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HomeMy WebLinkAboutBuilding Permit #834-16 - 203 BOXFORD STREET 1/25/2016/ BUILDING PERMIT ✓a�,p�� 1(, ,rj j it) TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: . Date Received Date Issued: IMPOR4'ANT: ADDlicant must comblete all items on this pane iPrint9 /� ��4Sf�c rb46 vo� 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: (p . 6�6 AWI D Se tic 1® UVell Water,/Sewer �® Flood Iain [] UVetlan �' a V1/atershed Dis`tr ctn =–� DESCRIPTION OF WORK TO BE PERFORMED: �4 c�A�l 3'olA✓{ e (�G t�^iG /JQ/!L!S At 7 Identification - Please Type or Print Clearly OWNER: Name: T A» r �/��z� Gor,,,�„y Phone: Address: laRi%l Sup, eryQConstt0-e o IILJi- nse: _X s t ARCHITECT/ENGINEER Phone: Address:,- :g �rweu _ s�..�la�re &IV Qy�'oZ Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASK O $125.00 PER S.F. Total Project Cost: $ o7/ ODD FEE: Check No.: �0Receipt No.: 1 ` NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature_ofAgent/Qwne `., Signature�of�contractor.< L ti Oda on 0 N Date Check # TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL s - Building Inspector Plans Submitted ❑ Plans Waived.[] Certified Plot Plan ❑ Stamped Plans X TYPE OF SEWERAGE DISPOSAL Public Sewer tJP ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ PA Well ❑ Tobacco Sales PIS ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On COMMENTS Signature_ CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Sianature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments Water & Sewer Connection/Sic nafure &Date Driveway Permit DPW Town Engineer: Signature: Located384 Osgood Street FIRE DEPARTMENtTI iTmp D,umpsterontsite� T tYeS.��? FMted at��24 ainf-IND tment�44iiafure%date_ j ., 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 Call Email 1 Date Time Contact Name Doc.Building Permit Revised 2014 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 10TE: 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 TOTE: 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 in - Z G) r Z:� n O Z rnrn Cl) ic cn n 0 rn Z cni �o ^^c Cl) `+ .I Z z::rft Cl) < 00-0 – �o = o v _ N < cr <D N y �u. o CD n O O � C. CC 0 ') � T Z p a" O O -+ C. m oo�MN 0cn N �D C : CD0 ELM 2 OCO C. o O O � ;� �;0 ��. CD -0 c� 0 Eto CD 0 h ��� cCD 0, Cr rt .j. rt c rt n CD CO) C. cn < C. O t. _O O C. — N C. C y C� O C C. N W CnC 0 GD�O 0 0 CD �' C f. CD �0 D CD �cn -n ."O C -n � vCD CD @� o °1 v O CD CDo-0 CL N CL c C. co : -a 0 _T vCD CD S 0Q O m O — CD CD O . C CD Q O N. cam• CDD I � v O CD z 0n 0 '"t' CD a Cl 04 CD in - Z G) r Z:� n O Z rnrn Cl) ic cn n 0 rn Z cni �o ^^c Cl) `+ .I Z z::rft Cl) < 00-0 – �o = o v _ N < cr <D N y �u. o CD n O O � C. CC 0 ') � T Z p a" O O -+ C. m oo�MN 0cn N �D C : CD0 ELM 2 OCO C. o O O � ;� �;0 ��. CD -0 c� 0 Eto CD 0 h ��� cCD 0, Cr rt .j. rt c rt n CD CO) C. cn < C. O t. _O O C. — N C. C y C� O C C. N W CnC 0 GD�O 0 0 CD �' C f. CD �0 • ti y 0 a W CD �cn -n ."O 0 -n vCD CD @� o °1 v � o o � N d • ti y 0 a W -n ."O -n N N d C. : O _T Z7 O T S O O m O O . (D '"t' S Cl 04 VO 2 Uq 7 Q z O = S m S n O N N ro m o� 0 .� r W o (D m C C 3 m W yW v yr z z y to r 6l 6 O mmiZ T N N H 2 3 -i 'o '0 m z•�-I -ri i • ti y 0 a I# January 20, 2016 RE: Project/Job # 0183371 Project Address: AH] SC Office Design Criteria: CERTIFICATION LETTER Gorman Residence 203 Boxford St North Andover, MA 01845 North Andover Wilmington - Applicable Codes = MA Res. Code, 8th Edition, ASCE 7-05, and 2005 NDS - Risk Category = II - Wind Speed = 100 mph, Exposure Category C - Ground Snow Load = 50 psf - MP1: Roof DL = 10.5 psf, Roof LL/SL = 35 psf (Non -PV Areas), Roof LL/SL = 35 psf (PV Areas) - MP2: Roof DL = 13.5 psf, Roof LL/SL = 32.5 psf (Non -PV Areas), Roof LL/SL = 17.5 psf (PV Areas) - MP3: Roof DL = 14 psf, Roof LL/SL = 32.5 psf (Non -PV Areas), Roof LL/SL = 17.5 psf (PV Areas) Version #53.6 - TBD PIL Note: Per IBC 1613.1; Seismic check is not required because Ss = 0.33365 < 0.4g and Seismic Design Category (SDC) = C < D To Whom It May Concern, A jobsite survey of the existing framing system of the address indicated above was performed by a site survey team from SolarCity. Structural evaluation was based on site observations and the design criteria listed above. Based on this evaluationI certify that the existing structure directly