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HomeMy WebLinkAboutBuilding Permit # 10/23/2015 BUILDING PERMIT TOWN OF NORTH ANDOVER 1 � APPLICATION FOR PLAN! EXAMINATION err rlt hid: Date Received_�__w Date Issued:.. CHU` IMPORTANT:T: all itaWrns cin this a e TYPE OF IMPROVEMENT _ PROPOSED USE Residential Non- Residential �'. New Building �,.,..�,�.._.�.�..._. _ : One family .� �..._.._..�. __..__�... Addition Two or more family Industrial Iteration_ No, of units: 1: Commercial Repair, replacement Assessory Bldg i:3 Others:_ w Demolition :.. {ether ,rr 2-u ai 5cAc.\rvL&n '-\ , I Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: 7✓���,�s?/�• Pr,- ,i t`r'y �+�j%rr�, C r1,r�� pf v�lx� i r 1 / a ARCHITECTINOINEER .., Phone: w + i Address: Reg. No. FEE SCHEDULE,BULDING PERMIT,$12.00 PER$1000,00 CP THE TOTAL ESTIMATED COST BASED ON$126.00 PER SIF" Total Project Cost: PEE: e1_ � Check No.: IJ Q4L, Receipt No.: NOTE: rsrrns contracts".n rvzth unregistered contractors do not have. accts to tic guarantyfund y� DocuSd by: DocuSigned by: .;;',' " f fi"'j� Ta..y�/� „tea ,.. f ��s.�,,Cl(ia �Yy !� % y /N!'✓ni J' �r P, rV: �u ��y,`1 t ':rr s,C�Cfi sir F"j"�`I' —50212AA3A46A4C5... *WMMaA46A4C5... t4®RTH town of ndover ® ,: 0 LAKE h ver, Mass, I J COCKICNEw,CK I.�S RATE O 11 BOARD OF HEALTH Food/Kitchen P 1: �RM IT T L D Septic System THIS CERTIFIES THAT ................... Lu.. ... .. ................. . ............................................................ BUILDING INSPECTOR has permission to erect buildings on �.. Foundation .......................... .. .. . ......� . ..... ................. Rough .. .. .............................. Chimney to be occupied as ... .:�: ...1�. ....... .. . .. ... .....�?�1........ ...... y provided that the person accepting this permit shall in every respect conform to the ter of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final IT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONRough Service .................... ... . ............................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Wtig i ass,4 890 STRUCTURAL WIMMEEK-4 na amw September 19,2015 Mr. WissemTaboubi NRG Solar 89F Washington Ave Natick,MA 01760 RE: Miller Residence Solar Installation 1094 Salem Street North Andover,MA 01845 Structural Assessment of Roof Framing MPP Project No: 15-2465 Dear Mr.Taboubi: Pursuant to your request,MPP Engineers has performed a limited structural evaluation of the roof framing at the above referenced site to determine if the roof has adequate capacity to support the proposed solar panels. Our analysis was based on the framing information and configurations provided by NRG Solar. It is our understanding that the structural components of the existing roof framing are in good condition. It is further understood that all existing connections between the various roof framing members,including ceiling joists,rafters and collar ties are adequate to resist the current loading conditions and behave in the manner that a typical rafter and ceiling tie system is intended to behave prior to installation of the solar panels. Results South Roof and West Roof—adequate to support the proposed solar panels Structural Data and Code Information Our analysis was performed in accordance with the requirements of the 780 CMR 51.00:Massachusetts Residential Code which has adopted the 2009 International Residential Code with Massachusetts amendments. Per Table R301.2 (1),the ground snow load to be used for each town is in accordance with Table 8301.2(5). Similarly,the wind speed for each town is in accordance with Table R301.2(4).The roof framing was analyzed in accordance with Section RI 04.11 of the of the 2009 International Residential Code which allows for alternate approved design such as using the ASCE 7 code for determining actual snow loads on roofs(e.g. deriving flat or sloped roof snow loads from the specified ground snow load referenced in Table R301.2(5)). Wood members were analyzed and designed in accordance with the NDS 2005. The roof areas for the solar panels of this residence are framed in a gable configuration with conventional MPP Engineers,LLC 1 34 South Main Street, Suite D I Allentown,NJ 08501 609-489-5511 (office) I www.mt)t)eir�-,ineer•s.comj 609-489-5916 (fax) Miller Residence Solar Installation 1094 Salem Street North Andover,MA 01845 2x roof rafters and collar ties. The existing roof structure is in good condition and is assumed to have two layers of asphalt shingles. The pertinent data is listed below: South Roof(13 Panels Total): Rafters: 2"x 10" (#2 Spruce-Pine Fir Assumed) Spacing: 16" O.C. Roof Slope: 22 Degrees Horizontal Projected Length of Rafter (Horizontal Projection): 12 feet Ceiling Joists: Present Collar Ties: Present Roof Sheathing: Wood Boards and Plywood Sheathing Condition of Framing: Good Roof Covering: Asphalt Shingles Ground Snow Load,Pg: 50 PSF from Table R301.2 (5)of Massachusetts Residential Code Importance Factor,L• 1.0 Exposure Factor, Ce: 1.0(Conservatively taken as Partially Exposed) Thermal Factor,Ct: 1.1 with Panels(Cold Roof) 1.0 existing condition(Warm Roof) Design Snow Loads On sloped roof: 35.00 PSF(Existing—Unobstructed Warm Roof) 30.80 PSF(New—Slippery Surface on Cold Roof) West Roof(13 Panels Total): Rafters: 1.75"x 6"TRUE(#2 Spruce-Pine Fir Assumed) Spacing: 16" O.C. Roof Slope: 23 Degrees Horizontal Projected Length of Rafter (Horizontal Projection): 12 feet Ceiling Joists: Present Collar Ties: Present(At every alternate rafter) Roof Sheathing: Wood Boards and Plywood Sheathing Condition of Framing: Good Roof Covering: Asphalt Shingles Ground Snow Load,Pg: 50 PSF from Table R301.2 (5)of Massachusetts Residential Code Importance Factor,I: 1.0 Exposure Factor,Ce: 1.0(Conservatively taken as Partially Exposed) Thermal Factor,Ct: 1.1 with Panels(Cold Roof) 1.0 existing condition(Warm Roof) Design Snow Loads On sloped roof: 35.00 PSF(Existing—Unobstructed Warm Roof) 30.16 PSF(New—Slippery Surface on Cold Roof) Miller Residence Solar Installation 1094 Salem Street North Andover,MA 01845 Wind Speed: 100 MPH from Table R301.2 (4)of Massachusetts Residential Code Exposure B Analysis Results: General Considerations ➢ Materials such as metal roofs or solar panels are considered slippery surfaces. Since the solar panels are mounted slightly above the roof line, it would be conservative to consider a thermal factor Ct of 1.1,treating the panel surface as a cold roof rather than a warm roof.Based on the roof slope and considering it as a slippery surface,the snow load is reduced by 12%for the South Roof and 14%for the West Roof compared with the snow loading directly on the existing shingled roof surface.This reduction equates to 4.20 PSF for the South Roof and 4.84 PSF for the West Roof which essentially offsets the weight of the solar panels. Gravity Loading: South Roof and West Roof—adequate to support the proposed solar panels It is our understanding that the panels will be installed using Unirac rail with L-feet(or equal)at approximately 48 inches on center(e.g. every two to three rafters).The leveling feet will be fastened directly into the existing joists with 5/16" diameter lag screws with a minimum embedment of 2.5".In addition, it is important that the leveling feet support locations be staggered between adjacent panels so that no single rafter supports more load than under the existing conditions. Wind Loading Based on our calculations,the net wind loads imposed on the roof framing with an attachment spacing as indicated above will be less than the current loading on the roof framing. In addition,provided that the leveling feet are attached to the roof framing members in a typical staggered fashion,the overall wind loading imposed on the structure and the individual framing members will not be impacted to any great extent. Miller Residence Solar Installation 1094 Salem Street North Andover,MA 01845 If you have any questions regarding this matter,please feel free to contact my office at 609-489-5511. We appreciate the opportunity to assist you with this evaluation. Sincerely, MPP Engineers, LLC / Chiranjib Mukherjee �3'VjkA oF��ps ' ASHu , CD Na.4 3a ' ISTS ` JNAL ��a Ashutosh Patel,P.E. MA Prof.Eng.Lic.No. 48235 SERVICE INFO INVERTER SPECS MODULE SPECS nrg. UTILITY COMPANY NGRID ENPHASE QUANTITY 26 Home MAIN SERVICE VOLATGE 240V INVERTER TYPE M250-60-2LL-S22 MODULES TYPE LG275S1C-B3 SOLAR MAIN PANEL BRAND -- QTY 26 WATTAGE 275W MAIN SERVICE PANEL 200 A WATTAGE 210-30OW NOCT WATTAGE 202W 1�EDAgCH MAIN CIRCUIT BREAKER RATING: 200 A SERVICE VOLTAGE: 240V FRAME THICKNESS 35MM v.Per EDF: MAIN SERVICE LOCATION SOUTH-WEST WALL CEC EFFICIENCY 96.5% FRAME COLOR BLACK uo.st621: SERVICE FEED TYPE OVERHEAD Voc 38.70V 3`xowELL, MAIN SERVICE PANEL GROUND EXISTING GROUND ROD Vpmax 31.70V ��� of Isc 9.26A Imp 8.68A TO UTILITY C) FA i - JUNCTION BOX ( E)MAIN SEIMCE PANEL 200A J RATED BUS BAR L-GATE 120 PV 1ODA SOLAR ONLY SOLAR ARRAY (7.150 kWstc) ~U 604 AC PRODUCTION LOAD CENTER JUNCTION BOX CTI— B❑ 1 - L-GATE 120 PRODUCTION METER (q zoDyzP ons MP 3 DISCONNECT3 METER 3 C ,D„ 2 A 1 BRANCH 1 BRANCH ji O D B IN PARALLEL CONNECTED IN BRANCH V 1 - t0A/SOLAR ONLY LOAD CENTER ° _ o° ,°° K. 13 aRcur� z w 2 - 20A/2P SOLAR BREAKER ° x T W 1 - 20A/2P ENVOY BREAKER o° ----_ ---------- ----------- t3 MODULES LC LC2]551C-B3 (E)�� ___________ i ________ _�___ L Q D❑ 1 - 60A AC DISCONNECT METER F� WIXIM min MU"G — 4 fDLS DYR S[ Q M23 S. LL MP 1 - 35A SOLAR BREAKER + 2 1 BRANCH 2 RRANcH#2 a ECC,CEC i MODULES IN PARALLEL CONNECTED IN BRANCH O O I �- 13 CIRCUIT (92P 120% RULE I xi 3 MODULES LC U3275=-113 4 �------- BUSBAR RATING: 200A I DUU3-�- X LpDUt6 MIM GR°0lNNG --DEC.�� � MAIN BREAKER RATING. 200A �rEas,wD drtNSE (200 x 1.2)-200 40A MAX BACKFEED: 40A L PROPOSED SYSTEM: 35A I Ut ' 35A<40A I(D GROUND __________ _______ ----------- ROD _________ROD 2-X12 THWN-2 N~O 1 -Al2 TNWN-2 EGC/GEC MONITORING N IN 3/4'EMT CONDUIT h r D En W U.1 W W Sw C) WEATHER STATION IF lY U)z INFORMATION Q LAWRENCE MUNI ASH RAE 2%AVG. 3-C 13-90 MM ABOVE W O NOTES: ROOF SURFACE TEMP 54 C 1. ALL MODULES WILL BE GROUNDED IN ACCORDANCE WITH O CODE AND THE MANUFACTURERS INSTALLATION INSTRUCTIONS. 3 2 1 Z 2. ALL PV EQUIPMENT SHALL LISTED BY A RECOGNIZED 3- 18 TiWN-2 3-MB THWN-2 ENGAGE CABLE a TESTING LAB. 7- /6 111WN-2 EGC/CEC 1- /''6 TMWN-2 EGC/GEC CONDUCTORS G BARE COPPER ARE ABAW 3. NOTIFY SERVING UTILITY BEFORE ACTIVATION OF PV SUPPORTED ON PV GND G FREE AIR SYSTEM. IN i'EMT CONDUIT IN i'EMT CONDUIT RACKING SYSTEM NOT Df NO.: 4. WHEN A BACKFED BREAKER IS THE METHOD OF UTILITY voc:240VAC VOC:24DVAC EXPOSED TO DIRECT VOC:240VAC g' INTERCONNECTION,BREAKER SHALL NOT READ LINE AND LSC: 2.. Isc: 13.aA4c SUNLIGHT Isc: 13.0AAc Drg.By.: TMG LOAD. 5. WHEN A BACKFED BREAKER IS THE METHOD OF UTILITY ENPHASE INVERTER TOTAL SYSTEM CALC'S JUNCTION BOX TO LOAD CENTER CALC'S ENPHASE INVERTER BRANCH 1&2 CALC'S Rev. B INTERCONNECTION,THE BREAKER SHALL BE INSTALLED y: --- AT THE OPPOSITE END OF THE BUS BAR OF THE MAIN QTY:26 MAX AC:32.50A QTY:13 MAX AC:16.25A QTY:13 MAX AC:16.25A Date: 22-SEP-I5 BREAKER 6. WORK CLEARANCES AROUND ELECTRICAL EQUIPMENT WILL NOC:1 (Ott z NOC).1.25 NOC:1 (OTY.NOG).125 NOC:1 (OTY x NOD)X 1.25 TITLE SHEET: BE MAINTAINED PER NED 110.26(A) (1), 110.26(A) (2) & 110.269A) (3) WIRE GAUGE:#8 WIRE OCP:47.00A WIRE GAUGE:#8 WIRE OCP:33.50A WIRE GAUGE:#12 WIRE OCP:23.50A ELECTRIC 7. ALL EXTERIOR CONDUITS, FITTINGS AND BOXES SHALL BE TEMP RATING:75'C AMP RATING.TEMP DE-RATE TEMP RATING:75'C AMP RATING.TEMP DE-RATE TEMP RATING:75'C AMP RAnxc,TEMP OE-RATE LINE RAIN TIGHT AND APPROVED FOR USED IN WET DIAGRAM LOCATIONS PER NEC 314.15 AMP RATING:50 A MAX AC TO BE LESS OR EOUAI. AMP RATING:50A MAX AC TO BE LESS OR EQUAL AMP RATING:25A MAX AC TO BE LESS OR EQUAL S. ALL METALLIC RACEWAYS AND EQUIPMENTS SHALL BE TO WIRE OCP FOR WIRE TO BE TO WIRE OCP FOR WIRE TO BE TO WIRE OCP FOR WIRE TO BE BONDED AND ELECTRICALLY coNTlNuous. TEMP DE-RATE:0.94 APPROVED B 20„NEc TEMP DE-RATE:0.67 APPROVED BY 2011 NEc TEMP DE-RATE: 0.94 APPROVED BY 2011 NEC Pv-.4 nng: Home SOLAR w EDA C a x r No.Jti (E) DOWNSPOUT o NUN�u �iM or �U F- ul <w w 77 ILL W a 0< 0 � Oo E//0 [If uj Ln y FROM PV ARRAY I FROM UTILITY PROVIDER w z (OVERHEAD) to EV r to ® I O to oc w & W �Qo w0= WoT- w O z Drg.No.: --- (N) JUNCTION (E) UTILITY METER Drg.By.: TMG BOX FOR ENVOY (EXTERIOR WALL) Rev. By: - -- Date: 22-SEP-15 CENTER (EXTERIOR WALL) (N) 100AMPV LOAD (E) TO MAIN SERVICE PANEL TITLE SHEET: ELECTRICAL 1 (INTERIOR WALL) (N) UTILITY AC DISCONNECT 1 ELECTRICAL&SIDE ELEVATION DETAIL SIDE ELEVATION (N) L—GATE 120 CELLULAR DETAIL PRODUCTION METER (EXTERIOR WALL) (EXTERIOR WALL) PV_3A SCALE: NTS FV-3A nrg.. Home SOLAR QgEo aRC Q�pp'yF ET�p Y r 110.31521 i NOW ELL. NJ Wn U U� �W OF- zW �w Q UNIRAC SOLARMOUNT GROUND WEEB & Q RAIL WITH ECOFASTEN MODULE CLAMP LL O L-FOOT PV MODULE O COMPOSITE ASPHALT SHINGLES GREENFASTEN FLASHING: z c ECO-GFI-BLK-812 WITH Q OD ECO-CP-SQ COMPRESSION BRACKET N LLJ W Q 5/16"X4" S.S LAG BOLT WITH 2.5" W MINIMUM PENETRATION SEALED WITH F 0 APPROVED SEALANT w W Lu a:-,O r C) � QL cn Q Lu OE O z --- Drg.By.: TMG Rev.By: --- Det.: 22—SEP-15 TITLE SHEET: 1 ATTACHMENT DETAIL ROOF ATTACHMENT PV-3 SCALE: NTS DETAILS PY-3 ARRAY & ROOF AREA CALC'S n4- ROOF R-1 Home ARRAY AREA : 231.25 ft' SOLAR ROOF FACE AREA : 317.97 ft' 231.25/317.97 = 72.737 ROOF FACE AREA COVERED BY ARRAY aR�OAec,, ROOF R_2 �N 31521 F- o. t621?= ARRAY AREA 231.25 ft' No EIL, ROOF FACE AREA : 652.09 f `*r, of t' 231.25/652.09 = 35.467 ROOF FACE AREA COVERED BY ARRAY Lf)C) U� O 5 zw Qw ROOF DESCRIPTIONO 2�,9" R-1:COMP. SHINLGES �' 6 c. LL oc AZIMUTH 159' PITCH : 22 O SHADING : 927 ` R-2:COMP. SHINLGES AZIMUTH : 249' ` PITCH : 23' > SHADING : 807, ` ffi >• z Ln LEGEND ` ENPHASE MICRO-INVERTERS F- O M250-60-2LL-S22to W Q ® ROOF ATTACHMENTDEI > 13 PV MODULES I y:-- RAFTER CHIMNEY (N) PV LOAD CENTER UNIRAC SOLAR MOUNT RAIL F Lu O PIPE VENT L-GppARpSpU2CCTppNELLUF�TL�AEER SKYLIGHT (N)7C DI�CON O s- 37 ATTACHMENT® 48"O.0 MAX = Q w U-1 O AIR VENT o -1" w J O --- CONDUIT (E) UTILITY METER F U Q 0 SATELLITE i" PVC/EMT CONDUIT F to �i ELECTRICAL EQUIPMENT ANTENNA r. m ENPHASE MICROINVERTERS O WHIRLYBIRD , W O M250-60-2LL-S22 t G O MODULE SPEC'S v 13 PV MODULES z 53 ? 27 ATTACHMENT®48"O.0 MAX a 3'-3' O- \ Gj � '� Drg.No.: --- �� iT. �• _.,� r�'' Drg.By.: TMG 16 _ Rev. BU: --- I Date: 22-SEP-I5 "--� p•�� NORTH TITLE SHEET: ROOF PLAN t \ / 1 ROOF PLAN WITH PANELS rT� PANELS LG275S1C-B3 �. r PANELS-275W ; 5 PV-2 SCALE: 1/8'= 1'-0' LG PANELS PV-2 PROJECT DESCRIPTION: SHEET INDEX rE„ PV-, SITE PLAN &VICINITY MAP PROjT SITE nrg PV-2 ROOF PLAN & PANELS HOC T1@ 26X275W ROOF MOUNTED PV-3 ROOF ATTACHMENT DETAILS SOLAR SOLAR PHOTOVOLTAIC MODULES PV-3A ELECTRICAL&SIDE ELEVATION DETAIL 5 Gt PV-4 ELECTRIC LINE DIAGRAM f°i SYSTEM SIZE: 7.150 kW DC STC o aR h PV-5 LABELING �¢ae PV-6 SPECIFICATION DETAILS �6ay.Peri Fy ARRAY AREA: PV-7 SPECIFICATION DETAILS dSx $ m R-1: 231.25 ft' PV-8 SPECIFICATION DETAILS r# xa.atazi e R-2: 231.25 ft' PV-9 SPECIFICATION DETAILS " NO ELL, t PV-10 SPECIFICATION DETAILS / PV-11 SPECIFICATION DETAILS PV-12 SPECIFICATION DETAILS PV-13 SPECIFICATION DETAILS Lf) /\ /,.s4 Sakm st U J \ ~ti / to F- Z Q ua � � o / ;;erad4t Q z Q / L-OC / �Q (E) UTILITY METER / / 2 VICINITY MAP PV-1 SCALE:NTS / PROTECT SITE z .� I ,. Q 00 R / N W Q W =WO t_ 13 PV MODULES / r cA z Lil DRIVEWAY z v _ 13 PV MODULES Drs.Bu.:By.: TMG Rev.B9: --- Date: 22-SEP-15 PIAN NORTH TITLE SHEET: SIT1 SITE PLAN WITH ROOF PLAN ICI PLAN P VICINITY MAP PV-1 SCALE: 1/32'= 1'-0' 3 HOUSE PHOTO PV-1 SCALE: NTS P V—I MM x x z z G) C I FF1 M M M n n nn ul > F- IJ f TI M > k) O ul T- M F--U F- F 70 > LIJ co, x i --n n TN , j ul fD 13`-2" 0 OD >—E 0 F M ncn cp > U Z Ki - J,m 70 n n _q rn In CLIENT INFORMATON SOLAR SYSTEM nrg� 1.1:50 <u,DC Home MILLER RESIDENCEMICRO INVERTERS L'('% AR ; TON PETERSEN ROOF DIAGNOSTICS 10019 SALEM STREET, 26 '1-250-60-2LL-522 ARCHITECT,LLC s0LA�AND FL[(,,TRI(-,LL PANELS HOCOELNT,NJ0NE 1 DATE °iajs NORTH ANDOVER,"A 0111911 26 MODULES s 275 PER MODULE THOMAS F.PETERSEN DLU,-- NO.: 4543 NY ARCH.LIC.0352910 T32. 30.T63 BY: cz DocuSign Envelope ID:7239A81C-709E-4CA5-8E9D-OFDC975083D8 The Commonwealth of 3fassachusetts Department ofIndustrial Aceiclents I Congress Street,Suite 100 Boston, JVA 02114-20,17 www.mass.govIiiia w-kers'Compensation Insurance Affidavit:Builders/Contractors/ElectriciansTlumbers. TO BE FILFD W*1TI1 TEE PERINIlTMG AUTHOMY. AA licant Information Please Print Le blv P_P_ 3 n OrM3 'on Name (Businessi'Oraaiii7.ation/Individiial): u ss"Orgar ea (B i�ne i mfio dividit, Address: City/State/ziP:bk,�__,,A`,�­)� Vholle 4: 1 Are you an employer?Check the appropriate titm Type of project(required): I.M I am a employer with__!�"I _I,iuployees(full and/or part-time),* T 0 New construction 2Q I am a sale proprietor or partnership and have no employees working for me in & f-] Remodeling any capacity,[No workers'comp, insurance required.] 9. Demolition 3,F-1 I am a w homeoner doing all work myself.[No workers'comp.insurance required,)t 4,Fj I am a horneownerand will be hiring contractors to conduct all work on my property. twill l0 Building addition ensure that all contractors either have workers'compensation insurance or are sole ll.F�Electrical repairs or additions proprietors with no employees, 12. Plumbing repairs or additions Sf-I I am a general contractor and I have hired the sub=contractors fisted on the attached sheet. 'these sub-contractors have employees and have workers'comp.insurance., 13, Roof repairs 6.[]We are a corporation and its officers have exercised their right of exemption per NIGL c, 14,N Other—r-W-1 152,§1(#),and we have,no employees,[Cao workers'comp.insurance required..I *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 a new affidavit indicating such, lComractars;that check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am tin employer that isprovidin -worIcers'coinpensadon insurance fir ntp einplQvees. Below is the policy and joh site information. Insurance Company Name: Anl�- 01 Policy#or Self-ins,Lic.4: D Expiration Date: Job Site Address:, CALA "!x,,\gy� City/State/Zip:l,)_C�7,Ok;vc,(-, Mrs o19%- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). .Failure to saute coverage as required under IVIGL c, 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebv cer i Y under bye parrs and penalties of perjury that the inforination provided above Is true and correct, t�acu&gned by: Date: J 2-0 Phone phoi� o 4. (012�23� one- Official use only. Do not write in this area,to be completed by city or town official City or Town, Permit/License ft Issuing Authority(circle one); .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6,Other Contact Person, Phone th DATE(MM/DD/YYYY) A��®® CERTIFICATE OF LIABILITY INSURANCE 7/15/2015 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 Darlene Mulcahy y Malcolm & Parsons Insurance Agency PHONE Est: (781)344-3200 NC No: (781)399-1425 713 Washington Street E-MAADDRESS: P.O. BOX 527 INSURERS AFFORDING COVERAGE NAIC# Stoughton MA 02072 INSURER A Northland Insurance Company INSURED INSURERB:Sentinel Insurance Company Ltd 39098 Certified Safe Electric, Inc. INSURERCNautilus Insurance Company 50 Tower Avenue INSURERD:CNA Surety INSURER E: Marshfield MA 02050-5131 INSURERF: COVERAGES CERTIFICATE NUMBER:CL157602635 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 IMAGE TA CLAIMS-MADE �OCCUR PREM SESOEa oceurrence $ 100,000 x ISO Form CG0001 TBI 7/15/2015 7/15/2016 MED EXP(Any one person) $ 5,000 X Contractual Liab PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 '.. X POLICY F JECT PRO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 '.. OTHER: General Aggregate $ 5,000,000 AUTOMOBILE LIABILITY CEa OMaccidentBINED SINGLE LIMIT $ 1,000,000 BANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 08UECZJ8251 3/7/2015 3/7/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X NON-OWNED HIRED AUTOS X AUTOS Per accident x ISO CA0001 PIP-Basic $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 C X EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 2,000,000 DED I I RETENTION$ TBI 7/15/2015 7/15/2016 $ WORKERS COMPENSATION PER OTH- '.. AND EMPLOYERS'LIABILITY YIN STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under '... DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ D FIDELITY- EE DISHONESTY 62447764 7/1/2015 7/1/2016 $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION certifiedsafeoffice@gmail. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Amne Parsons/DARL ©1988-2014 ACORD CORPORATION. All rights reserved. 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