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25A-151 (4)
BP-2023-1692 38 WOODBINE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25A-151-001 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-2023-1692 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2023 Contractor: License: Est. Cost: 1000 ENERGY PROTECTORS INC 101 143 Const.Class: Exp.Date: 06/16/2024 Use Group: Owner: JESSICA DAWSON, Lot Size (sq.ft.) Zoning: URB Applicant: ENERGY PROTECTORS INC Applicant Address Phone: Insurance: 64 PAXTON RD (774)253-0277 6S621JB0G29826021 Spencer, MA 01562 ISSUED ON: 11/30/2023 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERIZATION 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: if 1 Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner +ti.10519 ik.T ffie 1Di iiT S''j-►r 6+9 NF►e 1( - . REG ' i-_) MO The Commonwealth of Massachusetts q ,; pplic$tion To Construct,Repair, Renovate Or Demolish a DFPT OF BUILDING 1 onT q��rTON.Ana n 060 One-or Two-Family Dwelling --- /T is ection For Official Use Only Building Permit Number: _d0 6 / Date Applied: /Ciit....) 7Z,-; ___—,--77-- - B-340-7425 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.I a Is this an accepted street?yes, no_ , Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arca(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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: .- Outside Flood Zone? 0 On site system 0 Private 0 - Check if yes❑ Municipaldisposal 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: . . k-nctvv-t h),A 41- Gt 06 C) Name(Print) ('ity.State,ZIP k;00c.D to,r..e fl 0 e "‘ 3 - 3157 -ct ti p 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 tTSpecify: On S t,/` Wll().J1_ Brief Description of Proposed Work2: 41 r' S e r ( 4 v cj \n S 1 Ct 4* 4--it`d, _ __ c: Cam } S. iiS � I t% herCpci.S5 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ 1 0 p 0 I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ) 0 Standard City/Town Application Fee 0 Total Project Cost (Item 6)x multiplier____ x 3. Plumbing $ 2. Other Fees: $ _____ 4.Mechanical (HVAC) $ List: ______. 5.Mechanical (Fire $ Total All F�$1 /,(� � Suppression) Check No._ Check Amount: Cash Amount: 6.Total Project Cost: $ ( t 0 0 0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) cs 1oua3 a,wza Joshua Dada License Number Expiration Date Name of CSL Holder List CSL Type(see below)u 64 Paxton Rd No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) spencer,MA 01562 R Restricted l&2 Family Dwelling City/Town,State.ZIP M Masonry RC RoofingCovering WS Window and Siding SF Solid Fuel Burning Appliances 774.253.0277 pade79Ihotma6.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 172960 6/19/24 Energy Protectors Inc H1C Registration Number Expiration Date HIC Company Name or HIC Registrant Name 64 Paxton Rd ideda794S►olmell.00m No.and Street Email address spencer,MA 01562 774-253-0277 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 Issuanncc of the building permit. Signed Affidavit Attached? Yes CY 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 to act on my behalf,in all matters relative to work authorized by this building permit application. 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. tuSn 06tUtk t l I a (0I Z3 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 Lo/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 halfbaths 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" IN, The Commonwealth of Massachusetts �v. Department of Industrial Accidents -± =°E53 \--: - '',k Office of Investigations ' Lafayette City Center .- a 2 Avenue de Lafayette, Boston, MA 02111-1750 �_� www.mass.gov/dia Workers'Compensation insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant lnformatjon Please Print Legibly Name (Busincss!0rganiiation/lndividuat):Energy Protectors Inc Address:64 Paxton Rd City/State/Zipi,Spenoer,MA 01562 Phone #:774-253-0277 Are you an employer? Check the appropriate box: Type of project(required): I.® 1 am a employer with 1 1 4. 0 I am a general contractor and i• 6 ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. 0 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These subcontractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 4 iofficers have exercised their 11.0Plumbingrepairs or additions 3.❑ 1 am a homeowner doing all work p No workers.m self ' right of exemption per MGL Y [ comp. 12.0 Roof repairs insurance required.] ` c. 152, §1(4), and we have no weetherization • employees. (No workers' 13.�Other — comp. insurance required.] Any applieunk that chocks box N I must also till out the section betoe sbowin5 their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ore doing*II work and Then hire outside eentractnrs must submit a new affidavit indicating such. tContractotx that chock this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employcat. If the sub-contractors hate employees,they must provide their workers'comp.policy number. 1 am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:National Liability& Fire insurance Company Policy#or Self-ins. Lie. #:V9WC421284 _ • Expiration Date:9/1/24 Job Site Address: 3 ' L OO 0 t rkt A`/e- _City/State/Zip: AUc c tr^1p kt/l an Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).V t° 6U Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of tt fine up to 51,500.00 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 veritication. 1 do hereby cert(6,under the pains and penalties of petjary that the Information provided above its true and correct. 5i nature: i -64 (iLe(_. Date: ' t I Xi Z 3 Phone#: 774-253-0277 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License # Issuing Authority(che one): 1❑Board of Health 2U Building Department 30City/Town Clerk 4.0 Electrical Inspector 51:3PlumbIng Inspector 6.0Other Contact Person; Phone N: City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yJ`. Northampton, MA 01060 4411; ..14; 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: tnergy rrotectors inc 64 Paxton Rd Spencer, MA 01562 Location of Facility: The debris will be transported by: Name of Hauler: Signature of Applicant: Date: r 6 I L I ACORE• DATE(MM/DDIYYYY) �� CERTIFICATE OF LIABILITY INSURANCE 8/23/2023 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 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 CONTACT Coonan Insurance Agency, Inc. PHONE Nina Arroyo FAX 267 Main Street WC,No.Ertl:508-987-7122 IA/C.No):508-987-7152 Oxford MA 01540 ADOREss: nina@coonaninsurance.com INSURER(S)_AFFORDING COVERAGE NAIC E _______ _ License*:1782985 INSURER A:AIX Specialty Insurance Co INSURED ENERPRO-01 INSURER a:Safety Insurance Company Energy Protectors, Inc. 64 Paxton Road INSURER C:National Liability&Fire Insurance Company Spencer MA 01562 INSURER 0:Philadelphia Ins Companies_ INSURER E:Century Insurance Company _. INSURER F: COVERAGES CERTIFICATE NUMBER:309612825 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 AU. THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INTR POLICY EXP TYPE OF INSURANCE .NSD I WVD POLICY NUMBER (MMI DYIYYYY) IMM/D YYYYI LIMITS A X 1 COMMERCIAL GENERAL LIABILITY Y ' L1N-H714840-02 8/31/2023 ' 8(31/2024 EACHOCCURRENCE $1,000,000 CLAIMS-MADE f X OCCUR - PREMISES(Ea occurrence)ce) $50,000 MED EXP(Any one person) $5,000 I PERSONAL&ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JECCT- ,LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER- $ B AUTOMOBILE LIABILITY Y 6236519 112/23/2022 12/23/2023 COMBINED SINGLE LIMIT S 1000,000 (Ea accident) ANY ALTO I BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per occident)_ $ E X UMBRELLA LAB X 'OCCUR Y CCP1166257 8/31/2023 8/31/2024 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE S DED X RETENTIONS 1n1,(XX1 $ C WORKERS COMPENSATION V9WC421284 9/1/2023 9/1/2024 X PER OTH- AND