HomeMy WebLinkAboutBuilding Permit #849-2016 - 12 FOSS ROAD 2/1/2016 BUILDING PERMIT No Dr"quo TOWN OF NORTH ANDOVER � - 0 APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �Q Q�Rwreo 41V (9 SSACNUSE� Date Issued: 2-1, DIPIPPORTANT:Applicant must complete all items on this page LOCATION )19- r�,s . Print PROPERTY OWNER Cr1c,,5�op4.jr l YA Q��.,�e 100 Year Structure yes no MAP �PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no Print TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑Addition ❑Two or more family ❑ Industrial A Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑r:Sept�c° ❑W"elli ��� ❑'Floodlain0 etlan�dsn ❑ VON-, ❑`1lVate/Sewers _ C _ m� DESCRIPTION OF WORK TO BE PERFORMED: ' \ .4 f , 1 Y w NNS_ Identification- Please Type or Print Clearly OWNER: Name: 4- cc&.Af 6o�, Phone:q-n•u%,,i- -7g9 Address: 12 Cc>5s e-aN, Contractor Name: P,- .,AL. p"v Phongz,i-Lfl2(P-y25% Email:c�c- ����s�, �o �c� Co-'�ac�n;\.corK1 Address: 50 -rn r �v� r�u ���� X)nf�, 0205p Supervisor's Construction License:_jowiLt r) Exp. Date: o\I►9(I% Home Improvement License: i Logi oy Exp. Date: oLpt2-(t o t ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �GGov FEE: $ 2-3� Check No.: �� 1 Receipt No.: �A01!J NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i, y I Location ,2— + No. Date }rJ . - TOWN OF NORTH ANDOVER Certificate of OccupancyTIAN $� _= Building/Frame Permit Fee21, ` Foundation Permit Fee $— % Other Permit Fee TOTAL $ Check# ' t 29974 Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanuing/Massage/Body Art ❑ S` im,-nnig Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS it CONSERVATION Reviewed on Signature COMMENTS h i HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes ;Planning Board Decision: Comments 1-Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ,•, w 5 'F ,9..:2'x: z ., ) a+,• wn: 1k- 'l + . PR ,FIRE DEPARTMENT `Temp Dumpsterzon4syiite�xaybes��,_�,si" 7 Located at 124 Main Street. „ ,��� `�dRj 'tR {�,k , . ' r ,s+�r a. +ate�T t r+ i�J"fk"r, h ;Fire Department sign turQe/date� � a ';� x , x , } , t � �} l�x�; if ��=r3; f��`� � i�t..$ �a �i'fi4 .�«.. x.' ` '3tY�at�l��'y,� ,t�l'.�:..5lv.w�irL47�� jy t`^�#t• � Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. j j Total land area, sq. ft.: ELECTRICAL,: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— (For department use) I i i I I I ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 _ - ----- r Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 4. Building Permit Application 4. Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses 4, Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building PP Permit Application Certified Surveyed Plot Plan iL Workers Comp Affidavit � Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract 4� Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 r 1 N�RTM : :. .( . -. ver Q •..,- 'y`• ~" X11 No. _ 6 * "T IIt t2a o h , ver, Mass, COCNICM{WICK U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR ..... ... ...... .. . ..... ... .....L �!�11 .......................... . Foundation �. Q ..:. . .. has permission to erect .......................... buildings on ............. .......... .... ......................... Rough to be occupied as Chimney p ........�. ............ .... � ... i !�i ............ ...�..r'. ................ y provided that the person accepting this permit shall in every respect conform to the erms 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES INj6 NT ELECTRICAL INSPECTOR UNLESS CONSTRUCT Rough Service ............. ...... '........................