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Home My WebLink AboutBuilding Permit #828-15 - 27 EAST PASTURE CIRCLE 4/21/2015i BUILDING PERMIT 3b1 I' �N OF NORTH ANDOVER � APPLICATION FOR PLAN EXAMINATION Permit No#: O —6 Date Issued: 4�1 1'5 IMPORTANT: MAP PAR Date Received ►pplicant must complete all items on this page nnt # nnf' ``� 100.YearStructure'yes no ONING DISTRICT Historic Distnct yes ;',no Machine Shop;Village ,"` yes < no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building @6ne family ❑ Addition ❑ Two or more family ❑ Industrial ['Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic El�Well ❑ Floodplain ❑ Wetlands ❑ Watershed District 0 Water/Sewer DESCRIPTION OF WORK TO BE P r 0 /� - Identification - Please Type or Print Clearly (4n OWNER: Name: ilc�n q 2 r2z i m en Phone: 9 ?k - `/M' - GZt S ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 00 FEE: $ 26q Check No.: % 3�a b Receipt No.: NOTE: Persons contracting with uIregistered contractors do not have access to the guaranty fund .A _ nature of Aaent/Owner/'V�J ./, tfY Sianature Location No. f52g_ i5 Check #—� -7156 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ s, Building/Frame Permit Fee $004 Foundation Permit Fee $ Other Permit Fee $ r TOTAL $ Building Inspector a 0 Plans Submitted Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ TYPE'bF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS b Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comme Conservation Decision: Comme Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street 4 Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Nu i is and LJA I A — (I -or department use ❑ Notified for pickup Call Emai Date Time Contact Name Doc.Building Permit Revised 2014 M Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. P 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 N TE: 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 No TE: 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 NO E: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit ir4l all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals t1lat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording .m�st be submitted with the building application Doc: Building Permit Revised 2014 9 4 y r �avm OoSo� cJu X W QN z w..p� in H LU ><¢ O o W J U p U U W Q J W t S Z l r¢ Z U W Cn¢�UJ o w O �' Q F CN C Cl. wY�F- U- W¢ a rr > W tr Jlr L z x N M')dLr) ��.. < > > > > > Cl- CL CL Cl- CL U LU > * x C r v U Y W � 1 v Z L�f i r 1 i r'L . 1 W LLJ Q cl� of wa F-- LLJ r-' �� w F7- f--� • w V) z : Y LLI� '-'_No W Zo 1 0 z z 0 ' 1--I O 4 • Q + Ock�� 11 �" °O LLJ 00 Quo co z<< o LLJ a �z > Zm F- m z MNIot�\O r- m w� m O �� ~a Jvi o 8�NZ 2 zN W0 J �'(r) F-� ¢Of p 2iC> >- N - p C9 2 0 LLI Z a CDLU�� ¢ W¢ o ? 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CCD N CD n VOL0 OWA O C N C*) CD CD CD N� CD U) v O O CD O 0 Z m Cl)C O Cl) CO) C/) D Cn W r Z N m O m cn Z O m O= O O = io O —h r r N N CD -0 N OCL ' O n CD 0 � rt CL n � i77 O N = N „O,r FD TI O O CL o m CD 2 N -0 W �CD cD = y CD to Q 0 - N � n v rt LIN CD CD CD -0 p1 < cv UW)' O v, h U=) : OCD 0, cr CD U) � n � Q 0 O N < CD �• O CD 103 ;dIP � m � * O U) 0 2.0 '� •d� ora` o cl y CD CD C7 N odwool O ;: �. �� 0 1-0r a) o v v CL � (n O 77 � Ul)W N Z O C = m D m0 T N v Z1 O C W Z H —Ai T N N fD C m C UQ m m D r M m 0 T D1 A O DQ C z G7 m 0 T >• n S rD 'G A O " T O = d ''*. � W C M LA m m A N (D Ln -< n T O Q �* n S = M v O D r _ ZONA y 0 7IA ��,45olarCit . oo. y April 13, 2015 Project/Job # 0181637 RE: Project: To Whom It May Concern, CERTIFICATION LETTER Pizzimenti Residence 27 E Pasture Cir North Andover, MA 01845 Version #43.1 Date: &son Toman 10:11:10 -07'00' A jobsite survey of