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
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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
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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
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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.
ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD
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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 #: