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17A-239 (3) BP-2021-2295 61 LAKE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: I7A-239-001 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-2021-2295 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est.Cost: 4833 COZY HOME PERFORMANCE 102169 Const.Class: Exp.Date: 12/10/2022 Use Group: Owner: ANDREWS GILLIAN L Lot Size (sq.ft.) Zoning: URB Applicant: COZY HOME PERFORMANCE Applicant Address Phone: Insurance: 80 PLEASANT ST#200 4135290200 46-845373-01 EASTHAMPTON, MA 01027 ISSUED ON:12/15/2021 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 14 (� ' . 1 • II Fees Paid: $65.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner S , // }'� The Commonwealth of Massachusetts 0FC FOR w Board of Building Regulations and Standards,T .i�� MLTI EIPALITY Massachusetts State Building Code, 780 CMR;? , c�j i USE ' Building Permit Application To Construct, Repair, Renovate Or LZemolis'h a Re/sed 7ar 2011 One-or Two-Family Dwelling T;,� R��99 This Sec'on For Official Use Only ' Buildi Permit Number:64-0 P. A Aq( Date Applied: Euito Z5.3 _/ 2 12 1-i 2aZ1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Cc( Lc(& 51 Florence 1.la 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: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1�O. wner'of Record: (! U.&r 46,-+lac F/orence , Al A 0166 Z Name(Print) City,State,ZIP 61 1..A. . 5T 11/3-566- (,3?3 :mPn 1•.►\ P c:`,n\A-,l • Co a11 - No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKZ(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 5 Specify: I nSc,,(Q-cc,-) Brief Description of Proposed Work'-: Mess 4�v-e.. 1v.,Sc..lr.,J-z-ch, / GO e`- t-i zp. , - a-W c. / hkseme-nt l SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1, 533 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard 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.)9 I Check Amount: Cash Amount: 6.Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: .1 w SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C55 L"I o a I b9 i(3.\\QA1s , rn A 2 K LA Aj r z. License Number Expiration Date Name of CSL Holder _LL 1 d o MCI5/4/1 1 s f ¢07OQ List CSL Type(see below) M No.and Street Type Description /� U Unrestricted(Buildings up to 35,000 Cu.ft.) f 1151 r,R('Y4) �M,; fr T' of Q a,--) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding p� SF Solid Fuel Burning Appliances 413"Sa 1 040 Mcint1 Q my co Z y hunt•a?►1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) l--) O y 5iii3 coy), Nom F. per CUf m f n C.L HIC Registration Number Expiration Date I-K Co pan frame or HICRegistrant Name 4 le4,3�in St �300 Mctivii;;Crayco2-)horny.Cu No.and Str et Email address i.RS n‘krv�'c ' rc�A p1Ua.'i H13. e,-.5 U q , flAt0A� r-9e e tnyLeLI I� ,-, e .4.,• cc,� City/Town,Stat ,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT IM.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. SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN CONTRACTOR OR OWNER'S AGENT APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize CO Z 113` m. Q,2 r ku('t`n k f\it. to act on my behalf.in all matters relative to work authorized by this building permit application. Owner's Signature Date t SECTION 7b: APPLICANT 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. ��%'�?r Ztc.g__ /a-/Sr/2-f Contractor//Owner s Agent/Owner ignature Date 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 tlwt 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" DocuSign Envelope ID:809A62C1-5D73-4270-9726-A82FCC4C59D6 \wi R I S E ENGINEERING OWNER AUTHORIZATION FORM Gillian Andrews (Owner's Name) owner of the property located at: 61 Lake Street (Property Address) Florence, MA 01062 (Property Address) hereby authorize Subcontractor(to be filled in by office) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform 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. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. �DocuSigncd by: alitt4A, QIn,I.ittws OwPive;5°fr d ire 11/7/2021 1 4:00 PM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com •-, 114 10 The Commonwealth of Massachusetts '—o— Department of Industrial Accidents J Office of Investigations Lafayette City Center =y— 2 Avenue de Lafayette, Boston,MA 02111-1750 /s '�t im`` www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): C 21 Address: 1$° P1Pasc r+ i- , Si1.t ZC'O City/State/Zip: easy-1 c w p}trn m . 0 t n a? Phone #: LA3 •- 5 2 7 -O 2-0 U Are you an employer?Check the appropriate box: Type of project(required): 1.® 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. D 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.❑ 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.E Other ►1 SN 1a 4-to r, comp. insurance required.] • *Any applicant that checks box#I 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. :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. � � -f Insurance Company Name: `-Ord` vQ.A4&l 1,1c4.emrt11-1 Co Policy#or Self-ins. Lic. #: L(c - $L15i-4,-7,3 •...o -1 t7 Expiration Date: jt Icy-/ 2e22 Job Site Address: (o I LaKc. ST City/State/Zip: F/ore ,c.& MA- o lO(o Z 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 certi under the pains an penalties of perjury that the information provided above is true and correct. Signature: ! lr Date: / 2-/../ 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(check one): 1❑Board of Health 212 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: RI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ACOR/7 11/11/2021 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 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: Berkshire Insurance Group Inc PHONE FAX 43 East St (A/C,No,Ext): (877)234-4420 (A/C No): (877)234-4421 Pittsfield, MA 01201 EMAIL ADDRESS: PRODUCER (413)447-7376 CUSTOMER IDd INSURER(S)AFFORDING COVERAGE NAIC• _ INSURED INSURER A; Continental Indemnity Co. 28258 INSURER B: Cozy Home Performance, LLC - 180 Pleasant St INSURERC: Easthampton, MA 01027-1287 INSURERD: INSURER E: CTL 1273 1679258 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 SUBR POUCYEFF POLICY EXP LTR TYPE OF INSURANCE BIER WVD POLICY NUMBER (MMIDDIYYY)SMM/DDIYYYY) LYR'S GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABIUTY DAMAGE TO RENTED • CLAIMS MADE OCCUR PRFMI,SFS_(Fat irrence) S MED EXP(any one person) _$ PERSONAL&ADV INJURY $ GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPUES PER: PRO- PRODUCTS-COMP/OP AGG $ POLICY JECT LOC AUTOMOBILE LIABILITY ANY AUTO Ea aent)SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per ac dent) $ HIRED AUTOS PROPERTY DAMAGE (Per accident) S NON-OWNED AUTOS S S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE S DEDUCTIBLE S RETENTION 5 t WORKERS COMPENSATION X IWTIM tat AND EMPLOYERS'LIABILITY Y I N ANY A OFFICER/MEMBER PEXCLUDED?ECUTIVE N I N/A 4 6-8 4 5 3 7 3-0 1-1 7 11/02/2021 11/02/2022 E.L.EACH ACCIDENT S 1,000 r 000 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE S 1,000,000 S yes,CALPRO ISIO EL.DIRFASE-POLICYLIMIT $ 1,000,000 SPECIAL PROVISIONS beknv DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach Aeord 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION Cozy Home Performance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Mill 180 180 Pleasant Street BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Easthalttpton, MA 01027 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATN� J 1783118 ACORD 25 (2009/09) ©1988-2009/CORD CORPORATION. All rights reserved ® DATE(MMIDDIYYYY) A CERTIFICATE OF LIABILITY INSURANCE 4/22/2021 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 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 The Dowd Agencies, LLC PHONE Diane LaFleche FAX 14 Bobala Road IA1c.No,Exn:413-437-1062 (A/C,No):413-437-1462 E-MAIL Holyoke MA 01040 ADDRESS: dlaflecheadowd.com PRODUCER CUSTOMER ID#:COZYHOM-01 INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURER A:Selective Insurance of South Carolina 19259 Cozy Home Performance LLC 180 Pleasant St. INSURER B: Easthampton MA 01027 INSURER C: INSURER D: ___ INSURER E: _ ___ INSURER F: l COVERAGES CERTIFICATE NUMBER:620509354 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. ILICY EXP TR TYPE OF INSURANCE !JNSR DDL SWUD POLICY NUMBER (MM/DDYNYYYYI (MM DO//YYYY1 LIMITS A GENERAL LIABILITY S 2206979 4/17/2021 4/17/2022 EACH OCCURRENCE S 1,000,000 DAMAGE D X •COMMERCIAL GENERAL LIABILITY PREMISESO/EaE occurrence) $500.000 7 CLAIMS-MADE t I OCCUR MED EXP(Any one person) S 15,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT AP�PLIESPER: PRODUCTS.COMP/OP AGG $3,000,000 —I POLICY n a I ^ LOC $ AUTOMOBILE LIABILITY ` COMBINED SINGLE LIMIT $ -- I (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS -- 1 BODILY INJURY(Per accident) S SCHEDULED AUTOS • PROPERTY DAMAGE $ • HIRED AUTOS (Per accident) NON-OWNED AUTOS I S I S A X UMBRELLA LIAB X OCCUR S 2206979 I 4117/2021 4/1712022 EACH OCCURRENCE 32,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 DEDUCTIBLE S X RETENTION SO $ ^—WORKERS COMPENSATION wC STATU- 1 OTH- AND EMPLOYERS'LIABILITY Y/N _ TORY LIMITS I FR ANY PROPP.I£TORIPARTNERIEXECUTIVE N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below , _ E.L.DISEASE-POLICY LIMIT S I i DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE HOLDER CANCELLATION 30 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. To Whom It May Concern AUTHORIZED REPRESENTATIVE -104 �4 - 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD COMMOlaweatMh a.IwdssacIlusstre DIw EIcn al Profiseslouul Licarisure �7 Board O;am Regulations 4ilit Steilii4l'Ua ,kirrsi`fuatiki`!/til rviiwr SOvuli; MARK M LANTZ 180 Pt.EASANT STREET. EASTHAMPT3M MA 010 f Plypri _ ._ Construction Supervisor SpeCialt1' Restricted to: CSSi.-IC Insulation Contractor • Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For Inforr:lation about this license Cali(S17)7273200 or visit w..w.mas$.govfdpi Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC COZY HOME PERFORMANCE, LLC. Registration: 162770 180 PLEASANT STREET Expiration: 04/05/2023 EASTHAMPTON, MA 01027 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 162770 04/05/2023 1000 Washington Street -Suite 710 COZY HOME PERFORMANCE, LLC. Boston,MA 02118 MARK LANTZ 1414'4- 180 PLEASANT STREET g4.4 ' EASTHAMPTON, MA 01027 Undersecretary Not valid witho signature ;,_ . City of Northampton • , ti,. ;i4 IC,. /11\ d/f � Massachusetts .� �`' r� ddQ • �ti lg *.M. e.! I ' .r. '� DEPARTMENT OF BUILDING INSPECTIONS y. 11 M1 ' `;'41,!t 212 Main Street Al Municipal Building ss �� - Northampton, MA 01060 +h' 3'?� Property Address: !al kit&c. Sr, t/or'e, cc Contractor Name: C.0.1:/ 1A'•a mC_ R..4af C.3 x'rc\G%I\[_q_ Address: \ e6 O 1 Q i\5112s"Ie S\ City, State: P.2TRvk Phone: ‘dt\ '%3-- 5?#.°lP O a0.% Property Owner Name: C;I1i4h /4h J,-ems Address: to I Lao sr City, State: F (o reh cc />? 4- d 10 6 Z 1, Mt1' 44714, (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 signature//14 :.../ /1/17 Date /-2--/e 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:RISE Engineering,60 Shawmut Rd,Unit2,Canton,MA 02021 or email to Eversourcelnfo@RISEengineerIng.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 harriers. Learn more at masssave.com/en/saving/residential-rebates/heat-loan-program CUSTOMER INFORMATION Customer Name: Gillian Andrews Client#or Site ID: 330970 Site Address: 61 Lake Street City: Florence State: MA ZIP: 01062 Phone Number: 413-586-6393 Email: jmmuhn©gmail.com 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: Q'Attic Floor Q Attic Wall Q Attic Slope Q Exterior Wall Q)Basement Q Other 0 Other. Q I have performed my inspection and determined there is no active knob and tube wiring in the areas selected below. is Attic Floor 0 Attic Wall Q Attic Slope Q Exterior Wall @ Basement Q Other: 0 Other. Contractor Name: Michael Nelson Address:96 Bushy Hill Rd _ City:Granby State:CT ZIP: 06035 Company Name: MD Electrical Construction Inc. License Number: 22709A Contractor Signature: Michael Nelson tY°:�.";'t'W - """°""�° Date: 11-17-21 My signature confirms that I have performed my inspection of the electrical 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. MECHANICAL SYSTEM EAPPI`RS;up to ',Su t;Lei out by I.•".i c; HighLI:..h Ca.4.....Monoxide P\.-ie Failure Carbon vv„,,v„vn,�� v,u,• ,uu,c Existing CO ppm. • ;revised Draft Ra *Mating-System Het-Weter-Nester +�R I Q Heating _t_m Q Q eti< Contractor Name: �ddre s: City: Ctatc: 71P Company Name: I feeinee-NteeNeee: Date: