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14 VISTA AVE - BUILDING INSPECTION (4) (P Ck s1 so The Commonwealth of Massachusetts �INsFECTIONAL $ER V� �cI V Board of Building Regulations and Standards - . SALEM Massachusetts State Building Code, 780 CMR '1p1b JAM 1:3 AviAliW 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied:. ` Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 14 vista Ave fI Lla Is this an accepted street?yes no Map Number Parcel Number l 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq In Frontage(fit) 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: Michael Alessi Salem, MA 01970 Name(Print) City,State,ZIP 14 vista Ave. 339-227-0933 alessil4@aol .com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) LDS Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of ProposedWorkz: Install 18 pv solar panels on south facing roof SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 11700 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $7800 ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: �Y ��7 �('����� �• � 5. Mechanical (Fire r $ Su ression Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $19500 0 Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 104740 01/19/2018 Bruce Davis License Number Expiration Date Name of CSL Bolder 0 List CSL Type(see below) 50 Tower Ave. No.and Street Type Description Marshfield, MA 02050 U Unrestricted(Buildings u to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 781-626-4258 certifiedsafeoffice@gmail .com I I Insulation 7'ele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 160104 06/25/2016 Certified safe Electric HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 50 Tower Ave certifiedsafeoffice@gmail .com No.and Street Email address Marshfield, MA 02050 781-626-4258 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... 12 No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Bruce Davis- Certified safe Electric to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in 4l;pJWp is true and accurate to the best of my knowledge and understanding. bmu,yaxtis 1/11/2016 Print Owner's AW ffl6ff-$d em's Name(Electronic Signature) Date NOTES: I. 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 www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (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 half/baths 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" w 21 Drydock Avenue, 2"d floor ii next step living TM Boston, MA 02210-2384 home energy soLutlons 866-867-8729 NextStepLivi ng.com September 18, 2015 City of Salem Inspectional Services/Building Department 120 Washington Street,Third Floor Salem, MA 01970 RE: Michael Alessi Residence Solar Panel Installation 14 Vista Avenue Salem, MA 01970 Structural Assessment of Roof Framing NSL Project No: SP252424 Dear Sirs, Next Step Living, Inc.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 proposed solar PV panels. This analysis has been based on field measurements,framing Information and configurations observed at the proposed site.The existing residence is located at 14 Vista Avenue,Salem, MA 01970. Structural Data and Code Information Our analysis has been performed in accordance with the requirements of the MA Residential Building Code 780 CMR—Eighth Edition.The main roof of this residence is framed with conventional roof rafters with collar ties in a gable configuration.The existing roof structure is in good condition and currently has one layer of asphalt shingles as roof covering. The pertinent data is listed below: Main Roof Rafters:I%"x 7 X"(#2 Spruce Pine Fir, Hem Fir, D Fir Assumed) Rafter Spacing:IV on center Roof Slope: 23 Degrees Horizontal Projected Length of Rafter: 13.33 feet Ceiling Joists: Present Collar Ties: Present every other rafter Roof Sheathing:Plywood sheathing Roof Covering: Asphalt shingles Condition of Framing: Good Ground Snow Load,Pg.:40 PSF from Table R301.2(5) Importance Factor,I: 1.0 Exposure Factor,Ce: 1.0(Partially Exposed) Michael Alessi Residence Solar Panel Installation 14 Vista Avenue Salem, MA 01970 Page 2 Thermal FactorCt: 1.0 Existing condition(Warm Roof) 1.1 With panels(Cold Roof) Design Snow Loads: 28 PSF(Existing—Unobstructed Warm Roof) 24.12 PSF(New Condition—Slippery Surface on Cold Roof) Basic Wind Speed: 100 MPH from Table R301.2(4) Importance Factor: 1.0 Exposure: B Analysis Results General The proposed solar panels impose a total weight of approximately 3 pounds per square foot (PSF) on the roof surface.The International Residential Building Code allows up to two(2) roof coverings on a residential dwelling. Each roofing layer of asphalt shingles imposes a dead load of 2.5 to 3.0 (PSF) on the roof. Because the existing roof has only one layer of shingles, the code allows a second layer to be added without analysis.The weight of the second layer of shingles is approximately the same as the solar panels which will be installed instead of the second layer of shingles. Solar panels are considered a slippery surface and are mounted a small distance above the existing roof. Therefore, one would be cautious in considering a thermal factor,Ct,of 1.1,treating the panel surface as a cold roof, rather than a warm roof.After considering the roof slope factor,Cs,from figure 7-2, ASCE 7-10,the snow load is reduced by 14%for the main roof compared with the snow loading on the existing shingled roof,which is not considered a slippery surface.The reduction in snow load due to this consideration is about 3.98 PSF for the main roof,which essentially offsets the weight of the solar panels. Gravity Loadine: Given the size,spacing and configuration of the existing roof framing,we have determined that the existing framing for the residence is adequate to support the additional loading from the weight of the solar—electric system, including the panels, racking system, and all connections without any need for additional bracing or framing members. The panels will be installed using Unirac Solar Mount rails with L-brackets in a landscape configuration with a rail toward the top and bottom of each panel edge.The L-brackets will be fastened directly to the roof rafters with 5/16" diameter lag screws.The fastener layout shall start near each corner and for landscape orientation shall have a maximum spacing of 36" on center parallel to the roof slope and 48" on center perpendicular to the slope(e.g., every third rafter), except the maximum spacing shall be 32" on center perpendicular to the slope(e.g.,every other rafter) if the rail and roof attachment are within six(6)feet of the edge of the roof. Each 5/16"diameter lag screw shall have a minimum of 3" thread penetration into the existing rafter. Michael Alessi Residence Solar Panel Installation 14 Vista Avenue Salem, MA 01970 Page 3 It is also important that the L-bracket attachment locations be staggered between adjacent rails so that no single rafter supports more load than under the existing conditions. Wind Loading: Provided that the L-bracket attachments to the roof are made in a typical staggered pattern,the overall wind loading imposed on the structure will not be impacted to any great extent.The net wind loads on the roof framing with attachment spacing as described above will be less than the current loading on the rafters. Conclusions: Our evaluation of the proposed solar-electric installation has established that the roof framing is adequate to support the addition of the solar panels to the existing roof as indicated on the Solar PV plans.We have only reviewed the adequacy of the connection to the existing rafters and the capacity of the existing rafters to support the vertical and lateral loads from the solar electric system.We do not take responsibility for any other portion of the solar panel array support system,the existing roof framing construction, or the integrity of the structure as a whole. Do not hesitate to contact my office at 866-867-8729 should you have any questions or if you require any additional information. Respectfully, Next Step Living, Inc. a GFaux 1�► s o { Dean E. MA Prof. Ent. License#50405 ELECTRICAL DESIGN a PV MODULE RATINGS 6 STC SOURCE COMBINER RATINGS INVERTER RATINGS 0 � Temperatures INVERTER MODEL:Enphase Microinv rter E MODULE MANUFACTURER: LG Average High:28' C MAX OCPD RATING(A):20 MODEL:M250-60-2LL.S22 Q MODULE MODEL#:LG300N1C-A3 Record Low:-34.4°C OCPD AMPERAGE RATING(A):20 MAX DC VOLT RATING(V):48 ' pl M OPEN-CIRCUIT VOLTAGE Voc : 39.80 MAX POWER@40°C(W):250 M M ( ) OCPD VOLTAGE RATING(V):240 NOMINAL AC VOLTAGE(Vtr 240 U j c") OPERATING VOLTAGE(Vmp): 32.0 NOMINAL AC CURRENT(A):1.OA Q OPERATING CURRENT(Imp): 9.40 2 x#10 THWN-2 Wire BLACK MAX BRANCH AC CURRENT(A) t3An3A SHORT-CIRCUIT CURRENT(Isc):9.98 MAX BRANCH OCPD CtJRRENT(A):20A N _ N 2 x#10 THWN-2 Wire RED MAXIMUM POWER(W):300 2 x#10 THWN-2 WHITE A N Voc TEMP COEFF(mV or%d°C)=-0.29%d°C 1 x#6 THNN-2 EGC nL Z It W Isc=0.040/./°C 1"EMT INDOORS a W LOAD pr N 0 7WIRES - - .............. ............................• E w .. O ` o C .......... n a o First End-Fed Branch of 13-M250 Inverters a o a 20A �1 .e . n. a, a ^' iJ-box CU O E En We.mo ""•n.w•e EnAaa.ma EnAm O° [nAaa.ma A .is66 ... .3EOd 35 : ...f }, ................................... L Second End-Fed Branch of 5-M250 Inverters m..o. .,.°... J (a Al .. E.A... E°A„de E.A,s LGak: so sa tID V//� -z .._....._...._....................... - .zsm ..................... zLL r yr .� ` _ VJ tV INSIDE M X = NOTE:A GEC(grounding electrode conducto/CONNECTIONTO FUSED AC O not required for M250-60-2LL ENVOY COMMUNICATIONS DISCONNECT Z GATEWAY 60A 240V 25AMPS t- ETHERNE BROADBAND ROUTER 120 VAC POWER CABLE OUTSIDE AC ma ) svmml cor,vemore. 1x#10 THWN-2 Wire LACK DISCONNECT 1 2-Pole Licensed Electrician Assumes All Responsibility For 1 x#10THWN-2 Wire RED 30A240V ^— Circuit Breaker CL Determining Onsite Conditions and Executing 1 x#10 THWN-2 WHITE MSP 1 x#6 THWN-2 EGC Fuse Installation In Accordance with NEC 2014 Codes 1"EMT INDOORS N 4WIRES �.+ a E ewe Visible Break pC DISCONNECT RATINGS CONDUIT SIZING SERVICE PANEL RATINGS ! ------------- .c o/o Knife Switch -'------------------- 1"PVC OUTDOOR MEP BRAND:SQUARE D DISCONNECTAMP RATING(A):30/60 V EMT INDOOR BUS AMP RATING(A): 200 1 x#6 THHN-Wire BLACK o DISCONNECT VOLT RATING(V):240 SERVICE VOLTAGE(V):240 1x#6 THHN-Wire RED E u eN NEMA 3R MAIN AMP RATING(A):200 1 x#6 THHN-Wire WHITE GrmWhg BREAKER RATING(A):LST 1 x#6 THWN-2 EGC Condor 1"EMT INDOORS = 4 WIRES GROUNDING ELECTRODE Drawn ble, H.Menkari MODULE DATA DETAILS F X K z { L { L y M MECJMMICAL PROPERTIES EIECIRR'ALPROPFItTffS(SF[h { Q O ci`h CbYy� NF4cdYxle?NnF6S tRA CI 4 N L-,eEl 94vn++n to Stiw mxraaat } �— ._imi � " N Cdld4orzYmx =5'e+3�'.mmlcXKmn� w++:. } xi 393 s'<Lti4eLlf Y 16Y2 Li(NK c.RBttY IkLY g43 Z a (0 M (Alaussi?K(E.Y}q sA{( i8n¢x5tl(M x.':�ituf {fi�;W,tlt n£uWtY;:S} i$) 0 v €as7X3ar,.Y-;Km �4cuay exe�ynsm.�t'Ct ss-sa E seueu wawa satin aan�.� r ewmm�nsr�m�+xeka�s@5 ko53t�ca M.x+(YaF O m p d 3axx aam tnx3 S!d).0.i t5c G� Har3mamsnlrs Mrco rxi fN �'* " � I� C uroagnY ssaY ns�rsc�nl.aa lawrsbcmm(a➢ a_s j � � t '. 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Ma k ~ t S wyw.mr [a�uxNr roYm[nnaw:.nxw N.a ARRAY DESIGN / SITE DIAGRAM HEIGHT OF HOUSE PANEL ORIENTATION (TRUE) ROOF PITCH (DEGREES) R1=240",R2=120" 192' 230 Q Vista Ave Iff av DRIVEWAY U_ j M Q O ocoirr� E � t` E N N UTILITY METER Z O M � O AC DISCONNECT M ° i o LGATE 120 ***PROPOSED CONDUIT RUN'EMT o d o d THROUGH THE ATTIC/ELEC TRICIAN « c WILL FIELD VERIFY*'* j a rn 0 UQoO_ PIPE TO BE RELOCATED Quick Mount PV E Landscape & Portrait M o Total's C rn c� 366 Total#of Panels: 18 12" Total#of Splice Bars: 2 J ca ' Total#of Bonding Jumpers: 2 rn `-------------------------------- Total# End Clamps: 32 W C Total#of Mid-Clamps: 26 J �a)s4a r � X C In asap{a4 i-1 ,,.. ***CENTERED ARRAY*** LG � o F39 37"—> •.. .* PLACE PV LOAD CENTER OUTSIDE TO THE RIGHT OF THE UTILITY METER, THE CUSTOMER IS RESPONSIBLE FOR MOVING 1W ***ARRAY LAYOUT IS NOT TO OBSTRUCTIONS V FROM PVLC LOCATION; PLACE ENVOY SCALE MONITORING EQUIPMENT TO THE LEFT OF THE MAIN ELECTRICAL v eo Quick Mount PV Solar Flashings PANEL x will be used on every roof penetration Customer Signature: Date: TYPICAL ATTACHMENT DETAILS THIS E"IGE tOWARDS ROOF RIDGE _ RACKING COMPONENTS 1 % NOT INCLUDED Na OESCRIP1Ci� Rit'.�E4�. �� 5 j I T52.MILL I r L GK!OCK,CLASSIC,,d,39j.1 CASIAL,DA9L I %I 3 --� � 3 ! PLUG,SEiAIING,.�I�S'�;MI.,Ei�UlA 1 i88SS , i i A jLaGSCSLVI,HE7 HEd,CI,s{Ib''x.rl�2',1935 J .. _ .._ ~fi _ (tJ�- ___._____.._I_L_ e, iV�r~,SH=R,F�ND�''.S,'1b'la'K1•tE5"�O}.1�BSSI 4.50 9'oo Lag pull-out • •s) in typical lumber Lag Bolt Specifcations 4 F Specific Gravity 5116'shaft per 3"thread depth 5116'shalt per 1"thread depth Douglas Fir, Larch � 150 798 266 s I Douglas Fir, South .46 705 235 I Engeelmann Spruce.Lodgepole Pine(MSR 1650 f&higher) .46 705 235 Hem,Fdr .43 636 212 Hem, Fir(Northl .46 705 235 Southem Pine .55 921 307 Spruce,Pine,Fr .42 1 615 205 Spruce,Pine,Fir(E of 2 million psi and Ivgtorgrades of MSR and MEL) �.50 798 266 . —SEE ENGINEERING Next Step Living Inc. Quick Mount PV REPORT FOR ATTACHMENT neAxt step llvin T, Module and Roof QMSE-LAG:QMPV E-MOUNT SPACING"-" to home energy solutions Attachment Detail WITH LAG BOLT A�® CERTIFICATE OF LIABILITY INSURANCE 9/16/2015 OATE(MM/ Y) 015 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 Mulcah NAME: y Malcolm & Parsons Insurance Agency PHONE (781)344-3200 q/C No:(781)344-1425 713 Washington Street ADDRESS: P.O. BOX 527 INSURERS AFFORDING COVERAGE NAIC N Stoughton MA 02072 INSURER A Northland Insurance Com an INSURED INSURER B:Sentinel Insurance Company Ltd 39098 Certified Safe Electric, Inc. INSURER C Nautilus Insurance Company 50 Tower Avenue INSURER D: INSURER E: Marshfield MA 02050-5131 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1573102731 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 ADOL SUBR POLICY NUMBER MMIDDYIYYYV MMIDD/VYYY LIMITS TICY EXPINFO X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 A CLAIMS-MADE OCCUR PREMISES Ea occurrence $ WS256559 7/15/2015 7/15/2016 MILD EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICYEPRO- ❑ LOC PRODUCTS-COMP/OP AGG $ 2,DOO,000 JECT OTHER: General Aggregate $ S,D00,000 AUTOMOBILE LIABILITY (E. cP ED. SINGLE LIMIT $ 1,000,000 O INED B ANY AUTO BODILY INJURY(Perpemon) $ ALL OWNED X AUTOS X SCHEDULED O8UECZJ8251 3/7/2015 3/7/2016 BODILY INJURY(Per accident) $ AUTOS X NON-OWNED PPReOPPERTn DAMAGE $ HIRED AUTOS AUTOS PIP-Basic $ 8,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 L, X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED RETENTIONS M021275 1 7/15/2015 7/15/2016 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ` ANY PROPRIETORIPARTNEWEX(ECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandmony in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS be. EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addi tonal Remarks Schedule,may be attached if more space is required) Electrician, Solar, Roofing Contractor CERTIFICATE HOLDER CANCELLATION certifiedsafeoffice@gmail. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 93 Washington St ACCORDANCE WITH THE POLICY PROVISIONS. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Amne Parsons/DARL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 0014n1) CERTIFICATE OF LIABILITY INSURANCE DATE 91172 /YYYYI T FICATE 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 term;and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: MALCOM&PARSONS INS AGE PHONE FAX 6 FREEMAN STREET (A/C,No,EXt): (A/C,No): E-MAIL STOUGHTON,MA 02072 ADDRESS: 73KDR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERIC CERTIFIED SAFE ELECTRIC INC INSURER B: INSURER C: INSURER D: 50 TOWER AVENUE INSURER E: MARSHFIELD,MA 02050 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 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MNIMMYYYY) (MWDDIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [::]OCCUR. PREMISES(Ea occurrence) ED EXP(Any one person) $ ERSONAL&ADV INJU RY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE $ POLICY [—]PROJECT [::]LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALLOWNEDAUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNEDAUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-OG177738-15 08/01/2015 08/01/2018 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED9 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS be. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 93 WASHINGTON ST IN ACCORDANCE WITH THE POLICY PROVISIONS. SALEM,MA 01970 AUTHORIZED REPRESE NT VE I D ,� ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. 4 Massachusetts Department of Public Safet+Y Board of Building Regulations and Standards License: CS-1O8740 Construct9on Supervisor BRUCE A DAVIS So TOWER AVENUE MARSHFtELD MA 020Or �.0 Expiration: Commissioner O1H8I2018 }PA .. P F�0 SAFE, ECTRIC I"C D . ,�A `�`�1t1EfN�E�Y�1� EL��'RICI Y CCry q/�y,��✓y. Cpj e�, �(��� p 4014£t . License or registration valid for individui use only Office of Consumer Affairs&Business Regulation _ before the expiration date. If found return to: J .. ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation istradon 100iO4 Type! 10 Park Plaza-Suite 5110 pIndion 01? t tfi6; Private Corpormlo: Boston,MA 02116, !_ . CERTIFIED SAFE ELECTRIC;INC. ' BRUCE DAMS ,� 50 TOWER AVE . .o r �.,,a..�1,� . HFIELD MA 02050UndersecretaryNot valid without signature MARS DocuSign Envelope ID:7239A81C-709E-4CA5-8E9D-OFDC975083D8 The Commonwealth of-Massachusetts Department oflndustrialAceidents I Congress Street, Suite 100 Boston,414 0211 4-2 01 7 www.moss.govldia Avt rkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERZiUTTLNG AUTHORITY. Applicant Information Please Print Le 'blv C < h18IDe {Business/Organizationlindividuai)' Address: Are you an employer?Check the appropriate box: Type of project(required): I,M, I am a employer with _employees{full andtor part-nme).° 7. Q New construction 2TQ I am a sate proprietor or partnership and have no employees working For me in 8. Remodeling any capacity,NO workers'Minn uvsurance required.) 3.0 I ant a homeowner doing all work myself.Tro wadies'comp.insurance required.)r 9. Demolition Q 4,❑I am a homeowner and aril/be hSring w:2xnetors to conduct at!work on my property. I will 10 Building addition e-rinre thatalt contractors either have workers'compensation insurance or an,sole 11.{ Electrical repairs or additions proprietors with no employees, 12.0?hlmbins repairs or additions 5.[ I am a general contractor and l have hired the sub-wntra+:tors li>^:ed on the attached sheet I3. Roof repairs These sub-coikactors nave emaloyees and have workers'comp,ssurance+ E We are a co oration and its officer,have exercised their right of exemption 14.©Other ❑ mper c. 152,§1(4),and we have no employees.[No vrorkers'comp,insurance required., 'A.nv applicant that checks box nl a=also fill out the section below showing the workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire omside contractors must submit a new affidavitini icating such, tConcoutors that check this box must attached an additional sheet showing the name o`,the sub-contractors and state whether ornot those entities have employees, if the subcontrnGors have employees,they most provide their workm,comp_pallet number lam an employer that is providin,workers'compensation insurancefor my employees. Below is thepolley and job site information. { u Insurance Company Name: Policy r or Self ins. Lic.4: U&d__7 _ J -_V-S Expiration Date: {,}�(����.t,..✓��C) Job Site Address:ItA lJ��a P.ye_. Citv1State/Zip-50cxn pC( A QJ!J'?0 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under NIGL 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 D1A for insurance coverage verification. I do hereby cernnfye u ad�Me a tthhe pains and penalties ofperjury that the information provided above Istrue and correct Siansture: llfl,ty_ AV is - - Date' OX- \\- %ko Phone#: az z�3nacnns "- \ 4cJ Official use only. Do not write in ibis area,to be completed by city or town official City or Town: Permit/License 9 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical InspectofPlumbingg ector 6.Other Contact Person: Phone#•