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Miscellaneous - 21 EASY STREET 4/30/2018 (3)
co ir:�� Thiscertifies that...................................................:.............................................................. has permission to perform ...... .......... 00 ............ It .... I ............. ...... ...... 15 .......... wiring in the building of ........... ................................................................ at ..... 23 .......... :E� ... 5.1 ....................................................... . North Andover, Mass. Fee ..... .. . ...... Lic. No.. ....................... ELECTRICAL INSPECTOR Check ol-T19b Date........................ . .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 13 i 87-1 Tj - zo _ - _ �rnulonausat�tia o�cc�aaaaaf>.esae�a _ = elJePar�trwn� o��}irrr �aruicoa HOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ %1 A Occupancy and Fee Checked Rev. 1107] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be perrornied in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12 00 WORK (PLEASE PRIATT Ild INK OR TYPE ALL IWORAMTION) ' Date: 3I S/[(o City or Town of: IV A>^dovtir To the 1nspectol• of Wires. By this application the undersigned gives notice of his or Fier intention to perform the electrical work described below. Location (Street & Number)., a l ray S��r vt' Owner or Tenant T,S Telephone No. Rly-K&9-oaay Owner's Address Is this permit in conjunction r►ith a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No, Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters t New Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters t Number of Feeders and Ampocity Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system panels rated i I[Atfl kW na STC Grid Tied In conjunction with a Buildina Permit ---- - CO»IDlehml nFeA� fnllrn�i„Q �,.Afe ,.,,.., f.,......:.._1 i.. •�-- '---_ _-- �.,,. No. of Recessed Luminaires No, of Ceil,-Susp. (Paddle) Fans a• of ota Transformers KVA No. of Luminaire outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool A ove ❑ n -o. ❑ of Emergun—cy Lighting find. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No, of Switches No. of Gas Burners o. ol vetection an Iuitiatin Devices No. of Ranges No. of Air Cond, Tans No. of Alerting Devices No, of Waste Disposers teat limp Totals: umber '[ onsK a. of elt antained Detection/Alertim Devices No. of Dishwashers Space/Area Heating Iii' Local ❑ luuictpal ❑ Other Connection No. of Dryers Heating Appliances KW ccurity yystems: Devices No. of aterNo. Heaters KW o• of I o. o of or uivalent Data Wiring: Signs Ballasts No. of Devices or Equivalent No. hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: ertac i aaamonai detail trdasired, or as i equlred by lire Inspector of (rires. Estimated Value of Electrical Work: 11000 (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 X BOND ❑ OTHER ❑ (Specify:) 1 cerfify, under the pains and penalties of perjury, that the it fontuxtion oil tills I plication is tale and can fete. FIRM NAME: SOLARCITY CORPORATION LIC. N0.:113tiMR Licensee: MATTHEW T. MARKHAM Signature LIC. NO.:1136MR (If applicable. enter "exempt" in ilia license nambet• line.) Bus. Tel. No.:774'25&8188 Address: 24 ST MARTIN DRIVE (WL01NG' - UNIT 11) MARLBOROUGH, MA 01752 Alt. Tel, No.: 774-258-8505 *Per M.G.L. c. 147, s. 57-61, security work requires Department ol'Public Safety "S" License: Lie, No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. I am the (check one) [3 ownerOwner's a ent. Owner/Agent SignatureTelephone No, PERMIT FEE: $ �-j .._ �/�►'i.°.�'F��ttilll�1'?t.,f"�!�A,��'���i'; 04, �f1!�^l4?G I Office 01- onstin-l4r Affiah ' .incl Business Regulation t 10 Park Pima - Shite 5170 y, Boston, Massachusetts 0? 116 flome Improvement Contractor Registration SOLAR CITY CORPORATION MATT MARKHAM 3055 CL,EARVIEW WAY SAN MATEO, CA 94402 d"I is 4 kacarwttantnr + . 14, F f'.1R MK+114MV',I /f/t ./ . 4..W10 ^` tlfTace of Consumer Albb-4 A Ilusiuet~5 Rtgolation L HOME IMPROVEMENT CONTRACTOR Roylstration: 1$38,672. Typo: l:npication: '41,2017 Supplement Catd SOLAR CaT t iPi-JRA 1O. MATT IVIARI-A VV w 24 ST MARTIN S"IRLLi 13LD 2UNI iV1AkLB0ROUGII, M,A 01752 ltndersenetar� _ Registration: 168572 Type: Supplement Card Lxpiration: 318!2017 Update Address and return card-lklark reason for change. Address Renewal Employment last Card •icense or registratioaa valid Cor individtd use only hefnre the expiratiou date. 1f found return to: Office of Consumer Affairs and Business Regulation 10 Park pl,79 - Suite 51711 Boston.'11A 112116 r itiot valid without signature • Cid�l�'1 L , ELECTRICIANS ISSiit.S THE FOLLOWING LICENSE AS At, REG I S`CERCI7 MASTER EI.ECTR I t' I AN :' g SOI,AItC I TY C0 RPORA'I ION MATTHi'W T MARKNA,H ""II ?4 SAINT MARTIN DR U [IG 2 ON 17 I I �• ISAR1.80ROUG11 MA 0179,Q- 060 I I t. The Commen wealtis ofMassacfi usetts Department of IndustrialAccidents 0A7 CC of In vestigatioas I Congress &=4 Suite 100 Boston, MA 02.114-2017 www.treassgov/alis Workers'Compensation Insurance Affidavit.- Builders/Contractors/Electricians/Plumbers AppMeant Information Please Print La ibl Ntune($usincsS/prganization/individuaD-. SolarCity Corp. Address: 3055 Clearview Way City/State/Zi : San Mateo CA. 94402 phone #: 888-765-2489 Are you an employer? Check the appropriate box: 1.1 it employer 5, 000 4. E] I aro a general contractor and I Type of project (required): r P am with 6 n New construction employees (full and/or part-tirn$).* have hired the sub -contractors 2. ❑ I am it sole proprietor or partner.- listed on the attached sheet. 7. ❑ Remodeling shipand hemployees have no ernIt ie These sub -contractors have S. 0 DCrit01tti8;1 working for the in any capacity, employees and have workers' 9. Building addition w two orkers comp. insurance required.l Q insutmtce i 5. [ comp. We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I ant a horneowner doing all work officers have exercised their l LE] Plumbing repairs or additions rnyselil [No workers' comp. -Ar,)it of exeurp-ion per MGL I2.❑ Roof repairs insurance requireAl t c. 152, §1(4), and we have no employees. [No workers' l3 ✓�iher Solar/PV -- coma. insurance required.l *Any applicant that ehtcks box # 1 mast also fdt ata the section below showing their worktxs' cornpetsontion ppilay infortrtulion. t Momeuwnas who submit this affidavit indicating they are doing all work and thrn hire outsitic coatrecmts mast submit a new atTdavit ladicating such, tContraetprs that cheek this box must attached on additional sheet showing the name of ttrc sub-corarattars and state whethet or not those entities have *nploytxs. if the sub.cantraetors have employees, they must provide tt k workers' comp policy ntnnber. rant au employer that is providing workers' campensatfon Insurance for my entpiayeas. Below is the policy and job site irrfornratiou. Insurance Company Name. Zurich American Insurance Company Policy 9 or Self -ins, l.,ic. #: WC0182015-00 Expiration Date: 9/1/2016 Job Site Address. 21 Fl"4 Sf. City/State/zip: N. Avw6e-r, MA �tis'tS Attach a espy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required undcr Section 25A of MGL c. 152 can lead to the imposition of criminal paulties of a fine up to S 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. "7 r��-m rccr��zcri� X do hereby ees!(ly under the palrts and penalties of perjury that Ilse in, formation provided above is true and eorretct. 3igpahtre: � � Date: 3�tsll� Phone Oiridal rare only. Do not wrtfa hr this area, to be eatrtpieted by city or town. ayplat. City or Town: Permiitn•lcease i Issuing Authority (circle one): I. Board of stealth 2. Building Department 3. City/Town Clerk 4, Electrical Ipspector S. Plumbing Inspector b. Other Contact Person: Phone #r A� 0 CERTIFICATE OF LIABILITY INSURANCE DATEIMIAIP11) YYYI R, 0811712015 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(les) must 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 endomement(s). PRODUCER CONTACT NAtNL:_. _....---.._.. MARSH RISK& INSURANCE SERVICES .............._. ._... _.._.... .... ....... PHONE T FAX 345 CALIFORNIA STREET, SUITE 1300 lA1c. No.J"aEtl ..............._ ... _ ... _......... ..........: ln!c. Np]i ...... _ ..........................._ EMAIL CALIFORNIA LICENSE NO. 0437153 .. _.... _........ . _ SAN FRANCISCO, CA 94104 Aqn SIIalmon SCOU 115-743 $334 -APPR€1"......................................._...._............ 7 INSURERIS� AFFORDI#G CQYERA(3EE. ... .........._._ ... NAIC.0._..... 99MOISTND-GAWUE•15.16 116 INSURER A; Zurich American Insurance Company_.. __. INSURED INSURER B : NIA . .. . NIA .. _ . _. PR R .. .............._ . +. ......... SoWity Corporation c.: NIA NIA 3055 Clearview Way _PtSURER ............... ....._................................. ........... _ ......... ......_ .... San Mateo, CA 94402 tNSURER.D : American Zurich Insurance Company 40142 GEN'LAGGREGAT_ELIMIT APPLIESPE'R GENERALAGGREGATE $ 6,0OO,OQO INSURER F: 9-M1=eeri_Ce !_CDTICI!_ATF MIItURFrt• SFA-UU2113831:•UB ht1=VISIUN NUBRE3t:K:4 V MS 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. ....- ._... ....._._.. ...._ ._.. ._ _.. ...__._.._..... ....... .... .:.... ..... ......[ItIL'SIIBftT._.—................._...._... _.......... ... 06U6E00 POLICY EXP' .. ...... ...... ..._........._. LIMITS �.. TYPE OF INSURANCE POLICY NUMBER Dr Charles Marmolejo---- A X COMMERCIAL GENERAL LIABILITY iGLOO182016-00 6910112015 0910112018 EACH OCCURRENCE S . _ I ....... 3,000,000 -- --- ---- j i I CIAIMS rMpE OCCUR i ......... _. ACISI -- .............t DAMAGE TO. RENTEF7 PR! IyAE.S.ES {E$ pgcurrere� ....r .... ............ _ 0,0 00 .. 3,000,0 X SIR: 8250,000 MED EXP (Any one person) $ 5,006 PERSONAL & ADV INJURY S 3,000,000 GEN'LAGGREGAT_ELIMIT APPLIESPE'R GENERALAGGREGATE $ 6,0OO,OQO XI POLICY F j JPERC L. ! ± PRODUCTS - COMPIOP AGG : $ 4-. .. ..... .__....... .. .. .... .. .... ._...... 8000,000 .. .. ... ..JLOC i OTHER! A ; AUTOMOBILE LIABILITY :8AP0182017-04 :0910112015 0910112016 IN S lr E L MIT g 6,000,000 X ANY AUTO BODILY INJURY (Per person) . $ X : ALL OWNED X SCHEDULED BODILY INJURY (Per aecidenq; $ AUTOS AUTOS X I.... NDN -OWNED HIRED AUTOS X AUTOS a..........- ...... ......_... ................. - PROPERTYDAMAGE ............ ... .. . . _ ......... i, COMPICOLL DED' $ $5,000 ' UMBRELLA LIAB OCCUR EXCESS LIAR CIAIMS-MADE F AGGREGATE DED i RETENTION $ I( $ D ':WORK ERS COMPENSATION WC0182014-00(AOS) '09101!2015 09701!2(110 i X '; PER ORH• STATl1T! ;......i E. ;AND EMPLOYERS' LIABILITY A Y 1 N ' :WC0182015.00 MA ANY PROPRtETORIPARTNERIEXECUTIVE ( F -.....i . 09101Y1015 09101P2016 E.L EACH ACCIDENT S . 1.600,000 :OFFICERIMEMBEREXCLUDE07 N N/A1 {Mandatory 1n NH) WC DEDUCTIBLE' $500,000 F_.....____._.._ ............... .....{. ........ E.L DISEASE - EA EMPLOYE S 1,000,000 H yes. describe under DESCRIPTION OF OPERATIONS MOW E L DISEASE -POLICY LIMIT 5 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more space Is required) Evidence of insurance. rieetvClriArr UAI r1CD t ANCFI I ATIAN SohircIly cowrAon SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Cearview Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo, CA 99402 ACCORDANCE WITH T14E POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo---- ©1933-2014 AGOR© COKPOKATfON. All rtgnt s reserves. 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O: O D o _ :o: N O cD O iv{:3:A �El{�. ;rel q. N S O: A O <' ,� < < <. o w:< 0°' C \ << <' v Pv x?\:3 P'CID N N{ N n• O. :c, tn; �.D o A O O \.0 I j N o : v :3 - Ti 87 i� 2 Date. 1SIA . . TOWN OF NORTH ANDOVER i PERMITIFOR PLUMBING This certifies that ...i. G.., ....../10.5.... . . has permission to perform plumbing in the buildings of ... l, /4,qvp — ................. at ..Q.(... „S ...S7L` ................. North Andov-erf, Mass. Fed".0 .Q.. Lic. No... ! ..... ... ,�i� 2 PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS _ Date S�1 I a01 (90 J 0 Building Location / P/}S y S '% Owners Name �� &V/ /I /i /h S permit # Amount 3d. S'p Type of Occupancy.5jug bIL j �-�; 1/ New Renovation Replacement ❑ Plans Submitted Yes ❑ No F1XT1TR F C (Print or type) Installing Company Name %6 L O 7hS A.-A-1(- Check one: Certificate ©- Corp. Cr Partner. Firm/Co. Name of Licensed Plumber: _/ice/C �lA % /,;— :,7� LD 7A4 -s, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 13- Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations p under Permit I ued for this application will be in compliance with all pertinent provisions of the Massachusetts at 1 b' ter f the General Laws. By: Signature o ice se um er Title Type of Plumbing License ' City/Town icense um er Master Journeyman ❑ PPROVED (OFFICE USE ONLY • i i ;.,; ilk ........... ..... .........■ ♦ / f .W.--W ...................� .........................■ .........................■ ' . f .........................■ . f ...-..-...-t-------------■ 1 . f .............M -..M.---..-■ . f -------------------------■ . f .........................■ (Print or type) Installing Company Name %6 L O 7hS A.-A-1(- Check one: Certificate ©- Corp. Cr Partner. Firm/Co. Name of Licensed Plumber: _/ice/C �lA % /,;— :,7� LD 7A4 -s, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 13- Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations p under Permit I ued for this application will be in compliance with all pertinent provisions of the Massachusetts at 1 b' ter f the General Laws. By: Signature o ice se um er Title Type of Plumbing License ' City/Town icense um er Master Journeyman ❑ PPROVED (OFFICE USE ONLY COMMONWEALTH OF MASSACHUSETTS U.,Ivgoc,rx%p Palmw %7morymm TTTLF" REGISTERED AS A PLUMBING CORP ISSUES THIS LICENSE TO MICHAEL G ZOLOTAS ZOLOTAS BROS IMC M 98,09 .515 LOWELL ST pi • PEABODY MA 0191.0 - rsa2 • 1361 05/01/12 759,857 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 3: 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 a 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 ifhe—.. _ 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 Chapter 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. 8 — Permit/Date Closed: ❑ Permit Extension Act—'Permi+ma+a rf—il. *** Note: Reapply for new permit 9-6Y I I .-%. �-'(" Date ...... :% ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... ......... .................... has permission to perform ........../ ....... ... . . ..................... wiring in the building of .............. . .... Sir ........................................ at ......... ZY .... !�.AeW ........... X) . . ............. ......... North Andover, Mass. jol Fee .,�' Lic. No; ...31 ...... .. ................. ELECTRICAL =C;i�R Check # avrrrrrrarerVvV aeaea aye r� / Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (ieaveblank) 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 17V INK OR TYPE ALL INFORMATION) gOR.7[7E-J[ 1ND®b gives notice of his or her City or Town of: By this application the undersi Location (Street & Number) Owner or Tenant _ (� / t / Gi Owner's Address oZ n�j Is this permit in conjunction with a Purpose of Building . permit? Yes Date: oq'.-10 % lU _ To the Inspector of Wires: to perform the electrical work described below. Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service -7-400 Amps % d Z�U Volts Overhead ❑ Overhead ❑ New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:' No. of Recessed Luminaires No. of Ceil: Susp. No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool I No. of Receptacle Outlets !7 No. of Oil Burner No. of Switches 3 No. of Gas Burne. No. of Ranges No. of Air Cond. No. of Waste Disposers HeatPump Totals: Num No. of Dishwashers Space/Area Heati No. of Dryers Heating Applianc No. of Water Heaters KW No. of Sim No. Hydromassage Bathtubs No. of Motors OTHER: Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters table may be waived by the (Paddle) Fans _ Transformers KVA Generators KVA aboveIn- ivo. of L+merg, rrnd. El 1% ❑ Batter Units ALARMS INo. of Zones rs 11No. of lJeieciiol[i auu TnitiatinLy Devices No. of Alerting Devices Detection/Alerting Devices ivluniclpai Other ng KW 11 Local ❑ Connection ;es KW No. of Devices or Equivalent . No. of Data Wiring: Ballasts No. of Devices or Equivalent Total HP Telecommunications Wiring: No. of Devices or Equivalent •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: �(� 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 cove age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and penalties of perjury, that the information on this application is true n complete. FIRM NAME: Licensee: ()�/ !c Signature LIC. NO.: (If applicable enter " xena t" int a license aim er Ili t Bus. Tel. No.: � Address: (J cc �a v Alt. Tel. No.: 9? ' 37.2 L5' 7f 7 *Per M.G.L c. 147, s. 57-61, security work requ' es Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have th6 liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent Telephone No. PERMIT FEE: $- Signature 1 Yfj The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers n lease Printl±gibly Applicant Information Name (Business/Organization/Individual):�61JU " 'Ir Address C', J (,,,_J0 City/State/Zip: d �,�Gt �� �� Phone #: -Z R, 3 d Are you an employer? Check the appropriate box: 4. ❑ I am a general contractor and I 1. ❑ I am a employer with mployees (full and/or part-time).* I have hired the sub -contractors listed on the attached sheet. # 2. [j am a sole proprietor or partner- These sub -contractors have ship and have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance S. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. E] Electrical repairs or additions ILEI Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 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. • beet showing the name of the sub -contractors and their workers' comp. policy information.#Contractors that check this box must attached an additional s 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. Lie. #: 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 andpenalties of perjury that the information provided above is true and correct. Signature: Date: 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 Contact Person: Phone