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0004 CRESCENT DRIVE - BUILDING JACKET RECEIVED Z (0 INSPECTIOPIAC SER The Commonwealth of Massachusetts 14 AUG 12 A 11 Board of Building Regulations and Standards CITY OF 1.1 Massachusetts State Building Code,780 CMR RevisedMar LE 20// Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use my Building Permit Number: Date Appli g �vlK Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Is pro�perty�A� s^ �. 1.2 Assessors Map&Parcel Numbers L I a Is this an accepted/street?eyes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq to Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.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' 2.1 Owner'of Record: Salvatore Orlando Solemn MA. Name(Print) City,Slate,ZIP 4 Crescent 978-202-2040 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction b(I Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': V 0.1G S01,0.r— It CA- r r41 Z F SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials) Official Use Only I.Building $ tG9f 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical ❑Standard CityPrown Application Fee $ - �'� ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression) Total All Fees:$ �r�� Check No._Check Amount: Cash Amount: 6.Total Project Cost: $��'t ❑Paid in Full ❑Outstanding Balance Due: Alt 141� .0 , SECTION 5: CONSTRUCTION SERVICES 5.11_Construction Supervisor License(CSL) 6�S 2`5 4 2$ , -1U.me,S ense Number Ezp anon ate Name of CSL Holder ,i� 1 ko�In SI rf�C"LC '1 List CSL lype(see below) U No.and Street Type Description SQL L LS A t C) O co 11 Unrestricted(Buildings u to 35,000 cu.f �"l _1%IP M Masonry R Restricted 1&2 FamilyDwellin own,S r•City/T f!D Roofin CoverinWindow and Sidin� ��CCSolid Fuel Huming Appliances us YVICIBo(OY0—vied {Sp�I Insulation Tele hone Email address rn Demolition 5.2 Registered Home Improvement Contractor(HIC) �, t—'I 0�6t-k`t3 l 1 wirct So'Qr Deve.lopeY ULC- HIC Registration Number E piston ale HIC Com any Name or HIC R gistrant Name 4g3PN. �0Q �. Yy\,0.Solpx@vtvtvL}s0kLY-, No.and Street Email address CsDrvt Provo LTE '64coc)4 1$13053oLOS 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 ..........A No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize VI V ltt So IcL to act on my behalf,in all matters relative to wok authorized by this building permit application. J � 0 8/3/14 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in th' - p tibn is true and accurate to the best of my knowledge and understanding. Print Ow s r rized Agent's Name(Electronic Signature) Dale 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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 sysle(n Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" A�® CERTIFICATE OFIIABILITY INSURANCE °1IM12013 """' nrov2Bta 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: 122517TH STREET,SUITE 13DO PHONE FAIT - DENVER,CO 80202-5534 D ac xo Alin:Demer.cetrequest@marsh.com,Fax:212.948.4381 ORE S: INSURE S AFFORDING COVERAGE NAICIf 462738-STND-GAWUE-13-14 INSURER A:Evanston Insurance Company 35378 INSURED INSURER B:National Union Fire Insurance Co of PA Vivint Solar,Inc. 4931 N 300 W INSURERC:New Hampshire Insurance Company 23841 PmYq,UT W04 INSURER 0: 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. I�TR TYPE OF INSURANCE ADOLS R POUCYNUMSER u&gU MIOWDDM'EY11 LIMITS A GENERAL LIABILITY 13PKGWE00274 11/0112013 11/01/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISS Ea occurrence) $ 50,000 CLAIMS-MADE M OCCUR MED EXP(My one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE Is 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG E 2,000,000 X POLICY PR0. LOC E B AUTOMOBILE LIABILITY 9701087 11/01/2013 11101/2014 COMBINED SINGLE LIMIT Ea accident) 1,000,000 B X ANY AUTO 9701088 11/012013 11/0112014 BODILY INJURY(Per person) $ ALL OS SCHEDULED BODILY INJURY Per acadenl $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTYDAMAGE AUTOS Per actlmde S A UMBRELLA LIae X OCCUR 1JEFXWE00088 11/01/2013 11/012014 EACH OCCURRENCE $ 10,000,000 X ��LV18 CLAIMS-MADE AGGREGATE $ 10,000,000 DED I I RETENTIONS $ C WORRERS COMPENSATION 029342334; 029342335 11101/2013 11101/2014 X WC STATU- OTH- AND EMPLOYERS'L°BILITY D ANY PROPRIETOWPARTNERIE)ECUTIVE YIN 029342336; 029342337 111012013 11MI12014 E.L.EACH ACCIDENT $ 1,000,000 D OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) 029342338 1110112013 11/012014 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 U yas,describe under DE8, RIPTION OF OPERATIONS be. E.L.DISEASE-POLICY UMIT is 1,000,000 A Elmrs&Omissions& 13PKGW00029 11N1I2013 11I01/2014 LIMIT 1,000,000 Conbactors Pollution DEDUCTIBLE 5,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ASaeh ACORD IN,AddiHoml Remarks Schedule,x more apace Is required) The Ceniticate Holder and others as defined in the written agreement are included as additional insured where required by written Contract with respect to General Liability.This insurance is primary and non- ntributoryover any existing insurance and limited to liability arising out of the operations of the named insured and where required by written Contract Waiw:r of subrogation is applicable where required by written nhact 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. AUTHORRED REPRESENTATIVE of March USA Inc. Kathleen M.Parsloe ./�F,(�A.�x7/f. ffiZ4&s1_ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD at,Provo,UT 84604 Employer Identification No.: 80-0756438 vivint solar""""'PMnc:(877)404-4129 Fax (80p 765-5758 Massachusetts HlC License NO: 170848 E-Mail: Support�ilvivimsolar.com pp n�f�1/yam www.vivintsolarcom AR No.: 3pg'IJ✓V RESIDENTIAL POWER PURCHASE AGREEMENT This RESIDENTIAL POWER PURCHASE AGREEMENT his"Agieeaftmr)is entered into by and between VIVINT SOLAR DEVELOPER,LLC,a Delaware limited liability company("We","Os","Our")and t e undersigned Customers)("You", Your"),as ofthe Transaction Date set forth below. Full Name frt.,,,an.i,s, ell Name fFlrza,v[,ea ei Cus[omer(s): t'a'ry a„—D r.,Dv. perry Owner:❑3'ea 0 No Telephone No.: -9J0* 00. .1O O E-Mail: Properly Street Address: AeC Address: City,County,State.Zip: 1.SERVICES A. DESIGN AND INS"TALLATION. We will design install,service and maintain a solar hotovolmic s tam on Your Pro e solar panels,inverters,meters,and other components(collectively,the"System'1 as funher described in the Costumer packet spud the Workwrll include all wilI provide to you hereafter. All mammal portions of the System will be installed by Our employed tecMicians and electricians,and not sbconlrac[orse With Your cooperating We will (i)design, install and connect the System in ma[enal compliance with all applicable laws; (ii)comple[e all required inspections;and(iii)obtain all required cc atat 'arts and permus. In notes to design a Systam that meets Your needs,You agrre that We may obmin Yom electrical usage history from Your elecvic utility(the"(IN/iry, and You shall provide Us with copies of Your Utility bills as We may reasonably request. Other than the activation lee described In Seci m 1 B,We will design and install the System at o cost to You. 6. ACTIYA'1'ION. Yuu agree to pay Us.. s a one-time activation fee in the amount of$ We will interconnect the System with the Utility,and cause the System to generate energgyy measured in kilowatt hours(kWh"))(the "£netpp'' slallation of the System generally takes one day and is anticipated to begin and be subatannally complete between two(2)and six(6)weeks hereafter. C. DWNERSIIIP OF SYSTEM. We shall own the System aS Our sole personal propetty. You will have no property interest in the System. D. OPERATIONS AND MAINTENANCE. We will operate and mainmin the System(i)a[Our sole cost and expense;(if,in good condition;and(iii)in material compliance with all applicable laws and permits and the Onliry's requirements. E. INSURANCE. We carry commercial general liability insurance,workers'compensation insurance,and property insurance on the System. For more inform anon con cc ing Our insurance,and to nbmain a copy of Our certificate of insurance,please visit: www.vivintsolarcom/Incurance. 2.TERM,PRICE,PAYMENTS,AND FINANCIAL DISCLOSURES A. ENERGY PRICE. For all Energy produced by the System,You she Us So.