HomeMy WebLinkAboutBuilding Permit #036-16 - 60 MIDDLESEX STREET 7/7/2015 t TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION._—WO _ :M _
gf
. . .. ..int -
PROPERTY OWNER
r Print yes Ono.
MAP NO: !_��PARGEL:_ '� ` ZONING DISTRICT Histonc'District yes yes
TYPE OF IMPROVEMENT, PROPOSED USE
Residential Non- Residential
ew Building ane family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Septic. ❑1Nell .❑,Floodplain W,Al
pr ds ❑ Watershed Distrief=
El Water/Sewer s.A
DESCRIPTION OF WORK TO BE PERFORMED:
�I
U�identifiiiip�`rP�ease Type or Print Clearly) 07S
���`� Q
OWNER: Name: II�6 II (( Phone: d
Address: Add 10 k�
CONTRACTQRName = _� .� � ---.--Phone:
Adtlr_eSS.: -
((��CCr���
Supervisor's Construction License l)-1�>�1+)� � t._ Exp: Date; _ L.
_.
{
mpr
Home Loyement Lie I Exp Date:
ARCHITECT/ENGINEER Phone:
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: $ FEE: $ �
Check No.:t42 Receipt No.: 0 Z ��
NOTE: Persons co tracting with u istered contractors do not have access to the guaranty f did
Sigrid atu.Fe f Agert/Qwner�w _ :` S� ature of contractor_.:.
Plans Submitted PlanWaived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Building Department
The foltowingIs-'a list of the required,forms to befilled out-foe appropriate.permit tube obtained.
Roofivg, Siding, Interior Rehabilitation Permits
❑ B,uilding Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/O-r 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
a Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ 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
o 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of—Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp tlie decision from the Board of Appeals
that the apw•al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subwted with the building application
Doe: Doc.Buhding permit Revised 2012
- f
Plans Submitted ❑ ..'-Plans Waived-0 . .--:-,Certified Plot Plan ❑ Stamped Plans ❑
T y OPSEWERAGEDISP:OSAL"
Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑
Well ❑ . Tobacco.Sales ❑
Tood Packaging/Sales ❑
Private(septic tank,etc:_ ❑ _permanent Diunpster on Site ❑
HE.FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE-.REJECTED: DATE:APPR.OVED
PLANNING & DEVELOPMENT [] ❑
COMMENTS
.CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Pv lanning Board Decision: Comments
1
conservation Decision: Comments
Water & Sewer Connection lSigna#ure Da#e Driveway Permit
DPW Tow;2 Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTI, SIT' Temp Dump-stet onsite .yes no
cate 'Street r 4't
Lo d at;124;Mair _
Fire "
Departme �t sgnatureldate 4
-COMMENTS
®ii'tienSlon
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.Z®NE LITERATURE: Yes No
MGL-Chapter-166 section 21A—..F and G min.$10041000 fine
NOTES and DATA— For department use
i
El Notified for pickup - Date
j E
3
Doo.Building Permit Revised 2010
Location l.c V
No. Date
• - TOWN OF NORTH ANDOVER
Certificate of Occupancy $
� t Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee tTED
Z �
t. $
TOTAL $ in < ..-.
Check
Building Inspector
29027 ,
r NORTH .
ic ve" **
201 � oh ver, Mass, -- t�
coc.uc.uwicw y1.
�,9 AERATED �,PP�,�S
S V
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT ......... .. ` t„!` BUILDING INSPECTOR
has permission to erect .......................... buildings on JQo.....Add�,Qi&- `
&z- ':............................ Foundation
'- ` � .A�. Rough
to be occupied as ........ ..d. .. ... /..W..... V ................................................................... Chimney
provided that the perso accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIONS S Rough
Service
111111 ................. ... ..... ................................................. Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Buildinz Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
4931 North 300 West,Provo,UT 84604 Employer Identification No.: 80-0756438
tivint. so I a rrM Phone:(877)404-4129 Fax:(801)765-5758 Massachusetts HIC License No.: 170848
E-Mail: support@vivintsolar.com J
www.vivintsolar.coni AR No.: Lq 1 Y r6 0 S
RESIDENTIAL POWER PURCHASE AGREEMENT
This RESIDENTIAL POWER PURCHASE AGREEMENT(this"Agreement')is entered into band between VIViNT SOLAR DEVELOPER,LLC,a
Delaware limited liability company("We","Us","Our")and the undersigned Customer(s)("You", `Your"),as of the Transaction Date set forth below.
Full Name(First,mi.cosi
Full Name rF,rsi r,Last) I n J )
i Pro,qv Omer. Yes❑No \ e /`1 1 ( ProN rry Oxrrer:❑
yes No
Customer(s). P
( Telephone No.: C1 vlq 2 Fr b 1E_Ma!I-4- _AJ'.Cryk.__ U[ 00• c-o'
Property i Street Address: C.3 �-
Address: City,County,State,Zip: of P
AA 4
I L SERVICES
A. DESIGN rXND INSTALLATION. We will design,install.sen ice and maintain a solar photovoltaic system on Your Property,which will include all
solar panels,inverters,meters,and other components(eollectivcly,the':S}srrm")).as further deseribed to the Customer Packet and the Work Order that We
will provide to:You hertaller. All material portions of the System will be insuilled by Our employed technicians and electricians,and not subcontractors.
With Your enti'pemritm,We will (i}design. mstalJ and connect the System in material compliance with all applicable laws;(ii)complete all required
inspections;antl(iii)obtain all required cemficahons and permits. [n order to design n S stem that mems Your needs,You agree that We may obtain Your
elet:trical usaga histol} from Your electric utility(the"trillry ))and You shall provide.�s with copies of Your Utility bills as We may reasonably request.
Otter than the activagon fee described in Section I.Q,We will'desi fm and itisittll the System at no cost to You.
B. ACTIVATION. You agree to pay Us a one-time activation fee in the amount of S� We will interconnect,the System with the Utility,and
cause the System to generate energy measured in kilowatt hours("kWli')(the"Energy-, nstallation of the System generally takes one day and is
anticipated to begin and be substantially complete between two(2)and six(6 weeks hereafter.
C. OWNERSHIP OF SYSTEM. We shall own the System as Our sole personal property. You will have no property interest in the System.
D. OPERA17ONS AND MAINTENANCE. We will operate and maintain the System(i)at Our sole cost and expense;(ii)in good condition,and(iii)in
material compliance with all applicable laws and permits and the Utility's requirements.
E. INSURANCE. We carry commercial general liability insurance,workers'compensation insurance,and property insurance on the System. For more
information concerning Our insurance,and to obtain a copy of Our certificate of insurance,please visit: www.vivintsolar.com/insurance.
i E TERM,PRICE,PAYMENTS.AND FINA ISCLOSURES
A. ENERGY PRICE. For all Energy produced by the System,You s p $0. per kWh(the"Energy Price"),plus applicable taxes.
The Energy Price shall increase each year by two and nine-tenths perc t(2.9/o A estimate of the System output measured m kilowatt hours
will be provided to You in the Customer Packet THIS AGREEMENT E S ENERGY BY US TO YOU AND NOT FOR THE SALE OP
A SOLAR ENERGY DEVICE.
B. TERM. This Agreement shall be effective as of the Transaction Date and continue until the twenti th(20'h)a niversary of the In-Service Date(the
"Term'). Ther"In-Service Date"shall be the first day after all of the following have been achieved: (i) m has been installed and is capable of
genemhng Enc rgy;(ii)all permits necessary to operate the System have been ob timed,Qu)the System has been!nterconnerted with the Utility,and(iv)all
inspections and certtficatcs required under applicable law.or by the Utility have been completed or received.
C. PAY14E*TS. Beggroningg with the first month following the in-Service Date and ttroueliout the Term,We will send You an invoice reflecting,the
charges for Energy produced by the System in the previous month. You shall make monthly`payments to Us by automatic payment deduction from Your
designated chetkiitg account or credit card, it is Your responsibility to ensure that there are adequate funds or adequate credit limit. 'There is no Tinancin
charge associated with this Agreement. For All payments more than ten(10)d7s past due,We may impose a Into charge equal to Twenty-Five Dollars($25
and interest at kin annual rate of ten percent(10%).plus applicable takes. If Yon continue to rail to make any payment within ten(101 days after We give
You written notice.then.We may exercise all remedies available to Us pursuant to Section 130).
