Loading...
32C-082 (5) BP-2024-0286 24 WILSON AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32C-082-001 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-2024-0286 PERMISSION IS HEREBY GRANTED TO: Project# Contractor: License: Est. Cost: 0 BRYAN HOBBS CS-083982 Const.Class: Exp.Date: 05/02/2024 REGAN, KATHLEEN, LESHIN,JEFFREY, SELL, Use Group: Owner: STEVEN, & LESHIN,JULIA Lot Size (sq.ft.) Zoning: URC Applicant: BRYAN HOBBS REMODELING LLC Applicant Address Phone: Insurance: PO BOX 1535 (413)775-9 06 ECC600400 1 1 332023A GREENFIELD, MA 01301 ISSUED ON: D3/19/2024 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: ,4444 fYii1M�G�fV Fees Paid: $104.39 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner I J f , I ,/j The Commonwealth of Massachusetts /•,� N..o�© S(90(2 J� W Board of Building Re lations and Standards - 3). cMUNICI:ALIT Massachusetts State Bui ding Code, 780 CMR c) ,ti a Building Permit Application To Const I ct,Repair, Renovate Or Demolish a' ;, Y,Mar 7b11 One-or Two-Family Dwelling ��,,yy This Section For Official Use Only . Building Permit Number:JPj/"'6Gei,? � ' Date Applied: L.ouki s Has6Y ovl c-(c c77/ 61,- 3 j lay Building Official(Print Name) Signature Da e SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 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: _ utside Flood Zone? Municipal IDOn site disposal system 0 heck if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 pcaner'of Record: cj L.whin UN-I-harvIt.n. H8 Name(Print) I City,State,ZIP aq Wllscn Auc_ 50E-5N - 9' / Jeff'. Le.01in@smarm-. No.and Street Telephone Email Ad ss 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 A..Specify:b(jf ollkedtitAnelt Brief Description of Proposed Work':Zy (,V I lsni - y"d nc peel- Co.4)vim e y kriu- (,JG.its, Z" Ok11s. rim J014), AP WIlV") r ak S 3. , 4', ch n,:C(cc1• 4-°1U-�4_ eYk SIR, 7"n..0., klrt .11 �.gv t1 W'(jgnvl dl. k c:�.I. [ i . A-rt;f 11.1'1'QQV%lI S) , lc)'' c to alitct1`.Ilk. C. o ''Y, CGi1.4 T'' Y:,I4ISn t y1S�r(r,41) {ir:,i), Zf'(.J it. Mid", CI talnil r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building1. Building Permit Fee: $ Indicate how fee is determined: $ `Y I O ��'�� ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ 3� Suppression) Total All F $ Check No.12)OCheck Amount: LO *Cash Amount: 6.Total Project Cost: $'LD,04.21. 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) N 2pC� t '('j�(�'j;/'/�� �¢� License Number Expiration e o'I'-CSL Holder List CSL Type(see below) ) "g No.nd Stree - I��J Type Description brQnQ� (\ ) j A c` U Unrestricted(Buildings up to 35,000 Cu.ft.) ���,,,,,,JJJIII C Q� )"�, R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances y 6.11 SOtko l(\ AIDri 1 S' iY _ I Insulation Telephone mail address C t•'� D Demolition 5.?)& Registered Home Imp vement Contractor(HIC)GA m •S LUu _ )q `IS— HIC Registration Number I a nExpiratio HI on ny or HIC Registrant Name 3ro � .,/ \��S nd S ��tt Email s Qn u/ H a- 0134a y)3`'7)f 5'o s City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 2.5C(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 .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 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. (2,-._ 4 ,)- 31 )d zt/ Print owner's .r Authorized Agent's Name(Electronic Signat Date NOTES: 1. An Owner who obtains a building permit to do his/l#er 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" Permit Authorization mass save Form r �smr5r,�r Site ID: 5174083 Customer: JEFFERY LESHIN I, Jeffrey Leshin , owner of the property located at: (Owner's Name,printed) 24 Wilson Ave Northampton, MA 01060 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Jeffrey Lexh& Owner's Signature: Date: 02 / 27 / 2024 44.4k Oro 4 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: 1\\C/1 , S eqr(14\6. 1)/1li C,if Participating Contractor cl Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Orly Document Ref:RN9CT-FBYDK-2JWP9-NWGMF Page 8 of 9 AptiPermit Authorization mass save Form Site ID: 5174052 Customer: STEVEN SELL Steven Sell I, , owner of the property located at: (Owner's Name,printed) 26 Wilson Ave Northampton, MA 01060 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. 5����c V C�lit� Owner's Signature: ] Date: 02 / 27 / 2024 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Z146/\. 