE: $65.00 „_r 7619 o,40 .o, City of Northampton Den 0R '.>>/"' " Building Department , f21 RoMain om 00 et INSULATION ,,,- Northampton, MA 01060 _. ____- - - phone 413-587-1240 Fax 413-587-1272 ONL Y APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 Property Address: Map / /A- Lot GO Unit 35 Chestnut Avenue Northampton MA 01053 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Leslie Gravel 35 Chestnut Avenue Northampton MA 01053 Name(Pant) Current Mailing Address: See Attached (413)330-4118 Telephone Signature 2.2 Authorized Anent: Adam Glenn 235 Essex Street, Whitman, MA 02382 Name(Print) , Current Mailing Address: 64/(4 781-205-4484 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2,000 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) e 5. Fire Protection 6. Total = (1 +2+3+4+5) 2,000 Check Number 705)- This Section For Official Use Only Building Permit Number:/5 1 as .. i ,` /'Q I su "f t ssued: Signature: ;/ - ---'' I 1- 2- Z)Z Z Building Commissioner/Inspector of Buildings Date wxpermitting @ homeworksenergy.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder_Adam Glenn 106148 License Number 235 Essex Street, Whitman, MA 02382 07/30/2024 AcclicjlreL Expiration Date 781-205-4484 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ HomeWorks Energy 181138 Company Name Registration Number 235 Essex Street, Whitman, MA 02382 03/02/2023 Address ] Expiration Date Telephone 781-205-4484 SECTION 5-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 RI J No ❑ Brief Description of Proposed Work Residential weatherization/ Air sealing. No structural changes. SITE ID CAP-3967 Adam Glenn , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Adam Glenn Print Name cac, 10/24/2022 Signature of Owner/Agent Date Leslie Gravel ,as Owner of the subject property hereby authorize HomeWorks Energy to act on my behalf, in all matters relative to work authorized by this building permit application. See Attached 10/24/2022 Signature of Owner Date City of Northampton 0. H4MY� r•'" Massachusetts 4'4?` A._. 1 P ' DEPARTMENT OF BUILDING INSPECTIONS + r` 212 Main Street • Municipal Building a se '` Northampton, MA 01060 s�W..3( 6`.� AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction,alteration, renovation,repair, modernization, conversion, improvement, removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by redstered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work:Weatherization Est. Cost:2,000 Address of Work:35 Chestnut Avenue Northampton MA 01053 Date of Permit Application: 10/24/2022 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 10/24/2022 Adam Glenn 181138 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton ir r'..;!›'.1;, I,;t1r< ) ,,5 •si Massachusetts 3 . ''�!�G DEPART14ENT OF BUILDING INSPECTIONS S f� 212 Main Street •Municipal Building J o b C- Northampton, MA 01060 r �� Debris 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. The debris from construction work being performed at: 35 Chestnut Avenue Northampton MA 01053 (Please print house number and street name) Is to be disposed of at: McNamara Waste Services LLC, 24 E Longmeadow Rd, Hampden,MA 01036 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) cilla.4 c)(:)10a:d- 10/24/2022 Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. Cit y of Northampton a[H�MP-o � ,r, I,.' Massachusetts �}' ',� H= • 's . ,, DEPARTMENT OF BUILDING INSPECTIONS yt ijs' 212 Main Street • Municipal Building `�y.;•,, O' Northampton, NA 01060 % MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 35 Chestnut Avenue Northampton MA 01053 Contractor Name: HomeWorks Energy Address: 235 Essex Street City, State: Whitman, MA 02382 Phone: 781-205-4484 Name:Property Owner Leslie Gravel Address: 35 Chestnut Avenue Northampton MA 01053 City, State: I Adam Glenn (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signatureciaL ,, ;i0eis-d- cte.._ Date 10/24/2022 The Commonwealth of Massachusetts 1; l i Department of Industrial Accidents T_ 1 Congress Street,Suite 100 "'�,�— Boston, MA 02114-2017 www mass.gov/dig Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILET)WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): HomeWorks Fncrg y Address: 235 Essex Street City/State/Zip: Whitman, MA 02382 Phone#: 781-2054484 Are you an employer?Check the appropriate box: Type of project(required): I LJ am a employer with 500 employees(full and/or part-time).*2. i 7. ❑New construction am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑1 am a homeowner doing all work myself [No workers'comp.insurance required.]t 10 ❑Building addition 4.0 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.❑Plumbing repairs or additions 5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.: 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MCiL c. 14 ther WEATHERIZATION 152,§I(4),and we have no employees.[No workers'comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infonnation. 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: NH Employers Insurance Company Policy#or Self-ins.Lic.#:#4001017 Expiration Date: 01/01/2023 Job Site AdrlrPcc• 35 Chestnut Avenue Northampton MA 01053 City/State/Zip: 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. I do hereby certify under the pains and pe • of perjury that the information provided above is true and correct Signature: 10/24/2022 Date: Phone#:781-205-4484 II wxpermittingAhomeworksenergy.com 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#: i....,N HOMEENE-01 LLARIVIEI A�ORO CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYV) 1/3/2022 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 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 NAM• CT Lisa Lariviere Foster Sullivan Insurance Group,LLC PHONE FAx 163 Main Street Miss, L cA,�No,Ext):(978)686-2266 301 I lac,No):(978)686-6410 North Andover,MA 01845 ESS,certificates@fostersullivangroup.com INSURER(S)AFFORDING COVERAGE NAIC X INSURER A:Central Mutual Insurance Company 20230 INSURED INSURER B:NH Employers Insurance Company 13083 Homeworks Energy,Inc INSURER C:Markel Insurance Company 38970 Homeworks IIC LLC 101 Station Landing Suite 100 INSURER D: Medford,MA 02155 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 PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLN:Y NUMBER POLICY EFF POLICY EXP LIMITS LTRINSR WVD (MM/DD/YYYYI PIM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CLP 8698469 1/1/2022 1/1/2023 DPREMISAMAGEES(TOEa RENTEDm eno� S 300,000 occu MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY_ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITYCOMBINE deD`SINGLE LIMIT $ 1,000,000 — ANY AUTO BAP 8698470 1/1/2022 1/1/2023 BODILY INJURY(Per penwn) $ OWNEDSCHEDULED _ AUTOSRE� ONLY v AUTOS BODILY BBRODILY INJURYp (Per accident) $ X AUTOS ONLY X AUTO'ONLY (Pero E TYnM) GE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE CXS 8698471 1/1/2022 1/1/2023 AGGREGATE $ 1,000,000 DED , X RETENTION$ 0 $ B AANND EEMPLOYERS'LIABILITY Y/N ON X STATUTE Elf ANY PROPRIETOR/PARTNER/EXECUTIVE ECC-600-4001017-2022A 1/1/2022 1/1/2023 1,000,000 �FFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1'000'000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ C Pollution Liability CPLMOL109278 1/1/2022 1/1/2023 $10,000 Deductible 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) Evidence Only CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Homeworks Energy Inc. ACCORDANCE WITH THE POLICION DATE YRPROVISIONS.NOTICE WILL BE DELIVERED IN 101 Station Landing Ste 100 Medford,MA 02155 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t.c7Z- /..ye jacieokt," Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston. Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 181138 HOME WORKS ENERGY,INC. Expiration: 03/02/202'3 101 STATION LANDING STE 110 MEDFORD,MA 02155 Update Address and Return Card. SCA 1 0 20M1.060117 t Office of Consumer Affairs&Business negotiation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Supplement Card before the expiration date. If found return to: pegistralop EJ(Qira1(arl Office of Consumer Affairs and Business Regulation 181138 03/02/2023 1000 Washington Street -Suite 710 HOME WORKS ENERGY,INC. Boston,MA 02118 101 STATION LANDING STE-110 aretilseNd-i. MEDFORD,MA 02155 Not valid without signature Undersecretary Commonwealth of Massachusetts Division of Occupational Licensure ResVQ� edlo Construction Supervisor Specially Board of Budding Re ulations and Standards CSSL.iC .Insulation Contractor C:onstructiQ i.trer' r Specialty CSSL-106148 * 61toires: 07/30/2024 ADAM GLE .• i - m 19 CHARGE WAREHAM M . **)� 1st Failure topossess a current edition of the Massachusetts Ytjav ) State Building Code is cause for revocation of this license For information about this license Carl(617)7273200 or visit www mass govidpi COMMiSSICiiCT r f,. v�itrrrii�, Massachusetts Low-Income Weatherization Assistance Program rCliera Education Material: Receipt Confirmation Agency Name: LO MUI'JI N friCTIDN Ff0 t (& V -L1.V '( : i' r' I Auditor: Client Name: � ___ — —Tv— Job Number: Address: City/'Town: 1 Phone No: I have received the following information as part of my participation in the Massachusetts Weatherization Assistance Program and consent to proceed forth with weatherization work at my dwelling. ❑Asbestos Education/General information regarding asbestos,asbestos dangers,and ways to avoid asbestos exposure are provided in the EPA's"Protect Your family"information sheet. Education was provided to me relating to the following specific to my dwelling: ❑Asbestos shingles/siding ❑Asbestos on pipes/heating systems ❑Potential asbestos in vermiculite insulation fi Lead-Safe Education/A copy of the EPA pamphlet"The Lead-Safe Certified Guide to Renovate Right", informing me of the potential risk of lead hazard exposure from weatherization/renovation activities to be performed at my dwelling unit. ❑ Mold&Moisture Education/A copy of the EPA pamphlet"A Brief Guide Mold, Moisture and Your Home" informing me of best practices in cleaning up residential mold problems as well as how to prevent mold gro 0 Pest Prevention Education/A copy of the EPA pamphlet:"Preventing Pests at Home"informing me of b practices in pest prevention. ❑ Radon Education/The following were provided to me: 1)Copy of the EPA's"A Citizens Guide to Radon"otthe EPA's"Basic Radon Facts",2)Massachusetts"Radon Fact Sheet"informing me of the natural presence of rado�I in the ground and the hazards of exposure to radon,and 3)Massachusetts"WAP Radon Information Sheet". ❑ Ventilation&Indoor Air Quality Education/General information regarding the purpose and need for mechanical ventilation as well as a copy of the EPA pamphlet: "Care for Your Air:A Guide to Indoor Air Quality". Cl Sign Here: �Z Date: i(i IV_ el/tr0 4 �YC�� SE�/1%i /��//6'fCG/wr Li Refusal to Sign/I certify that I have m a goiaslfaith effort to deliver the information to the client of the dwelling unit fisted above on the date indicated,and that the client has refused to sign the Client Education Confirmation of Receipt and Consent form. I certify that I have left copies of the information listed(checked) above at the dwelling unit with the client. c 1 `ba • [I Sign Here: Date: tiLlency au/Ater 5:7��m ' — __ The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNICIPALITY 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 Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.I Property Address: 1.2 Assessors Map& Parcel Numbers l.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Usc 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 Zone: Outside Flood Zone? _ Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP 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 Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ IDStandard 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 Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due: Attic Inspection Form Mandatory for all Attic Insulation Jobs CLIENT NAME: Leslie Gravel JOB NUMBER: 22-945WX DATE: 7/29/2022 Section A- To be filled in by WAP Auditor during the initial interview with the client. Are there any recessed lighting fixtures in this dwelling? No If Yes, Location(s) Section B - To be filled in by WAP Auditor upon visual inspection of the ceiling beneath the attic. Recessed Lighting Fixtures Other Potential Heat Producers Section C - To be filled in by the Insulation Contractor at the time of Installation. 1)Number of Recessed Lights (Should agree with B): 2)Furnace Flues: 3) Heat Producers: 4)Total Guards Needed: Section D - To be signed by the Insulation Contractor after completion. I have installed Insulation guards. Signed Date Subgrantee/Company Section E - To be signed by the Weatherization Client. I agree that the number of insulation guards indicated have been installed as noted above. I have received the Notice to the Client attached below. Signed Date (DETACH BELOW AND GIVE TO CLIENT) Notice to Weatherization Clients: The purpose of the insulation guards is to ensure that your dwelling is in compliance with the National Electric Code and that the insulation used meets all Federal test specifications. However, since insulation retains heat, it is essential that heat producing sources be protected. For this reason, it is important that insulation guards not be removed, altered or covered. Be sure to use insulation guards if you install new recessed light fixtures or some similar fixture.Also be certain not to obstruct any attic ventilation devices. SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) • License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street -- Type Description U Unrestricted(Buildings up to 35.000 cu.IL) — — R Restricted 1&2 Family Dwelling City/Town,State.ZIP Masonry RC Roofing Covering — --- ——------------- WS N'indow and Siding SF Solid Fuel Burning Appliances Insulation Telephone Email address t) - Demolition 5.2 Registered Home Improvement Contractor(111C) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP fclepltone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 0 No 0 SECTION 7a:OWNER AUTHORIZATION TO RE 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. LIS tie ChAlAttfailir 1412/2 2 Print Owner's Name(Electron 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 oldie information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) 1, lc 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. 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" Work Order Community Action Pioneer Valley Job Number:22-945WX P.O.Box 1432 Work Order Date:7/29/2022 Greenfield,MA 01302 Ownership:Owner Phone:413-774-2310 Green Collar Auditor:Alexandra Sullivan 570 Newton Street Email:auullivan@communityaction.us South Hadley MA 01075 Cell:413 834-3618 Email:brian@greencollarma.com Phone:413 376-1116 Phone:(413)532-1817 Leslie Gravel NGRID Electric $1,029.66 35 Chestnut Ave Total $1,029.66 Leeds Ma 01053-9723 413-330-4118 Additional Contractor Instructions: Authorized Actual Measure Description Comments Qty Price Total Qty Total Basement Insulation 6 ml poly on ground-Standard 180 $1.34 $241.20 either tape and seal old,or replace.cover dirt poly crawl and seal/bathtub poly up the wall,not currently sealed Perimeter 2"THERMAX or 50 $4.61 $230.50 for above grade wall and roof over bulkhead/ equivalent foam board*** basemetn door.cover w thermax,and seal with foil tape Health&Safety Replace Clothes Dryer/Exhaust Fan 1 $67.00 $67.00 Transition Duct only Misc Insulation Domestic water pipe wrap 12 $4.58 $54.96 R5 first 6'of hot and cold DHW.tape and seal,include elbows Page 1 Work Order: Job Number: 22-945WX Misc Measures Attic/basement blower door guided 3 $105.00 $315.00 update chimney flashing(needs caulk), sealing with one-part foam basement door/bulkhead area(block squirrel access?) Blower Door Testing with Zonal 1 $71.00 $71.00 Pressure-Pre&Post Permit Building Permit 1 $50.00 $50.00 Total $1,029.66 Contractor Instructions: Before Starting,the Job: During the Job: 1. Please notify us 24 hours before starting or scheduling a job. 1. Incorporate lead safe practices as applicable. 2.Obtain required building permit. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. 3.Photograph any air sealing or other work to be covered by insulation. Your Invoice Must Include: 1.Client name,client address and job number. 2.Signed and dated copy of the work order. 3.Pre and post blower door test results. 4.Attic inspection form. 5.Copy of certificate of insulation. 6.Copy of building permit. 7. Manufacture labels from replacement doors and windows. 8.Photographs of air sealing or other work covered by insulation. I certify that: *I am a licensed MA Lead-Safe Renovator Supervisor and was responsible for the above job site. *All work was completed consistent with MA DLS RRP and DOE LSW requirements. Contractor: Date: Print Name: Page 2