D. RENEWAL. At the end of the Term,You may elect to(i)continue with this Agreement on a year-to-year basis:.(ii)enter into a new Agreement with
Us and cancel this Agreement(iii)purchase the System at the and of the Term and cancel tliis Agreement(the"Purchase Option-);or(iv)cancel this
Agrccmrni an have the System removed at no cost to You. You will need to notify Us in writing concerning Your election sixty(60)days prior to the end
of the Term.1lf You elect the Purchase Option.die"Purchase Option Price" will be the then-cu rent fair market value of the System based on an
independent appmiser's valuation of cimiiarly sized photovoltaic systems in Your ggcugmphic sit ion. The appraiser Is valuation will be provided to You in
B,LF,T',ONTOCANCFLBYSIE,NDINGourAMIRITTEN ,NOTI '
andw ll bebinding. IfWe receive Your payment.of the Purchase Option Price,costsofthe appraisal,appliarble tares and all other amounts then
nd unpaid hereunder,We will transfer ownership ofthe System to You at the end of the Term on an"As Is.Where Is"basis. IfYou elect to have the
removedWe will remove the System from YProperty within ninetyy 90}dayys after the end ofthe Tenn. IF YOU DO NOT NOTIFY US OF
tt TO US.THEN THiS AGREEMENT WiLL AUTOMATICALLY
RENEW ON iA YEAR-TO-YEAR BASIS UNTiL YOU NOTIFY US IN WRITING OF YOUR ELECTION TO CANCEL AT LEAST SIXTY(60)
DAYS PRIOR TO THE END OF THE RENEWAL TERM.
E. CREDITiCHECK. In connection with the execution of this Agreement and at any time during the Term,You hereby authorize Us to(i)obtain Your
credit rating and report from credit reporting agencies;(ii)to report Your payment performance under this Agreement to credit reporting agencies;and
disclose this and other information to Our affiliates and actual or prospective lenders,financing parties,investors,insurers,and acquirers.
WE MAYHAVE PRESCRE.ENFD YOl JR CREDIT. PRESCREENING OF CREDIT DOES NOT IMPACT YOUR
CREDIT SCORE. YOU CAN CHO OSF TO STQP RECEIVING"PRESCREENED"OFFERS OF CREDIT FROM
US AND OTHER COMPANIES BY CALLING TOLL-FREE (888) 567-8688. SEE PRESCREEN & OPT-OUT
NOTICE(SECTI.ON 29)BELOW FOR MORE INFORMATION ABOUT PRESCREENED OFFERS.
t
3.LIMITED WARRANTY
A. LIMITED INSTALLATION WARRANTY. We provide a workmanship warranty that the System shall be free front aterial defeats>r",c,
sign and
workmanship under normal operating conditions for the Teem. We further warrant that ai(roollop penetrations We install sh: be waterti t ascdate of
installation. We do not provide any warranty to You with respect to any comp,tnent of the S stem. Any manufacturer's war tyisinadditionotinlieu
of,this limited installation warranty. This warranty does not cover problems resulting from exposure to hamilbl materia. flood.
earthquake,or:other acts of god,vandalism,alteration of system by anyone not authorizedby Us.or any other cause beyond Our control.
B. MANUFACTURERS'WARRANTIES. The System's solar modules carry a minimum manutacturer's warranty of twenty(20)years as follows:
(a during the first ten(10)years of use,the modules'electrical output will not degrade by more than ten percent()0%)from the originally rated output;and
(b�during the'first twenty(20)years of use,the modules'electrical output will not degrade by more than twenty percent(20%)from the originally rated
output. The System's inverters carry a minimum manufacturer's warranty often(10)years against defects or component breakdowns. During the Term,We
will enforce these warranties to the fullest extent possible.
C. DISCLAIMER OF WARRANTY. EXCEPT AS SET FORTH IN THIS SEC! N 3, WE MAKE NO OTHER WARRANTY TO
YOU OR ANY OTHER PERSON, WHETHER EXPRESS, IMPLIED OR STATUT RY, AS TO THE MERCHANTABILITY OR.
FITNESS FOR ANY PURPOSE OF THE EQUIPMENT, INSTALLATION, DESIGN, OPERATION. OR MAINTENANCE OF THE
SYSTEM, THE PRODUCTION OR DELIVERY OF ENERGY. OR ANY OTHER ASSOCIATED SERVICE OR MATTER
HEREUNDER, ALL OF WHiCH WE HEREBY EXPRESSLY DISCLAIM. OUR LIABILITY FOR ANY BREACH OF ANY
WARRANTY iS LIMITED TO REPAIRING THE SYSTEM OR YOUR PROPERTY TO THE EXTENT REQUIRED UNDER THIS
AGREEMENT. YOU ACKNOWLEDGE THAT WE ARE RELYING ON THiS SECTION 3.C.AS A CONDITION AND MATERIAL
INDUCEMENT TO ENTER INTO THIS AGREEMENT. THERE ARE NO WARRANTIES WI-IICII EXTEND BEYOND THE
DESCRIPTION OF THE FACE HEREOF.
4.REMOVAL OF THE SYSTEM
You shall not make an Alterations(as defined in Section 9 c)to the S stem. if You want to make repairs or improvements to Your Property that require
the temporary;removal of the System or that could inter ere with its performance or operation,You must give Us at least thirty(30)days'prior written notice
(a"Cas ested Shutdown"). You agree that any repair or improvement to Your Property shall not materially alter Your roof'where the System is
instal d. As c ip sation for Our removal,storage,and reinstallation of the System,You agree to ay to Us a fee equal to Four Hundred and Ninety-Nine
Della -($499 befor We remove the System. You shall be required to pay the Shutdown Payment 4 defined in Section IS if the System is not reinstalled
withi thirty�30) ys of removal. In the event of an emergency affectin the System,You shall contact Us imine late y. if We are unable to timely
respon ou m at Your own expense)contract with a licensed and qualified solar installer to remove the System as necessary to make repairs required by
the emergency. ou shall he responsible for any damage to the System that results from actions taken by Your contractor.
5.ARBITRATION OF DISPUTES
Most custoiter concerns can be resolved quickly and amicably by calling. Our customer service departmenCat77)404-4129. Our
customer service department is unable to resolve Your concern,You and We agree to resolve any Dispute(as debelow)through nding
arbitration or small claims court instead of courts of general Jurisdiction. BY SIGNING BELOW, YOU ACKN�AGREE
THAT(I)YOU ARE HEREBY WAIVING THE RIGHT TO A TRIAL BY JURY;AND(II)YOU MAY BRING CLAIMS AGAINST US
ONLY IIN YOUR INDIVIDUAL CAPACITY,AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR
REPRESENTATIVE PROCEEDING. You and We agree to arbitrate all disputes, claims and controversies arising out of or relating to
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YOL R I\SL ItA\CE CCIMPA\Y OF THIS RUF\SI BOX 505 \\'OODLYN, PA 19094: E(,)L"IFA\ OPTIONS, P.O.
20. :\Yif~1,p111:\TS \\i)1Y-\(\(•.RS 11 is\gmamunt nue<mi%tie w3endcd tar BOX 7-1(11_'3 A 1 L.:1NTA.GA 30374-01?1.
(i)any aspect of the relationship between You and Us,whether based in contract,tort,statute or any other legal theory;(ii)this Agreement or
any other agreement concerning the subject matter hereof; (iii) any breach; default, or termination of this Agreement; and (iv)the
nyerpreta;ion;validity;or enforceability of this Agreement,including the determination of the scope or applicability of this Section 5(each;a
bigpute'). Prior to commencing arbitration,a party must first sena a written"Notice of Dispute"via certified mail to the other party, The
Notice of Dispute must describe the nature and basis for the Dispute and the relief sought. IfrYou and We are unable to resolve the Dispute
within thirty (30) days, then either part may commence arbitration. The arbitration shall be administered by JAMS pursuant to is
Streamlined"itralion Rules and Procedures(available at: hup:Uwww.'aatsadr.comfn lcs-streamlined-arbitration,the"JAMS Rules")and
under the rules set forth in this Agreement. The arbitrator shall be bo is
the ternis of this Agreement. No matter the circumstances,the
arbitrator shall not award punitive,special,exemplary,indirect,or consequential damages to either party. if You initiate arbitration.You
shall be responsible to pa $250. All auorneys' fees,travel expenses,and other costs of the arbitration shall be borne by You and'Us in
accordance ivith the JAM Rules and applicable law The arbitration shall be conducted at a mutually agreeable location near Your Property.
Judgment on an arbitration award may a entered to any court of competent jurisdiction. Nothing in this Section 5 shall preclude You or We
from seekingprovisional remedies in aid of arbitration from a court ofpcompetent jurisdiction.
NOTICE:By INITIALING IN THE SPACE BELOW YOU ARE AGREEING TO HAVE ANY DISPUTE ARISING OUT OF THE
MATTERS INCLUDED IN THE".ARBITRATION OF DISPUTES"PROVISION DECIDED BY NEUTRAL ARBITRATION AS
PROVIDED'BY APPLICABLE LAW AND YOU ARE GIVING UP ANY RIGHTS YOU MIGHT POSSESS TO HAVE THE
DISPUTE LITIGATED IN A COURT OR JURY TRIAL. BY INITIALING IN THE SPACE BELOW YOU ARE GIVING UP
YOUR JUDICIAL RIGHTS TO DISCOVERY AND APPEAL. IF YOU REFUSE TO SUBMIT TO ARBITRATION AFTER
AGREEING, TO THIS PROVISION, YOU MAY BE COMPELLED TO ARBITRATE. YOUR AGREEMENT TO THIS
ARBITRATION PROVISION IS VOLUNTARY. YOU HAVE READ AND UNDERSTAND THE FOREGOING AND AGREE TO
SUBMIT DISPUTES ARISING OUT OF THE MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES"PROVISION
TO NEUTRAL ARBITRATION. ds I Is;
t I/WE AGREE TO ARBITRATION AND WAIVE THE RIGHT TO A JURY TRIAL:
(Z
6.NOTICE TOCUSTOMERS
A. LIST OF DOCUMENTS TO BE INCORPORA'T'ED INTO THE CONTRACT: (i)this Agreement,(ii)the Additional Tetras and
Conditions.(Iii)the Customer Packet,and(iv)the Work Order. These documents are expressly incorporated into this Agreement and apply
to the relationship between You and Us.
B. IT IS NOT LEGAL FOR US TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE
TO REMOVE GOODS INSTALLED UNDER THIS AGREEMENT.
C. DO NOT SIGN THIS AGREEMENT BEFORE YOU HAVE READ ALI,OF ITS PAGES. You acknowledge that You have read
and received;A legible copy of this Agreement,that We have signed the Agreement,and that You have read and received a legible copy of
every document that We have signed during the negotiation.
D. DO NOT SIGN THIS AGREEMENT IF THIS AGREEMENT CONTAINS ANY BLANK SPACES. You are entitled to a
completely filled in copy of this Agreement,signed by both You and Us,before any work may be started.
E. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO THE LATER OF: (1)MIDNIGHT OF THE THIRD
(3RD)BUSINESS DAY AFTER THE TRANSACTION DATE,OR(II)THE START OF INSTALLATION OF THE SYSTEM. SEE
THE NOTICE OF CANCELLATION BELOW FOR AN EXPLANATION OF THIS RIGHT.
V[VINT SOLAR DEVELOPER,LLC ,Q CUSTOMER(S):
By: iLr/1 (/[;��� By: A-]4
Printed Na mC: t A.A c.C(c((e-- Printed Name: —s -k -C
Title: By:
Printed Name:
Ii Transaction Date: Z '
FOR INFORMATION ABOUT CONTRACTOR REGISTRATION REQUIREMENTS, CONTACT THE MASSACHUSETTS
OFFICE OP CONSUMER AFFAIRS AND BUSINESS REGULATION:TEN PARK PLAZA,SUITE 5170,BOSTON,MA 02116,
(617)973-8700 OR 888-283-3757.
tx-------- 1 ------------------------------------------------------------------------------------------------
-( NOTICE OF CANCELLATION
Transaction Date: AR No.:
t
YOU MAY CANCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE(3)BUSINESS
DAYS OF THE ABOVE DATE, OR (IF LATER) UNTIL THE START OF INSTALLATION OF THE SYSTM. IF YOU
CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE,BY YOU UNDER THE CONTRACT OR SALE,AND ANY
NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS
FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST
ARISING QUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO
THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS
DELIVERED TO YOU UNDER THIS CONTRACT OR SALE, OR YOU MAY, IF YOU WISH, COMPLY WITH THE
INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE
AND RISK.;IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP
WITHIN TWENTY(20)DAYS OF THE DATE OF YOUR NOTICE OF CANCELLATION,YOU MAY RETAIN OR DISPOSE
OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE
SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN
LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION,
MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN
NOTICE,09 SEND A TELEGRAM,TO VIVINT SOLAR§DEVELOPER,LLC,AT 4931 N 300 W,PROVO,UT 84604 PRIOR TO
THE LATER OF: (T)MIDNIGHT OF THE THIRD(3 )BUSINESS DAY AFTER THE TRANSACTION DATE,OR(1I)THE
START OF INSTALLATION OF THE SYSTEM. I HEREBY CANCEL THIS TRANSACTION:
t
Date: Customer's Signature:
i F
1
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rri:.� It n un•I • , n."Id .III rr,r, , ,, -:L, t , ,•,;.n,nt equal In i.. 0,411 1e1.far, .,Ili mailed ,Oal.1i
t -h It rt. al.ka 1h-p 'fit a •+p ( It f , I tna nim , 11, ei,04 iwr sea - n(cal.11.Alk, Iran,ier I'avmcat tiii"w '
i Pu x tq unI h, i '<t , +I r.;,x a,, x ullivl1 rll.inait.4m r t tthc Trunifri'Ya \na pill Y it '
are al . n a.. s(. 11_ 1 .1 \.,.-ol) 1''.I. I J v-, • ,•t.c f a,:c.D_y n,rm.\ie it rau+..r af,.•alp,d the�,ar:a...It—
r u�, Ir.,q 1141 i,. i car Ill ,u'+'c'111 5 P ,• \., n t•h ,Vh.rr t-1\I NAl.111'ta,dloa aner dil
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h'„ d na rte' , , ata. 41 I v.r 1F 1 ,.nxmt i nh 1IW 'fi eco, h r'I't 1 l Ira,,I.r 11 11 Y air thereto, Its Prnne'rty 1 Mu,feree n a ka.c ._vlhLT �
nm, 1., e : 1 ..or,.0 a d n an n:ak. , i ua.a tf i•e mrpl. '11. Y.v(111 amain r'sr ii,Ibk f,r�rh ro mac ,f
n .0, •'1 I A a , , 1 it,, ,a. Y ria.m. nn e,• Ii it re, itYou.r aez h•t 'h.Je,a .0_: t „wen— i.
it, ((r. r..+:r ,n,f ro•t•a I rel 11 „r r 1 _ 1,11, ix- h r in I Jac•-uu 1'rl).to 0 N .,r I'n,puty. Ind Na0 o.'k,t fl.l\aur '
1110,41"',,v,•,n,.,.,, u unam rI e\„pl t ;ler + e',r t \.rumeul , ,..r•:n:d nein m to:n,fcr :v+\}rccm,m,,;:nuant to Ih,fella,and aonduroa s f
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n- - n-hl rte•, I' i(f T 6+Ma s y d ii r r I r ,,Lia f t C\C N'('�ill'DEF 1l Ll la• r uwlm t l,),mull it 'Caarnener 11clua(P+F i '
an t Iv r (cur Ile,• 11i is a. 11 L d 1 1 1 u a n ih, „ anon.nt any .4 IltlTo
', nra: crrYr krill lidnic,N mak:Ani,pa;ment
urI 1 ,til•1c.. r'i m a ,t Y 1.,,>rc I, . 1,,o ata t tn1,r. hl s c, t a 'l11 doim v,, \ nu Illul ten 11,11&1,.x(alto cue and+uch liolurk, nw m'n! 1
Y•.,a rnlff,,11, !J j,;. i•(),,' 1 1 m - 1\ 1 (L--$it..1 ur ,a ilio V.(IC d.!,1 net lac lc fall i,lillenl noli f,4ch!allure:i It Y •tallOn
ln..n aux t.,Lro, it I . •,.h 1l ,nal,ha 1RIcP.. 4r--fie' o pall"flo rn tin.ti+1 of'r illi \�nvncnt o'1+14th ficnurc u and ,atad wuhln
mar.116vt. \N c.,It n ,rp..r card%.a4r-rata Ill,ii elcr A I,,,.-I u,N.41 1111%,All,da„anal tA:c o-,,ti oil aniLsm acihe.it+uch fat!avo (jilt IV.,,{fain t 1
rot,:1,w-tee n:Uv.10— dsl'I'll nl v Your ray.nenl•'Sbtj Ill.4 cd,:d rnef laic O1❑ :,,dil aall•t,bi ultorlitn" •'1 (tic I rrhn A"tG I.-No 1 1 '
11”if pe-a.Kl. '1 mae,unt.. JO 1,' I)".
rte. a;ape ra p b- + rn •n.lahn Pap ria illi( .flan Je La k+t YI Rinnm thfR 4,1i 11 dA.1.illh \
y ( n,
<t ia,e Ya
Y, it la ala:L, 11 4 a ill 111,n•t 1'4d 191r U anrn t 'atilrt 1 all A'{irrl,. we iia o ht,"f die'all oe 1)pratxic+141`1 611-1.�t i Y awl hanla lkillc),,n,ol\may 1
n;. 11,11N Y 0i 'i r:x 5hord+"1 1'111,,01 .h l l,u,lt I t l6e`e tam ., e ido—, ri A YII tr,n lit lth J.•pat Yr,ur J bit as lhr}ma(urc ur(s Your lT+re;\
dart'r;, . do kru„d M lira Ift,ty fl .! e,,rihq(1 ., it iif r h •ice.r t„'Ain' ,untinp.011 Iti.i t1f,lo illi rs xctdiu +h•13s•Inritita 1 r l lrmM ntt,.ltlr Il
<,yah,a"l'u.ii Fw•nt I.v,.,cd h\(AI c.e'•:ax ll,at Jt rn rr d.lepan mo a Cu,unrp )1•lau,l .a.un, kite may ea&fV1W any of the o,ns�n; retnrdln 1
erlau'11,,tont uatt m rt+,-I,ill!tic,a+iu r ae n i. t't.i i i r::all a !loll! r sunup „ ht \tavamcnt alto Jeniati t)pit lClic De pill Patrrtonl, ml kat,;the
etioJttr•r If lite"t•11111',d m:quaf•4,Ja�!rn\cd•. I t 1(Iua y I.,rill,ttI,olov,)hii I'\^1011 11 r 111,an Y-.all pt(ry)Rty hill deny You a.,c++.o and use A Ir I ner{;y u �
Out ,nsucawc. 1tc n,a% al Ons try ,r r 1 sal r nal rc+nuc til Sa,tem au y s, nn,fu„r +Inch nkat tx redu.A.10 and old it tlur elmitaxi t,udl•r„mxet or take
u.,rk'.n: u,nvrnrr ar I:II erva tte au, lgi.vill•nt aoj.. al Yr:r ch.non eifle, ha k Ile•t},taa IS rcrmntd h\artilILahIa•I..%,fat Ipirt:c m,n YInar Prl1t�t\ t
,.I'rtry Ih.•iy,l .n a a,+ix ,auutF 11dnan 1 11 her( li.L•lav li,t ilo tt afg a .Iftlno+n agaalev tel nl'-tai(pnnrcni.!rano tun'rte a npr,rt Your Jefaull �.
alabnnll.d..n»n.�anar•,x limo,_1h.tie urn It-a't+ ir Pru,a:n+ 'I
(h_ ,��t�, ',�,*n (r,r,t�n ref*xrtl�, ac.•ncru.acrd to %o 1 rcrraa+. ov axh(T rrnla$a-la,;flablc to�.+m 1
11' rnf k e 1114%aauw the',Nrnv 41"V df,ewmtdrd It,.411 ole t :int-”,1«aliifiltiii dfo Ypatthlrn s.r Aiu a etipl,whiL fM ecl'?citlt,(1>ii 11 It 1".Sr!/ar Orf'+7i'+hall r
'•+T_1�t keQuea•W fr 1�„m1cuU,:n.,r\l,are etjuimd Ik,Jo o wwo nkil .lite ISR ficin like,N..nrltki tit and J!ills halit`'ItIr. (i)1-1141 IJiIUfI to i7Crh,na 4. •.r1UJ '
9. Y'Ot,R Ill I fit S. ff the Sy.trm Y io.nail ow it,:I .1,•t<,d t,.,1 x.11111 ohh}iaron,.Ind ir fli, 4v7coti nt rttd the cllcit of ,ueb Fmlurc I,n C"1'111 '
nmT,nc> x,l oo or atm .I+atanm•ng Nat! qt ell nme� I..ii if an,.ne ,nthtn sh•ny r,Ot J.+Yu
s after Y ,;illI %
i , -rata,nno,c or ouch(allure o ,out i
.hal
he
Pnrrvtl} ragman, ar[ .amotcaJ to 11re (al.,) 'la'ir.adh,nut LJtama� n,u.ktupl,t,m ,h.reA xadtmsuw,u(iunaubtiihtl,pit}thrJeMsaidre�•rwtun '
4 ZtJs4 Y ti miler r,,wl h the S}_em 111th c maid nu ", c+1„A+«ho.runp ptl KCQjL-Jj11 Gyk(tel Da Iaah It,,S(•lto Default teem,and a*alum am,You
olI neat . rce nr.l nah o4 v led{'them t no i.ai:t a ndanl;{,e cal oaflel at You til,• o wiroirele l i, \rr•tinent and tayncss t11noval of the`;y+tens inns Y,:ur i
1,14 U%,,I fail a at nun bI,,llauJ ill sell"I'r cl-tn d".1r t M I,i a�raid.d Psppx.t a anal or nu Cs,p, rou,l{ed lhdow,ctnclse am then remedy aeallahtc w r
.nil iti ma) ar 1 LN tilt l)it(!:lien 111\ it'll. 1 Vis.tat�i Y�!,t 415!11, tt+ha+l Y n lir US Altfit7aa7nt iif under dFirl Kellie uai NutwahStandtngn die Ill, rills'.Yvu
a,rt .AW NT-l' fr Yw+,m,edlr 111 nntion nt crin,,beim r,,.h,ctnell adt hof,:In(vhl III clam{damage,,.o a ntiuh of IN wnnntaton ofthis 11:ra:melx. 1
"lilt tell rrts",,anti ISII•:tk Wli,t1,N1 ilial a'f-slid,.,d 4'!❑npa11 M1II}win,anty fe taflny '\a'tln,,r1(tl the do 11811 ea,i}in mitotic the 1 Ana,If\\'C fad it,nttnite dnc,utero r
to the SrAcm 1 .11 he atip,n,Me 101 any dam 1 t the S,tiro drat�• a.,cd"t (ricin I 'Iprrly pununnl to Scchlm.L.,rod tvt am.damag it,Your Pngicrt%
any unix ht Y.x Or Y.nlf luaus. Ann•,', uuvsac2r., as aaults �dt Prt714t1I r'hme fitlnt the Rnx.til .,t e(r S1stm1 ht (:er hill canirn(xan (a) i_k�ti�1(i I)
Alenia^o N , .Wi or Ann d ItCe' n Y'nlr t a'r,n1 n uatgll 4n,eanr..ri u"It, JI ill,\ \crimen{n tTmtnau,l her•In\lea t,n,other thrall pnrwutlr W the
Pon mvr and tee this r h'a 41St+to Ate:�re ill:t+ludin), .!ih1'sy+t.an Ir m• otkc al(rutrllaiaifn•Yasiµgt( +r a SrlJe,[hfault-You wffl ray m l s the 1)etiiuh
Ili(m iht f iaosaet n!late:auo ill I ulatnt mi n b,wi ondnnne amt opal. P tyro w ill•"Defoutt lbnr»r 11 ahall he an am,xtlll a tial to Seton Dollar,IV)per
Ilse nxd.rod All alcetn,xl ,ten»of Y oar P op sly (a)lf;ho,rzz.0+V'n, Y•ou,hs1J auto an+inflad,•uhject u,a r,dlrufa,.,I'lite ixticrnl(S°ll pix year leg n y ar!4,the
,,l'um from Y oar muar4gc ho/n mneoiAs fxI'll c t,stay othrr pper14W with An thlauh 1,2Pa,trterl%Ili he �(i$M want otialallcdl-pill,applu4W taxes. You ig.5c
,mint in I oke ihclxtta ilJ auth(.t r.nWn,n a.�,ary for s,to mstatl,„pirate,and ,hill the Default Patment fail iy re len Lite talus of the"yetan,anti in IV else of it
Imolu In the 1Y,tem Your'allure(o mlxmm dirge Aulli m1ki ur A'Inch nc:nrry Cuatomer ikfault.i,a lair rcntsenwf,n ill the dintive>and L,sw,that N r e\pctI n, 1
alay rcvuil it +ttmmmun tit flits \ler+molt fel f,_\. Y'ar 'kil ext>'All to\e, ,cur. Alto YI u tiny to t a the Detyidi Rasmrm•\lZ aull irnlnsfer ownership of the tI
.1"ie,tnl cn or to ln,faun.n+ullatn ,I r Fluntmn i lilt Sy,fena ImluJtn�t.±nv sv,lcnt to You,man"\a le%k hull ti'nasi+
lateral cx"Se+t ,.Iles las,n the Civ , ptnuu,d by the S ikfein. \\c shall b I4TER1,11 1'Id()N. {.ai Tet nnntou h, Sell_'r tic{nay.In Our sole discretion, i
n,pl n+ill(for'nevrov ta\and prliptrts oft as,vmcd In al ur
mifinl to Ow of latnori thl. \ mlm
yeyeent iIi,t prier tf" ,cTn-$(ntcv Date,upon delnrn of wfiuck, f i
the ty,tena. (zlVI ,,
lh� If Y ifal,dh t ittify, +,r,nl\¢snrmnu•»lal Ag
cacv nttutns Iii to Ytw,of tit)upon the octanreno:of i Cullum r miauh. Within ninety l')n)
ti ane ctlangl h,til,S;aslem alta ttr kowIlao+m,Y.0;hall ow\Our itantlant pani and stay.atter tcintuutnrn of fltia Ygrc,•roant,uthcr than urcfat the eircumtitanee,(it which .I
la�chargct..m tat!hat tt(r;ll ally to\.fa., it other charge in relation n Ute I;Nem the 4yetcm It tr,a,frned I.t Y,,If ind,Y Section?$eLellon Ir,or,;ell(m��,t�.\4e will t
o this Ae;t anent after lite jn-tiCn,a Data•, (hen Y•,'u 1,311 lila oe'j"k Fic Ir' roadie IIt,.S—Ion and reslfe,It rootloll i cnann,il%(,1 be Ire'e front Tia If t\'c
realnburse L',fir.uch fat, cc f atlicr char•c(a\c.in fav tw•ome and prul!arta late, eleel to loniinalc this igicern We will have a" funhat liahlhty to Vola w
ttu,uY trill re\p x+ihliny and r S(a(iLa"�1. uhf LtrrQerr(14}rw_sc4 L pan r ler (h)Ter urau'.n h 1st ma' Yin may t(inmat ilii el ntirnen((it pufw rot 141 the
nyucu, You Jta!I prora h s1647 anal n•uirn til am appltulfun agrcentnn or uthai hark n ill,:Notice of .,mu.halon,ar I u{rvI A Selicr Default t
dI um,al nc,".ulok for L's t +htanl.m/ cred�;.tetmi,,.irxcutive+.mfowanccl,of Ic ,%'STEM Slit C1H)YYi� lal \4,111� iAl,mn, In addition in Our right tn\hut
ertitSetres that are attributed,All caicu.or ref,ocd to the Sy tem die Fnrn•y, , ohmn the i'slenl for nrain(n utee.Wo mac no on,❑die'.stem d We rca+mahty r
atn\Ir nmemtal auribula, twin f Scall Tlively, the '51-vem,lveivvf''I: III Am hChete Itiat proprny nmdittens or aetokine,Of ina un+on thr•Prrtrcrt),which arc not i
pcmtds.mtreunnxlmn,net RKWITIP agnmcmfs, cud aiha J„cumcros required by under Otil corral witettter,r ntx under Your enntnd,am) unertel:with die safe
the Liifo5-.and(,ill,tn\doeuroeat nccr,cari,to verify our,l+vn11wh1r imea f to the a talion of the S\-kon fa"Jtr/esU,Shutdown 1. During thratdency of a Sato\
System and Sy,irm Inter'+1s, (r)t,�iy_to\a(1_ti Ynu c1101 rwmp(h natio 1.s if if) +hutdawnt,Ynu will pat l.,•f the Bila own Payment. (1,1�m.�+e,1t��ii aimed In the '
Yiitl mm,•.:any liemitt or thing interfering w r l_the olacrition(-)'the Sv\tertl:iii)Youl ,%cnt that You\:kali Yi,ur Pialp nv lit any pp noxi rat Ulric n+i resui(eoT {trent that
Ptt t ortyF m{in_nnce or r(rnnr ,nal-tion,or eltenrit-4m( t.'iat may r rveme is not a fere.:_\{3tcure Flivro&renter Drjautt'you vAll^_nnt•.mre2r Trey(1t'finratt the
k1naper`moan ftenialtiue:or(m)You yak•in,cps•rPenvk acitoo ,.fit re,pcct m,div Friers\pnvhw(d},v[he Sy.tem tcI In len:nrimit I rLaa iet5 II-tnttrconnreutft
SSturm. Yaxlr failure tiI mmrtty nonly L.:ul,uch manor,ahnll to a t.u\tomer widl'Ohe L'tdny Ixiom,a akulv5tn tar maux»That art not(a)A Fur.'c kiajeorc i
lkfllllr tmda S Lunn 1 st r {-tent.of(h)('u.cd fn or related to{kir uneacused action or inautiun.such that the
10 SSI..E OF•SAt:Z)1 F'NERCY. (.it Sale a,i_Ic irlcnl. Be tllnln2 11111k the In- Ststent t,no Imi•er ah),:to rIjee ct,•tu'ltltg or transfer e1e'ctnarn ur You or to the '
Sen we Date, tl ,cill s'cll to You and uu i,r. ,aI from I„all of the F.netgt t4iliv_ Yon 11-Ill pa, I. tilt• .Shutdim11 Pawner!! ((I)Shutdol\n I •men I. -File
pr,,(hiced by the Sv.tero. l ilk'to,and ri F 11 lo,. lith tepeet to lite Fnere,shat) "Shunion•n Pnrment"\hall equal[he sum of(i)pl}ments of- e 'utf_•y ace that 1I
tran•;fer tfimn( 1,,You at the point whirr the S>\e,kk 1,intemkin•cfed liri Y'nur You nmid[I blade 1,I 11s its desenhed in Section+.i,.for tete Path.}thatirouIll ll
Propw)',electneal ,tiring, Cncro front the',!,term will he delketed to You ill have been pnduo•d h}file System during elm nd
petof"the shutdtnvn;(u)the ealuc to '
ea", itace with oil m)mnrotnt,if the Lilht Ih1 I'atrnent. Yin agree khat the i\of the ap+tem Incam+cs thal\tee would hnlc reccn(d with M pco fit the Fart}y i
uhiigatrun to pay all, amount dile under dfr\ taneinrnt v)m(t be absolute and that die Srstm would hate produced foll,ovirm,vets shuldofni,ant!(tit)ap ti;:able
unumdldontd-and shall nix be nthirci to enc atta[cn art detetksu.coumtard:nal,sctgfl', taw. Dderminauon of the ani of Energy Ilfut would h7tc been pmduc during
tnaupmant or mhictiun. You .ofd We agree that all Amounts pa}ablt h Yeti the Fiend of the shuldimn 4kall fit iwiat(A)during the ilr l}•car alter the bt Since
hereunder,hall he rwahle ht all etemi including Icy Your heir.and c-tore k\cCpt tie Deur,rn eaunand Mtrls al'rlr,duetirnr and tRt alter the fast}ear p11.'r the hr 1en`icc 1
permitted b\the Notice of C.mcelhttiun•You ne,rhy ,a;sc all rt his You m:1e have r1, Dare.based on alnan)operauon of tit S(.tcm during the,ami ptnnd to the previous
IT)att or calix!the, Agr eni lm to retake accr,4llhY of Ih( sum.at to alma n ear. fl a shutJawn naalnt to tart. dor tilt.,' fa,. ; ri i
1 y pu )yq_...... }a to L continues formic hundred 1
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IA ARK VNl f 1R(it ARAN it E rl fivlOt'N' f 1F 7"y ,`-PROU!'t'F!7 if%. \m,nent and nyyAve Yon w puy the Default Pa1•rnrm
1l IF.WY TI M FOR ANY f ERit If)OR ,tr Ciri l 1,\Y'Iti(iC \\c in;not a anility Id. F'<)RCF..\L Et*E. If You or\\a Are unable to pedonn env of tike obliptlitns {
Of public aectwe urmpan and J., 1 not some:illy obligation ref a utilit(or puhlie unds thio,nereeim•1n Nc.ittsc OILA Force 41ajeura F%cnt,ouch affected pnlzy(till he r
un-tcc caropany to.0 plyYour eocrw nquuartents. ole are Oen svbjvet.Ill talc meuud!tela uhldc,cr rc;hirntnme as.afl'cei,d In dic Faree tin con.L;+tut,pnmrs/rr1 '
rcuew by rolemnlcrtfal aothoviba+. During flit:Term,You and kitvld Ula{Vito Inas that Ila+sts}nn�lstn of,och ohlieauwt,to of no g�ff'late,<eope auit' nu lungger JtlmtiOn
trgwre nwm cicetnett [!fall the S),tcnt jinn plirfate if Yuu need any such th:nr n requilad by tilt:Poco Nfaicinv Film "hirrel-Majeare riven',1141411 mean any
eda,konal clergy,then l oil ihali he soiel)resfivasb,lc to obtain such atctyy from lite. dent,eonhtlt n t r eircunr>laneclyond file control of the affected party wh ch.Ilk,ilii
Utllltt at.'rour incl. c\ereiw ufduc hfaligh!+uch j�,.[tnv coifed not reasonably hire been erpe"ed to avuld,
I.I.Ov.vEp-silIP OF Sit S li Ia)(Jill 4:h\narshrp,If talc S3st4•�I>). N c Jnall awn :And Mich bit the a'\crlie of title dilltrence u h Pill,+I shout fault attrtbutabie it,a I. i
and Wili all pri lit,n•,ht,in tilt Svacm end die`;y+ttiri bdrrcov Y'pu,hill hate nn unable to ovetrunie.indukiin' but alit Jrnnted(o action b1 a menurferlial authority, '
pr,gl,•t,y tmcrcs m the Sveteira or the S%,Icrn Int•n.t;e\ccpt for ill fila 1"llovy that the Work:fit au on[tic part. ,tali go/exrunalud authority or tlxie Cnlit)tpruwde-ithat
tilt cy+tem gcntml ,and nfl ata cnedle\or jInia}taent i,adahle under Your ttilit%% such action has Nell timely rcgnehad and dilipoil y p'ursucdl.failure to obtain or �
"net meterulc proknm for Itc rnerev that tf,e'`iy,ten;inencrntr Y +u igive In keep raalntimt a pinna,license.coitwill or approval(pp"'.0i f that;uch pant:has nrade '
the S)Ytem and S,1Icm Imre•,free farm all Was amt(afeUmbr'In•es tilt P rK,nal tinct\ and rca,onablc commercial dtnris it)'Nail and Inuantain the salla'), Ishol '
r" -t Nature f The.';S\t Vin, N+.twtth+tanduie the manner in which the System is (liytulc,stnkc,%kvrk-aoppavv,stou-dellen,IoA•out,flood,uanhquAc•fire,lightning.
aril!•Ita•(1 tt aur I'nfen},nor ant Ilstufr filing n t c,)'tai and tt o hereby ainee that %,Ind,pid,tnae,ate•lernin+m,{lin. comm!:s,"clion or cmhargo,cu it disturbance, i
the st,jv and the Syxlcm hventls+hall rollam 6or ail.•r,tnanal rn,pcm end+hull Act of gmi, »m\uilatnln ,t ckcrtcily nmol the t'lliaN, equlpmcnt, +urvla,•s w
not
he'le"neJ r.hmacnrteed t a`fi.Mur ,ar am I'All tit file"wilt,'.as Illxe terms awxlu(:f, flat+r at\Yl(whe,ure,ems •(I'h}—meow mita Liu..the alfecs vl parry.or i
roily IV dehlhd h, lirrlicuhic law. it t,ttunher'et,tard that the inatalhiuo n of the iadun ofequrppnrcnt nut unhA•d h,or unddrihc ctmtnd of the al)ecle(i put}. •I
Sv�iem,hall not fit a repair,rem(nicl rn
ahcuot,ekm\ei ion.rmalerifirauon pU`l 1t.or 17.1 1'1ON OF 1.1,\19DST), York undclswid that, (,t)We are not,ill Ifhmtt
addiu.n to..Y•olr 14op.Cii (e)(1 t E i ycis, You hereto grenf Ill I s and Chn of Your Pu I emy,penscwal pmpcny,or notional safety of pii"ons in ur on Yoko i
•otploycoi.a;teul&.Ain't ernnrxuf,Il?c n�fu to ileitis,and u.c Yom Pn'reny w that fmt:erty.flip Yuu ere aaleh n%pokk;thlc fr tinr\iding Ouy msunmec with n ,pect to 'I
N c oat Ili entail.operatc and mamilla Il',a ws[eIn dtrou"hm.n lite Tenn.til)enforce Yoix Pn,rmi,and its cora nr t(I the ium+unl You pay in U+k based md4 On the
Gua n6is as to[his Agreement unit Qh Syefan,and?ill)Like any other action tali al•I le Energy produced by the Systcm:and not on the,:due ur Y(nr Pnilterny or ,
rra,finebla iwccs,m in con moon villh file cou'lnsnon, lmtalhiuun. operuauu, it+ ort nus.(d)the Svscol roily npl aiwny opemw properly lir variuu,.na,arI(e)a i
imuntmiite,rcralr.or rem li'rl,i tilt:St'terk flu lingoln�neht of rwccv:to Your is ddti vh to mm Jclmtna :dunce die ialue of the ecunronem+of the Syvtem that I
1'n.pem+hall co-irate a ii en.•,n,pW l,iilk an intenst and,Gull he-Im\mAtc her nnuht be lo,t or Jewelled 11'the Sy,tcm fait(o operate rn,perlt;(1)it K difficult to 1
ur to ninny I'M))Jati after this A(„•rrearI e\pnes orf pmt Ilii Ls,i ah tante to remote deremmrt fn ddlnoty IIhna pillion,It'am of any property!tom prrwnal mµuy m a
the S),icm of the erid of the lana. (dl N th:�14.1)Z,t,Jq f),\pctsjilr Yw authnrirc death urndd t+r pntsnuatdy calrua!h)Our failure to perfnnm,(�ur utghucmee.or a 1
l,w make ulna •uml a1m'ihng,,nil retclant gp eI if it a) 114th,ret rs as ncq'h1 failure O the Sy+tun,or the Systen mstallavon
n1ea„w'y so rn.elda notice f Uur o+a,r 1111 in the s}stm An til S,<teln Intrelt+'. t
and Uur nght u,aa...s Y'wr Pngnony Upon termination of til \'.w vTWai each such
ANY BREACH OF THIS AGREEMENT,
tiling fit(h-tarntfnaacd Y,w andersnand thin the�;ysicln.hall Tit umr!.cd;ltd ANY FAILURE OF THE SYSTEM,OR ANY NEGLIGENT ACT :1
ideutffted11()nr prnt±eits THAT CAUSED ANY INJURY OR LOSS (WHETHER iI
1'_. \SSH'\\it`C R'i'kANSFtR (il \„i••1ll nt 1\t may es, ni .111.or PROPERTY DAMAGE, PERSONAL INJURY OR DEATH) TO 1
tant,kr tin+!hole or n pato Ih, Ygn,ncn.the Stiwtn,or dl, Systcm l.0 resiti +
Mahout Y rw conxttt and wadinun a. l 'u•h a: Ice e n�'tri.m wrunlg t 'I sums ANYONE. WE AND YOU AGREE THAT, UNLESS SUCH 1
Our right.-will h, A-rcun ut lite,d!ht a no funh r lillt_iBt or t bhcalitn ander' INJURY OR LOSS WAS CAUSED BY A PARTY'S GROSS
th.,%givematopal ilicc ,ioena., ,u0,j—poncot (I'))ruli ,+ItrurtI NEGLIGENCE, FRAUD, OR WILLFUL INJURY, SUCH it
You,mail pro,idc I,,lilt thin}(101 da,s'prior amen uaucr uTa srirrpaw-ii'icc PARTY'S LIABILITY ARISING OUT OF OR RELATING TO
simple cafe of Your Property (ins lcntfen notue.+hall include the name nt 0e
pnrpo,cd rao.hiwi(v Imnntct\I'Pru/rerh• I''mmf•ree"1:md the prIN-1 dot,o! THIS 'AGREEMENT SHALL IN NO EVENT EXCEED THE 1
sal .M trm,lal Y as fill also pnf,de in addauoriai aittnnumoo rept hoe Fr open} DEFAULT PAYMENT. YOU AND Wi:. AGREE THAT THIS
fmn+tTat that\\e rej orkahbi rtljocal You win n.qucsa dru Propcnv iran+fercc AMOUNT IS A FAiR REPRESENTATION OF THE DAMAGES '
agree tit wnhng viii ,that pro)lerly Trm»itlre wdi as,ume fournbligauo,under
( THAT YOU OR WE EXPECT TO INCUR IN THE CASE OF ANY 1
Fr. Luccnto'i I n pill\'Frun,lercc,hall enter into such,I t'ettunl on.if bvliolc the
date Y'i'ur Prnpem n.old. \Iwriauidy,it We dcscnnune that lard rt; Fran,fierce is INJURY OR LOSS HEREUNDER. i
not adeciiii h urtlinla,nhy to axunie Your ahhgatons under t�KI \ufeetnent.Or NO CLAIM SHALL BE MADE BY YOU AGAINST US OR ANY I
Plopeny Truri+lege aline+In amttllw Your ohtieatwn under film Agnenlent, il'e
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1 1
solar 3301 North Thanksgiving Way, Suite 500
Structural Group Lehi, LIT 84043
P: (801)234-7050
Scott E. Wyssling, PE
Head of Structural Engineering scoff.wyssling@vivintsolar.com
June 29, 2015
Mr. Dan Rock, Project Manager
1 9
Vivint Solar
24 Normac Road
Woburn MA 01801
Re: Structural Engineering Services
Allard Residence
60 Middlesex St, North Andover MA
S-4288056
4.16 kW System
Dear Mr. Rock:
Pursuant to your request, we have reviewed the following information regarding solar panel installation on the roof
of the above referenced home:
1. Site Visit/Verification Form prepared by a Vivint Solar representative identifying specific site
information including size and spacing of rafters for the existing roof structure.
2. Design drawings of the proposed system including a site plan, roof plan and connection details for
the solar panels. This information was prepared by the Design Group and will be utilized for
approval and construction of the proposed system.
3. Photovoltaic Rooftop Solar System Permit Submittal identifying design parameters for the solar
system.
4. Photographs of the interior and exterior of the roof system identifying existing structural members
and their conditions.
Based on the above information we have evaluated the structural capacity of the existing roof system to support
the additional loads imposed by the solar panels and have the following comments related to our review and
evaluation:
Description of Residence:
The existing residence is typical wood framing construction with the roofs stem consisting of two attic section(s):
• Roof Section 1 (Main House): Roof section is composed of assumed 2x6 dimensional lumber at
16" on center. The attic space is unfinished and the photos indicate that there was limited access
to visually inspect the size and condition of the roof rafters. Based on the span of the existing
rafters, a knee wall or purlin must be installed prior to installation of solar panels. The interior knee
wall or purlin shall be placed within 12"of an interior wall below the attic space.
• Roof Section 3 (Garage): Roof section is composed of assumed 2x6 dimensional lumber at 16"
on center.
The attic space is finished and the photos indicate that there was no access to visually inspect the size and
condition of the roof rafters. All wood material utilized for the roof system is assumed to be Spruce-Pine-Fir#2 or
better with standard construction components. The existing roofing material consists of composite asphalt
shingles. Our review of the photos of the exterior roof does not indicate any signs of settlement or misalignment
caused by overstressed underlying members.
Stability Evaluation:
A. Wind Uplift Loading
1. Refer to attached Ecolibrium Solar calculations sheet for ASCE/SEI 7-10 Minimum Design Loads
for Buildings and other Structures, wind speed of 100 mph based on Exposure Category "B" and
6, 17, & 32 degree roof slopes on the dwelling areas. Ground snow load is 50 PSF for Exposure
"B", Zone 2 per(ASCE/SE17-10).
wowonl SO I a r
Page-2.of 2
2. Total area subject to wind uplift is calculated for the Interior, Edge and Corner Zones of the
dwelling.
B. Loading Criteria
10 PSF= Dead Load roofing/framing 50 PSF = Live Load (around snow load)
5 PSF= Dead Load solar panels/mounting hardware
Total Dead Load=15 PSF
The above values are within acceptable limits of recognized industry standards for similar structures and in
accordance with the 2009 International Residential Code. Analysis performed of the existing roof structure utilizing
the above loading criteria indicates that the existing rafters will support the additional panel loading without
damage, if installed correctly.
C. Solar Panel Anchorage
1. The solarP anels shall be mounted in accordance with the most recent "Ecolibrium Solar
Installation Manual', which can be found on the Ecolibrium Solar website (ecolibriumsolar.com). If
during solar panel installation, the roof framing members appear unstable or deflect non-
uniformly, our office should be notified before proceeding with the installation.
2. The solar panels are 1 '/"thick and mounted 4 1/2"off the roof for a total height off the existing roof
of 6". At no time will the panels be mounted higher that 6"above the existing plane of the roof.
3. Maximum allowable pullout per lag screw is 205 lbs/inch of penetration as identified in the
National Design Standards (NDS) of timber construction specifications for Spruce-Pine-Fir
assumed. Based on our evaluation, the pullout value, utilizing a penetration depth of 2 '/z", is less
than the maximum allowable per connection and therefore is adequate. Based on the variable
factors for the existing roof framing and installation tolerances, using a thread depth of 2 1/2"with a
minimum size of 5/16" lag screw per attachment point for panel anchor mounts will be adequate
with a sufficient factor of safety.
4. Considering the roof slopes, the size, spacing, condition of roof, the panel supports shall be
placed at and attached to no greater than every fourth roof rafter as panels are installed
perpendicular across rafters and no greater than the panel length when installed parallel to the
rafters (portrait). No panel supports spacing shall be greater than four (4) rafter spaces or 64" o/c,
whichever is less.
5. Panel supports connections shall be staggered to distribute load to adjacent rafters.
Based on the above evaluation, with appropriate panel anchors being utilized and the addition of a knee wall or purlin,
the roof system will adequately support the additional loading imposed by the solar panels. This evaluation is in
conformance with the 2009 International Residential Code, current industry standards and practice, and based on
information supplied to us at the time of this report.
Should you have any questions regarding the above or if you require further information do not hesitate to contact
me.
Ve truly yours,
_ U0 Y
CIN
o.5
Scott E. Wyssli , PE 9 FcIST
EPA
MA License No. 505 �FFSSIONA\-
wow-OnI solar
EcolibriumSolar
Customer Info
Name:
Email:
Phone:
Project Info
Identifier: 34882
Street Address Line 1: 60 Middlesex St
Street Address Line 2:
City: North Andover
State: MA
Zip: 01845
Country: United States
System Info
Module Manufacturer: Trina Solar
Module Model: TSM 260-PD05.08
Module Quantity: 16
Array Size (DC watts): 4160.0
Mounting System Manufacturer: Ecolibrium Solar
Mounting System Product: EcoX
Inverter Manufacturer: SolarEdge Technologies
Inverter Model: SE380OA-US (240V)
Project Design Variables
Module Weight: 43.0 lbs
Module Length: 65.0 in
Module Width: 37.0 in
Basic Wind Speed: 100.0 mph
Ground Snow Load: 50.0 psf
Seismic: 0.0
Exposure Category: B
Importance Factor: II
Exposure on Roof: Partially Exposed
Topographic Factor: 1.0
Wind Directionality Factor: 0.85
Thermal Factor for Snow Load: 1.2
Lag Bolt Design Load - Upward: 820 Ibf
Lag Bolt Design Load- Lateral: 288 Ibf
EcoX Design Load - Downward: 722 Ibf
EcoX Design Load - Upward: 765 Ibf
EcoX Design Load - Downslope: 297 Ibf
EcoX Design Load - Lateral: 233 Ibf
Module Design Moment—Upward: 3655 in-Ib
Module Design Moment—Downward: 3655 in-Ib
Effective Wind Area: 20 ft2
Min Nominal Framing Depth: 2.5 in
Min Top Chord Specific Gravity: 0.42
EcolibriumSolar
Planq Calculations (ASCE 7-10): Roof 3
Roof Shape: Hip Edge and Corner Dimension: 3.0 ft
Roof Type: Composition Shingle Stagger Attachments: Yes
Average Roof Height: 25.0 ft Include Snow Guards: No
Least Horizontal Dimension: 16.1 ft
Roof Slope: 17.0 deg
Truss Spacing: 24.0 in
Snow Load Calculations
Description Interior Edge Corner Unit
Flat Roof Snow Load 42.0 42.0 42.0 psf
Slope Factor 0.97 0.97 0.97
Roof Snow Load 40.7 40.7 40.7 psf
Wind Pressure Calculations
Description Interior Edge Corner Unit
Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf
Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf
Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0
Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf
Design Wind Pressure Downforce 16.0 16.0 1 16.0 Jpsf
ASD Load Combinations
Description Interior Edge Corner Unit
Dead Load 2.6 2.6 2.6 psf
Snow Load 40.7 40.7 40.7 psf
Downslope: Load Combination 3 12.1 12.1 12.1 psf
Down: Load Combination 3 39.7 39.7 39.7 psf
Down: Load Combination 5 12.1 12.1 12.1 psf
Down: Load Combination 6a 37.6 37.6 37.6 psf
Up: Load Combination 7 -10.2 -17.7 -27.3 psf
Down Max 39.7 39.7 39.7 psf
Spacing Results(Landscape)
Description Interior Edge Corner Unit
Max Allowable Spacing Between Attachments 53.5 53.5 53.5 in
Max Spacing Between Attachments With Rafter/Truss Spacing of 24.0 in 48.0 48.0 48.0 in
Max Cantilever from Attachment to Perimeter of PV Array 17.8 17.8 17.8 in
Spacing Results(Portrait)
Description Interior Edge Corner Unit
Max Allowable Spacing Between Attachments 40.2 40.2 40.2 in
Max Spacing Between Attachments With Rafter/Truss Spacing of 24.0 in 24.0 24.0 24.0 in
Max Cantilever from Attachment to Perimeter of PV Array 13.4 13.4 13.4 in
EcolibriumSolar
LaydUt
Skirt
o Coupling Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal
expansion and contraction. See Installation Guide for details.
O Clamp Warning: PV Modules may need to be shifted with respect to roof trusses to comply with
Q Bonding Jumper maximum allowable overhang.
EcolibriumSolar
Roof Weights
In Conformance with Solar ABC's Expedited Permit Process
Module Quantity: 6
Weight of Modules: 258 lbs
Weight of Mounting System: 88 lbs
Total Plane Weight: 346 lbs
Total Plane Array Area: 100 ft2
Distributed Weight: 3.45 psf
Number of Attachments: 44
Weight per Attachment Point: 8 lbs
EcolibriumSolar
Plane Calculations (ASCE 7-10): Roof 1
Roof Shape: Gable Edge and Corner Dimension: 3.5 ft
Roof Type: Composition Shingle Stagger Attachments: Yes
Average Roof Height: 25.0 ft Include Snow Guards: No
Least Horizontal Dimension: 35.0 ft
Roof Slope: 32.0 deg
Truss Spacing: 24.0 in
Snow Load Calculations
Description Interior Edge Corner Unit
Flat Roof Snow Load 42.0 42.0 42.0 psf
Slope Factor 0.7 0.7 0.7
Roof Snow Load 29.4 29.4 29.4 psf
Wind Pressure Calculations
Description Interior Edge Corner Unit
Net Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf
Net Design Wind Pressure Downforce 19.4 19.4 19.4 psf
Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0
Design Wind Pressure Uplift -20.7 -24.3 -24.3 psf
Design Wind Pressure Downforce 19.4 19.4 19.4 psf
ASD Load Combinations
Description Interior Edge Corner Unit
Dead Load 2.6 2.6 2.6 psf
Snow Load 29.4 29.4 29.4 psf
Downslope: Load Combination 3 14.6 14.6 14.6 psf
Down: Load Combination 3 23.3 23.3 23.3 psf
Down: Load Combination 5 13.8 13.8 13.8 psf
Down: Load Combination 6a 26.8 26.8 26.8 psf
Up: Load Combination 7 -11.1 -13.3 -13.3 psf
Down Max 26.8 26.8 26.8 psf
Spacing Results(Landscape)
Description Interior Edge Corner Unit
Max Allowable Spacing Between Attachments 65.2 65.2 65.2 in
Max Spacing Between Attachments With Rafter/Truss Spacing of 24.0 in 48.0 48.0 48.0 in
Max Cantilever from Attachment to Perimeter of PV Array 21.7 21.7 21.7 in
Spacing Results(Portrait)
Description Interior Edge Corner Unit
Max Allowable Spacing Between Attachments 43.7 43.7 43.7 in
Max Spacing Between Attachments With Rafter/Truss Spacing of 24.0 in 24.0 24.0 24.0 in
Max Cantilever from Attachment to Perimeter of PV Array 14.6 14.6 14.6 in
EcolibriumSolar
Layout
i
Skirt
o Coupling Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal
expansion and contraction. See Installation Guide for details.
O Clamp Warning: PV Modules may need to be shifted with respect to roof trusses to comply with
Bonding Jumper maximum allowable overhang.
EcolibriumSolar
Roof Weights
In Conformance with Solar ABC's Expedited Permit Process
Module Quantity: 8
Weight of Modules: 344 lbs
Weight of Mounting System: 88 lbs
Total Plane Weight: 432 lbs
Total Plane Array Area: 134 ft2
Distributed Weight: 3.23 psf
Number of Attachments: 44
Weight per Attachment Point: 10 lbs
EcolibriumSolar
Plano Calculations (ASCE 7-10): Roof 2
Roof Shape: Hip Edge and Corner Dimension: 3.0 ft
Roof Type: Composition Shingle Stagger Attachments: Yes
Average Roof Height: 25.0 ft Include Snow Guards: No
Least Horizontal Dimension: 6.4 ft
Roof Slope: 6.0 deg
Truss Spacing: 24.0 in
Snow Load Calculations
Description Interior Edge Corner Unit
Flat Roof Snow Load 42.0 42.0 42.0 psf
Slope Factor 1.0 1.0 1.0
Roof Snow Load 42.0 42.0 42.0 psf
Wind Pressure Calculations
Description Interior Edge Corner Unit
Net Design Wind Pressure Uplift -21.2 -32.6 -45.5 psf
Net Design Wind Pressure Downforce 8.3 8.3 8.3 psf
Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0
Design Wind Pressure Uplift -21.2 -32.6 -45.5 psf
Design Wind Pressure Downforce 16.0 16.0 16.0 psf
ASD Load Combinations
Description Interior Edge Corner Unit
Dead Load 2.6 2.6 2.6 psf
Snow Load 42.0 42.0 42.0 psf
Downslope: Load Combination 3 4.6 4.6 4.6 psf
Down: Load Combination 3 44.1 44.1 44.1 psf
Down: Load Combination 5 12.2 12.2 12.2 psf
Down: Load Combination 6a 40.9 40.9 40.9 psf
Up: Load Combination 7 -11.2 -18.0 -25.8 psf
Down Max 44.1 44.1 44.1 psf
Spacing Results(Landscape)
Description Interior Edge Corner Unit
Max Allowable Spacing Between Attachments 50.8 50.8 50.8 in
Max Spacing Between Attachments With Rafter/Truss Spacing of 24.0 in 48.0 48.0 48.0 in
Max Cantilever from Attachment to Perimeter of PV Array 16.9 16.9 16.9 in
Spacing Results(Portrait)
Description Interior Edge Corner Unit
Max Allowable Spacing Between Attachments 36.2 36.2 36.2 in
Max Spacing Between Attachments With Rafter/Truss Spacing of 24.0 in 24.0 24.0 24.0 in
Max Cantilever from Attachment to Perimeter of PV Array 12.1 12.1 12.1 in
EcolibriumSolar
Layout
Skirt
o Coupling Note: If the total width of a continuous array exceeds 35 ft, break array to allow for thermal
expansion and contraction. See Installation Guide for details.
O Clamp Warning: PV Modules may need to be shifted with respect to roof trusses to comply with
Q Bonding Jumper maximum allowable overhang.
EcolibriumSolar
Roof Weights
In Conformance with Solar ABC's Expedited Permit Process
Module Quantity: 2
Weight of Modules: 86 lbs
Weight of Mounting System: 88 lbs
Total Plane Weight: 174 lbs
Total Plane Array Area: 33 ft2
Distributed Weight: 5.21 psf
Number of Attachments: 44
Weight per Attachment Point: 4 lbs
EcolibriumSolar
Bill Of Materials
Part Name Quantity
ECO-001_101 EcoX Clamp Assembly 44
ECO-001_102 EcoX Coupling Assembly 7
ECO-001_105B EcoX Landscape Skirt Kit 5
ECO-001-105A EcoX Portrait Skirt Kit 1
ECO-001_103 EcoX Composition Attachment Kit 44
ECO-001_116 EcoX Flat-Tile Flashing 0
ECO-001_117 EcoX S-Tile Flashing 0
ECO-001_118 EcoX W-Tile Flashing 0
ECO-001_363 EcoX Lower Support-Tile 0
ECO-001_109 EcoX Electrical Assembly(optional) 3
ECO-001_106 EcoX Bonding Jumper Assembly 12
ECO-001_104 EcoX Inverter Bracket Assembly 0
ECO-001338 EcoX Connector Bracket 0
ECO_001-359 EcoX Lower Support- Low Slope 0
1
The Commonwealth of Massachusetts
Department of In dustelial Acc dents
Office of Investigations
1 � I Congress Street,Suite 100
1�- �
=/ Boston,MA 0211 4-2017
waves rnass<gov/dia
Workers' Compensation Insurance Affidavit: builders/Comte-actors/Electlricians/PlUlmbea-s
Appffirant Information Please Print Legibly
Name (Business/Organization/individual): Vivint Solar Developer, LLC
Address:3301 North Thanksgiving Way, Suite 500
itv/Statel,7ip: Lehi, UT 84043 Phone#:801=377-9111
Are you an employer? Check the appropriate box: Type of project(required):
L I ars a employer with 1 4- u I "a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have
8. F�Demolition
working for me in any capacity. employees and have workers'
insurance.$ g• ❑Building addition
coin
[No workers' comp. insurance p.
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.[]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGI
12.[]Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.�
employees. [No workers' Other Solar Installation
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 are doing all work and then hire outside contractors must submit anew 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.
I am an employer that is providing workers'compensation insurance for any employees. below is the policy and job,site
information.
Insurance Company Name:Zurich American Insurance Company
Policy#or Self-ins. Lic #.WC 509601300 Expiration Date: 11/1/2015
Job Site Address: City/State/Zip: Mac
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify sander the pains and penalties of perjury that the information provided v is trace and correct
Signature: Date:
Phone#: 801-2296459
i Official use only. Ido 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#:
A� CERTIFICATE OF LIABILITY INSURANCE DATE/2015 /YYYY)
01/0512015
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 CONTACT
MARSH USA INC. NAME:
122517TH STREET,SUITE 1300 A/C No Ext); FAX
No):
DENVER,CO 80202-5534 E-MAIL
Attn:Denver.CertRequest@marsh.com Fax:212-948-4381 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC q
INSURER A:Evanston Insurance Company 35378
INSURED INSURER B:Zurich American Insurance Company 16535
Vivint Solar Developer LLC
3301 North Thanksgiving Way INSURER C:American Zurich Insurance Company 40142
Suite 500
Lehi,UT 84043 INSURER D
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: SEA-002524287-01 REVISION NUMBER:2
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.
/CTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDPOLICY EFF MM/DD POLICY EXP LIMITS
A GENERAL LIABILITY 14PKGWE00274 11/01/2014 11/01/2015 EACH OCCURRENCE $ 1,000,000
PXCOM,VMERCIAL GENERAL LIABILITY DAMAGES(RENTED50,000
PREMISES Ea occurrence $CLAIMS-MADE M OCCUR MED EXP(Any one person) $ 5,000
0 Ded.BI&PD PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICYFX]PRO- LOC $
jECT
B AUTOMOBILE LIABILITY BAP509601500 11101/2014 11/01/2015 COMBINED SINGLE LIMIT 1,OQO,000
Ea accident $
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
A UMBRELLA L11B X OCCUR 14EFXWE00088 11101/2014 11101/2015 EACH OCCURRENCE $ 5,000,000
X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
DED I I RETENTION$ $
C WORKERS COMPENSATION WC509601300(CA,HI,MD,NJ,NY,OR,UT) 11/01/2014 11/01/2015 X WC STATU- OTH-
Y/N WC509601400(MA) 11/0112014 1110112015
AND EMPLOYERS'LIABILITY TORY M T ER
B ANY PROPRIETOR/PARTNERIEXECUTIVE 1,000,000
OFFICEWMEMBER EXCLUDED? � N/A E.L.EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
A Errors&Omissions& 14PKGWE00274 1110112014 11101/2015 LIMIT 1,000,000
Contractors Pollution DEDUCTIBLE 5,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required)
CERTIFICATE HOLDER CANCELLATION
Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
1600 Osgood St. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Building 20 Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS.
North Andover,MA 01845
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Kathleen M.Parsloe Lc,(lurr hr. f9LdhW_
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD me and logo are registered marks of ACORD