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31B-303 (2) BP-2023-1594 22 EDWARDS SQ COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-303-001 CITY OF NORTHAMPTON Permit: Solar Build PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-1594 PERMISSION IS HEREBY GRANTED TO: Project# SOLAR 2023 Contractor: License: TRINITY HEATING&AIR INC DBA Est. Cost: 18000 TRINITY SOLAR CSL108025 Const.Class: Exp.Date:04/22/2024 Use Group: Owner: R KULLBERG MATTHEW C&RONNA Lot Size (sq.ft.) TRINITY HEATING&AIR INC DBA TRINITY Zoning: URC Applicant: SOLAR Applicant Address Phone: Insurance: 4 OPEN SQUARE WAY, SUITE 410 (413)203-9088 (1522) WC 13588107 HOLYOKE, MA 01040 ISSUED ON: 11/15/2023 TO PERFORM THE FOLLOWING WORK: INSTALL 18 PANEL 729 KW ROOF MOUNT SOLAR SYSTEM WITH STRUCTURAL UPGRADES (NO BATTERY) POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: (� Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner r- The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR MUNICIPALITY Massachusetts State Building Code,780 CMR USE WBuilding Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: I3i7-2073— /Sgt.1 Date Applied: ). Cv,i..J/Z5 Il-ty-202 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 22 Edwards Square,Northampton,MA 3(g - 303 - bO l 1.1 a Is this an accepted street?yesJ no Map Number Parcel Number 1.3Uononing Information: 1.4 Property Dimensions: Residential-Solar ,0 acre. Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 IN Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal 0. On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Matthew Kullberg Northampton MA 01060 Name(Print) City,State,ZIP 22 Edwards Square (413)221-4822 mattkullberg(gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other nSpecify:Solar Brief Description of Proposed Work2: Install 7.29 kW DC solar on roof(1 8 panels) Structural upgrades as described in engineering letter. Will not exceed building footprint, but will add 6"to roof height. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $11,000 I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $25'000 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire o9 Suppression) $ Total All Fees: $ — _oo Check Nof�/c/`? Check Amount:75 Cash Amount: 6.Total Project Cost: $36,000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-108025 4/22/2024 Phil Smith License Number Expiration Date Name of CSL Holder List CSL Type(see below) L 6 Torrey St No.and Street Type Description Easthampton,MA 01027 U Unrestricted(Buildings up to 35,000 Cu.ft.) p R Restricted 1&2 Family Dwelling City/To to ZIP M Masonry OPP. RC Roofing Covering X ''T ` ' WS Window and Siding SF Solid Fuel Burning Appliances 413-203-9088 x 1524 applications.westma@trinity-solar.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 170355 10/11/2023 Trinity Solar Inc DBA Trinity Solar HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 20 Patterson Brook Road-Unit 10 applications.westma(ri t rin ity-solar.com No.and Street Email address West Wareham MA 02576 413-203-9088 x 1524 City/Town, State,ZIP Telephone 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 ll 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 Please See Attached 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:OWNER'OR AUTHORIZED AGENT DECLARATION By entering m name belo I hereby attest under the pains and penalties of perjury that all of the information containe i app ' on is true and ccur to to the best of my knowledge and understanding. X 11/Q7/2023 Print Owner' 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" City of Northampton Massachusetts1.7 zPs DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building '.) >C's 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: Casella- 295 Forest Street, Peabody, MA 01960 The debris will be transported by: Name of Hauler: Trinity Solar Date: 11/8/2023 Signature of Applicant: • NJ,Electrical Contractor business permit number 34EB01547400 NJ,HIC reg.#13VH01244300 SOLAR For other jurisdictions,please visit:http://www.trinity-solar.com/about-us/locations-and-licenses HOMEOWNERS AUTHORIZATION FORM Matthew Kullberg (print name) am the owner of the property located at address: 22 Edwards Square Northampton,Massachusetts 01060 United States (print address) I hereby authorize Trinity Solar Inc. ("Trinity Solar") 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 includes the 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 the foregoing I specifically 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 certification documents("Approvals Paperwork"), including those for which signature pages are included herewith for my signature, in furtherance of the related transaction, 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 these authorizations are not required to proceed with the transaction and are 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. Electric Utility Company: National Grid Ele tric U ility Account No.: 6320664066 N e lectric Utilit Unt: Matthew Kullberg cioctitA) Cu o rSignature Matthew Kullberg Print Name September 21, 2023 Date Corporate Headquarters 1-877-SUN-SAVES 2211 Allenwood Road Ph: 732-780-3779 Wall, New Jersey 07719 Fax: 732-780-6671 www.trinity-solar.com FOR INFORMATION ABOUT CONTRACTORS AND THE CONTRACTORS' REGISTRATION ACT, CONTACT THE NEW JERSEY DEPARTMENT OF LAW AND PUBLIC SAFETY, DIVISION OF CONSUMERS AFFAIRS AT 1-888-656-6225. SOLAR Northampton, MA November 6, 2023 212 Main St. Northampton, MA 01060 RE: KULLBERG, MATTHEW C; KULLBERG,RONNA R Trinity Solar No. 22 Edwards Square 2023-06-893141 Northampton, MA 01060 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 Roof R4 is 2x6 at 20 o.c.;existing rafter span=8'6"; (horizontal projection) Conventional roof framing at Roof R6 is 2x6 at 20 o.c.; existing rafter span= 11'6"; (horizontal projection) Conventional roof framing at Roof R8 and R9 is 2x6 at 20 o.c.;existing rafter span=9'0"; (horizontal projection) Note: Field verify all framing sizes, spacing, and spans prior to installation. 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 • Wind criteria-Exposure Category B, 117 mph wind 3. Existing Roof modification at Roof R6-Existing roof rafters to be"sistered"with new 2x6 rafters extending the full length of the existing rafters and terminated before the existing rafter support connection. Non-full-length rafter sisters must"overlap"its accompanied sister a minimum of 24"with nailing from each side in the overlap. Typical sister nailing consists of 10d nails top and bottom at 12"o.c.Within overlap, same nailing at 6"o.c. If sistering is not feasible, provide 2x4(@20"o.c.)"knee wall"reinforcing to limit the maximum span of the existing rafter to 9'-9". Locate bottom of"knee wall"within one foot of existing bearing wall below. 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 of the mounting brackets-the ClickFit Smart Foot and/or Rocklt Smart Slide by EcoFasten®(or approved equal)-cannot exceed a maximum of 48"o.c. between mounting brackets and will be fastened using#14x3"long(min.)lag screws per bracket(2 min.)for a rail system or#12x3"long(min.)lag screws per bracket(2 min.)for a rail-less system. The minimum thread penetration(embedment)is 2W'beyond all roofing materials-this is adequate to resist all stated demand loads above, including wind shear. In order to evenly distribute the PV load across the roof framing, in multi-row PV layouts there shall be a minimum of 2 mounting brackets per rafter/truss chord. Pilot holes for EcoFasten self-drilling screws are not required. Regards, Thor Bojcun, PE Structural Engineer-Trinity Solar .� s N taw 'yam MA License No.56687 Trinity Solar 1 4 Open Square Way,Suite 410 1 Holyoke,MA 1(413)203-9088 .... .. . „ ,„„,,.„,t, , , ,..,,,,,,„,,, „,„,—,,. •.,. — , ;- ,-;•,*• ce ':' — ''„' ,',,fet.:4-' '` —"' -34' 'A"'"e7:‘7 7-''';;•• •'';•:'--,,,-"'-'-"e • ',,,„- ' - ' ' ''1,,i:'' ',S.0,::,c''- 1,0-0t7!,"''-- -'i;;"--,' '-7'-•-,'i"'''e 7' ' ''''''•''' e •Z.'"4,!-- ' - "'''' , ' • -, ,5,1_, . „.;,,i ,-• ,,,,.:,,-:z - -,,,, ...-- tti-mo-,,ii.*:.:‘414itiic',/•,=:',,I4,77.v;i1k4-•ar,0040040,-/m- -'• - '- ,......---:•,=:;: •-,•:i.,==:-.,4,-• ".-,-,.,---- -----,•- ,-;r .0 :-.?,„:, - -'-' „ '-o,'- '"''- -4-,4''',e ' '— '-'7;'"'' ' :'1';ii„,:',' ,',„',%,-,"14''rtt-AmM4werwP-*Irqi lc,7.-,... :,,,--,4-„,. . „•.,,,. „„. e „, „.„ . „.„ „:::-?,..1,16.6,415mwagilaynelvo;,,love,,, , ;4> vaiwv---, ,:,,,,,, '-,4, ,,,,',,,,',1,,,---",:t, 4g,','", ,, -'.,•4',,•-•..4L,, „ . .„-,..F,4„„„ . ,„,,„,.•;..,,„ ,;,, „,--N'' .4,...„ Commonwealth of Massachusetts . .., .. 1:.., Division of Occupational Licensure ,... . . . Board of Building Reoulations and Standards . ,, .: Cons , -,, . . C S-1 08 0 2 5 ..,... P,',,:t• . . - spires: 04122/2024 ,.,4?,::::;t(!"'''.,::': ' •,. '" fr'"C A''-•- 1100"4:giali te It.„ .:! t 411!11.,'. .,,:::„.:,:::,,r:•••• ,,r,„ • • ..:, :, .•„.,:.••,. ...,••• . , •,,,,, t - ,,:,,in*:4:.,Taf"MV'>•••,•:::.•:!;:.:•:.:i' 4 PHIL SMITH ,,,,,,,,,,„. , ioarlii :' 7r 6 TORREY Si =.:,,,,,,,.„.,,.,:„...., :. ,„...„,,....„,:,..„,:,... ,,,,,, ;., ,,stAllfr :..0., '-!!!!:1T''' '--i , =;:; lig;i,ii.:Ii,, .,1:,„:,...:-.,...ir EASTHAMP104 MA-7o, 'it,4::fiii:::.'' ,*: .. ... '-' ,:;;ki,,,,,., 41f I.LVV *A*1 7,..-. ' • ' e".".. Corn " aa.one r 171. ,-•--,,,, -- - -'''-- ' ,-- ' - '' ''''''''' - --'- '' '''''' '"A, - '''', ''';;;,*kAliiiiiiiiiiiiiiii4iii .. ... :: :aliiiiii64,2111i3';:i, ',t;;;rtitiAtHig'iiE4ii4.;it4L4!:4',aji.';'?;;:qWTTijie ::'.':'''''-''-'-7'''';''-'77::::::::'t':-..''''--' .::'',4:44,I, A',',.• -,.f '::0t*aMNNMNEVae.AijinMgiNQg',W,;lrIVOKA'Vk::,;;,t,Aj;,41AiMMC;;A.t4.'4":ri. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs-.andBusiness Regulation 1000 Washingto 9r t- Suite 710 Boston,Massachusetts-:02118 Home I m•ro`.e ie v. ,tractor=a istration t" C ""____ Type: Supplement Card , �' 'station: 170355 TRINITY SOLAR,LLC = E piration: 10/11/2025 2211 ALLENWOOD ROAD - 1 WALL, NJ 07719 *" pp1 � mm. „,, Nei+` eed, $/ _ .... Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE;Suppr&rfrent Card Office of Consumer Affairs and Business Regulation Reaistratio4 w gxplratton 1000 Washington Street -Suite 710 170355 10/11/2025 Boston,MA 02118 TRINITY SOLAR,LLCs, -%z. `� PHIL SMITH n�rr / 20 PATTERSON BROOK ila ► r A,µ ¢ cicty[r n �Fmt WEST WAREHAM.MA 0257Ct J ,,�', ` . Undersecretary Not valid without signature © ACOR[ CERTIFICATE OF LIABILITY INSURANCE DATE(M M/DD/YYYY) ki.....--' 5/26/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Arthur J. Gallagher Risk Management Services, LLC PHONE FAX 4000 Midlantic Drive (A/c,No,Ext):856-482-9900 (A/C,No):856-482-1888 E-MAIL Suite 200 ADDRESS: CherryHill.BSD.CertM©AJG.com Mount Laurel NJ 08054 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Gotham Insurance Company 25569 INSURED TRINHEA-03 INSURER B:National Union Fire Insurance Company of Pittsburg 19445 Trinity Solar Inc. INSURERC:Endurance American Specialty Ins Co 41718 4 Open Square Way, Suite 410 Holyoke, MA 01040 INSURER D:Liberty Insurance Underwriters Inc 19917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:129732996 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY GL202100013378 6/1/2023 6/1/2024 EACH OCCURRENCE $2,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X PEa LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY CA 2960145 6/1/2023 6/1/2024 COM(EaaccBINEDident)SINGLE LIMIT $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ A UMBRELLA LIAB X OCCUR EX202100001871 6/1/2023 6/1/2024 EACH OCCURRENCE $5,000,000 C X— —EXCESS LIAB ELD30006989101 6/1/2023 6/1/2024 CLAIMS-MADE 1000231834-06 6/1/2023 6/1/2024 AGGREGATE 55,000,000 DED RETENTION$ Limit x of$5,000,000 $19,000,000 B WORKERS COMPENSATION WC 13588107 6/1/2023 6/1/2024 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE7 N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $1,000,000 B Automobile CA 2960145 6/1/2023 6/1/2024 All Other Units $250/500 Comp/Collusion Ded. Truck-Tractors and Semi-Trailers $250/500 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUTHORIZED REPRESENTATIVE e<,Q:...__:z).... ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents anallat ; =unillit,.... � Office of Investigations " �-- zt 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):Trinity Solar Inc. Address:2211 Allenwood Road City/State/Zip:Wall, NJ 07719 Phone#:732-780-3779 Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with 2730 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 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 12.❑✓ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.■ OtherSolar Installation employees. [No workers' ❑ comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:National Union Fire Ins. Co. Policy#or Self-ins. Lic.#:WC 013588107 Expiration Date:06/01/2024 Job Site Address: 4 Open Square Way, Suite 410 City/State/Zip: Holyoke MA 01040 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 th.violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ins.:ranee coverage verification. I do hereby certify and the pains and penalties of perjury that the information provided above is true and correct. Signature: 411eae- Date: sl. `YI. Phone#: 732-780-37 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): 10Board of Health 20 Building Department 3.0City/Town Clerk 4.0 Electrical Inspector 5Ek'lumbing Inspector 6.0Other Contact Person: Phone#: