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HomeMy WebLinkAboutBuilding Permit #714-15 - 240 GRAY STREET 3/13/2014i Permit NO: 1 Date � i� AIM 4, L:p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I 'IMPORTANT: Applicant must complete all items on this pane I LOCATION 240 Gray Street Print. PROPERTY Provost Print 100 Year Old Structure yes tno MAP NO: PARCEL:b17-1 ZONING DISTRICT: Historic District yesi no Machine Shop Village yes V no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential D New Building ® One family D Addition D Two or more family ❑ Industrial ® Alteration No. of units: D Commercial D Repair, replacement D Assessory Bldg ❑ Others: ❑ Demolition ❑ Other D Septic D Well ❑ Floodplain ❑ Wetlands ❑ Watershed District D Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Installation of a 10.75 kw (43 panels) rooftop solar array Identification Please Type or Print Clearly) OWNER: Name: Amy Provost Phone: 617-803-7903 /Auuress CONTRACTOR Name: Romain Strecker Phone: 781-462-8702 Address: 10 Churchill Place, Lynn MA 01902 Supervisor's Construction License: 096385 Exp. Date: 10/8/2016 Home Improvement License: Date: 7/27/2015 ARCHITECT/ENGINEER lamesA.Clancey Phone: Address: 601 Asbury Avene, National Park, Ni 08063 Reg. NO. 46775 FEE SCHEDULE. SULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST RASED $125.00 PER S.F. Total Project Cost: $ 37,625 FEE: $ ` Check No.: 9c/42 -(Lf Receipt No.: U\b . NOTE: Persons contracting with unregistered contractors do not have access to tle uarantyfund Signature of Agent/Owner -- Signature of contractor Plans Ri ihmittari n Plan,-- W;tivari n (:arfifiari Pint Plan n Cf=mns=H Planc R1,n-4 � 5f el slteslfi Location No. -7 `q,` ►j Check #A2—A, 2356 Date ,L) TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ �- Other Permit Fee $ TOTAL $ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -FER-AGBDISPOSAL ❑ Tanning/MassageBody Art ❑. Swimming Pools 0 ❑ Tobacco Sales .❑ Yood Packaging/Sales 0 Private (septic tank, etc.. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT* COMMENTS .CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature Date Driveway Permit DPW Tow;! Engineer: Signature: Located 384 Os ood Street FIRE DEPA.RTMf NT - Temp Dumpster on site yes- no Located'at 124 Mair. Street Fire Department signature/date - t COMMENTS 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 Doc.Building Permit Revised 2010 Building Department • The following is'a list of the required forms to be filled out for the appropriate permit to be obtained. Roofir�g, Siding, Interior Rehabilitation Permits o Building Permit Application a Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Hydraulic Calculations (If Applicable) ❑ Copy of Contract Be Returned) to Include Sprinkler Plan And ❑ Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the arm al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Buil;iing Permit Revised 2012 A 14 Y Location 24 No. 1 1 1 " /� 1 Date Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Pert Fee C $��'�""�' TOTAL Y��1D Building Inspector LaN 2 LL O m O L = Y \ O O LL E ♦O+ N U Q. a) In U G a Z C7 Z m O O O "O 7 O LL L � O K al C t U _ O C LL O a y Z Z co J d L O O cc _ C LL O Wa to z cQJ va J W t � O K U _ al Ln _ O C LL O U a Z C7 3 O d' _ O O LL �- Z � Q w p LU LL E O m Z a� N a1 a) aJ Y O E In ti w W o OC o o z o o � 01 - CD •-CD .