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357 LAFAYETTE ST - BUILDING INSPECTION (4) -7-6--It/- /8b2 CK, zziy # ZS The Commonwealth of Massachusetts REC EIVLU A Board of Building Regulations and Standards INSPECTIONAL SEBMaS Massachusetts State Building Code, 780 CMR SALEM RevjseWat V I I Building Permit Application To Construct,Repair,Renovate Or D&WIN91 H �U1 vV One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Dat pplied: Building Official(Print Name) Signature Date ( SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers �S Llr—IQ.•�L H2- J 4IR M 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: JV.ntEr;c.seln �11AcM to (16 �o Name(Print) City,State,ZIP �S� Lo.,l-a,"-t kh, S� y�-r��'- �3� "fi`31 • 2Sy . 3oSb No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(,) Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Descriptionof Proposed WorkZ:Mrlssca.L It10 twhon QW. tide Wh-%A u1luk-t K ih Q }h (_ ,t vtyyrl�roroL,l- f OU- VM+ i •rh(rn.a.l ha h(h A n fb2 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ Z O ID y , -)1T 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier X 3.Plumbing $ 2. Other Fees: $ L 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ 1 Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ZO S• "I S ❑Paid in Full ❑Outstanding Balance Due: 26y aqV 61e18 SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �,t' I u�1.SfaZ 5 Z.� t S" K �it — Cl (,J t�t'LY' License Number Expiration Date Name of CSL Holder �U List CSL Type(see below) \(�V l QO 1 2 4 U1'�`�✓� No.and Street Type Description \ 1 (�Y� r 1 Y� o A 3� U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 FamilyDwelling Cit Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel BurningAppliances °` 3Sb 346j 5Ay\�lzrinwlret�Z'i 9L(- I Insulation Telephone Email address D Demolition 5V.2 Registered Home Improvement Contractor(HIC) T I l0 b' c l tP J✓A—t"e(aJ' ,,1 k-�� HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name r' t, o,Niq a�e>JIY�itr �svlr 'ov��avtnu,( CMIL^ No.and Street 93J Email address 1�Daw1 thf-lYk Dt Cr /Town,State,ZIP 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 Issua e of the building permit. Signed Affidavit Attached? Yes .......... If No ...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest trader the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. KIJitC-1w.JVhJ-U- uI u I IN Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will 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.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" � �19,G �O�/'/9/J920�12L1JP�?iL�12 d�C���GLl�JOCG(i�7iU/.IP�- , Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration -^ Registration: 173410 _ Type: Individual . . . Expiration: 10/1/2016 Trp 257812 KURT GAUTHIER KURT GAUTHIER (: P.O. BOX 344 _ IPSWICH, MA 01938 — --- .J aa \ Update Address and return card.Mark reason for change. Address 0 Renewal Employment -] Lost Card SLR1 ll ]OMOYiI office of Consumer Affairs&Business Regulation License or registration valid for individul use only W OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: eglst Pn: 173410 Type: Office of Consumer Affairs and Business Regulation xpiratlon:. 10/1/2016 Individual 10 Park Playa-Suite 5170 Boston,MA 02116 KURT GAUTHIER s e KURT GAUTHIER 44 ESSEX RD 4 a IPSWICH,MA 01938 Undersecretary MMM���''�� of 4.14.ut,�g..re } ,d,iasslCfL.A4119 •iripai.:npgt 3,.5'r;y�ra:,.,ejv Baarci,;'.Sy;rldrrtt;Raguiasinro8 xrrtt;"s W�^^yy astla F.iCtlgSC:C98L•10l69�• ur � . _ s7QUE"S9 it-q HOLYOK8 MA elOiO N, � Go.mzov xs aox, 07fJID1Q16 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 u,p Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): g1wI'I'wcr I (\s y 11 ex O,\ � \ A Address: P600Y 3yH City/State/Zip: � t Gh IA K- C) R 3B Phone #: q.TZ 3SU , 3�1 El3 Are you an employer? Check the appropriate box: Type of project (required): 1.® I am a employer with 5 4. ® I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ® New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling ship and have no employees These sub-contractors have g, ® Demolition working for me in any capacity. employees and have workers' 9. ® Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ® We are a corporation and its 10.0 Electrical repairs or additions 3.® 1 am a homeowner doing all work officers have exercised their I I.® Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.® Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. //�� Insurance Company Name: I" Co_a i tk_ Policy#or Self-ins. Lic. #: W(-- L O - Zb<' �Ovl1 kJUa • 0,4 Expiration Date: t01 3 OI 1S- Job Site Address: zx�Ckk� 1� �(J�Z City/State/Zip: S(,� M14 61G To 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 thepains and penaltiesof perjury that the information provided above is true and correct. Si[mature:6� l^^�-�'�-� Date: l I I Phone#: 9 -J'9 . 3 Slo - 3`4 '6 3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: BTS FAX 10/31/2014 10 : 02: 19 AM PAGE 2/002 Fax Server U41 G 1\IMM1l I,1N\hY) x.r.:> Tt< >` CERTIFICATE OF LIABILITY INSURANCE ,N3,/2D14 4� ..• THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AIID CORFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES OELOW. THIS CERTIFICATE OF INSHRANCE DOES NOT CONSTITLrtE A CONTRACT BETWEEN THE ISSUING INSUREII(S), AUTHORIZED REPRESEIITATIVE Oil PRODUCEIL AND THE CERTIFICATE HOLDER. IMPORTAI'IT: if the cert fcafe holder is an ADDITIDIIAL INSURED,the policy(Has)must he endorsed. If SUBROGATION IS WAIVED,sut1lecl.to the Lelms and condilions of the policy, cerlaln Polities may require an cndom LvnetIL. A Aatement on IN, vertlDeaLe dom not confer nghlL In the cenlfca We holder In Ileu of_uch P0,50,tM "' . . .. --. - o�rJLncTBerkle Assi ned Risk Services _ Clayton Martin J Ins Agency Inc Am.Ne.F,I 900 634- 5D9 i'c N, 866 215-8118 1649 Northampton St AaB"Q.s PJ>IicyServlces(berkle Isk.a>tn PO Box 989 ll.n. . L- Rowe cove 1AGI, RACO Hol oke MA 01041 `IIGFO INS LRER 6. _ Gauthier Insulation Inc INSURED c PO Box 344 IW'PERn Ipswich, MA 01938 IN.,NFn F. N.LNER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLK:IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOICATED, tJC17WITHSTANDINIi ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRAUr 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 CANDITKINS OF SUCHPOLICES.LWIFTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIR l'Yr[Or INt11RaN�:[ INSF WVp PnI II;Y NIIMRFR MM:DoLwYT [MUQO WYY IIMI!S GENERAL LIABILITY AUTOMOBILE IIASILITY E WORKERS COMPEMATWN WC S'1'AIV Ct N AND E MPIOYERS'LIABILITY N iORY LIM,Ts ER A.NY VFOI'RIETORIpARTNF.0.:f YFC11TIV4El cL LAIN Of tIUcNI E50D,ODO a. ornl lMEMom cxavocD, NIA WC 20-2NODiB81AB 1N3N2014 1N302015 Dlnnnnpnv In HHl I 1 - E S00,000 nBscR,r.nu of OPFun-lnus Enlow ase.roncr oel nL5CII 'Ir.,NDl O^[RAiI>IJp LOCO, 1, -I II.L IAII>[A N: RAel.4leiler„I nr»r, r <I.n<.r M, rnOl+Aprn+ e r»pu�+!) Coverage Election Category Elect.Status Name States) All Entities/Location, OBTcer Exclude Kurt Gauthier MA Gauthier Insulation Inc 016cer Include Brittaie Aiello 44 Essex Road Ipswich,MA 01938 CFRTI FICA19 HOLDERLL SHOULD ANY OF THE ABOVE DESCRIBED POLICI ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE W ILL BE DELIVE14ED IN ACCORDANCE WITH THE POLL GY PROVISIONS Marblehead Building Dept IAIIVL 7 Widget Road Marblehead, MA 01945 Signature: ACORD 25(201010.5) 8RAC 3139 Acc v CERTIFICATE OF LIABILITY INSURANCE io/z9i2o a) 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 Nancy Usher Martin J Clayton Insurance Agency, Inc. PHONE (413)536-0804 FAX (413)534-7874 1649 Northampton Street EMAll_ P. 0. BOX 989 INSURERS AFFORDING COVERAGE NAICIs Holyoke MA 01041-0989 INSURER A:Nationwide Mutual-Harleysville NATIO INSURED INSURERB:Allied World Natl Assurance Cc Gauthier Insulation INSURER C: 44 Essex Road INSURER D: INSURER E Ipswich MA 01938 INSURER F: COVERAGES CERTIFICATE NUMBER:CL148800843 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMDO LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocr,urrancel $ 50,000 A CLAIMS-MADE OCCUR SL43487F /6/2014 /6/2015 MED EXP(Myono person $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,000 X POLICY JECT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea actldent ANY AL-PO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Par accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X H $ B 4UMBRELLALIAB OCCU E020792125 0/18/14 O/18/15 EACH OCCURRENCE $ 1,000,000 CESS LIAB CLA EXIMRS-MADE AGGREGATE $ 1,000,000 DED RETENTIONS $ WORK ERSCOMPENSATION WC STALIMTU- OTH- AND EMPLOYERS'LIABILITY Y I N TORY LIMITS ANV PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERM,EMBER EXCLUDED? NIA (Mandator,In NH) E.L.DISEASE-EA EMPLOYE $ Ifyea,ileac antler DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD fill,Additional Remarks Schedule.if more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GAUTHIER INSULATION ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel Sullivan/SARAH '- 4 ACORD 25(2010/05) 9)1988-2010 ACORD CORPORATION. All rights reserved. F OPIdi'tOdd with pdf Factory tri�P v�f iBR QoyDCN fPaCtD7V.CifP17'__w_ A nnn CONTRACT FOR Cons0era PRODUCTS SERVICE WORK Services Group This service is brought to you through support from your local utility ts�l fteemeatf€N NOW ces .......... e I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will periom or cause to be performed the following work on these"Premises"in a profeadonal trainer and in accordance with the nutria of this Contact,including the attached mcontruendationstwodc order desciribW the work in detail(the-Work-)which are incorporated hemin,by reference Description Quantity Location Attic Floor Open E31I Cellulose,10"_...... ------------------- 1,1qz pV-qiam­j--­- ­ ­-- -- — - . -­t _91 -, Install 8"Roof Vent 2 Attic $199.30 I Attic $M.21 --------------- Hatch:Thermal Barrier Polylso 2 inch(AMc) 1 LPA'n m.....IlSpa 40 -rUA- $87.60 --- -- --- --i1,65-6-.83 Utility Incentive Sham $1,169.87 Customer Contribution $389.96 Pre-Weatherizadon Incentive $330.00 Remaining Customer Contribution— RHO MW For oRke use only Printed:10P2=14 Pagel of It. PAYMENT Customer agrees to pay Contractor for the Work the Customer Share of the Contract Price as follows:Payment#1:$ as a Deposit payable to CSG upon signing the Contract(not to exreedl/3 of the WWI retail costs).bW4 check&contract to CSG,Attic RCS,50 Washington ft,Ste. 3000,Westborough,MA 01581.FMW Payment$ 3'1 .V 7 m the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon rd c in leti'ma of the Work.customer understands that hevahe will not be required to pay the Utility Incentive share of the of$$jMc7 Changes to individual line items and/or previous incentives may increase,or decrease the size of the UdW Incentive Contract price in the amount Z_ Sham Ill.DISPUTE RESOLUTION The UG and G%smener hereby nuituall,agree in advance,that in the everit this the lIC has a dispute conmerfing this Contract,the IIG may submit such dispute to a pnvAe artittramon service which has been approved by the Office of ConsmnerAffahs and Business Regulation and Cusbomer shall be required to subral to such arbitration as provided in XG-1.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 bLrness day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARx-ANY BLANK SPACES. June Ericson(Nov 3,2014) Nov 3,2014 none Customer Signature C� h ow selected IIC hem,if applicable (1e) initial hem if you want CY the program to assign a CSG Signature Date Name of CSG Representative(Printed) Participating Contractor TERM AND CONDMIONS APPEAR ON T=REVERSE. W14 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 byand.annonq and Conservatioru Services Group(CSG) 357 LafayeBe StApt-2 - Attu:RCS - Sdem,MA'01970.5346 - 50:WashuigtorfStreet,.:Suite.3000 . .Site IDc•500002221547 . . Westbocough;ME.0L681- Project ID,P00040226924 .:. Reg.:No d7S484 CunomerID-00000023i612_ FederalID•No.222457170' Contact TiY 20141022_ASEAL (Mau completed.c-b;aa toaddteas above). I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be perforrued the following work on these"Prentiscs"M aprofesvonal manner and In accordance with the terms of this Contract,including the attached recommeadarioaWwork order describing the work In detail(the'Work-)wtuch are incorporated hereon by reference: Description Quantity Location Perform Air SeaSnp at rxtlmafeC 62.5 CFld50 Per hour 6 - -- -- Sub Total: $505.92 Utility Incentive Share $605.92 Customer Contribution $0.00 ❑� F`0 Fw olllee use tiny Printed:10/2Tf2014 Pepe 1 of 1 It. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$ C/ as a Deposit payable to CSG upon signing the Contract(not to exceed 1/3 of the total retail costs).Mall check&contract to CSG,Ater:RCS,50 Washington St,Ste. 9000,Westboroaglr,MA 01581.Final Payment$ O as the final payment for the Work shall be payable to the Independent Installation Contractor("Do")upon satisfactory completion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price In the amount of$ SLAS Ad.Changes to individual Itne hems and/or previous incentives may increase or decease the size of the Utility Incentive Shane. III.DISPUTE RESOLUTION The IIC and Customxherftraut alhagvsIn afvancethatin the eventttn[the RC has a&Wtae concembig drs ConnaM the RC may silunitsudtdispute to aprwate arbihatim savior whichhas been appnwedby the office ofCo smr¢Affien.sand Busbtess Regulation,and Cusanoer shall be miubedtosubnutto suchanbHra[iwras provided ioMGY 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 vie day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THEREANY-BLANK SPACES. une Encson(Nw3,20t4) /� Nov 3,2014 none E Custommee jSignature (/� Date Indica�te�f ur selected IIC here,if applicable (OR) Initial here Uyou want 10� 1 /t(4 / C'J' , the Program to assign a Sig MWM Date Name of CSG Representative(Printed) Participating Contractor TOMS AND CONDITIONS APPEAR ON 17E REVERSE. &14 1 - RCS PLANVIEW DIAGRAM Customer: 'Jfie. Er tCLO N Home Phone: ( 7gl )- 5 4 ?oS 6 Address �5 7 4� eik 5 - Work Phone: Town: -QCM / Cell Phone: Any limitations for access by W o truck? No Yes If yes,describe: Any seecifs directions or landmarks? No Yes_ If yes,describe: Site ID: (S (,� Energy Specialist: /,u�� Reviewed by: I© �� b10W 10" celi i4 �037 :F`/taf ® TnSTbt1 turn, g" rd�F ut�AtT J,^sWt1 d' tler+w� ��cr✓iPt/ zpo(rfS 0 OA CWic 1+ � ® Uewt• W4 •CCIA -fo MO Pet AIM Cv�✓ a:/'sca� it I f— 13 —� S l `r 1 Isr M I r cN 119 S OL — — - - (y I I \ � �I I I St�rezl- j 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 0-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 01/13 • ��i�p II,1� mass save C CNTRACTOR Swmgs though energy affxlemy PERMIT AUTHORIZATION FORM I, June Ericson owner of the property located at: (Owner's Name,printed) 357 Lafayette St Apt 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 permit to perform insulation and/or weatherization work on my property. X Owner's Signature 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 01 s� Fur Office Use Only Rev. 12132011