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HomeMy WebLinkAboutBuilding Permit # 1/12/2016 ................ .. i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 1 �oodlea Cle m PROPERTY OWNER r�tr Sa , „ � ///��/// i//i/i/ �l�i� �iiil/ �i� i O / °' Pant ;��� 100 Year C71d Sfrueture: yes no IyIAP NOPARCEL ZONING DIS, RIrvTNistanc Distriofi yes no Mechin'd Shop Village yes ne TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building R1 One family ❑Addition ❑ Two or more family 11 Industrial 9 Alteration No. of units: ❑ Commercial 0 Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition ❑ Other 0 Septic ❑Well O'Floodplain 0 Wetlands El Watershed District D Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Installation of an 11,445 kw (35 L)anels) rooftop solar arra} Identification Please Type or Print Clearly) Y) OWNER: Name: Amir Satam Phone: 508 423 0911 Address: 19 WpodLea "ircle CONTRACTOR game: Itoinn tecker Phone: 781-462-9,702 Address: 5sixthtoad ,,oht A l 01 ti Supery�sor's ConstrOction License: ` 3 �,: „f ;,Exp Date: g/ , '1 Horne Improvement License: 1696,99, Exp. Date: 7/27/2017 ARCHITECT/ENGINEER Idog er T A.Iworth Phone: M i & Address: 9138 S Street, Sande U'r Reg. No. 47740 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �� Total Project Cost: $ 50,743 FEE: $ I Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund { Signature of Agent/Owner see signed cont:rac.t Signature of contractor AM FtAORTf -rown ot Andover I Oo 201C, ver, j_ 2, (op h Mass, O LANE COCNICHE WICK RATED V BOARD OF HEALTH Food/Kitchen PERMIT T Septic System THIS CERTIFIES THAT .......... BUILDING INSPECTOR .................. ......1 .1�°..... . .�. .. .......................................... has permission to erect ...... buildings on ... CFoundation .................. Rough tobe occupied as ............... ...®... ... ..... ................. .........plN. ..�................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT IN c O T S ELECTRICAL INSPECTOR UNLESS CONSTRUC S TS Rough Service __, �� .......... .. ..... ... ........ , ,��!................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building Rough Displayin a Conspicuous Place on the Premises — ® ®t Remove Final No Lathingr Dry Wall To Be Done FIRE DEPARTMENT Until s ec e and Approvedthe Building Inspector. Burner Street No. Smoke Det. Sandy ECTORLayton �00 E n s i n E t=- R S St. George Project Number: U1876-0077-161 January 8,2016 Boston Solar 55 Sixth Road Woburn,MA01801 ATTENTION: Race Traver REFERENCE: Amir Satain Residence: 19 Woodlea Circle,North Andover,MA 01845 Solar Panel Installation Dear Mr.Traver: Per your request, we have reviewed the layout and photos relating to the installation of solar panels at the above- referenced site.The following materials and components are proposed in the installation of the solar panels. Roof Structure:2x8 Rafters @ 16"O.C. Roof Material:Composite Shingles Solar Panels:SPWR E20-327 Rail Connection System:Invisimount Mounting Connections:5/16"Diameter Lag Bolt with 2.25"Embedment,Minimum Based upon our review,it is our conclusion that the installation of solar panels on this existing roof will not adversely affect the structure of this house. The design of solar panel supporting members is by the manufacturer and/or installer. The adopted building code in this jurisdiction is the 2009 International Residential Code and ASCE 7-05. Appropriate design parameters which must be used in the design of the supporting members and connections are listed below: Ground snow load:50 psf per Massachusetts amendments to the IRC(verify with local building department) Design wind speed for risk category 11 structures: 100 mph(3-sec gust) Wind exposure:Category C Our conclusion regarding the adequacy of the existing roof is based on the fact that the additional weight related to the solar panels is less than 3.5 pounds per square foot.In the area of the solar panels,no 20 psf live loads will be present. Regarding snow loads,it is our conclusion that since the panels are slippery,effective snow loads will be reduced in the areas of the panels.The attached calculations verify the capacity of the connections against wind,the governing load case. Solar panels will be flush-mounted, parallel to and no more than 6" above the roof surface. Thus, it is our conclusion that any additional wind or seismic loadings related to the addition of these solar panels is negligible. During design and installation,particular attention must be paid to the maximum allowable spacing of attachments and the location of solar panels relative to roof edges. The use of solar panel support span tables provided by the manufacturer is allowed only where the building type, site conditions, and solar panel configuration match the description of the span tables.Attachments to existing roof joist or rafters must be staggered so as not to over load any existing structural member. Waterproofing around the roof penetration is the responsibility of others. All work performed must be in accordance with accepted industry-wide methods and applicable safety standards. Vector Structural Engineering assumes no responsibility for improper installation of the solar panels. Please note a representative of Vector Structural Engineering has not physically observed the roof framing. Our conclusions are based upon the assumption that all structural roof components and other supporting elements are in good condition,free of damage and deterioration,and are sized and spaced such that they can resist standard roof loads. Very truly yours, VECTOR STRUCTURAL ENGINEERING,LLC F1 ER T. A IV Roger T.Alworth,P.E. 0 Principal RTA/mbt AL Jan. 08, 2016 9138 S. State St., Suite 101 /Sandy, UT 84070 J"r(801)990-17751 F (801)990-1776 1wwwxecfor sexom JOB NO.: U1876-0077-161 DESIGNED: MBT VECTOR DATE: 01/08/16 �� E�z F- n o i n F— E R S Oooo PROJECT: Amir Satam SUBJECT: CONNECTION CAPACITY Lag Screw Connection Capacity: Demand: Lag Screw Size: 604 Wind Pressure: 32.63 psf Cd: '1.6 Tributary Area: 16 sf Embedment: 2.25, in Demand: 522 lbs Capacity: 206 lbs/in.emb. Number of Screws: I Total Capacity: 738 lbs Demand<Capacity: CONNECTION OKAY BOSTON SOLAR Solar System Purchase and Installation Agreement Overviews installer Owner The Boston Solar Company,LLC Sandhya Lonial 55 Sixth Rd 19 Woodlea Road Woburn,MA 01801 North Andover,MA,01845 Major Components System Size: Sunpower E20.327 (p,0 35 11.45 kW inverter Solaredgettg RGM Estimated Year 1 Production Production Monitoring Automated 12,079 kWh Total System Cost $50,742.99 Payment Schedule: Federal Tax Credit $15,222.90 At Signing(refundable ) $1,000.00 State Tax Credit $1,000.00 At Design Sign Off $14,222.90 At Installation $30,445.80 MA Solar or Utility Rebate' At System Commissioning $5,074.30 Final System Cost $34,520.09 Total of Payments: $50,742.99 Payment Type: CASH These financial estimates are provided for illustrative purposes,For actual financial and tax advice,please consult an independent tax advisor. £1000 deposit is refundable if price increases by more than 5%,production decreases by more than 5%of it is determined customer needs to replace roof. Overv/et+w. As part of this Agreement,The Boston Solar Company will: •Handle all aspects of the project from initial paperwork through to installation and activation of your Solar System •Secure State or Utility rebates(if applicable),permits,and utility interconnection approval •Install revenue grade monitoring,giving you real time insight Into your system's performance,and allowing you enjoy automatic production reporting to generate your SRECs(Owner is required to have secure and stable Internet connection on the Property) •Set up your brokerage account with SRECTrade,the largest SREC aggregator,who will sell your SRECs and pay you quarterly(starting approximately six months after your system is activated) •Provide you with all related manufacturer warranties Time for Completion.- It ompledan.It Is expected that installation will be completed within 90 days after contract signing.The actual Installation is expected to take 2-3 days.Once installation is completed,the Owner will need to make the Property available for electrical and building inspections within two weeks after Installation.After inspections,the utility is expected to give us final approval to turn on the system within 2-4 weeks.The entire process from contract signing to system commissioning is expected to take 4 months,but may take longer depending on town and utility approvals,weather and equipment availability. Addldonal Contact Provlslons: All payments are due immediately upon completion of each stage of the project.Quoted system price includes permit costs and utility interconnection fees.This Solar System Includes a 10-year labor warranty,25-year inverter warranty and 25-year panel power warranty. Agreement This Attachment forms part of the Solar Purchase and Installation Agreement. Boston Solar Repr ntative Signature✓ Date; �_ - �- Owner's Slgr�S urea' Date. �. 12/29/2015 Co-Owner's Sfgnaturh�' Date: ROSTON S01 AR SOLAR SYSTEM PURCHASE AND INSTALLATION AGREEMENT Owner: oo Wv (�� (the"Owner") i� dVr Site Address: + ] �)Q � '�. 1�(the"Property„) Date: This Solar System Purchase and installation Agreement("Agreement")is entered into effect as of the latest date of signature of the parties below by and between The Boston Solar Company LLC, 55 Sixth Rd, Woburn,MA 01801("TBSC")and the Owner,who is the owner of the Property.All capitalized terms used in this Agreement but not defined herein shall have the meanings set forth in The Boston Solar Company Proposal attached hereto(the"Attachment"). 1. THE WORK TBSC shall perform work,provide the Services,supply such Equipment and furnish such other materials, supplies and other items as It determines are required to install the System described in the Attachment(the "Work").TBSC will perform or cause its subcontractors to perform the Work in a good and workmanlike manner,in accordance with prudent industry standards and practices.TBSC shall not make any changes in the Work unless agreed to in writing by the Owner. 2. REQUIRED PERMITS TBSC shall be responsible for acting as the Owner's agent to secure any permits required for the installation. All permit costs are included In the price for the Work.If you secure your own permits,you will be excluded from the Guaranty Fund provisions of Chapter 142A of the Massachusetts General Laws. 3. WARRANTIES TBSC warrants that,under normal use and service conditions,the System will be free from defects in workmanship and/or materials for ten(10)years after the date of the Work being completed(this"Limited Warranty").This Limited Warranty includes servicing manufacturer warranties free of charge.TBSC warrants any damage to Owner's roof within a five(5)inch radius of roof penetrations during performance of the Work, If a defect is discovered,TBSC will,at no additional cost to Owner,provide such labor and materials as required to restore the System to its originally installed state.If TBSC finds that the problems were not caused by the Work,or if the problems are not an actual problem of the System(e.g.shade or unauthorized alterations to the System),Owner will pay for any.new parts and materials,and TBSC reserves the right to charge Owner a service charge of$100 per hour with the minimum service charge equal to$200. 1 ,101, SOLAR SYSTEM PURCHASE AND INSTALLATION AGREEMENT 8. PRE-EXISTING CONDITIONS AND PROPERTY PROTECTION TBSC shall not be responsible for any damages as a consequence of the Work performed on the site due to pre-existing conditions(e,g.cracked or broken shingles,faulty electrical wiring,etc.) TBSC reserves the right to suspend performance of the Work or terminate this Agreement with no liability to TBSC whatsoever if it discovers unanticipated site conditions that will increase the cost to perform the Work. If such termination occurs,TBSC shall refund all monies paid to TBSC reduced by any expenses actually Incurred.However,if Owner and TBSC agree,the price may be renegotiated to reflect the true cost of the Work. TBSC will make best efforts to protect any property of the Owner,but the Owner is responsible for removing and replacing appliances,floor coverings,and any other obstacles or hazards required to perform the Installation.TBSC is not responsible for replacement of or damage to these items if they are removed by TBSC, 9. CUSTOMER OBLIGATIONS Owner agrees to:(a)notify TBSC immediately upon discovery of an emergency condition relating to the System,damage to the System,or theft of the System;(b)only have the System repaired pursuant to the Limited Warranty(as defined herein);(d)not modify the Property in a way that shades the System;(e)not do anything,permit or allow to exist any condition or circumstance at the Property which would cause the System not to operate as Intended;and(g)permit TBSC,after providing reasonable notice,to inspect the System for proper operation,and to make any necessary repairs.Customer agrees to not make any modifications,improvements,revisions or additions to the System or take any other action that could void the Limited Warranty(as defined herein)without TBSC's prior written consent.if Owner fails to comply with the provisions of this paragraph,Owner's Limited Warranty shall be automatically voided. I 10. GENERAL PROVISIONS Any disputes which may arise between the Owner and TBSC shall not impede or interfere with the diligent performance by TBSC of the Work.This Agreement shall be subject to and interpreted in accordance with the laws of the State of Massachusetts. Title,ownership and risk of loss to the System shall pass to Owner immediately upon Owner's payment of the final payment required under this Agreement.Owner shall provide all insurance necessary for the coverage of the System and risks to the Property related thereto after such payment. 3 BOSTON SOI AR I Homeowner's Agent Authorization Foran (Print Name) am the owner of the property located at address: h, (Print Address) I hereby authorized The Boston Solar Company to act as my Agent for the limited purpose of applying for obtaining local building and other permits from the Authority Having Jurisdiction as required for the installation of a Photovoltaic System located on my Property. Print Name: f.--� Customer Signature: Hata: The Boston Solar Company 55 Sixth Road Woburn,MA 01801 BostonSolar.us (617)858.1645 ysiem In ormation System Rating: 11.445 kWdc 10 kWec --Gas Meter Module: (35)Sum.—E20-327 N Inverter. SolarEdge 10000A-US Racking: Invisimount Design Factors System Rating: MA CMR 780 51.00 IBC-2009,ASCE 7-05 2005 NDS,NEC-2014 Ground Snow Load: 50 pef Wind Speed: 100 m h Interior Conduit Rune i i Roof 1 i ! � Azimuth:186"N Tilt:32' ' Solar Access:87% i 5 Panels-1.258 i Roof 4 ; = � - Azimuth:276°N Tilt:32° t Roof 2 Solar Access:85% Azimuth:96'N Tilt:32° 11 Panels-0.938 E Solar Access:92% 0 10 Panels-1.076 i I I Roof 5 1 Azimuth:276°N Tilt.32° ZL Solar Access:79% u 6 Panels-0.889 Roof 3 Azimuth:186°N Tilt 32° ' Solar Access:93% 3 3 Panels-1.322 r N e BOSTON SOLAR <=i C O 1 1 A'! Y - —bostonsolanus I info@Bostonsolar.us —MSP Drawing Name: Site Plan xter€o,Conduit Rul1 Date: January 11,2016 rnv rpt �s � Drawn By: BG Utltlty Mete— Client Information: Reviewed By: Pu tat ltv Disconnect-� Amir Satam Rev#: 00 19 Woodlea Circle PV- 1.1 North Andover,MA 01845 (508)423-0911 Scale: As Noted 17'-9 7/8" 01-51/81, I I AX CANTILEVER 14 ee II H j H 1 ' 33 t Ii I! 6 II t� co M — I d I, I i II ? it s M it r 3 i iI it I4I 11 l� Is � IE H CID j } t CY) Attachment Detail H it s E C} i Solar Modul Invisimount Rai Invisimount L-Foo Deckin oFlashin MAX SPAN 32" Deckin Lag Boit A�i �\\ N \� Motlule S�ecificatlorls SPWR E20-327 Model: Dimensions[LxWxH]: 41.2"x61X'x1.81" 41 Lbs Weight 2x8n@16'OC EIa(ne A.Huang Racking SpecificationsProona Invisimount CT fessil Engineer Model; Type: Flush Mount Licence#.28776 Weight 0.54 Lbs/Ft 1r.E Array Information s BQ �N SOLAR a 4 r #of Modules: 7 3 D #of Mounts - cr P a Array Area: 87.85 224.43 Array Weight: www.bostonsolecus ; infoQeastonSolacus Array Dead Load: z.ss 13.22 Drawing Name:Date: Array Layout Array Point Load: January 11,2015 Structure Information Drawn By: BG zxa Reviewed By: Rafter Size: Client Information: 00 Rafter Spacing: 1s•oC I 31" 131" i Amir ata. Rev#: Max.Rafter Span: 3z Roof Pitch: _ 19 Woodlea Circle PV-2. Decking: 5t8`Ply+�ood North Andover,MA 01845 Roof Material: Asphalt shingle Scale: As Noted Building Height: 24' (508)423 0911 Exposure Category: s 33' 20'-6" 15'-5 3/4" Ll J i (I II € I I M _ i ' s1 (! et r co � I II Attachment Detail Solar Modul !, h , �..-I I. �I [ Invisimount Rail— Invisimount L-Foo —' Sunmodo Flashin l Deckin LagBolt Rafter �� m MAX SPAN 48" MAX CANTILEVER 22" � r M Module Specifications Model: SPWR E20-327 Dimensions[LxWxH]: 41.2"x61.4"x1.81" Weight 41 Lbs Racking Specifications Model: InvisimountElaine A.Huang Type: Flush Mount 2X8"@16"oc CT Professional Engineer Weight 0.54 Lbs/Ft Licence#28776 Array Information #of Modules: 10 1X8" 48"oc #of Mounts Array Area: 17570 t BOSTON SOAR Array Weight 467.73 - c 0 u 1 a n r Array Dead Load: 2.66 -_.. Array Point Load: 12.31 www.bostonsolecus I info@6ostonSolsr.us Structure Information Drawing Name: Array Layout Rafter Size: 2x6 Date: January 11,2016 Rafter Spacing: 16.0cj Drawn By: BG Max.Rafter Span: 147" 147' Client Information: Reviewed By: Roof Pitch: 32 = ' Decking: 51W Plywood y i Amir Satam Rev#: 00 Roof Material: A.phelt shingle 19 Woodlea Circle PV-2.2 Building Height 24' North Andover,MA 01845 Exposure Catagory: s (508)423-0911 Scale: As Noted 13'-10" '-11 1/8" !: E t Op + t AX CANTILEVER 1 " H €°€: I� { rl --MAX SPA 32" _ t I M S � I 3 ' ' - : I + 79 1. I I =1 Attachment Detail 1j — jCIDIE Solar Module---- I Invisimount Rai CO Invisimount L-Foo Sunmodo Flashing— Decking lashing Deckin Lag Bolam �� (') Rafter Module Specifications 1 Model: SPWRE20-327 Dimensions[LxWxH): 41.2"x61.4"x1.81" Weight 41 Lbs Racking Specifications W"q@1 6"oc Model: Invisimount EI®ins A.Huang Type: Flush Mount Weight 0.54 Lbs/Ft CT Pmfessionel Engineer Licence#28776 Array Information #of Modules: 3 #of Mounts 11 3 2 r r E Array Area: 52.71 a; BOSTON SO [j R Array Weight 134.61 ..,.� C a:1 P 1 avr�.t Array Dead Load: 255 Array Point Load: 12.24 w .bosionwlar.us I info@BostonSolar.us Structure Information Drawing Name: Array Layout RafterSize: 2X6 Date: January 11,2016 Rafter Spacing: 16"OC ' Drawn By: BG Max.Rafter Span: 126^ Client Information: Reviewed By: Roof Pitch: 32 ' [ Decking: SieaPlywood 126° AmirSatam Rev#: 00 Roof Material: Asphalt shingle 19 Woodlea Circle PV-2.3 Building Height: 24' — North Andover,MA 01845 Exposure Category: B (508)423-0911 1 Scale: As Noted 10 21-611 10 71-511 ------------ ---------- H iI it r L CY) H it 77- % C3 it --------------------------4 co co CY) Attachment Detail Solar Modulll------ :nvisimount Rail nVisimou nt L-Foot-- " BID Sunmod0 Flashing LAAX CANTILEVER 14 Decking— Lag Bolt fter MAX SPAN 32" Rafter — Module Spec cations Model: SPWR E20-327 Dimensions[LxWxH]: 41.2"x61.4!'x1.81' Weight 41 Lbs Racking Specifications Model: Invisimount x8"@16"oc Type: FlushMount Elaine A.H-9 Weight: 0.54 Lbs/Ft CT Professional Engineer Array Information 1x8"@48"oc #of Modules: 11 Licence#28776 #of Mounts 33 Array Area: 19327 3 T H,E Array Weight 493M & Array Dead Load: Z56 '111L,-_,J BOSTON SOLAR Array Point Load: 1 4.97 4W C 11 1 P A N 7 —bostonsolar.us I Info@BostonSolar.us Structure Information Drawing Name: Array Layout Rafter Size: 2x8 Rafter Spacing: 16"0C Date: January 11,2016 Max.Rafter Span: 147" —J Drawn By: BG Roof Pitch: 32 —1470 Client Information: Reviewed By: Decking: 5/8"Plywood AmirSatam Rev#: 00 Roof Material: Asphalt shingle Building eight: 2,V 19 Woodlea Circle Exposure Catagory: 8 North Andover,MA 01845 PV-2.4 (508)423-0911 Scale: As Noted], 12'-8" 10 10'-5 1/8" co E� if E 6 C�? i;�- i[ F 1 II i 'C H l= - 3 I ; 1 k ' : r I M co co } - --_ I€ Attachment Detail co Solar Modul Invisimount Rai /��/ n I unmoounta-Foot _ MAX SPAN 3211 op 00 Sunmodo Flashing Deckin y \ Lag Bolt r Rafter �� AX CANTILEVER 1411 e� Module Specifications Model: SPWR X21-335(BK) Dimensions[LxWxH]: 41.2"x61.4"x1.81" Weight: 41 Lbs Module Specifications Model: SPWRE20-327 i ZXsrr@1 Too Elaine AHua Dimensions[LxWxH]: 41.2"x61.4"x1.81" A.Huang Weight 41 Lbs CT Professional Engineer Array Information Licence*28776 #of Modules: 6 1X8" 48°OC #of Mounts 20 Array Area: 269.32 T Ne Array Weight: 269.35 BOSTON SOLAR Array Dead Load: 2,56 C O N P A M Y Array Point Load: 13.47 A www.bostonwlar.us I info@BostonSolanus Structure Information Drawing Name: Array Layout RafterSize: 2x8 Date: January 11,2016 Rafter Spacing: 16"00 Max.Rafter Span: 2 Drawn By: BG Client Information: Reviewed B Roof Pitch: 322 Y: Decking: yrs^Plywood 1389 Amir Satam Rev#: 00 Roof Material: AaPh.uShing le € 19 Woodlea Circle P�-2.5Building Height: 24' North Andover,MA 01845 Exposure Catagory: B i AI (508)423-0911 Scale: As Noted IFF Solar Edge P400 Optimizer 327 Max Input Voltage 80V Design Conditions:LAWRENCE MUNICIPAL oageaxower(VMPP) 57.3V Max Input Current 12.5A Annual extreme high temperature(0.4%):34°C Current Max Power(IMPP) 5.71A Max Output Current 15A 2%Average high temperature:32°C Short Circuit Current(ISC) 6.07A Max Output Voltage 60V Annual extreme low temperature:-18°C Open Circuit Voltage(VOC) 67.6V Min/Max Per String 8/15 Temperature at 3.5"above roof 49°G SolaDeck DC Pass Through __ _... (10)#10 THWN-2 wire 3 (1)#10 THWN-2 Ground (3)#6 THWN-2 Wire , V EMT Outdoor (1)#10 THWN-2 Ground + _ (3)#6 THWN-2 Wire 1"EMT (1)#10 TH WN-2 Ground 1 2 10 SolaDeck 1"l MT O DC Pass Through Meter# 2853975 + + - . . . + 1 200 200A Bus 2 5 I i Integrated DC Inverter SolarEdge AC Load Center Disconnect 10000-US Interface SOI.D-k DC Pass Through DC+ t 7 I � 3 EAC DC- ; t 6 ( rcc l $ 1 ! SolaDeckcdc 3 0 0 0 0 0 e DC Pass Through } PV Combiner cryo - 20A Fuses Output:10,000w i AC Volt:240V Utility Service - Max Amps:42A Disconnect Disconnect - _ i Eff:97.5% _ + + + — I 60A Switch 60A Switch 60A Fuses SolaDeck 1 (4)#10THWN-2 Wire DC Pass Through - (1)#10 THWN-2 Ground L71"EMT Outdoor + — + _ + — I 1 211 BOSTON SOLAR C o1 P A a r —loostonsolacus I info@BostonSolacus Drawing Name: Line Diagram Date: January 6,2015 Drawn By: BG Client Information: Reviewed By: Amir Satam Rev#: 00 19 Woodlea Circle North Andover,MA 01845 PV-3.1 (508)423-0911 Scale: As Noted ALL-\ The Commonwealth of Massachusetts Department ofIndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass._kyov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lejgibly Name(Business/OrganizatioMndividual):The Boston Solar Company Address:55 Sixth Road City/State/Zip:Woburn MA 01801 Phone#:617-858-1645 Are you an employer?Check the appropriate box: Type of project(required): 1.E]I am a employer with 20 employees(full and/or part-time).* 7. New construction 2.[]1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[—]1 am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 E]Building addition <1 I un a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 12.[JPlumbing repairs or additions 5.C]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.MRoof repairs These sub-contractors have employees and have workers'corup,insurance,t 14.[Z]other solar 6.n we are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp,insurance required.] *Any applicant flint checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. -Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I air#air employer that isproviding workers'compensation insurance for my employees, Below is the policy and job,site information. Insurance Company Name:HDI-Gerling America Insurance Company Policy#or Self-ins.Lie.#:EWGCCO001 53815 Expiration Date: 1/14/2017 1 Job Site Address: 19 Woodlea Circle City/State/Zip: North Andover MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pain i i Ides of perjury that the information provided above is true and correct. Date: 1/1112016 Si nature: Phone M 617-858-1645 Official use only. Do riot write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Client#: 103109 BOSSO DATE(MM/DDNYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE 1/08/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME:CT Peggy J.Merati People's United Ins.Agency CT AIPHONENo 860 524-7624 Alc No): 844 702-8075 (TCNNE,, One Goodwin Square n DRESS : peggy.merati@peoples.com Hartford,CT 06103 INSURER(S)AFFORDING COVERAGE NAIC# 860 524-7600 INSURERA:HDI-Gerling America Insurance C 41343 INSURED INSURER B:Merchants Mutual Insurance Co 23329 The Boston Solar Company,LLC INSURER C:Philadelphia Indemnity Insuranc 18058 55 Sixth Road,Suite 1 INSURER D: Woburn,MA 01801 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. IN RI TYPE OF INSURANCE NSRL WVD POLICY NUMBER MM/DDY EFF MOLDpY LIMITS A X COMMERCIAL GENERAL LIABILITY EGGCC000153814 1/01/2016 01/01/2017 EEAACMHq�OECTCURRENCE $1,000,000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- PRODUCTS-COM P/OPAGG $2,000,000 POLICY�JECT F-1 LOC $ OTHER: COMBINED SINGLE LIMIT C AUTOMOBILE LIABILITY PHPK1438834 1/01/2016 01/01/201 Ea accident $1,000,000 C X ANY AUTO PHPK1438838 0110112016 01101/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE X HIRED AUTOS X $ NON-OWNED Per accident AUTOS $ B X UMBRELLA LIAB X OCCUR CUP0001367 1/01/2016 01/01/201 EACH OCCURRENCE $5 000 OOO EXCESS LIAB CLAIMS-MADE AGGREGATE s6,000,000 DED X RETENTION$10,000 $ A WORKERS COMPENSATION EWGCC000153815 1/14/2016 01/14/201 X PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S6576241M655319 SMGCT `;/•f �"�.eir i�arirnrna�/l r�/ 'lt ir.uerr�r.�r/C� Office of Consumer Affairs&Business Regulation license or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: l�r Registration: 169598 Type: Office of Consumer Affairs and Business Regulation Expiration: 7/27/2017 LLC t0 Park Plaza-Suite 5170 Boston,MA 02116 THE BOSTON SOLAR COMPANY LLC ROMAIN STRECKER 55 SIXTH ROAD WOBURN,MA 01801 _ _.._._.. Undersecretary Not valid without signature Massachusetts - nepartment of Public Safety Board f Building tsl fi and, Standards . "ani°tail"tit iiwuil � tuI"tct"uk�imp License: CS-096385 + ��� ,o t b'� ✓,,� I � d X� Pik ROMAIN D STREP` 10 CHURCHILL PL./1 M LYNN MA 01902 �I Expiration lissio er 10/08/2016