EMPLOYERS'LIA61LrrV Y/N STATUTE ER ANYPROPRIETOR!PARTNER/EXECUTIVE E.L EACH ACCIDENT $500.000 /M OFFICEREMBEREXCLUDED? N N/A ---------- (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $500.000 If yes.describe under --- -"-- DESCRIPTION OF OPERATIONS below EL DISEASE•POLICY LIMIT $500,000 D Pollution Liability 1Y PPK2510236 1/6/2023 1/6/2024 Aggregate urn* 500,000 Occurence 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 10t,Additional Remarks Schedule,may be attached if more space is required) Tiffany Circle Townhouses&Phoenix Company,Inc are named as additional insureds and coverage is primary and non-contributory.The additional insured applies to ongoing and completed operations. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tiffany Circle Townhouses ACCORDANCE WITH THE POLICY PROVISIONS. c/o Phoenix Company Inc 650 Lincoln Street AUTHORIZED REPRESENTATIVE Worcester MA 01605 ' 'to- t ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Division commonwealth of Occupational Board of gugdin Pat+onal Lice 9 Repulatron nsure a dar Cads, rtgitr sand Standards i CS-101143 .& 'sor y ! JOSHUq 4r • 64 Pg1(Tp y�o IZOq t ! 6iprres:06;16/2024 SPENCER Mif 0151 ._ - F f .... r 1i 15. S:Crttr 4 ^' e THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aftaittand Business Regulation 1000 Washington atr -Suite 710 Boston, Massa(' - =a 118 Home lmpro a : 4 ' :-..;.-„ _ .I. ......................r ........ # Type- Corporation . 172�} ENERGY PROTECTORS INC. file -- • - 08/19I202 64 PAXTON RD. ..-• . ._..tee r SPENCER,MA 01562 " ""' � .,..,, 1 ' 4y16 _ update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS OM{crt of Consumer Aftaets 4 Business Regulation Registration valid for individual use only before the HOME IMPROVEMEHTCONTRACTaft expiration date. if found return to: TYPE:CriffZfation Office of Consumer Affatcs and Business Regulation Refi41E-4* % Egigiltson 1004 Washington Street -Suite 710 172900 08/1972024 Boston_MA 02118 ENERGY PROTECT. ;-__ rir:-- -_ ice• JOSHUA DADA 4 `s_ .i. s i Jtc 64 PAXTON RD. -�4: :t ':;, SPENCER-MA dt$ti2 t valid without signature WEATHERIZATION CONTRACT EVERS=URCE CUSTOMER PHONE DATE CUENT WORK ORDER Jessica Dawson (413)387-9951 09/07/2023 547801 61602 SERVICE STREET BILLING STREET PROPOSED BY: 38 Woodbine Avenue 40 Woodbine Avenue Jeff Ledoux SERVICE CITY.STATE.ZIP BILLING CITY.STATE.ZIP Program Northampton, MA 01060 Northampton, Ma 01060 EGMA-HES Page 1 DESCRIPTION QTY COST INCENTIVE TOTAL INCENTIVE:WHOLE BUILDING Eversource,as a Sponsor of the Mass Save program,offers a Whole Building 100% insulation incentive per unit for eligible insulation and air sealing measures.This incentive is for a non-owner occupied single-family or, all units in a 2-4 building where all eligible major insulation measures in all units are being completed at the same time. KNOB&TUBE WIRING(Northhampton) We have identified that your home might have Knob&Tube wiring J.D. (initials) present.The following contract is not valid unless accompanied by the Weatherization Barrier Incentive form,signed by your licensed electrician.Work will not proceed with this work until we receive a copy of the form. HOME AIR SEALING 2 $213.18 $213.18 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 0-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. BASEMENT SILLS-6"FIBERGLASS 140 $427.00 $427.00 Provide labor and materials to install R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. Document Ref:3KDSW-MSZOB-9DKWW-GTACU Page 3 of 6 WEATHERIZATION CONTRACT EVERSSURCE CUSTOMER PHONE DATE CLIENT# WORK ORDER Jessica Dawson (413)387-9951 09/07/2023 547801 61602 SERVICE STREET BILLING STREET PROPOSED BY. 38 Woodbine Avenue 40 Woodbine Avenue Jeff Ledoux SERVICE CITY,STATE.ZIP BILLING CITY.STATE.ZIP Program Northampton, MA 01060 Northampton, Ma 01060 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL PREPARE YOUR HOME Homeowner is responsible for the removal of any items stored in the J.D. (initials) areas where the weatherization measures will be installed. The workers will need the space cleared to safely bring their tools and materials into these work areas. If you have any questions or specific concerns, please bring them to the attention of your subcontractor when they call to schedule your work. Total: $838.12 Program Incentive: $838.12 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. tle{feiy Wow' JP,J'rza. Da((aok RISE Representative Client Signature 09-29-2023 Printed Name Date of Acceptance Document Ref:3KDSW-MSZQB-9DKWW-GTACU Page 4 of 6 mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM I, Jessica Dawson owner of the property located at: (Owner's Name) 38-40 Woodbine 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. Jessica Dakrsou Owner's Signature 09-29-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: cAM—bC-i! ( t/( S ( Z Particip ing Contractor Date Document Ref:3KDSW-MSZQB-9DKWW-GTACU Page 5 of 6 ..04,/,„tr. mass save 2022-23 Weatherizatian Barrier Incentives Based on your Energy Specialist's recommendations,your home can benefit from program-eligible insulatioe ervt/or air sealing improvements.Before moving forward,please follow ail the instructions below to remediate your weatherieation barriers. CUSTOMER INSTRUCTIONS 1.Hire a qualified,licensed contractor to evaluate arid/or rernodiate the weathenzation barrier(s) 2.Submit signed and completed copies of this form and a copy of the paid contractor invoice(s)within C0 days of your Home Energy Assessment to:RISE Engineering,76ii Attucks Lane,Hyannis,MA 02601 or email to tinassSavecgRISEenginecring.com. 3,The weatherieation incentive will be deducted from the customer co-payment amount of tee weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount. 4.Complete the recommended went herization improvements, CUSTOMER I,NFOf;MATIONS,... . Customer Name: Jessica Dawson __. Client u or Site ID: 546705 40 Woodbine Avenue Avenue Northampton state; MA ZIP 01060 Site Address; oh,. ......_-- • Phone Number: 413-387-9951 Lrn,,ri:fessica.h.dawson@gmail.Com Customer/Homeowner Signature: Date:_........._.. KNOB•ANb'TUBE WiRth4G '.� ..+' .; 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: �/ Attic Floor r'Attic Wall '` Attic Slope 0 Exterior Wall r j Basement '_,, Other: Other: le I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below. t.,)Attic Floor Attic Wallf�l Attic SlopeExteriorWall B 0 asement -,,:. ter. � --� Oh _- �=th2r. Contractor Name: V/)Ale t no I L1.4,1--s,c Address: 4A R. i J,/4 et < • / City: r00L e State/ rib ZIP: 01 Cl62 Company Name: III' License Number:Ac l e/F / Contractor Signature: Date: 1i1/d7 2.3 My signature confirms t: .ve perfon aed my inspection of tnc decimal systems listed above and have corrected any barriers as indicated.My signature a,n confirms that I have read and agree to the Terms and Conditions outlined on the back of this form- • MECHANICAL SYSTEM BARRIERS:lab.-' i...i,�;.,i t; :.::c i c :ran,' t,., High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and redirect - C .• `t o de:f ie 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. High Carbon Monoxide Draft Failure Existing CO Ppm Revised CO ppm Existing Draft Pa Revised Draft Pa Heating System Hot Water Heater Other 1 . .. _ ._ Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical rystem(s).Must not spill after CO seconds of operation. !� Heating System _,+Hot Water Heater i, Other: Contractor flame: _. Address: _ __ City: __.__ .. Stater.-_,. _._._ZIP. Company Name: License Nurnbei Contractor Signature: ‘ Date: Mi sign.ttur+:confim is that I have perlurrnc-d my inspection of the mechanical systtans!stud stove+and h,we carroct-ci zany lac rners,-is indicated My signature also confirms that 1 have read and agree to the Terms,and Conditions outlined on the back of this form