51 GALLOWS HILL RD - BUILDING INSPECTION 11 4o C-'r-
ECEIVEO
SZ, The Commonwealth of Massachusetts CINS�p$ NAL SERVI
CES
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Board of Building Regulations sand Standards SALEM
Massachusetts State Building Code,780 CMR Revised EM B A 3
Building Permit Application To Construct,Repair,Renovate Or emolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) -Signature Date -
SECTION 1:SITE INFORMATION
1.1'Property Address: 1.2 Assessors Map&Pat cel Numbers
51 Gallows Hill Road I
L Is Is this an accepted street?yes_ no - Map Number Parcel Number
1.3 Zoning Information: i
1.4 Property Dimensions:
single family residence
Zoning District Proposed Use Lot Area(sq it) Frontage(a)
1.5 Building Setbacks(ft)
Front Yard - Side Yards; - Rear Yard '
Required Provided Required Provided Irequired Provided
1.6 Water Supply:(Ivt.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Munic ipal❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
1.1 Owner'of Record:
David Coleman Salem,MA 01970
Name(Print) City,State,ZIP
51 Gallow Hill Road 978-745-6853
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheel all that apply)
New Construction❑ Existing Building[A Owner-Occupied ❑ Repairs(s) ❑ Alto (a) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Cl Number of Units' Other ® pecify: solar
Brief Description of Proposed Work':
Installation of a 6.060 kw(28panels)rooftop solar aria -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials I Official Use Only
1.Building $ 8,000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Applical ion Fee
13 210 ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No.I Check Amo t: Cash Amount:_
6.Total Project Cost: $ 21,210 ❑Paid in Full ❑Outst inding Balance Due:
�"13 iy
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 096185 10/8/2014
Romain Strecker License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
10 Churchill Place
No.and Street Type Description
U Unr 'cted(Buildingsu to 35,000 cu.ft.)
Lynn,MA 01902 R Restri red 1&2 Family Dwellin
CitylTown,State,ZIP M Maso ry
RC Roofl a Covering
WS Wind w and Siding
SF Solid 7uel Burning Appliances
781-462-8702 permits@bostonsolar.us I Insu1 ion
Telephone Email address I D Dean lition
5.2 Registered Rome Improvement Contractor(HIC) 1696 8 7/27/2015
The Boston Solar Company HIC Regi nation Number Expiration Date
HIC Company Name or HIC Registrant Name
10 Churchill Place per its@bostonsolar.us _
No.and Street Email address
Lynn.MA 01902 781-462-8702
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDA (M.G.L.c.152.§ 25C(6)),
Workers Compensation Insurance affidavit must be completed and submitted with 's application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........Q No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject properly,hereby authorize Romain Strecker
to act on my behalf,in all matters relative to work authorized by this building penuil application.
C61Q0.144 � 9/7/2014
Aim Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and derstanding.
Romain Strecker `�l 5/7/2014
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner ho hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not iave access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information 4 on the HIC Program can be found at
MM niass.gov/oca Information on the Construction Supervisor License can be found at 35ww.mass.¢ov/dos
2. When substantial work is planned,provide the infomnation below:
Total floor area(sq.ft.) (including garage,finisheasementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room ount
Number of fireplaces Number c be ms
Number of bathrooms Number of ha aths
Type of heating system Number of declait porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
r CITY OF S�.E>�I, �' -'SSACHUSETTS
'• I D4�fG DEP.I aT�iF1vT
130 WAsHttdGToN Sr Er ,3'D FI.00R
'ILL(978)7.59595
FAx(978)7 9846
KIa>BERi.EY DRISCOLL
MAYOR Noma ST. Imm
DIRWMIL OF PUBLIC PROPERTY BU DING CONMIESSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cede,780 CMR section It 1.5
Debris, and the provisions of MGL c 40,S 54;
Building Permit# is issued with the condil'on that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 150A.
The debris will be transported by:
Boston Solar
(name of hauler)
The debris will be disposed of in:
Boston Solar
(name of facility)
35 Industrial Parkway,Woburn MA
(address of facility)
signature of permit applicant
5/7/2 14
We
dcbrimlfdoc
�e�a�xneo,iaaxe�ll ty"(�/�ira�ir.�,t1a/2
Rce of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
gistraboo 169698 Type: Office of Consumer Affairs and Business Regulation
xpiration r 7/27/2015 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
THE BOSTON SOLAR,COMPANY-:LLC -
t
ROMAIN STRECKER
10 CHURCHILL PLACE::
LYNN,MA01902 ---'---
Undersecretary Not valid without signature
IBI Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-096385
ROMAIN D STRE �_...
10 CHURCffILL LA s
i LYNN MA 0190E yy
I � 6
Expirafion
Commissioner 1 010 8/2 01 4 d
I
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/Organizabon/Individual): The Boston .Solar Company
Address: 10 Churchill Place
City/State/Zip: Lynn, MA 01902 Phone#:617-858-1645
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑■ I am a employer with 20 4. ❑ I am a general contractor and 1
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. ❑ Remodeling
ship and have no employees These sub-contractors have 8• ❑Demolition
working for me in any capacity. employees and have workers'
o workers' com comp. insurance.t 9• ❑Building addition
[N comp. P•
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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, §1(4),and we have no 12.❑ Roof repairs
employees. [No workers' 13.❑■ Other Solar installation
comp insurance required.]
