87 FLINT ST - BUILDING INSPECTION (2) a
7
The Commonwealth of Massa RECEIVED
'I Board of Building Regulations an NAL SERVICE CITY OF
!� SALEM
VV9,� Massachusetts State Building Code; 780 CMR
pp p �n,r U&� A t .Revised Mar 207t
BuildingPermit Application To Construct,Re air, I� a li
One-or Two-Family Dwelling
This Section For Off ' 1 Use Only
Building Permit Number: D e Applied:
1
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fin Frontage(ft)
1.5 Building Setbacks(it)
.Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record:
13t2,45FA (.awl 5ALP- I , MAz 0 1170-223 2
Name(Print) Ctty,Stale,ZIP
d� �l.ttil7, S"T, soco -s-s,4-ISlv7
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other Specify: t
Brief Description of Pioposed Work : 11QCAA ► L
gAMW-4L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ?�1 � �p 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
3.Plumbing $ 2. Other Fees: $
4.Mechanical (ITVAC) $ List: v
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ , OS ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 1-5 -7(P O 3 1 S
JAtM1$cj A� 1'C; --T 1 M License Number Expiration Date
Name of CSL Holder }�,, , I
'ID p1 k11*. kf L4vu. (/ic-I�/� List CSL Type(see below) (�J
No.and Street 'q Type Description
'cp�Y �� I I/y I/ O 1( Unrestricted(Buildings u to 35,000 cu.ft.
V�� r •T 6 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tel hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 40 S 1
—TA,VkA P' ion-iiA HIC RegisVa[ion Number Exp lion Date
HIC Company Name or HIC RegisVant Name
In Pt,t� KNeLt_ b►z.
No.and Street Email address
City/Town,State, Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J
1,as Owner of the subject property,hereby authorize �1�^�([C{1{'(' Gl.)�,47H iL..111E^('10 LL C._.
to act on my behalf,in all matters relative to work authorized by this building permit application.
&AIUe+J LAyl g Z LlL is;—
Print Owner's Name(Electronic Signature) Date
. SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hjmby attest under the pains and penalties of perjury that all of the information
c lain t this aatior ' e and accurate to the best of my knowledge and understanding.
o — L �-1"1A?IVJ S /2-
riot Owner's or Authorized enf s Name(Electr me Signature) Date
NOTES:
1. An Owner who obtains a building perm t to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oc Information on the Construction Supervisor License can be found at yi w.mass.gov/d�s
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
, jm-%i- i
'w
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 ._\c� day of < d} , 2014, before me personally appeared
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.
Notary Public oE1ERT A. MONAHAN
y Notary Public
VC0MM0NW5ALTH0FMASSACHUSETTS
My Commission Expires
Print Name: September 17, 2021
My commission expires:
u ,- !
r1 , Office 01 Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 021 16
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 3fl5/2016 Tr# 248557
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR.
BEVERLY, MA 01915
Update Address and return card.Mark, reason for change.
SC;,, Z. zem;• 1 Address i Renewal Employment Lost Card
.vx .tiOf tce ,f(.i-nsonwr:%rrairs R llanncss Itcgulalintt License or registration valid for iodividul use noly
ps$ fHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ARegistreti0o: 165640 Type: Office of Consumer Affairs and Business Regulation
.'�"s•Expiration: 3/1512016 LLC III Park Plaza-Suite 5170
Boston,NIA 02116
AIR-TIGHT LLC.WEATHERAZATION
JAMES FORTIN R1,
10 PINE KNOLL DR.
BEVERLY,MA 01915Ihulcrsenrl:vl
Not vn id without signature
o'rd a> 3w 'x1 f ion:
t CS-0525764.
.l.x A7 P:S 1:' FOR I IN ( n
Ilt 111NCKNOIA.OR -
Btsarlr llA IW 5
10/03/2015
The Contntonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
—' :— I Congress Street, Suite 100
G�
Boston, MA 02I14-2017
? ✓ www.inass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:_ l �- c,�`` , C C��`��.1 \Lc-A`c-` I
Address: (�� - �•L_.' `` �C'rl��L
City/State/Zip: Phone#:
Are,you an employer? Check the appropriate box: Business Type(required):
I. I am a employer with % _employees (full and/ 5• ❑ Retail
or part-time)." 6. ❑Restaunmt/Bar/Gating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales(incl. real estate,auto,etc.)
employees working tier me in any capacity.
[No workers' comp. insurance required) 8. ❑Non-profit
3.❑ We are a corporation and its olticcrs have exercised 9. ❑ Entertainment
their right of exemption per c. 152, ,vs'](4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]"
4.ElWe are a non-profit organization, st.•dted by volunteers, I I.❑ Health Care
with no employees. [No workers' comp, insurance req.j 12.❑ Other
'Any applicant that checks box Nl must also fill out the section below showing their workers'compensation policy information,
'"tf the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box i 1.
I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy information.
Insurance Company Name:_ �Iy', ��
insurer's Address:��`;_ --_--
t --
City/State/Zip: ._ Vx, ; L-\-c
Policy it orSelt=ins. Licit 0I [...'C `J-7 Expiration Date: C•i��_---
Attach a copy or 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 S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
crop to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date'
Phone 'Cl Lt ce
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License k
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#:
%wiv.mass.gov/dia
\`'�� CERTIFICATE OF COMPLETION
sccrv;ic:es Group _ - r�
50 Washington St. Suite 3000
Westborough,MA 01581 _
Braden Lamb Phone(Eve): 206-554-1867
87 Flint St Phone(Day): 206-554-1867
Salem, MA 01970-2232 E-Mail: braden.d.lamb@gmail.com
SitelD: S00002310755 Combustion Safety Test Completed YIN
Pre Blower Door# (If applicable)
Post Blower Door# (if applicable)
Contract ID: 20141212 WORK Company: Air-Tight Weatherization
Sub-contractor Work Order#: S10755P20074C271
Location `&v h `mot Quant(fY.,.. Ins6_al_I_efl
Living Space Hatch: Thermal Barrier Polyiso 2 inch (Attic) 1
Damming 8
Living Space Attic Floor Open Blow Cellulose 10" 184
Living Space Insulate Vinyl Sided Wall With 4" Dense Pack Cellulose 1,248
Contract ID:20150127ASEAL
Sub-contractor Work Order#: S10755P20074C271
Loca lon, h;.:DESGGI�JItJf1 ,%Nw ii utkiv+ ,v.awa�Tsb - �-53_f Crd� L`� ` +� �'?ristS�rm. U21'141ty Fi "�nSt2l�Edl
Living Space Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 4
Door Sweep 2
Exterior Door Weather Stripping 2
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
�A_ 4 CONTRACTOR WORK ORDER
ej, k.A
vic:c,.s Co (>L-lp
50 Washington St.Suite 3000 Printed: 2/11/2015
Westborough,MA 01581 Work Order Id: S10755P20074C271
.Contrac tor Infointraif
� I I 1 904�"! _�,
Air-Tight Weatherization Braden Lamb Email: braden.d.lamb@gmaii.com
Phone(Eve): 206-554-1867
9 Story Ave 87 Flint St Phone(Day): 206-554-1867
Beverly,MA 01915 Salem, MA 01970-2232 Site ID: S00002310755
Location Description Quantity Unit$ Total $
Living Space Hatch Thermal Barrier Polyiso 2 inch (Attic) 1 $41,71 $41.71
Damming 8 $2A9 $17.52
Living Space Attic Floor Open Blow Cellulose 10" 184 $1,73 $318,32
Living Space Insulate Vinyl Sided Wall With 4" Dense Pack 1,248 $2,41 $3,007,68
Living Space Perform Air Sealing at Estimated 62.5 CFM50 4 $84.32 $33728
Door Sweep 2 $23,18 $46.36
Exterior Door Weather Stripping 2 $27.59 $55A8
Installed Measures Total $3,824.05
Incentive Payments
Air Sealing Incentive $438.82
Weatherization Incentive $2,000.00
Total Incentive Payments $2,438.82
Customer Share
Total Customer Share $1,385.23
Less Deposit Of $461.74
Customer Share Balance(Due Contractor) $923.49
Conservation Services Group- 50 Washington Street Suite 3000-Westborough, MA 01581 -(508) 836-9500
Residential Air Sealing Work Order
Printed: 2/9/2015 Pg: 1
1,--Priscr�)a ic)r-1
k�r v! s Group
50 Washington Sit Suite 3000
Westborough,MA 01581
rnedSite C"I 3,-,
Braden Lamb Phone(eve): 206-554-1867
87 Flint St Phone(day): 206-554-1867
Salem, MA 01970-2232 Site ID: S00002310755
!1omeJnfqr ation Fla
M
-E MON R RM.
Heating Fuel: Natural Gas Building Volume: 12,080 BAS cfm50: 775
Distribution Type: Boiler-One Pipe Steam
Existing Insulation: Rock Wool Batts Depth: 2,0
Truss Construction: Can Blower Door Be Completed? No
Are citeg�
Rzk
M
2� e� i s'
Attic Easement/C rawls pace
All Accessible Penetrations. Yes Exterior Penetrations: Yes
Therma-Dome. No Ceiling Penetrations: No
w/carpentry. No Exterior Door Weatherstrip. No
WFIF Box. No Vapor Barrier(Sqft). No
Additional Areas of Concern... Additional Areas of Concern...
seal up peretratitons in the attic as well as top plates seal up around rim joist
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 and side doors
Conservation Services Group- 50 Washington Street Suite 3000-Westborough, MA 01581 -(508) 836-9500
' Residential Air Sealing Work Order
�. Printed: 2/9/2015 Pg. 2
50 Washington St. Suite 3000
Westborough,MA 01581
Customer/Site Details: Braden Lamb 87 Flint St Salem, MA 01970-2232
contractor Notes j f a
✓_
Start time: Stop time:
AS Techs:
Pre CFM 50: Post CFM 50:
CFM 50 Reduction:
Combustion Safety Test Completed? Yes No
Pass or Fail?
GCONTRACT FOR
conser atlon PRODUCTS I SERVICE WORK
Services Group
This service is brought to you through support from your local utility
This Agreement is made by and among
and
Braden Lamb Conservation Services Group (CSG)
87 Flint St
Attu: RCS
Salem,MA 01970-2232
50 Washington Street, Suite 3000
Site ID: S00002310755 Westborough,MA 01581
Project ID: P00000320074 Reg. No. 173484
Customer ID: C00000320890 Federal ID No. 222457170
Contract ID: 20150127 ASEAL
— (Mail completed contract to address above)
I. DESCRIPTION OF WORK TO BE PERFORMED
Comtractor will perromr or cause to be performed the following work on these"Premises"In a professional manner and in accordance wil:h the terms or
this Conina:t,includlmg the attached reconnuendations/work order describing the work in detail(the"Work")which are,incorporated herein by reference:
Description Quantity Location
Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 4 Living Space _ __$337.28
Door Sweep„ _ 2 N/A ..._._ ._ _$46.36.
Exterior Door Weather Stripping 2 N/A ._ $55,18
Sub Total. $438.82
Utility Incentive Share $438.82
Customer Contribution $0.00
Q f'O
For office use only Printed: 1/27/2015 Page 1 of 1
II. PAYMENT
Cuslon,cr agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment HI:$ 0.00 as a Deposit.
payable to CSG upon signing the contract(not to exceed 1/3 or I:he total retail costs).Mail check&contract to CSG,Attn:RCS,50 Washington St.,Ste.
3000,Westborough,MA 01581.Pmal Paymmnl.:$ 0.00 as the final payment for the Work shall be payable to the Independent Installation
Contractor("IIC")upon satisfactory completion of the Work Customer undersimak that helshe will not be required to pay the Utility Incentive Share of the
C'.olirna t.price in the amount of$—A38 R2 .Changes to individual line items and/or previous incentives may increase or decrease the size of the Utilily Incentive
Share.
III. DISPUTE RESOLUTION
The IIC and Customer hereby numudly agree in advzmue that in the event that the IIC has a dispute concerning this Contract,the IIC may submit such dispute to a priv.LLe arbitiat'.ion
service which has been approvcxl by the Office of Consumer Affairs and Business Regulation and C uslomer shall be required to submit to such arbitration as provided in MGL.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
ass � f ing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERT-�ARE ANY BLANK SPACES.
Airtight Feb 6, 2015 q
ht Weatherizahon LLC '
Customer Signature Date Indicate your selected TIC here.iP applicable (oil) Initial here il'you want.
Ethan Seaman 1/27/15 Ethan Seaman the Program to assign a
1 ar0cipating Contractor
OSG fligual:urn Date Name of CSG Representative(Printed)
TERMS AND CONDITIONS APPEAR ON THE REVERSE. 3114
CONTRACT FOR
Conner 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
Braden Lamb Conservation Services Group (CSG)
87 Flint St Attn: RCS
Salem,MA 01970-2232
60 Washington Street,, Suite 3000
Site ID: S00002310755 Westborough, MA 01581
Project ID: P00000320074 Reg. No. 173484
Customer ID:C00000320890 Federal ID No. 222457170
Contract ID:201412 t2_WOl (Mail completed contract to address above)
I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be performed the following work en these"Premises"in a professional manner and in accordance with the loos of
this Conhact,including the attached reconmhendaticnvs/worJc order describing the work in detail(the"Wai<")which are incorporated herein by reference'.
Description Quantity Location
Attic Floor Open Blow Cellulose 10" 184 _ Living Space— ____$318,32___
Hatch:Thermal Barrier Polyiso 2 inch(Attic) . 1 Living Space $41.71
Damming _ _— 8 N/A $17.52
Insulate Vmy I Sided Wall With 4' Dense Pack Cellulose _ _1,248 Living Spa __ce $3,007 68._
.
Sub Total: $3,38523
Utility Incentive Share $2,000.00
Customer Contribution $1,385,23
�t•�
IJK
Printed: 12I19/2014 Page 1 of 1
For office use only
11. PAYMENT
Cwstomr ag
rees to pay Contractor for(lie Work,the Customer Share of the Contract Price as follows:Payment#1:4 461 74 as-a Deposit
payable to CSG upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CSG,Attar:RCS,50 Washington St.,Ste.
300o,Westborough,MA 01581.15nal Payment,:$__�23 49 as the final payment for the Work shad be payable to the Independent Installation
Contractor("rfC")upon satisfactory completion of the Work.Customer wuierstands that he/she will not be required to pay the Utility Incentive Share of the
Contract,pace in the amount of$--2,0DD QD__.Changes to individual line items and/or previous incentives may increase or decrease the size of the Lobry Incentive
Skure.
III. DISPUTE RESOLUTION
'rhe Ile and Customer hereby mutually agreo in advance that in the event drat Ole IW has a dispute concerning Iht%Conh'act,the IIC may submit such dispute to a.private arbitration
sorvice tvhidh lets boon approved by the Office of CUnSIAnict Affairs and Bushiesi Repladon mid Oistnmer shall be requited to submit to such arbitration as provided in M.C.L.c 1/fLA
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
business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
yhl- wor'l11LI i uiv — `II
Customer Signature Date Indicate your'selected IIG here,if applicable (CO) lethal here if you wazrt
the Program to assign a
Ethan Seaman 12/19114 ,than Seaman Participating Contractor
G9G Signature Date Name of CSG Representative(Printed)
TERMS AND CONDITIONS APPEAR ON THE REVERSE. :1/19
Customer Name: BRADEN LAMB Site ID: S00002310755
CSG Enclosed CavityInsulation 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.
Vinyl Siding
This type of siding can crack or break during removal or reinstallation.Older siding that has square channels interlocking the panels is
harder to remove and reinstall than newer siding with rounded channels.Cold weather can also be a factor.When removing and
reinstalling the siding in cold temperatures(below 32 degrees)there is a greater risk of cracking. The contractor assigned to install your
insulation will notify the homeowner and CSG if there are any problems or issues,which may result due to the air temperature on the day
of installation or the type of channels contained on the siding. Note:When damage has occurred to vinyl siding every effort will be made
to repair the damaged area.When repair is impossible,the contractor can move the damaged piece to an area not readily visible or a new
piece of siding that closely matches the existing siding can be installed. It is very difficult to order a new piece of siding that will match
exactly,because of fading that happens to siding when it has been exposed to the climate and older styles that may no longer be in
production.Customer is responsible for cleaning of fingerprints that may be left on the siding.
No Additional Areas Specified at Assessment
No Additional Areas Specified at Assessment
Customer Signature: X Jam/ �T Date: lZ� IZ . Ara
0
For more information please visit the interactive house web site at
http://masssave.csgrp.com/masssave—content.htm I
For ice Use Only
ii�� RCS PLANVIEW DIAGRAM
Customer: QL` ��C n LeAM-h Home Phone: ( )-
Addre55:' t t Work Phone: -( )
Town: ��lY\ - - , Cell Phone: ( .)-•
Any limitations for access by forge hack? _ No Yes If yes,describe: ,
lr
Any specific directions or landmarks? i No L— Yas r - If.yes,describe'. i
Site ID: Q�]$5 Energy Specialf5t: r� Reviewed by:
T W. .CQ�IV _ _ -� .�
l�r gyp-, , . - _
V12),Hater; Ttlelmm( b6�1reQ a" � ao
Q3
is
al
a
3`I I do
i
v
RON 15
1
o� f (q)
For Office Use 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
=Vents Note in Triangle R=B••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,repalr,and painting regulations.
Occupant Confirmation
pamphlet Receipt
have received a copy of the lead hazard Information pamphlet informing me of the
potential risk of the lead hazard exposure from renovation activityto be performed in my
dwelling unit.I received this pamphlet before the work began.
Braden Lamb
Printed N m?of Owner-occupant
Jan 19, 2015 ttV
Signature of Owner-occupant Signature Date
Renovator's Self Certification Option(fortenant-occupied dwellings only;
Instructions to Renovator:If the lead hazard information pamphletwas delivered but a tenant
signatire was not obtainable,you may check the appropriate box below.
