HomeMy WebLinkAboutBuilding Permit #960-16 - 280 FARNUM STREET 3/9/2016Permit NO: %0 -1 �
Date Issued: 47 -""1 —
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
IMIPORTANT: Applicant must comr)lete all items on this
LOCATION 280 Farnum Street
Print
PROPERTY OWNER_ George Perna
411 Print
MAP NOA.?4PARCEL:/�� ZONING DISTRICT: Historic District yes no
0
Machine Shor) Villacie ves (no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
VOne family
11 Addition
El Two or more family
11 Industrial
El Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
El Others:
El Demolition
VOther: rooftop solar
El Septic El Well
El Floodplain El Wetlands
El Watershed District
11 Water/Sewer
I I
Installation of an interconnected rooftop solar PV system:
�Tu
9.625 KW DC/ 35 solar panels
Identification Please Type or Print Clearly)
OWNER: Name: George Perna Phone: 978-683-8948
Address: 280 Farnurn St, North Andover MA 01845
1 CONTRACTOR Name:
Address:
Phone: 978-793-7881
734 Forest St, suite 400, Marlborough MA 01752
Supervisor's Construction License: Exp. Date:
CS -040622 1/22/17
Home Improvement License: Exp. Date:
180120
10/14/16
ARCH ITECT/ENGI NEER PZSE, Inc. / Paul K. Zacher Phone: 916-961-3960
Address: 8150 Sierra College Blvd, suite 150, Roseville CA 95661 Reg. No. 50100
FEE SCHEDULE: BULDING PERMIT. $1Z00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER &F.
Total Project Cost: $ 20,116.25 FEE: $ 'Pq I --
Check No.: P Receipt No.: k'
NOTE: Persons contracting with unregistered contractors do not have aees7s k dre guaranty fund
ature
AN
er
of contractor
0)
Location r--'x!kV -k70/7,.J e4
N Date .3 A
4�d �,, -.41 -, .
Check # - -1 3>
--� ) -4,�L 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Building Inspector
Plans Submitted Plans Waived F1 Certified Plot Plan Stamped Plans F1
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Mas s age[B o dy Art
Swimming Pools 11
well
Tobacco Sales 11
Food Packaging/Sales 11
Private (septic tank etc.
Permanent Dumpster on Site F1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
I
PLANNING & DEVELOPMENT
Comm
Reviewed On
Signature,
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on Sicinature
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 Town Engineer: Signature:
L.Ocatea W4 US900CI 6treet
E 41 E PR A -; UT I - NM-- Te'rh * Q t 6 n s ite,,.,. .yq§ c.4: n
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p unips ei
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IWITM'710 R" N
F; i r e i;�� e p. a ft;� 64�k�
m, gt Mgnaturefflat
RNT
0 'M"
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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.$100-$l 000 fine
Doc.Building Pen -nit 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
,6 Copy of Contract
4� Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
OTE: All dumpster permitsrequire sign off from Fire Department prior to i ssuance 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)
... Eng . in . eer . ing - Aff - id - avi . t s - for - E - ng .- i , neered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
Building Permit Application -
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
E: 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
Doe: Building Permit Revised 2014
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STRU(TURAL ENGINEERS
March 3, 2016
Sunrun Inc.
133 Technology Dr, Suite 100
Irvine, CA 92618
Attn.: To Whom It May Concern
re: Job 2016-02836: George Perna - 221R-28OPERN
The following calculations are for the structural engineering design of the photovoltaic panels
located at 280 Farnum St. , North Andover, MA 01845. After review, PZSE, Inc. certifies that the
roof structure lacks sufficient structural capacity for the applied PV loads. See the following
calculations and Plan Sheets for location and repair to bring the roof structure up to the required
capacity.
If you have any questions on the above, do not hesitate to call.
jVk OF
ULK.
Prepared By: CHER
0 STRUCTURAL
PZSE, Inc. - Structural Engineers 0 No.50100 Cn
Roseville, CA I . , )
8150 Sletto Col4e Wevatd, Suh I SO * Rmville, U 9S661 * 9116,9611.3960 P - 916.961.376S 0 WW%v,pzW.00M
1 of 8
Gravity Loading
Roof Snow -Load Calculafi;"ns,
p, = Ground Snow Load 50 psf
C, = Exposure Factor 0.9 (ASCE7 - Table 7-2)
Ct = Thermal Factor = 1.1 (ASCE7 - Table 7-3)
1 = Importance Factor 1
pf= 0.7 CeCt I Pq
where p,!5 20 psf, Pf min = I x p. =
where pg > 20 psf, Pf min = 20 x I =
Therefore, pf = Flat Roof Snow Load =
35 psf (ASCE7 - Eq 7-1)
WA min snow load p�f,,Ope � 15-)
N1A min snow load (mof dope < e)
35 psf
P, = CJh
----7
(ASCE7 - Eq 7-2)
Cs = Slope Factor =
0.867
ARRAY VARRAY 41 ARRAY5
Cs = Slope Factor =
0.867
ARRAY 21 ARRAY 6
Cs = Slope Factor =
1.000
ARRAY 3
Ps = Sloped Roof Snow Load
30.0 psf
ARRAY I/ ARRAY 4/ ARRAY5
Ps = Sloped Roof Snow Load
30.0 psf
ARRAY 21 ARRAY 6
Ps = Sloped Roof Snow Load
34.7 psf
ARRAY 3
PVDead Coad =-3 psf (ie -r Su-nrun lgc-)'
-
Roof Live Load = 20 Psf,
Note: Roof live load is removed in area's covered by PV array.
Riif Dead-Co-ad.ARRAYl
----7
Composition Shingle
2.00
Roof Plywood
1.50
2x6 Rafters @ 16"o.c.
1.13
Vaulted Ceiling
0.00 (Ceiling Not Vaulted)
Miscellaneous
0.00
Total Roof OL ARRAY 1
4.6 psf
DL Adjusted to 18 Degree Slope
4.9 psf
Roof Dead.Load ARRAY -21 ARRAYJ6
Composition Shingle
2.00
Roof Plywood
1.50
2x6 Rafters @ 16'o.c.
1.13
Vaulted Ceiling
0.00 (Ceiling Not Vaulted)
Miscellaneous
0.00
Total Roof DL ARRAY 21 ARRAY 6
4.6 psf
DL Adjusted to 18 Degree Slope
4.9 psf
RoofNaR Load ARRAX-3,
Composition Shingle 2.00
Roof Plywood 1.50
Double 2x6 Rafters @ 16"o.c. 2.26
Vaulted Ceiling 0.00 (Ceiling Not Vaulted)
Miscellaneous 0.00
Total Roof DL ARRAY 3 5.8 psf
DL Adjusted to 18 Degree Slope 6.1 psf
RER Di7ad C-oad ARRAY --41 ARRAY5
Composition Shingle
2.00
Roof Plywood
1.50
2x6 Rafters @ 16"o.c.
1.13
Vaulted Ceiling
0.00 (Ceiling Not Vaulted)
Miscellaneous
0.00
Total Roof DL ARRAY 41 ARRAY5
4.6 psf
DL Adjusted to 18 Degree Slope
4.9 psf
2 of 8
Wind Calculations
Per ASCE 7-05 Components and Cladding
kFp—itViiia les
Wind Speed
100 mph
Exposure Category
C
Roof Shape
Gable/Hip
Roof Slope
18 degrees
Mean Roof Height
26 ft
Building Least Width
25 ft
Effective Wind Area
10.9 sf
Desig—n Wi—nd Pressure Calculatiion�� — — -------
Wind Pressure P = qh*(G*Cp)
qh = 0.00256 * Kz * Kzt * Kd * VA 2 * I (Eq -6-15)
Kz (Exposure Coefficient) 0.948 (Table 6-3)
Kzt (topographic factor) 1 (Fig. 6-4)
Kd (Wind Directionality Factor) 0.85 (Table 6-4)
V (Design Wind Speed)= 100 mph
Importance Factor 1 (Table 6-1)
qh 20.63
Standoff Uplift Check.'
Maximum Design Uplift = -584 lb
Standoff Uplift Capacity = 700 lb
700 lb capacity > 584 lb demand Therefore, OK
if Fastener Capacity Checle,
Fastener = I - 5/16" dia Lag
Number of Fasteners = I
Minimum Threaded Embedment Depth = 2.5
Pullout Capacity Per Inch = 205 lb
Fastener Capacity = 820 lb
820 lb capacity > 584 lb demand Therefore, OK
3 of 8
Ptandoff Uplift Calc@itions�
Zone 1
Zone 2
Zone 3 Positive
GCp =
-0.90
-1.69
-2.59 0.50
Uplift Pressure =
-18.54 psf
-34.96 psf
-53.51 psf 10.27 psf
Max Rail Span Length =
4.0 ft
4.0 ft
4.0 ft
Longitudinal Length =
21 ft
2.7 ft
2.7 ft
Attachment Tributary Area =
10.9 sf
10.9 sf
10.9 sf
Footing Uplift =
-202 Ib
-382 Ib
-584 Ilb
Standoff Uplift Check.'
Maximum Design Uplift = -584 lb
Standoff Uplift Capacity = 700 lb
700 lb capacity > 584 lb demand Therefore, OK
if Fastener Capacity Checle,
Fastener = I - 5/16" dia Lag
Number of Fasteners = I
Minimum Threaded Embedment Depth = 2.5
Pullout Capacity Per Inch = 205 lb
Fastener Capacity = 820 lb
820 lb capacity > 584 lb demand Therefore, OK
3 of 8
Framing Check
ARRAY I PASS
w = 51 pff
Dead Load 4.9 psf
PV Load 3.0 psf
rs
Snow Load 30.0 psf Oc�'
Member Span = 12'- 2"
Governing Load Comb. DL+SL Note: Attachments shall be Staggered.
Total Load 37.9 psf
Mgm-ge—r0r—operfiis7,
Member Size S (in A 3) 1 (in'4) Lumber Sp/Gr Member Spacing
2x6 7.56 20.80 SPF#2 @ 16"o.c.
F-- C WlBiiniding �Ue"ss
Fb (psi) = fb x Cd x Cf x Cr (NDS Table 4.3.1)
875 x 1.15 x 1.3 x 1.15
Allowed Bending Stress = 1504.3 psi
Maximum Moment = (wLA2)/8
= 935.782 ft#
= 11229.4 in#
Actual Bending Stress = (Maximum Moment) I S
= 1484.9 psi
Allowed :-Actual -- 98.8% Stressed - Therefore, OK
F t$e7c0ifiectidif
Aiiowea ueTiecuon k i oiai Loaa)
U-1 zu kt i4uuuuu psi t-er iiub)
1.216 in
Deflection Criteria Based on
Simple Span
Actual Detection (Total Load)
(5"w"L-4) / (384'E"1)
0.630 in
U232 < L/I 20 Therefore OK
Allowed Deflection (Live Load)
U1 80
0.811 in
Actual Deflection (Live Load)
(5*w*LA4) / (384*E*I)
0.679 in
L/216 < Ul 80 Therefore OK
CQIC7$K—ea�, - --- - - -- -- - -- - - -- – ---- ---
F--
Member Area 8.3 in A 2
Fv (psi) 135 psi (NDS Table 4A)
Allowed Shear = Fv *A
1114 lb Max Shear(V) =w*L/2 = 308 lb
Allowed > Actual -- 27.7% Stressed – Therefore, OK
4 of 8
Framing Check
ARRAY 2/ ARRAY 6 PASS
w = 51
Dead Load 4.9 psf
PV Load 3.0 psf
Snow Load 30.0 psf �2W 1-6"o.c.:-
__R RQers @ f6 o.c7
77
Member Span = 6'- 5'
Governing Load Comb. DL + SL Note: Attachments shall be Staggered.
Total Load 37.9 psf
Member Properties,
Member Size S (in A 3) 1 (in'4) Lumber Sp/Gr Member Spacing
2x6 7.56 20.80 SPF#2 @ 16"o.c.
�CkiW ii—gSlieis�
Fb (psi) = fb x Cd x Cf x Cr (NDS Table 4.3.1)
875 x 1.15 x 1.3 x 1.15
Allowed Bending Stress = 1504.3 psi
Maximum Moment = (wLA2)/8
= 260.286 ft#
= 3123.43 in#
Actual Bending Stress = (Maximum Moment) / S
= 413.1 psi
Allowed > Actual - 27.5% Stressed — Therefore, OK
CWe—cktiflecti6n-
Allowed Deflection (Total Load)
Deflection Criteria Based on
Actual Deflection (Total Load)
Allowed Deflection (Live Load)
Actual Deflection (Live Load)
Ul 20 (E = 1400000 psi Per
= 0.641 in
Simple Span
(5-w-LA4) / (384-E-1)
= 0.049 in
= U1572 < U120 Therefore OK
Ul 80
0.427 in
(5-w-1-114) / (38,PE"1)
0.053 in
U1453 < U1180 Therefore OK
--- Me—ck-Srea—r)
nber Area 8.3 in A 2 Fv (psi) 135 psi (NDS Tabl74—A
Allowed Shear = Fv *A = 11141b WxShearM=w*L/2 162 lb
Allowed > Actual -- 14.6% Stressed — Therefore, OK
5 of 8
Framing Check
ARRAY3 PASS - With Framing Upgrades
w 58
Dead Load 6.1 psf
PV Load 3.0 psf
Snow Load 34.7 psf b7o"ub—Ii2WRift "rs.T6�—oc.,"
9 -
Member Span = IT- 4"
Governing Load Comb. DL + SL Note: Attachments shall be Staggered.
Total Load 43.8 psf
ke—mberPropertiiis-- Bised`oTn—UFg—ra—ded Secfion-
Member Size S (in'3) I (in'4) Lumber Sp/Gr Member Spacing
Double 2x6 15.13 41.59 SPF#2 @ 16'o.c.
CfiiWBi-n-din—g Str—ess
Fb (psi) = fb x Cd x Cf x Cr
875 x 1.15 x 1.3 x 1.15
Allowed Bending Stress = 1504.3 psi
Maximum Moment = (wLA2)/8
= 1296.3 ft#
= 15555.6 in#
Actual Bending Stress = (Maximum Moment) / S
= 1028.5 psi
Allowed :,-Actual - 68.4% Stressed — Therefore, OK
(NDS Table 4.3.1)
Allowed Defiection (Total Load)
L/1 20
(E 1400000 psi Per NDS)
1.333 in
Deflection Criteria Based on
Simple Span
Actual Deflection (Total Load)
(5 -w -L,14) / (384"El)
0.474 in
U338 < L/1 20
Therefore OK
Allowed Deflection (Live Load)
L/1 80
0.888 in
Actual Deflection (Live Load)
(5"w"LA4) / (384'E"1)
0.565 in
U284 < L/1 80
Therefore OK
Checl�Slie—ar,
Member Area= 16.5 in12
Fv (psi)
135 psi (NDS Table 4A)
Allowed Shear = Fv * A
2228 lb
Max Shear (V) = w L 2 = 389 lb
Allowed > Actual -- 17.5% Stressed -- Therefore, OK
ZOW.
Framing Check
ARRAY 41 ARRAY5 PASS
w = 51 pff
Dead Load 4.9 psf
PV Load 3.0 psf
Snow Load 30.0 psf
�6o.c.
Z�6
"I Member Span = 8' - 2'
Governing Load Comb. DL+SL
Total Load 37.9 psf
r— -- --- --
2x6
7.56 20.80
Note: Attachments shall be Staggered.
Lumber Sp/Gr Member Spacing
SPF#2 @ Wo.c.
Fb (psi) = fb x Cd x Cf x Cr (NDS Table 4.3.1)
875 x 1.15 x 1.3 x 1.15
Allowed Bending Stress = 1504.3 psi
Maximum Moment = (wl-12) / 8
= 421.62 ft#
= 5059.44 in#
Actual Bending Stress = (Maximum Moment) I S
= 669.1 psi
Allowed > Actual -- 44.5% Stressed — Therefore, OK
'ChWWD iic—ti—n--
Allowed Deflection (Total Load)
Ul 20 (E 1400000 psi Per NDS)
0.816 in
Deflection Criteria Based on
Simple Span
Actual Deflection (Total Load)
(5-w"L-4) / (384-E-1)
0.128 in
1-1766 < L/I 20 Therefore OK
Allowed Deflection (Live Load)
Ul 80
0.544 in
Actual Deflection (Live Load)
(5-w-LA4) / (384'E"1)
0.138 in
U711 < Ul 80 Therefore OK
Member Area= 8.3 in12
Fv (psi) 135 psi (NDS Table 4A)
Allowed Shear = Fv *A
11141b MaxShearM=w*L/2 = 207 lb
Allowed > Actual -- 18.6% Stressed — Therefore, OK
7 of 8
Lateral
2009 IBC CH34
Existing
Weight of Effected
Buildin4
Level
Area
Weight (psQ
Weight (lb)
Roof
15.00 sf
4.9 psf
7350 lb
Ceiling
1500 sf
6.0 psf
9000 lb
Vinyl Siding
170 ft
2.0 psf
8840 lb
Int Walls
170 ft
6.4 psf
28288 lb
Existing Weight
of Effected Building
53478 lb
Proposed Weight of PV Systed
Weight of PV System (Per Sunrun Inc.) 3.0 psf
Approx. Area of Proposed PV System 621 sf
Approximate Total Weight of PV System 1863 lb
I-
il 0-%.—C—Ompa -n, i -0-1i
10% of Existing Building Weight (Allowed) 5348 lb
Approximate Weight of PV System (Actual) 1863 lb
Percentincrease 3.5%
5348 lb > 1863 lb, Therefore OK
8 of 8
(26'Wall Height)
March 3, 2016 STRU(TURAL ENGINEERS
Sunrun Inc.
133 Technology Dr, Suite 100
Irvine, CA 92618
Subject: Structural Certification for Installation of Solar Panels
Job Number: 2016-02836
Client: George Perna - 221 R-280PERN
Address: 280 Farnum St. , North Andover, MA 01845
Attn.: To Whom It May Concern
A field observation of the condition of the existing framing system was performed by an audit team from Sunrun Inc..
From the field observation of the property, the existing roof structures was observed as follows:
The existing roof structure consists of:
e Composition Shingle over Roof Plywood is supported by 2x6 Rafters @ 16"o.c. at ARRAY 1. The rafters are sloped at
approximately 18 degree and have a maximum projected horizontal span of 12 ft 2 in between load bearing walls.
a Composition Shingle over Roof Plywood is supported by 2x6 Rafters @ 16"o.c. at ARRAY 2/ ARRAY 6. The rafters are
sloped at approximately 18 degree and have a maximum projected horizontal span of 6 ft 5 in between load bearing
walls.
e Composition Shingle over Roof Plywood is supported by 2x6 Rafters @ 16"o.c. at ARRAY 2/ ARRAY 6. The rafters are
sloped at approximately 18 degree and have a maximum projected horizontal span of 6 ft 5 in between load bearing
walls.
Composition Shingle over Roof Plywood is supported by 2x6 Rafters @ 16'o.c. at ARRAY 4/ ARRAY5. The rafters are
sloped at approximately 18 degree and have a maximum projected horizontal span of 8 ft 2 in between load bearing
walls.
Desi.qn Criteria:
• Applicable Codes = 2009 1 BC, ASCE 7-05, and NDS -05
• Ground Snow Load = 50 psf
• Roof Dead Load = 4.9 psf ARRAY 1 ; 4.9 psf ARRAY 2/ ARRAY 6; 6.1 psf ARRAY 3
• Basic Wind Speed = 100 mph Exposure Category C
• Solar modules = as indicated in attached drawings
As a result of the completed field observation and design checks:
ARRAY I is adequate to support the loading imposed by the installation of solar panels and modules. Therefore, no
structural upgrades are required.
ARRAY 2/ ARRAY 6 is adequate to support the loading imposed by the installation of solar panels and modules.
Therefore, no structural upgrades are required.
ARRAY 3 is inadequate to support the loading imposed by the installation of solar panel and modules. New 2x6 SPF#2
rafters are required to be sistered to the existing roof rafters to support the additional loading.
ARRAY 4/ ARRAY5 is adequate to support the loading imposed by the installation of solar panels and modules.
Therefore, no structural upgrades are required.
I certify that the capacity of the structural roof framing that directly supports the additional gravity loading due to the solar panel
supports and modules had been reviewed and determined to meet or exceed the requirements in accordance with the 2009 IBC.
If you have any questions on the above, do not hesitate to call. �k OF
Prepared By: PAUL K.
ZACHER
PZSE, Inc. - Structural Engineers 0 STRUCTURAL
Roseville, CA No. 50100
06/.30/
150 Sierm Colter 8W60A, SA 150 * Rowde. (A 95661 * 916.96 13960 P * 916 A . - . ..A'
DocuSign Envelope ID: 257A6C3D-5429-483F-AB30-E5F5lD35D68D
22. NOTICE OF RIGHT TO CANCEL
YOU MAY CANCEL THIS TRANSACTION AT ANYTIME PRIOR TO MIDNIGHT OF THE 10TH CALENDAR DAY AFTER YOU SIGN
THIS AGREEMENT AND ANY DEPOSIT PAID WILL BE REFUNDED. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR
AN EXPLANATION OF THIS RIGHT.
By initialing below, you expressly acknowledge that you have been advised on your right to cancel this Agreement and have received duplicate copies of
the Notice of Cancellation.
DS
CD
FACTCpted by (Initials):
SUNRUNINC.
Date: 6/27/201
DocuSigned by:
Signatu,e["' h"
1CD4F8C6ECD74FA
PrintName: Adam Murray
Title: OpOrations Associate
SALES CONSULTANT
Bysigningbelowlacknowledgethatiamsunrun accredited that
1presented this agreement according to 'The Right 5tuff"and the
5unrun Code of Conduct and thatI obtained the homeowneK5
signature on this agreement.
Name.-william Paulin
DocuSlgnedafnt Name]
Signatur wiwm PAZW
I C111E39D8D06F94AA
5unrunlD#.* 571—R3420311
[10-dgit numberyou received from 5unrunj
CUSTOMER
P
.dmao�Alccount
E] 5/1/2015
DocuSigned by:
S S
,SnatUre.
ignature:
E'eeC06BD4Q&C4'0—
rge erna
[Account email a gc1pe-r-naftamcas-t—net
*7his emafl address will be used by5unrun for official correspondence, such assending
month4ebills or otherinvoices. Sunnin willnevershare orsellyour einailaddress to any
thirdpardes.
Account phone number: (979)--683--994&-
Secondd�yAlccount htdMer
Signature:
Print Name:
05/01/2015 PK1 3VRNKZRAZ-H (Custom PPA Fixed) Page 12 of 18
The Commonwealth ofMassachusetts
4-3) Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
117orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information - Please Print Le2ibl
Name (Business/Organization/Individual): Sunrun Installation Services, Inc.
Address: 775 Fiero Lane, Suite 200
City/State/Zip: San Luis Obispo, CA 93401
Are you an employer? Check the appropriate box:
Phone #: 978-549-9438
I.E] I am a employer with 35 employees (full and/or part-time).*
2.n I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.F1 I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.[:]l am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.M I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.:
6. n We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers'comp. insurance required.]
Type of project (required):
7. E] New construction
8. E] Remodeling
9. El Demolition
10 E] Building addition
I I. Electrical repairs or additions
12. Plumbing repairs or additions
13.E:]Roof repairs
14. E] Other Rooftop Solar
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
� 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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: Zurich American Insurance Company
Policy 9 or Self -ins. Lic. #: WCO 13696001 & WCO 13696101
Expiration Date: 10/0 1 /2016
Job Site Address: 280 Famum St, North Andover MA 01845 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
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 #:
AeCOR& CERTIFICATE OF LIABILITY INSURANCE
DATE [MM/DD/YYYY)
F 10/0112015
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(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 endorsement(s).
PRODUCER
MARSH RISK & INSURANCE SERVICES
345 CALIFORNIA STREET, SUITE 1300
CALIFORNIA LICENSE NO. 0437153
SAN FRANCISCO, CA 94104
CONTACT
-NAME:
PHONE FAX
(A/C. No. Ext): (AfC, No):
E-MAIL
-ADDRESS:
-NUMBER
000641241
-
10/01/2015
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : James River Insurance Company 12203
104960339-STND-GAX-15-16
INSURED
Sunrun Installation Services, Inc.
INSURER B: N/A N/A
INSURER C : Houston Casualty Company 42374
and REC Solar, Inc.
775 Fiero Lane, Suite 200
San Luis Obispo, CA 93401
INSURER D:
TOTAL POLICY LIMIT $ 10,000,000
-INSURER E:
INSURER F:
COVERAGES CERTIFICATF NI]MRFR- SEA -002994222-03 PF:VIqIe)M Kil IMPF:11P.5
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
LTR
I TYPE OF INSURANCE
ADDLSUBR
POLICY
POLICY EFF
(MMIDDNYYY)
POLICY EXP
(MM/DDIYYYY)
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE M OCCUR
-NUMBER
000641241
-
10/01/2015
10/0112016
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence) $ 300,000
EXP (Any one person) $ 10,000
-MED
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICYF PRO-
—1 JECT F__] LOC
X OTHER� Host Liquor Liability
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COM P/OP AGG $ 2,000,000
TOTAL POLICY LIMIT $ 10,000,000
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COM BINED SINGLE LIMIT
(E, a..id.rt) $
BODILY INJURY (Per person) $
BODILY INJURY (Pe accident) $
PROPERTY DAMAGE
(Par accident) $
C
X
UMBRELLA LIAB
I EXCESS LIAB
X
�
OCCUR
CLAIMS -MADE
H15XC5023203
10/01/2015
10/01/2016
EACH OCCURRENCE $ 10,000,000
AGGREGATE $ 10,000,000
I DED I I PFTENTION$
$
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED? F_�
(Mandatory In NH)
Ifies, describe under
D SCRIPTION OF OPERATIONS below
N/A
PER OTH-
ISTATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
Re: Permitting within jurisdiction.
%,r -F,. i iri%,m i rz ri%jL_LPr_r% LANLtI_LA I lUIN
Town of North Andover
120 Main Street
North Andover, MA 01845
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
of Marsh Risk & Insurance Services
Stefan Szulc
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
0
ACC)RV CERTIFICATE OF LIABILITY INSURANCE
DATE [MMIDD/YYYY)
110/8/2015
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(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 endorsement(s).
PRODUCER
Arthur J. Gallagher & Co. Insurance Brokers of CA.
1255 Battery Street #450
San Francisco CA 94111
CONTACT
NAME:
FAX
= Ext)' 415-546-9300 (AQ� N,I, 415-536-8499
E A
A iM) RILE S S'
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A:Zurich American Insurance Company 16535
EACH OCCURRENCE $
INSURED SUNRINC-01
INSURER B:
Sunrun Installation Services Inc.
775 Fiero Lane, Suite 200
San Luis Obispo, CA 93401
INSURER C :
INSURER D:
GENERAL AGGREGATE $
- COMP/OP AGG $
-INSURER E:
INSURER F:
AUTOMOBILE
r0VFRAr.FA rFRT11:IrAT1: mi imptriz. 9443(32624 0I=X1IQIf%KI KIIIHIRAM11=110-
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
LTR
TYPE OF INSURANCE
ADULSUBR
INSD
WVD
POLICY NUMBER
POLICY EFF
(MM/DDIYYYY)
POLICY EXP
(MM/DDIYYYYI
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE 1-1 OCCUR
EACH OCCURRENCE $
DAMAGE TO RENTED
PREMI_ ES (Ea occurrence) $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY [7 PRO- 7 LOC
JECT
OTHER:
GENERAL AGGREGATE $
- COMP/OP AGG $
-PRODUCTS
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED q SCHEDULED
AUTOS AUTOS
NON -OWNED
HIREDAUTOS AUTOS
COMBINED SnTGrI7Tr9T__
(Ea accident) $
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERT DAMAGE
(Par a.cdant) $
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
I DED I I RETENTION$
$
A
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUE El
(Mandatory In NH)
If ies, describe under
D SCRIPTION OF OPERATIONS below
NIA
y
WC013696001
WC013696101
10/1/2015
10/1/2015
10/1/2016
10/1/2016
x SPTERT OTH-
- A UTE ER
_
E.L. EACH ACCIDENT $1,000,000
E.L. DISEASE - EA EMPLOYEE $1,000,000
E.L. DISEASE - POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
WC013696001 - $25,000 Deductible; WC013696101 - FL, HI, MA, NJ, NY, OR, VA, WI only.
Evidence of Insurance
CERTIFICATE HOLDER CANCFILLATIONI
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of North Andover
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
120 Main St
North Andover MA 01845 USA
AUTHORIZED REPRESENTATIVE
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 18v 12v
Type: Supplement Card
Expiration: 10/14/2016
OUNMUINI
STEPHEN KELLY
775 FIERO LANE SUITE 200
SAN LUIS OBISPO, CA 93401
SCA 1 0 2om-osni -
of Consumer Affairs & Business Regulation
IMPROVEMENT CONTRACTOR
k�-� N
SUNRUN INSTALLATIOW SERVfr;E
STEPHEN KELLY
775 FIERO LANE
SAN LUIS �OBISPO, CA 93401
Type:
Supplement CaM
INC.
Update Address and return card. Mark reason for change.
E] Address E] Renewal F-1 Employment n LostCard
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
A—
Undersecretary �eafld without S ure
4�rl`
V�i�SAC IftIJSETTS-- DOWS
UCENSE
4d NIOM
Nm sowi292-
-0-743-201 S"'
W EV
48-01-2020 959.
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STEM" A
S wVAS'"A�w-SM9
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS -040622
Construction Supervisor
STEPHEN A KELLY
16 PARKWAY ROAD
STONEHAM MA 021liO -4
Expiration:
Commissioner W011120117
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