(D m m a0� Q 0 o CL CL Q 0= Cc M V J -0 .CL o .rte) =z 0 U U) CL is r. O O •� L 4) :�• m Q o N(D EQ CD(A CD (A CD CD o �DE�, �0 MOM*_Cc O d . V (a oCc J N CL S: C N(1) CO) O G) > 4= O 'a C N Q C O O 7 p N O O C on > C � . CL(DCD �0 O 0*01 0 �=_ occ i L O 2 as O CD '� v1 V m N O co m W O 'a O O .r Li 2 )N C O N �E = — Z � LV r ami a O N CL 0-0 d J 2 cc v= C O L C O 1— .a .I CLOOw, >!. ti w W o OC o o z o o � 01 - CD •-CD .(D m m a0� Q 0 o CL CL Q 0= Cc M V J -0 .CL o .rte) =z 0 U U) CL is E w 0 3 0 ENO rA J Z LL 0 m L U LL a0+ > N N O N z z m O O (YO LCL W v U I.J.. O V LLI N cz co G J d �' LL O N Z u LU d' {n I.1. cc Z O LLI CL IA N Q K T W aC Q {JJ ui ui LL CO O z N +� 4J N O _ _ O O •� L J C. CD Cl)a hoo E Q L N Y � _ — Q ip• E ai L = h = Cc Q" O () L CL cC N J i m d. Ln _ = N (DN o -a 0 _(Da = • _0b1 r.. t O E o R O - N c o CD �> c c Q 0 N a) U o� a L R o 2 Q ( :3 N O y V m N LU = -0-ooCD EL LU`" o .r W CJ m •= L O U) m> ;F N -0o O cL o L) > 2 Z G Z w CL W H W CL EF 0 kl v O W O o o Z cn I (D CM ^` a r... W Q N CL_~ M c O �+ Q Q CL O CF)a o -� cc cv v_ J •CLOt; U) Z � O V t( ca _ N 3 JAMES A. CLANCY PROF]E3SIONAL ENGINEER 601 ASBLJRY AVENUE NATIONAL PARK, NJ 08063 18561358-1125 FAX: 18561358-1511 Date: February 19, 2015 Re: Structural Roof Certification Subj: Amy Z Provost Residence, 240 Gray St., North Andover MA 01845 We have provided a review of the house roof construction of the above named property in regards to verifying the capacity of the existing roof for installation of a new Solar Panel Array. We have found the residence roof to be of wood frame construction bearing walls with Roof 1 of 2x10 @ 16" rafter framed roof with 2x6 collar ties @ 16" o.c. and is sheathed with 5/8" ext -ply decking and a single layer of composite shingle roofing. The wood framed roof structure bears directly upon the framed exterior wall system. The existing members as installed meet the required (MA 780 CMR) IRC -2009 table 802 design span ratings with sufficient capacity to carry the 2.89#/sf additional load imposed by the proposed solar array per the details below. ' Installation of solar rack systems shall be as follows: Each panel row shall be supported upon 2 mounting rails. Rails shall be screw anchored through roof and directly to rafters or purlins below. Rail attachment points to rafters shall be staggered each row with exception to the first fastener row from the gable end which is attached to two adjacent rafters/trusses with Stainless Steel fasteners. Rail attachment to roof shall be fastened 16-24"o.c. at corners and 48" o.c. through the field. Rails are to be placed at 24-48" o.c. on the roof. When installed per the above specifications the system shall meet the required 100 MPH wind load and 50 PSF ground snow load requirements. Should you have any further question or comment please feel free to contact our office. F J F 1\ JAMES A. CLANCY, PE Installed weight of PV System PV Module Weight = 44 lbs Area = 39" x 65" nominal (17.6 SgFt) Mounting Rail (IronRidge XRS) Weight = 1.03/lf There are 80" of rail per module = 6.87 lbs Module + Rail = 50.87 lbs over 17.6 SgFt = 2.89 #/SgFt Typ. Rail spacing is 32" o.c. across panel width with 2 rows per module. Typical layout provides 13 feet on one rail for each 10 modules in a row. This provides for an average of 1.3 feet/module/rail x 2 rails = 2.6 feet/module. Module + Rail weight distributed per mounting foot = 50.87 lbs / 2.6 feet = 19.56 lbs/mtg foot. Composite Shingle Roofing = 2.8 #/sf 5/8" Ext -Ply Decking = 1 psf Installed Solar Array = 2.89#/sf (above) Total load = 6.69 #/sf IRC -2009 Table R802.5.1(3) Rafter Spans for Common Lumber Species DocuSign Envelope ID: 697E32CA-A204-41EA-8CB9-BC8396DE5DFB Homeowner's Agent Authorization Form State of Massachusetts 1, Amy Z Provost (print name) am the owner of the property located at address: 240 Gray St North Andover MA 01845 (print address) I hereby authorize Sungevity or its subcontractor to act as my Agent for the limited purpose of applying for and obtaining local,building and other permits from the Authority Having Jurisdiction as required for the installation of a PhotoVoltaic System located on my Property. DowIgned by: Customer Signature: PAI%J' � f rwi 8E1B48836EB346E... Date: 2/22/2015 Print Name: Amy Z Provost Sungevity MA Home Improvement Contractors License # 168430 66 Franklin Street, Suite 310 G 510.496.5500 866.SUN.4ALL Oakland, CA 94607 USA f 510.496.5501 www.sungovity.com !' . P a 41 O 0 z Z m [7 m N r2 2 ° ° -�? a Z z°��o=a<a a 3 w mss=�fo c 'ozC r W V5 Z o N O¢ f U K ®®o MOB ❑o Z F F f o 0 9-.6z 1 � F <�o�s ° is Z Q ❑ o g z Q o wsu ° opwi�3rc �a a� o O a a Q K K } Q W z w a N w m 0 LL 0 Q 1- 2 rc ;moo W uu0_Q's �3o 04 W w5 s t7Q a o M 0, W W > Z O w a❑ w w W w Z xli w w rc > j o >KQ O W Z p O U O 0 Z m R ? J Q K 1-K ��� J c0— Q awm �,oyozie F G zQ WN U. O LL 1- M to >� O U( X a g W PKC Fes_ s ww ao wrc 1- aU) W Z1- C O a Z O ❑ 000 N LLaLL wa Fm rcO-MO-3 saa°2FWOSv2i Z .. �W°�pz�au Z > z z� q 2 0 M > �' 01-08 m £ W p oz w g z �w ¢° rc O a -> J �Z _ w U W w Q - 0❑� 0 U y�Z QK Z=� 5 ❑ ❑ Z(9Z aha oz U O rcarc �wIW jHM H t t UwawoUK�w C HO _� a LL' W mo rn 0 )-Z � W 4! 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CO M CO 7 M v n eon O No n a to N wof n aomrrlomin In O [O N O x� Q on v c_ �i L n oln000 oo�NM�l�mr 000ufoo oo�Nc4i�IQim 000ln000 n oo�NM�IQim 00 r �U m a F o p w w 0 mm MU x U U Iap�i� 4 8 c �r i7 0 Y 7 Z ziQ Q 2 �w zo wo 5` az � I o c � 1 x ® ' Aa2 $x e !hill �r i7 0 Y 7 Z ziQ Q 2 �w zo wo 5` az � I o c � 1 x ® ' Aa2 E E� JRg� $x e b g f $ S E E F 2 2 AM E E� JRg� u I ' Inmuul W W N g^ o I Y •— � o e L gg a N m N; a J pp y aQ3ip § a I °eQ„ Z �� w w oo yE 121 7 r d 8 g e � 6= c a � � J � LL y E W i u a 4 0 '> _ N N z 0 g E o f u >? r Q Q N L C V N C 0= cw L 8:5N j.L p q c '.° O T C T E V R rs m c w y v o o m O r, n a i ve ', E u c n a N a aav a ° E d i m E L _ > _o c o T o v� rna ¢ m ai o 2`rn� S >o=gym m E'O o ca5 c m m m vm � a q� m m °v= T °' 3 o O o m n 0 > o �O E 'c E; d m - c y o' o c E a a c- a' m m 3 m 9 a L T c a '—O °' v y w E o 5 o u m u. -• o' m c c '� o" c a 3 c o m 76 w L. o f n a m .°1- 3 o' Q' w E 3 Y a • o° o c° n E� ON S v c - E 2 C T o y O J 0 w N ai v c J T« (� y - c L E d c i D c 'S E '~ o m • T atg o a 5 E d • Y C P a N .0 3 a u¢ U E W m c E c m 0 Q o d °' 3 O o H Z o o c u o rn a E M,� o c c o c a �^ m u m o ani v u c p •m K 'W o m as J n u c 'y u N y o m °� .o Ey u u w E o O c 333 75 a z v� u�i i ¢a0o vao, omo v w E o a n iv v W a T z. c m 3 LL ----------------- ------------------------- a ----------------------0 - e ------------------------ p O O LL (7 fn O_ N L CV Lt 3 0 z Z T v 3 Q C U C O E C O t N L C roc cm 3i vii > AEe m xc c4 c>5 � m� 2 r— m U .��'— G' o `s cm_i �i Eai mapm c4 dam _ �' xTC.oa X12a�' fe N I-Tt�n v� K Q .n tpn in Q ' : f \)\) $k) }ko\ k: 41( \\� \ 777 �\ �k��0 � �\{ /«l (kk 2/k )E {| E a ��� c ■ , ./22§ \\� MLU ■ .®_r/ \ }k(k\ \\\ �s� PV PHOTOVOLTAIC WIRE 2000 VOLT A P P L I C A T 10 N S Suitable for use as follows: • For use in solar power applications • Rated 90°C for exposed or concealed wiring in wet or dry locations • Rated for direct burial SPECIFICATIONS • Stranded copper conductors • XLP insulation • UL Subject 4703 • UL 44 • Meets the requirement of UL 854 for TYPE USE -2 CONSTRUCTION • Southwire PV Photovoltaic Wire is manufactured using stranded copper conductors with single layer XLP insulation • Bare or Tinned Conductors • -40°C to +90°C • Sunlight Resistant • RoHS Compliant • Direct Burial • Sample Print Legend: SOUTHWIRE E316464 (0) (UL) PV WIRE 10 AWG (5.26m M2) CU 2000V 90C WET OR DRY (-40°C) WET OR DRY -40°C SUN RES DIRECT BURIAL VW -1 OR RHW-2 2000V — RoHS W99MV@0lu]QQ�3nl3QC]i Ga4a lam@ U)MO NGM AWG SIZE NO. OF STRANDS INSULATION THICKNESS NOMINAL O.D. NET WEIGHT 14 19 0.075 0.220 31.9 12 19 0.075 0.237 41.3 10 19 0.075 0.261 56.6 8 19 0.085 0.312 85.7 14 7 0.075 0.220 31.9 12 7 0.075 0.237 41.3 10 7 0.075 0.261 56.6 8 7 1 0.085 1 0.312 1 85.7 Other sizes and strand configurations are available upon request. Also available in various colors. STRANDED COPPER CONDUCTORS F- -J O O O O N W CL Bare or Tinned Stranded Copper Conductors XLP Insulation Direct Burial -40°C to +90°C 2000 Volts @sree�(os,' 01, SOutllwlt'eRoNSCompliant OEM Division 040 N M CL � H 07 � E L I VW co N w v4 LU r-. L r1b N ddy C •C d L L T.`L �au.scFl� C 9 a c u EE`0 d d C c A E : m 0dE .0 L q w �C a r d d d ! •0 9 6 6 c to a S N amM ad 7 I d C7 m « m - •V m > C O C 7 d L N O r. m 0N S U d T C « M M G m « O. OcYm «mm dE WCN 7— O O '•O Cm am wON ow E . E c ocm pm mO v oNm 0 ° « moao 0m O IM r V r m N OT0 R ML c .o.WNd OCcm EC° 7N Gm D N tl! m N mN°F O c OO 'cO«Lw wC •r- EC c'�«m CO y cd lcO0 Y dL O E N y M c0 w�IM O S O vU) rV N«O 0 NN O 0 m mO Z C «C O MVC mC S a d 0 mN a 0. c CL m ocE u CL E mm o c CY rn CO m c r. M E m c O O m O O M 0 m c d C NC MO M NO 7uriw Y c m G 0 O N W m O `«O- O E V A O 1 p 7 m o i. V a O 1 0 Gm m K o yo E w ccoc Nvl o VO m «VO = «y O Y O m d M E N C VN c c C ui d0 y L 7 NO=4) m O O y m 0 z r C4 !"f O FN fG h CO Or O r r N � 040 N M CL � H 07 � E L I VW co N w v4 LU r-. L r1b N ddy C •C d L L T.`L �au.scFl� C 9 a c u EE`0 d d C c A E : m 0dE .0 L q w �C a r d d d ! •0 9 6 6 c to a S N amM ad 4 3 2 1 D ELI D 6.89 [175] 6.81 [173] 5.73 (145] 6.36 [162] 1 .3419) N O Q O O OF CONCENTRIC KNOCKOUTS FOR TANGENTIAL KNOCKOUTS FOR 10/2. CONDUIT 1/2, 3/4 CONDUIT 2 ° n ANTf3/4 h OUANTITY 4 .27(6.87 DIA. 3 MOUNTING HOLES 3.75 [95] 2.46 [621 .88 [22] B 4.75 E121] B 1.01 [26] TANGENTIAL KNOCKOUTS FOR 1/2, 3/4, 1 CONDUITQUANT 1 NOTE: 1. METRIC DIMENSIONS (IN MILLIMETERS)) ARE SHOWN IN BRACKETS. .281 [5.5j DIA. KNOCKOUf 2. WIRE RANGE OF LUGS IS AS FOLLOWS AND O4AD LUGCOPP6R#OR 14 COPPER R ALUMINUM OUANNIY 1 .82 [46 .82 [46 NEUTRAL dLINE 6.10 [155) A A WNiREN SIDE a/;9ro6 CUTLERU-HAMMER p E _ u 1R ria R 9 98 vu PIR58DIM PA PIGRp1ASNA /� / DIMENSION SHEET 6 30 AMP TYPE 3R GENERAL DUTY y F 2' 9s-1ws.DPc 557/0001 � 1—�2 t c —95-1445 t or i 4 3 2 1 p B O O p p m Y Y Y Y Y L��yy C 2 Q 3{Lp W �� 000m YYYZZ mp o Fig eL cS� � gg [g� g6S L3 bl wS " � E b•F 111111 111111 m �' om NZ s E m Spm H "goQ a Qomsm �? �8g c�yR m Ilg"MIIII E 1 m ae��m c eI g8 c e S- P�E�R�EI g$ ' e S a8 RaSE&I 185188 � W -8' Ran � gsml 3 2n� "O • m a m NISo la 6 s e —0 ° °o_ -o-� •; i�ry a -0�tH o- E W G i'i tt w 50x0 mm tl s tl Y Y Y Y Y � Y Y Y fpc� m Rtl {tl� �pp� pm m Y Y Y Y Y �Y5 A � � 3 S S >8 ;g{ 3 +8 gj + gj S & QjS �2n n ry n n n n n n n n a n n n n r n n n n n n n n n n n o T i gg a Z 3 m • o .o = m d zmm q 'd 9 o7Q n Z C� WOIM �-p � � W W€ y Q t b m W-'S2t mow m Z'; @c m n W C au$`° -m; scam E9 L H• N W G` J CW 1C C .m W Y S o o O LL �q'.W Sm 7fN NY `.9%lr i„-('TT[)T[CT![[KY[�II Of�•7YlT1SClCI[l3CII7 016ce of Consumer Affairs & Business Regulation OMEIMPROVEMENTCONTRACTOR C egison169698Type: xpiration: 7,2712015 LLC THE BOSTON SOLAR COMPANY LLC ROMAIN STRECKER 10 CHURCHILL PLACE LYNN, MA 01902 undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature Massachusetts - Department of 'Public Safety Board of Building Regulations and Standards Construction Supeiiisor License: CS -096385 ROMAIN D STRE6KIER _ �'!•� 10 CHURCHILL PLAN; - LYNN MA 0190f , sl.— _-9P1_4W— Expiration Commissioner 10/08/2016 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiicians/Plumbers Applicant Information Please Print Ley-ibly Name (Business/Organization/Individual): The Boston Solar Company Address: 10 Churchill Place Lynn, MA 01902 Phone #: 617-858-1645 Are you an employer? Check the appropriate box: 1. ❑■ I am a employer with 20 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 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. employees and have workers' [No workers' comp. insurance comp. insurance.