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: Already Had MS AssessmentNeeds MS Assessment Health/Safety Concerns Note any potential health or safety concerns including location. The Mass Save Energy Specialist will verify your observations and determine any effect on the work scope. Knob and Tube Wiring Asbestos Comb. Safety Issues Moisture Structural Eligibility Primary Heating Fuel Gas Oil Other Other Primary Heat Gas Provider (if applicable) Eversource National Grid Other Other Gas Provider Electrical Provider Eversource National Grid Other Other Electrical Provider Contractor Recommendations AIR SEALING Recommend Airsealing? Yes No Locations Attic Basement Living Space Attic Floored? Yes No Partial T-Dome? Yes No Whole House Fan? Yes No Vapor Barrier? Yes No ACCESSES Existing Proposed Proposed Type Quantity Temp Sheathing Finished Roof ATTIC VENTILATION Existing Types Roof Soffit Gable Ridge Need Propavements? Yes No If needed, check proposed types: Roof Soffit Gable Ridge Notes Enter any additional notes about the work scope: 650 Characters Max. Date Please sign below: *The MassSave Form will not be valid without a signature Δ
