HomeMy WebLinkAboutMiscellaneous - 29 MASSACHUSETTS AVENUE 4/30/2018cn,
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This certifies thatf�16.1 ZAll"'llp ...... .....................................................
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has pennission to perform ....... ...... ........ uj
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winng in the buildi of (,j A—Je L
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at .......... ............ .. ..... .. ...... . . ..................... .......... P4.CNorth Andover, Mass.
Fee . ....... Lic. No.
. ..... .......... ................. ....................................................................................
Date.4�/ AA ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
ELECTRICAL INSPECTOR,
Ch eck 4t
12421
I Official Use Only
commonweaa 0/ Majdal"M
0/ Permit No. -A
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS I[Rev- 1/071 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cope 7 CMR 12.00
(PLFEASE PREVT 12V EVK OR 7TPE ALL TIOA9 Date: w 93'f(, T
City or Town oh . 'AraMwi6r(y To the Inspector bf Wires:
By this application the undersignedgive dfiZe of hi h * t the electrical work described below.
Location (Street & NW v1 or
.P�r _ Im 01.)
Telephone No. !I'
04 W-4 rw.-mv. )v
Is this permit in conjunction with a building permit? Ye�,� No E] (Check Appropriate Box)
Purpose of Building C,�,k n 12 J,,Q � fQfy-) I I L4 fT)M�-e, Utility Authorization No.
Existing Service '��Co Am Overhead [-]
ps tcA0 84D Volts - Undgrd No. of Meters _
New Service Amps Volts OverheadF-� U.ndgrd F� No. of Meters —
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: (4 mY4-, me -b V-Vro
Completion of thefollowing table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of CeiL-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In-
Swimming Pool grnd. gmd. El ,
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JNo. of Zones
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pum
Tot=
JAW ...........
of Self -Contained
Detection/Alertine Devices
No. of Dishwashers
Space/Area Heating KW
Local M Municipal F-1 Other
LJ Connection
No. of Dryers
Heating Appliances KW
Sic-ur-ity �vstems: *
No. of Devices or Equivalent
No. of Water KW
Heaters
0.0 No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wn�mft:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desirec4 or as required by the Inspector of Wires.
Estimated Vable D Eleptn'c (V&en required by Municipal policy.)
Work to Startj� I Q b U Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cov
,,qne is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCFZ BOND M OTHER El (Specify:)
I cerdft, under the pains andpenalfies ofpedury, that the informadon on this appficadon is 19t"d conTlde.
FIRM NAME: V kV I nt 'Sc)�Y- A.Q \[�g /,/ LIC. NO.,:' 12ALI 1,4
Licensee: fft\1 I n 'p- Z O[MQ �� �\ 0� Signatur' LIC. NO.: I' !�J Lf I A-
(Tf applicabIT, —entgr "lempt - in the ricen?e number line) Bus. TeLNo.-
;It,;��Alt Tel. No.:iQi-4-1e1q-
Address: -JQdaX1nrfV4A
*Per M.G.L. c. 147, s. 57-61, security worlCrequires Department of Pubre �a�&S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage norm
required by law. By my simature below, I hereby waive this requir Tt I am t4e (check one) E] owner , 0 owner's age
Owner/Agent I-- __r q, I DLIDA"Ir VVL1. r
Ct
Address: 3301 North Thanksgiving Way, Suite 500
Lehi, UT 84043
Phone 9: 801-377-9111
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
4. E] I am a general contractor and I
Department of IndustrialAccidents
have hired the sub -contractors
Office of Investigations
listed on the attached sheet.
I Congress Street, Suite 100
These sub -contractors have
Boston., M4 02114-2017
employees and have workers'
www.massgovIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AMlivant Information
Please Print Lezibl
Name (Business/Organization/individual): Vivint Solar Developer, LLC
Address: 3301 North Thanksgiving Way, Suite 500
Lehi, UT 84043
Phone 9: 801-377-9111
Are you an employer? Check the appropriate box:
1 I am a employer with 10
4. E] I am a general contractor and I
employees (fWl and/or part-time)."
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' camp. insurance
camp. insurance.1
required.]
5� We are a corporation and its
3. 0 1 am a homeowner doing all work
officers have exercised their
myself [No workers' camp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
camp. insurance reauired.1
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10. Electrical repairs or additions
I ITI Plumbing repairs or additions
12.E] Roof repairs
13.0 Other Solar Installation
*Any applicant that checks box* I must also fill out the section below showing their workers' compensation policy information.
� Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 riot 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 workeFs ' compensation lasurancefor my employees. Below is thepolicy andjob 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:
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 cerd
,fy under the pains andpenalties ofperjury that the information provided above is Pue and correct
-1 P 1^ — -d —
Phone #: 801-2296459
IOfficial use ottly. Do not write in this area, to he 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 C[lerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
Phone 4:
VIVIUT SGLARDEVELOPER. LLC
PHILIP F ZAMPITELLA JR (EL)
4931 N 300 w
PROVO UT 84604
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01845
DRAWN BY: AN 42348-56
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MA LICENSE: MAHIC 170848
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UTILITY ACCOUNT NUMBER� 28710-16047
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Last Modified: 5/26/2015
Vivint Solar - PV Solar Rooftop System Permlit Subnuittal
1. Project Information
Project Name: Paola Fernandez
Project Address: 29 Massachusetts Ave, North Andover MA
A. System Description:
The array consists of a 3.64 kW DC roof -mounted Photovoltaic power system operating in parallel with the utility grid. There are (14)
260 -watt modules and (14) 215 -watt ri-iicro-inverters, mounted on the back of each PV module. The array includes (1) PV circult(s). The
array is mounted to the roof using the engineered racking solution from Ecolibrium. Solar.
B. Site Design Temperature: (From Lawrence MUNI weather station)
Average low temperature: -24.3 OC (- 11.74 -F)
Average high temperature:
37.6 OC (99.68 -F)
C. Minimum Design Loads:
Ground Snow Load: 50 psf (State Board BR&S)
Design Wind Speed:
100 mph (State Board BR&S)
2. Structural Review of PV Array Mounting System:
A. System Description:
1. Roof type: Comp. Shingle
2. Method and type of weatherproofing roof penetrations: Flashing
B. Mounting System Information:
1. Mounting system is an engineered product designed to mount PV modules
2. For manufactured mounting systems, following information applies:
a. Mounting System Manufacturer:
b. Product Name:
c. Total Weight of PV Modules, Microltiverters, and Racking:
d. Total number of attachment points:
e. Weight per attachment point:
E Maximum spacing between attachment points:
g. Total surface area of PV array:
h. Array pounds per square foot:
i. Distributed weight of PV array on roof sections:
-Roofsection 1: (14) modules, (24) attachments
Ecolibriurn Solar
621.6 lbs
24
25.9 lbs
* See attached engineering calcs
246.54 square feet
2.52 lbs/square foot
23.91 pounds/attachment
3. Electrical Components:
A. Module (UL 1703 Listed) Qty
TrinaTSM 260-PDO5.08 14 modules
Module Specs
Pmax - nominal maximum power at STC 260 watts
Vmp - rated voltage at maximum power 30.6 volts
Voc - rated open-ctircult voltage 38.2 volts
Imp - rated current at maximum power 8.5 amps
Isc - rate short circuit current 9 amps
B. Inverter (UL 1741 listed)
Qty
Enphasc M215-60-2LL-S22
14 inverters
Inverter Specs
1. Input Data (DC in)
Recomrnended input power (DC)
- 260 watts
Max. input DC Voltage
- 45 volts
Peak power tracking voltage
- 22V - 36V
Min. /Max. start voltage
- 22V/45V
Max. DC short circuit current
- 15 amps
Max. input current
- 10.5 amps
2. Output Data (AC Out)
Max. output power
- 215 watts
Nominal output current
- 0.9 amps
Nominal voltage
- 240 volts
Max. units per PV circuit
- 17 micro -inverters
Max. OCPD rating
- 20 amp circuit breaker
C. System Configuration
Number of PV circuits
PV circuit 1 - 14 modules /inverters (20) amp breaker
2011 NEC Article 705.60(B)
vwonu,,.� solar
D. Electrical Calculations
1. PV Circuit current
PV circuit nominal current 12.6 amps
Continuous current adjustment factor 125% 2011 NEC Article 705.60(B)
PV circuit continuous current rating 15.75 amps
2. Overcurrent protection device rating
PV circuit continuous current rating 15.75 amps
Next standard size fuse/breaker to protect conductors 20 amp breaker
Use 20 amp AC rated fuse or breaker
3. Conductor conditions of use adjustment (conductor ampacity derate)
a. Temperature adder
Average high temperature 37.6 OC (99.68 -F)
Conduit is installed 1" above the roof surface Add 22 'C to ambient
Adjusted maximum ambient temperature 59.6 OC (139.28-F)
b. PV Circuit current adjustment for new ambient temperature
Derate factor for 59.6 'C (139.28-F) 71%
Adjusted PV circuit continuous current 22.1 amps
c. PV Circuit current adjustment for conduit fill
Number of current -carrying conductors 3 conductors
Conduit fill derate factor 100%
Final Adjusted PV circuit continuous current 22.1 amps
Total derated ampacity for PV circuit
22.1 amps
Conductors (tag2 on I -line) must be rated for a minimum of 22.1 amps
THWN-2 (90 'C) #12AWG conductor is rated for 30 amps (Use #12AWG or larger)
4. Voltage drop (keep below 3% total)
2 parts:
1. Voltage drop across longest PV circuit rrticro-inverters (from modules to j -box)
2. Voltage drop across AC conductors (from )-box to point of interconnection)
1. N/firco-Invcrter voltage drop:
The largest number of rr:ticro-Inverters in a row in the entire array is 14 inCircuit 1. According to
manufacturer's specifications this equals a voltage drop of 0.55 %.
2. AC conductor voltage drop:
=IxRxD (—* 240 x 100 to convert to percent)
= (Nominal current of largest circuit) x (Resistance of #12AWG copper) x (Total wire run)
= (Circuit 1 nominal current is 12.6 amps) x (0.00201 Q) x (90) + (240 volts) x (100)
2011 NEC Article 705.60(B)
2011 NEC Article 705.60([3)
2011 NEC Article 705.60(B)
2011 NEC Article 705.60(B)
0.55%
0.94%
Total system voltage drop: 1.49%
& 0
�Avnnl. so I a r
EcolibriumSolar
Customer Info
Name: 4234856
Email:
Phone:
Project Info
Identifier: 35554
Street Address Line 1: 29 Massachusetts Ave
Street Address Line 2: -
City: North Andover
State: MA
Zip: 01845
Country: United States
System Info
Module Manufacturer: Trina Solar
Module Model: Trina TSM 260-PA05.18
Module Quantity: 14
Array Size (DC watts): 3640.0
Mounting System Manufacturer: Ecolibrium Solar
Mounting System Product: EcoX
Inverter Manufacturer: Enphase Energy
Inverter Model: M215
Project Design Variables
Module Weight: 47.0 lbs
Module Length: 64.7 in
Module Width: 38.8 in
Basic Wind Speed: 100.0 mph
Ground Snow Load: 50.0 psf
Seismic: 0.0
Exposure Category: B
Importance Factor: 11
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 lbf
EcoX Design Load - Upward: 765 Ibf
EcoX Design Load - Downslope: 297 Ibf
EcoX Design Load - Lateral: 233 Ibf
Module Design Moment — Upward: 3655 in -lb
Module Design Moment — Downward: 3655 in -lb
Effective Wind Area: 20 ft2
Min Nominal Framing Depth: 2..5 in
Min Top Chord Specific Gravity: 0.42
. Plarpa Cali; u lations (ASC E 7-10): Roof 1
Roof Shape: Gable
Roof Type: Composition Shingle
Average Roof Height: 25.0 ft
Least Horizontal Dimension: 32.75 ft
Roof Slope: 40.0 deg
Truss Spacing: 22.0 in
Snow Load Calculations
Edge and Corner Dimension: 3.275 ft
Stagger Attachments: No
Include Snow Guards: No
EcolibriumSolar
Description
Interior
Edge
Corner
Unit
Flat Roof Snow Load
42.0
42.0
42.0
psf
Slope Factor
0.55
0.55
0.55
psf
Roof Snow Load
23.1
23.1
23.1
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
psf
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
2.7
2.7
2.7
psf
Snow Load
23.1
23.1
23.1
psf
Downslope: Load Combination 3
13.1
13.1
13.1
psf
Down: Load Combination 3
15.6
15.6
15.6
psf
Down: Load Combination 5
13.7
13.7
13.7
psf
Down: Load Combination 6a
21.0
21.0
21.0
psf
Up: Load Combination 7
-11.2
-13.3
-13.3
psf
Down Max
21.0
21.0
21.0
psf
Spacing Results (Landscape)
Description
Interior
Edge
Corner
Unit
Max Allowable Spacing Between Attachments
72.0
72.0
72.0
in
Max Spacing Between Attachments With Rafter/Truss Spacing of 22.0 in
66.0
66.0
66.0
in
Max Cantilever from Attachment to Perimeter of PV Array
1 24.0
24.0 1
24.0 1
in -J
Spacing Results (Portrait)
Description
Interior
Edge
Corner
Unit
Max Allowable Spacing Between Attachments
48.8
48.8
48.8
in
Max Spacing Between Attachments With Rafter/Truss Spacing of 22.0 in
44.0
44.0
1 44.0
1 in
Max Cantilever from Attachment to Perimeter of PV Array
16.3
16.3
1 16.3
1 in
EcolibriumSolar
Layout -
� Skirt
tm Coupling
0 Clamp
Bonding Jumper
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.
Warning: PV Modules may need to be shifted with respect to roof trusses to comply with
maximum allowable overhang.
EcofibriumSolar
Ro6i Wei'hts
9
In Conformance with Solar ABC's Expedited Permit Process
Module Quantity: 14
Weight of Modules: 658 lbs
Weight of Mounting System: 48 lbs
Total Plane Weight: 706 lbs
Total Plane Array Area: 244 ft2
Distributed Weight: 2.89 psf
Number of Attachments: 24
Weight per Attachment Point: 29 lbs
EcolibriumSolar
Bill Of Materials
Part
Name
Quantity
ECO -001101
EcoX Clamp Assembly
24
ECO -001102
EcoX Coupling Assembly
22
ECO -001-105B
EcoX Landscape Skirt Kit
0
ECO -001-105A
EcoX Portrait Skirt Kit
5
ECO -001103
EcoX Composition Attachment Kit
24
ECO -001-1 16
EcoX Flat -Tile Flashing
0
ECO -001-1 17
EcoX S -Tile Flashing
0
ECO -00 1 —118
EcoX W -Tile Flashing
0
ECO -001363
EcoX Lower Support - Tile
0
ECO -001109
EcoX Electrical Assembly (optional)
1
ECO -001106
EcoX Bonding Jumper Assembly
2
ECO -001104
EcoX Inverter Bracket Assembly
14
ECO -001338
EcoX Connector Bracket
14
ECO001-359
EcoX Lower Support - Low Slope
1 0
7 0
'ACOORL3111' CERTIFICATE OF LIABILITY INSURANCE
lllt.�
DATE (MMIDDNYYY)
01/05/2015
F
-
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 enclorsement(s).
PRODUCER
MARSH USA INC.
1225 17TH STREET, SUITE 1300
CONTACT
NAME:
PHONE FAX
(AIC, No. Ext): (A/C, No):
E-MAIL
ADDRESS:
DENVER, CO 80202-5534
Attn: Denver.CertRequest@marsh.com Fax: 212-948-4381
11/0112014
11/01/2015
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA: Evanston Insurance Company 35378
MED EXP (Any one person) $ 5
INSURED
Vivint Solar Developer LLC
3301 North Thanksgiving Way
INSURER B: Zurich American Insurance Company 16535
INSURER C: American Zurich Insurance Company 40142
INSURER D:
Suite 500
Lehi, UT 84043
PRODUCTS - COMP/OP AGG $ 2,000,000
$
INSURER E:
INSURER F:
LIABILITY
ANY AUTO
ALL OWNED S HEDULED
AUTOS A TOS
X NON -OWNED
HIRED AUTOS AUTOS
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.
INSR
LTR
TYPE OF INSURANCE
ADDL
IM11
SUBR
POLICY NUMBER
POLICY EFF
(MMIDDNYYY)
POLICY EXP
(MMIDDIYYYY)
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
ICLAIMS -MADE M OCCUR
X $5,000 Ded. B1 & PD
of Marsh USA Inc.
14PKGWE00274
11/0112014
11/01/2015
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 50,000
PREMISES (Ea occurrence) $
MED EXP (Any one person) $ 5
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
7 POLICY FX] PRO-
jECT 7 LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
$
B
AUTOMOBILE
X
"X
LIABILITY
ANY AUTO
ALL OWNED S HEDULED
AUTOS A TOS
X NON -OWNED
HIRED AUTOS AUTOS
BAP509601500
11/01/2014
11/01/2015
MBINED INGLELIMIT
(CEO, .identS $ 11000,000
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPER AMAGE
d I $
(P.,.c. '�W
A
X
UMBRELLA LIAB
EXCESS LIAB
�J
OCCUR
CLAIMS -MADE
14EFXWE00088
11101/2014
11/01/2015
EACH OCCURRENCE $ 5,000,000
AGGREGATE $ 5,000,000
IDED RETENTION $
$
C
B
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE
OFFICER/M MBER EXCLUE F7N
(MandatoryIn NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
WC509601300(CA,H1,MD,NJ,NY,OR,UT)
WC509601400 (MA)
11/01/2014
11/0112014
11/01/2015
11/01/2015
X WC STATU- I _1OTH_
1 IQRY LIMITS I ER
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
DISEASE - POLICY LIMIT $ 1,000,000
A
Errors & Omissions &
Contractors Pollution
1
14PKGWE00274
1111112114
1110112015
-E.L.
LIMIT 1,000,000
DEDUCTIBLE 5,000
DESCRIPTION OF OPERATIONS I LOCATIONS I 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
ACORD 25 (2019,/05)
@ 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered m rks of ACORD
0
CHU
47
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .....
........................ I ...............................................................
has permission to perform ...................... ...................................
wiring in the building of ...........
-- ip ...........................................................
at ............................................ . North Andover, Mass.
re;e:.�.O.. ..... ............ Lic. No. ....... F ...... ................
ELECTRICAL INSP�7�11-
Check #
7144
A
Commonwealth of Massachusetts Official Use . Only
Permit No.
R Department of Fire Services
Occupancy and Fee Checked CPO,
BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] Qpveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 0JR 12.00
(PLEASE PRINT 1N INK OR TYPEALL JXFORMA TION) Date: 0 ;7
City or Town of: It e 0� Wires:
k il e_l< To the Imp' ctor
By this application the undersigned gives notice of his or her int6ntion to perfon-n the electrical work described below.
Location (Street & Number) ,I, C,> /'JA:S� :5,4 0 7--X J 40:/-f-5 A L/f—
Owner or Tenant
Telephone No.
Owner's Address i
Is this permit in conjunction with a building permit? Yes El No 121, (Check Appropriate Box)
Purpose of Building I - Utility Authorization No.
Existing Service Amps Volts , Overhead Undgrd
New Service Amps Volts Overhead Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
-
No. of Meters
No. of Meters
r, le!j0!? �fthp fnilnwing tnhlp may he waived by the InSDector ol Wires.
. Attach additional detait y desired, or as requ re
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the pen -nit issuing office.
CHECK ONE: INSURANCE F1 BOND [-] OTHER [I (Specify:)
I certift, under the pat s andpenalties ofperjury, that the information on this application is true and complete.
lip
0.:
FIRM NAME: LIC. N 6- 11V
Licensee: Signature LIC. NO.:
wber line) Bus. Tel.
(If applicab
Address: e"'ve—e Alt. Tel. No.:, -
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage non-nally
required by law. By my signature below, I hereby waive this requirement. I am the (check one)E] owner Downer's agent.
Owner/Agent
Signature - Telephone No. PERMIT FEE: $
No. of Total
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above El In-
grnd. grnd.
No ot-Em-ergencyLliliting
Baiter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALA�RMS
No. of Zones
N—o.of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
.................
o. f Self -Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
M municipal 0 Other
Local 0 Connection
Heating Appliances KW
Security Systems:*
Devices Equival
No. of Dryers
No. of or nt
No. of Water KW
0.0 No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
Telecommunications W- I
No. Hydromassage Bathtubs
No. of Motors Total UP
No. of Devices or Equiva ent
OTHER:
I ; 'I a, rn —orfWires
. Attach additional detait y desired, or as requ re
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the pen -nit issuing office.
CHECK ONE: INSURANCE F1 BOND [-] OTHER [I (Specify:)
I certift, under the pat s andpenalties ofperjury, that the information on this application is true and complete.
lip
0.:
FIRM NAME: LIC. N 6- 11V
Licensee: Signature LIC. NO.:
wber line) Bus. Tel.
(If applicab
Address: e"'ve—e Alt. Tel. No.:, -
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage non-nally
required by law. By my signature below, I hereby waive this requirement. I am the (check one)E] owner Downer's agent.
Owner/Agent
Signature - Telephone No. PERMIT FEE: $
�4z
rz)
1�
9
Date.L.-.o..:.q.( . .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ !�7..os ......................................................................
has permission to perform ... ..... .........................
wiring in the building of ....... . ......
at e.V-4 ............................... . North Andover, Mass.
...... .. ..... .
Fee ..... "OX) ....... Lic. No. .......... ELEc . rR . ICAL . ..........
Check #
6764
Official Use Only
Commonwealth of Massachusetts
Permit No.
(-�
Department of Fire Services
A.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 (1 .... blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMA TION) Date:
City or Town of. A -)Q, a , 1 (0 (6 V QA To the Inspector of Wires. -
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 9,19 144
Owner or Tenant A2614 f LN E 9 Telephone No. aogcml
Owner's Address mig6e
�)dq e- 14 L) 6 IF IT,'6 go Ve
Is this permit in conjunction with a building permit? Yes El No X (Check Appropriate Box)
Purpose of Building_ 106 5 16 6A)TI A 4- Utitity Authorization No.
Existing Service le—e Amps Z07,j9/c2j/t) Volts Overhead A Undgrd [:] No. of Meters
New Service Amps V016 Overhead Ej UndgrdF] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: CAAA,66 ahMR- DANA6&D BA 63 E 4 -
Completion of thefolloiWng table may be waived by the Inspector of Wires -
No. of Rec ssed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
INo. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming P I ool Above Ei In El
grnd. grnd.
"�o- �om�ergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones.
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
I
Tons
I
KW
I
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Mun'c'P?l El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data W' * g:
No. lorfinDevices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
rciecommunications W;�'ng:
No. of Devices or E urvallent
OTHER:
Attach additional detail iftlesired, or as required 1�i, the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such c crage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE � BOND 0 OTHER [I (Specify:) �Expiration Date)
Estimated Value of Electrical Work: '750,00 (When required by municipal policy.)
Work to Start: &— inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains andpenaltiesofper'uty, that the information on this application is true and complete,
FIRM NAME: LIC. NO.:
Licensee: Signatu LIC.NO.-
(If applicable, enter "exempt in the license number line,) Bus. Tel. No.-,0?71!%6
If -Y !E;�r
Address: 6-2-00 __e e A�V Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner El owner's agent.
Owner/Agent
Signature Telephone No. rPERMIT FEE: $
cilwa)- C7 �.
/- Id - oz: 5
Date.....................
I IN TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..................
has permission for gas -installation . .......
in the buildings o .. ................................
at aZ7 ....... -
....... ... North Andover, Mass.
..........
Fee--'7-� ..... Lic. No
Check#
5396
NIASSACHUSErIS UNNORM APPUCATON FOR PERNIN TO DO GAS FTMNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Locations Permit #
Amount $
Owner's Name
New 0 Renovation El Replacement 0 Plans Submitted
(Print or type)
Name
Address 4 4 �— 9- on ( o M
Name of Licensed Plumber or Gas Fitter
one: Certificate Installing Company
Cff Corp.
Partner.
Ftmi/co.
INSURANCE COVERAGE - Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0-� NoO
If you have checked yes, ple dicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity [3 Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
I hereby certify that all of the details and information I have suorruttea (or enterea) in aDove appucation are true ana accurate to ine
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
VED (OFFICE USE ONLY)
Signature of L
ID Plumber
[D Gas Fitter
ERMaster
Joumeymah'
Or
J�*Emcwc &NVL-t��-C--y u
jL(A.V q, C-V"A Y"); wo vz g. yp- Nei
�V5 ,�j szy rs
� uf-��I- ifaF<rL
3RD.FLOOR
6TH. FLOOR
(Print or type)
Name
Address 4 4 �— 9- on ( o M
Name of Licensed Plumber or Gas Fitter
one: Certificate Installing Company
Cff Corp.
Partner.
Ftmi/co.
INSURANCE COVERAGE - Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0-� NoO
If you have checked yes, ple dicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity [3 Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
I hereby certify that all of the details and information I have suorruttea (or enterea) in aDove appucation are true ana accurate to ine
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
VED (OFFICE USE ONLY)
Signature of L
ID Plumber
[D Gas Fitter
ERMaster
Joumeymah'
Or
J�*Emcwc &NVL-t��-C--y u
jL(A.V q, C-V"A Y"); wo vz g. yp- Nei
�V5 ,�j szy rs
� uf-��I- ifaF<rL