[ 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' coma. insurance reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑■ Other solar *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: HDI -Gerling America Insurance Company Policy # or Self -ins. Lic. M EWGCC000153815 Expiration Date: 1 /14/2016 Job Site Address: 240 Gray Street City/State/Zip: North Andover, MA 01845 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. 1 do hereby certify under mains and penalties of perjury that -the information provided above is true and correct Phone #: 6178581645 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone M # lH 60 4111241110 RnsSn ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 1 1/13/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER People's United ins. Agency CT ON NAME T Peggy J. Merati PHONE 860 524-7624 844 702-8075 Arc Ne E:l : Arc No ADDRESS: peggy.merati@peoples.com One Goodwin Square INSURER(S) AFFORDING COVERAGE NAIC # Hartford, CT 06103 INSURER A: HDI -Gerling America Insurance C 41343 860 524-7600 INSURED The Boston Solar Company, LLC 55 Sixth Road, Suite 1 Woburn, MA 01801 INSURERS: Merchants Mutual Insurance Co 23329 INSURERC: INSURER D INSURER E: INSURER F: PREJ RISES FaEuErtence $1 OO OOO /`f%%1=0AGCC CPRTIFICATIP NIIMRIF - KtVIS1UN NUMUMM 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 CONTRACTOR 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 LTR TYPE OF INSURANCE ADDIL IN R UB MIND POLICY NUMBER POLICY EFF MM/DD LICY EXP LIMITS MM/PODD A GENERAL LIABILITY EGGCC000153814 0/03/2014 01101/201 EEAACMH�OECCURRENCE $1,000,00 0 X COMMERCIAL GENERAL LIABILITY PREJ RISES FaEuErtence $1 OO OOO CLAIMS -MADE 5XI OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- JECT El LOC $ A AUTOMOBILE LIABILITY EAGCC000153814 0/03/2014 01/01/201 Eaaccide tSINGLELIMI 1,000,000 A ANY AUTO EAGCC000153914 0/03/2014 01101/201 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS IX NON -OWNED PROPERTY DAMAGE $ HIRED AUTOSX AUTOS Per accident $ B X UMBRELLA UAB X OCCUR CUP0001367 0/03/2014 01/0112016 EACH OCCURRENCE $5,000,000 EXCESS LIAR CLAIMS -MADE AGGREGATE $5,000,000 DED I X RETENTION $1 O OOO $ A WORKERS COMPENSATION EWGCC000153815 1/14/2015 01/14/201 X WC STATU- ED, AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE — N E.L. EACH ACCIDENT $1.000,000 OFFICER/MEMBER EXCLUDED? D (Mandatory In NH) N / A E.L. DISEASE - EA EMPLOYEE $1.000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) RE: Permit Work Certificate Holder is included as Additional Insured per the terms, conditions and exclusions of the referenced general liability and umbrella policies, if required by written contract or agreement. Town of North Andover 1600 Osgood Street North Andover, MA 01845 ACORD 25 (2010/05) 1 of 1 #S565647/M565467 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE )O� ()A*d rAW1dka ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SMGCT