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Building Permit #542-2015 - 50 HAY MEADOW ROAD 11/2/2015
Permit NO: Date Issued: 1* TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I IMPORTANT: Applicant must complete all items on this one LOCATION 50 Hay Meadow Rd Print PROPERTY OWNER Jessica Kirk Print MAP NJ.Ly� PARCEL -.6k O2— ZONING DISTRICT: TVPF AND ITSF OF RITH,DING HISTORIC DISTRICT YES ❑ NORTH Of �ta-eo ,a gti0 :t SACHU`''Et'C`'� TYPE OF .IMPROVEMENT PROPOSED USE Residential Non- Residential U New Building U ddition Alteration VOne family U Two or more family No. of units: U Industrial U Repair. replacement U Demolition U Assessory, Bldg U Commercial U Moving relocation U Other Others: sour U Foundation only DESCRIPTION OF WORK TO BE PREFORMED install 13.78 kw solar panels on roof. will not exceed roof panel but will add 6" to roof height. 53 panels total Identification Please Type or Print Clearly) OWNER: Name: Jessica Kirk Phone: 978-649-1466 AdrlrPcc• 50 Hay Meadow Rd CONTRACTOR Name: Gregg LaCasse Phone: 508-291-0007 Address: 20 Patterson Brook Road West Wareham, MA 02176 Supervisor's Construction License: 103631 Exp. Date: 8/30/17 Home Improvement License: 170355 Date: 10/12/17 ARCHITECT/ENGINEER Richard Gordon Name: Phone: 434-574-6138 Address: PO Box 264 Farmville, VA 23401 Reg. No. 49993 FEE SCHEDULE: BULDING PERU11T.• 512.00 PER $1000.00 OF THE TOTAL ESTIb14TED COST BASED ON 5125.00 PER S. F Total Project Cost :$ 445,,-000 xl2.00=FEE:$ 540 Check No.: 9 t C) Receipt No.: r Page loP4 11 TYPE OF SEWERAGE DISPOSAL Taiuiing/MassageBody Art ❑ Swimming Pools L Public Sewer ❑ F1Tobacco Sales ❑ Food Packaging/Sales L! Well ❑ ❑ Permanent Dempster on Site Private (septic tank, etc. Electric Meter location to proj ect NOTE: Persons contracting unr 'stere I contractors do not have access to the guaranty.fund 1 Signature of Agent/Own;//'- Signature of contractor la Plans Submitted I Plans Waived ❑ Certif ed Plot Plan ❑ Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Zoning .Board of Appeals: Variance, Petition N Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED DATE APPROVED ❑ 171 Conunents Comments Water & Sewer connection/SiMature & Date Driyewav Permit Temp Dumpster on site yes—no— Fire Department signature/date 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 t5 and DA IA — (For department use ❑ Notified for pickup Call Ema I Date Time Contact Name Doc.Building Pennit Revised 2014 No 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 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 ❑ 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 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 Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products VOTE: 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 Location No. Date Check 4tI? TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Building Inspector N.. j o: r L k'n Q W L=L D C' O�_ co L Y \ O LL +u Ln V y O In °C W d z z Z m G fu -O 0 LL t cc N C U LL p W yaj z z m J �' t b o cr LL O W N Z U u W W t � 0 O' v U i Cu N C LL X O U a Z H t 0 C c LL H z W Q W 0 LU °c LL 3 Co 6 +� (% +% 9J N Q N ;v 0 w 'I O � L O z N � Q � •4) m m L - m m ca .� o i>%� (D 0 `—I o CL a � EF) Q o V J � .a CL o }; �z � U CL U) m m N O 2 p O U v W • i C' N m Z +�+ C Z_ C O � v J CL m �+ C O CO OC Jri a M O N V L O �+ 7 cn O L m a z F- Cl) .> (D LU ti O �' �~ CL a a Xz O w foo WY- Ci V / ` I Q y 0 O Cl) �.'> LL W 0 3 c W J �- - m � (J 0 "'' = L. 0 = � ' tm a� �M Q i O = c cc O E- �2m N O .r to m LL •� � � fn C O .E W V o C 0 U a> 0-0 U) .O ;v 0 w 'I O � L O z N � Q � •4) m m L - m m ca .� o i>%� (D 0 `—I o CL a � EF) Q o V J � .a CL o }; �z � U CL U) m Optimize Engineering Co., LLC P.O. Box 264•Farmville•VA 23901 Ph: 434.574.6138.E -mail: grichardpe@aol.com Richard B. Gordon, P.E. President September 14, 2015 N. Andover Building Department N. Andover, MA To Whom It May Concern: Re: Solar Electric Panels Roof Structural Framing Support I hereby certify that I am a Licensed Professional Engineer in the State of Massachusetts. Please note the following conclusions regarding framing structure, roof loading, and proposed site location of installation: 1. Existing roof framing: Conventional framing 2x8 at 16"o.c. with 11' span (horizontal rafter projection). This existing structure is definitely capable to support all of the loads that are indicated below for this photovoltaic project. 2. Roof Loading • 4.33 psf dead load (modules plus all mounting hardware) • 33 psf snow live load (55 psf ground snow live load reference) • 4.5 psf dead load roof materials • Exposure Category B, 115 mph wind uplift live load of 19.6 psf (wind resistance) 3. Address of proposed installation: Residence of Jessica Kirk, 50 Hay Meadow Rd. North Andover, MA This installation design will be in general conformance to the manufacturer's specifications, and is in compliance with all applicable laws, codes, and ordinances, and specifically, International Residential Code/ IRC 2009, 2011 NEC, and 2012 ICC Energy Code. The spacing and fastening of the Unirac mounting brackets is to have a maximum of 64" o.c. span along the rail between mounting brackets and secured using 5/16" x 3 %" length corrosive resistant lag bolts. In order to evenly distribute the load across the roof rafters, there shall be a minimum of 2 mounting brackets per rafter & min. 2" penetration of lag bolt per bracket, which is adequate to resist all 115 mph wind live loads including wind shear. The mounting brackets shall alternate between adjacent rafters between rail rows for better distribution of roof load. Penetration to be 3" minimum of anchors for modules mounted within 18" of ridge and edges of roof. Rails may be attached to either of two mounting holes in the L -feet. Mounting in the lower hole for a low profile, more aesthetically pleasing installation or mount in the upper hole for a higher profile to maximize airflow under the modules to cool them more. Slide the 31 -inch mounting bolts into the footing bolt slots. The rails will be attached to the footings with the flange nuts. Very truly yours, Optimize Engineering Co., LLC t ,, va Richard B. or ,' ' _ f Massachus t P2 Li6se No. 49993 MECHANICAL ENGINEERING ELECTRICAL ENGINEERING CIVIL ENGINEERING �{ OF ,-3,sA:ti.,,.vf O � RICHARD 6. z GOROUN O f is Ci I:CHANICA'_ jr p 4998-: rte* - h " tA. Optimize Engineering Co., LLC P.O. Box 264•Farmville•VA 23901 Ph: 434.574.6138.E -mail: grichardpe@aol.com Richard B. Gordon, P.E. President September 14, 2015 N. Andover Building Department N. Andover, MA To Whom It May Concern: Re: Solar Electric Panels Roof Structural Framing Support I hereby certify that I am a Licensed Professional Engineer in the State of Massachusetts. Please note the following conclusions regarding framing structure, roof loading, and proposed site location of installation: 1. Existing roof framing: Conventional framing 2x8 at 16"o.c. with 11' span (horizontal rafter projection). This existing structure is definitely capable to support all of the loads that are indicated below for this photovoltaic project. 2. Roof Loading • 4.33 psf dead load (modules plus all mounting hardware) • 33 psf snow live load (55 psf ground snow live load reference) • 4.5 psf dead load roof materials • Exposure Category B, 115 mph wind uplift live load of 19.6 psf (wind resistance) 3. Address of proposed installation: Residence of Jessica Kirk, 50 Hay Meadow Rd, North Andover, MA This installation design will be in general conformance to the manufacturer's specifications, and is in compliance with all applicable laws, codes, and ordinances, and specifically, International Residential Code/ IRC 2009, 2011 NEC, and 2012 ICC Energy Code. The spacing and fastening of the Unirac mounting brackets is to have a maximum of 64" o.c. span along the rail between mounting brackets and secured using 5/16" x 3 %" length corrosive resistant lag bolts. In order to evenly distribute the load across the roof rafters, there shall be a minimum of 2 mounting brackets per rafter & min. 2" penetration of lag bolt per bracket, which is adequate to resist all 115 mph wind live loads including wind shear. The mounting brackets shall alternate between adjacent rafters between rail rows for better distribution of roof load. Penetration to be 3" minimum of anchors for modules mounted within 18" of ridge and edges of roof. Rails may be attached to either of two mounting holes in the L -feet. Mounting in the lower hole for a low profile, more aesthetically pleasing installation or mount in the upper hole for a higher profile to maximize airflow under the modules to cool them more. Slide the 3B -inch mounting bolts into the footing bolt slots. The rails will be attached to the footings with the flange nuts. Very truly yours, Optimize Engineering Co., LLC n a Richard B. G rd Massachus Li nse No. 49993 MECHANICAL ENGINE RING ELECTRICAL ENGINEERING CIVIL ENGINEERING OF h1ti. ti c, r / RICHARD !3. t. GORDON J a C``: ' Massachusetts Home Improvement Sample Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include siandurd language to protect homeowners. Seek legal advice if necessary Any person planning heme improvements should first obtain a copy of "A Massachusetts Consumer Guide to Home improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline zt 617-973-8787 or 1-888-283-3757 or on our website. Homeowner Infolitnation Contractor Information ],'ante Company Name Jessica Kirk Trinity Solar Street Address (do not use a Post 011ice Box address) Contactor/ Salcslnrson/ Owner Nmne 50 Hay Meadow Rd M . Gregg LaCasse Ci lyrrovm Ratc Zip Code Business Address (must inc Inde a strrei address) North Andover, MA 01845 20 Patterson Brook Rd Daytime phone Evening Phone Cityrrown State 741 Code 978-649-1466 Wareham, MA 02571 Tfailing.4d:iress(11 different .from above) Business Phone 508-291-0007 1 Federal Employer iD nr S,S, Number name finpovmudl Cwha keg, N—t,, :t.aen trite Law'-Ili",a" mat hwlr ImpmvrmmI venhvCon have 170355 10/12/17 wlad rgtshanod aumbv The Contractor agrees to do the following work for the Homeowner: iDesaibe in detail the work to completed, specifying rhe type, brand, and grade of materials to be used use additional sheets if reoessaa s Install 13.78 kw solar panels of roof. Will not exceed roof panel but will add 6" to roof height. 53 total panels. Panel type : Trina 260 please see attached snap rack uired Permits - The following building pemtifs are recuired Proposed Start and Completion Schedule - The following schedule will will be secured by the contactor as the hameovme> s agent: be adhered to unless circumstances beyond the contractor's control mise nners who secure their own permits will be TBD luded from the Guaranty Fund provisions of Date when contractor will begin contracted work: MGL chapter 142A.) TBD Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule $45,118.88 The Contractor agrees to perform the work., furnish the material and labor specified above for the total sum of: {�) Payments will be made according to the following schedule: please see attached 5 upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) S by or upon completion of S by _!_!_ or upon completion or S upon completion of the contract (Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment MUST be slr: ciel S to be paid for ordered before the contracted work begins in order to mcztthe completion scbedde.(•') S to be paid for NOTES: (`) hrcluding all finance charges (-l Law requires flat any deposit or clown -payment required by the contractor before work begins may not exceed the greater of (a) one-third of the total contract price or N) the actual cost of any special equipment or custom merle material which must be special ordered in advance to meet the completion schedule. uw-s - beln ted i r= ra rR. [IN. 8 mult hyalitnc uthe rn Subcontractors -The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any thind. party/subcontractor utilized by the contractor- The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement not applicable to solar Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shell not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is ncleor • Make stare ft cornmetothas n valid Home Improvement Coaunewr.Rectistmtion. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston- lv1A 02116 or by calling 617-973-8787 or 888-283-3757- • Dees the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage. or ask to seee a copy of a -proof of insurance" document. • Know your rights and responsibilities:. Read the Important Information on the reverse side of this foram and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You in ay cancel this agrcem ent if ithas been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at hislher main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agrcwcnt- See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE A -NY BLANK SPACES!!! 'lino identical copies of the cantrvd mug be c Tleted and signed. One copy Jleuld go to the Homeowner- ", other copy stmuld be kqd by she coounctm please see attached Homeowner's Signature� raclor's Signature 10/28/15 10/28/15 Fate Date Contractor Arbitration Tlx: Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not: automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court artless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private at firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided .In Massachusetts General Laws, chapter 142,A. please see attached Homeowners Signature ntracto's Signahue NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alterative dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability -and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of -all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract trust be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a .fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him"herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit die OCABR website at http /%www mass gowocabr.., If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza -,Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at htto:i/wtv%v.mass.eoviocabr,' Go online to view the status of a Home Improvement Contractor's Registration r t :tr .Slglc.ran.its+"hometnl�n}vemcnt(licensceiist.asu For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND!OR Better Business Bureau 508-652-4800, 509-755-2548 or 413-734-3114 Version 2.1 - 1112 212010 -10 East {'rrect�way Plaza Stc 4?S, Houston. TX 77046 S u n nn va T 281.98.9900 www.sunnovaxom Estimated Solar Energy Production Payment Terms Schedule A: Value Statement Estimated First Year Annual Production: 12,722 kWh Estimated Initial Term Total Production: 299,535 kWh Amount Due at Contract Signing: $0.00 Installation Fee: $0.00 Annual Increase of Solar Energy Rate: 2.90% / year First Year Solar Energy Rate, if paid by ACH: $0.144 / kWh First Year Solar Energy Rate, if not paid by ACH: $0.159 / kWh Monthly Bill in First Year, if paid by ACH: $152.79 / month Monthly Bill in First Year, if not paid by ACH: $168.07 / month Homeowner's Initials By your initials here you acknowledge that you have reviewed this Schedule A: /,� Per Section 3(c) of the PPA, after each Year, Sunnova may adjust the Estimated kWh per Year based on the historic production of the System. Any increase in the Estimated Annual Production for any Year shall not be -greater than 110% of the Estimated Annual Production for the first Year. z Per Section 4 6) of the PPA, the prepayment amounts shown above reflect a 5% present value discount rate; provided, however, such amounts are subject to an adjustment at the time of prepayment on the basis of the estimated kWh output per Year from the time of prepayment to the end of the Term. Any such adjustment shall not exceed 110% of the estimated kWh per Year for the first Year. I Per Section 9 of the PPA, the price you will pay to purchase the System will be the greater of the System's fair market value ("FMW) and the amount shown above on Schedule A. Contract ID: Solar EZ Powcr Purchase Agreement version p02172014 13 00 2008-2014 Sunnma Energy Corporation. All Rights Reserved. Prepay Option Purchase Option End of Year Annual Price per kWh (assuming payment by Credit Card) Annual Price per kWh (assuming payment by ACH Estimated kWh per Year' ("Estimated Annual Production") Estimated Price to Prepay the Remainder of the Term' Minimum Cash Purchase Price' 1 $0.159 $0.144 12,722 $33,471.30 $0.00 2 $0.163 $0.148 12,658 $33,216.76 $0.00 3 $0.168 $0.153 12,594 $32,903.50 $0.00 4 $0.173 $0.157 12,531 $32,527.48 $0.00 5 $0.178 $0.162 12,468 $32,088.99 $0.00 6 $0.183 $0.166 12,405 $31,574.67 $43,198.06 7 $0.188 $0.171 12,342 $30,984.08 $41,105.27 8 $0.194 $0.176 12,280 $30,312.22 $38,852.07 9 $0.199 $0.181 12,218 $29,558.01 $36,434.03 10 $0.205 $0.186 12,156 $28,707.61 $33,829.42 11 $0.211 $0.192 12,095 $27,759.15 $31,436.57 12 $0.217 $0.197 12,034 $26,706.40 $30,068.18 13 $0.223 $0.203 11,973 $25,546.52 $28,576.96 14 $0.230 $0.209 11,913 $24,265.30 $26,946.63 15 $0.237 $0.215 11,853 $22,858.99 $25,172.91 16 $0.243 $0.221 11,793 $21,319.88 $23,246.99 17 $0.250 $0.228 11,734 $19,642.79 $21,380.75 18 $0.258 $0.234 11,675 $17,813.37 $19,395.42 19 $0.265 $0.241 11,616 $15,825.42 $17,243.49 20 $0.273 $0.248 11,557 $13,669.40 $14,914.95 21 $0.281 $0.255 11,499 $11,337.16 $12,401.33 22 $0.289 $0.263 11,441 $8,814.43 $9,687.42 23 $0.297 $0.270 11,383 $6,091.87 $6,763.47 24 $0.306 $0.278 11,326 $3,157.71 $3,617.13 25 $0.315 $0.286 11,269 $0.00 $0.00 Per Section 3(c) of the PPA, after each Year, Sunnova may adjust the Estimated kWh per Year based on the historic production of the System. Any increase in the Estimated Annual Production for any Year shall not be -greater than 110% of the Estimated Annual Production for the first Year. z Per Section 4 6) of the PPA, the prepayment amounts shown above reflect a 5% present value discount rate; provided, however, such amounts are subject to an adjustment at the time of prepayment on the basis of the estimated kWh output per Year from the time of prepayment to the end of the Term. Any such adjustment shall not exceed 110% of the estimated kWh per Year for the first Year. I Per Section 9 of the PPA, the price you will pay to purchase the System will be the greater of the System's fair market value ("FMW) and the amount shown above on Schedule A. Contract ID: Solar EZ Powcr Purchase Agreement version p02172014 13 00 2008-2014 Sunnma Energy Corporation. All Rights Reserved. DocuSign Envelope ID: 9EE65726-C85F-4D1E-8002-674137C9F10B SOLAR SYSTEM WORK ORDER AMENDMENT This Work Order Amendment is hereby made and entered into by and between Sunnova Energy Corporation and Trinity Heating and Air Inc. ("Parties") on September 18, 2015. WHEREAS, the above stated parties have previously entered into Solar System Work Order Agreement ("Work Order") and the Parties wish to amend the Work Order as stated below. Sunnova and Contractor agree as follows: 1. The Solar System that is the subject of this Work Order shall be designed, engineered, procured, constructed, and installed as follows: Sunnova System ID OOPZYR Contract Amount ($) $45,118.88 Job Site Address 50.0 Hay Meadow Road North Andover, MA 01845 Job Site Utility Company Massachusetts Electric - National Grid System Size (STC DC kW) 13.78OkW Incentives (Rebate) Authority Commonwealth Solar II Incentives (Rebate) Amount $0.00 Module Model and Count Trina Solar TSM-260PD05.08 (16) Trina Solar TSM-260PDO5.08 (30) Trina Solar TSM-260PDO5.08 (7) Inverter Model and Count SolarEdge SE 1140OA-US (240V) (1) SolarEdge SE I I40OA-US (240V) (0) SolarEdge SE I1400A-.US (240V) (0) Racking IronRidge Monitor Itron Year 1 Annual Production 12722 IN WITNESS WHEREOF, the Parties have caused this Amended Work Order to be executed as of the respective dates set forth below. Sunnova Energy Corporation Trinity Heating and Air Inc. OocuSii'gned byy:'' By: ECF0586497CA147C 1At0h._. Lynda Attaway Ef Name: SVP Operations Title: Sunnova Energy Corporation Date: Copyright © 2013 by Sunnova Energy Corporation All rights reserved. 20 East Greenway Plaza Ste 475. Houston. TX 77016 'r 281.985.9900 www.Suntiw a.com SUMMARY Homeowner Name and Address Jessica Kirk 50 Hay Meadow Road, North Andover, MA 01845 Contract I D OOPZYR sun neva Co-Owncr Name (if Any Installation Location Contractor License Estimated Solar Energy Production Payment Terms 1. Introduction. 50 Hay Meadow Road, North Trinity Heating and Air Inc. Andover, MA 01845 Trinity Solar 2211 Allenwood Rd Wall, New Jersey 07719 13VH01244300 New Jersey Estimated First Year Annual Production: 12,722 kWh Estimated Initial Tenn Total Production: 299,535 kWh Annual Increase of Solar Energy Rate: 2.90% / year First Year Solar Energy Rate, if paid by ACH: $0.144 / kWh First Year Solar Energy Rate, if not paid by ACH: $0.159 / kWh Monthly Bill in First Year, if paid by ACH: $152.79 / month onthly Sunnova in First Year, if not paid by ACH: $168.07 / month This Power Purchase Agreement (this "Power Purchase Agreement" or "PPA") is the agreement between you and Sunnova Energy Corporation (together with its successors and assigns, "Sunnova" or "we"), covering the sale to you of the power produced by the solar panel system (the "System") described below. Sunnova agrees to sell to you, and you agree to buy from Sunnova, all of the power produced by the System on the terms and conditions described in this Power Purchase Agreement. The System will be installed by Sunnova or a contractor acting on Sunnova's behalf at the address you listed above. This Power Purchase Agreement will refer to this address as the "Property" or your "Home." Sunnova provides you with a Limited Warranty (the "Limited Warranty"). The Limited Warranty is attached as Exhibit 1. This is a legally binding agreement with disclosures required by law, so please read everything carefully. If you have any questions regarding this Power Purchase Agreement, please ask the sales consultant who provided you this PPA. Note that references in this PPA to the term "day" means a calendar day. 2. Term. Sunnova agrees to sell you the power generated by the System for 25 years (300 months), plus, if the Interconnection Date is not on the first day of a calendar month, the number of days left in that partial calendar month. We refer to this period of time as the "Term." The Term begins on the Interconnection Date. The "Interconnection Date" is the date that the System is turned on and generating power. A "Year" is the twelve (12) month period beginning on the Interconnection Date and Contract ID: Solar EZ Power Purchase Agreement version p021720.14 continuing until the day prior to the anniversary of the Interconnection Date. Sunnova will notify you by email when the System is ready to be turned on. 3. Power Purchase Aereement Payments; Amounts. (a) Power Price. You are purchasing the power the System produces. The price of that power is set forth on the "Value Statement" attached as Schedule A. (b) Payments. Schedule A details, among other things, (i) the price per kWh you will be charged per Year; (ii) the annual price per kWH percentage increase (if any); (iii) Sunnova's estimate of the power that is expected to be produced by the System during the first Year; (iv) Sunnova's estimate of the amount of power that is expected to be produced by the System over the entire Term (excluding any renewal period(s) extending the Term as provided in Section 10); and (v) your Monthly Payment amount for the first Year. Your "Monthly Payment" is calculated based on the following: (A) the annual price per kWh multiplied by (B) the estimated kWh output per Year ("Estimated Annual Production") divided by (C) twelve (12). Each Monthly Payment is due on the seventeenth (17th) calendar day of the month for the previous calendar month unless it is not a business day, in which event, the Monthly Payment for such month will be due on the first business day after the seventeenth calendar day of such month. Any payments due upon installation are due immediately prior to commencement of installation. You will not make a Monthly Payment if you fully prepay this PPA as provided in Section 40). 2008-2014 Sunnova Energy Corporation. All Rights Reserved. 20 East Greeii ay Plaza Ste 475. Houston. TX 77046 't' 281.935.9900 www.sLinnova.coni 25. NOTICE OF RIGHT TO CANCEL. YOU, THE OWNER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO sun nava MIDNIGHT OF THE SEVENTH CALENDAR DAY AFTER THE DATE OF THIS TRANSACTION. SEE EXHIBIT 4, THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. 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. Owner's Name: Jessica Kirk Signature: Date: 9/10/2015 Co -Owner's Name (if any): Signature: Date: Sunnova Energy Corporation: ynda Attaway ° SVP Operations Sunnova Energy Corporation Date: Contract ID: Solar EZ Power Purchase Agreement version p02172014 12 D 2008-2014 Sunnova Energy Corporation. All Rights Reserved. Trinity Solar 20 Patterson Brook Road Wareham, MA 02571 508-291-0007 Date: 8/26/15 I, Jessica Kirk , do hereby grant Trinity Solar the right to sign on (H nmemcrei s Nome) my behalf in all matters regarding the permit applications through the township of Town of North Andover for the installation of solar panels and all other ('t_,ap nt>) related work on my property at 50 Hay Meadow Road Please accept this (Street Address) document, with full signature, in place of all application signatures. Furthermore, should there be any issues or discrepancies with the paperwork, please contact Danielle DeVito at Trinity Solar, 732-780-3779 ext. 9044 or danielle.devito@trinitysolarsystems.com. Sincerely, Homeowner's Signature Jessica Kirk Print name 978-649-1466 Phone Number 50 Hay Meadow Road Street Address North Andover MA 01845 City, State, Zip Code FTE F W W (n F- z 00 o zF- z ,u < o Q U 0 a Z J C7 H z w W Q Zw tn0w x (� ` O z W ch w Z J =5Q U U d H V z 00-1 Q F U 0� w w N M W W w m aaa z � s 1 /� s r o LL LU Q00 +4 W p w150Nn0 '. J W zN < LU W c 'a/+�'i0 Iz O z i nz _ O O aui� lia a� JUU.»p w `OOw O LL O00=pJw-- C:) = _ m 4L� s � W o= Z 'r��� Ln O o a° _� - o OV pN3 oil ° -p ,gyp O 5. zd p=aim t3 - lw ° Xm vEUC nCWZG1w� C+� Z ' ct Z l 6 . a` D p s N = tt c C w C f- W _ C Z 7 � = — � W � � iE C _ i LLo W u Ittf! ElliM s -qtr .�....�-,� to a O _ .. 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In addition to grounding and bonding, the roof mount system, Series 100 UL, is Class A Fire Rated when in- stalled with Type I and Type II Modu€es. SnapNrack's UL 2703 Certification and CoJn- pliance ensures that SnapNrack installers can continue to provide the best in class installations in quality, safety and efficiency. Appealing design with built-in aesthetics No grounding lugs required for modules All bonding hardware is fully integrated into the components Rail splices bond rails together, no rail jump- ers required Proprietary SnapNrack grounding lug snaps in the rail channel • No drilling of rail or reaching for other tools required Class A Fire Rating for Type 1 and 2 modules System Features Include Snap in Single Tool Easy Hardware Installation Leveling Integrated Wire Preassembled Integrated bonding Management hardware No Cutting or Drilling UL 2703 Certified Resources snapnrack.com%resources Design con fig ure.snapnrack .corn Where to Buy snapnrac.k.corn; buy Snap rack - Solar Mounting Solutions . I trls, ;tai h5 o.t , th Split Lo,l, l a5her napMr K riding rll I� 71 rid snaph dl'I+ -i itl^S i3 rn l m,n j M1t 6 la "iim;tllN& E;II.A ® hma:'rl N �t - SnapNrack Bonding SnapNrack Bonding -irapnir,x-I. Honiliir-; 4Phce lwrt -Soap'Jr�ck �. PIIca H.V. r9r9_XI) Split . cck .+ shers Adjustable End Clamp Mid Clamp SnapNrack Bonding _ Standard Rail Splice SnapNrack Bonding Standoff Clamp ASS•smbiy SndpAiraCk� Rubber Ram Collar SneloNrack Mill Fullih Standoff - SnepWack-1 Min Fmxh 1 Staiutoff Base {I•t{de' BastShown) `�... rack Bondina Standoff Assembly 5:apN� nck 3tm+Cur<1 R.,d (3 a.1 IY+J tdin l2 .5 - 1 4111( Ilt E� t .ICI art _x c " a511eY S iaF'Jracl+ -� Coppar V,,i:e SnapNrack Ground Lug Assembly (ONE REQUIRED PER RO W OF MODULES) serratedstMn{efg, 7-SnapNrack Eondinu _,,& 5trat FlarVe Nut Balding Channai er.1taNl Ssiess Nut vti=hannel NIA ^Stainless 1 Flanyr nut StP@i Flange Bat-SnaANrtick^Stainless 92Degrre 9arye Olt L Foot SnapNrack I Purp— L Fo t SnapNrack Soapllh-k S1dpNrack L Font Metal Roof Mill Fetish Fier N., L Font ease Base Assernbiy ..... 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SEYWOA JS SL6000A-Us SE760VA•us SEtuauuA-Us SE'Ll4f3uA-Us OUTPUT •rI,r.:, I Iii i, rac.,. ., i ..: .. . .. _. ,. - J., fir,. -r r,mnF,' -ridwt - - t ar,;i xr; t..-.ble f 'r_sraaios tt. 'tes INPUT i•Jl'imnom UL •,`7':dr: i -e, l_�, l:.l'•"." i..(J 1.1411 ,..,, '..0ltl; :i "'J .0 IranstO(r�r-es, txi,;rixanded f�� r,,lar 7npuC Volt Ari(, .Pi, :'Joel. I)l 111put'JUI'�i'N,P i2' °D ;•;`;�' r i4C i. . � .v vdt -G.�) iu; Awl', 1K ?d 33 iD 2'.!8'! Aur. ".S 7 r.' NOV 3l: 6i 24p�, !,alas, npW',hort t:.r..tit Currort 45 Zest Reverse Pr9a;t-r ?rO'�ctictt °Fpy Gr.31u,U f 1 1 w lh(- Dek cho, GOM,S SPnutivifV PA--ir'imn Iflt; �.r ((.r r ;'p(rc uJ J% !' 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M-e SolarEdge Power Optimizer Module Add -On For North America P300 / P400 ( P405 PV power optimization at the module -level — Up to 25% more energy — Superior efficiency (99.5%) — Mitigates all types of module mismatch losses, from manufacturing tolerance to partial shading Flexible system design for maximum space utilization — Fast installation with a single bolt — Next generation maintenance with module -level monitoring — Module -level voltage shutdown for installer and firefighter safety "Al 'IV V,1.50'0 so lar=#v SolarEdgePower Optimizer Module Add -On for North America P300 / P400 P405 P300 P400 P405 (for 60 -cell modules) (for 72 & 96 -cell mudules) (for thin film modufesl INPUT it; oocs, torr [011, 1A 11 101, Alli W::%: r-:, ni __7: 1 n rr i I r i, A, 1i We 1) 1i 3 Ovel voltage i dtogory it OUTPUT DURING OPERATION (POWER OPTIMIZER CONNECTED TO OPERATING SOLAREDGE INVERTER) 15 Atit Maximum OUtpUt V010PP flic 3`0 vdf, OUTPUT DURING STANDBY (POWER OPTIMIZER DISCONNECTED FROM SOLAREDGE INVERTER OR SOLAREDGE INVERTER OFF) Safety 014put Voltdgf-, per Pcwer Optium7er I Vdc STANDARD COMPLIANCE i'('(. Class B, 1EC.61000 6 2, IEC61000 6 Sdfetv IIC62109- 1 lass 1safety'), UL! e4l, INSTALLATION SPECIFICATIONS Maxin-min Allowed `ayitvfri Voltag(- :G lrft Pxm 2 %(-14-." xk 34 x 1_1,9 :lith P w Dirnorsmns (W x I, x H) 128 x 15) x )_1;.5 �2 x 2 x 128 x 1r52 x 48 PKxx Swries tarn (trt 1; x 5.3 1 x 1.C8 97 c 1 !,17 5 x 5.97 x L.89 PXXX4 Sol les Ff /Ih Weight (inducting cables) P(Xx 770 1 i (im j 2.04 It, -,put oml,ec^)f vV;e i ypt,. C:)imecuol DOL11312 lr`,sLli-IteJ No, 4 �_,d7 Wi, e 1 Opp,atvg1 Te'li.perat'l- �.Arge -40 35 -40 F'12tr-,!-,on ial;�!g 13'el'itivi, Humidity 0 10t, PV SYSTEM DESIGN USING A SOLAREDGE INVERTER() SINGLE PHASE THREE PHASE 208V THREE PHASE 480V Knimum String t-enit h 8 1.8 (Powef Optimizers) Maximum String Length (Dower Optirn:zeis) so M,1?d[T1LJrr1 Power per Stvin� ipso 6000 12750 W parallel Sirin.,s of Different Length,, oi Cr;entatiow, ..T- iH,E Universal 60 CELL MULTICRYSTALLINE MODULE 245-26OW POWER O-UTPUT RANGE 15*9% MAXIMUM EFFICIENCY 0-,-+3% POWER OUTPUT GUARANTEE Trinasolar tv" D U'L.E- PA05.08 Our most ,-,ersifi:e P(Oduct One of the indusiry's most trusted mcduies HigbiV reliable d,,je to stringent quality control ^erfified to MIThslancl challe-aging en,41ronmental ACzz.C% conditions LINEAR PERFORMANCE WARRANTY 10 Year Product Warranty y TME Universa! MODULE TSM-PA05 08 DIM EANSI(NN5 Of "" h;ODUtP urlit:mm 941 �rrClWn aav ,0:.Y414w01 a 0 I-V CUR'd ESCF PV &I CodiE(245'N) Peck Power Watts -P- tWp) 245 250 255 ;60 Power Output Tolerance -Peat. (9G} Maximum Power Voltage-Va p M 2716 28.0 28.1 28.3 0-+3 1A) 6.59 6.65 6,74 o, Maximum Power Voltoge-Vary JV) 0 11-9.9 30,3 30,5 30.6 Max imuin Power Current 1- (A) 8.20 8.27 8.37 8.50 Open Ciicuii Vollage-S V} 37.3 38.0 38.1. 38.2 Short Circuit Current-hc. (A} 8.75 8.79 8-88 9.00 Module Fffciency q, (%j 1.5.0 15.3 15.6 15.9 0 Volloge (VI c tEC ikl "-. O.�fc (niOC . Nominal Operating Cell Maximum Power -PR.;,:. MW 182 166 190 193 Maximum Power Voltage-Va p M 2716 28.0 28.1 28.3 Maximum Power Current -l- 1A) 6.59 6.65 6,74 6.84 Open Circuit Voltage -V- M 35.1 35.2 35.3 35.4 Short Circuit Current -L- (A) 7.07 7.10 7.17 727 `d�C46i i11".., .iA rc Solorcells Multfcrystaliine, 156. 156 mm (6 inches; Cell orientation 60 cells (6 - 10) Nodule dimensions 1650 , 992 - 35 min (64.95.39.05x1.37 inches) Weight 18.6k_q (41.0 lbs) Glass 3.2 min 10.13 inches),High Transmission, AR Coated Tempered Glass 700/1000 mm Backsheet While Frame Black Anodized Aluminium Allay J -Box IP 65 or IP 67 rated Cables Pholovoltalc Technology cable 4.0 mm' (0.006 inches% 700/1000 mm Connector MC4 orMC4Compaflble TENI 0-RAT1 RE Ra.fI NGS Nominal Operating Cell 44`C(3 2°(,) Temperature (NOCT) Temperature Coefficient of P- - 0.41%/°C Teniperaivie Coefficleni of Vo: - 0.32%/°C Temperature Coefficient of Isc 0.05%/"C !kAAl N.AJ'VR; INGS Operatfonoi Temperature -40-+651C Maximum System 600VDC(Ul) Voltage Max Series Fuse Rating 15A WARRANTY 10 year Product Workmanship Warranty 25 year linear Power Warranty CERT'F'CAT CN C@US - EA i..!c AC>ihlC -Ct�N FIC:1; tt .'Ii )N X. USTWModules per box: 30 pieces iyf I Modules per 40' container: 840 pieces tU �w1{1 _ ke94i•K' Tr nasolar , C0 CERTIFICATE OF UABILITY INSUPANCE DATE (MM(D D/ VYY', 10/29/ 2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS y CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i BELOW THIS CERTIFICATE OF INSURANCE DOES N07 CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE[) 1 r REPRESENTATIVE OR PROCUCER, ANC THE CERTIFICATE HOLDER. ( IMPORT.AN. If ,he certificate holder Is an ADDITIONAL INSURED, the pollcy(Ies' must be endorsed. If SUBROGATION IS YtJAIVED. subiect tc i the terms and cenditicns of the policy certain aoticies may reauire an endorsemer,L A statement cn this certificate does not confer rights 10 the I certificate holder in lieu of such endorsement(s). PRODUCER cDNTACT Barbara Hayder. NAME; DIT' MAR. AGENCY PHONE(732) 90'2-2343 ac No • 1 32% g0-84: a 78 Court S_reef EtA hahaydanedittnari.nsurance.cam P'G' V. n O K ]. i v rNSUREn SS ArroRDINC covcRAOE i MAIC _=r®Ehol: N G 728 1IN5URERAHr1-C-erlin5j America Insurance INSURED INSuRERBsL-TOrtl'x River Insurance Com -an r Trinity Heating & P=_ Inc, , DFA Trinity SClar WSURERC:Llo d's London EPTP Future Holdings LLC INSu a: 2211 Allenwood Road INSURIOte: Wali NJ 07719 INSURER F . n COVERAGES CERTIFICATE NUMBER:2014-15 Liab Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEC TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD WDICATED, NOTrMTHSTANCING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI7H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED EY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS sHnwN UAV WAvc PPcru Rcni iron PV PAIn r1 AIMS L IrrvR TYPE OF INSURANCE _ POLICY NUMBER POL/C9EFP —149DZffnPOLICYEx LIMITS -GENERAL LIABILITY EACH OCCURRENCE 4 11000,0400 X CCMMET2CIAL GENERAL LIABILITY A CLAIMS -MADE Q OCCUR 000065614 1/±/2014 2/'1/2015 PREMISES �t� 00 , 000 S -9001000 MED EXP one person) S` PERSONAL SADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: .X POLICY PRO LOC PRODUCTS-COMPIOP AGG S 2 , 000 , OOQ $ AUTOMOBILE IJABILITY A X ANY AUTO AUUTOS�ED AUTOS 0000065624 /1/2014 1/1/2055 COMBINEDS1 LIMIT Me de _ 1,000,000 BODILY INJURY (Per person) It BODILY INJURY (Per accident) S HIRED AUTOS NON -OWNED AUTOS DAMAGE 8 LeasaiLoon Gap $ UMBRELLA LIABOCCUR HCLAOAS-MAOE UMER21012014 1/l/2014 /1/2015 EACH E S 15,000,000 B X EXCESS Line tLNDER11012014 AGGRe� s 15 , O QO , 00 D D RETENTIONS. j; WORKERS COMPENSATIDN AND EMPLOYSMLIABIU Y YIN ANY PROPRIETO VPAR'Lyemmr-UTTVE OFFICEwMEM9Ea EXCLUOSD� � N 1 A (Mandatory in NH) UNIt desm'7ro under IPTiONOFOPERATIONS.1 000065614 /3/2014 t/2/2018 1/1/2015 1/ i /2O LS UMItx0f;10,000,000 5TATU- OTB• tFR S $1510001000 £,!k EAC#i ACCIDENT ; 1 000 000 E1 DISEASE • EA EMP 3 I---00-0-1-000 E.L,DISEASE- POLICY LIMIT ; 1 000 000 C Errors & Omissions GZARtCO201402 '130/2014 /30/2015 Par Occw-ance $2,000,000 Pollut-ton Liability Aggregate $2,000,000 DESCRIPTION OF OPERATIONS t LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, a more space is required) KJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Trinity Heating & Air, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. T/A Trinity Solar 2211 Allenwood Road AUTHORIZED REPRESENTATIVE Wall Twp, NJ 07719 i Barbara Kayden/SAH ACORD 25 (2010105) © 1988-2010 ACORD CORPORATION. All rights reserved. Mons :201005).01 The ACORD name and logo are registered marks of ACORD iit$3'e'$b'bteser%tj. A, C .._ 'tt';t9'I{''- !ir?➢a]:iL'i73;2:'1t7r3 ]]d:Sit.f97a+�� afrliati3't: 1i331ii9;p'4/I{31'1�.iCBCt()<rill'.,ie�t:£r9�ii�n3i1'iv4rR'17CS. T'!� 8E FIUl DD V1T1-1 T?dF PER`if $T";'IV� k1 'r 11CYriIIN Trinity Solar •�c1::1';':i'su:�rt�.,.>;i)r�ramz<ltlnr:%in<:,� iduul; Y A do res:,: 2211 Allenwood Rd. I_'ity/Statet'Zip: Wall, NJ 07719 Are you an employer:" Check the appropriate box: Phone rte#; 732-780-3779 ! 0 1 am a employer with 300 employees t flt!1 andlor pan -time I 2.[] f am a sole proprietor or partnership and have no employees working for me in any capacity [No workers' comp_ insurance required.1 3 f am a homeowner doing all work myself [No workers comp insurance requlred.1 ' 4 1 aro a homeowner and will be hiring contractors to conduct all work on my property I will ensure that all ccntractors either have workers' compensation insurance or a e sole proprietors with no employees - 3,M f am a general contractorand 1 have hired the sub -contractors listed on the attached sheet Ullese sub -connectors have employees and have workers' comp insurance r 6 1:1 We are a corporation and its officers have exercised their right of exemption per [MGT- c t52, §It 4). and we have no employees. (No workers' comp insurance required.] Type of project (required): 7. tE] New construction 8. ❑ Remodeling 9, 0 Demolition 10 ® Building addition 11,E] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13.®Roof repairs 1.4. C] Other 'Any applicant that checks box #1 must also Ell out the seetior, below showing their workers' compensation policy infoctttation. y Homeowners who submit this afidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractor, that check this box must attached an additional sheet showing the name of Ute 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 insurance for my employees. Below is tine policy and job site information. ,, Insurance Company Name: Policy #ter Self -ins. Lic. #: Expiration Date: I/%; . /- . L Job Site Address: 50 Hay Meadow Rd cityistate zip: N Andover, MA 01845 Attach a copy of the workers' compensation policy dMaration page (showing'the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25th is a criminal violation punishable by a fine up to $1,500.00 and/or one -yeas 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. Ido hereby eerd y under the pains a► eualdies of perjury that tire information provided above is true and correct. Phone .#: Of;{i ial:ase Unty 13o not write in this area, to be completed by rad or #otvra od` iciat City or I'own- PermitfLiceinse # 10/23/15 Issuing Authority (circle nese): ?. Board of health 2. Suilding Department 3, City/TlDw n 0erk a. Electrical Inspector 5.. Plasmbine Inspector b, Other Contact Person: Phone #. -- e" - - jord j - /.(I, ve; "e/n C -71w, 6 , �Vjl? I A) 1// 0- 1 0� *1 (l Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 021.16 Home Improvement Contractor Registration Registration: 170355 Type: Corporation Expiration: 1 011 2/2 01 7 TRINITY HEATING & AIR, INC. TOM BEUMETTI^ - - 20 PATTERSON BROOK ROAD UNIT 10 WEST WAREHAM, MA 02576 SCA t e. 20M-051? 1 Tr# 271078 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑ Employment E] Lost Card '-l/�,• Tl+»csrt�YirrC�Csrrl��ft n��<Gaaeerr�a.:.a�1'Y office of Consumer Affairs & Business Regulation License or registration valid for individul use only iHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 170355 Type: Office of Consumer Affairs and Business Regulation Expiration: 10/12/2017 Corporation 10 Park Plaza - Suite 5170 Boston, MA 02116 TRINITY HEATING & AIR, INC. TOM BLUMETTI 20 PATTERSON BROOK ROAD U WTV WAREHAM, MA 02576 Undersecretary I Not va td without signature %� �{''c�l?' l" C// F Office of Consumer Affairs dnd Business Regulation y 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 170355 Type: Supplement Card TRINITY HEATING & AIR, INC. Expiration: 1 011 2/201 7 GREGG L-ASASSE 20 PATTERSON BROOK ROAD UNIT 10 -- --- - -- - - - - -- WEST WAREHAM, MA 02576 -- SCA 1 CS 20ne-05r11 '"11 le." "ll nurraAle r, 3 uadcrt.%rrr<tnfl ace or Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR Registration: 170355 Type: Expiration: 10112/2017 Supplement Card TRINITY HEATING & AIR; INC. GREGG LACASSE 20 PATTERSON BRCOIf ROAD U-- WEV WAREHAM, MA 02576 \Undersecretary Update Address and return card. Mark reason for change. Address J Renewal i ] Employment j Lost Card 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 �� thputsiature 0 a $S 8.3 E;' aS-,,(Cs )3 .z!' -- ,-,! , Jdt?! ?•'.�7'I � .'�'; rte..-.�. 'S'r� �..�T.,z �� d.: ,'.-j=d.':z.1rT.'_.a -cerise CS -103631 GREGG LACASSE 14 PINE ISLAND RD.V p MATTAPOISETT MA. ,1e. ✓t_.. expiration ,air+rnrsssa #er 08/30/2017