11A-051 (2) BP-2024-0129
9 VILLONE DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
11A-051-001 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-2024-0129 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2024 Contractor: License:
Est.Cost: 9000 SUPERIOR INSULATION LLC 106237
Const.Class: Exp.Date: 06/15/2025
Use Group: Owner: SARLIN, ASHER &JUSTINE SHAKESPEARE
Lot Size (sq.ft.)
Zoning: URA Applicant: SUPERIOR INSULATION LLC
Applicant Address Phone: Insurance:
14B ENTERPRISE LANE (401)515-4524 67872
SMITHFIELD, RI 02917
ISSUED ON: 02/07/2024
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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 414 y 11-11 .lQ
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
113-- —.1067
�, The Commonwealth of Massach setts 2024
Vt Board of Building Regulations and tank' 4� F R
Massachusetts State Building Code, 7g(1.C1 q n i,„ �Nc E ITY
S',-.. 7:ri pCr
Building Permit Application To Construct,Repair,Renovate Or ticaos Vise Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
BuildingPermit Number: 6�>-01 V' /all Date Ap 1'
i //7 c-v ��055 2-1-ZOZy
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1,�,�rp�Gz AEI s �� 1.2 Assessors Map&Parcel Numbers n 1�
1.11 a IsIs this an`accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: vm 1.4 Property Dimensions: yl l
cks
Zoning District Proposed Use` Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) r l a
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: 11
Public 0 Private 0 'n /� Zone: _ Outside Flood Zon ? Municipal❑ On site disposal system� 0 —
1I rk(Jt.
Check if yes❑
SECTION 2: PROPERTY 0 RSHIP'
��QwnerI of R r�4 n Leeds Uv b i a s
nf'.r 1
harm(Thiov
City,State,ZIP
tor. 2-1*- 2)141- 3�"9- i
N .an 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 11 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Unit Other Specify: a lam' D Yl
Brief Description of Proposed Work2: Air cut ayot in W ig aT l l(' an/
INa1.l1S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ c D{qj 1. Building Permit Fee: $ Indicate how fee is determined:
�1 `,�' ❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All F336�� �
n o Check No. eck Amoun : Cash Amount:
6.Total Project Cost: $ 1100 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) I1)(0223+ I i ( 2S
's�, 1 `olLk 'J License Number Expirlion Date
Name of Colder T
�, t IS vexp - ' `,.� List CSL Type(see below) J-�
No.and Street l Type Description
r - 1 4 �p 1 n t 0�� U Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,StateL�Z►IPA{/'� l 11�•l R Restricted 1&2 Family Dwelling
M Masonry
4
r 1�^� RC Roofing Covering
v � p��V �b b `�po WS Window and Siding
L., �� SF Solid Fuel Burning Appliances
`"t I Insulation
Telephone Email address D Demolition
Registered Home Improvement Contractor(HIC) I-iG/ 1/ / 7.,S
x�C�r ,�,ki HIC Registration Number E on Dope
tAt ni`Tame �� �strant Name
U'- / -e—
`l`1
o.and e L U0 t 6(s'152 Email address
City/Town,State
4l/l Telephone_1
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 Issuance of the building permit.
Signed Affidavit Attached? Yes �`1✓ 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 Se"� et,
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
conta' ed in this applicati is true and accurate to the best of my knowledge and understanding.
e - -- ' I
Print i
r' o uthoriz Agent's Name(Electronic Signature) / Dye
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 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"
City of Northampton
�,?-'" Massachusetts c'i
a. ec,
" •4 DEPARTMENT OF BUILDING INSPECTIONS
ti%
212 Main Street • Municipal Building y0 Ca
4 Y Northampton, MA 01060 S6:15, Tos
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: Ur\ -A/n*0 CIA
The debris will be transported by:
Name of Hauler:
SU19e)rt ti •
, '
Signature of Applicant: A Date: 1,212/_24.
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
� `k-- .? ; 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Superior Insulation, LLC
Address: 140 Point Judith Rd,A7
City/State/Zip: Narragansett, RI 02882 Phone#: 401-515-4524
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 12 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.x❑ Other Insulate
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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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: Beacon Mutual
Policy#or Self-ins.
.LLic.#: 67872 Expiration Date: 8/2/24_
Job Site Address: - 1 VI 11(0 Vi bY*-= City/State/Zip:t�. j LAVI-
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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 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 verification.
I do hereby certify under the pains a %and penaltiesof perjury that the information provided above
is/tr true and correct
Signature: /1G •��-0.% Date: ' / �_�c/ / ?Li
Phone#:
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#:
•
SUPEINS-01 MLONGOLUCCO
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
7/14/2023
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 COMNTACT
NAE:
Mansfield Insurance Agency Inc. PHONE FAx
115 High Street (A/C,No,Est):(401)596-2096 (ac,No):(401)348-2060
Westerly,RI 02891 ADDRIESS:info@mansfieldins.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Employers Mutual Casualty(EMC)Company 21415
INSURED INSURER B:Beacon Mutual Insurance Co. 30325
Superior Insulation LLC INSURER C:Evanston Insurance Company
Michael O'Connor
140 Point Judith Road,Unit A7 INSURER D:
Narragansett,RI 02882 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 POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSD WVD IMMIDD/YYYYI IMM/DD/YYYYI
A X COMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR X x 6D23763 8/2/2023 8/2/2024 PREMISESO(Ea occ RENTED
rrence) $ 500,000
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER:General Aggregate
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
(Ea accident)
X ANY AUTO X X 6B23763 8/2/2023 8/2/2024 BODILY INJURY(Per person) $
OWNED SCHEDULED
_ AUTEO�S ONLY _ AUTOS BODILYBODILY INJURY(Per accident) $
- AUTOS ONLY _ AUUTOS ONLY (Per ardent DAMAGE
A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000
EXCESS LIAB CLAIMS-MADE X x 6N23763 8/2/2023 8/2/2024 AGGREGATE $
DED X RETENTION$ 10,000 $ 5,000,000
B WORKERS COMPENSATION X STATUTE OTH-
ER
AND EMPLOYERS'LIABILITY X 67872 8/2/2023 8/2/2024 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE -1 E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? I I N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
C Pollution Liability x x CPLMOL118083 7/6/2023 7/6/2024 Per Occurrence 250,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101 Additional Remarks Schedule,may be attached if more space is required)
Residential Insulation Contractor-14B Enterprise Lane,Smithfield,RI 02917
Pollution Liability Aggregate Limit$500,000
National Grid and all divisions are named as additional insured per written contract or agreement.Waiver of subrogation is provided in favor of National Grid
and all divisions per written contract or agreement.
Pollution Liability includes mold
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
40 Sylvan Rd
Waltham,MA 02451
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
il
sen
Commonwealth of essachu turn
Division of OCcupational
Board of Building It 5ulattons and Standards
ConstructiQl4upe4lagr Specialty
CSSL•106237 s lures:0611 520 2 5
KYLE L LEDItC
3760 DIAMOND HILL RD -
CUMBERLANq fa 02664Q THE COMMONWEALTH OF MASSACHUSETTS
',3. 7,' Office of Consumer Affairs and Business Regulation
'lrruvaa) 1000 Washington Street-Suite 710
Commissioner droepa g.YE/Ita„.., Boston,Massachusetts 02118
" Home Improvement Contractor Registration
t^ __ - e•(1ype: Supplement Card
SUPERIOR INSULATION LLC. �- 175445
140 POINT JUDITH RD UNIT A7 �__ '`,tine: 05112l21125
NARRAGANSETT,RI 02882 ............ w
t
41k �,e•"
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEfyytE,�NICONTRACTOR expiration date.H found return to:
TYPE;SuppI8it tit.Card Office of Consumer Affairs and Business Regulation
'_. 1000 Washington Street-Suite 710
Re175445 Etskillign
175,.IA45''#.1:05J12R025 Boston,MA 02116
Construction Supervisor Specialty SUPERIOR INSULATION u�.. :y.
T5
Rnlrunad to: l/ I I -I
csSL.IC-Insulation Contractor KYLE LEDUC v ,*�,,= :i , fii4A,
140 POINT JUDITH RD t{NI r- - - ey.,.A a.7 /t
NARRAGANSETT,RI 02852, ,'.,. Undersecretary Not valid without signature
Feline to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this ticete.
For information about this hc:te
Call(617)727-3200 or visit www.mass.gov/del
•
WEATHERIZATION CONTRACT EVERS=URCE
CUSTOMER PHONE DATE CLIENT# WORK ORDER
Asher Sarlin (201) 341-3271 11/15/2023 553303 11802
SERVICE STREET BILLING STREET PROPOSED BY:
9 Villone Drive 9 Villone Dr Cole Payne
SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program
Leeds, MA 01053 Leeds, MA 01053 EGMA-HES Page 1
DESCRIPTION QTY COST INCENTIVE TOTAL
INCENTIVE 75%
For eligible weatherization measures, Eversource is offering an
incentive of 75%for insulation measures and 100%for the air sealing
measures, both with no limit.You are eligible to apply for the 0% Heat
Loan to finance your co-pay,applications must be submitted before
the weatherization work begins.
KNOB&TUBE WIRING SIGN-OFF-FSC 1 $250.00 $250.00
The wiring in the areas weatherization work is proposed will be
reviewed by a licensed electrician to determine if there is any existing
live knob&tube wiring.
VERMICULITE HAZARD MUST MITIGATE
We have noted there is vermiculite insulation in your home which 4.4. (initials)
might contain asbestos fibers,a known carcinogen.Weatherization
work cannot proceed until the vermiculite is properly mitigated.
HOME AIR SEALING 12 $1,279.08 $1,279.08
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.)
ATTIC DAMMING 30 $83.40 $62.55 $20.85
Provide labor and materials to install an approved damming material
in the attic
ATTIC FLAT-15"OPEN R-49 CELLULOSE 1,500 $4,305.00 $3,228.75 $1,076.25
Provide labor and materials to install a 15"layer of R-49 Class I
Cellulose to open attic space.
HATCH-INSULATE RIGID BOARD 1 $53.96 $40.47 $13.49
Provide labor and materials to insulate the back of an attic hatch with
2"rigid insulation board at R-10.
WALLS-VINYL SIDED 4" 690 $2,104.50 $1,578.38 $526.12
Install blown in Class I Cellulose to vinyl-sided exterior walls.
Homeowner has received a copy of the EPA's Renovate Right Lead-
Safe information guide explaining the potential risk of the lead hazard
exposure from the weatherization work to be performed.Your
signature is your acknowledgement of receipt and agreement to
proceed.
COMMON WALL-DRILL AND PLUG 4" 20 $59.60 $44.70 $14.90
Provide labor and materials to install blown in Class I Cellulose to
exterior walls through an interior surface drill and plug method. Plugs
Document Ref:JP6WQ-YCQFT-CGBVJ-QJEDV Page 1 of 3
•
WEATHERIZATION CONTRACT EVERS=URCE
CUSTOMER PHONE DATE CLIENT# WORK ORDER
Asher Sarlin (201) 341-3271 11/15/2023 553303 11802
SERVICE STREET BILLING STREET PROPOSED BY:
9 Villone Drive 9 Villone Dr Cole Payne
SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP Program
Leeds, MA 01053 Leeds, MA 01053 EGMA-HES Page 2
DESCRIPTION QTY COST INCENTIVE TOTAL
will be spackled and left with a rough finish. Finish sanding and touch-
up priming/painting will be the customer's responsibility. Homeowner
has received a copy of the EPA's Renovate Right Lead-Safe
information guide explaining the potential risk of the lead hazard
exposure from the weatherization work to be performed.Your
signature is your acknowedgement of receipt and agreement to
proceed.
VENT BATH FAN TO ROOF OR OTHER 2 $333.06 $249.80 $83.26
Install an insulated exhaust hose to a flapper vent to exhaust existing
bathroom fan(s). Fan will be vented through the roof or an acceptable
alternative if contractor cannot vent through the roof.
INSULATED BATH EXHAUST HOSE 4 INCH 2 $64.46 $48.35 $16.11
Provide labor and materials to install an insulated 4"exhaust hose to
existing bathroom fan(s).
TURBINE ROOF VENT 1 $198.21 $148.66 $49.55
Provide labor and materials to install a roof mounted turbine vent.
RECESSED LIGHTS-FSC 1 $200.00 $200.00
We have identified that there are recessed lights present in your
home. unless the recessed lights are certified by a licensed
electrician as being IC-rated (Insulation Contact Rated)we will
proceed with boxing the lights in with customer built covers
maintaining a minimum 3"clearance on all sides of the fixture. If the
lights are signed off as being IC Rated we will remove the Recessed
Light Box measures from your contract via change order.
Total: $8,931.27
Program Incentive: $7,130.74
Client Total: $1,800.53
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.
—Ca& P—at/A e ofrker
RISE Representative Client Signature
Cole Payne 11-17-2023
Printed Name Date of Acceptance
Document Ref:JP6WQ-YCQFT-CGBVJ-QJEDV Page 2 of 3
mass save
Savings through energy efficiency
PERMIT AUTHORIZATION FORM
I, Asher Sarlin owner of the property located at:
(Owner's Name)
9 Villone Drive Leeds
(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.
4,rker Sara&
Owner's Signature
11-17-2023
Date
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor
to the above referenced project:
Participa ing Contractor Date
Document Ref:JP6WQ-YCQFT-CGBVJ-QJEDV Page 1 of 1