B-20-538 - 0027 VALLEY STREET - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
' Massachusetts State Building Code,780 CMR,7`h edition MUNICIPALITY
USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised January
One- or Two-Family Dwelling I, 2008
lis eat ztrt Far Official Uge Only
Building Fem*Num`a. , -r Dare Applied:
L
i lluilalka.cc spec ;cif`'lurdin s Date
ETfiId�N :SIIB VJV OR;4IATION
1.1 Property Address: 1.2 Assessors Map arc Parcel Numbers
1.1a Is this an accepted street'?yes no Map Number Parcel Number
1.3 Zoning Information: , 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 )Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERS.fliil
2.1 Ownerl of Record: _,,a •. - ti: �...
Eybu lArzlebDuca A-1 Vattev 5J'
Name(Print) Address for Service:
See C0( +frAC� .2�,`t�
Signature Telephone
SECTIWN S:DESCRIPTIO Of PROP6SE6 WORKS(r:1meek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ,Specify: j,
Brief Description of Proposed_Work•
SECTION 4,&S`I`UMATED COltiS'1'R11_<.TION COSH'S
Item Estimated Costs:
(Labor and Materials) Department sign €ffs
1. Building $ Jr lC>
?. Electrical $
Board of Health.
3.Plumbing Ta:a_Office
4. Mechanical (HVAC) $ Eire Dept
5. Mechanical (Fire Conservation
Suppression) Pub& Worlcs��. . '
6. Total Project Cost: $ 0. vp For notice purposes only.Signature does not constitute approval.
JUN 15;;m11:17
JUN
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(d SI,) C.S—I Q a%A� �9 2 0 PZ,2..
rd-:1�4r= License Number Expiration Date
Name of CSL-Holder
2y O J31A4.aA9Q%ALE �,g. 5l.►i'3.C_ List CSL Type(see below)
Addres WM-f*M*4a-Mr1 Mar �i 00� fi4 � ` ' Description
�.t U Unrestricted(up to 35,000 Cu.Ft.
Sign R Restricted 1&2 Family Dwelling
���t ��' ® M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
3F Residential 31jlitl Fuel Bunihig AppliWlLe Installation
D Residential Demolition
5.2 egistered Home Improvement Contractor(HIC) �-
HIC Company Name or HIC Registrant Name Registration Number
AtLA0.0VP4X= 1T Malt_sMrtACe�=rt t4a l31Qy
Addres. 0% 10%4 [Z.®22
-30(&j Expiration Late
Signa'tdg Telephone -
SECTION 6:WORKERS' COMPENSATION NSURANCE AF` MA IT 044. I.c ')fz.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........... ❑
OWNER'S AGENT OR CONTRACTOR ARP14-S� BEllllL DING PERMIT
I, &Jbo Pselfbay as Owner of the subject property hereby
authorize %J% U►17- l C-0ces"s p,4ct on my behalf;ig_all matters
rcln.tive to work authorised by th%i building pewit upplicubon.
.� cat'ri eA.; _r-
Signature of Owner Date
SECTION lb:OWNElftt'OR h,,U,1fl0RfZED AGENT PECLARATION
-- ? �1. thn i m 1 A gc—ntbPrnhy,'—If-;ar, _,_ �
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Pritit N e r kti
_
Signat re Owner or Authorized gent Date
(Si ned under thepains and penalties of perjury)
MARS:
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
n-4
Y
\ 1
A p® DATE(M�voOmm)
CERTIFICATE OF LIABILITY INSURANCE 11112/2019
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 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 endorsements.
PRODUCER C
MARSH USA INC.
122517TH STREET,SUITE 1300 PHONE FAX Mal:
DENVER,CO 80202-5534 B MNL
Attn:Derrver.CerlRequest0maish.com Fax:212-948-4381 ADOJlEM:
INSURER AFFORDING COVERAGE NAIC 0
INSURER A:AXIS Specialty Europe SE
INSURED INSURER B:Zurich American Insurance Company 16535
Vlvint Solar Developer,LLC
1800 W Ashton Blvd INSURER C:American Zudch Insurance Company 40142
Lehi,UT 84043
- INSURER O:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: SEA-003173759-27 REVISION NUMBER: 7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE L POLICY EFF POLICY EXP
L POLICY NUMBER LIMITS
A X COMMERCIAL GENERAL LIABILITY 3776500119ES 12101/2019 1110112020 EACH OCCURRENCE _ $ 1,000,000
CLAIMS-MADE OCCUR PREMISES Me occurrence S 1,000,000
MED EXP Any one personf $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY JECT I LOC PRODUCTS-COMPIOP AGG $ 1,000,000
OTHER- I S
B AUTOMOBILE LIABILITY BAP509601505 1110112019 1110112020 21W=?MGLE LIMIT S 1000000
Ix
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED BODILY INJURY(Per b
AUTOS ONLY AUTOS t )
HIRED X NON-OWNED PROPERTYDAMAG $
AUTOS ONLY AUTOS ONLY Per } nt
X UMBRELLA LIAR X OCCUR 3776500219ES 12i0112019 1110112020 EACH OCCURRENCE_ $ 5,000,000
EXCESS UAS CLAIMS-MADE
AGGREGATE $ 5,000,000
DED RETENTION S S
C WORKERS COMPENSATION W 509601305 AIDS 111 112026 X PTA E RH
B AND EMPLOYERS'LIABILITY YIN T T
ANYPROPRIETORIPARTNERIEXECUTiVE WC504601405(MA) 11I01/2019 1110112020
OFFICERIMEMBEREXCLUDED? I N 1 A E.L.EACH ACCIDENT $ 1,000,000
(Mandatory in NH) (I E.L.DISEASE-EA EMPLOYEE $ 1,000.000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000
I Ii
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
The Certificate Holder and others as defined in the written agreement are Included as additional insured where requeed by wriliea contract with respect to General Liability.This insurance is primary and non-
contributory 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 subrogalion 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.
Jan Lindstrom ]
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department of Industrial Accidents 1
1
1 Congress Street,Suite 100 ;
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. i
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(BusinesstOrganization/(ndivicltril): 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):
l.®I an a employer with 253 employees(full and/or part-time).* 7. [:]New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling
any capacity.[No workers'comp.insurance required.)
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
i 10[]Building addition
I 4.❑[am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole I LE3 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.[]1 am it general contractor and I have Iiiied.thesub-contractors listed on the attached sheet. j 3.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6. We are a corporation and its officers have exercised their right of axe 14.(3 Other SolaL.installati n,
❑ rpo gh tttption per MGL c. ?--
i
152,§I(4),and we have no employees.[No workers'comp,insurance required.] t
D
'Any applicant that checks 6oic#I must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating they ace 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 subcontractors and state whether or not those entities have
employees, if the sub-contractors have employees,they must provide their workers'comp,policy number.
I ant an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name: Zurich Ametcan Insurance Company
Policy#or Self-ins.Lie.#: WC5096014-05 Expiration Date: 11/01/2020
Job Site Adders:__& \G 11 e-LI 5+ City/State/Zip: Sq�Q try
Attach a copy of the workers'com pinsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL a 152,p25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
l do hereby certify under the pai, ; fidpeupftifs of per jury that the information provided above is true and correct.
Signature: ,Gti. ., Date: 10/31/2019
Phone#: 801-845-0286
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#:
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, ESTIMATE
S-6368770 Whole Roof Tear-Off .
Customer Prepared By Prepared On
Evbu Adebayo Heath Edwards May 28,2020
27 VALLEY ST. 1800 Ashton Blvd,Lehi,UT
SALEM,MA 01970-1925 84043
(385)352-3700
heath.edwards@
vivintsolar.com
ARooFSNAP
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ESTIMATE S-6368770 WHOLE ROOF TEAR-OFF
Estimate- items
Description
Materials
Owens Corning TruDefinitionO Duration'a Shingles:SureNail Tech,TruDefinition Color Platform,130 MPH Wind Resistance,Limited
Lifetime Warranty
Owens Corning 4'x 250'Deck Defense High Performance Roof Underlayment-10 SQ.Roll
Owens Corning WeatherLock Flex Ice&Water Shield
Owens Corning ProEdge Hip and Ridge Shingles
Owens Corning 11"x 20'VentSure°Rigid Roll Ridge Vents
Vent Flashing
2"Standard Drip Edge
2"Standard Drip Edge
Chimney Flashing-Paint&Seal
Included Services
Installation of Roof
Procurement of Roofing Permit
Final Inspection
Dry Rot Included up to$500(Material*Labor)
Job Site cleanup
Site Survey
Registration of Owens Corning Preferred Roof Warranty
Other
nRooFSNAv ESTIMATE(5-6368770 WHOLE ROOFTEAR-OFF
Scanned with CamScanner
ESTIMATE I S-6360770 WHOLE ROOF PEAR,OFF
Estimate items
Doscription
Warranty
Summary
Description Amount
Total $5,610.00
gV6
(�
ARooFSNAa ESTIMATE S-6368770 WHOLE ROOF TEAR-OFF
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