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Miscellaneous - 45 BRIDGES LANE 4/30/2018 (2)
/ 45 BRIDGES LANE 210/104.D-0120-0000.0 ` I I i r t j 1 6/17/2016 Date: June 17, 2016 20609 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20609 %-Tr TOWN OF NORTH ANDOVERPERMIT FOR WIRING This certifies that Matthew T Markham has permission to perform Install solar electric photovoltaic (PV) system 46 panels rated 11.96 kW Qj) STC Grid Tied. In conjunction with building permit. wiring in the buildings of FOX, MICHAEL at 45 BRIDGES LANE , North Andover, Mass. Lic. No. 1136 1/1 6/17/2016 Date: June 17, 2016 20609 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20609 • ' • s�2'r�r''�r . � t`• TOWN OF NORTH ANDOVER �' '[Nil PERMIT FOR WIRING This certifies that Matthew T Markham has permission to perform Install solar electric photovoltaic (PV) system 46 panels rated 11.96 kW (a) STC Grid Tied. In conjunction with building permit. wiring in the buildings of FOX. MICHAEL at 45 BRIDGES LANE , North Andover, Mass. Lic. No. 1136 1/1 •L1-4Pewa— , u F � C Cl h�,s:(�harif�rrbvama.vtevlpoh>�Iaud oom/Y./recoru�/2fp� Y�'- ii:ears O s1eeas Town of North Andover,86A C. Sea ch - 20609 -Electrical Permit-IN Conjunction with a Building Permit[Commercial or Residential) TIMELINE ----- - Submission rece'i ed pm 16,2016 a:1:33pm l OEleCMwCal Re%4 ✓ aPvp<ann O PI.-It Fee Allison Kelley 45 BRIDGES LANE,NORTH ANDOVER, <978215-2383 !MA Q allison-keliey@solar.- (�''"a` OFe niit 1=waure FOX MICHAEL 7 Attachments tuu!oea ic:x V -OT70XLIOOIF Thujun 16 2016 17:39:.PDF -catlxr 1:;:.e;.f.3.;"�E2 Ai::.on rt::!:•,. Primary Contractor Search for your contactor using the search bar below.Either the Firm's Name or license i Is required. Name _nenser Matthew T Markham .icenze a^ �censx"c�pi�ano.^.Gex 1136 07!302016 ..cense Tp,• Jttnsx 4a:r Master Eleadclan Class MR J 2-zI Thursday,Jun 16,2016 01:48 PM � I Co►n++xors+aaadG+ o�lflaa3acfruaetfa Official Use Only Permit No.2enarbm o eraSaraico3 Occupancy and Fee Checked i BOARD OF FIRE PREVENTION REGULATIONS [Rev. t/07] (leave 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 PRIATT IN INK OR TYPE ALL JAW ORMATION) Date: (o City or Town of: N0 r-Ch. An Ctc1V 2..f To the Ins ect"ol of Wrs es: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) L14j '6 r!d C,-S 1_ x Owner or Tenant M 1 tom— FOS Telephone No. 7 " 7 qy Owner's Address Is this permit in conjunction with a building permit? Yes [E] No ❑ (Check Appropriate Box) Purpose of Building R-eSi cU_YN fi1'0,,t Utility Authorization No. Existing Service Amps ! Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Fork: Install Solar Electric - Photovoltaic (PV) system [4-(0] panels rated [I 0(d kW t- STC Grid Tied. In conjunction with a Buildina Permit Cam leriort of the follonvrr table rrray be lraived by the Inspector of(fires. No.of Recessed Luminaires No,of Ceil,-Susp,(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators tCVA No. of Luminaires Swimming Pool Above ❑ n- ❑ No.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners EIRE ALARMS No,of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No,of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Tot Pump umber 'I•ons It o.of elf- ontaiBed Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating IMI Local lumcrpal Other p g Connection No.of Dryers Heating Appliances KW Security ystems: No.of Devices or Equivalent No.of Water No. o€ 1 0.o KW Data Wiring: Heaters Ballasts Si ns Ba as . No.of Devices or Equivalent No.I•iydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: teach additional derail if desired,ar as required by the Inspector of 111res. Estimated Value of Electrical Work: Z 1, f 20 (When required by municipal policy.) Work to Start:ASAP 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 permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) 1 certrfj,,urrder thepains crud penalties ofperjut},,that the btfonnation on this application is true and complete. FIRM NAME: SOLARCITY CORPORATION LIC,NO.:1136MR Licensee: MATTHEW T. MARKHAM Signature949;4LIC.NO.:1136MR (!f applicable,eraser "exempt"in the license dumber line) Bus.Tel. No.:714-25&818D Address: 24 5T MARTIN 0RiyE(BU1Ld1NG 2-UNIT 11)MARLBOROUGH,MA 01752 Alt.Tel.No,:774'258-8505 *Per M.G.L.c. 147,s.57-b1,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: l 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) owner owner's a en t. Owner/Agent PERMIT FEE: $ Signature Telephone 1\'1r. +rr t:., 01IIce O1 LonS tinlc.t' r i# tti F... nd Business Re ulatiion 10 Pat l Plaza - Shite 5170 Boston, MassachUSetts 02116 Home Improvement Contractor Registration Registration- 168572 Type; Supplement Card SOLAR CITY CORPORATION Lxpiratlon: 318/2017 MATT MARKHAM 3055 CLEARViEW WAY SAN MATEO, CA 94402 Update,Address and return card.., ark reason for ehsaugc Address Renewal Employment Last Card 0111ce ofConsumer Aft'olrs& liijsinem lirguletion License or rrgistratioo vaalid for indivittul use ouia HOME IMPROVEMENT CONTRACTOR before the expiration date. If found i cturn to.- Office o:Office of Consumer Affaim.und Business ltegulaition Roglnlraat on: 151+672. Typo: 10 Park Plnia-Suite 5171) I?.xteirxtiOW 1,12017 Supplement Coad Boston.NIA 02116 MATT MARI':I V .1 24 ST MARTIN SIRL.Lt BLD2UNI UNI-BOROUGH,MA 01752 �tlgdersceretaar? ^� Not valid without signaaturr ISSUES 'THE fO:t.OWiNi LICENSE AS A , I REGISTERED MASTER l ECTR I C I AN \g OL ARC I TY COPPORAI 1 ON NATTHLW T MARKHAM � 74 SAINT MARTIN DR LOG 2 UNIT 11 � 4ARLBOR0I3GH MA 01152-3060 ' The Common wealth ofMassach usetts Ulf Department of IndustrialAccidents Drae of In vestigatinns I Congress Street,Suite 100 Boston,MA 02.1.14-2017 1VWW.M a$s.fyVV1dl0 Workers'Compensation Insurance Affidavit;Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Nauta(]3usincss/Qrganization/fndividual): SolarCity Corp. Address: 3055 Clearview Way City/State/Zip: San Mateo CA. 94402 Pbane 1: 888-765-2489 Are you an employer?Check the appropriate box: Type of project(required): j.0 am a ernpdoyer with 5,000 4- El I ani a general coniractar and I employees(full and/or part-tirne).'F have hired the sub-contractors El 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 S. 0 Demolition working for the in any capacity. employees and have workers' insurance? 9. Q Building addition (No workers comp.camp.insurance P• required.) 5. We are a corporation and its I0.[3 Electrical repairs or additions 3.❑ I aut a hutneowrner doing all work officers have exercised their 11.[3 Plumbing repairs or additions rnybolL [No workers' camp. iisiiuf excuiptLian per MG I2.El Roof repairs insurance rcquired,j t c. 152,§1(4),and we have no !3 Sher Solar/PV employees. [No workers' ✓ camp.insurance required.] *Any applicant that checks box 01 must also rat out The section below showing thcif wot*ws'comps Nation polloy intannstion. I Homeowners who submit this affidavit indicating they are doing all work and then hire oulsido cantraernrs mast submit a new affidavit Indicating such. tContractm that check this box must attached an additional sheet showing tlrc norm of the sub-contractors and state whethet or not those entities have employees. If the subcontractors 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 tfre poficy and job site information. Insurance CompanyNatne: Zurich American Insurance Company Policy-9 or Self-iris.Liu.#: WC0182015-00 Expiration Date; 9/1/2016 Job Site Address: y S J,1-)r i-d Cy-S Ln City/State/Zip: Y ' C-r Attach a eopy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of HILL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 tip to$250.00•a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certd under the pains and penaitles ofperjurJ,that the information provided above is true and correct. Si tore: Date: JQ lo Phone .: Ofricial uya only. Do not write in this area,to be completed by eft, or town.offleial. City or Town: Permit&legase Issuing Authority(circle one)- .Board of Health 2.Building Department 3.City/Town Clerk-4,Electrical Inspector S.Plumbing Inspector ti. Cather Contact Person: Phone#: AC RL> CERTIFICATE OF LIABILITY INSURANCE °08117120151°°`YYYY' AT�`MMs 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 RISK&INSURANCE SERVICES NAI" -..................._... ... ............. . .. . . ... .. -. .._.. PHONE FAX 345 CALIFORNIA STREET,SUITE 1300 lAta�xt7:................. ...... .. ... .. ..... . . ...... ..i.talc,No7;.......... ......... .................. CALIFORNIA LICENSE NO.0437153 E-MAIL SAN FRANCISCO,CA 94104 _ADDRESS:. ..... ..... .1..... _...- _ Af1n:Shannon Scott 415-743-$334 INSURERIS]AFFORDING COVERAGE. + NAIC# 998301-STND-GAWUE-15.16 INSU....... 1..... t_.......... _........ INSURED INSURER B:NIA NIA SolarCity Corporation 3055 Clearview Way INSURER C:NIA11,11A.. ................................. ..... ..................+........ San Mateo,CA 94402 .INSURER.D!American Zurich Insurance Company 140142 INSURER E:,., ..,-,..., INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002713636.06 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE; LISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAMED A13OVE FOR THE POLICY PERIOD tNOICATED. 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. ...... ........... '... .. .....AD6_SUB_._R...—........ . ... .....EFILR OLIC IYYTTYPE INSURANCEPOLICY NUrBERMY .... ...... ................_. ..LIMITS .................. ...... ...... A X COMMERCIAL GENERAL LIABILITY j61.00182016-00 0910112015 EACH OCCURRENCE $ 3,000,000 i I DAMAGE TO RENTEEI.......... .. ._.... CLAIMS MADE f X I OCCUR i PREItAESES(Ea occurrence}....*_$.... .............. 3,000,000 X SIR,$250,000 I Ms ............. ...._.... .... ...... D EXP(Any one person) �� ..... . ._ . S,oQa PERSONAL&ADV INJURY $ 3,000,000 GEML AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE g 6,000,000 X PRO. r..., 1 POLICY I JECTL. ...;LOC PRODUCTS-COMPIOP AGG :$ 6,000,000 i OTHER $ A AUTOMORH-F LIABILITY 'BAP0182017-00 '0910112015 091012016 COMBINED SINGLE LIMIT S 5.000,000 X ANY AUTO : BODILY INJURY(Per person) $ X I ALL OWNED X SCHEDULED BODILY INJURY(Par accident):$ :..... AUTOS AUTOS : i_....................... .... .,... ........ ... .. ... ... X l X NDN-OWNED i : PROPERTY DAMAGE �.... HIRED AUTOS F.... AUTOS i IFeracc'tdent). ..... ..... _....+.. .. ...... ..... ................ COMPICOLL DED: $5,000 UMBRELLA LIAB OCCUR I EACH OCCURRENCE. .. }.$... EXCESS LIAB '.CLAIMS MADE' ' AGGREGATE $ DED RETENTIONS D 'WORKERS COMPENSATION VC0182014-00(AOS) :0910112015 :0910112616 X 5TAR7U OTH- :AND EMPLOYERS'LIABILITY F..._...�---......T;._........L ER.....i.... ... . ............ .. A Y r N! WC0162015.00 MA .09101/2015 0910112016 ;ANY PROPRtETORIPARTNERIEXECUTIVE I I E.L EACH ACCIp ENT 5 1.000,000 OFFICERIMEMBEREXCLUpEO� N N1A1 F_.....___----..._.............. . . ....�_ (Mandatory In NH) WG DEDUCTIBLE:$500,000 E.L DISEASE-EA EMPLOYEE[S 1,000,000 N yesCR.descnbe under _.... ... .... ... . ........ . DESIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT I S 1,000,000 i I I I DESCRIPTION Of OPERATIONS 1 LOCATIONS I VEHICLES(ACORD.101,Additional Remarks Schedule,may be attached If more space Is required) Evidence of insurance. CERTIFICATE HOLDER CANCELLATION SolarCity Corporation SHOULD ANY OF THE ABOVE OF-SCRIBED POLICIES BE CANCELLED BEFORE 3055 Clea(view Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 1N San Mateo,CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk&Insurance Services Charles Marmolejo' p 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ABBREVIATIONS ELECTRICAL NOTES JURISDICTION NOTES a A AMPERE 1. THIS SYSTEM IS GRID—INTERIIED VIA A AC ALTERNATING CURRENT UL—LISTED POWER—CONDITIONING INVERTER. BLDG BUILDING 2. THIS SYSTEM HAS NO BATTERIES, NO UPS. CONIC CONCRETE 3. A NATIONALLY—RECOGNIZED TESTING DC DIRECT CURRENT LABORATORY SHALL LIST ALL EQUIPMENT IN EGC EQUIPMENT GROUNDING CONDUCTOR COMPLIANCE WITH ART. 110.3. (E) EXISTING 4. WHERE ALL TERMINALS OF THE DISCONNECTING EMT ELECTRICAL METALLIC TUBING MEANS MAY BE ENERGIZED IN THE OPEN POSITION, FSB FIRE SET—BACK A SIGN WILL BE PROVIDED WARNING OF THE GALV GALVANIZED HAZARDS PER ART. 690.17. GEC GROUNDING ELECTRODE CONDUCTOR 5. EACH UNGROUNDED CONDUCTOR OF THE GND GROUND MULTIWIRE BRANCH CIRCUIT WILL BE IDENTIFIED BY HDG HOT DIPPED GALVANIZED PHASE AND SYSTEM PER ART. 210.5. 1 CURRENT 6. CIRCUITS OVER 250V TO GROUND SHALL Imp CURRENT AT MAX POWER COMPLY WITH ART. 250.97, 250.92(B). Isc SHORT CIRCUIT CURRENT 7. DC CONDUCTORS EITHER DO NOT ENTER kVA KILOVOLT AMPERE BUILDING OR ARE RUN IN METALLIC RACEWAYS OR kW KILOWATT ENCLOSURES TO THE FIRST ACCESSIBLE DC LBW LOAD BEARING WALL DISCONNECTING MEANS PER ART. 690.31(E). MIN MINIMUM 8. ALL WIRES SHALL BE PROVIDED WITH STRAIN (N) NEW RELIEF AT ALL ENTRY INTO BOXES AS REQUIRED BY NEUT NEUTRAL UL LISTING. NTS NOT TO SCALE 9. MODULE FRAMES SHALL BE GROUNDED AT THE OC ON CENTER UL—LISTED LOCATION PROVIDED BY THE PL PROPERTY LINE MANUFACTURER USING UL LISTED GROUNDING P01 POINT OF INTERCONNECTION HARDWARE. PV PHOTOVOLTAIC 10. MODULE FRAMES, RAIL, AND POSTS SHALL BE SCH SCHEDULE BONDED WITH EQUIPMENT GROUND CONDUCTORS. S STAINLESS STEEL STC STANDARD TESTING CONDITIONS TYP TYPICAL UPS UNINTERRUPTIBLE POWER SUPPLY V VOLT Vmp VOLTAGE AT MAX POWER VICINITY MAP INDEX Voc VOLTAGE AT OPEN CIRCUIT W WATT 3R NEMA 3R, RAINTIGHT PV1 COVER SHEET PV2 SITE PLAN PV3 STRUCTURAL VIEWS PV4 UPLIFT CALCULATIONS LICENSE GENERAL NOTES PV5 THREE LINE DIAGRAM _r Cutsheets Attached GEN #168572 1. ALL WORK TO BE DONE TO THE 8TH EDITION ELEC 1136 MR OF THE MA STATE BUILDING CODE. 2. ALL ELECTRICAL WORK SHALL COMPLY WITH THE 2014 NATIONAL ELECTRIC CODE INCLUDING MASSACHUSETTS AMENDMENTS. MODULE GROUNDING METHOD: ZED SOLAR AHJ: North Andover REV BY DATE COMMENTS REV A NAME DATE COMMENTS * * * * * * UTILITY: National Grid USA (Massachusetts Electric) 41 CONFIDENTIAL— THE INFORMATION HEREIN JOB NUMBER JB-0183884 0 0 PREMISE OWNER: DESCRIPTION: DESIGN: CONTAINED SHALL NOT E USED FOR THE MIKE FOX Mike Fox RESIDENCE George Puckett , solarCity.BENEFlT OF ANYONE EXCEPT SOLARCnY INC., MOUNTING SYSTEM: � NOR SHALL IT BE DISCLOSED IN WHOLE OR IN ZS Comp V4 w Flashing—Insert 45 BRIDGES LN 11.96 KW PV ARRAY PART TO OTHERS OUTSIDE THE RECIPIENT'S NODDLES: NORTH ANDOVER MA 01845 ORGANIZATION, EXCEPT IN CONNECTION WITH 24 St. Martin Drive.Building 2,Unit 11 THE SALE AND USE OF THE RESPECTIVE (46) TRINA SOLAR # TSM-260PDO5.18 PAGE NAME: SHEET REV: DATE T: (650)636-1028. MA A( 617 638-1029 SOLARCITY EQUIPMENT, WITHOUT THE WRITTQJ INVERTER: PERMISSION OF SOLARCITY INC. SOLAREDGE SE1000OA—USOOOSNR2 COVER SHEET PV 1 6/14/2016 (666)—sa-clTr(765-2489) www.galaraityaam PITCH: 32 ARRAY PITCH:32 MPI AZIMUTH:201 ARRAY AZIMUTH: 201 MATERIAL: Comp Shingle STORY: 2 Stories PITCH: 32 ARRAY PITCH:32 MP2 AZIMUTH: 111 ARRAY AZIMUTH: 111 MATERIAL: Comp Shingle STORY: 2 Stories {apt 1, PITCH: 32 ARRAY PITCH:32 MP3 AZIMUTH:21 ARRAY AZIMUTH: 21 JASON WILLIAM tiN MATERIAL: Comp Shingle STORY: 2 Stories o PITCH: 32 ARRAY PITCH:32 STRUCTUTURAL TONMP4 AZIMUTH:291 ARRAY AZIMUTH: 291 v cn No.51554 09 qS �o �Q MATERIAL: Comp Shingle STORY: 2 Stories Oc /STEP FSS/ANAL ENG\ 016 C Digitally signed by Jason Toman Date:2016.06.14 10:35:29-07'00' Pitch 12 3 ° v LEGEND a 0 (E) UTILITY METER & WARNING LABEL J INVERTER W/ INTEGRATED DC DISCO U) y� Iry & WARNING LABELS D £d T B (E) DRIVEWAY ® DC DISCONNECT & WARNING LABELS m In AC AC DISCONNECT & WARNING LABELS DC JUNCTION/COMBINER BOX & LABELS DISTRIBUTION PANEL & LABELS D , , , r��� i emP1 LC LOAD CENTER & WARNING LABELS A A O DEDICATED PV SYSTEM METER O STANDOFF LOCATIONS —� CONDUIT RUN ON EXTERIOR --- CONDUIT RUN ON INTERIOR Front Of House GATE/FENCE O HEAT PRODUCING VENTS ARE RED r,_-i INTERIOR EQUIPMENT IS DASHED SITE PLAN N Scale: 1/8" = 1' 01' 8' 16' W 5 CONFIDENTIAL— THE INFORMATION HEREIN JOB NUMBER: J B-0183884 00 PREMISE OWNER: DESCRIPTION: DESIGN: CONTAINED SHALL NOT USED FOR THE MIKE FOX Mike Fox RESIDENCE George Puckett SolarCity. BENEFIT OF ANYONE EXCEPT SOLARCITY INC,. MOUNTING SYSTEM: �. NOR SHALL IT BE DISCLOSED IN WHOLE OR IN ZS Comp V4 w Flashing—Insert 45 BRIDGES LN 11.96 KW PV ARRAY or PART TO OTHERS OUTSIDE THE RECIPIENTS ORGANIZATION, EXCEPT IN CONNECTION HATH NODDIES NORTH ANDOVER, MA 01845 S4 SALE AND USE OF THE RESPECTIVE (46) TRINA SOLAR # TSM-260PDO5.18 24 St. Martin Drive, Building 2,Unit TT SOLARCIT EQUIPMENT, WITHOUT THE WRITTEN PAGE NAME SHEET: REV: DATE Marlborough,MA 01752 PERMISSION OF SOLARCITY INC. INVERTER: PAGE SE1000OA–USOOOSNR2 SITE PLAN PV 2 6/14/2016 (888)-SOL (765---2489js e�°I°maty om S1 S1 S1 13'-5- 01 4" 13'-6" ol 1'— (E) LBW 11— (E) LBW 1'— (E) LBW A SIDE VIEW OF MP1 NTS B SIDE VIEW OF MP2 NTS SIDE VIEW OF MP3 NTS C MP1 X-SPACING X-CANTILEVER Y-SPACING Y-CANTILEVER NOTES MP2 X-SPACING X-CANTILEVER Y-SPACING Y-CANTILEVER NOTES LANDSCAPE 64" 24" STAGGERED LANDSCAPE 64" 24" STAGGERED MP3 X-SPACING X-CANTILEVER Y-SPACING Y-CANTILEVER1 NOTES PORTRAIT 48" 17" PORTRAIT 48" 17" 1 1 LANDSCAPE 64" 24" STAGGERED ROOF AZI 201 PITCH 32ROOF AZI 111 PITCH 32 PORTRAIT 48" 17" ROOF AZI 21 PITCH 32 RAFTER 2x8 @ 16' OC STORIES: 2 RAFTER 2x8 @ 16' OC STORIES: 2 ARRAY AZI 201 PITCH 32 ARRAY AZI 111 PITCH 32 RAFTER 2X8 @ 16"OC STORIES: 2 ARRAY AZI 21 PITCH 32 C.J. 2x8 @16"OC Comp Shingle C.J. 2X8 @16"OC Comp Shingle C.I. 2X8 @16"OC Comp Shingle PV MODULE 5/16"x1.5" BOLT WITH 5/16" FLAT WASHER JASON WILLIAM ti� INSTALLATION ORDER TOMAN 1-14 ZEP LEVELING FOOT 00 STRUCTURAL C LOCATE RAFTER, MARK HOLE No.51554 ZEP ARRAY SKIRT (1) LOCATION, AND DRILL PILOT S1 10 9��isTEP``� Q HOLE. --------- --- -------- FSS�ONAL EN� ZEP MOUNTING BLOCK (4) ATTACH FLASHING INSERT TO 016 (2) MOUNTING BLOCK AND ATTACH ZEP FLASHING INSERT (3) TO RAFTER USING LAG SCREW. 4LAU 13'-5" (E) COMP. SHINGLE (1) INJECT SEALANT INTO FLASHING 1'— (E) LBW (E) ROOF DECKING (2) (3) INSERT PORT, WHICH SPREADS SEALANT EVENLY OVER THE SIDE VIEW OF MP4 NTS 5/16" DIA STAINLESS ROOF PENETRATION. D STEEL LAG SCREW LOWEST MODULE SUBSEQUENT MODULES (2-1/2" EMBED, MIN) INSTALL LEVELING FOOT ON TOP MP4 X-SPACING X-CANTILEVER Y-SPACING Y-CANTILEVER NOTES (4) OF MOUNTING BLOCK & SECURELY FASTEN WITH BOLT. LANDSCAPE 64" 24" STAGGERED (E) RAFTER STANDOFF PORTRAIT 48" 17" RAFTER 2X8 @ 16"OC ROOF AZI 291 PITCH 32 STORIES: 2 1 ARRAY AZI 291 PITCH 32 C.I. 2x8 @16"OC Comp Shingle JB-0183884 0 0 PREMISE OWNER: DESCRIPTION: DESIGN: CONFIDENTIAL- THE INFORMATION HEREIN JOB NUMBERMIKE FOX Mike Fox RESIDENCE George Puckett t•So�arCit CONTAINED SHALL NOT BE USED FOR THE __ J BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: Io1\ NOR SHALL IT BE DISCLOSED IN WHOLE OR IN ZS Comp V4 w Flashing—Insert 45 BRIDGES LN 11.96 KW PV ARRAY PART OTHERS THE RECIPIENT'S MODULES NORTH ANDOVER MA 01845 ORGANIZATION, EXCEPTEPT IN IN CONNECTION WITH , THE SALE AND USE OF THE RESPECTIVE (46) TRINA SOLAR # TSM-260PDO5.18 1 24 St. Martin Drive,Building 2,Unit 11 01752 SOLARCITY EQUIPMENT, WITHOUT THE WRITTEN INVERTER: PAGE NAME SHEET: REV DATE T: (650)638-1028 FA(650)638-1029 PERMISSION OF sOLARCITY INC. SOLAREDGE SE1000OA—USOOOSNR2 STRUCTURAL VIEWS PV 3 6/14/2016 (888)-SOL-CITY(765-2489) www.solarcity.corn UPLIFT CALCULATIONS SEE SEPARATE PACKET FOR STRUCTURAL CALCULATIONS. JB -0183884 0 0 PREMISE OWNER: DESCPoPTION: DESIGN: CONFIDENTIAL THE INFORMATION HEREIN JOB NUMBER: CONTAINED SHALL NOT BE USED FOR THE MIKE FOX Mike Fox RESIDENCE George Puckett ,solarCity. BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: Ai t NOR SHALL IT BE DISCLOSED IN WHOLE OR IN ZS Comp V4 w Flashing—Insert 45 BRIDGES LN 11.96 KW PV ARRAY PART TO OTHERS OUTSIDE THE RECIPIENTS MODULES NORTH ANDOVER MA 01845 ORGANIZATION, EXCEPT IN CONNECTION WITH 24 St. Martin Drive, Building 2, Unit 11 THE SALE AND USE OF THE RESPECTIVE (46) TRINA SOLAR # TSM-260PDO5.18 PACE NAME SHEET: REV. DATE Marlborough, MA 01752 PSOLARCITYERMISO EQUIPMENT, WITHOUT THE WRITTEN INVERTER: T: (650)638-1028 F: (650)638-1029 PERMISSION of SOLARCITY INc. SOLAREDGE SE1000OA—USOOOSNR2 UPLIFT CALCULATIONS PV 4 6/14/2016 (BB8)-SOL-CITY(765-2489) www.edarcity.com GROUND SPECS MAIN PANEL SPECS GENERAL NOTES INVERTER SPECS MODULE SPECS LICENSE BOND (N) #8 GEC TO TWO (N) GROUND Panel Number:G3030MB1200 Inv 1: DC Ungrounded INV 1 -(1)SOLAREDGE #SE10000A-USOOOSNR2 LABEL: A -(46)TRINA SOLAR # TSM-260PDO5.18 GEN #168572 ODS AT PANEL WITH IRREVERSIBLE CRIMP Meter Number:05033237 Tie-In: Supply Side Connection Inverter; 1000OW, 240V, 97.5�q w Unifed Disco andZB,RGM,AFCI PV Module; 215OW, 236.9W PTC, 40MM, Black Frame, H4, ZEP, 1000V ELEC 1136 MR ` Underground Service Entrance INV 2 Voc: 38.2 Vpmox: 30.6 INV 3 Isc AND Imp ARE SHOWN IN THE DC STRINGS IDENTIFIER E 200A MAIN SERVICE PANEL E 20OA/2P MAIN CIRCUIT BREAKER SolarCity (E) WIRING CUTLER-HAMMER Inverter 1 5 A 1 Disconnect CUTLER-HAMMER 20OA/2P Disconnect 6 SOLAREDGE DC. - B 60A SE1000OA-USOOOSNR2 DC- MP1: 1x18 C EGC A LI0240V ------------ -- - --- --- ---------- -- --- 2 3 - B L2 I - - - N DG i q DC- MP3,MP4: 1x12 (E) LOADS GND _ ____ GND _-___________-___________ _ EGC/ DC+ DC. - MP2,MP3: 1x16r7j," GEC N DC- -__ GND __ EGC_-_ EGC--------- ------------ - ----- -- ---------- -�---- I N (1)Conduit Kit; 3/4" EMT _J o EGC/GEC Z I I I � _ GEC T-1 TO 120/240V i I SINGLE PHASE UTILITY SERVICE I I I I i I I - i I I I I PHOTO VOLTAIC SYSTEM EQUIPPED WITH RAPID SHUTDOWN Voc* = MAX VOC AT MIN TEMP POI (2)Grpd Rod B (1)CUTLER-HAMMER ly DG222NRB A (1)SolarCityy 4 STRING JUNCTION BOX 5 8 x 8, per Disconnect; 60A, 24OVac, Fusible, NEMA 3R AC 2x2 STR GS, UNFUSED, GROUNDED DC -(2)ILSCO/IPC�0-�6 -(1)CUTLER-HAMMER �I DG10ONB Insulo ion Piercing Connector; Main 4/0-4, Tap 6-14 Ground eutral isit; 60-100A, General Duty(DG) PV (46)SOLAREDGE 300-2NA4AZS S SUPPLY SIDE CONNECTION. DISCONNECTING MEANS SHALL BE SUITABLE -(1)CUTLER-HAMMER g DS16FK PowerBox imizer, 30OW, H4, DC to DC, ZEP AS SERVICE EQUIPMENT AND SHALL BE RATED PER NEC. Class R Fuse Kit (1)AwG #6, Solid Bare Copper -(2)FFu�AZ6oSAA2M50V,#gassORK5 PV BACKFEED OCP nd -(1)Ground Rod; 5/8" x 8', Copper C (I CUTLER-HAMMER DG222URB N ARRAY GROUND PER 690.47(D). NOTE: PER EXCEPTION N0. 2, ADDITIONAL Disconnect; 60A, 240Vac,Non-Fusible, NEMA 3R (N) -(1)Gra,nd�NeuMuRK'tDso OOA General Duty(DG) ELECTRODE MAY NOT BE REQUIRED DEPENDING ON LOCATION OF (E) ELECTRODE (l)AWG#6, THWN-2, Black � 1 AWG#6, THWN-2, Black (1)AWG 18, THWN-2, Black Voc* =500 VDC ISC =30 ADC 2)AWG g10, PV Wire, 60OV, Black Voc* =500 VDC Isc =15 ADC O (1)AWG/6, 1HWN-2, Red ©it(1)AWG#6, THWN-2, Red ® (1)AWG /8, THWN-2, Red Vmp =350 VDC Imp=20.53 ADC O (1)AWG#6, Solid Bare Copper EGC Vmp =350 VDC Imp=13.2 ADC (1)AWG 16, THWN-2, White NEUTRAL Vmp =240 VAC Imp=42 AAC (1)AWG#10, THWN-2, White NEUTRAL Vmp =240 VAC Imp=42 AAC 0 AWG 10, THHN WN-2, Green EGC IJ . . . . . . . . . . . . . . . . . . . . . . - 1 AN#6,.Solid Bare.Copper. GEC. . . -0)Conduit.Kit;.3/47.EMT. .. . . . . . . . . . .. .. .-(1)AWG$8,.TFIWN-2,.Green _ . EGC/GEC,-(1)Conduit.Kit;.3/47.EMT. . . . . . . . . . (1 AWG#10, 1HWN-2, Block Voc* 500 VDC Isc -15 ADC (2)AWG X. . PV More, 600V, Black Voc* =500 VDC Isc .15 ADC O RF (1)AWG 110, THWN-2, Red Vmp =350 VDC Imp=13.2 ADC O (1)AWG X16, Solid Bare Copper EGC Vmp =350 VDC Imp=8.8 ADC (1)AN #10, THHN/THWN-2, Green EGC (2)AWG X110, PV Wire, 60OV, Black Voc* =500 VDC Isc =15 ADC O (1)AWG X16, Solid Bare Copper EGC Vmp =350 VDC Imp=11.73 ADC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . CONFIDENTIAL- THE INFORMATION HEREIN JOB NUMBER: JB018 3 8 8 4 O 0 PREMISE OWNER: DESMPTION: DESIGN: ' CONTAINED SHALL NOT BE USED FOR THE Nk MIKE FOX Mike Fox RESIDENCE George Puckett 'IQ BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: h�� SolarCity. NOR SHALL IT BE DISCLOSED IN WHOLE OR IN ZS Comp V4 w Flashing-Insert 45 BRIDGES LN 11.96 KW PV ARRAY , PART OTHERS OUTSIDE THE RECIPIENT'S MODULES NORTH ANDOVER MA 01845 ORGANIZATION,EXCEPT IN CONNECTION WITH r 24 St.Martin Drive,Building 2,Unit 11 THE SALE AND USE OF THE RESPECTIVE (46) TRINA SOLAR # TSM-260PDO5.18 Marlborough,MA Building 2, SOLARCITY EQUIPMENT, WITHOUT THE WRITTEN PAGE NAME: SHEET: REV: DATE: PERMISSION OF SOLARCITY INC. INVERTER: 1. (650)638-1028 F- (650)638-1029 SOLAREDGE SE1000OA-USOOOSNR2 THREE LINE DIAGRAM PV 5 6/14/2016 (888)-SOL-CITY(765-2489) www.Warcitycom Label Location: Label Location: Label Location: (C)(CB) (AC)(POI) • (DC) (INV) Per Code: Per Code: _ Per Code: NEC 690.31.G.3 ° • NEC 690.17.E ° ' NEC 690.35(F . -• . •- s ) Label Location: o 'C o - • • • •- TO BE USED WHEN ® ® ® ® (DC) (INV) ••D D e[�• -D -• s s • • INVERTER IS Per Code: .p • UNGROUNDED NEC 690.14.C.2 Label Location: Label Location: • • • 'I "0 • (POI) -'® - (DC) (INV) - ° ° ® Per Code: ° Per Code: •-o D• • • NEC 690.17.4; NEC 690.54 NEC 690.53 • o -• o e- !;! Label Location: '- • k' • (DC) (INV) Per Code: .® D e ® NEC 690.5(C) • ® D e �JPOI Label Location: ( ) • . •- ® -• - •_• -® Per Code: ® ® ® NEC 690.64.B.4 Label Location: • (DC) (CB) ® •-D Per Code: V Label Location: D® ® ® NEC 690.17(4) (D) (POI) • D Per Code: ®•' '-® : D NEC 690.64.B.4 ® o e •o Label Location: • (POI) _ Per Code: Label Location: ® ® •• NEC 690,64.6.7 ® (AC) (POI) ®• • • (AC): AC Disconnect Per Code: ®® - (C): Conduit NEC 690.14.C.2 (CB): Combiner Box (D): Distribution Panel (DC): DC Disconnect (IC): Interior Run Conduit Label Location: II (INV): Inverter With Integrated DC Disconnect (AC) (POI) (LC): Load Center •' Per Code: (M): Utility Meter NEC 690.54 (POI): Point of Interconnection CONFIDENTIAL— THE INFORMATION HEREIN CONTAINED SHALL NOT BE USED FOR ��tvr g� 3055 Clearview Way THE BENEFIT OF ANYONE EXCEPT SOLARCITY INC., NOR SHALL IT BE DISCLOSED •: San Mateo,CA 94402 �• ' (650)638-1028 F:(650)638-1029 EXCEPT IN CONNECTION W IM WHOLE OR IN PART TO OTHERS OUTSIDE THE RECIPIENTS ORGANIZATION, Label Set WITH THE SALE AND USE OF THE RESPECTIVE ��+�®� ��Tv (888)SOL-Cm(765-2489)www.wlarcity.com SOLARCITY EQUIPMENT, WITHOUT THE WRITTEN PERMISSION OF SOLARCITY INC. 0 solar=01 z Solar=qq SolarEdge Power Optimizer Module Add-On for North America P300 / P350 / P400 SolarEdge Power Optimizer .......... ........... ......j.......... P300 P350 P356 12400- ............ Module Add-On For North America (for (for 7 (for 9111 P mo modules) P300 P350 P400 I..NPU.T ............. -------i�o Rated Input DC Powerru 300 400 W ..... ...... .... .............. ........ . ........ ...... Absolute Maximum Input Voltage__(Voc at lowest temperature) 48 60 80 Vdc M.P.PT Operating Range 8 Maximum Short Circuit Current(sc) 10 ..M�ximum DC.Inpu 5 Adc ............... ......... ........ Maximum Efficiency ........................................ ........................ .............1..99. Weighted Efficiency 98.8 Ovewoltage'C*a*tego*ry It OUTPUT DURING OPERATION(POWER OPTIMIZER CONNECTED TO OPERATING INVERTER) Maximum Output Current _ .15 u Adc ............. Maximum Output Voltage ......... ...........60 Vdc OUTPUT DURING STANDBY(POWER OPTIMIZER DISCONNECTED FROM INVERTER OR INVERTER OFF) Safety Output Voltage per Power Optimizer -STANDARD COMPLIANCE EMC.... ..................................................................... FC P rt15.CIass B,IEC61000-6-2 -6-3 !IEC61000 IEC62109-1(class 11 safety), ... ........ ........... ............................................... JRoHS Yes ..................................._.__........... ........ INSTALLATION SPECIFICATIONS ........... Ma 1000 Vdc ............. .................................................. �.x 212 x 40.5/5,55 x 8.34 x 1.59 ............... ........ .................;.i................ Weight(including cables) 959 ............................. gr/!Ib_ Input Connector .. M4AmphenolTyco� .......... ........ ..... ......... .. Output t Wire Type Connector Double insulated;Amphenol . . ' '' 095/3.0 �.------I... .... .... .... In ft Output,. Wire Length .................................................. ........... ....I I............," Operating Temperature 172 IA:?' Range ....... .......I........ 4.0 +85/.--.40..-.+185 ......... ...... ... Protection Rating Reatiyellumidity'.. 0-1 % ............. ........... ...... ............. .......... ....................... .......... ...................- .............. PV SYSTEM DESIGN USING A SOLAREDGE THREE PHASE THREE PHASE INVERTER SINGLE PHASE 208V 480V PV power optimization at the module level' Minimum String Length(Power Optimizers) 8 T——10 ..................... .............. ........ ...... Maximum String Length(Power Optini 25 2. 50 Upto 25%more energy ........... .....................I.......................... ........... ........I................................. um Power per String 5250 6000 12750 Su p eri o r effici ency(99.5%) .........I".......... .............. ............ ... .... .. .......... .......... W Maxii — Mitigates all types of module mismatch losses,from manufacturing tolerance to partial shading Par.a.I I.e.I.Sti of.Different Lengths or Orientations Yes Flexible system design for maximum space utilization Fast installation with a single bolt Next generation maintenance with module-level monitoring Module-level voltage shutdown for installer and firefighter safety USA - GERMANY - ITALY - FRANCE - JAPAN CHINA - ISRAEL AUSTRALIA www.solared.-e.us THE 79;tmmount MODULE TSM-PD05.18 Mono Multi Solutions DIMENSIONS OF PV MODULE ELECTRICAL DATA @ STC unit:mm Peak Power Watts-P-(Wp) 250 255 260 265 941 Power Output Tolerance-PN.nx(%i 0-3 en"cnoN Maximum Power Voltage-V- 30.3 30.5 30.6 30.8 Eaz Maximum Power Current-IMar(�o Tun E (A) 8.27 8.37 8.50 8.61 HAA1EPuk. Open Circuit voltage-Voc(v) 38.0 38.1 38.2 38.3 0 <m vx,z Short Circuit Current-Isc(A) 8.79 8.88 9.00 9.10 INSTR LING N°LE O = Module Efficiency h,,(%) 15.3 15.6 1 16.2 STC:Irradiance 1000 W/m',Cell Temperature 25"C,Air Mass AM1.6 according to EN 60904-34-3. Typical efficiency reduction of 4.5%at 200 W/m'according to EN 60904-1. o � ° o ELECTRICAL DATA Q NOCT Maximum Power-P-Wp) 186 190 193 197 60 CELL Maximum Power Voltage-V. (V) 28.0 28.1 28.3 28.4 Maximum Power Current-l-(A) 6.65 6.74 6.84 6.93 MULTICRYSTALLIN'E MODULE "°°"°'rvG"oLE PD05.18 A A Open Circuit Voltage(V)-Vac{V) 35.2 35.3 35.4 35.5 ,roxury NOLE WITH TRINAMOUNT FRAME Short Circuit Current(A)-Isc(A) 7.10 7.17 7.27 7.35 1 NOCT:Irradiance at 800 W/m',Ambient Temperature 20°C.Wind Speed 1 m/s. 812 1 180 Back view MECHANICAL DATA POWER OUTPUT RANGE Solar cells Multicrystalline 156 x 156 mm(6 inches) Cell orientation 60 cells(6 x 10) ------ Fast and simple to install through drop in mounting solution Module dimensions 1650 x 992•40 mm(64.95 N 39.05 x 1.57 inches) - Weight 19.6 kg(43.12 lbs) % v s Glass 3.2 mm(0.13 inches).High Transmission,AR Coated Tempered Glass MAXIMUM EFFICIENCY Backsheet White A-A Frame Black Anodized Aluminium Alloy .., Good aesthetics for residential applications J-Box IP 65 or IP 67 rated Q Cables 1200 mmhotovolt(47.2enches)gy cable 4.0 mm'(0.006 inches'), -_-......_. _ ........... _._...--....__... _._-...... __.. --- I-V CURVES OF PV MODULE(260W) POSITIVE POWER TOLERANCE Connector H4 Amphenal Eo.00 oao f000W m, _ Fire Type UL 1703 Type 2 for Solar City Highly reliable due to stringent quality control • Over 30 in-house tests(UV, CL',HI,and man, more) '0° a As a leading global manufacturer • In-house testing goes well beyond Certification requirements ` 80° I saowm TEMPERATURE RATINGS MAXIMUM RATINGS of next ration photovoltaic PID resistant $00 J imNominal OperatingCell Operational Temperature -40-+85°C procucts,vve believe dos m - Temperature(NOT) 44°C( **-2°C) coc Aeration with Our partners aoa ` Maximum System 1000V DC(IEC) is critical to success. With local z.W w- Temperature Coefficient of P.x -0.41%/°C Voltage 1000V DC(UL) presence around the globe, r+na is IM Temperature Coefficient of Voc -0.32%/°C Max Series Fuse Rating ISA able to provide exceptional service °00 so w so Temperature Coefficient of tsc 0.05%/°C to each casia r In each m rket Certified to withstand challenging environmental 0 m z° and sur> lem nt our y°lt•9•m conditions reliable products with the backing 2400 Po wind load WARRANTY c`Tina as a strong,bankable 5400 Pa snow load partner. We are CarT'mllied 10 year Product Workmanship Warranty to building siratogic,mutuaily CERTIFICATION beneficial collaboration with 25 year Linear Power Warranty a nstailers,develaper=_,distributors' c UL US a (Please mfertoproduct warranty for details) Q us and curler partners' aners as the16fE0 0 backbone o:our shared sijccestin 6f?3 r driving smart Energy Tag er LINEAR PERFORMANCE WARRANTY �w. Iii PACKAGING CONFIGURATION EI128 EEE .---------_ 10 Year Product Warranty•25 Year Linear Power Warranty CO Nr Modules per box:26 pieces w Trino Solar Limited ._ Modules per 40'container:728 pieces w,w.trinasolor.com y1o0% : Addif]anal d 9o% valuE from Trina Saiar's fi p n@ar warr{yn CAUTION.READ SAFETY AND INSTALLATION INSTRUCTIONS BEFORE USING THE PRODUCT. pOMPATjO ® o fY ® ®2015 Tr na Solar Limited.All rights reserved.Specifications included in this dotasheet are subject to Wa '�o solar O 80% 111ra n-asolar changewilhoutnolice Smart Energy'L,ogether Smart Energy rogether e tz Years 5 10 IS 20 25 � Trinastendard ® Intu':" I so I a r ® Single Phase Inverters for North America ® s o I a r ® SE3000A-US/SE3800A-US/SE5000A-US/SE6000A-US/ SE7600A-US/SE1000OA-US/SE1140DA-US SE3000A-US SE3800A-US SESOOOA-UUP SE6000A-USJ SE7600A-USi SE10000A-US SE11400A-US OUTPUT SolarEdge Single Phase Inverters _ __ . __. _. __ Nominal AC Power Output � 3000 3800 5000 6000 7600 9980 @ 208V 11400 VA 9 9 ..... . . . . . .."............ . . ... . . . . . ....... ........... �ooaa z4oy.�......... . ................. Max.AC Power Output 3300 41-50. 150 0 @ 208V 6000 8350 10800 @ 208V 12000 VA For North America .............5450.@?4QY.................. ..... ... .......�095o@240y. .......... ....... ... AC Output Voltage Min.-Nom:Max.i11 SE3000A-US/SE3800A-US f SE5000A-US/SE6000A-US/ 183-zo8,z 9Vas......... ... . ..... .......:........ ....... ........................;....... ....... .".............. .... .. ........ ... .. ... ... ........... . AC Output Voltage Min.-Nom:Max.i11 i i ✓ ✓ ✓ ✓ SE760OA-US/SE10000A-US/SE1140OA-US 211-240-264 Vac ±...............:"............"".".................................................... ....... ... .................. AC Frequency Min.-Nom.-Max.1' 59.3-60-60.5(with HI country setting 57-60-60.5) Hz . 24 @ 240V 32 48 @ 208V Max.Continuous Output Current 12.5 16 I 25 47.5 A ... . . . ....... ... . . .. �. z1 @ zgov I .... 4z @ zaov .... GFDI Threshold 1 A Utility Monitoring,Islanding Protection,Country Configurable Thresholds Yes ( Yes INPUT _ _ - _ F - -'rvalta� -Maximum DC Power(STC)T 4050 5100,-�6750 8100 7 10250 13500 15350 W a .. ... ....................... .Pwe. ` A �-�, q2CJ ° Transformer less,Ungrounded Yes w4 ............... ... .. . .. . . . s m Veal .�'. - Max.Input Voltage 500 Vdc g Wa m �aa1Y l .... ..... . ..... . ... . . . .. . . . . . . . . . . , . . ... .. ......... Nom.DC Input Voltage 325 @ 208V/350 240V Vdc ...._� p\ 16.5 @ 208V33 @ 208V 1. Max.Input Current)�) 9.5 13 18 23 34.5 Adc .. .......... ... ....... . . ... ... ... ....... ... . ..... .......15.5.@240V ... ... ... ... ..........30.5,4a1,240V..) ... ....... ........... f Max.InPut Short Grcuit Current 45 Adc Reverse Pola..rity.Protection. ... . Yes .......... .... .. . . .. .............. ... ... ..... .. .. .... .. ..........-.............. ....... ...... ... ........ ........................ { Ground-Fault Isolation Detection 600ku Sensitivity ` Mawmum Inverter Efficiency 97J 98.2 j 98.3 98.3 98 98 98 / .. ..... ..... ... ............ .... .. 97.5 @ 208V 1 97 @ 208V .. ... CEC Weighted Efficiency 97.5 98 1 97.5 97.5 97.5 ........................................ ................�...............;..9$.@.240V..I................I...................97:S.@.240V..(,.................. Nighttime Power Consumption <2.5 <4 W t ADDITIONAL FEATURES �._. 1 : Supported Communication Interfaces R5485,RS232,Ethernet,2igBee(optional) . . ... . .... ..... .. .. ... ...P. .. . .. i Revenue Grade Data,ANSI C12 1 O tionali 1 .. .. .... ... ... .... ...... .......... .. . ................. Rapid Shutdown NEC 2014 690.12 f Functionality enabled when SolarEdge rapid shutdown kit Is installed14) -I STANDARD COMPLIANCE Safety " " U14741,UL36996,UL1998.CSA 22.2 Grid Connection Standards IEEE1547 .. .. Emissions FCC part15 class B INSTALLATION SPECIFICATIONS output conduit size/AWG range 3/4"minimum/16 6 AWG 3/4"minimum/8-3 AWG DC input conduit size/q of strings 1 3/4"minimum/1-2 strings/ 3/4"minimum/1-2 strings/166AWG i . ,AWG range... ... ... . . ..... .. . .. .... .. . .. 14 6 AWG ........ Dimensions with Safety Switch 30.5 x 12.5 x 10.5/ in/ 1 30.5 x 12.5 x 7.2/775 x 315 x 184 ! ..�HxWxD)............. ... .......... . ............ .. ... ... ... . .775x315 x.260.. .. ...mm.... . Weight with Safety Switch " , ,,, ,,, 51.2/23.2 54.7/24.7, „ ,,,,,., 88.4/40.1„ ,"Ib/,kg,,, . .... .. .. .I........... ...... . . .. .. . . . ... ... ..... Natural i _ convection Cooling Natural Convection andinternal Fans(user replaceable) fan(user The best choice for SolarEdge enabled systems .. .. . .. ... .replaceable),, ,.,..., Noise <25 <50 d8A 1 - Integrated arc fault protection(Type 1)for NEC 2011.690.3.1 complianceMin.-Max.Operating Temperature 13 to+140/-25 to+60(40 to+60 version availableis)) F/'C - Superior efficiency(9830 -Range. - . .......................... Protection Rating NEMA 3R ........".. ... .. ....act Sol... ..... . .. .... ... .... .. .... Small,lightweight and easy to install an provided.bracket ;,; " " " ' " ' " ' " " " "" " i � Far other regional settings please contact SolarEdge support o Ah gher current source may be used,the inverter will limit is input current to the values stated - Built-in module level monitoringnRevenue gad inverter P/N:SE-AUSDOONNR2(for 760OW m,n,,tr5E760DA-US002NNR2). s, Rapid shutdown kit P/N.SE1000-RSD-Sl. '• Internet connection through Ethernet Dr Wireless isi�10version P/N:SE-A-US000NNU4 ifor760OW inverter:SE7600A-US00214141.14). - Outdoor and indoor installation - Fixed voltage inverter,DC/AC conversion only Pre-assembled Safety Switch for faster installation - Optional-revenue grade data,ANSI C12.1 sunsa�c USA-GERMANY-ITALY-FRANCE-JAPAN-CHINA-AUSTRALIA-THE NETHERLANDS-ISRAEL. WWW.solaredge'.US e zl� ^'So1arCity I ®pSolar Next-Level PV Mounting Technology '^Solar�ity ®pSolar Next-Level PV Mounting Technology ZS Comp Components . for composition shingle roofs O O O Mounting Block Array Skirt Interlock Part No.850-1633 Part No.850-1608 or 500-0113 Part No.850-1388 or 850-1613 Listed to UL 2703 Listed to UL 2703 Listed to UL 2703 Flashing Insert Grip Ground Zep V2 Part No.850-1628 Part No.850-1606 or 850-1421 Part No.850-1511 Listed to UL 2703 Listed to UL 2703 Listed to UL 467 and UL 2703 GOMPq j� Description PV mounting solution for composition shingle roofs Works with all Zep Compatible Modules °pMPp�� Auto bonding UL-listed hardware creates structural and electrical bond • ZS Comp has a UL 1703 Class"A"Fire Rating when installed using modules from any manufacturer certified as"Type 1"or"Type 2" Captured Washer Lag End Cap DC Wire Clip U` LISTED Pad No.850-1631-001 Part No. Part No.850-1509 Specifications 850-1631-002 (L)850-1586 or 850-1460 Listed to UL 1565 850-1631-003 (R)850-1588 or 850-1467 • Designed for pitched roofs 850-1631-004 • Installs in portrait and landscape orientations • ZS Comp supports module wind uplift and snow load pressures to 50 psf per UL 2703 • Wind tunnel report to ASCE 7-05 and 7-10 standards • ZS Comp grounding products are UL listed to UL 2703 and UL 467 • ZS Comp bonding products are UL listed to UL 2703 • Engineered for spans up to 72"and cantilevers up to 24" • Zep wire management products listed to UL 1565 for wire positioning devices Leveling Foot Part No.850-1397 zepsolar.com zepsolar.com Listed to UL 2703 This document does not create any express warranty by Zap Solar or about its products or services.Zep Solar's sole warranty is contained in the written product warranty for This document does not create any express warranty by Zep Solar or about its products or services.Zep Solar's sole warranty is contained in the written product warranty for each product.The end-user documentation shipped with Zep Solar's products constitutes the sole specifications referred to in the product warranty.The customer is solely each product.The end-user documentation shipped with Zep Solar's products constitutes the sole specifications referred to in the product warranty.The customer is solely responsible for verifying the suitability of ZepSolar's products for each use.Specifications are subject to change without notice.Patents and Apps:zspats.com. responsible for verifying the suitability of ZepSolar's products for each use.Specifications are subject to change without notice.Patents and Apps:zspats.com. Document#800-1839-001 Rev D Date last exported:April 29,2016 11:22 AM Document#800-1839-001 Rev D Date last exported:April 29,2016 11:22 AM 1010 r Date . 71.31_3. . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . . . A- e . . . . . . . . . . . . . . . . . . has permission to perform . . l�?1 �re�+, 4�4�� . �!--�� . . . . . . . . . . plumbing in the buildings of. . .+C7( . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . A/Z� v .44. . . 'rte! , North Andover, Mass. Ld 1*ee . C'. . . Lic. No. t� .?t.2-. 1� . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # bt lq� - �P --� 1-`q MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 9. CITY _S _ �. MA DATE - I PERMIT# /,M�o JOBSITE ADDRESS es �_I/1 OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL RESIDENTIAL 5r' N PRINT CLEARLY NEW: 0I RENOVATION:5Z REPLACEMENT: ® PLANS SUBMITTED: YES 0 NOF—] Q. FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 � BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM F DEDICATED GREASE SYSTEM = __._I DEDICATED GRAY WATER SYSTEM 1-7 DEDICATED WATER RECYCLE SYSTEM i _( .DISHWASHER _.DRINKING FOUNTAIN i JFOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ I _r i J i ..__ ( _( I .._.._._� _..._._. __._ i ___._ ..._.__... KITCHEN SINK LAVATORY IW-71rn, _ROOF DRAINSHOWER STALLSERVICE/MOP SINKTOILET I _ URINAL -WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ( ( I 1 I _( _.__. ----- I ---_f OTHER _ I _-_-_J _ I ____(I__.._-_I _._._--_JI---- F-71= __ I ( ; € _.._._._1 I __l .__. I -__ .._( _._ .._( _( _._.._ a .._ -I _I I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESO NO 0 IF YOU CHECKED YES,PLEASE INDICATE TH YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND Q OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 144'ssachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME o.tn�e LICENSE# UKId �---- SIGNATURE PVIP d JP i---i, CORPORATION 0#PARTNERSHIP 0# LLC j COMPANY NAME �(u�w•�0.,,� t ��,,� — IJ ADDRESS CITY t,1 �w-�'ylC�cn_ STATE jy N ZIP I ILg ( TEL �. - $gY- `7 3 FAX CELL h7r,474',-Fs4I_ EMAIL -- -._....._...... ROUGH PLUMBING INSPECTION/NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No "? Il1 f S C l 3 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ b FEE: $ PERMIT# PLAN REVIEW NOTES l 1 K The Commonwealth of Massachusetts Department ofIndustriglACCidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/,Plumbers Applicant Information Please Print Legibly e-17'AA Name(Business/Organi'zatiorAndividual): Address:—D C v-e h F - City/State/Zip: U A w,,v,c\-c^ V4 h 0(y7 7-7 Phone#: Q 7� - Are you an employer?Check the appropriate boa: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time),* have hired the sub-contractors 2V I am a sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.D Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *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 Hie 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 their workers'comp.policy information. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy 4 or Self-ins.Lie.#: Expiration Date: 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 requiredunder 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. B e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby cero under the pains andpenalties ofperjury that the information provided above is true and correct. - Sim atur0: Date: Phone#: 2 6q Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone ff: Information %nd Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required" chapter c Additionally,MGL 152 25C a Y p ,§ (7)states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP floes have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' . compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials -Please be sure that-the affidavit is-com-complete rintecl le ibl : The De arimenthas rovided a s ace of the botEom p p g Y p p- P----- of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be.used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: `Z`hc GomY!aonweajthof rassachuset s Department offadustdal.Accidents Ofte of%Vcstigatio'm 600 Washington Street Boston? 02111. Tel,#61.7-727-4900 QYt 406 or 1:-877,MASSAFF, Revised 5-26-05 Faze#617-727;7749 'R ` I ICOMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS` LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: I JAMES P WHITE 2 CHRISTINE DR � WILMINGTON MA 0188 , , 1803a 15132 05/01/14 1.52848 ti I I qq Date......1...'..12,`..�..�....... O�r►ORT�y,h �; co TOWN OF NORTH ANDOVER PERMIT FOR WIRING 7 °.aw«•�q4 83.�(.•MU$F. This certifies that .................... .....,:,..c.�`Z c Tf� .... .....0.......................... has permission to perform ..... ..................l i < 7�,�................... wiring in the b/uilding of.................. .?x.....................:..................................................... at ... .....A24... .. ........L ........................:North Andover,Mass. Fee.... s' """..,Lic.No. ...1....7.Z 39,4 .`,................ ......�..... ELECTRICAL INSPECTQR� v Check# � t'sc 0111+ "—�---- Commonwealth of Massachusetts kl _ ZPermit No.�1 IL Department of Fire Services Occupanc\ and Fee Checked •;;,�; .>� BOARD OF FIRE PREVENTION REGULATIONS I.R+v.y U_ 1 (leat+e blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK j MI\+ork to be perliornied in accordance,+ith the\las.achusetts Electrical Nude(\t iC).527 C'\1R 12.00 WLA'.-ISE l'RLVT l.V 1.VK OR TYI 1 41.1. 1;4'F'OrN R.-t-1,-1770 ) Date: �z Cit' or'Town of: �1 �I7ro - To lltc Inst ccvur o/ if tic:.y: B\ this application the undersigned�sives notice of-his or her intention to perform the electrical work described below. Location(Street & Number) l GT ()+vner or Tenant `J� elephfi ie No. Owner's Address Is this permit in conjunction with a building }permit? 1'es No Q (C,%xk Approolizte Box) Purpose of Building ) �(. 111 utility Authorit-elm-0 .' %L l:\isting Service Zd0 Amps �?,0/ZY0 Volts overhead� ' ' Undgrd❑ 1a of Meters New Service amps 3 Volts Overhead❑ tttadrd ❑ 'fin,q[Meters _ Number of Feeders and Anipacity j Location and Nature 9f Propose Electrical Work: ArLCI (/"X), , Completion of the Jidlon ine table Intl-he ti'crir.d Iry the Injre'c'tor•n! It', tio.of I otat No,of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot'Tubs Generators Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rntt. ❑ rnd. ❑ Battery units No.of Receptacle Outlets No.of Oil Burners EIRE :l1,ARv1S No.of!ones Vo.o etection and No.of S+vitches No.of Gas Burners Initiating Devices 10.of Ranges ZNo.of:lir Cond. Total No.of Alerting Devices Pons ! eat Yump 'Number 'Ions hNN; No.of.eIT 'ontaine No.ofWaste Disposers � Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating K44' t Deal❑ Municipal Connection 1:1 Other Heating Appliances Security Systems:* No.of Dryers g° t p K44 No.of bevices or Equivalent No.of Water K44 No.o tio.o Data Wiring: Itcatet s Signs Ballasts No.of Devices or Equivalent i'elecominunications 41'iring: No. Hydromassage Bathtubs No.of Nlotors Total HP No.of Devices or Equivalent OTHER: d land ` Ittoc•h Ili h/itiurtctl(Iewil it tlesir ell.or os r•eyuire(i ht.the brspec lot'oi'I1 Fstinrtted Value of l=lcctr'cal \fork: V.3ZS (\\'hen required by municipal policy.) ` \Vork to Start;, /z f j Inspections to be requested in accordance+with \dF:C" Rule 10,and upon completion. INSLRANC'F C( VE AGE: U mess+vaived by the owner.no permit for the performance of electrical work nim issue un; the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. "(h undersigned certilics that such coverage is in force.and has exhibited proof of same to the permit issuing of7ice. Ul IF(7K ONE.: INSURANCE Q BOND ❑ OTHER ❑ (Specify:) I certi/i•,uneler the pants and penalties ojperjterr.that the information on this application is trite and complete. t.1C'.NO.: 177 ,J8 " A FIRM N*ANIE: - --- Licensee: Richard J. Are!. Signature ` I.IC. ti().: 3 141? ill o r11 rlicablc. erncr c.rc•nr rl"ill file license nrrrnher•line.! Bus.Tel. No.:x)78-3 7.�-1 V, / Address: + alt.Tel. No.:(178-302 715 -r73 � Street nvr--F-b-t �I ij1L ��1��2 is re aired for this++Dila sf applicable.enter tine license number here: °Security System Contractor(.. ensc y pp OWNER'S INSURANCE WAIVER: i am aware that the Licensee does nut have the liability insurance coverage norniall I am the(check one} owner ❑owner's a•• required by law. By my signature below. 1 hereby waive this requirement. ❑ (honer/:!gent 'EE: S No. Signature 'Telephone ` �ev �f �� �� .0 d� // �1 � ��� , . --_ - �._ r-'�r �� . � � . . z , ; ',-- -_ .,_ , _, ,• .. 9 h The Commonwealth ofMassachusetts - Department oflntlustrialAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): C— Address: City/State/Zip: &A-) Phone#: ArYou an employer?Check the appropriate box: Typo of project(required): L I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2111 am a sole proprietor or partner- listed on the attached sheet. '1• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL I L ]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12,Q Roof repairs insurance required.] employees.[No workers' 13.❑Other 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. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the,policy and job site information. Insurance Company Name:" /_/1 S C-1k 0 U dv/ Policy#or Self-ins.Lic.#: �Q C� D� 7 SD Expiration Date: 3 16 kv Job Site Address: 7 S /J>G/ f'4 C1Ljl City/State/Zip: Attach a copy of the workers'compensation policy ileclaration page(showing the policy number and expiration date). Failure to secure coverage as required-under Section 25A of MGL o. 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. X do hereby certi n er the ins anti lite fperjury that the information provid7 - Sigriature: ve is t ue and correct. - � Date: � /3 Phone 4: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone M - r Information and Inst ucti®�s ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,- express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phonenumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/lice'nse number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only.submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license oz permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho CoMyAO.UWDalthofMassarhusPtts Dopa imentofIndustdat.Aceldonts Office QUAYestigatitons 600 Wash Voa St tet Boston}MA.021 X 1 Tel,#617-727-4900 ext 40 -S ; �or 1. _77,MAS Revised 5-26-05 Fax#617-727-7749 Date. . . .. . .. .. .. . . .... .. . ,,ORT" Of 1,b 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACHUS Et This certifies that . . . . . . . . . .. . . . . . . . . . . . . . . . . . . has permission for gas installationxt--- in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . .. . . . . . North Andover, Mass. Fee.- :�-. :7 Lic. Nom- ' /. . . . Check# 7,7//0 Ti 15 ' u MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) N A rJ L) Mass. City, Town Permit # Building Owner 's AT: Location `'J 5 +� 4e-_s La Ne Name-----w ( r Type of Occupancy: �e5 i ALW�. New El Renovation ® Replacement Plans Submitted Yes ❑ No of W N Z WW Z Z . tll LY W ¢ pCC W = H W J W Zr O W F• a ir Z D 0 h W O h mcc 0 W 6 W Z C IL C W 49 xW W co h = _� h Za` t., W W O O > V4 h V x N OC a W a oc h j h W a W > Z W O Z d aa Q O O W 5 Ic M. O t7 z W O It C t7 J V Z > C o. F- O SUB—BSMT. 1 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 6TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) Check One: Certificate Installing Company Name J'In P_� j ( I nr (7J Corp. 1 Address I,I/1 Pl t f e [� '{"rP�-�- PQ ❑ Partnership ❑ Firm/Company Business Telephone Name of Licensed Plumb or Gasfitt S eu,�ri I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the 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. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owns/Agent I have a current liability insurance policy to include completed operations coverage. El D By TYPE LICENSE: lA�'M M1�� Title ❑ Plumber Signature of Licensed City/Town L ,...,ld/Gasfitter Plumber or Gasfitter � APPROVED(OFFICE USE ONLY) ❑ Master 30 1 ❑ Journeyman Licese Number FORM 1243 A.M.suutiN oo. 1989 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING 1 NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC.NO. PERMIT GRANTED DATE GASINSPECTOR The 401* nwea th of Massochitsafts Depa rthWitt ej�rdust d Accidents Office of Investigations 600 Washington,Street Boston,MA 02111 w"vw nmsssg#vldia. Workers' Compelhsatioin Inwurance Affidavit: Builders/Contractors/Electrieans/i'lumbers An:pli+eant Information Please Print Legib y Name (Business,/Oww=ton/incividual): I ( 1 I Inc Address: !VI n n-fit �l d G+ f.� V CrtylState/dip:P Q 1 q Ph.M.#: 9 Are :ou an employer?Check the,appropriate bote Type of protect(required): 1. I am a eimployer with _ 4: 0 I am a general contractor and T employees(full and/or part-time)'" have hired the sub=contractors 6, 0 New construction. 2.❑ I am a sole proprietor or partner- listed on the allached sheet: #: 7. ❑Remodeling ship and have no employees These sub-contractors have $. n Demolition working forme in any capacity. workers'comp. insurance. o workers' Com tnsivance 5. 9• ❑Building addition : [N p E,W.e:are a;corporat on and its required.] officers:have exercised their 10,❑Electrical repairs or additions 3..(] I am a,honteowner.doing,all work right of exemption per MGL '11.El Phanbing repairs or:additioi s x myself. [No workers'comp. c. 152;.§1'(4),and we have no 1.2:0 Roof repairs insurance requited.],f employees.[No'Workers' comp.:insurance.required.] 13.❑ Other "Any applicant that;ctiecks'1 ox#1 must also fill out the sectiop below-sh i owuig thcw?workers pmpensation:poltcy mfoemation. t Hbtneownerswh'o submittl is affidavit indicating they are doing ail'work and'then hire.butside contraetors must su6nit.11new affidavit.indicatin such: 'Contractors that check this box.must.attached an.additional sheet showing the name of the sub�contTactors and their workers'comP ." oli ,cy`iriforcrAation.: I am an employer thatis.providing workerscompemsadon insurance for my employees. ,Below-is.lh informainformation. epoliey andjob site Insurance Company Name Q►1� I n -�� P��s Cn 1 V Policy#or Self ins..Lic.#r E jr V .t-1 Ex . irationDate: I / Job'Site Address: 01.1 1State/dip:, Attach a co py of'the workers comperisaiion policy declat•ation page(showing the policy.number and expiration date). Failure to secure coverage a&required under Section 25A of MqL c .152°10an lead•to;the im ositiono p f 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$256:D0 allay against the violator. Be advised thata copy of this statement may be forwarded"to the Office of Investigations of the MA for insurance coverage vert'fl,ation. I da hereby cerci u r the:pawsandpen es oJpErjury that the:in f orr►nnation provided above is true and correct: Signature DhW — C) Phone,M j_ a Official use.only,.Do not write in.th s area,to be completed by rity,or town of iciaL City or Town: PermittLlcense#. Issuing Authority(circle one): 1 Board of Health 2.Building-Department 3:.