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Jazab Permit Apps
The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Dwelling FOR MUNICIPALITY USE Revised Mar 2011 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: ____________________________________________ 1.1a Is this an accepted street? yes_____ no_____ 1.2 Assessors Map & Parcel Numbers _____________________ ____________________ Map Number Parcel Number 1.3 Zoning Information: _______________ ___________________ Zoning District Proposed Use 1.4 Property Dimensions: _____________________ ____________________ 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) Public Private 1.7 Flood Zone Information: Zone: ___ Outside Flood Zone? Check if yes 1.8 Sewage Disposal System: Municipal On site disposal system SECTION 2: PROPERTY OWNERSHIP1 2.1 Owner1 of Record: ________________________________________ _________________________________________________ Name (Print) City, State, ZIP _____________________________________________ _________________ ___________________________________ No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition Demolition Accessory Bldg. Number of Units_____ Other Specify:________________________ Brief Description of Proposed Work2:_________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ 1. Building Permit Fee: $_______ Indicate how fee is determined: Standard City/Town Application Fee Total Project Cost3 (Item 6) x multiplier _______ x _______ 2. Other Fees: $_________ List:_________________________________________________ ____________________________________________________ Total All Fees: $_______________ Check No. ______Check Amount: _______Cash Amount:______ Paid in Full Outstanding Balance Due:__________ 2. Electrical $ 3. Plumbing $ 4. Mechanical (HVAC) $ 5. Mechanical (Fire Suppression) $ 6. Total Project Cost: $ SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) ________________________________________________________ Name of CSL Holder _________________________________________________________ No. and Street _________________________________________________________ City/Town, State, ZIP __________________ ______________________________________ Telephone Email address _____________________ ______________ License Number Expiration Date List CSL Type (see below) _______________ Type Description U Unrestricted (Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation D Demolition 5.2 Registered Home Improvement Contractor (HIC) ______________________________________________________________ HIC Company Name or HIC Registrant Name ______________________________________________________________ No. and Street ________________________________________ ____________________ City/Town, State, ZIP Telephone _____________________ ______________ HIC Registration Number Expiration Date _______________________________________ Email address SECTION 6: WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ………. No ……….. SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER’S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize_____________________________________________________ to act on my behalf, in all matters relative to work authorized by this building permit application. ______________________________________________________ ______________________ Print Owner’s Name (Electronic Signature) Date SECTION 7b: OWNER1 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) Date NOTES: 1.An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2.When substantial work is planned, provide the information below: Total floor area (sq. ft.) _________________________ (including garage, finished basement/attics, decks or porch) Gross living area (sq. ft.) __________________ Habitable room count ______________________ Number of fireplaces______________________ Number of bedrooms _____________________ Number of bathrooms ____________________ Number of half/baths ______________________ Type of heating system ___________________ Number of decks/ porches __________________ Type of cooling system_____________________ Enclosed ______________Open _____________ 3.