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5 COTTAGE STREET - BUILDING JACKET 5 COTTAGE STREET 1 i UPC No. 5310333 3 HASTINGS, MN Certificate No: 724-11 Building Permit No.: 724-11 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the SINGLE FAMILY DWELLING located at Dwelling Type i 5 COTTAGE STREET in the CITY OF SALEM Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY 5 COTTAGE STREET This pernut is granted in conformity with the Statutes and ordinances relating thereto, and expires unless sooner suspended or revoked. Expiration Date _ Issued On: Thu Aug 25, 2011 GeoTMSOO 2011 Des Lauriers Municipal Solutions,Inc. 4 GIS ". I)j : d"r'C?til �'1(�1vW9+',�� f11� {�Fv3.re4Sr1C`,l41JE CITY OF SALF Block; M i�.ot Ca+u rnv RL}sGGhL - / Yen„it F 24-! 1 : `�I� DVI NTG PERMIT Prq)e,t4 is2(111-oot'2f - ESt Cost: ato5.00t1+tD - - PceChalgcd: S740 00 Balance Due- oo PC:li,1 USS.d+' N IS HFREP,Y GRANTED.TO:. Cnrst '.-luss . eaI*,—aclnr: License: a- > (is Gow)- {Burgos!'al ;ivctioi� LlC ^r1NSTRiJcTIORLPERVISOR-91I!0 i�S .:rpi Ieai r Rt App bcaat: Burgas o nstnwtion L1 r.. 1,74ins Lost: - 9 t = �:OTTAGE S rRE;ET - u; S a re#: f,SSfJED O!0' 14-Apr-2011 A WYDIED ON: E.YP[RF,S OM 14-Sep-2011 x TO PERFORM THE FO LOW NG WORK: T(-)T'ALREit40DELINO OF SINti[.E FAMILY DWELLING, NEW ROOF SIDING PLI TN4BTNG,Pt F,LECTRI('AL(SANfu L`AS'TING FLOOR LAYOT.IT')Jbh.. POST THIS CARD SO IT IS VISIBLE FROM TIM STREET Electric Gas' Plumbing Buililine --- ifnt4il,rcnn-;rl: I' !ergroinid: - Underground: Excavation: ieter:� / f tQ' Fnritings: IIlimrgh:...?�': ,•?.-�/�'/ uugh:' Fsundation: q�. ) Filial: Filial: Fmul: !_'/•/�.j� a' �...�-URough Frame: J/�yj ( � Filace/C'himne P y. ` !D P.�N', Fire � Health rc~� } P - r Insulation: i l( [fit I 6 ilnuxe_q i, ,t L t f Fina!: a{- V7-' vv I11'atnr; o r ' Treasury: Assessor.�SSeSSOr Sewer: S wVtorr— Filial: €'TILS.PERI UT LMAY BE REVOKED SY TiilE CITY OF SALEM UPON V OI:ATION OF ANY OF ITS RULES AND REGULATIONS. _ Signeltur ''- ��"" iw'o rca T}pe; lteacipt NO; Vate 1'aid: ` Check No: Amount: - - rT7�INER OA rONTAAr, � RF%ERIODICiNS.' � TE1f$'�1�1�� 101}43 11pr-il Ifild' � b74q.00 LONSTAUGTIdN.SEE OUR pECr Ti r45 I)URjNj CF{lV'TEfl 7fOR LIST OF REt]IPIj ED IRNSPE T7)Q$. . CFd.L yTg-fi IT Ttl SC.HEOtIi-E AN!NSPEC*ION Ccn i:415:h?ol t Des 1,auriers AAinicipa!Sulutilins.Lre. BUTTERWORTH & O'TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971.8294 ADJUSTERSIAPPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE (978)741-5731 FAX (978)740-9109 April 03, 2001 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS . GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall City/Town Hall ADDRESSES Salem, MA 01970 Salem, MA 01970 RE: Insured: Felix Kocur Address : 5 Cottage Street Salem, MA 01970 Policy No. : HP0638993 Loss of : 03/30/01 File or Claim No. : 14-0698 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000 . 00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number . If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Patrick Tobin Adjuster Michael Winston & Associates, LLC Innovative Risk Specialists POB 10721 Bedford,New Hampshire 03110 iil Tel: 603-494-2366 Fax: 603-889-0241 - E-mail: michaelwinston@comcast.net November 4,2010 Building Commissioner/Building Inspector Board of Selectman/Board of Health 93 Washington Street Salem,MA 01970 RE: James Cajigal 5 Cottage Street Salem,MA 01970 Type of Loss: Fire Date of Loss:November 3,2010 Policy: HO12330549 Claim number: HC 167221 Our File#: MW IO-392 Location of Loss: Same To whom it may concern: The above captioned clam has been made involving damages or destruction of property which may exceed$1,000.00 or cause Massachusetts General Laws, Chapter 143,Section 6 to be applicable. If I notice under Massachusetts General Laws, Chapter 139B is appropriate, please direct it to the attention of the undersigned and include a reference to the captioned insured, location,policy number, date of loss, cause of loss and claim or file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above via first class mail. Sincerely,' Michael Winston Adjuster .0 J SYniKv m:��.� nll.• - 1 fhe Commonwealth of Massachusetts CITY Board of Building Regulations and Standards �r !` Massachusetts State Building Code, 780 CMR, 71n edition OF SALEM Krrlsed Junrrun• n Building Permit Application To Construct,Repair, Renovate Or Demolish a /• 2008 One-or Ttvo-Family Dwelling This Sec n or Official Use O Building Permit Number: a li : Signature: t/ Building Commissioner/In ctor of Buildings Date SECTION 1:S E INFORMATION I.1 Property Address: 1.2 Assessors Map At Parcel Numbers $- G.v-r'rSGIT 57T 190-r- I.la Is this an accepted street?yes `ono Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided T r 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ p P y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: TQrMV5S Name(Pri ) Address for Service: Si re Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': p...i,t///:✓ NFiv St of Plea-rbi.-. .r�e.r�-e'rTtt2s� �.�.ni4rrro.. SECTION J: ESTIMATED CONSTRUCTION COSTS item Estimated Costs: Official Use Only Labor and Materials I. Building S 7,0,G1;7 , I. Building Permit Fee:S Indicate how Ice is determined: oa ❑Standard City/Town Application Fee 2. Electrical S /ht OLi7• ❑Total Project Cost'(Item 6)x multiplier x 3. ['lambing S /2 OUO."' 2. Other Fees: S 4. Mechanical (IIVAC) S if pup,•' List: 5. Mechanical (Fire Suppression) ota S e Tl All Fees: S— C cc No._Check Amoun . Cash Amount:_ 6.Total Project Cost: .S ens .� ❑Paid in Full ❑Outstanding Balance Due: Pcv1` fly ( On><lit� l�Olr 7 r-i= 7`fly SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) v!/(/D Z� lti�Z �� I�OS I.icense Number I(spirauuq Dme Name of CSI.- I[older List C'SL Type[see below) :\JJress I't.oe Descri Lion Il Unrestricted(tip to 35,000 Cu.Ft.) It Restricted 1&2 Family Dwellin Sig natu ki %lason Only Me q3Z &J/Z RC Residential Rooting Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2Mi tog�p IIIC Company Nwn W IIIC Rc r t N Registration Number 5 W/(1II--5 �f- rhGls� ,faq.pz/5o Add ss i 5� Gf32Bl/Z� TnDate Signatur '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 ..........❑ No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. !YZ?- SiwatdWof Owner Date SECTION 7b:O/WNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on Me foregoing application are true and accurate,to the best of my knowledge and behalf Print Name 2 // Signature ofownermA6flibrized Agent Dale (Signed under the pains and penalties ofperjury) 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(IIIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Ilabitable 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 he substituted for"Total Project Cost" CITY OF S:u.E%1, ,NAXSSACHL•SETTS 3t;1LDD4G DEPARTNIEINT • 120 WASHINGTON STREET, 3w FLOOR TEL (978) 745-9595 F.4x(978) 740-9846 ICI.\tg F Rf F_Y DRiSCOLL T140bMS ST.PIERRE MAYOR DIRECTOR OF PUBLIC PROPERTY/BU QDING COJL%IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractor9/Electricians/Plumbers A a Ilcant Information Please Print Legibly Name 10usitw•snUrytnimtiorvindividtnp: Address: � City/State/Zip: ltIGh Phone#: Are you an employer"Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction to eea full and/or part-time)-* have have hired the sub-contractors` y ( P listed on the attached sheet 7• ❑ Remodeling rt 2. I am a sole proprietor or paner- ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers comp. insurance 5. 0 We are a corpomlion and its 10.0 Electrical repairs or additions required.) officers have exercised their right of exemption r MGL 1 1.❑ Plumbing repairs or additions 3.❑ I ys a homeowner doing all work c.6152, 1(4), nd we have no myself.[\o workers' comp. � 12.❑ Roof repairs insurance required.)t employees. [No workers' 13.0 Other comp. insurance required.) -Any uppllcaaa char ducks box 01 must alwr rill out the wtien ba me a wwina thou wahca'compensation Policy mfurmallon. 'I1,.owwws who submit this affidavit indicating they are doing all work and then hits wlside cummmom must soh no a new aitldavit indicting such. :('ammeters that short this box most anochod an astdiounul shoes showing rho name o(the subsontracton and their worker'wmp.policy infamution. I am um employer that is providing workers'compensadan insurance jar my employees. Below/a the policy and Jab site information. insurance Company Name: Policy o or Self-ins. Lie.M Expiration Date: Job Site Address: .r 4!ff -e City/State/Zip: 4;/AU4� %Itaeb 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 line up to 51.500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line of up to 525o.00 a day against the violator. 13e advised that a copy of this statement may be rurwarded to the Office or Investigwima ol'the DMA fur insurance coverage verilicaliun. 1 do hereby ce Bjy rutdi the p r d penult/es ujper/ary that the information provided above is slue and correct r F0thcr ___.. ly. Du not write in this area,to be completed by city or town ajjlchrL _-_ ._.— rily(circle one): allh Z.Building Department 3.Cilytruwn Clerk 1. Electrical Inspector 5. Plumbing Inspector _ _. Ctrntact Person: _ .._.. _ Phone th Information and Instructions \Iassachusciis Ucmeral Laws chapter 132 acquires all employers to provide workers' compensation list their employees. I'ldrstlaan to tnls aWluic, an rmplurrr is defined as"...every per:son in the service of mother under any contract of hire. C\prc%s or Implied, ural or written.- \n e,epluyer is defined as"an individual, partnership,.association,corporation or tither legal ennry, or any two or inure �r the foregoing engaged In a joint enterprise,and Including the legal representatives of a deceased employer,or the aeceaver or trustee of an individual,pwmershap,assocsalioa or other legal entity,employing employees. However the uwner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling Bowe of another who employs persons to do maintenunce,cunstruclion or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." N.IGL chapter 152. §25C(6)also stales that ''every irate or local licensing agency shall withhold the Issuance or renewal of s license or permit to uperate a business or,to construct buildings In the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally. MGUchapter 152. a25C(7)states"Neither the commonwealth not any of its political subtbvisions shall enter into any contract for the perfomwnce ufpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if necessary, supply sub-contractor(s) name(s), address(es)and phone nuanber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the uflldavfL The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their .elf-insurance license number on the appropriate line. City or Town Officials Please he stare that the affidavit is comptete amd.primcd legibly. The Department has provided u space ut the bottom Of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. lll:ase be sure to till in the permit/license number which will be used as a reference nunsher. In addition,an applicant that mwt submit multiple pennitilicensc applications in any given year,need only submit cane affidavit indicating current policy information pif necessary) and under"lob Site Address"the applicant should write"all locations in (city or tuwnl."A copy of the affidavit that has been officially stamped of marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e. it dog license air permit to bum leaves etc.)said person is NOT required to complete this affidavit. I he 011ice of Invesrigations would like to thank you in advanec for your cooperation and should yuu Ila%c:my questions, please do not hesitate to give us a call. fhe Dcparnnent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents h Office of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Fax 0 617-727-7749 www.mas3.gov/dia CITY OF S.3LE.�r1, lL-ksSACHUSETI'S • Bt:ILDLNG DEPARTMENT t 130 W.�.iHLNGTON STREET, 3'D FLOOR Tm (978) 745-9595 FAX(978) 740-9846 Ki BERIEY DRISCOLL MAYORTHou+s ST.PtEalts DIRECTOR OF PCBLIC PROPERTY/BCILDLNG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5 Debris, and the provisions of MGL a 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by 1VIGL c 111, S 150A. The debris will be transported by: �. i tar re-� (name of hauler) The debris will be disposed of in : WODp 4t A s%r-r— plll-ln r4a�✓ (name of facility) (address of facility) signs re of permit cant date dubnvlr d-e: The Commonwealth of tMassachusetts ° Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SdMarI 77 � Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Dem fish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Numberr Date Applie Building Official(Print Name) Signatd re - ` - Date SECTION L SITE lNFORINGIT rolq 1.1 Property ddress: L2 Assessors Map& Parcel Numbers �i'~SVJ� < r.I -ISGUiMtW)A 1.1a Is this an accepted 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❑ SECT16N2: PROPERTY'OWNERSHIPL pwnert of Rec r : SOS LI/1/Vl ? �l l} O j pi iAM - ��r�iGtP1 L- NPe(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Cl I Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Nu Units_ Other ❑ Specify: Brief Description of Proposed Work': C) 1A2 G A ,ra e S 6 x �e SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only.., Labor and Materials) I. Building S I. Building Permit Fee S indicate how fee is determined: ❑ Standard. ❑'C City/Town Application Fee 2 Electrical $ 3 . - oral Project Cast. (Item 6)s multiplier. x 3. Plumbing S 2. Other Fees:'S i. Mechanical (IIVAC) S List: 5. Mcchanical (Fira S Stippression) L ,StalAll Fees: cck i Io. Check Amount: Cash ;Amount 6. Futal I'rniect Cost S 0 Paid in Fill 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) License Number Expiration Date Name of CSL Ilolder List CSL Type(sae below) No. and Street Type Description U Unrestricted Buildin s u to Ii,000 cu, ft. R Restricted L&? F;unil Dwallin City/Town, State, ZIP II %,Iasonr RC Rootin Covcrin WS Window and Sidi— SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(FIIC) HIC Registration Number Expiration Date I IIC Company Name or MC Registrant Name No.and Street Email address 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 .......... ❑ 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 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: OWNEW OR AUTHORIZED AGENT DECLARATION By enteri -my name below, I hereby attest under the pains and penalties of perjury that all of the information cont.' edit this application is true and accurate to the best of my knowledge and understanding. JkmtS CAJKaA--( � I kI -d13 Print Owner's or Autburized:4gent's Nome(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 Houle Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty tund tinder M.G.L. c. 142A. Other important information on the FI IC Program can be found at www.mass.,,ov oca Information on the Construction Supervisor License can be found at www.mass,!L)�aL 2. When substantial work is planned,provida the information below: Total floor area(sq. It.) _ _(including garage, finished bascment/attiu, decks or porch) dross living :Irea(sq. ft.) Ifabitable room count Number oftireplaeas -- Number of bedrooms - -----_-- Number of bathrooms Number of halt'baths type of heating System" -_—_ _--- Number of decks/porches ----_--- — — peofeoolimgsyilent----------- _ Enclosed---- ---" -- Open — —_-- 1. I'M,II Pnyec[Syu;lro Footage may be Subiunucd Ira'"'I'ortal I'ruleit ('o;t CITY OF SM-E.M PUBLIC PROPERTY DEPARTMENT a,.�ae.ar o•a� `�� i]0 e/.s•wnv,lnaaT•s�u,ti ws�ow ssrn 01•'e r1tL rai,sss»•V,.X r.ar+o.1w HOMEOWNER LICLNS6 EXE.I "10,V P1eaM Mat Dam 1 Job Location Home Owner Address e. S S w l v1Q>r Hesme owosr Telephone xs— — 1 Present Mailing Address S A The current exemption of"Homeowners"was extended to include ownaroccupied dwellings of two Units or lea and to allow such homeowners to engage an individual for hire who does not possess a licenser provided that the owner acts as auperviaat DEFlNM0N OF HOMEOWNER Person(s) who owns a peed o[land on which W&M resides or intends to resider on which there is, or is intended to bsr a one or two laically dwellinf ansehod or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shag not be considered a homeowner. Such -homeowner"shall submit to the Building Odfcial,on a form acceptable to the Building OfAcial, that he/she be responsible for ail such work performed under the Building Permit The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner'certifies that helshe understands the City of Salem Building Department minimum inspection procedures and requirements and that hdshe .vial comply with said procedure and requirements. HOMEOWNERS SIGNATURE — 4 /� .APPROVAL OF BUILDING 4�iSPECTOR L/ Sce other side for state code CITY OF S U _ ,_ t 1�Lass.1 c HLSETTS Bc;ItDa�G DEP.1RTJtE.VT 110 CV.{SHLNGTON STREET, " ET, 3 FLOOR TEL (978) 745-9595 K1J[3ERLF-Y DRISCOLL F•`.r(978) 749344 AMR THoxu ST.PtERRS DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONWISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tk is issued ued with the condition that the d Is work shall be disposed of in a properly dens resulting front p perly licensed waste disposal faelll l 1 l S l50 as define A. t3' d b � Y t iGL c The debris will be transported by: (name of hauler) The debris will be disposed of in (name ot•facility) (address of Facility) s g azure of pa•mit applicant date �1 2A,(o � 13 L4 g '�O RECEWED INSPECTIONAL SERVICES 1 The Commonwealth of Massachusetts B^ Board of Building Regulations and Standards 2014 APR U 'Ay"1 Massachusetts State Building Code,780 CMR ALEM 1 _ Revised Mar 2011 e 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: AN Building Official(Print Name) Signature I I Date SECTION 1:SITE INFORMATION 1.1 Property Ad,dyrf s�s�:�1 1.2 Assessors Map&Parcel Numbers 1.I a Is[his an accepted street?yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sit ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yazd 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? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' fName Owner'of Rec (IY1 )OA M lacd Salem Mlk Dlgt-)c) _( at)at) /�. - City,State,ZIP Aia No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction I( Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: ,%-X-� p p ho'�DV }0.1G SolG1r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ iGJ�.C�o 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost}(Item 6)x multiplier x P 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: // 1 5. Mechanical (Fire $ Su ression Total All Fees:$ a Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ,"j •06 ❑Paid in Full ❑Outstanding Balance Due: q 90� NIL U/�.tom (_e riA � L>a uL-l;�D 511 - rit CLi To SECTION 5: CONSTRUCTION SERVICES 5.11-Construction Supervisor License(CSL) 1' �t �wleS �VtPF} 1�Q Yl LicenseNumber I Expiration raon late Name of CSL Holder List CSL Type(see below) U No.and Street 1 Type Description A ` u s / A I OI/] b U Unrestricted(Buildings u to 35,000 cu.ft.) �`�l _1 A Restricted 1&2 FamilyDwelling city/Town, IP M Masonry RC Roofin CoverinWS Window and SidinSF Solid Fuel Burning Appliances YJ N/1rxSDINo VIVlt�sp�pr. Insulation Tele hone Email address C0 D Demolition 5.2 Registered Home Improvement Contractor(HIC) t-70�6�-}$ �_ V 1 V I lnt So lal' D V21 op2Y L LC HIC Registration Number E prra on ate HIC Com any Name or HIC R gistrant Name �— W.d PN. �oD Z. �LSoa.rQ„IVtnA-sa Y. No.and Street Email address C.Drvt PVrDVO uT ��1 )C)q "l$13D53DLpS City/Town,State,ZIP Tele hone 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.........:A 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 V IV 1✓kt SD l0.1^ to act on my behalf,in all matters relative to work authorized by this building permit application.VA 23 !/ Y Print Ownefs Name(Electronic Signature) Date SECTION 7b:OWNER'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 IN p . tion is true and accurate to the best of my knowledge and understanding. V I t � 23 N. Print s r rized Agent's Name(Electronic Signature) I Date NOTES: 1. 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. oe v/oca Information on the Construction Supervisor License can be found at www.maaLgov/dos 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" A CERTIFICATE OF LIABILITY INSURANCE °A1 "YY"' 11/011201312013 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 MARSH USA INC. NAME: 1225 11THSTREET,SUITE 1300 PHONE FAX ac No: DENVER,CO 80202-5534 EMAIL Attn:Denver.cerhequest@dmarsh.cem,Fax:212.948.4381 ADDRESS: INSURE S AFFORDING COVERAGE NAIC9 462738-STND43AWUE-13-14 INSURER A:Evanston Insurance Company 35378 INSURED INSURERS:National Union Fire Insurance Co of PA Vivint Solar,Inc. 4931 N 300 W INSURER c:New Hampshire Insurance Company 23841 Prove,UT 84604 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002368030-06 REVISION NUMBER:0 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. IN$R AODL SUER POLICY EFF POLICY UP LTR TYPE OF INSURANCE POLICY NUMBER MMID MMIDD LIMITS A GENERAL LIABILITY 13PKGWE00274 11/01/2013 11/0112014 EACH OCCURRENCE $ 1A00,000 X COMMERCIAL GENERAL LIABILITY PREMISE E T S Eaacwrrence $ 50,000 CLAIMS-MADE MOCCUR - MED EXP(Any one percent $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000.000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY PPCT' LOC $ B AUTOMOBILE LIABILITY 9701087 11/01/2013 11/01/2014 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ S X ANY AUTO 9701088 11/0112013 11/01/2014 BODILY INJURY(Per person) $ ALL OMNED AUTOS SULED BODILY INJURY(Par accident) $ X MIRED AUTOS X NONOWNED PROPERTY DAMAGE AUTOS Par acdtlent $ $ A UMBRELLA LULB X OCCUR 13EFXWE00088 11101/2013 11101/2014 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAS CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTIONS $ C WORKERS COMPENSATION 029342334; 029342335 11101/2013 1110112014 X WCSTAT1J- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS C ANY PROPRIETOR/PARTNERIEXECUTIVE N 029342336; 029342337 11/01/2013 11/01/2014 E.L.EACHACCIDENT $ 1,000,000 Rd C OFFICEREMSER EXCLUDED'! ❑N NIA (Mandatory In NH) 029342338 1110112013 11/01/2014 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yse.describe under DESCRIPTION OF OPERATIONS below E.LOISEASE-POUCYUMIT $ 1,000,000 A Enors&Omissions& 13PKGW00029 11/01/2013 11101/2014 LIMIT 1,000,000 Contractors Pollution DEDUCTIBLE 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Atlach'CORD 101,Additional Remarks Schedule,V mom apace is required) The Certificate Holder and others as defined in the written agreement are included as additional insured where required by written contract with respect to General Uability.This insurance is primary and non nMbutory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract.Waiver of subrogation is applicable where required by written ntract with respect to General Liability and Workers Compensation. CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 93 Washington Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M.Parsloe ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 4931 North III West,Provo,UT 84604 Employer Identification No.: 800756438 VlVlllt. so I a r M Phone:(877)404-0129 Fax:(80U 765-5758 Massachusetts HIE Licene No s 170848 E-Mail support@vwintoolmenno 3 a y 160 y (4 www.,ivmxdImcmn AR No.: f RESIDENTIAL POWER PURCHASE AGREEMENT This RESHy-NTIAL POWER PURCHASE AGREEMENT' his"Agmemea')is entered into by and between VIVIAT SOLAR DEVELOPER,LLC,a Delaware limited liability company("We","Us","Our")and the undersigned Customers)("You","Year'),as ofthe To m etion Dodson forth below. Full Name Ie;.,,,m<o..q JR Full Name rrr,r w.v,q Customer(s): ^e rn moa..�m'4,o,w nw...yo»„n:❑r.,o xo Telephone No.: ill - IV-Wfa46� E-Maih i'sb T-glCuweAn G4sao-Ce ll Property Strect Address: S CoVrCkll Si-' Address: CIty,Counl Slme,Zip: MR Oldl+O 1.SERVICES A. DESIGN AND INSTALLATION. We will design,install service and maintain a solar photovoltaic system on Your P hick will include all solar panels,inverters,meters,and other components(collectively,the"Syrrem'T.as further described m the Customer IT d[e Work Order that We will provide m You hereafter. All material portions of the System will be installed by Our employed technicians and clectnciens,and not subcontractors. With Your coope'soon, We will(r)design,install and connect she Systurn in material compliance wish all applicable laws; )corm�lete all required inspemions;end('iii)obtain all required cenitwirsins and econits. In order to design a Syystem that meets Your needs,You agree�at We may obtain Your electrical usage history firm Your electric utility jthe"UhO and You shall provide❑s with copies of Your Oolity bills as We may reasonably request. OaTer than tee ativanon fee described in Stthun LB,We will 1esign and install the System B. ACTIVATION. You agree to pay Us a u -time amivation fee m the amount of$ We will imerconnect rim System witM1 the Utility,and cause the System to gencon eno, mcasurd,' kilowatt houe('truth "Frier nvalletmn of the System generally oleos one day mJ a anticipated I. begin and be subslanua ly complete between twr(2)and six(6) asks heree�er. C. OWNERSHIP OF SYSTEM. We shall own the System as Our sole personal property. You will have no property interest in the System. D. OPERATIONS AND MAINTENANCE. We will uIum a and maintain the System Ill at Our sole cost and expense;(it)in good condition;and(iii)in material compliance with all applicable laws and permits and the Utility's requirements. E. INSURANCE. We carry commercial general liability insurance,workers'compensation insurance,and propertyy insurance on the System. For more information concerning Our insurance,and to obtain a copy of Our cenificate of insurance,please visit: caw t,vlvintsola.conommramce. 2.TERM PRICE,PAYMENTS,AND FINANCIAL DISCLOSURES A. ENERGY PRICE. For all Energy produced by the System,You sh�aaDlLypppyy Us S0. (d 10 per kWh fthe"Energy Price"),plus,applicable taxes. The Energy Pace shall increase each year by two and nine-tenths P cntY2:9elal A geed lank estirnale of the S output,messu-d m k Iowan hours, ill be yrovided to You a the Customer Pee it. THIS AGREEMENT IS FO -TTHE SALE OF ENERGY BY US JansenTO YOU AND NOT FOR THE SALE OF A SOLAR ENERGY DEVICE. B. TERM. This Agreement shall he effective as of the Transaction Dam and continue until the twentieths{ ? anniversary of the In-Smite Date(the "Tani'). The"laServive Doh" bull be the first day after all of the following have been achieved: (i)the stem has been installed and is capable of generating Energy.(ii)all permits necessary to operate the System have been obtained,(ill)the System has been mtermnnectN with the Utility,and fin)all mspections and cemficates required under applicable law or by the Utility have been crmpleted or received. C. PAYMENTS. Beginningg with the first month following the InServiw Date and throughout the Term,We will send You an invoice reflecting the charges for Energy produced by the System in the previous month. You shall make monthly ppayments to L's by automatic pay�mnant deduttion from Your designated checking account or credit card. It is Your responsibility to ensure that them are adequae funds or adegsaw credit limit. There a no financing charge associaled who this Agrcement. For all payments more than ten(10)days past due,We may impose a late charge equal to Twenty-Five Dollars($251 and interest ar an annual rate of ten percent(I0 0).plus applicable axes. If You continue to fail a make any payment within ten(10)days after We give You won.notice,then We may d. w all remedies avat able to Us pursuant to Sermon 13fb1. D. RENEWAL. A[the and of the Tenn,You may elect to(i)con6nue with this Agreement ore a year-on-year basis;fit enter into a new Agreement with Us and cancel this Agfecmrnq(iii)purchase the System at the end of the Term aria cancel this Agreement(Ike"Purchase Ondon") or Uv)cancel this A -cant and have the System removed at no cost to You. You will need to notify❑s in writrng conceminQ Your election sixty(60)days prior m the and ol�e Term. If You elect the Purchase Option,the Purchase Option Price"will be the[hen-cure-fair market value of the System based on an -dependent appraiser's valuation of ximilarly sized photovoltaic systems m Your Ion owphic regina. The tip raiser's valuation will be provided to You in wnnng and will be binding. If We receive Your payment of the Purchase Option Price casts of Ne appmisaP applicable taxes,and all odser nmouvts then owing and unpaid hereundeq We will[mnsfer owmcrshtp of tee Syskm to You at the end of the Tenn on an`As Is,Where Is bans. If You clam to M1ave the 8ystam removed.We will remove the Systam from Your P-Party ithin ninety(9U dayyss after the end of the Term. IF YOU x a NOT NOTIFY US OF YOUR ELECTION I'O CANCEL BY SENDING A WRITTEN NOTICE �O US,THEN THIS AGREEMENT WILL AUTOMATICALLY RENEW ON A YEAR-TO-YEAR BASIS UNTIL YOU NOTIFY US IN WRITING OF YOUR ELECFIUN TO CANCEL AT LEAST SIXTY(60) DAYS PRIOR TO TILE END OF THE RENEWAL TERM. E. CREDIT CHECK. In connection with the execution of this Agreement and at any time during the Tern,You hereby Window Us to(it chain Your credit ruing and report firm credit reporting agencies;(ii)to repon Your payment performance under this Agreement to credit reporting agencies;and (iii)discloac this ansl other information to Our alhholes and actual or p-spretive lenders,financing parties,inves-rs,insurers,and acquirers. WE MAY HAVE PRESCREENED YOUR CREDIT. PRESCREENING OF CREDIT DOES NOT IMPACT YOUR CREDIT SCORE. YOU CAN CHOOSE TO STOP RECEIVING"PRESCREENED"OFFERS OF CREDIT FROM US AND OTHER COMPANIES BY CALLING TOLL-FREE (888) 567-8688. SEE PRESCREEN & OPT-OUT NOTICE(SECTION 29)BELOW FOR MORE INFORMATION ABOUT PRESCREENED OFFERS. 3.LIMITED WARRANTY A. LIMITED INSTALLATION WARRANTY. We rovide a workmanship woman that the System shall be flee firm material defects in desi and workmanship under normal operating conditions for rim Tenn. We Culler warrant that ell rooftop penetrations we instill shell be welertiuyt as ofthe�te of installation. We do not provi0e any warranty to You with respect to any component of the Systwo. Any inanuacmrer's warranty is in addition to,not in lieu of,this limited installation warranty. This warranty does not cover problems resulting tram exposure to harmful materials and chemicals,fire,Brand, earthquake,or other acts ofgod,vandalism,freedom of system by anyone not authorized by Us,or any other cause beyond Om control. B. MANUFACTURERS'WARRANTIES. The Systen's solar modules tarty a minimum manufacturer's warranty of twenty(20)yeas as follows: ((a))during the firs[ten(10)yyeears of use,the modules'electrical output will not degrade by more than ten percent(10%)firm the ongrnaify rated cut Wt;all (b)during[he firsl twenty(20)year of use,the modules'elecwcal output will not degrade by more than twenty percent(20%)hem the on'gi illy re[Vcd output. a Syatem's inverters carry a minimum manufacturer's waranty often(10)years against defects w component breakdowns. During Ina will enforce these warranties to tee fullest extent possible, C. DISCLAIMER OF WARRANTY. EXCEPT AS SET FORTH IN THIS SECT[�N3,WE MAKE NO OTHER WARRANTY TO YOU OR ANY OTHER PERSON, WHETHER EXPRESS, IMPLIED OR S—T)TOYbRl' AS TO THE MERCHANTABILITY OR FITNESS FOR ANY PURPOSE OF THE EQUIPMENT, INSTALLATION, DESIGN, OPERATION, OR MAINTENANCE OF THE SYSTEM, THE PRODUCTION OR DELIVERY OF ENERGY, OR ANY OTHER ASSOCIATED SERVICE OR MATTER HEREUNDER, ALL OF WHICH WE HEREBY EXPRESSLY DISCLAIM. OUR LIABILITY FOR ANY BREACH OF ANY WARRANTY IS LIMITED TO REPAIRING THE SYSTEM OR YOUR PROPERTY TO THE EXTENT REQUIRED UNDER THIS AGREEMENT. YOU ACKNOWLEDGE THAT WE ARE RELYING ON THIS SECTION 3.C.AS A CONDITION AND MATERIAL INDUCEMENT TO ENTER INTO THIS AGREEMENT. THERE ARE NOPT ES WHICH EXIhND BEYOND THE DESCRIPTION OF THE FACE HEREOF. 4.REMOVAL OF THE SYSTEM You shall art make any Alterations(as defnW in tin c��to the System. HYou want to make repairs or ire rovemrn[s to Yow Property that require Ilia temporary removal oCae Syystem or that could m e wiih its peRormance or opemtin You must give Us a[Reest thirty(30)days'prwr wnnrn rtona {a"CuxramervRequesred Shurdawn"). You agrco that an repair or improvement to Your Property shall not materially all Your roof where tee Syskm a msalle ompensation fnr Our removal,storage and iemsalletion of the S}�lam,You agree to dpay to Us a fee equal to Four Hundred and Ninety-Nee On" 5499 before We-move the System. You shall be required to pay. ay the Shutdown Payne t as defined in S coon IS fin tee System is no[reinsalled within O)days rf removal. In the event of an emttgency affecting the System.You sha��Il1111 comact Us Im u tale y. If We are enable to timely respond,You mayy(at Year own expense)rantmcl wiN a licensed and quali M sole insalla[o remove the System as necessary In make repairs required by the emergency. Vru shall be responatble for any damage to the System tha reau16 from actions taken by Your comans. 5.ARBITRATION OF DISPUTES Most customer concerns can be resolved quick)y and amicably by calling Our customer service department at(877)404-4129. if Our customer service department Is unable to resolve Vow snncem,You and Were to resolve any Dispute(as defined below)throu¢h bindLy arbitration or small claims court instead of coons of general'urisdic[ion. BGNING BELOW,YOU ACKNOWLEDGE AND AGREE THAT(I)YOU ARE IIERE13Y WAIVING THE RIGHT T�A TRIAL BY JURY;AND(II)YOU MAY BRING CLAIMS AGAINST US ONLY IN YOUR INDIVIDUAL CAPACITY,AND NOT AS A PLAIMiFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. You and We agree to arbitrate all disputes,claims and conrrovernes arising out of or relating to cos"A).nor v;.:.x s,m,11-1,,111 nito_u.x., ,L (i)a ny any aspect of the relationship between You and Us,whether based in contact,tort,'tattle or any other legal theory;(ii)[his Agreement or any other agreement concertung the subject matter hereof; (iii) any breach, default or ternunation oC(his Agreement; and (iv)the interpretation,validity,or enforceability o this Agrcenrent including the determination of the scope or applicability of this Section 5(each,a Dispute"). Prior to commencing a' die iuq a party must first send a written"Notice of Dis ute"via cemfied mail to the o[— e�patty. The Rl Wi Notice of Dspute must describe the name and basis for the Dispute and the relief sought IfPYou and We are unable to rewlve the Dispute within thirty (30) days, then either party mayy commence arbitration. The arbi0soon shall be administered by JAMS pursuant to iss Streamlined Arbitration Rules end Pre ores(o"'i.ble at. httpp://www.amsadr.erpam es-streamlined-nrbitation,the"JAMS Rules")and under the rules set forth in this Agreement The arbitrator shal I be boun�by the terms of this Agreement. No matter the circumstances,the arbitrator shall no[award puve,sppecial,exemplary,indirect,or consequential damages to either party. If You initiate arbitation,You shall be responsible to pa $250. All attorneys' fees,travel expenses,and other costs of the arbi[ration shall be borne by You and Us in accordance with the JAM$Rules and applicable law. The arbitration shall be conduc(ed at a mutually agreeable location near Your Properrttyy Judgment on an arbitration sward may a entered in eny court ofcorn ¢tentjurisdiction Nothing in this Section 5 shall preclude You or We from seeking provisional remedies in aid at inbiusorm from a court ofDcompCie.,juriashtursn. NOTICE:BY INITIALING IN THE SPACE BELOW YOU ARE AGREEING TO HAVE ANY DISPUTE ARISING OUT OF THE MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES^PROVISION DECIDED BY NEUTRAL ARBITRATION AS PROVIDED BY APPLICABLE LAW AND YOU ARE GIVING UP ANY RIGHTS YOU MIGHT POSSESS TO HAVE THE DISPUTE LITIGATED IN A COURT OR JURY TRIAL. BY INITIALING IN THE SPACE BELOW YOU ARE GIVING UP YOUR JUDICIAL RIGHTS TO DISCOVERY AND APPEAL. IF YOU REFUSE TO SUBMIT TO ARBITRATION AFTER AGREEING TO THIS PROVISION, YOU MAY BE COMPELLED TO ARBITRATE. YOUR AGREEMENT TO THIS ARBITRATION PROVISION IS VOLUNTARY. YOU HAVE READ AND UNDERSTAND THE FOREGOING AND AGREE TO SUBMIT DISPUTES ARISING OUT OF THE MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES"PROVISION TO NEUTRAL ARBITRATION. C.o-e*imir 4: 1/WE AGREE TO ARBITRATION AND WAIVE THE RIGHT TO A JURY TRIAL: 51- ❑ 6.NOTICE TO CUSTOMERS A. LIST OF DOCUMENTS TO BE INCORPORATED INTO THE CONTRACT: (i)this Agreement,(ii)the Additional Terms and Conditions,(iii)the Customer Packet,and(iv)the Work Order. These documents are expressly incorporated into this Agreement and apply to the relationship between You and Us. B. IT IS NOT LEGAL FOR US TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REMOVE GOODS INSTALLED UNDER THIS AGREEMENT. C. DO NOT SIGN THIS AGREEMENT BEFORE YOU HAVE READ ALL OF ITS PAGES. You acknowledge that You have read and received a legible copy of this A cement that We have signed the Agreement,and that You have read and received a legible copy of every document that We have signed during the negotiation. D. DO NOT SIGN THIS AGREEMENT IF THIS AGREEMENT CONTAINS ANY BLANK SPACES. You are entitled to a I completely filled In copy of this Agreemeut signed by both You and Us,before say work may be started. E. YOU MAY ( 31m)BUSINESS DAY AFTER THE TRANSACEL THIS CTION DATE,OR(11)N AT ANY TIME THE START OF IN TOALLATION OF THEYSDNIGHT OF TEM. SEE THE NOTICE OF CANCELLATION BELOW FOR AN EXPLANATION OF THIS RIGHT. r� ` VIY7NT SOLAR DEVE PEB/ LC CUSTOMER(S): 11 By 4 1 Printed Name: 14 07- jk- Printed Name: j AT-AIFS il;- C J Title: akr By: Printed Name: Transaction Date: 3 I g 2d(4 FOR INFORMATION ABOUT CONTRACTOR REGISTRATION REpUIREMENTS, CONTACT THE MASSACHUSETTS OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATION:TEN PARK PLAZA,SUITE 5170,BOSTON,MA 02116, , (617)973-8700 OR 888-283.3757. ------------------------------------------------------------------------------------------------------------ NOTICE OF CANCELLATION Transaction Date: AR No.: YOU MAY CANCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE((3)BUSINESS DAYS OF THE ABOVE DATE,OR(IF LATER) CNTIL_7TIE START OF I[�CTA_LI ATION OF THE CYSTF`M LE YOU CANCEL,ANY PROPERTY TRADED IN,ANY PA4MEP' 3 MADEBPYDUIINDERTHELUNTRAu s UKKK�AZ�AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN TEN ((10) BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE, OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY(20)DAYS OF THE DATE OF YOUR NOTTCE OF CANCELLATION,YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALI,OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM,TO VIVINT SOL DEVELOPER LLC,AT 4931 N 300 W,PROVO,UT 84604 PRIOR TO THE LATER OF: (D MIDNIGHT OF THE THIRD(3I BUSINESS DAY AFTER TILE TRANSACTION DATE,OR(In THE START OF INSTALLATION OF THE SYSTEM. I HE CANCEL THIS TRANSACTION: Date: Customer's Signature: c;,oneni a.:aia e. s.ia u�,n,m.uc+n a�w i.asr+w. mo-•,.moi i,vrn.,_., ___ _ ___ a ww.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Ianformation Please Print Legibly er, LLC Name (Business/Organization/Individua(): Vivint Solar Developer, Address:4931 North 300 West City/State/Zip-Provo, UT 84604 Phone #:801-704-9389 Are you an employer? Check the appropriate box: Type of project(required): 1. ® I am a employer with 10 4_ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling These sub-contractors have ship and have no employees 8. � Demolition � working for me in any capacity. employees and have workers' tom [No workers' comp. insurance P- insurance.t 9. Building addition required.] 5. Q We are a corporation and its 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] •Any applicant that checks box k l 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. '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 acre an employer that is providing workers'compensatiox insu,ance for my employees. Below is the policy and job site information. Insurance Company Name:New Hampshire Insurance Comany Policy# or Self-ins. Lic.`#:029342228 Expiration Date: 11-01-14 Job Site Address: City/State/Zip:Sou Po 1'}') p pt Attach a copy of ulna workers' counpeasatoo®policy declarati®® 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 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. d do hereby ce r under pai and penalties of perjury that the information provided above is true and correct. Si-onature: ;% /�� i/\'�� Date Phone#: 801-704-9389 Official use only. Do not write in this area, to be completed by city or town =Plumbing City or Town: Permit/ eeuse # Issuing Authority(circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Elect6. Other Contact Person: Phone# Office of Consumer Affairs sand Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Dome Improvement Contractor Registration Registration: 170848 Type: Supplement Card VIVINT SOLAR DEVELOPER LLC. Expiration: 1/b/2016 JAMES SHERMAN 4931 NORTH 300 WEST PROVO, LIT 84604 Update Address and return card.Mark reason for change. SCA1 is 20M-05n1 ❑ Address Renewal ❑ Employment Lost Card (Lomcnwruoeall/c o�P/�a5tac�ue ice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration: 170848 Type: 10 Park Plaza-Suite 5170 WffExpiration: 1/512016 Supplement Card Boston,MA 02116 VIVINT SOLAR DEVELOPER LLC_ JAMES SHERMAN 4931 NORTH 300 WEST J PROVO, UT 84604 Undersecretary Not valid without signature — s Massachusetts -Department of Public Safety Board of Building Regulations and Standards Omstruction Supervisor License:CS-045254 i 3A31F.S R SF&ERTV 61vt Q b2 81 MAIN ST t SAUGUS MA 01906 s Expiration Commissioner 08/28/2014 4 2781 Fries Mill Road,Williamstown,NJ 08094 Tel: 856.770.4473; rdeipolla@verizon.net Vivint Solar April 17, 2014 24 Normac Road Woburn MA, 01801 Attn: Mr. Paul Greene, Operations Manager Re: Structural Assessment Report for Roof Mounted Photovoltaic (Solar) Panel Installations—Cajigal Residence, 5 Cottage Street, Salem, MA AR#3624100 Dear Paul: We are providing you with this structural assessment report of Vivint Solar's photovoltaic (solar) roof installations to be completed at the above referenced dwelling. The assessment criteria are based upon Vivint's recent dwelling site visit including roof framing photographs and field notes. We have also reviewed Vivint's PV Solar Permit Submittal, calculations, installation layouts and notes,PV 1.0 "Site Plan",PV 2.0 "Roof Plan", and PV 3.0, "Mounting Details". All were supplied for information on the proposed solar panels installation on the dwelling's roof framing members for our assessment summary. The dwelling is timber framed of older construction age with an"A" framed main roof, 5'-6"'+/- high (estim.), assumed to be built from nominal 2" x 6" or 2" x 8" dimensional lumber joists at 16" to 19", typical of similar dwellings. No other attached roofs are receiving PV panels. The maximum roof joist span length is 14' — 6" +/- excluding reductions for mid-span supports. Two layers of roof shingles are assumed. Materials are assumed as minimum Hem-Fir #2 grade, conservatively (low allowable stresses), with standard construction components (better grade lumber may have been used). No collar ties could be confirmed to be installed below the ridge beam in the main "A" roofs'/attic's full length, in panel installations areas, due to the finished upper floor/attic. However, the flat ceilings are typically framed with newer or original collars ties attached to roof joists at each end for reinforcing. The partial height upper floor rooms' interior and sidewalls will also act as mid-span joist supports. The main attic and roof framing were not accessible by crawl spaces or access panels at the site inspection and evaluation, therefore a partial assessment and confirmation of framing spacing, sizes and condition was able to be performed for this roof. No architectural drawings were available at the time of this report preparation. Refer to plans and documents prepared by Vivint for dwelling dimensions, locations and sizes of solar panel units. The roof framing members were reviewed and checked for their capacity of new loadings. A. CAPACITY OF EXISTING ROOF TO SUPPORT PROPOSED SOLAR PANELS: 1. Our assessment included using the proposed solar panels dead load that were given to us in the ZEP calculation sheets and the live and dead loads described below. Our review of the roof information shows that there are no visible undulations or unevenness, indicating that the roof framing members are not visibly overstressed or weakened by past heavy snow loads. F Mr. Paul Greene April 17, 2014 Page 2 2. Given the dwelling's roof construction and condition, the existing roof joists' load carrying capacity will be able to carry the added dead and redistributed live loads from the new solar panels if installed correctly. The dwelling's roof members will also redistribute the snow live loads, and additional solar panels dead load to the adjacent framing members. These additional loads should not produce stresses beyond the allowable stress range for roof framing members assumed as Hem-Fir 42 materials. Considering the lower roof slopes, array sizes; lack of complete access to confirm roof joists' size, spacing, condition; and collar ties,the panel supports shall be set/ attached to every second foist for lateral installations over joists. No panel support spacing shall be rg eater than two(2)roof ioist spaces, or 38"+/-o/c, whichever is less to be shown in the PV 2.0 Roof Layout plan(s). Note -Layout Array Drawing#1 submitted for review, shows this maximum panel support spacing, and does not need spacing revisions. The panel supports shall be installed in staggered patterns to ensure proper load distribution, and with no more than three supports placed on any single roof joist, except at ends of layouts. This layout can be used for permit submittals and installations, with the staggering of supports being done in the field. All panels shall be installed as shown on the layout plans, with 38"+/- o/c maximum support spacing, or two joists spaces (w.i.l.)and staggered, to be shown in the final PV 2.0 Roof Layout plan(s), as stated above. Framing member sizes, spacing and condition must be properly verified by Vivint's installers, prior to any installations. Send any differing information to this engineer for review and approval, prior to continuing with any installations. 3. This assessment meets current Massachusetts Building Code, 8ffi Edition—Residential —Amendments to International Residential Code, (IRC), 2009 Edition, for one and two family dwellings. B. SOLAR PANEL ATTACHMENT TO ROOF STRUCTURE: 1. The solar panels shall be mounted in accordance with the latest"ZEP Company's Code Compliant Installation Manual" found on the ZEP website and not included herein. No additional reinforcing requirements are required for these installations. However, if during solar panel installations, the roof framing members feel unstable, or show interior or exterior evidence of minor or excessive movement,then this engineer should be notified as soon as possible prior to proceeding with installations. 2. Vivint should notify the homeowners that long term build-up of accumulated snow in the event of extreme snowfall conditions, may produce some roof deflections. These deflections will be temporary in nature and will not affect the roof s structural integrity. The solar panels do not need to be cleared of such accumulated snow. C. WIND UPLIFT LOAD: 1. Refer to attached ZEP calculation sheet for ASCEISEI 7-10 Minimum Design Loads Mr. Paul Greene April 17, 2014 Page 3 For Buildings and Other Structures, for wind speed at this location of 100 miles per hour* for Exposure Category `B", and 27 degree roof slopes on the dwelling's roof areas. Ground snow load is 40 p.s.f.* for Exposure`B",Zone 1 (per ASCEISEI 7- 10) of the roof s interior portion, and effective wind speed of 100 mph*,uplift is shown. 2. Total area subject to wind uplift is calculated for the Interior,Edge and Corner Zones. A maximum and user selected support(foot) spacing is shown for each location zone. D. PANEL ANCHORAGES: 1. Maximum allowable pullout per lag screw=235 #/inch from National Design Standards(NDS)timber construction specifications for Hem-Fir-North lumber (assumed). Using 4 lag screws, the pullout value is less than 235 Winch of screw thread and OK. Considering the variable factors for the existing roof framing members, and installation tolerances, use a 2 Yz"threaded depth with a minimum 5/16" lag screw per attachment points in roof joists ("rafters") components for panel anchor mounts. This should give a sufficient factor of safety. E. LIVE, DEAD AND SNOW LOADS: 1. Live load=40 p.s.f. ground snow load; 10 p.s.f. attic storage(trusses only) Dead Load= 10 p.s.f.- roofing/framing; 5 p.s.f. - panels, mounting hardware Total Live Load=40 p.s.f.; Total Dead Load= 15 p.s.f. 2. These values are within acceptable limits of recognized industry standards for similar structures. The roof members will be able to sustain the solar panel attachments without damage, if installed in a workmanship like manner according to the above criteria. We have based our structural capacity determination on applicable building codes, professional engineering inspection and design experience, opinions and judgments. This report covers this dwelling's assessment for only the areas for solar panel installations that were made according to generally recognized structural analysis standards and procedures. The normal structural engineering industry standard of care utilized for this type of work was used during this report preparation. The assessments and recommendations in this report were reviewed to ensure a proper level of quality and uniformity. This report adheres to accepted State and National practices for current building code standards and can be used for construction purposes. If you have any questions or require further information, please�.t�hesitate to contact m . Respectfdlly subm Pe , 7 RussellDCip lI .lie 'stered r g; Structural Engineer, Owner Mass. License No. EN-47478- RUSSELL CIPOLLA $ STRUCTURAL cn * or as specified locally per the State Board of Bldg. Regs. and Stds., whichever g No.47478 Q RDC/rdc O FGISTER�G��`� SS/ONALEN Vivint Solar - PV Solar Rooftop System Permit Submittal 1. Project Information Project Name: James Cajigal Project Address: 5 Cottage St,Salem MA A.System Description: The array consists of a 7.75 kW DC roof-mounted Photovoltaic power system operating in parallel with the utility grid.There are (31) 250-watt modules and(31)215-watt micro-inverters,mounted on the back of each PV module.The array includes(2) PV circuit(s).The `array is mounted to the roof using the engineered racking solution from Zep Solar. B.Site Design Temperature: (From Boston Logan INTT ARPT weather station) Average low temperature: -21.1 °C (-5.98°F) Average high temperature: 38.4°C (101.12°F) C. Minimum Design Loads: Ground Snow Load: 40 psf (State Board BR&S) Design Wind Speed: 100 mph (State Board BR&S) 2. Structural Review of PV Array Mounting System: A.System Description: 1.Roof type: Camp.Shingle 2.Method and type of weatherproofing roof penetrations: Flashing B.Mounting System Information: 1.Mounting system is an engineered product designed to mount PV modules 2. For manufactured mounting systems,following information applies: a.Mounting System Manufacturer: Zep Solar b.Product Name: ZS Comp c.Total Weight of PV Modules and mounting hardware: 1333 Ibs d.Total number of attachment points: 78 e.Weight per attachment point: 17.08 Ibs/square foot f.Maximum spacing between attachment points: * See attached engineering talcs g.Total surface area of PV array: 545.91 square feet h.Array pounds per square foot: 2.44 Ibs/square foot i.Distributed weight of PV array on roof sections: -Roof section 1: (31)modules,(78)attachments 17.08 pounds per square foot I vivint. sour 3. Electrical Components: A. Module (UL 1703 Listed) Qty Trina TSM 250-PA05.18 31 modules r Module Pmax-nominal maximum power at STC - 250 watts Vmp-rated voltage at maximum power - 30.3 volts Voc-rated open-circuit voltage - 37.6 volts Imp-rated current at maximum power - 8.27 amps Ise-rate short circuit current - 8.85 amps B. Inverter (UL 1741 listed) Qty Enphase M215-60-21,L-S22 31 inverters Inverter Specs 1. Input Data (DC in) Recommended input power(DC) - 260 watts Max.input DC Voltage - 45 volts Peak power tracking voltage - 22V-36V Min./Max.start voltage - 22V/45V Max.DC short circuit current - 15 amps Max.input current - 10.5 amps 2.Output Data (AC Out) Max.output power - 215 watts Nominal output current - 0.9 amps Nominal voltage - 240 volts Max.units per PV circuit - 17 micro-inverters Max.OCPD rating - 20 amp circuit breaker C.System Configuration Number of PV circuits 2 PV circuit I - 16 modules/inverters (20) amp breaker PV circuit 2 - 15 modules/invetters (20) amp breaker vivint. s G! a r D.Electrical Calculations 1.PV Circuit current PV circuit nominal current 14.4 amps Continuous current adjustment factor 125% 2011 NEC Article 705.60(B) PV circuit continuous current rating 18 amps 2.Overcurrent protection device rating PV circuit continuous current rating 18 amps Next standard size fuse/breaker to protect conductors 20 amp breaker Use 20 ama AC rated fuse or breakeIr 3.Conductor conditions of use adjustment(conductor ampacity derate) a.Temperature adder Average high temperature 38.4°C (101.12°F) Conduit is installed 1"above the roof surface Add 22°C to ambient 2011 NEC Table 310.15(B)(3)(e) i Adjusted maximum ambient temperature 60.4°C (140.72°F) b.PV Circuit current adjustment for new ambient temperature Derate factor for 60.4°C (140.72°F) 71% 2011 NEC Table 310.15(B)(2)(a) Adjusted PV circuit continuous current 25.3 amps c. PV Circuit current adjustment for conduit fill Number of current-carrying conductors 6 conductors Conduit fill derate factor 80% 2011 NEC Table 310.15(13)(3)(a) Final Adjusted PV circuit continuous current 31.6 amps Total derated ampacity for PV circuit 31.6 amps Conductors (tag2 on 1-line)must be rated for a minimum of 31.6 amps THWN-2(90°C)#1 OAWG conductor is rated for 40 amps (Use#10AWG or larger) 2011 NEC Table 310.15(13)(16) 4.Voltage drop(keep below 3%total) 2 pacts 1.Voltage drop across longest PV circuit micro-inverters(from modules to j-box) 2.Voltage drop across AC conductors(from j-box to point of intereonncction) 1.Mirco-inverter voltage drop: 0.48% The largest number of micro-inverters in a row in the entire array is 10 inCircuit 1. According to manufacturer's specifications this equals a voltage drop of 0.48%. 2.AC conductor voltage drop: =I x R x D C 240 x 100 to convert to percent) _ (Nominal current of largest circuit)x (Resistance of#IOAWG copper)x (rota]wire run) Total system voltage drop: # vivin#. s of S r 4/15/2014 3624100 roof 1-Zepulator ®. ZepSolar Engineering Calculations 3624100 roof 1 Name: Street Address:5 Cottage St. Email: Suite/PO#: Phone: City,State,Zip:Salem,Massachusetts Country:United States System Details Module Manufacturer Trina Solar Mounting System Zap Solar PV Module TSM-250-PA05.18 Manufacturer Quantity of PV Modules 31 Mounting System Type ZS Comp Array Size (WO 7.750 Roof type Composition Shingle Attachment Type Comp Mount,Type C Module-level Enphase Energy-M215-Z electronics Lhttp:IA,w-zepulator.conVproj is/55675/summarl engineeringyrint 1/4 4/15/2014 3624100 roof 1-Zepulator Engineering Calculations Design Variables " Description(Symbol) Value Unit Module Orientation Landscape Module Weight 44.8 Ibs Average Roof Height(h) 35.0 ft Least Horizontal Dimension(Ihd) 30.0 ft Edge and Corner Dimension"a" 3.0 It Roof Slope(0) 27.0 deg Rafter/Truss spacing 16.0 in Rafter/Truss dimension Min.nominal framing member depth of 4" Basic Wind Speed(V) 110 mph Exposure Category B Ground Snow Load(Pg) 40 psf Risk Category II Topographic Factor(Kit) 1.0 Thermal Factor for Snow Load(Ct) 1.2 Exposure Factor for Snow Load (Ce) 0.9 Effective Wind Area 10 ft2 Snow Load Calculations (Using calculation procedure of ASCE 7-10 Chapter 7) Description (Symbol) Interior Edge Corner Unit Flat Roof Snow Load(Pt) 30.2 30.2 30.2 psf Slope Factor(C.) - 0.8 0.8 0.8 Roof Snow Load 23.6 23.6 23.6 psf Wind Pressure Calculations (Using simplified procedure of ASCE 7-10 Chapter 27) L tion(Symbol) Interior Edge Corner Unit gn Wind Pressure uplift(Pnet3oup) -19.9 -34.7 -51.3 psf gn Wind Pressure downforce(Pnet3odawn) 12.5 12.5 12.5 psf ulatw.conVprojects/55675/summary wgineeringyrint 214 4/152014 3624100 roof 1-Zepulator Adjustment Factor for Height and Exposure Category(A) 1.1 1.1 1.1 Design wind Pressure uplift(W.P) -20.9 -36.4 -53.9 psf Design Wind Pressure downforce(Wdown) 16.0 16.0 16.0 psf ASD Load Combinations (Using calculation procedure of ASCE 7-10 Section 2.4) Description(Symbol) Interior Edge Corner Unit Dead Load (D) - 2.5 2.5 2.5 psf Snow Load (S) 21.1 21.1 21.1 psf .Load Combination 1 (D+0.75*(0.6*Wdown)+0.75*S) 23.5 23.5 23.5 psf Load Combination 2(D+0,6*Wdown) - 11.9 11.9 11.9 psf Load Combination 3(D+S) 21.0 21.0 21.0 psf Uplift Design Load(0.6*D+0.6*W„p) -11.2 -20.5 -31.0 psf Maximum Absolute Design Load(Pays) 23.5 23.5 23.5 psf Spacing Calculations Description (Symbol) Interior Edge Corner Unit Max allowable spacing between attachments 72.0 72.0 72.0 in User selected spacing between attachments given a rafter/truss spacing of 16.0 in 32.0 64.0 64.0 in Max cantilever from attachments to perimeter of PV array 24.0 24.0 24.0 in Distributed and Point Load Calculations (In conformance with Solar ABC's Expedited Permit Process for PV System (EPP)) Description (Symbol) TT _ A Value Unit Weight of Modules 1388.8 Ibs Weight of Mounting System 172.44 Ibs Total System Weight 1561.24 Ibs Total Array Area 546.01 ft2 Distributed Weight 2.86 psf Total Number of Attachments 78 Weight per Attachment Point 20.02 psf http:/Aw ..zepulatu.coni/projects/556751sununarylenginmrirgjxint 3/4 4/15/2014 3624100 roof 1-Zepulator http:/Aw ..zepulator.canVprojmts/55675/sun rr engineerirg_print 4/4 m o p1 PV SYSTEM SIZE: U c 7.75 kW DC NNom N -Z 0EI � z mN m0 0 O U yQ O L V J JUNCTION BOX ATTACHED T — — — — ARRAY USING ZEP ZS-GAB TO KEEP JUNCTION BOX OFF ROOF O I I I I a cn I W v) I I e d Jm � o ¢ cu N p I I F W I rn 4-0 > j 4-0 > L O K N J J z m J Z C.) z < w ,^ 3 i N o L / PV INTERCONNECTION POINT, 31)Tnna Solar TSM-250 PA05.16 MODULES WITH A SHEET LOCKABLE DISCONNECT SWITCH, Enohase M215-60-2LL-S2x-ZC MICRO-INVERTER NAME: ANSI METER LOCATION, MOUNTED ON THE BACK OF EACH MODULE &UTILITY METER LOCATION _ LLJ Q 70"OF 1"PVC CONDUIT J FROM JUNCTION BOX TO ELEC PANEL (n 0- SHEET NUMBER' PV SYSTEM SITE PLAN r SCALE: 1/16"= T-a" a 0 0.Zl �g0 N3U �A zt O >y r�z �O m m m I � v c m z c1 mG m 0- Op y On rC my Nk O .G uA On OC C-y mu NN � V D C r cn m � w Cn m 0 II � o X _ 0 m 0 9/ T r D Z zw zm INSTALLER:VIVINTSOLAR J{ 1r Cajigal Residence m mm. ROOF m INSTALLER NUMBER:70M8 04.4129 ® 5vo nl S® J a ry 5 Cottage St. PV 2.� A MA LICENSE MANIC 170&8 v u 10' A Salem,MA 01970 PLAN DRAWN BY:Jerry S1 AR 3624100 asl Modified:4I15/2014 UTILITY ACCOUNT NUMBER:3821 7-00 03] U C N MOUNTING m PV3.0 DETAIL A&CMA) LEVELINGSTEEL M.B.;TORQUE=1fix1 PAEs r�U E2vCOMP MOUNT � .0WASHER PACKAGE"WATERPROOFING SEALAWITH COMP MOUNT v' Q PV MODULE,TYR MOUNT AS NEEDED :^ TO RAFTERS OF COMP. (� 71 SHINGLE ROOF,PARALLEL U WITH PLANE OF ROOF a PV ARRAY TYP. ELEVATION tlG'Br°„4'MI"'MUM s' Z STAINLESS STEEL LAG SCREW TORQUE=1J,Q H EP. NOT TO SCALE _ Dry V ! LEVELING FOOT ON COMP MOUNT PERMITTED LEVELING FOOT SPACING NOT TO SCALE �® p o LEVELING FOOTIZSLFB) j ICI FRAMINGBELOWSHOWN r r DASHES FOR CLARITY C ZEP COMPATIBLE P WMODULE HYBRI"INTERLOCK < ' o I I I I I I I I Be F W 2 N CANTILEVER=DJ L=PERMITTED SPACING , E N 0 L GEE CODE COMPLIANCE LETTER FOR gLLOWABLE BPALING —PHOTOVOLTAIC MODULE Z LL Z VWl I I I I JJW3 I I M� "JQ HYBRID INTERLOCK SHEEt LEVELING FOOT zsLFG INTERLOCK IZSILBI NAME: 1 ) ROOFFBAMING LEVELING FWT DSLFB) Z O LE LI I I ❑ 0�.OR(ZS°UB) FOO SPACINGELING �PV SYSTEM MOUNT DETAILSYSTEM MOUNT DETAIL SHEET NUMBER' SCALE:318'=1'-W '� 0 MODULES IN PORTRAIT/LANDSCAPE cl; NOT TO SCALE Inverter Ratings(Guide Section 4) inverter Maine/Model Formed M21sB6211 SiO Conduit and Conductor Schedule MODULE DETAIL Max DC vet Rasing Tag Dearreaon yarn Gauge #of cardamon CreditType Cmant sae Max Favor a 40°L 1 Enpnase engage qUu-THWN-2 12 AWG 4 NIA-Free Air NIN-Free ArtNominal AC Voltage 1 Ben Copper Ground tEGGGEC) 6AWG 1 N/A-Fne Ar N. rustNrTIine Solar TSM-250 PA05.18 Max AC current 2 THWN-2 1nAWG 9 PVC 0.1'SOLAR MODULE Max OCPO Rating 2 THrni-Ground 5AWG 1PVL 0'-1° C:Max Number W Panescirnit 3 THWNd BAWG 3 PVC 0'-1' yJso 3 THWN-0-Gmuntl BAWG 1 PVC I 0'A' out NOTES FOR INVERTER CIRCUITS(Guide Section 0 and 9), Arin 61 om 1.)IF UTILITY REQUIRES A VISIBLE-BREAK SWITCH,DOES THIS y2 Pro' MEET THE REQUIREMENTS? PV Module Ratings @ STC(Guide Section 5) /�/ Model MakelMadel Tana Solar TSM-250 PA0518 ly o I Enphasa M215-80.2LL-52z-ZC YES NO %NA Max Pead int Current(Imp) 0.27 Amps _NaEiz MICRO-INVERTER AT 2.)IF GENERATION METER REQUIRED.DOES THIS METER Max Power-Point Voltage(Year) 30.3 Volts w0 EACH MODULE,ATTACHED SOCKET MEET THE REQUIREMENTS? Open-Om:ui1 Voltage(Vast 3].6 volts U WITH ZEP HARDWARE YES NO XNA Sheart rcuit Current(Iss) B.BS Amps 0) ¢ 3.)SIZE PHOTOVOLTAIC POWER SOURCE OCT CONDUCTORS Max Banes Fuse(OCPD) 15 Amps i BASED ON MAX CURRENT ON NEC 690.53 SIGN OR OCPD Nominal Maximum Power at STC(Pmax) 1 250 Walls U RATING AT DISCONNECT. Maximum System Voltage 1000(IECYBM(GI) j 4.)SIZE INVERTER OUTPUT(AG)CONDUCTORS ACCORDING Vac Temperature Coefficient MICROINVERTER CONNECTION TO INVERTER OCPD AMPERE RATING tree Guide Section 9). TO ENGAGE TRUNK CABLE 5J TOTAL OF 2 INVERTER OCPD(M.ONE FOR EACH NOTES FOR ARRAY CIRCUIT WIRING(Guide Section 6 and a and Appendix 01, PV CIRCUIT.OOE6 TOTAL SUPPLY BREAKERS COMPLY WITH 120%BUSBAR EXCEPTION IN T)Lowest expected ambient temperature based on ASHRAE minimum mean extreme NEC 6SoIW(B)(2)(a)? RYES NO dry bulb temperature for ASHRAE location most similar to installation location: -19°C #6 BARE CU GROUND r Signs(See Guide Section 7) 2.)Highest continuous ambient temperature based on ASHRAE highest month 2%dry bulb �� (GROUNDING ARRAY) temperature for ASHRAE location most similar to installation location: 39°C Sign for inverter OCPD and AC Disconnect: 3.)2005 ASHRAE fundamentals 2%design temperatures do not exceed 47°C in the United Slates(Palm Springs,CA Is 44.1°C).For less than 9 current-cavying conductors Solar PV System AC Point of Connection in meopmounted sunlit conduit at east os°above rout and using the outdoor design AO Output Current 27.900000 Amps temperature of 47°C or less(all of United States), JJ�am• Nomin al AC Voltage 240 Vdta aJ 12 AWG,90°C remainders are generally acceptable for modules with Ise of 7,68 Amps or less when protected by a 12-Amp or smaller fuse. n THIS PANEL FED BY MULTIPLE SOURCES b.)10 AWE,90-C conductors are generally acceptable for modules with Ise of 9.6 Amps (UTILITY AND—SOLAR) or less when protecteredb a 1 5-Arria or smaller fuse. •Q < 16 So •� of PV CIRCUIT 1: 16 MODULES/PARALLEL se Sr 6 • • • O O Ca F POINT OF DELIVERY e n AND INTERCONNECTION S: I m O se I re Ir rwiad E ¢ Z' -———————— ----T VISIBLE/LOCKABLE M > Z faj � m COMBINER SREC/ANSI 'KNIFE'A]C of ¢ w � at z m PV CIRCUIT 2: 15 MODULES/PARALLEL i PANEL METER DISCONNECT U 3 a ¢ — E 1.0 zeo,K z z ¢ t5 • • • O O I 20A SHEET NAME: _ Z w __________ _ __ _______ _ _ ______ __ __ J f7 VisionMelering Siemens 1 240V1200A Q 2 ,3 V25-25 3 #LNF222R '1 LOAD-CENTER � JUNCTION BOX 60AI240V 3 SHEET E 1.0 yyINC IRREVERSIBLE E 1.0 E 1.0 E 1.0 UNFUSED E 1.0 NUMBER: GROUND SPLICE NEMA3 O NOTE:NEUTRAL CONDUCTOR(S)OMITTED FOR CLARITY Ti ALL IMVERTER OUTPUT CIRCUITS WILL HAVE A NEUTRAL CONDUCTOR UJ Fhe Commonwealth of Massachusetts CITY ►^ Board of Building Regulations and Standards OF SALEM YJ Massachusetts State Building Code. 730 C•MR. 7ih edition Revised ionuurl- Building Permit Application To Construct, Repair, Renovate Or Demolish a l• 'I111'Y One- or Tu•u-FurnilP Duelling This Sr on For t)icial Usr On Building Permit Numb r: D e Applied: r ll Signature: / Building commissioner/InsrKtor of Juildin Date SECT[ ' TE NFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 5 GoTr c—Sm �r M Number Parcel Number I.I a Is this an accepted street Map�� no. P 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy Il) Frontage lt)) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.1 Flood Zone Information: IS Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes13 SECTION 2: PROPERTY OWNERSHIP' ------------------- 2.1 Ownert of Record: SS +tS GS r o r_ Name(Print) Address for Service: Signature 'relephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': / `AZ v `� l�_ TPf3 r✓T a� /ram 7 Gar rJ 1�. A t° 00 SECTION d: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Offic[al Use Only Item Labor and Materials I. Building S 1. Building Permit Fee: S Indicate now fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Total All Fees: S Su rrssion Chick No. Check Amount: Cash Amount:_ 6.Total Project Cost: S JrPD �O 0 Paid in Full ./�...�) 0 Outstanding Balancee/��Duu'e: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) zMlz2 lZ3 2�?2 �jYlc/S(.l7 r�/2!�-ylC' License Numher Expiration Date Nance of CSI.•I)older ` /}�� nn �� 7f Gl ;11rSw9 S, I//1e&1 9 I.isI CSL 1')pe(see below) Add t So Ft PC I Description 11 1 1'nrestricted(tip to 35,000 Cu. Ft.) Sign or R Restricted I&2 FamilyUwcitin `l� 1132 M//Z Mason Only RC Residential RootingCowrin Telephone WS Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation 1) 1 Residential Demolition 5.2 R istered Home Improvement Contractor(HIC) GovS��'�-� /lPi SYi/ IIC Company am r I IIC Rcgisltnl N n• Registration Number - j5Y��t ,b1� 1�lo AJJre s fop 9328J1Z Expiration Date Signatur Tcicphone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... ❑ No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. " � � r')-P /J , as Owner of the subject property hereby authorize _ S /'�SfYLl�Gg'TDr✓ �C,G _ to act on my behalf, in all matters relative to work a orized by this building permit application. Si azure of On er Date SECTION 7Qb:O�WNEW OR AUTHORIZED AGENT DECLARATION 1, 71G�Ga �r i�/`�f a 5 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf.�� Print No e 3�i S�ll Signature of O ner or Akhorizq Agent Date Signed under the pains an alties ofperjury) 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 Ilome Improvement Contractor(HIC)Program),will Lrol have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Ilabitable room count Number of fireplaces - Number of bedrooms Number ol'bathrooms Number of halt%baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. 'Total Project Square Footage'inay he iobstituted fir"Total Project Cost" CITY OF SU. E.NI, LL1SS.-kCHUSET'CS • BUUMLNG DEPARTMENT 120 W.+SHLNGTON STREET, Y"FLOOR T-EL (978) 74S-9595 FAX(978) 740.9846 IUD(BER t=Y Dwscou MAYORITiO.WS ST.PIEARB DIRECTOR OF PUBLIC PROPERTY/81:UMLNG CO\OIISSIONER Construction Debris Disposal Affidavit (requited for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5 .Debris,_and_the provisions-of-MGL c 40 S 54; ------ — — - - -- Building Permit Al is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris wi 11 be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) signditureofpc a ant 3 �,5 Jrl date kbnvird.a CITY OF SALEM tt. 'Put, PUBLIC PROPRERTY a' DEPARTMENT .�tn::s:tr axtxan I �I situ 12�^Wn.ttl.Nt ION 57xH¢T 0 SALEM.MAMA(,III it i nJ197� 15:i.:978-713-9593 0 FAX, 919.14V.)S46 Workers' Compensation Insurunce Atfidavit: Builders/Contractors/Electricians/Plumbers kri ilicant informalion Please Print LeeiM V:IITC llhtuikss/OrSantratintvinJividuull: �I�/`�"1 G�� /d'�-J LLG • City,Sratci%ip G7 i�r-5✓� 1'huneil: :\re you an employer:'Check the appropriate box: 'Type of project(required): 1.❑ 1 wn a employer with 4. ❑ I ;on a-general contractor and 1 (i. ❑New construction et iployces(full andlur part-tinie).• have hired the.ub-contractors 2. 1 ant a sole proprietor or partner- listed on the anachcd sheet. 7• ❑ Remodeling ship and have no employees These subcontractors have S. Demolition working for Inc in any capacity, workers' camp, insurance. 9. Building addition I No workers'cutup. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 7.❑ 1 am a homeowner doing all work right of exemption per NICL 11.0 Plumbing repairs or additions myscif. (No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.) t employees.(No workers' 13.❑ Other comp. insurancerequircd.J •any:grphcanl ittw chccka boa of must a6u rill uut Ihc. ,;Ilt n bcluw aiewina iwir wurkas atmpunudiws p iicy int:antatiun 'I Iamcuwn rs who stdirnit this affidavit indicating shay ore doing all warts and ihen biro uuisido cumrmtom must.uhmit anew 401davil indiutina aa•h. •(.mimctun thin chvek this bust mutt ailwhad an additiurwl.haet.hawing the nmtw of iM suhsontraob and their wurkon'comp.pdicy information. lain ups eoq)layer that-lr providing ivarkers'coinpensatioir insurance fur uty eatpluyeer. Behnv is the pu/fry uad fob.vile, iujornrufian. Insurance Company Name: Policy 4 or Scif-ins. Lie.d: . __ Expiration Date: Job SiteAddress: 5— fo�57—, C•ityistatesLip:'S/fit, -a* /�/� Attach It copy of the workers' compensation policy deClarallart page(showing the policy number and expiration date). !i Failure to sccurto coverage as required uodcr Section 25A ul':vIGL c. 152 can lead to the imposition of criminal penalties of a tine op to St 500.00 and/or one-year imprisonment,as Wcll as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 if Jay against the violator. Ile advised thus a copy of Ibis slumnent may be forwarded to the Office of Invcshgaunns dl'the UTA for insur:uxc dovera-gc wrificatam. /da hereby rerti y111under the pas . t ena/tiev uf•perfnry shut the infbrtnallon provided above is true anal correct. Ph 5�8i 2 001cial use duly. DO nat n•rife in slits area.tube rumplefed by city or/mvn official i i City or fown: _ _ Perinit/1.lceme x Issuing.\uihorily(circle title): i t. III,arJ of Ilealtb 2. Iluildin:j Department .1. f.ilw 1'umt Clerk 4. Electrical Inspector i• Plumbing Inspector I 6. Other l'uulael 1'cnwi: _ .. I'hunc 7: Infor mation and Instructions - \Llss.ichusetts GCOeral Laws chapter 152 requires al employers to provide workers' compensation for their employees. Pursuant to this statute, an empfored is defined as"...every person in the service of another under any contract of hire, e,,press or implied, oral or written." An employer is defined as"an individual,Partnership,association,corporation or other legal entity,or any two or more ,,r the toreguing engaged in a Joint enterprise" Lind including the legal representatives of a deceased employer,or the receiver or trustee of .m individual,pwmership,associatioa or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dweiling house of another who employs persons to do maintenance,cuntruction or repair work on such dwelling house or un the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." \IGL chapter 152, p25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally. MGL,chapter 152, 4. 25C(71 states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomrunce of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), addresses)and phone nuttrbet(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial \ccidents for confirmation of insurance coverage. Also be sure to sign and date the aflldavIL The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete ;and printed legibly. The Department has provided u space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pl.asc be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennitAiceise applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof-that a valid affidavit is on rile for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture t i.e. a dog license or permit to bum leaves ctc.) said person is NOT required to complete this affidavit. I Inc t)t I ice ut investigations would like to dank you in advance fur your cooperation and should you have any questions, phcose du nut hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 0113ce of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 www.mass.gov/dia The Commonwealth of tMassachusetts ° Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SdMarI 77 � Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Dem fish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Numberr Date Applie Building Official(Print Name) Signatd re - ` - Date SECTION L SITE lNFORINGIT rolq 1.1 Property ddress: L2 Assessors Map& Parcel Numbers �i'~SVJ� < r.I -ISGUiMtW)A 1.1a Is this an accepted 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❑ SECT16N2: PROPERTY'OWNERSHIPL pwnert of Rec r : SOS LI/1/Vl ? �l l} O j pi iAM - ��r�iGtP1 L- NPe(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Cl I Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Nu Units_ Other ❑ Specify: Brief Description of Proposed Work': C) 1A2 G A ,ra e S 6 x �e SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only.., Labor and Materials) I. Building S I. Building Permit Fee S indicate how fee is determined: ❑ Standard. ❑'C City/Town Application Fee 2 Electrical $ 3 . - oral Project Cast. (Item 6)s multiplier. x 3. Plumbing S 2. Other Fees:'S i. Mechanical (IIVAC) S List: 5. Mcchanical (Fira S Stippression) L ,StalAll Fees: cck i Io. Check Amount: Cash ;Amount 6. Futal I'rniect Cost S 0 Paid in Fill 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) License Number Expiration Date Name of CSL Ilolder List CSL Type(sae below) No. and Street Type Description U Unrestricted Buildin s u to Ii,000 cu, ft. R Restricted L&? F;unil Dwallin City/Town, State, ZIP II %,Iasonr RC Rootin Covcrin WS Window and Sidi— SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(FIIC) HIC Registration Number Expiration Date I IIC Company Name or MC Registrant Name No.and Street Email address 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 .......... ❑ 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 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: OWNEW OR AUTHORIZED AGENT DECLARATION By enteri -my name below, I hereby attest under the pains and penalties of perjury that all of the information cont.' edit this application is true and accurate to the best of my knowledge and understanding. JkmtS CAJKaA--( � I kI -d13 Print Owner's or Autburized:4gent's Nome(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 Houle Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty tund tinder M.G.L. c. 142A. Other important information on the FI IC Program can be found at www.mass.,,ov oca Information on the Construction Supervisor License can be found at www.mass,!L)�aL 2. When substantial work is planned,provida the information below: Total floor area(sq. It.) _ _(including garage, finished bascment/attiu, decks or porch) dross living :Irea(sq. ft.) Ifabitable room count Number oftireplaeas -- Number of bedrooms - -----_-- Number of bathrooms Number of halt'baths type of heating System" -_—_ _--- Number of decks/porches ----_--- — — peofeoolimgsyilent----------- _ Enclosed---- ---" -- Open — —_-- 1. I'M,II Pnyec[Syu;lro Footage may be Subiunucd Ira'"'I'ortal I'ruleit ('o;t CITY OF SM-E.M PUBLIC PROPERTY DEPARTMENT a,.�ae.ar o•a� `�� i]0 e/.s•wnv,lnaaT•s�u,ti ws�ow ssrn 01•'e r1tL rai,sss»•V,.X r.ar+o.1w HOMEOWNER LICLNS6 EXE.I "10,V P1eaM Mat Dam 1 Job Location Home Owner Address e. S S w l v1Q>r Hesme owosr Telephone xs— — 1 Present Mailing Address S A The current exemption of"Homeowners"was extended to include ownaroccupied dwellings of two Units or lea and to allow such homeowners to engage an individual for hire who does not possess a licenser provided that the owner acts as auperviaat DEFlNM0N OF HOMEOWNER Person(s) who owns a peed o[land on which W&M resides or intends to resider on which there is, or is intended to bsr a one or two laically dwellinf ansehod or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shag not be considered a homeowner. Such -homeowner"shall submit to the Building Odfcial,on a form acceptable to the Building OfAcial, that he/she be responsible for ail such work performed under the Building Permit The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner'certifies that helshe understands the City of Salem Building Department minimum inspection procedures and requirements and that hdshe .vial comply with said procedure and requirements. HOMEOWNERS SIGNATURE — 4 /� .APPROVAL OF BUILDING 4�iSPECTOR L/ Sce other side for state code CITY OF S U _ ,_ t 1�Lass.1 c HLSETTS Bc;ItDa�G DEP.1RTJtE.VT 110 CV.{SHLNGTON STREET, " ET, 3 FLOOR TEL (978) 745-9595 K1J[3ERLF-Y DRISCOLL F•`.r(978) 749344 AMR THoxu ST.PtERRS DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONWISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tk is issued ued with the condition that the d Is work shall be disposed of in a properly dens resulting front p perly licensed waste disposal faelll l 1 l S l50 as define A. t3' d b � Y t iGL c The debris will be transported by: (name of hauler) The debris will be disposed of in (name ot•facility) (address of Facility) s g azure of pa•mit applicant date �1 2A,(o � 13 L4 g '�O RECEWED INSPECTIONAL SERVICES 1 The Commonwealth of Massachusetts B^ Board of Building Regulations and Standards 2014 APR U 'Ay"1 Massachusetts State Building Code,780 CMR ALEM 1 _ Revised Mar 2011 e 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: AN Building Official(Print Name) Signature I I Date SECTION 1:SITE INFORMATION 1.1 Property Ad,dyrf s�s�:�1 1.2 Assessors Map&Parcel Numbers 1.I a Is[his an accepted street?yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sit ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yazd 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? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' fName Owner'of Rec (IY1 )OA M lacd Salem Mlk Dlgt-)c) _( at)at) /�. - City,State,ZIP Aia No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction I( Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: ,%-X-� p p ho'�DV }0.1G SolG1r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ iGJ�.C�o 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost}(Item 6)x multiplier x P 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: // 1 5. Mechanical (Fire $ Su ression Total All Fees:$ a Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ,"j •06 ❑Paid in Full ❑Outstanding Balance Due: q 90� NIL U/�.tom (_e riA � L>a uL-l;�D 511 - rit CLi To SECTION 5: CONSTRUCTION SERVICES 5.11-Construction Supervisor License(CSL) 1' �t �wleS �VtPF} 1�Q Yl LicenseNumber I Expiration raon late Name of CSL Holder List CSL Type(see below) U No.and Street 1 Type Description A ` u s / A I OI/] b U Unrestricted(Buildings u to 35,000 cu.ft.) �`�l _1 A Restricted 1&2 FamilyDwelling city/Town, IP M Masonry RC Roofin CoverinWS Window and SidinSF Solid Fuel Burning Appliances YJ N/1rxSDINo VIVlt�sp�pr. Insulation Tele hone Email address C0 D Demolition 5.2 Registered Home Improvement Contractor(HIC) t-70�6�-}$ �_ V 1 V I lnt So lal' D V21 op2Y L LC HIC Registration Number E prra on ate HIC Com any Name or HIC R gistrant Name �— W.d PN. �oD Z. �LSoa.rQ„IVtnA-sa Y. No.and Street Email address C.Drvt PVrDVO uT ��1 )C)q "l$13D53DLpS City/Town,State,ZIP Tele hone 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.........:A 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 V IV 1✓kt SD l0.1^ to act on my behalf,in all matters relative to work authorized by this building permit application.VA 23 !/ Y Print Ownefs Name(Electronic Signature) Date SECTION 7b:OWNER'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 IN p . tion is true and accurate to the best of my knowledge and understanding. V I t � 23 N. Print s r rized Agent's Name(Electronic Signature) I Date NOTES: 1. 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. oe v/oca Information on the Construction Supervisor License can be found at www.maaLgov/dos 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" A CERTIFICATE OF LIABILITY INSURANCE °A1 "YY"' 11/011201312013 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 MARSH USA INC. NAME: 1225 11THSTREET,SUITE 1300 PHONE FAX ac No: DENVER,CO 80202-5534 EMAIL Attn:Denver.cerhequest@dmarsh.cem,Fax:212.948.4381 ADDRESS: INSURE S AFFORDING COVERAGE NAIC9 462738-STND43AWUE-13-14 INSURER A:Evanston Insurance Company 35378 INSURED INSURERS:National Union Fire Insurance Co of PA Vivint Solar,Inc. 4931 N 300 W INSURER c:New Hampshire Insurance Company 23841 Prove,UT 84604 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002368030-06 REVISION NUMBER:0 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. IN$R AODL SUER POLICY EFF POLICY UP LTR TYPE OF INSURANCE POLICY NUMBER MMID MMIDD LIMITS A GENERAL LIABILITY 13PKGWE00274 11/01/2013 11/0112014 EACH OCCURRENCE $ 1A00,000 X COMMERCIAL GENERAL LIABILITY PREMISE E T S Eaacwrrence $ 50,000 CLAIMS-MADE MOCCUR - MED EXP(Any one percent $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000.000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY PPCT' LOC $ B AUTOMOBILE LIABILITY 9701087 11/01/2013 11/01/2014 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ S X ANY AUTO 9701088 11/0112013 11/01/2014 BODILY INJURY(Per person) $ ALL OMNED AUTOS SULED BODILY INJURY(Par accident) $ X MIRED AUTOS X NONOWNED PROPERTY DAMAGE AUTOS Par acdtlent $ $ A UMBRELLA LULB X OCCUR 13EFXWE00088 11101/2013 11101/2014 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAS CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTIONS $ C WORKERS COMPENSATION 029342334; 029342335 11101/2013 1110112014 X WCSTAT1J- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS C ANY PROPRIETOR/PARTNERIEXECUTIVE N 029342336; 029342337 11/01/2013 11/01/2014 E.L.EACHACCIDENT $ 1,000,000 Rd C OFFICEREMSER EXCLUDED'! ❑N NIA (Mandatory In NH) 029342338 1110112013 11/01/2014 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yse.describe under DESCRIPTION OF OPERATIONS below E.LOISEASE-POUCYUMIT $ 1,000,000 A Enors&Omissions& 13PKGW00029 11/01/2013 11101/2014 LIMIT 1,000,000 Contractors Pollution DEDUCTIBLE 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Atlach'CORD 101,Additional Remarks Schedule,V mom apace is required) The Certificate Holder and others as defined in the written agreement are included as additional insured where required by written contract with respect to General Uability.This insurance is primary and non nMbutory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract.Waiver of subrogation is applicable where required by written ntract with respect to General Liability and Workers Compensation. CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 93 Washington Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M.Parsloe ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 4931 North III West,Provo,UT 84604 Employer Identification No.: 800756438 VlVlllt. so I a r M Phone:(877)404-0129 Fax:(80U 765-5758 Massachusetts HIE Licene No s 170848 E-Mail support@vwintoolmenno 3 a y 160 y (4 www.,ivmxdImcmn AR No.: f RESIDENTIAL POWER PURCHASE AGREEMENT This RESHy-NTIAL POWER PURCHASE AGREEMENT' his"Agmemea')is entered into by and between VIVIAT SOLAR DEVELOPER,LLC,a Delaware limited liability company("We","Us","Our")and the undersigned Customers)("You","Year'),as ofthe To m etion Dodson forth below. Full Name Ie;.,,,m<o..q JR Full Name rrr,r w.v,q Customer(s): ^e rn moa..�m'4,o,w nw...yo»„n:❑r.,o xo Telephone No.: ill - IV-Wfa46� E-Maih i'sb T-glCuweAn G4sao-Ce ll Property Strect Address: S CoVrCkll Si-' Address: CIty,Counl Slme,Zip: MR Oldl+O 1.SERVICES A. DESIGN AND INSTALLATION. We will design,install service and maintain a solar photovoltaic system on Your P hick will include all solar panels,inverters,meters,and other components(collectively,the"Syrrem'T.as further described m the Customer IT d[e Work Order that We will provide m You hereafter. All material portions of the System will be installed by Our employed technicians and clectnciens,and not subcontractors. With Your coope'soon, We will(r)design,install and connect she Systurn in material compliance wish all applicable laws; )corm�lete all required inspemions;end('iii)obtain all required cenitwirsins and econits. In order to design a Syystem that meets Your needs,You agree�at We may obtain Your electrical usage history firm Your electric utility jthe"UhO and You shall provide❑s with copies of Your Oolity bills as We may reasonably request. OaTer than tee ativanon fee described in Stthun LB,We will 1esign and install the System B. ACTIVATION. You agree to pay Us a u -time amivation fee m the amount of$ We will imerconnect rim System witM1 the Utility,and cause the System to gencon eno, mcasurd,' kilowatt houe('truth "Frier nvalletmn of the System generally oleos one day mJ a anticipated I. begin and be subslanua ly complete between twr(2)and six(6) asks heree�er. C. OWNERSHIP OF SYSTEM. We shall own the System as Our sole personal property. You will have no property interest in the System. D. OPERATIONS AND MAINTENANCE. We will uIum a and maintain the System Ill at Our sole cost and expense;(it)in good condition;and(iii)in material compliance with all applicable laws and permits and the Utility's requirements. E. INSURANCE. We carry commercial general liability insurance,workers'compensation insurance,and propertyy insurance on the System. For more information concerning Our insurance,and to obtain a copy of Our cenificate of insurance,please visit: caw t,vlvintsola.conommramce. 2.TERM PRICE,PAYMENTS,AND FINANCIAL DISCLOSURES A. ENERGY PRICE. For all Energy produced by the System,You sh�aaDlLypppyy Us S0. (d 10 per kWh fthe"Energy Price"),plus,applicable taxes. The Energy Pace shall increase each year by two and nine-tenths P cntY2:9elal A geed lank estirnale of the S output,messu-d m k Iowan hours, ill be yrovided to You a the Customer Pee it. THIS AGREEMENT IS FO -TTHE SALE OF ENERGY BY US JansenTO YOU AND NOT FOR THE SALE OF A SOLAR ENERGY DEVICE. B. TERM. This Agreement shall he effective as of the Transaction Dam and continue until the twentieths{ ? anniversary of the In-Smite Date(the "Tani'). The"laServive Doh" bull be the first day after all of the following have been achieved: (i)the stem has been installed and is capable of generating Energy.(ii)all permits necessary to operate the System have been obtained,(ill)the System has been mtermnnectN with the Utility,and fin)all mspections and cemficates required under applicable law or by the Utility have been crmpleted or received. C. PAYMENTS. Beginningg with the first month following the InServiw Date and throughout the Term,We will send You an invoice reflecting the charges for Energy produced by the System in the previous month. You shall make monthly ppayments to L's by automatic pay�mnant deduttion from Your designated checking account or credit card. It is Your responsibility to ensure that them are adequae funds or adegsaw credit limit. There a no financing charge associaled who this Agrcement. For all payments more than ten(10)days past due,We may impose a late charge equal to Twenty-Five Dollars($251 and interest ar an annual rate of ten percent(I0 0).plus applicable axes. If You continue to fail a make any payment within ten(10)days after We give You won.notice,then We may d. w all remedies avat able to Us pursuant to Sermon 13fb1. D. RENEWAL. A[the and of the Tenn,You may elect to(i)con6nue with this Agreement ore a year-on-year basis;fit enter into a new Agreement with Us and cancel this Agfecmrnq(iii)purchase the System at the end of the Term aria cancel this Agreement(Ike"Purchase Ondon") or Uv)cancel this A -cant and have the System removed at no cost to You. You will need to notify❑s in writrng conceminQ Your election sixty(60)days prior m the and ol�e Term. If You elect the Purchase Option,the Purchase Option Price"will be the[hen-cure-fair market value of the System based on an -dependent appraiser's valuation of ximilarly sized photovoltaic systems m Your Ion owphic regina. The tip raiser's valuation will be provided to You in wnnng and will be binding. If We receive Your payment of the Purchase Option Price casts of Ne appmisaP applicable taxes,and all odser nmouvts then owing and unpaid hereundeq We will[mnsfer owmcrshtp of tee Syskm to You at the end of the Tenn on an`As Is,Where Is bans. If You clam to M1ave the 8ystam removed.We will remove the Systam from Your P-Party ithin ninety(9U dayyss after the end of the Term. IF YOU x a NOT NOTIFY US OF YOUR ELECTION I'O CANCEL BY SENDING A WRITTEN NOTICE �O US,THEN THIS AGREEMENT WILL AUTOMATICALLY RENEW ON A YEAR-TO-YEAR BASIS UNTIL YOU NOTIFY US IN WRITING OF YOUR ELECFIUN TO CANCEL AT LEAST SIXTY(60) DAYS PRIOR TO TILE END OF THE RENEWAL TERM. E. CREDIT CHECK. In connection with the execution of this Agreement and at any time during the Tern,You hereby Window Us to(it chain Your credit ruing and report firm credit reporting agencies;(ii)to repon Your payment performance under this Agreement to credit reporting agencies;and (iii)discloac this ansl other information to Our alhholes and actual or p-spretive lenders,financing parties,inves-rs,insurers,and acquirers. WE MAY HAVE PRESCREENED YOUR CREDIT. PRESCREENING OF CREDIT DOES NOT IMPACT YOUR CREDIT SCORE. YOU CAN CHOOSE TO STOP RECEIVING"PRESCREENED"OFFERS OF CREDIT FROM US AND OTHER COMPANIES BY CALLING TOLL-FREE (888) 567-8688. SEE PRESCREEN & OPT-OUT NOTICE(SECTION 29)BELOW FOR MORE INFORMATION ABOUT PRESCREENED OFFERS. 3.LIMITED WARRANTY A. LIMITED INSTALLATION WARRANTY. We rovide a workmanship woman that the System shall be flee firm material defects in desi and workmanship under normal operating conditions for rim Tenn. We Culler warrant that ell rooftop penetrations we instill shell be welertiuyt as ofthe�te of installation. We do not provi0e any warranty to You with respect to any component of the Systwo. Any inanuacmrer's warranty is in addition to,not in lieu of,this limited installation warranty. This warranty does not cover problems resulting tram exposure to harmful materials and chemicals,fire,Brand, earthquake,or other acts ofgod,vandalism,freedom of system by anyone not authorized by Us,or any other cause beyond Om control. B. MANUFACTURERS'WARRANTIES. The Systen's solar modules tarty a minimum manufacturer's warranty of twenty(20)yeas as follows: ((a))during the firs[ten(10)yyeears of use,the modules'electrical output will not degrade by more than ten percent(10%)firm the ongrnaify rated cut Wt;all (b)during[he firsl twenty(20)year of use,the modules'elecwcal output will not degrade by more than twenty percent(20%)hem the on'gi illy re[Vcd output. a Syatem's inverters carry a minimum manufacturer's waranty often(10)years against defects w component breakdowns. During Ina will enforce these warranties to tee fullest extent possible, C. DISCLAIMER OF WARRANTY. EXCEPT AS SET FORTH IN THIS SECT[�N3,WE MAKE NO OTHER WARRANTY TO YOU OR ANY OTHER PERSON, WHETHER EXPRESS, IMPLIED OR S—T)TOYbRl' AS TO THE MERCHANTABILITY OR FITNESS FOR ANY PURPOSE OF THE EQUIPMENT, INSTALLATION, DESIGN, OPERATION, OR MAINTENANCE OF THE SYSTEM, THE PRODUCTION OR DELIVERY OF ENERGY, OR ANY OTHER ASSOCIATED SERVICE OR MATTER HEREUNDER, ALL OF WHICH WE HEREBY EXPRESSLY DISCLAIM. OUR LIABILITY FOR ANY BREACH OF ANY WARRANTY IS LIMITED TO REPAIRING THE SYSTEM OR YOUR PROPERTY TO THE EXTENT REQUIRED UNDER THIS AGREEMENT. YOU ACKNOWLEDGE THAT WE ARE RELYING ON THIS SECTION 3.C.AS A CONDITION AND MATERIAL INDUCEMENT TO ENTER INTO THIS AGREEMENT. THERE ARE NOPT ES WHICH EXIhND BEYOND THE DESCRIPTION OF THE FACE HEREOF. 4.REMOVAL OF THE SYSTEM You shall art make any Alterations(as defnW in tin c��to the System. HYou want to make repairs or ire rovemrn[s to Yow Property that require Ilia temporary removal oCae Syystem or that could m e wiih its peRormance or opemtin You must give Us a[Reest thirty(30)days'prwr wnnrn rtona {a"CuxramervRequesred Shurdawn"). You agrco that an repair or improvement to Your Property shall not materially all Your roof where tee Syskm a msalle ompensation fnr Our removal,storage and iemsalletion of the S}�lam,You agree to dpay to Us a fee equal to Four Hundred and Ninety-Nee On" 5499 before We-move the System. You shall be required to pay. ay the Shutdown Payne t as defined in S coon IS fin tee System is no[reinsalled within O)days rf removal. In the event of an emttgency affecting the System.You sha��Il1111 comact Us Im u tale y. If We are enable to timely respond,You mayy(at Year own expense)rantmcl wiN a licensed and quali M sole insalla[o remove the System as necessary In make repairs required by the emergency. Vru shall be responatble for any damage to the System tha reau16 from actions taken by Your comans. 5.ARBITRATION OF DISPUTES Most customer concerns can be resolved quick)y and amicably by calling Our customer service department at(877)404-4129. if Our customer service department Is unable to resolve Vow snncem,You and Were to resolve any Dispute(as defined below)throu¢h bindLy arbitration or small claims court instead of coons of general'urisdic[ion. BGNING BELOW,YOU ACKNOWLEDGE AND AGREE THAT(I)YOU ARE IIERE13Y WAIVING THE RIGHT T�A TRIAL BY JURY;AND(II)YOU MAY BRING CLAIMS AGAINST US ONLY IN YOUR INDIVIDUAL CAPACITY,AND NOT AS A PLAIMiFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. You and We agree to arbitrate all disputes,claims and conrrovernes arising out of or relating to cos"A).nor v;.:.x s,m,11-1,,111 nito_u.x., ,L (i)a ny any aspect of the relationship between You and Us,whether based in contact,tort,'tattle or any other legal theory;(ii)[his Agreement or any other agreement concertung the subject matter hereof; (iii) any breach, default or ternunation oC(his Agreement; and (iv)the interpretation,validity,or enforceability o this Agrcenrent including the determination of the scope or applicability of this Section 5(each,a Dispute"). Prior to commencing a' die iuq a party must first send a written"Notice of Dis ute"via cemfied mail to the o[— e�patty. The Rl Wi Notice of Dspute must describe the name and basis for the Dispute and the relief sought IfPYou and We are unable to rewlve the Dispute within thirty (30) days, then either party mayy commence arbitration. The arbi0soon shall be administered by JAMS pursuant to iss Streamlined Arbitration Rules end Pre ores(o"'i.ble at. httpp://www.amsadr.erpam es-streamlined-nrbitation,the"JAMS Rules")and under the rules set forth in this Agreement The arbitrator shal I be boun�by the terms of this Agreement. No matter the circumstances,the arbitrator shall no[award puve,sppecial,exemplary,indirect,or consequential damages to either party. If You initiate arbitation,You shall be responsible to pa $250. All attorneys' fees,travel expenses,and other costs of the arbi[ration shall be borne by You and Us in accordance with the JAM$Rules and applicable law. The arbitration shall be conduc(ed at a mutually agreeable location near Your Properrttyy Judgment on an arbitration sward may a entered in eny court ofcorn ¢tentjurisdiction Nothing in this Section 5 shall preclude You or We from seeking provisional remedies in aid at inbiusorm from a court ofDcompCie.,juriashtursn. NOTICE:BY INITIALING IN THE SPACE BELOW YOU ARE AGREEING TO HAVE ANY DISPUTE ARISING OUT OF THE MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES^PROVISION DECIDED BY NEUTRAL ARBITRATION AS PROVIDED BY APPLICABLE LAW AND YOU ARE GIVING UP ANY RIGHTS YOU MIGHT POSSESS TO HAVE THE DISPUTE LITIGATED IN A COURT OR JURY TRIAL. BY INITIALING IN THE SPACE BELOW YOU ARE GIVING UP YOUR JUDICIAL RIGHTS TO DISCOVERY AND APPEAL. IF YOU REFUSE TO SUBMIT TO ARBITRATION AFTER AGREEING TO THIS PROVISION, YOU MAY BE COMPELLED TO ARBITRATE. YOUR AGREEMENT TO THIS ARBITRATION PROVISION IS VOLUNTARY. YOU HAVE READ AND UNDERSTAND THE FOREGOING AND AGREE TO SUBMIT DISPUTES ARISING OUT OF THE MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES"PROVISION TO NEUTRAL ARBITRATION. C.o-e*imir 4: 1/WE AGREE TO ARBITRATION AND WAIVE THE RIGHT TO A JURY TRIAL: 51- ❑ 6.NOTICE TO CUSTOMERS A. LIST OF DOCUMENTS TO BE INCORPORATED INTO THE CONTRACT: (i)this Agreement,(ii)the Additional Terms and Conditions,(iii)the Customer Packet,and(iv)the Work Order. These documents are expressly incorporated into this Agreement and apply to the relationship between You and Us. B. IT IS NOT LEGAL FOR US TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REMOVE GOODS INSTALLED UNDER THIS AGREEMENT. C. DO NOT SIGN THIS AGREEMENT BEFORE YOU HAVE READ ALL OF ITS PAGES. You acknowledge that You have read and received a legible copy of this A cement that We have signed the Agreement,and that You have read and received a legible copy of every document that We have signed during the negotiation. D. DO NOT SIGN THIS AGREEMENT IF THIS AGREEMENT CONTAINS ANY BLANK SPACES. You are entitled to a I completely filled In copy of this Agreemeut signed by both You and Us,before say work may be started. E. YOU MAY ( 31m)BUSINESS DAY AFTER THE TRANSACEL THIS CTION DATE,OR(11)N AT ANY TIME THE START OF IN TOALLATION OF THEYSDNIGHT OF TEM. SEE THE NOTICE OF CANCELLATION BELOW FOR AN EXPLANATION OF THIS RIGHT. r� ` VIY7NT SOLAR DEVE PEB/ LC CUSTOMER(S): 11 By 4 1 Printed Name: 14 07- jk- Printed Name: j AT-AIFS il;- C J Title: akr By: Printed Name: Transaction Date: 3 I g 2d(4 FOR INFORMATION ABOUT CONTRACTOR REGISTRATION REpUIREMENTS, CONTACT THE MASSACHUSETTS OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATION:TEN PARK PLAZA,SUITE 5170,BOSTON,MA 02116, , (617)973-8700 OR 888-283.3757. ------------------------------------------------------------------------------------------------------------ NOTICE OF CANCELLATION Transaction Date: AR No.: YOU MAY CANCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE((3)BUSINESS DAYS OF THE ABOVE DATE,OR(IF LATER) CNTIL_7TIE START OF I[�CTA_LI ATION OF THE CYSTF`M LE YOU CANCEL,ANY PROPERTY TRADED IN,ANY PA4MEP' 3 MADEBPYDUIINDERTHELUNTRAu s UKKK�AZ�AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN TEN ((10) BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL,YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE,IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED,ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE, OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY(20)DAYS OF THE DATE OF YOUR NOTTCE OF CANCELLATION,YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER,OR IF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO,THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALI,OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND A TELEGRAM,TO VIVINT SOL DEVELOPER LLC,AT 4931 N 300 W,PROVO,UT 84604 PRIOR TO THE LATER OF: (D MIDNIGHT OF THE THIRD(3I BUSINESS DAY AFTER TILE TRANSACTION DATE,OR(In THE START OF INSTALLATION OF THE SYSTEM. I HE CANCEL THIS TRANSACTION: Date: Customer's Signature: c;,oneni a.:aia e. s.ia u�,n,m.uc+n a�w i.asr+w. mo-•,.moi i,vrn.,_., ___ _ ___ a ww.tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Ianformation Please Print Legibly er, LLC Name (Business/Organization/Individua(): Vivint Solar Developer, Address:4931 North 300 West City/State/Zip-Provo, UT 84604 Phone #:801-704-9389 Are you an employer? Check the appropriate box: Type of project(required): 1. ® I am a employer with 10 4_ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling These sub-contractors have ship and have no employees 8. � Demolition � working for me in any capacity. employees and have workers' tom [No workers' comp. insurance P- insurance.t 9. Building addition required.] 5. Q We are a corporation and its 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] •Any applicant that checks box k l 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. '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 acre an employer that is providing workers'compensatiox insu,ance for my employees. Below is the policy and job site information. Insurance Company Name:New Hampshire Insurance Comany Policy# or Self-ins. Lic.`#:029342228 Expiration Date: 11-01-14 Job Site Address: City/State/Zip:Sou Po 1'}') p pt Attach a copy of ulna workers' counpeasatoo®policy declarati®® 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 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. d do hereby ce r under pai and penalties of perjury that the information provided above is true and correct. Si-onature: ;% /�� i/\'�� Date Phone#: 801-704-9389 Official use only. Do not write in this area, to be completed by city or town =Plumbing City or Town: Permit/ eeuse # Issuing Authority(circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Elect6. Other Contact Person: Phone# Office of Consumer Affairs sand Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Dome Improvement Contractor Registration Registration: 170848 Type: Supplement Card VIVINT SOLAR DEVELOPER LLC. Expiration: 1/b/2016 JAMES SHERMAN 4931 NORTH 300 WEST PROVO, LIT 84604 Update Address and return card.Mark reason for change. SCA1 is 20M-05n1 ❑ Address Renewal ❑ Employment Lost Card (Lomcnwruoeall/c o�P/�a5tac�ue ice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration: 170848 Type: 10 Park Plaza-Suite 5170 WffExpiration: 1/512016 Supplement Card Boston,MA 02116 VIVINT SOLAR DEVELOPER LLC_ JAMES SHERMAN 4931 NORTH 300 WEST J PROVO, UT 84604 Undersecretary Not valid without signature — s Massachusetts -Department of Public Safety Board of Building Regulations and Standards Omstruction Supervisor License:CS-045254 i 3A31F.S R SF&ERTV 61vt Q b2 81 MAIN ST t SAUGUS MA 01906 s Expiration Commissioner 08/28/2014 4 2781 Fries Mill Road,Williamstown,NJ 08094 Tel: 856.770.4473; rdeipolla@verizon.net Vivint Solar April 17, 2014 24 Normac Road Woburn MA, 01801 Attn: Mr. Paul Greene, Operations Manager Re: Structural Assessment Report for Roof Mounted Photovoltaic (Solar) Panel Installations—Cajigal Residence, 5 Cottage Street, Salem, MA AR#3624100 Dear Paul: We are providing you with this structural assessment report of Vivint Solar's photovoltaic (solar) roof installations to be completed at the above referenced dwelling. The assessment criteria are based upon Vivint's recent dwelling site visit including roof framing photographs and field notes. We have also reviewed Vivint's PV Solar Permit Submittal, calculations, installation layouts and notes,PV 1.0 "Site Plan",PV 2.0 "Roof Plan", and PV 3.0, "Mounting Details". All were supplied for information on the proposed solar panels installation on the dwelling's roof framing members for our assessment summary. The dwelling is timber framed of older construction age with an"A" framed main roof, 5'-6"'+/- high (estim.), assumed to be built from nominal 2" x 6" or 2" x 8" dimensional lumber joists at 16" to 19", typical of similar dwellings. No other attached roofs are receiving PV panels. The maximum roof joist span length is 14' — 6" +/- excluding reductions for mid-span supports. Two layers of roof shingles are assumed. Materials are assumed as minimum Hem-Fir #2 grade, conservatively (low allowable stresses), with standard construction components (better grade lumber may have been used). No collar ties could be confirmed to be installed below the ridge beam in the main "A" roofs'/attic's full length, in panel installations areas, due to the finished upper floor/attic. However, the flat ceilings are typically framed with newer or original collars ties attached to roof joists at each end for reinforcing. The partial height upper floor rooms' interior and sidewalls will also act as mid-span joist supports. The main attic and roof framing were not accessible by crawl spaces or access panels at the site inspection and evaluation, therefore a partial assessment and confirmation of framing spacing, sizes and condition was able to be performed for this roof. No architectural drawings were available at the time of this report preparation. Refer to plans and documents prepared by Vivint for dwelling dimensions, locations and sizes of solar panel units. The roof framing members were reviewed and checked for their capacity of new loadings. A. CAPACITY OF EXISTING ROOF TO SUPPORT PROPOSED SOLAR PANELS: 1. Our assessment included using the proposed solar panels dead load that were given to us in the ZEP calculation sheets and the live and dead loads described below. Our review of the roof information shows that there are no visible undulations or unevenness, indicating that the roof framing members are not visibly overstressed or weakened by past heavy snow loads. F Mr. Paul Greene April 17, 2014 Page 2 2. Given the dwelling's roof construction and condition, the existing roof joists' load carrying capacity will be able to carry the added dead and redistributed live loads from the new solar panels if installed correctly. The dwelling's roof members will also redistribute the snow live loads, and additional solar panels dead load to the adjacent framing members. These additional loads should not produce stresses beyond the allowable stress range for roof framing members assumed as Hem-Fir 42 materials. Considering the lower roof slopes, array sizes; lack of complete access to confirm roof joists' size, spacing, condition; and collar ties,the panel supports shall be set/ attached to every second foist for lateral installations over joists. No panel support spacing shall be rg eater than two(2)roof ioist spaces, or 38"+/-o/c, whichever is less to be shown in the PV 2.0 Roof Layout plan(s). Note -Layout Array Drawing#1 submitted for review, shows this maximum panel support spacing, and does not need spacing revisions. The panel supports shall be installed in staggered patterns to ensure proper load distribution, and with no more than three supports placed on any single roof joist, except at ends of layouts. This layout can be used for permit submittals and installations, with the staggering of supports being done in the field. All panels shall be installed as shown on the layout plans, with 38"+/- o/c maximum support spacing, or two joists spaces (w.i.l.)and staggered, to be shown in the final PV 2.0 Roof Layout plan(s), as stated above. Framing member sizes, spacing and condition must be properly verified by Vivint's installers, prior to any installations. Send any differing information to this engineer for review and approval, prior to continuing with any installations. 3. This assessment meets current Massachusetts Building Code, 8ffi Edition—Residential —Amendments to International Residential Code, (IRC), 2009 Edition, for one and two family dwellings. B. SOLAR PANEL ATTACHMENT TO ROOF STRUCTURE: 1. The solar panels shall be mounted in accordance with the latest"ZEP Company's Code Compliant Installation Manual" found on the ZEP website and not included herein. No additional reinforcing requirements are required for these installations. However, if during solar panel installations, the roof framing members feel unstable, or show interior or exterior evidence of minor or excessive movement,then this engineer should be notified as soon as possible prior to proceeding with installations. 2. Vivint should notify the homeowners that long term build-up of accumulated snow in the event of extreme snowfall conditions, may produce some roof deflections. These deflections will be temporary in nature and will not affect the roof s structural integrity. The solar panels do not need to be cleared of such accumulated snow. C. WIND UPLIFT LOAD: 1. Refer to attached ZEP calculation sheet for ASCEISEI 7-10 Minimum Design Loads Mr. Paul Greene April 17, 2014 Page 3 For Buildings and Other Structures, for wind speed at this location of 100 miles per hour* for Exposure Category `B", and 27 degree roof slopes on the dwelling's roof areas. Ground snow load is 40 p.s.f.* for Exposure`B",Zone 1 (per ASCEISEI 7- 10) of the roof s interior portion, and effective wind speed of 100 mph*,uplift is shown. 2. Total area subject to wind uplift is calculated for the Interior,Edge and Corner Zones. A maximum and user selected support(foot) spacing is shown for each location zone. D. PANEL ANCHORAGES: 1. Maximum allowable pullout per lag screw=235 #/inch from National Design Standards(NDS)timber construction specifications for Hem-Fir-North lumber (assumed). Using 4 lag screws, the pullout value is less than 235 Winch of screw thread and OK. Considering the variable factors for the existing roof framing members, and installation tolerances, use a 2 Yz"threaded depth with a minimum 5/16" lag screw per attachment points in roof joists ("rafters") components for panel anchor mounts. This should give a sufficient factor of safety. E. LIVE, DEAD AND SNOW LOADS: 1. Live load=40 p.s.f. ground snow load; 10 p.s.f. attic storage(trusses only) Dead Load= 10 p.s.f.- roofing/framing; 5 p.s.f. - panels, mounting hardware Total Live Load=40 p.s.f.; Total Dead Load= 15 p.s.f. 2. These values are within acceptable limits of recognized industry standards for similar structures. The roof members will be able to sustain the solar panel attachments without damage, if installed in a workmanship like manner according to the above criteria. We have based our structural capacity determination on applicable building codes, professional engineering inspection and design experience, opinions and judgments. This report covers this dwelling's assessment for only the areas for solar panel installations that were made according to generally recognized structural analysis standards and procedures. The normal structural engineering industry standard of care utilized for this type of work was used during this report preparation. The assessments and recommendations in this report were reviewed to ensure a proper level of quality and uniformity. This report adheres to accepted State and National practices for current building code standards and can be used for construction purposes. If you have any questions or require further information, please�.t�hesitate to contact m . Respectfdlly subm Pe , 7 RussellDCip lI .lie 'stered r g; Structural Engineer, Owner Mass. License No. EN-47478- RUSSELL CIPOLLA $ STRUCTURAL cn * or as specified locally per the State Board of Bldg. Regs. and Stds., whichever g No.47478 Q RDC/rdc O FGISTER�G��`� SS/ONALEN Vivint Solar - PV Solar Rooftop System Permit Submittal 1. Project Information Project Name: James Cajigal Project Address: 5 Cottage St,Salem MA A.System Description: The array consists of a 7.75 kW DC roof-mounted Photovoltaic power system operating in parallel with the utility grid.There are (31) 250-watt modules and(31)215-watt micro-inverters,mounted on the back of each PV module.The array includes(2) PV circuit(s).The `array is mounted to the roof using the engineered racking solution from Zep Solar. B.Site Design Temperature: (From Boston Logan INTT ARPT weather station) Average low temperature: -21.1 °C (-5.98°F) Average high temperature: 38.4°C (101.12°F) C. Minimum Design Loads: Ground Snow Load: 40 psf (State Board BR&S) Design Wind Speed: 100 mph (State Board BR&S) 2. Structural Review of PV Array Mounting System: A.System Description: 1.Roof type: Camp.Shingle 2.Method and type of weatherproofing roof penetrations: Flashing B.Mounting System Information: 1.Mounting system is an engineered product designed to mount PV modules 2. For manufactured mounting systems,following information applies: a.Mounting System Manufacturer: Zep Solar b.Product Name: ZS Comp c.Total Weight of PV Modules and mounting hardware: 1333 Ibs d.Total number of attachment points: 78 e.Weight per attachment point: 17.08 Ibs/square foot f.Maximum spacing between attachment points: * See attached engineering talcs g.Total surface area of PV array: 545.91 square feet h.Array pounds per square foot: 2.44 Ibs/square foot i.Distributed weight of PV array on roof sections: -Roof section 1: (31)modules,(78)attachments 17.08 pounds per square foot I vivint. sour 3. Electrical Components: A. Module (UL 1703 Listed) Qty Trina TSM 250-PA05.18 31 modules r Module Pmax-nominal maximum power at STC - 250 watts Vmp-rated voltage at maximum power - 30.3 volts Voc-rated open-circuit voltage - 37.6 volts Imp-rated current at maximum power - 8.27 amps Ise-rate short circuit current - 8.85 amps B. Inverter (UL 1741 listed) Qty Enphase M215-60-21,L-S22 31 inverters Inverter Specs 1. Input Data (DC in) Recommended input power(DC) - 260 watts Max.input DC Voltage - 45 volts Peak power tracking voltage - 22V-36V Min./Max.start voltage - 22V/45V Max.DC short circuit current - 15 amps Max.input current - 10.5 amps 2.Output Data (AC Out) Max.output power - 215 watts Nominal output current - 0.9 amps Nominal voltage - 240 volts Max.units per PV circuit - 17 micro-inverters Max.OCPD rating - 20 amp circuit breaker C.System Configuration Number of PV circuits 2 PV circuit I - 16 modules/inverters (20) amp breaker PV circuit 2 - 15 modules/invetters (20) amp breaker vivint. s G! a r D.Electrical Calculations 1.PV Circuit current PV circuit nominal current 14.4 amps Continuous current adjustment factor 125% 2011 NEC Article 705.60(B) PV circuit continuous current rating 18 amps 2.Overcurrent protection device rating PV circuit continuous current rating 18 amps Next standard size fuse/breaker to protect conductors 20 amp breaker Use 20 ama AC rated fuse or breakeIr 3.Conductor conditions of use adjustment(conductor ampacity derate) a.Temperature adder Average high temperature 38.4°C (101.12°F) Conduit is installed 1"above the roof surface Add 22°C to ambient 2011 NEC Table 310.15(B)(3)(e) i Adjusted maximum ambient temperature 60.4°C (140.72°F) b.PV Circuit current adjustment for new ambient temperature Derate factor for 60.4°C (140.72°F) 71% 2011 NEC Table 310.15(B)(2)(a) Adjusted PV circuit continuous current 25.3 amps c. PV Circuit current adjustment for conduit fill Number of current-carrying conductors 6 conductors Conduit fill derate factor 80% 2011 NEC Table 310.15(13)(3)(a) Final Adjusted PV circuit continuous current 31.6 amps Total derated ampacity for PV circuit 31.6 amps Conductors (tag2 on 1-line)must be rated for a minimum of 31.6 amps THWN-2(90°C)#1 OAWG conductor is rated for 40 amps (Use#10AWG or larger) 2011 NEC Table 310.15(13)(16) 4.Voltage drop(keep below 3%total) 2 pacts 1.Voltage drop across longest PV circuit micro-inverters(from modules to j-box) 2.Voltage drop across AC conductors(from j-box to point of intereonncction) 1.Mirco-inverter voltage drop: 0.48% The largest number of micro-inverters in a row in the entire array is 10 inCircuit 1. According to manufacturer's specifications this equals a voltage drop of 0.48%. 2.AC conductor voltage drop: =I x R x D C 240 x 100 to convert to percent) _ (Nominal current of largest circuit)x (Resistance of#IOAWG copper)x (rota]wire run) Total system voltage drop: # vivin#. s of S r 4/15/2014 3624100 roof 1-Zepulator ®. ZepSolar Engineering Calculations 3624100 roof 1 Name: Street Address:5 Cottage St. Email: Suite/PO#: Phone: City,State,Zip:Salem,Massachusetts Country:United States System Details Module Manufacturer Trina Solar Mounting System Zap Solar PV Module TSM-250-PA05.18 Manufacturer Quantity of PV Modules 31 Mounting System Type ZS Comp Array Size (WO 7.750 Roof type Composition Shingle Attachment Type Comp Mount,Type C Module-level Enphase Energy-M215-Z electronics Lhttp:IA,w-zepulator.conVproj is/55675/summarl engineeringyrint 1/4 4/15/2014 3624100 roof 1-Zepulator Engineering Calculations Design Variables " Description(Symbol) Value Unit Module Orientation Landscape Module Weight 44.8 Ibs Average Roof Height(h) 35.0 ft Least Horizontal Dimension(Ihd) 30.0 ft Edge and Corner Dimension"a" 3.0 It Roof Slope(0) 27.0 deg Rafter/Truss spacing 16.0 in Rafter/Truss dimension Min.nominal framing member depth of 4" Basic Wind Speed(V) 110 mph Exposure Category B Ground Snow Load(Pg) 40 psf Risk Category II Topographic Factor(Kit) 1.0 Thermal Factor for Snow Load(Ct) 1.2 Exposure Factor for Snow Load (Ce) 0.9 Effective Wind Area 10 ft2 Snow Load Calculations (Using calculation procedure of ASCE 7-10 Chapter 7) Description (Symbol) Interior Edge Corner Unit Flat Roof Snow Load(Pt) 30.2 30.2 30.2 psf Slope Factor(C.) - 0.8 0.8 0.8 Roof Snow Load 23.6 23.6 23.6 psf Wind Pressure Calculations (Using simplified procedure of ASCE 7-10 Chapter 27) L tion(Symbol) Interior Edge Corner Unit gn Wind Pressure uplift(Pnet3oup) -19.9 -34.7 -51.3 psf gn Wind Pressure downforce(Pnet3odawn) 12.5 12.5 12.5 psf ulatw.conVprojects/55675/summary wgineeringyrint 214 4/152014 3624100 roof 1-Zepulator Adjustment Factor for Height and Exposure Category(A) 1.1 1.1 1.1 Design wind Pressure uplift(W.P) -20.9 -36.4 -53.9 psf Design Wind Pressure downforce(Wdown) 16.0 16.0 16.0 psf ASD Load Combinations (Using calculation procedure of ASCE 7-10 Section 2.4) Description(Symbol) Interior Edge Corner Unit Dead Load (D) - 2.5 2.5 2.5 psf Snow Load (S) 21.1 21.1 21.1 psf .Load Combination 1 (D+0.75*(0.6*Wdown)+0.75*S) 23.5 23.5 23.5 psf Load Combination 2(D+0,6*Wdown) - 11.9 11.9 11.9 psf Load Combination 3(D+S) 21.0 21.0 21.0 psf Uplift Design Load(0.6*D+0.6*W„p) -11.2 -20.5 -31.0 psf Maximum Absolute Design Load(Pays) 23.5 23.5 23.5 psf Spacing Calculations Description (Symbol) Interior Edge Corner Unit Max allowable spacing between attachments 72.0 72.0 72.0 in User selected spacing between attachments given a rafter/truss spacing of 16.0 in 32.0 64.0 64.0 in Max cantilever from attachments to perimeter of PV array 24.0 24.0 24.0 in Distributed and Point Load Calculations (In conformance with Solar ABC's Expedited Permit Process for PV System (EPP)) Description (Symbol) TT _ A Value Unit Weight of Modules 1388.8 Ibs Weight of Mounting System 172.44 Ibs Total System Weight 1561.24 Ibs Total Array Area 546.01 ft2 Distributed Weight 2.86 psf Total Number of Attachments 78 Weight per Attachment Point 20.02 psf http:/Aw ..zepulatu.coni/projects/556751sununarylenginmrirgjxint 3/4 4/15/2014 3624100 roof 1-Zepulator http:/Aw ..zepulator.canVprojmts/55675/sun rr engineerirg_print 4/4 m o p1 PV SYSTEM SIZE: U c 7.75 kW DC NNom N -Z 0EI � z mN m0 0 O U yQ O L V J JUNCTION BOX ATTACHED T — — — — ARRAY USING ZEP ZS-GAB TO KEEP JUNCTION BOX OFF ROOF O I I I I a cn I W v) I I e d Jm � o ¢ cu N p I I F W I rn 4-0 > j 4-0 > L O K N J J z m J Z C.) z < w ,^ 3 i N o L / PV INTERCONNECTION POINT, 31)Tnna Solar TSM-250 PA05.16 MODULES WITH A SHEET LOCKABLE DISCONNECT SWITCH, Enohase M215-60-2LL-S2x-ZC MICRO-INVERTER NAME: ANSI METER LOCATION, MOUNTED ON THE BACK OF EACH MODULE &UTILITY METER LOCATION _ LLJ Q 70"OF 1"PVC CONDUIT J FROM JUNCTION BOX TO ELEC PANEL (n 0- SHEET NUMBER' PV SYSTEM SITE PLAN r SCALE: 1/16"= T-a" a 0 0.Zl �g0 N3U �A zt O >y r�z �O m m m I � v c m z c1 mG m 0- Op y On rC my Nk O .G uA On OC C-y mu NN � V D C r cn m � w Cn m 0 II � o X _ 0 m 0 9/ T r D Z zw zm INSTALLER:VIVINTSOLAR J{ 1r Cajigal Residence m mm. ROOF m INSTALLER NUMBER:70M8 04.4129 ® 5vo nl S® J a ry 5 Cottage St. PV 2.� A MA LICENSE MANIC 170&8 v u 10' A Salem,MA 01970 PLAN DRAWN BY:Jerry S1 AR 3624100 asl Modified:4I15/2014 UTILITY ACCOUNT NUMBER:3821 7-00 03] U C N MOUNTING m PV3.0 DETAIL A&CMA) LEVELINGSTEEL M.B.;TORQUE=1fix1 PAEs r�U E2vCOMP MOUNT � .0WASHER PACKAGE"WATERPROOFING SEALAWITH COMP MOUNT v' Q PV MODULE,TYR MOUNT AS NEEDED :^ TO RAFTERS OF COMP. (� 71 SHINGLE ROOF,PARALLEL U WITH PLANE OF ROOF a PV ARRAY TYP. ELEVATION tlG'Br°„4'MI"'MUM s' Z STAINLESS STEEL LAG SCREW TORQUE=1J,Q H EP. NOT TO SCALE _ Dry V ! LEVELING FOOT ON COMP MOUNT PERMITTED LEVELING FOOT SPACING NOT TO SCALE �® p o LEVELING FOOTIZSLFB) j ICI FRAMINGBELOWSHOWN r r DASHES FOR CLARITY C ZEP COMPATIBLE P WMODULE HYBRI"INTERLOCK < ' o I I I I I I I I Be F W 2 N CANTILEVER=DJ L=PERMITTED SPACING , E N 0 L GEE CODE COMPLIANCE LETTER FOR gLLOWABLE BPALING —PHOTOVOLTAIC MODULE Z LL Z VWl I I I I JJW3 I I M� "JQ HYBRID INTERLOCK SHEEt LEVELING FOOT zsLFG INTERLOCK IZSILBI NAME: 1 ) ROOFFBAMING LEVELING FWT DSLFB) Z O LE LI I I ❑ 0�.OR(ZS°UB) FOO SPACINGELING �PV SYSTEM MOUNT DETAILSYSTEM MOUNT DETAIL SHEET NUMBER' SCALE:318'=1'-W '� 0 MODULES IN PORTRAIT/LANDSCAPE cl; NOT TO SCALE Inverter Ratings(Guide Section 4) inverter Maine/Model Formed M21sB6211 SiO Conduit and Conductor Schedule MODULE DETAIL Max DC vet Rasing Tag Dearreaon yarn Gauge #of cardamon CreditType Cmant sae Max Favor a 40°L 1 Enpnase engage qUu-THWN-2 12 AWG 4 NIA-Free Air NIN-Free ArtNominal AC Voltage 1 Ben Copper Ground tEGGGEC) 6AWG 1 N/A-Fne Ar N. rustNrTIine Solar TSM-250 PA05.18 Max AC current 2 THWN-2 1nAWG 9 PVC 0.1'SOLAR MODULE Max OCPO Rating 2 THrni-Ground 5AWG 1PVL 0'-1° C:Max Number W Panescirnit 3 THWNd BAWG 3 PVC 0'-1' yJso 3 THWN-0-Gmuntl BAWG 1 PVC I 0'A' out NOTES FOR INVERTER CIRCUITS(Guide Section 0 and 9), Arin 61 om 1.)IF UTILITY REQUIRES A VISIBLE-BREAK SWITCH,DOES THIS y2 Pro' MEET THE REQUIREMENTS? PV Module Ratings @ STC(Guide Section 5) /�/ Model MakelMadel Tana Solar TSM-250 PA0518 ly o I Enphasa M215-80.2LL-52z-ZC YES NO %NA Max Pead int Current(Imp) 0.27 Amps _NaEiz MICRO-INVERTER AT 2.)IF GENERATION METER REQUIRED.DOES THIS METER Max Power-Point Voltage(Year) 30.3 Volts w0 EACH MODULE,ATTACHED SOCKET MEET THE REQUIREMENTS? Open-Om:ui1 Voltage(Vast 3].6 volts U WITH ZEP HARDWARE YES NO XNA Sheart rcuit Current(Iss) B.BS Amps 0) ¢ 3.)SIZE PHOTOVOLTAIC POWER SOURCE OCT CONDUCTORS Max Banes Fuse(OCPD) 15 Amps i BASED ON MAX CURRENT ON NEC 690.53 SIGN OR OCPD Nominal Maximum Power at STC(Pmax) 1 250 Walls U RATING AT DISCONNECT. Maximum System Voltage 1000(IECYBM(GI) j 4.)SIZE INVERTER OUTPUT(AG)CONDUCTORS ACCORDING Vac Temperature Coefficient MICROINVERTER CONNECTION TO INVERTER OCPD AMPERE RATING tree Guide Section 9). TO ENGAGE TRUNK CABLE 5J TOTAL OF 2 INVERTER OCPD(M.ONE FOR EACH NOTES FOR ARRAY CIRCUIT WIRING(Guide Section 6 and a and Appendix 01, PV CIRCUIT.OOE6 TOTAL SUPPLY BREAKERS COMPLY WITH 120%BUSBAR EXCEPTION IN T)Lowest expected ambient temperature based on ASHRAE minimum mean extreme NEC 6SoIW(B)(2)(a)? RYES NO dry bulb temperature for ASHRAE location most similar to installation location: -19°C #6 BARE CU GROUND r Signs(See Guide Section 7) 2.)Highest continuous ambient temperature based on ASHRAE highest month 2%dry bulb �� (GROUNDING ARRAY) temperature for ASHRAE location most similar to installation location: 39°C Sign for inverter OCPD and AC Disconnect: 3.)2005 ASHRAE fundamentals 2%design temperatures do not exceed 47°C in the United Slates(Palm Springs,CA Is 44.1°C).For less than 9 current-cavying conductors Solar PV System AC Point of Connection in meopmounted sunlit conduit at east os°above rout and using the outdoor design AO Output Current 27.900000 Amps temperature of 47°C or less(all of United States), JJ�am• Nomin al AC Voltage 240 Vdta aJ 12 AWG,90°C remainders are generally acceptable for modules with Ise of 7,68 Amps or less when protected by a 12-Amp or smaller fuse. n THIS PANEL FED BY MULTIPLE SOURCES b.)10 AWE,90-C conductors are generally acceptable for modules with Ise of 9.6 Amps (UTILITY AND—SOLAR) or less when protecteredb a 1 5-Arria or smaller fuse. •Q < 16 So •� of PV CIRCUIT 1: 16 MODULES/PARALLEL se Sr 6 • • • O O Ca F POINT OF DELIVERY e n AND INTERCONNECTION S: I m O se I re Ir rwiad E ¢ Z' -———————— ----T VISIBLE/LOCKABLE M > Z faj � m COMBINER SREC/ANSI 'KNIFE'A]C of ¢ w � at z m PV CIRCUIT 2: 15 MODULES/PARALLEL i PANEL METER DISCONNECT U 3 a ¢ — E 1.0 zeo,K z z ¢ t5 • • • O O I 20A SHEET NAME: _ Z w __________ _ __ _______ _ _ ______ __ __ J f7 VisionMelering Siemens 1 240V1200A Q 2 ,3 V25-25 3 #LNF222R '1 LOAD-CENTER � JUNCTION BOX 60AI240V 3 SHEET E 1.0 yyINC IRREVERSIBLE E 1.0 E 1.0 E 1.0 UNFUSED E 1.0 NUMBER: GROUND SPLICE NEMA3 O NOTE:NEUTRAL CONDUCTOR(S)OMITTED FOR CLARITY Ti ALL IMVERTER OUTPUT CIRCUITS WILL HAVE A NEUTRAL CONDUCTOR UJ Fhe Commonwealth of Massachusetts CITY ►^ Board of Building Regulations and Standards OF SALEM YJ Massachusetts State Building Code. 730 C•MR. 7ih edition Revised ionuurl- Building Permit Application To Construct, Repair, Renovate Or Demolish a l• 'I111'Y One- or Tu•u-FurnilP Duelling This Sr on For t)icial Usr On Building Permit Numb r: D e Applied: r ll Signature: / Building commissioner/InsrKtor of Juildin Date SECT[ ' TE NFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 5 GoTr c—Sm �r M Number Parcel Number I.I a Is this an accepted street Map�� no. P 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy Il) Frontage lt)) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.1 Flood Zone Information: IS Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes13 SECTION 2: PROPERTY OWNERSHIP' ------------------- 2.1 Ownert of Record: SS +tS GS r o r_ Name(Print) Address for Service: Signature 'relephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': / `AZ v `� l�_ TPf3 r✓T a� /ram 7 Gar rJ 1�. A t° 00 SECTION d: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Offic[al Use Only Item Labor and Materials I. Building S 1. Building Permit Fee: S Indicate now fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Total All Fees: S Su rrssion Chick No. Check Amount: Cash Amount:_ 6.Total Project Cost: S JrPD �O 0 Paid in Full ./�...�) 0 Outstanding Balancee/��Duu'e: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) zMlz2 lZ3 2�?2 �jYlc/S(.l7 r�/2!�-ylC' License Numher Expiration Date Nance of CSI.•I)older ` /}�� nn �� 7f Gl ;11rSw9 S, I//1e&1 9 I.isI CSL 1')pe(see below) Add t So Ft PC I Description 11 1 1'nrestricted(tip to 35,000 Cu. Ft.) Sign or R Restricted I&2 FamilyUwcitin `l� 1132 M//Z Mason Only RC Residential RootingCowrin Telephone WS Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation 1) 1 Residential Demolition 5.2 R istered Home Improvement Contractor(HIC) GovS��'�-� /lPi SYi/ IIC Company am r I IIC Rcgisltnl N n• Registration Number - j5Y��t ,b1� 1�lo AJJre s fop 9328J1Z Expiration Date Signatur Tcicphone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... ❑ No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. " � � r')-P /J , as Owner of the subject property hereby authorize _ S /'�SfYLl�Gg'TDr✓ �C,G _ to act on my behalf, in all matters relative to work a orized by this building permit application. Si azure of On er Date SECTION 7Qb:O�WNEW OR AUTHORIZED AGENT DECLARATION 1, 71G�Ga �r i�/`�f a 5 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf.�� Print No e 3�i S�ll Signature of O ner or Akhorizq Agent Date Signed under the pains an alties ofperjury) 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 Ilome Improvement Contractor(HIC)Program),will Lrol have access to the arbitration program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Ilabitable room count Number of fireplaces - Number of bedrooms Number ol'bathrooms Number of halt%baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. 'Total Project Square Footage'inay he iobstituted fir"Total Project Cost" CITY OF SU. E.NI, LL1SS.-kCHUSET'CS • BUUMLNG DEPARTMENT 120 W.+SHLNGTON STREET, Y"FLOOR T-EL (978) 74S-9595 FAX(978) 740.9846 IUD(BER t=Y Dwscou MAYORITiO.WS ST.PIEARB DIRECTOR OF PUBLIC PROPERTY/81:UMLNG CO\OIISSIONER Construction Debris Disposal Affidavit (requited for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5 .Debris,_and_the provisions-of-MGL c 40 S 54; ------ — — - - -- Building Permit Al is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris wi 11 be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) signditureofpc a ant 3 �,5 Jrl date kbnvird.a CITY OF SALEM tt. 'Put, PUBLIC PROPRERTY a' DEPARTMENT .�tn::s:tr axtxan I �I situ 12�^Wn.ttl.Nt ION 57xH¢T 0 SALEM.MAMA(,III it i nJ197� 15:i.:978-713-9593 0 FAX, 919.14V.)S46 Workers' Compensation Insurunce Atfidavit: Builders/Contractors/Electricians/Plumbers kri ilicant informalion Please Print LeeiM V:IITC llhtuikss/OrSantratintvinJividuull: �I�/`�"1 G�� /d'�-J LLG • City,Sratci%ip G7 i�r-5✓� 1'huneil: :\re you an employer:'Check the appropriate box: 'Type of project(required): 1.❑ 1 wn a employer with 4. ❑ I ;on a-general contractor and 1 (i. ❑New construction et iployces(full andlur part-tinie).• have hired the.ub-contractors 2. 1 ant a sole proprietor or partner- listed on the anachcd sheet. 7• ❑ Remodeling ship and have no employees These subcontractors have S. Demolition working for Inc in any capacity, workers' camp, insurance. 9. Building addition I No workers'cutup. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 7.❑ 1 am a homeowner doing all work right of exemption per NICL 11.0 Plumbing repairs or additions myscif. (No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.) t employees.(No workers' 13.❑ Other comp. insurancerequircd.J •any:grphcanl ittw chccka boa of must a6u rill uut Ihc. ,;Ilt n bcluw aiewina iwir wurkas atmpunudiws p iicy int:antatiun 'I Iamcuwn rs who stdirnit this affidavit indicating shay ore doing all warts and ihen biro uuisido cumrmtom must.uhmit anew 401davil indiutina aa•h. •(.mimctun thin chvek this bust mutt ailwhad an additiurwl.haet.hawing the nmtw of iM suhsontraob and their wurkon'comp.pdicy information. lain ups eoq)layer that-lr providing ivarkers'coinpensatioir insurance fur uty eatpluyeer. Behnv is the pu/fry uad fob.vile, iujornrufian. Insurance Company Name: Policy 4 or Scif-ins. Lie.d: . __ Expiration Date: Job SiteAddress: 5— fo�57—, C•ityistatesLip:'S/fit, -a* /�/� Attach It copy of the workers' compensation policy deClarallart page(showing the policy number and expiration date). !i Failure to sccurto coverage as required uodcr Section 25A ul':vIGL c. 152 can lead to the imposition of criminal penalties of a tine op to St 500.00 and/or one-year imprisonment,as Wcll as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 if Jay against the violator. Ile advised thus a copy of Ibis slumnent may be forwarded to the Office of Invcshgaunns dl'the UTA for insur:uxc dovera-gc wrificatam. /da hereby rerti y111under the pas . t ena/tiev uf•perfnry shut the infbrtnallon provided above is true anal correct. Ph 5�8i 2 001cial use duly. DO nat n•rife in slits area.tube rumplefed by city or/mvn official i i City or fown: _ _ Perinit/1.lceme x Issuing.\uihorily(circle title): i t. III,arJ of Ilealtb 2. Iluildin:j Department .1. f.ilw 1'umt Clerk 4. Electrical Inspector i• Plumbing Inspector I 6. Other l'uulael 1'cnwi: _ .. I'hunc 7: Infor mation and Instructions - \Llss.ichusetts GCOeral Laws chapter 152 requires al employers to provide workers' compensation for their employees. Pursuant to this statute, an empfored is defined as"...every person in the service of another under any contract of hire, e,,press or implied, oral or written." An employer is defined as"an individual,Partnership,association,corporation or other legal entity,or any two or more ,,r the toreguing engaged in a Joint enterprise" Lind including the legal representatives of a deceased employer,or the receiver or trustee of .m individual,pwmership,associatioa or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dweiling house of another who employs persons to do maintenance,cuntruction or repair work on such dwelling house or un the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." \IGL chapter 152, p25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally. MGL,chapter 152, 4. 25C(71 states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomrunce of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), addresses)and phone nuttrbet(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial \ccidents for confirmation of insurance coverage. Also be sure to sign and date the aflldavIL The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete ;and printed legibly. The Department has provided u space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pl.asc be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennitAiceise applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof-that a valid affidavit is on rile for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture t i.e. a dog license or permit to bum leaves ctc.) said person is NOT required to complete this affidavit. I Inc t)t I ice ut investigations would like to dank you in advance fur your cooperation and should you have any questions, phcose du nut hesitate to give us a call The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 0113ce of Investigations 600 Washington Street Boston, MA 02111 Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 www.mass.gov/dia