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Miscellaneous - 66 RUSSELL STREET 4/30/2018
� � �u,ss� // s r��e T l Date..... ....................... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SQgCHU This certifies that ....... ...... ............. has permission to perform ..... J).. ...................................... T1 2* wiring in the b Ilding of.........&zn....... ........................................... 'j --// 5 T at ............................................ N6rith Andover,Mass. /Y ....... Feef�.....................Lic. NO ..r�o...................................... ELECTRICAL INSPECTOR Check# � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.w7j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),52277 CMR 12.00 (PLEA SE PRINT IN INK OR TYPE A LL BWORMA TION) Date: City or Town of: NORTH ANDOVER To theIn pector of Wires: By this application the undersigned i es notic�ppf his or her' ention toperformthe electrical work described below. Location(Street&Number) S3L's/ ._r Owner or Tenant /�/�c �j/•,� r� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps l-,�)/ &'olts Overhead [q-'- Undgrd❑ No.of Metersy� New Service Amps - / l olts Overhead Undgrd ❑ No.of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE 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 No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "J.-...""."'"""'" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as regidred by the Inspector of W1res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cU5%BOND is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:) Ycertify, under the pai ndpen es ofperjury,tl e infor do this appli 'on is true and complete. FIRM NAME: _ G�/y/ f//`iG�c-��/ LIC.NO.: ���� Licensee: Signature LIC.NO.: C (If applicable,ent ex t"in the li nse number 'ne.) /� Bus.Tel.No.•_�Q� Address: ,�e C L �'� Alt.Tel.No.• *Per M.G.L c1147,s.57-6,1-;securiJy<ork requires Dep en of Public S, ty"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PEhMIT FEE. $ iJ 2 Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32, . I electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible fort e notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed0 - Re Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: l� Pass[N Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: v✓ Inspectors Signature: Date: FINAL]INSP TION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: 404 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 1 .The Commonwealth of Massachusetts _. 0 Department oflndustrialAccidents n M„�_ •�~•-' I Congress Street,Suite 100 N d Boston,MA 02114-2017 www mass.gov/dia Workers'Compensationlnsurance Affidavit:Builders/Contxactors/Electricians/Plum ers. TO BE TILED WITH THE PERMITTING AUTHORII S'. please Print Le 'bl A licantInformation S /�U Name(Business/OrganizationAndividual): Address: Phone#: City/State/Zip: Are you an employer?Check the appropriate box: Type of project(required): 7. Iff I am a employer with _.employees(frill and/or part-time). ❑Nevi'constriictlon 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 40 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repaixs or additions ensure that all contractors either have workers'compensation insurance or are sole 12�D.Pliunbing repairs or additions „•+. proprietors with no employees. I am a general contractor and l have hired the sub-contractors listed on the attached sheet. 13•.[]Ro6f repairs 5.❑ These sub-contractors have employees and have workers'comp.insurance.# 14.0 Other 6.QWe are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),andvre have no employees:[No workers'comp.insurance required.] *Any,applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi homeowners who submit•this affdavrt indicating they are doing all work}tand nhe e hire rthe sub contractors and state whetters must submit a r or now noot thos pntitiess.have h $Contractors that check flus Uox must attached'an additional sheet showing employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providingworkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Dates Policy#or Self-ins.Lie. City/State/Zip: Job Site Address: / / Attach a copy of the wolrkers'compensation policy declaration page(showing the policy number and expiration date). 0.00 Failure to secure coverage as requu ed a d r MpenaltiesGL o.152,§25A is form of criminal OP violation WORK ORDER and f�f up to $2050.00 a and/or one imprisonment,as w day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cernder z s and penalties of perjury that the information provided above is true and corret. c Date: Si ature: Phone 53a Official use only. Do not-write in this area,to be completed by city or town official Permit/License# City or Town: Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Pe son: Information and Instrn.ctions 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'defiiied 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 receivet'6ktrustee ofan 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 b6 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 applicantwho has not produced-acceptable evidence of compliance with the insurance coverage req'ui'red." 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 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 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/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"fob 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 home owner 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Datel.01 ............. 0 r TOWN OF NORTH ANDOVER 1 0 PERMIT FOR WIRING sS�CHU Thiscertifies that ................................................................................................................. has permission to perform ..................................... T ................... ........................................ wiring in the building of......... ................................................................... at .( -5e, i� S-�Z-�4 ..... izA.,:................................................................North Andover,Mass. Fee ...........Lic.No,�3�...... ....................... ...................................INSPECTOR ....................... ELECTRICAL Check# C.-11n0l0►1:ra04A1L 01/I/adaaclrud¢tb Official Use Only C� q—i _ .� 1 UIV elJaparafrnnnc ol�irrr Sorvico9Permit No. 12 Occupancy and tee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11071 (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 INFORMATION) Date: (0 lot is City or Town of: NorA_ Armdover To the InsTpectorT of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �� u,sS¢�� - tgbr 44-�, AtAutrA& 019q5 Owner or Tenant �.�Q YrV. 4��1.NY11,1 Telephone No. —PI SO Owner's Address �T Is this permit in conjunction with a building permit? Yes 56 No (Check Appropriate BOX) Purpose of Building I Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd D No.of Meters New Service Amps / Volts Overhead❑ Undgrd Q No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system panels rated [ 7.011 kW aQ STC Grid Tied. In conjunction with a Buildina Permit Completion ojtlre jglai n table Yray be haired by the Iny.ectorLf Ifires. No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Tans Transformers KVA No. of Luminaire Outlets Na.of Hot Tabs Generators [CVA No. of Luminaires Swimmin Pool Above ❑ n- Elo.o Emergency Lighting g rnd. rnd. BAttery Units 1y No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones �i No.of Switches No.of Gas Burners o.o etectton and InitiatingDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons K o.of It antaine Totals: Detection/Alcrtin Devices No.of Dishwashers Space/Area Heating KR' "cal❑ Iunicipal ❑ Other Connection No.of Dryers Heating Appliances KW ccurrty ystems: No.of Devices or Equivalent No.of Water KW o. of I o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No,of Devices or uivalent OTHER: Estimated Value of Electrical Work: 12 t d Attach additional detail if desired,or as required by the Inspector of 111res. O (When required by municipal policy.) Work to Start:ASAP Inspections to be requested in accordance with MBC 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 ® BOND ❑ OTHER ❑ (Specify:) 1•certifj,,udder thepains andpenalties ofperfur}p,that the information ott this tepplicatlon Is true and complete. f FIRM NAME: SOLARCITY CORPORATION LIC.NO.:1136MR Licensee: MATTHEW T. MARKHAM Signature LIC.NO.:1136MR (1f applicable, enter"exempt"In the license nimeber line-) Bus.Tel. No..774-258-8180 Address: 24 ST MARTIN DRIyE(BUILDING 2-UNIT 11)MARLBOROUGH,MA 01752 Alt.Tel.No.:774-258-8505 *Per M.G.L. c. 147,s.57-61,security work requires Department ol'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. 1 am the(check-one)❑owner Cj owner's agent. Owner/Agent Signature Telephone Na. PERMIT FEE.• {$ �Z� i it" 0/t 11(4 ja4l, 1111wom Ottice of Consumer AffaiK' and BLISiliess Regulation .a 10 1'arl< Plaza - Suite 5170 Boston, Massachusetts 021 16 How Improvement Contractor Reg istration Registration 168572 Type: Supplement Card SOLAR CITY CORPORATION expiration: 3/8/2017 MATT MARKHAM 3055 CLEARVIEW WAY SAN MATEO, CA 94402 Update Address rod return card..Mark reason for change. N A .Address Renewal F.mpkryment Lost Card .. "� r 1...IM. h•r�.1��/t •/ //t...I•�.I llrif� O ice of Consumes Allah-q& Dusiness Nrxulation I•icense or registration valid for indh idul use only HOME IMPROVEMENT CONTRACTOR before the expiration(late. If found return to: L» 1138577. Office of Consumer Affairs and Business Regulation Registratlon: Type: 10 Park Plaia-Suite 5170 Fxti(ratron: z s?07 Supplement Card Roston,\t:1 02116 SOLAR C . ;Fi MATT MARFJ COA 24 ST MARTIN S1i'LLLi BLD2UNi t.s� f--•�.s-�4-- ` , i lk ITA/NI-BOROUGH,MA 01752 Undcrscnetar� Not,6alid without signature 1 v ELECTRICIANS ISSUES THE FOLIOWING LICENSE AS A., REGISTERED MASTER ELECTRICIAN SOLARCITY CORPORA11ON MATTHEW T MARIiHAM .4 SAINT MAR71N DR tit OG 1 UN 11 11 S� AARt,BOROUGH MA O Jr,1. W60 I r The Commonwealth ofMassadouset+ts Deperintent of IndustrialAccidents O)rce of In pasdgations I Congress Street, Suite 100 Boston,MA 02114-21117 IVWW.MgSS,goV1d!a Workers'Compensation Insaranue Affidavit:Baildcrs/ContractordElectricians/.Plumlbers AnpLimint Info atian Pl se Print La ibl Name(13usincss/organization/individual}: SolarCity Corp. Address: 3055 Clearview Way I City/State/Zip: San Mateo CA. 94402 Phone#: 888-765-2489 Are you an employer?Check the appropriate box: Type of project(required): 1.Ir Pam s employer with 5,000 4- E] l am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑New Construction 2.❑ 1 am it sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have a. ❑Demolition working for the in any capacity. emplvyocs and have workers' []Building IIuildi addition tm lNo-vorkers'comp,insurance comp.rnsuree 1 required.] 5. ❑ We are a corparatian and its 10.0 Electrical repairs or additions 3.❑ I airs a homeowner doing all work Officers have exercised their I d.❑plumbing repairs or additions to oelf [No workers' comp. Pipit of excerption pox MOL t c. 152,§1(4),and we have no 12.[3 Roof repairs insurance required.) employees. (No workers' l3 ✓�then Solar/PV comp. insurance required.] *Any applicant that ebultt box y(most also fill am the section below showing,their woft a,cominvation Panay infOMMiort. t blomeownera who submit this affidavit indicating they are doing all work and then hire onside contrado s mast submit anew affidavit fndicating such. =Contractors that duck this box must attached an additional sheet showing the name of the sub-comractors and state whether or not those entities have employees. If the sutrconttacttxs stave rmployces,they must provide their workers'comp policy number. 1'arty an employer that isproiWing workers'ct?nWensation insurance for my ettiployon Below is the policy anti job site information. InsuranmCompanyName: Zurich American Insurance Company Policy-$or Selr4m.Uc.4: WC0182015-00 Expiration Date: 9/1/2016 Job Site Address_" ,ZytS � City/State/zip:�•�Mltr M&01 e-q 5 Attach a copy of the workers'compensation poriey declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 132 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 S250.00•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. Ido hereby eert0y under the pools andpena/ties ofperjury that the informationprovided above is true and Correct 0 1 1 fine [6, Ot al me only. Do not write hr this area,lobe completed by city or fawn aelai. or Town: Permit/L•lcanse 4 g Authority(circle ot►e): ard of Hcalth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector her act Person: Phone#: ��0 DATE(MM1DDIYYYY( A � CERTIFICATE OF LIABILITY INSURANCE 08117�015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER: TITS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THk POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORI7ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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 NAntE_............... ..... ._... ... ...... FAX -. ..-. P HONIz 345 CALIFORNIA STREET,SUITE 1300 IAtF.dsz`Eatl:................. ...... .. ... ... ..... . . ...... ..i.lnlc,Nol;.......... ......... .................. CALIFORNIA LICENSE N0,0437153 £•MAR SAN FRANCISCO,CA 94104 _ADDREss:. ..... ..... ....... Attn:Shannon Scott 415-743-8334 AFFORDING COVERAC}E NA1C 998301-STND•GAWUE•15.16 INSURER A:Zurich American Insurance Company 116535 INSURED INSURER B.:NIA N1A SolarCity Corporation . ....... .... t.. .. .... ... .... 3055 Clearview WayINSURER C.:_NIA WA ..... ... .. ..... ........ ..... ............................ ..... San Mateo,CA 94402 .................+........ ..... ..... .. .... INSURERO:American Zurich insurance Company _. _.... ... ..........140142 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002713836.08 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE; LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1)158 ...... .................... i)f1L lIRTtT....—........_........_. .......- ............ PouCY EFF `. POLICY EXP -- ..-......_. ...... ...... .................. ...... ...... LTR TYPE OP INSURANCE POLICY NUMBER I MMIDDIYYY MMI iNYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 1GLO0182016-00 09101/2015 0910112018 EACH OCCURRENCE $ 3,000,000 CLAIMS-MADE f X I OCCUR I i ('REgAESES{Ea QvrrencgZ....+_$.... ............_ 3,000,000 X SIR:$250,000 MED EXP(Anyone person) S 5,000 .................. .......... .... ...... I ,.......... PERSONAL&ADV INJURY S 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER i GENERAL AGGREGATE g 6,000,000 PRO. r.... I X POLICY IJECT t. ...) LOC ! PRODUCTS•COMPIOP AGG`.S 6,000,000 i OTHER $ A ,AUTOMOBtLE LIABILITY `BAP0182017-00 :0910112015 0910112016 COMBINED SINGLE LIMIT $ 5,000,non r ago amdenJ.......... x ANY AUTO BODILY INJURY(Per person) $ X ALL OWNED X SCHEDULED BODILY INJURY(Per at accident)': S AUTOS ON N OYVtiEO PROPERTY DAMAGE AUTOS X.a HIRED AUTOS f.X. AUTOS r aceldeml. .... . ..... ......+ .. ...... ..... ....--.........- COMIPICOLL DED: S $5,000 ;UMBRELLA LIAB .:'OCCUR I EACH OCCURRENCE {.$ _... .......... .... .... EXCESS LIAR CLAIMS-MADE' AGGREGATE 5 DED REWTiONS 3 D 'WORKERS COMPENSATION 'WC0182014-W(AOS) ;0910112015 :0970112016 X PER ;OTB• ; AND EMPLOYERS'LIABILITY f.......i-STATUTI ........i .....f... ... A YIN! YYC0182015.00 MA 0910112015 0970112016 ANY PROPRIETORIPARTNERIEXECUTIVE, N ( E.L EACH ACCIDENT. y 1.000,000 OFFICER/MEMBEREXCIUDEII7 NIAI r-.....----.._..._._......_.... . ....{. (Mandatory In NH) ! WC DEDUCTIBLE:$500,000 E.L DISEASE-EA EMPLOYEE+S 1,000,000 N yes,describe under -- ----- _. . ... ..- DESCRIPTION OF OPERATIONS below I E L DISEASE--POLICY LIMIT I S 1,000,000 i DESCRIPTION OF OPERATIONS I 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 DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Clearvlew Way THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN San Mateo,CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk&insurance Services Charles Marmolejo ©1888~2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD f ABBREVIATIONS ELECTRICAL NOTES JURISDICTION NOTES A AMPERE 1. THIS SYSTEM IS GRID—INTERTIED VIA A AC ALTERNATING CURRENT UL—LISTED POWER—CONDITIONING INVERTER. BLDG BUILDING 2. THIS SYSTEM HAS NO BATTERIES, NO UPS. CONC 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 POI 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 THREE LINE DIAGRAM LICENSE GENERAL NOTES 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: ZEP SOLAR AHJ: North Andover REV BY DATE COMMENTS REV A NAME DATE COMMENTS * * UTILITY: National Grid USA (Massachusetts Electric) * * * J B-0182812 0 0 PREMISE OWNER: DESCRIPTION: DESIGN: CONFIDENTIAL— THE INFORMATION HEREIN JOB NUMBER` CONTAINED SHALL NOT BE USED FOR THE BUNNELL, HARRY BUNNELL RESIDENCE Matt Morse ':,;So�arCity BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: A''O NOR SHALL IT BE DISCLOSED IN WHOLE OR IN Comp Mount Type C 66 RUSSELL ST 7.02 KW PV ARRAY PART TO OTHERS OUTSIDE THE RECIPIENTS Moou�s NORTH ANDOVER, MA 01845 TMK OWNER: ORGANIZATION, EXCEPT IN CONNECTION WITH 24 St.Martin Drive,Building 2,Unit 11 THE SALE AND USE OF THE RESPECTIVE 27 TRINA SOLAR # PAGE NAME: SHEET: REN. DATE TSM-260PD05.18 7�Ir��I * Marlborough.MA 01752 /tVAIfV. SOLARCITY EQUIPMENT, W1IHOUT THE WRITTENINVERT(R: Tm : (650)638-1026 F: (650)638-1029 PERMISSION OF SOLARCITY INC. SOLA GE SE6000A—USOOOSNR2 (978) 771-7303 COVER SHEET PV 1 10/27/2015 (BBs)—SOL-CITY(765-2489) www.solarcity.ao PITCH: 35 ARRAY PITCH:35 MP1 AZIMUTH:258 ARRAY AZIMUTH: 258 MATERIAL: Comp Shingle STORY: 2 Stories PITCH: 35 ARRAY PITCH:35 MP2 AZIMUTH:78 ARRAY AZIMUTH: 78 MATERIAL: Comp Shingle STORY: 2 Stories STAMPED & SIGNED ' FOR STRUCTURAL ONLY JASON WIL IA ° ® 4 TOMAN STRUCTURAL No.51554 fi PSTN , son Toman A Date: 11:53:25-0700' LEGEND B (E) UTILITY METER & WARNING LABEL Inv INVERTER W/ INTEGRATED DC DISCO & WARNING LABELS © DC DISCONNECT & WARNING LABELS AC DISCONNECT & WARNING LABELS Inv M Q DC JUNCTION/COMBINER BOX & LABELS AC I AC 0 DISTRIBUTION PANEL & LABELS © i � i ' _ 1I L- Lc LOAD CENTER & WARNING LABELS ODEDICATED PV SYSTEM METER 0 STANDOFF LOCATIONS CONDUIT RUN ON EXTERIOR --- CONDUIT RUN ON INTERIOR GATE/FENCE Front Of House (E) DRIVEWAY O HEAT PRODUCING VENTS ARE RED 1%�`1 INTERIOR EQUIPMENT IS DASHED L-"J 66 Russell St SITE PLAN N Scale: 1/8" = 1' W E 0 1' 8' 16' Rd momm S J B-0182812 00 PREMISE OWNER: DESCRIPTION: DESIGN: CONFIDENTIAL THE INFORMATION HEREIN JOB NUMBER: CONTAINED SHALL NOT BE USED FOR THE BUNNELL, HARRY BUNNELL RESIDENCE Matt Morse ';;,So�arCity. BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: •� NOR SHALL IT BE DISCLOSED IN WHOLE OR IN Comp Mount Type C 66 RUSSELL ST 7.02 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 (27) TRINA SOLAR # TSM-260PDO5.18 SHEET: REV: DATE Marlborough,MA 01752 SOLARCITY EQUIPMENT. WITHOUT THE WRITTEN INVERTER: PAGE NAME T: (650)63B-1028 F: (650)638-1029 PERMISSION OF SOLARCITY INC. ISOLAREDGE SE6000A—USOOOSNR2 (978) 771-7303 SITE PLAN PV 2 10/27/2015 (BBB)—SOL-CITY(765-2489) •ww.solarcity.com e PV MODULE 5/16" BOLT WITH LOCK INSTALLATION ORDER & FENDER WASHERS LOCATE RAFTER, MARK HOLE ZEP LEVELING FOOT (1) LOCATION, AND DRILL PILOT ZEP ARRAY SKIRT (6) HOLE. S1 (4) (2) SEAL PILOT HOLE WITH POLYURETHANE SEALANT. ZEP COMP MOUNT C ZEP FLASHING C (3) C(3) INSERT FLASHING. 4 11 _6° 01 (E) COMP. SHINGLE (1) (4) PLACE MOUNT. 1'-2' (E) LBW (E) ROOF DECKING (2) INSTALL LAG BOLT WITH SIDE VIEW OF MP1 NTS 5/16" DIA STAINLESS (5) (5) SEALING WASHER. STEEL LAG BOLT LOWEST MODULE SUBSEQUENT MODULES INSTALL LEVELING FOOT WITH A WITH SEALING WASHER (6) BOLT & WASHERS. MP1 X-SPACING X-CANTILEVER Y-SPACING Y-CANTILEVER NOTES (2-1/2" EMBED, MIN) LANDSCAPE 66" 24" STAGGERED (E) RAFTER PORTRAIT 44" 18" S 1 STAN DOFF RAFTER 1-7/8"X5-7/8" @ 22"OROOF AZI 258 PITCH 35 C ARRAY AZI 258 PITCH 35 STORIES: 2 C.I. 2"x6" @24" OC Comp Shingle STAMPED SIGNED FOR STRUCTURAL. ONLY S 1 JASON WIL IAM 7OMAN 4" 0 11'-6" STRUCTURAL � No.51554 1'— (E) LBW SIDE VIEW OF MP2 NTS '�� JasonToman B Date:2 .10.28 11:53:35-07'00' MP2 X-SPACING X-CANTILEVER Y-SPACING Y-CANTILEVER NOTES LANDSCAPE 66" 24" STAGGERED PORTRAIT 44" 18" RAFTER 1-7/8"x5-7/8"@ 22"OC ROOF AZI 78 PITCH 35 STORIES: 2 ARRAY AZI 78 PITCH 35 C.I. 2"x6"@24"OC Comp Shingle JB-01 82812 0 0 PREMISE OWNER. DESCRIPTION:- DESIGN: CONFIDENTIAL- THE INFORMATION HEREIN JOB NUMBER: "44 ■ CONTAINED SHALL NOT BE USED FOR THE BUNNELL, HARRY BUNNELL RESIDENCE Matt Morse ';,,So�arCity. BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: �"r NOR SHALL IT BE DISCLOSED IN WHOLE OR IN Comp Mount Type C 66 RUSSELL ST 7.02 KW PV ARRAY PART TO OTHERS OUTSIDE THE RECIPIENTS Moo�E� NORTH ANDOVER MA 01845 ORGANIZATION, EXCEPT IN CONNECTION WITH ' 24 St. Martin Drive, Building Z Unit 11 THE SALE AND USE OF THE RESPECTIVE (27) TRINA SOLAR # TSM-260PDO5.18 PAGE NAME SHEET: REV: DATE Marlborough,MA 01752 SOLARCITY EQUIPMENT, WITHOUT THE WRITTEN INVERTER: T. (650)638-1028 F. (65D)638-1029 PERMISSION OF SOLARCITY INC. SOLAREDGE SE6000A—USOOOSNR2 (978) 771-7303 STRUCTURAL VIEWS PV 3 10/27/2015 (BBB)-SOL-CITY(765-2489) www.solarcity.com GROUND SPECS MAIN PANEL SPECS GENERAL NOTES INVERTER SPECS MODULE SPECS LICENSE BOND'(N) 8 GEC TO TWO N GROUND Panel Number:NoMatch Inv 1: DC Ungrounded - 7.TRINA SOLAR TSM-260PDO5.18 GEN #168572 ( ) # ( ) M Tie-In: Supply Side Connection INV 1 -(1)SOLAREDGE#SE6000A-USOOOSNR� LABEL: A � ) ## ELEC 1136 MR ODS AT PANEL WITH IRREVERSIBLE CRIMP Meter Number:91813382 PP Y Inverter; 6000W, 240V, 97.5% w Unifed Disco and ZB,RGM,AFCI PV Module; 26OW, 236.9W PTC, 40MM, Black Frame, H4, ZEP, 1000V Overhead Service Entrance INV 2 Voc: 38.2 Vpmax: 30.6 INV 3 Isc AND Imp ARE SHOWN IN THE DC STRINGS IDENTIFIER E 200A MAIN SERVICE PANEL E 60A/2P MAIN CIRCUIT BREAKER Inverter 1 E WIRING CUTLER-HAMMER ( ) CUTLER-HAMMER 1 Disconnect - 60A/2P 4 Disconnect 3 SOLAREDGE Dc' A 35A SE6000A-USOOOSNR2 e c MPI: 1x15 -------------------- ------------ --------------------� A L, zaav �- I 6 L2 DC+ I NDG I 2 I (E) LOADS GND _ ____ GND ___ -_______-- - EC -- T N DG C+ MP2: 1x12 13) r---� G EGC G ----------------- tJ N I (1)Conduit Kit; 3/4' EMT I _J o EGC/GEC Z I � I GEC_r_{ TO 120/240V i SINGLE PHASE i UTILITY SERVICE 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)Groygd Rod A (1)CUTLER-HAMMER $DG222NR8 /fj PV (27)SOLAREDGE AP300-2NA4AZS D� 5 pill 8, per Disconnect; 60A, 240Vac, Fusible, NEMA 3R /� PowerBox Optimizer, 300W, H4, DC to DC, ZEP -(2)ILSCO t IPC 470-#6 -(1)CUTLER-kIAMMER A DG100NB nd (1)AWG #6, Solid Bare Copper Insulation Piercing Connector; Main 4/0-4, Tap 6-14 I Ground eutral it; 60-100A, General Duty(OG) S SUPPLY SIDE CONNECTION. DISCONNECTING MEANS SHALL BE SUITABLE -(1)CUTLER-HAMMER #DS16FK -(1)Ground Rod; 5/8' x 8', Copper Class R Fuse Kit AS SERVICE EQUIPMENT AND SHALL BE RATED PER NEC. -(2)FERRAZ SHAWMUT B TR35R PV BACKFEED OCP (N) ARRAY GROUND PER 690.47(D). NOTE: PER EXCEPTION NO. 2, ADDITIONAL Fuse; 35A, 25OV, Class RK5 ELECTRODE MAY NOT BE REQUIRED DEPENDING ON LOCATION OF (E) ELECTRODE B (1)CUTLER-HAMMER II DG222URB Disconnect; 60A, 24OVac, Non-Fusible, NEMA 3R -(1)CUTLER-tIAMMER 9 DG100146 Ground/Neutral it; 60-100A, General Duty(DG) �_. 4 � 1 AWG ii THWN-2,Black g(1)AWG#B, THWN-2, Black 2)AWG X110, PV Wore, 600V, Block Voc* =500 VDC Isc =15 AD O L`L(1)AWG #6, THWN-2, Red FC3 (1)AWG ii THWN-2;Red O (1)AWG 6, Solid Bare Copper EGC Vmp =350 VDC Imp=11 ADC L (1)AWG #6,THWN-2, White NEUTRAL Vmp =240 VAC Imp=25 AAC (1)AWG g10, THWN-2, White NEUTRAL Vmp =240 VAC Imp=25 AAC 1 Conduit Kit; Vi".EMT �. . . . . . . . . . . .. . . . . . -(1)AWG/6,.Solid Bare.Copper. GEC, . , .-(1)Conduit.Kit:.3/4'.EMT, , , , , , , , , , , , , , , , ,-(1)AWG#8,,THWN-2,.Green . . EGC/GEC. 0)Conduit.Kit;.3/4'.EMT. . . . . . . . . . (2)AWG#10, PV Wire, 60OV, Black Voc* =500 VDC Isc =15 ADC O 9(1)AWG#6, Solid Bare Copper EGC Vmp =350 VDC Imp=8.8 ADC . (1)Conduit Kit;.3/4' EMT JB-01 82812 0 0 PREMISE OWNER: DESCRIPTION: DESIGN: CONFIDENTIAL S - THE INFORMATION HEREIN JOB NUMBER: �,�SolarCity. CONTAINED SHALL NOT BE USED FOR THE BUNNELL; HARRY BUNNELL RESIDENCE Matt Morse . BENEFIT OF ANYONE EXCEPT SOLARCITY INC., MOUNTING SYSTEM: 'r o'" NOR SHALL IT BE DISCLOSED IN WHOLE OR IN Comp Mount Type C 66 RUSSELL ST 7.02 KW PV ARRAY PART TO OTHERS OUTSIDE THE RECIPIENTS Moou NORTH ANDOVER MA 01845 ORGANIZATION, EXCEPT IN CONNECTION WITH ° 24 St. Martin Drive,Building 2,Unit 11 THE SALE AND USE OF THE RESPECTIVE (27) TRINA SOLAR # TSM-260PDO5.18 PAGE NAME: SHEET: REV: DATE: Marlborough,MA 01752 SOLARCITY EQUIPMENT, WITHOUT THE WRITTEN INVERTER T: (650)638-1028 F: (650)638-1029 PERMISSION OF SOLARCITY INC. SOLAREDGE SE6000A-USOOOSNR2 (978) 771-7303 THREE LINE DIAGRAM PV 4 10/27/2015 (868)-SOL-CITY(765-2489) www.solarcity.com CAUTION POWER TO THIS BUILDING IS ALSO SUPPLIED FROM THE FOLLOWING SOURCES WITH DISCONNECTS LOCATED AS SHOWN: - Address: 66 Russell St INVERTER AND DC DISCONNECT AC --------------- DISCONNECT L� r J L, rJ I I fF---------L AC DISCONNECT UTILITY SERVICE r--------------------------� SOLAR PHOTOVOLTAIC ARRAYS) i PHOTOVOLTAIC BACK-FED CIRCUIT BREAKER IN MAIN ELECTRICAL PANEL IS AN A/C DISCONNECT PER NEC 690.17 OPERATING VOLTAGE = 240V JB-0182812-00 PREMISE OWNER: DESCRIPTION: DESIGN: CONFIDENTIAL— THE INFORMATION HEREIN [JOB NUMBER JB-0182812 00 Matt Morse �SolarCityCONTAINED SHALL NOT BE USED FOR THE BUNNELL, HARRY BUNNELL RESIDENCE �,�,BENEFIT OF ANYONE EXCEPT SOLARCITY INC., NTING SYSTEM: ,NOR SHALL IT BE DISCLOSED IN WHOLE OR INomp Mount Type c66 RUSSELL ST 7.02 KW PV ARRAY PART TO OTHERS OUTSIDE THE RECIPIENTS ULES NORTH ANDOVER, MA 01845THEORG�SALEnAND USE OF ON. EXCEPT ITHE RES ECTIVEN CONNECTION�TM 7) TRINA SOLAR # TSM-260PD05.18 PAGE NAME 24 St. Martin Drive, MA01g 2 Unit 11 SHEET: REV: DATE Marlborou�,MA 01752SOLARCITY EQUIPMENT, WITHOUT THE WRITTENERTER: T: (650)638-1028 F: (650)638-1029 PERMISSION of SOLARCITY INC. OLAREDGE SE6000A-USOOOSNR2 (978) 771-7303 SITE PLAN PLACARD PV 5 10/27/2015 ces8>-sa-clnr(7s5-24x9) .Salarcitrcam Label Location: Label Location: Label Location: WARNING:PHOTOVOLTAIC POWER SOURCE WARNING ' WARNING Code:Per •• NEC Code: NEC ELECTRIC SHOCK HAZARD ELECTRIC SHOCK HAZARD' • DO NOT TOUCH TERMINALS '• ' NEC THE DC CONDUCTORS OF THIS Label • • TERMINALS ON BOTH LINE AND PHOTOVOLTAIC SYSTEM ARE TO BE USED WHEN LOAD SIDES MAY BE ENERGIZED UNGROUNDED AND PHOTOVOLTAIC DC D IN THE OPEN POSITION MAY BE ENERGIZED UNGROUNDED INVERTERIS DISCONNECT Code: NEC .•0 Label Location: Label • • PHOTOVOLTAIC POINT OF '• INTERCONNECTION Per ••_ MAXIMUM POWER- A WARNING: ELECTRIC SHOCK POINT CURRENT(Imp)- Per Code: HAZARD.DO NOT TOUCH NEC 690.17.4; 690-54 MAXIMUM POWER- VNEC 690.53 TERMINALS.TERMINALS ON POINT VOLTAGE(Vmp)- BOTH THE LINE AND LOAD SIDE MAXIMUM SYSTEM V MAY BE ENERGIZED IN THE OPEN VOLTAGE(Vocj POSITION. FOR SERVICE SHORT CIRCUIT A DE-ENERGIZE BOTH SOURCE CURRENT(Isc) AND MAIN BREAKER. PV POWER SOURCE MAXIMUM AC A OPERATING CURRENT MAXIMUM AC V Label Location: OPERATING VOLTAGE WARNING Code:Per NEC ELECTRIC SHOCK HAZARD • IF A GROUND FAULT IS INDICATED NORMALLY GROUNDED Label • - • CONDUCTORS MAY BE CAUTION UNGROUNDED AND ENERGIZED DUAL POWER SOURCEPer Code: SECOND SOURCE IS : PHOTOVOLTAIC SYSTEM Label • • WARNING ' Location:Per Code: Label ELECTRICAL SHOCK HAZARD NEC 6.0 CAUTION P' DO NOT TOUCH TERMINALS TERMINALS ON BOTH LINE ANDPer Code: NEC LOAD SIDES MAYBE ENERGIZED PHOTOVOLTAIC SYSTEM : IN THE OPEN POSITION CIRCUIT IS BACKFED DC VOLTAGE IS ALWAYS PRESENT WHEN SOLAR MODULES ARE EXPOSED TO SUNLIGHT Label • • Per WARNING ..- INVERTER OUTPUT Location:Label CONNECTIONNEC PHOTOVOLTAIC AC DO NOT RELOCATE Disconnect DISCONNECTPer ••" THISODVERCC�RRENTConduit (CB): Combiner Box NEC 690.14.C.2 (D): Distribution Panel (DC): DC Disconnect (IC): Interior Run . • LabelIntegrated DC Disconnect MAXIMUM AC ' Load Center OPERATING CURRENT - APer Code: (M): Utility Meter MAXIMUM AC VNEC 690.54 Point of • • OPERATING VOLTAGE 1 1 1 1 1' 1 55 Cleatyiew . / 1 1 •'r 1' I r l 1 San Mateo,CA ,1 29 1 1 1 1 •1 1' 1 1il �• 1 1 1' 1 •. r 1 •/ 1 •1 I � • 11 1 7 1 1 1 =` ® Next-Level PV Mounting Technology '^5oiarCit Z Solar Next-Level PV Mounting Technology SolarCity I ZepSolar 9 9Y Y Zep Solar System Components OEM for composition shingle roofs y Up roof ~ Medoc orwmd Zep - - - to-lino Few I - .,compatible w Module HCl. - zcp G,we _ R-f Anxhmmt Array Sk A —e . GoMPA* .Fgri- Description PV mounting solution for composition shingle roofs Works with all Zep Compatible Modules u� • Auto bonding UL-listed hardware creates structual and electrical bond • Zep System has a UL 1703 Class"A"Fire Rating when installed using Vmodules from any manufacturer certified as"Type 1"or"Type 2" Comp Mount Interlock Leveling Foot LISTED .� Part No.850-1382 Part No.850-1388 Part No.850-1397 Listed to UL 2582& Listed to UL 2703 Listed to UL 2703 Specifications Mounting Block to UL 2703 Designed for pitched roofs ., Installs in portrait and landscape orientations vn Zep System supports module wind uplift and snow load pressures to 50 psf per UL 1703 • Wind tunnel report to ASCE 7-05 and 7-10 standards 71 • Zep System grounding products are UL listed to UL 2703 and ETL listed to UL 467 • Zep System bonding products are UL listed to UL 2703 f) Engineered for spans up to 72"and cantilevers up to 24" • Zep wire management products listed to UL 1565 for wire positioning devices Ground Zep Array Skirt,Grip,End Caps DC Wire Clip • Attachment method UL listed to UL 2582 for Wind Driven Rain Part No.850-1172 Part Nos.500-0113, Part No.850-1448 Listed to UL 2703 and 850-1421,850-1460, Listed UL 1565 ETL listed to UL 467 850-1467 zepsolar.com zepsolar.com Listed to UL 2703 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 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 Zep Solar's products for each use.Specifications are subject to change without notice.Patents and Apps:zspats.com. responsible for verifying the suitability of Zep Solar's products for each use.Specifications are subject to change without notice.Patents and Apps:zspats.com. 02 27 15 ZS for Comp Shingle Cutsheet Rev 04.pdf Page: 1 of 2 02 27 15 ZS for Comp Shingle Cutsheet Rev 04.pdf Page: 2 of 2 solar • • • solar • • e SolarEdge Power Optimizer Module Add-On for North America P300 / P350 / P400 SolarEdge Power Optimizer __ _ P300 P350 P400 Module Add-On For North America (forodules PV (formodules_ (fmor modules)PV modules) modules)_ modules) INPUT P300 / P350 / P400 - — — - - ——- Rated Input DC Power" 300 I 350 400 W Absolute Maximum Input VOltage,Voc at lowest temperature) 48 .............60...............I 80..... .... ........ MPPTOperadn Ran a 8-48 8-60 f 8-80 Vdc ...................g....................................................................................................................................I............. . Maximum Short Circuit Curren[(Isc) 30 I Adc ., - -Maximum DC Input Ad Current ....................................12:5............................. c ............. Maximum Efficiency 99.5 % Wei hted ETciencY ......................................98:8......................................1............. vervoltage Cate Ogory II I :'' OUTPUT DURING OPERATION(POWER OPTIMIZER CONNECTED TO OPERATING INVERTER) _ Maximum Output Current 15 Adc Maximum Output Voltage 60 Vdc OUTPUT DURING STANDBY(POWER OPTIMIZER DISCONNECTED FROM INVERTER OR INVERTER OFF) Safety Output Voltage perPower Optimizer ....___.._._........— ._— dc .......... 7 STANDARD COMPLIANCE EMC......................................................... FCC PartlS Class B,lEC61000-6-2,IEC61000-6-3 ....... ............................................................................................... ............. -._..-.,----IEC62109-1(class 11 safery):UL3741................... ............. Safety............................................................................ RoHS Yes INSTALLATION SPECIFICATIONS _ _.—__._._....._......_ _.-........ - Maximum Allowed System Voltage 1000 Vdc ........ ........................................................................... .......................................I............. Dimensions(W xLx H) 141z212x40.5/S.SSx8.34z1.59 mm/in .......................................................................................................................................................I............. Weight(including cables) ................ ................................ 950/2.1 .......................................................................................... . ..................... ............. - Input Connector MC4/Amphenol/Tyco ........................................................................................................................................................... ............. Output Wire Type/Connector Double Insulated;Amphenol -- . ...... .......... .. ..... ...........................................I......................... ...... i Output Wire Length 0.95/3.0 1.2 0:? / Operating Temperature Range.....................................................................40-+85/:40-+185 ... .. - Protection Rating...................................................... .................IP6S/,NEMA4 Relative Humidity 0-100 ��wree srew.�+or rx�nnnz�,rwmnea�o m•sx wr<+�ok.,Me,b..a. PV SYSTEM DESIGN USING A SOLAREDGE SINGLE PHASE THREE PHASE THREE PHASE INVERTER 208V 480V PV power optimization at the module-level Minimum String Length.... Opt mixers) 8 10 18 ....................................................... Maximum String Length(Power Optimizers) 25 25 SO ..................................................................................................................... — Up to 25%more energy Maximum Power per String .-....-,..SZ50......................6000 12750 W ............................................................................. ...............I......................................... — Superior efficiency(99.5%) Parallel Strings of Different Lengths or Orientations Yes — Mitigates all types of module mismatch losses,from manufacturing tolerance to partial shading '------ "---- ----- - - -- --- ----- - - -- - - -- -- -- --- - - ---- - -- -- --- - - Flexible system design for maximum space utilization - Fast installation with a single bolt — Next generation maintenance with module-level monitoring — Module-level voltage shutdown for installer and firefighter safety USA - GERMANY - ITALY - FRANCE - JAPAN - CHINA - ISRAEL - AUSTRALIA www.SOlaredge.US 71 THE 'baamount MODULE TSM-PD05.18 Mono Multi Solutions DIMENSIONS OF PV MODULE ELECTRICAL DATA @ STC unit:mm Peak Power waits-P-(Wp) 245 250 255 260 ® 941 Power Output Tolerance-Pmdx(%) 0-+3 THE V57nFOIE-- mount Maximum Power Voltoget-lv (V) 29.9 30.3 30.5 30.6 tnu o Maximum Power Current-IMYP(A) 8.20 8.27 8.37 8.50 xnnxrure Open Circuit voltage-Voc(V) 37.8 38.0 38.1 38.2 0 Short Circuit Current-Isc(A) 8.75 8.79 8.88 9.00 pG H[xE MODULE Module Efficiency r,m(%) 15.0 15.3. 15.6 15.9 STC:Irradiance 1000 W/m'.Cell Temperolure 25°C.Air Mass AM1.5 according to EN 60904-3. Typical efflciency reduction of 4.5%at 200 w/m'according to EN 60904-I. 0 0 ELECTRICAL DATA @ NOCT 6 O CELL Maximum Power-P-(Wp) 182 186 190 193 Maximum Power Voltage-Vvv(V) 27.6 28.0 28.1 28.3 MULTICRYSTALLINE MODULE ,�+3arcwo�cNaE Maximum Power Current-I.,(A) 6.59 6.65 6.74 6.84 A A Open Circuit Voltage(V)-Voc(V) 35.1 35.2 35.3 35.4 WITH TRINAMOUNT FRAME ".max xxE Short Circuit Current(A)-Isc(A) 7.07 7.10 7.17 7.27 NOCT:Irradiance at 800 W/m'.Ambient Temperature 20°C.Wind Speed I m/s. 245-26OW PD05.18 812 180 Back View POWER OUTPUT RANGE MECHANICAL DATA U� Solar cells Multicrystalline 156 x 156 mm(6 inches) Fast and simple to install through drop in mounting solution Cell orientation 60 cells(6 x 10) Module dimensions 1650 x 992 x 40 mm(64.95 x 39.05 x 1.57 inches) Weight 21.3 k9(47.0 lbs) MAXIMUM EFFICIENCY Glass 3.2 mm(0.13 inches).High Transmission.AR Coated Tempered Glass A-A Eacksheef White Good aesthetics for residential applications Frame -t a Black Anodized Aluminium Alloy with Trinamounf Groove- I-V roove 1-V CURVES OF PV MODULE(245W) J Box IP 65 or IP 67 rated 0--+317o Cables Photovoltaic Technology cable 4.0 mm'(0.006 inches'). POWER OUTPUT GUARANTEE lo9.mt IOOOw/m;. Fire Rating Type m(47.z inches) ._.._ _ 8mi Am. 80ow Highly reliable due to stringent quality control -bm; 6WW/rr?. • Over 30 in-house tests(UV,TC,HF,and many more) s.-' As a leading global manufacturer In-house testing goes well beyond certification requirements u 4.r' 400W/mz- - - TEMPERATURE RATINGS MAXIMUM RATINGS of next generation photovoltaic am 200w/m' Nominal Operating Cell Operational Temperature -40-+85°C 2.m..�....-_____ 44°C(±2°C) prOdUCiS.We believe CIOSe -----�- -- -- Temperature(NOCT) cooperation with our partners 'w - - 1 Maximum system 1000V DC(UL) a° Temperature Coefficient of PM,x -0.4196/°C Voltage IOOOv DC(UL) is critical to success. With local o.. lo.- tom aom 40.- presence around the globe,Trina is Vdfoge(V) Temperature Coefficient of voc -0.32%/°C Max Series Fuse Rating 15A able to provide exceptional service ---� to each customer in each market Certified to withstand challenging environmental Temperature Coefficient of Ise o.os%/°C and supplement our innovative, conditions reliable products with the backing 2400 Pa wind load of Trina as a stlong,bankable WARRANTY • 5400 Pa snow load partner. Weare committed 10 year Product Workmanship Warranty to bu;iding strategic,mutually b 25 year Linear Power warranty beneficial Collaboration with installers,developers.distributors (Please refer to product worrontyfordetails) < and other partners as the backbone of our shared success in CERTIFICATION driving Smart Energy Together. LINEAR PERFORMANCE WARRANTY ( PACKAGING CONFIGURATION a 10 Year Product Warranty•25 Year Linear Power Warranty �wTEo� °spa Modules per box:26 pieces Z Trina Solar Limited w www.ifinasolar.com Modules per 40'container.728 pieces 3: 0% _ a A '11"onp/value �w. E- EHE from Trl 9o% na Solan o s 11f1eCr N'nrroA CAUTION:READ SAFETY AND INSTALLATION INSTRUCTIONS BEFORE USING THE PRODUCT. QGanPd>iq� L1 o ryT�1�1 02014 Trino Solar Limited.All rights reserved.Speciflcatlons included In this datasheet are subject to H r �po��solar L2 80% �U [J J{J�Solar changewilhoutnolice. Smart Energy Together / Smart Energy Together pa��e Years 5 10 IS 20 25 Trina standard I.0 r"t, J THE TrTnamount MODULE TSM-PD05.18 Mono Multi Solutions DIMENSIONS OF PV MODULE ELECTRICAL DATA @ STC unit:mm Peak Power Watts-Pr (Wp) 250 255 260 265 • 941 Power Output Tolerance-P-(%) 0-+3 THE Trinamount i Maximum Power Voltage t-1 (v) 30,3 30.5 30.6 30.8 rx- � Maximum Power Current-INw(A) 8.27 8.37 8.50 8.61 ".,rsaf u, Open Circuit voltage-Voc(V) 38.0 38.1 38.2 38.3 0 Short Circuit Current-Isc(A) 8.79 8.88 9.00 9.10 psT"LLlle Neff O D E Module Efficiency r,m(%) 15.3 I 15.9 16.2 STC:Irratliance 1000 W/m'.Cell Temperature 25°C.Air Mass AM1.5 according ding to EN 60904-3. Typical efficiency reduction of 4.5%at 200 W/m'according to EN 60904-I. o � b � 0 ELECTRICAL DATA R NOCT Maximum Power-PN (Wp) 186 190 193 197 60 CELL Maximum Power Voltage-VM (V) 28.0 28.1 28.3 28.4 Maximum Power Current-l., (A) 6.65 6.74 6.84 6.93 MULTICRYSTALLINE MODULE "°"LR0 NeM4M"` A A Open Circuit Voltage(v)-Voc(V) 35.2 35.3 35.4 35.5 WITH TRINAMOUNT FRAME PD05.18 an NNaf Short Circuit Current(A)-Isc(A) 7.10 7.17 7.27 735 NOCT:Irradiance of 800 w/m'.Ambient Temperature 20°C.Wind Speed I m/s. 812 180 250-265W Bock view MECHANICAL DATA POWER OUTPUT RANGE Solar cells Multicryslalline 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 x 40 mm(64.95 x 39.05 x 1.57 inches) 1 6.2 Weight 19.6 kg((0.13 ilbs) 1�Q Gloss 3.2 mm(0.13 inches).High Transmission,AR Coated Tempered Glass MAXIMUM EFFICIENCYA-A Backsheet white _ Frame Black Anodized Aluminium Alloy Good aesthetics for residential applications ,_Bax IP 65 or IP 67 rated ///������JJJ Cables Photovoltaic Technology cable 4.0 mm'(0.006 inches'), 0--+3% /y+ (v�O 1200 mm(47.2 inches) 1-V CURVES OF PV MODULE(260W) Connector H4 Amphenol POSITIVE POWER TOLERANCE Fire Type UL 1703 Type 2 for Solar City Highly reliable due to stringent quality control �� • Over 30 in-house tests(UV,TC,HF,and many more) T'0° As a leading global manufacturer 'til In-house testing goes well beyond certification requirements 3 °'00 m TEMPERATURE RATINGS MAXIMUM RATINGS of next generation photovoltaic PID resistant 4.ro Operating ee(NtiOnCTj ell qq°C(t2°C) Operational Temperature -40-+85°C products,we believe close Temperature cooperation with our partners Maximum System 1000V DC(IEC) is critical to Success. With local zao masvba-- Temperature Coefficient of P_ -0.41%/°C Voltage 1000V DC(UL) presence around the globe,Trina is 00 Temperature Coefficient of Voc -0.32%/°C Max Series Fuse Rating 15A able to provide exceptional service °'0°e e p 4e w Temperature Coefficient of Ise 0.05%/°C ---- -- -- -. to each customer in each market Certified to withstand challenging environmental and supplement our innovative, conditions reliable products with the backing • 2400 Pa wind load of Trina as a strong,bankable • 5400 Pa snow load WARRANTY partner. We are committed 10 year Product Workmanship Warranty to building strategic,mutual) CERTIFICATION g 9 Y 25 year Linear Power Warranty ( beneficial collaboration with installers.developers,distributors eters .ca- (Please refer to product warranty for details) Nusi and other partners as the r backbone of our shared success in driving Smart Energy Together. LINEAR PERFORMANCE WARRANTY i.-- PACKAGING CONFIGURATION 10 Year Product Warranty•25 Year linear Power Warranty CON"""r Modules per box:26 pieces Z Trina Solar Limited Modules per 40'container:728 pieces www trnasolar.cor^, -l00% y- --- - --�- Addillon dal value 0 9096 • from Trirlq Solgr's Ilrlepr N orrahly • CAUTION:READ SAFETY AND INSTALLATION INSTRUCTIONS BEFORE USING THE PRODUCT. ","FA, aNPAT Trinasolar Tr�nasolar m201gewitSolar tnotictetl.All rights reserved.SpeciBcotionsincluded inthis tlotosheetore subject 80% change without notice. Smart Energy Together Years s to Is 20 25 Smart Energy Together ■Trinastandard t 1.J r r =* @ $QIaf'' ' • • Single Phase Inverters for North America soIar SE3000A-US/SE380OA-US/SE5000A-US/SE6000A-US/ SE760OA-US/SE10000A-US/SE1140OA-US SE300.OA-US SE380OA-US I SE5000A-US I SE6000A-US I SE760OA-US I SE10000A-US I SE1140OA-US _OUTPUT SolarEdge Single Phase Inverters 9980 @ 208V Nominal AC Power Output 3000 3800 5000 6000 7600 11400 VA 10000 @240y- Max.AC Power Output 3300 4150 5400 @ 208V 6000 8350 10800 @ 208V 12000 VA Bso@?4RY....... .io9so.@zaoy. ............................. For North America ...................................!... ................ ..................1.... ........... ................ AC Output Voltage Min:Nom:Max'I 183-208-229 Vac SE3000A-US/SE380OA-US/SE5000A-US/SE6000A-US/ ...0utp.......a'e' ................... ................ ................................................ .................................. ............................. AC Output Voltage Min:Nom:Max!'I � � � � � � � SE760OA-US/SE10000A-US/SE1140OA-US 211-240-264 Vac �.AC Frequency Min.:Nom:Max.�'�.,�� ..�-.�,�-�-�-� 59.3-60-60.5(with Hl country setting -_60,-60.51............. ................ ..Hz. ......... .... ................ .... ....... A sv Max.Continuous Output Current...... .....12.5......1......16......1...21 @ 240V...I.......25......1......32.......1...42 @ 240V...1......47.5...........A..... GFDI Threshold Utility Monitoring,Islanding Protection,Country Configurable Thresholds __'_F. Yes Yes INPUT Maximum DC Power STC 4050 5100 6750 8100 10250 13500 15350 W ( ) T.1 ..........-ll... .. ....mm.-(.. - I............... ........................................... Transformer-less,Ungrounded ................................................ Yes .............................................I.,....... 1 lafs o .. .. Max.Input Voltage................... .......................................... ...... ....500... .. ..... ........................................... Vdc... waR'yntY� - Nom.DClnputVoltage 325@.208V/3501 240.V..-.... .............. .Vdc.... Max.Input CurrenNal 9.5 13 16.5 @ 208V 18 23 33 @ 208V 34.5 Adc .,''..,- ... .... ...................................... ................1............... .15;S,�A 240y..1................ ..................30.5 @ 240V............................... r Max.Input Short Circuit Current 45............................................................... Reverse-Polarity Protection Yes ...... ........................................... .................................................... ... ..... ................................................................... Ground-Fault Isolation Detection 600ka Sensitivity .................................. ............................. i MaximuminverterEfficiency 97.7 98.2 98.3 98.3 98 98 ........................................... ................ ................................ .................................. .................... 97.5 @ 208V 97 @ 208V CEC Weighted Efficiency 97.5 98 97.5 97.5 97.. % .................975@,240V.. ............................. Nighttime Power Consumption <2.5 ADDITIONAL FEATURES Supported Communication Interfaces R5485,RS232,Ethernet,zlgBee(optional) ........................................... ..................................................................................................................................... Revenue Grade Data,ANSI C12.1 Optionallal Rapid Shutdown-NEC 2014 690.12 Functionality enabled when SolarEdge rapid shutdown kit is installed' STANDARD COMPLIANCE _ Safety .......UL3741,UL1699B,UL1998,CSA 22.2 Grid Connection Standards ...................................IEEE1547......................................... .......................... - - Emissions FCC part15 class B INSTALLATION SPECIFICATIONS - t AC output conduit size/AWG range 3/4"minimum/16-6 AWG 3 4.minimum 8..AWG l ................................. .. ................................................................. 3/4"minimum/1-2 strings DC input conduit size/p of strings/ / . . . . - - - - . . - -3/4'minimum/1-2 strings/16-6 AWG- '.- - - - , AWG.I;ang?...:........... ..... 30.5 x412Stx 10.5./...........i�`/ Dimensions with Safety Switch 30.5 x 12.5 x 7.2/775 x 315 x 184 a .P?twW p)............ 775 x 315 x . 260 . .........mm.._. ' Weight with Safety Switch............. ..........51.2/23.2..........(....................54:7/.24.7.. ............................88,.4,/.40.1.............Ib/.kg... Natural i convection Cooling Natural Convection and internal Fans(user replaceable) fan(user ..NO15e................................... .............................. 2s............................... .�ep�a�eable)......... So...........................daA... The best choice for SolarEdge enabled systems ........< ............................ ............................................................. ................. .... ........ - Integrated arc fault protection(Type 1)for NEC 2011690.11 compliance Min-Max.Operating Temperature g p P -13 to+140/.25 to+60(-40 to+60 version available(')) 'F/'C - Superior efficiency(98% Range......Rating,,,,,,,,,,,,,„-,,,-„. „-,,, eY ) Protection Rating NEMA 3R ...... ......... ......... - Small,lightweight and easy to install on provided bracket "'For other regional settings please contact SolarEdgesupport. la A higher current source may be used;the Imener will limit its input current to the values stated. - Built-in module-level monitoringmRevenueg a de lmerte,P/N:5EotniA-A000NNR71for 760OW imener.SE7600A-USOD]NNR]I. Rapid shutdown kit P/N:SEI000-RSD-S1. - Internet connection through Ethernet or Wireless pl40 vemlon P/N:SE-A-USOOONNU4(for 760M Imerter5E7600A-US002NNU4). - 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 sunsaEcRoHS USA-GERMANY-ITALY-FRANCE-JAPAN-CHINA-AUSTRALIA-THE NETHERLANDS-ISRAEL www.solareclge.us Date.. . . . Of`NORTH '1'V 0� TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION . 11 �9SSACNUSEt I` This certifies that . ! . . . _. �.+... 1 . . . . t has permission for gas installation ,v.. . . . . . . .{". . . . . . . . . in the buildings of . 11-.f��:�. . . . . . . . . . . . . . . . . . . . . . . . . . . . at !�.�. . . .. . . ._.-: . . . . ., North Andover, Mass. Feed? . . . Lic. No.a!�Yf?. . �'* :j!��� . . . . . . . . . . . . GAS IMSPCTOR Check# �/�y I' MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date 3j 19 I LO NORTH ANDOVER,MASSACHUSETTS - Building Locations l0 USS �y ` �� Permit# — � I p Amount$ �Q"�!/o ����-'PC�� Owner's Name ` New❑ Renovation ❑ Replacement ® Plans Submitted ❑ x w � � z Q w w ° a Gw z ¢ a `� w w A H x W Q a H o > w F vv a W w > w O z rx Q O O m o m 3 a a v a > SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLO O R 7TH . F L O O R STH . FLOOR , i F1 (Print or ��v� type) �n p i -" Check one: Certificate Installing Company Name Rria- (/ !7 VSb- r�,' ❑ Corp. ��j�Y7�► �7 Address ZI� ❑ Partner. usmess a ep one Firm/Co. ' Name of Licensed Plumber or Gas Fitter Aw-HO(�f Lunt----H.0 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesNo❑ If you have checked,yes,please indicate the type coverage by checking the appropriate boi� Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have sub ed(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and insta a'ons p ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachu State C d hapter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas itter Title ❑ Plumber 2— & City/Town ❑ Gas Fitter Eicense Nurntier ❑ Master APPROVED(OFFICE USE ONLY) ® Joumeyman The Commonwealth of Massachusetts Department of Indush al Accidents Office of Litrestigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Orgmization/Individual): NA-0e -14i:;� 50 Address: 4— r2 City/State/Zip: A� T1a( +,�� (�( _ Phone#:_(_e1 5-`16 cC_ Are you an employer?Check the appropriate box: 1.❑ I am a em to er with 4. Type of project(required): P Y ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.A I am a sole proprietor or partner- listed on the attached sheet : 7. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp..insurance 5. 9. ❑Building addition❑ We are a corporation and its required.] officers have exercised their 10.[] Electrical repairs or additions 3.[] .❑ I am a homeowner doing all work right of exemption per MGL 11 4N Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no insurance required.]t 12.0 Roof repairs Q ] employees. [No workers' comp.insurance required] 13.❑ Other =m applicant teat_checks box#1 must also fill out the section belo,v sn-vi g the wori;e:s'compensation policy info.-:uadon H t omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub, ontractors and their workers'comp Policy information. I am an employer that is providing workers'compensation information. insurance for my employees Below is the policy and job site t Insurance Company Name: Policy#or Self-ins.Lic.#: 'n p p Expiration Date: Job Site Address: Cy(0 /U,59(_ /V_ 1/0k r /� f/�/� City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the im osition of fine u to$1 500.00 P criminal penalties P and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER P es of i of up to$250.00 a da a and a fin y against the violator. Be advised that a co of this e PY statement may be forwarded Investigations of Y to the Office g the DIA for insurance coverage verification. of I do hereby cern nder he pans nd a aloes of perjury that the information provided1110ove is true and correct. Si ature: Date: Phone#: FOther only. Do not y write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: Y Information and Instructions 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 apartalents 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-contractor(s)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 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 D==m--nt 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/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 home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 � Revised 5-26-OS t7 � VVIAMI.mass_gov/dia r