(To Be Submitted with Signed Agreement) 1. Notice Please notify my company of matters pertaining to the enclosed agreement by mail to: Full Name Title Company Name Physical Address City State Zip Mailing Address City State Zip By telephone: By email: 2. Operations Contact Please notify the following person of all worksite-related matters, including work assignments, quality control reports and customer service issues: Full Name Title Physical Address City State Zip Mailing Address City State Zip Office Phone Cellular phone Email Address 3. Public Posting Please use the following contact information for all public-facing contact information, including posting on the Mass Save website: Company Name City Where Office is Located State Phone Number Website or Email Address 4. On the line below, select the member Utility Program Administrator for which you indicated acceptance of the background check requirements: I am willing to serve WMECO customers 1
5. Disclosures I, or my company, have (or has) been cited for a violation of a wage or benefit-related Federal or State law: (check one) no yes (If yes, please attach a brief explanation) I, or my company, have (or has) been cited for OSHA Health and Safety violations: (check one) no yes (If yes, please attach a brief explanation) I, or my company, have (or has) been debarred from providing services by the Commonwealth of Massachusetts or in any Massachusetts city or town: (check one) no yes (If yes, please attach a brief explanation) 6. I am willing to do work in the following Massachusetts Counties: (A map is provided on page 9 for your convenience. Check all that apply) Northern Berkshire Southern Berkshire Eastern Franklin Western Franklin Eastern Hampden Western Hampden 7. Please indicate your technical proficiencies below Eastern Hampshire Western Hampshire I am only willing to perform air sealing and do not wish to perform insulation measures If you checked the box above, please skip to Section 8, the Enclosures Checklist If you did not check the box above, check one of the two boxes below I am willing to perform insulation AND air sealing work I am willing to perform insulation and air sealing work AND will also accept work orders that contain only air sealing Check one or both of the two boxes below, but only if they apply to you I am willing to accept Work Orders that contain wall insulation with ASBESTOS siding I am willing to accept Work Orders that contain wall insulation with ALUMINUM siding 2
8. Enclosures Checklist I have included my W-9 (tax ID) form. I have included my Certificate of Insurance meeting terms of paragraph 7d through 7g and the limits noted in attachment 3 of the enclosed agreement). I have enclosed a completed Background Check Compliance Certification (the 2-page form of which is provided in Section 11of this document) attesting that the background check requirements of the enclosed agreement have been met, for which employees my company is in compliance, and listing the name and contact information for the vendor who supplied me services in this regard. I have enclosed a completed Supplier Diversity Commitment form (provided in Section 12 of this document) attesting that the background check requirements of the enclosed agreement have been met, for which employees my company is in compliance, and listing the name and contact information for the vendor who supplied me services in this regard. I have enclosed proof of my company s compliance with the credentials requirements of Attachment 3 of the agreement, including: A copy of my company s valid Massachusetts Construction Supervisor License (or Insulation Specialty Construction Supervisor License) Copy of valid HIC License Copy of valid Lead Safe Certificate Copies of all valid license cards and/or certificates held by each Crew Chief that I wish utilize to supervise Work under the Program (if applicable) A copy of my company s valid BPI-Accredited Contracting Company Certificate 9. Hiring CSG and the participating Utilities it represents encourage local hiring. Upon request, CSG will make available to all subcontractors a list of known Massachusetts training initiatives that might be inclusive of the technical aspects of weatherization. 3
10. Agreement Submittal Please complete this form and submit it with the entire, 24 pages Agreement; (If by mail) to: Conservation Services Group Attn: Contractor Services 50 Washington Street Westborough, MA 01581 (If electronically) scan and email to: contractorinbox@csgrp.com (Maximum of 5MB per message, please) 4
11. INDEPENDENT INSTALLATION CONTRACTOR BACKGROUND CHECK COMPLIANCE CERTIFICATION ( CONTRACTOR ) participates as an (Company Name) Independent Installation Contractor in the Mass Save Home Energy Services Program (the Program ). In accordance with the terms and conditions of the Independent Installation Contractor Participation Agreement by and between Conservation Services Group, Inc. and CONTRACTOR (the Agreement ), I,, of CONTRACTOR, hereby certify that CONTRACTOR is in (Principal s Title) (Principal s Name) compliance with the requirements set forth in Section 7 (a) and Attachment 1 of the Agreement and that the following information is true and accurate: a. List the names and contact information of any agencies or firms engaged by Contractor to perform employee background checks. Company Name/Contact Address Phone b. The following employees are employed by [CONTRACTOR NAME] as of the date set forth below and [CONTRACTOR NAME] completed a background check in compliance with Section 7 (a) and Attachment 1 of the Agreement as of the date set forth below: EMPLOYEE NAME TITLE DATE OF BACKGROUND CHECK 5
c. Officer/Principal Name Signature Date 6
12. Conservation Services Group Supplier Diversity Commitment It is the policy of Conservation Services Group (CSG) that small businesses, veteran-owned small businesses, service disabled veteran-owned small businesses, HUBZone small businesses, small disadvantaged businesses, and women-owned small businesses shall have the maximum practicable opportunity to participate in performing contracts awarded by any CSG led program, including contracts and subcontracts for any and all related energy efficiency programs. CSG further agrees to cooperate in any studies or surveys as may be conducted by the Small Business Administration as may be necessary to determine the extent of the CSG s progress toward this commitment. CSG, acting in good faith, relies upon written representations by our subcontractors and Participating Contractors regarding their status in these matters. Please indicate if your company meets the Small Business Administration definition of any of the following. Check all that apply: small business veteran-owned small business service-disabled veteran-owned small business HUBZone small business small disadvantaged business women-owned small business Note that federal law prohibits misrepresentation of a firm s status as a small business concern. Also note that your answers to this survey do not impact your eligibility to participate in the Mass Save Home Energy Service program, nor will it impact the volume of work that the Program may award to your firm. CSG has committed to develop a subcontracting plan. We are collecting supporting data from all of our subcontractors and Participating Contractors to complete this commitment. I, the undersigned, hereby certify that the above information is true to the best of my knowledge. Furthermore, I will notify CSG within 30 days of a change in status and/or execution of an agreement of merger or acquisition that would change the company eligibility to be classified as one or more of these small business categories. Signature: Date: Printed Name and Title: Business Name: Business Address: 7
Contractors seeking a determination on their small business status are encouraged to visit the US Small Business Administration (SBA) website at: www.sba.gov. CSG cannot make such a determination, however our general understanding of the categories on the survey are as follows: Small Business Concern: It is our understanding that weatherization contractors fit into the US SBA category of Special Trade Construction businesses. According to US SBA, this category is a small business if it has annual receipts that do not exceed $7 million. Veteran-Owned Small Business Concern: The terms veteran and service-disabled veteran are defined in 38 U.S.C. 101(2) and (16) respectively, the Department of Veterans Affairs, United States Code. The term "veteran" means a person who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable. Service-Disabled Veteran-Owned Small Business Concern: A Service-Disabled Veteran is a person who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable, and whose disability was incurred or aggravated in line of duty in the active military, naval, or air service. HUBZone Small Business Concern: The Historically Underutilized Business Zones (HUBZone) program of the US SBA helps small businesses in urban and rural communities gain preferential access to federal procurement opportunities. These companies generally employ staff who live in a HUBZone, and the company must also maintain a "principal office" in one of these specially designated areas. Small Disadvantaged Business Concern: A Small Disadvantaged Business (SDB) is a small business that is at least 51 percent owned by one or more individuals who are both socially and economically disadvantaged. Businesses must be certified by the Small Business Administration (SBA) to qualify for SDB status. Women-Owned Small Business: To qualify as a Women-Owned Business (WOB), a small business concern must meet the following two conditions: 1) At least 51 percent owned by one or more women; or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and 2) Management and daily business operations are controlled by one or more women. 8
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