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117 WEBB ST - BUILDING INSPECTION (2) � loy�5$go fn� The Commonwealth of Massachifgo L SERVICES �7 W Department of Public Safety Massachusetts State Building Code(780 CMR) ��LL ''^^�� A 11t 32 Building Permit Application for any Building other than a One-or{usvo�PElht Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ j Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other Specify: 1 O KL lOUJ,V Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering$Peer Review required? Yes ❑ No Brief Description of Proposed Work: 1)t.CJ W 1 C..ft l.W tl�Slrt� {1.15 U t,k�10�. L(1 Cpp2 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR,OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A 4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ 1 IHA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7,SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Dis osal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:0 �1 Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ UIN e-114L- Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or NoX Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: C� �alLEO oi-1 / � - SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Guru So usA- t�.1 W ef,6 5T, S4c-� . 4 , c�lo?'I o Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the propertyowner hereby authorizes I 17 inn�t �r.- A11L-"Tttxd 1 w*4-1 (7147fo� JS-Ty" AV . Cl '�1fM" Irlr-� OI ( 7 Name Street Address I City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor A1fL---ft&gT Wc4iftR Ig.4-rtotJ LLL Company Name lky► ti P. F012- 14 GS os'ZS"l (P U/J U- TY14tL-1 -1 Name of Person Responsible for Construction License No. and Type if Applicable 10 rAWe, `W4mA, p2. N,\1 1LIA� M- o lq I5— Street Address City/TovA State Zip !EL:��1�+ _ Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the' suance of the building permit. Is a signed Affidavit submitted with this application? - Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ �� 'L Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 01, 10& ZZ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 tot�he est my owledpQge and understanding. W t C2o wL rry/ (//r r ,A'_. ,J-( Or—Al1VTt 4+J T Please print and sigr�name r Title Telephone No. Date Street Address City/Town A State Zip / Municipal Inspector to fill out this section upon application approval: A Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot# for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107.The checklist below is a compilation of the documents that may be required for this.The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Re uired 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program IV 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Re ort 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street ,A n Address City/Tow State Zip Discipline Expiration Date A Registration Number Name(Registrant) Telephone No. e-mail address Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address 6 /Town State Zi Discipline Expiration Date , 1Tdlit' To Whom It May Concern, I, James Fortin, do authorize William M. Crowley to act as my agent in the process of applying for building permits and other necessary documentation pursuant to the conduct of my business by Air-Tight Weatherizaiton LLC. ignature State of Massachusetts County On this ��} day of <> % , 2014, before me personally appeared C v' ` i to me known to the person (or persons) described in and who executed the foregoing instrument, and acknowledgement that he/she/they executed the same as his/her/their free act and deed. J OBERT A. MONAHAN Notary Public e� Notary Public COMMONWEALTH OF ssion Expires My commission Ezplree Print Name: September 17, 2021 My commission expires: 'ti�pn L1 Office of Corisunler Affairs and Business Regulation > 10 Park ark ( lazy - Suite 5170 Boston, 1V ssachLISCUS 021 16 FIome Improvement Contractor Registration Registration: 165640 Type: LLC Expiration: 3/15/2016 Tr# 246557 AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 Update Address and return card.Mark reason for change. 5c:.: ;:• Mr.+os I Address Renowal b;mployment Lost Crud ` License or registration valid for indisidul use onl'v (IILec of Consunmr:\ffnu's S Ilusincss Itegula lion I, t�f before thed expiration ate. If found return to: '+ter";HOME IMPROVEMENT CONTRACTOR )1^d�Regislration: 165640 Type: Office of Consumer Affairs:md Business Regulation '.r."Expiration: 3/15/2016 LLC 10 Park Place-Suite 5I70 Boston,MA 02116 AIR-TIGHT LLC.WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY,MA 01915 •`Undcrsccrcnur Not va id without signature Gl Nrl (:I 1 ul 1ncJ f1 1 t�T;:; i ,. - CS-052576 .I,\Allis F.IcUfL'1'In . In I'INEKNOIA, I}crerly NIA 0171U J-•'� 'f�"•�� 1o10312015 The Commonwealth of Massachusetts Department of Industrial Accidents Ogee of Investigations I Congress Street, Suite 100 -' Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 1 l t\`-t c,-,VA— �C&Ayy x l2 0 Address: City/State/Zip: Phone#: CCl Is C:H K L,(q C �f Are you an employer?Check the appropriate box: Business Type(required): 1.3-59, I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We arc a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** I I ❑ 1{eal[h Care 4.El We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ••If the corporate officers have exempted themsch a,but the corporation has other employees,a workers'compensation policy is required and such an organisation should check box#1. I am an employer that is providing workers'camp nsation insurance for my employees. Below is the policy information. Insurance Fc) Company Name: �-�j ;�I(Y�� ` t Insurer's Address: � \�$--\X, y" ,- ��n �e �\J'L'r ' 'CTe- City/State/Zip: y.1�t s �O IA- ,1Z _742 Policy Nor Self-ins.Lic.# RXtX Shp 4 -D Expiration Date: 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 ofperjury that the information provided above is true and correct $iftnaturc7 �-�f Date: Phone#: � l�ti C,' t ��Cr�-4 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wvtv.mass.gov/dia Acoao CERTIFICATE OF LIABILITY INSURANCE DATE, BDNYY �� 12/5/2014 Y) 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 endorsements). PRODUCER CONTACT Jlll DeBetre NAME: TGA Cross Insurance, Inc. PHONE jd(781)914-1000 FAX No: (781)224-5777 401 Edgewater Place E"MAIL . ehetre@tgacross.corn Suite 220 INSURERS AFFORDING COVERAGE NAIC tt Wakefield MA 01880 INSURER A:Arbella Protection 41360 INSURED INSURERBAr'bella Mutual 17000 Air-Tight Weatherization, LLC INSURER C: 9 Story Ave. INSURER O: INSURER E Beverly MA 01915 INSURER F: COVERAGES CERTIFICATE NUMBER:CL14111923181 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 I TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR LUaftWVDPOLICY NUMBER fMMIDDIYYYYI IMMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE 51 OCCUR 8500046432 /8/2014 /8/2015 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S 2,000,000 ENT POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 1020015286 /8/2014 /8/2015 X AUTOS AUTOS BODILY INJURY Per accident) $ X X NON-OVNJED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccitlent $ Ph scial Dama a Perils $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ $2,000,000 DEO X RETENTION$ 10,000 4600052930 /5/2014 /5/2015 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory,in NH) E.L.DISEASE-EA EMPLOYE 8 II yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 City of Salem ACCORDANCE WITH THE POLICY PROVISIONS, Inspectional Services 120 Washington Street, 3rd Fl. AUTHORIZED REPRESENTATIVE Salem, MA 01970 Thomas Gregory/TD2 +'- IL ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(2010oe B1 The ACORD name and logo are registered marks of ACORD ACDATE(MMIDD Y) �. ® CERTIFICATE OF LIABILITY INSURANCE 01/15I2015 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 Jacqueline Marie Melanson, CLCS MassPay Insurance Services, LLC NAME 27 Garden Street, Unit 1 B PHo"o I (978)774-4338 xl05 lac Nol: (978)774-1318 Danvers,MA 01923 E-MAILADDRESS: I @p ackie hilrichaminsurance.com INSURERS)AFFORDING COVERAGE _ NAIC A__ INSURER A: ATGUARD Insurance Company 42390 INSURED Air-Tight Weatherizalion,LLC INSURER B: 9 Story Ave INSURER C: Beverly,MA 01915 INSURER D: 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 rypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR S POLICY NUMBER MMIDDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Eaoccurrence $ CLAIMS-MADE 0 OCCUR MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY E PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) IS ALL OWNED F7 SCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AIWC576437 07/01/2014 07/01/2015 \IIwesTATu- I OTH- AND EMPLOYERS'LIABILITYBE ANY PROPRIETORIPARTNERIEXECUTIVE YIN EL EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED' NIA (Mandatory,in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach AC ORD 101,Addid onal Remarks Schad We,if more space is required) Proof of Workers Compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Salem Inspectional Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington St.,3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Conser atlon CERTIFICATE OF COMPLETION Services Group 50 Washington St.Suite 3000 CA,U S Y 71,(�' — �' Westborough,MA 01581 j t� —1 LA1.401I.-OMP — Michael Mckenzie Phone(Eve): 978-744.4623 117 Webb St#3 Phone(Day): 978-744-4623 Salem,MA 019704018 E-Mail: SitelD: S00002245751 Combustion Safety Test Completed YIN Pre Blower Door# (If applicable) Post Blower Door# (if applicable) Contract ID:20141022_ASEAL Company: Air-Tight Weatherization Sub-contractor Work Order#: S45751P51281C271 Location Q 60-1 P ^" © ras tlFy Ilnstalfe Living Space Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 4 Exterior Door Weather Stripping 8 Door Sweep 8 Spa ce ace Attic Stair Cover Thermal Barrier with carpentry 1 Contract ID:20141022 WORK Sub-contractor Work Order#: S45751 P51281C27.�1p Damming 52 Living Space Attic Floor Open Blow Cellulose 8" 324 Living Space Insulate Vaulted Roof From Interior With 6"Dense Pack Cell 39 PLEASE NOTE:The Inspection of the house is for the purpose of finding CUSTOMER AUTHORIZATION OF CERTIFIED WORK out whether the Contractor completed the work. I confirm that the measures listed above have been completed to my CUSTOMER SHOULD NOT RELY ON THE INSPECTION FOR satisfaction. I have received a copy of the Certificate of Completion and ASSURANCE THAT THE CONTRACTOR'S WORK NECESSARILY hereby authorize the release of any final payments to the Contractor. I COMPLIES WITH ALL LAWS AND STANDARDS RELATED TO understand that this Authorization of Completed Work does not in any SAFETY. - manner void any warranties provided to me by the Contractor. It was the Contractor's sole responsibilty to assure that the measures were installed properly and safely. In addition, this Post-Installation Inspection does not replace inspections by licensed inspectors where required by state or local law. It is the duty of the Customer to obtain such required inspections. Contractor's Signature Customer's Signature Date Date Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 CONTRACTOR WORK ORDER Conser atlon Services Group 50 Washington St.Suite 3000 Printed: 12/31/2014 Westborough,MA 01581 h Work Order Id: S45751 P51281 C271 :C,gnt(actor nfotfitatlon ,`�'.=°"` µstotn Y .� ail I-0 �B Air-Tight Weatherization Michael Mckenzie Email: 9 Story Ave 117 Webb St#3 Phone(Eve): 978-7444623 Phone(Day): 978-744-4623 Beverly,MA 01915 Salem, MA 019704018 Site ID: S00002245751 Location Description Quantity Unit$ Total$ Living Space Perform Air Sealing at Estimated 62.5 CFM50 4 $84.32 $337.28 Exterior Door Weather Stripping 8 $27.59 $220.72 Door Sweep - 8 $23,18 $185.44 Living Space Attic Stair Cover Thermal Barrier with carpentry 1 $260.23 $260.23 - Damming 52 $2.19 $113:88 - Living Space Attic Floor Open Blow Cellulose 8" 324 $1.60 $518.40 Living Space Insulate Vaulted Roof From Interior With 6" De 39 $2.57 $100.23 Installed Measures Total $1,736.18 Type Status Notes Asbestos UNKNOWN .�Mv- s,.�M1 k.�.:. .., - � _ tl� .} _ice F�2�rlAt n[S�•'- n a� a � r ,- z�;%"E 5 Incentive Payments Air Sealing Incentive $1,003.67 Weatherization Incentive $549.38 Total Incentive Payments $1,653.05 Customer Share Total Customer Share $183.13 Less Deposit Of $61.04 Customer Share Balance(Due Contractor) $122.09 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 I ��1 �t,,//�� RCS PLANVIEW DIAGRAM Customer:_l_I LL110.Q.I VIAeinip— Home Phone: Address: � �1.�2�ob �T '#2 Work Phone: - Town: ,KA t t no Cell Phone: ( )- Any limitations for access by large tmcki No Yes If yes.describe: Any specific directions or landmarks? No _ Yes If yes.tlescribe) Site ID:Qa IL,7 ' Energy Specialist \I ems\ I'0. �.T� ReVlewed by: a13 Cell $ ' 3;'/ Q �nsulp/t UGC jled Roof -,L'ror? in4eerer w f k7 (7 OP cell 3967 -C;MM"tnok �31='i" Agra Sk C'o✓e� 7'1) iv Jh Ca/laen ,g ;eo% yti,s �Dao2 yr�S j2).O /wee/�r -- 1 Q L-3� or -03 I IN Pi c For Office Ilse Only Bushes Ladder Neighbor Proximity Pocket Doors Insert Radiators Fence(s) Existing Conditions X=Access ❑=Vents Note Inside Square R=Roof S=Soffit G=Gable RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Drip Edge T=Triangle Install O=New Access Note in Circle C=Ceiling W=Wall S=Sheathing Temp Unless Noted Otherwise 0=Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For Access -- Rev 1/14 Residential Air Sealing Work Order Cons®raion Printed: 12/15/2014 Pg: 2 Services Group 50 Washington St.Suite 3000 Westborough,MA 01581 Customer/Site Details: Michael Mckenzie 117 Webb St#3 Salem MA 01970-4018 06 InC rnlafto sa - "s. I Start time: Stop time: ____ _. .. .... ... AS Techs: Pre CFM 50: Post CFM 50: _.........__........-...____ ....... ...... . CFM 50 Reduction: -- ----- "-- - - - - - Combustion Safety Test Completed? Yes No Pass or Fail? . Residential Air Sealing Work Order Printed: 12/15/2014 Pg: 1 Conser at ion Services Group 50 Washington St.Suite 3000 Westborough,MA 01581 lh-q a ilk Michael Mckenzie Phone(eve): 978-744-4623 . 117 Webb St#3 Phone(day): 978-744-4623 Salem, MA 01970-4018 Site ID: S00002245751 Flemaln�8rr�-a4rnn ie v`y�e�� "�"r^ Heating Fuel: Electricity Building Volume: 12,000 BAS cfm50: 1,071 Distribution Type: Electric Resistance- Electric Baseb Type:Asbestos Status: UNKNOWN Notes: Existing Insulation: Fiberglass Batts Depth: 4.0 Existing Insulation: Fiberglass Batts Depth: 4.0 Truss Construction: ... ....-.._. Can Blower Door Be Completed? No Areabi`xes_ i _.. .. yam. ;, .. ., , ,., .. :, -••i'� Attic Basement/Crawlspace a All Accessible Penetrations: Yes Exterior Penetrations: Yes Therma-Dome: - Yes Ceiling Penetrations: No w/carpentry: Yes Exterior Door Weatherstrip: Yes WHF Box: No - Vapor Barrier(Sgft): No Additional Areas of Concern... Additional Areas of Concem... Garage Living Space _ All Penetrations: No Plumbing: Yes Weatherstrip Door to Living Space: No Weatherstrip Exterior Doors: Yes Additional Areas of Concern... Additional Areas of Concern... front,first front,first back,second irontsscond,back,third back,back, basement,(b) Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 Customer Name: Michael Mckenzie Site ID: s00002245751 CSG Enclosed Cavity Insulation Fact Sheet Your Energy Specialist has determined that your home would benefit from insulation. Below is a list of the problems that might be encountered during this process.We have selected those which may pertain to your existing siding material or interior areas being treated.Please read carefully each potential issue and sign at the bottom.A copy of this signed fact sheet must be returned with a signed contract or the scheduling of the insulation work will be delayed. At the time of your Home Energy Assessment the Energy Specialist evaluated the current condition of your exterior siding and interior materials.It has been determined that the process of removing certain areas of your siding,drilling holes and blowing in the insulation could result in some damage to the siding or to the esthetics of the paint. Prior to the start of the insulation job,the contractor will demonstrate to the homeowner a sample of the siding removal and reinstallation. Interior Drill&;Blow Interior drill and blow requires holes to be drilled from the inside of the living space or garage and can be a very intrusive and dusty process.In order for this job to go smoothly,the homeowner must make sure that all furniture and any clothing located in adjacent areas to the exterior walls,garage ceiling or slopes(that are being treated)must be moved away from those areas and covered with plastic prior to commencement of the job for that day.Once the insulation is blown in,the contractor's responsibility will be to plug the access holes and treat the surface with an initial application of spackle/filler.Note:The homeowner is responsible for any additional work to the treated areas,including cleaning,dusting and painting to achieve the desired finish conditions. 7; No Additional Areas Specified at Assessment No Additional Areas Specified at Assessment Ann E Sousa a`°Customer Signature: X `°.;��.;,:.�°m -�� Date: November 2014 0 For more information please visit the interactive house web site at http://masssave.csgrp.com/masssave_content.html For GFrlae Use Only CONTRACT FOR Conner atlon PRODUCTS 9 SERVICE WORK Services Group This service is brought to you through support from your local utilip This Agreemeht fS made 6y a?d aanong and hdich Conservation Services Group(CSG) X19 Wehtz St#3 . Attu:RCS Salom MA`0f9,70 gti11) 60 Washington Street,Suite 3000 Site 1D SOQbbZ3 751 Westborough,MA 01681 Prol�tlll#?d00b J28X Reg.No. 173484 Ctierotngr1C1aGQOi�pQ 5fr822 Federal ID=No.22M7170 Contfaot1I72014ib22 V+70RK (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor wW perform or cause to be performed the following work on these"Prenuses"in aprofessional manner and in accordance with the terms of this Contra"including the attached recommendations/work order describing the work in detail(the"Work")which ere incorporated herein by reference: Description Quantity Location Attic Floor Open Blow Cellulose 8" 324 Living Space Insulate vaulted Roof From Interior With 6"Dense Peck Cellulose 39 Uft Specs _ $10023 Damming 62 NIA $119,88 . . . . Sub Total; $732.51 Utility incentive Share $549.38 Customer Contribution $183.13 IF ForotBceuseonly Printed:1012212014 Paget of2 IL PAYMENT �'• 0� Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment ail:$ as a Deposit payable to CSG upon signing the Contract(not to axc@@e��ii 1/9 oP the total retail costs).Mail check&contract to CSG,Attn:R09,50 Washington St.,Ste. 3000,Westborough MA 01681.Final Payment:$ 1 y—• D 7 as the final payment for the Work shall be payable to the Independent Installation Contractor('I[C")upon satin tgry c [npletion of the Work Customer underalands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$.`�`Y4.3,y .Changes to Individual line items and/or previous incentives may Increase or decrease the size of the Utility Incentive Slave. Ill. DISPUTE RESOLUTION The IIC and Cuslomerhereby mutually agree in advancethatin the event thatthe IlC has atimputeconcemingthis Contract the RC may mV mit such dispute to apnvate arbitration service which has been approved by the Office ofConsmnerAffehs andBusiness Regulabonand Customersha0 be required W submit to such arbitration as provided in PdG7,,c 142A You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the sel ler in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busin da fo owing the signing of this agre ment. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. �L CI d3 4fi,��iE (r1#tf4(art, CustargyQ�i& / D Indiest�Yo �selected�jC here,if pllcable (G Initial here if you want // �... /C7 di 1l{ the Program to assign a CONTRACT FOR Conner atlon pROD !C"TS ! SERVICE WORK Services Group This service is brought to you through support from your local utilit Ihrs Agr'eerrlerti#,fs cY7a#�e by arfd af»ohg C0lt8erk oa'Sernees:Group.(PSG) Mlchae�lV�dlto > ,' 6A,U -ROW 417 W0bb gl#3 K &0 Washiri&tQti Street,Suite 3000 Salem,M�;otJg0�401$ " 4Jeathr+rough &1A 01581 Site iDs S0000�20S9S1 ? a®8 No 178464 IrrojatlD 1'ODOOb2a281 Federal ID Nq 222467170 pia m,ar ip C0001YD23$SZ2 (dIaB compYeted Cdnttaae to address above) . . • �:ofiirkot`hyp"2b]��.022,.y�.`&�AL .. .. 1. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these Prerrdses In a pmfesmonal manner and in accordance with the terms of this Contract,including the attached moonunendadonshvork order describing the work in detail(the Worle which are Incorporated herein by reference: Description Quantity Location A81c Statr CoverThermai Banlerwllh carpentry _ 1 Living Space. $280.23 Perform Air Sealing at Eall Tell d 82.8 CFM5o Per Hour ..,_ _. 4 Living SpeCO.. .. $337.28 Door Sweep. - . . 8 . N/A _ . . . . $186.44 8 NlA. $220.72 Exterior Door WeeMerSMPPI90_ . .. __ .. „ _.. .. : - - Bub Total: $1,003.87 . Utility Incentive Sham $1,003.67 Customer Contribution - $0.00 QFr� Printed:1p122i2014 Page 2 of 2 For oRleo use only IL PAYMENT aea Deposit Customer agrees to pay Contractor for the Work,the Customer Sham of the Contract Price as follows:Payment#1:$ payable to CSG upon signing the Contract(not to exceed ll3 the total retail coats).Mail cheek&contract to CSG,A RCS,80 Washington.St.,Ste. 8000,Weatborough,NA 01881.Final Payment$ as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon eatls'.Pepj�ry core etion of the ork.Customer understands that he/she will not be required to pay the Utility Incentive Share of the c ontract price in the amount of$_.((X 1{. - ,Changes to indhddual line items and/or previous incentives may increase or decrease the else of the i3Ulhy Incentive Slam. III.DISPUTE RESOLUTION 8' The IIC and Customer hereby mutually agree inad`�ancaatin the eventtlattha IIC has a dispute concerting this Conimct,the IIC may submit such dispute to apnvate arbitration service which has been approved by the Cflce of ConsrmerABake and Business Regulation and Customer shall be required to submit to such arbitrumn asprovided In M.G.L c 142A You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the thirl busine he signing of this agreement. D�Op NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. .7,;�i ki "isC Indicate yo acted here,if llcable (oil)'Initisl here U you want � i0�J�7 �Pfs the Program toa�signa IIC Combustion Safety Test Form CUSTOMER NAME: SITE 1D: Equipment/Fuel Type Hot Water Heater Heating Sys. iAtmospheric induced Powered Vent' sealed' "B"Vent• PVC Vent' Stainless 5C' DHW IND TANKLESS ELEC. BOILER FURN. OTHER Heating: Fuel: Fuel: Hot Water. ---- — - - - - - - - ' llyes•OOTOTORILL A'TEST BOLL Othertn%mllbew pletedasapprWp elCOatvmfsermiindon-) Were any gas leaks detected lit applicable)? YES NO Are there broken,detatcbed or corroded flue pipes?: YES NO Are there any unvented gas appliances(does not include ovens)?: YES NO SWas there a working carbon monoxide detector in the home?: YES NO TEST IN TEST OUT Combustion Appliance Zone(CAZ),Depressurization Outside Temp: Bath: Kit: IDYer, Outside Temp: Bath: Kit: Dryer: CAZ Baseline Pressure- Air Handler: ON OFF N/A M CAZ Baseline Pressure: Air Handler: ON OFF N/A CAZ Wont Case Pressure: 18asement Door: OPEN CLOSED McAz Worst Case Pressure: jElasement Door: OPEN CLOSED Total Pressure Change: 10ther Doors: STotal Pressure Change: 101her Doors: Domestic CO Draft Draft w/HeatingSys On CO Draft Daft w/Heating Sys On Pass Spillage Test Pass Draft Test Pass CO Test Pass spillage Test Pass Daft Test Pass CO Test ❑Yes❑No❑NJA ❑Ves❑No❑N/A ❑Yes❑No❑N/A ❑Yes❑No❑NJA ❑Yes ❑No❑NJA ❑Yes❑No❑N/A Heating System Worst CO Draft CO Draft Passspillage Test Pass Orak Test Pass CO Test Pass Spillage Test Pass Draft Test Pass CO Test ❑Yes❑No QN/A ❑Yes❑No❑N/A ❑Yes❑No❑N/A ❑Yes❑No❑N/A ❑Yes❑No❑N/A ❑Yes ONO❑N/A Ambient CO in CAZ: Ambient CO in Living Space: Ambient CO in CAZ: jAmbient CO in Wing Space: Natural Conditions Retest(Only If Necessary) Equip Type Pass Spillage Draft CO Equip Type Passspillage Draft CO ❑Yes❑No❑N/A J ❑Yes❑No❑N/A ❑Yes❑NO❑N/A I I ❑Yes❑No❑N/A CO(Measured at exhaust port): CO(Measured at exhaust port): Ambient CO: Ambient CO: Technician Name: Company Name: Test.Dates: Conservation Services Group fin (� All Righs Rese,r l .er.212011 I I'T f w . 1M I'm IV 1711 Jim Jim M IV M k TRH EEA`D 'FE CERTIF°IED;GUIDE TO V41 i �:� t ��, ar�r>S ivµ� ��,it}„ � a ✓��, s �+ sy h k� � .�+' N ygww a `• f t��y S � k� iY'FfMI 1 E A 0. � A rm WWW x Fv i k F N 41 1 4 f C- qq'1111 A; � wtF k:t ° 4N t � ,n s. YNhLi "a'f ]Ai*-ha3 ; ',Cf �lfN J i , vG ill i[} a fu4} a i ? G pyY J,fir 48, Wlll t 2 IT'S THE LAW! Federal law requires contractors that disturb painted surfaces in homes,child care facilities and schools built before 1978 to be certified and follow specific work practices to prevent lead contamination.Always ask to see your contractor's certification. Federal law requires that individuals receive certain information before renovating more than six square feet of painted surfaces in a room for interior projects or more than twenty square feet of painted surfaces for exterior projects or window replacement or demolition in housing,child care facilities and schools built before 1978. •Homeowners and tenants:renovators must give you this pamphlet before starting work. •Child care facilities,including preschools and kindergarten classrooms,and the families of children under six years of age that attend those facilities:renovators must provide a copy of this pamphlet to child care facilities and general renovation information to families whose children attend those facilities. WHO SHOULD READ THIS PAMPHLET? This pamphlet is for you if you: •Reside in a home built before 1978. •Own or operate a child tare facility,including preschools and kindergarten classrooms,built before 1978,or •Have a child under six years of age who attends a.child care facility built before 1978. You will learn: •Basic facts about lead and your health. •How to choose a contractor,if you are a property owner. D Z '� •�,^ •What tenants,and parents/guardians of a child in a child care facility or school ,�'•Q. .�. should consider. - s- •How to preparefor the renovation or repairjob. h' �sT 1„! -What to lookforduring thejob and afterthejob is done. `t° V,. VJ' •Where to get more information about lead. a� n This pamphlet is not for. 'tj. t;'k,` •Abatement projects.Abatement is a set of activities aimed specifically at ,:^ •'�°^' eliminating lead or lead hazards.EPA has regulations for certification and training of abatement professionals.If your goal is to eliminate lead or lead hazards,contact the National Lead Information Center at 1-800-424-LEAD(5323)for more information. •"Do-it-yourself'projects.If you plan to do renovation work yourself,this document is a good start,but you will need more information to complete the work safely.Call the National Lead Information Center at 1-800-424-LEAD(5323)and ask for more information on how to work safely in a home with lead-based paint. -.- -Contractor education.Contractors who want information about working safely with lead should contact the National Lead Information Center at 1-800-424-LEAD(5323) , for information about courses and TMTM resources on lead-safework practices. 'x ` t RENOVATING, REPAIRING, OR PAINTING? LEAD AND YOUR HEALTH •Is your home,your building,or the child care facility Lead is especially dangerous to children or school your children attend being renovated, under six years of age. repaired,or painted? _ Lead can affect children's brains and developing -- -_- +y •Was your home,your building,or the child care facility nervous systems,causing: �•'"✓- �� . or school where your children under six years of age .Reduced IQ and learning disabilities. +* ya attend built before 1978? ,V. .-Behavior_Problems ` `� •+ If the answer to these questions is YES,there are a ' * few important things you need to know about lead-based paint. Even children who appear healthy can have dangerous levels of lead in their bodies. This pamphlet provides basic facts about lead and Lead is also harmful to adults.In adults,low levels information about lead safety when work is being of lead can pose many dangers,including: done in your home,your building or the child care pressure High blood and facility or school your children attend. 9 P hypertension. •Pregnant women exposed to lead can transfer lead to their fetuses.Lead gets into the body when it is swallowed or inhaled. - •People,especially children,can swallow lead dust as they eat,play,and do other normal hand-to-mouth activities. •People may also breathe in lead dust or fumes if they disturb lead-based paint. People who sand,scrape,burn,brush,blast or otherwise disturb lead-based The Facts About Lead paint risk unsafe exposure to leads •Lead can affect children's brains and developing nervous systems,causing reduced IQ,learning disabilities,and behavioral problems.Lead is also harmful to adults. What should I d0 if I am concerned about myfamlly's exposure to lead? •Lead in dust is the most common way people are exposed to lead.People can also •A blood test is the only way to find out if you or a family member already has lead get lead in their bodies from lead in soil or paint chips.Lead dust is often invisible. poisoning.Call your doctor or local health department to arrange for a blood test. •Lead-based paint was used in more than 38 million homes until it was banned for •Call your local health department for advice on reducing and eliminating residential use in 1978. exposures to lead inside and outside your home,child care facility or school. •Projects that disturb painted surfaces can create dust and endanger you and your •Always use lead-safe work practices when renovation or repair will disturb family.Don't let this happen to you.Follow the practices described in this pamphlet painted surfaces. to protectyou and yourfamily. For more information about the health effects of exposure to lead,visit the EPA lead website at erm nov/lead/nubs/leadinfo or call 1-800-424-LEAD(5323). There are other things you can do to protect your family every day. •Regularly clean floors,window sills,and other surfaces. •Wash children's hands,bottles,pacifiers,and toys often. •Make sure children eat a healthy,nutritious diet consistent with the USDA's dietary guidelines,that helps protect children from the effects of lead. •Wipe off shoes before entering the house. 2 3 WHERE DOES THE LEAD COME FROM? CHECKING YOUR HOME FOR LEAD-BASED PAINT Dust is the main problem. Percentage of Homes Likely to Contain Lead The most common way to get lead in the body is from dust.Lead dust comes from deteriorating lead-based paint and lead-contaminated soil that gets tracked into w eetwee" y� your home.This dust may accumulate to unsafe levels.Then,normal hand to-mouth E 1960-1978 AAA 24% activities,like playing and eating(especially in young children),move that dust from o 1940-1 �� JA iA y►, JA 69/o surfaces like floors and window sills into the body. 0 r94o-r9so. *tCl*LC7rCClrtif o Home renovation creates dust. Common renovation activities like sanding,cutting,and demolition can create rn zo 3o so s1 61 io eo 0 �w hazardous lead dust and chips. - Proper work practices protect you from the dust. Older homes,child care facilities,and schools are more likely to contain The keyto protecting lead-based paint. P g yourself and your family during a renovation,repair or painting Homes may be single-family homes or apartments.They may be private,government- job is to use lead-safe work practices such as containing dust inside the work area, assisted,or public housing.Schools are preschools and kindergarten classrooms.They using dust-minimizing work methods,and conducting a careful cleanup,as described in this pamphlet. may be urban,suburban,or rural. Other sources of lead. You have the following options: Remember,lead can also come from outside soil,your water,or household items You may decide to assume your home,child care facility,or school contains lead. (such as lead-glazed pottery and lead crystal).Contact the National Lead Information Especially in older homes and buildings,you may simply want to assume lead-based Center at 1-800-424-LEAD(5323)for more information on these sources. paint is present and follow the lead-safe work practices described in this brochure during the renovation,repair,or painting job- Youcan hire a certified professional to check for lead-based paint. These professionals are certified risk assessors or inspectors,and can determine if your home has lead or lead hazards. s.•� t ft` •A certified inspector or risk assessor can conduct an inspection telling you whether t �.. your home,or portion of your home,has lead-based paint and where it is located. This will tell you the areas in your home where lead-safe work practices are needed. gr -A certified risk assessor can conduct a risk assessment telling you if your home currently has any lead hazards from lead in paint,dust,or soil.The risk assessor can also tell you what actions to take to address any hazards. i •For help finding a certified risk assessor or inspector,call the National Lead Information Center at 1-800-424-LEAD(5323). _ c You may also have a certified renovator test the surfaces or components being disturbed for lead by using a lead test kit or by taking paint chip samples and sending them to an EPA-recognized testing laboratory.Test kits must be EPA-recognized and are available at hardware stores.They include detailed instructions for their use. 4 5 FOR TENANTS AND FAMILIES OF CHILDREN UNDER SIX FOR PROPERTY OWNERS YEARS OF AGE IN CHILD CARE FACILITIES AND SCHOOLS - You have the ultimate responsibility for the safety of your family,tenants,or children You play an important role ensuring the ultimate f �, in your care. safety of your family. This means properly preparing for the renovation and keeping persons out of the work This means properly preparing for the renovation area(see p.8).It also means ensuring the contractor uses lead-safe work practices. and staying out of the work area(see p.8). ,R€g --(;Yt 7 Federal law requires that contractors performing renovation,repair and painting projects Federal law requires that contractors performing that disturb painted surfaces in homes,child care facilities,and schools built before 1978 - painte Surrepairandpainting projects that disturb e certified"and follow specific work practices to prevent lead contamination. � �: - - - before- � --- ----,-. - painted surfaces in homes built 1978 and in Make sure your contractor is certified,and can explain clearly the details of thejob child care facilities and schools built before 1978,that -rr and how the contractor will minimize lead hazards during the work. a child under six years of age visits regularly,to be •You can verify that a contractor is certified by checking EPA's website at certified and follow specific work practices to prevent j I" eoa.gov/oetleadsafe or by calling the National Lead Information Center at lead contamination. r 1-800-424-LEAD(5323).You can also ask to see a copy of the contractor's The law requires anyone hired to renovate,repair,or do firm certification. • -painting preparation work on a property built before •Ask if the contractor is trained to perform lead-safe work practices and to see a 1978 to follow the steps described on pages 9 and 10 unless the area where the work copy of their training certificate. will be done contains no lead-based paint. •Ask them what lead-safe methods they will use to set up and perform thejob in your home,child care facility or school. If you think a worker is not doing what he is supposed to do or is doing something •Ask for references from at least three recentjobs involving homes built before 1978, -that Is unsafe,you should: and speak to each personally. •Contact your landlord. Always make sure the contract is clear about how the work will be set up, •Call your local health or building department,or performed,and cleaned. •Share the results of any previous lead tests with the contractor. •Call EPA's hotline 1-80b-424-LEAD(5323). •You should specify in the contract that they follow the work practices described on If you are concerned about lead hazards left behind after he job is over,you can pages 9 and 10 of this brochure. check the work yourself(see page 10). •The contract should specify which parts of your home are part of the work area and specify which lead-safe work practices will be used in those areas.Remember,your contractor should confine dust and debris to the work area and should minimize spreading that dust to other areas of the home. >? •The contract should also specify that the contractor will clean the work area,verify that it was cleaned adequately,and re-clean it if necessary. If you think a worker is not doing what he is supposed to do or is doing something o- r that is unsafe,you should: •Direct the contractor to comply with regulatory and contract requirements. •Call your local health or building department,or f.. � � •Call EPA's hotline 1-800-424-LEAD(5323). . If your property receives housing assistance from HUD(or a state or local agency that uses HUD funds),you must follow the requirements of HUD's Lead-Safe Housing Rule - and the ones described in this pamphlet. 6 7 PREPARING FOR A RENOVATION DURING THE WORK The work areas should not be accessible to occupants while the work occurs. Federal law requires contractors that are hired to perform renovation,repair and painting The rooms or areas where work is being done may need to be blocked off or sealed projects in homes,child care facilities,and schools built before 1978 that disturb painted with plastic sheeting to contain any dust that is generated.Therefore,the contained surfaces to be certified and follow specific work practices to prevent lead contamination. area may not be available to you until the work in that room or area is complete, The work practices the contractor must follow include these three simple procedures, cleaned thoroughly,and the containment has been removed.Because you may not described below: - have access to some areas during the renovation,you should plan accordingly. . ._ ._ ... __.. ____. . .. ,_. .. . . . . . _ -_.. . .. .. . 1.Contain the work area.The area must be contained so that dust and debris do not escape You may Geed: from that area.Warning signs must be put up and plastic orother impermeable material y and tape must be used as appropriate to: •Alternative bedroom,bathroom,and kitchen arrangements ifwork is occurring in those areas of your home. •Cover the floors and any furniture that cannot be moved. •A safe place for pets because they too can be poisoned by lead and can track lead •Seal off doors and heating and cooling system vents. dust into other areas ofthe home. •Forexterior renovations,coverthe ground and,in some instances,erectvertical •A separate pathway for the contractor from the work area to the outside in order to containment or equ ivalent extra precautions in containing the work area. - ' bring materials in and out of the home.Ideally,it should not be through the same These work practices will help prevent dust or debris from getting outside the work area. entrance that your family uses. 2.Avoid renovation methodsthat generate large amounts of lead-contaminated dust. •A place to store your furniture.All furniture and belongings may have to be moved Some methods generate so much lead-contaminated dustthattheir use is prohibited. from the work area while the work is being done.Items that can't be moved,such as - They are: 7q. u; Y 1 m- s cabinets,should be wrapped in plastic. •Open flame burning or torching. VAN Div •To turn off forced-air heating and air conditioning systems while the work is being done.This prevents dust from spreading through vents from the work area to the •Sanding,grinding,planing,needle gunning rest of your home.Consider how this may affect your living arrangements. or blasting with power tools and equipment ; t. r. STG.r�x not equipped with a shroud and HEPA You may even want to move out of our home temporarily while all or art of the Y Y P Y P vacuum attachment. work is being done. z •Using a heat gun at temperatures greater Child care facilities and schools may want to consider alternative accommodations than 1100°F. k ' for children and access to necessary facilities. There is no way to eliminate dust,but some renovation methods make Tess dust than others. Contractors may choose to use various methods to minimize dust generation,including using water to mist areas before sanding or scraping;scoring paint before separating components;and prying and pulling apart components instead of breaking them. - -' - - 3.Clean up thoroughly.The work area should be cleaned up dailyto keep it as clean as y possible.When all the work is done,the area must be cleaned up using special cleaning methods before taking down any plastic that isolates the work area from the rest of the home.The special cleaning methods should include: �,. U ' ! 