"Any applicant that checks box#1 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 a new affidavit indicating such,
tContractors 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 am an employer that iv providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Liberty Mutual Insuarance
Policy#or Self-ins. Lic. #:WC2-31S-384393-014 Expiration Date: 1/14/2015
Job Site Address: 51 Gallows Hill Road City/State/Zip: Salem,MA 01970
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 the pains enalties of perjury that the information provided above is true and correct.
Suture: Date 4/16/2014
Phone#: 6178581645
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#:
02/20/2014 00:22 17815955820 AMBROEE INSURANCE PAGE 07/08
'd�COltl� CERTIFICATE OF LIABILITY INSURANCE 2i2;(IMDO 9
HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE GERFFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NECATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOROEO BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CORTRACT OETWEEN THE ISSUING IMSURER(SL AUTHORISED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the e(IltRlmte holden is an ADDITIONAL INSURED,the POIICYPOS)must ba 4mdors6d. If SUBROGATION Is WAIVED,subject is
the terns Ord eandRlans of th r Policy,ccr/aln P011eiea MAY reAWra ad eddorsnmerl A atatomsnt on this DSNtRInate aces not coder rights to the
ceTggmte holder In lieu of aDOh eNlbMaeRlent(91,
PRODUCSR I NNAE:
? Ambrose Insuxaxce Agency, 7no. PNIONE , 7$1-592-8200 ticNe781-595-$B20
56 Central Ave,
Lynn, MA 01901 AODItEs -
INsunERlsl aFroADINa ca'auoe N,pr;p
NSURcR A:C010n
NSUREa The Boston Solar Cc. , LLC HSURERe:SM y '
INSJRERC:Nation TTal on t sa Of pi11tqb=qkk
10 Churchill Pl. I INSJREX 0:Liberty Matual.
Lynn, MR 01902 N3JRERG;
INSURER F
COVERAGES CERTIFICATE NUMBER; REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTVATH87ANDINO ANY REQUIREMENT,TERM OR 004DITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESFE07 70 WHICH.THIS
CERT1=1CATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE 19 SUBJECT TO ALL THE TERMS.
EXCLOSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
n8R
LTR T1'F1=OF MB:IRANCE IMia Vl4o POLIO NJMIRR k 1 NMloarrrn UNITS][ CO1ALR•ACIAL GETYRAL UADLITn
EACH OCCURRINGE s 1 000 000
CLAIMSAlAOE OCOLR 'REMISES Es C"Ifmnce 'a 100,000
MEO DIP IArY a re Mrs t 5 OOQ
A - t�4097103 2/1B/142/1$/1 PERSONAL aADVINJURY I 1,000,000
Dal
AGGREGATE LIMIT APPLIES PER. x GENERAL AGGREGATE T z 000,000
PO�CYOx ��oT �LOO PRDDBCTS-COMPIOPAGG s 2,000,000
OTHER t
PUTOAIOELE LIANUTY I artltlen " 1.000,
OOa
AUYOWNAYTQ BODILY INJURY PNce•II t
.AIL OWNEDI
CINSDULAD
I! ALTOS LTOS BODILYrA ruaY(PorAWdenq 1
x HIREDAVIDB NON
ALTOS NED 62Z6592 1/23/141/23/1 itleMUMePEL1�uPs Drava I I WH OCCULREN�E a 5,000,000
C x EJ�ESS ltAB �LAIMS.A%DE x 'AGGREGATE 5 5,000,000
Dm 'RETENRONS REU013492750 /I$/142/18/1
yYUdcERS COMPENEATrDN
AND W PLOYERV LU3ILITY yiR 3'ATUTa R ER J
AIR Mb`IREICRPnkrswR>eECIr',E
I0 CfFmIlemrb1eD! =xawmT Y NfA E.L.EACH nGGTENT S 1 000,000
incAdew,m HHI - WC2-318-384393-014 1114/142/14/15
Ifre CeN,Ihe wder E.C,DISEASE-EA_MPLOYEE 1 1,000,000 ,
DESCRIPTION Or OPERATIONS telmy EL.DEF,ASE-POLICYLIrAIT a 1,000,
ooa
DESCRPTTON 0$OPEPATIONS i LOCATTONb1 VEHICLES (ACCRD 10r.ACdNIONOI R"RAn SchRUI,may IN,wr hee:Vmoro eras N nculred)
Solar Panel Installation
:ERTIPICATE HOLDER CANCELLATION
City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POUCIFS BE CANCELLED BEFORE 1
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNF,RED IN
A.ttn. - Sull,dyng Dept, ACCORDANCE WITH TF'E 'OLICY PROVISIONS.
City Hall
Salem, MA 01970 AUTMR¢ED ;Dn"ArT�_&�4988-20IJ133ACORD CORPORATION- AJI rightl resenrod.
1CORD25(2013/04y Tha ACORD name an4ID00 3111 lo9istered marks of ACORO