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10B-009 (2) BP-2024-0276 54 AUDUBON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10B-009-001 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-2024-0276 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 11000 SUPERIOR INSULATION LLC 106237 Const.Class: Exp.Date: 06/15/2025 Use Group: Owner: BURNS, ALYXANDER &ZOE CRABTREE Lot Size (sq.ft.) Zoning: URB Applicant: BURNS, ALYXANDER &ZOE CRABTREE Applicant Address Phone: Insurance: 54 AUDUBON RD LEEDS, MA 01053 ISSUED ON: 03/15/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ER I ZATI ON 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: 2z '• / •L.4,44. Fees Paid: $71.50 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner SJ. The Commonwealth of Ma`;sachusntts i ' /::, Board of Building Regulations andaptdards ` FOR 0): Massachusetts State Building Code, {8;'C,MR ',0. MUNICIPALITY Building Permit Application To Construct,Repair, Ren '�o .Or De 'sh a Revised Mar 2011 One-or Two-Family Dwelling . ):r',^ This Section For Official Use Only /,,�`., , Building Permit Number: 64,A V' ?7 4i Date Applied: �'',ao°zs L,aat s l-dstreLia, ,e- / . " ark9 21 Building Official(Print Name) Signature Da SECTION 1:SITE INFORMATION 1.1 PropKrty Addres : 1.2 Assessors Map& Parcel Numbers ,u lObn 12OOc/ iY \ ber 1.1 a Is this an accepted street?yes no Map Num Parcel Number 1.3 Zoning Information: ► 1 a_ 1.4 Property Dimensions: In Zoning District Proposed Use Lot Area(sq ft) FrontaA(ft) 1.5 Building Setbacks(ft) VI'Cu 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: mw 1n Zone: Outside Flood Z ne? Public 0 Private 0 r 1 — Check if yes❑ , Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 24 L4eer' f Record. Le_BAS, 1A- D l 1() 3 Name(Pri City, ZIP State, • 6y pr l I2a a - a-q-y — c-lc.(3 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) ❑ Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. P Number of Units Other p(Specify:T,(lit, +i Oil rief Description of Proposed Work SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ l l 000 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ p Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: ,,_++ 4i t�,�"il Check No. ,.Z Ciheck Amount: �" 6. Total Project Cost: $ t l 1000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1019131 L/r5 ' 1 V Leduc, License Number Expifation Date Name f SL Holder 146 �"', t re t.,J,.., List CSL Type(see below) No.and Streuet ( �G Type Description S WitttrIV1 61dt � tof—`t UUnrestricKf d(Buildings up to 35,(1UU cu.ft.).•� R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry Ciroai@ Suer;o rnn tRS ` COM RC Roofing Covering WS Window and Siding 1 1 O L1 4 f33 2-1 SF Solid Fuel Burning Appliances 1•� 1 Insulation Telephone Email address D Demolition 5 2 Registered SuvHome prove' nt Contractor(HIC) r -S/ )/ 6 Z ��� sw iati V 11 HIC Registration Number Ex iration ate Cbm an Nor C R gistrant Name t,1n t SL. No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. t52.§ 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 No . ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FQR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize see_ ativained to ad on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Aectronic 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. 7-14 Print or luthoru d.Agent's Name(Electronic Signature) 3/CQ Hate 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 halflbaths 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 O�� Abtf U Massachusetts f of t ix" DEPARTMENT OF BUILDING INSPECTIONS , ` " 212 Main Street • Municipal Building ti Northampton, MA 01060 $ ‘" 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 Bf -A 2342 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. v. N , R The debris will be disposed of in: 4Ary etr; 41191 Location of Facility: ( IfY1erif1 1CI(A RA The debris will be transported by: Name of Hauler: SiTe.X'10 StAtaj-1 r) Signature of Applicant: 7,g,tte, Date: 441.14_ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 7 = = 