1 •Using a HEPAvacuum to dean up dust and debrison all surfaces,followed by i -Wet wiping and wet mopping with plenty of rinse water. When the final cleaning is done,look around.There should be no dust,paint chips,or debris in the work area.if you see any dust,paint chips,or debris,the area must be re-cleaned. 8 9 FOR PROPERTY OWNERS: AFTER THE WORK IS DONE FOR ADDITIONAL INFORMATION When all the work is finished,you will want to know.if your home,child care facility,or You may need additional information on how to protect yourself and your children school where children under six attend has been cleaned up properly. while ajob is going on in your home,your building,or child care facility. EPA Requires Cleaning Verification. - The National Lead Information Center at 1-800-424-LEAD(5323)or In addition to using allowable work practices and working in a lead-safe manner, epa.gov/lead/-nlic can tell you how to contact your state,local,and/or tribal programs EPA's RRP rule requires contractors to follow a specific cleaning protocol.The protocol or get general information about lead poisoning prevention. requires the contractor to use disposable cleaning cloths to wipe the floor and other -State and tribal lead poisoning.prevention or environmental protection programs - surfaces of the work area and compare these cloths 4o an EPA-provided cleaning � can provide information about lead regulations verification card to determine if the work area was adequately cleaned.EPA research and potential sources of financial aid for reducing has shown that following the use of lead-safe work practices with the cleaning lead hazards.If your state or local,government has , verification protocol will effectively reduce lead-dust hazards. requirements more stringent than those described in Lead-Dust Testing. this pamphlet,you must follow those requirements. _ EPA believes that if you use a certified and trained renovation contractor who follows •Local building code officials can tell you the the LRRP rule by using lead-safe work practices and the cleaning protocol afterthe regulations that apply to the renovation work that you job is finished,lead-dust hazards will be effectively reduced.If,however,you are are planning. interested in having lead-dust testing done at the completion of yourjob,outlined liiw below is some helpful information. •State,county,and local health departments can {y_ provide information about local programs,including k What is alead-dust test? assistance for lead-poisoned children and advice on •Lead-dust tests are wipe samples sent to a laboratory for analysis.You will get ways to get your home checked for lead. report specifying the levels of lead found after your specificjob. SpFE`' The National Lead Information Center can also provide D�„awp�. How and when should I ask my contractor about lead-dust testing? a variety of resource materials,including the following "gin •Contractors are not required by EPA to conduct lead-dust testing.However,if you guides to lead-safe work practices.Many of these want testing,EPA recommends testing be conducted by a lead professional. To materials are also available at locate a lead professional who will perform an evaluation near you,visit EPA's - epa.gov/lead/pubs/brochure website at epa gov/lead/nubs/locate or contact the National Lead Information Center at 1-800-424-LEAD(5323). •Steps to Lead Safe Renovation,Repair and Painting. •If you decide that you want lead-dust testing,it is a good idea to specify in your •Protect Your Family from Lead in Your Home contract,before the start of the job,that a lead-dust test is to be done for yourjob •Lead in Your Home:A Parent's Reference Guide and who will do the testing,as well as whether re-cleaning will be required based on the results of the test. •You may do the testing yourself. , If you choose to do the testing, ^ some EPA-recognized lead 'Fs� laboratories will send you a kit A '"' =' X x For the hearing impaired,call the Federal Information Relay Service at 1-800-877-8339 that allows you to collect samples ` to access any of the phone numbers in this brochure. and send them back to the ,3 ' laboratory for analysis. Contact the National Lead Information. - CenterforlistsofEPA-recognized testing laboratories. m 10 tt EPA CONTACTS OTHER FEDERAL AGENCIES EPA Regional Offices CPSC HUD Office of Healthy Homes and Lead EPA addresses residential lead hazards through several different regulations. The Consumer Product Safety Hazard Control EPA requires training and certification for conducting abatement and renovations, Commission(CPSC)protects the public The Department of Housing and Urban education about hazards associated with renovations,disclosure about known lead from the unreasonable risk of injury or Development(HUD)provides funds paint and lead hazards in housing,and sets lead-paint hazard standards. death from 15,000 types of consumer to state and local governments to Your Regional EPA.Office can provide further information regarding lead safety and products under the agency's jurisdiction. develop cost-effective ways to reduce lead protection programs at - 'CPSC warns the public and private I - — p p g �a gov/lead. - P P� lead-based paint hazards in America's- - - -- sectors to reduce exposure to lead and privately-owned low-income housing.In Region 1 Region Region 7 increase consumer awareness.Contact. _addition,the office enforces the rule on (Connecticut,Massachusetts,. (Alabama,Florida,Georgia, (Iowa,Kansas,Missouri,. CPSC for further information regarding disclosure of known lead paint and lead Maine,New Hampshire, Kentucky,Mississippi,North Nebraska) regulations and consumer,product safety. hazards in housing,and HUD's lead safety Rhode Island,Vermont) Carolina,South Carolina, Regional Lead Contact regulations in HUD-assisted housing, Regional Lead Contact Tennessee) U.S.EPA Region 7 CPSC provides public outreach and technical U.S.EPA Region 1 Regional Lead Contact 901 N.5th Street 4330 East West Highway assistance,and conducts technical Suite 1100 U.S.EPA Region 4 Kansas City,KS 66101- Bethesda,MD 20814 studies to help protect children and their One Congress Street 61 Forsyth Street,SW (913)551-7003 Hotline 1400)638-2772 families from health and safety hazards Boston,MA 02114-2023 Atlanta,GA 30303-8960 c ov in the home.Contact the HUD Office of (888)372-7341 (404)562-9900 Region 8 Healthy Homes and Lead Hazard Control (Colorado,Montana, (DCChIIdh00d Lead PolsonlR for information on lead regulations, Region 2 Region 5 North Dakota,South Dakota, g (New Jersey,New York, (Illinois,Indiana,Michigan, Utah,Wyoming) Prevention Branch outreach efforts,and lead hazard control Puerto Rico,Virgin Islands) Minnesota,Ohio,Wisconsin) Regional Lead Contact - research and outreach grant programs. 9 - The Centers for Disease Control and Regional Lead Contact Regional Lead Contact U.S.EPA Region Prevention(CDC)assists state and local U.S.Department of Housing and Urban U.S.EPA Region 2 U.S.EPA Region 5 1595 Wynkoop Street childhood lead poisoning prevention Development 2890 Woodbridge Avenue 77 West Jackson Boulevard Denver,CO 80202 Building 205,Mail Stop 225 Chicago,IL 60604-3507 (303)312-6312 programs to provide a scientific basis Office of Healthy Homes and for Edison,NJ 08837-3679 (312)886-6003 policy decisions,and to ensure that Lead Hazard Control (732)321-6671 Re health issues are addressed in decisions 451 Seventh Street,SW,Room 8236 Region 9 about housing and the environment. Region 6 (Arizona,California,Hawaii, Washington,DC 20410-3000 C Region 3 (Arkansas,Louisiana,New Nevada) Contact CDC Childhood Lead Poisoning HUD's Lead Regulations Hotline (Delaware,Maryland, Mexico,Oklahoma,Texas) Regional Lead Contact Prevention Program for additional (202)402-7698 Pennsylvania,Virginia, Regional Lead Contact U.S.Region materials and links on the topic of lead. hud.gov/offices/lead/ Washington,DC,West U.S.EPA Region 6 75 Hawthorne Street Virginia) 1445 Ross Avenue, San Francisco,CA 94105 CDC Childhood Lead Poisoning Regional Lead Contact 12th Floor (415)947-8021 Prevention Branch U.S.EPA Region 3 Dallas,TX 75202-2733 4770 Buford Highway,MS F-40 1650 Arch Street (214)665-7577 Region 10 Atlanta,GA 30341 Philadelphia,PA (Alaska,Idaho, (770)488-3300 19103-2029 Oregon,Washington) cdc.gov/nceh/lead (215)814-5000 Regional Lead Contact U.S.EPA Region 10 1200 Sixth.Avenue Seattle,WA 9 81 01-11 2 8 (206)553-1200 12 13 SAMPLE PRE-RENOVATION FORM This sample form may be used by renovation firms to document compliance with the Federal , pre-renovation education and renovation,repair,and painting regulations. Occupant Confirmation Pamphlet Receipt 1 have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit.I received this pamphlet before the work began. A Sousa � . .Printed Name of Owner_occupant_. ._._ .-.-_ _. .___.. ...__. _... .. .... -. Ann E Sousa 11/18/14 Signature of Owner-occupantm Signature Date r Renovator's Self Certification Option(for tenant-occupied dwellings only) Instructions to Renovator:If the lead hazard information pamphlet was delivered but a tenant r^. signature was not obtainable,you may check the appropriate box below. . . ❑Declined-I certify that I have made a good faith effort to deliver the lead hazard -r ; information pamphlet to the rental dwelling unit listed below at the date and time indicated -�_ _ and that the occupant declined to sign the confirmation of receipt.I further certify that I have left acopy of the pamphlet at the unit with the occupant. ❑Unavailable for signature-I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below and that the occupant -7 s , was unavailable to sign the confirmation of receipt.I further certify than have left a copy of the pamphlet at the unit by sliding it under the door or by(fill in how pamphlet was left) Printed Name of Person Certifying Delivery Attempted Delivery Date Signature of Person Certifying Lead Pamphlet Delivery ' Unit Address Note Regarding Mailing Option—As an alternative to delivery in person,you may mail the lead hazard information pamphlet to the owner and/or tenant.Pamphlet must be mailed at least seven days before renovation.Mailing must be documented by a certificate of mailing from the post office. , 1 40l- Rib Conser d't;f up CERTIFICATE OF COMPLETION Services Group 50 Washington St.Suite 3000 Westborough,MA 01581 Ann Marshall Phone(Eve): 978-7444623 117 Webb St#2 Phone(Day): Salem, MA 019704018 E-Mail: aesousa@verizon.net SIteID: S00002245718 Combustion Safety Test Completed YIN Pre Blower Door# (If applicable) Post Blower Door# (if applicable) Contract ID:20140717-1_WORK Company: Air-Tight Weatherization Sub-contractor Work Order#: S45718P51248C271 �Lo=ation� � =-"'Pescrlpfiork• _. "n, � >x, „Q anima. '� stalle' Living Space Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 1,275 PLEASE NOTE:The Inspection of the house is for the purpose of finding CUSTOMER AUTHORIZATION OF CERTIFIED WORK out whether the Contractor completed the work. I confirm that the measures listed above have been completed to my CUSTOMER SHOULD NOT RELY ON THE INSPECTION FOR satisfaction. I have received a copy of the Certificate of Completion and ASSURANCE THAT THE CONTRACTOR'S WORK NECESSARILY hereby authorize the release of any final payments to the Contractor. I COMPLIES WITH ALL LAWS AND STANDARDS RELATED TO understand that this Authorization of Completed Work does not in any SAFETY. manner void any warranties provided to me by the Contractor. It was the Contractor's sole responsibilly to assure that the measures were installed property and safely. In addition, this Post-Installation Inspection does not replace inspections by licensed inspectors where required by state or local law. It is the duty of the Customer to obtain such required inspections. Contractor's Signature Customer's Signature Date Date Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 , r Conser CONTRACTOR WORK ORDER Services Group 50 Washington St.Suite 3000 Printed: 1/1 212 0 1 5 Westborough,MA 01581 Work Order Id: S45718P51248C271 Co`ttrtiir,lntomt oCj"; rJhjeSlt It. _ _ Air-Tight Weatherization Ann Marshall ^Email: aesousa@verizon.net 9 Story Ave - 117 Webb St#2 Phone(Eve): 978-7444623 Beverly,MA 01915 Salem,MA 01970-4018 Phone(Day): Site ID: S00002245718 Location Description Quantity Unit$ Total$ Living Space Insulate Clapboard Sided Wall With 4" Dense 1,275 $2.27 $2,894.25 Installed Measures Total $2,894.26 Type Status Notes Asbestos UNKNOWN none visable ut homeowner disclosed there was in past Incentive Payments Weatherization Incentive $2,000.00 Total Incentive Payments $2,000.00 Customer Share Total Customer Share - $894.25 Less Deposit Of $298.08 Customer Share Balance(Due Contractor) - $696.17 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-95000 Ann Marshall 117 Webb St#2 Salem,MA 019704018 Site 11):S00002245718 Project ID:P00000251248 Customer ID:C00000255789 Contract ID:20140717-f WORK Description Quantity weation Insulate Clapboard Sided Wall With 4•Dense Pack Ce0ulose 1,276 U Ang Space $2,894.25 Sub Total: $2,894.25 Utility incentive Share $2.000.00 Customer Conbibutlon $894.26 Q For office use only Printed:7/1 712 0 1 4 Page 1 011 GCONTRACT FOR Conser atlon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and Ann Marsha6 Conservation Services Group(CSG) 117 Webb St#2 Attn:RCS Salem,MA 01970-4018 50 Washington Street, Suite 3000 Site 1D:500002245718 Westborough,MA 01581Reg. No. 173484 Project ID:P000002S,1248 Federal ID No.2224fi7170 Customer ED:C00000255789 Contract m:2014071771 WORK (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contactor will perform or cause to be performed the following work on these"Premises"in a professional manner mid in accordance with the terms of this Contract,including the attached tecommendlations/work order describing the work in detail(the"Work'D which me incorporated herein by reference: Description Quantity Location Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 1,275 Living Space $2.894.25 Sub Total: $2,894.25 Utility Incentive Share $2,000.00 Customer Contribution $894.25 RNE1 For office use only Printed:7/1712014 Page 1 of 1 It. PAYMENT Customer agrees to w pay Contactor for the Work,the Customer Share of the Contract Price as follows:Payment 46$ (1' /� V/'j as a.Deposit. payable to CSG upon signing the Contract(not to exc?�e¢1/3 of the total retail costs).Mail check&contact to CSG,Attn:RC9,50 Washington St.,Ste. 3000,Westborough,MA 01581.Final Payment:$ .'S `I(+.t 7 as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon eetlePB,ptory cornylotion of the Work.Customer understands that he/ahe will not be required to pay the Utility Incentive Shme of the Contact price in tine amount of$ r�.oOC.LKJ .Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Ill. DISPUTE RESOLUTION the IN.'and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Connect,the IIC may entail,such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Ctsomershall be required m submit to ma arbitration as provided in M.G.L c 142A. You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busin ay foll wing the signing of this ag ee ant. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (".usto x ignatrrre D&I Inch to you '' 1/g4eted IIC/here,ff appli able 1Dg) IS'al herei f youy want �� Q�GI �/2 C(,//1 S,4YlA�� the Program to assign a CSG Signature D e Name of CSG Representative(Printed) Punctpating Contractor TERMS AND CONDTTIONS APPEAR ON THE REVERSE. 3/14 Customer Name: arm marshall Site ID: s00002245718 CSG Enclosed Cavity Insulation Fact Sheet Your Energy Specialist has determined that your home would benefit from insulation.Below is a list of the problems that might be encountered during this process.We have selected those which may pertain to your existing siding material or Interior areas being treated.Please read carefully each potential Issue and sign at the bottom.A copy of this signed fact sheet must be returned with a signed contract or the scheduling of the insulation work will be delayed. At the time of your Home Energy Assessment the Energy Specialist evaluated the current condition of your exterior siding and interior materials.It has been determined that the process of removing certain areas of your siding,drilling holes and blowing in the Insulation could result In some damage to the siding or to the esthetics of the paint.Prior to the start of the insulation Job,the contractor will demonstrate to the homeowner a sample of the siding removal and reinstallation. Wood Clapboard&Shingle Siding The present condition and age of the exterior shingle or clapboard plays an important part as to how easily the siding can be removed and reinstalled.Older siding that has been exposed to the elements and has numerous layers of paint or stain has a greater risk of being split o cracked in the removal process.Under these conditions a shingle or clapboard may crack in half when trying to remove It.When this occurs the contractor will try to reinstall the shingle or clapboard so the split or cracked areas butt up tight together.When It is not possible to reinstall a cracked shingle or clapboard,because the split or cracked areas will not butt up tight together,the contractor can repair the crack with exterior wood patch or as a last option replace the damaged area with a similar type of shingle or clapboard.Note:It is the homeowner's responsibility(if needed)to touch up paint or stain on shingles or clapboards that have been removed. No Additional Areas Specified at Assessment No Additional Areas Spedfled of Assessment Customer Signature: X l A p �{9n.-Q_ Date: / 7 ' 11M. For more information please visit the interactive house web site at http://masssave.csgrp.com/masssave_content.htmi For orrice use onry RCS PLANVIEW DIAGRAM ' Customer: on 11 1 Mars A / Home Phone: ( IZ )- Address:_11, W.e•b h Sf/9 C �/5 Work Phone: Town: iSQ&,I—' //�/ 7d Cell Phone: Any limitations for access by large truck? No_ Yes If yes,describe: Any specific directionsor landmarks) No Yes_ If yes.describe: 17 Site ID: P�r'jj 0 Energy Specialist: �T Reviewed by: ��5Ul Si(K�Lf 1�� f^'rF�l y DF-ce � 1 w+�lq�abawd 0kS r I 50 5-0 V V � - lo _ For Office Use Only 1. 1 Bushes - Ladder V Neighbor Proximity Pocket Doors Insert Radiators Fences) Existing Conditions X=Access ❑=Vents Note Inside Square R=Roof �� - S=Soffit G-Gable RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Drip Edge T=Triangle Install O=New Access Note in Circle C=Ceiling W=Wall S=Sheathing Temp Unless Noted Otherwise =Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For Access Rev 104 SAMPLE PRE-RENOVATION FORM This sample form may be used by renovation firms to document compliance with the Federal pre-renovation education and renovation, repair,and painting regulations. Occupan nfirmation Pam et Receipt have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my d ling unit.I r ceived this amph let before the work began. wAh ngrs �� Printed Name of owner-occupant ._ � c 7/7 S g ature of Owner occupant Sign Lure to Renovator's Self Certification Option(for tenant-occupied dwellings only) Instructions to Renovator:If the lead hazard information pamphlet was delivered but a tenant signature was not obtainable,you may check the appropriate box below. ❑Declined-I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below at the date and time indicated and that the occupant declined to sign the confirmation of receipt.I further certify that I have left a copy of the pamphlet at the unit with the occupant. ❑Unavailable for signature-I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below and that the occupant . was unavailable to sign the confirmation of receipt.I-further certify that I have left a copy of the pamphlet at the unit by sliding it under the door or by(fill in how pamphlet was left). Printed Name of Person Certifying Delivery Attempted Delivery Date Signature of Person Certifying Lead Pamphlet Delivery Unit Address Note Regarding Mailing Option—As an alternative to delivery in person,you may mail the lead hazard information pamphlet to the owner and/or tenant.Pamphlet must be mailed at least seven days before renovation.Mailing must be documented by a certificate of mailing from the post office. Customer Name: arm marshall Site ID: s00002245718 Date: 7/17/14 Mass Save Customer Disclosure and Preparation Requirements At your Home Energy Assessment your Energy Specialist has reviewed and identified applicable cost-effective opportunities,potential health and safety concerns as well as any customer required actions to facilitate improvements in your home. Your Energy Specialist is trained to evaluate and propose appropriate site-specific improvements that will reduce energy consumption and improve comfort. The following conditions were noted at the time of the Home EnerRv Assessment: Combustion Safety: initial mere No Issues Detected otAssessment Combustion Appliances: Initial mere No Issues Detected at Assessment Pipe Disclaimer: Initial Rare No Issues Detected at Assessment Moisture Concerns: Initial Nero. No issues Detected at Assessment Customer Weatherization Preparation Requirements: Storage Removai ❑ Platform Buildup ❑ CO DeWtor Roaring Removal Q Specified Measures AgreCme t(SmA) Customers are responsible to complete any noted required actions in order to be eligible for program weatherization work at their home. The participating Contractor will be confirming the completion of these required actions prior to lnidalNer—• scheduling an installation date. customer is removing vinyl siding wood clapboard will be siding This notice does not constitute an endorsement or warranty regarding the presence or absence of other real or potential health and safety hazards that may exist at this address or premises.If you have questions regarding this information,or to schedule a follow-up inspection after the noted pions h ve been corrected,please call our Customer Service at 800-4 0-747 . Customer Signature: 4-_ Date: 711XIIV Energy Specialist: Igo vecchiarello 252 Phone: 508-439-7436 Email: Kyle. vendsen@csgrp.com 1 Conservation Services Group • 50 Washington Street,Suite 3000 0 Westborough,MA 01581 r Offln .o 1� Muanp mass save PAcounuS Sw+rrrtlaeupt Mal9Y dhdeKv m. PERMIT AUTHORIZATION FORM I; ann marshall ,owner of the property located at: (Owner's Name,primed) 117 webb st#2 salem (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 permitto perform insulation and/or weatherization work on my property. x9-t/?'� Owner's Signature �/17 l Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: �rf+L Participating Contractor Date Of'O 01 �°• For OfNce Use Onty Rev. 12132011 IIC Combustion Safety Test Form CUSTOMER NAME: SITE ID: - Hot Water Heater Heating Sys. Atmospheric Induced Powered Vent' Sealed' "B"Ven1' PVC Yeni' Suinkess st." CHIN IND TANKLESS ELEC. BOILER FURN. OTHER Heating: Fuel; Fuel: Hot Water: ' 11 yes,DO NOT OARIATESP HOLE Otlmr tests wi8 be tompleled as appropriate(COae vent ldmirWdon.) Were any gas leaks detected(if applicable)? YES NO Are there broken,detached or corroded flue pipes?: YES NO Are there any unventetl gas appliances(does not include wens)?: YES NO Was there a working carbon monoxide detector in the home?: YES NO Outside Temp: Bath: Kit: • Dryer , Outside Temp:P: Bath: Kit: Dryer: CAZ Baseline Pressure: All Handles ON OFF N A / CAZ Baseline Pressure: Air Handler. ON OFF N/A CAZ Wont Case Pressure: Basement Odor: OPEN CLOSED CAZ Wont Case Pressure: Basement Door: OPEN CLOSED Total Pressure Change: Other Doors- Total Pressure Change:8 Other pours: , •• CO Draft Draft W/Heating Sys On CID Draft Draft w/Heating Sys On / / I Pass Spillage Test I Pass Draft Test Pass CO Test Pass Spillage lest Pass Draft Test Pass CO Test ❑Yes ❑No❑N/A ❑Yes❑No❑N/A ❑Yes El No N/A❑ ❑Yes El No El N/A I ❑Yes ❑No ❑N/A 1 ❑Yes❑Np❑NJA ' CO Draft CO Draft Pass Spillage Test Pass Draft Test I Pass CO Test Pass Spillage Test Pass Draft Test ❑Yes — No❑N/A ❑Yes❑No❑N/A ❑Yes No Pass CD Test ❑ ❑N/A ❑Yes ❑No❑N/A Oyes ❑No ❑N/A ❑Yes[]No❑N/A I Ambient CO in CAZ: Ambient CO in Living Space: Ambient CO in CAZ Ambient CO in Wing Space: Equip Type Pass Spillage Draft CO Equip Type Pass Spillage Draft ❑Ves❑No❑NJA CO ❑Yes❑No❑N/A ❑Yes❑No❑N/A _ ❑Ves❑No❑NJA a - • - CO(Measured at exhaust port): - CO(Measured at exhaust port): Ambient CO; - Ambient CO: ' Technician Name: Company Name: Test Dates: Conservation Sources Gmup All R-ghu Rcser.ed �, cornier atiorti Services Group Olt/ CERTIFICATE OF COMPLETION 50 Washington St.Suite 3000 L --1 Westborough,MA 01581 � ) _ z p t— � — Allen Roy Phone(Eve): 978-744-4623 117 Webb St#1 `a Phone(Day): 978-744-4623 Salem,MA 01970-4018 7 ry E-Mail: SitelD: S00002245744 / /�ki`1� Combustion Safety Test Completed YIN `J Pre Blower Door# (If applicable) Post Blower Door# (if applicable) Contract ID:20140717_WORK Company: Air-Tight Weatherization Sub-contractor Work Order#: S45744P51274C271 ['oca'tim I1esnpd©�i 4)uant litsfalle Living Space Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 1,577 PLEASE NOTE:The Inspection of the house is for the purpose of finding CUSTOMER AUTHORIZATION OF CERTIFIED WORK out whether the Contractor completed the work. I confirm that the measures listed above have been completed to my CUSTOMER SHOULD NOT RELY ON THE INSPECTION FOR satisfaction. I have received a copy of the Certificate of Completion and ASSURANCE THAT THE CONTRACTOR'S WORK NECESSARILY hereby authorize the release of any final payments to the Contractor. I COMPLIES WITH ALL LAWS AND STANDARDS RELATED TO understand that this Authorization of Completed Work does not in any SAFETY. manner void any warranties provided to me by the Contractor. It was the Contractor's sole responsibilty to assure that the measures were installed properly and safely. In addition, this Post-Installation Inspection does not replace inspections by licensed inspectors where required by state or local law. It is the duty of the Customer to obtain such required inspections. Contractor's Signature Customer's Signature Date Date Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 C CONTRACTOR WORK ORDER onse r�atton Services Croup 50 Washington St.Suite 3000 Printed: 1/12/2015 Westborough,MA 01581 Work Order Id: S45744P51274C271 �Contl`ac«^r-�nfb1' rft�ion � . ,*.Cs ihti�/9 t��tai � � „ ea ��- •, �s Air-Tight Weatherization Allen Roy Email: 9 Story Ave 117 Webb St#1 Phone(Eve): 978.744.4623 - 623 Beverly,MA 01916 Salem,MA 01970-4018 Phone(Day): S0000 24574 Site ID: S00002245744 Location Description Quantity �. Unit$ Total$ Living Space Insulate Clapboard Sided Wall Wth 4" Dense 1,577 $2.27 $3,579.79 Installed Measures Total $3,579.79 Type Status Notes Asbestos UNKNOWN customer disclosed there was asbestos in house before none visable Incentive Payments Weatherization Incentive $2,000.00 Total Incentive Payments $2,000.00 Customer Share Total Customer Share $1,579.79 Less Deposit Of $526.60 Customer Share Balance(Due Contractor) $1,063.19 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 Allen Roy 117 Webb St#1 Salem,MA 01970,4018 Site ID:S00002245744 Project ID:P00000251274 CustornerID:C00000255815 Contract ID:20140717 WORK Description quantity Location Insulate Clapboard Sided Wall With 4'Dense Pack Cellulose 1 577 Livtno Space $3 579.79 Sub Total: $3,579.79 utility Incentive Share $2.000.00 Customer Contribution $1,579.79 0 For office uca only Printed:7/17/2014 Page 1 of 1 GCONTRACT FOR Conser atlon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and Allen Roy Conservation Services Group (CSG) 117 Webb St#I Attn:RCS Salem,MA 01970-4018 50 Washington Street,Suite 3000 Site ID:800002245744 Westborough,MA 01581 Reg. No. 173484 Project er PX000 0255 Federal ID No. 222457170 Customer R):.000000255815 Contract ID:20140717 WORK (Mail completed contract to address above). I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the teens of lids Contract,Includbng the attached reconuucuulaflons/work order describing the work in detail(the"Wis k")which me incorporated herein by reference: i Description quantity Location Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 1,577 Living Spaca $3,579.79 Sub Total: $3,579.79 Utility Incentive Share $2,000.00 Customer Contribution $1,579.79 o o ` For office use only Printed:711712014 Page 1 of 1 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Rice as follows:Payment#1:$ J t7L 1u as a Deposit. payable to CSG upon signing the Contract(not t,RnCy(coed I/ of the total retail costs).Maa check&contract to CSG,Attn:RCS,50 Washington St-,Ste. 3000,Westboroug MA h, 01581.Final Payment:$ I �. I I as the Anal payment for the Work shall be payable to the Independent Installation Contractor(91C")upon sati la, tory cow,pletion of the Work.Customer understands that he/she will not be required to pay tire Utility Incentive Share of the Contract price in the amount of$ V(7.Changes to individual line Items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III.DISPUTE RESOLUTION rlbe➢C and Customer hercby mutually agree in advance that in tine event that One➢C has a dispute concenning this Contract,dne➢C may submit such dispute to a private arbib icon service which has been appruvetl by the Office ol'(1onsumerAffairs and Business Regula0on and Customer shall be rugimed to submit to such arbitration aspr Aded inMG.L.c 142A You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third busine a follAAwin-g the signing of this agre m nt. DO NOT SIGN1 THIS CONTRACT IF THERE ARE ANY BLANK SPACES. V ' CJ-tz!) e4. /t� /Ktr IltfGL WG.dS�/tt (oa) 'G� f Cmt rnee/y'Signal a Indicate yo selle/cted I1C/here,if app1J�cc ble dial here i you want /' /� -� � / /6f o V1C t-/�r�4Yzc_///)_ the Program to assign a s•�--' Participating Connacmi rR Signature tc Name of CSG Representative(Prinfe ) TERMS AND CONDTTIONS APPEAR ON TILE REVERSE. 