❑Declined-I certifythat I have made a good faith effortto deliver'he lead hazard
Information pamphlet to the rents l dwelli ng a nit listed below at the date and time i ndicated and that the occupant declined to sign the confirmation of receipt.I further certify that I
have lefts copy of the pamphlet at the unit with the occupant.
Unavailable for 5ignature—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 certifythat 1 have left a copy of
the pamphlet at the unit by sliding it under the door or by(fill in how pamphletwas lefti.
Printed Name of Person Certifying Delivery Attempted Delivery Date
' Signature of Person Certifying Lead Pampn et 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/ortenant.Pamphlet must be mailed at
least seven days before renovation.Mailing must be documented by a certificate of mailing
' from the post off ce.
Customer Name: BRADEN LAMB Site ID: S00002310755 Date: 12/12/14
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 Here
No Issues Detected at Assessment
Pipe Disclaimer: tnitlat Hare
No Issues Detected at Assessment
Moisture Concerns: initial Here
No Issues Detected of Assessment
❑ storage Removal ❑ Platform Buildup ❑ CO Detector
Customer Weatherization Preparation Requirements: ❑ Flooring 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 scheduling an nitial Here
installation date.
Must have contractor agree to do work in the attic space prior to issuing of insulation contracts.
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 conditions have been correct d, please call our Customer Service at 800-480-7472.
Customer Signature: 1,�-- Date:
Energy Specialist: Ethan Seaman-303 Phone: 508-948-7628 Email: Ethan.Seaman@csgrp.com
Conservation Services Group 9 50 Washington Street,Suite 3000 • Westborough,MA 01581 wam••v.mn
Eel
PAR7ICIPAFING
mass save CONTRACTOR
savings through energy e"Kiency
PERMIT AUTHORIZATION FORM
I, BRADEN LAMB owner of the property located at:
(Owner's Name,printed)
87 Flint St SALEM
(Prbperty Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
X
Owner's Signature
I ;L-, 1,2-, (4
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:
Participating Contractor Date
Of`0
For Office Use Only
Rev. 12132011
IIC Combustion Safety Test Form
CUS;OM EP, NAPAE: SITE lE) _
Equipment/Fuel Type
ot Wat Ha s t-no.phe::c Nduced Powered`vent' Sea3_=d"'g"y¢n[' PVC Pent' Stainless St,'
77777Y757,01wat
OTHER Heat!,=:Hct:x,'ater �.
if yr,DG NOT DRILL ATE57 HOLE, pthtt[ss's wii36e campwaed a3 apRtcprlate lC9 as vent'e;minaUon.)
Safety Inspection
kkere an}gas leaks detected {appiicable)7 YES Nn Are{here croken,detached or corroded flux I -?:
" � P Pe=. YES NO
Are there any unvented gas appliances(does not indud2 ovens]?: YES NO was thereaworking carb-.monoxide deteaorm the home?: YE5 NO
DepressurizationTEST IN
TEST OUT
Combustion
Outside Temp: Bata: Y,it Dryer; :. OuUide Temp: Bath: Kit; Dryer
CA7 Baseline Pressure: Air Handier. ON OFF NIA CAZ 8aseiine Pressure: Air Fia,ndle, ON OFF N/A
CA West rase?ressure: Basement Door: OPEN CLOSED CAZ Worst Case Pressure. Basemera Duor. OPEN CLOSED
Total Pressure Change: Other Doors: - --
TotalPressure Caange Ocher Doo,;
Domestic
CO Draft Graft.W Hea6 no Sys On CO Craft y y
r
Draft w, eating S}s On
Pass Soillaga Test Pass Oraft lest Pass CO st Pass Sm-Nige Test Pass Draft-Test Pass CO Test
E]YEODoo l=N%A 1 7 Yes ❑No l_,NIA =Y2s �TJ 't;A `—' '�
LJ. i7 L,i Yes No ..#J/A Lj Yes 0N0 ]N/A `]Yes `l iVo !]NSA
Heating System
�O Draft Worst -. - _
I Co I_ Draft
Pass S illage Tes; i Pas Draft Test _ s rC1 + Pass S -e Test Pass Craft Pas CO Test
Yes ❑No,^N{A 7 _YAs �i NO IN/.4 Y_ `, [;Po - es _!No L,N/R 1 Dyes l No I�N-
Ambient CO in CAA- Ambient CO in Gviig Space: Ambient CO in.CAZ: Ambient CC Ir. ivirE Space:
Ecu!p Type Pass Sui(tage Draft -
-qa�p lace r s Spifage Craft
A Co
e N /A
^Ye lo�:'%A. YesjK- ❑NiA
! C r sureG Or ellaust pee):
i
=cn giri0c,4am=- Company Name: Ted Dom[=
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