���5 per (The Energy Price shall increase each year by two and nine-tenths percen A good faith es[tmate of the Shslemnou [,rgir rmeacupred inpkpilowatL hours will be ro ENE to You in the Customer Packet THIS AGREEMENT IS FORTHE SALE OF ENERGY RY US TO YOU AND NOT FOR THE SALE OI' A SOLAR ENERGY DEVICE. B. TERM. This Agreement shall be effective as of the Transaction Date andcontinue until the twentieth(20')anniversary of the In-Service Date(the Te."). The"fit-Service Date"shall be the first day after all of the following have been achieved: (it the System has been installed and is capa generating Energy,(ill all permits necessary la operate the System have been obtained,(in)the System has been m[ercounected with the Utility,and(iblv)e allof inspections and certificates required under applicable law or by the Utility have been completed or received. C PAYMENTS. Beginning with me first month following the In-Service Date and throughout the Tenn,We will send You an invoice reflecting the designs for Energy paccount r the System in the previous math. You shall make monthly payments to Us by automatic payment deduction from Yom grated checking amount or credit card. It is Your responsibility to ensure that there are adequate funds or adequate credit Iran. There is nit financinng� charge crest in an with this Agreement For all y,plus s more thin ten(10)days past due,We may impose a late charge equal toTwenty-Five Dollars rac' ) and interest ar an annual rate of ram percent(l80),plus applicable taxes. If You continue to rail in make any payment within ten(10)days after We give You written notice,then We may exercise all remedies available to Us pursuant to Section 13161. D. RENEWAL. At Ne end of the Tenn,You may elect to(i)continue with this Agreement on a year-to-year basis,(ii)enter into a new Agreement with Us and cancel this Agr '"Ou purchase the System at the end of the Tenn aatl cancel this Agraement(the"Purchase Option")-or(tv)cancel this Agreemeet and have the System removed al no cost to You. You will need to notify Us in writing concerning Your election sixty(60)Jays prior W the end of the Term. If You elect the Purchase Option, the"Purchase Option Price"will be the[hen-crurent fair market value of the System based on an _ inJependent apynrser's valuation of similarly s�z<d phomvolmic systems in You'geographic reRinn. The ap raiser's valuation will he provided to You in TT�' writing and will he binding. If We receive Vour payment Tithe Purchase Option Price costs of the appraisaP applicable nixes,end all other amounts then owing and unpaid hereunder,We will vansfer ownership of the System to You a[tM1e end of the Term on an"As Is,Where Is"basis. [f Yau elect to have the Syysem removed,We will remove the System from Your ProPen within ninetyty(90)dayyss after the end of the Perm. IF VOU DO NOT'NOTIFY US OF men' YOUR ELECT'IUN TU CANCEL BY SENDING A WRITTEN NUTICE TO US, THEN THIS AGREEMENT WILL AUTOMATICALLY RENEW ON A YEAR-TO-YEAR BASIS UNTIL YOU NOTIFY US IN WRITING OF YOUR ELECTION TO CANCEL AT LEAST SIXTY(60) DAYS PRIOR TO TIIE END OF THE RENEWAL TERM. E. CREDIT CHECK. In connection with the execution ofthia Agreement and at any time during the Term,You hereby authorize Us to(i)obmin Your credit rating and report from credit reporting a comes;(ii)to report Your payment perormance under this Agreement to credo reporting agencies;and (iii)disclose this and other information W Our alia[es and actual or prospective lenders,financing panics,investors,insurers,and acquirers. WG MAY HAVE PRESCREENEll YOUR CRF,DIT. 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 provide a workmanship warranty that the System shall be free from material defects in design and workmanship under normal operating conditions far the Term. We further warrant that all rooftop penetrations We install shall be watenigtit as ofthe date of installation. We do not provide any warranty to You with respect[o any component ofthe System. Any manufacturer's warranty is in addition to,not in lieu of, utia IimiteJ insinllehon waranmy. This warranty does not cover problems resulting from exposure to harmful materials and chemicals, fire, flood, earthquake,or other acts of god.vandalism,alteration of system by anyone not authorized by Us,or any other cause beyond Our control. B. MANUFACTURERS' WgRRAN'f1E5. The Syysstem's solar modules carry a minimum manufacturer's warranty of twenty(20)years as follows: (a�during the fern fain(10)ppears of use,the modules'elcetrical output will not degrade by more than ten percent(10%)from the orginally rated output;and (b during the first twenty(20)years of use,the modules'electrical output will not degrade by more than twenty percent(20%)from the originally rated outptit The Systcm's invencrs carry a minimum manufacturer's warranty often(10)years against defects ur component breakdowns. During the"term,We will enforce these warranties to the t"idlest extern passible. YOU OR LANYI OTHER PERSOY,TWHETHER EXPRESSFORTH I HIISSSEC�RY,WE MAKE NOOTHER WARRANTY RRMERCHANTABILITY OR FITNESS FOR ANY PURPOSE OF THE EppUIPMEN'C INSTALLATION, DESIGN, OPERATION, OR MAINTENANCE OF THE SYSTEM, THE PRODUCTION OR DELIVERY OF ENERGY, OR ANY OTHER ASSOCIATED SERVICE OR MATTER WARRANTY',,, ALL OF WHICH WE HEREBY EXPRESSLY DISCLAIM. OUR LIABILITY FOR ANTO REPAIRING THE SYSM OR YOUR PROPERTY TO TH EXTENT REY BREACH OF ANY IS LIMUIRED AGR EEME T. Y UT ACKNOWLEDGE, THAT WE ARE RELYING ON THIS SECTION 3.CEAS A O'DITION AND MUATERIAIL INDUCEMENT TO ENTER INTO THIS AGREEMENT. THERE ARE NO WARRANTIES WHICH EXTEND BEYOND THE DESCRIPTION OF THE FACE HEREOF. 4.REMOVAL OF THE SYSTEM You shall not make any Alterations(as defined in Section 9 c to the System. If You want to make repairs or improvements to Your Property that require the temporary removal ofthe Syystem or that could rate ern wit its performance or operation,You must give Us at least thirty(30)days'pnor women notice (a"Customer-RepuesleJ Shudown'"). You agree that any repair or improvement to Your Property shall not materially alter Your roof where the System is msmlle om nsation(or Our removal,storage,and reinstallation of the System,You agree to pay to Us a fee equal to Four Hundred and Ninety-Nine Dollars befo a We remove the System. You shall be required to pay the Shutdown Payment(as defined m Section 15)ifthe System is not reinstalled wit thirty 30)days of removal. In the event of an emergency affecting the System, You shall contact Us Imm'�e tally. if We arc unable m timely respond,You may(at Your awn expense)contract with a licensed and qualified solar installer to remove the System as necessary to make repairs required by the emergency. You shall be responsible for any damage to the System that results from actions taken by Your contractor. 5.ARBITRATION OF DISPUTES Most customer concerns can be resolved quickly and amicably by calling Our customer service department a 8 7 412 If Our customer service department'alla in [o resolve Yourgconce Jm,You ificand W'e agree to resolve anOy Dis' ute(as detin a ow t on bunchbindinCCgg THATt(I)YUU ARE HEchurn'REBEL BY WAIVINGcTHE RIGHT TO A TRlt a JURYNI G I)Y U MAY RRINKINO CLA MS AGAINSTIIUS cou ONLY IN YOUR INDIVIDUAL CAPACITY,AND NO'f AS Awns PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING. You and We agree to arbitrate all disputes, claims and controversies arising out of or relating to /.M1*Alii a.'_iIL:\':anti i.,6irf4Gl'a.LIE'..\II e1n�N'�'.i"fLL OF OUR APFILIATLN. DIRECT(1R5, EMPLOY FPS. 4GFNIS nt E II 'I r Writing - 'dh b1hy dL Olt CONTRACIOILS FOR ANY SPECIAL EXEMPLARY 1 EDrIRr rC'RENU1 nT n . Ar + n aw r - a"I l d1 U.. 1 11,11h W kt1J nlu.. I are n. INDIRI'CI, INCIUI:NTAL, CONSEQUENTIAL OR PUNITIVE f I r nr1 'II II n i1I tl u ae- m oI c VrI AUs D ,M A( ES (WHETHER OR NOT THE CLAIM THFREEOR[ IS - dhol s""' l`�w1 lion o�c� su Ilon 0l nvu i rr 1 d mvl BASED ON CON TRACT.TORT,DUTY UMI OSED B} LAW OR zz NwUlxr Il NIR l +Ny n I Anil I' I d I - t,me pIHERAVISE),IN CONNECTION WITH,ARISING OUT OF OR hIt1I `r I1" Io1 dYou �1 he � Inpr' IN ANY' WAY RELATED ID FHE FR ANSACTIONS t s o and 1 o d s k 11, t tl Pr i pn 1 I 'n d is CONTEMPLATED BY 1111S ACRE EMFNT OR ANY ACT OR +ti 1 m I T ,. On, n a I r r 1 I1l. cu h n .l I I dh V hh a0 r a1@n OMISSION OR EVENT OC(,URRING IN CONNEIIION ; ,I are - nent Y II 1n rI 'ol I aI III -id 'FHERI3WITH. YOU HEREBY WAIVI--,RI-LEASE—AND ACRLE 21 coVFRNIN2. NASA B 1gn I d my - r meal NOF TO SUE UPON ANY SUCH ('11AIM FOR ANY SUCH g1'rd b dh+ I on,lonsd. d".i1n,Int,nnIiil Iias, D AMAGHS, W'I1 EL'H E2 012 VO'T ACCRUND AND WHETHER :I r l it' 1 rmI 1 f C)R NOI' KNOWN OR SUSILC ED 'r0 EXIST IN YOUR. 2i �,�16at,d til>I� ..rli n+l'.r41 Inilon+ bdlltr 'n nlncJ 11 m{ 1-1111�1 FAVOR YOU FURTHER AGREE THAT NO CLAIM aPl lloall p m 1m uldl 11on111 m V It -1oluch.rh ido,,,rrl LA WSUII'. OR ANY OTHER LEGAL OR ARBITRATIU4 rvf�n n d 'jW1 1n r in hr a a rah d 'In" , a 21:WIN IN N V 1 1 n p n1 1 1h G, 1 a I v PRCIC.FLDING IN C ONNFCTION WI'TFI,ARISING OUJI'O OR 'I th 1 1 r a1 ..+n 1 I d 1 - 1 I 1 n lI IIvR +hell IN ANY WAY Itl LA1FU TO THIS AGRFEVIFNT %lAY BE tnc rd (v,ahon1I c 'Ilollool 21511 ❑ In 17Iv ondl) BROHGHT, CCOMMENCLD OR FILM MORF III AN ONE (1) 36 h)INx 11t Yu1711 Y,q, t1 c hl Ill h ai I L, F IFlrtc mpni'cunt YEAR AFTER IIih INCIUE.-.NTGIV LNG RISK 10 SUCH CLAIM � o, unlh tyr l uhltb :'d -dl 'm and hP . '- sh 0lb YOU ACKNORLEDCE THrAT WE ARE RELYIN o G ON THIS Ica+d mC'ot Ili, xt 11 Li d I d [I pvh hid 10 I nuvhl. SLCLION 17 AS A CONDITION AND MATFRIAI I-n all Ilnr l .r 11 ->E„ 1st II n lot t adflk,. tv 1. N CU Eh1F,NT TO ENTER IN rO THIS AGRFFMENT- lbu,'1.1�1wchl�r, o o shalllhle dttnnl ioba m bmitid and slut l h ndartlotihlalwv�hc ISM DEYINI FICA PION To the fullest exlent perattd ha nxi n 1 'uMn Pn1 II I: c nre applicable Ialt. }'uu hereby nrrez to indemnity. ud1, expzu 291r t(nI�1ERaallls the nlurp rc}sh db d-m d1s co rti+t ne,'1 vnme u. end hold h.lrntle+ U., and Our affiliates. drectors. employee.. v f In parnbl d u em I nut f df Y sI II uum vn 'le' 1d rot' agents 6oetrnctor and Our successors and atSsi as (=t 4A PI RI ICtIY. >• h r t II L + 1 v d Y f i "Cm ered Person t IImt any and ill third part, claims, action 1 1 c0 is et nHes Unc ludinp[casomblc attonrevs fe s wot c'xpe0Se4) p nt+ 1 I at d 16 v In 1-n11 d a d t I 1 e al rliIl p dhn1[o Inirlul 'I nil cp 11+h tNe v.thrAb Il dvD 1pcc liabilius pumCtic's, In'4es ohliTiaU ns ut)uncs', cnotnoS 11 I r} prs Ih 1 nly + mI to ( P1 v. 1,+-rvdd.iu and hen'nl any Amd ur nurnre m c mne'uun++alh ansirlg not of or ti 1 l ) s gin' A 10 cr or rc e.uc U Inr v rt o�p 1 r tar a Io or� .IoF n In an} way rdnad t>(i)Your bn u<.h nl Ihia A lcunenL or(Ill YOUI <NT a e.1 0cehgeo.:c or w1hPu1 nuS ondun, prm uled that Yoor 29.PRU E N AND (1PT-OUT NOIICN. THIS indemniTlwbnn vbL aGuns and r ChF Szetion 18 ,hall not apply if "pR C N) - U ' C SC ON the harm or dams e that is the blsi or sac tlurtl purl, cluuu INFl 1RMAI fON IN }'OLi It CREDIT RGPORI INDICATING natnnred while nn of 11ur emplu))tie r r agents a'aS at Four Property THA I YOU MflC!T CERTA W(1t191 IiIA. 'FELLS OTHER IS NOT attd such harm nr l un ac ties sr lel� ulsad by the active iERIA. IF reeligenre YOURDO NO"I'y W ANT(IO R C IV Lt PRE CU LLNED OFFERS or++III Yul mi>conduct of such cmployr r ur;agent. 19.SUBROCATION. Ynu au ce to rcleas alI Covered Persons OF CREDIT FROM US AND OTHER COMPANIES CALL.THE from any clamis of ,+ny parries wmg through Yc w-wthmtt, u1 m CONSUMER II EPURTINC' N PIT IEU TOP.OLL FREE, I AL EN, Your more, such a+ Your mSuruoez eompmryt and 10 � *ree y TX OR\V 12I R N XPLRI ON OPT SILT, OV L O TI N. P.O. defend Us aminst ane such clean. YOL) \GREE TO N�TIEY TX 7y011. OOHLI)(1. PA NANIH. REMOVAL OPTION, P.O. YOURINYjV\NCL C'ONIPANY OT THIS RELEASE RUX SUS WOOD[YN. PA 19094, EQlr123i AM OPTIONS, P.O. 20 \NIENU\1ENIS ANDWMVERS. n � �Eu:r„ n ,only hemnr Nod or BOX 790123 A'II.ANTA.GA 3037d-01 b. (i)any as of the relationship between You abd Us,whether based in cnot Ter,tort,statute or any other legal theory (ii this any offer agreement concemmg the subject matter he cut, m any breach, default, or tennmation of this A ) Agreement or interptetalioq validit C ( ) greement; and (iv)the y,or enforceability o his Agreement Bement,including he determination of he scope or applicability of th s Section 5(each,a Orspute'"). Pdor to commencing afiitmhoq a arty mfo ust firs[send a written"Notice of Ditspute'via certified mad[o the otTier— wnhin lhirtys(30) daysalhenbei her panre may�co[mmen,e DarbPualioa tTheeerbi[ration sha I be ad islered bI.' JAMS l ursuant to its ANY d y p patty: The Streamline Arhitration Rules and Procedures(available ar: httpp//www.J"amsadr.com/rules-streamlined-arbitration,the"JAMS RhuleDc")and under[he rules set forth in this Agreement. The arbitrator shall be bound by the terms of this Agreement. No matter the circumstances,the arbitrator shall not award puni[ivo,special,exemplary, indirect,or conseyuen[ial damages to erthcr party. If You initiate azbitra[ioq You shall be responsible to Pay$250. All attorneyys' fees,travel expenses,and other costs of the arbitration shall be borne m You and Us in E L accordance with the JAMS Rules and appplicable law. The arbitration shall be conducted at a mutually agreeable location near Your Propertrtyy. Judgment on an arbitration award may be In in any court of cumpetentjurisdiction. Nothing in this Section 5 shall preclude You or We @om seeking provisional remedies m aid ofarbitran. tiom a court of competentjorisdiction. NOTICE:BY INITIALING IN THE SPACE BELOW YOU ARE AGREEING TO HAVE ANY DISPUTE ARISING OUT OF THE PH D MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES^PROVISION DECIDED BY NEUTRAL ARBITRATION AS D SPU'DE LIB CAfEDI IN ACABLCO RT ORJ URY TAW AN WAL IBY IITIALINC IN THRIGHTSE SPACF-IBELOW YOU ARE GIVING UP ARBITRATE. YOUR JUDICIAL RIGHTS TO DISCOVERY AND APPEAL. IF VOU REFUSE TO SUBMIT TO ARBITRATION AFTER AR ION PROVISION ISOVISVOLUNT RY. YOU HA VE READ AND UNDERSTAND THEFOREGOIUR AINNG AND ACREEITO SUBMIT DISPUTES ARISING OUT OF THE MATTERS INCLUDED IN THE"ARBITRATION OF DISPUTES^PROVISION TO NEUTRAL ARBITRATION.UWE AGREE TO ARBITRATION AND WAIVE HE RIGHT TO A JURY TRIAL..2C . tsj I—�I 6.N'OTICE TO CUSTOMERS O A. LIST OF DOCUMENTS TO BE INCORPORATED INTO THE CONTRACT: (i)this Agreement, a the Additional Terms and Conditions,(iii)the Customer Packet,and(iv)the Work Order. These documents are expressly ( ) to the relationship between You and US. P Y incorporated into this Agreement and apply 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 HIS AGREEMENT BEFORE YOU HAVE READ ALL OF ITS PAGES. You acknowledge that You have read and received a leg�blc co y of this Agreement,that We have signed he Agreement,and that You have read and received a Icgihlc copy of every document that We have signed during the negotiation. on are entitled to a D. DO NOT SIGN THIS AGREEMENT H' THIS AGRN:EMEN"1' CONTAINS ANY BLANK SPACES. Y completely Rlled in copy of this Agreement,signed by both You and Us,before any work may 6e started.Transaction Dato�K E. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO THE LATER OF: (t)MIDNIGHT OF THE THIRD (38D)BUSINESS DAY AFTER THE TRANSACTION DATE,OR(II)THE START OF INSTALLATION OF THE SYSTEM. SEE TTHE NOTICE OF CANCELLATION BELOW FOR AN EXPLANAT'!ON OF THIS RIGHT. VIVINT SOLAR DEVELOP CUSTOMER(S): By: Printed Name Title : Printed Name: n ! .� --S2►ctr By: Printed Name: FOR INFORMATION ABOUT CONTRACTOR REGISTRATION REQUIREMENTS, CONTACT HE MASSACHUSETTS OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATION: TEN PARK PLAZA,SUITE 5170,BOSTON,MA 02116, (617)973.8700 OR 888-283-3757. _ K___________________________ NOTICE OF CANCELLATION Transaction Date: 'OUT AR No.: THE TRA UK (IF NS Y O WITHIN THREE(3)BUSINESS CANCEL,ANY PROPERERT TY TRADED IN pry ppYML, THE STA OF THE SYSTEM. IF YOU NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED RWIIHIN TERN C((1 OR BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECRITV 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 CONDI DELIVERED TO YOU UNDER THIS CONTRACT OR SALE, OR YOU MATION AS WHEN RECEIVED,ANY GOODS Y, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT HE SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SF,LLER DOES NOT PICK THEM UP WITHIN TWENTY(20)DAYS OF THE DATE OF YOUR NOTICE 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 ALL OBLIGATIONS UNDER THE CONTRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF HIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE,OR SEND ) TELEGRAM TO HEVIVINTTHIRD D(. #,DEV ELOPER,LLC,AT 4931 N 300 W,PROVO,UT 84604 PRIOR TO THE,LATER OF: (O MIDNIGHT E THE THIRD(3 ) BUSINESS DAY AFTER THE TRANSACTION DATE,OR(11)THE START OF INSTALLATION OF THE SYSTEM. I HEREBY CANCEL THIS TRANSACTION: Date: Customer's Signature: i_ _ ._m.c vn�sotiaw,:wro.i ii.nn s�.m.aw,o.a. .. af.\vv w..n..TV.4;..;,,, VDDIIIONAI TERNS VND con DIEIONS 7. RFPRESENI CEIONS VND WIkssl IFh. A t I t d )rot In th A41rr Doll r IDJ Y Jrl t stil Ia l l�s lb��r�o a tbl h tlls III l oI II u S I' J Tu frla I I 'll he "Leol heto l 1 IIr flYu . ICI I 'I IN tut I,I P I Ipr Iry llfp Y( II all 1 nl p 11 I 11 Pll IA ) Sl Stull Inr11 nii J�-II nl Vt hill trn ltrb nrhje'�fi ht lh Cl ton ra (t ll.. 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Unseat l o t i 1 d lh s Is,[ 1 m I'h A01 Y FAI LURF,OL THL SYSTF M,OR AN1 NFGLLGGNT ACT N b I I b Fill h a I Y l i d ttri d S l I'IIF k d J TIIA7 CAUSbD ANY INJURY OR LOSS IWHETFIER enluto, )o P prat IROIERIY DAMAGE. PERSONAL IN.IURY OR DLAIH) TO R SSSI(NAII\l 3 ffMNS1 FR f 1 A' In nt R n 1 ell r 1NY ONIljjty . WF AND 1'OL (in»I I pmI II tr l Ty9 ten t'th S t Ier a.: l AGRt E THAT U1I kSS SUCH GROSS wll IY I ImJ 'dr ut I 11 'I . b r. l t,1 u )It, I.tvwnuni I'll lhwlf it'p If hi 11 f dII1 h5blialo flrb ilPr Ptn� NCJ((IIiIiNICILO1RAl.0 IORIS WI LFI L INJURY. �Sl(.'ll fill u .full prat 1 C al Jilt (Jot J P x u I'r r ° Si e 1 ARTY S LIABILITY ARISING OUT OF OR RELATING TO pl vc IY rp'ov ua1 nu hl Iu.ht lhr l v '.l lh THIS AGREEMENT SHALL IN NO EVENT EXCEhD THE p1:slluFHAI THIS hoe n' If lPrrp nl ire ul're 71 Jthc prp d Cuf a 1 U to Y II r 1 1J'f' I lit I aV dY 1 ly U4IUU NIh l �\ Fi\IRIRI PRISh RTAI'ION'OF THE 17Ai11(iLS 1rllas,r 1hnt W -� 'llv uy o lc 11 4 z llrllm I R' .I c °r'fn� Ih L th n proy p f dIn a II r m Yuv lhllb 1 an ndc' THAT YCIIJ OR 1Y C EYPEC I TO INCUR IN THE CASE OF.ANY d ' 1N v 1 r' ❑ 'l h u n )t .0 I o t h e the INJURY OR LOSS HEREUNDER. J t Y lop l (J 41t I I f W lu n d l p xv n '1 r d nIa" II. edtwo llYu sIn V' e )bl'Fv Uuli 'II1': 46 rI t .r NO CLAIM SIIAILHE MADE BY YOU A( AIASI'US OR ANY I rput. 'Imnt r f eu n u r A t hl'_�I 1.under Ih': !A(,I uuem,ttie _„ o. r. - a. , .....r .:gngl.. n.a.- • r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Vivint Solar Developer, LLC Address: 4931 North 300 West City/State/Zi`: _Provo UT 84604 Phone#: 801-704-9389 Are you an employer?Check the appropriate box: Type of project(required): 1.❑X I am a employer with 10 4. ❑ I am a general contractor and I employees(full and/or part-time). • have Fired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have g ❑ Demolition working for me in any capacity, employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its l0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' .com right of exemption per MGL P 12.❑ Roof repairs insurance required.]$ c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] 'Any applicant that checks box#I most 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 anew 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 most provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: New Hampshire Insurance Company Policy#or Self-ins. Lic.#: 029342228 Expiration Date:a 11/01/14 Job Site Address:.,_1 Cir�S� _ - - City/State/Zip: XJIU Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under pains idpenah�rvfperjurp I it e information provided above is truet. l and correct Si e " nature: Date: O Phone 9: o1-704-9389 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: v Office of Consumer Affairs nd Busin(� WJess Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 170848 Type: Supplement Card VIVINT SOLAR DEVELOPER LLC. Expiration: 1/5/2016 JAMES SHERMAN 4931 NORTH 300 WEST PROVO, UT 84604 Update Address and return card.Mark reason for change. SCA 1 c: 20M-05/11 Address Renewal ❑ Employment ❑ Lost Card tit Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor C =— ' License: CS-045254 JAMS R SHERMAN 6 Fox Hollow Dr16e = SAUGUS MA 01406 Ia >I W 11\ Expiration 0812812016 Commissioner vovont. solar 4931 North 3110 West Structural Group Provo,UT84604 P: (801)234-7050 Scott E. Wyssling, PE Head of Structural Engineering scott.wyssling9vivintsolar.com July 22,2014 Mr. Dan Rock, Project Manager Vivint Solar 24 Normac Road Woburn MA 01801 Re: Structural Engineering Services Orlando Residence 4 Crescent Drive, Salem MA AR#3193600 7.65 kW System Dear Mr. Rock: Pursuant to your request, we have reviewed the following information regarding solar panel installation on the roof of the above referenced home: 1. Site Visit/Verification Form prepared by a Vivint Solar representative identifying specific site information including size and spacing of rafters for the existing roof structure. 2. Design drawings of the proposed system including a site plan, roof plan and connection details for the solar panels. This information was prepared by the Design Group and will be utilized for approval and construction of the proposed system. 3. Photovoltaic Rooftop Solar System Permit Submittal identifying design parameters for the solar system. 4. Photographs of the interior and exterior of the roof system identifying existing structural members and their conditions. Based on the above information we have evaluated the structural capacity of the existing roof system to support the additional loads imposed by the solar panels and have the following comments related to our review and evaluation: Description of Residence: The existing residence is typical woad framing construction with the roof system consisting of assumed 2 x 6 dimensional lumber at 16" on center. The attic space is finished and photos indicate that there was no access to visually inspect the size and condition of the roof rafters. All wood material utilized for the roof system is assumed to be Spruce-Pine-Fir #2 or better with standard construction components. Our review of the photos of the exterior roof does not indicate any signs of settlement or misalignment caused by overstressed underlying members. Stability Evaluation: A. Wind Uplift Loading 1. Refer to attached ZEP calculations sheet for ASCE/SEI 7-10 Minimum Design Loads for Buildings and other Structures, wind speed of 100 mph based on Exposure Category"B" and 22, 5 and 24 degree roof slopes on the dwelling areas. Ground snow load is 40 PSF for Exposure"B", Zone 2 per(ASCE/SEI 7-10). 2. Total area subject to wind uplift is calculated for the Interior, Edge and Corner Zones of the dwelling. vivi t. solar Page 2 of 2 B. Loading Criteria 10 PSF=Dead Load roofing/framing 40 PSF=Live Load(ground snow load) 5 PSF= Dead Load solar panels/mounting hardware Total Dead Load=15 PSF The above values are within acceptable limits of recognized industry standards for similar structures. Analysis performed of the existing roof structure utilizing the above loading criteria indicates that the existing rafters will support the additional panel loading without damage, if installed correctly. C. Solar Panel Anchorage 1. The solar panels shall be mounted in accordance with the most recent "ZEP Code Compliant Installation Manual', which can be found on the ZEP website (zepsolar.com). If during solar panel installation, the roof framing members appear unstable, deteriorated, structurally compromised or deflect non-uniformly, our office should be notified before proceeding with the installation. 2. Maximum allowable pullout per lag screw is 235 Ibs/inch of penetration as identified in the National Design Standards (NDS) of timber construction specifications for Hem-Fir (North Lumber) assumed. Based on our evaluation, the pullout value, utilizing a penetration depth of 2 Yz', is less than what is allowable per connection and therefore is adequate. Based on the variable factors for the existing roof framing and installation tolerances, using a thread depth of 2 Yz'with a minimum size of 5/16"lag screw per attachment point for panel anchor mounts should be adequate with a sufficient factor of safety. 3. Considering the roof slopes, the size, spacing, condition of roof, the panel supports shall be placed at and attached to no greater than every fourth roof rafter as panels are installed perpendicular across rafters and no greater than the panel length when installed parallel to the rafters (portrait). No panel supports spacing shall be greater than four(4) rafter spaces or 64"o/c, whichever is less. 4. Panel supports connections shall be staggered to distribute load to adjacent rafters. Based on the above evaluation, it is the opinion of this office that with appropriate panel anchors being utilized the roof system will adequately support the additional loading imposed by the solar panels. This evaluation is based on information supplied to us at the time of this report and current industry standards and practices. Should you have any questions regarding the above or if you require further information do not hesitate to contact me. ery truly yours, OF (� / Y t m Scott E.Wy ling, aw MA License No. ,➢OF FG$7'cQ'0 FSSIONAA- bieint. solar 4 Crescent Dr, Salem MA 01970 a a F-- -—-— - -—- -—-—- -—-—- room 0'OF V'PVC CONDUIT LL m FROM JUNCTION BOX TO ELEC PANEL OO d i �'yO 0 I I PV INTERCONNECTION POINT, LOCKABLE DISCONNECT SWITCH, ANSI METER LOCATION, l`J B UTILITY METER LOCATION I I fl I 1 .e PV SYSTEM SIZE: 7.65 kW DC I .o I I a 5m � ^ o f a w U JUNCTION BOX ATTACHED TO— ARRAY USING ZEP ZS-GAB TO ) 12 �+ KEEP JUNCTION BOX OFF ROOF I y w Z m Z < r 3 N N Q Z Z E O (30)Trine Solar TSM-255 PA05.18 MODULES WITH A I SHEET Enppase M215-60-2LL-S2x-ZC MICR04NVERTER MOUNTED ON THE BACK OF EACH MODULE W Z I 1 ----- ------ ---- ----------- J � a SHEET NUMBER: PV SYSTEM SITE PLAN SCALE: 1/8" = 1'-0" 0 � .o v3 — \:\\\\X\ O o0 N bH spa m 0 ND ' m y m A u O v to C m z m m A O 0 q D � m v m z O m i o �e a < m - �0 0.0 'm w sm X O O T r D Z 2Cm 0 Yi INSTALLER.VIVINT SOLAR Orlando Residence P\/ 1 o m M ROOF m y INSTALLER NUMBER:1.8]].404.4129 `����,j solar 4 Crescent Dr V L y la A LICENSE:MAHIC 170848 v u u. Salem,MA 019]0 PLAN DRAWN BY:EF I AR 3193600 ast Modified 7/212014 UTILITY ACCOUNT NUMBER 0086759006 a� c Pow MOUNTING Hamm PV3.0 DETAIL �'c<m y<' 511E-0.1B:r STAINLESS Z LEVELING FOOT STEEL M,B.:TORQUE=1611 PJEs, OU v2 COMP MOVNT DE-CMA) a N O WATERPROOFING SEALA i WITHWAS"COMP MOUNT° Q PV MODULE,TVP.MOUNT AS NEEDED (� TO RAFTERS OF COMP. L SHINGLE ROOF,PARALLEL O j WITH PLANE OF ROOF a E PV ARRAY TYP. ELEVATION "'P-NUESSW"IMAM L.. i STAINLESS STEEL LAG SCREW S TOR°VE=1112 XACs. �,V} NOT TO SCALE 0 V • LEVELING FOOT ON COMP MOUNT + e PERMITTED LEVELING NOT TO SCALE •� ? FOOT SPACING LEVELING FOOT IZSLFB) FRAMING BELOW SXOWIN �DASHEO FOR AMITY ZEP COMPATIBLE FV MODULE HYBRIOINTERLOCK Q m O m G, U 2 m < LANtILEVER=L/3 L=PERMITTED SPACING �_ Q LL O LESS SEE CODE COMPLIANCE LETTER FOR ALLOWABLE SPACING PHOTOVOLTAIC MODULE > 2ujW EDEDML , II IFEEEEE JJ ED Zm I I I I I QaJQ LO N Q p II I zz � o I I I I I I I- ID INTERLOCK SHEET m reRL LEVELING FOOT IZSLFB) ocK(2SILe) ROOF FRAMING NAME: LEVELING FOOT(ZSLFR Z Q ¢ LU\ C Q NTER QLKaSXB) `FOOT ELInG �PV SYSTEM MOUNT DETAIL SHEET FQor SPACING NUMBER 1 MODULES IN PORTRAIT/LANDSCAPE SCALE:3/8"=V-0- O� NOT TO SCALE a Inverter Ratings(Guide Section 4) Inverter Mak.MaIal Ershase M21S6b2LL-52x-ZC Conduit and Conductor Schetive MODULE DETAIL Max oe von Fern, 45 vm. Tag o.amlm.. Geuga U.oIx.os. Cm 1w T, cvsAA sn. Max Power a girc 215 wane Ermnase iii an.-rlmm-2 Asia pON a) Nominal AC Vei 240 eare coppor Gi EG(Visi aAwG sax-Imi a.-Trans, y Tons Solar TSM-255 PA05.18 Max AC Coning o9 Amps tpnwc SOLAR MODULE Max 0i Rating zd Amos Im ,x-cm.m eAwG rT Met NUmEer of Panels/CiM1ViI 1T 1 wG T O THi2 aMG 1 Vv. V O NOTES FOR INVERTER CIRCUITS(Guide see0on 9 and St a mi Giww s.r A�A,�omm 1.)IF UTILITY REQUIRES VISIBLE-BREAK SWITCH,DOES THIS PV ModU a RBIIn S $TC(Guide$eeIIQD 5 W o Q 7 Enphase M215-60-2LL-52x-ZC SWITCH MEET THE REQUIREMENTS? g ( I wom, MICRO-INVERTERAT YES NO XNA Model Mekedgeml Tons Solar TSM-255 PA05.t8 2EI— Max Pew'er4mint Current(Imp) 8.36 Amps EACH MODULE,ATTACHED Qa°'. WITH ZEE HARDWARE 2)IF GENERATION METER ftEQUIREO,GOES THIS METER Max Power-Point Vpdaga(Vmpl 30.5 Volts yQ SOCKET MEET THE REQUIREMENTS? Open-ciibui,Voltage(Vest 37.7 Volts U YES NO XNA Short-circuit Current([a.) 8.92 Amps < 3.)SIZE PHOTOVOLTAIC POWER SOURCE(OC)CONDUCTORS Mix Banco Fuse(OCPD) ,5 Amps c BASED ON MAX CURRENT ON NEC 690.53 SIGN OR OCPD Nominal Maximum Power at SIC(Pmax) 255 Warts L MICROINVERTER CONNECTION RATING AT DISCONNECT. Maximum System Voltage 10006ECy67(UL) O j TO ENGAGE TRUNK CABLE 4.)SIZE INVERTER OUTPUT(Act CONDUCTORS ACCORDING Voc Temperature Coe2cien, -0.32 %PC ^ TO INVERTER OCPD AMPERE RATING(See Guide Season 9). V 5.)TOTAL OF 2 INVERTER OCPDX).ONE FOR EACH NOTES FOR ARRAY CIRCUIT WIRING(Guide Section 6 and B and Appendix D): PV CIRCUIT.DOES TOTAL SUPPLY BREAKERS COMPLY i! WITH 120%BUSBAR EXCEPTION IN 1.)Lowest expected ambient temperature based on ASHRAE minimum mean extreme NEC 69e64(B)(2)(a)? XYES NO by bulb temperature for ASHRbiE location most similar to Installation location'. -19-C #6 BARE CU GROUND --- IM (GROUNDINGARRAY) Signs(See Guide Section 7) 2J Highest continuous ambient temperature based on ASHRAE highest month 2%dry bulb ate+ 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 C United States(Palm Springs,CA Is 44.1-C).For less than 9 current-carrying conductors ( Solar PV System AC Point of Connection roof-mounted sunlit conduit at least 0.5-above reef and using the outdoor design AC output Current 27.000000 Amps temperature of 47-C or less(all of United States). • Nominal AC Voltage I .0 Voha a.)12 AWG.90-C conductors are generally acceptable for modules with live of 7,68 Amps or less when protected by a 12-Amp or smaller fuse. ry AND BOIAR THIS PANEL FED B SOLARLTIPLE SOURCES bJ 10 AWG,90-C condoctone are generally acceptable for modules with Ise of 9.6 Amps (UTILITY AND ) or less when protectedb a 15-Arnip or smaller fuse. •C bz 16 - NOTE: NEUTRAL CONDUCTOR(S)OMITTED FOR CLARITY •� ALL INVERTER OUTPUT CIRCUITS WILL HAVE A NEUTRAL CONDUCTOR PV CIRCUIT 1: 17 MODULESIPARALLEL ENVOY BOX be ca co ax MURRAY - POINT OF DELIVERY ac < COMBINER AND INTERCONNECTION < re m oip PANEL 125011 SIEMENS as 4 \Gas-b LW004NR 6ON240V F to U PO\F 2Q OR EQUIVALENT UNFUSED NEMA3 M z m Q PV CIRCUIT 2: 13 MODULESIPARALLEL Q'Dxt),iP is SREC/ANSI LNF222R oR O,;'o C METER EQUIVALENT \0 EXISTING W J z be 11A LOAD240 ,CENTER\ It A zQ K15A �\Y/� ? ? E aE 1.0 \ SHEET _ NAME \ MILBANK 1 W Q VISIBLEILOCKABLE Z IX JUNCTION BOX 2 \\ 3 100A OR 3 'KNIFE'A,C 3 J Ur NEC 2014 Compliant WITH IRREVERSIBLE E 1.0 \x EQUIVALENT DISCONNECT M Q GROUND SPLICE E 1.0 U5934-XL-BLG E 1.0 O SHEET NUMBER' C=) U-1 Vivint Solar - PV Solar Rooftop System Permit Submittal 1. Project Information Project Name: Salvatore Orlando Project Address: 4 Crescent Or,Salem MA A.System Description: The array consists of a 7.65 kW DC roof-mounted Photovoltaic power system operating in parallel with the utility grid.There are (30) 255-watt modules and(30)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 INT'L 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 (Stare Board BR&S) 2. Structural Review of PV Array Mounting System: A.System Description: 1.Roof type: Comp. 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: 1410 Ibs d.Total number of attachment points: 81 e.Weight per attachment point: 17.4 Ibs/square foot f.Maximum spacing between attachment points: * See attached engineering talcs g.Total surface area ofPV array: 528.3 square feet h.Array pounds per square foot: 2.66 Ibs/square foot i.Distributed weight of PV array on roof sections: -Roof section 1: (22)modules,(52)attachments 19.88 pounds per square foot -Roof section 2: (4)modules,(20)attachments 9.4 pounds per square foot -Roof section 3: (4)modules,(9)attachments 20.88 pounds per square foot vivint. sold " t f 3. Electrical Components: A. Module (UL 1703 Listed) Qty Trina TSM 255-PA05.18 30 modules Module Specs Pmax-nominal maximum power at STC - 255 watts Vmp-rated voltage at maximum power - 305 volts Voc-rated open-circuit voltage - 37.7 volts Imp-rated current at maximum power - 8.36 amps Ise-rate short circuit current - 8.92 amps 8. Inverter (UL 1741 listed) Qty Enphase M215-60-2LL-S22 30 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 1 - 17 modules/inverters (20)amp breaker PV circuit 2 - 13 modules/inverters (15)amp breaker 2011 NEC Article 705.60(B) vivint. solar D. Electrical Calculations 1.PV Circuit current PV circuit nominal current 15.3 amps Continuous current adjustment factor 125% 2011 NEC Article 705.60(B) PV circuit continuous current rating 19.125 amps 2.Overcurrent protection device rating PV circuit continuous current rating 19.125 amps Next standard size fuse/breaker to protect conductors 20 amp breaker Use 20 amp AC rated fuse or breaker 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 Article 705.60(B) 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 Article 705b0(B) Adjusted PV circuit continuous current 26.9 amps c.PV Circuit current adjustment for conduit fill Number of current-carrying conductors 6 conductors Conduit fill derate factor 801/ 2011 NEC Arudc 705.60(B) Final Adjusted PV circuit continuous current 33.6 amps Total derated ampacity for PV circuit 33.6 amps Conductors (tag2 on 1-line)must be rated for a minimum of 33.6 amps THWN-2(90°C)#10AWG conductor is rated for 40 amps (Use#10AWG or larger) 2011 NEC Arudc 705.60(B) 4.Voltage drop(keep below 3%total) 2 parm 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 interconnection) 1.Mirco-inverter voltage drop: 0.24% The largest number of micro-inverters in a row in the entire array is 7 inCircuit 2.According to manufacturer's specifications this equals a voltage drop of 0.24%. 2.AC conductor voltage drop: = I x R x D (-240 x 100 to convert to percent) _(Nominal current of largest circuit)x(Resistance of#10AWG copper)x(Total wire run) _ (Circuit 1 nominal current is 15.3 amps) x (0.00126Q)x(180� -(240 volts)x (100) 1.44% Total system voltage drop: 1.68% vivin#. solar EcolibriunnSolar Customer Info Name: 3193600 Email: Phone: Project Info Identifier: 6125 Street Address Line 1:4 Crescent Dr Street Address Line 2: City: Salem State: MA Zip: 01970 Country: United States System Info Module Manufacturer: Trina Solar Module Model: TSM-255 PA05.18 Module Quantity: 30 Array Size (DC watts): 7.65 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: Enphase Energy Inverter Model: M215 Project Design Variables Module Weight: 44.8lbs Module Length: 65.5 in Module Width: 39.625 in Basic Wind Speed: 110.0 mph Ground Snow Load:40.0 psf Seismic: 0.0 Exposure Category: B Importance Factor: II Exposure on Roof: Partially Exposed Topographic Factor: 1.0 Thermal Factor for Snow Load: 1.2 Lag Bolt Design Load-Upward: 820 Ibf Lag Bolt Design Load - Lateral: 300 Ibf EcoX Design Load-Downward:493 IV EcoX Design Load -Upward: 568 Ibf EcoX Design Load- Downslope: 353 Ibf EcoX Design Load- Lateral: 233 Ibf Module Design Moment—Upward: 3655 in-lb Module Design Moment—Downward: 3655 in-lb Effective Wind Area: 20 ft2 Min Nominal Framing Depth: 2.5 in Min Top Chord Specific Gravity: 0.42 Plane Calculations (ASCE 7-10): 2 Roof Type: Composition Shingle Average Roof Height: 30.0 ft Least Horizontal Dimension: 8.0 ft Roof Slope: 5.0 deg Truss Spacing: 16.0 in Edge and Corner Dimension: 3.0 ft Snow Load Calculations Description Interior Edge Corner Unit Flat Roof Snow Load 33.6 33.6 33.6 psf Slope Factor 1.0 1.0 1.0 Roof Snow Load 33.6 33.6 33.6 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -21.2 -32.6 -45.5 psf Net Design Wind Pressure Downforce 8.3 8.3 8.3 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 Design Wind Pressure Uplift -21.2 -32.6 -45.5 psf Design Wind Pressure Downforce 8.3 8.3 8.3 psf ASo Load Combinations Description Interior Edge Corner Unit Dead Load 2.5 2.5 2.5 psf Snow Load 33.6 33.6 33.6 psf Downslope: Load Combination 3 3.1 3.1 3.1 psf Down: Load Combination 3 35.8 35.8 35.8 psf Down: Load Combination 5 7.5 7.5 7.5 psf Down: Load Combination 6a 31.2 31.2 31.2 psf Up: Load Combination 7 -11.2 -18.1 -25.8 psf Down Max 35.8 35.8 35.8 psf Spacing Results(Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 50.0 50.0 50.0 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 16.7 16.7 16.7 in Spacing Results(Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 30.3 30.3 30.3 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 16.0 16.0 16.0 in Max Cantilever from Attachment to Perimeter of PV Array 10.1 10.1 10.1 in Layout i:. TV s (i wM1 \ wv 7E`F 6 i i r c. z Skirt e Coupling 0 Clamp Plane Calculations (ASCE 7-10): 1 Roof Type: Composition Shingle Average Roof Height: 30.0 ft Least Horizontal Dimension: 15.0 ft Roof Slope: 22.0 deg Truss Spacing: 16.0 in Edge and Corner Dimension: 3.0 ft Snow Load Calculations Description Interior Edge Corner Unit Flat Roof Snow Load 33.6 33.6 33.6 psf Slope Factor 0.88 0.88 0.88 Roof Snow Load 29.6 29.6 29.6 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Design Wind Pressure Downforce 11.4 11.4 11.4 psf Aso Load Combinations Description Interior Edge Corner Unit Dead Load 2.5 2.5 2.5 psf Snow Load 29.6 29.6 29.6 psf Downslope:Load Combination 3 11.2 11.2 11.2 psf Down: Load Combination 3 27.7 27.7 27.7 psf, Down: Load Combination 5 9.1 9.1 9.1 psf Down: Load Combination 6a 26.5 26.5 26.5 psf Up: Load Combination 7 -10.3 -17.8 -27.4 psf Down Max 27.7 27.7 27.7 psf Spacing Results(Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 61.9 61.9 61.9 in Max Spacing Between Attachments With RaftedTruss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 20.6 20.6 20.6 in Spacing Results(Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 39.1 39.1 39.1 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 13.0 13.0 13.0 in k 1° �P h tlr# Y@b £ `fit ✓�gf�4�..�..o � '�� � P P 5 Py '4 ie'3 V 'Wzu Plane Calculations (ASCE 7-10): 3 Roof Type: Composition Shingle Average Roof Height: 20.0 ft Least Horizontal Dimension: 10.0 ft Roof Slope: 24.0 deg Truss Spacing: 16.0 in Edge and Corner Dimension: 3.0 ft Snow Load Calculations Description Interior Edge Corner Unit Flat Roof Snow Load 33.6 33.6 33.6 psf Slope Factor 0.84 0.84 0.84 Roof Snow Load 28.2 28.2 28.2 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Design Wind Pressure Downforce 11.4 11.4 11.4 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.5 2.5 2.5 psf Snow Load 28.2 28.2 28.2 psf Downslope:Load Combination 3 11.5 11.5 11.5 psf Down: Load Combination 3 25.8 25.8 25.8 psf Down: Load Combination 5 9.1 9.1 9.1 psf Down: Load Combination 6a 25.1 25.1 25.1 psf Up: Load Combination 7 -10.3 -17.8 -27.4 psf Down Max 25.8 25.8 25.8 psf Spacing Results(Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 64.1 64.1 62.3 in Max Spacing Between Attachments With RafterfTruss Spacing of 16.0 in 64.0 48.0 64.0 in Max Cantilever from Attachment to Perimeter of PV Array 21.4 21.4 20.8 in Spacing Results(Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 42.0 42.0 42.0 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 14.0 14.0 14.0 in Layout yy X "'•r. z +ti��1 6�X X41M Lid II y��3� Y SX } I i�i 11 i t A �i x e Mai Skirt e Coupling 0 Clamp Distributed Weight (All Planes) In Conformance with Solar ABC's Expedited Permit Process for PV System (EPP) Weight of Modules: 1344 Ibs Weight of Mounting System: 162 Ibs Total System Weight: 1506 Ibs Total Array Area: 541 ft2 Distributed Weight: 2.79 psf Number of Attachments: 81 Weight per Attachment Point: 19 Ibs Bill Of Materials Part Name Quantity ESEG01 CLASA EcoX Clamp Assembly 81 ESEG01COASA EcoX Coupling Assembly 36 ESEG01 SKKTA EcoX Landscape Skirt Kit 13 ESEG01 SKKTA EcoX Portrait Skirt Kit 4 ESEG01 CPKTA EcoX Composition Attachment Kit 81 ESEG01 ELASA EcoX Electrical Assembly 3 d b� `� . �' J- Thc Comnwmti�alth uf Mass:ichusetts i y i ;,• `"'= 13uurd uf 13uilding Rrgulations and StanJ:ir�s Pc>I2 i � i I� . ,i, 11l''Vll'll'.\I.I'll M:�ssachusetts titate Building ('ude. 780 C'MR. 7 eJition � 1 �, .I. 1 I'.til[ � � . 'I a l3uilding Permit Applicatiun To C'unstruct. Rrpair. Renocate Or Demulish a Krris.JJ,uu��u, i aO�u-- ur Tiru-Funul� D�rrlliii,4 /. 'nnJ' \ Thiti Secliun Fur Officiul Use Only -- � Building Pern�il � ' unber. � Date Applied: L ' 5ignature: -- <S Ti 8�----— 13 I � Cummfssi�mrr/ �pertur uF BuiWings U:uc � �Fc�rtoN i: .ti���F i;vFoitni,��r�oN —___-� �-- - Ll Properq� :�ddress: 11 :�ssessurs M1lap .`F P�rccl Vumbcrs . __------ ------ ------ �------- I � � 'ia Nunihcr P:ir:cl Numhcr �L la Is thii an acrep[ed alreeY. yes_,_ nu . ,_�-- -------_ -- ;_: Lo�ing InPurm•rtion: �i.4 Prrsperty Uimemiuns: � � -- — i Zuning Diilrici. PruposeJ Use _ '_.' Lut Arc_�Isy tt) _ Frunnige ilil _ _� I------— I 1.5 itaul�3i�;g SriF,:irks (ftl — ---_----� �-------�..._ —.�—�—. —. j F�nnc Yard � 5ide 1'arUs Roar Yurd �-------�-- P.equircd F�ov�ded Reyuireel Nrovided RcywreJ Pruvi�!,�,1 __ �' __�.____---__ ___— _._ -- __--.--______ ,___-- �—___ I �------�----- ' ----1 1 Y.fi Nn[er 5upply: :t.i.G I.c. 40. §511 1J F'lood 7_une Inform.mtior.: 1.8 Sewage Disposal S�strm I Zone: OutsidH Floud."l.onc7 "ublic ❑ P;i�,sie C . __.— _._ ._ biunicipal ❑ On si.c dispusa; sy;!cu: ❑ Chccki(yesC I ,---_ i ` ' SEC'PIOY 2: PROPGRTY OWNERSHIP� __ _J F-------� , I � 2.1 ���ner uf Recor ' �-�✓4 ����-- -�-����������� -- ; i ��amt iYnntl � Ad.l�e�a lui Servicc. I � _aL'��Z�`( 2 '_�---- ; jSigrature -- _ "felephone _.. _ � i---- I ; 5EC':'ION 3: UESCRIPTIO\ OF PROPOSED WORK' (check all ths�[apply) �------- — ! `+z��Cr;nseru_:ion C Exivtine Building ❑ Owne�-Occupied ❑ Repairs(>J ❑ Alteration(s) ❑ Addit���n ❑ F--------'—�-- � _ � --� i I'�emeiition ❑ � Accessury 81dg. ❑ ( Number uf Units_ Orher L� Snecify:_ --- ; --`---_._ J_— -' � i�rie�f)escr.utio�of Pro};uszd �VurkZ: n - 14�P_ �X i S T� 3 �F _ .o� d _ �ee,� � 5�61 So r, _��cP_C._� � ; o�.�__..�'—_.�_ ----- - i -�--- ------ ----- r ----- - - i SECTION 4: ES'�Ih1ATED CONS'CRUCTION COSTS _ � �� Estimated Costs: � Eiem � OFfcial.Use Only � ILaburandMaterial�t � ` i' ---F L Duildine Permit F�e: $ - Indic�re hu�.� fre i,J�tr:minrJ: � L [3uildin@ .`S S' 00� ma � i ❑ Standard City/Tcwn Applir�tiun Fee � Electric�l � --. I ❑Tutal Project Cost' (Item 6) x multipliar_ x _.__ ' �. Plumbing 3 l �. Other Fees: $ ! a. Merhanical (HVACI '6 Lisc _ I i. Mechanical IFire � � � Su� retiai�m) �Cot:�l All Fees: S $�y- Cherk Nu. ChecA Amuunt C:uh :\mnuni:___ � j c�. To[al Projec[ Cost: '6 +�sp,p, � ❑ P�id in Full � Outsumding B:il:mce Dua:— ---_ I I � �a-� � ��S�ryy �r. � SECTION 5: CONSTRUC"PION SF.RV7CFS I $.� Licensed Construclion Supervisor ICSL) / 2 Z� �� O�=Zp=��O_ /�,.� ' //�1 �O '( ( '7'/�0��7'�. ���/r'✓O S �O r'�S T,�ha Liccnse Nwnhtr Ilspir:uiun Uai� Namc u(CS{.- Ilul�cr f ' � 1 `��( �G �C('�J y 1' J�� LLcI CSL Typc Iscc hclu�c)_V — ,. "I' c Ucscri i�i�m � .\J�rra. ) �y�q . �� � �jQ'�/�/'7� ///v' l� l�nresu�icirJtu ioli.lN10('u. l=�.i - R Rcctnrtcd 18c'_ Famil`; D����Iline Si�na t �1 �1:uunn� Unlv �_ RC Rcsidrntial Nuolinc Cc�.cr:ns—- rir ic _ ^ � q • � �S ` L�d ,� � \F'S Rr.i�rr,li.tl \l'u;����: :utd;liviny_ ' �� 0 SF I�•+iJcnu.d Soliil Furl Bw�mn�: .\ppli�.imr Inu.�llaw�u D Rniil�nii:�i UcnwLliun . . 5.2 Regis[ered ume Improve en[ Cu tractor(N!C) — � � / � ? Z n. e l� �_ ,�-- -i � � ' --- HIC Cumpuny Name or HIC Rceistrant Namc Rreisvauun i\'umbcr - .a��ress — .S�_l 1. c�'J � _' . _._ ._______ I f�.piroti�_m D.ur — -— S�cr,:v��rc . . Te!rphnnc � _"..__.---_�._— �—.._..__ . __ SECTION 6: WOSLKERS' COMPENSA'fiON INSIJtt1NCE AFF7DAV[T(D9.L:.L. c. i�:. y _'SC!fip . Wurkers Cumpensa[iun Insur.�nce affidavit must be completed :md su6eti[t�d with [his :ienlicatiun. Failurc U� pru��icie Ihis aftid�vii :vill result in the denial uf the Issuance ut�the buiiding permi;. _ _ __ ___I 1 Signed Affid:rvit Acn:ched? Yc� ........_ �� Mo ........ . ❑ � ----�------- -- � �-- �- -- -- .. . --�----- C6:CTION 7a: OWNER AUTFIfiR�s�_ ctV GO BN' CC3 .IiT1 G'CF.D SVHGN I l�'vVNER'S AGEN'f OR CONTRACTtIR �Yt'..i£� �'GT� �►11�UiNG PERMI'1' ________� �f. — - - _, as C•xner of!^e subject pruperry hereby au[horize --- —_ to act un rny behulf. in ;ill m:itters � reiative w work uuthorized by this building permit applicatioa .. _ I Si- nawrc uf Owner Uy�c _. ._ -��- . SECTION 7b: OWNER� OR AUTHOR(ZED aCFNT Ds;(,LARA'f10N �, __ , as Owner or Authorizcd Agent hereby Jeclare I �h,it ttie statements and informatiun on the foregoing �ppliration are true and accur:ue, ro the best of my knuwledge und behalf. Print Name Signature of Ownrr or AuthorizcJ Agent � Dutc (Si ned under[He pains anJ penaltics of perjury) ___ . IYOTES: i. An Ownzr who ubtains a building permit :o do hi:;lher own �cu�k ur:m u�rner wh�� hires :in um�egistered runtranur (nut registered in Ihe Home Impruvement Cuntranor IH[C) Prugram), will no! have accesx to the :ubitra�iun � pre�ram or guaranty�fund under M.G.L. c. I-t'_A. Other impurtant infurmatiun on the HIC Program and ICimstrurtion Supervisur Licensirg ICSL)ran be found in 780 CMR Regulati�ms I10.RG :�nd I IO.R$, respectively. � _' When substantial work is plamied, pro�iide the in�i>rmariva bel.;w: � T�ttal fluurs arca(Sq. Ftl lincluding gurage, tinished busemenda[tics, de��ks��r purrhi . � Cirotis livmg ure� i Sq. Ft.)_ Habi[able ruum cuunt _ ; � I Number uf tireplaces _ Number uf bedmum, _ �,' Nuntber�if bathruums_ Numbtr�>f h;ilf76:nh, __ '1'ype��f heating rystem Number uf dtcks/ p�xnc�s - - ---- � - 'Cype �if couling syuem Lnclo,ed Upcn _ : I 3. "Tut:d Project Square Fuot:��e" may be substituted fur"Tutul Pru�ert C�uY' , • ,•�� , CITY UF SALEM ��;�� �--' PUBLIC PRUPKER'I'Y �% DEPART:�IENT - . „ „:., , ,� : . ...� ��I.��• at I': U-�.i�:�.�,:�,�i:,� � i • ��;: ��. \I�..�� ��.; , � . :1 ��= . I�� i . �i'tl.-�;_��;�r • I���: �rS.-+:.•+�Y�„ Nurkrrs' C'4mp9qsation Insur�nce :\ftida�it: l3uilders/CuntrartorsiElcrtrici•rns/Nlumbers \ i �li�eut InPurnirti�rn Ple•�se Print LreiblY �.Illli ilfu.ric.. tlr_.uui.�u��n Iudi�:du.Jl'�4�alCi� � � N9 ( \�I�lr�is: 7 �✓� TG 4 C r 4vS' T �� _ — ��Y�P - /r1� � �g 70 �h���� .�: � �8- '�' / s" - �/� 7 '1 ('ity Statc.Zip: - .\r. �uu an cmplu��er.' Chr.k the apprupri�te box: �f��pr of project(rryuired): I.❑ I :�m a emplupar��ith ;. ❑ I am a gcntral cumracWr �nd I h � Vtw iu�utructiun emplayaes ltull an�l'ur part-time).' I18�'C hircd ehe sub-cuntracmrs � � RemuJeling . li,te�l on the �nached,heet. • �.❑ I ,Illl J SUIC F1fU�fICIUf Uf F1llfI11Cf- I I]C5C 5Ub-l'OIIIf:IC1UfS I1:IYt 8. ❑ Uem��li�iun ;hip and have nu empluyees . ��i�rkers' cump. insur�nce. y. � I3uilding addition _ �curking li�r mr in �ny �:�p��i�y. ��u wurkrn' rwup. in,urance 5. \Ve �rc a corpuration �nd its 10.[] Electrical repairs or additions .. rcyuircJ.� ��itieers huve cxercistd �heir - �""� n �ht of�xem «on er MGL I LQ Plumbing rcpairs ur�dJitions '" i,❑ I am a homeowner duing all wurk `SI S?. ��(,�1, and w have nu I_'.Q Rouf rrpairs �"'"•.�� myself. [Nu wurkers' �ump. , insurance reyuired.J � rmployeas. [No wurkers �}.� pther - _ eump. insurance rryuired.� •:1ny,ipplic�m iha�checks bua N I mm[al>u I711 uw�he sectwn below.huwing�heu worken'cumpensntiun policy infurmalion. �� � I lu�nc�wners whu>uhmie thie affiJavit indicabng�hey nre Juing all work and then hirc uuuide coNraUurs mu>t submh a n<w�ftiJavit inJicaling such. �(',nnrac�ors�h��:heck ihis hua must altaeheJ un adJilinnal sheet.huwing ihe n�me ol�he sub-cuNroclnrs and�heir wurkrm'cump. po��cy m���+�ion. /um un rmpluyrr thut is pruviJing wnrken'i'amprn.�'u�ion insurunee jar nry emplrryrrs. Brluw is�he polic•y�nJjob sitt "^ � UlfO!/IIG(%I/tl. In>urance Company tiamt:-- Espiratiun Dare: Policy �or Selt-ins. Lic. a: � Ciry,State/7ip: J��b tiile ,\d�rcss: .\ttach a copy of the workers' compens•rtion polky decl•rr•rlion p•age (showing the policy numbrr and ecpiratlon date). F;iilurc �o,ccurc eu�cr�ge as rcyuiicJ unJer Src�iun _'SA ut�IGL c. 452 c�mlead tu the impositiun uf criminal.�enalties of a' iii�� i�p p� $�,i01L0U ;uid,'ur �me-year-imprisonment. as ��'cll :is civil p�naltics in tha tixm nf a STOP \VORK ORDFR and a fine „1�u�� �,� )-50.00 a J:1)' ,lL�lll�t Illl' �IUI:IIUf. ISC :ItI\'I�CtI fI1JI LL CU(1Y of ihis sroirinrnt Ill:lY t1C li�ncar�rd to thc (�)ftice uf lu�a,tiu:��i��n: of di�• UI:\ Gir iiuurancc �o�arage �rnti.annn. � /Ju hrrrb�• rrrt� i' ����iler d�r �in.v unJ pa•nulfia���oJ prrjurp dmr d�r infi�rrnuiion pru��idrJ��borr i.c mir miJ a orrrcA I);ue 5 � '2" � -sl d <i,�n.uura. . I'P,ni.c = ��//iriul u�r unl�•. Du n��r �rrirr in N�i.r �rr�. �o hr a unqilerrJ Ay rily or t�ncn i�jfirruL I'. Pcrmivl.icrnse N _ - .- - ._ .. ._ . . -_-- -- ..— (�ilc nr I�u��n: . . _ . -. . __.__. . . _. - � I.�uin� .\u�horily�lrin9c anc): . 1. Ituurd ul Hcnith 2. IfuilJin�; Dcpartmcnt 1. ('ih��fnwn Clcrk J. F:Icc�ri.�l Insp.c�nr 5. PlumAinK Inspector 6. Olher .—. ----- -� -----�----- , Cuntact Pcnon: ----- Phonr q:--- .---- [nformation and [nstructions " � � •- � \I.i...i.l�,u.ctt� (irnrr:il I .m..L:ipirr I �' rryuirrs .ill rinplu�rr. �����ro�i�c ����rl�rrs� :��in�irn>.w��n f��r ihcir cmplu�ecs. I'ui,u.in� ia ihis ,t.uut�. .in rmplurer i. ,Irth�r�l .is " ��rr� prr.on u� thr .ct�iec „(.ni�nhrr unJrr .im :�mtra:t �if hirt. :y�i:.: ,�r iin��li�J. or�l or ��nurn." � • \r. .�mplurrr i. J.•IiniJ .�, ".in in.b�;�lu.il. ��.irir.rnlup. .i,a�:i.iuon. ��n�p�iran�m ��r ��ihrr Irc�l rnut��. ��r .ui� h���or murr ��� ihr (��i:_„in� rn_:�grJ in a I�nn� rnirrpri.e. .uid in:lu.line d�r Ir_al reprrsrnt�t��r, ��f� �c:r.i.rd rmpl�»rr. or dte ;r..•ner nr �ru,icc ��(.m inJi�iJu�l. p:u�mrr,hip. ,i>s��ciduun ��r�nhrr la�al rnuip. rmplo�inv�rmpl��res. Il���c�cr ihe ,�•.�nar ��f:i .lotlhng housr ha�in� n�n ;n,�rc ih.in thrcr .ip.inmrnt. ,in� nh�� rrsiJ�•. ihrrrin. ��r dte oc:upant ��fihe J��:i!in� h,�u,r ��1.m��thcr ��h��tny�l���. �.�•n�m, i.� �lu m.untrnanie. c�m>Irurnon ��r rrpair ���irk �m ,urh il��tlling hoiur � ,�r �,n ihr ��n�un.is ��r huil�ing.�ppunrnaiu �hrr.io .hall n�q hr:.w�c ���.u:h rmpl�n n��•nt be �ermcd tu be .in rmplu}er.�• >Ie IL ,hapier I�'. :'`Cln� �I,�� .�atr, ihat "c.cry s��te ur local licensing agenc�' �hall ��i�hhuW �hr issuance or rcne���l uf a licrnse ur parmit tu uperate � business ur �o runstruct builJings in ihr .ummonrre•rlth for any appli.ant �.hu h•r� not pruJuced acrept�bir e�iJencr uf cumpli•rncr ��i�h ihr insurance curerage reyuired." .\Jih�i�rnally. �I(iL rhapter I S?. j'i(�1�I .,�.�trs "\'�•i�hrr thr c�mimi�mcralth nur:my ��f its p��litiral :uhJivi.ions ;hull .w.r iniu any romr:�c� for �he �CfIUI'111dfICl' �I'public ��urk unnl acerptabk r�iJrncr uf iU111PI1:lOCC WIII7 lFir 111511fJI7CC rcyuu�cmrnts uf thu rhapter huvr been pre�enrcd �u ihe convac�ing:wth��rity." . \ licunt pp s I'Ir:�sa lill out the wurkars' comprnsation alfid�vit completely, by checking the buxes that appiy tu yuur.ituatiun and, if nrccssary, supply wb-cuntractorls) 17:11112(ti), JtIlIfC55�CS):IfiJ�IlUI1C OUI71bCf�Y)JIUII�Y WIIII fflCi�CCf[I�II�fC�S)Uf insurwice. Limitrd Liability Cumpanies �LLC) ur Lintitcd Liability Partncrships�LLP) with no employees uther than the mrmbers or partners, arc nut reyuircd tu carry workers' rumpensation insurance. If an LLC ur LLP Jues have employcrs, a policy is reyuired. De adviseJ that �his�tfiJavit may be submitred to the Department of InJustrial :\�riJrn�s for contirmation of insurance cuveragr. Also be sure to sign and d•rte the •rl'fidavit. The aftidavit should - br rcturneJ w the ciry or town thut �he applic�tiun for the permit ur license is being «yuasted, not the Department of � InJustrial Accidents. ShoulJ you have any yurstiuns regurJing the law or if you are rcquired w ubtain a workers' � - c��mpensation policy, please call the Department at �he number listed below. Self-insurcd companirs should enter their . ,clF-insurance license number on the appropriate line. Ci[y or Town Offici•rb Pleasa bc surc that the aftiJavit is cumplete and printed legibly. The Department has proviJed a space �t the bottom � uf the alfiduvit liir yuu to fill uut in the c��ent the Office uf Im�rstig�tiuns hus io contact yuu regarding thr applicant. Ple�se be surc to lill in the permic license number whieh will be used �s a reference number. In addition,an applicant diat must submit multiple pemiiulicense applicatiuns in ;my giv�n year, n�eJ only submit one attidavit inJicating current liulicy int��rtnation ��f necessary) ;ind under"Job Sire AJdress"the uppiicant�huuld write "all bcutions in �city or �u«n)." A copy UPIIIC BIIItIaVlt II7�I IIOS hCCfl UIrICI�IIY .tamped or marked by the eiry or town may be provided to the - :ipplirant as pruuf'that a valid a(tiJavii is on lile fitt future permit.or licenses. A ncw aftidavit must be tilled out each y�•ar. Whcre a humc owner or citizrn is ubraining a �ic.iuc or pennit not rclateJ W any busincss or cummercial centure 1 i.r. a �Ing licensc �rc pcnnit tu burn Ir�vcs rtc.) ,:�iJ pers.wn is \�e)T rcyuircd ro euinplcm dii, �IfiJa��it. flic 1�Iliir of Imr,tig:uions �.���ul� like tu �hank }ou in nJ��ance (ur y���ur cuupera�iun anJ shoul� ynu ha�e ;my yurstions, �Jr.i.r Jo not hr,it.rtc rn gi��c us � :all. I�hr I)rp,uiumnt'; .iJJrc,s. ieleph�me .mJ lax numb�r: The Commonweaith of Massachusens Department of Industrial Accidents Offlce of[nvestlgatlons 600 Washington Street Boston, MA 021 I 1 Tel. q 61�-727-4900 ext �106 or 1-877-MASSAFE ii`��."� ;-,��-��; Fax q 617-727-7749 www.mass.gov/dia , .� ;.��:' :�� CITY C)F SALLM � Y � �L`�.i- � =`��i PUBLIC PROPRERTY ����; ' ` ` -"J�'' DEPART?v1ENT p??TK Y�% ;'.I!': F:I I�.': I•I:b� ��e I ..—' . . '�� �'."'�: I'� N�.\illl`:�.:��'\$1It17�T � $.\I i'\i. \I.\iiAt !li iP I � -1'� .,. �I��I�: v7N�?�i�l;Y; � I�:�s: 9'SJ�:-'�tiaG Construction Debris Uisposal Aftidavit (r«�uir�a li�r �II dcnrolition and r�novatiun wurk) In accordancc with the sistl� edition oFthe State [3uilding CoJe, 7S0 CN1R section i 11.� pebris, and Ihe provisions uf MGL c 40, S 54; Quilding Permit N is issued with the conJition that the dcbris resultin� front this «vrk shali be disposed of in a properly liccused wa,te disposal facility as detined by MGL c I 11. S I SUA. The debris will bc h'ansportcd Uy: ��a.-s � .�9 'l�i �°y __ .. • 1 name of hauler) l'hc debris will be disposed of in : �UO J' i \f i c� 8 �--f�/�r� n-S -- � ---__ _..... Y� name uf f�cilit So� �en, �uddrees uf'larility) ---- ��tiign�tw'c oC p�rmit applican[ datc �----� �i��b�i:�:�,.��. � �' * • : � . . . . �...._._...�.. � �X 8 f�t� ��t�(�. � �,v t�. (���t c N � . . � t �.� � S�g 'F[RD�' A� on Roo f ___.,._._..._.- ; � /�ad� � �`�.. 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Y . . `� ' . . . . � � �� Fo:,�aAft•ov� +.'' , � ��� �t�5�r,((�.y �---�-�-=_. ,, f�m c�/a T� �� � � �` I b N , r� S�� 1��� '�h'_._.`_........ --,� �� o �, _ . , _. _ .'n' tl � �� �' F G _ , � E _ . , , _ _ r�� _ _ . _ . _ . _... . ... .... . . _. _ ....._.,. . ... ....,_.. .. ..: � . ... _ .... ., . . _ . , , .. . . . x . _.... ,._u�: .. . .._._. .. __. .. . .. . ._� _.,.._..�.�_. . rt.,�,.., __.,.... r_ ._ _. ... .. . ... .. . . _ _ ._ , .__. _ � � � � . . � � . � 3CALE:/ �I� / APPROVEDBY: DRAWNBY �` . , � . . . � .. � � " . � � . �. ' �. . . . DATE: . REVISED . . . . . . . . . . • . . . _. ` . . . , . . . . .. �- - . . . � � . ` : . � � DRAWINO NUMBER . .. . , � / , . . ' ZR%0I PRINTED ON NQ/000N CLGpPHIM'a • � . . � ; . . . .. .. ' � . . _._._.. .. . . . . ___. � . ._. ._. .. . . ... ._.__.. . . . _ . ._ . . , .. . .... ._� . — ___.. . .. __....___....-__.. . . .._ �__ . ...... . . ... . .. __._._._.._..'.__.'___ ..._.__.. .. .. _.,..._.___._._ _ .. �-, ._._.�_..� . .. . _ . ._. . ._ . . . . . _ _. . . ._.. _. . . . . .. y�.. __ ... . . . . . . . _ _- '_.._ _.__. _"`. � I E 4 CRESCENT DRIVE i i , 17 7- Si rJ' i I I I � : I � - 6- -7 T , : I , f � --- I I - 's� ax/o' /6 eci o_ O_ — — t—, — — — II ---- - 1�4ZL S t�PPROVED r _ e oth : , I -- --- '� -_ —L`y� S —— — — --- — —----- — -- 33�eccto apP%a� I vj.. c> s-ALEM Mss 1O - — --.- -- ENT_ '4 BIMY"'Lil -- - ! — � c.',•• o • o.� __ 1/9, � Ute' IQ�. --- - - - ! --i ---.---- ---- -_ ._-- _-_. B� IS-AREAPPR�, YVFDSOLELY" F�T I TIOtl. OF- PROTECTION DEVC-CT-TO- . "MES ARE SlJH7ECT-TO' ALL FIE PROT TIG i DEY' - MPIJ� --FMiAN ESf«,1_: 1'ECTIOY,FOR TIM +�__-_ 4NCF.qAT THE FIRE CODE. : ! I ' r I v . I I ; /6---- --- -------- .2216 is d -- --- _ — - -- ------ -- - k 44 -- ---- CDA: - /' - I 1 V - ---- — — s — — — - -- — - = — - - --- - - - - -- - ' 'yc/ o i6 aX � a a r r r 5 r � --- I 10p- le - - - --- - —= - --- - - --- - e' C 1 r I I I lose I i I I ------------ i -- �10 <-'. --- - -G — - — -- i- --- --- I I : I I i I : I i I I � 2 54321 I I : i I I � I i --- I i 1 : i I rSZ v�- - - ---- ----- - — bio 6 X/.Z .ce,2i'!5 - -- vX9 ly 6 , i I i II ' I , I i PERMIT # OWNER S.�/� LOCATION ®ATE ISSUED C�-1D-96 PERMIT TO bU 1 I cl Q dd-,r+1'on coPv - CERT►f C SE Of OCCUPANCY L-sic. o. �permd W Issued t• City of Salem Build Dept.. �°. CITY OF SALEM p1970 q c SALEM, MASSACHUSETTS :81_1996 ti �� PERMIT NO. JUNE 1� 19 �D XT ` (GONTR'S LIGENSEI cirnne LLEN ---1635 96 OB DATE ADDRESS �NO) (STREET) 5121B"J "" Q 1'36121 TEL.NO. TOM LEONARD MA ZIP CODE - 1 STATES NUMBER OF APPLICANT DWELLING UNITS PERSODY ONE FRMS 11 p°STIa1cT------ STORY— AD'CITY ) STORy (PROPOSED USE) ADDITION No. PERMIT TO (TVPEOFIMPROVEMENT) DRIVE 0@0G CRESCENT caosssTREET) Sc FT AND ISO 1.�6 A7(LOCATION) (NO1 (STREET) QQIIZ17 SIZE ON (CROSSSTREETI LOT--0§-42 BLOCK- BETWEEN pIAP 1 J LOTS FF.IN HEIGHT AND SHALL CONFORM IN GONSTRUCTI BDIVISION FF.LONG SU VPE) FT.WIDEBY- L. E. T. BASEMENT WALLS OR FOUNDATION AS pER PLANS. BUILDING IS TO BE- gED RMS USE GROUP Y RM LATH & ` 5 00 TorvPE ADDITON: FAMILY pEaMIT$ 3= BUILD -2-ND FL 5@ LALA I FEE REMARKS: • ESTIMATED COST BUILDING DEPT. AREAOR (CUBICISOUARE FEET) BY VOLUME TORE P ORLANDO SALVR OWNER 4 CRESCENT DR . ADDRESS Speed Letter. 44-902 To 67Speed Lettero =? `�' From - 77 7­7 Subject— 'r —No ae iormo MESSAGE C( ` tL i Dateo2 Signed w� ` A w"I4' REPLY _r.o erou - ovoiu Date Signed WilsonJones RECIPIENT—RETAIN WHITE COPY, RETURN PINK COP`,' GRAYLINE FORM«-902"ART L198 .PRINTED IN LLS A 1164 SENDEP—DETACH AD.'D -.STAIN YELLOW COPY. SEND WHIT_ AND PINS COPIES WITH CARBON INTAC` F r .,�.�c,„a�. h:4 y,, ,. .. , NEW tNGLAND CLAIMS StRVICE, INC. 365 BROADWAY LYNNFIELD. MASSACIIUSEI IS 01940 form of Noti.ce of casualty Los, to Building Under 11a>s.(;chAAwsi Ch . 1390 Sec. 3U I TOO' building Conunilai.oner or Board of health or 1lislidetor of Buildings Board of Selectmen 1 ( , y r. �\' -) addresses �1� I REI insuredfir- 1 ri opefty address: 4 Ges �� 7� i— McX 61icy No. -760S / Loss of la �ao 0 dile or Ciaim No. Claim has been made involving loss, damage or destruction of the above=captioned propertj1► Whic1l may either exceed $1ytl00: 00 6k cause Mas9 .Od1j1baWs; Cila )ter i43, Section G to be hliolibd6ie. ' if any not ce • unhcer P1ass .Gen.LaWs ; C—h 71 39 , Se6: "3B i5 . npproprlate pleage direct- t, to the attent qn of t e Wr ter tilid include a reference to the captioned , insUred , loeatibnl policy number, date of loss and claim br, fide number 1 � f ` ; ' (Signature) Tit Ie i ' bn this date , 1 cauge"d copies of this notice to be sent td the persons named a6oje at the addresses indicated above by flist• class mails ' 4S91latUre an ate NEW ENGLAND CLAIMS SERVICE, INC. 365 ©ROADWAY LYNNFIELD. MASSACHUSE1 T'S 01940 i Form of Notice of Casualty Luss to Building Under t9ass .Gcn . l,aws, Ch . 139 , Sec . 313 i TO: Building Conun.issi.oner or Board of Health or inspector of Buildings Board of Selectmen i addresses 17�- RISA l� ) RE: Insured: Property address : Cress 7�— policy No. -6q-766S c Q� Loss of [a / 19 zsd File or Claim No. jam, �(0(E-(3 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 G to be applicable. If any notice under Mass .Gen .Laws , C_hT1_39 � Sec. 3B is appropriate please direct it to the attention of Me writer and include a reference to the captioned insured , location, policy number, dale of loss and claim or file number . (Signature) Title: On this date , I caused copies of this notice to be sent to the persons named above at the addresses indicated . above by first- class mail . ' r , Signature and( to NEW ENGLAND CLAIMS SERVICE, INC. 365 Broadway- Lynnfield, MA 01940 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws , Ch. 139 , Sec. 3D . TO: Building. Commissioner or Board of Health or �Snspector of of , Board of Selectmen addresses RE: INSURED: �0.�C �r2, PROPERTY ADDRESS: POLICY NO. : LOSS OF: cZ� 1 195 FILE OR CLAIM NO. : /S-7 -1 Claim has been made involvingloss , 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 ; Chapter 139 , Section 3D 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. TITLE On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. 7 /7 SIGNATURE AND DAT 'pi IAM GRANTED CITY OF SLEM TWA Dab - ;?_'oLoodw u h• adr�nb rt�� "Min b powb Loons b SI`M PMT APPIMATION MR: Pmm toc (Chb waidwwr low Roof, Raroof, bwlal Oft, ConM W.Docks fl vK PoK R 1 .1 IR�plaoa, n PLEAlw PN.L OIR LILY A COYPIi mLY TO AVOW DILAYi IN PIIODNf TO-THE INSPECTOR OF W LDML- ffffdaf hweby apple. for a pamfR to bWW a000 ft to Vo laflmmmimn MC awYy Ownaea Nanw .5w v c Y ( J r /oo n N o Ad*W A Phofw L/ CreS c e n L r i ✓e (9,291 9 3 AMNM'a Nwna Addmu a MOM L 1 M@Wnnin Nanw (UP s „t lld*m A Phew J r91991 �y 5-- 229 wfrr b�popoa M Ou1ip1 � •S/�r Le .-F��M, �ti 7;i W W of 0iidl0t a dnfrq,Ow Aar Mnp k~ mono°°at',/P 41►Lj a • N 0` afti.uomw• r� Z z 3 Lin. /�_ ofX1 UNMIR Apploari ofiscRfPTTDN oPwCiKTO M ode ofof= THI Pfil � MAIL POW 4 CCU pc e o T 0 , v<1 . .�► J _. � o 4 6 • t' •ac. is .d PUSUc PROPERTY DEPARTMENT p'Y 120 WASNINOTON ST11aaT, aRD FLOOR SALaM.NIA 01 S70 TXL. (978)74n-S595 EXT.300 FAX M78) 740-9846 STANLEY J. USOVMZ. JIL MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In acco>•danu with the proviaiom of MGL c 4%SK I aclmowledgs that as a coo&dm of Bnildin Permit S .aIl debris muhMS Som the ooftmctwn activity Sovemed by this Building Permit shaft be d grand of in a properly licensed solid-wmb disposal Scilly,as defaad by MOL c nL SIMA. 7be debris wM be disposed of me // " "`f Z S LDcadan ofFaality O SSipmU p��hao 7 Data FULLY complete the followmS iufomrsom (PLEASE PRINT CLEARLY) 6PorI6 . 6f-y J Name ofPeamitApplipmt Y m Name,if any Address,City&State Mw above statute mpues that debris from the demolitioq remvation,rrhab or other alteration of bm'l ft or atructum be disposed in a properly-licensed solid-waste disposal Saliry as defined by MGL cIII,S150A,and the building permits or licemes ere to indlate the location of the lircilty. +� C01YLIWnYlalahk 01 M466AciLf, eth 6 .1Jepa.Iaa.al a j,.deirelaf..?etiaaaG' n eoo ryw�. L.11.3i ed James J.Caa,00al 021 It Commarasrw Workers' Compensation Insurance AffidaYk 1, . . wirh-a principal place of business a= . . iovise.✓ars do hereby'certify under the pains and penalties of perjury, thus: () I am an employer providing workers' compensation ccvera=e for my employees working on shN job. Insurance Company Policy Number vlll� I am a%ole proprietor and have ne one working for me in any capatiey. () 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contracsn listed below who-have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor insurance Company/Policy Number Contractor insurance Company/Policy Number () I am a homeowner performing all the work myself. I ueeasauwa enae a cool e(oru weemem WS be fex+.arwe ro ON Onee ee le.e MXd of she D1I,for ca.erne+11WAselm raw 0121{autos w owwo co.erate as rewr9a ewer Secaon ISA of MGL 152 can kaO to ove inoowiee of crk� v1m6"eor-orrt Of a hoe el e4 sets I.SOOAD&w/r one nary'ir�roemrenl a tee»em omwav in the Iorm of a STOP WORK ORDER wA a for of S 100.00 a an "mink on. signed this . 3 day of J1v., C — �� y crs�rrmittt 6uTding Depamr► ent 'icensing Eoart Seieamens Office -se2ith Deparmen•