the existing framing system was performed by a site survey team from SolarCity. Structural review was based on site observations and the design criteria listed below: Design Criteria: - 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 = 38.5 psf (Non -PV Areas), Roof LL/SL = 21 psf (PV Areas) Note: Per IBC 1613.1; Seismic check is not required because Ss = 0.33365 < 0.4g and Seismic Design Category (SDC) = C < D On the above referenced project, the components of the structural roof framing impacted by the installation of the PV assembly have been reviewed. After this review it has been determined that the existing structure is adequate to withstand the applicable roof dead load, PV assembly load, and live/snow loads indicated in the design criteria above. I certify that the structural roof framing and the new attachments that directly support the gravity loading and wind uplift loading from PV modules have been reviewed and determined to meet or exceed structural strength requirements of the MA Res. Code, 8th Edition. Please contact me with any questions or concerns regarding this project. Sincerely, Jason W. Toman, P.E. Professional Engineer Main: 888.765.2489 email: jtoman@solarcity.com 3055 Clearview Way San Mateo, CA 94402 T (650) 638-1028 (888) SOL -CITY F (650) 638-1029 solarcity.com 04.13.2015 �\_`! PV System Structural Version #43.1 �=o;SolarCit ,° y Design Software PROJECT INFORMATION & TABLE OF CONTENTS Project Name: Pizzimenti Residence AHJ: North Andover Job Number: 0181637 Building Code: MA Res. Code, 8th Edition Customer Name: Pizzimenti, Anthony Based On: IRC 2009 / IBC 2009 Address: 27 E Pasture Cir ASCE Code: ASCE 7-05 City/State: North Andover, MA Risk Category: II Zip Code 01845 Upgrades Req'd? No Latitude / Longitude: 42.641682 -71.086700 Stamp Req'd? Yes SC Office: Wilmington PV Designer: Niko Cantrell Calculations: I Lisa Whitwell EOR: Jason W. Toman, P.E. Certification Letter 1 Project Information, Table Of Contents, & Vicinity Map 2 Structure Analysis (Loading Summary and Member Check) 3 Hardware Design (PV System Assembly) 4 Note: Per IBC 1613.1; Seismic check is not required because Ss = 0.33365 < 0.4g and Seismic Design Category (SDC) = C < D 27 E Pasture Cir, North Andover, MA 01845 Latitude: 42.641682, Longitude: -71.0867, Exposure Category: C 04.13.2015 • PV System Structural Version #43.1 moa SolarGt Y Design Software PROJECT INFORMATION & TARLF nF cnNTFNTS Project Name: Pizzimenti Residence AHJ: North Andover Job Number: 0181637 Building Code: MA Res. Code, 8th Edition Customer Name: Pizzimenti, Anthony Based On: IRC 2009 / IBC 2009 Address: 27 E Pasture Cir ASCE Code: ASCE 7-05 City/State: North Andover, MA Risk Category: II Zip Code 01845 Upgrades Req'd? No Latitude / Longitude: 42.641682 -71.086700 Stamp Req'd? Yes SC Office: Wilmington PV Designer: Niko Cantrell Calculations: I Lisa Whitwell EOR: Jason W. Toman, P.E. Certification Letter 1 Project Information, Table Of Contents, & Vicinity Map 2 Structure Analysis (Loading Summary and Member Check) 3 Hardware Design (PV System Assembly) 4 Note: Per IBC 1613.1; Seismic check is not required because Ss = 0.33365 < 0.4g and Seismic Design Category (SDC) = C < D 27 E Pasture Cir, North Andover, MA 01845 Latitude: 42.641682, Longitude: -71.0867, Exposure Category: C STRUCTURE ANALYSIS - LOADING SUMMARY AND MEMBER CHECK - MP1 Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (Ct) (IS) pg; Ce=Ct=I5=1.0 Member Design Summary per NDS Governing Load Comb CD CL + CL - CF Cr D + S 1.15 1.00 1 0.36 1 1.2 1.15 Member Properties Summary mary Maximum MP1 Roof Pitch Horizontal Member -Spans Overhang 1.16 ft Rafter Pro erties Actual W 1.50" Roof System Properties San 1 13.66 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 A2 Re -Roof No Span 4 SX 13.14 in A3 Plywood Sheathing Yes San 5 I 47.63 in.