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. 21 Drydock Avenue, 2"" floor next step Livi 1g TM Boston, MA 02210-2384 home energy solutions 866-867-8729 NextStepLiving.com August 20, 2015 Town of North Andover Building Department 1600 Osgood Street Building 20,Suite 2035 North Andover,MA 01845 RE:Christopher Bowe Residence Solar Panel Installation 12 Foss Road North Andover,MA 01845 Structural Assessment of Roof Framing NSL Project No: SP252090 Dear Sirs, Next Step Living, Inc. has performed a limited structural evaluation of the roof framing at the above referenced site to determine if the roof has adequate capacity to support proposed solar PV panels.This analysis has been based on field measurements,framing information and configurations observed at the proposed site. The existing residence is located at 12 Foss Road,North Andover,MA 01845. Structural Data and Code Information Our analysis was performed in accordance with the requirements of the MA Residential Building Code 780 CMR--Eighth Edition.The main roof of this residence is framed with conventional roof rafters with i some collar ties in a gable configuration.The existing roof structure is in good condition and currently has one layer of asphalt shingles as roof covering. The pertinent data is listed below: Main Roof Rafters:l%z"x 7 Y"(#2 Spruce Pine Fir,Hem Fir, D.Fir Larch Assumed) Rafter Spacing:16"on center Roof Slope: 30 Degrees Horizontal Projected Length of Rafter:14.83 feet Ceiling Joists:Present Collar Ties: Present every third rafter Roof Sheathing:Plywood sheathing Roof Covering: Asphalt shingles Condition of Framing: Good Ground Snow Load,Pg:50 PSF from Table R301.2(5) Importance Factor,I: 1.0 Exposure Factor,Ce: 1.0(Partially Exposed) Christopher Bowe Residence Solar Panel Installation 12 Foss Road North Andover, MA 01845 Page 2 Thermal Factor Ct: 1.0 Existing condition(Warm Roof) 1.1 With panels(Cold Roof) Design Snow Loads: 35 PSF(Existing—Unobstructed Warm Roof) 25.68 PSF(New Condition—Slippery Surface on Cold Roof) Basic Wind Speed: 100 MPH from Table R301.2(4) Importance Factor: 1.0 Exposure: B Analysis Results General The proposed solar panels impose a total weight of approximately 3 pounds per square foot(PSF)on the roof surface.The International Residential Building Code allows up to two(2) roof coverings on a residential dwelling. Each roofing layer of asphalt shingles imposes a dead load of 2.5 to 3.0(PSF)on the roof.Because the existing roof has only one layer of shingles,the code allows a second layer to be added without analysis.The weight of the second layer of shingles is approximately the same as the solar panels which will be installed instead of the second layer of shingles. Solar panels are considered a slippery surface and are mounted a small distance above the existing roof. Therefore,one would be cautious in considering a thermal factor,Ct,of 1.1,treating the panel surface as a cold roof, rather than a warm roof.After considering the roof slope factor,Cs,from figure 7-2,ASCE 7-10,the snow load is reduced by 27%for the main roof compared with the snow loading on the existing shingled roof,which is not considered a slippery surface.The reduction in snow load due to this consideration is about 9.32 PSF for the main roof,which essentially offsets the weight of the solar panels. Gravity Loading: Although the addition of solar panels results in a net reduction in the overall loading,the existing rafters are overstressed.As such,we recommend that a 2 x 6 collar tie be added at every set of rafters.The collar ties should be at least eight(8)feet long,cut flush to the roof sheathing,and shall be fastened to each existing rafter with a minimum of 6—16d nails OR 6 Ledger Lock screws as manufactured by Fasten Master. I The panels will be installed using Unirac Solar Mount rails with L-brackets in either a landscape or portrait configuration with a rail toward the top and bottom of each panel edge.The L-brackets will be fastened directly to the roof rafters with 5/16"diameter lag screws.The fastener layout shall start near each corner and for landscape orientation shall have a maximum spacing of 36"on center parallel to the roof slope and 32"on center perpendicular to the slope (e.g.,every other rafter), or for portrait orientation shall have a maximum spacing of 54"on center parallel to the roof slope and 32"on center perpendicular to the slope(e.g.,every other rafter). Christopher Bowe Residence Solar Panel Installation 12 Foss Road North Andover,MA 01845 Page 3 Each 5/16 diameter lag screw shall have a minimum of 3 thread penetration into the existing rafter. It is also important that the L-bracket attachment locations be staggered between adjacent rails so that no single rafter supports more load than under the existing conditions. Wind Loading: Provided the leveling feet attachments to the roof are made in a typical staggered pattern,the overall wind loading imposed on the structure will not be impacted to any great extent.The net wind loads imposed on the roof framing will be less than the current loading with an attachment spacing described above. Conclusions: Our evaluation of the proposed solar-electric installation has established that the framing is NOT adequate to support the addition of the solar panels to the existing roof as indicated on the Solar PV plans without strengthening the structure as previously discussed herein.Once the roof framing is reinforced,it will be adequate to support the solar panels.We have only reviewed the adequacy of the connection to the existing rafters and the capacity of the existing rafters to support the vertical and lateral loads from the solar electric system.We do not take responsibility for any other portion of the solar panel array support system,the existing roof framing construction,or the integrity of the structure as a whole. Do not hesitate to contact my office at 866-867-8729 should you have any questions or if you require any additional information. Respectfully, Next Step Living, Inc. .Ms• Dean A. o er,P.E. MA Prof. Eng. License#50405 21 Drydock Avenue, 2nd floor za g-rmBoston, MA 02210-2384 home energy solutions 866-862-8729 NextStepUving.com January 19, 2016 To Whom This May Concern, With this letter, I Joseph Wyld-Chirico (CSL93115, HIC 162111) am notifying the Town of North Andover of our retraction as contractor and electrician for the rooftop PV Solar Installation located at 12 Foss Rd. This project has been reassigned to Certified Safe Electric, and they will be acting as contractor and electrician for the remainder of this project. Kind Regards,, 9 , Jose Wyld-Chirico CSL 93115 1 J DocuSign Envelope ID:C295CA79-EDC3-4204-9D23-F021864232CD Attn: Town of North Andover, With this letter, I Chris/Laura Bowe of 12 Foss Rd., formally authorize Certified Safe Electric and Bruce Davis CL 104740 to