HomeMy WebLinkAboutBLDE-23-000864 SCOPE OF WORK GENERAL NOTES LEGEND AND ABBREVIATIONS TABLE OF CONTENTS
PAGE# DESCRIPTION
•SYSTEM SIZE 5110W DC,3800W AC •ALL WORK SHALL COMPLY WITH MA 9th Ed.CMR 780(2015 IRC/IBC/IEBC), r 1 SOLAR MODULES
•MODULES:(14)LONG!GREEN ENERGY TECHNOLOGY CO MUNICIPAL CODE,AND ALL MANUFACTURERS'LISTINGS AND INSTALLATION SERVICE ENTRANCE PV-1.0 COVER SHEET
LTD LR4-60HPH-365M INSTRUCTIONS. I `I ' LI
° " PV-2.0 SITE PLAN
•INVERTERS (1)SOLAREDGE TECHNOLOGIES •PHOTOVOLTAIC SYSTEM WILL COMPLY WITH NEC 2020.
SE3800H-USMN •MP MAIN PANEL 1 0 of --a PV-3.0 LAYOUT
•RACKING:RL UNIVERSAL,SPEEDSEAL TRACK ON COMP, •ELECTRICAL SYSTEM GROUNDING WILL COMPLY WITH NEC 2020. PV-4.0 ELECTRICAL
SEE DETAIL SNR-DC-00436 O
SNR MOUNT
•SERVICE ENTRANCE CONDUCTORS TO BE REPLACED. •PHOTOVOLTAIC SYSTEM IS UNGROUNDED.NO CONDUCTORS ARE SOLIDLY SP SUB-PANEL SNR MOUNT&SKIRT PV-5.0 SIGNAGE
•MAIN PANEL REPLACEMENT EXISTING 100 AMP MAIN PANEL GROUNDED IN THE INVERTER.SYSTEM COMPLIES WITH 690.35.
WITH 100 AMP MAIN BREAKER TO BE REPLACED WITH NEW
125 AMP MAIN PANEL WITH 100 AMP MAIN BREAKER. •MODULES CONFORM TO AND ARE LISTED UNDER UL 1703. LC PV LOAD CENTER
CHIMNEY
ADD NEW 100A MAIN DISCONNECT WITH 100A MAIN
ENCLOSURE •INVERTER CONFORMS TO AND IS LISTED UNDER UL 1741.
SM SUNRUN METER
•RACKING CONFORMS TO AND IS LISTED UNDER UL 2703. ATTIC VENT
•SNAPNRACK RACKING SYSTEMS,IN COMBINATION WITH TYPE I,OR TYPE II PM DEDICATED PV METER FLUSH ATTIC VENT
MODULES,ARE CLASS A FIRE RATED. PVC PIPE VENT
•RAPID SHUTDOWN REQUIREMENTS MET WHEN INVERTERS AND ALL INV INVERTER(S) METAL PIPE VENT
CONDUCTORS ARE WITHIN ARRAY BOUNDARIES PER NEC 690.12(1). . . T-VENT
•CONSTRUCTION FOREMAN TO PLACE CONDUIT RUN PER 690.31(G). IAC I AC DISCONNECT(S) ,_
SATELLITE DISH
•ARRAY DC CONDUCTORS ARE SIZED FOR DERATED CURRENT. DC
•11.43 AMPS MODULE SHORT CIRCUIT CURRENT.
['^I DC DISCONNECT(S) FIRE SETBACKS
•17.85 AMPS DERATED SHORT CIRCUIT CURRENT[690.8(a)&690.8(b)[. CB IQ COMBINER BOX . HARDSCAPE
•PV INSTALLATION COMPLIES WITH THE NEC 2020 ARTICLE 690.12(B)(2).
CONTROLLED CONDUCTORS LOCATED INSIDE THE ARRAY BOUNDARY ARE EINTERIOR EQUIPMENT —PL— PROPERTY LINE
LIMITED TO 80 VOLTS WITHIN 30 SECOND OF A RAPID SHUTDOWN INITIATION L J SHOWN AS DASHED
SCALE'NTS
A AMPERE s u n r u n
AC ALTERNATING CURRENT
AFC] ARC FAULT CIRCUIT INTERRUPTER
AZIM AZIMUTH
VICINITY MAP COMP COMPOSITION
DC DIRECT CURRENT #180120
(E) EXISTING 6B5 MYLES STANDISHBLVDTAUDTON LID o2ThO.73„
ESS ENERGY STORAGE SYSTEM PHONE
1ONE0
EXT EXTERIOR a<o
INT INTERIOR CUSTOMER RESIDENCE
MAG MAGNETIC PAOLA LIMA
ProvI cetovvn MSP MAIN SERVICE PANEL 12 GILL AVE,YARMOUTH,MA,
(N) NEW 02673
NTS NOT TO SCALE
10An OC ON CENTER TEL.(508)367-0094
d PRE-FAB PRE-FABRICATED
PSF POUNDS PER SQUARE FOOT APN:YARM-000063-000051
PV PHOTOVOLTAIC PROJECT NUMBER
RSD RAPID SHUTDOWN DEVICE 223R-012LIMA
TL TRANSFORMERLESS DESIGNER: (415)580 892o ex3
L GIII =+,y,t-' TYP TYPICAL
c* ' 1?-,; •}-, +�'� V VOLTS JYOTISH PURI
We+ d3` 0,' . . F,,,I,S W WATTS
SHEET
/ REV NAME DATE COMMENTS COVER SHEET
!mouth REV:A 8/13/2022
PAGE PV-1.0
ct€_23-
ücc e(d4
SITE PLAN-SCALE=3/64"=1'-0" ARRAY TRUE MAG PV AREA
PITCH AZIM AZIM (SOFT)
40, AR-01 25° 180° 194° 274.5
WI
PL PL PL PL
\ \
\ \
\ --.
(E)RESIDENCE
AMP _p H -L �.- I (N)ARRAY AR-01
INV IACIPMSE - _j sunrun
#180120
NS NVLES STAHOLSH BLVD TAUNTON NA 027e0-733+
PHONE 0
FAX 0
CUSTOMER RESIDENCE\ .. .
' \
PAOLA LIMA
12 GILL AVE,YARMOUTH,MA,
02673
TEL.(508)367-0094
APN YARM-000063-000051
PROJECT NUMBER
PL PL PL PL 223R-012LIMA
GILL AVE
DESIGNER (415)580.6920 e43
JYOTISH PURI
SHEET
SITE PLAN
REV A 8/13/2022
PAGE PV-2.0
ROOF INFO FRAMING INFO ATTACHMENT INFORMATION DESIGN CRITERIA
Name Type Height Type Max OC Detail Max Landscape Max Landscape Max Portrait Max Portrait Configuration MAX DISTRIBUTED LOAD:3 PSF
Span Spacing OC Spacing Overhang OC Spacing Overhang SNOW LOAD:30 PSF
RL UNIVERSAL,SPEEDSEAL TRACK ON WIND SPEED:
AR-01 COMP SHINGLE-RLU 1-Story 2X6 RAFTERS 12'-1" 16" COMP,SEE DETAIL SNR-DC-00436 5'-4" 2'-1" 4'-0" 1'-11" STAGGERED 140 MPH 3-SEC GUST.
S.S.LAG SCREWS:
5/16":2.5"MIN EMBEDMENT
D1-AR-01-SCALE:1/4"=1%0" STRUCTURAL NOTES:
AZIM:180°
PITCH:25° • INSTALLERS SHALL NOTIFY
ENGINEER OF ANY POTENTIAL
STRUCTURAL ISSUES
OBSERVED PRIOR TO
PROCEEDING W/
INSTALLATION.
• IF ARRAY(EXCLUDING SKIRT)
IS WITHIN 12"BOUNDARY
`1-4 34-9 REGION OF ANY ROOF PLANE
•
EDGES(EXCEPT VALLEYS),
THEN ATTACHMENTS NEED
y_g TO BE ADDED AND OVERHANG
• REDUCED WITHIN THE 12"
♦_1-- _._ �1..... _... _._ _.. _. f1--_ _.._ f�h--- __. ♦-1 _... BOUNDARY REGION ONLY AS
FOLLOWS:
•
••ALLOWABLE ATTACHMENT
SPACING INDICATED ON
PLANS TO BE REDUCED BY
--- -. - ••ALLOWABLE OVERHANG
11.-7" INDICATED ON PLANS TO BE
• ''' 10�-3„ 1/5TH OF ALLOWABLE
ATTACHMENT SPACING
5'-4"TYP r INDICATED ON PLANS
6'-10" t t LE_ iJ
Q...O __ _ Q Q sunrun
7 2 28�_11" • #180120
ME MYLES STANDISH BLED.TAUNTON MA,Men-7301
PHONE 0
CUSTOMER RESIDENCE:
PAOLA LIMA
12 GILL AVE,YARMOUTH,MA,
02673
STRUCT
ON1(.....3
TEL.(508)367-0094
!' APN:YARM-000063-000051
PROJECT NUMBER:
223R-012LIMA
DESIGNER: (415)580-6920 ex3
�/ JYOTISH PURI
SHEET
LAYOUT
REV:A 8/13/2022
SEE SITE PLAN FOR NORTH ARROW. PAGE PV-3.0
120/240 VAC
SINGLE PHASE
SERVICE
M O METER#: NOTE:TOTAL PV BACKFEED=20A
EVERSOURCE 1935930 USED FOR INTERCONNECTION
UTILITY CALCULATIONS
GRID NEW 125A MAIN
DISCONNECT WITH
1 100A MAIN
l ENCLOSURE
LOAD SIDE TAP (N)LOCKABLE
BLADE TYPE (N)MA SMART SOLAREDGE TECHNOLOGIES:
FUSED AC UTILITY SE3800H-USMN WITH
DISCONNECT REVENUE REVENUE GRADE METERING
3. METER ; 3800 WATT INVERTER
3 JUNCTION BOX PV MODULES
3 2 OR EQUIVALENT 1 LONG!GREEN ENERGY TECHNOLOGY
(I NEW 100A MAIN `.„,. .r — • �_ /// CO(14)LTD:MOD LR4-6U OLES HPH-365M
BREAKER O `—�� •
(lj)• ` OPTIMIZERS WIRED IN:
I 20A FUSES --{ i I (1)SERIES OF(14)OPTIMIZERS
SQUARE D 240V METER SOCKET LOAD RATED DC DISCONNECT
NEW 125A MAIN D221NRB 100A CONTINUOUS WITH AFCI,RAPID SHUTDOWN L SOLAREDGE POWER OPTIMIZERS
"---` PANEL 3R,30A UTILITY SIDE OF CIRCUIT COMPLIANT P401
.--\ 120/240VAC CONNECTS TO TOP LUGS-
FACILITY — (LINE AT TOP LOAD AT BOTTOM)
LOADS FACILITY
oriONNO
CONDUIT SCHEDULE
# CONDUIT CONDUCTOR NEUTRAL GROUND
1 NONE (2)10 AWG PV WIRE NONE (1)10 AWG BARE COPPER
2 3/4"EMT OR EQUIV. (2)10 AWG THHN/THWN-2 NONE (1)10 AWG THHN/THWN-2 - sun ru n
3 3/4"EMT OR EQUIV. (2)10 AWG THHN/THWN-2 (1)10 AWG THHN/THWN-2 (1)8 AWG THHN/THWN-2
#180120
ae5 MYLES STANDISH BLVD,TAUNTON MA,022e0-7..1
PHONED
FARO
CUSTOMER RESIDENCE
PAOLA LIMA
12 GILL AVE,YARMOUTH,MA,
02673
MODULE CHARACTERISTICS P401 OPTIMIZER CHARACTERISTICS: TEL.(508)367-0094
LONG!GREEN ENERGY MIN INPUT VOLTAGE: 8 VDC APN:YARM-000063-000051
TECHNOLOGY CO LTD: MAX INPUT VOLTAGE: 60 VDC PROJECT NUMBER:
LR4-60HPH-365M: 365 W MAX INPUT ISC: 11.75 ADC 223R-012LIMA
OPEN CIRCUIT VOLTAGE 40.7 V MAX OUTPUT CURRENT: 15 ADC
MAX POWER VOLTAGE: 34.2 V
SHORT CIRCUIT CURRENT: 11.43 A DESIGNER (415)580-6920 ex3
JYOTISH PURI
SYSTEM CHARACTERISTICS-INVERTER 1
SYSTEM SIZE: 5110 W SHEET
SYSTEM OPEN CIRCUIT VOLTAGE: 14 V ELECTRICAL
SYSTEM OPERATING VOLTAGE: 380 V
MAX ALLOWABLE DC VOLTAGE: 480 V REV:A 8/13/2022
SYSTEM OPERATING CURRENT: 13.45 A
SYSTEM SHORT CIRCUIT CURRENT: 15 A PAGE PV-4.0
A INVERTER 1 NOTES AND SPECIFICATIONS:
•SIGNS AND LABELS SHALL MEET THE REQUIREMENTS OF THE NEC 2020 ARTICLE
ELECTRICAL SHOCK HAZARD PHOTOVOLTAIC DC DISCONNECT 110.21(B),UNLESS SPECIFIC INSTRUCTIONS ARE REQUIRED BY SECTION 690,OR
IF REQUESTED BY THE LOCAL AHJ.
MAXIMUM SYSTEM VOLTAGE: 480 VDC •SIGNS AND LABELS SHALL ADEQUATELY WARN OF HAZARDS USING EFFECTIVE
TERMINALS ON LINE AND LOAD
WORDS.COLORS AND SYMBOLS.
SIDES MAY BE ENERGIZED IN •LABELS SHALL BE PERMANENTLY AFFIXED TO THE EQUIPMENT OR WIRING
THE OPEN POSITION LABEL LOCATION: METHOD AND SHALL NOT BE HAND WRITTEN.
INVERTER(S),DC DISCONNECT(S). •LABEL SHALL BE OF SUFFICIENT DURABILITY TO WITHSTAND THE ENVIRONMENT
PER CODE(S):NEC 2020:690.53 INVOLVED.
LABEL LOCATION: •SIGNS AND LABELS SHALL COMPLY WITH ANSI Z535.4-2011,PRODUCT SAFETY
INVERTER(S),AC/DC DISCONNECT(S), SIGNS AND LABELS,UNLESS OTHERWISE SPECIFIED.
AC COMBINER PANEL(IF APPLICABLE). •DO NOT COVER EXISTING MANUFACTURER LABELS,
PER CODE(S):NEC 2020:690.13(B) q /r
I.'v'AR V'NG. PHOTOVOLTAIC;
A POWER SOURCE
LABEL LOCATION:
DUAL POWER SUPPLY INTERIOR AND EXTERIOR DC CONDUIT EVERY 10 FT,
SOURCES:UTILITY GRID AT EACH TURN,ABOVE AND BELOW PENETRATIONS.
ON EVERY JB/PULL BOX CONTAINING DC CIRCUITS.
AND PV SOLAR ELECTRIC PER CODE(S)NEC 2020:690.31(0)(2),IFC 2012
SYSTEM 605.11.1.4
LABEL LOCATION. CAUTION .
UTILITY SERVICE METER AND MAIN ■
SERVICE PANEL.
PER CODE(S):NEC 2020.705.12(C) -
r — � - MULTIPLE SOURCES OF POWER
� L � .
POWER SOURCE OUTPUT CONNECTION 'kaF:•(,SCJ At C,p j S`s EM C.:111
DO NOT RELOCATE THIS
OVERCURRENT DEVICE LABEL LOCATION:
INSTALLED WITHIN( :OFNEC202SHUT DOWN $unrun
LABEL LOCATION: SWITCH PER CODE(S):NC 2020:890.58(C)(2),IFC -
ADJACENT TO PV BREAKER AND ESS 2012.605.11.1,IFC 2018:1204.5.3
OCPD(IF APPLICABLE).
PER CODE(S):NEC 2020: , - 4„ _
705.12(6)(3)(2) -.. -
A SOLAR PV SYSTEM EQUIPPED #180120
PHOTOVOLTAIC SYSTEM sPHONELossTANosHaLVo,A 111
UNTON MA 0Pe0.133t
COMBINER PANEL WITH RAPID SHUTDOWN `
DO NOT ADD LOADS CUSTOMER RESIDENCE:
LABEL LOCATION. -- MAIN PANEL(INT) 12 GILL AVE,YARMOUTH,MA,
PHOTOVOLTAIC AC COMBINER(IF
APPLICABLE). 02673
PER CODE(S)NEC 2020-705.12(D)(2)(3)(c) 3" TURN RAPID SHUTDOWN SOLAR PANELS ON ROOF SERVICE ENTRANCE
SWITCH TO THE"OFP' SOUR.•m= TEL.(506)367-0094
POSMON TO SHUT DOWN APN:YARM-000063-000051
PV SYSTEM INVERTER (EXT)-
PV SYSTEM DISCONNECT PROJECT NUMBER:
MAXIMUM AC OPERATING CURRENT. 15.83 AMPS SHOCK HAZARD IN THE 1111
PV PRODUCTION METER FUSED AC DISCONNECT 223R-012LIMA
NOMINAL OPERATING AC VOLTAGE. 240 VAC ARRAY.
DESIGNER: (415)560-0920 ex3
LABEL LOCATION: .1 JYOTISH PURI
AC DISCONNECT(S),PHOTOVOLTAIC SYSTEM POINT OF 1 2 GILL AVE, YARMOUTH, MA, 02673 li
INTERCONNECTION. SHEET
PER CODE(S):NEC 2020.690.54 LABEL LOCATION:
ON OR NO MORE THAT 1 M(3 FT)FROM THE SERVICE PER CODE(S).NEC 2020:705.10,710.10 SIGNAGE
DISCONNECTING MEANS TO WHICH THE PV SYSTEMS
ARE CONNECTED. REV:A 8/13/2022
PER CODE(S):NEC 2020:690.56(C)
PAGE PV-5.0
Commonwealth of Official Use Only
Nit Massachusetts Permit No. BLDE-23-000864
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/07]
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:8/18/2022
City or Town of: YARMOUTH 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) 12 GILL AVE
Owner or Tenant PAOLA LIMA Telephone No.
Owner's Address 12 GILL LN,WEST YARMOUTH, MA 02673
Is this permit in conjunction with a building permit? Yes 0 No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd 0 No.of Meters
New Service Amps Volts Overhead 0 Undgrd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Installation of solar PV system (14 Panels 5.110 KW)
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 Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above 0 In- ❑ No.of Emergency Lighting
grnd. grnd. 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 No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local 0 Municipal 0 Other:
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KW No.of No.of Ballasts Data Wiring:
Heaters Signs 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.)
Work to start: Inspection to be requested 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 0 BOND 0 OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: Nathan A Ashe
Licensee: Nathan A Ashe Signature LIC.NO.: 21136
(If applicable,enter"exempt"in the license number line.) Bus.Tel.No.:
Address: 166 Hunt Rd, Chelmsford MA 018243747 Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License:
OWNER'S INSURANCE WAIVER:I am aware that the License does not have the liability insurance coverage normally required by law. But my
signature below,I hereby waive this requirement.I am the(check one) 0 owner 0 owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $150.00
OkC . 2.4 (
1
Commonwealth,of�addachusettd Official Use Only
_r1 _ e23 '- C sly
4 c� Permit No.
a i apartment o f_tire Serviced
�{� Occupancy and Fee Checked
t+��'-i'l:' BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07
,k.,„=. j (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 PRL'VT IN INK OR TYPE ALL INFORMATION) Date: 08/15/2022
City or Town of: Yarmouth 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) 12 Gill Ave, Yarmouth MA 02673
Owner or Tenant Paola Lima Telephone No. 508-367-0094
Owner's Address Same as Above"AA
Is this permit in conjunction with a building permit? Yes V No I I (Check Appropriate Box)
Purpose of Building Residential Utility Authorization No.
Existing Service 100 Amps 120 /240 Volts Overhead V Undgrd❑ No.of Meters 1
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Installation of an interconnected Roof Mounted PV system
14 Panels, 5.110 KwDC. No battery Storage
Completion of the following table may be waived by the Inspector of Wires.
l
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. Tot
Trans formers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- No.of Emergency Lighting
No.of Luminaires Swimming Pool grnd. ❑ grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No. n Detenon and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection
Other
CLi
No.of Dryers Heating Appliances KW SecN o yyf Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications NofDeeorWiring:q l
Y g No.of Devices Equivalent
OTHER:Roof Mounted Solar
Attach additional detail if-desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: $6976.00 (When required by municipal policy.)
Work to Start: ASAP Inspections to be requested 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 II application is true and complete.
FIRM NAME: Sunrun Installation Services I
LIC.NO.:4316 Al
Licensee: Nathan Ashe Signature L1C.NO.:21136A
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:978494-3519
Address: 695 Myles Standish BLVD Taunton MA 02760 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
required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $