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Building Permit #549-15 - 123 FRENCH FARM ROAD 12/15/2014
TOVVN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION " Date Received Permit N0: Date Issued: U, IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER �a - D1 "� I Print 100 Year Old Structure yes no MAP NO: PARCEI-15 - ZONING DISTRICT: Historic District yes no Machine Shop Village yes o TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition [I Two or more family El Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) A2t-Lk� OWNER: Name: fJJQQlY1Q ��. iU"a o Phone: CXU Address: CONTRACTOR Name: .� C� 12's fn Phone: `7' 1) 3LQ Address: �� - T ��' �� Supervisor's Construction License: Exp. Date: nl Zhl 1 La Home Improvement License: VI Ui4��� Exp. Date: ARCHITECT/ENGINEER Phone: AddTess�- - - - Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. g-*'u2-00{@'.al4g18.0o FEE: $ �� Total Project Cost: $ a9 0-50 ZO ---- Check No.: �J ( Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu ranty fund Signature of Agerit/Owner o 1; Igilature of contractor Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location�'�� `"�-�•r.�� � i�/� No. Date .'- TOWN OF NORTH ANDOVER • � �2t4,r)r���' • _ � A Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# (;>5 � Building Ins p or - . - Plans Submitted ❑ Plans Waived-❑ ...-_.Certified Plot Plan ❑ Stamped Plans ❑ TYPE-01:SEWERNGEDISROSAL Public Sewer ❑ Tanning/MassageBody Art ❑. . Swimming Pools ❑ Well ❑ . Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,ete:_ ❑ = Permanent Dumpster on Site ❑ THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM "DATE REJECTED DATE:A_PPR.OVED PLANNING'& DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature . COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection lSic(nature Date Driveway Permit DPW Tow's. Engineer: Signature: Located 384 Osgood Street 'FIRE-DEPARTMENT =Temp Dumpster on site yes no Located-at-124 Mair Street -Fire Departine►ifisignature/date`" COMMENTS . -Dimension- Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area; sq. ft.: ELECTRICAL: Movement of Meter Iocatton, 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.$100-$1000 fine NOTES and DATA— For department use ® Notified for pickup - Date i Doc.Building Permit Revised 2010 Building Department The fohowing is'a list of the'required forms to be filled out-for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit LiPhoto Copy Of H.I.C. And/O'rC:S:L Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building pp 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 ❑ Mass check Energy Compliance Report _ ❑ Engineering Affidavits for Engineered products NOTE: 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 apo•,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subwted with the building application Doc: Doc.Building Permit Revised 2012 F NoK rM Town of t ndover _ 0 ?,, h ver, Mass, coc KIc"t WICK S U BOARD OF HEALTH Food/Kitchen PERMIT T L D,,f Septic System THIS CERTIFIES THAT .......'D. .. eA"�.'-d- ... . ..0.............................. BUILDING INSPECTOR ulb'.3 �� .` Foundation has permission to erect .......................... buildings on ... ....... ....................... ..... ....l.✓..�.... ........ • Rough to be occupied as .....C .......KIP.......!,,. .�. r. ... rt..... � . .......................... Chimney in v respect conform to the term f thea plication provided that the person accepting this permit shall eery p pp 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 MON S ELECTRICAL INSPECTOR • UNLESS CONSTRUCT RTS 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. ,eco CERTIFICATE OF LIABILITY INSURANCE DATE 10131//20142014 /YYYY) 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(les)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 MARSH USA INC. NAME: 122517TH STREET,SUITE 1300 A/C.N xt : FAX No): DENVER,CO 80202-5534 ADDRESS: Attn:Denver.certrequest@marsh.com,Fax:212.948.4381 INSURERS AFFORDING COVERAGE NAIC# 462738-STND-GAWUE-14-15 INSURER A:Evanston Insurance Company 35378 INSURED Vivint Solar,Inc: INSURER B:Zurich American Insurance Company 16535 ViAmerican Zurich Insurance Company vint Solar Developer LLC INSURER C: P Y 40142 3301 North Thanksgiving Way INSURER D: Suite 500 Lehi,UT 84043 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002368004-08 REVISION NUMBER:1 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 TYPE OF INSURANCE A DL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MMIDDIYYYY LIMITS A GENERAL LIABILITY 14PKGWE00274 11101/2014 11/01/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO Rl!RTEff___ X COMMERCIAL GENERAL LIABILITY 50,000 PREMISES Ea occurrence) $ CLAIMS-MADE M OCCUR MED EXP(Any one person) $ 5,000 X $5,01( Ded.BI&PD PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC $ B AUTOMOBILE LIABILITY BAP509601500 11/01/2014 11/0112015 (CEO,accident $MBINED SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED d P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ NON-OWNED PROPERTY Yt $DAMAGE X HIREDAUTOS X AUTOS $ A UMBRELLA LIAB X OCCUR 14EFXWE00088 11/0112014 11101/2015 EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTION$ $ C WORKERS COMPENSATION WC509601300 11101/2014 11/0112015X vOC STATU- orH- AND EMPLOYERS'LIABILITYLIMIT B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC509601400 11101/2014 11/01/2015 1,000,000 OFFICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yyes describe under 1,000,000 DESGtRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Errors&Omissions& 14PKGWE00274 11101/2014 1110112015 LIMIT 1,000,000 Contractors Pollution DEDUCTIBLE 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) The Certificate Holder and others as defined in the written agreement are included as additional insured where required by written contract with respect to General Liability.This insurance is primary and non- contributory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract.Waiver of subrogation is applicable where required by written contract with respect to General Liability and Workers Compensation. CERTIFICATE HOLDER CANCELLATION Town of Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 36 Bartlett Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Andover,MA 01810 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M.Parsloe -rYr&lGa�xhf. fQt¢lsG @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 4931 North 300 West,Provo,UT 84604 Employer Identification No.: 80-0756438 r ��• O a r A M Phone:(877)404-4129 Fax:(801)765-5758 Massachusetts HIC License No.: 170848 E-Mail: suppocom ntsolar.com � www.vivint5olar.ar.com AR No.: Ntt/SL—� RESIDENTIAL POWER PURCHASE AGREEMENT This RESIDENTIAL POWER PURCHASE AGREEMENT(this"Agrermmnd')is entered into b�and between VNINT SOLAR DEVELOPER LLC;a Delaware limited liability tympany("We","Us","Our")and the undersigned Customer(s)("Yoe', 'Your),as of the Transaction Date set forth below. Full Name(F;rar,AfI cmrl Full Name(Fiw.ea,tmq "�'—.— Customer(s): P,-P"—.-)9 °"� 4 Fro Omnis:C1 Yer a No Telephone No.: — E-Mail: Property Street Address: --mnwr- Address: City,County,State,Zip: Vg k 01,0()eje– {1'1 r, 60 I" 1.SERVICES A. DESIGN AND INSTALLATION. We will design install,service and maintain a solar photovoltaic system on Your Property'which will include all solar panels inverters,meters and other components(collectively,the"System"))as further described in the Customer Packet and the Work Order that We will provide to You hereafter. All material portions of the System will be instal�ed by Our employed technicians and electrician and not subcontractors With Your cooperation,We will(i)design install and connect the System in material compliance with all applicable laws; ti)complete all'required inspections;and(iii)obtain all required certifications and permits. In order to design a System that meets Your needs,You agree at We may obtain-Your electrical usage history from Your electric utility(the"UWiN and You shall pprovide Us wi copies of Your Utility bills as We may reasonably request. Other than tbe activahon fee described in Section l.B.We willl esign and iastalIthe Systemlu&o cost to You. B. ACTIVATION. You agree to pay Us a one time activation fee in the amount of 5 . We will interconnect the System with the Utility,and cause the System to generate en measured in kilowatt hours(rcWh" (the"Erieinstallation of the System generally takes one day and is anticipated to begin and be substantr ly complete between two(2)and six(6;weeks It C. OWNERSHIP OF SYSTEM. We shall own the System as Our sole personal property. You will have no property interest in the System D. OPERATIONS AND MAINTENANCE. We will=and maintain the System(i)at Our sole cost and expense;(ii)in good condition;and(iii)m material compliance with all applicable laws and permits and the Utility's requirements. E. INSURANCE. We carry commercial general liability insurance,workers'compensation insurance,and property insurance on the System For more information concerning Our insurance,and to obtain a copy of Our certificate of insurance,please visit: www.vivintsolar.com/msurance. 