act as agent and installer on my behalf and may apply for all permits pertaining to my NRG Solar System. I recognize that Certified Safe Electric is a sub- contractor of NRG Home Solar DocuSigned by: DocuSigned by: f,&YiS aaAJ (AWOL bbWf- Customer Signature Bruce Davis ELECTRICAL DESIGN W PV MODULE RATINGS 0 STC SOURCE COMBINER RATINGS INVERTER RATINGS O Ln Temperatures INVERTER MODEL:EnphaseMicroinverter00 m MODULE MANUFACTURER: Trina Average High:28°C MAX OCPD RATING(A):20 MODEL:M215-60-2LL-S22-IG W D 0 MODULE MODEL#:TSM-260PA05.08 Record Low:-28.9"C OCPD AMPERAGE RATING(A):20 MAX DC VOLT RATING(V):45 x a OPEN-CIRCUIT VOLTAGE(Voc): 38.2OCPD VOLTAGE RATING(V):240 MAX POWER @ 40°C(W):225 d O a OPERATING VOLTAGE(Vmp): 30.6 NOMINAL AC VOLTAGE(V):240 , O W in NOMINAL AC CURRENT(A):0.9A CD OPERATING CURRENT(Imp): 8.50 2 x#10 THWN-2 Wire BLACK MAX BRANCH AC CURRENT(A):9.9A/6.3A9 W Pr SHORT-CIRCUIT CURRENT(Isc):9.00 2 x#10 THWN-2 Wire RED MAX BRANCH OCPD CURRENT(A):20A W 0 > w MAXIMUM POWER(W):260 x u. O m 2 x#10 THWN-2 WHITE Voc TEMP COEFF(%/°C)=-0.32%/°C U N a ib � L2 Isc TEMP COEFF %/°C--0.05°/D/°C 1 x#6 THWN-2 EGC 20A1 PV LOAD Z ( ) 1"EMT INDOORS CENTER y a Qr 7 WIRES t--------------------------- ------------------------ (PVLC) E v) x .. r i C N C 0 O End-Fed Branch of 11-M215 Inverters a z a -1f or 11 panels co--d p AOc9c1nbr h Maximum aup .—It 1111<n10.9A rma petpenel TSM-260 TSM-2fi0 TSM-260 TS M-260 D PA05.08 D.. PA05.OB ° PA05.08 D PA05.08 • • — box 15A Q En�apa Enpiaso Eny.ase Enyuse i - L }, -2155 -2156 -2+56 •2155 ' 2LL 2LL 3LL ---- /U End-Fed Branch of 7-M215 Inverters •> CIO — T-1.17 p..1 t.a AO uBLranch TSM-260 Maximum°up ut laul tncu«ent 0.9A rma perpanel TSM-26D TSM-260 TSM-260 D PAOS.OB D PA05.OB ° PA05.OB Fu� PA05.00 /I� \r/ Enpiaao En,has Ehlhasa Eh{hose LGele _` -2i56 •21S° -3155 M-2+56 �7D fa) •- 2LL ...............................................................2LL .......-............. 2LL ...-................. 2LL ..-................� ' _1_/ L UTILITY (!,I ) ^, CU AC DISCO METER V/ INSIDE MOL NOTE:A GEC(grounding electrode Conductor)is AC DISCO FUSIBLE X i required only for M215-60-2LL.It is not required :COMMUNICATIONS OUTSIDE 60A RATING O for M215-60-2LL-IG GATEWAY NON-FUSIBLE 25A FUSES Z 30A RATING GF222N GNF321R iL " ETHERNE CONNECTION TO 1 x#10 THWN-2 Wire BLACK BROADBAND ROUTER 120 VAC POWER CABLE 1 x#10 THWN-2 Wire RED Symbol Conventions: 1 x#10 THWN-2 Wire WHITE zou ) •, 1 x#6 THWN-2 EGC 2-Pole Licensed Electrician Assumes All Responsibility For 1"EMT INDOORS 20 OA Circuit Breaker Determining Onsite Conditions and Executing 4 WIRES MSP Installation In Accordance with NEC 2014 Codes Otis Fuse w oho Visible Break CONDUIT SIZING SERVICE PANEL RATINGS Knife Switch AC DISCONNECT RATINGS i D/p 1"PVC OUTDOOR MEP BRAND:GOULD DISCONNECT AMP RATING(A):60 1"EMT INDOOR BUS AMP RATING(A):200 DISCONNECT VOLT RATING(V):240 SERVICE VOLTAGE(V):240 __________________ Equipment NEMA 3R MAIN AMP RATING(A):200 c) Groundng BREAKER RATING(A):25 Conductor v 4 MODULE DATA DETAILS THE Universal MODULE TSM-PA05.08 W 3 gar r MIMAZ m in : � i : d>Ta oho 941 W .wt O w o0i -`� r' s„�pwre srtrxra arotix�ga tic(v$ sJ.df4 rt ;31 2d r fn 00 qp F.: _ LL O i0 8. ieef`ietcrxy ems 1e.6 i:..l r 3Y'�•�:a W1 w~,-7—Slany—Y W',atr l Z � 3�er.,3+weartw.,+-y'.•+ru�wn nz x rz:ro�ars� -gym•rv-.+.un"sp.esus ngtra�r O Q � N A6Yau xu3�to-Vr i'Srawb 1wph 102 1W i 1" 310 Vl M 1 ielaarie�� e,+w'Sr +�i''1 --: £ s3.FA .: e V Q Z d .— \V !ami clivuii Cullmd-=it+.l Y�Y f.TLi PAY XV r} �atx•r•rr.n<sn�,.�we-e ic�a�+..�R,a,a..nr r.�.q�.µo�.� ^,ys-r-.wmn c�.�n i� /� O � ,.vro�.r $aunr e'3?t6 MSr#f�e"9'yIlF1YFNrtt� �n t+'vwe¢rrrr[. irncine��j IR ,,'"Yers �l:'&krii tSt[•+tesx+tF \\".,. c ir4o..3rited eociuTaru is"o."44 4A.c 'Ca mm€&�ir,e+ '7Ct.»3 3;Y .e essy / Q (� lof{t (a s mnx iA13 iePwt,3.HT Ttotuaar[twn,.3KF. :«o9mei T^auxipirtv3 CTptx a� sY�.acyON tesxr .. 4-0 ea+crr�w 3iiRCk A69v+rliRtf9 mkaruaicst�nrer p ca : rGs �i`is«t�Y�sc�a6asv^�tsGE a..iSeeim t�-F�YE itscc3sev F 3�litbl"1&kV,1 tvl i-:ti:t9..�` �`a e' .`�`.` r4aa,3LFEda „ «. ���\ \\��� 14trd•i5Ya4.33'U t�i � ```�\\\ \\�\ �.... \�� 7eR"' Z O fl9d1!' i MIRf3ie`�'36}it 3(tiLf3YFilT�3 Aldi YCt tyP,n` 3?t?+'<31!`Y ha�is:r+�¢ 4v«r�rr,.co�.era�R�o"esrmraC} ,ate ase �.vv�vc �.. v \; #s'r- .. - �arsti^erar rw811ritsey�w � nY i7§K7'"t €`'Reascte[a;rrou�^tm®ramsrr ills ;1 Oparaiicxeaid Terraiamt�ateita�-#0-•+:1T5"� :. t3S F to ROt,-tg 1.5A E 4 T'R€.MAra:.iTkC,<"��:.d TBS w a AYQP.�39%6e4fhY: 'i7T TZ9PL^R.K ARRAY DESIGN / SITE DIAGRAM HEIGHT OF HOUSE PANEL ORIENTATION (TRUE) ROOF PITCH (DEGREES) 225" 213* 30* w Quick Mount PV Solar Flashings FOSS ROAD o will be used on every roof penetrationX39.05°� 00 DRIVEWAY00r. 0 C5 *`*ARRAY LAYOUT IS NOT TO SCALE'** a 0 a to OW �m UTILITY METER \a, co PLACE PV LOAD CENTER OUTSIDE TO THE LEFT OF THE ��� " a: o > 00 LGATE120 \` U N 0 00 UTILITY METER, THE CUSTOMER IS RESPONSIBLE FOR MOVING OBSTRUCTIONS T FROM LOAD CENTER � � AC DISCONNECT Ew LOCATION; PLACE ENVOY MONITORING EQUIPMENT TO C d °1 THE RIGHT OF THE MAIN ELECTRICAL PANEL PROPOSED CONDUIT THROUGH IL) Z a ATTIC,DOWN EXTERIOR TO S PVLC.;ELECTRICIAN WILL FIELD PIPE TO BE RELOCATED VERIFY (U O QUICKMOUNT PV 'CU 34-8 (416 ) PORTRAIT/LANDSCAPE '> •C Total's -� U) 12"TYP. Total#of Panels: 18 C Total#of Splice Bars: 8 }, J 0 t Total#of Bonding Jumpers: 8 (n 12"TYP. \\ \ Total#End Clamps: 14 X %M o O\ . \ \\ \ a \ Total#of Mid-Clamps: 36 See Engineer's Structural Assessment � O _ca \� N 1 14 +1-11' \\ \ \\ \ W 1010\00,14 \ O 1a +1WINDvvvo��Ov 717 E �s Customer Signature: Date: TYPICAL ATTACHMENT DETAILS -r1 �:EDGE TOWARDS RM RIDGE_ RACKING COWIG NENTS IiE � "NOT INCLUDEDESD 40 S ) 0.,CCK,CLASSIC,AX.I Ck AL.MILL 1 PLUG: E�tfPJ , > v'. .� ` E` _tri S I !l - t 4 ;AG;SCREW,HD;EEXD,�5JI X 10 184 S, 1 3 4'+' H=R, LdDR, CI :K1•I " 315 2 111 Ewg....,.....v.....4:JV......... capacitiesLag pull-out(withdrawal) Lag Beit Specifications Specific Gravity 51W shaft per 3"thread depth 5116"shaft per 1"thread depth i Douglas Fir, Larch M 798 266 Douglas Fir,South .46 705 235 Engelman:-a Spruce,Lodgepafe Pine(A SR 1650 f&higher) AB 705 235 Hem F r X13 6636 212 I Hem, Fir(No4h .46 705 235 � Southern Pure 55 921 307 Spruce Pine,Fir 42 615 205 Spruee,Pine,Fk(E cf 2 million psi and Nghersgrades of MSIR and MEL) .50 798 266 Next Step Living Inc. ORT ENGINEERING � Quick Mount REPORT �N��cl-��ll" ,- �� � �� � living,.,. Module and Roof QMSE-LAG:QMPV E-MOUNT r�, WITH LAG BOLT home energy sotutions Attachment Detail DocuSign Envelope ID:7239A81C-709E-4CA5-8E9D-OFDC975083D8 The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,3JM 02114-2017 www.mass.aov1dia AVorliers'Compensation Insurance Affidavit:Builders/Coiitractors/Electricini3sTiumbers, TO BE FILED WITIT THE PER.NIITMN- G AUTHORITY. Applicant Information Please Print Lepqbl Name tBusL?iess/Or.aaniz,,tiom'Individiwd):. Address: tl Nok. AM -��� hone#:- Are you an employer?Check the appropriate box. Type of project(required): I I,W I am a employer with�eraployees(full andlor part-dme,. 7. El New construction 2,F-1 1 am a sole proprietor or partnership and have no employees;working for me in 8. �Remodeling any capacity.[No workers'comp,irtsurancL required.] No worsens'eo,,�mer doing all work myself C ke!;'comp..insurance required;]t Demt 3,7 1 am a hom' 9, f olition 4,17 1 am a homeowner ox-1 will be hiring contractors to conduct all work on my property. I will 10 7 Building addition ensure that all conna�;either have workers'compensation insurance or are sole 1.152 Electrical repairs or additions proprietors with no employees. 12,�]Plumbing repairs or additions 5,17 1 am a general contractor and I have hired the sub-contracton listed on the attached sheet. These sub-contractors have employees and haveworken'comp,insurance.3 13.E]Roof repairs 6,17 We are a corporation and its officen,have exercised their right of exemption per1MGl,c. 14 []Oth-ei 152,§1(4),and we have no employees.[No workers'comp,immr%ice required..', Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information ffomeownms who submit this afflidavit indicating they are doing all work and then hire onside contractors m=submit a nonx affidayrit indicating such, *Cont; that check this box must attached an additional sheet showing the name at the sub-contractors;mid state whether or not'those entities have employees.. If the sub-contractors have employees,they must provide their workers'camp,policy number. ............. lam an employer that isprovidin,,-workers'compensation insurance for my employees. Below is the policy and job site information, -1 ' Insurance Company Niaine: "IllcC.—ge Policy#or Self-ins.Lic. -UL4: Expiration Date:�-L' , 0-1 LX A L Job Site Address:_ t V:ans Attach a COPY of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure Coverage as required unckrMG1,c, 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofla STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certg�under the pains and penalties of perjury that the information provided above is true and correct �uSigned by: Sismature: Eb— Date: Z)I- 0L2.-J.L-,* hone 4: 02 2 'iA Official use only. Do not write in this area,to be completed by city or town offieial. City or Town: Permit,"License 4 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector G.Other Contact Person._._ 'Phone AC40REP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 7/15/2015 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, EXTEND 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Darlene Mulcahy y Malcolm & Parsons Insurance Agency IPOExt: (781)344-3200 NC No:(781)344-1425 713 Washington Street AD RIESS: P.O. Box 527 INSURERS AFFORDING COVERAGE NAIC# Stoughton MA 02072 INSURERANorthland Insurance Company INSURED INSURERB:Sentinel Insurance Company Ltd 39098 Certified Safe Electric, Inc. INSURERCNautilus Insurance Company 50 Tower Avenue INSURER D:CNA Surety INSURER E: Marshfield MA 02050-5131 INSURERF: COVERAGES CERTIFICATE NUMBER:CL157602635 REVISION NUMBER: 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, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TY OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDYEFF/YYYY MWDDY EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ x ISO Form CG0001 TBI 7/15/2015 7/15/2016 MED EXP(Any one person) $ 5,000 X Contractual Liab PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY FI JEPRCT O ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: General Aggregate $ 5,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS X AUTOS OBUECZJ6251 3/7/2015 3/7/2016 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident) ccident $ x ISOCA0001 PIP-Basic $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 C X EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 2,000,000 DED I I RETENTION$ TBI 7/15/2015 7/15/2016 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE OERH ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If Yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D FIDELITY— EE DISHONESTY 62447764 7/1/2015 7/1/2016 $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION certifiedsafeoffice@gmail. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Amne Parsons/DARL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I N S02519014nt i ACOR�►OD DATE(MMIDD/YYYY) ��. CERTIFICATE OF LIABILITY INSURANCE 01/14/2016 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, EXTEND 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Darlene Mulcahy MALCOLM & PARSONS INSURANCE AGENCY INC PHONE Ext),. (781)344-3200 FAX No: E-MAIL C P ADDRESS: dm@rnalcolmandparsons.com ' 6 FREEMAN ST. INSURER(S)AFFORDING COVERAGE NAIC# STOUGHTON MA 02072 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: CERTIFIED SAFE ELECTRIC INC INSURER C: INSURER D: 50 TOWER AVENUE INSURER E: MARSHFIELD MA 02050 INSURER F: COVERAGES CERTIFICATE NUMBER: 24268 REVISION NUMBER: 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, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDTYPE OF INSURANCE INSD WVDSUBR POLICY NUMBER MMIDD/YYYY MPOLICY EFF M LICY EXP LTR /DDIYYYY LIMITS ' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO CLAIMS-MADE 1:1 OCCUR PREMISES (E.occurrence) $ ! MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY� PRO ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED Pe accident)DAMAGE $ HIREDAUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ ' DED RETENTION$ $ WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY X STATUTE ERH YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? I NIA1 N/A N/A 7PJUBOG17773815 08/01/2015 08/01/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEEI $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 Os B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St Bldg 20 STE 2035 AUTHORIZED REPRESENTATIVE North Andover MA 01845 Daniel M.CrcW y,CPCU,Vice President—Residual Market—WCRIBMA i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts ct l sp rtment 6t Public Safety Board of Building Regulations and Standards License: CS4O4740 r � BRUCE A DAVIS 50 TSR AVENUE.. / MARswIELD DAA 02*, Exvj rat Crar�rxt=sslr��er 01!'t$12018 �' � e/ ,• ///fir` .��'1 ��/r�/ i �r/&rrrP wo Qr Fw y� T AS AM- 7;71n '7Y °� ... 0/1,/r,;,. _ ¢ sv� � '. ......... ......................«.w+....,..."'+Mn 'a.., ,.,.......,w,w r .�..,.«.v...m,wii»w. U. ✓ ✓ ...a,..r.� ,.,,,i,.....,,.,,,.�,.,...........,,..w :.1 + -tr�r ysrr rrrrar XrJ rYLf rz zrn�rr r � 3 License or registration valid for individul use anty =,.C3ffict of Consumer Affairs&Business RtguIR008 before the expiration date. if found return to: ME IMPROVERAENT CONTRACTOR Office of Consumer Affairs and Business.Regulation i isiratlan t`6fl144 Tye' 10 Park Pima-Suite 5170 xplmdon 625616 Private Corporatio Boston,MA 02116 CERTIFIED SAFE ELECTDkTC .INC. i 5.. BRUCE DAVIS 50 TOWER AVE �''.��-.-., _,�,�---. ` dYY� J MARSHFIELD,AAA 02050 Undersecretary Nat valid vvithaui signature I