PERMISSION FORM FOR WEATHERIZATION

RENTAL HOUSING

Address of home _________________________________________ When was this home built (approximate)? _________

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Does your home have:

A roof leak? Yes( ) No( ) Water in the crawlspace? Yes( ) No( )

Any rot/decay or mildew? Yes( ) No( ) Plumbing leaks? Yes( ) No( )

Moisture noticeable on windows? Yes( ) No( ) A furnace which works properly? Yes( ) No( )

Termite/carpenter ants? Yes( ) No( ) Carpet that has been soaked? Yes( ) No( )

Cars parked in attached garage? Yes( ) No( ) Indoor pets? Yes( ) No( )

Any household member pregnant? Yes( ) No( ) Leaks or stains on ceiling? Yes( ) No( )

Any household member with asthma, respiratory problems or flu like symptoms? Yes( ) No( )

Paints, solvents, thinners, or pesticides stored within the home? Yes( ) No( )

Any household members who smoke inside the home? Yes( ) No( )

Comments ________________________________________________________________________________________

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For your consideration:

1. Some attic areas are difficult to access in order to install insulation. Access may be necessary through the roof, gable end and/or the interior. All penetrations are to be properly sealed and holes for ceiling access, if any, drilled and plugged. In these instances the auditor and/or installer is to clarify the access method(s).

2. In order to insulate walls, holes must be drilled either through the outside siding or the inside wall if the contractor cannot remove and replace the siding. In either case, the contractor will plug and patch holes. The homeowner is responsible for any finishing and painting.

3. When adding floor insulation, additional vents may be added in the foundation. The added vents provide air ventilation and reduce moisture problems.

4. To make your home healthier, it may be necessary to install an exhaust fan, range hood or ventilation system.

5. It may be necessary to service or repair the furnace or heating system.

6. It may be necessary to make minor repairs to prepare for the weatherization. Minor repairs may include limited roof patching, dry rot repairs, electrical repairs and pest control.

7. The weatherization program may provide a new energy efficient refrigerator if the following two conditions are satisfied: (1) we must calculate that purchase of a new refrigerator will be cost effective and (2) the existing refrigerator(s) must be removed and decommissioned by the appliance dealer (so that inefficient refrigerators are no longer functional). The owner of the existing inefficient refrigerator shall be the owner of the new efficient refrigerator.

8. Homes built before 1978 may contain lead based paint and weatherization activities could disturb that paint. On rare occasions, testing the paint for lead is necessary. If lead exists, the paint is not removed or abated. Instead lead hazards in the work area are safely removed. The building owner receives copies of initial and follow-up test reports and is responsible for disclosing to any future workers on the home and renters or purchasers of the home the presence of lead based paint. The typical weatherization project, however, does not require paint testing. Workers follow a “Safe Work Practices” approach to their work, whether lead is known to be present or not, in order to avoid exposing household members to possible lead debris.

9. Replacing windows is not a routine part of the weatherization since window replacement is not often cost effective.

Please comment on any concerns regarding weatherization: ________________________________________________ _

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I hereby give my permission to weatherize my home. It is understood that the weatherization program will cover the costs of eligible measurers noted above. Only cost effective energy upgrades and necessary related repairs will be addressed. Some improvements may require landlord funding contributions, including all or part of costs of furnace replacement, window replacement, significant related repairs, etc. KCHA will communicate with the landlord if funding contributions for specific improvements are necessary.

I hereby release and pledge to hold harmless King County Housing Athority and its staff from any liability in connection with the work performed or any act or eventuality arising from the work.

I understand that my participation in the weatherization program is subject to funding availability and that, upon completion of my weatherization project, a minimum of two years must elapse before I may again participate in this program.

Both the tenant and the landlord (building owner) must indicate their agreement by signing below.

Signed _____________________________ _______ Date____________

(Tenant)

Signed __________________________________ __ Date____________ (Building owner)

Building owner information: Address ______________________________ Phone Number _________________

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