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Thiscertifies that .......................................................................
has permission to perform ............ na -
.cs ............ . ...........................
wiring in the building of .............. ...............................................................
at .... 2q.4 ..... ........ ................... . North Andover, Mass.
% .... ..... ...... ... .....
Fee.............................. Lic. No. 4V.4) .........................................................
ELECTRICAL INSPECTOR
'0 %
Datell ... ............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Check #
j I "'�" , -') '! '�5 , /
4(
10
Commonwealth of Massachusetts Official Use Only
v/ = Department of Fire Services
Permit No. 12112 --
Occupancy
2.x"12.Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank
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 ININK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER 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 � kom!g! � AQ, ICK Telephone No. 7 10 l �
Owner's Address _ � m 4-,
Is this permit in conjunction with a building permit? j Yes X No ❑ (Check Appropriate Box)
Purpose of Building t e ✓r %j n d ®oo t Utility Authorization No.
- Existing Service Amps I Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
Location and Nature of Proposed Electrical Work: w; re at 6v Vke of'
No. of Meters
No. of Meters
Completion of the following table may be waived by the Inspector of Transres.
No, of Recessed Luminaires
No'of G'�1 Susp. (Paddle) Fans
s Total
Trsformers K'VA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaire
Swimming Pool Above In- ❑
rnd. rnd.
o. o 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
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Dis posers
p
Heat Pump
Totals:
Number
Tons
"'
KW
.......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S
Space/Area Heating KW
P g
Local ❑ Municipal E] other
Connection
No. of Dryers
Heating Appliances KW
Secu toNo. Devics s or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Qrr1 Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: v (When required by municipal policy.)
Work to Start: /f Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VERAGE: 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 cove age ism force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, itn(lei, I gains and penalfies of perjury, that the information on this application is true and complete.
FIRM NAME:. M Pn vA LTC. NO.:
Licensee: ) i Mtv�,� . c� J e Signature ��� LTC. NO.:
(If applicable, enter "ex pt" in the licit se number line.) Bus. Tel. No.:
Address: r 1 W vAJAlt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requites Department of ublic 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) ❑ owner ❑ owner's agent.
Owner/Agent FppRMIT FEE: $,!6 �—
Signature Telephone No.
9-
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed 0
Re -Inspection Required ($.) ❑
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPE ION:
Pass
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:�zWX--&kDate:
to &
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
O
-Workers' Compensation Tmurance Affidavit: Builders/Contractors/Electricians/Plunnbers.
' TO BE FILED WITH THE PERMITTING AUTHORITY. ,., - - Tb..'.,4. 7
Name , (Business/Orgabization/lndividual):^
Address: S5 ]-
City0ate/Zip: A -
Are you an employer? Cheek the appropriate box:
Phone 4 77 _
1.[, I am a employer with , . employees (frill and/or part-time).*
2.am a sole proprietor or partnership and have no employees working for mein
I n
any capacity. [No workers' comp. insurance required.]
3.Q I am a homeowner doing all work myself [No workers' comp. insurance required] t
4.1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑I am a general coniracfo>! and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.:
6.0 We are a corporation and its, officers have exercised their right of exemption per MGL c.
152 §1(4) and we have no employdes: [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New'd'onstruciion
8. E] Remode.119
9. ❑ Demolition
10 [] Building addition
11.KElectrical repays or additi9ns
124(.Piumbing repairs or additions
13%[] Rb6f repairs
14.[] Other
*Any applicant that check's bbac#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 anew. affidavit indicating such
uu
i o Homeowners
that check files box must attached an additional sheet showing the name of the sub contractors and state whether or not those entities have
employees. If the subcontractors 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 jots site
information.
>�"surance Company
Policy # or Self -ins. -- .- - -
: U C
tA. City/State/Zip:
�A.ob Site Address
iiach a copy of the workexs' coti ac �� �'`�^dd�F2✓
�mpensat' n policy declaration page (showing the policy number and expiration date).
ed under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
Failure to secure coverage as requir
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. A copy of this statement may be forwarded to the Office of fnvestigations of the DIA for insurance
coverage verification.
T do hereby c tify under the pains and penalties of perjury that the information p: ovided above is trate and correct.
V_ -,,17na+P LD 1(A D t
official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
permit/License
Issuing Authority (circle one):
1. Board of Health. 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact Person:
t
The Commonwealth of Hassachusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
_
F
Boston, MA. 02114-2017
�<
www mass.gov/dia
-Workers' Compensation Tmurance Affidavit: Builders/Contractors/Electricians/Plunnbers.
' TO BE FILED WITH THE PERMITTING AUTHORITY. ,., - - Tb..'.,4. 7
Name , (Business/Orgabization/lndividual):^
Address: S5 ]-
City0ate/Zip: A -
Are you an employer? Cheek the appropriate box:
Phone 4 77 _
1.[, I am a employer with , . employees (frill and/or part-time).*
2.am a sole proprietor or partnership and have no employees working for mein
I n
any capacity. [No workers' comp. insurance required.]
3.Q I am a homeowner doing all work myself [No workers' comp. insurance required] t
4.1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑I am a general coniracfo>! and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.:
6.0 We are a corporation and its, officers have exercised their right of exemption per MGL c.
152 §1(4) and we have no employdes: [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New'd'onstruciion
8. E] Remode.119
9. ❑ Demolition
10 [] Building addition
11.KElectrical repays or additi9ns
124(.Piumbing repairs or additions
13%[] Rb6f repairs
14.[] Other
*Any applicant that check's bbac#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 anew. affidavit indicating such
uu
i o Homeowners
that check files box must attached an additional sheet showing the name of the sub contractors and state whether or not those entities have
employees. If the subcontractors 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 jots site
information.
>�"surance Company
Policy # or Self -ins. -- .- - -
: U C
tA. City/State/Zip:
�A.ob Site Address
iiach a copy of the workexs' coti ac �� �'`�^dd�F2✓
�mpensat' n policy declaration page (showing the policy number and expiration date).
ed under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
Failure to secure coverage as requir
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. A copy of this statement may be forwarded to the Office of fnvestigations of the DIA for insurance
coverage verification.
T do hereby c tify under the pains and penalties of perjury that the information p: ovided above is trate and correct.
V_ -,,17na+P LD 1(A D t
official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
permit/License
Issuing Authority (circle one):
1. Board of Health. 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact Person:
t
0
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of We,
express or implied, oral or written."
An employer is defuied as "an individual; partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of deceased employer, or the
receiver'or trusted of an individual, partnership, association or other legal entity, employing emplbyees..However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicaM who has not produced -acceptable evidence of compliance with the insurance coverage reg4red."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial•Accidenis. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAYE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Claim.# 26516:37
Advantage Claim Services
522 Chickering Road #B
North Ahdover, MA 01845
Adjuster Assigned: Glenn Guarente
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To: Building Commissioner o,E
Inspector of Buildings
Town Hall
North Andover, MA 01845
Re: Insured:
� Thomas Rinqler
'Property address:
204 Coventry Lane
Policy #:
Loss of:
North Andover, MA 01845
2651637
2014/07/15
File or Claim No. AD 1514
Board of Health or
Board of Selectmen
Town Hall
North Andover, MA
Claim has been made involving loss, damage or destruction of the ab
captioned property, which may either exceed
Mass._ Gen._ Laws,_ Chapter_ 143 $1,000.00 or above
notice under Mass—Gen Law— 3, 51391Sec6 to be a cause
applicable. If any'
direct it to the attention of the writer and-incis luudepalreference ate eto
captioned insured, location, policy number,.date of loss and claim or
file number, the
Glenn Guarente
Title: Adjuster
On this date, I caused copies of this notice to be sent to the persons
named at the addresses indicated above by first class mail.
Signature and"date 07-23-14
OF p10RTy qti
SSACHUSE
This certifies that .
Date Q"1.7.1
Z
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
so I� 0,, /
.........................
has permission to perform ... . !e ... . /� ✓,� J
wiring in the building of ....Y 1'4 .n.,, -,j ........................
at ......A-? NortAndover, Mass.
Fee f5 -a. . Lic. No. 20 �.7/ .. /% .... .
At ELECTRICAL INSPECTOR
Check # //D Y
1 1 0 4 €3
Commonweald o` 1/lamaclsudeitd Official Use 0 1
c� �7 Permit No.
o
Apartmon! of .line Jewked
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07j 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:j�a,rnu6+,
City or Town of: MoC;h (rj To theIn pector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 0,04 Coys&U t Lc ne-
Owner or Tenant-j'kOMa4 Telephone No.
Owner's Addressyc w�Q- aLs Q loos c
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building SAc r -CN) FLc,,jels Utility Authorization No.
Existing Service aO b Amps Q -o / ayc3 Volts Overhead ❑ Undgrd No. of Meters 1
New Servicg Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
,
Number of Feeders and Ampacity
LocattionAand Nature
�/of Proposed/Electrical /Wtork: �6A� % unto t GoEou�kic( �)
Comvlellnn ofthe fnllnu,lnn anhla mmr by watvnd by ahn /xcn�ri•Im•nf Lt/iruc
No, of Recessed Luminaires
No. of Cell,-Susp. (Paddle) Fans
o. o ota .
Trnnsformers KVA
No. of Luminalre Outlets
No. of Hot Tubs
Generators KVA
No, of Luminaires
Above n-
Swimming Pool rnd. ❑ rnd. ❑
o. o Emergency Lighting
Batter Units
No, of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones•
No. of Switches
No. of Gas Burners
_
o. of Detection an
InitiatingDevices
No, of Ranges
.l
No. of Air Cond. oons
No, of Alerting Devices
No. of Waste Dis posers
p
eat um p
Totals:
Ni ,er
,ons
""
"KW ..•.
"'""•".""-'
o. oSelf-Contained
Detection/Alerting Devices
No, of Dishwashers
Space/Area Heating KW
Local ❑ municipalEl Other
Connection
No. of Dryers
Henting Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. o Water KW
Heaters
o. o o• o
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Ilydromassage Bathtubs
No. of Motors Total HP
Telecommunications r ng
No. of Devices or Equivalent
OTHER: —d
Allach additional detail if desired, or us required by the Inspector of Mires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to StattA$. A. P. _ 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:
OIECK UNE: INSURANCE X i30ND ❑ OTliGIt E] (Specify:)
/ certify, under the ains and penalties of perjury, hint lite information on thiv applicadon is trae and complete.
FIRM NAME: 9 gf1__�. LIC. NO.: a 7 I AM�
Licensee: - Signature _ LIC. NO.: al e 7 TR,
(Ifopplicable, enter "exempt" in the license number line.) Bus. 'fel. No.:, ��!� o5
Address:cj . Alt. Tel. No.: 603 396 /7DS
*Per M.G.L. c. 147, s. 57-61, security rk requires Department o ublic Safety "S" License: Lie. 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) ❑ owner E owner's a ent.
Owner/Agent
Signature Telephone No._�___ __ �_ PERAfIT FCsli: $__.___ �..
rob. Thw 13e=dv A" AJ P*th
COMMONWEALTH OF MASSACHUSETTS
BOARD ELECTRICIANS
EL REGISTERED MASTER ELECTRICIAN
tSSUES THE ABOVE 11GENSE TO
TYPE SOLARCITY CORPORATION
KtVIN S GAGNON
-A 178 STERLING RD
N BILLERICA MA 01862-2518
6577 20571 A 07/31/13 6577
Em
""n Dol A" A& PaWle.-h"
i;Ur4l"UNWI:-Al. (o F F5 UUMASSACtiuSk I IS
4
i;, ;i; - " f
. �
ELECTRICIANS
ASA REG JOURNEYMAN ELECTRICIAN
IVI ill f 0, , 1
MA,ri-jiEw T HARXHAM
73 GLASS ST
PEMBROKE If" 03275-1505
2787JR 07/31/13
146666
The Commonwealth t?fMassachusetts Print Form
-- Department of Industrial Accidents
Dice of Investigations
1 Congress Street, Suite 100
7 Boston, MA 021142017
www.massgov/d1a
Workers' Compensation Insurance Affidavit: Btailders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):SolarCity Corporation
Address:3055 Clearview Way
City/State/7il):San Mateo, CA 94402 Phone #:650 963-5100
Are you an employer? Check the appropriate box:
1. ❑✓ I am a employer with 1 500
4. [] 1 am a general contractor and 1
employees (full and/or part-time).'
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner=
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and Dave workers'
[No workers' comp. insurance '
comp. insurance.t
required.]
S. [, We are a corporation and its
3. ❑ .I am a homeowner doing al work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I. E] Plumbing repairs or additions
12.❑ Roof repairs
13.❑✓ OtherSolar Installation
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information
I 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 emplr?vees Below is tite policy and job site
information.
Insurance Company Name: Zurich American Insurance Company
Policy # or Self -ins. Lie. #:WC96734670
Expiration Date:9/01/20124
Job Site Address: Q Cay t3,f long— CitylStsnc//.ip:_i�.►�v�do�gr _pt Y`t S"
1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required tinder 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 $250.00 a day against the violator: Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do herelt1 veM under 'he eaL), nt#dkeijrr/tles uJ'lirrrjurr that the inJortmtto provided above is true and correct
'ane #:802 299-5885
0JJ'7cial use only. Do not write in this area, to be completed by city or town official
City or Town-
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact. Person:
Phone #:
cea CERTIFICATE C�� LIABILITY INSURANCE
DATE i 5/ 011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED, BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE [$SUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. N SUBROGATION IS WAIVED, subject to
the berms 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 Hsu of such endorsement(s).
PRODS 0726293 1-415-546-9300
Lem
Arthur J. Gallagher a Co.
Insurance Brokers of California, Inc., License #0726293
_
ORNERAL LIABMUTY
X COMMERgALOENERALUABRITY0XIMM
CLAIMS -MADE � OCCUR
X Deductibles $25,000
one irarket Plans, Spear Tower
INSURERS)AFFOROINt1COVEPUOB •
Suite 200
Bart lrrancisco, a& 94105
011A: ZURICH AUBR INN CO 16535
INSPIRER
SolarCity Corporation
9:
wsu C.-
w RERD:
3055 Clearview Nay
wSUR" E •
Ban Irateo , CA 94442
$
CeVFRAaF8 CERTIFICATE NUMBER: 22017495 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 i:IOCUMENT 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.
19
TYPE OFW$URANCE_
ADOL
WON
N
Lem
D.
_
ORNERAL LIABMUTY
X COMMERgALOENERALUABRITY0XIMM
CLAIMS -MADE � OCCUR
X Deductibles $25,000
WA967364403
09/01/1
09/01/12
EACH OCDURRENOE 6 1, 000,000
TO Nik 61,000,000
MED W Ma aneporam 6 10.000
PERSONAL& ADV INJURY 6 1,000,000
GENERAL AGGREGATE $2,000,000
0ENLAGME41ATELIMITAPPUESPER:
-'il PDt)CY' LOC.
PRODUCTS -COMPK)PAOO f 2,000,000
$
A
AUTOMfOD"LNWKM
ANY AUFO
AU.OWNED MULED
X AUTOS
HIRED AUTOS AUTOS ED
Ix
1
S T 1,000,000
BODILYINJURY(Pa'person) 6
BODILY INJURY (PwaoddeM) $
D $
i
UMBRELLA UAB
Excess LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE 6
AGGREGATE S
RETENn
s
A
WORKWIS COMPENSATION
AND EMPLOYERS' LIABRJIY
ANY PROPR(EfO"ARTNERMXECUTWC Y 1 N
OFFICERIMEWFR EXCWDED? a
(Mandatory In NN)
11yw.dewAbetxKWr
3 IPTIO OPERATIONS
N / A
NC967346103
09/01/1
09/01/12
#
X
E.L. EACH ACCIDENT 6 1,000,000
F---DISEASE-EA EMPLOYEE 61,000,000
E.L. DISEASE - POLICY LIMIT S 1,000,000
DESCRIPTIONOF OPERATIONS.1 LOCATIONS I VEIRCLBS (Atdroh ACORD 101, AdMonai Renr„ks Sdhedule. N mon span Is required)
Proof of General Liability, Autanwbiie and Workers Compensation Insurance.
roof of Insurance
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1806.2010 ACORD
%CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
ijosaa
2517495
All rights reserved.
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CSA INTERNATIONAL
Certificate of Compliance
Certificate: 1841082 Master Contract: 173688
Project: 2439384
Issued to: Power -One, Inc
740 Calle Plano
Camarillo, CA 93012
USA
Attention: Robert White
Date Issued: July 19, 2011
The products listed below are eligible to bear the CSA
Mark shown with adjacent indicators 'C' and 'US' for
Canada and US or with adjacent indicator 'US' for
US only or without either indicator for Canada only.
CD 0 r2oir}fe�a�arly
Issued by: Rob Hempstock, AScT.
C us
PRODUCTS -
CLASS 531109 - POWER SUPPLIES - Distributed Generation Power Systems Equipment
CLASS 5311 89 -POWER SUPPLIES -Distributed Generation -Power Systems Equipment
- Certified to U.S. Standards
Utility Interactive Inverter, Models PVI-6000-OUTD-US, PVI-6000-OUTD-US-W and PVI-5000-OUTD-US,
permanently connected.
For details related to rating, size, configuration, etc. reference should be made to the CSA Certification Record,
Annex A of the Certificate of Compliance, or the Descriptive Report.
APPLICABLE REQUIREMENTS
CSA -C22.2 No.]07.1-01 - General Use Power Supplies
UL Std No. 1741 -Second Edition - Inverters, Converters, Controllers and Interconnection System Equipment
For Use With Distributed Energy Sources (January 28, 2010)
DQD 507 Re, 2009-09-01
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Date. A// 0 .........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that... .!` ..: ,,wc . .............. .
has permission for gas installation .......... .
in the buildings of
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a&,7 el �at .. ZQ?.. .....
. , North Andove , ass.
Fee•. �;ov . Lic. No. /xr � ?.. . !7ic�r� 4-,.!�i1 .
�7 GAS INSPECTOR
Check #5�/
7903
Un
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
CITY17OWN: 4 r . ... 0- _ - STATE: MA APPLICATION DATE:.
all pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the G Laws.
JOB ADDRESS:. \ ..._.. _. J
GAS PIPING
OCCUPAN TYPE: COMMERCIAL RESIDENTIAL PLANS SUBMITTED: YES E]NO
i
NEW -- ALTERATION REPLACEIIAEN7"REMOVALIDEMOUTION
I' NATURAL & LIQUEFIED PETROLEUM GAS: PIPING - EQUIPMENT - APPL1ANCES - SYSTEMS Z
CMT= TATAI ANAI INT CAD cA Pu cn cnr,nN n ,u,rrn r� rn,r m u,,.•rn•, n
AIR ROTATION UNI
FURNACE: ALL TYPES
;TEMP HEATING EQUIPMENT
all pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the G Laws.
BOILER ALL TYPES
M-`
GAS PIPING
; THERMAL OXIDIZER
i
BOOSTER
GENERATOR(STATIONARY ENGIN
€ TURBINE
BROILER
"_ ILLUMINATING APPLIANCE
UNIT HEATER
Signature Licensed Plumber t Gas FittInspector
BURNER: ALL TYPES
INCINERATOR
_
WATER HEATER: ALL TYPES
(
license Number:
CO -GENERATION UNIT
INDUSTRIAL AIR HANDLER
1 EQUIPMENT OVER 1 500MBH
_
COFFEE ROASTER
- ` I INFRARED HEATER
rOTHER NOT LISTEDZ
COOK APPLIANCE HOUSEHOLD
: " ] KILN I GLORY HOLE 1 CRUCIBLE
- -
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LABORATORY COCKS
DECORATIVE APPLIANCE
-I MAKEUP AIR UNIT
DIRECT VENT APPLIANCE
MECHANICAL EXHAUST EQUIPMENT
DRYER: ALL TYPES
.' OVEN: ALL TYPES
- -_,
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POOL HEATER�-
FRYOLATOR ;--7
ROOF TOP UNIT
Ate_
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PLUMBING J GAS FITTING FIRM INFORMATION CHECK ONE ONLY
JQL
NAME:. C.`i!� G4-. `
�t11 p �Q DCorPoration Business # L _ t
a'
-
+ ADDRESS:
- _ QPar nership Business # E---.---.�
CITY: ___-I(�(l�(2.(, A-_ _.aYr1.G('a
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TEL: "1 -Qb3.. . � FAX ... _-
EMAIL:.::.. -
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NAME OF LICENSED PLUMBER I GAS FITTER: I V V,C- k-11 S R
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES LYJ N Q
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy
Other type of indemnity E]Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General
Laws, and that my signature on this permit
application waives this requirement
CHECK ONE ONLY
OWNERE) AGENT E]
Signature of Owner or Owner's Agent
OWNER'S NAME: ;:-. _ _ .
_ _ .... _ .. _ .. _ _ TEL' FAX
I hereby certify that all of the details and information 1 have submitted (or entered) regarding this permit application is true and accurate to
the best of my knowledge. I certify
that all plumbing work and installations performed under the permit iss ed, will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the G Laws.
(OFFICE USE ONLY)
Type icense:
Perrrnt#
Plumber QGasfi#er
d0las�ter Journeyman
Signature Licensed Plumber t Gas FittInspector
Undiluted LP Installer
(
license Number:
Foe:
a Limited LP Installer
F
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4e
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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9192
Date . /`f./,? J i . .
TOWN OF NORTH ANDOVER
o .,•o;.�tic
PERMIT FOR PLUMBING
1>1f
This certifies that . 1'%4. . -�, '/.� .-.......... ....... .
has permission to perform .. j�P�/�'�T :. /,?a ?� ......
plumbing in the buildings of.. !.. /Il�lQ!" ................ .
at ............ ,/North Andover, Mass.
Fee Lic. No. /�.L° Z- .thy �c1! .l f� ........
PLUMBING INSPECTOR
Check # 2401S-%
AIN
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: NO " MDDJ Q2 ,MA. Date: H -110-t( Permit#
Building Location: ab� Owners Name: Ro\)6 ('Vz-
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: 0 Renovation: ❑ Replacement: [Plans Submitted: Yes ❑ No ❑
FD(TURES
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No ❑
If you have checked Yes. please indlca the type of coverage by checking the appropriate box below.
A [labil'nY insurance policy Other tiPa of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement
Check One Only
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) regardin this application are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit s�or this a on will be in compliance with all
Pertlner9j provision of the Massaytfusetts Stage Plumbing Code and Chapter 142 of th en Ls�d
By 19CY Type License:
Title Z t jumber
City/Town [ Master
A nnnn.,rn ,nrr.nc . Ic r n►u %n []journeyman
Signature of Lionsn Plumber
License Number. (38
FAS
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Check One Only Certificate #
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Name of licensed Plumber: `Z M L
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No ❑
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A [labil'nY insurance policy Other tiPa of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement
Check One Only
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) regardin this application are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit s�or this a on will be in compliance with all
Pertlner9j provision of the Massaytfusetts Stage Plumbing Code and Chapter 142 of th en Ls�d
By 19CY Type License:
Title Z t jumber
City/Town [ Master
A nnnn.,rn ,nrr.nc . Ic r n►u %n []journeyman
Signature of Lionsn Plumber
License Number. (38
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