^4 Board Sheathing None Total Span 14.82 ft TL Defl'n Limit 120 Vaulted Ceiling No PV 1 Start 1.08 ft Wood Species SPF Ceiling Finish 1/2" Gypsum Board PV 1 End 14.25 ft Wood Grade #2 Rafter Sloe 370 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 Emin 510000 psi Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (Ct) (IS) pg; Ce=Ct=I5=1.0 Member Design Summary per NDS Governing Load Comb CD CL + CL - CF Cr D + S 1.15 1.00 1 0.36 1 1.2 1.15 Member Loading mary Maximum Max Demand Roof Pitch 9/12 Initial Pitch Adjust Non -PV Areas PV Areas Roof Dead Load DL 10.5 psf x 1.25 13.1 psf 13.1 psf PV Dead Load PV -DL 3.0 psf x 1.25 -499 psi 3.8 psf Roof Live Load RLL 20.0 psf x 0.75 15.0 psf Bendin + Stress Live/Snow Load LL/SL 1,2 50.0 psf x 0.77 1 x 0.42 38.5 psf 21.0 psf Total Load(Governing LC I TL 51.6 psf 1 37.9 psf Notes: 1. ps = Cs*pf; Cs -roof, Cs -pv per ASCE 7 [Figure 7-2] 2. pf = 0.7 (Ce) (Ct) (IS) pg; Ce=Ct=I5=1.0 Member Design Summary per NDS Governing Load Comb CD CL + CL - CF Cr D + S 1.15 1.00 1 0.36 1 1.2 1.15 Member Anal sis Results Summary Maximum Max Demand @ Location Capacitv DCR Shear Stress 43 psi 1.2 ft. 155 psi 0.28 Bending + Stress 1057 psi 8.1 ft. 1389 psi 0.76 Governs Bending - Stress -42 psi 1.2 ft. -499 psi 0.08 Total Load Deflection 0.91 in. 225 8.0 ft. 1.71 in. 120 0.53 Bendin + Stress 1 1057 psi 1 8.1 ft 1389 psi 0.76 Pass CALCULATION OF DESIGN WIND LOADS - MP1 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 Tvoe C Section 6.5.6.3 Roof Slope qh 370 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 moh 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 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 I 1.0 Table 6-1 Velocity Pressure qh qh = 0.00256 (Kz) (Kzt) (Kd) (VA2) (I) Equation 6-15 3.0 psf 20.6 psf T -actual Wind Pressure Ext. Pressure Coefficient U GC -0.95 Fig. 6-11B/C/D-14A/B Ext, Pressure Coefficient Down GC Dow 0.88 Fig. 6-11B/C/D-14A/B Design Wind Pressure p p = qh (GC) Equation 6-22 Wind Pressure U -19.6 psf Wind Pressure Down 18.0 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 -315 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 62.9% X -Direction Y -Direction Max Allowable Standoff Spacing Portrait 48" 65" Max Allowable Cantilever Portrait 18" 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 -392 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 1 78.5% CALCULATION OF DESIGN WIND LOADS - MPI Mounting Plane Information Roofing Material KZ Comp Roof Table 6-3 PV System Type Krt SolarCity SleekMountTm 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 370 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 Krt 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 25 ft Section 6.2 Wind Pressure Calculation Coefficients Wind Pressure Exposure KZ 0.95 Table 6-3 Topographic Factor Krt 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) (1) Equation 6-15 3.0 psf 20.6 psf T -actual Wind Pressure Ext. Pressure Coefficient U GC -0.95 Fig. 6-11B/C/D-14A/B Ext. Pressure Coefficient Down G Wn0.88 Fig. 6-11B/C/D-14A/B Design Wind Pressure p p = qh (GC) Equation 6-22 Wind Pressure Up Pfup)-19.6 psf Wind Pressure Down Pfdoyml 1 18.0 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 -315 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 62.9% X -Direction Y -Direction Max Allowable Standoff Spacing Portrait 48" 65" Max Allowable Cantilever Portrait 18" 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 -392 lbs Uplift Capacity of Standoff T -allow 500 lbs Standoff Demand/Capacity DCR 78.5% DocuSign Envelope ID: FA1202E9-DE97-48D5-9686-92OBBCAE33E5 `PO` ' 'TV ` • Power Purchase Agreement Here are the key terms of your SolarCity Power Purchase Agreement System installation cost 11r Electricity rate per kWh Our Promises to You 2/6/2015 Date: /M 0 years Agreement term • We insure, maintain, and repair the System (including the inverter) at no additional cost to you, as specified in the agreement. • We provide 24/7 web -enabled monitoring at no additional cost to you, as specified in the agreement. • We warranty your roof against leaks and restore your roof at the end of the agreement, as specified in the agreement. • The rate you pay for electricity, exclusive of taxes, will never increase by more than 2.90% per year. • The pricing in this PPA is valid for 30 days after 2/6/2015. • We are confident that we deliver excellent value and customer service. As a result, you are free to cancel anytime at no charge prior to construction on your home. Estimated First Year Production Customer's Name & Service Address Exactly as it appears on the utility bill Customer Name and Address Customer Name Anthony Pizzimenti 27 E Pasture Cir North Andover, MA 01845 Options for System purchase and transfer: • If you move, you may transfer this agreement to the purchaser of your Home, as specified in the agreement. • 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. 8,623 kWh Installation Location 27 E Pasture Cir North Andover, MA 01845 Options at the end of the 20 year 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 VP/AY, SAN MAI EO, CA 94402 888.SOL.CITY 1888.765.2489 I. SOLARCITY.COM MA HIC 168572/EL-1136MR Document Generated on 2/6/2015 550176 0 . DocuSign Envelope ID: FA1202E9-DE97-48D5-9686-920BBCAE33E5 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. IN ADDITION TO ANY RIGHTS YOU MAY HAVE TO CANCEL THIS PPA UNDER SECTION 22, YOU MAY ALSO CANCEL 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 2/6/2015. If you don't sign this PPA and return it to us on or prior to 30 days after 2/6/2015, SolarCity reserves the right to reject this PPA unless you agree to our then current pricing. 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: Anthony Pizzimenti DocuSigned by: Signature �t�J�jtw�un�1 8637DBAFSA3D425... Date: 2/6/2015 Customer's Name: Signature: Date: t° 50lar0ty Power Purchase Agreement SQLARCITY APPROVED Signature: r. -y"'". _..----:•.... Y ....� ...-�' UNDON RNE, CEO (PPA) Power Purchase Agreement 11�+1. ��r�SvtarCirty Date: 2/6/2015 [oil "11:01 Solar Power Purchase Agreement version 8.3.0 550176 Address: 3055 CLEARVIEW WAY ono 7CG .fAnA City/State/Glp: J„" Iwr` I r=W, %/r. O`fYVL rnone a: —�� The Commonwealth of Massachusetts r --- Department of Industrial Accidents -' Office of Investigations 6 ❑ New construction I Congress Street, Suite 100 - x Boston, MA 02114-2017 ship and have no employees www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlieant Information ^ Please Print Legibly Name (Business/Organizationllndividual): SOLARCITY CORP Address: 3055 CLEARVIEW WAY ono 7CG .fAnA City/State/Glp: J„" Iwr` I r=W, %/r. O`fYVL rnone a: —�� Are you an employer? Check the appropriate box: Type of project (required): 1. ❑■ I am a employer with 5000 4. ❑ 1 am a general contractor and 1 6 ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance.: 9. ❑ Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.E Other SOLAR / PV employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they arc 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. l am an employer that Is providing workers' compensation insurance for my employees. Below is fire policy and Job site Information. Insurance Company Name: LIBERTY MUTUAL INSURANCE COMPANY _ Policy # or Self -ins. Lic. #: WA7-,6,6�D 066265-024 Expiration Date: 09/01/2015 Job Site Address: 20 E. 7�1� � n- —, City/State/Zip: &C� h 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 forth of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the painsand penal8es of perjtrry that the information provided above is true and correct. Phone #• O/jricial use only. Do not write in this area, to be completed by city or Lown official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #• A p® CERTIFICATE ()F LIABILITY INSURANCE DATE 12014 IYYYY) 0812'MM 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. 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(fes) 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 COWT NAME: MARSH RISK & INSURANCE SERVICES PHONE_9 345 CALIFORNIA STREET, SUITE 1300 M, -- CALIFORNIA LICENSE NO. 0437153 E-MAIL aDDREss SAN FRANCISCO, CA 94104 DAMA E TO RENTED INSURERS) AFFORDING COVERAGE NA_IC a 998301-STND-GAWUE-14.15 Liberty Mutual Fire Insurance Company 16586 INSURERA___ _ _ _ INSURED INSURER B : Liberty Insurance Corporation 42404 1650) 963 5100 _ NIA NIA Sdar0ty Corporation INSURER C: _ 3055 Ciearview Way INSURER D: San Mateo, CA 94402 INSURER E: INSURER F: rnvcOAnC& L`CDTICICATC 1dna11R1:R• SFe.fMl9Edn9fiCW7 REVISION NUMBER.4 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. INS ADDL UBR POLICY EFF POLICY EXP LIMITS TYPEOF INSURANCE POLICY NUMBER MM/DD MMIOD/YYYY A GENERAL LIABILITY ACCORDANCE WITH THE POLICY PROVISIONS. 782-661-066265-014 09101/2014 09101/2015 EACH OCCURRENCE $ 1'000,000 DAMA E TO RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMIE Ea occurrence _ $ CLAIMS4dADE [�__i OCCUR MED EXP (Any orw pereon) S 10,000 PERSONAL & ADV INJURY $ 1'000'000 _GENERAL AGGREGATE $ 2,000,000 $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG _X1 POLICY I X1 PRO- LOC Deductible $ 25,000 A AUTOMOBILE LIABILITY AS2.661-066265.044 09/0112014 09101/2015 COMBINED SINGLE LIMITsEe accident_ $ 11000'000 ANY AUTO BODILY INJURY (Per person) $ BODILY INJURY (Per accident) ALL OWNED SCHEDULED $ AUTOS AUTOS X NON•OWNED PROPERTY DAMAGERlxx HIRED AUTOS , AUTOS (Per accident)Phys. Damage COMP/COLLDED: $ $1,000/$1,000 UMBRELLA LIAB OCCUR Id EACH OCCURRENCE $_ _^ EXCESS LIAB -CLAIMS-MADE AGGREGATE $ DED RETENTION $ B WORKERS COMPENSATION WA7-66D-066265.024 09/0112014 09/01/2015 X wcsTATu- orH- 9J3MMT,uS ER g AND EMPLOYERS' LIABILITY YIN WC7-661-066265.034 (WI) 0910112014 09/01/2015 E L EACH 1,000,000 $ ANY PROPRIETOR/PARTNER/EXECUTIVE a NIA ACCIDENT B OFFICERIMEMBER EXCiUDED? {Mandatory In NH) WC DEDUCTIBLE: 5350,000 E L DISEASE - EA EMPLOYEE $ 1,000,000 "M 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) Evidence of Insurance. w a -e 1^ATt IJAI ntee F`AAIl2F1 I ATInN (O 1855-2070 AGORD GVRPVRA f i0N- All rfgms reserves. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD _ SolarCity Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Clearview Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo. CA 94402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services CharlesMarmolejo��— (O 1855-2070 AGORD GVRPVRA f i0N- All rfgms reserves. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD A� DATE (MMIDDNYYY) 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 MARSH RISK 6 INSURANCE SERVICES 345 CALIFORNIA STREET, SUITE 1300 CALIFORNIA LICENSE NO. 0437153 SAN FRANCISCO, CA 94104 CONTA T NAME: —_.. ffAX PHONE Ext)' -- Vc=----.---- --. — E-MAIL ADDRESS —-. INSURER(S) AFFORDING COVERAGE _ NA_IC N - _ INSURER A : Liberty Mutual Fire Insurance Company — 16586 998301-STND-GAWUE-14-15 INSURER B: Liberty Insurance Corporation 42404 — -` _ _ INSURED Ph (650) 963-5100 SolarCity Corporation INSURER C: NIA N/A INSURER D: 3055 Clearview Way San Mateo, CA 94402 - INSURER E: INSURER F: DAMA E TO RENTED PREMI_ E Ea occurrence rrnvUnwr_ee r-=DTIGICATI= Idl IRARFR- RFA On9ddn9fi4n7 REVISION NLIMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE INSURANCE ADDL SUER NUMBER MMIDDY EFF POLICPOLICY PLICYEX MM DDnryYYIi LIMITS A -OF GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE O OCCUR Charles Marmolejo T82-661-066265.014 09/0112014 09101/2015 EACH OCCURRENCE a 1,000,000 DAMA E TO RENTED PREMI_ E Ea occurrence 100,000 S .__ $ 10'000 MED EXP (Any one person) PERSONAL & ADV INJURY $ 1'000,000 $ 2,000,000 $ 2,000,000 GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY I X PRO- LOC PRODUCTS - COMPIOP-AGG Deductible $ 25,000 A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS X X NO OWNED HIRED AUTOS AUTOS X Phys. Damage AS2-661-066265-044 09101/2014 09/0112015 COMBINED SINGLE LIMIT Es accident) 1,000,000 S $ $ T _ $ $1,0001$1,000 BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Per accident? COMP/COLL DED: UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ DED RETENTION $ B B B WORKERS COMPENSATION AND EMPLOYERS'LIABILITYWG7661-066265.034(WI) ANY PROPRIETORIPARTNERIEXECUTNE Y ! N OFFICERIMEMBER EXCLUDED? ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WA7-66D-066265.024 - 'WC DEDUCTIBLE: $350,000 09/0112014 09/01/2014 09/01/2015 09/01/2015 X WC STIAMT! - ER 1,000,000 $ $ 1,000,000 $ 1,000,000 E L EACH ACCIDENT E.l. DISEASE - EA EMPLOYEE E L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Evidence of Insurance. (`FRTIFINATE HOLDER IftANCFLLATION SolarCity Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Clearview Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo, CA 94402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD r � � . J �T.e �G�'n✓!7ZU�iZt'.l�f',,G� IG(,f�' ,l1-,�,.%�.C.%c1:1fx.!.�ZCI.Gf P� Office of Consumer Affairs and Business Regulation �r g 10 Park Plaza - Suite 5170 T tly � Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168572 Type: Supplement Card SOLAR CITY CORPORATION Expiration: 3/8/2017 CRAIG ELLS -- 3055 ' - . 3055 CLEARVIEW WAY - SAN MATEO, CA 94402 __..—.. Update Address and return card. Mark reason for change, ` - Address Renewal ; , Employment Lost Card ,. .!hr I r,/M rror.„/rrvtfl/I r�. //�.WIr It4MM�iJ 011iee orConsumer AtTairs & Business Regulation License or registration valid for individul use only f tt HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation i Registration: 168572 Typo: 10 Park Plaza - Suite 5170 Expiration: 3/812017 Supplement Card Boston._ MA 02116 SOLAR CITY CORPORATION CRAIG ELLS 24 ST MARTIN STREET BLD 2UNI c WALBOROUGH, MA 01752 Undersecretary Not valid ,,ithout signature `.1.rtiF.IC.,h�intl2; .}ttp.r++.•��„t .+ .� ,:3 i.r•r+f , e Bodrtt of t3+niUuly Re41u1.1Lt�++y �s7 �! ,near<iti C41++{c CS -107663 CRAIG ELLS 206 BAKER STREET Keene NF1 03431 08/29/2017 F1 e- (00?l?.1fio1/11(VC't!l1111 0/ �GCG11�t'C11llJf' 1 Off ce of Consumer Affairs and Business Regulation ,. 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168572 Type: Supplement Card SOLAR CITY CORPORATION Expiration: 3/8/2017 ASTRID BLANCO 3055 CLEARVIEW WAY — — SAN MATEO, CA 94402 _ Update Address and return card. Mark reason for change. SCA I Ca 20M-05111 Address F Renewal �1D Employment Ej Lost Card �7l, C `��rvrrrunarr.Crr�/� flice of Consumer Affairs &Business Regulation License or registration valid for individul use only hOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation Registration: 168572 Type: 10 Park Plaza - Suite 5170 -9' Expiration: 3/8/2017 Supplement Card p pp Boston, MA 02116 . . SOLAR CITY CORPORATION ASTRID N —� 24 ST MARTIN STREET BLD 2UNI ls' UALBOROUGH, MA 01752 Undersecretary Not valid without signature k t