supporting the PV system is adequate to withstand all loading indicated in the design criteria above based on the requirements of the applicable existing building and/or new building provisions adopted/referenced above. Additionally, I certify that the PV module assembly including all standoffs supporting it have been reviewed to be in accordance with the manufacturer's specifications and to meet and/or exceed all requirements set forth by the ASCE 7 standards for loading. The PV assembly hardware specifications are contained in the plans submitted for approval. Additionally a summary of the structural review is provided in the results summary tables on the following page. Sincerely, Digitally signed by HKariuki Humphrey Kariuki, P.E. Date: 2016.01.20 06:23:45 U STRUCTURAL NO. 51933 Professional Engineer -0 R p T: 443.451.3515 -05 '00' FC)S76��G email: hkariuki@solarcity.comfONAL 3055 Clearview Way San Mateo, CA 94402 T (650) 638-1028 (888) SOL -CITY F (650) 638-1029 KJIM4_ cX> i c, BQA! .,'r + ; %:?27?81, w.,L..,; e£-; HQ ;';10 it!$s. 11 C-75' 29? , %G', I6.'N72. D. , ..r > .ate OR£.�Y' 2-7006, WA£.:,1.'�Jl.a R i Version #53.6 - TBD PIL HARDWARE DESIGN AND STRUCTURAL ANALYSIS RESULTS SUMMARY TABLES Landscape Hardware X -X Spacing Hardware - Landscape Modules' Standoff Specifications X -X Cantilever Y -Y Spacing Y -Y Cantilever Configuration Uplift DCR MP1 64" 23" 39" NA Staggered 56.6% MP2 64" 24" 39" NA Staggered 56.2% MP3 64" 24" 39" NA Staggered 56.2% Portrait Hardware X -X Spacing Hardware - Portrait Modules' Standoff Specifications X -X Cantilever Y -Y Spacing Y -Y Cantilever Configuration Uplift DCR MP3 32" 15" 65" NA Staggered 47.0% MP2 48" 20" 65" NA Staggered 70.1% MP3 48" 20" 65" NA Staggered 70.1% Structure Mounting Plane Framing Type Spacing Pitch Quaffication Results Member Evaluation Results MPI Stick Frame @ 16 in. O.C. 180 Member Impact Check OK MP2 Vaulted Ceiling @ 16 in. O.C. 400 Member Impact Check OK MP3 Vaulted Ceiling @ 16 in. O.C. 400 Member Impact Check OK Refer to the submitted drawings for details of information collected during a site survey. All member analysis and/or evaluation is based on framing information gathered on site. The existing gravity and lateral load carrying members were evaluated in accordance with the IBC and the IEBC. 3055 Clearview Way San Mateo, CA 94402 T (650) 638-1028 (888) SOL -CITY F (650) 638-1029 solarcity.com :A (_-'I :, fa7 E., 2'7,.c(. r„T 'si,32,7 11; . +'1014-8 'If,S.11 's&s .;T M,1-A..t:<s,...h3 VH.:., 2E`S:P,, `t31 ,, ,}:: > u A- IX t- .�w ..4 f­L-...... t i'1` .a...,j :Vii s.. c.. .. 'STRUCTURE ANALYSIS - LOADING SUMMARY AND MEMBER CHECK - MP1 NOles: 1. ps = Ls?PT; I -s -roor, Ls -pv per Hast i Lhgure i-tI G. pr = U./ (ce) (Lt) (15) p9; Ce=U.9, 4=1.1, 15=1.0 Member Design Summa(per NDS Governing Load Comb CD CL + CL CF Cr D + S 1.15 1.00 1 0.47 1 1.2 1.15 Member Anal sis Results Summary Governing Analysis I Pre -PV Demand Post -PV Demand Net Impact Result Gravity Loading Check 1 1045 psi 1092 psi 1.05 Pass Member Properties Summary Summa MP1 RoofPitch Horizontal Member Spans, Overhang 0.66 ft Rafter Pro erties Actual W 1.50" Roof System Proernes San 1 12.25 ft Actual D 7.25" Number of Spans (w/o Overhang) 1 San 2 Nominal Yes Roofing Material Comp Roof San 3 A 10.88 in.^2 Re -Roof No Span 4 S. 13.14 in.^3 Plywood Sheathing Yes San 5 I 47.63 in.^4 Board Sheathing None Total Rake Span 13.57 It TL DefPn Limit 120 Vaulted Ceiling No PV 1 Start 5.67 ft Wood Species SPF Ceiling Finish 1/2" Gypsum Board PV 1 End 12.00 ft Wood Grade #2 Rafter Slope 180 PV 2 Start Fb 875 psi Rafter Spacing 16" O.C. PV 2 End F„ 135 psi Top Lat Bracing Full PV 3 Start E 1400000 psi Bot Lat Bracing At Supports PV 3 End Em;,, 510000 psi NOles: 1. ps = Ls?PT; I -s -roor, Ls -pv per Hast i Lhgure i-tI G. pr = U./ (ce) (Lt) (15) p9; Ce=U.9, 4=1.1, 15=1.0 Member Design Summa(per NDS Governing Load Comb CD CL + CL CF Cr D + S 1.15 1.00 1 0.47 1 1.2 1.15 Member Anal sis Results Summary Governing Analysis I Pre -PV Demand Post -PV Demand Net Impact Result Gravity Loading Check 1 1045 psi 1092 psi 1.05 Pass Member Loading Summa RoofPitch 4/12 Initial Pitch Adjust Non -PV Areas PV Areas Roof Dead Load DL 10.5 psf x 1.05 11.0 psf 11.0 psf PV Dead Load PV -DL 3.0 psf x 1.05 3.2 pg Roof Live Load RLL 20.0 psf x 1.00 20.0 psf Live/Snow Load LL/SL 1,2 50.0 psf x 0.7 1 x 0.7 35.0 psf 35.0 psf Total Load(Governing LC I TL 1 1 46.0 psf 1 49.2 sf NOles: 1. ps = Ls?PT; I -s -roor, Ls -pv per Hast i Lhgure i-tI G. pr = U./ (ce) (Lt) (15) p9; Ce=U.9, 4=1.1, 15=1.0 Member Design Summa(per NDS Governing Load Comb CD CL + CL CF Cr D + S 1.15 1.00 1 0.47 1 1.2 1.15 Member Anal sis Results Summary Governing Analysis I Pre -PV Demand Post -PV Demand Net Impact Result Gravity Loading Check 1 1045 psi 1092 psi 1.05 Pass • t CALCULATION OF DESIGN WIND LOADS -MP1 Mountino Plane Information Roofing Material KZ Comp Roof Table 6-3 PV System Type KA SolarCity SleekMountTm Section 6.5.7 Spanning Vents V No Fig. 6-1 Standoff Attachment Hardware 1 Comp Mount Type C Section 6.5.6.3 Roof Slope qh 180 Fig. 6-11B/C/D-14A/B Rafter Spacing h 16" O.C. Section 6.2 Framing Type Direction Y -Y Rafters T -allow Purlin Spacing X -X Purlins Only NA DCR Tile Reveal Tile Roofs Only NA Tile Attachment System Tile Roofs Only NA ,Standing Seam/Trap Spacing SM Seam Only NA Wind Design Criteria Wind Design Code KZ ASCE 7-05 Table 6-3 Wind Design Method KA Partially/Fully Enclosed Method Section 6.5.7 Basic Wind Speed V 100 mph . Fig. 6-1 Exposure Category 1 C Section 6.5.6.3 Roof Style qh Gable Roof Fig. 6-11B/C/D-14A/B Mean Roof Height h 25 ft Section 6.2 Wind Pressure Calculation Coefficients Wind Pressure Exposure KZ 0.95 Table 6-3 Topographic Factor KA 1.00 Section 6.5.7 Wind Directionality Factor Kd 0.85 Table 6-4 Importance Factor 1 1.0 Table 6-1 Velocity Pressure qh qh = 0.00256 (Kz) (Kzt) (Kd) (V^2) (I) Equation 6-15 3.0 psf 20.6 psf T -actual Wind Pmccurp Ext. Pressure Coefficient U GC -0.88 Fig. 6-11B/C/D-14A/B Ext. Pressure Coefficient Down; G „n 0.45 Fig. 6-11B/C/D-14A/B Design Wind Pressure p p = qh (GC) Equation 6-22 Wind Pressure Up Pf „ -18.0 Psf Wind Pressure Down Pfdoml 10.0 Psf ALLOWABLE STANDOFF SPACINGS X -Direction Y -Direction Max Allowable Standoff Spacing Landscape 64" 39" Max Allowable Cantilever Landscape 23" NA Standoff Configuration Landscape Staggered Max Standoff Tributary Area Trib 17 sf PV Assembly Dead Load W -PV 3.0 psf Net Wind Uplift at Standoff T -actual -283 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 56.6% X -Direction Y -Direction Max Allowable Standoff Spacing Portrait 32" 65" Max Allowable Cantilever Portrait 15" NA Standoff Configuration Portrait Staggered Max Standoff Tributary Area Trib 14 sf PV Assembly Dead Load W -PV 3.0 psf Net Wind Uplift at Standoff T -actual -235 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capnity DCR 47.0%0 ......... :STRUCTURE ANALYSIS - LOADING SUMMARY AND MEMBER CHECK MP2 Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (CO (IS) py; Ce=0.9, Ct=1.1, I,=1.0 Member Design Summa(per NDS Governing Load Comb CD CL + CL - Cf Cr D + S 1.15 1.00 1 1.00 1 1.2 1.15 Member Ana! sis Results Summary Governing Analysis Pre -PV Demand Post -PV Demand Net Impact Result i Gravity Loading Check 998 psi 774 psi 0.78 Pass Member Properties Summary mary MP2 Roof Pitch Horizontal Member Spans Overhang 0.66 ft Rafter Pro ernes Actual W 1.50" Roof System Proernes San 1 11.47 ft Actual D 7.25" Number of Spans (w/o Overhang) 1 S an 2 Nominal Yes Roofing Material Comp Roof S an 3 A 10.88 in.^2 Re -Roof No Span 4 SX 13.14 in.^3 Plywood Sheathing Yes San 5 1 47.63 in,^4 Board Sheathing None Total Rake Span 15.83 ft TL Defl'n Limit 180 Vaulted Ceiling Yes PV 1 Start 0.92 ft Wood Species SPF Ceiling Finish 1/2" Gypsum Board PV 1 End 11.08 ft Wood Grade #2 Rafter Sloe 400 PV 2 Start Fb 875 psi Rafter Spacing 16" O.C. PV 2 End F„ 135 psi Top Lat Bracing Full PV 3 Start E 1400000 psi. Bot Lat Bracing I Full PV 3 End E,„;,, 510000 psi Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (CO (IS) py; Ce=0.9, Ct=1.1, I,=1.0 Member Design Summa(per NDS Governing Load Comb CD CL + CL - Cf Cr D + S 1.15 1.00 1 1.00 1 1.2 1.15 Member Ana! sis Results Summary Governing Analysis Pre -PV Demand Post -PV Demand Net Impact Result i Gravity Loading Check 998 psi 774 psi 0.78 Pass Member Loading mary Roof Pitch 10112 Initial Pitch Adjust Non -PV Areas PV Areas Roof Dead Load DL 13.5 psf x 1.31 17.6 psf 17.6 psf PV Dead Load PV -DL 3.0 psf x 1.31 3.9 psf Roof Live Load RLL 20.0 psf x 0.70 14.0 psf Live/Snow Load LL SL1,2 50.0 psf x 0.65 f x 0.35 32.5 psf 17.5 psf Total Load(Governing LC TL 50.1 sf 39.0 psf Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (CO (IS) py; Ce=0.9, Ct=1.1, I,=1.0 Member Design Summa(per NDS Governing Load Comb CD CL + CL - Cf Cr D + S 1.15 1.00 1 1.00 1 1.2 1.15 Member Ana! sis Results Summary Governing Analysis Pre -PV Demand Post -PV Demand Net Impact Result i Gravity Loading Check 998 psi 774 psi 0.78 Pass 'CALCULATION OF DESIGN WIND LOADS - MP2 Mounting Plane Information Roofing Material KZ Comp Roof Table 6-3 PV System Type _ KA SolarCity SleekMountT'" Section 6.5.7 Spanning Vents V No Fig. 6-1 Standoff Attachment Hardware I Comp Mount Type C Section 6.5.6.3 Roof Slope qh 400 Fig. 6-11B/C/D-14A/B Rafter Spacing . h _ _ _ 16" O.C. Section 6.2 Framing Type Direction Y -Y Rafters T -allow Purlin Spacing X -X Purlins Only NA DCR Tile Reveal Tile Roofs Only NA Tile Attachment System Tile Roofs Only NA ,Standing Seam/Trap Spacing SM Seam Only NA Wind Design Criteria Wind Design Code KZ ASCE 7-05 Table 6-3 Wind Design Method KA Partially/Fully Enclosed Method Section 6.5.7 Basic Wind Speed V 100 mph Fig. 6-1 Exposure Category I C Section 6.5.6.3 Roof Style qh Gable Roof Fig. 6-11B/C/D-14A/B Mean Roof Height h 15 ft Section 6.2 Wind Pressure Calculation Coefficients Wind Pressure Exposure KZ 0.85 Table 6-3 Topographic Factor KA 1.00 Section 6.5.7 Wind Directionality Factor Kd 0.85 Table 6-4 Importance Factor I 1.0 Table 6-1 Velocity Pressure qh qh = 0.00256 (Kz) (Kzt) (Kd) (V^2) (I) Equation 6-15 3.0 psf 18.5 Psf T -actual Wind Pressure Ext. Pressure Coefficient U GC -0.95 Fig. 6-11B/C/D-14A/B Ext. Pressure Coefficient Down GC(Down) 0.88 Fig. 6-11B/C/D-14A/B Design Wind Pressure p p = qh (GC) Equation 6-22 Wind Pressure U „ -17.6 psf Wind Pressure Down 16.2 psf ALLOWABLE STANDOFF SPACINGS X -Direction Y -Direction Max Allowable Standoff Spacing Landscape .... 64" 39" Max Allowable Cantilever _ Landscape _ 24" NA Standoff Confi uration Landscape Staggered Max Standoff Tributary Area Trib 17 sf PV Assembly Dead Load W -PV 3.0 psf Net Wind Uplift at Standoff T -actual -281 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 56.2% X -Direction Y -Direction Max Allowable Standoff Spacing Portrait 48" 65" Max Allowable Cantilever Portrait 20" NA Standoff Configuration Portrait Staggered Max Standoff Tributary Area Trib 22 sf PV Assembly Dead Load W -PV 3.0 psf Net Wind Uplift at Standoff T -actual -350 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 70.1% -- -- ... STRUCTURE ANALYSIS -LOADING SUMMARY AND MEMBER CHECK - MP3 Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (C0 (IS) pg; Ce=0.9, Ct=1.1, I5=1.0 Member Anal sis Results SummarV Governing Analysis Pre -PV Demand I -PV Demand Net Impact Result Gravity Loading Check 447 psi 1 1 350 psi 0.78 Pass Member Properties Summary mary MP3 Roof Pitch Horizontal Member Spans Overhang 0.66 ft Rafter Pro erties Actual W 1.50" Roof System Proernes San 1 9.74 ft Actual D 9.25" Number of Spans (w/o Overhang) 1 San 2 Nominal Yes Roofing Material Comp Roof San 3 A 13.88 in A2 Re -Roof No Span 4 SX 21.39 in.^3 Plywood Sheathing Yes San 5 11 98.93 in.^4 Board Sheathing None Total Rake Span 13.58 ft TL DefPn Limit 180 Vaulted Ceiling Yes PV 1 Start 1.92 ft Wood Species SPF Ceilina Finish 1/2" Gypsum Board PV 1 End 9.50 ft Wood Grade #2 Rafter Slope 400 PV 2 Start Fb 875 psi Rafter Spacing 16" O.C. PV 2 End I F„ 135 psi Top Lat Bracing Full PV 3 Start E J 1400000 psi> Bot Lat Bracing Full PV 3 End Em;,, 1 510000 psi Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (C0 (IS) pg; Ce=0.9, Ct=1.1, I5=1.0 Member Anal sis Results SummarV Governing Analysis Pre -PV Demand I -PV Demand Net Impact Result Gravity Loading Check 447 psi 1 1 350 psi 0.78 Pass Member Loading mary Roof Pitch 10/12 Initial Pitch, Ad'ust Non -PV Areas PV Areas Roof Dead Load DL 14.0 psf x 1.31 18.3 psf 18.3 psf PV DeadLoad PV -DL 3.0 psf x 1.31 3.9 pisf Roof Live Load RLL 20.0 psf x 0.70 14.0 psf Live/Snow Load LL/SL 1,2 50.0 psf x 0.65 1 x 0.35 32.5 psf 17.5 psf total load(Governing LC TL 50.8 PSf 39.7 psf Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (C0 (IS) pg; Ce=0.9, Ct=1.1, I5=1.0 Member Anal sis Results SummarV Governing Analysis Pre -PV Demand I -PV Demand Net Impact Result Gravity Loading Check 447 psi 1 1 350 psi 0.78 Pass CALCULATION OF DESIGN WIND LOADS - MP3 Mounting P ane Information Roofing Material Ext. Pressure Coefficient Down G . Comp Roof Wind Design CodeASCE PV System Type 7-05 SolarCity SleekMountTm Wind Design Method Spanning_ Vents Partially/Fully Enclosed Method No Basic Wind Speed Standoff Attachment Hardware 100 mph Comp Mount Type C Exposure Category Roof Slope C 400 Roof Style Rafter Spacing _ Gable Roof 16" O.C. _ Mean Roof Height Framing Type Direction 15 ft Y -Y Rafters T -allow Purlin Spacing X -X Purlins Only NA DCR Tile Reveal Tile Roofs Only NA Tile Attachment System Tile Roofs Only NA Standing Seam/Trap Spacing SM Seam Only NA Wind Design Criteria -0.95 Fig. 6-11B/C/D-14A/B Ext. Pressure Coefficient Down G . Wind Pressure Exposure KZ Wind Design CodeASCE Table 6-3 7-05 1.00 Wind Design Method Wind Directionality Factor Kd0.85 Partially/Fully Enclosed Method Table 6-4 Basic Wind Speed V 100 mph Fig. 6-1 Exposure Category qh = 0.00256 (Kz) (Kzt) (Kd) (V^2) (I) C Section 6.5.6.3 Roof Style 18.5 Psf Gable Roof Fig. 6-11B/C/D-14A/B Mean Roof Height h 15 ft Section 6.2 Wind Pressure Calculation Coefficients -0.95 Fig. 6-11B/C/D-14A/B Ext. Pressure Coefficient Down G . Wind Pressure Exposure KZ 0.85 Table 6-3 Topographic Factor KA 1.00 Section 6.5.7 Wind Directionality Factor Kd0.85 NA Table 6-4 importance Factor I 1.0 Table 6-1 Velocity Pressure qh qh = 0.00256 (Kz) (Kzt) (Kd) (V^2) (I) Equation 6-15 PV Assembly Dead Load W -PV 18.5 Psf Wind Pressure Ext. Pressure Coefficient U GC -0.95 Fig. 6-11B/C/D-14A/B Ext. Pressure Coefficient Down G . 0.88 Fig, 6-11B/C/D-14A/B Design Wind Pressure p p = qh (GC) Equation 6-22 Wind Pressure U „ -17.6 psf Wind Pressure Down Pfdownl 16.2 psf ALLOWABLE STANDOFF SPACINGS X -Direction Y -Direction Max Allowable Standoff Spacing Landscape 64" 39" Max Allowable.. Cantilever. Landscape 24" NA Standoff Configuration Landscape Staggered Max Standoff Tributary Area Trib 17 sf PV Assembly Dead Load W -PV 3.0 psf Net Wind Uplift at Standoff T -actual -281 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 56.2% X -Direction Y -Direction Max Allowable Standoff Spacing 48" 65" Max Allowable Cantilever _Portrait Portrait 20" NA Standoff Configuration Portrait Staggered Max Standoff Tributary Area , Trib 22 sf PV Assembly Dead Load W -PV 3.0 psf Net Wind Uplift at Standoff _ T -actual -350 lbs Uplift Capacity of Standoff T -allow, 500 lbs Standoff Demand Ca paci DCR 70.1% DocuSign Envelope ID: 87324FE8-1D6F-4AF1-9681-FDF64E39AOE9 Customer Name and Address John Gorman 203 Boxford St North Andover, MA 01845 System installation cost Installation Location Date 203 Boxford St 1/12/2016 North Andover, MA 01845 Here are the key terms of your Power Purchase Agreement Electricity rate Dg' k /W`h oU— j- - Initial here_____._ The SolarCity Promise • We guarantee that if you sell your Home, the buyer will qualify to assume your Agreement. • We warrant all of our roofing work. • We restore your roof at the end of the Agreement. • We warrant, insure, maintain and repair the System.................................................................................................................................... • We fix or pay for any damage we may cause to your property. + • We provide 24/7 web -enabled monitoring at no additional cost. • The rate you pay us will never increase by more than 2.90% per year. • The pricing in this Agreement is valid for 30 days after 1/12/2016. Your SolarCity Power Purchase Agreement Details Amount due at contract signing $0 Est. amount due at installation $0 Est. amount due at building inspection $0 Est. first year production 10,675 kWh Your Choices at the End of the Initial Term: • SolarCity will remove the System at no cost to you. • You can upgrade to a new System with the latest solar technology under a new contract. • You may purchase the System from SolarCity for its fair market value as specified in the Agreement. • You may renew this Agreement for up to ten (10) years in two (2) five (5) year increments. 3055 Clearview Way, San Mateo, CA 94402 1 888.765.2489 j solarcity.com Power Purchase Agreement, version 9.1.0, November 11, 2015 SAPC/SEFA Compliant Contractors License MA HIC 168572/EL-1136MR Document generated on 1/12/2016 Copyright 2008-2015 SolarCity Corporation, All Rights Reserved Agreement Tgrm (�L6_1___ Initial here.....