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B-19-776 - 0004 BERUBE ROAD - Building Permit SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C).�, fYU 1`v� �J 'J L License Number Expiration Date Name of CSL Holder v List CSL Type(see below) Q, No.and Street Type Description U Unrestricted(Buildings u to 35,000 cu.ft.) 4� 1 wn1'4 R Restricted 1&2 FamilyDwelling City/Town,Town,,State,ALB i���1Y�� � M Masonry RC Roofing Covering WS Window and Siding t _ _ SF Solid Fuel Burning Appliances a I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ` 'Zz� :Expi-ration � HIC Registration Number Date H[C HCompany Name or C Registrant Name� \i \J iCr.0 No.and Street Email address City/Town,S e,ZIP Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIIDAVIT(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 V �cc- LLC to act on my behalf, in all att s relative to work authorized by this building permit application. +P ni Owgzr's,Na e(_Electro& tgnature)7 Date SECTION 71b: 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 this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) ate 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. ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 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 halfibaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" t c w dodoes oSolar� Reroof Bid • • , CONTRACTOR • Service Number. 4261049--0 Company Vivint Solaro Customer Name: KERRY GRIFFIN ' Email fiomeupgrades@vrvintsolar.com t Address_ _ 4 BERUBE RD,SALEM,MA 01970 � 'Phone: r (877)404-4129 ., I ')CRIPTION Whole^ of Tear-Off and Reroof-1600 Sq Ft-10°and 40°Tilt 1. Remove existing roofing layers. 2. Inspect sheathing to verify no repairs are needed at an additional cost before reroof. 3. Install new ice$water shield and drip edge metal at perimeters. 4. Install new undedayment. 5. Install new Owens Coming Duration@ Trudefinition®Shingles. 6. Install new boots and flashing as needed. 7. Install new Owens Corning Hip R Ridge Shingles. 8. Clean up working materials and supplies used on site. 'Note:There is an additional cost of$499 for removal and reinstall of the existing system that is not included in this cost. Vivint Solar to remove solar panels prior to reroof. Includes all labor,materials and warranty • Total Cost: $7690.00 *Includes all labor,materials and warranty EDUCTSIlk w owenscornina.com/ro' e-hip-ridoe https://www owenscomino com/roofing/shingles/trudefinition-duration/ http://stcgjxfmpy0 mybigcommerce com/content/26188°/2OAbie°/ 0 017°/2OR1 Ddf httr)7//M,,yw.interwrar).com/rhinoroof/ l� C�feer+� ouom l f ' ACORN CERTIFICATE OF LIABILITY INSURANCE r �r 1012612018 I� f THIS CERTII=ICATE 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. TEIIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 I MARSH USA INC. NAME' 1225 17TH STREET,SUITE 1300 PHONE AX UENVLR,CO 90202-5534 DOR8SL �y Attn:Dealvtr.CertRequestre-)marsh.cmn Fax:212-948-4381 A I INSURERS AFFORDING COVERAGE NAIL A INSURERA:Axis Specialty Europe I INSURED INSURER B:Zurich American Insurance Company 16535 Vlvint Solai,Inc. Vlvint Solar Developer LLC INSURER C:American Zurich Insurance Company 40142 1800 W.Ashton Blvd INSURER D.: Lehi,U 1 8,1043 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-0031 73 7 59.23 REVISION NUMBER: 4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSURANCE ADOL SUBS POLICY EFF POLICYEXP LTR POLICY NUMBER Mloor"M (11111111000YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY 3116500118EN 1110112018 1110112019 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE AI OCCUR PREMISS occur're ncaI $ 'I'M 1,000 MED EXP(Any one person) $ 10,000 PERSONAL BADV INJURY $ 1,000,0(X) GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,0M X POLICY[�ECOT- FLOC PRODUCTS-COMPIOPAGG $ 1,(1(X1,0(Xl OTHER: $ 8 AUTOMOBILE LIABILITY BAP509601504 11/0112018 OINED SINGLE LIMIT $ 1,00R000 acctden Nx ANY AUTOBODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY IN ent( )JURY Per accid $ HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY per $ $ UMBRELL;ALIAB x OCCUR 3776500218EN tU01/2018 11101/2019 EACHOCCURRENCE $ 5•�•� EXCESS LIAS CLAIMS-MADE AGGREGATE .$ 5,000,000 DIEDRETENTION$ $ C WORKERSCONIPENSATION WC509601304(AOS) T 0 11 Ol 2019 X PER EMPLOYERS'LIABILITY T U E -__ € B ANYPROPRIETOR/PARTNER/EXECUTIVE YIN WC509601404(MA) 1110112018 11/0112019 1,0000 OFFICERIMEMBER EXCLUDED? a NIA E.L.EACH ACCIDENT $ 0A (Mandatory In N,H) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more apace is required) The Certificate Holder arxl 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- rontributory 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 contract 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 nc71r.fiawlw- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD Miss Commonwealth of Massachusetts � ! Division of Professional Licensure Board of Building.Regulations and Standards Con struCtOr1'S type rvisor CS-108068 Ecpires:01/20/2020 ff r' KYLE GREENE si• ` 458 WEST STREET METHUEN MA 018" •�• Commissioner C C�//tes r[.es�ieorar.�ernuall�a�i?Gl�curne��ate!!d OHfoe of Consumer Affairs&Business Regulation DOME IMPROVEMENT CONTRACTOR TYPP►:Suriolement Card Regi;Uat n Expiration 170W4 01/04/2020 VIVINT SOLAR DEV9L-0PER1Lt: *' 4 KYLE GREENE 1800 W.ASHTON BLVD. LEHI,UT 84043 UndersecrotM The Commonwealth of Massachusetts Department of Industrial Accidents J Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AApplicanrt Information Please Print Lepibly Name (Business/Organization/Individual): Vivint Solar Developer, LLC Address: '1800 W Ashton Blvd City/State/Zip: Lehi, UT 84043 Phone#:801-845-0286 Are you an employer? Check the appropriate box: Type of project(required): 1.91 I am a employer with 300 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition working; for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Pl bing repairs or additions myself. No workers' com right of exemption per MGL Y [ P� 12 oof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant thtt checks box#1 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Zurich American Insurance Company Policy#or Self-ins. Lic.#!; WC509601404 Expiration Date: 11/01/2019 Job Site Address: j ,�, City/State/Zip: Ltza��_ 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 ulid a pa' an a !ties of perjury that the information provided above is true and correct. Signature: Date: v 0 20l Phone t#: 801-845-028 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. „ Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association 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 dwelling house of another who employs persons to do maintenance,construction 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." MGL chapter 152, §25C(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, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter'into any contract for the performance 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-contractors)name(s),address(es)and phone number(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 affidavit. 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 be sure that the affidavit is complete and printed legibly. The Department has provided a 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. Please 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 permit/license applications',in anp,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 i town). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided tot th e applicant as proof that a valid affidavit is on file 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 (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents e Office of Invesilgations F 600 Washington Street °* Boston,MA 02111 www.rnassgov/dia .ff Workwrs' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apnlicanit Information Please Print Legibly Name(Business/organization/individual): Vivint Solar Developer,LLC Address: 18W W Ashton Blvd City/S : Lehi, UT 84043 Phone#:801-845-0286 Are you an employer?Check the appropriate box: Type of project(required): 1.91 I am a employer with 300 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling shipand have no employees These sub-contractors have S. E]Demolition working for me in any capacity. employees and have workers' insurance.: 9• El Building addition comp.[No wcurkers'comp.insurance P- required.] 5. 0 We are a corporation and its ME]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 12.❑Roof repairs insurance required.]t C. 152,§1(4),and we have no 13.❑Other employees.[No workers' comp.insurance required.] *Any applicant th Yt,checks box#1 must also fill out the section below showing their workers'� g compensation policy infomration. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors 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;ub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providbng workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Zurich American Insurance Company ;t Policy#or Self-ins.Lic.#: WC509601404 Expiration Date:11/01/2019 Job Site Address: �t �" �c,o �� City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secwe coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the foam of a STOP WORK OER aid Aka fine of up to$250.00 a day against the violator. Be advised that a copy of this statement aray be forwarded to the ` ice our ;: Investigations�f the DIA for insurance coverage verification. I do herebycer 1 .: .fY p of perjury that the information provided above is truexand c r cl♦ Signature: Date: 801-845-028 fi Phone#: Tu L Offwial use only. Do not write in this area,to be completed by city or town official City or Towia• Permit/License# ` Issuing Aut) ority(circle one): 1.Board of gealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#•