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HomeMy WebLinkAboutBuilding Permit # 9/29/2016 pORTFj BUILDING PERMIT �� � ' 04 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 41 - Permit NO:--39 e,17 Date Received ` 1-7 Gate Issued: �'4SsacHus�i�' IMPORTANT: Applicant must comp lete all items on this page s� " F W TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg Others: ❑ Demolition ❑ Other Install rooftop solar array and connect to existing utility. Identification Please Type or Print Clearly) OWNER: Name: Christian Ampenberger Phone: 9/23/2016 Address: 122 Marblehead Street, North Andover, MA 01845 KIM 9 u U v " ` f n ARCHITECT/ENGINEER Roger Alworth phone: 801-990-1775 Address, 9138 S. State St., Sand UT 84070 Reg. No. 47740 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost, $ 26752 FEE: $ 3 p --- Check No.: m.'9- Receipt No.:� � NOTE: Persons contracting with unregistered contractors do not have access to he guaran and 14ORTphl Town ofndover :� _ 4 0 Ta No. 3q 91N . -A * 0L��� h ver, Mass, al $ • o j 10 coc"Ic"Ewi[x sArEv BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ..... ,. QI „�„r�,. MS .Glr ........:...... ...... BUILDING INSPECTOR has permission to erect ............ buildings on ...� . Rbleh ' T ... Foundation Rough to be occupied as ............ ........ ............ ...� ...�.,............�..,..� .......................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. . PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT4q STA T Rough ...... ...... ..................... Service BUILDING INSPECTOR. Final GAS INSPECTOR OccuEageE Permit Required to Occupy Ruildiu Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. DocuSign Envelope ID: 431 C9AAD-0944-4784-82OC-El 77CBOFCI 04 REVOLU(S'UN, S, THIS HOME IMPROVEMENT SOLAR ENERGY CONTRACT (this "Contract") IS BETWEEN: Chris Arnpenberger ("Client") located at 122 Marblehead North Andover, MA 01845 ("Client's Property") -AND- Northeast Solar Services, Inc.@ ("Contractor") of 'I North Ave Suite A Burlington, MA 01803 , with Home Improvement Contractor Reg. No. 178137, which expires on March 17, 2016, and Federal Employer ID 46 0569853. Contractor's sales person for this contract is Matt George. The parties to this Agreement agree as follows: lWTOISIN A. Installation of PV System, The above Client(s) has engaged Contractor to perform the following residential contracting work (the "Work") in connection with the installation of the following photovoltaic solar energy system (the "PV System"): 15 SunPower - Sunpower 345 WHT watt modules (or equivalent) with I Solar Edge - Solar Edge SE 5000A inverters (or equivalent) and all mounting, disconnects, and all other PV System components necessary for a National Electric Code compliant PV System, totaling 5.175kW, located at Client's Property. B. Other Inclusions The Work shall further include: Installation of the PV System in accordance with all State of Massachusetts interconnection standards. • All reasonable engineering and permitting costs. • The following building permits are required and will be secured by Contractor as Client's agent: Building and Electrical Permit. • Following the installation, Client will receive a PV System orientation and a PV System Client's manual. Notice: It shall be the obligation of the Contractor to obtain all permits related to the Work. Clients who secure their own permits will be excluded from the guaranty fund provisions of Chapter 142A of the Massachusetts General Laws. 11, COMPENSATION AND SCHEDULE A. Contract Price For Contractor's performance of the Work Linder this Contract, Client will pay Contractor a total of: $ 26,751.97 (TWENTY SIX THOUSAND SEVEN HUNDRED FIFTY ONE AND 97/100) DOLLARS USD (the "Contract Price"). B. egyment Schedule The Contract Price will be payable in accordance with the following payment schedule: Date Paid: S 13,375,98 Initial Payment - 50% (Due upon Contract signing, which is an amount less than the cost of the materials and equipment which must be specially ordered in advance of commencement of PV System installation) S 12,038.38 Progress Payment - 45% (Due upon Substantial Completion) S1 337.61 Final Payment - 5% (Due upon Final Completion) C.Schedule The "Start Date" of this Contract is the date Contractor receives the full amount of Client's initial payment of 50% of the Contract Price. Subject to adjustment for any Force Majeure reason stated in Section IV,J,, the Work is estimated to begin within 12-16 weeks from the Start Date of this Contract. The parties agree that this date shall be automatically extended to the date of delivery of all materials and equipment which mut be specially ordered. Substantial Com -gletion is estimated to Occur within 16-20 weeks from the Start Date of this Contract, but the parties agree that this date shall be automatically shortened or extended to the date on which all racking and electrical work are complete and the PV System Is capable of generating power and ready and available for use subject to final government and utility approval. Final Completion is defined as the date on which all punch list items are complete, all permits are closed, all other government and utility approvals are obtained and the Work is complete to the satisfaction of Contractor and Client. Client acknowledges and agrees that the Work involves permits, inspections and approvals from various government agencies and utilities, and therefore the timing of the Work may vary and is not within Contractor's control. Client further agrees that Contractor shall not be liable for any losses, costs or damages related to any delays for reasons beyond Contractor's control, including all causes noted in the Force Majeure section of this Contract below, Northeast Solar I North Ave SUIte A Burlington, MA 01803 781,240.6555 1 $ t q 74 V, 1 15.01 ON 12 Id 0 1 G Docu,5ign Envelope ID: 431 C9AAD-0944-4784-B20C-El 77CBOFC104 REVOLU(SUN, S, Ill. IMPORIANLNOTICES A. Contractor's EggisLratj: All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisions of Chapter 142A of the Massachusetts General Laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director of the following state agency: Office of Consumer Affairs and Business Regulation Home Improvement Contractor Registration Ten Park Plaza, Room 5170 Boston, MA 02116 (617) 973-8700 B. Client's Cancellation Rights: Client may cancel this Contract, without penalty or obligation, within three business days following the date on which Client signs this Contract. A Notice of Cancellation is attached hereto for Client's convenience, C. Warranties: For a period of ten (10) years from Substantial Completion, Contractor warrants that the PV System has been designed and installed in a good, workmanlike and substantial manner in accordance with all applicable building codes. In the event Contractor is required to penetrate the roof of the Client's property in the course of installation, and causes damage to the roof within a three (3) inch radius of a penetration, Contractor will repair such roof damage for a period of twenty (20) years from Substantial Completion or the remaining term of the roofs existing installation warranty, whichever is shorter, to prevent any water, rain or other moisture leak, seepage or entry directly caused by such penetration. These warranties are for normal use and conditions only. All warranty coverage to equipment and workmanship installed by Contractor will be VOID if any alterations or repairs are performed by any person or persons not expressly authorized, in writing, by Contractor, THIS WARRANTY DOES NOT COVER: (a) Damage caused by external forces Such as, but not limited to, vandalism, theft, terrorism, fire or act of God; (b) Damage caused by weather effects exceeding manufacturer tolerances; (c) Normal wear and tear or aging of a PV System; (d) Any implied warranties: (e) Electric bills, water damages or any other consequential damages; or (0 Damage to the PV System or its efficiency due to adjustment, moving, or tampering with the PV System or any of its components by individuals not approved by Contractor, D. Change Orders: Any alteration or deviation from above specifications involving extra costs must be subject to a written change order signed by both parties, which shall be incorporated into this Contract, and Client shall be liable for any additional costs resulting from each change order. By initialing the space below, Client hereby specifically agrees to execute a change order, and pay the additional costs, if it becomes necessary for Contractor to repair or replace un-apor n -code compliant electrical work in order to complete the PV System installation and satisfy code requirements. Client's Initials Client's Initials. ARBITRATION: CONTRACTOR AND CLIENT HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT CONTRACTOR HAS A DISPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE DIRECTOR OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND CLIENT SHALL BE REQUIRED TgT6dOUCH ARBITRATION AS PROVIDED IN M.G.L. c. 142A. Client: �Tv* W 8/15/2016 U e V Client: PirQFrAin. Date: ----"nEJJ1r 8/16/2016 Contractor: I 1'W1U,(,W rowv) Date: �--8BBBFA29CF8A4E6 NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by Contractor. Client may initiate alternate dispute resolution even where this section is not separately signed by the parties. E. Incentive Guarantee: By Client's initials below, Client acknowledges and agrees that Contractor has not and does not guarantee Client's qualification for, receipt of or amount of any tax credit, rebate, solar renewable energy credit (SREC) or other incentive arnount in connection with the PV System, and any estimates of incentives (wither in a PV System proposal or otherwise) are not guaranteed to be accurate or available. Client is responsible for determining Client's and/or the PV System's eligibility for any incentives and should consult with tax, legal and other advisors regarding availability and possible tax consequencra b laiming the sarne, Client's Initials: Client's Initials: Northea,,.0 Solar 1 North Ave Suite A Burlington, MA 01803 781.240,6555 10KV8 V0 5,079 01311W,015 DocuSign Envelope ID: 43IC9AAD-0944-4784-B20C-EI77CBOFC104 REV0LU(S'UN,,, *11 A. Access: To enable Contractor to perform its Work hereunder, Client shall grant during daylight hours adequate space on Client's property, as mutually designated by Contractor and Client, for the complete and proper installation, operation, maintenance and repair of the PV System as well as rights of ingress and egress to, through and from such property and the space designated for the PV System. B. Scarcity of Materials; Rights of Termination: The PV System components to be obtained under this Contract are scarce commodities. In order to meet the performance requirements of the PV System described in this Contract, Contractor may substitute the specified brand of solar module or inverter for a similar brand of module or inverter that allows for more timely completion of the installation. Such substitution, if necessary, shall be of UL approved devices, with aggregate performance criteria the same as equipment specified. The governing body for determining performance criteria shall be the CEC (California Energy Commission) that rates all UL approved modules. The key module statistic used for performance criteria will be the DC STC rating of the sum of the modules. The key inverter statistic used for performance criteria will be the AC output of the device. If, due to code requirements, equipment substitution, final engineering, space availability, etc., the size of a PV System decreases, Contractor shall re- calculate the Contract Price using its standard pricing method and the Contract Price shall be automatically reduced. Client shall be credited by the reduced amount. If due to substitution the DC STC size of the PV System increases slightly, then Client shall not have to pay Contractor similarly. Contractor shall make every reasonable effort to ensure that PV System size does not decrease from the specifications. If the DC STC size of the PV System decreases more than 15% from the Contract's specification amount for any of the reasons stated in this paragraph, Client shall have the right to terminate this Contract within ten (10) days of Contractor's written notification to Client of such decrease, and Contractor shall then refund in full all funds paid to date under this Contract, but shall have no other liability to Client. Contractor reserves the right to unilaterally terminate this Contract within 45 days of its approval without any liability to Client if any of the PV System components required for the completion of Contractor's Work in a timely manner are not available. In the event of such termination, Contractor shall refund all monies paid by Client to Contractor as of the date of termination, C. Limitation of Liability: In no event shall Contractor be liable in an amount exceeding the compensation paid by Client to Contractor under this Contract. Contractor shall not be liable for any incidental, consequential or special damages or for economic loss or expense of for loss or profits or income Of Client, or Client's consultants or agents or employees, or any of them, including but not limited to any electricity costs incurred should installation of the PV System be delayed beyond the commencement or completion schedule set forth above. D. Zoning: Client shall pay for all variances, special permits, or other costs related to zoning, including without limitation any fees or costs related to attorneys or engineers. E. Client's Property: Client agrees to remove or to protect any of Client's personal property, inside or out, which may interfere with or obstruct the Work, including but not limited to landscaping, and Contractor shall not be held responsible for damage to such property. Client understands and acknowledges that proper operation of the PV System purchased hereunder is dependent on Client's existing roof and equipment and Contractor shall have no obligation or liability for the condition thereof, or any other part of Client's improvements or equipment not purchased hereunder. Client expressly represents that the roof of the property upon which the PV System will be installed is in good condition, with no known water infiltration problems or other structural defects. F. Insurance: Client must carry all fire, casualty, hurricane, earthquake, theft, and other insurance related to Client's real and personal property. G. Cancellation of ConlLgct: If Client cancels or breaches this Contract after the opportunity to execute three (3) day rescission has passed but before commencement of construction, Client shall pay Contractor the amount of expenses incurred to that date plus 20% of the Contract Price. If Client fails to pay said amounts within thirty (30) days of Contractor's demand for payment and Contractor files suit, Contractor shall be entitled to recover all of its damages including its loss of net profits and attorneys' fees and costs if Contractor is the prevailing party. H, Costs of Collection: If Client fails to pay any amounts owed to Contractor when due, Client shall be liable for all costs of collection, including reasonable attorneys' fees, plus 18% interest per annum on the unpaid balance. Contractor also shall have option of removing all or part of the PV System from Client's premises in addition to receiving payment equal to the Value of the unpaid balance to cover all or a portion of Contractor's consequential damages. 1. Liens: Contractor, any subcontractor(s) and any other persons or entities supplying labor and materials to Client under this Contract, have the right under applicable law to impose a lien on Client's real property for the value of the labor or materials provided. Upon Client's payment of all amounts due under this Contract, Contractor will provide, upon Client's request, a release and waiver of any liens. J. Force Majeure: Contractor shall not be liable for any delay in material and/or equipment delivery or for failure to deliver or failure to perform the Work which results from any cause beyond the Contractor's control, Such causes include but shall not be limited to: an act of God or of the public enemy; an act (or failure to act) of any government or utility; a fire, flood or epidemic; quarantine, restriction, strike, freight embargo, terrorism, theft or unusually severe weather; Contractor's inability to obtain necessary materials, labor or transportation; custom permitting caused by Client's site conditions; homeowner association review or approval; building or other code requirements relating to Client's existing electrical system or building characteristics; and any other impediments to the installation of the PV System arising from Client's acts or omissions and/or the condition of Client's property. Northeast Solar 1 North Ave Suite A Burlington, MAO 1803 781240.6555 108'VR V0 5,Wq 06MYN016 DocuSign Envelope ID-. 431C9AAD-0944-4784-B20C-EI77CBOFC104 REVOLU, SUM, K. Legal Compliance and Spyerability: Contractor and Client acknowledge that the form, substance, content and notices contained in this Contract are intended to comply with Chapter 142A of the Massachusetts General Laws, and regulations promulgated thereunder. In the event of any instance of non- compliance, only such portion shall be invalid and the remainder of this Contract shall be in full force and effect. In addition, any such portion not in compliance shall be read and interpreted so as to have its intended meaning to the Maximum extent allowed under Such law and applicable regulations. L. Entire Cg[)tragJ; No Waiver Unless In Writing: This Contract constitutes the entire contract between the parties; there is no representation, warranty, collateral contract or condition affecting this Contract except as expressed in it. No provisions of this Contract shall be changed or modified, nor shall this Contract be discharged or waived, in whole or part, except in writing signed by both parties. This Contract shall not be effective until fully executed by Client and an Authorized Representative of Contractor. M. Qlionl's- Ropmsentation of Authority: If this Contract is signed by less than all of the persons or entities who own the subject property, then Client who signs this Contract (or any of the provisions hereof) represents to Contractor that he, she or it has full legal authority to bind the other persons and/or entities. N. Governing Law: The laws of the Commonwealth of Massachusetts shall govern any proceeding or dispute related to this Contract. 0: Production Gap Guarantee: This production guarantee covers 90% of estimated production in year 1 and decreases at .5% each year for a total terra often (10) years. This guarantee is determined on an accrual basis and payments are made when the aggregate system production falls below total production estimated on the schedule above. Payments will be made at the end of each anniversary of the system's in service date of interconnection. Production Gap Garranty is void if site con i iws and solar access change after the date of interconnection. f Al Client's Initials: Client's Initials: P. 3rd party Financing: Should the client obtain financing from a 3rd party which is approved by the Contractor, the payment terms of the lender will apply. DocuSliined by: Client: — R S� al& AL�,ftkkb it �—OF154E1542ED413— Date: 8/15/2016 Contractor: DocuSigned by: FP 6WILYS Name: Matthew owersBFA29CF8A4E5... BP Title: coo Date: 8/16/2016 Northeast Solar 1 North Ave Suite A Burlington, MA 01803 781,240,6555 9UM V,1.5,611q OrV171205 Project Number U1883-0229-161 September 20, 2016 RevoluSun I North Avenue Burlington, MA 01803 ATTENTION: Ian Clifford REFERENCE: Chris Ampenberger Residence: 122 Marble Head Rd, North Andover, MA 01845 Solar Panel Installation Dear Mr, Clifford: Per your request, we have reviewed the layout and photos relating to the installation of solar panels at the above - referenced site. Tile following materials and components are proposed in the installation of the solar panels. Roof Structure: 2x8 Rafters at 16 in" O.C. Roof Material: Composite Shingles Based upon our review, it is our conclusion that the installation of solar panels on this existing roof will not adversely affect the structure of this house. The design of solar panel supporting members and connections is by the manufacturer and/or installer. ']File adopted building code in this jurisdiction is the 2009 International Building Code and ASCE 7-05. Appropriate design parameters which Must be used in the design of the supporting members and connections are listed below: Ground snow load: 50 psf per Massachusetts amendments to the IRC (verify with local building department) Design wind speed for risk category 11 structures: 100 mph (3 -sec gust) Wind exposure: Category C Our conclusion regarding the adequacy of the existing roof is based on the fact that the additional weight related to the solar panels is less than 3 pounds per square foot. In the area of the solar panels, no 20 psf live loads will be present. Regarding snow loads, it is our conclusion that since the panels are slippery and dark, effective snow loads will likely be reduced in the areas of the panels. Solar panels will be flush -mounted, parallel to and no more than 6" above the roof surface. Regarding wind loads, we conclude that any additional forces will be negligible due to the low profile of the flush -mounted panel system, It is our conclusion that any additional seismic loadings related to the addition of these solar panels is negligible. During design and installation, particular attention must be paid to the maximum allowable spacing of attachments and the location of solar panels relative to roof edges. The use of solar panel support span tables provided by the manufacturer is allowed only where the building type, site conditions, and solar panel configuration match the description of the span tables. Attachments to existing roof joist or rafters must be staggered so as not to over load any existing structural member, Waterproofing around the roof penetration is the responsibility of others. All work performed must be in accordance with accepted industry -wide methods and applicable safety standards, Vector Structural Engineering assumes no responsibility for improper installation of the solar panels. Please note a representative of Vector Structural Engineering has not physically observed the roof framing. Our conclusions are based upon the site assessment and information provided by Revolusun and the understanding that all structural roof components and other supporting elements are in good condition, free of damage and deterioration, and are sized and spaced as outlined in the site assessment perfon-ned by Revolusun. Very truly yours, VECTOR STRUCTURAL ENGINEERING, LLC Roger T. Alworth, P.E. Principal RTA/djf 9138 S. State St., Suite 101 / Sandy, UT 84070 / T (801) 990-1775 / F (801) 990-1776 / www.vectorse.com . . . . . . . . .................. Project Number: U1883-0229-161 September 20, 2016 RevoluSun I North Avenue Burlington, MA 01803 ATTENTION: Ian Clifford REFERENCE: Chris Ampenberger Residence: 122 Marble Head Rd, North Andover, MA 01845 Solar Panel Installation Dear Mr. Clifford: Per your request, we have reviewed the layout and photos relating to the installation of solar panels at the above - referenced site. The following materials and components are proposed in the installation of the solar panels. Roof Structure: 2x8 Rafters at 16 in" O.C. Roof Material: Composite Shingles Based upon our review, it is our conclusion that the installation of solar panels on this existing roof will not adversely affect the structure of this house. The design of solar panel supporting members and connections is by the manufacturer and/or installer, The adopted building code in this jurisdiction is the 2009 International Building Code and ASCE 7-05. Appropriate design parameters which must be used in the design of the supporting members and comiections are listed below: Ground snow load: 50 psf per Massachusetts amendments to the IRC (verify with local building department) Design wind speed for risk category 11 structures: 100 mph (3 -see gust) Wind exposure: Category C Our conclusion regarding the adequacy of tile existing roof is based on the fact that the additional weight related to the solar panels is less than 3 pounds per square foot. In the area of the solar panels, no 20 psf live loads will be present. Regarding snow loads, it is our conclusion that since the panels are slippery and dark, effective snow loads will likely be reduced in the areas of the panels. Solar panels will be flush -mounted, parallel to and no more than 6" above the roof surface. Regarding wind loads, we conclude that any additional forces will be negligible due to the low profile of the flush -mounted panel system. It is our conclusion that any additional seismic loadings related to the addition of these solar panels is negligible. During design and installation, particular attention must be paid to the maximum allowable spacing of attachments and the location of solar panels relative to roof edges. The use of solar panel support span tables provided by the manufacturer is allowed only where the building type, site conditions, and solar panel configuration match the description of the span tables. Attachments to existing roof joist or rafters must be staggered so as not to over load any existing structural member. Waterproofing around the roof penetration is the responsibility of others. All work performed must be in accordance with accepted industry -wide methods and applicable safety standards. Vector Structural Engineering assumes no responsibility for improper installation of the solar panels, Please note a representative of Vector Structural Engineering has not physically observed the roof framing. Our conclusions are based upon the site assessment and information provided by Revolusun and the understanding that all structural roof components and other supporting elements are in good condition, free of damage and deterioration, and are sized and spaced as outlined in the site assessment performed by Revolusun. 11 --IN Very truly yours, VECTOR STRUCTURAL ENGINEERING, LLC Roger T. Alworth, P.E. Principal RTA/dJf 09/20/2016 9138 S. State St., Suite 101 / Sandy, UT 84070 / T (801) 990-17751 F (801) 990-17761 www.vectorse.com r 0- 06 z R" z 2?? 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U., z U) z ,SWE-ffit '0 ul z I, Wo 6 o z , 0 mo 0 0 Lu WW < z ,00 0 R20 W- 1 Oz U) Im Q5 < z 6 In 'zD ':91 lw-- Tw wl< zl, 0 u)z 8'd', - I 20w�ogKzw,() CI , 3 j� C) -L', R, -0 :� � w z 0 lul)) OZ SO W, 0 In Z w w 0, 0 Ow<z -z z z T 9 �, w w " 0� o 0, U0 05 z *n Q ZOL J:j 020 , �, 0 Z. 0 niDo W o0 Z zU 5 w :J o<OODAcL>Oj (-3 W C) oi C6 "Ai u. 0 C7 h 7- z CO LLQC? x > 0 a. OZ z Lu 0 a C7 Lu- WZ T 7 "Ai u. 0 C7 h 7- milli imlaimi I Ll co LO cr z TOM 12 H I U�' 'D Z— <..s 0 Z� J �4 v w a- 0 < ui all C( - • • • • as • • ml zt, co 8x ze,o -,E 3, Di 8x ze,o -,E co 0 — N bw Ln CD vi LLJ a) Q- -0 CD 0 CY) u A r0 0 0W W:j I 0 z LD w V Z;? 0 < L W-- zo,< z z U) A r0 0 0W The Commonwealth of Massachusetts Department of IndustrialAccidents Office of -Investigations 1 Congress Street, Suite 100 Boston, MA 02114-20.17 www.naass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl Name (Business/Organization/Individual): Northeast Solar Services Inc. Address: I North Avenue, Suite A Citv/State/ZiD: Burlington, MA 01803 Phone #: (781) 270-6555 Are you an employer? Check the appropriate box: 1. FX -1 I am a employer with 25 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2j:1 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' cornp, insurance comp. insurance.' required.] 5. F] We are a corporation and its 3. [:] I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MG1, insurance required.] f c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required): 6. E] New construction 7. [:] Remodeling 8. [] Demolition 9. F-1 Building addition 10. E] Electrical repairs or additions 11.0 Plumbing repairs or additions 12.® Roof repairs 13.0 Other Solar PV *Any applicant that checks box 41 roust also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 ain an employer flair' is providing workers' compensation insurance for niy employees. Below is the policy and jab site injornuaion. Insurance Company Name:_Federated Mutual Insurance Company Policy I/ or Self' -ins, Lic. fl: 9884086 Expiration Date: 12/31/2016 Job Site Address: 122 Marblehead St. City/State/Zip:North—.1- Andover MA 01845 .. ....... . -- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine LIP 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Itlohereby eei-tifyunder tliepaiiisatidpeiialliesopeijitrythat the iii00inration provided above Is true and correct ,Joseph Vaccaro /Z.. 1z"fe—A Date: 09/24/2016 (781) 270-6555 Official use only. Doitolwrite litililsare(i,lobecotitpletedbyeityortoipiiofficiaL 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 #: '�" CERTIFICATE OF LIABILITY INSURANCE I 11/18120L5 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, EkTEND 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 poticy(les) must he endorsed. if SUBROGATION 19 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder PRODUCER FEDERATED MUTUAL INSURANCE COMPANY ROME OFFICE: P.O. BOX 326 OWATONNA, MN 55060 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 297-673.13 INSVRSR 6: NORTHEAST ELECTRICAL INC INSVRERCI 1 NORTH AVE INSURERD: BURLINGTON, MA 01603 INSURER EI INSURER F: COVERAOES CERTIFICATE NUMBER: 0 REVISLOrf mumtmR: U 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, TEAM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS o.aen IJGOOIrd m silo MIT Yrf Al I TkIf TFRiAA_ PYCLUB16MA y41i.p.vr.,wln.'..a,w.vvvwv v,.,.m•.a...n•1'••�••��••••••�•••••�••�---•••-•--._._____ AND CONDITIONS OF SUCH POLICIES. LIMITS 8HOWN ... MAY HAVE BEEN REDUCED BY PAID CLAIMS, SR 10.11 TYPE OFINSURANCE D UBR POLICY NUMBER OUOY fiFF P011CY EXPLIMITS CC A GINBRALLIABILITY X COMMERCIALDENERALUABILITY CLNM&MADE OCCUR N N 9884084 12/31/2015 12/3112016 EACHOCCORRENCB $1000,OOC D SfiTED 0 IR$100,OOC Mao Exp pm ON person) EXCLUD15C PERSONAL S ADV INJURY OENERALAOOREOATR $2,000,OOC PRODUCTS=COMPIOPA00 $21000100( OEN'LAOOREOATSLIMIT APPLIESPSR: X POUCY nlfik LOC A AUTOMOBILE LIABILITY X AJIY AUTO A 708mED AUTOS BOHEOULTO HIRBDAUTOS RON-OWNED AUTOS N N 9884085 121311201$ 12131!201$ OMBI ED SINOLE LIMIT $1,000,00( BODILY INJURY (Por person) BODILY INx1RYIPere6ddenQ OPB A18A0E Q. A 4X UMBRELLAt1AS RX000 LIAR X OCCUR cLAms-ums N N 9884087 12/31/2015 12131/2016 EACHOCCURR$NCE $2,000,OOC AOORtOATE $2,000,000 DED I 11111TENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITYY.LtR ANYFAOpAIETORIPAATNERIEXECUTIVB OFHOERIMEMem Excumao? (Mandatory 1n NN) Hppia, deserlko Under DESOAIPTION OF OPERATIONS below NIA N 9664088 12131/2015 121311201$ i( fORYLIMITB OETR E.L 4AOHAOCI08NT $1,00O,OOC BI DESEASS•EAEMPLOYEE $11000,000 E.1 DISEASE • POLICY OMIT $1,000,00[ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES lAMuh ACORD 101, Addltonsl Rems*s Schedule, If more space 1/ nQelred) THIS COPY IS NOT TO BE REPRODUCED FOR ISSUANCE OF CERTIFICATES. I City of North Andover 00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 11 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIIED REPRESSNTATiVE 0 1982-2010 ACORD CORPORATION. All ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD reserved b � 0 ra, r sinrnn+ ��� f77�'� §# 6 k' # . kty ■ C) \\ F4 � , ;o cm §2 �c �k� ��■ e�1