__.........._._._... DS Initial here DS Initial hereP0U_C7__ _ Options for System Purchase: • At certain times, as specified in the Agreement, you may purchase the System. • These options apply during the 20 year term of our Agreement and not beyond that term. 1480965 0:X0 DocuSign Envelope ID: 87324FE8-1D6F-4AF1-9681-FDF64E39AOE9 23. NOTICE OF RIGHT TO CANCEL. YOU MAY CANCEL THIS CONTRACT AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE YOU SIGN THIS CONTRACT. SEE EXHIBIT 1, THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. 24. ADDITIONAL RIGHTS TO CANCEL. I have read this Power Purchase Agreement and the Exhibits in their entirety and I acknowledge that I have received a complete copy of this Power Purchase Agreement. Customer's Name: John Gorman DocuSigned by: Signature:. tr"" IN ADDITION TO ANY RIGHTS YOU MAY HAVE TO CANCEL THIS PPA UNDER SECTION 23, YOU MAY ALSO CANCEL Date THIS PPA AT NO COST AT ANY TIME PRIOR TO COMMENCEMENT OF CONSTRUCTION ON YOUR HOME. 25. Pricing The pricing in this PPA is valid for 30 days after 1/12/2016. If you don't sign this PPA and return it to us on or prior to 30 days after 1/12/2016, SolarCity reserves the right to reject this PPA unless you agree to our then current pricing. Customer's Name: Signature: Date: 1/12/2016 Power Purchase Agreement Signature: Date SolarCity approved Lyndon Rive, CEO 1/12/2016 Power Purchase Agreement, version 9.1.0, November '.1, 2015 [oil A 10 1.480965 :1P -- 7 T'lte Cansmonwealtli ofMassaefsusdts Dei admen! of IndristrialAcciltents Offlt"e of In vesdgations I Congress Stye 4 Suite IIID Boston} 11I4 0211 4- 01f `�' �tmt�cr3rasS.got�/rico Workers, Cumpettsarilion Insaratnce Affidavit; Buildfwa/Contracters/Electricisns/Ptumibers A 11MM >in ormation Please krirltt Le ibi Nanrta(Husincss/graanization/fndividual): SolarCity Corp. Address: 3055 Clearview Way phone #: 888-765-2489 Are you art employer? Check the appropriate box: l . 0 am a employer with 5,000 4- D I are} a general contractor and I empla}ym:s (Bull andtar part-time).* bavc birerl the sub -contractors 2. Q 1 am a sole proprietor or par mer- listed on the attached shea ship and have no employees working for mein any capacity. 1No-morkers' comp. insurance required.) 3.0 I ant a homeowner doing all work mystic; (No workers' comp. insurance roquired.) t These sub -contractors have employees and have workers' comp. insurance s 5. [ We are a corporation and its officers have exercised their Ti*1t V[ GXeT1TPti&fi1 PDX ta' G11 c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. Q New construction y. Remnodeling R. D Demnolftion 9. []Building addition 10.0 Electrical repairs or additions ILEI Plumbing repairs or additioas I2.[] Roof repairs 13EPther Solar/PV -Any appmtcarse ti}at cnccksbox ff t mast afim fOl out the section below showing their woricas' contpcnsntimt poiicy iaforrnstion. t blomeawncrs who submit this affidavit indicating they are doing all work and then hire outsidc contramrs mast submit anew affidavit ladicatingsueh. =Contractors tical cheek this box must anached on additional sheat showing the numc of the sub -contractors and state whether or not those entities have employem. If the sub-contramiors have ernployees, they must provide their workers' comp policy number. I am as employer shpt is_rrovMng War kers' Corrapenserliar! frasetrerrce far tray earaployees. Below is 1ha policy acrd job site ire, fornratiuta. Insurance CompanyNamne. Zurich American Insurance Company Policy -9 or Soli ins. lac. #: WC0182015-00 Expiration Date: 9/1/2016 Job Site A,ddress.4 ­6�yX�-_ tie l City/State/zip: AK" ' v c r'.1�f At:tRch a copy of the workere eompensatiota poi:sy declsr~tion page (showing the Policy number and expira:ior. date). Failure to secpre coverage as required under So4tion 25A of MOL c. 252 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one year imprisownent, as well as civil penalties in the form of a STOP WORK OR DER and a fine of (w to S250,00•a day against the violator. Be advised that a copy of this statement maybe €on arded. to the Office of Investigations of the DIA far insurance coverage verification. do hereby certl y under the patys and pertalties ofperjarlr that the informad en provided above is true and earre'ct Phane ti. '.9 01.383 Of'rWiast umr only: Lin not wrier in !itis area, is be completed by 410 or town affficiat. City or Town: PermitILle nse Issuing Authority (circle one): I. Btrurd of Health 1 RLIK 1 a ne!?Brimcnt z, Cit„/7-nwn !'}�t+L .f� Flaofr:no) t✓..e.aa. tC. a us....r.t... r.. .. .� .. .. - v . ............ ...^..,...... 6. Other Contact Person: Phone CERTIFICATE OF LIABILITY INSURANCE FDATEIMMIDD1YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 0811712015 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, EX'T'END OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL, INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not Confer rights to the certificate holder in lieu of such endorsemontls)_ PRODUCER MARSH RISK& INSURANCE SERVICES CONTACT -NAME_ - PHONE 345 CALIFORNIA STREET, SUITE 1300 FAX dAt� 1iR.lwxtl ....._.. _............. _......... ... ..i tAl�. Nr+lt...... CALIFORNIA LICENSE NO. 0437153 ....• _ ..._................._..... EMAIL SAN FRANCISCO, CA 94104 ADDR€"v+s�. ..... ._ .. ....:.. ... ...... .. ... _.... ........_._.... ........ _....__ .._.... Alin: Shannon SW11416-743-'8334 INSURERIS] AFFORDING COVERAGE NAIC #._. 998301-STND-GAWUE-15.16INSURER A.:— Zudc4 American Insurance Company 116535 - — 5,000 SolarCity Corporation NIA �N1A 3055 Clearvlew Way San Mateo, CA 94402 INSURER C: . _._ ..... ..............._.._._. +._._.. ................ _INSURER.D : American Zurich Insurance Company 40142 INSURER E. G NERALAGGREGATE g INSURER F: j GOVeRAGES CERTIRCATE NUMBER-- SEA -002713836.08 Dr-VLClnbl All HVIRIZIPbA 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 ...... ._...._......... .. _... .... ...:: .._.. _ ... .DDL`StIDTt ._. _..._... _....__ ..._...-......... _ LTR TYPE OF INSURANCE POLICY NUMBER .. _............. ...... _.. ................ EFF � •POLICY EXP' .. ...... _.. M D Y MMIDDIYYYY LIMITS ....... _... A X COMMERCIALGENERALLIABILITY iGL00182016-00 0910112015 >0910112016 4 EACH ' CH OCCURRENCE $ 3,000,000 CLAIMS -MADE X OCCUR bAMAGE fQ I#@rJTED 3,300,000 .. � ; S X SIR:$250,000 ...._ _............ ....... i � � MEDEXP(Anyoneperson) : $ 5,000 _..._............._.... __._....._ .._. ...- I PERSONAL&ADVINJURYS 3,000,000 ~ GEN'L AGGREGATE LIMIT APPLIES PER I i G NERALAGGREGATE g 6,000,000 X POLICY PRO- r...., 1 F ...... ........ ........ ........... I JECT I ;LOC ! PRODUCTS - COMPIOP AGG : $ 6400,00D i OTHER 3 A ' AUTOMOBILE LIABILITY BAP0182017-00 091O1f1015 09/0111016 ' CO BINE S GLE LIMIT 5.000,000 X ANY AUTOBODILY ..... r INJURY (Per person) : $ • • • - - --- _ X ' ALL OWNED X SCHEDULED AUTOS AUTOS 1..... NDN -OWNED X :..... .. BODILY INJURY (Per acadent)! S L_..._.._._...__. ......... ..... HIRED AUTOS X AUTOS FROPERTYDA{NPGE y F... - t (Per accident) ..,•, , _ . COMPICOLL DER: ; S $5,000 'UMBRELLA LIAB OCCUR I :EACH OCCURRENCE $ EXCESS LIAR CLaIMB MADE i ,...... f...... r.... ..... ......... i....._..---._ ; ............ ....... DED RIFTENTION S I r g .. ................ D !:WORKERS COMPENSA ION ?WC0162014-00 (AOS) :0910112015 .0810112016 X ; PER OTH- ;AND EMPLOYERS' LIABILITY A ,ANY PROPRIETORIPARTNERIEXECUTIVE YIN 4VC0182015.00 (MA) OFFICER/MEMBEREXCLUDED7 N NIAI �+ I.._..1 STATUTE, .......L FR ..... ` 09101/2D75 ;0910 112 0 1 6 EACH ACCIDENT 's f :�...............±. ....... 1000000 '....'...., (Mandatory In NF) WC DEDUCTIBLE $500,000 1,400,0.0.0 H eS, descrtbe under E L DISEASE - EA E JPLOYEE . DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT I S 1.000,000 i 1 1 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD. 101, Additional Remarks Schedule, may be attached If more space is required) Evidence of insurance. SolarCity, Corporation 3055 Gearview Way San Mateo, CA 99402 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmelejo V 1988-2014 ACORD CORPORATION. All rights reserved. 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I � 5 �, � � �.: , S N: u: u m. c. o: . z. 0 lwOC z u < o u > > -5 o�: -S 0 E: E: -:Ei V, '-i ::o u: , o� E .5 < o� �& � U L t2: - o� o:o. -1 u : R E 0 0 E: >� -: -- >- 2 : S E- > a 1 �.L u:u X 7a o �E o Z Ld .1 u u �< :z; o: u ul: m: . 6: z : — �:.g z F ri V RS v La r 0 O , �p u 'w :t:f < r- M V 76 0 E 'c m— 2 oo -r- tw -76 W , W -0 to cb > v) i"n r- d) E w to 4-1 -0 0 u m E 40 E o 0 > i 0 Q 76 to vEi x W CO 6 if a o I 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the Permit application form to provide notice of installation of wiring shall be uniform throughout the Com On the prescribed form. After a permit application has been accepted by an Inspector Of Wires appoi monwealth, and applications shaU be filed electrical permit shall be issued to the person nted pursuant to M. G.L c. 166, § 32, an , furn. or corporation stated on the permit application. Such entity shall be, responsible for the notification Of completion of the work as required in M.G.L. c. 143, § 3L. - Permits shall -be limited as to the time oforigoing construction activity, and maybe-deemed-byth - sp tor -of -Wires ab doned- I valid e— . or she has determined tl�at the aufhorized work has e In cc an an in -ifJ application, an extension of time for completion of not commenced or has not progressed during the preceding 12 -month period. Upon written work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or -the installing entity stated on the pennit application. TheYernilt Extens'ion Act was created by Section 173 of Chapter 240 of the A cts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of the Acts of 2012, The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act farthers this Purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect Or existence' during the quaU*g period beginning on August 15�008 and extcnding�ffirough August 15, 2012. 8 — PermitlDlate Closed:/ 2-e7 -,/ F -I Permit Extension Act — PerinibDate Closed: * * * Note: Reap'ply for new 9-6 6"U" TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... / .......... .......... e'l ..................................................... has permission to perform ...... f ....... . .. wiring in the building, o e.. 17 ........ /7.e:.�� ................. at �ak. A, . ............ .................. North Agdover, Mass Fee..k� ..... Lic. No. Z.f,��,ht ..... CTOR Check # r�0 �,vmrns�iiw��csoc ern e9ew��se�araa��:aa.s Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Dater City or Town of. NORTH ANDOVER To the Inspector of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) DIQ 3 2X vorA S+ Owner or Tenant Owner's Address YN Telephone No. -Is this permit in conjunction wit a building permit? Yes ®• No ❑ (Check Appropriate Box) Purpose of Building ��Y1�Q �M� �`1 QLV-o\, -n(� Utility Authorization No. Existing Service Amps Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ + a No. of Meters No. of Meters tW /SVv Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires �ZC? No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches <�O No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers i Heat Pump Totals: I Number. Tons KW No. of Self -Contained 3 Detection/Alerting Devices No. of Dishwashers \ Space/Area Heating KW Local v Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. of -No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: -Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in'force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under Ute pains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: Q% Ccd, Q Cx 'r— LIC. NO.:7, D52,0 6 Licensee: iG�`�; ��{ Signature(- LIC. NO.: 3g0�°1 (If applicable enter "exempt" in the license number line.) Bus. Tel. No. -,:70 Address: f L(Gfy' S- -edie �-� sc�y!5 VS Alt. Tel. No.: '-I- 7L01 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have th6 liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent [PERMIT FEE.$Signature Telephone No. 14 /Z p`-4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 �,4 ,,• • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Lel4ibly Name (Business/Organization/Individual): r t CG (-8 �C ' Address: G re-YS�t� City/State/Zip: Sc�&, 9 V Phone #: Are,you an employer? Check& appropriate box: i,ani 4. ❑ I am a contractor and I l a employer with general employees (full and/or part - lime).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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 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 a information. Insurance Company Policy # or Self -ins. Lic. �S Expiration Date: 1 d a'a` i O Job Site Address: a -U3 \� \�(- (��A City/State/Zip: 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 her ebcertify under the ams and penalties of perjury that the information provided above is true and correct. c Signature: \ 1- �� K5�Gc�/� _ Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 #: