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29 VALLEY ST - BUILDING INSPECTION (4)i tJ Ti3 - IU - iI � � 3s&q 2- The Commonwealth of Massachusetts RECEIVE Ulf Board of Building Regulations and StandarJOSPECTIONAL S MVICET OF Massachusetts State Building Code,780 CMR` SALEM ��tllI��ll�� 11''''�ld1 CC Rpditgar2011 Building Permit Application To Construct, Repair,Renovate F9ICAN1215a lCC LL One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date plied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers l.la Is this an ac epted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions:) ` Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private.❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1:n;rnr4 gcrrug err/. Name(Print) City,State,ZIP _ 2�( Uall c r Sd. q79 - 7�P5-7Rg9 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ElAddition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other EKSpecify: PJ S J6 r Brief Description of Proposed Work': J n54,,J( 23 Ptl Set,, nnn.et5 on fvnT SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ `�60� �d 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 23 r 57. �� ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: rl ' ew 5.Mechanical (Fire $ - Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $Zei R 5 7, ❑Paid in Full ❑Outstanding Balance Due: ti SECTION 5: CON'STRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 11 1111 / 6S- 0g3l1S 5 -50 SeOtr EN,i I -t . ; fi(d License Number Ex iratio Date Name of CSV Holder List CSL Type(see below) K3 R,e�P No.and Street Type Description U Unrestricted Buildings up to 35,000 cu.ft. A-94'e�,3 10 A 0216 d R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding /�l1 SF Solid Fuel Burring Appliances -l.dl - 57q-661? I Insulation Telephone Email address D Demolition 5.2(�Registered Home Improvement Contractor(HIC) 'hvo-"F D,,0.4rtosik's >olr,.r 1702onN (x Is HIC Company Na or HIC Registrant Name HIC Registration Number Expira'on Date No.,and Street S Email address A/o�:�k t�4 CL(aC) .�SG`3�-SAS-n��q Cit /Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... 19`� No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize '3¢5 e p6 Wi l u- C—k;r`;r_r, to act on my behalf, in all matters relative to work authorized by this building permit application. See le4e-r- Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. rr,co cr (o/ZSA/t( Print Owners or Authorized Agent's Nam (Electronic i ure) Date NOTES: L An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at w�xryv.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.fl.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ROOF DIAGNOSTICS changing the way we buy electric i ty S`, LAR Attention: Inspectional Services G �: With this letter I, t� �"�� -�� ^� � authorize you to recognize Joseph Wyld Chirico of Roof Diagnostics Solar of MA, LLC, (CSL# 93115 HIC# 170279) as my Agent, and acting on my behalf may apply and sign for permits pertaining to my Photovoltaic ` Solar System installation project located at VC6l .� By my signature, I recognize and approve the construction of which the plans are submitted, and willfully accept the responsibility as owner/builder of this project. OwnO.Signature Date Joseph Wy d-Chirico - Authorized Agent Date �T ROOFDIAGNOSTICS.COM ,per The Commonwealth of Massachusetts \ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NamC(Busutess/Organization/Individnal): Roof Diagnostics Solar of MA LLC Address: 89 F Washington Ave City/State/Zip: Natick,MA 01760 Phone#: 508-545-0989 Are you an employer?Check the appropriate box: Type of project(required): 1.dam a employer with 3_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 [J Building addition [No workers' comp. insurance comp.msurance.t required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions myself. ' might of exemption per MGL Y [No workers' comp. 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.EJ,6ther I c r comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. - e Homeowners who submit this affidavit indicating they are doing all work a,rd 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 sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:The Hamilton Group/Continental Indent.Co. Policy#or Self-ins.Lie. #: 468185310104 Expiration Date: 10/5/14 Job Site Address: 2C( )CAF,i eS4. City/State/Zip: 5aAl er., s IU4 ()Ia70 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby certify under the pains andpenafties of perjury that the information provided above is true and correct Si iet ature � %yYy>! Date Phone#:508-545-0989 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: i ,Acoiza CERTIFICATE OF LIABILITY INSURANCE DATE(MMNDMYY) 10/4/2013 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 CONTAC The Hamilton Group, LLC NAME:PHONE FAX 3 Wing Drive C No Eat: - - AIL No: - -2441 Cedar Knolls NS 07927 ADDRESS: PRODUCER CUSTOMERID :ROOFD-3 INSURER(S)AFFORDING COVERAGE NAICIf INSURED INSURERA:Selective Way Ins (I ROOF Diagnostics Solar Of Mass LLC INSURER B:Slect ive Ins Cc of the S. East 89F Washington Avenue INSURERC:Continental Indemnity Company Natick MA 01760 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE N UMBER:2079777279 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 MAYBE 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. ILTR TYPE OF INSURANCE IR LSUBR POLICY NUMBER MMIDOIYYYY IEFF MMNUY�Y UNITS A GENERAL LIABILITY S2000721 10/3/2013 10/3/2014 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMI E Ea occurrence $100,000 CLAIMS-MADE %❑OCCUR MED EXP(Any on a person) $10,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $3,000,000 POLICY PRO LOG $ B AUTOMOBILE LIABILITY A9093006 10/25/2013 10/3/2014 COMBINED SINGLE LIMIT $1,000,000 % ANY AUTO (Ea awtlent) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per account) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ 8 A X UMBRELLA LIAB X OCCUR S2000?21 10/3/2013 10/3/2014 EACH OCCURRENCE $1,000,000 EXCESS DAB CLAIMS-MADE AGGREGATE '$1,000,000 DEDUCTIBLE § RETENTION - $ C WORKERS COMPENSATION 468185310104 30/5/2013 10/5/2014 WCSTLATU- OTH- ANDEMPLOYERSUABIUW Y PROPRIETORIPARTNEREXECUIYIN RV LIMIT AN PROPRIETORIPARTNEREXECUTIVE EL.EACH gLCIDENT $1,000,000 OFF EXCLUDED? NIA (Mandatoryln NN) - E.L.DISEASE-EA EMPLOYE $1,000,000 Ilyes desu n ibeuder DE SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) This certificate does not afford Coverage for additional insureds. The certificate is only evidence of insurance coverage for the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Commonwealth of Massachusetts ' PO BOX 7010 Boston MA 02204 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD GSHA�e N �qR/t Massachusetts -Department of Public Safety ^^+••^�•^�� Board of Building Regulations and Standards C'nnoruction Supenivor This csfd acknowledges that the recipient has Successfully completed a License: CS-093115 30-houi Occupational Safety and Health Tialning Course in Construction Safety and Health JOSEPH M WYLDCHIIiICO K3 Regent Street; k t North Attleboro MA 027b JOSEPH WYLD-CHIRICO � Michael Millsap 4/22/2011 �� , „ ,t n`J Expiration -- (Trainer name—pool of type) (Courseenddale) Commissioner 05114/2015 Tice of Consumer Atlairs C Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: F Office of Consumer Affairs and Business Regulation Registration 170279 Type, i 10 Park Plaza-Suite 5170 - Expiration 1615f2015 Supplement;and Boston,111A 02116 ROOF DIAGNOSTICS SOLAR OF.MASS,LLC. JOSEPH WYLD-CHIRICO - 89WASHINGTON AVE.-.;a'k' C,&�-A -- # NATICK,MA 01760 Undersecretary id without signature -