-City/Townn Clerk 4 Electrical Inspector 5 Plumbng:)(nspector 6.Other Contact Person: Phone;#: 44 Commercial Street Raynham, MA 02767 Tel: (508)880-0233 Fax: (508)880-7232 September 30, 2011 North Andover Board of Health 1600 Osgood Street OCT 1 e 2011 North Andover, MA 01845 F TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Attention: Health Agent Reference: FAST' Wastewater Treatment System- Serial Number: 24751 Attached please find the Field Inspection& Service Report with field test results for services performed on 9-2-11 at the property of Michael Fox located at 45 Bridges Lane, North Andover, MA. Please call if you have any questions or require additional information. Sincerely, Wastewater Treatment Services, Inc. Service Department Enclosures Copy to: Michael Fox Massachusetts DEP Massachusetts Department of Environmental Protection Bureau of Resource Protection -Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems 16244 A. Installation Michael Fox Owner 45 Bridges Lane Facility Street Address North Andover 01845 City Zip Mailing address of owner, if different: 45 Bridges Lane Street Address/PO Box: North Andover MA 01845 City State Zip Telephone Number B. Authorized Service Provider Wastewater Treatment Services, Inc. 0&M Firm 44 Commercial Street Street Address Raynham MA 02767 City State Zip 508-880-0233 Telephone Number David Zavelle 12920 Certified Operator Name Certification Number C. Facility/System Information 24751 Bio-Microbics, Inc. MicroFAST.5 DEP ID Manufacturer ID Model Number 5/17/2005 5/17/2005 Installation Date Start of Operation Approval Type: [] General [] Provisional [] Piloting [x] Remedial Seasonal Residence—used less than 6 mo./year: []Yes [x] No D. Operating Information 9-2-11 Inspection Date Previous Inspection Date Pumping Recommended []Yes [x] No Sludge Depth(to be checked yearly) 1 t i JI Massachusetts Department of Environmental Protection Bureau of Resource Protection -Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems 16244 E. Field Testing Field Inspection: Color: [J gray [] brown [x]clear []turbid [] Other(specify): Odor: [] musty [x] earthy [] moldy [] offensive []turbid Effluent Solids: [x] no []some pH 7 SU DO. 6.01 mq/L Turbidity 6.77 NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken: [] Influent [] Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: 440 gpd Parameters sampled: Influent. [] pH [] BOD [] CBOD []TSS []TKN [] Nitrate [] Nitrite [] Phosphorus [] Spec. Cond. []Ammonia []Alkalinity [] Oil Grease []VOC [] Fecal Coliform Effluent: [] pH [] BOD [] CBOD []TSS []TKN [] Nitrate [] Nitrite [] Phosphorus [] Spec. Cond. []Ammonia []Alkalinity [] Oil Grease []VOC [] Fecal Coliform G. Inspection and Maintenance Description of any maintenance performed since previous inspection &during this inspection: Cleaned Filter, Checked Splash Recycle, Checked Distal Pressure Pump(s) Inspected Float(s) Inspected Notes and Comments: Distal Pressure Readings: DPR#1 7": DPR#2 8 DPR#3 10 DPR#4 10" 2 Massachusetts Department of Environmental Protection LlBureau of Resource Protection -Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems 16244 H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massachusetts certified operator in accordance with 257 CMR 2.00. 9-2-11 Operator Signature Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use— by January 31 st of each year for the previous calendar year PilotingUse -within 4 i s t 5 days of inspection date Provisional Use—by March 31 th of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 3 , I N C 0,.R P-O RAT&.0 8450 Cole Parkway, Shawnee, KS 66227, Phone 913-422-0707, Fax 913-422-0808 e-mail:onsite(d)biomicrobics.com, www.biomicrobics.com, 800-753-FAST(3278) FIELD INSPECTION & SERVICE REPORT For Bio-Microbics Single Home FAST'System 16244 ?INSTALLATION,, AUTHORIZED SERVICE PROVIDER. Installation Address. 45 Bridges Lane Name:Wastewater Treatment Services,Inc. North Andover,MA 01845 Owner Name:Michael Fox Mail Address: 45 Bridges Lane Mail Address: 44 Commercial Street North Andover,MA 01845 Raynham,MA 02767 Phone: Fax: e-mail: Phone:(508)880-0233 Fax:(508)880-7232 e-mail: INSTALLATION INFORMATION Model No. Serial No. Date of Installation Date of last pump out MicroFAST.5 24751 5/17/2005 EQUIPIv1ENT YES NO MAINTENANCEPERFORMEDRND COMMENTS Electrical Panel(s) Visual Alarm Operating x Audio Alarm Operating x P g (if present) Blower(s) Air Inlet Filter Clean x Blower Hood Vents Clear x Excessive Noise x Excessive Vibration x Treatment unit(s) Unusual Odor x Pumpout Required x Primary Settling Zone Aerobic Treatment Zone EFFLUENT(optional) T IMIT RESULT ; Estimated Daily Flow 440 gpd pH(Standard Units) 7 Color Clear Temperature 71 Odor Earthy Comments:Distal Pressure Readings:DPR#1 T;DPR#2 8';DPR#3 10";DPR#4 10" TECHNICIAN SERVICE DATE` David Zavelle 9-2-11 Date...........`..... ..a. ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................ ...................... has permission to perform ..... wiring in the building of...*A�'—"I' ..................................................... at... ....... .............. .North Andover,Mass. Fee�.6.-.'��...... Lic.No.&447 .... ............... ELECMICA0NSPECT r Check # 5719 Commonwealth of Massachus s Official Use only q Permit No. �f 71 / Department of Fire Servic s �- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REG LATIONS [Rev. 11/991 leaveblank APPLICATION FOR PER IT T PERFORM ELECTRICAL WORK All work to be performed in accordance ith the assachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFO TI N) Date: City or Town of: tp A N o '� To the Inspector of Wires: By this application the undersigned gives notice/of his or r intention to perform the electrical work described below. Location(Street&Number) � 891 d e-� LAdc Owner or Tenant M 1ct(I ko N 10.1, Telephone No. Owner's Address 5A l an e Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps 1 Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: LJ lR: p �} Jj _�! Completion o the following table may be xaived by the Inspector of iirires. No.of Recessed Fixtures No.of Ceil:SusP•(Paddle) TransFans Total rsformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency Lighting No.of Lighting Fixtures Swimming Pool rnd ❑ rnd. ❑ Battery Units • No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of Gas Burners No. InDetection and Initiatin Devices a No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices Disposers Heat Pump Number Tons KW No.of Self-Contained No.of Waste Dis P Totals:I Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local ❑ Connection ❑ Other No.of Dryers Heating Appliances KW Sec No ofDevicesor Equivalent No.of Water KW No.of No.of Data Wiring: Beaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP l Telecommunications Wiring: c /� No.of Devices or E uivalent OTHER: Attach additional detail ifdesired,or as required by 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 coverage is in force,and has exhibited proof of same tt�the permit issuing office. CHECK ONE: INSURANCE Z BOND ElOTHER El (Specify-.) C_)(,/ '1'1 le (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 4- .30 00� Inspections to be requested in accordance with MEC Rule 10,and upon completion. 1 certify, under the pains and(pen�alrties operj�/tat the information on this application is true and complete FIRM NAME: �llvl c( W t/p/jIFe LIC.NO.:- -- Licensee: 5-19 me Signature LIC.NO.: p ld 6 (If applicable,enter "e-rempt in the license number line.) V Bus.Tel.No.,97F-S3a — p Address: Alt.Tel.No..�- S-'4gd2 OWNER'S INSURANCE WAIVER: 1 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)❑owner ❑ owner's agent. „ Owner/Agent PERMIT FEE: $ Signature Telephone No. _ I �i � Commonwealth of Massachusetts Official Use Only Permit No. -,5-7✓ V Department of Fire Services Occupancy and Fee Checked 4145� BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/99] leave 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 INFORW TION) Date: 4 -,20q-0J- City rteCity or Town of: AloANcl©Vu4 To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. [r Location(Street& Number) � 8rZt d e� 1.1. 1.'-'A " 1^ Owner or Tenant 1 1E e N 1 TelephonNo�--,r ) Owner's Address 5-A00-e Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: t;e Djpi-j l q�T . y 7 J �)%,A/4 l Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA AboveIn- o.o mergency Lighting No.of Lighting Fixtures Swimming Pool rnd. ❑ rnd. El Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection an Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local El Connection Connection P g ❑ Other No.of Dryers Heating Appliances KW Security Systems: rY No.of Devices or Equivalent No. oTWater KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. P Hydromassage Bathtubs No.of Motors Total Ht,-3 Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by 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 coverage is in force,and has exhibited proof of same/t�the permit issuing office. CHECK ONE: INSURANCE ZBOND [I OTHER El (Specify) (J(\1 'F! ,P (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ¢ 3(7 o-I IInspections to be requested in accordance with NIEC Rule 10,and upon completion. !certify, under the aitrs and]pen�alrties/o . erg ry,that the information on this application is true and complete. FIRM NAME: Avi-�( (RJ ee ? LIC.NO.: Licensee: 54 Me Signature J p LIC.NO.: Flo)6 A ff opplicable, enter "erempt-in the license number line.) Bus.Tel.No. j D Address: Alt.Tel.I - 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)❑ owner ❑ owner's agent. ti Owner/Agent PER1t1IT FEE: $ Signature Telephone No. ,4 • � �'"/w't�L 0� ,� -`moo f /� (/�i'7 Location rz'� o. a v Date �U°l • .,.y�RTly TOWN OF NORTH ANDOVER /0 9 ` S Certificate of Occupancy $ ss�CMus<�' Building/Frame Permit Fee $ c S 3 t' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 Check # C 15405 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 60c;? DATE ISSUED: !/ "2 ® � SIGNATURE: e Building Colnmissionerfl for of Buildings Date SECTION 1-SITE INFORMATION a 11.1 Property Address: 1.2 Assessors Map and Parcel Number: ( 01.) lao N ✓✓ 8 C Z en R Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonm- District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Reqwred Provide RegLured Provided Rewired Provided 1.7 Water Supply XMI-C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ NO SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT n 2.1 Owner of Record Name(Print) Address for Service: 5330 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: C 2 Signai&e Telephone rl SE!"7ON 3-CONSTRUCTION SERVICES 3.1 Ltsed Construction Supervisor: Not Applicable ❑ ✓. _ Licensed Construction Supervisor: C S (D y�� 1 a _ 1� 1 1, S License Number Address.: (416 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name ) (j Registration Number Address ra e-tn� VJL�`� ? 6`6 Expir ton Date 11 /04 Si nature Telephone SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result ' in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check altapplicable) New Construction ❑ Existing Building Q Repair(s) ❑ Alterations(s) Cl" Addition ❑ i I j Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: t S C lZ.--e ,,.., r2 L 2-e-e S-e c, S O SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed b rmit a licant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of - Construction 3 Plumbing Building Permit fee(e)x(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 S p U Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize S �`""e S T $ `� to act on My b a ,in all matters relative to work authorized by this building permit application. Signatuh of Owner Date SECTION 7b OWNERIAUTHORIZED AGENT DECLARATION I, L) ca-y �� as Owner/Authorized Agent of subject property !. Hereby declare that the statements and information on the foregoing application are true and accurate,.to the best of my knowledge and belief Print Nam Si ature of wner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X . MATERIAL OF CHIMNEY ' IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U LOT RELEASE FORM «II�y INSTRUCTIONS: This form is used to verify that all necessary approvals%permits from, Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *******************'**********APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT 0—z c l 1C,0 : PHONE `l"?T to %l ^ 53.E o LOCATION: Assessor's Map Number i © `� PARCEL SUBDIVISION LOT(S) S T R E E S �A ,, ST. NUMBER L-1 S FFICIA L USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CO SERVATION ADMINISTRATOR DATE APPROVED / DATE REJECTED COMMENTS ND td9yk All ,0tKr�l Q.ICi��e A TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED IJ SEPTIC INSPECTOR-HEALTH DATE APPROVED I I 01 DATE REJECTED COMMENTS I 0 �r> - AIr Ak<.S� lab-)f, PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR_ DATE Revised 9\97 jm N.6 xz A Z�AF. ............ c) 74,1.2V 0 1-17- i I Office of the.Building Department Community Development and Services +- n 27 Charles Street. : a North Andover,M assaebusetts 01845 ��SSgCHU � D. Robert Nlieetla, Telephone(978)688-9545 Badding dr'Fi"ImISSlfdtter FAX(974)644-9512 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, s 150a. The debris will be disposed of at/in: (Site location) Signattie of permit applicant Date Michael McGuire,Local Building Inspector James Decola,Electrical Inspector James Diozzi,Gas/Plumbing Inspector MAY-10-2000 10:07 -'TY- LORR I COV I TZ 978 470 2656 P-002/009 . ., COviMON%t-FALTH OF MASSACHUSETTS EXEct:TIVE OFFICE OF ENVIRONMENTAL AFFAIRS bEPARTXLE\'T OF ENVIRO-NMENTAL PIZOTECTION ONF WINTER STREET. 80STO.S. Sl+ 02109 617.29245 dO w1LU1�1 F v►J+1.D TRUDY COKE Govcrao: Sccrcur. . AROEA PAUL CFS LUCCE Re-VI$ t7 DAVID P.MtRiS U Go ensor SU11SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Contraiuioner PART A tt�� CERTIFICATION OrProperty Address: q5' r tI6, 3 LaAe, A4 A•c4 Address of Owner: Orate of Inspection: g-�3/�j8 a1Qf301Q�Q (([,different) Name of Intpeetor: Bl.F1Jl�MIN�C. di 661) I an a DEP approved system inspector pursuant to Section 15.340 of Title S 010 CMR 15.0001 Company Name: NEW ENGLAND ENGINEERING SERVICES,. INC. Mailing Address: 33 WALKER ROAD�NORTH ANDOVER, MA 01845 Telephone Number: 508-686=1768- C ERTIFICATIQU 08-686-176.8CERTIf1CATIQU STATEMENT ' I cenity that 1 have personally inspwgd the sewage disposal system at this address and that the in(ormatton rooned below is true,accurate and complete as of the time of rnspectton. The Inspection was performed based on my tiaining and experience in the proper function and matntcrlance of on-site sewage disposal si•stems. The system: �asxs % &ndrltonallt Passes t needs Funher Evaluation By the Local Approving Authority Fails Inspector': Signature: C ' Qatc: 3A 5 The System lnspector shill submit a copy of this inspection report to the Approving Authority twin thirty(30)days of conVieting this inspection, if the system is a shared system or hoc a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regions(office of the DepariAwat of Environmental Protection. The original should be Sent to the system owner and copies sent to the bqm. if applicable,and the approving authority INSPECTION SUMMARY: Check A, 8, C, or D: AI PASSES: —711,ave not found any information which indicates that the systerr.%iol:tes any of the failure ac:ia u defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES,. One or more system components as described in the'Conditional Pass`sectio,need to be replaced or repaired. The system,upon , completion of the replaeetnent or repair,as approved by the Board of Health,'Will pass. lndkme yes. no.of not determined(Y,N.or NOI. Describe basis of determination in&it instances: if'not determined'.explain why not. _ The{optic tank is metal,unless the owner or operates has provided Inc syftcm.atspectdr with a Copy o(a CWtifiutc of Compliance W(acbi:4 indicting that the tatlk was insullad within twenty(201 years prior to the date o!the inspection:or the sWic tank, whether or not metal, Is crack;td, structurally unsound. shows subsuntiil inrittration or e>fi(tation. or tank failure is imminent. The system will pus inspection it the existing septic tank is reptace4 with a conforming septic tank as approved by the Boatel of Health. <r•�i•.a 04/0!/!71 ' ��0� t of to i MAY-10-2000 10:0? —TY. LORRI COVITZ 978 470 2656 P.003i009 SUSSURFACE SEWAGE DiSFOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �S Ql`t tC_L t�-C7A6 /(j. R• VeG Owncr: Date of Inspection: 81 SYSTEM CONDITIONALLY PASSES Imulnuodt Sewage bxkup or breakout at high stack water level observed in the distribution box is due to broken or obstructed pipctsl or due to a broken, Settled or uneven distribution bou. The system will pass iospecdion I(Iwkh approval of the Board of Health)• Dtsaibo obuxvatiow: broken Pipets)are replaced obstruction is removed distribution box is levelled of teplaccd The system required pumping more than four tiaras a year due to broken or obstructed pipc(sl. The.systern will pass inspection if twah approval of the Board of Health): broken pipets)are replacc6 cbstruction is remover! Cl FURTHER EVALUATION IS SLEQWREO BY THE BOARD OF HEALTH; Conditions exist which nrovite,further evaluation by the Soard of Health in order to determine if the system,it fall)nR to protect the public health. safety and the environment: 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL;ROTECT THE PUBLIC HEAM AND SAFETY AND THE ENVIRONMENT; Cesspool or pri%T o wahat SO 140 of a surfm water „T Cesspool ax piny is within 50 feet of s botdtnna vegetated wetland or a salt nosh. 2) SYSTEM WILL FAiL UNLESS THE BOARD OF HEALTH(IND PUBLIC WATER SUPPLIER,IF APPROPRIATS DETERMINES THAT THE SYSTEM IS FUNCTIONING INA MANNER THAT PROTECTS THE PUSUC HEALTH AND SAFETY AND THE EWRONMFNT. , _•_, The system has a septic tatsk and foil absorption system ISIS)and the SAS is within 100 feet to a su dace walet SWPIY or tributary to a wriaae water stpply. t — The system has a septK tank and$00 absorption systcnt and the SAS is within a Zone I of a public."aw wpP'Y well. The system ttas,a septic Conk and soil absorption system and the SAS:is within SO fat of a private wetter svPPIY well. The system has a septic tank Sad Solt absorption system and the SM::is kss than 100 feet but SQ fed or"re kora a private water supply wen,unless a well water Analysis for coliform bat tcda and volatile organic Cott>powsds indiates that the well is free Irom pollution front that facility and,the presence of,amnwnia nittoten and nitrate OhMen is equal to Or less than S ppem Method osed to determine distance (app(oximation not valid). 3) OTI4ER rr.vt..a otnsistt ..o. x of It MAY-10-2000 10:0e TTY. LORRI COVITZ 978 470 2656 P.004i009 smuRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '`~ PARC A CERTIFICATION (Continued) Property Address: 13r;4,6e4 1-4..c, ,t/. r}rn�o✓K Owner. sa Date of Inspection: t :A 91A1g)j 01 SYSTEM FAILS: You must trndiicate eklner"Yes"or"No'as to each of the following: I have determined that the systers+'iolatcs one or More of the Mowing failure&h4ttu as debited in 310 CMR 15.303. The basis for this detcmrtautton is idodified below. lite BOW of meatth should be contacted to determine what will be ne=sary to aw e� the failure. Yes No NO Backup of sewage into facility or system component due to an overloaded or clogged SAS of cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded.or clogged SAS or cesspool ..... Static liquid level M the disirrbuuon boa above outlet tnvert due to an overloaded or clo4ed SAS or cesspool, Ltqutd depth in cesspool is less than 6'below invert of available volume is less ItNn 112 day flow. .�. Required purnptng more than 4 times in the last year NOT due to dogged of obstructed pipafsl. Number of urines p roped Ant,purl on of the Soil Absorption System,cesspool of privy is below the high groundwater elevation Ant,portion of a cesspool or prwy is within 100 feet of a surface-Water supply or tributary to a surface water suppls•. S 1 Any porton of a cesspool or privy is within a Zone 1 of a public weli. Any portion of a Cesspool of privy is within SO feat'of a privzte water supply well Ant,portion of a cesspool or privy is less than 100 kat but grcater than So feet from a private water supply Veil VAh no .� acceptable Nater qualky analysis. If the well has been analyzed to be acceptable. attach copy of well water analysis for colsiorm bactFria,volatile organic compounds,ammonia nitrogen and.nitrate nitrof". El LAME SYSTEM FAZES: You must indseate either'Yet u ch t 'No'as to eaof the following: The iollowing criteria apply to large systems in addition to the criteria above: The system serves a fadility with'a design flow of 10,000 gpd or greater(Large Syslcml and the system is a significant threat to public health and safeq•and the environment because one arta more of the following conditions exis: Yes No _ . the system is within 400 feet of a surface drinking;water supply _... the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive aro (Interim Wellhead Protection Area• IVVPA)or a mapped zone 11 of a public water supply well) The owner or operator of any such system shalt bring the system and facility into full compliance With the groundwater ucatrrnent program vurerrnents o(314 CMR 5.00 and 6.00. Pieue consult the local regional office of tits Depanment for further information, i i tswl#Wd 94/33/0VI 1•y• a of so I MAY-10-2000 1008 -TY. LORRI COVITZ 978 470 2656 P.006i009 • SUBSVRfACE SEWAGE DISPOSAL SYSTEM iNWKnON•PORM PART C SYSTEM INFORMAT90N rroptrtr Addras: Sri t� a� �-ant� N. Owner: Date of Inspection: FLOW CONDITIONS RFSIQ5NTIAL: • Design(low; _Z .pdA)edroom(or t•Iuaiw of bedrooms:„ Number of current reskknu:,— Garbage g•er der lyes or nol: u� - Laundry eormeaed to system tyes or no):4,,, Seasonal use Lyes or na);_! Water meter readings, if available (last two(11 yeu usage tgpol: .Sump Pump(yes or no):_Aep e � Cast date of occupanc}:.C.i•-r j COMMERQAtA NDUSTRI 6L: Type of establishmatt: Design(low.— „•„ zW1ons/day Grease trap present:ty"or A01— Industrial'ftste HoWaV Tank oresenu ryes Non-sanitary waste discharged to the rale 3 svuem•ryes or nol_ Water mew readings.if available- Last date of orcu macr..,,,,,,w„_ . OTME14 (Oesaibe) Last date of occupancy. GENEW INFOWATION PUMPING RECORDS and source of utiomauon r r 3 v W u emits ct c Systm pumped as put of inspeawttye{a f+�o_" f(Yes,volume Pumped: ,, callohs Reason for pumping- TYPE OF SYSTEM Septic tankldistribotion box/soil absorption system Single cesspool OveA)ow cesspool _ Privy Shared systeni.(ya or no) fif yes,attach previous inspection (ecords, if any) VA Technology etc.Copy of up to date coniraaf Other APPROXIMATE AGE of all tompo+,ents.date msulied(if known)and source of information; fa? "'4%7 ei" �crne.0 Sewage odors detected when arriving at the sae:(yes or no)Il�t7 ts�rt��a oaltS/s>) ►.v Sot iv MAY-10-2000 1009 ' -Y. LORRI COVITZ 978 470 2656 P.007i009 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION (continued) Property Address; Ivy- Sri. > spection; fir,c iv. Date of in �.a rGk Owner. / � O til � l 1713 a BUILDING SEWER: (LocKe•on site plan) Depth below grade::& � Material of construction:—cast iron t✓40 PVC_other(explain) pistance from private water supply well or suction la V Ourrtetcr / Comments:(condition of joints,venting,evident of leakage.cic.) ^ 196 SEPTIC TANK:_ (lacate on sae plan, Depth below grade:" Material of Construction: oncrete_mcul ,Fiberglas} _,_,Polyethylene ___othertcxptaaU If tank is metal,list age_ Is age conirtened by Cenrfrcate of Conwhance —(YeslNQI ' Dimensions: /<Sbo G at�3 Sludge depth Distance from top of sludge to bottom of outlet tee or baiffp:,YZ_ t Scum thickness!_ j0 Distance from top of scum to top of outlet tee or bahle: 10 Obtance from bottom of scum to bottom of outlet let or baffle: Mow dimensions.were determined: MMji.,.t 04Y19ec Comments: (recommendation (or pumping, condition of inlet and ovtltt fees w bafAcs,depth o(liqu4 level in relation to outlet invert,stru u at iy,,evidence of leakage,etc) 4mg Nsr( GREASE TRAP:,�� (locale on site plarn) Depth below grade• Material of construction:_concre(e_meat(_FiberElass _Polyethylene_,other(exptain) Dimertsions: Scum thickness: Distance from top of scum to top of optlet tee or baffle: 04(anee from bottom Of scum to bosom of outlet tee or baffle: Dice of last pumping: Corrnrrnents: IrKomme dation (or pumping, condition*(Wet and outlet tee:or baffles.depth of liquid lcvcl in relation to outlet invert. strvctural ieteVity,evidence of leakage.etc.l . i Is�.•i..6 <tt/ZS/f7n ?%V@ t or IO MAY-10-2000 10:09 _. ...• r-�-Y• LORR I COV I TZ 978 470 2656 P.008i 009 SUSS(!!tl'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t•. PART C SYSTEM INFORMATION kontinutd) Property Address: 'Ag- i 01�•rler• tgi'r•c�cs r�+a�tG, N� f9'.�9v✓eit Date of tnsped'ronr TIGHT.09 HOLDING TANIC;QC ?ank must be pumped prior to.Ora;time.of inspectiorll (locate on she plus) e Depth belowy wade. material of eOnsttvaton;_conaete mets!fiberglass_Polyethylene other(explain) Dimensions CapaCitr._galionS oesign it*%- gatlon•/da% Mum leve!_Alarm in kwrkrng order_ Yes: Ivo Otte of previous pumping: ,,,, Comments: icondkion of rntet tee,condition of alarm and ffosi switches.tic.$ • •it - __ - - M r OISTRISUTION-BOX:_ r t (locate on sat plan! Depth of liquid level above owlet invert: Z ,,_ Commenu: (note ii levet and distribution is equal, evidence of solids\carryofer. evidence of leakage into Of out of box, etc) qfm~ leveA •� (I` u Cl a c t4dA1 G l:Z �:.ni.+rs Cti��,c. /4��at e'ldyi�. 1rGJ >tc.r.�rcQ. PUMP CHAMSt:R:&d. (locate on site PI" Pumps in working order:(Yes or Nor Alarms in working order(Yes or Nol Cornirxnu: (note Condition of Pump chamber, condition of pumps and appunenmces, etc.) �rw{��t e�JJS�Jtt Popo 1 0l 10 I I I MAY-10-2000 1009 -TY. LORRI COVITZ 978 470 2656 P.009/009 r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,•r.;5. SYSTEM IN(MA&TION (continued} Property Addeess: I-Ij- Owner: A&L✓ tri�c� Z.w„e� N• I�'.�d/o✓e2 oats of Insptctioei ^°t / zc ii{ X148 s rDI3a jq Depth to Grovndwater_y Feet Please indicate alt the Methods used to determine High Graundwitet Elevation: ' Obtained tram Design Pians on record 'f'Observaaon of Site tAbutting propos)•, observation hole,bawment sump etc.) Determine it Irom local conditions Cheek with taa! Suard of health Chea FEMA haps Check pumping recotds r Check bol exavators, installers Use USCS Daa DescrAbe M vqw ovw%•voids hoar you established the High Groundwater Ilevatron.l Adu t be eompletedl ��. V S,S.C. C. 1��4•P� 51•tw" wc� 'off' yG•o�. f3'i�u,.. o� '�'v+r•�G4.ey YIC� bee^ C%k r S G.�� '�V v-% r r ZA tr.vt..d a<I)�/1tt - ►.y. to et se TOTAL P.009 NORTH � 4dover 0 o 0 o LA E o dover, Mass., '/7/9 COCHICHEWICK %S RATED P 'C4�1 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System o� L/ / BUILDING INSPECTOR THIS CERTIFIES THAT....... �/ / f!.d.G1.......... 0 e�v ��............................................... . .. ................... . . ............................... Foundation has permission to erect...��«ON6' !"pct buildings on ......1� .... �?.� �f 5.... A V. ................ Rough to be occupied as............/..'y. .� .:.� �.e. ! .... C fI r '�'� 7m t,C_ Dov_ 710 /CD Chimney ............... ....................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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. �(av�-3, — PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Y' Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION aTA9TS ELECTRICAL INSPECTOR Rough .0............................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. E E REVERSE.SIDE / FORM U - LOT RELEASE FORM R°eeU�'s�Dead u�K o 1 t7—K +Sto%IfS INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT , J< ' IG o e 4y, 15 PHONE CV-M LOCATION: Assessor's Map Number 3 PARCEL 1 -4 o SUBDIVISION LOT(S) STREET R/��t-S ST. NUMBER ) ************************************OFFICIAL USE ONLY*********************************** RE MMENDATIONS OF TOWN AGENTS: CONSERVATION AD MI STRATOR DATE APPROVED DATE REJECTED 6bi1 aa COMMENTS Tr"i' ts erriJ Was 0,,A 0-00r-ove,� as 6004 S{-c�yeJ de.ak a„ c Ltx k wo s ra ese�. -R�-s age 1;,— -0 cL fl iL1 G�•,��,-���� n, Grc1-c,�d wov tC �nvolv�d n.�d we.iia.-45 to IDo ' J TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED / DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm i ► TOWN OF NORTH ANDOVER f BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING j BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Conunissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide ft[Fired. Provided Required Provided 1.7 Water Supply M.G.L.C.40.t 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT 2.1 Owner of Record iy%tc ke=y\ Ic L Name(Print) '' Address for Service Signatu a Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ --s—H —T 4e- Licensed Construction Supervisor: t-:S 6 y 7 / g License Number Address Gi'7`b b Expiration Date Signa re lephone k� (�I sob-509- 75o5 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name t 0 5 Registration Number Addre s ttI tg � � -3 �i✓we-� vl Z i;— '�fj 3 Expiration Date Si nat re Telephone i SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) I Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0-- No.......0 SECTION 5 Description of Proposed Work check all applicable) Ij New Construction ❑ Existing Building ❑ Repair(s) [ Alterations(s) 8'- Addition ❑ ' Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I \ c.Y- ( yrs lY 9 1 go A)+ deck uGw Leel SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by t a licant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUnDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, Q as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief + Print N e s- Signature o Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3RD SPAN DEVIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations Boston, Mass. 02119 Workers'Compensation Insurance Afdavit Please Print Name: ._SfA YY`e s `Y-e 4-,(A Location: S Pp p 1 City t` a (Z I.Vx nd (-\ Phone am a homeowner performing all work myself. �I am a.sole proprietor and have no one,working in any capacity I am an employer providing workers'compensation for my employees working on this job. Gomoany name: Address CiIty: Phone Inautan.ce Co _ PQlicv Cioripanv name: Address City: Phone#- Insurartce:.Go. Pollcy l=ai61 to secure roverage as n6clulmd urider Section 25A or AfiG_152 can MQd tothe Wpo$Wm d criminal pen .of a fine up:to s-1:50t]_00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK 0AMM and a fine of(31t�o 00)a day against me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage version_ I do herby certiil under th0e pains and penaties of pedes that the infoanation piovidrd above a true ani!correct Signature 01�� Date b Print name �e 1 Phone# ��- 6 -�0 � Official use only do not write in this area to be completed by city or town official' Builds , pEheck if immediate response is requireD n9 Dept Building Dept o Licensing Board Contact person: Phone# Q Selectman's offlc60 Health Department ❑ Other ?sf WORfCMAN S COMPENSATION North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant j }c c Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 7.2 6 rLop 10 X 1 02 Wei 201-+- t i \ V � Wti /� r to L01-4.- tu Ra N7 _ V.V.ecA' 7- 13 IAI Ojr 7411,'VA 3.s- 392 Date�,�:.. .. .. ........... � NORTI{ TOWN OF NORTH ANDOVER f PERMIT FOR WIRING SSACMUS� This certifies that .. ............ -.. .. ............................................................ has permission to perform ... ....... ..................... wiring in the building of ............................................................... _ , at 7... ........ ate.. ``"�..........U......... ,North Andover,Mass. �v y FeeA5.....-........ Lic.Nolue".F.......t� ../ :...... �................... ELECTRICALINSPECTOR Check # 1,1197 vrnciaiuseuniy g Permit No. �b at. c od�u�lle Saaet�y Occupancy&Fee Checked BOARD OF FIRE PREVENTION RECULATIONS.527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date y To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number /L.Yc �- / L .�/'V Owner or Tenant c Q/44a Owner's Address SA';-)&Y- is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Buildings l/ iL�/V Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters New ServiceAmps Volts Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work G -hWeef <ME rv� Total No.of 6ghting LightingOutlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of,'Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA f No.of Emergency Lighting No.of Receptacles Outlets 7 No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners f FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di osal No. Pum s Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices i ❑ Municipal ❑ Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water H liters KW Si ns Bailases Wiring i No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE- Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start ?-Z -0 L Inspection Date Resquested 6U,/ 9L L _Rough Final Signed under the Penalties of per) /^ FIRM NAME C�t 11a� � 1H s- LIC.NO. A634 I Licensee Signature LIC.NO.L'-_/79f.2, Address Otr/� 4(–' ' IV, yb�( BAIt Tel.No ' OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE (Signature of Owner or Agent)