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Building Permit #Exception - 85 LACONIA CIRCLE 5/1/2018
OT BUILDING PERMIT of NJ-D TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '- z7%I Pcrm►t Nod. Date Received R` �SSACHUSE� II Date Issued: EVIPORTANT:Applicant must complete all items on this page -..;x. +rr ..�, k_"'ykla g2 wv "�w •is�k✓'•. �. � g� .►" ]at� �"w�.y.". ,.!+,$rw .A �R.'9�'�1s_"., .rcw .('�,`f..r�..y4. . ir .y�� `y� �"-t la�,+,d �'> �p'�°�.tiS-:t�.'�"�-�ks '...r. �r��'C..J1'E:�ec�-f•, ��,Cyr� Y�.,� '�-°� rwg '•C'*' ��� k.Fc r�`"S,i � . , �'id' +�' y +-t=' ,- 3,eS ,_ `.r ° �9 *„ '.,ti... ?'�,.,,,.5,'�4 'i."{y;,g,; r.-� '.ti " s.+` Vis, ' ,fid, '� { ti •PROPERT,Y ®WNER� r ar, 1 Pnnt 1DD YearStructure.Ayes� no �IVIAP" i r-' 'PARCEL` - NINE DISTRICT storig,D►st et "ayes}' . i o I K .x t k s +, . Mach►ne-Sh�op,_V►Ilage ,_yes _ _no. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑ Well ❑ Floodplarr EWetlands E 1%Vatershed R►sfricf O Water/Sewer. ,r DESCRIPTION OF WORK TO DE PERFORMED: Identification- Please Type or Print Clearly' OWNER: Name: Phone: Address: Phone : Supe'rvisor's Construct►on Licensee. __ Exp Date Home;Improvement License: __ Exp Date ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. ► _,Total Project Cost: $ FEE: $ Check No.: Receipt No,, DOTE: Pers"s contracting with unregistered contractors do not have.access to the guaranfv'furid 5igrature_ufi_Agent%0wher Signature of contractors Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ YPF-OF SEWERAGE DISPOSAL - .-T Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ .COMMENTS I CONSERVATION Reviewed on Signature I COMMENTS HEALTH Reviewed on Signature 6 COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafer & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Lo .ated at 124 Main Street F e-D,partment signatureldate COMMENTS ,cr "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,.-"r res approval of Electrical Inspector lies No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) Ll Notified for pickup Call Email ate Time Contact Name Doc.Building Pennit Revised 2014 - : - - Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o 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 o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract a 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 (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products 40TE: 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 :y Doc:Building Permit Revised 2014 Location b/y I No. �is� - }0!'� Date / 1 ' GY a� £�A& • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $./07:;;� Foundation Permit Fee $ Other Permit Fee $ TOTAL Check#,574 h s �j Buildi g Inspector NORTH own of L ndover No. �A�, h ver, Mass, /� . �•/ �i A- COC meCMIWKK 1,95 ItArED U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT W%(!M�ACBUILDING INSPECTOR . Foundation .............. W.T has permission to erect ............ buildings on ... .......0 44. .�.. '....... .1.O. Rough to be occupied as ....$5.w.... .. . ............................... Chimney provided that the person accep Ing 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 CONSTRUCTI STA S Rough 4a(awService .......... .. ...........................................:: Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. EXISTING PV SYSTEM SIZE: O PLUMBING 5.72 kW DC VENT(S) ❑ ROOF VENT(S) EXISTING SOLAR M 0 o SATELLITE y m Q N DISH TJ 2� 1A NEW A/C DISCONNECT IY PV SYSTEM SIZE: 85 Laconia Cir, North Andover MA 01845 CHIMNEY F2A EXISTING A/C DISCONNECT m Q 4.050 kW DC Y Q r 28 EXISTING INVERTER Z ^_—_-----_—_---_—_—_—_---_-----_—_—_—_—_—_---------------_— SKYLIGHT (157 JA Solar JAP660.2]o/48B MODULES WITH (151 S131T'C P300 ULE.zers ON THE BACK Of EACH MODULE. i i ® 15 STII NO 11 MODULES 45'OF 1'PVC CONDUIT FROM JUNCTION BOX TO ELECTRICAL PANEL I _--_--_____ I 26 I �.. PV INTERCONNECTION POINT,INVERTER, I 2q &LOCKABLE DISCONNECT SWITCH,8 UTILITY METER LOCATION;TIE INTO I 1A METERN 25110785 0 i M i (AI JUNCTION BOX ATTACHED TO TOARRAY KE USING MOUNTING HARDWARE TO KEEP I 197 I < JUNCTION BOX OFF ROOF •C v ❑ Roof Type:Comp.Shingle V Roof Section 1 O Roo(Azim.1h:302 Roor ruc n i i 9 I 5; uiISm SHEET NAME: 1 I W Z F- L-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-—-- fn SHEET NUMBER: PV SYSTEM SITE PLAN SCALE:1/8"=V-0" a CLAMP+ATTACHMENT COUPLING CLAMP ASSEMBLY (INCLUDES GLIDER) LEAF SPRING $ i GLIDER ; o MODULE CLAMP+ATTACHMENT c a PERMITTED Y t COUPLING CLAMP SPACING 0 I f STRUT NUT RAFTER 7 T ECOX BASE SEALING WASHER I i i RAFTER FLASHING--,,, COMP SHINGLES L=PORTRAIT MODULE 'CLAMP N z N 5/16"x41/2" SS LAG SCREW g IL=LANDSCAPE CLAMP SPACING TORQUE=13±2 FT-LBS •o r •Q. 1 MODULES IN PORTRAIT/LANDSPACE PV 3.0 NOT TO SCALE MOUNT DETAIL - ECOX z WITH METAL FLASHING PV 3.0 NOT TO SCALE \ z MOUNTING PV 3.0 DETAIL CANTILEVER L/3 OR LESS s m L=MAX 64" n 2 rn COUPLING CLAMP - O PV MODULES,TYP.MOUNT OF COMP SHINGLE ROOF, / MODULE SHEET PARALLEL TO ROOF PLANE z 5 * RAFTER 2 0 PV ARRAY TYP. ELEVATION SHEET NOT TO SCALE NUMBER: 3 PV SYSTEM MOUNTING DETAIL PV 3.0 NOT TO SCALE N a I Photovoltaic System Conduit Conductor Schedule(ALLCONDUCTORS MUST BE COPPER) DC System Size 4050 Tag N Description Wire Gauge I M of Conductors/Color Conduit Type Conduit Size ,n t 2 AC System Size 3800 1 PV Wire 10 AWG 2(V+,V-) N/A-Free Air N/A-Free Air ---- _ Total Module Count 15 1 Bare Copper Ground(EGC/GEC) 6 AWG 1 BARE N/A-Free Air N/A-Free Air a ry 2 THWN-2 10 AWG 2(1V+,1V-)B/R PVC 1" t 2 2 THWN-2-Ground 8 AWG 1(GRN) PVC 1" E - =! 3 THWN-2 10 AWG 3(1L1,11.2,IN)B/R/W PVC 1" v 3 THWN-2-Ground 8 AWG 1(GRN) PVC V, g+� to Existing Inverter Information: 4 THWN-2 6 AWG 3(1L1,1L2,1N)B/R/W PVC 1" `0 t t > YP count:l 4 THWN-2-Ground 8 AWG 1(GRN) PVC 1 a Z = Lj L Existing Module Information: O Type:Trina Solar TSM-260 PD05.08 count:22 VISIBLE LOCKABLE KNIFE'A/C • '� DISCONNECT N 1 Siemens LNF222R N i 60A1240V i UNFUSED NEMA3 OR EQUIVALENT v v` m N 1 � n 3 Solar Edge I 0 z o' SE380OA-US t 'Conforms to ANSI Z C12.1-2008 Poi nt of Interconnection,Supply Side > 705.12(A),Conforms to NEC 2014 > Z w t SQUARE D D222NR0 w on � 240V/60A FUSED Z NEMA3 OR EQUIVALENT Q Q j up WITH 75•C TERMINATIONS M SHEET Existing240V/200A NAME: Servi ce Pa nel,Si ngl e Phase,with 200A Mai n on OA Disconnect •3 STRING 1:15 PVPT MODULES 3 2OA3 SHEET NUMBER: 'S -Y 15PV MODULES PER INVERTER=4050 WATTS inl mum GEC Ol e4 AWG STC VISIBLE/LOCKABLE'KNIFE'A/C copper ri DISCONNECT IN SIGHT OF TAP W DC Safety Switch Conductor Calculations m Rated for max operating condition of inverter e PV Module Rating @STC -Wire gauge calculated from NEC code 310.15(8)(16)with ambient temperature calculations c m NEC 690.35 compliant m Module Make/Model JAP6-60-270/488 from NEC 310.15(2)(a). ¢ *opens all ungrounded conductors w v g ,n Max Power-Point Current(Imp) 8.65 Amps For"On Roof"conductors we use the 90'C column ampacity,0.5"-3.5"off-the-roof temperature � ,• � Max Power-Point Voltage(Vmp) 31.23 Volts adjustment from 310.15(B)(3)(c),and raceway fill adjustments from 310.15(8)(16). `o Optimizer Solar Edge P300 - o Open-Circuit Voltage(Voc) 38.48 Volts For"Off Roof'conductors we use the 75°C column ampacity,or the 90"C column ampacity with v c'o DC Input Power 300 Watts a c the relevant ambient temperature and raceway fill adjustments,whichever is less. sc v+ ¢ DC Max Input Voltage 48 Volts Short-Circuit Current(Isc) 9.26 Amps „ r < P g The rating of the conductor after adjustments MUST be greater than,or equal to,the continuous 5 r l DC Max Input Current 12.5 Amps Max Series Fuse(OCPD) 15 Amps duty uprated output current. a O '- Nom.Maximum Power at STC(Pmax) 270 Watts Z j DC Max Output Current 15 Amps Calculation Example-Wire Rating(90°C)x Ambient Temperature Adjustment x Conduit Fill Max String Rating 5250 Watts Maximum System Voltage DC 1000V(UL) Adjustment>=Continuous Duty Output Current Inverter Make/Model SE380oA-US Voc Temperature Coefficient -0.33 %/C (On Roof,Tag 2):10 gauge wire rated for 40 A, 40 A x 0.76 x 1(2 Conductors)=30.4A>=18.75 CEC Efficiency 98 % A AC Operating Voltage 240 Volts PV Module Rating @ STC (Off Roof,Tag 3):10 gauge wire rated for 35 A, 35 A>=19.79 A L Continuous Max Output Current 16 Amps Module Make/Model Trina Solar TSM-260 PD05.08 CID DC Maximum Input Current 13 Amps Max Power-Point Current(Imp) 8.5 Amps 0 Short Circuit Current 17.5 Amps Max Power-Point Voltage(Vmp) 30.6 Volts Max Output Fault Current 17.5 20ms Open-Circuit Voltage(Voc) 38.2 Volts �= Short-Circuit Current(Isc) 9 Amps Max Series Fuse(OCPD) 15 Amps Optimizer Nom.Maximum Power at STC(Pmax) 260 Watts n Solar Edge P300 0 DC Input Power Maximum System Voltage 1000 V(IEC)/600 V(UL) N 300 Watts .. DC Max Input Voltage 48 Volts Voc Temperature Coefficient -0.32 %/C v DC Max Input Current 12.5 Amps v DC Max Output Current 15 Amps Max String Rating 5250 Watts AC Output Current According to NEC 690.8(B)(1) 15.83 Amps Nominal AC Voltage 240 1 Volts n Inverter Make/Model SE6000A-US THIS PANEL IS FED BY MULTIPLE SOURCES(UTILITY AND SOLAR) OCPD Calculations CEC Efficiency 97.5 % AC Operating Voltage 240 Volts ROOFTOP CONDUCTOR AMPACITIES DESIGNED IN COMPLIANCE WITH NEC 690.8,TABLES 310.15(B)(2)(a),310.15(B)(3)(a), Breakers sized according to continuous duty output current.PV circuit nominal current based off z n Continuous Max Output Current 25 Amps g m 310.15(B)(3)(c),310.15(B)(16),CHAPTER 9 TABLE 4,5,&9. inverter continuous output current X(1.25(NEC code 210.19(A)(1)(a)). DC Maximum Input Current 18 AmpsdE o, LOCATION SPECIFIC TEMPERATURE OBTAINED FROM ASHRAE 2013 in z Short Circuit Current 27.5 Amps DATA TABLES. Inverter 1:SE3800 A-US-U Max Output=15.83 A x 1.25(NEC code 210.19(A)(1)(a)) z o Max Output Fault Current 27.5 A/20ms ASH RAE 2013- =19.79 A<20 A(OCPD) Z aj Highest Monthly 2%DB Design Temp:32.3 Celsius system output current w/continuous duty=19.79<20A(System OCPD) W ac H z � Lowest Min.Mean Extreme DB:-21.5 Celsius a a v Other Notes N ¢ SHEET •ALL INTERIOR RACEWAYS CARRYING DC CURRENT SHALL BE METALLIC NAME: •All ampacity calculations are made in compliance with NEC 220.5(B) v w m Z° a SHEET NUMBER: - N 41 f m a � v Inverter Grounded Systems Per 690.5(C Main Service Panel Signage v u a _ (Installed on the Face of the Service Meter) •• •• • ••• . Per 690.54,690.56(6),&705.10 o '"• • • . . • • • Note:Roofline placard not needed.unless PV disconnect is not as the '• • • • • • • • • se a Q u 75 t Q DC Disconnect Per 690.53 z Combiner Boxes,J-Boxes,Disconnects,Devices,& -• • • • • • -• • • • ,• • • - • Inverters In Un-Grounded Systems Per 690.35(F) • • • _ • • • o • -• •• p h[ V ,l•, • • • • • . \ tl�� 4 . '• • CID Conduit and.Racewa s Labeled Eve. 10' AC Disconnect and Any Load Centers.(Combiner Panel) - • •• • r+ • •• - • •i DC Disconnect Per 690.17 a U N C W II Inverter Output Connection(Solar Breaker)at O " a, a Main Service Panel Per 705.12 z w m z o • • • > z Lii z • • J J J Rapid Shutdown Per 690.56(C) Rapid Shutdown Disconnect Per,690.12(5)Installed_!On AC Disconnect SHEET • . •• NAME: to c tka c y y a SHEET NUMBER: ALL STICKERS DESCRIBED HERIN SHALL BE MADE OF WEATHERPROOF ADHESIVE,THEY SHALL BE REFLECTIVE,THEY M SHALL CONTAIN NO SMALLER THAN 3/8"WHITE ARIAL FONT TEXT,AND HAVE A RED BACKGROUND W • h CAUTION:SOLAR ELECTRIC SYSTEM CONNECTED WARNING:DUAL POWER SOURCE WARNINGWARNING m 1 Property of Vivint Solar 4 SECOND SOURCE 15 A PHOTOVOLTAIC SYSTEM ELECTRICAL SHOCK HAZARD 12 ELECTRICAL SHOCK HAZARD v -- MAIN BREAKER DE-RATED TO***DUE TO SOLAR _ RATED AC OUTPUT:***A --` IF A GROUND FAULT IS INDICATED, THE DC CONDUCTORS OF THIS PHOTOVOLTAIC SYSTEM ARE N CIRCUITS NOM.OPERATING AC VOLTAGE:***V NORMALLY GROUNDED CONDUCTORS UNGROUNDED AND MAY BE ENERGIZED 'a 0 2 MAX OF***AMPS PV SOURCE ALLOWED Property of Vivint Solar MAY BE UNGROUNDED AND ENERGIZED Property of Vivint Solar o -- DO NOT INCREASE MAIN BREAKER RATING WARNING:PHOTOVOLTAIC POWER SOURCE Property of Vivint Solar SITE PLAN PLACARD SHOWING ADDITIONAL POWER S A c'o Property of Vivint Solar 5 Property of Vivint Solar 13 "' P rtY WARNING ' SOURCE AND DISCONNECT LOCATIONS.PLACARD �c m Q WARNING --- PHOTOVOLTAIC AC DISCONNECT 10 INVERTER OUTPUT CONNECTION ---l SHALL BE MOUNTED ON EXTERIOR OF ELECTRICAL 'O t a C3� o ELECTRICAL SHOCK HAZARD RATED AC OUTPUT CURRENT:'**A DO NOT RELOCATE THIS OVERCURRENT DEVICE PANEL(only when necessary) a z --_ DO NOT TOUCH TERMINALS.TERMINALS ON BOTH 6 NOM.OPERATING AC VOLTAGE:***V Property of Vivint Solar Property of Vivint Solar THE LINE AND LOAD SIDES MAY BE ENERGIZED IN --- Property of Vivint Solar PHOTOVOLTAIC POWER SOURCE DC DISCONNECT PHOTOVOLTAIC RAPID SHUTDOWN THE OPEN POSITION PHOTOVOLTAIC SYSTEM EQUIPPED WITH RAPID 11 RATED MAXIMUM POWER POINT CURRENT(IMP) ***A 14 DISCONNECT Property of Vivint Solar 7 SHUTDOWN -- RATED MAXIMUM POWER POINT CURRENT(VMP) ***A - Property of Vivint Solar Property of Vivint Solar MAXIMUM SYSTEM VOLTAGE(VOC) V L PHOTOVOLTAICDC DISCONNECT SHORT CIRCUIT CURRENT(ISC) '**A ((5 8 Property of Vivint Solar Property of Vivint Solar O *'•-value calculated for each NONEaccount,for specific value see the previous warning label page n d 11 : 14; 4 7 i ROOFTOP ARRAY 8 12 6 6 I 6 2 r 4 13 f IF APPLICABLE EVERY 10'AND a WITHIN,V OF o ELBOWS c 5 90GSFG20 39 5 3 5 3 5 5 3 5,,, cq o � m�9F( j o MICRO-INVERTER > z SYSTEMS ,OP DC ! O O z w w � 9 DISCONNECT a Y INSIDE (O'Rll _ - _ I—_— I—__— SHEET SOLAR INVERTERS COMBINER PANEL VISIBLE/LOCKABLE VIVINT SOLAR METER VISIBLE/LOCKABLE SUB PANEL J- MAIN SERVICE NAME: 12 VUNCTl.. (MAY BE ON ROOFTOP (WHEN USED) A/C DISCONNECT (WHERE REQUIRED) A/C DISCONNECT WHEN REQUIRED} DISCONNECT PANEL m STRING,-INVERTER OX 5� INTEGRATED WITH, (WHERE REQUIRED), d SYSTEMS ARRAY) TYPICAL SOLAR GENERATION INSTALLATION 10,+ INSIDE PANEL (NOT ALL DEVICES ARE REQUIRED IN EVERY JURISDICTION), -- " 3 a SHEET NUMBER: ALL STICKERS DESCRIBED HERIN SHALL BE MADE OF WEATHERPROOF THESE PLACARDS SHALL BE PLACED ON ALL INTERIOR AND EXTERIOR DIRECT-CURRENT(DC)CONDUIT,ENCLOSURES,RACE-WAYS,CABLE ADHESIW ,THEY SHALL BE REFLECTIVE,THEY SHALL CONTAIN NO ASSEMBLIES,JUNCTION BOXES COMBINER BOXES,AND DISCONNECTS TO ALERT THE FIRE SERVICE TO AVOID CUTTING THEM.MARKINGS SMALLER THAN 3/8"WHITE ARIAL FONT TEXT,AND HAVE A RED SHALL BE PLACED ON ALL DC CONDUIT EVERY 10 FT(3048 MM),WITHIN 1 FT(305MM)OF TURNS OR BENDS AND WITHIN 1 FT(305 MM),ABOVE 'Cr BACKGROUND AND BELOW PENETRATIONS OF ROFF/CEILING ASSEMBLIES,WALLS OR BARRIERS LJ solarO I a r 1800 W Ashton Blvd. Structural�G7roup Lehi, UT 84043 Jon P. Ward, SE, PE Clint C. Karren, PE Structural Engineering Manager Structural Engineering Manager ion.wardC vivintsolancom clintkarrenL7a vivintsolar.com December 05, 2016 Revised December 07, 2016 Mr. Dan Rock, Project Manager Vivint Solar 1800 W Ashton Blvd. Lehi, Utah 84043 Re: Structural Engineering Services Keating Residence 85 Laconia Cir, North Andover, MA S-5321696; MA-01 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. i i V riff i . Site Vi s t/ a cat on Form prepared by a representative from our office under my supervision identifying g specific site information including size and spacing of members for the existing roof structure. 2. Proposed layout of the system including connection details for the solar panels. 3. 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 roof system consisting of the following: • Roof Section: Dimensional lumber - 2x10 at 16" on center. The attic space is finished and photos indicate that there was no free access to visually inspect the size and condition of the roof members. The rafter dimensions were verified through the ridge gap. This roof section has a 4' eave. 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 a maximum of two layers of composite shingle. A. Loading Criteria 12.5 PSF= Dead Load (roofing/framing) 2.4 PSF= Dead Load (solar panels/mounting hardware) 14.8 PSF=Total Dead Load 50 PSF=Ground Snow Load (based on local requirements) Wind speed of 100 mph (based on Exposure Category B- the total area subject to wind uplift is calculated for the Interior, Edge, and Corner Zones of the dwelling.) Page 1 of 2 wo V o LJ l solar B. Solar Panel Anchorage 1. The solar panels shall be mounted in accordance with the most recent "Ecolibrium Solar Installation Manual", which can be found on the Ecolibrium Solar website (www.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 11/2' thick and mounted 4'/2" off the roof for a total height off the existing roof of 6". At no ' time will the panels be mounted higher than 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 i Specifications (NDS) of timber construction specifications for Spruce-Pine-Fir. Based on our evaluation, the pullout value, utilizing a penetration depth of 2'/2", is less than the maximum allowable per connection and therefore is adequate. 4. The maximum allowed spacing was calculated for the Wind Speed shown in paragraph A above, using the wind load uplift procedures of ASCE 7-10 and is specified below. The following values have been verified by in- house testing and the mounting hardware manufacturers' data, which are available upon request. Panel support connections shall be staggered to distribute load to adjacent members. Modules in Landscape Modules in Portrait Roof Zone Interior Ede Corner Interior Ede Corner Max Vertical Spacing in 40 40 40 66 66 66 Max Horizontal Spacing in 64 64 64 64 64 64 Max Uplift Load Ibs 161 132 125 271 223 211 C. Summary Based on the above evaluation,with appropriate panel anchors being utilized the roof system designed on will adequately support the additional loading imposed by any solar array size and configuration, if installed correctly. This evaluation is in conformance with the 2009 International Residential Code with Massachusetts Amendments, current industry standards and practice, and the 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. AA,, OF ,{ Regards, N P cyG i Jon P. Ward, SE, PE AR MA License No. 52584 No. s25 �FCfSTE:lx 161 sSfONAI ►Pry TV � Page 2of2 dnw onto solar r tr RESIDENTIAL SOLAR POWER PURCHASE AGREEMENT V ��0 SO I rQ Customer Name and Contact Information: Transaction Date V V V a Name(s) Paula Keating Service No.2016-11-07 i Installation Location Address 85 Laconia Cir Approximate Start and 85 Laconia Cir North Andover MA 01845 Completion Date North Andover2017-05-06 Home Phone(617) 962-2499 MA 01845 Cell Phone 6179622499 E-Mail pj.keating@yahoo.com Our Promises + We will design,install, maintain,repair, + We will not place a lien on Your Property. monitor,and insure the System at no additional cost to You. + You are free to cancel this Agreement any time prior to Our commencement of + We warranty all of Our work,and that Our installation work at Your Property. roof penetrations will be watertight,for the initial 20 year term. + The Energy Price includes a$5 monthly discount for paying by automatic debit + Your Energy Price will not increase by more from Your bank account. than 2.9%per year. + You will not be responsible for any + After five years,if You need to make property tax assessed on the System. Property repairs,We will remove and reinstall the System if You pay Our + We will fix or pay for any damage We may estimated costs. cause to Your Property or belongings. Your Commitment Pay for the Energy produced by the System. Maintain a broadband"internet connection. • Keep Your roof in good condition throughout Continue service w.ith.Your Utility for any the Term. energy used above and beyond the System's • and to Our sales and support production. Respond pport teams when scheduling.and completing paperwork. At the End of Your Initial Term ' You can renew the Agreement You can request that We remove the System for a subsequent term; at no additional cost. • You can purchase the System;or If You Move ' We guarantee You can transfer the You can relocate the System to Your Agreement to the new owner,regardless of new home;or credit rating; • After.the sixth anniversary,You can purchase You can prepay the Agreement; the System. Vivint Solar Developer, LLC(EIN: 80-0756438) is a licensed contractor in each state in which we operate,for information about our contractor licenses please visit www.vivintsolar.com/licenses. WE MAY HAVE PRESCREENED YOUR CREDIT. PRESCREENING OF CREDIT DOES NOT IMPACT YOUR CREDIT SCORE. YOU CAN CHOOSE TO STOP RECEIVING"PRESCREENED"OFFERS OF CREDIT FROM US AND OTHER COMPANIES BY CALLING TOLL-FREE 888.567.8688. SEE PRESCREEN &OPT-OUT NOTICE BELOW FOR MORE INFORMATION ABOUT PRESCREENED OFFERS. The Notice of Cancellation may be sent to this address: support@vivintsolar.com I vivintsolar.com 1800 W Ashton Blvd., Lehi, UT 84043 Phone 877.404.4129 1 Fax 801.765.5758 Copyright©2016 Vivint Solar Developer,LLC All Rights Reserved PPA(8/2016,v3.2.2)1 Page 1 SIGNATURE PAGE AND NOTICE TO CUSTOMERS A. INCORPORATED DOCUMENTS. These documents G. You have the right to require Us to have a are incorporated into this Agreement and apply to the performance and payment bond. relationship between You and Us: (1) Residential Solar H. CUSTOMER'S RIGHT TO CANCEL. YOU MAY Power Purchase Agreement, (2) Exhibit A: Notice of CANCEL THIS CONTRACT AT ANY TIME BEFORE THE Cancellation, (3) Exhibit B: State Notices and LATER OF: (1) MIDNIGHT OF THE THIRD (3RD) Disclosures, (4) Exhibit C: Certificates of Insurance, BUSINESS DAY AFTER THE TRANSACTION DATE, OR and (5) Customer Packet. (II) THE START OF INSTALLATION OF THE SYSTEM OR B. WE HAVE NOT GUARANTEED, PROMISED OR ANY OTHER WORK WE PERFORM ON YOUR OTHERWISE REPRESENTED ANY REDUCTION IN PROPERTY. IF YOU WISH TO CANCEL THIS CONTRACT, ELECTRICITY COSTS IN RELATION TO THE SYSTEM YOU MUST EITHER: (1) SEND A SIGNED AND DATED THAT WILL BE INSTALLED ON YOUR PROPERTY. WRITTEN NOTICE OF CANCELLATION BY MAIL,E-MAIL, C. IT IS NOT LEGAL FOR US TO ENTER YOUR PREMISES OR FAX; OR (2) PERSONALLY DELIVER A SIGNED AND UNLAWFULLY OR COMMIT ANY BREACH OF THE DATED WRITTEN NOTICE OF CANCELLATION TO: PEACE TO REMOVE GOODS INSTALLED UNDER THIS VIVINT SOLAR DEVELOPER, LLC, 1800 W ASHTON AGREEMENT. BLVD, LEHI, UT 84043, ATTN: PROCESSING D. DO NOT SIGN THIS AGREEMENT BEFORE YOU DEPARTMENT. IF YOU CANCEL THIS CONTRACT HAVE READ ALL OF ITS PAGES. You acknowledge that WITHIN SUCH PERIOD, YOU ARE ENTITLED TO A FULL You have read and received a legible copy of this REFUND OF YOUR MONEY. REFUNDS MUST BE MADE Agreement, that We have signed the Agreement, and WITHIN 10 DAYS OF OUR RECEIPT OF THE that You have read and received a legible copy of every CANCELLATION NOTICE. SEE THE ATTACHED NOTICE document that We have signed during the OF CANCELLATION FOR AN EXPLANATION OF THIS negotiation. RIGHT. DO NOT SIGN BELOW UNLESS WE HAVE GIVEN E. YOU RISK THE LOSS OF ANY PAYMENTS MADE TO YOU THE "NOTICE OF CANCELLATION". A SALES REPRESENTATIVE. I. Unless You are provided with a longer period in F. DO NOT SIGN THIS AGREEMENT IF THIS Exhibit A,You may not terminate this Agreement after AGREEMENT CONTAINS ANY BLANK SPACES. You are three(3) business days of the Transaction Date. If You entitled to a completely filled in copy of this seek to cancel thereafter, then You will forfeit any Agreement, signed by both You and Us, before any amounts previously paid and You may owe Us the work may be started. Default Payment. VIVINT SOLAR DEVELOPER, LLC CUSTOMER(S): �- - Signature: o, b Signature: Printed Name: Mckenzie Watts Printed Name: Paula Keating Salesperson No.: Date: 2016_11-07 Date: 2016-11-07 Signature: Printed Name: Date: 2016-11-07 Copyright© 2016 Vivint Solar Developer, LLC. All Rights Reserved. PPA(812016,v3.2.2)/Page 18 I i '^ EcolibriumSolar Customer Info Name: Email: Phone: Project Info Identifier: 5321696 Street Address Line 1: Street Address Line 2: City: State: Zip: Country: System Info Module Manufacturer:JA Solar Module Model: JAPE-60-270/4BB Module Quantity: 15 Array Size (DC watts):4050.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: SolarEdge Technologies Inverter Model:v.SE3800-US (240V) Project Design Variables Module Weight:40.124084 lbs Module Length: 64.960665 in Module Width: 39.0157691 in Basic Wind Speed: 100.0 mph Ground Snow Load: 50.0 psf Seismic: 1.5 Exposure Category: B Importance Factor: I 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 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 Plane Calculations (ASCE 7-10): North West Roof 5 Roof Shape: Edge and Corner Dimension: 3.0588324609346017 ft Attachment Type: Composition Shingle- ES Flashing Stagger Attachments:Yes Average Roof Height: 25.0 ft Include Snow Guards: Yes Least Horizontal Dimension: 30.588324609346 ft Include North Row Extensions: No Roof Slope: 11.0 deg Truss Spacing: 16.0 in Snow Load Calculations Description Interior Edge Corner Unit Flat Roof Snow Load 33.6 33.6 33.6 psf Slope Factor 1.0 1.0 1.0 Roof Snow Load 33.6 33.6 33.6 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 16.0 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.3 2.3 2.3 psf Snow Load 33.6 33.6 33.6 psf Downslope: Load Combination 3 6.7 6.7 6.7 psf Down: Load Combination 3 34.6 34.6 34.6 psf Down: Load Combination 5 11.8 11.8 11.8 psf Down: Load Combination 6a 33.7 33.7 33.7 psf Up: Load Combination 7 -10.3 -17.8 -27.4 psf Down Max 34.6 34.6 34.6 psf Spacing Results(Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 55.8 55.8 55.8 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 18.6 18.6 18.6 in Spacing Results(Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 43.3 43.3 43.3 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 14.4 14.4 14.4 in • EcolibriumSolar I Layout I Ill l I j. "I I ij I 4t�' I 1 Ili I G, S rt Coupling End Coupling Note: If the total width of a continuous array exceeds 35 ft, break ® Clamp array to allow for thermal expansion and contraction. See End Clamp Installation Guide for details. ® North Row Extension Warning: PV Modules may need to be shifted with respect to roof Q Row-to-Row Bonding Clip/Bonding Jumper trusses to comply with maximum allowable overhang. i EcolibriumSolar Roof Weights In Conformance with Solar ABC's Expedited Permit Process Module Quantity: 15 Weight of Modules: 602 lbs Weight of Mounting System: 62 lbs Total Plane Weight: 664 lbs Total Plane Array Area: 264 ft2 Distributed Weight: 2.51 psf Number of Attachments: 31 Weight per Attachment Point: 21 lbs Roof Design Variables Design Load-Downward: 918 Ibf Design Load-Upward: 720 Ibf Design Load - Downslope:460 Ibf Design Load- Lateral: 252 Ibf ' EcolibriumSolar Bill Of Materials Part Name Quantity ES10260 EcoX Row-to-Row Bonding Clip 4 ES10121 EcoX Coupling Assembly 10 ES10146 EcoX End Coupling 2 ES10103 EcoX Clamp Assembly 26 ES10136 EcoX End Clamp Assembly 5 ES10144 EcoX Junction Box Bracket 1 (Optional) ES10132 EcoX Power Accessory Bracket 15 ES10333 PV Cable Clip 75 ES10334 4 PV Cable Clip 30 ES10195 EcoX Base, Comp Shingle 31 ES10197 EcoX Flashing, Comp Shingle 31 i AUTHORIZATION FROM CONTRACTORS FOR SECOND PARTIES TO PULL PERMITS COMPANY DATE_ , ), To whom�/it may concern, ] C1 t G fecne, authorize to pull permits for this company using my licenses. T Signature: Printed Name:.&` . GCC��e r- . Signed thi J5 day of ot5 Notary: Comm. Ex . i 02 i.,4 jai fdi�LOiOCIPo51`vil c;"r �:r � 1 r. Massachusetts -Department of Public Safety Board of Building Regulations and Standards License:cs-108068 KYLE GREENE 44 MAIN STREET:' North Reading KA 01864 Expiration Commissioner 01/20120113 Aho lv CERTIFICATE OF LIABILITY INSURANCE DATEfMWDD"""t 01Yt7/2016 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°NN Ext): _ FAX Not: _ DENVER,CO 80202-5534 ADDRESS: Attn:Denver.CertRequest@marsh.com I Fax:212-948-4381 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A:AXIS Specialty Europe INSURED Mvint Solar Developer,LLC INSURER B:Zurich American Insurance Company 16535 3301 North Thanksgiving Way,Suite 500 INSURER C:American Zurich Insurance Company 140142 Lehi,UT 84043 INSURER D:N/A N/A INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002920030-04 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. INSR ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER IMMIDDNYYYI (MMIODNYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 3776500116EN 01/29/2016 01/29/2017 EACH OCCURRENCE $ 25,000,000 CLAIMS-MADE MOCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 25,000,000 X POLICY❑PRO- JECT [:] LOC PRODUCTS-COMP/OP AGG '$ 25,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAP509601501 1110112015 11/01/2016 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) XHIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per acddentI $ Comp/Coll Ded $ 1,000 UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC509601301 11/01/2015 11/01/2016 X PER OTH- AND EMPLOYERS'LIABILITY Y/N AZ,CA,CT,HI,MD,NJ,NY,NV,NM, STATUTE ER ANY PROPRIETOR/PARTNER/F�(ECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? E N/A (Mandatory in NH) OR,PA,UT E.L.DISEASE-EA EMPLOYEE $ 1,000,000 B If yes,describe under DESCRIPTION OF OPERATIONS below WC509601401(MA) 11/0112015 11/0112016 E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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 @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 ' Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affldavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Please Print Legibly Name(Business/Organizatio0ndividual):Vivint Solar Developer LLC Address:1800 W Ashton Blvd City/State/Zip:Lehi,UT 84043 Phone#:855-877-2974 Are you an employer?Check the appropriate box: Type of project(required): I.✓❑I am a employer with 254 employees(full and/or part-time)" 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in $. ❑Remodeling any capacity.f No workers'comp.insurance required.) 9. ❑Demolition 3.1:1 am a homeowner doing all work myself,[No workers'comp.insurance required.] 10❑Building addition 4.[]l am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and i have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These subcontractors have employees and have workers'comp.insurance.t p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and we have no employees.(No workers'comp.insurance required.] "Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Marsh USA Inc Policy#or Self-ins.Lic.#:WC509601302 Expiration Date,11/01/2017 Job Site Address: �\ �, City/State/Zip: "' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DEA for insurance coverage verification. I do hereby certify under th and penalties of perjury that the information provided ab a I iru and correct. -- , I1b Sit.�uaturc:8615 Z � "'�"'� Date: a� Phone#: - 1 r Z"l I 1111 Oficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts t�- - Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 r www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant information Please Print Legibly Name(Business/Organization/individual):Vivint Solar Developer LLC Address:1800 W Ashton Blvd City/State/Zip:Lehi,UT 84043 Phone#:855-877-2974 Are you an employer?Check the appropriate box: Type of project(required): I.❑✓ 1 am a employer with 254 employees(full and/or part-time).* 7. [)New construction 2.r_1 1 am a sole proprietor or partnership and have no employees working for me in S. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[]l am a homeowner doing all work myself.[No workers'comp.insurance required:]' lU Building addition 4.[:][am a homeowner and will be hiring contractors to conduct all work on my property. twill ensure that all contractors either have workers'compensation insurance or are sole l IQ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.o t am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-conlr'aclors have employees and have workers'comp.insurance 1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing thcirworkers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Marsh USA Inc Policy#or Self-ins.Lic.#:WC5109601302 Expiration Date:11/01/2017 1� Job Site Address: ` la �� I City/State/Zip: MG Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, I do hereby certify under th and penalties of perjury that the information provided ab a Istrue�and correct. Si itt taturc: '� �w Date: Phone Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of H alth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i i i I z 011 Wlelld Office of Consumer Affairs end Business Re lation 10 Park Plaza- Suite 5170 Boston, Massachusetts 021 t6 Home Improvement Contractor Registration ReptstmOon: 170846 TWO: Supplement Card VIVINT SOLAR DEVELOPER LLC. Exnirallen: 1'/5124f8 KYLE GREENE 3301 N THANKSGIVING WAY SUITE 500 LE'HI, UT 84043 _ Opdntc Address and return eard:Mark mason for d"j& ecR d +,nnryer AQclrclt RenMvnl [:1 EmPleyment 0 Lost Card I I 1 i ► i uS ' K� .Oa,)- r�tent of Public Safety Sn,,.a} of 3i11"tisnn a ul ilr -t .. �icense: CS-108068 KYLE GRE ENE 44 MAIN STREET North Reading MA 018+64 Expiration i f 01120 018