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): LEI 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' P h' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 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 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.0 Other Insulate 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 ouV contracgors Gust submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name Atha s -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 providltlP ipMers°compensation insurance for my employees. Below is the policy and job site information. ,y. i L - Insurance Company Name: Beacon Mutual Policy#or Self-ins.Lic.#: 67872 - Expiration Date:_8/2/24 Job Site Address: 5 1 l/lJ)' Q� City/State/Zip: �- c J j m' 1 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 and penalties of perjury that the information provided above is true and correct. Signature: /l Date: 1/29/24 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#: �....441 SUPEINS-01 MLONGOLUCCO '4��o CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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 CONTACT NAME: Mansfield Insurance Agency Inc. PHONE FAX 115 High Street INC,No,Ext):(401)596-2096 �(A/c,No(401)348-2060 Wester) RI02891 E-MAL info mansfieldins.com Yr ADDRESS: INSURERIS)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 ADDL SUER POLICY EFF I POLICY EXP TYPE OF INSURANCE POLICY NUMBER LTR INSD WVD IMM/DDIYYYY! IMM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X X 6D23763 8/2/2023 8/2/2024 PREMISESO(Eaoccurr nce) $ 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 JE- n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY n 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 AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTO ONLY (Per accident) $ 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 STPERTUTE OTH- AND EMPLOYERS'LIABILITY Y/N 67872 8/2/2023 8/2/2024 A ER 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE XE.L.EACH ACCIDENT $ CRory B EXCLUDED? N I A E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 I 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/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$500,000 National Grid and all divisions are named as additional insured per written contract or agreement.Waiver of subrogation is provided in favor of National Grid and all divisions per written contract or agreement. Pollution Liability includes mold CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Rd Waltham,MA 02451 AUTHORIZED� REPRESENTATIVE 'Virus 1st'tor i *ia I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Messechusens sTi Division of Occupational Licensure IF Board of Building Regulations and Standards ConstructicOgupel 4Dgr Specialty C S SL•106237 l l res:06/15,2025 KYLE L LEDt}C rez 3750 DIAMOND HILL RD.. CUMBERLANy R1 028e4 THE COMMONWEALTH OF MASSACHUSETTS -4. ry1* Office of Consumer Affair and Business Regulation 1"r.tv,L1' 1000 Washingtoq.$jre1t-Suite 710 Commissioner v'ep K.81irr}an. Boston,-Mascarhusetts-02118 Home Im ro' ,; Ha•• _Re iissttration -_ r µ Type: Supplement Card is SUPERIOR INSULATION LLC. - �.__ . 175445 140 POINT JUDITH RD UNIT A7 o` - .` oil: OS/12/2025 NARRAGANSETT,RI 02882 f{ S `.., n _ Y(. '41h "/O/f _- Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date.)(found return to: TYPE;Suap160Ient Gard Office of Consumer Affairs and Business Regulation gggj Ii tt Lattf tion 1000 Washington Street-Suite 710 175495'',.11,05t12/2025 Boston,MA 02118 Construction Supervisor Specially SUPERIOR INSULATOR LLQ, -4i Ji Re t ed te: u /�I�j I//1 R cssc-IC n oncolt m aa KYLE 'V /oy�/1/ IUI�U'V/VI"V"/ 140 POINT JUDITH RDsUNI IV6-=--• eysda/aaG(wy: NARRAGANSETT,RI 02If82.:• Undersecretary Not valid without signature Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For infomution about this license Call(817)721a200 or visit wwwmass.govidpl • WEATHERIZATION CONTRACT EVERSeURCE CUSTOMER PHONE DATE CLIENTS WORK ORDER Zoe Crabtree (559) 974-4543 11/06/2023 553001 11802 SERVICE STREET BLLINO STREET PROPOSED BY. 54 Audubon Road 54 Audubon Rd Cole Payne SERVICE CITY,STATE,ZIP SLUNG 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. HOME AIR SEALING 4 $426.36 $426.36 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- 10"OPEN R-37 CELLULOSE 364 $859.04 $644.28 $214.76 Provide labor and materials to install a 10"layer of R-37 Class I Cellulose to open attic space. SLOPE-4"DENSE R-13 CELLULOSE 400 $1,064.00 $798.00 $266.00 Provide labor and materials to install a 4"layer of R-13 Class I Cellulose to sloped ceiling area. 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. TEMPORARY ACCESS 1 $109.07 $81.80 $27.27 Provide labor and materials to make a temporary access through roof or interior sheathing to an attic area. The opening will be closed with materials similar to those existing. Finish sanding and painting is not included. WALLS-CLAPBOARD SIDED 4" 1,780 $5,233.20 $3,924.90 $1,308.30 Install blown in Class I Cellulose to clapboard sided exterior walls. Touch-up painting,if needed,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 • WEATHERIZATION CONTRACT EVERSeURCE CUSTOMER PHONE DATE CLIENT Y WORK ORDER Zoe Crabtree (559)974-4543 11/06/2023 553001 11802 SERVICE STREET SLUNG STREET PROPOSED BY. 54 Audubon Road 54 Audubon Rd Cole Payne SERVICE CRY,STATE,ZP SLUNG CRY,STATE,ZIP Program Leeds, MA 01053 Leeds, MA 01053 EGMA-HES Page 2 DESCRIPTION QTY COST INCENTIVE TOTAL signature is your acknowedgement of receipt and agreement to proceed. BASEMENT CEILING-6"FIBERGLASS 590 $1,569.40 $1,177.05 $392.35 Provide labor and materials to install R-19 faced fiberglass batt 0.C. (initials) insulation to the basement ceiling.This will be installed with the paper backing up against the floor above.The un-papered fiberglass side will be facing the basement,and these exposed fiberglass fibers will be the visible side when standing in the basement. Your initials are your agreement and understanding of this measure CRAWLSPACE CEILING-6"FIBERGLASS 194 $537.38 $403.04 $134.34 Provide labor and materials to install R-19 faced fiberglass batt 0.C. (initials) insulation to the open crawlspace ceiling.This will be installed with the paper backing up against the floor above.The un-papered fiberglass side will be facing the basement,and these exposed fiberglass fibers will be the visible side when standing in the basement. Your initials are your agreement and understanding of this measure CRAWLSPACE CEILING-2"RIGID BOARD INSULATION 194 $1,076.70 $807.53 $269.17 Provide labor and materials to install 2"rigid board to the crawlspace ceiling. INSULATED BATH EXHAUST HOSE 4 INCH 1 $32.23 $24.17 $8.06 Provide labor and materials to install an insulated 4"exhaust hose to existing bathroom fan(s). • • WEATHERIZATION CONTRACT EVERSeURCE CUSTOMER PHONE DATE CLIENTS WORK ORDER Zoe Crabtree (559) 974-4543 11/06/2023 553001 11802 SERVICE STREET SLUNG STREET PROPOSED BY: 54 Audubon Road 54 Audubon Rd Cole Payne SERVICE CITY,STATE,ZP SLUNG CITY,STATE,ZIP Program Leeds, MA 01053 Leeds, MA 01053 EGMA-HES Page 3 DESCRIPTION QTY COST INCENTIVE TOTAL INACCESSIBLE ATTIC AREA We have identified an opportunity to insulate an attic area in your 2.C. (initials) home that is not presently accessible.We are making our recommendations based upon an educated understanding of your home's construction,but upon gaining access to this space,your home's work-scope might need to be modified. The insulation contractor will guide these changes and discuss them with you prior to proceeding. Total: $11,294.74 Program Incentive: $8,640.15 Client Total; $2,654.59 t.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. Ccr(ePaqte ° .e` RISE Representative Client Signature Cole Payne 11-29-2023 Printed Name Date of Acceptance mass save Savings through energy efficiency PERMIT AUTHORIZATION FORM 1, Zoe Crabtree owner of the property located at: (Owner's Name) 54 Audubon Road 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. Owner's Signature 11-29-2023 Date FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project:II -,' S U,10 eY- r Ifl2, itw t0Ce 214 g Participatin Contractor ! Da