BP-84166 Permit No. BP-84166 BUILDING ' .4 41 '
G1s#: =.3330 00 Co cutme aL bits
Maw 0066 ice,,,,._ - =4 TH ov'o
Lot. -0002 /44tt;
00 c tit 47*s t
S1t7-Lot. ,011E k+ a '#��s L $�
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?Category:, 113IILA .`Pfx e
g Cy ' T10 - '4'i aaa
'Project# 3S-20P7-001922 PERMISSION If TO: D
.Eat.C-tut $4433 00 Contractor. a # A3 / nse �+ 44 t�o'ne
}Fee 3750o CHARLESE L� 3 _ Eai1 ( 6�a i2
'Lodsk Class
,Ti'UseGroup -i R3-i " x - ` Engineer is { F",'1 4,POne9#o'
LotSize(sq ft.) 1 OA- - c 1 - _ t, 4. s" " "
s ,
Zonmps �IiRB Applicant a ti
Aquifer Zone N/A ' -
:Flood Zone .ZONE.X - Ow .n:DELISLE EN .:�. INC .-� 0&}6 .
OwrvER:
NewCohat:•' N/A GOUVEIAST .e '. �
Alt Co.nst /
DateTyped:: 02-03 2017 - DATE ISSUED: fi"., „A.: . ASA s - "j a- -
' s4%$o® ow .0
Jr
TO PERFORM THE FOLLOWING WORK: la ee a�oarma.0asn0 ""
• Blown in cellulose insulation and miscellaneous weatherization
.` argjsa ti� ER WY
Approved/Issued By: l . L. i piPAUL M MURPHY,DIRECTOPE ONAL SERVICES
All work shall comply with 780 CMR 8'"Ed.(MOL Chap.143)and any other applicable s.Laws or Codes and plans on file.
Schedule appropriate inspections as required. Upon completion of work,final inspection is required.
I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his agent
and to receive this permit, I further understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not
withstanding the issuance of this Building/Zoning Permit.
Signature of Owner/Agent: ( -44"2` ( l
"Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)"
Inspector of Inspector of D.P.W.Inspector Building Inspector - Inspector of Gas Fire Department
Plumbing Wiring
Water Service if: Footings: Underground: Oil:
Underground: Service:
Foundation:
Rough: Smoke:
Rough: Rough: Sewer Service#: Rough Frame:
Insulation: Final:
Final: Final:
Cross Connection Final: Final:
Board of Health E-911
Additional Comments:
Planning Board III
Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary
inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of
the building permit.
POST CARD SO IT IS VISIBLE FROM THE STREET
TOWN OFilli DARTMOUTH - BUILDING DEPARTMENT RECEIPT 8 4 1.6 6
PHONE: 508.910.1820 FAX, 5 910-1838
Name: t / Z` " /`f /` s`- 1/4tbpe✓rty Owner: /e /t�/7� Date/%///
Job Location: 1/0 rat Zip ' ✓ ' Map: (G' ( ! Lot:(/ - ,
Mo
Description Gener e r#'sl9 Ref. # Amount
Building & Building Misc. 0 eb0-44105 •rt11i `{25i /4.)/ J
Electrical 0 000-$4106
Plumbing & Gas 01 0-4410' 5 cs,
%preo
Trench Safety 01000-4 2--
Other Department Revenue 01000-42420
J;
White-Collector's Office Yellow CopyCustomer's Receipt Pink BuildingDepartment Received By � '/
- P Copy- l/y�. Y�
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
RESIDENTIAL ❑ Phased Ap
proval(,R106.3.3)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE at NON-TRANSFERABLE
��`OUT� DATE RECEIVED
f`®`a"re ,: DARTMOUTH BUILDING DEPARTMENT
i 2 t'_=r:�^I 400 Slocum Road gi i - / //
z - Dartmouth, MA 02747 `/
\\°a og y Phone: 508-910-1820 Fax: 508-910-1838
\ ' www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SEC3TIOtt FQR OPFICUIL USE ONLY
ARECEIVED BY: - BUILDINGEERMIT NUMBER:
taait
DATE ISSUED: ,
SIGNATURE: !I� C DATE
Building Commi ner/lnsp of Bdildiags
Zoning Distrtoti Proposed User Zone U X GB ❑A ❑V Aquifer zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED. DPW
i13 Board of ❑Board of ' ❑Cons. .0 Planning - O Address , ❑Engineering El Cross
Appeals `. Health - ComVnlssion Card -Connection
O Fire 0 Gas ❑Electric L1 Other O Watercard ❑8ewerCard
Chief _ - Cutoff- .dut Off ` - t Cut-off -Cut Off"
bEPARt11rMENTA",'APfW OVALS) "
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed:
SECTJO1-r SITE INFES MATJQN='
1.1 Property Address: Z (k2W CLK t.M-u 7 1.2 Assessors Map&Lot Number: sL
Contact Person: G/ , 6-auvu4 Map 4 co Lot �/ /7 (c::,
Phone Number: sbe-g.,_ za io Cs
1.3 Historical District ❑Yes 17 No
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built %Rq 9
'Municipal . unicipal 0 Altering more than 25%per side of building
❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
0 Yes 0 No Date:
Revised 5/13
❑ CONSTRUCTION PLANS 0 SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SEGTION 2 PROPER'pY OWNtRSHIP/P.iJiHORl��6 AfiENT„ . , „ ;
2.1 Owner Record:
Or Arm C—oc✓c2A 2w4 c.,e2 c444h.f 7fttnnoi./7ti ia? 9n— 2L
Name(print) Contact Address / Phone Number
2.2 Authorized Agent:
CHf s e_ ?)tusr.t 323 iiiivgGerc4 Sir re--A-(2- RfuC.c, SV5' (07Z-13o7
Name(print) Contact Address
d z7 2 / Phone Number
SECfIQN>'� ,CONSTRf�GFfON'SERVIGES 's, _.
3.1 Licensed Construction Supervisor/Specialty License: License Number: CS' 7/?V 7
Company Name/Contractor Name: CawtLes E
1,
Address: 373? 4 7Ltrc4 sr i3u- /L/ t-s-;f/1- (;)rpiratlonDate: r 3/Z7/jf
Signature: , Cl 1y'1 Telephone: S28-(o'7z-1!3 e ., J ,
3.2 Homeowner Exdmptfon-One&Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that ifa Homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.
For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which
there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures: A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
„_SEG7{f3N WORIS�R&COII!Ip.ENS�4590N-1NSURANCE}tFF!!?I1V1�'(MGLc 3�§25) . ; .. ,. .,, ._.
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure toyrovide this
- affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: C Yes 0 No
s� ,��CTj0�15-'rbESGItIP,TIONf3F PRQPQ$EQ,WOl2�S�Cbgtfk�jll 5pp!(cati(e} � , T_ . �,t'„„"_.,
❑ Deck 0 Pool ["Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
kvskly7oM VPG. of
❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding 0 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No.of windows Doors
❑ DEMOLITION (specify):
Location of debris removal(per MGL C.40 Sec 54): ❑Dumpster on site Cl Dumpster On Street
Facility Name: Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms No. of Baths
Two Family: No of Bedrooms Unit 1 No.of Baths Unit 1
No of Bedrooms Unit 2 No.of Baths Unit 2
❑Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify):
❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify):
❑HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify):
❑Air conditioning-(separate unit)
❑None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
. EOt[ N 6..xESllMAS.bb aJRQetr11 fN�GOSi. :'
Item Estimated Cost($)to be completed by permit applicant
1. Building 'f ` 933
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5 Total= (1 +2+ 3+4) ' qq3 3
SECTION 7ArQ)tIINEI� t� HO'R1ZATtQN
tto,be ca7npietetf when_owner's agent r coM)actoPi$pn for buiEdrng permit)
(Please Print)
I, Co q+ i--e W L iA- , as Owner of the subject property hereby authorize C(ictic £ 2)6.u./ut
to act on my behalf, in all matters relative to work authorized by this building permit application.
Sup' frrmeiFt7 Y`o2N�
Signature of Owner Date
'SECTION 7B_OINNERIAUTHORIZED AGENT DECLARATION
I, C4Li1-,t es c it: /)ittc-r-r L.L ,as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Signature of Owner/Authorized Agent Date
SECT[oN.e-OFF1cE11NSPECtORSJ40TES
Less Application Fee:$25.00 Remaining Balance: $
Total Permit Fee: $
Other$Amount$
Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.ft.
Permit Issued to:
•
0 ,urrrr
Permit Authorization 0c
tra
mass save Form
PARTICIPAllNG
sA'ionw+owa'^.^> or•ffideKr WNiAliCTORCT08
Site ID: S00050148348 Customer: GINA GOUVEIA
I, GINA GOUVEIA ,owner of the property located at:
(Owner's Name,printed)
2 Warbler Way DARTMOUTH
(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.
Owner's Signature: •
Date:, 12, aQ
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the.following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
•
CYt*-ems 731 A7
Participating Contractor Date
•
•
Of'O
Conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472 tin
For Office Use Only
Rev.102015..
The Commonwealth of Massachusetts
1 -MI=_ t Department of Industrial Accidents
Hi"ell, 1 Congress Street,Suite 100
• -{ Boston,MA 02114-2017
_ www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/ndividual):Delisle Enterprises, Inc. d/b/a Energy Doctor
Address: 323 America St.,
City/State/Zip: Fall River, MA 02721 Phone#:508-672-4302
Are you an employer?Check the appropriate box: Type of project(required):
I. I am a employer with 6 employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp. insurance required.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
4.0I am a homeowner and will be hiringcontractors to conduct all work on my ]0 El Building addition
property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.0Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑✓ Other Weatherization/Insult
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Guard Insurance Group
Policy#or Self-ins.Lic.#: DEWC712952 Expiration Date�6/23/2017
Job Site Address: 2- L✓Ll/G ,L gc tl/ City/State/Zip: . )172. xoV)W kiiki UZ7f1
Attach a copy of the workers' compensation declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.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: G'/,.�Ly,L Date: //7
Phone#:508-672-4302
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
f Commonwealth of Massachusetts ®. Massachusetts Department of Public Safety
�J Department of Public Safety Board of Building Regulations and Standards
Oil Burner technician Certificate License: CS-071847
License: BU-023388 Construction Suoer:isar ,�� '�.
` ‘ t is rt4riet a�lf.
CHARLES E DENS 'f CHARLES E DELISLE "t(l"1 /
323 AMERICA St >A ,g 323 AMERICA ST
Fall River MA 02721 - FALL RIVER MA 02721
J.4".."l!„"T".if"'e0 Expiration:
Commissioner 03/27/2017 Commissioner
o Expiration.
ner 0 3/2712 018
•,•.•�••,_• ••••_•••� ://r 15,in Pre mnen///(y' d/;:nr/„e//,
,.>. Office of Consumer Albin&Business Regulation License or registration valid for individual use only
„T"" _ „,,HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
'� ' Office of Consumer Affairs and Business Regulation
s Registration: 105447 Type: �
- r- Expiration: 7/17/2018 Private Corporation 10 Park Plaza-Suite 5170
Boston.N A 02116
DELISLE ENTERPRISES,INC
Charles
De
le
323 Am rica St. \
323 America St. 0�,fi e / '
Fall River,MA 02721 Undersecretary Not valid without signature
OSHA ('-�9 <9 i 1
t1• 6." 2147:14`'>,JLE
.4.Dq.a ,rrsta3t _
tali s:n fesea ,,,,pi! nl 'a, 3,¢r-h an arru ,sval.o-
Tlia cats acknosaedges that the recipient has success y"' ,
oC-fnu•Occupational Safety and Health Training Caarse.r,
Construction Safetyy and is
())Healthlt
f ✓/ Y 1 /t1 as. C rM cx+peta a o-rrnr Octupatrci Sareir,vsa Hrnrt;
_.�� T.. nxi,,w�n
/ {�_ 6 9 _ _ - -_ � `" Cons.. ' Safety&Health
'gene.; fererwced —_.e n t u:tyFn)
;t�� .i:er..;
Charles£detisie
ft -timilLFnasi.
pi 't„ z;if <.
___,.. ENERG-1 OP ID: RC
ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
�..� 1111 DI2016
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(les) 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
Durfee Buffinton Ins.Agcy,inc PHONE Christopher E. Brown -_ FAX
377 Second Street _NC.No Fa();508-679-6486 JJNC,No): - .._-
Fall River,MA 02721 EMAIL
ADDRESS:
Christopher E.Brown
INSURER(S)AFFORDING COVERAGE _ NAIC#
INSURER A:Western World Insurance Co.
INSURED Delisle Enterprises Inc., DBA INSURERB:Safety Indemnity Insurance Co 33618
EnergyDoctors Insulation
INSURER C_GuardIns Group 14702
323 America St. - --- --- — --- "-
Fall River, MA 02721 INSURERD:Nautilus Insurance Company
INSURERE: _
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.
ILTR TYPE OF INSURANCE ANZ SIMINVD POLICY NUMBER IMM/DD/YYYPOLICY Y) (MM/DDPY/YYPY) LIMITS
LTR INSD WVD
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE CX OCCUR X NPP8384021 06/09/2016 06/09/2017 pREM 5Es(OEa ocourwncel $ 100,000
MED EXP(My one person) $ 5,000
X Lead Liability PERSONAL BADV INJURY $ 1,000,000
' GF NI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
__ POLICY F_1 PRo L . LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER'. $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000 000
_ (Ea accident) !___
B —1 ANY AUTO 6218580 06/09/2016 06/09/2017 BODILY INJURY(Perperson) $
ALLOWNED _X SCHEDULED BODILY INJURY(Per accident) $
_ IAVTOS AUTOS
—X HIRED AUTOS X AUTOSWNED PROPERTY DAMAGE $
I 111 $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
D - EXCESS LIAB _ CLAIMS-MADE AN028696 06/09/2016 06/09/2017 AGGREGATE $
DEC X RETENTION$ 0 — $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A DEWC712952 06/23/2016 06/23/2017 E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,
esRTIN under OPERATIONS below
DESCRIPTIONE.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
CLEAResult, Eversource and National Grid are listed as additional insureds
on the General Liability Policy on a non-contributory basis.
CERTIFICATE HOLDER CANCELLATION
CLEARES
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION
NOTICE WILL BE DELIVERED IN
CLEAResult ACCORDANCE WITH THE POLICY PROVISIONS.
Contractor Services Dept.
50 Washington St. AUTHORIZED REPRESENTATIVE
Westborough,MA 01581 t/ DR� YCW3 1/157,4e+--- -
I
4,1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
r
CONTRACTOR WORK ORDER
CLEAResult
50 Washington St.Suite 3000 Printed: 1/10/2017
Westborough,MA 01581 Work Order Id: 548348P70009C103
Contractor Information Customer/Site Details
Energy Doctor Gina Gouveia Email:STEVE@ECSELECTRICAL.COM
Phone(Eve): 508-989-2066
323 America St 2 Warbler Way Phone(Day): 508-989-2066
Fall River,MA 02721 Dartmouth,MA 02747-5310 Site ID: S00050148348
Total Installed Measures # i
Location Description Quantity Unit$ Total $
Living Space Perform Air Sealing at Estimated 62.5 CFM50 16 $84.32 $1,349.12
Exterior Door Weather Stripping 4 $27.59 $110.36
Door Sweep 4 $23.18 $92.72
Living Space Attic Stair Cover Thermal Barrier 1 $226.34 $226.34
Damming 92 $2.19 $201.48
Living Space Attic Floor Open Blow Cellulose 6" 1,220 $1.47 $1,793.40
Attic Vent bath fan to roof flapper 3 $129.21 $387.63
Attic Propavent 2'or 4' 71 $3.83 $271.93
Installed Measures Total $4,432.98
WorkOrder Notes
Payments...
Incentive Payments
Air Sealing Incentive $1,778.54
Weatherization Incentive $1,990.83
Total Incentive Payments $3,769.37
Customer Share
Total Customer Share $663.61
Less Deposit Of $221.20
Customer Share Balance(Due Contractor) $442.41
For questions regarding assigned work: Contractorinbox@CLEAResult.com. For questions while performing work: 855-821-2205.
Permit No. BP-84166 ProjectLocation: 2 WARBLER WY
Commonwe achusetts
TO C
r a w erg Y v
,per $ �'�, r } . .q-i: ,i awk. + , s
°40rSL i t t A 034w
� xx
Contra I E 7,1 e: i One#
CI3AR ISL . e i' ,r1 7 I ;) 672-4302
� " � �" s �� %,�� r
Architect:, III
-kw fte .Phone#:
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Applicant: ®@ ,_ mesa Phone #: `:' t
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OWNER: ��®�®��� m��m�w��a m {r:c � ,�t 1r .x a . .. r,t
GOUVEIA STEVEN&
DATE ISSUED:
TO PERFORM THE FOLLOWING WORK.•
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Blown in cellulose insulation and miscellaneous weatherization
DATE TIME ,� JJ TYPE OF INSPECTION&REMARKS INITIAL
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