2.TERM PRICE PAYMENTS AND FINANCIAL DISCLOSURES A. ENERGY PRICE. For all Energy produced by the System,You s y $ .j -per kWh(the"Erie Price'),plus applicable taxes.. The Energy Price shall increase each year by two and nino-tenths t(2.9 0. d estunate of the System ou�put measured in kilowan howl will be provided to You in the Customer Packet THIS AGREEM IS FOR S LE OF ENERGY BY US TO YOU AND NOT FOR THE SALE OF A SOLAR ENERGY DEVICE. B. TERM. This Agreement shall be effective as of the Transaction and continue until the twentieth(20mm')anniversary of the In-Service Date( the "Tam). The"ln Srrvlu Dare"shall be the first day atter all of the following have been achieved: (i)the System has been installed and is cable of geneiahng Energy,{ii)all permits necessary to operate the System have been obtained,(iii)the System has been interconnected with the Utility,and(iv)all inspections and certificates required under applicable law or by the Utility have been completed or received. C. PAYMENTS. Be¢itming with the first month following the In-Service Date and throughout the Term,We will send You an invoice reflecting the charges for Energy prroodduced by the System in the previous month. You shall make monthly payments to Us by automatic ppayment deduction from Your designated checkmp,account or credit card. It is Your responsibility to ensure that there are adequate funds or adequate credit limit There is no financia charge associated with this Agreemen (U paents more than ten(10)days past due,We may impose a late charge equal to Twee Five Dollars($2 and interest at an annual rate often t 1000 lus applivable taxes. If You continue to fail to make any payment within ten(IOJdays after We give You written notice,then We may exercise all remedies available to Us pursuant to Section 13(bl. D. RENEWAL. At the end of the Term,You may elect to(i)continue with this Agreement on a year-to-year basis;(ii)enter into a new Agreement with Us and cancel this Agreement;(iii)purchase the System at a end of the Term and cancel this Agreement(the"Purchase Optfon")- Agreementor(tv)cancel this and have the System removed at no cost to You. You will need to notify Us in writing conceming Your election sixty(60)days prior to the end of the Terra. If You elect the Purchase Option,the"Purchase Option Pr(ee'will be the thee current fav market value of the System based on an independent appraiser's valuation of similarly sized photovoltaic systema m Your geographic region. The appraiser s valuation will be provided to You in wndng and will be binding. If We receive Your payment of the Purchase Option Price costs of the appraisal,applicable taxes,and all other amounts then owing and unpaid hereunder,We will trayynsssfer ownership ofrtohpeerStyystem to Youtyat the)endyosf the Term on an"As Is,Where Is"basis. If You elect to have the O R ELECTION T01 CANvCEL S13Yt SENDING APWRITTEN NOTIC��1`O U�,a THENeeTHIS AGREEMENT WI�LLNAVI'OMOTA CALLY RENEW ON A YEAR-TO-YEAR BASIS UNTIL YOU NOTIFY US IN WRITING OF YOUR ELECTION TO CANCEL AT LEAST SIXTY(60) DAYS PRIOR TO THE END OF THE RENEWAL TERM. E. CREDIT CHECK. In connection with the execution of this Agreement and at any time during the Term,You hereby authorize Us to(i)obtain Your credit rating and report from credit reporting aggencies;(ii)to report Your payment performance under this Agreement to credit reporting agencies;and (iii)disclose this and other information to Out affiliates and actual or prospective lenders,financing parties,investors,insurers,And acquirers. WE MAY HAVE PRESCREENED YOUR CREDIT. PRESCREENING OF CREDIT DOES NOT IMPACT YOUR CREDIT SCORE. YOU CAN CHOOSE TO STOP RECEIVING"PRESCREENED"OFFERS OF CREDIT FROM US AND OTHER COMPANIES BY CALLING TOLL-FREE (888) 567-8688. SEE PRESCREEN & OPT-OUT NOTICE(SECTION 29)BELOW FOR MORE INFORMATION ABOUT PRESCREENED OFFERS r3.LIMITED WARRANTY A. LIMITED INSTALLATION WARRANTY. We provide a workmanship warranty that the System shall be free from material defects in desist and workmanship under normal operating conditions for the Tenn. We further warrant that ali rooftop penetrations We install shall be watertight as of the date of installation. We do not provide any warranty to You with respect to any component of the System. Any manufacturer's warranty is in addition to,not in lieu of, this limited installation warranty. This warranty does not cover problems resulting from exposure to harmful materials and chemicals,fire,flood, earthquake,or other acts of god,vandalism,alteration of system by anyone not authorized by Us,or any other cause beyond Our control. B. MANUFACTURERS'WARRANTIES. The System's solar modules carry a minimum manufacturer's warranty of twenty(20 years as follows: �a during the first ten(10) ears of use,the modules'electrical output will not degrade by more than ten percent(I o%)from the ongiaall'y rated output;and b�during the first twenty20)years of use,the modules'electrical output will not degrade by more than twenty percent(20%)from the on yy rated otrtput. The System's inverters carry a minimum manufacturer's warratrty often(]0)years against defects or component breakdowns. During the Term,We wilt enforce these warranties to the fullest extent possible. C. DISCLAIMER OF WARRANTY. EXCEPT AS SET FORTH IN THIS SECTION 3 WE MAKE NO OTHER WARRANTY TO YOU OR ANY OTHER PERSON, WHETHER EXPRESS, IMPLIED OR STA RY, AS TO THE MERCHANTABILITY OR FITNESS FOR ANY PURPOSE OF THE EQUIPMENT, INSTALLATION, DESIGN, OPERATION, OR MAINTENANCE OF THE SYSTEM THE PRODUCTION OR DEL RY OF ENERGY, OR ANY OTHER ASSOCIATED SERVICE OR MATTER HEREUNDER, ALL OF WHICH WE HEREBY EXPRESSLY DISCLAIM. OUR LIABILITY FOR ANY BREACH OF ANY WARRANTY IS LIMITED TO REPAIRING THE SYSTEM OR YOUR PROPERTY TO THE EXTENT REQUIRED UNDER THIS AGREEMENT. YOU ACKNOWLEDGE THAT WE ARE RELYING ON THIS SNCTION 3.C.AS A CONDITION AND MATERIAL INDUCEMENT TO ENTER INTO THIS AGREEMENT. THERE ARE NO WARRANTIES WHICH EXTEND BEYOND THE DESCRIPTION OF THE FACE HEREOF. 4.REMOVAL OF THE SYSTEM You sha of y Alterations(as defined in Secti to the System. If You want to make repairs or improvements to Your Property that require the rary remova f the Syysstem or that could int ere with its performance oropera�on,You must give Us atteast thirty(30)days'poor written notice {a"C Requtstt Shuulown"). You agree that any repair or improvement toYour Property shall not materially alter Your roof where the System is instal As co on for Our removal,storage,and reinstallation of the System,You agree topay to Us a fee equal to Four Hundred and Ninety-Nine Dol 5499)before remove the System. You shall be required to pay the Shutdown Pa t�as defined m Section 15)if the System is not reinstalled wi n irty 30)days f removal. In the event of an emergency affecting the System,Yoon ssha contact us imin tate y. If We are unable to timely re nd,You ma (at our own expense)contract with a licensed and yualif¢d solar installer to remove the System as necessary to make repairs required by the ergy. You 1 be responsible for any damage to the System that results from actions taken by Your contractor. 5.ARBITRATION OF DISPUTES Most customer concerns can be resolved quit an amicably by calling Our customer service department at(877)404-4129. If Our customer service department is unable to resolve Your concern,You and We awe to resolve a Dispute(as defined below)through binding arbitration or small claims court instead of courts of general unsdiction. BY SIGNING BELOW YOU ACKNOWLEDGE AND AGREE THAT(I)YOU ARE HEREBY WAIVING THE RIGHT TO A TRIAL BY JURY;AND(Il)YOU MAY BRING CLAIMS AGAINST US ONLY IN YOUR INDIVIDUAL CAPACITY,AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENT?, IVE PROCEEDING. You and We agree to arbitrate all disputes,claims and troversies arising out of or relating to (:op}right c;_013 tivi� Im OcveY,mer,LLC,All aighes Rnmed MASWIlErLIMS PPA N2.8/ ^ .., mndifted an insuunivit in.writin signed b bWtt a(o and Us. • OFA OUR AFFILIATES, DIRECTORS, EMPLOYEES, AGBI�ITS, � B Bn. 1' 4 OR CONTRACTORS FOR ANY, SPECIAL, .EXEMPLARY, 21.ENTIRE AGREEMENT.' Thrs A'gr-ement,.the Additional Teras and INDIRECT, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE Conditions, the Customer Packet,the Worlt Order.'and-ito other agiseatepts_or QQ documents incorporated herewith constitute the.entire agreement lSetwe Ypu end Us DAMAGES(WHETHER OR NOT THE CLAIM THEREFORE 1S and supersede alllprior oral and written negotiations,communications d�scussions.ihd ..• BASED ON CONTRACT,TORT,DUTY IMPOSED BY LAW OR c�sppupnno "ppccrtaimn tothesubjectmatterhdretif. OTHERWISE).IN CONNECTION WITH,ARISING OUT OF,OR 22 8 DING EFFEC This Agreemen,shall be binding upon and inure to the benefit of You suit Us and,(Air and Your-respective heirs,:egaI representatives, IN ANY WAY RELATED TO THE TRANSACTIONS successors,and permitted assigns. Except as otherwise ex ressly provided in this CONTEMPLATED BY THIS AGREEMENT OR ANY ACT,OR Agreement,or by operation oC law• nr diet-this Agreemen nor any of the rights. OMISSION OR EVENT OCCURRING IN CONNECTION interests,or obligations hereunder may be assigned byYouWithout(aur pr or written THEREWITH. YOU HEREBY WAIVE,RELEASE,AND AGREE consent Any assigtment by You without Our prior written consent shall be void. 23.GOVERNIN(; LAW. This A meet, and any instrument or agreement NOT TO SUE UPON ANY SUCH CLAIM FOR ANY SUCH required hereunder,shall be governed,land construed under,the internal laws of the DAMAGES, WHETHER OR NOT ACCRUED AND WHETHER state where thc Pro is located. OR NOT KNOWN OR SUSPECTED TO .EXIST IN YOUR_ pe NOTICE. All notices,requests,demands,and other c writincadrfiv req�iredor he permitted to be given under this Ag�merit shall be in writing delivered to the FAVOR. YOU FURTHER AGREE THAT NO CLAIM,. applicable party at the address set forth in this Agreement or to such other addrgss as . LAWSUIT, OR ANY OTHER LEGAL OR ARBITRATION any pj,mi designate from time to time by written notice to the other party. PROCEEDING IN CONNECTION WITH,ARISING OUT OF,OR 25..SU.VI AL. After termination or expiration of this A t any provisions IN ANY WAY RELATED TO THIS AGREEMENT MAY BE which by their,nature are intended to survive such terming tai.a cancellation shall survive mcludmg(without limimtion) ct S 5,I1,1�,l4 17,18 and L BROUGHT, COMMENCED OR FILED MORE THAN ONE (1) 2&SE ERABILITY.. I{any provision o is greement is el to be invalid YEAR AFTER THE INCIDENT GIVING RISE TO SUCH CLAIM. prohibited, or otherwise unenforceable by an arbitrator or court of compecetn YOU ACKNOWLEDGE THAT WE ARE RELYING ON THIS adueeemed inoperative to henexten bt s deemed invalidb,le an4 tibuited or urionlnliameable SEC O 17 AS A CONDITION AND MATERIAL and in all other respects this Agreement shall remain in tit lP 1 fonce.and effect-provided TO ENTER INTO THIS AGREEMENT. however that if any such provision may be made enforceable by limtatiod thereof. then such provision shall be deemed tote so limited and shall be enforceable to the 18.i1NDEMNIFICATION. To the fullest extent permitted by maximum extent Pp�ermitted byy�applicable law. applicable law,You hereby agree to indemnify.,advance expenses, 27.COUNTERPARTS. this Agreement may be executed. in one or more gr pe count ,and all such coup shall be deemed to constitute one instrumem. and hold harmless Us and Our affiliates, hectors; em Ioyees, agents, contractors, and Our successors and assigns each, a pupryous mer�f p°nable document format.("pdP')shall constitute nn original for "Covered Person") from any and all third pa claims, actions, 2&PUBucigrY. You hereby authorize Us to use Your and Your Pmperty's voice. costs, expenses(including reasonable attorneys'TCes and expenses), photograph,video'and likeness in print media,radio,television e-mail,social media, damages,liabilities, nalties, losses,obligations,jn arias,demands web materials,and an audio or video recording;provided ibat We agree that We will peI. not disclose an of Your personully r entifyihitt mfonoation(except as provided iii and.liens of any kind or nature in connection with,arising on of,or u 2 e . You waive end forever release U.s`for any Dispute relating to or arising in any way related to(i)Your breach of this Agreement,or(ii)Your ora o r ms on . tie ligence or willful misconduct; provided that Your 29. AND OPT-OUT N TI E. THIS indemnification obligations under this Section 18 shall not apply if '.PKESCKEENELY OFFER OF CREDIT 15 BASED ON the harm or damage that is the basis or sued third partyy claim INFORMATION IN YOUR.CREDIT REPORT.INDICATING occurred while one of Our employees or agents was at Your Property THAT YOU MEET CERTAIN CRITERIA. THIS OFFER IS NOT and such harm or damagge was solely caused by the active negligence GUARANTEED IF YOU DO NOT MEET OUR CRITERIA. IF or willful misconduct ofsuch employee or agent. -' - YOU DO NOT-WANT TO RECEIVE PRESCREENED OFFERS 19.SUBROGATION. You agree to release all Covered Persons OF CREDIT FROM US AND OTHER COMPANIES,CALL THE tiom any claims of any parties suing through Your authority or in CONSUMER REPORTING AGENCIES TOLL-FREE, (888) 567- Your name, such as Your insurance cornpany and You agree to 8688;OR WRITE: EXPERIAN OPT OUT,P.O.BOX 919 ALLEN, defend Us against an such claim. .YOU AdREE TO NOTIFY TX 75013; TRANSUNION NAME REMOVAL OPTION, P.O. YOUR INSURANCE COMPANY OF THIS RELEASE. BOX 505 WOODLYN, PA 19094; EQUIFAX OPTIONS, P.O. 20.AMENDMENTS AND WAIVERS. This Agrectieht may only be amended or BOX 740123 ATLANTA,GA 3037410123. t � t c.,ry-lei¢<,r.:niw.;�csr.u,tt.,�iwi�,.i.i,c wastx:kzx„�n. e stnseruiacrnrrn Tc, 0 G)any aspect of the relationship between You and Us,whether based in contra to Py other agreement concerning the sub'ect matter hereof; 'tort,statute or any other legal theo (ii)this Agreement interpretatio validity.,or enforceability ot'this Agreement includin the determination of the sco ora Iicabili toy ( ) or n, (iii) any.breach, default or termination of this AI ment; and (iv)the J. `Dispute Prior to commencing arbitration,a pp g pp >„e . PP, ty f this ti n ar((eeach a Nottce of must describe the nature and basis for the Dispute and the relief written"Notice of and Wei a Bbl to thesolve the Di The within thirty (30) days, then either party may commence arbitration. The arbitration shall be administered by JAMS pursuant to its Streamlined Arbitration Rules and Procedures(available at: http://wwwjarnsadr.com/niles-sftamlined-arbitrafion,the`:7MfS Rules")and under the rules set forth in this Agreement The arbitrator shall be bound by the terms of this Agreement. No mutter the circumstances,the arbitrator shall not award punitive,special,exemplary,indirect or consequential damages to either party. If You initiate arbitration,You shall a responsible to ay x les All attorneys fees travel expenses,and other costs of the arbitration shall be bome by You and Us in accordance With the JAMS Rules and applicable law. We arbitration shall be conducted at a mutual( petty Judgment on an arbitration award may tie entered in an court of competent jurisdiction. Nothing inthis$ceectbionl5s all preclude I'o or We from seeking provisional remedies in aid of arbitration from a court of competent jurisdiction. NOTICE:BY MATTERS INCLUDED IN THIN E"ARBITRATION OF DISPUTESARE "PROVISION RO SON REEING TO HAVE BY NEUTRAL ARISING AS DYOUR ISPUTE ELITIGATED IN ALCOURT OR JURE LAW AND Y TRIAL BY INITIALD APPEAL. ING IN TfNY IE SPACE YOU BELOW YOU ARE GIVING UP AGREEING TO TffiS PROVISIGHTS TO ON,DISCOVERY MAY BE COMPELLYOUED TO FUSE RAI UB YIT T ARBI MEI TOTNO THIS SUBMIT DISPUTES ION PROVISION OUT OF THE MATTERS INCVE LUDED IN ARBITRATE. DpT ON FOREGOING G PRTO O ION TO NEUTRAL ARBITRATION. I/WE AGREE TO ARBITRATION AND WAIVE THE RIGHT TO A JURY 6 6.NOTICE TO CUSTOMERS ConditionST s, DOCUMENTSthCustme0 BE INCORPORATOrder ED INTpese doCONTRACT: urOitNTtRAC x r(i)(i)this (ii)the nal Terms and A.to the relationship between You and Us. expressly rporated into this A ement and apply B. IT IS NOT LEGAL FOR US TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REMOVE GOODS INSTALLED UNDER THIS AGREEMENT. C. DO NOT SIGN HS AGREEMENT BEFORE YOU HAVE READ ALL OF ITS PAGES. You acknowledge that You have read and received a leg�'ble copy of this Agreement that We have signed the Agreement and that You have read and received a legible copy of every document that We al signed during the negotiation. D. DO NOT SIGN THIS AGREEMENT IF THIS AGREEMENT CONTAINS ANY BLANK SPACES. You are entitled to a completely tilled in copy of this Agreement signed by both You and Us,before any work may be started. E. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO THE LATER OF: MIDNIGHT OF THE THIRD (3RD)BUSINESS DAY AFTER THE TRANSACTION DATE,OR(IO)HE START OF INSTALLA ON OF THE SYSTEM. SEE HE NOTICE OF C ELLATION BELOW FOR AN EXPLANATION OF THIS RIGHT. VIVINT SOLAR DE PE L CUSTOMER(S). I;y: By: Printed Name: Printed Name: Title: By: Printed Name: Z-- CONTACT FOR INFORMATION ABOUT CONTRACTOR REGISTRA ION RE tion DaUIREOFFICE OF CONSUMER'AFFAIRS AND BUSINESS REGULATION:T N PAp .THE MASSACHUSETTS (617)973-8700 OR 888-283_3757. LAZA,SUITE 5170,BOSTON,MA 02116, x- -------- — ---- - ����_.-------------- ------,� NOTICE OF CANCELLATION Transaction Date: AR No.: YOU MAY CANCEL THIS TRANSACTION WITHOUT ANYPENALTY OR OBLIGATION,WITHIN THREE(3)BUSINESS DAYS OF THE'ABOVE DATE, OR (IF LITER) UNTIL THE START OF INSTALLATION OF THE SYSTEMF CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE.AND ANYYOU FOLLOWING RECEIPT BY THE SELLER OF OUR CANCELLATIOED BY You WILL BE NRNOTICE,AN TEN (E) RITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED ANY GOODS INSTRUCTIONS OF THE SELLERDELIVERED TO YOU UNDER THIS CONTRACT OR SALE, OR YOU MAY F YOU WIS COMPD WITH THE AND RISK. F YOU DO AKE THE GOODS AVAARDING ILABLE TO TTURNHE SHIPMENT AANDTHE SELLER DGOODS AT OESE SELLER'S NOT ICK THEM UP OF THE WITHIN TWENTY(20)DAYS OF THE DATE OF YOUR NOTICE OF CANCELLATION YOU MAY RETAIN OR DISPOSE SELLER,LIABLE FOR ORO IF OOUTIO UT ANY GRE TO O REFURTHER T H NR HELIGATION. IF GOODS TO THYOU SELLER AND FAILTp DO3p,4THEN y�pU TO THE MAILR DELIVER ASG EDAND DATED CO Y OF TH SRCANCELLA T. TOCANCE CE OR ANYHIOTH R SVV I fEN NOTICE OR SEND A TELEGRAM,TO VIVINT SOL DEVELOPER,LLC AT 4931 N 300 W,PROVO,UT 84604 PRIOR TO THE LATER OF: (p MIDNIGHT OF THE THIOID(3BUSINESS DAY A�7'ER THE TRANSACTION DATE,OR(In THE START OF INSTALLATION OF THE SYSTEM. I HERE Y CANCEL THIS TRANSACTION: Date: Customer's Signature: Copyright O, Vi AI) DONAL3'ERMSAND CONDITIONS' obligate to 7. ,REPRESENTATIONS AND 1YARRANTIES. You'represetif, warrant,and may wrtnina(e this Agreement ora written notice S You watt installed,subjecct o la that each of the following is true And correct.:(i)all information,concerning You .pa to Us an amount equal Iq Four:Dollars.LS4)pEr61 'h,�em_is true, Oct. and comylrte:(ii)You are the only fee simftle ow;ner(s,of the ruction.of five pen;eni just per yrer(a q..tn,car.To Transfer P, eat w�11.be . Property(i.e.You have full and exclusive quiiership ri�tits to ibq Property);,(��i!Ygir $1.56 per wad Installedl,phis ep t.ble t res the"Tra»sjer PayNtEn A1tCr Ytstt P pp e wdI Otis er ownershr oft he 5 tdYdu on are at least eighteen(1g years of aea;fiv)YOU current) have and agree to iitsmtam pay to Us the Transfer aymtnt�V P.. customary 77rroperty and�iabihty insurance with res1wcet 5 Your Property'and(v)You an"As is,Where ls',basis, Ntxwithstandiag any other provrsrnn.in this Agreement if have had the oppoconny ro review and discuss. this Agreement with Our sales agent the proposed transfer of Your Property to.Pruperty ransferee is a or othof er and any other advisor You may desire to consult. You understand that an mistake, transfer that isnot a fee snnple sale,You will remain responsible for p orrnance rs misrepresentation,or omission m dors.Agreement made You is a"material breach of Your obligations under this Agreement.'Yar agree that the death of a P Customers this Agreement and,entitles Us to die remedies provided for in Section 13(b). We hereunder shall he deemedd-a transfer of Your Properly,and We will w'xk with Your make no representations or warranties except as expressly sot forth in is greeinent. successors and heirs tQ transfer dtis Agreement putnuant to the tams and conditions of S. UUR SERVICES. (al w n We will install per(urmance meter(s)as needed i to measure the Energy p uce y the System:'We will collect performance data OF DEFAULT. 1a) usto fa t. A"Cris'make Pny?natt remotely or use Our personnel to collect tfic data. We will provide this data to You mean the uccurrtnce of any of the u owing: i our'failure,to'idake on eat upon Your reasonable request. You agree to allow Our personnel reasonable access to under this Agreement within ten(10)days,of w e i due and such failure is zofcured Your Property to collect such data. At Our discretion,We may test the accuracy of the within ten(tU)days after We give You wenloand su ice qucNhifitirc is'not cYilr�ed w[thin ormance meters from time to time. If testing indicates that the meter is inace'umte.. to perform any obligation under this A f., y more than+/-5%,.We will(i)repair and recalibrate the metet,at no cost to You; thirty(30)days after Wr give You written rarer of such 6dure (iii)You dcny_Us and(ii)make retroactive adjustments to Your payments based on cortected meter data Our contractors;or agents,,govemmeattil.authorities,or the Utility aceess to You[ for the period of such inaccuracy. If the meter is inoperable fire any reason,including Property_and such access is nil given within thiirrttyy(,30}da aftm.\lye give You Your failure to maintain workmg broadband internet or electrical connections,We car tten notice of the fix ilure to provide such ucccs;.(iv Your banktVp77;.il ,uiro�roenc may,charge You for the Shutdown Payment. (h) sualt• . ly the System is or admission of Your inability to paPy��tleb@,s thhey mature;or(q damaged or destroyed by fire,storm,dial,earthq e,oro er isaster or accident becoming sub'x4 to u foreclosure m . R t f (each,a"Casaaltp EveaP 1 covered by Our insurance,We will promptly repair and a Customer fault orris„We may exercise any o e o orem TV the damaged puma is of the System as necessary to restore it to good working ,(l)terminate this Agreement and demand You pay the Default Peyme� leave to condition. d the Sysfem to damaged of destroyed by a t asuahy Event not covered by System in place on Your Pmperty,but deny You access to'and.use of a Energy.rt Our insurance,,We may,.at Our option(i)repair and restore the System to good pinduces,which may be redirected and sold at Our electioh;(iii)disconnect or thke working condition:or(u)terminate this veement and at Your election,either back the System as permitted by applicable law;(iv)place a hen tin Youc,Pro convey the System m its then-misting condition,"As is,Where Is",to You for no (v)eneage a collection agency to collect payments from You:(vu repoh Your tfau i additional consideration or remove the System from Your Property. (c) i on i to creait reporting agencies;and/or vu)_exercise.an other y available to Us in of em. We may cause the System to be disconnected from the Utility s ac rhes l this A entbr underapplicable law. jc) f u A"Seller na any shall t ey tare such disconnection or We are required to do so under applicable low. mean 17te occurrence of any of the following:. r r at arc to pafam agy of Our 9. Y�R DUTIES.(a) of the 'tem. You shall use the En for residential .material obligations under this Agreement and e,effect of such ffilurt is not cured purposes only and not f'or eat erg a swinutiing pool. At.all times You shelf Insure within dtirty.(30 days,after You give Us written notice of such failure or{ii)Our ills( der property remains id-conn ted to the Utility. (b)Broad d Interact hankmptcy.rnso�venc or admission of Our inability to pay Our debts as IheX:mtnturot Con You must provide the System with cominuouu§§access ton ncnMet .(d) e n e if a Sella.Default occurs and is cmtinhnng You Conn et connection with one carred Ettiemer port and standard electrical oudct',at Your mny: t termnate is Agreement and request removal of the System front Your cost [f You fail w maintain broadband intemei or electrical connection for a period of Property and/or(ii)except as provided below,exerciseanyotl!enremody-avatlable o time We may charge You the Shutdown Payment. (c) ste terafo is. You shall You m ibis Agreement or under applicable law. Notwithstanding the foregoing,You not ti)alter,repay.or othmvise modifyy any compoment,o a ysLem collectively will have no right to dram damages at a result the termination of this Agreerttrht. not ji mriuns}:and lir)take any modifction hat court void or impair any warranty relating except for(x the actual costs to remove the-System,tt We fail to remove the System to the System.You will be responsible for any damage to the Svstem that is caused at front Your pursuant to i n 14-andsany damages.to Your Pro any time by You or Your guests, Invitees contractors, or agents. (d) Proper[% resulting from the,removal of a system by Us or Our contractor (e) f t any titi . You sor (i)trim all trees tin Ytwr Property[not install structures on Pay�itents. 11-this Agreement is terminated fdr any reason,other than purartcla, o e our lou,and take other reasonable seeps[o ensure that shading of the System is no i Mice o Cancellation,S�c�h� 1616,or o Seller iktwlt.You will��aay Lolls Me Default worse than on the Transaction Date;and(ii)maintain,in mud condition and repair Payment. The"Defaultenerl shall be an amount ualto nevem Rollers($7.per the roof and all electrical systems of Your Property., (e)A_witth�r z_aIiuns. You shalt was installed subject to a reduction of five percent(5° per year(e.g:iq year 2 the obtain from Your mortgagee,home owners'association.or any other person with an Default paymerN will be S2:tr�per watt instaHod),p1a5 8ppircable t�e Y�agree interest in Your p�opc7 all authorizations necessary for,Us,to install,operate,and that the Default Payment fhir(y reflects the value 6 te3ystepr,�, maintain the,System: Your failure to obtain these authorizations in a.umety manner Customer Default,is a fair reppresentation of the damagges and Imsses sit We expect to may result m termination of this Agreement. (f)Tomes. You will pay all taxes incur. After You pad to Us the Default Payment,We will transfer ownership of.die assessed on or arising from installation or operation ot"the System,including any System M You on an`As 3s.TermiWheris'o basis. general.excise or sales tax on the Energy produced by the System. We shall be 14.TERMINATION. (a)Terminatitm by Seller. We may,in Our stale dixretim, responsible for income tax and perty tax assessed in relation to Our ownership of terminate dhis Agreement h rl pna e a n- custom Date upon Withindeliver ip written the System. (g)Changes. If You the Utility,or any governmental agency requires notice to You;of(u)upon Ote occurrence of a Cristoma Dp��feult. Within ninety, i �i)any change to thR ystem after its installation,You shall pay Our standard parts and days after termination of this Agreeinen other a mt�wder the citettmnstances in wfii e will a charges;ur lir)that We pay any tax;fee,or other charge in relation to the Svstem the System is transferred to You under cti cans trio bleZ free ,tmonlelal3r'slVIf We or,this Agreement after the In-Service Date, then You shall be responsible to remove the System and restore all loo op pen reimburse s for such tax,fec,or other char a(except for income and prooerty taxes elect to terminate this Agreement We will hast no further liability to You. that are Our respun ibil ty under t (h)F su 1U1pon Our (b)Termination by Customer. You may terminate this Agreement(i)pursuant to the request,You shall prampptly sign a return t)any epp uauon,agreement or other terms o e otice o ancellatioo a(ii)u a Sella Default. document necessary for Us to obtain any c its,rebates incentives,allowances,or 15,SYSTEM SHUTDOWNS. (a� t In addition to Our right to shut dorutle cit that are attributed a0 nr related o tlie.Systetn the Energy.or down the.System for maintenance, a may shut own the System if We reasonably environmental attributes thereof (coNectively, the "System Inteersts"),.(ii .MY believe AM Property conditions or activities of parsons onthe Ptnperty4 which are tlot permit .interconnection,net metering agreements,and'other dryctlments uirtd by under Otp codtrol whether,or ho[.under You mbDrtrol;.may,mtenfen'y of 6 S safe s, tlre3 pedeney of t+Sitfet the Utility;and(tri)any documenfheeessary to verify Our nwnershipinuxestm the tion of the tem(a"Ser ey Sha/iilAwit -bek4ng y S stem and System Interests. (i)D oti You shall promptly notify Us if(i) utdown,You w Il pay Us the Shutdown Pa ,cit (b)P r V fmaL 1n-due Yyou notice any person or thing mut enng w i e operation of the System;(u)Your event that You vacate Your Pmpe for any nlod oaf timMas �t y an evunient -J —, mny lino-say acdinauce�r.psa�tt yrnlatiatt:a ertcu+ubraP� -Ptevwt.ienoR�6gtceyr� aatar Da System permitting;or(ii,)you take any,emergency action with respect W the Energy pToducrdby the System. (c) leer n D v II mtemonnection " Mdri. Your failure to romptly notify Us of such matters shall be a Customer with the Utihty,becomes.deacuvat or reasons- at ere not(i)a Force Majeure Default ands on Event,or(ii)caused byy or related to Our imexcused'scrum or inaction,such that the 10.SALE O ERGY. (a)Sale f leder i ing with the In- System is no longer able to roduce electricity or transfer electricity to You or to the Service Date,We will sell to You and ou wi uy own, s all of the Energy Utility, You will payy Us tie Shutdown Payment (d) td 77te . produced by the System. Title to and tisk Of loss with respect to the Enema shall "Shutdown PaymerM shall equal the,sum of 0)payments a ce that transfer from Us to You at the point where the System is:interconmttted with Your You would have made to Us as described in ort2 A.for dim En that would Property's electrical wiring. Energy from the Svstem wilt be delivered to You in have been produced by the System during the pen of Ne shutdown;(rr the value to compliance with all requirements of the Utility. (b)Py re. You agree that the Us of tVystein Incentives that We would have received with respect to the Eneerr�+ obligation w pay any amount due.under thus Agreement shall be absolute aril that the ysten wiwld have produced folbwing such shutdown;and.(nr)eppbcable In- unconditional,and shall not be subject to any abatement,defense,counterclaim,setoff, taxes. Determination of the amount of En y that would have been produced during recoupment 1, reduction.It You and We ogee that all aotmmts payable by You the period of the shutdown shall be based(A during the first year after the In-Service hereunder shall be payable in all events including by Your heirs and estate. Except as Date,on estimated levels of production;and B)after the first year after the In Service permitted by the Notice of Cancellation,You hereby waive all rights You may have to Date,based on actual operation of the System[during,the same Period in the previous refect or.cancel this Agreement,to revoke aces tante of the S>>stem;or to grain a year. If a shutdown pursuant to&$�qc��pf�l�4 or this tion I contuiues for one Luadred . heronry interest in the System. (c is on C1ppyL' ti o Eve. WE DO NOT and eighty(1g0)days or longemay m t discretion,terminate this W ARRANT OR GUARANTEE Yl AM()11F�i� �� RODUCEU BY Agreement and ire You W y the Default Atyniatt. rreeqquu peau of We uaeble to amt nn nfthe obligations THE SYSTEM FOR ANY PERIOD of ANY COST SAVINGS. Wean ria a utility 1 FORCE MA eat because If Y, � y axil ebe a public service company and do not assume any obligations of a utility a pirate under this Agreement because a a Forel Majeure Event,such affected party service company to supply Your energy;requirements. We are not subject to rate excused from whatever performance is affected by.due Force Ma cum Event,prow,abed review by govemmentul authorities: During the Tenn.You understand that You may that the suspension of such obligations is of no g�eena�r xooppre and'of no Ionga duration. re erre more electricity than the System may generate. If You need any such than is required by the Force Ma}�ure.Event. "Foree:Aftyeare Ef'shall mean any additional energy,[hen You shall be solely responsible to obtain such energy from the event'condition er circumstance tiCyond the control of due affected party wbichtby the Utilityy at Your cost. exercise of due foresight such y could not reasonably,have been expected to avoid, I1.ORNERSHIP OF SYSTEM. (a)Our Owrocrshim of the Svstersh. We shall own and which by the exercise of ne diligence such party without fault attributable to itis and hold all property rights in the System an f ht t c System—Tnte�ests•-5 ou shall have no tenable to overcome,including burg of limited to,aches by a govemme ro tFiat property interest in the System or the System interests except for(i the Enerw that the failure to act on the rt of any governmental authorityorlhe Utility eche System generates•anti(it)anyy credits or paymrents available umfer Your Utility's such action has been timely requested and diligently pursued),failure to obtain or net metering' program for the Energy that the System generates.You agree to keep maintain a permit,license,consent or approval(provided that such party has made the System and System Interests free from all liens and encumbrances. (bl Personal timely and,reasonable commercial efforts to obtain and maintain the same Is or Proocvly Nahire of the SysteLi. Nutwithstandio the manner in which the System rs duspme•strike,work-sto e,sbw down,lockout flood earth rake,fire li tom amacFieTto nu rope ,nor any fixwre filing�y Us,You and We hereby agree that wind,epidemic,war,teironsm cid,economic sanction or embargo,civil disturbance, the Svstem and the System interests shall remain Our sole pensonul property and shall act of god, unavailability of electricity from the Utility, equipment, supplies or not tie deemed or chameterized as a"fixture"or airy pan of-the"realty',as those terns products,power or voltage surge caused by sexnerme doer than the affected party,or may be defined hy applicable law. It is further agreed that the installation of the T"oiluie of equi meat not utilize3 by or under the control of the effected party. Syystem shall not be a repair.remodel,alteration,conversion,modernization of,or 17.LIMITA ION OF LIABILITY. You understand that: (a)We are not an insurer eddiuon to,Your Properly. (c)C t of c•ss. You hereby ant to Us and Our of Your Property,personal property,or nal safety of persons m,or on Your employe,agents,and contractors erg t to access and use our Prope,, so that Property;(b)You are solely responsible otprproviding any insurance with respect to We may(i}nstall,operate,and mainle the System thm out the Term,(u enforce Your Property and its crotents;(c)the amount You pay to Us is based only on the Our rights as to this Agreement,and the System, and,iii)take any other action value of the Energy produced by the System and not ro the value ri Your Property or reasonably necessary in connection with the construction, installation, operation, its contents;(d)the System may not always operate property for various reasons;l that t maintenance repair,.or removal of the System. The foregoing rip�ts of access to Your is difficult to determine in advance the value of the components of the System that Property shall constitute a license coupled with an interest and sfiall be irrevocable for might be lost or destroyed if the System fails to operate I ,M it is difficult to up to timely(90)days after this Agreement expires to provide Us with time to remove determine in advance what porion,if any,of any property loss.personal injury or the System at the end of the Tam. (d)Notices of System Ownership. You authorize death would be proximately caused.by Our failure to perform,Our negligence,or a Us to make filings and recordings with re evanl goven ata ut onties as may be failure of the System,or the System installation. necessary to provide notice of Our ownership in the System and the System Interests, NOTWITHSTANDING ANY BREACH OF THIS AGREEMENT aril Our right to access Your Property. Upon termination of this AVement,each ANY FAILURE OF THE SYSTEM,OR ANY NEGLIGENT ACY such tiling will be terminated. Yuu undoastand that the System shell tc marked and THAT CAUSED ANY INJURY OR LOSS (WHETHER identified as Our property. 12:ASSIGNMENT&TRANSFER. (a)qs�r t�men�t. We may assign,sell,ur PROPERTY DAMAGE, PERSONAL iNJIJRY OR DEATH)TO transfer(in whole ur m part)this Agreement t �astem,or the System Interests ANYONE, WE AND YOU AGREE THAT, UNLESS SUCH without Your consent and wi out nonce. if such assignee agrees in wnting to assume Our rights tinder this Agreement,We will have no further liability or obligation under INJURY OR LOSS WAS CAUSED BY A PARTY'S GROSS this Afgatent upon the effectiveness of such assignment. (b)T NEGLIGENCE, FRAUD OR WiLLFUL INJURY, SUCH You shall provide Us with thirty.(30)days'prior written nonce u a V. PARTY'S LiABILITY AMSING OUT OF OR RELATING TO simple sale of Your Pro . 7Siis written notice shall include the name of the THIS AGREEMENT SHALL IN NO EVENT EXCEED THE proposed purchaser or transferee("Property Trgnsjem")and the proposed date of sale or transfer. You will also provide an additional information regardin&Property DEFAULT PAYMENT. YOU AND WE AGREE THAT THiS Transferee that We reasonably request. yYou will,request that Property ,ransferer AMOUNT IS A FAIR REPRESENTATION OF THE DAMAGES agree m writingg with Us that Pmperty Transferee will assume Your obligations under THAT YOU OR WE EXPECT TO INCUR IN THE CASE OF ANY this Agreement. Pro it Transferee shall enter into such ag[cement on or before the date Your Property is sold. Altematively,if We determine toat Property Transferee is INJURY OR LOSS HEREUNDER. not adequately creditworthy to assume Your ob'gations under this Agreement,or NO CLAIM SHALL BE MADE BY YOU AGAINST US OR ANY Property Transferee refuses to assume Your tions under this Agreement.We sa, h,.u;;,i:;r.rrv��a.xi t'npyriFla t.'!n?�ivnu nlxr Ircr4{h,..U e.:111 Righ:,ac..®®. IC�EF T. The Commonwealth of Massachusetts ) Department of Industrial Accidents !y k Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 I✓�==' wwry mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leltibly Name (Business/Organization/Individual): Vivint Solar Developer, LLC Address:3301 North Thanksgiving Way,Suite 500 Citv/Mate/Zip:Lehi, UT 84043 Phone #:801-377-9111 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 10 4. ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' insurance. 9. �Building addition comp.[No workers' comp. insurance required.] 5. F-1We are a corporation and its 10T Electrical repairs or additions 3.E] I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' com right of exemption per MGL p• 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no Solar Installation employees. [No workers' 13.©Other comp. insurance required.] 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Zurich American Insurance Company Policy#or Self-ins. Lic.#:WC 509601300 Expiration Date:11/1/2015 Job Site Address: V�-Q VlcA*Nt.t Y►'Y' City/State/Zip: N G�Y,1Q� 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 up 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sianature: �/?�---¢ –'— Date: la•l�'l� Phone#: 801-2296459 Official use only. Do not write in this area,to be completed by city or town official. 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#: ___--- U !'Gt'i C��flJ'�2!'12flYl�lU-eG?iL�LJ2 d UI�I�Q'/J,1�'fil2ZC::ZPiLL;1, Office of Consumer Affairs nd Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 170848 Type: Supplement Card VIVINT SOLAR DEVELOPER LLC. Expiration: 1/5/2016 JAMES SHERMAN 4931 NORTH 300 WEST PROVO, UT 84604 Update Address and return card.Mark reason for change. SCA 1 0 20M-05/11 ❑ Address Renewal ❑ Employment E] Lost Card Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-045254 � . JAMES R SHERM,AN 6 Fox Hollow Drive - SAUGUS MA 015M rs s JAM Expiration 08/28/2016 Commissioner 0 O n L": n 5 7 Wl VT �0 3301 'North Thanksgiving Way,Suite 500 Structural Group Lehi,LT 84043 P: (801)234-7050 Scott E. Wyssling, PE Head of Structural Engineering scott.wyssiing@vivintsolar.com December 4,2014 Mr. Dan Rock, Project Manager Vivint Solar 24 Normac Road Woburn MA 01801 Re: Structural Engineering Services Dibenedetto Residence 123 French Farm Rd, North Andover MA S-4075047 5.61 kW System Dear Mr. Rock: Pursuant to your request, we have reviewed the following information regarding solar panel installation on the roof of the above referenced home: 1. Site Visit/Verification Form prepared by a Vivint Solar representative identifying specific site information including size and spacing of rafters for the existing roof structure. 2. Design drawings of the proposed system including a site plan, roof plan and connection details for the solar panels. This information was prepared by the Design Group and will be utilized for approval and construction of the proposed system. 3. Photovoltaic Rooftop Solar System Permit Submittal identifying design parameters for the solar system. 4. Photographs of the interior and exterior of the roof system identifying existing structural members and their conditions. Based on the above information we have evaluated the structural capacity of the existing roof system to support the additional loads imposed by the solar panels and have the following comments related to our review and evaluation: Description of Residence: The existing residence is typical wood framing construction with the roof system consisting of 2 x 8 dimensional lumber at 16" on center with 1 x 8 collar ties every 32". The attic space is unfinished and photos indicate that there was free access to visually inspect the size and condition of the roof rafters. All wood material utilized for the roof system is assumed to be Spruce-Pine-Fir #2 or better with standard construction components. Our review of the photos of the exterior roof does not indicate any signs of settlement or misalignment caused by overstressed underlying members. Stability Evaluation: A. Wind Uplift Loading 1. Refer to attached Ecolibrium Solar calculations sheet for ASCE/SEI 7-10 Minimum Design Loads for Buildings and other Structures, wind speed of 100 mph based on Exposure Category "B" and 39 degree roof slopes on the dwelling areas. Ground snow load is 50 PSF for Exposure"B", Zone 2 per(ASCE/SEI 7-10). 2. Total area subject to wind uplift is calculated for the Interior, Edge and Corner Zones of the dwelling. 0`I 0 V WE : 'Do Page 2of2 B. Loading Criteria • 10 PSF= Dead Load roofing/framing 0 50 PSF=Live Load(around snow load) • 5 PSF= Dead Load solar panels/mounting hardware Total Dead Load=15 PSF The above values are within acceptable limits of recognized industry standards for similar structures. Analysis performed of the existing roof structure utilizing the above loading criteria indicates that the existing rafters will support the additional panel loading without damage, if installed correctly. C. Roof Structure Capacity 1. The photographs provided of the attic space and roof rafters show that the framing is in good condition with no visible signs of damage caused by prior overstressing. D. Solar Panel Anchorage 1. The solar panels shall be mounted in accordance with the most recent "Ecolibrium Solar Installation Manual', which can be found on the Ecolibrium Solar website (ecolibriumsolar.com). If during solar panel installation, the roof framing members appear unstable, deteriorated, structurally compromised or deflect non-uniformly, our office should be notified before proceeding with the installation. 2. Maximum allowable pullout per lag screw is 235 lbs/inch of penetration as identified in the National Design Standards (NDS) of timber construction specifications for Hem-Fir (North Lumber) assumed. Based on our evaluation, the pullout value, utilizing a penetration depth of 2 1/2", is less than what is allowable per connection and therefore is adequate. Based on the variable factors for the existing roof framing and installation tolerances, using a thread depth of 2 1/2' with a minimum size of 5/16" lag screw per attachment point for panel anchor mounts should be adequate with a sufficient factor of safety. 3. Considering the roof slopes, the size, spacing, condition of roof, the panel supports shall be placed at and attached to no greater than every fourth roof rafter as panels are installed perpendicular across rafters and no greater than the panel length when installed parallel to the rafters (portrait). No panel supports spacing shall be greater than four (4) rafter spaces or 64"o/c, whichever is less. 4. Panel supports connections shall be staggered to distribute load to adjacent rafters. Based on the above evaluation, it is the opinion of this office that with appropriate panel anchors being utilized the roof system will adequately support the additional loading imposed by the solar panels. This evaluation is based on information supplied to us at the time of this report and current industry standards and practices. Should you have any questions regarding the above or if you require further information do not hesitate to contact me. Ve truly yours, �\k\OF sy fI• Y1 N CNi Scott E.Wyssl' PE 0 50 MA License N .500 50 90 FGISTEPO �FSSIONAI- �Ir�IuL::7)�'a t 123 FRENCH FARM RD NORTH ANDOVER MA 01845 � NN I - ----- - - ------- - - ------- - - - - ------- - - /?-� •VI�OV V INTERCONNECTION POINT, LL LOCKABLE DISCONNECT SWITCH, 5'OF 1"PVC CONDUIT x>Z ANSI METER LOCATION, FROM JUNCTION BOX TO ELEC PANEL JUNCTION BOX ATTACHED TO O z o F- &I UTILITY METER LOCATION I �w Z Z ARRAY USING ECO HARDWARE TO �x¢x KEEP JUNCTION BOX OFF ROOF F o N u ' c�Z< I I M p I I I � � O � o cC N r -wm v \\ y IN Q � r 0 0 m � I I ,j) N u U I( 03 > _ 6i m� Z W K K z } J J W Z N Z- Q ' Z Z g p PV SYSTEM SIZE: SHEET (22)Yingli Energy YL255P-29b MODULES WITH'_j NAME: 5.61 kW DC Enohase M215-60-2LL-S2x-ZC MICRO-INVERTER MOUNTED ON THE BACK OF EACH MODULE W Z I, � g Fn �- - - - - - - - - - - - - - - - SHEET NUMBER: PV SYSTEM SITE PLAN o SCALE: 3/32"= 1'-0" > a. Fn allo Z O O N 0 O 00 m � m �3c # OECD .5n m'O' v r C 3 D1 z ,n 2 < m z z j N n O 2 z 0 r m 0 A C t7 rC M-i U D r Cf) m I Nq'\ w � rn � II mK X O O 0n � o� D MC Z N Z(n zCo INS TALLER:VIVINTSOLAR o o _�� DiBenedetto Residence 3 m ROOF K m INSTALLER NUMBER:1.877.404.4129 m m m m ,/I ,/I 11 123 FRENCH FARM RD PV 2,0 A � MA LICENSE:MAHIC 170848 �J •�/ ..O NORTH ANDOVER,MA 01845 1 PL/`1N DRAWN BY:BRG I AR 4075047 Last Modified:11/17/2014 UTILITY ACCOUNT NUMBER:4117234003 CLAMP () MOUNTING SEALING � PV3.0 DETAIL WASHER �ooa LOWER w SUPPORT LL w ® OU'oz .FEW oZ PV MODULES, TYP. MOUNT N�aa .:. �•: .,t,.,:.t.�;..:. OF COMP SHINGLE ROOF, FLASHING C PARALLEL TO ROOF PLANEj 2 1/2" MIN m D 5/16"0 x 4 1/2" MINIMUM PV ARRAY TYP. ELEVATION STEEL AG SCREWS NOT TO SCALE TORQUE=13±2 ft-lbs CLAMP ATTACHMENT -mm NOT TO SCALE n O: _] CAMP+ ~ d ATTACHMENT S CANTELEVER U4 OR LESS Of COUPLING N L=PERMITTED CLAMP ECO SPACING SEE CODE COMPLIANT o COMPATIBLE LETTER FOR MAX ALLOWABLE MODULE CLAMP SPACING. o 0 COUPLING o PERMITTED g o v CAMP+ CAMP CAMP vOi ATTACHMENT SPACING ~ "' COUPLING PHOTOVOLTAIC MODULE z m di .. � 0� Unr w w Z m J J V ? J �> Q Z Z SHEET NAME: L=PORTRAIT I.-: CLAMP SPACING ? Q ECO 2 p L=LANDSCAPE MODULE PV PV SYSTEM MOUNTING DETAIL SHEET CAMP SPACING NUMBER: 0 MODULES IN PORTRAIT/LANDSCAPE NOT TO SCALE 1 M NOT TO SCALE a Inverter Ratings(Guide Section 4) Inverter Make/Model Enphase M215-60-2LL-S2x-ZC O Conduit and Conductor Schedule MODULE DETAIL Max DC Volt Rating 45 volts Tag Deacnpnon Wire Gauge #of Conducmrs Conduit Type CaWult size Max Power @40°C 215 Watts 1 Enphase engage cable,-THWN-2 12 AWG 4 cord N/A-Free Air C O Nominal AC Voltage 240 Volts 1 Bare Copper Ground(EGC/GEC) 6AWG 1 N/A-Free Air N/A-Free Tr is O Yingli Energy YL255P-29b Max AC Current 0.9 Amps 2 THWN-2 10AWG 6 PVC 0'-1• -0 N SOLAR MODULE Max OCPD Rating 20 Amps ° a 2 - - round 8AWG 1 PVC 0'-1• � Max Number of Panels/Circuit 17 THWN2GN D O•-•- 3 THWN-2 8AWG 3 PVC 0'-1' O r PVC 0'-1• NOTES FOR INVERTER CIRCUITS(Guide Section 8 and 9): 3 THWN-2-Ground 8AWG 1 / w 1.)IF UTILITY REQUIRES A VISIBLE-BREAK SWITCH,DOES THIS PV ModRLL LL w Module Ratings @STC(Guide Section 5) Enphase M215-60-2LL-S2x-ZC SWITCH MEET THE REQUIREMENTS? Q x>> O O z MICRO-INVERTER AT YES NO X NA Model Make/Model Yingli Energy YL255P-291b ♦-a Z O r Max Power-Point Current(Imp) 8,32 Amps �r W Z Z EACH MODULE,ATTACHED Q��Q o 2.)IF GENERATION METER REQUIRED,DOES THIS METER Max Power-Point Voltage(Vmp) 30.6 Volts tl=O WITH ECO HARDWARE SOCKET MEET THE REQUIREMENTS? `2 t-v Open-Circuit Voltage(Voc) 38.7 Volts � YES NO X NA Short-Circuit Current(Isc) 8.88 Amps W O Q 3.)SIZE PHOTOVOLTAIC POWER SOURCE(DC)CONDUCTORS Max Series Fuse(OCPD) 15 Amps C Z BASED ON MAX CURRENT ON NEC 690.53 SIGN OR OCPD Nominal Maximum Power at STC(Pmax) 255 Watts J MICROINVERTER CONNECTION _ RATING AT DISCONNECT. Maximum System Voltage 1000(IECy600(UL) M TO ENGAGE TRUNK CABLE 4.)SIZE INVERTER OUTPUT(AC)CONDUCTORS ACCORDING Voc Temperature Coefficient -0.32 TO INVERTER OCPD AMPERE RATING(See Guide Section 9). Q V 5.)TOTAL OF 2 INVERTER OCPD(s).ONE FOR EACH NOTES FOR ARRAY CIRCUIT WIRING(Guide Section 6 and 8 and Appendix D): PV CIRCUIT.DOES TOTAL SUPPLY BREAKERS COMPLY WITH 120%BUSBAR EXCEPTION IN 1.)Lowest expected ambient temperature based on ASHRAE minimum mean extreme NEC 690.64(B)(2)(a)? X YES NO dry bulb temperature for ASHRAE location most similar to installation location: -19°C #6 BARE CU GROUND -- _ (GROUNDING ARRAY_) r Signs(See Guide Section 7) 2.)Highest continuous ambient temperature based on ASHRAE highest month 2%dry bulb temperature for ASHRAE location most similar to installation location: 39°C Sign for inverter OCPD and AC Disconnect: 3.)2005 ASHRAE fundamentals 2%design temperatures do not exceed 47°C in the United States(Palm Springs,CA is 44.1°C).For less than 9 current-carrying conductors Solar PV System AC Point of Connection in roof-mounted sunlit conduit at least 0.5"above roof and using the outdoor design AC Output Current 19.800000 Amps temperature of 47°C or less(all of United States). O Nominal AC Voltage 2401 Volts v a.)12 AWG,90°C conductors are generally acceptable for modules with Isc of 7.68 Amps or less when protected by a 12-Amp or smaller fuse. - N THIS PANEL FED BY MULTIPLE SOURCES )C (UTILITY AND SOLAR) b.)10 AWG,90°C conductors are generally acceptable for modules with Isc of 9.6 Amps or less when protected by a 15-Amp or smaller fuse. Oil NOTE: NEUTRAL CONDUCTOR(S)OMITTED FOR CLARITY ✓ o ALL INVERTER OUTPUT CIRCUITS WILL HAVE A NEUTRAL CONDUCTOR O', 20 ✓ J N V PV CIRCUIT 1: 11 MODULES/PARALLEL ENVOY BOX g co 11 . . • O 0 0 W V WP � Co< MURRAY POINT OF DELIVERY > z w of COMBINER AND INTERCONNECTION W W z co 1 1P PANEL 125A/240V SIEMENS a a �\Gs GZ LW004NR 60A/240V U, U) O P OR EQUIVALENT UNFUSED NEMA3 M Z Z g o PV CIRCUIT 2: 11 MODULES/PARALLEL °\\f�F ,5 SREC/ANSI LNF222ROR SHEET 1 �`\� L EQUIVALENT METER NAME: \O EXISTING c� 11 • • • O2 tQ I \� 200 240V/200A W 15A LOAD-CENTER Z M J E 1.0 15A ch Q In • • • f x,f� I \\ 30A I N SHEET ---- -- ---- ---- - - NUMBER: \\ MILBANK VISIBLE/LOCKABLE JUNCTION BOX 2 \\ 3 100A OR 3 'KNIFE'A/C 3 O NEC 2014 Compliant WITH IRREVERSIBLE E 1.0 \\ E 1.0 U5 EQUIVALENT E 1.0 DISCONNECT E 1.0 GROUND SPLICE w Vivint Solar - PV Solar Rooftop System Permit Submittal 1. Project Information Project Name: DIANE DIBENEDETTO Project Address: 123 FRENCH FARM RD, NORTH ANDOVER MA A.System Description: The array consists of a 5.61 kW DC roof-mounted Photovoltaic power system operating in parallel with the utility grid.There are(22) 255-watt modules and(22)215-watt micro-inverters,mounted on the back of each PV module.The array includes(2)PV circuit(s).The array is mounted to the roof using the engineered racking solution from Ecolibrium Solar. B.Site Design Temperature: (From Lawrence MUNI weather station) Average low temperature: -24.3°C (41.74°F) Average high temperature: 37.6°C (99.68°F) C.Minimum Design Loads: Ground Snow Load: 50 psf (State Board BR&S) Design Wind Speed: 100 mph (State Board BR&S) 2. Structural Review of PV Array Mounting System: A.System Description: 1.Roof type: EcoX Comp.Shingle 2.Method and type of weatherproofing roof penetrations: Flashing I B.Mounting System Information: 1.Mounting system is an engineered product designed to mount PV modules 2.For manufactured mounting systems,following information applies: a.Mounting System Manufacturer: Ecolibrium Solar b.Product Name: Ecorail c.Total Weight of PV Modules and mounting hardware: 926.3 lbs d.Total number of attachment points: 35 e.Weight per attachment point: 26.46 lbs f.Maximum spacing between attachment points: *See attached engineering talcs g.Total surface area of PV array: 386.84 square feet h.Array pounds per square foot: 2.39 lbs square foot i.Distributed weight of PV array on roof sections: -Roof section 1: (22)modules,(35)attachments 26.46 pounds "- r (� d d T 4 I 3. Electrical Components: A.Module (UL 1703 Listed) Qty Yingh Energy YL255P-29b 22 modules Module Specs Pmax-nominal maximum power at STC - 255 watts Vmp-rated voltage at maximum power - 30 volts Voc-rated open-circuit voltage - 37.7 volts Imp-rated current at maximum power - 8.49 amps Isc-rate short circuit current - 9.01 amps B. Inverter (UL 1741 listed) Qty Enphase M215-60-2I:L-S22 22 inverters Inverter Specs 1. Input Data (DC in) Recommended input power(DC) 260 watts Max.input DC Voltage - 45 volts Peak power tracking voltage 22V-36V Min./Max.start voltage 22V/45V Max.DC short circuit current - 15 amps Max.input current 10.5 amps 2. Output Data (AC Out) Max.output power - 215 watts Nominal output current - 0.9 amps Nominal voltage - 240 volts Max.units per PV circuit - 17 micro-inverters Max.OCPD rating - 20 amp circuit breaker C.System Configuration Number of PV circuits 2 PV circuit 1 - 11 modules/inverters (15)amp breaker PV circuit 2 - 11 modules/inverters (15)amp breaker 2011 NEC Article 705.60(B) 6 p 'UrX 7L a 1 1 � v D. Electrical Calculations 1.PV Circuit current PV circuit nominal current 9.9 amps Continuous current adjustment factor 125% 2011 NEC Article 705.60(B) PV circuit continuous current rating 12.375 amps 2.Overcurrent protection device rating PV circuit continuous current rating 12.375 amps Next standard size fuse/breaker to protect conductors 15 amp breaker Use 15 amp AC rated fuse or breaker 3.Conductor conditions of use adjustment(conductor ampacity derate) a.Temperature adder Average high temperature 37.6°C (99.68°F) Conduit is installed 1"above the roof surface Add 22°C to ambient 2011 NEC Article 705.60(B) Adjusted maximum ambient temperature 59.6°C (139.28°F) b.PV Circuit current adjustment for new ambient temperature Derate factor for 59.6°C (139.28°F) 71% 2011 NEC Article 705.60(B) Adjusted PV circuit continuous current 17.4 amps c.PV Circuit current adjustment for conduit£ill Number of current-carrying conductors 6 conductors Conduit fill derate factor 80% 2011 NEC Article 705.60(B) Final Adjusted PV circuit continuous current 13.9 amps Total derated ampacity for PV circuit 13.9 amps Conductors(tag2 on 1-line)must be rated for a minimum of 13.9 amps THWN-2(90°C)#14AWG conductor is rated for 25 amps (Use#14AWG or larger) 2011 NEC Article 705.60(B) 4.Voltage drop(keep below 3%total) 2 arts: 1.Voltage drop across longest PV circuit micro-inverters(from modules to j-box) 2.Voltage drop across AC conductors(from j-box to point of interconnection) 1.iN irco-inverter voltage drop: 0.58% The largest number of micro-inverters in a row in the entire array is 11 inCircuit 1.According to manufacturer's specifications this equals a voltage drop of 0.58%. 2.AC conductor voltage drop: =I x R x D (=240 x 100 to convert to percent) _ (Nominal current of largest circuit)x(Resistance of#14AWG copper)x(Total wire run) _(Circuit 1 nominal current is 9.9 amps)x(0.0031952)x(1 707 _(240 volts)x(100) 2.23% Total system voltage drop: 2.81% n e EcolibriumSolar Customer Info Name: Email: Phone: Project Info Identifier: 17200 Street Address Line 1: 123 FRENCH FARM RD Street Address Line 2: City: NORTH ANDOVER State: MA Zip: 01845 Country: United States System Info Module Manufacturer: Yingli Solar Module Model:YL255P-29b Module Quantity: 22 Array Size (DC wafts): 5610.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: Enphase Energy Inverter Model: M215 Project Design Variables Module Weight: 40.8 lbs Module Length: 65.0 in Module Width: 39.0 in Basic Wind Speed: 100.0 mph Ground Snow Load: 50.0 psf Seismic: 0.0 Exposure Category: B Importance Factor: II Exposure on Roof: Partially Exposed Topographic Factor: 1.0 Wind Directionality Factor: 0.85 Thermal Factor for Snow Load: 1.2 Lag Bolt Design Load- Upward: 820 Ibf Lag Bolt Design Load- Lateral: 288 Ibf EcoX Design Load- Downward:493 Ibf EcoX Design Load- Upward: 568 Ibf EcoX Design Load-Downslope: 353 Ibf EcoX Design Load-Lateral: 233 Ibf Module Design Moment—Upward: 3655 in-Ib Module Design Moment—Downward: 3655 in-Ib Effective Wind Area: 20 ft2 Min Nominal Framing Depth:2.5 in Min Top Chord Specific Gravity: 0.42 EcolibriumSolar Plane Calculations (ASCE 7-10): R1 Roof Shape: Gable Edge and Corner Dimension:4.45 ft Roof Type: Composition Shingle Stagger Attachments:Yes Average Roof Height: 25.0 ft Include Snow Guards: No Least Horizontal Dimension:44.5 ft Roof Slope: 39.0 deg Truss Spacing: 16.0 in Snow Load Calculations Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.57 0.57 0.57 Roof Snow Load 23.9 23.9 23.9 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Net Design Wind Pressure Downforce 19.4 19.4 19.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf Design Wind Pressure Downforce 19.4 19.4 19.4 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.3 2.3 2.3 psf Snow Load 23.9 23.9 23.9 psf Downslope: Load Combination 3 13.2 13.2 13.2 psf Down:Load Combination 3 16.3 16.3 16.3 psf Down:Load Combination 5 13.4 13.4 13.4 psf Down:Load Combination 6a 21.4 21.4 21.4 psf Up: Load Combination 7 -11.3 -13.5 -13.5 psf Down Max 21.4 21.4 21.4 psf Spacing Results(Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 71.1 71.1 71.1 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 64.0 64.0 64.0 in Max Cantilever from Attachment to Perimeter of PV Array 23.7 23.7 23.7 Ti- n Spacing Results(Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 48.4 48.4 48.4 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 16.1 16.1 16.1 in EcolibriumSolar Layout bq e a X° Skirt Coupling O Clamp Warning: PV Modules may need to be shifted with respect to roof trusses to comply with Q Bonding Jumper maximum allowable overhang. EcolibriumSolar Distributed Weight (All Planes) In Conformance with Solar ABC's Expedited Permit Process for PV System (EPP) Weight of Modules: 898 lbs Weight of Mounting System: 70 lbs Total System Weight: 968 lbs Total Array Area: 387 ft2 Distributed Weight: 2.5 psf Number of Attachments: 35 Weight per Attachment Point: 28 lbs Bill Of Materials Part Name Quantity ECO-001_101 EcoX Clamp Assembly 35 ECO-001_102 EcoX Coupling Assembly 21 ECO-001_105B EcoX Landscape Skirt Kit 5 ECO-001-105A EcoX Portrait Skirt Kit 0 ECO-001_103 EcoX Composition Attachment Kit 35 ECO-001_116 EcoX Flat-Tile Flashing 0 ECO-001_117 EcoX S-Tile Flashing 0 ECO-001_118 EcoX W-Tile Flashing 0 ECO-001_363 EcoX Lower Support-Tile 0 ECO-001_109 EcoX Electrical Assembly 1 ECO-001_106 EcoX Bonding Jumper Assembly 5 ECO-001_104 EcoX Inverter Bracket Assembly 22 ECO-001338 EcoX Connector Bracket 22 BUILDING PERMIT E NORTy _ O�C, Zxl TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION W4- +� Permit NO. / Date Received "goRwrEo'�a,'y Date Issued: AC US IMPORTANT:Applicant must complete all items on this page C�- F '" ', x_ yrs 91--^ r tyl ;;,! i y �' ,•'".-�3 �3- _ �� t f' u SUP €i ��r A, � ? 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'S\�,_`y�c�.s„ a..L i�'�" ,�. ,!�� W�..".,t{x _ 'n ''C�' r - -. +,. ��-3ylr. :�,;;y+tom-�a::•+i r-F�+ i,.'`r, Cx�!s z T�r±ei[:.a2-l-+N`#'r�".a�,'��-v�a qs�"7 p-�t�7�},�it ��r�^�r,.s��H r�"f},�t�--ys ..x�'�ri.:a -�'n.n.r_...�.-z-;..�,.e�<e.'..if:r. _-'ti�5'c_- _r'�,'i<.i. �`a.yrf '"r:�+a5�'stY:35' }`fav,�"�.�r+i�•�5'`>-.w r, 7 i i i '�- � +t E,F.� T TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building VOne family Addition Two or more.family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition ` Other ab r, " r qua ��� � e iIN ac3 (`Se ' J2:r �� s 4 ° y r00 Yr �. ,._ .._ ..._... __..-... ......._._�._. r_ r . rs"- R T PREFORMED: -re DESCRIPTIONWORK OF WO K O BE P FORMED: r0 (1 lbo0r Q n& s tichor Identifin PIease T or Print Clearly) GINNER: Name: tio1 i Phone: ��( (-)8GJ Address: 1 ��f)C)A qf',M Rd ND °.z � m k..;'7,�- �, �Fu,�kt�! ^w-r �i-✓nrs'r'" '�i:z`os.!�;r',"'L. <i s.ii.us. v C 1 ( YT d I U {5 . ' : ti ;r,+��,13 'b:..s-,.dt�" - •,mac.- :u� ^�' ` 7 h;PIN srq +'. .x. l+�v'a+:-� �' +`' 't`ry` C �`�1^,.,' ti. "`�'.. �,t,2fF {" - -.+�`is#,xl ?✓7r7--'r}# kJ�.� � i,���.�+���`�'��ftt'y�.` �C"". Gln."..Y-„5. ,,r ^., `�'� �+s�`+�.��`�� k�• �� s��ks; +ry���d�,�.'.tF4krx� �� `�".rz��xF''�. �!t!�7x..� �'y� some-la Te7''�'+g r�"."'z--� a...1' y�,., In.�: 111191 d rot }p7s- k a t`, + T'-•net'� .c4 ] 4's °r- a _ r ' �a 'a `1��' ti+s- .Z ”. `Y'K7T".ti}a 8 t'��.r,�Xls � �f ,�. s; � . . (� a _ Is '� S v c e � _ b• «; V�_ ��'f - e c,Fi '?aJt rye - +-n _1 EBF l a-��, �'Yr t hr "` c f �v? &t'cl �.r + z -•r �W ? �`'" J,V, F br.;. .g'' s Y r �U B?'�A�.��"5 � 'Imp �+"a c-e�t'•'� h',�i+'. 7!rc..f.;.' w�x::r :,€v sem..{ .'�„y-i ���.�c � N+•f r t w-S�RL � �.� .. ...�:-.I- 4Y_�.cr.: t.r[�'��,',? ES,r. +I�.ucsh nl ", v R+-ILx�{717 ✓.�H' r ;II.1 'k �a'r 1. '"1'�-'`.. - 3 -M.�,�T tiM« `.F'—fib I:^ _ 'w:,�.�;:. _ �'s �+-zYls �+y,.�>✓.._r1�,r.;,r.Gf-u,,i �cf ='Jk=�R$: �si�ii'r, r(.4^`'�Y v�ti;..'`ty�t s.}z�.A frr SII Ig' 'zrins. a'�.-.+ ,T} 1+��:/.1�p ,d[,y.9ti�� r F y■ s z� �F'.. r I+���s- .8,..r v,�l4c -r �.. .l.�Xr'� z, r �` s,� e1. '"'�.$r�'s-ti.�.�„-1!1�+.�t,(a ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ .� FEE: $ Check No.: Is 6 Receipt No.: DO NOTE: Persons contracting with unregistered contractors do not have access to the g r nafur ��AgenfiJQanlner �:' = ' natur ofco` ractbi� . 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 ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or..Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/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 NOTE: 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 2008 Plans Submitted Plans Waived Certified Plot:Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments a Conservation Decision: Comments Water & Sewer Connection/Signature&Date Drivewav Permit DPW Town Engineer: Signature: Located 3, 4 Osgood St eet _ a 74TIEjNTfeerx��Dt�rpseT9te e '� .7:µ ri z' 4 ,Lrocafedfi9� rlain tree# 7 i f} t} g ��. t7•F7T.e r'i�Rar�r�ent s�,�n�r��,eldate -� �E� r y-�-, �� , - r,T�,. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. 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.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 Location A ✓L /�✓! No. — �Q Date • - TOWN OF NORTH ANDOVER FI)� ` Certificate of Occupancy � Building/Frame Permit Fee $ ry Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check#LLif 2— Building Inspector F NORT#i own of 1, ndover 0 - 0 OLAKIver Mass COCKIC141WICK S U BOARD OF HEALTH PER IT. T LD Food/Kitchen Septic System THIS CERTIFIES THAT ........... �.... .? l�lr...... .1...o�?�G...!'1.. . ....... ....... . BUILDING INSPECTOR .• Foundation has permission to erect .......................... buildings on .�..•• •,,,..... ........ /!!l!�••••••�•••••• Rough to be occupied as :.....Doay�,s..... .... .. .I�it,L•....(;p7••. ... Chimney provided that the person ac epting 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 S- PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO S 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. iu J j_7� i �} 7�0_z Owner's h Job Addrf Diane DiBenedetto 978-686-3561 3P G - WINDOWS - DOORS 123 French Farm Rd. Phone:- North Andover, MA 01845 family Owned And Operated Vvre the o:ner(s)of the premises men°oned below hereby cont._..... sh p, I rsta!'construct and place the;mprovements according to me fol'o;ming spec:f.at;ars.term and cor tons.on premises be'r.':dascroed Brand: (WINDOW)SPECIFICATIONS Quantity: Build Tie Into Low-E Metal PVC New Inside TOTAL$ Roof Overhang Argon Screens Grids Trim Trim Finish G Color: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No - //' S7 Double Hung 1/3 Deposit$ Picture Slider 1/3 Start of Job$ BOW/Bay Garden 1/3 Balance Upon Cas/Awn Completion$ NOTES: _ s — 7/1 j- (SIDING) (SIDING)SPECIFICATIONS Apply over body area of house.Type of insulation Items not covered or installed: Yes No Yes No Yes No Strip off Existing Siding Vinyl Shutters Roof Provide Container and remove all Window Mantels New Gutters debris Cover Fascia&Soffit Door Surrounds Gutter off&on Door Window Casing Ceiling Fluted Post 5Y2 Vinyl Fixture Accessories if needed PVC Trim Traditional Post 5112 4'Corners ON START OF ALL JOBS-HOMEOWNERS MUST REMOVE ALL ITEMS FROM WALLS&SHELVES Construction related permits:If the homeowner obtains his own construction-related permits for the work described under this agmement,the homeowner is here by advised that in the event of dispute,judgment and nonpayment of the contractorft homeowner will not be entitled to make a claim to or collect from Ms guaranty fund established by Chapter 142A,M.G.L. WARRANTY w ,..<.... _ ,. _,... ; _.... .. .. _. 1 Year _,ti,a L:/'I XC,''C-"F":J"CC•':'C':I r.'h 4.Zc.'tt ".b=k.p"rOF^O 0= oc E7, 7 c'_+...�. eF..:ts, :17"'3 ar": ,s7. -Mnees hel,ra3"T-cr:„^.a"a'"ao':3b D'3-e:,,,ao"C.C.Fv"3o+s 3 Vi- ;Ma z" `'�".ea..=z'?^1.:,z__3^z.d'-7 _ a or Ca.?R_'^XS_ :-Z3'7 re: ' =e" ai'S.BP.:.tCs s 9:'osaU^S::`7"' •' C:r A LBrtz";5 '": -r'a"'. S 2- :3S T -F-2: : ':.. .. . ^z'.:zrQ'^,C¢'a...e'¢._: eC`::.'^a's"9z"7_SE C':u^^eti. .."O(ai`ai.. 72 c":5'.� - �... Ca:ac Cd39" 3z'a rC"'; "'s':.'E•. "r'e['° ----o:: e- .. _._..as". ^'zcr.s - -- .e.:. •cx .',` a.,e ..,r�.:. _ ^ ., .. .:RER 3,,RA"7EESS:Aa.�"...4 e ;..5'.3T s'.;.,S 5..,a s-n:e :`2�c".,. _:e.,"ceair^x.'^a Oe zaJa.or�._•ce`xtC=az�cev,,�'aw�sc'cc"�cre•lo._ .�-c'ar-'zctl';x:^raaa:cK1C'.,c_:.-�e:..ro3c'astcr,^.. -r ...r. .,"•ass cZ:s:n'_. .-.._�i.'CaaL,.-. ,•�:r2_"•g� -;ros.erz.raol"..__.�^:aa�_„acc TOTAL$ Oy Brooks Vinyl Siding•Windows•Doors Payment to bem+d Name of CoMnicl.. :)-Z-tted R-S strmnt / 254 N.Broadway-Breckenridge Mall V3 IS Un signing Contract; Stmt Add._.e 1/3 (S_ ,L� Rtrt of Job Salem,NH 03079 ((60 3)894-4488 wwww.brookeswd.com tri is_ Balance upon completion 101682 99730 A- H:C k Rap_trxfo^• CSL a .. `a za•Ci _ _Te Ti•i. .i' .a":a'k s"2 'CC;.'e 3:.^gi,T: . ,,._..ce Nam f ' .,, - e-�-',.—. .-."ice-•�ct:�:earmz?.._"�._.:z�^..�.s��i3,-^-. V /)rL '/1 cr�'zc r ..?-3��:.�aa...�e:r9✓a"a%r'^...s a.... .. .. .'sic...rc% � - Aeeeptance of Proposal- ce".t t^e i•vssaro'-.-'s ora ie^a'i-s s?e o :a3r3'z-a?"ai ae-s;�"1,'^a e•c h:^c 25..'Cl sc^.=You,"Buyer awy cancel thls transactlan at any tires prior to midn!sht of the third business day after af3 data of tics tren--ccen.Cv=!!zdon must be Bort±in arming.We msxve the right to check your credo. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. IN WITNESS W/F}E oft pArtie hereunto ave signed their names this K2 _day of />Y I 20� Signed v ri e•?3mtn '1tr C=�]zc.,.c.:,�.c•^..s:'CC".^::`t ...,^c'_.o:fy!. ., r7:rcrc'C, _ ''C 7 e a' SIX, - 3.55 1.S. „5a Signed A . _//'' fL -"'c-'5._ ? .c._. a r Xis• ES.I to Owner XX�_ The Commonwealth ofMassachusetts • - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 1 ((wh s colqGkuG BV) IC_ Address: as� N , &Qcd W2:.A City/State/Zip: SgV M, t j VA ()3DY1 Phone M (D 03-N+q(4U Are you an employer?Check the appropriate box: Type of project(required): 1.911 am a employer with q 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/orpart-time)* have liiredthe sub-contractors 2.❑ 1 am a sole proprietor orpartner- listed on the attached sheet. -7. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp,insurance 5. F1 We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing.repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' .13.❑Other comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Mc.#: WC 3�a`�s Expiration Date: 560 1 e Job Site Address: X23 F 1`Qf& %gym City/State1Zi-o:_ U 0 rr1`WW O a 1&95 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine up 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certio under i d penalties ofperjury that the informationprovided above is true and correct. - Si afore:f4Date: LOther only. .Do not write in this area,to be completed by city or town offrcial. n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector - - - son: Phone#: Information and Instructions . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be,deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required?' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. IFan LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.More a homeowner or citizen is obtaizvng a license or permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT xequired to complete this affidavit. The Office of Investigations would Tike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Cox ouwealt�of assac usotts - Departent off dusidal,A,ccideats Office oi'znvestigatiom 600 Washingtola Stzeet Boston?MA,02111 Tel.#617-727,4900 at 406 or 1-877,MA.SSAFE Revised 5-26-05 FaY,0 617"727-7749 WWW-Mass,gov'/4ia A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 6/29/2015 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(les) 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 CONT NAMEACT Linda Bogdanowicz Insurance Solutions Corporation PHONE (603)382-4600 FAx C No):(603)382-2034 60 Westville Rd EMAIL DDRE .lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURERA:Peerless Indemnity Insurance 18333 INSURED INSURER B Brooks Construction Co. of Lawrence Inc, DBA: INSURERC:Excelsior Insurance 11045 254 N. Broadway INSURER D: INSURER E: Salem NH 03079 1 INSURER F: COVERAGES CERTIFICATE NUMBER CL1552621745 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. ILTR TYPE OF INSURANCE A L U POLICY NUMBER MM/DD�Y MM/DOI EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED100 0 PREMISES Ea occurrence $ , 00 A CLAIMS-MADE Fil OCCUR CBP8945793 /16/2015 /16/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ( ) AUTOS AUTOS accident BODILY INJURY Per $ HIRED AUTOS NON-0WNED PROPERTY DAMAGE $ AUTOS Per accident Medical payments $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ _ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ _ DED RETENTION $ C WORKERS COMPENSATION WC STA U- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 500,000 OFFICERIMEMBER EXCLUDED? N❑ $NIA -- (Mandatory In NH) 8836275 /16/2015 /16/2016 E.L.DISEASE-EA EMPLOYE $ 500,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Diane and Philip DiBenedetto ACCORDANCE WITH THE POLICY PROVISIONS. 123 French Farm Rd N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE Keith Maglia/CLS ` —- (���--- ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. msn9.r,nrrmnns)ni Tha Armon norma nnA Inn^ara ranic#arari mnr4e of annpn ""�'Office of Consumer Affairs&Business Regulation Fi4jegistration: a-ME IMPROVEMENT CONTRACTOR 101682 Type- Expiration: 6/29/2016 Supplement r BROOKS CONST.CO:,INC.OF LAW MARK DI PRIMA s 254C N.BROADWAY STE 110 SALEM,NH 03079 Undersecretary rd Massachusetts -Department of public Safet,r off Board of Building Regulations and Stand&;i7s Construction Supcni%nr Specialt-, License: CSSL-M730 MARK DIPRIMq; 18 HAWK DRIVE SALEM NH 03079 - CxPiration Commissioner 02/20/2016