The URL can be used to link to this page

Hanlon Permit AppsThe 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 Owner 1 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” Phil SmithPhil Smith 6 Torrey St6 Torrey St Easthampton, MA 01027Easthampton, MA 01027 413-203-9088 applications.westma@trinity-solar.com CS CS-108025 9/29/20234/22/2024 U Trinity Solar Inc DBA Trinity Solar 20 Patterson Brook Road - Unit 10 West Wareham MA 02576 413-203-9088 170355 10/11/202110/11/2023 applications.westma@trinity-solar.com Please See Attached X X X x x 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 03/10/2023 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”),includingthoseforwhichsignaturepages areincluded 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. Brian Hanlon February 22, 2023 15 Mary Jane Lane Northampton, Massachusetts 01062 United States National Grid 0365015078 Brian Hanlon Brian Hanlon Northampton, MA March 3, 2023 212 Main St. Northampton, MA 01060 Trinity Solar No. 15 Mary Jane Lane 2023-02-833350 Northampton, MA 01062 MA License No. 56687 RE: HANLON, BRIAN 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 R1 and R2 is 2x6 at 16 o.c.; existing rafter span= 10' 6"; (horizontal projection) 2. Roof Loading: • 3.0psf dead load (pounds per square foot - PV panels, mounting rails & hardware) • 5.7psf - existing roof loads (1.7 psf - 2x6 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 - none required; existing roof framing is acceptable for PV installation. 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 INSTALLATION OF NEW ROOF MOUNTED PV SOLAR SYSTEM 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 MARY JANE LANE P1 ISSUED TO TOWNSHIP FOR PERMIT 3/9/2023 NO.DESCRIPTION DATE HANLON, BRIAN- TRINITY ACCT #: 2023-02-833350 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 PROPOSED PV SOLAR SYSTEM DRAWING DATE:3/9/2023 DRAWN BY:HL REVISED BY: DC SYSTEM SIZE:9.315kW AC SYSTEM SIZE:7.6kW MODULE COUNT:23 MODULES USED:HANWHA 405 MODULE SPEC #:Q.PEAK DUO BLK ML-G10+ 405 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:0365015078 UTILITY METER #:23593292 DEAL TYPE:SUNNOVA P1 R 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com ROOF 1 MODULES: 10 PITCH: 18 ORIENTATION: 297 ROOF 2 MODULES: 13 PITCH: 18 ORIENTATION: 117 ROOF 3 MODULES: 0 PITCH: 10° ORIENTATION: 209° ROOF 4 MODULES: 0 PITCH: 10° ORIENTATION: 29° ROOF 5 MODULES: 0 PITCH: 10° ORIENTATION: 209° ROOF 6 MODULES: 0 PITCH: 10° ORIENTATION: 29° ROOF 7 MODULES: NA PITCH: NA° ORIENTATION: NA° ROOF 8 MODULES: NA PITCH: NA° ORIENTATION: NA° ROOF 9 MODULES: NA PITCH: NA° ORIENTATION: NA° ROOF 10 MODULES: NA PITCH: NA° ORIENTATION: NA° DC AC D ep M N S270 9013522545 31542.346518,-72.6648603 23 HANWHA 405 (Q.PEAK DUO BLK ML-G10+ 405) 1 SE7600H-US000BEi4 INSIDE OUTSIDE. OUTSIDE (UTILITY ACCESSIBLE)OUTSIDE. P1 ISSUED TO TOWNSHIP FOR PERMIT 3/9/2023 NO.DESCRIPTION DATE HANLON, BRIAN- TRINITY ACCT #: 2023-02-833350 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 PROPOSED PV SOLAR SYSTEM DRAWING DATE:3/9/2023 DRAWN BY:HL REVISED BY: DC SYSTEM SIZE:9.315kW AC SYSTEM SIZE:7.6kW MODULE COUNT:23 MODULES USED:HANWHA 405 MODULE SPEC #:Q.PEAK DUO BLK ML-G10+ 405 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:0365015078 UTILITY METER #:23593292 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 R 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 = 4 CCC: 0.80 (40*.96)0.80 = 30.72A 30.72A >_ 18.75A, THEREFORE WIRE SIZE IS VALID TOTAL AC REQUIRED CONDUCTOR AMPACITY 32.00A*1.25 = 40.00A AWG #8, DERATED AMPACITY AMBIENT TEMP: 30°C, TEMP DERATING: 1.0 RACEWAY DERATING <_ 3 CCC: N/A 55A*1.0 = 55A 55A >_ 40.00A, THEREFORE AC WIRE SIZE IS VALID CALCULATION FOR PV OVERCURRENT PROTECTION TOTAL INVERTER CURRENT: 32.00A 32.00A*1.25 = 40.00A --> 40A 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/ 40A FUSES SQUARE D PN: D222NRB ISOLATED NEUTRAL 240V 1Ø NOTE: INTERNAL REVENUE GRADE MONITORING CONTAINED WITHIN SOLAR EDGE INVERTER SOLAR EDGE PN. RWND-3D-240-MB 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 INVERTER #1 - SE7600H-US000BEi4 DC AC Imp 20 Pout 7600 Vmp 400 Imax 32 Voc 480 OCPDmin 40 Isc 30 Vnom 240 PV MODULE SPECIFICATIONS HANWHA 405 (Q.PEAK DUO BLK ML-G10+ 405) Imp 10.83 Vmp 37.39 Voc 45.34 Isc 11.17 A #6 THWN-2 GEC TO EXISTING GROUND ROD B 3/4'' CONDUIT W/ 2-#8 THWN-2, 1-#10 THWN-2, 1-#10 THWN-2 GROUND C 3/4'' CONDUIT W/ 4-#10 THWN-2, 1-#10 THWN-2 GROUND D 3/4'' CONDUIT W/ 4-#10 THWN-2, 1-#10 THWN-2 GROUND E 3/4'' CONDUIT W/ 2-#8 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-D SOLAR MODULES MOUNTED TO ROOF ON 2 ARRAYS 23 - 405W MODULES W/ 1 SOLAR EDGE S440 PER MODULE 15 ADC MAX PER STRING 1 STRING OF 11 MODULES IN SERIES - 400 Vmax 1 STRING OF 12 MODULES IN SERIES - 400 Vmax *2 STRINGS TO BE TERMINATED IN PARALLEL INSIDE INVERTER 1 f 8"x8" JUNCTION BOX P1 ISSUED TO TOWNSHIP FOR PERMIT 3/9/2023 NO.DESCRIPTION DATE HANLON, BRIAN- TRINITY ACCT #: 2023-02-833350 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 PROPOSED PV SOLAR SYSTEM DRAWING DATE:3/9/2023 DRAWN BY:HL REVISED BY: DC SYSTEM SIZE:9.315kW AC SYSTEM SIZE:7.6kW MODULE COUNT:23 MODULES USED:HANWHA 405 MODULE SPEC #:Q.PEAK DUO BLK ML-G10+ 405 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:0365015078 UTILITY METER #:23593292 DEAL TYPE:SUNNOVA P1 R 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com 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 1/12/2023 Arthur J. Gallagher Risk Management Services, Inc. 4000 Midlantic Drive Suite 200 Mount Laurel NJ 08054 Mark Grasela 856-482-9900 856-482-1888 CherryHill.BSD.CertM@AJG.com Gotham Insurance Company 25569 TRINHEA-03 National Union Fire Insurance Company of Pittsburg 19445Trinity Solar Inc. 4 Open Square Way, Suite 410 Holyoke, MA 01040 Liberty International Underwriters 1260165960 A X 2,000,000 X 100,000 5,000 1,000,000 2,000,000 X GL202100013378 6/1/2021 6/1/2023 2,000,000 B 2,000,000 X CA 2960145 6/1/2022 6/1/2023 A C C X 5,000,000 X EX202100001871 ELD30006989101 1000231834-06 6/1/2021 6/1/2022 6/1/2022 6/1/2023 6/1/2023 6/1/2023 5,000,000 Limit x of $5,000,000 19,000,000 B XWC 13588108 6/1/2022 6/1/2023 1,000,000 1,000,000 1,000,000 B Automobile Comp/ Collusion Ded.CA 2960145 6/1/2022 6/1/2023 All Other Units Truck-Tractors and Semi-Trailers $250/500 $250/500 Evidence of Insurance. Evidence of Insurance JOB NAME:HANLON, BRIAN- ADDRESS:15 Mary Jane Lane Northampton, MA 01062 42.346518,-72.6648603 50.438 ESTIMATED PERSONNEL HOURS 2.1 DAYS 1.58 DAYS 1.05 DAYS •23 HANWHA 405's (9.315KW)(CREW OF 3)(CREW OF 4)(CREW OF 6) •2 SEPARATE ARRAYS •14' PEAK TO GROUND •19 PORTRAIT & 4 LANDSCAPED •1 INVERTERS INSTALLED OUTSIDE •NO TRENCH ESTIMATED SENT TO JOB USED □HANWHA 405 (Q.PEAK DUO BLK ML-G10+ 405)23 ______ □S440 SE OPTIMIZERS 23 ______ □SE7600H-US000BEi4 1 ______ □60A OUTDOOR FUSED DISCONNECT W/ (2) 40A FUSES 1 ______ □60A OUTDOOR NON-FUSED DISCONNECT 1 ______ □SOLADECK BOX(ES) & HAYCO CONNECTOR(S)2 ______ □PV LEAD WIRE 100'______ □INSULATED BUG BITES (LINE TAPS)2 ______ □CASE(S) OF BLACK SPRAY PAINT 1 ______ □CASE(S) OF TAR 1 ______ □FLASHINGS ______ MATERIAL LIST R(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 15 MARY JANE LANE HANLON, BRIAN- 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 R APPENDIX CONTENTS LABELS, STICKERS, AND PLACARDS EQUIPMENT DATA SHEETS 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com 120 240 INSTALLATION OF NEW ROOF MOUNTED PV SOLAR SYSTEM 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 MARY JANE LANE P1 ISSUED TO TOWNSHIP FOR PERMIT 3/9/2023 NO.DESCRIPTION DATE HANLON, BRIAN- TRINITY ACCT #: 2023-02-833350 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 PROPOSED PV SOLAR SYSTEM DRAWING DATE:3/9/2023 DRAWN BY:HL REVISED BY: DC SYSTEM SIZE:9.315kW AC SYSTEM SIZE:7.6kW MODULE COUNT:23 MODULES USED:HANWHA 405 MODULE SPEC #:Q.PEAK DUO BLK ML-G10+ 405 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:0365015078 UTILITY METER #:23593292 DEAL TYPE:SUNNOVA P1 R 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com ROOF 1 MODULES: 10 PITCH: 18 ORIENTATION: 297 ROOF 2 MODULES: 13 PITCH: 18 ORIENTATION: 117 ROOF 3 MODULES: 0 PITCH: 10° ORIENTATION: 209° ROOF 4 MODULES: 0 PITCH: 10° ORIENTATION: 29° ROOF 5 MODULES: 0 PITCH: 10° ORIENTATION: 209° ROOF 6 MODULES: 0 PITCH: 10° ORIENTATION: 29° ROOF 7 MODULES: NA PITCH: NA° ORIENTATION: NA° ROOF 8 MODULES: NA PITCH: NA° ORIENTATION: NA° ROOF 9 MODULES: NA PITCH: NA° ORIENTATION: NA° ROOF 10 MODULES: NA PITCH: NA° ORIENTATION: NA° DC AC D ep M N S270 9013522545 31542.346518,-72.6648603 23 HANWHA 405 (Q.PEAK DUO BLK ML-G10+ 405) 1 SE7600H-US000BEi4 INSIDE OUTSIDE. OUTSIDE (UTILITY ACCESSIBLE)OUTSIDE. P1 ISSUED TO TOWNSHIP FOR PERMIT 3/9/2023 NO.DESCRIPTION DATE HANLON, BRIAN- TRINITY ACCT #: 2023-02-833350 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 PROPOSED PV SOLAR SYSTEM DRAWING DATE:3/9/2023 DRAWN BY:HL REVISED BY: DC SYSTEM SIZE:9.315kW AC SYSTEM SIZE:7.6kW MODULE COUNT:23 MODULES USED:HANWHA 405 MODULE SPEC #:Q.PEAK DUO BLK ML-G10+ 405 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:0365015078 UTILITY METER #:23593292 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 R 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 = 4 CCC: 0.80 (40*.96)0.80 = 30.72A 30.72A >_ 18.75A, THEREFORE WIRE SIZE IS VALID TOTAL AC REQUIRED CONDUCTOR AMPACITY 32.00A*1.25 = 40.00A AWG #8, DERATED AMPACITY AMBIENT TEMP: 30°C, TEMP DERATING: 1.0 RACEWAY DERATING <_ 3 CCC: N/A 55A*1.0 = 55A 55A >_ 40.00A, THEREFORE AC WIRE SIZE IS VALID CALCULATION FOR PV OVERCURRENT PROTECTION TOTAL INVERTER CURRENT: 32.00A 32.00A*1.25 = 40.00A --> 40A 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/ 40A FUSES SQUARE D PN: D222NRB ISOLATED NEUTRAL 240V 1Ø NOTE: INTERNAL REVENUE GRADE MONITORING CONTAINED WITHIN SOLAR EDGE INVERTER SOLAR EDGE PN. RWND-3D-240-MB 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 INVERTER #1 - SE7600H-US000BEi4 DC AC Imp 20 Pout 7600 Vmp 400 Imax 32 Voc 480 OCPDmin 40 Isc 30 Vnom 240 PV MODULE SPECIFICATIONS HANWHA 405 (Q.PEAK DUO BLK ML-G10+ 405) Imp 10.83 Vmp 37.39 Voc 45.34 Isc 11.17 A #6 THWN-2 GEC TO EXISTING GROUND ROD B 3/4'' CONDUIT W/ 2-#8 THWN-2, 1-#10 THWN-2, 1-#10 THWN-2 GROUND C 3/4'' CONDUIT W/ 4-#10 THWN-2, 1-#10 THWN-2 GROUND D 3/4'' CONDUIT W/ 4-#10 THWN-2, 1-#10 THWN-2 GROUND E 3/4'' CONDUIT W/ 2-#8 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-D SOLAR MODULES MOUNTED TO ROOF ON 2 ARRAYS 23 - 405W MODULES W/ 1 SOLAR EDGE S440 PER MODULE 15 ADC MAX PER STRING 1 STRING OF 11 MODULES IN SERIES - 400 Vmax 1 STRING OF 12 MODULES IN SERIES - 400 Vmax *2 STRINGS TO BE TERMINATED IN PARALLEL INSIDE INVERTER 1 f 8"x8" JUNCTION BOX P1 ISSUED TO TOWNSHIP FOR PERMIT 3/9/2023 NO.DESCRIPTION DATE HANLON, BRIAN- TRINITY ACCT #: 2023-02-833350 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 PROPOSED PV SOLAR SYSTEM DRAWING DATE:3/9/2023 DRAWN BY:HL REVISED BY: DC SYSTEM SIZE:9.315kW AC SYSTEM SIZE:7.6kW MODULE COUNT:23 MODULES USED:HANWHA 405 MODULE SPEC #:Q.PEAK DUO BLK ML-G10+ 405 UTILITY COMPANY:NAT'L GRID UTILITY ACCT #:0365015078 UTILITY METER #:23593292 DEAL TYPE:SUNNOVA P1 R 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com 01/20/2023 Webber & Grinnell 8 North King Street Northampton MA 01060 Barbara Grynkiewicz (413) 586-0111 (413) 586-6481 bgrynkiewicz@webberandgrinnell.com Valley Solar, LLC 116 Pleasant Street Suite #321 Easthampton MA 01027-2752 Merchants Preferred Merchants Mutual Continental Indemnity/AUW 28258 Master Exp 09/2023 A Y Y CTRI002161 09/01/2022 09/01/2023 1,000,000 500,000 5,000 1,000,000 2,000,000 2,000,000 B Y Y MCAI002963 09/01/2022 09/01/2023 1,000,000 Medical payments 5,000 B 10,000 Y CUPI003112 09/01/2022 09/01/2023 5,000,000 5,000,000 C N 376140840101 09/01/2022 09/01/2023 1,000,000 1,000,000 1,000,000 Trinity Solar Inc. is named as additional insured on a primary/non-contributory basis with respect to the above General Liability Policy for both (ongoing/completed operations) and Automobile Liability Policy as required by a written contract executed prior to services performed and per terms and conditions of the policy. Subcontractor Proprietor, Partner/Executive Officer/Member included in above Workers Compensation coverage. A waiver of subrogation is provided in favor of the contractor, its subsidiaries, agents, and affiliated companies and their respective employees, officers, and directors with respect to the above General Liability, Automobile, Umbrella and Workers Compensation Policies, but only to the extent permitted by law, if required by a written contract. With respect to equipment supplied by the contractor, the subcontractor shall maintain Property and Inland Marine coverage with limits equal to or greater than the maximum value of said equipment. Umbrella Liabiliity Policy Follows Form over that of the underlying policies. Trinity Solar Inc. 4 Open Square Way Ste 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 belowIf 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 HIREDAUTOS ONLY 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.] JOB NAME:HANLON, BRIAN- ADDRESS:15 Mary Jane Lane Northampton, MA 01062 42.346518,-72.6648603 50.438 ESTIMATED PERSONNEL HOURS 2.1 DAYS 1.58 DAYS 1.05 DAYS •23 HANWHA 405's (9.315KW)(CREW OF 3)(CREW OF 4)(CREW OF 6) •2 SEPARATE ARRAYS •14' PEAK TO GROUND •19 PORTRAIT & 4 LANDSCAPED •1 INVERTERS INSTALLED OUTSIDE •NO TRENCH ESTIMATED SENT TO JOB USED □HANWHA 405 (Q.PEAK DUO BLK ML-G10+ 405)23 ______ □S440 SE OPTIMIZERS 23 ______ □SE7600H-US000BEi4 1 ______ □60A OUTDOOR FUSED DISCONNECT W/ (2) 40A FUSES 1 ______ □60A OUTDOOR NON-FUSED DISCONNECT 1 ______ □SOLADECK BOX(ES) & HAYCO CONNECTOR(S)2 ______ □PV LEAD WIRE 100'______ □INSULATED BUG BITES (LINE TAPS)2 ______ □CASE(S) OF BLACK SPRAY PAINT 1 ______ □CASE(S) OF TAR 1 ______ □FLASHINGS ______ MATERIAL LIST R(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 15 MARY JANE LANE HANLON, BRIAN- 15 MARY JANE LANE NORTHAMPTON, MA 01062 42.346518,-72.6648603 R APPENDIX CONTENTS LABELS, STICKERS, AND PLACARDS EQUIPMENT DATA SHEETS 2211 Allenwood Road Wall, New Jersey 07719 877-786-7283 www.Trinity-Solar.com