“Total Project Square Footage” may be substituted for “Total Project Cost” NJ, ElectricalContractor business permit number34EB01547400 NJ, HIC reg. #13VH01244300 For other jurisdictions, please visit: http://www.trinity-solar.com/about-us/locations-and-licenses HOMEOWNERS AUTHORIZATION FORM I, , (print name) am the owner of the property located at address: . (print address) I hereby authorize Trinity Solar Inc.(“TrinitySolar”)and its employees, agents, and subcontractors, including without limitation, , to act as my Agent for the limited purpose of applying for and obtaining local building and other permits from the Authority Having Jurisdiction as required for the installation of a Photovoltaic System, Battery System, roofing or other Trinity Solar offerings located on my property, applying and obtaining permission and approval for interconnection with the electric utility company, and registration with any state and/or local incentive program(s). This authorization includesthe transfer/re-administering, and/or cancellation of any existing permits on file for the purpose of updating/applying with an alternate subcontractor. Without limitation to the generality of theforegoing Ispecifically authorize Trinity Solar et al. to populate technical details, fill-in, edit, compile, attach drawings, plans, data sheets and other documentation to, date, submit, re-submit, revise, amend and modify application, submission and certificationdocuments(“ApprovalsPaperwork”),includingthoseforwhichsignaturepagesareincluded herewith for my signature, in furtherance of the relatedtransaction, and I am providing any signatures to Approvals Paperwork for purposes of the foregoing. Trinity Solar will provide copies of Approvals Paperwork when submitted. My authorizations memorialized herein shall remain in full force and effect until revoked. I acknowledge that theseauthorizations are not required to proceed withthe transaction andare not a condition of the related agreement included herewith but are being given for my own convenience and benefit in order to expedite the approvals processes. ElectricUtility Company: ElectricUtilityAccount No.: Name on Electric Utility Account: Customer Signature PrintName Date CorporateHeadquarters1-877-SUN-SAVES 2211AllenwoodRoadPh:732-780-3779 Wall,NewJersey07719Fax:732-780-6671 www.trinity-solar.com FORINFORMATIONABOUTCONTRACTORSANDTHECONTRACTORS’REGISTRATION ACT, CONTACT THE NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY, DIVISION OF CONSUMERS AFFAIRS AT 1-888-656-6225. Ed Jazab November 22, 2022 9 Shepherds Hollow Road Northampton, Massachusetts 01062 United States National Grid 7548491048 Edmond Jazab Ed Jazab Northampton, MA January 31, 2023 212 Main St. Northampton, MA 01060 Trinity Solar No. 9 Shepherds Hollow Road 2022-11-797142 Northampton, MA 01062 MA License No. 56687 RE: DUFFY, PATRCIA A; JAZAB, ED Trinity Solar | 4 Open Square Way, Suite 410 | Holyoke, MA | (413) 203-9088 To the Building Official: The following information constitutes a summary of the relevant design criteria and recommendations for the support of a new photovoltaic [PV] system on the existing roof framing components at the above-referenced location. Criteria is as follows: 1. Existing roof framing: Conventional roof framing at R2 is 2x10 at 16 o.c.; existing rafter span= 17' 6"; (horizontal projection) Conventional roof framing at R3 is 2x10 at 16 o.c.; existing rafter span= 12' 8"; (horizontal projection) Conventional roof framing at R8 and R9 is 2x8 at 16 o.c.; existing rafter span= 8' 6"; (horizontal projection) 2. Roof Loading: • 3.0psf dead load (pounds per square foot - PV panels, mounting rails & hardware) • 6.9psf - existing roof loads (2.9 psf - 2x10 framing, 1.5psf roof sheathing, 2.5 psf shingles) • 6.3psf - existing roof loads (2.3 psf - 2x8 framing, 1.5psf roof sheathing, 2.5 psf shingles) • Ground Snow Load - 40psf - per AHJ (Authority Having Jurisdiction) • Wind criteria - Exposure Category B, 117 mph wind 3. Existing roof modification at R2 - A 2x4 “strongback” (L-shaped profile of two 2x4s) to be installed in low height areas to achieve a maximum span of 16' 6". This installation design is in general conformance with the manufacturers’ specifications and complies with all applicable laws, codes, and ordinances – specifically the International Building Code (2015 edition) and the International Residential Code (2015 edition), including all Massachusetts regulations and amendments. The spacing and fastening of the mounting brackets is a maximum of 48” o.c. between mounting brackets (staggered) and is secured using 5/16” diameter corrosive-resistant steel lag bolts. A minimum of 2½” of penetration (embedment) per lag bolt is required, which will resist all stated loads above – including wind shear. Per NDS Section 12.1.4, clearance holes - equal to the diameter of the shank - need to be bored into a primary framing member for the full-length of the threaded portion of the bolt to avoid splitting of the framing member. Regards, Ihor Bojcun, PE Structural Engineer - Trinity Solar City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ● Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number ________________ is that all 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 disposed of in: Location of Facility: ___________________________________________________ The debris will be transported by: Name of Hauler: ______________________________________________________ Signature of Applicant: __________________________________Date: ___________ Casella- 295 Forest Street, Peabody, MA 01960 Trinity Solar 2/10/2023 INSTALLATION OF NEW ROOF MOUNTED PV SOLAR SYSTEM 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 SHEPHERDS HOLLOW ROAD P1 ISSUED TO TOWNSHIP FOR PERMIT 1/24/2023 NO.DESCRIPTION DATE JAZAB, ED TRINITY ACCT #: 2022-11-797142 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 PROPOSED PV SOLAR SYSTEM DRAWING DATE:1/24/2023 DRAWN BY:RM REVISED BY: DC SYSTEM SIZE:14.4kW AC SYSTEM SIZE:10kW MODULE COUNT:36 MODULES USED:HANWHA 400 MODULE SPEC #:Q.PEAK DUO BLK ML-G10.a+ 400 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:7548491048 UTILITY METER #:14453001 DEAL TYPE:SUNNOVA P1 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com ROOF 1 MODULES: 0 PITCH: 40° ORIENTATION: 237° ROOF 2 MODULES: 23 PITCH: 23 ORIENTATION: 57 ROOF 3 MODULES: 6 PITCH: 40 ORIENTATION: 147 ROOF 4 MODULES: 0 PITCH: 40° ORIENTATION: 237° ROOF 5 MODULES: 0 PITCH: 40° ORIENTATION: 57° ROOF 6 MODULES: 0 PITCH: 40° ORIENTATION: 327° ROOF 7 MODULES: 0 PITCH: 23° ORIENTATION: 57° ROOF 8 MODULES: 3 PITCH: 18 ORIENTATION: 327 ROOF 9 MODULES: 4 PITCH: 18 ORIENTATION: 147 ROOF 10 MODULES: 0 PITCH: 27° ORIENTATION: 351° ROOF 11 MODULES: 0 PITCH: 40° ORIENTATION: 327° ROOF 12 MODULES: 0 PITCH: 43° ORIENTATION: 57° ROOF 13 MODULES: 0 PITCH: 43° ORIENTATION: 237° ROOF 14 MODULES: 0 PITCH: 43° ORIENTATION: 237° ROOF 15 MODULES: 0 PITCH: 43° ORIENTATION: 57° DC AC D ep M NS27090 13522545 31542.3400628,-72.7007034 36 HANWHA 400 (Q.PEAK DUO BLK ML-G10.a+ 400) 1 SE10000H-US000BEi4 BASEMENT OUTSIDE. OUTSIDE (UTILITY ACCESSIBLE)OUTSIDE. P1 ISSUED TO TOWNSHIP FOR PERMIT 1/24/2023 NO.DESCRIPTION DATE JAZAB, ED TRINITY ACCT #: 2022-11-797142 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 PROPOSED PV SOLAR SYSTEM DRAWING DATE:1/24/2023 DRAWN BY:RM REVISED BY: DC SYSTEM SIZE:14.4kW AC SYSTEM SIZE:10kW MODULE COUNT:36 MODULES USED:HANWHA 400 MODULE SPEC #:Q.PEAK DUO BLK ML-G10.a+ 400 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:7548491048 UTILITY METER #:14453001 DEAL TYPE:SUNNOVA P1 NOTES: 1.) ALL EQUIPMENT SHALL BE INSTALLED IN ACCORDANCE WITH THE MANUFACTURER'S INSTALLATION INSTRUCTIONS. 2.) 3.) ALL LOCATIONS ARE APPROXIMATE AND REQUIRE FIELD VERIFICATION. ALL OUTDOOR EQUIPMENT SHALL BE RAIN TIGHT WITH MINIMUM NEMA 3R RATING. M UD SP P DC AC ep D DC 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com SD TS CALCULATIONS FOR CURRENT CARRYING CONDUCTORS REQUIRED CONDUCTOR AMPACITY PER STRING [NEC 690.8(B)(1)]: (15.00*1.25)1 = 18.75A AWG #10, DERATED AMPACITY AMBIENT TEMP: 33°C, TEMP DERATING FACTOR: .96 RACEWAY DERATING = 6 CCC: 0.80 (40*.96)0.80 = 30.72A 30.72A >_ 18.75A, THEREFORE WIRE SIZE IS VALID TOTAL AC REQUIRED CONDUCTOR AMPACITY 42.00A*1.25 = 52.50A AWG #6, DERATED AMPACITY AMBIENT TEMP: 30°C, TEMP DERATING: 1.0 RACEWAY DERATING <_ 3 CCC: N/A 75A*1.0 = 75A 75A >_ 52.50A, THEREFORE AC WIRE SIZE IS VALID CALCULATION FOR PV OVERCURRENT PROTECTION TOTAL INVERTER CURRENT: 42.00A 42.00A*1.25 = 52.50A --> 60A OVERCURRENT PROTECTION IS VALID ARRAY CIRCUIT WIRING NOTES 1.) LICENSED ELECTRICIAN ASSUMES ALL RESPONSIBILITY FOR DETERMINING ONSITE CONDITIONS AND EXECUTING INSTALLATION IN ACCORDANCE WITH NEC 2020 2.) LOWEST EXPECTED AMBIENT TEMPERATURE BASED ON ASHRAE MINIMUM MEAN EXTREME DRY BULB TEMPERATURE FOR ASHRAE LOCATION MOST SIMILAR TO INSTALLATION LOCATION. LOWEST EXPECTED AMBIENT TEMP = -16°C 3.) HIGHEST CONTINUOUS AMBIENT TEMPERATURE BASED ON ASHRAE HIGHEST MONTH 2% DRY BULB TEMPERATURE FOR ASHRAE LOCATION MOST SIMILAR TO INSTALLATION LOCATION. HIGHEST CONTINUOUS TEMP = 33°C 4.) 2005 ASHRAE FUNDAMENTALS 2% DESIGN TEMPERATURES DO NOT EXCEED 47°C IN THE UNITED STATES (PALM SPRINGS, CA IS 44.1°C). FOR LESS THAN 9 CURRENT-CARRYING CONDUCTORS IN A ROOF-MOUNTED SUNLIT CONDUIT AT LEAST 0.5" ABOVE ROOF AND USING THE OUTDOOR DESIGN TEMPERATURE OF 47°C OR LESS (ALL OF UNITED STATES) 5.) PV SYSTEM CIRCUITS INSTALLED ON OR IN BUILDINGS SHALL INCLUDE A RAPID SHUTDOWN FUNCTION THAT CONTROLS SPECIFIC CONDUCTORS IN ACCORDANCE WITH NEC 690.12(A) THROUGH (D) 6.) PHOTOVOLTAIC POWER SYSTEMS SHALL BE PERMITTED TO OPERATE WITH UNGROUNDED PHOTOVOLTAIC SOURCE AND OUTPUT CIRCUIT AS PER NEC 690.41 (A)(4) 7.) UNGROUNDED DC CIRCUIT CONDUCTORS SHALL BE IDENTIFIED WITH THE FOLLOWING OUTER FINISH: POSITIVE CONDUCTORS = RED NEGATIVE CONDUCTORS = BLACK NEC 210.5(C)(2) 8.) ARRAY AND SUB ARRAY CONDUCTORS SHALL BE #10 PV WIRE TYPE RHW-2 OR EQUIVELANT AND SHALL BE PROTECTED BY CONDUIT WHERE EXPOSED TO DIRECT SUNLIGHT. SUB ARRAY CONDUIT LONGER THAN 24” SHALL CONTAIN ≤ 20 CURRENT CARYING CONDUCTORS AND WHERE EXPOSED TO DIRECT SUNLIGHT SHALL CONTAIN ≤ 9 CURRENT CARRYING CONDUCTORS. 9.) ALL WIRE LENGTHS SHALL BE LESS THAN 100' UNLESS OTHERWISE NOTED 10.) FLEXIBLE CONDUIT SHALL NOT BE INSTALLED ON ROOFTOP AND SHALL BE LIMITED TO 12” IF USED OUTDOORS 11.)OVERCURRENT PROTECTION FOR CONDUCTORS CONNECTED TO THE SUPPLY SIDE OF A SERVICE SHALL BE LOCATED WITHIN 10' OF THE POINT OF CONNECTION NEC 690.9(A)(3)(2) 12.) WHERE TWO SOURCES FEED A BUSSBAR, ONE A UTILITY AND THE OTHER AN INVERTER, PV BACKFEED BREAKER(S) SHALL BE LOCATED OPPOSITE FROM UTILITY NEC 705.12(B)(3)(2) 13.) ALL SOLAR SYSTEM LOAD CENTERS TO CONTAIN ONLY GENERATION CIRCUITS AND NO UNUSED POSITIONS OR LOADS 14.) ALL EQUIPMENT INSTALLED OUTDOORS SHALL HAVE A NEMA 3R RATING LOCKABLE 60A DISCONNECT FUSED W/ 60A FUSES SQUARE D PN: D222NRB ISOLATED NEUTRAL 240V 1Ø NEUTRALEXISTING MAIN BREAKER LOAD CENTER INSULATED LINE TAPS INSTALLED ON MAIN FEEDERS NEC 705.12(A) M 2p200AMAIN240V 1Ø 200A MAIN BREAKER 200A BUSBAR EXISTING 1Ø 120/240V UTILITY METER EG NOTE: INTERNAL REVENUE GRADE MONITORING CONTAINED WITHIN SOLAR EDGE INVERTER SOLAR EDGE PN. RWND-3D-240-MB INVERTER #1 - SE10000H-US000BEi4 DC AC Imp 27 Pout 10000 Vmp 400 Imax 42 Voc 480 OCPDmin 52.5 Isc 45 Vnom 240 PV MODULE SPECIFICATIONS HANWHA 400 (Q.PEAK DUO BLK ML-G10.a+ 400) Imp 10.77 Vmp 37.13 Voc 45.3 Isc 11.14 A #6 THWN-2 GEC TO EXISTING GROUND ROD B 3/4'' CONDUIT W/ 2-#6 THWN-2, 1-#10 THWN-2, 1-#10 THWN-2 GROUND C 3/4'' CONDUIT W/ 6-#10 THWN-2, 1-#10 THWN-2 GROUND D 3/4'' CONDUIT W/ 6-#10 THWN-2, 1-#10 THWN-2 GROUND E 3/4'' CONDUIT W/ 2-#6 THWN-2, 1-#10 THWN-2, 1-#10 THWN-2 GROUND F #10 PV WIRE (FREE AIR) W/ #6 BARE COPPER BOND TO ARRAY G 3/4'' CONDUIT W/ 2-#6 THWN-2, 1-#6 THWN-2, 1-#8 THWN-2 GROUND NOTE: CONDUIT TYPE SHALL BE CHOSEN BY THE INSTALLATION CONTRACTOR TO MEET OR EXCEED NEC AND LOCAL AHJD REQUIREMENTS INVERTER #1 PV+L1 L2 N PV-C SOLAR MODULES MOUNTED TO ROOF ON 4 ARRAYS 36 - 400W MODULES W/ 1 SOLAR EDGE S440 PER MODULE 15 ADC MAX PER STRING 1 STRING OF 12 MODULES IN SERIES - 400 Vmax 1 STRING OF 12 MODULES IN SERIES - 400 Vmax 1 STRING OF 12 MODULES IN SERIES - 400 Vmax *3 STRINGS TO BE TERMINATED IN PARALLEL INSIDE INVERTER 1 8"x8" JUNCTION BOXf P1 ISSUED TO TOWNSHIP FOR PERMIT 1/24/2023 NO.DESCRIPTION DATE JAZAB, ED TRINITY ACCT #: 2022-11-797142 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 PROPOSED PV SOLAR SYSTEM DRAWING DATE:1/24/2023 DRAWN BY:RM REVISED BY: DC SYSTEM SIZE:14.4kW AC SYSTEM SIZE:10kW MODULE COUNT:36 MODULES USED:HANWHA 400 MODULE SPEC #:Q.PEAK DUO BLK ML-G10.a+ 400 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:7548491048 UTILITY METER #:14453001 DEAL TYPE:SUNNOVA P1 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_________________________________________________ _ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. † 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:____________________________________________________________________________ Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________ Job Site Address: City/State/Zip:______________________ 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: ___________________________________ Permit/License #_________________________________ Issuing Authority (check one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ______________________________ Contact Person:_________________________________________ Phone #:_________________________________ Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13. Other____________________ 1. I am a employer with _________ employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † Are you an employer? Check the appropriate box: 4. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] 01/04/2023 Finck & Perras Insurance Agency Inc. 6 Campus Lane Easthampton MA 01027 Elizabeth Carballo, CISR, CPIA (413) 527-5520 (413) 527-5970 bcarballo@finckandperras.com Beyond Green Construction Inc, DBA: Sean Jeffords 13 Terrace View Easthampton MA 01027 RT Specialty Commerce Insurance Company 34754 AmGUARD Insurance Company 42390 CL231406967 A 948B001694 01/01/2023 01/01/2024 1,000,000 50,000 10,000 1,000,000 2,000,000 2,000,000 Employee Benefits B BGTDTS 01/01/2023 01/01/2024 1,000,000 C N BEWC487804 01/01/2023 01/01/2024 500,000 500,000 500,000 Proof of Coverage Trinity Solar 4 Open Square Way Suite 410 Holyoke MA 01040 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY JOB NAME:JAZAB, ED ADDRESS:9 Shepherds Hollow Road Northampton, MA 01062 42.3400628,-72.7007034 99.92 ESTIMATED PERSONNEL HOURS 4.16 DAYS 3.12 DAYS 2.08 DAYS •36 HANWHA 400's (14.4KW)(CREW OF 3)(CREW OF 4)(CREW OF 6) •4 SEPARATE ARRAYS •27' PEAK TO GROUND •36 PORTRAIT & 0 LANDSCAPED •1 INVERTERS INSTALLED OUTSIDE •NO TRENCH ESTIMATED SENT TO JOB USED □HANWHA 400 (Q.PEAK DUO BLK ML-G10.a+ 400)36 ______ □S440 SE OPTIMIZERS 36 ______ □SE10000H-US000BEi4 1 ______ □60A OUTDOOR FUSED DISCONNECT W/ (2) 60A FUSES 1 ______ □60A OUTDOOR NON-FUSED DISCONNECT 1 ______ □SOLADECK BOX(ES) & HAYCO CONNECTOR(S)4 ______ □PV LEAD WIRE 150'______ □INSULATED BUG BITES (LINE TAPS)2 ______ □CASE(S) OF BLACK SPRAY PAINT 1 ______ □CASE(S) OF TAR 1 ______ □FLASHINGS ______ MATERIAL LIST (FOR INTERNAL USE ONLY) 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com INSTALLATION OF NEW ROOF MOUNTED PV SOLAR SYSTEM 9 SHEPHERDS HOLLOW ROAD JAZAB, ED 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 APPENDIX CONTENTS LABELS, STICKERS, AND PLACARDS EQUIPMENT DATA SHEETS 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner’s Address Is this permit in conjunction Yeswith a building permit? No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / OverheadVolts Undgrd No. of Meters New Service Amps / OverheadVolts Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Transformers Total KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Abovegrnd. In- grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond.Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals:Number Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Municipal Connection Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. of Signs No. of Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work:(When required by municipal policy.) Inspections to be requesteWork to Start:d in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including “completed operation” coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND OTHER (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. LIC. NO.: required by law. By my signature below, I hereby waive this requirement. I am the (check one) owner owner’s agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ TBD 53681 Residential Licensee: Signature LIC. NO.: (If applicable, enter “exempt” in the license number line.) Bus. Tel. No.: FIRM NAME: Address: Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety “S” License: Lic. No. OWNER’S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally 855-970-8255 INSTALLATION OF NEW ROOF MOUNTED PV SOLAR SYSTEM 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 SHEPHERDS HOLLOW ROAD P1 ISSUED TO TOWNSHIP FOR PERMIT 1/24/2023 NO.DESCRIPTION DATE JAZAB, ED TRINITY ACCT #: 2022-11-797142 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 PROPOSED PV SOLAR SYSTEM DRAWING DATE:1/24/2023 DRAWN BY:RM REVISED BY: DC SYSTEM SIZE:14.4kW AC SYSTEM SIZE:10kW MODULE COUNT:36 MODULES USED:HANWHA 400 MODULE SPEC #:Q.PEAK DUO BLK ML-G10.a+ 400 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:7548491048 UTILITY METER #:14453001 DEAL TYPE:SUNNOVA P1 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com ROOF 1 MODULES: 0 PITCH: 40° ORIENTATION: 237° ROOF 2 MODULES: 23 PITCH: 23 ORIENTATION: 57 ROOF 3 MODULES: 6 PITCH: 40 ORIENTATION: 147 ROOF 4 MODULES: 0 PITCH: 40° ORIENTATION: 237° ROOF 5 MODULES: 0 PITCH: 40° ORIENTATION: 57° ROOF 6 MODULES: 0 PITCH: 40° ORIENTATION: 327° ROOF 7 MODULES: 0 PITCH: 23° ORIENTATION: 57° ROOF 8 MODULES: 3 PITCH: 18 ORIENTATION: 327 ROOF 9 MODULES: 4 PITCH: 18 ORIENTATION: 147 ROOF 10 MODULES: 0 PITCH: 27° ORIENTATION: 351° ROOF 11 MODULES: 0 PITCH: 40° ORIENTATION: 327° ROOF 12 MODULES: 0 PITCH: 43° ORIENTATION: 57° ROOF 13 MODULES: 0 PITCH: 43° ORIENTATION: 237° ROOF 14 MODULES: 0 PITCH: 43° ORIENTATION: 237° ROOF 15 MODULES: 0 PITCH: 43° ORIENTATION: 57° DC AC D ep M NS27090 13522545 31542.3400628,-72.7007034 36 HANWHA 400 (Q.PEAK DUO BLK ML-G10.a+ 400) 1 SE10000H-US000BEi4 BASEMENT OUTSIDE. OUTSIDE (UTILITY ACCESSIBLE)OUTSIDE. P1 ISSUED TO TOWNSHIP FOR PERMIT 1/24/2023 NO.DESCRIPTION DATE JAZAB, ED TRINITY ACCT #: 2022-11-797142 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 PROPOSED PV SOLAR SYSTEM DRAWING DATE:1/24/2023 DRAWN BY:RM REVISED BY: DC SYSTEM SIZE:14.4kW AC SYSTEM SIZE:10kW MODULE COUNT:36 MODULES USED:HANWHA 400 MODULE SPEC #:Q.PEAK DUO BLK ML-G10.a+ 400 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:7548491048 UTILITY METER #:14453001 DEAL TYPE:SUNNOVA P1 NOTES: 1.) ALL EQUIPMENT SHALL BE INSTALLED IN ACCORDANCE WITH THE MANUFACTURER'S INSTALLATION INSTRUCTIONS. 2.) 3.) ALL LOCATIONS ARE APPROXIMATE AND REQUIRE FIELD VERIFICATION. ALL OUTDOOR EQUIPMENT SHALL BE RAIN TIGHT WITH MINIMUM NEMA 3R RATING. M UD SP P DC AC ep D DC 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com SD TS CALCULATIONS FOR CURRENT CARRYING CONDUCTORS REQUIRED CONDUCTOR AMPACITY PER STRING [NEC 690.8(B)(1)]: (15.00*1.25)1 = 18.75A AWG #10, DERATED AMPACITY AMBIENT TEMP: 33°C, TEMP DERATING FACTOR: .96 RACEWAY DERATING = 6 CCC: 0.80 (40*.96)0.80 = 30.72A 30.72A >_ 18.75A, THEREFORE WIRE SIZE IS VALID TOTAL AC REQUIRED CONDUCTOR AMPACITY 42.00A*1.25 = 52.50A AWG #6, DERATED AMPACITY AMBIENT TEMP: 30°C, TEMP DERATING: 1.0 RACEWAY DERATING <_ 3 CCC: N/A 75A*1.0 = 75A 75A >_ 52.50A, THEREFORE AC WIRE SIZE IS VALID CALCULATION FOR PV OVERCURRENT PROTECTION TOTAL INVERTER CURRENT: 42.00A 42.00A*1.25 = 52.50A --> 60A OVERCURRENT PROTECTION IS VALID ARRAY CIRCUIT WIRING NOTES 1.) LICENSED ELECTRICIAN ASSUMES ALL RESPONSIBILITY FOR DETERMINING ONSITE CONDITIONS AND EXECUTING INSTALLATION IN ACCORDANCE WITH NEC 2020 2.) LOWEST EXPECTED AMBIENT TEMPERATURE BASED ON ASHRAE MINIMUM MEAN EXTREME DRY BULB TEMPERATURE FOR ASHRAE LOCATION MOST SIMILAR TO INSTALLATION LOCATION. LOWEST EXPECTED AMBIENT TEMP = -16°C 3.) HIGHEST CONTINUOUS AMBIENT TEMPERATURE BASED ON ASHRAE HIGHEST MONTH 2% DRY BULB TEMPERATURE FOR ASHRAE LOCATION MOST SIMILAR TO INSTALLATION LOCATION. HIGHEST CONTINUOUS TEMP = 33°C 4.) 2005 ASHRAE FUNDAMENTALS 2% DESIGN TEMPERATURES DO NOT EXCEED 47°C IN THE UNITED STATES (PALM SPRINGS, CA IS 44.1°C). FOR LESS THAN 9 CURRENT-CARRYING CONDUCTORS IN A ROOF-MOUNTED SUNLIT CONDUIT AT LEAST 0.5" ABOVE ROOF AND USING THE OUTDOOR DESIGN TEMPERATURE OF 47°C OR LESS (ALL OF UNITED STATES) 5.) PV SYSTEM CIRCUITS INSTALLED ON OR IN BUILDINGS SHALL INCLUDE A RAPID SHUTDOWN FUNCTION THAT CONTROLS SPECIFIC CONDUCTORS IN ACCORDANCE WITH NEC 690.12(A) THROUGH (D) 6.) PHOTOVOLTAIC POWER SYSTEMS SHALL BE PERMITTED TO OPERATE WITH UNGROUNDED PHOTOVOLTAIC SOURCE AND OUTPUT CIRCUIT AS PER NEC 690.41 (A)(4) 7.) UNGROUNDED DC CIRCUIT CONDUCTORS SHALL BE IDENTIFIED WITH THE FOLLOWING OUTER FINISH: POSITIVE CONDUCTORS = RED NEGATIVE CONDUCTORS = BLACK NEC 210.5(C)(2) 8.) ARRAY AND SUB ARRAY CONDUCTORS SHALL BE #10 PV WIRE TYPE RHW-2 OR EQUIVELANT AND SHALL BE PROTECTED BY CONDUIT WHERE EXPOSED TO DIRECT SUNLIGHT. SUB ARRAY CONDUIT LONGER THAN 24” SHALL CONTAIN ≤ 20 CURRENT CARYING CONDUCTORS AND WHERE EXPOSED TO DIRECT SUNLIGHT SHALL CONTAIN ≤ 9 CURRENT CARRYING CONDUCTORS. 9.) ALL WIRE LENGTHS SHALL BE LESS THAN 100' UNLESS OTHERWISE NOTED 10.) FLEXIBLE CONDUIT SHALL NOT BE INSTALLED ON ROOFTOP AND SHALL BE LIMITED TO 12” IF USED OUTDOORS 11.)OVERCURRENT PROTECTION FOR CONDUCTORS CONNECTED TO THE SUPPLY SIDE OF A SERVICE SHALL BE LOCATED WITHIN 10' OF THE POINT OF CONNECTION NEC 690.9(A)(3)(2) 12.) WHERE TWO SOURCES FEED A BUSSBAR, ONE A UTILITY AND THE OTHER AN INVERTER, PV BACKFEED BREAKER(S) SHALL BE LOCATED OPPOSITE FROM UTILITY NEC 705.12(B)(3)(2) 13.) ALL SOLAR SYSTEM LOAD CENTERS TO CONTAIN ONLY GENERATION CIRCUITS AND NO UNUSED POSITIONS OR LOADS 14.) ALL EQUIPMENT INSTALLED OUTDOORS SHALL HAVE A NEMA 3R RATING LOCKABLE 60A DISCONNECT FUSED W/ 60A FUSES SQUARE D PN: D222NRB ISOLATED NEUTRAL 240V 1Ø NEUTRALEXISTING MAIN BREAKER LOAD CENTER INSULATED LINE TAPS INSTALLED ON MAIN FEEDERS NEC 705.12(A) M 2p200AMAIN240V 1Ø 200A MAIN BREAKER 200A BUSBAR EXISTING 1Ø 120/240V UTILITY METER EG NOTE: INTERNAL REVENUE GRADE MONITORING CONTAINED WITHIN SOLAR EDGE INVERTER SOLAR EDGE PN. RWND-3D-240-MB INVERTER #1 - SE10000H-US000BEi4 DC AC Imp 27 Pout 10000 Vmp 400 Imax 42 Voc 480 OCPDmin 52.5 Isc 45 Vnom 240 PV MODULE SPECIFICATIONS HANWHA 400 (Q.PEAK DUO BLK ML-G10.a+ 400) Imp 10.77 Vmp 37.13 Voc 45.3 Isc 11.14 A #6 THWN-2 GEC TO EXISTING GROUND ROD B 3/4'' CONDUIT W/ 2-#6 THWN-2, 1-#10 THWN-2, 1-#10 THWN-2 GROUND C 3/4'' CONDUIT W/ 6-#10 THWN-2, 1-#10 THWN-2 GROUND D 3/4'' CONDUIT W/ 6-#10 THWN-2, 1-#10 THWN-2 GROUND E 3/4'' CONDUIT W/ 2-#6 THWN-2, 1-#10 THWN-2, 1-#10 THWN-2 GROUND F #10 PV WIRE (FREE AIR) W/ #6 BARE COPPER BOND TO ARRAY G 3/4'' CONDUIT W/ 2-#6 THWN-2, 1-#6 THWN-2, 1-#8 THWN-2 GROUND NOTE: CONDUIT TYPE SHALL BE CHOSEN BY THE INSTALLATION CONTRACTOR TO MEET OR EXCEED NEC AND LOCAL AHJD REQUIREMENTS INVERTER #1 PV+L1 L2 N PV-C SOLAR MODULES MOUNTED TO ROOF ON 4 ARRAYS 36 - 400W MODULES W/ 1 SOLAR EDGE S440 PER MODULE 15 ADC MAX PER STRING 1 STRING OF 12 MODULES IN SERIES - 400 Vmax 1 STRING OF 12 MODULES IN SERIES - 400 Vmax 1 STRING OF 12 MODULES IN SERIES - 400 Vmax *3 STRINGS TO BE TERMINATED IN PARALLEL INSIDE INVERTER 1 8"x8" JUNCTION BOXf P1 ISSUED TO TOWNSHIP FOR PERMIT 1/24/2023 NO.DESCRIPTION DATE JAZAB, ED TRINITY ACCT #: 2022-11-797142 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 PROPOSED PV SOLAR SYSTEM DRAWING DATE:1/24/2023 DRAWN BY:RM REVISED BY: DC SYSTEM SIZE:14.4kW AC SYSTEM SIZE:10kW MODULE COUNT:36 MODULES USED:HANWHA 400 MODULE SPEC #:Q.PEAK DUO BLK ML-G10.a+ 400 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:7548491048 UTILITY METER #:14453001 DEAL TYPE:SUNNOVA P1 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers’ Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_________________________________________________ _ Address:__________________________________________________________________________ City/State/Zip:_____________________________ Phone #:________________________________ *Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information. † 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:____________________________________________________________________________ Policy # or Self-ins. Lic. #:__________________________________________ Expiration Date:____________________ Job Site Address: City/State/Zip:______________________ 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: ___________________________________ Permit/License #_________________________________ Issuing Authority (check one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ______________________________ Contact Person:_________________________________________ Phone #:_________________________________ Type of project (required): 6. New construction 7. Remodeling 8. Demolition 9. Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13. Other____________________ 1. I am a employer with _________ employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers’ comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.] † Are you an employer? Check the appropriate box: 4. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers’ comp. insurance.‡ 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers’ comp. insurance required.] 01/04/2023 Finck & Perras Insurance Agency Inc. 6 Campus Lane Easthampton MA 01027 Elizabeth Carballo, CISR, CPIA (413) 527-5520 (413) 527-5970 bcarballo@finckandperras.com Beyond Green Construction Inc, DBA: Sean Jeffords 13 Terrace View Easthampton MA 01027 RT Specialty Commerce Insurance Company 34754 AmGUARD Insurance Company 42390 CL231406967 A 948B001694 01/01/2023 01/01/2024 1,000,000 50,000 10,000 1,000,000 2,000,000 2,000,000 Employee Benefits B BGTDTS 01/01/2023 01/01/2024 1,000,000 C N BEWC487804 01/01/2023 01/01/2024 500,000 500,000 500,000 Proof of Coverage Trinity Solar 4 Open Square Way Suite 410 Holyoke MA 01040 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY JOB NAME:JAZAB, ED ADDRESS:9 Shepherds Hollow Road Northampton, MA 01062 42.3400628,-72.7007034 99.92 ESTIMATED PERSONNEL HOURS 4.16 DAYS 3.12 DAYS 2.08 DAYS •36 HANWHA 400's (14.4KW)(CREW OF 3)(CREW OF 4)(CREW OF 6) •4 SEPARATE ARRAYS •27' PEAK TO GROUND •36 PORTRAIT & 0 LANDSCAPED •1 INVERTERS INSTALLED OUTSIDE •NO TRENCH ESTIMATED SENT TO JOB USED □HANWHA 400 (Q.PEAK DUO BLK ML-G10.a+ 400)36 ______ □S440 SE OPTIMIZERS 36 ______ □SE10000H-US000BEi4 1 ______ □60A OUTDOOR FUSED DISCONNECT W/ (2) 60A FUSES 1 ______ □60A OUTDOOR NON-FUSED DISCONNECT 1 ______ □SOLADECK BOX(ES) & HAYCO CONNECTOR(S)4 ______ □PV LEAD WIRE 150'______ □INSULATED BUG BITES (LINE TAPS)2 ______ □CASE(S) OF BLACK SPRAY PAINT 1 ______ □CASE(S) OF TAR 1 ______ □FLASHINGS ______ MATERIAL LIST (FOR INTERNAL USE ONLY) 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com INSTALLATION OF NEW ROOF MOUNTED PV SOLAR SYSTEM 9 SHEPHERDS HOLLOW ROAD JAZAB, ED 9 SHEPHERDS HOLLOW ROAD NORTHAMPTON, MA 01062 42.3400628,-72.7007034 APPENDIX CONTENTS LABELS, STICKERS, AND PLACARDS EQUIPMENT DATA SHEETS 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com