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Building Permit #758-16 - 19 LITTLE ROAD 12/23/2015
Nvn.ry BUILDING PERMIT 0? ° -JV TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMIN�N Permit NO: //-- S � �Y/ Date Received � C- 04q �RATID Date Issued: �� �� SSACHU IMPORTANT: A licant must complete all items on this page LOCATION I.-tTl Cl • - C C 2ra H° t. ` PROPERTY OWNERPrint 1y �QeZ Print MAP NOM � PARCEL: ZONING DISTRICT: Historic Districtye_ no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition 310ther ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer 19 OWNER: Name: Address: I q CONTRACTOR Name: Identification Please Type or Print Clearly) k Phone: 97k-(ok�1-0,o3-7 lot V(1(tK Address:(,, lV i'1ki i11 Supervisor's Constructio License: Exp. Date: Home Improvement License: }� Exp. Date: �� t ARCHITECT/E IA Phone: O %` 970-2 Address: q4070 Reg. No. 41ywo FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. '— Total Project Cost: $ 95�a/q FEE: $ <, z-.;; Check No.: ?, 6 2, Receipt No.: NOTE: Persons contracting with unregistered contractors do not have a cess to the guaranty fund Signature of Agent/Owner Sianature of contractor,, as r� BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received Date Issued: _ IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 100 Year Structure yes MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes no no no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ Addition ❑ Alteration ❑ One family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: ep-ti_c ❑'_ .; _r ®�Wate /Sewer 0 WetPantl _ Dyl/Vat shed` Disfinct ._ ' DESCRIPTION OF WORK TO Fat VtKl-UKmtu: Identification - Please Type or Print Clearly OWNER: Na OrlrJrccc- Contractor Name: Phone: Email: Address: Supervisor's Construction License: Home Improvement License: hone: Exp. Date: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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 NE: 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 I ECC Energy code Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 Plans Submitted ❑ Plans Waived [I Certified Plot Plan 11 Stamped Plans F1 OF SEWERAGE DISPOSAL FTYPE Public tuiblic Sewer Sewer 'r Tanning/Massage/Body Art ❑ Swimming Pools 0 well El 'I Tobacco Sales El Food Packaging/Sales 0 Private (septic tank, etc. 11 Permanent Dumpster on Site [1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS, Reviewed On Signature CONSERVATION- - R-eviewed-on------ ---------------Signature COMMENTS HEALTH COMMENTS_ Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: --Zoning Decision/receipt submitted yes Planning Board Decision: - Comm Conservation Decision: Comments Water & Sewer Connection Driveway Permit 4 1 ) ]DPW Town Engineer: Signature: 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 ®ANGER ZONE LITERATURE: lies No MGL Chapter 166 Section 21A –F and G min.$100-$1000 fine Doc.Building Permit Revised 2014 r— Location f L( PL No. O �? Date V Check # o 2, 29855 TOWN OF NORTH ANDOVER x Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL . C O O "O O = O ® y =h < CD-0fA d 2 �• m O Ci O Q' z c - a C ,•F OO - Q v STI O• h ID C1,..I C/1 CD 0 N _. - CD <D 2 O COcn =� CDov = CD CD Z �, C CD N CD to CL //A�CD J� _v D co %Z 0 rn o. o X D `° N -� �o� U' < C -�-I 70 < `CD c CDS O M ITI N CD a' A, n — �' o ' 'b MIR ' —� r -o: CD O " * rt n 0 u n �: CD Z 0= -?U) ,.,,� F c c CL p (D _ U b O o i# CD rt Z CD y cD0 .0 O � G7 : a : :• CD D �D NCD '0 N O m -a G m : c 2) O : 23 o N 3 ° rD � U) rD z p W c � T °—' X O w T °' °— V7 m n• m .T1 O m S T �' °—' � p ago S T �' °—' n � 3 7 m K .Z7 O a°a S T ° � Q v = O V) m �. ff L < N T O Q \ r o M D -1 Z y Z N m A m m '° D '— _ Z m M C W Z G1 _ Z to M O W C , v cZi _ Z H m m O 3 7 m :3 o0 v O m 2 a _. 0 LW THIS HOME IMPROVEMENT SOLAR ENERGY CONTRACT (this "Contract") IS BETWEEN: Leslie Lopez ("Client") located at 19 Little Rd N. Andover, MA 01845 ("Client's Property") -AND- Northeast Solar Services, Inc.® ("Contractor") of 1 North Ave Suite A Burlington, MA 01803, with Home Improvement Contractor Reg. No. 178137, which expires on March 17, 2016, and Federal Employer ID 46 0569853. Contractor's sales person for this contract is Kellie McManus. The parties to this Agreement agree as follows: A. Installation of PV System. The above Client(s) has engaged Contractor to perform the following residential contracting work (the "Work") in connection with the installation of the following photovoltaic solar energy system (the "PV System"): 15 SunPower - SunPower 327 watt modules (or equivalent) with 1 Solar Edge - Solar Edge SE 5000A Inverters (or equivalent) and all mounting, disconnects, and all other PV System components necessary for a National Electric Code compliant PV System, totaling 4.905kW, located at Client's Property. B. Other Inclusions The Work shall further include: • Installation of the PV System in accordance with all State of Massachusetts interconnection standards. - All reasonable engineering and permitting costs. The following building permits are required and will be secured by Contractor as Client's agent: Building and Electrical Permit. • Following the installation, Client will receive a PV System orientation and a PV System Client's manual. Notice: It shall be the obligation of the Contractor to obtain all permits related to the Work. Clients who secure their own permits will be excluded from the guaranty fund provisions of Chapter 142A of the Massachusetts General Laws. 11, COMPENSATION AND SCHEDULE A. Contract Price For Contractor's performance of the Work under this Contract, Client will pay Contractor a total of: $ 25,219.85 (TWENTY FIVE THOUSAND TWO HUNDRED NINETEEN AND 85/100) DOLLARS USD (the "Contract Price"). B. Payment Schedule The Contract Price will be payable in accordance with the following payment schedule: Date Paid: $ 12.609.92 Initial Payment- 50% (Due upon Contract signing, which is an amount less than the cost of the materials and equipment which must be specially ordered in advance of commencement of PV System installation) $ 11.348.93 Progress Payment - 45% (Due upon Substantial Completion) $ 1.261.00 Final Payment - 5% (Due upon Final Completion) C. SGhedule The "Start Date" of this Contract is the date Contractor receives the full amount of Client's initial payment of 50% of the Contract Price. Subject to adjustment for any Force Majeure reason stated in Section IV.J., the Work is estimated to begin within 12-16 weeks from the Start Date of this Contract. The parties agree that this date shall be automatically extended to the date of delivery of all materials and equipment which mut be specially ordered. Substantial Completion is estimated to occur within 16-20 weeks from the Start Date of this Contract, but the parties agree that this date shall be automatically shortened or extended to the date on which all racking and electrical work are complete and the PV System is capable of generating power and ready and available for use subject to final government and utility approval. Final Completion is defined as the date on which all punch list items are complete, all permits are closed, all other government and utility approvals are obtained and the Work is complete to the satisfaction of Contractor and Client. Client acknowledges and agrees that the Work involves permits, inspections and approvals from various government agencies and utilities, and therefore the timing of the Work may vary and is not within Contractor's control. Client further agrees that Contractor shall not be liable for any losses, costs or damages related to any delays for reasons beyond Contractor's control, including all causes noted in the Force Majeure section of this Contract below. RevoluSunxom Northeast Solar 1 North Ave Suite A Burlington, MA 01803 781.240.6555 A. Contractor's Registration: All home Improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by provisions of Chapter 142A of the Massachusetts General Laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director of the following state agency: Office of Consumer Affairs and Business Regulation Home Improvement Contractor Registration Ten Park Plaza, Room 5170 Boston, MA 02116 (617) 973-8700 B. Client's Cancellation Rights: Client may cancel this Contract, without penalty or obligation, within three business days following the date on which Client signs this Contract. A Notice of Cancellation is attached hereto for Client's convenience. C. Warranties: For a period of ten (10) years from Substantial Completion, Contractor warrants that the PV System has been designed and installed in a good, workmanlike and substantial manner in accordance with all applicable building codes. In the event Contractor is required to penetrate the roof of the Client's property in the course o ' Nat ont" a uses d -a naage to the roof within a three (3) inch radius of a penetration, Contractor will repair such roof damage for a period of ty (20) years from Substantial) pletion or the remaining term of the roofs existing installation warranty, whichever is shorter, to prevent any water, her-moisturEJea"gepage or entry directly caused by such penetration. These warranties are for normal use and conditions only. All warranty coverage to equipment and workmanship Installed by Contractor will be VOID if any alterations or repairs are perforated by any person or persons not expressly authorized, in writing, by Contractor. THIS WARRANTY DOES NOT COVER: (a) Damage caused by external forces such as, but not limited to, vandalism, theft, terrorism, fire or act of God; (b) Damage caused by weather effects exceeding manufacturer tolerances; (c) Normal wear and tear or aging of a PV System; (d) Any implied warranties: (e) Electric bills, water damages or any other consequential damages; or (f) Damage to the PV System or its efficiency due to adjustment, moving, or tampering with the PV System or any of its components by individuals not approved by Contractor. D. Change Orders: Any alteration or deviation from above specifications Involving extra costs must be subject to a written change order signed by both parties, which shall be incorporated into this Contract, and Client shall be liable for any additional costs resulting from each change order. By initialing the space below, Client hereby specifically agrees to execute a change order, and pay the additional costs, if it becomes necessary for Contractor to repair or replace un -approved or non -code compliant electrical work in order to complete the PV System installation and satisfy code requirements. Client's Initials: _ Client's Initials: ARBITRATION: CONTRACTOR AND CLIENT HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT CONTRACTOR HAS A DISPUTE CONCERNING THIS CONTRACT, THE CONTRACTOR MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE DIRECTOR OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND CLIENT SHALL BE REQUIREP TO (iUBDMIT0 SUCH ARBITRATION AS PROVIDE�D��I-N1 .G.L. C. 142A. Client: I�`�.I-AV Date: 1w Client: Date: Contractor: –� -- Date: iz�+_7 NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by Contractor. Client may initiate alternate dispute resolution even where this section is not separately signed by the parties. E. Incentive Guarantee: By Client's initials below, Client acknowledges and agrees that Contractor has not and does not guarantee Client's qualification for, receipt of or amount of any tax credit, rebate, solar renewable energy credit (SREC) or other incentive amount in connection with the PV System, and any estimates of incentives (wither in a PV System proposal or otherwise) are not guaranteed to be accurate or available. Client is responsible for determining Client's and/or the PV System's eligibility for any incentives and should consult with tax, legal and other advisors regarding availability and possible tax consequences of Claiming the same. Client's Initials: Lo -011 -- Client's Initials: Northeast Solar 1 North Ave Suite A Burlington, MA 01803 781.240.6555 108378 W 1.5.01 g 06/1712015 4 iW REVOLU(S'UIh A. ASS: To enable Contractor to perform its Work hereunder, Client shall grant during daylight hours adequate space on Client's property, as mutually designated by Contractor and Client, for the complete and proper installation, operation, maintenance and repair of the PV System as well as rights of ingress and egress to, through and from such property and the space designated for the PV System. B. Scarcity f Materials: Rights of Termination: The PV System components to be obtained under this Contract are scarce commodities. In order to meet the performance requirements of the PV System described in this Contract, Contractor may substitute the specified brand of solar module or inverter for a similar brand of module or inverter that allows for more timely completion of the installation. Such substitution, if necessary, shall be of UL approved devices, with aggregate performance criteria the same as equipment specified. The governing body for determining performance criteria shall be the CEC (California Energy Commission) that rates all UL approved modules. The key module statistic used for performance criteria will be the DC STC rating of the sum of the modules. The key inverter statistic used for performance criteria will be the AC output of the device. If, due to code requirements, equipment substitution, final engineering, space availability, etc., the size of a PV System decreases, Contractor shall re- calculate the Contract Price using its standard pricing method and the Contract Price shall be automatically reduced. Client shall be credited by the reduced amount. If due to substitution the DC STC size of the PV System increases slightly, then Client shall not have to pay Contractor similarly. Contractor shall make every reasonable effort to ensure that PV System size does not decrease from the specifications. If the DC STC size of the PV System decreases more than 15% from the Contract's specification amount for any of the reasons stated in this paragraph, Client shall have the right to terminate this Contract within ten (10) days of Contractor's written notification to Client of such decrease, and Contractor shall then refund in full all funds paid to date under this Contract, but shall have no other liability to Client. Contractor reserves the right to unilaterally terminate this Contract within 45 days of its approval without any liability to Client if any of the PV System components required for the completion of Contractor's Work in a timely manner are not available. In the event of such termination, Contractor shall refund all monies paid by Client to Contractor as of the date of termination. C. Limitation of Liability: In no event shall Contractor be liable in an amount exceeding the compensation paid by Client to Contractor under this Contract. Contractor shall not be liable for any incidental, consequential or special damages or for economic loss or expense of for loss or profits or income of Client, or Client's consultants or agents or employees, or any of them, including but not limited to any electricity costs incurred should installation of the PV System be delayed beyond the commencement or completion schedule set forth above. D. Zoning: Client shall pay for all variances, special permits, or other costs related to zoning, including without limitation any fees or costs related to attorneys or engineers. E. Client's Property: Client agrees to remove or to protect any of Client's personal property, inside or out, which may interfere with or obstruct the Work, including but not limited to landscaping, and Contractor shall not be held responsible for damage to such property. Client understands and acknowledges that proper operation of the PV System purchased hereunder is dependent on Client's existing roof and equipment and Contractor shall have no obligation or liability for the condition thereof, or any other part of Client's improvements or equipment not purchased hereunder. Client expressly represents that the roof of the property upon which the PV System will be installed is in good condition, with no known water infiltration problems or other structural defects. F. Insurance: Client must carry all fire, casualty, hurricane, earthquake, theft, and other insurance related to Client's real and personal property. G. Cancellation of Contract: If Client cancels or breaches this Contract after the opportunity to execute three (3) day rescission has passed but before commencement of construction, Client shall pay Contractor the amount of expenses incurred to that date plus 20% of the Contract Price. If Client fails to pay said amounts within thirty (30) days of Contractor's demand for payment and Contractor files suit, Contractor shall be entitled to recover all of its damages including its loss of net profits and attorneys' fees and costs if Contractor Is the prevailing party. H. Costs of Collection: If Client fails to pay any amounts owed to Contractor when due, Client shall be liable for all costs of collection, including reasonable attomeys' fees, plus 18% interest per annum on the unpaid balance. Contractor also shall have option of removing all or part of the PV System from.Client's premises in addition to receiving payment equal to the value of the unpaid balance to cover all or a portion of Contractor's consequential damages. I. Liens: Contractor, any subcontractor(s) and any other persons or entities supplying labor and materials to Client under this Contract, have the right under applicable law to impose a lien on Client's real property for the value of the labor or materials provided. Upon Client's payment of all amounts due under this Contract, Contractor will provide, upon Client's request, a release and waiver of any liens. J. Force Majeure: Contractor shall not be liable for any delay in material and/or equipment delivery or for failure to deliver or failure to perform the Work which results from any cause beyond the Contractor's control. Such causes Include but shall not be limited to: an act of God or of the public enemy; an act (or failure to act) of any government or utility; a fire, flood or epidemic; quarantine, restriction, strike, freight embargo, terrorism, theft or unusually severe weather; Contractor's inability to obtain necessary materials, labor or transportation; custom permitting caused by Client's site conditions; homeowner association review or approval; building or other code requirements relating to Client's existing electrical system or building characteristics; and any other Impediments to the installation of the PV System arising from Client's ads or omissions and/or the condition of Client's property. =s dzk 3 Northeast Solar 1 North Ave Suite A Burlington, MA 01803 R8V0)USUI1.COITt 781.240.6555 108378 V0.5.01g 08114!2015 K. Legal Compliance and Severability: Contractor and Client acknowledge that the form, substance, content and notices contained in this Contract are intended to comply with Chapter 142A of the Massachusetts General Laws, and regulations promulgated thereunder. In the event of any instance of non- compliance, only such portion shall be invalid and the remainder of this Contract shall be in full force and effect. In addition, any such portion not in compliance shall be read and Interpreted so as to have its intended meaning to the maximum extent allowed under such law and applicable regulations. L. Entire Contract: No Waiver Unless In Writing: This Contract constitutes the entire contract between the parties; there is no representation, warranty, collateral contract or condition affecting this Contract except as expressed in it. No provisions of this Contract shall be changed or modified, nor shall this Contract be discharged or waived, in whole or part, except in writing signed by both parties. This Contract shall not be effective until fully executed by Client and an Authorized Representative of Contractor. M. Client's Representation of Authority_: If this Contract is signed by less than all of the persons or entities who own the subject property, then Client who signs this Contract (or any of the provisions hereof) represents to Contractor that he, she or it has full legal authority to bind the other persons and/or entities. N. Governing Law: The laws of the Commonwealth of Massachusetts shall govern any proceeding or dispute related to this Contract. 0: Production Gap Guarantee: This production guarantee covers 90% of estimated production in year 1 and decreases at .6% each year for a total term of ten (10) years. This guarantee is determined on an accrual basis and payments are made when the aggregate system production falls below total production estimated on the schedule above. Payments will be made at the end of each anniversary of the system's in service date of interconnection. Production Gap Garranty is void if site conditions and solar access change after the date of interconnection. Client's Initials: 1, L, Client's Initials: P. 3rd party Financing: Should the client obtain financing from a 3rd party which Is approved by the Contractor, the payment terms of the lender will apply. Client: Contractor: QName: Date: t �� Title: Date: Northeast Solar 1 North Ave Suite A Burlington, MA 01803 781.240.6555 108378 W1.5.010 061122015 VECTOR E n O i n E E R S Project Number: U1883-0035-151 December 15, 2015 RevoluSun 1 North Avenue Burlington, MA 01803 ATTENTION: Ryan Stair REFERENCE: Leslie Lopez Residence: 19 Little Road, North Andover, MA 01845 Solar Panel Installation Dear Mr. Stair: Per your request, we have reviewed the layout and photos relating to the installation of solar panels at the above - referenced site. The following materials and components are proposed in the installation of the solar panels. Roof Structure: 2x6 rafters at 24" O.C. Roof Material: Composition Shingles Based upon our review, it is our conclusion that the installation of solar panels on this existing roof will not adversely affect the structure of this house. The design of solar panel supporting members and connections is by the manufacturer and/or installer. The adopted building code in this jurisdiction is the 2009 International Building Code and ASCE 7-05. Appropriate design parameters which must be used in the design of the supporting members and connections are listed below: Ground snow load: 55 psf per Massachusetts amendments to the IBC (verify with local building department) Design wind speed for risk category II structures: 110 mph (3 -sec gust) Wind exposure: Category B Our conclusion regarding the adequacy of the existing roof is based on the fact that the additional weight related to the solar panels is less than 3.05 pounds per square foot. In the area of the solar panels, no 20 psf live loads will be present. With an assumed roof dead load of 15 psf, roof snow load of 38.5 psf per above, solar panel dead load of 3.05 psf, and affected rafter span of 87% (maximum), the additional gravity load will be 4.9%. Because the increase is less than 5%, this alteration meets the requirements of the exception in Section 707.4 of the 2009 International Existing Building Code. Thus the existing structure is permitted to remain unaltered. Similarly, at arrays where the solar panel dead loads are 2.98 psf and 2.93 psf, a maximum affected rafter span of 89% and 91%, respectively, are allowed while still maintaining less than a 5% increase in additional gravity loads. Regarding wind loads, we conclude that any additional forces will be negligible due to the low profile of the panel system. It is our conclusion that any additional seismic loadings related to the addition of these solar panels is negligible. During design and installation, particular attention must be paid to the maximum allowable spacing of attachments and the location of solar panels relative to roof edges. The use of solar panel support span tables provided by the manufacturer is allowed only where the building type, site conditions, and solar panel configuration match the description of the span tables. Attachments to existing roof joist or rafters must be staggered so as not to over load any existing structural member. 'Waterproofing around the roof penetration is the responsibility of others. All work performed must be in accordance with accepted industry -wide methods and applicable safety standards. Vector Structural Engineering assumes no responsibility for improper installation of the solar panels. Please note a representative of Vector Structural Engineering has not physically observed the roof framing. Our conclusions are based upon the assumption that all structural roof components and other supporting elements are in good condition, free of damage and deterioration, and are sized and spaced such that they can resist standard roof loads. Very truly yours, VECTOR STRUCTURAL ENGINEERING, LLC Roger T. Alworth, S.E. Principal RTA/amw 15, 2015 9138 S. 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CD n 22 g M VI P L i ala JI > O� 0 < > IJ1 .0 80 Z 0 71 c C) pr -4 Fj U) rn rn n2z Ln Ln rn rn c w z 1 ne commonweatua of massacnitseus IG Department of Industrial Accidents - Office of Invesdgations I Congress Street, Suite 100 Boston, MA 02114-2017 ivtmmass gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization4ndividual): Northeast Solar Services Inc Address:/ North Ave Suite A City/State/Zip:Buriington / MA / 01803 Phone #: 781 - 270 - 6555 Are you an employer? Check the appropriate box: Type of project (required): L ❑✓ I am a employer with 12 _ _ 4. ❑ I am a general contractor and I 6: ❑ New construction employees (full and/or part-time).,* : 2. ❑ I am a, We proprietor or partner= have hired the sub -contractors listed on the attached sheer. 7. ❑ Remodeling ship and have no employees These sub -contractors have g; E] Demolition working _for me in any .capacity, employees and have workers' comp. 'insurance. # 9. ❑ Building addition [No workers' comp: insurance required.] _5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am ahomeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12: ❑ Roof repairs insurance required.] t c. '152, § 1(4), and we have no 13.❑✓ OtherSolaf PV employees. [No workers' comp. insurance.required.l *Any applicant that checks box # I .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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. Mthe sub -contractors have employees, they must provide their workers' comp. policy number. I arts wn en4ployer tliat is providuig workers' con;pei sation imuratice for my eh ployees. Below is the policy arid, job site Mformadoa, Insurance Company Name: Federated Mutual Insurance Company Policy # or Self -.ins. Lic. #: 9884086 Expiration Date1 /08/2016 - Job Site Address:_ _ _J _ l_ __ U' Job Q _ - City/State/Zip: N • �UVE�i (�A diT-� 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 informat on provided above is true and correct, Millm Phone #. 781-270-4899 Official use only. Do not write its this area, to be completed by city or town offaciaL 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 #: CORD®) CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDOrN 1>7A) M5 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 pollcy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may requlre an endorsement. A statement on this certificate does not confer rights to the certiflcate holder In lieu of such endorsement(s). PRODUCER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 OWATONNA, MN 55060 - - -- CONTACT CLIENT CONTACT - - CENTER NONNo 4949 FAX Nei: 50741464613A TcENTEROFEDINS.COM 1 UDA Ess: cuwcomc _.INSURERS AFFORDING COVERAGE NAIC # INSURER n: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED 297-673-6 NORTHEAST ELECTRICAL INC, NORTHEAST SOLAR SERVICES INC 1 NORTH AVE BURLINGTON, MA 01803 INSURER M INSURER C: INSURER D. INSURER E: INSURER P COVERAGES CERTIFICATE NUMBER: 54 REVISION NUMBER: 2 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. TYPE OF INSURANCE SL UR VBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS rA GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE NX OCCUR Y N 9864084 12/31/2014 12/31/2015 EACH OCCURRENCE $1,000,000 DAMAGE 01 .1T RENTED $100,000 MED EXP iMy one person) EXCLUDED PERSONALSAOVMJURY $1,000,000 GENERAL AGGREGATE $2,000,000 OEWL AGOREOATE LIMIT APPLIES PER: X POLICY jE o- 'LOC PRODUCTS - COMP/OP ADO - $2,000,000 -- A AUTOMOBILE LIABILITY X ANY AUTO AuTOOlSN1VAUTOS SCHEDULED HIRED AUTOS NON -OWNED AUTOS Y N 9884085 12/31/2014 12/31/2015 OMBINED SINOLE LIMIT $1,000,000 BODILY INJURY (Per person) BODILY INJURY (Per accideno ROPERTY DAMAGE A X UMBRELLA LIAR EXCESS X OCCUR CLAIMS•MADE N N 9864087 12/31/2014 12/31/2015 EACH OCCURRENCE $S.GDD,000 AGGREGATE $5,000,000 0H0 RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER(MEMBER EXCLUDED? (MandatoryIn HH) If Tea, describe Ander DESCRIPTION OF OPERATIONS below NIA N 9864086 12/31/2014 12/31/2015 WC STATU• 0TH - %t TORY LIMITS ER E.L. EACH ACCIDENT $1,00D,ODD LL DISEASE - EA EMPLOYEE $1,000,000 61 DISEASE -POLICY LIMIT $1,0001000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Wlach ACORD 101, Additional Remarks Schedule, N mora space Is required) THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED BY CONTRACT ENDDRSEMENT FOR GENERAL LIABILITY. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE CONDITIONS OF THE ADDITIONAL INSURED BY CONTRACT ENDORSEMENT FOR BUSINESS AUTO LIABILITY. SATE HOLDER c/WGtLLwIIVN 542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 11% ® 1988-2010 ACORD CORPORATION. All rights reserved. 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