3 CUY)AN1 S\1 d ui - Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office Use Orly Document Ref:QM6BY-IDBUH-J4NNV-NKGEB Page 8 of 9 Commonwealth of Massachusetts 111; Division of Occupational Licensure Board of Building Re a lotions and Standards t:onskribtiq� CS-083982 4spires:05/021202,4 BRYAN G HOBS P O BOX 153, GREENPIELI 'VIA 01302IP Commissioner (1t� l;. �irx.G�it THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,Massachusetts 02118 Home Improvement Contractor Registration Type: LLC BRYAN HOBBS REMODELING,LLC. Registration: 196045 P.O.BOX 1535 Expiration: 06125/2025 GREENFIELD,MA 01302 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. it found return to: TYPE LLC Office of Consumer Affairs and Business Regulation Registration EXeiration 1000 Washington Street-Suite 710 196045 08)25/2025 Boston,MA 02110 BRYAN HOBBSriEMODELING,LLC. BRYAN HOBBS 576 LEYDEN RD ,A.i;?,ids GREENFIELD,MA 01301 Undersecretary Not valid without signature • per' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • ' Lafayette City Center Pi jl`'J 2 Avenue de Lafayette, Boston,MA 02111-1750 z www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bryan Hobbs Remodeling, LLC Address:576 Leyden Rd PO BOX 1535 City/State/Zip:Greenfield, Ma 01302 Phone #:413-775-9006 Are you an employer? Check the appropriate box: Type of project(required): 1.II I am a employer with 7 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 shipand 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 12.0 Roof repairs insurance required.] t c. 152. §1(4),and we have no 13.0 OtherWeatherization 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. I.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:AIM Mutual Policy#or Self-ins. Lic. #:ECC60040011332023A Expiration Date:1 0/20/2024 Job Site Address:-.(AS 11 City/State/Zip: Y 1 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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:_6%tCr'\ Date: 3I) .\2, _/ Phone#: L. 13 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: A ® DATE(MMIDD/YYYY) f\ CERTIFICATE OF LIABILITY INSURANCE 07/25/2023 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 Adina Edgett,CISR NAME: Alera Group,Inc. PHO,EN Ext): (413)586-0111 FAX No): (413)586-6481 Webber&Grinnell Division E-MAIL aedgett@webberandgrinnell.com ADDRESS: 8 North King Street INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Selective Ins Co of S Carolina 19259 INSURED INSURER B: Selective Ins Co of America 12572 Bryan Hobbs Remodeling,LLC INSURER C: AIM Mutual PO Box 1535 INSURER D: Evanston/XS Brokers INSURER E: Greenfield MA 01302-1535 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 08/24 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 ADOL-SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE n OCCUR PREMISES(Ea oocccu ence) $ 500,000 MED EXP(Any one person) $ 15,000 A S2289042 08/04/2023 08/04/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO-JECT LOC OQ002O OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) __ __ ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED A9105300 08/04/2023 08/04/2024 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS _ X HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY (Per accident) Underinsured motorist BI $ 20,000 X UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ 2'000'000 EXCESS LIAR CLAIMS-MADE S2289042 08/04/2023 08/04/2024 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N 1,000,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE I I NIA ECC60040011332023A 1 O/2O/2023 1 O/2O/2024 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Per Occurance $250,000 Pollution D CPLMOL121333 01/19/2024 01/19/2025 Aggregate $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD City of Northampton oatr+rrpro�� o•- SC1� •"� Massachusetts �,?�S �. �.!<<, ' DEPARTMENT OF BUILDING INSPECTIONS �'• ' t c9. s•. 1I 212 Main Street • Municipal Building Jy., �b ' Northampton, MA 01060 Sj:•• %�� 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: UG.\�R« � c ly� - 7�"� ����-hnm l�n (� �� a • The debris will be transported by: Name of Hauler: c_ni" L� Signature of Applicant: Date: 4)el Z�( -40tikrE- mass save Weatherization Barrier Incentives Based on your Energy Specialist's recommendations,your home can benefit from program-eligible insulation and/or air sealing improvements.Before moving forward,please follow all the instructions below to remediate your weatherization barriers CUSTOMER INSTRUCTIONS 1. Hire a qualified,licensed contractor to evaluate and/or remediate the weatherization barrier(s) 2. Submit signed and completed Copies of this form and a copy of the paid contractor invoice(s)within 60 days of your Home Energ!: Assessment to.Pre-Wx Barrier incentive,t/0 CLEAReSUlt,41 i-ra iuoyouuri,MA 017S2 or email to prewxoffer o,cleeresult.com. 3. The weatherization incentive will he deducted from the customer co-payment amount of the weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount 4. Complete the recommended weatherization improvements. 5. The Mass Save HEAT Loan offers interest-free financing opportunities that may be used to remediate eligible weatherization ;,arrier" Learn more at MassSave.com/en/savinWresidenti . .,.bates/heat-loan Customer Name JEFFERY LESHIN w.. Client#or Site ID: 5174083 Site Address: 24 Wilson Ave City. Northampton State MA ZIP: 01060M__.,__ Phone Number 508-524-9654 Email:leff.leshin@omail.com Customer/Homeowner Signature: je re'fil 1--61 2/26J24 Date: 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 Attic Wall , Attic Slope • Exterior Wall Basement Other . . Other • I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below. Attic Floor Attic Wall Attic Slope •Exterior Wall e Basement Other: ^_„__. _ Other: .,___ ,- Contractor Name: Q4 . W. Address: 305 eI/S sired- City grezitied--_._ State: /''i4 ZIP' 0/30/ Company Name: ._ _Curi'!r1t"Eke-if-re , Le-G- License Number' �a/3B 8_- Contractor Signature: Date: �3/ao My signature confirms that I have performed _ action o th_e ectrical listed above and have corrected any barriers as indicated.My signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this form High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level. as measured in the undiluted flue gas,to below 100 parts per million(ppm). Draft Failure:Contractor is to correct the draft in the selected flue(s).Refer to table on reverse for acceptable draft ranges. • H'c i r.r .n.'-i. CO_ ppm Revised CC/pprn Existing g Draft Pa Revised Draft Pa t1eating System Not Water Heaton Other Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation. Heating System Hot Water Heater Other Contractor Name' Address.________ _ — —City: .,_ State. ZIP' — — .._.._. Company Name: __ .__._ License Number Contractor Signature: . Date My signature confirms that I have performed my inspection of the mechanical systems listed above and have corrected any harriers as indicated.My signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this form. Page 1 of 2 -74011i, mass save Weatherization Barrier Incentives Based on your Energy Specialist's recommendations,your home can benefit from program-eligible insulation and/or air sealing improvements.Before moving forward,please follow all the instructions below to remediate your weatherization barriers CUSTOMER INSTRUCTIONS 1. Hire a qualified,licensed contractor to evaluate and/or remediate the weatherization barrier(s) 2. Submit signed and completed copies of this form and a copy of the paid contractor invoice(s)within 60 days of your Home Energy Assessment to;Pre-Wx Barrier Incentive,d o CLEAResult,41 Brigham Street,Unit 10,Marlborough,MA 01752 or email to prewxoffer aclearesuit.com. 3, The weatherization incentive will be deducted from the customer co-payment amount of the weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount. 4. Complete the recommended weatherization improvements. 5. The Mass Save' HEAT Loan offers interest-free financing opportunities that may be used to remediate eligible weatherization barriers.Learn more at MassSave.corn/en/saving/residential-rebates/heat-loan-program CUSTOMER INFORMATION Customer Name. ..STEVEN_SELL _-. Client#or Site ID: 5174052 Site Address:.._26 Wilson Ave City:-Northampton State: MA ZIP. 01060 Phone Number: 718-213-5707 Email: stevenselk gmail.corn Customer/Homeowner Signature; allAe, 34' Date:—2/26/24 a.N L' F U t E W I I I N c;, .. 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 Attic Wall •Attic Slope •Exterior Wall „ Basement ." Other: KW Slope Other:______ I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below. Attic Floor .Attic Wall .Attic Slope Exterior Wall Basement •Other: Mir. Other;____ Contractor Name: _ 4a0_ 4✓,4'ti Address: 305 a..k.//.s "7/reet— City' r �Lr _ _ State: ZIP: 4�0/ / p a i� Company Name. Cirre#v1 /-/ t f41-6-� � License Number' .,��. / 30 U Contractor Signature: Date: aØ ?/2 .4' My signature confirms that I have perfo my inspection of the elec I systems listed above and have corrected any barriers as indicated.My signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this form. High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level, as measured in the undiluted flue gas.to below 100 parts per million(ppm). Draft Failure:Contractor is to correct the draft in the selected flue(s).Refer to table on reverse for acceptable draft ranges. High Carbon Monoxide Draft rairurr Existing CO ppm Revised CO ppm Existing Draft Pa Revised Draft Pa Heating System Hot Water Heater Other Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation. Heating System Hot Water Heater , t Other —... Contractor Name' Address: _City--- .�_.-. _..__ State:.. . ZiP' Company Name: _ License Number Contractor -- Contractor Signature: Date: My signature confirms that I have performed my inspection of the mechanical systems listed above and have corrected any barriers as indicated.My signature also confirms that I have read and agree to the Terms and Conditions outlined on the back of this form. Page 1 of 2