Please fill out as much of the form as you are able, then submit it and we'll help you do the rest. Contact Information Contractor Name Customer Name Phone Email Address Unit City State Zip I request that the contractor named above perform weatherization improvements through the Mass Save Home Energy Services Program. Customer must Check One: I have already had a Mass Save AssessmentI need to have a Mass Save Assessment Contractor must Check One: I have visited and assessed the home listed at the address aboveI have NOT visited the home listed at the address above Eligibility Primary Heating Fuel Gas Oil Propane Electricity Other Other Primary Heat Gas Provider (if applicable) Eversource National Grid Municipal Other Other Gas Provider Electrical Provider Eversource National Grid Municipal Other Other Electrical Provider Are you concerned about any of the following Flooring Removal Difficult Siding Difficult Bathroom Fan Vent Wall Contains 1 Insulation Gable Vent Install Headroom Under 4 ft Temp Access Blind Spec Vinyl Over Asbestos Siding Multi-Layer Siding Backplaster Walls Metal Lathe Gable Vent Access Roof Vent Access Recessed Light Covers Untreatable Crawlspace Cut & Finish Access Asbestos Siding Ridge Vent Install Difficult Ladder Setup Large Volume Insulation Removal Home Over 100' From Street Notes If any areas of concern are noted above please explain and indicate if the work can be completed to Program Standards below. Note any additional information about the work scope, customer interest, roadblocks, or non-standard work necessary to complete Program eligible work. 650 Characters Max. *By submitting this form the contractor acknowledges that CLEAResult is not responsible if the indicated scope of work cannot be completed. Δ