3/14 Customer Name: allen roy Site ID: s00002245744 CSG Enclosed Cavity Insulation Fact Sheet Your Energy Specialist has determined that your home would benefit from insulation. Below is a list of the problems that might be encountered during this process.We have selected those which may pertain to your existing siding material or Interior areas being treated.Please read carefully each potential issue and sign at the bottom.A copy of this signed fact sheet must be returned with a signed contract or the scheduling of the Insulation work will be delayed. At the time of your Home Energy Assessment the Energy Specialist evaluated the current condition of your exterior siding and interior materials.It has been determined that the process of removing certain areas of your siding,drilling holes and blowing in the Insulation could result in some damage to the siding or to the esthetics of the paint.Prior to the start of the insulation Job,the contractor will demonstrate to the homeowner a sample of the siding removal and reinstallation. Wood Clapboard&Shingle Siding The present condition and age of the exterior shingle or clapboard plays an important part as to how easily the siding can be removed and reinstalled.Older siding that has been exposed to the elements and has numerous layers of paint or stain has a greater risk of being split or cracked In the removal process.Under these conditions a shingle or clapboard may crack in half when trying to remove It.When this occurs the contractor will try to reinstall the shingle or clapboard so the split or cracked areas butt up tight together.When it is not possible to reinstall a cracked shingle or clapboard,because the split or cracked areas will not butt up tight together,the contractor can repair the crack with exterior wood patch or as a last option replace the damaged area with a similar type of shingle or clapboard.Note:It Is the homeowner's responsibility(if needed)to touch up paint or stain on shingles or clapboards that have been removed. No Additional Areas Specifled at Assessment No Additional Areas Specified at Assessment Customer Signature: X l j� Z/�-44A"a (2 . Date: EIJI T O For more information please visit the interactive house web site at http://masssave.csgrp.com/masssave_content.html ForOlnce Use Only RCS PLANVIEW DIAGRAM Customer, f-cd7/ /' Home Phone: Address: �7/ WbU s � Work Phone: - Town: 1 G) p P["t a/9 70 Cell Phone: ( 1- Any limitations for access by large truck? No yes_ If yes,describe: Any wp Oft di,cIiens—otf landmarks? NOS_ yes_ If yes.descrrbe: Site ID: aa4S /U Energy Specialist: /-O I r �'U �� Reviewed by: ftn/a�C CIO(h"rot S:oted Wsv,//t1,n v/� el" OPGe11 I577 10 3or I For Office Use Only V Bushes Ladder Neighbor Proximity Pocket Doors Insert Radiators Fence(s) Existing Conditions X=Access =Vents Note Inside Square R=Roof S=Soffit G=Gable RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Drip Edge T=Triangle Install O=New Access Note in Circle C=Ceiling W=Waif S=Sheathing Temp Unless Noted Otherwise Q=Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For Access Rev 1/14 SAMPLE PRE-RENOVATION FORM This sample form may be used by renovation firms to document compliance with the Federal pre-renovation education and renovation, repair,and painting regulations. Occupant confirmation Pam'phfiet Receipt have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my Aelling unit.I received this pa Met before the work began. llen nr Printeg Name of O ier-occup t Signature of Owner-occupant Signature to Renovator's Self Certification Option (for tenant-occupied dwellings only) Instructions to Renovator:If the lead hazard information pamphlet was delivered but a tenant signature was not obtainable,you may check the appropriate box below. ❑Declined-I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below at the date and time indicated and that the occupant declined to sign the confirmation of receipt.I further certify that I have left a copy of the pamphlet at the unit with the occupant. ❑Unavailable for signature- I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit by sliding it under the door or by(fill in how pamphlet was left). Printed Name of Person Certifying Delivery Attempted Delivery Date Signature of Person Certifying Lead Pamphlet Delivery Unit Address Note Regarding Mailing Option —As an alternative to delivery in person,you may mail the lead hazard information pamphlet to the owner and/or tenant.Pamphlet must be mailed at least seven days before renovation.Mailing must be documented by a certificate of mailing from the post office. Customer Name: alien toy Site ID: s00002245744 Date: 7/17/14 Mass Save Customer Disclosure and Preparation Requirements At your Home Energy Assessment your Energy Specialist has reviewed and identified applicable cost-effective opportunities,potential health and safety concerns as well as any customer required actions to facilitate improvements in your home: Your Energy Specialist is trained to evaluate and propose appropriate site-specific improvements that will reduce energy consumption and improve comfort. The following conditions were noted at the time of the Home Energy Assessment: Combustion Safety: Initial Here No Issues Detected at Assessment Combustion Appliances: Initial Nere No Issues Detected at Assessment Pipe Oisdaimer: Initial Rare No Issues Detected of Assessment Moisture Concerns: Initial Here No issues Detected at Assessment Customer Weatherization Preparation Requirements: ❑ Storage Removal 0 Platform Buildup 0 CO Detector Rowing Removal Specified Measures Agreement(SMA) Customers are responsible to complete any noted required actions in order to be eligible for program weatherization work at their home. The participating Contractor will be confirming the completion of these required actions prior to Initial Here scheduling an installation date. customer is removing vinyl stding and is repainting the clapboard this will be a clapboard sided house This notice does not constitute an endorsement or warranty regarding the presence or absence of other real or potential health and safety hazards that may exist at this address or premises.If you have questions regarding this information,or to schedule a follow-up inspection after the not 1 ns h ve been corrected,please call our Customer Service at 8001480 472. Customer Signature: -� 0 � �_ Date: / q Energy Specialist: leo vecchiarello 252 Phone: 508-439.7436 Email: Kyle.Svendsen@csgrp.com 0 Conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 r>mt,v..pyr VW rqrr_ c� mass save CONTRACTO PARTIMPATING _ sw.y.itia*s.wsr.Nr ��- PERMIT AUTHORIZATION FORM I, alien roy ,owner of the property located at: (Owner's Name,primed) 117 webb st#1 salem (prnpany SUM 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. Owner's Signature Da[e FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: _ Participating Contractor Date 0� For Office Use Only Rev. 12132011 IIC Combustion Safety Test Form CUSTOMER NAME: SITE ID: Equipment/Fuel Type Hot Water Heater Heating Sys. ATIM.@r.. II Powered vent• I Sealed' I "e"Vent' PVC Vem• Stainless St.• DHW IND TANKLESS ELEC. BOILER FURN. OTNER Heating: FuN: Fuel: Hot wafer: If yes,p0 NOT OR4l A TEST HOLE.Other tests will be rPmpleted as appropriate(CO at vent terminadon.) Safety Inspection Were arty gas leaks detected(it applicable)? YES NO Are there broken,detatched or corroded flue pipes?: YES NO Are there any unvented gas appliances(does not include ovens)?: YES NO was there a working carbon monoxide detector in the home?; YES NO TEST IN TESTOUT ressurization Outside Temp: Bath: Kit:Combustion Dryer:Appliance • Outs ide Temp; Bath: Kit: Dryer: CAZ Baseline Pressure: Air Handle(, ON OFF N/A CAZ Baseline Pressure: Air Handler. ON OFF N/A Tot Want Case Pressure: ON Door: OPEN CLOSED Tot CAZ Wont Case Pressure: Basement Door: OPEN CLOSED al Pressure Change: Other Doors: Total Pressure Change:g Other Doors: CO Daft Draft w/Heating Sys On CO Draft Draft w/Heating Sys On Pass Spillage Test Pass Draft Test Pass CO Test Pass Spillage Test Pass Draft Test Pass CO Test ❑Yes No❑N/q ❑yes ❑No❑N/A ❑Yes ❑No❑N/A ❑Yes No❑N/A ❑Yes ❑No❑N/A ❑Yes []No❑N/A Heating System Worst Case CO Draft Draft Pass Spillage Test Pass Draft Test Pass CO Test Pass Spillage Test Pass Draft Test Pass CO Test ❑Yes ❑No❑N/A ❑Yes ❑No❑N/A ❑Yes❑No❑N/A ❑Yes❑NO❑N/A ❑Yes❑No❑N/A ❑Yes(]No❑N/A Ambient CO in UZ: Ambient CO in Living Space: Ambient CO in CAZ: jAmbienj CO in Livin B$Pal¢' Equip Type r Pass Spillage Draft , CO Equip Type Pass Spillage Draft CO ❑Yes []No❑N/A No❑N/A ❑Yes ❑No❑N/A ❑Y�❑ ❑Yes❑No❑N/A CO(Measured at exhaust port): CO(Measured at exhaust port): Ambient CO: Ambient CO: Technician Name: Company Name: Test Dates: Consarvalipn Servkes Group All Rights Reserved eer.3(3p1? ! fir It 11p, FF lit L-