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Miscellaneous - 24 DARTMOUTH STREET 4/30/2018
91-) 4- 3055 Clearview Way, San Mateo, CA 94402 (888) -SOL -CITY (765-2489) f www.solarcity.com Project/Job # 018728 RE: Installation Approval Letter Project: Balogh Residence 24 Dartmouth St Amir Massoumi North Andover, MA 01845 2014.11.08 15:11:56 -08'00' To Whom It May Concern, On the above referenced project, the roof structural framing has been reviewed for additional loading due to the installation of the solar PV addition to the roof. The structural review, including the plans and calculations only apply to the section of roof that is directly supporting the solar PV system and its supporting elements. The capacity of the structural roof framing directly supporting the additional gravity loading due to the solar panel supports and modules had been reviewed and determined to be in accordance with the requirements of the MA Res. Code, 8th Edition. Plans and calculations were stamped & signed with my professional engineer's seal. The work has been completed in accordance with the provisions of the approved permits of the applicable code Should you have any further questions or requirements pertaining to this project, please do not hesitate to contact me. Sincerely, Amir Massoumi, P.E. Civil Engineer Direct: 650.963.5611 email: amassoumi@solarcity.com 3055 Clearview Way San Mateo, CA 94402 T (650) 638-1028 (888) SOL -CITY F (650) 638-1029 solarcity.com AZ RUC 243775. CA CSL9 88104, CU EC 8041, GT Hi C 0632; 7V, DC Hi0 7;10:466, DO HIS 711 U1466, HOT 2974 MA HIC 168572,'AD MHO 126948. N-7 13VN061606ik. OR C, GE IE*4%- PA 077343, TX TDLF! 27(308,'WA GCL: S©LAHQ'91907. 0 20!3 $o".ar0Ry. All ryhi:.. Date. ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that � (AA 49 J T . � C', vv\. - has permission to perform '.s(.?'.( ..... Gm:�l ... �wj+B f wiring in the building of ........ . .......... at I ZL� OCV4 vy-, V-� ......................................................................................................... ,North Andover, Mass. Foea,....... Lic. No. f2e ... EL CTRICAL INSPECTOR Check #--7-72-7o5 e e e-% L'2 -D -1 ce vi\ - L --T y C\— i..ommonweahk of Ma4laclwJelb Aparfinent of7ire Service! BOARD OF FIRE PREVENTION REGULATIONS Print Form OfficialUseOnly Permit No. 1(,�1�' 11( Occupancy and Fee Checked [Rev. 1/071 (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: a -/a -/'/ City or Town of: , k\f40 d cJ'�O- r- To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perforin the electrical work described below. Location (Street & Number) 214 D2` rLY>f1< til) S,,L Owner or Tenant LLAno =n-_ Owner's Address Is this permit in conjunction with a building permit? Purpose of Building w/ Solar - PV Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. 6P / ? - (4S-2 •-ODj'-� Yes ❑fi No ❑ (Check Appropriate Box) Utility Authorization No. n/a Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system 123 panels) rated 5',S105- kW -DC @ S.T.C. Grid Tied. In conjunction with a Building Permit. Completion of -the fbllm+ink table may he waived by the Inspector ol'Wiree. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Not Tubs Generators KVA .No. of Luminaires Swimming Pool Above❑ n- ❑ 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 o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: I Number I Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mumcipai ❑ Other Connection No. of Dryers Heating Appliances RW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters o. o 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: Attach additional detail i(Vesired. or as required by the Inspector of Wires. Estimated Value of Electrical Work: JQo0Q (When required by municipal policy.) Work to Start: A.S.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. CHECK ONE: INSURANCE ❑✓ BOND 0 OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that fire information on this application is true and con►plete: FIRM NAME: SOLARCITY CORPORATION LIC, NO.: 1136 MR Licensee: Matthew T. Markham Signature �`� - LIC. NO.: 1136 MR (1/'applicable, enter "exempt - in the license number line.) Bus. Tel. No.,• 774-258-8180 Address: 24 St. Martin Drive (Buildinq 2 / Unit 11). Marlborough, MA, 01752Alt. Tel. No.: 774-258-8505 *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) ❑ owner ❑ owner' a ent. Owner/Agent PERMIT FEE: $ Signatureturarl Telephone No. o' Mee of Consumer Affairs & Business Regulation DRi t7ME IMPROVEMENT CONTRACTOR ti JI tieglstration: 168572 Type Expiration: 3/8/2015 Supplement SOLARCITY CORPORATION MATTHEW MARKHAM 24 ST MARTIN STREET BLD 2UNI TAALBOROUGH, MA 01752 Undersecretary COMMONWEALTH OF MASSUSE TS BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED MASTER ELECTRICIAN SOLARCITY CORPORATION 'l MATTHEW T MARKHAM 24 SAINT MARTIN DR BLDG 2 UNIT 11 MARLBOROUGH MA 01752-3060 *i i .w i r 4-� 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 Applicant Information Please Print Legibly Name (Business/Organization/individual): SolarCity Corporation Address: 13055 Clearview Way City/State/Zip: 15an Mateo, CA, 94402 Phone #: 888-765-2489 Are you an employer? Check the appropriate box: 1. 1 am a employer with 5000 4. El I am a general contractor and i employees (full and/or part-time).* have hired the sub -contractors 2. 1 am a sole proprietor or partner_ listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ® 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. [1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. in New construction 7. g] Remodeling 8. Ej Demolition 9. ❑ Building addition 10.90 Electrical repairs or additions ll.® Plumbing repairs or additions 12.[j Roof repairs 13.0 Other Solar 'Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contra ctors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Company Policy # or Self -ins. Lic. #A766DObb2b5023: Expiration Date: 19/1/14 Job Site Address; City/State/Zip: ftr44') #Mbue 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 upAo $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true/and correct. Signature: `'� - r Date: Phone #: 888-765-2489 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 v '#�coRo°'CERTIFICATE OF LIABILITY INSURANCE D08/21ID01 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 08/?13 I2073 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 poitcy(ies) 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 endorsement(s). PRODUCER 0726293 1-415-546-9300 CONTACT Brendan NAME: Quinlan Arthur J. Gallagher i Co. J{u Insurance Brokers of California, Inc., License #0726293 WCNNo. E%I): 415-536-4020 ,No1._ 1255 Battery Street #450 _ E-MAIL brendan JnlanQa' con ADDRESS: q]4•u _ _ San Francisco, CA 94111 1113URER(S)AFFORDING COVERAGE 1 NAfC• -------- _---- -„ -- INSURER A: LIBERTY MOT FIRE INS CO 1230_35 INSURED SolarCity Corporation INSURER 8: LIBERTY INS CORP • 42404 — --- --- - ----- INSURER C: 3055 ClearvieM Way _ INSURER O: _-- —_ San Mateo , CA 94402 INSURERE:.- f( INSURER F: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE l ISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Willi 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. -- --- *NSR; Aebl SUBR' AM! OY EFF MIDDY E1fP LrMITS - — LTR . TYPE OF INSURANCE POLICY NUMBER A GENERAL LIABILITY TS2661066265053 1 09/01/1 09/01/141 EAGI i OCCURRENCES 1,000,000 X l COMMERCIAL CENERAt LIABILITY 1 CLAIMS MADE X I OCCUR j DAMAGE TO R TFD MtEMISES(Fp oct� n!ncgL Too 100, 000 +Deductible: $25,000 MEO EXP (Any aim person) $10,000 -X PERSONAL a ADV INJURY ; 1,000,000 F f( GENERALAGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER X rR0' ; I PROOIICTS_•_C_OMP_IOP AGG S. 2.000, 000 i POLICY I LOC $ 6 A 1 AUTOMOBILE LIABILITY AS i COMBINED SINGLE LIMIT , X j {Ea aac�Omy —� _ ; 1,000,000 ANYAUTO BOUILY INJURY {Pet person) ; ALL OWNED t SCHEDULED - - - ------•- AUTOS j _ AUTOS { eODILY INJURY {Per accident) f S ON-OHIRED AUTOS AUTOSWNEO A � 1'RO:ERTV DAMAGE _ i{Pel _uiConl _ ' UMBRELLAUAS OCCUR I EACH OCCURRENCE S EXCESS LIMB CLAIMS -MADE _ AGGREGATE $ DEO RETFNTION; 111; B AND WORKERS AND EMPLOYERS' LU181LITY WC7661066265033 (WI Retr )O9/01/13 09/01/141 WCSTATU• +OTH- B ANY PROPRIETORMARTNER/EXECUTIVE F�Y'q-I�N� OFFICFRIMEMRFR FXCI LIVED? NIA NA766DO66265023 (Dad) 09/01/13 09/01/14 tS 1,000,000 E.L EACHACCIOENT NHIL" J (Manddownstoly n and n es, doscnbe under DESCRIPTION , _ _ i E.L. DISEASE - EA EMPLOYE Ej I : 2,000,000 OF OPERATIONS below E L DISEASE - POLICY LIMIT I i 1, 000, 000 . I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANach ACORD 101, Additlonel Remark* Schedule. If more space Is required) Proof Of Insurance. i CERTIPWATG MAI nee of Insurance Only 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 (D1988-2010 ACORD CORPORATION. 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Floor Area Served :FM Leakage at 25 pa ,pprox % leakage for single system* Location Type of test O Total/ O To Outside Approx. Floor Area Served CFM Leakage at 25 pa Approx % leakage for single system* u Aaaress: &W 1 J44. IT— City, State Zip: rM04 00 Test DateW(, i?/ Test Time Qj 30 Point of Construction O Rough Final Location Type of -test O Total/ O To Outside Approx. Floor Area Served _ CFM Leakage at 25 pa _ Approx % leakage for single system* Location Type of test O Total O To Outside Approx. Floor Area Served CFM Leakage at 25 pa Approx % leakage for single system* Combined Results Total Conditioned floor area ?_,5'Z8 Sq. Ft. Leakage limit O 6% 08% A 12% Leakage limit cfm@25 Combined Leakage" j y cfm@25 2009 IECC Compliance Pass O Fail se only. ** Total combined duct leakage is required for 2009 IEEC Compliance. I certifv that this Tester's Signature HERS Rater Name: Dan Clark HERS Rater Company: Advanced Building Analysis, LLC HERS Rater Provider: Energy Raters of Massachusetts standards UL LU hl V. -cl .0 lu -vu t7 lu In 0 tO CL 0 IV cli LL in w Lu"':' o W 4— V IV IS' TO U7 9) E A tU CL tJ vi -w I El Tj FL N to IV > 0 I (j) ul - 0- 6 . 0i (n lu CL L qj uu )- rU IFT 0. rn u- ,u U) to u j-_ltU In tu 0- 0- u I kli jz In J) LL 2E: Date......: �/— �.? TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 8�Ix ............... has permission to perform / �UNQ mss..... �p.,T, �. t..r-G©...... _ wiring in the building of ......... .` .... "V ..C' .................. a.z..�� ........... `?`........leA ......... orth Andover, Mass. .. b Fee... ./.�0.. Lic. No....d. /.4/bxg............... ................ J� ELE ICALINSPECTOR% Check N �� f0 10769 It V4 Commonwealth of Massachuseds Official Use Only Department of Fire Services Permit No. I� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (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: 1l r % % — /—I City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives o �oMs or her intention to pe form the ele tric wor described below. Location (Street &Number) ,4 p 01 Ll Owner or Tenant G Q L Telephone No. Owner's Address P® 4?6 Z lo; Lv � � ,W Is this permit in conjunction with a building permit? Yes V No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service W Amps l J / Z Volts Overhead Und rd ? g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /,..1 t--po M 1-1,( r — C No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No, of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers o. of Water KW APatPra Hydromassage Bathtubs OTHER: Completion ofthe No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In- �rnd. Irn No, of Oil Burners No. of Gas Burners No. of Air Cond. Total Space/Area Heating KW Heating Appliances xvy No. of No. of Suns Ballasts No. of Motors Total HP An table may be waived bv the Inspector No. of Total Transformers KVA Generators KVA Nu. 61 Emergency Ligliting &ttery Units FIRE ALARMS No, of Zones No. of Detection and Initiating Devices No. of Alerting Devices No. of Self -Contained Detection/Alerting Devices Local ❑ Municipal ❑Other Connection Security Systems:*. No. of Devices or Equivalent Data Wiring: No. of Devices or Eauivalent 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 ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coy age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains an penalti Of, ury� that the information on this application is true and cor plete. FIRM NA :Ci — �� G l?, Licensee: LIC.NO.: Z/ gw . � Signature (If applicable, a er " empt, i he license mum er line.) LIC. NO.: Address: / r Bus. Tel. No. *Per M.G.L c. 147, S. 57-61, security work requires Department o ublic Sa eiy "S" License: Alt. Lic. No. " ���_ ll 6 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 a ent. Owner/Agent Signature Telephone No.PERMIT FEE: $ y Q ELEMICAL PFPMT NO. . WSPEMO REPORT. _ L+ �ECT�7[CA]Cr ���'�CT®h�. •,__ .. . RDUCS.XNSPCTON: 'assed S�aile8--j ]e-inspeeiion xequi�reci($50.OQ) •- �nspectoxs' comments: (xndV_ spectoxs'Signature-n als Pate ]Passed - Failed j Re -inspection required ($50.00) -- [ xngpectors' c eats: ([nspectors' Signatureo initial plate If 3, 'C MNR GROUND XNSPACTXON: �'assed•—[ ] �'azIecl— j ] Tete-inspeetzonxeciuirecT ($50.00) � [ ] �' Inspectors' comments: (inspectors, Signature -no initials) Date 5. J1'9S ECJlIO " OTRFIR:, passed--[ 7 +ailec�-- �'nspectors' conom.enfs: Re -inspection spectoxs' Signature no Xnitials} )late 1)0OR TAG,9 AR -^ TO DE FAILED OUT AND LEFT ON ISITE -W THE ARUBA. TO DE INSPECTED 19 NOT ACCESSIBLE AND A RE INSP: + CTZON OF _$50.00IS TO BE CHARGED. The Commonwealth of Massachusetts 07 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual): dygdler�i/ Address: Ptot, City/State/Zip: G,1 L° it-�/I' �j�d q Phone #: ?� f 1/7 Are you an employer? Check the appropriate box: L ❑ I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 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 insurance required.] t 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 L ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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 aie 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: - f r 1 e CG" /1I " Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sisrtature: � Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - II Contact Person: Phone #: 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 hire, express or implied, oral or written." An employer is defined 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 a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 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 be 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 applicant who has not produced acceptable evidence of compliance with the insurance coverage required" 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the r 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 Accidents. 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 M 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 'r 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. ## 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax ## 617-727-7749 www.mass.govldia The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uir www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information _ Please Print Legibl' Name (Business/Organization/Individual): 66 1%Gle%'(�i/ Address: /, r SQ 10 7 City/State/Zip: �G 16�&� 10161 Phone #: Are you an employer? Check the appropriate box: 1. F1 am a employer with 11 4. ❑ I am a general contractor and I 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 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 insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. t Insurance Company Name; Policy # or Self -ins. Lic. /rtCrch,GllI,j- Expiration Date: Job Site Address: City/State/Zip: m Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true ant. d correct Rianatnre ";>"C/� _ Date: G'/ -,f j S/L,4-�/ f / Phone # c �c 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 #: A I U Date.. .-. .� ..... .. /L TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... i.l,�.........(I .........................I........ has permission to perform ......�'�'.r �¢ 'r % wiring in the building of ...... If1. u......:�..! ................................. ........ r� , North And ver, MAss.e F/ ............ Lic. Nd�'. �' � � ... ELECTRICAL INSP CTOR p 7 Check # 14. Z-3 10874 e I t commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ Occupancy and Fee Checked [Rev. 1/07] (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 (PLEASEPAWTININKORTYPEALLINFORMATION) Date: ' ^�G, --- J City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentippn to perform the electrical work described below. Location (Street & Number) A 4-1 N a I--" na i -1—I'► < , Owner or Tenant r.1 L (� v Telephone No. Owner's Address r10 m R zn �� iej�— Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ /7...__7_.D _r,7 _ r No. of Meters No. of Meters No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans raoie may be waived by the Inspector o Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- nd. rnd. o mergency mg ing er Units No. of Receptacle Outlets '`2, No. of Oil Burners E ALARMS fNo. No. of Zones No. of Switches No. of Gas Burners of Detectionand Initiating Devices - No. of Ranges No. of Air Cond. TotTons No. of Alerting Devices No. of Self -Contained Detection/Alertin Devices Local ❑ Municipal Connection ❑Other No. of Waste Disposers No. of Dishwashers Heat Pump Number. Tons KVS' Totals:._........._.... ._._._._._......_........._..._........... Space/Area Heating KW No. of Dryers No. of Water Heaters ,y No. Hydromassage Bathtubs Heating Appliances KW No. of No. of SIRDS Ballasts No. of Motors Total HP Security Systemk No. ofDevices orEquivalent Data Wiring: No. of Devices orE uivalent Telecommunications Wiring: No. ofDevices orEauivalent v 1 H EX: f41tach additional detail 1fdes1red, 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 ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov3Kage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify:) I certify, under the aiinns`and enaltie oiperja , that the information otytTiis application is true and con tp,Ieie FIRM N : E' �v��GGLL4—_;,_ LIC. NO.: 1 IL/ Licensee: �j $ 5E'f^-Signature �',�,1�� Z / LIC. 2 �/� �%/l (Ifapplicable, e"exemp "in thelic��m:mberline.) Address: © 7 c�' Bus. Ta)t l�io.:_ _ /7 9 *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S"License: Alt. el. 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. Tam the check one owner Owner/Agent ( ❑ ❑ owner's a ent. Signature Telephone No. PERMIT FEE: $ S'lf _ E-ECTRXCAL PERMT Iii•®, )EEC F!C.AlG 3f � OPEk PTOR ~ ' 72�ssecT-•- j _ -- �+'ailed-• j 1 �e-fnspecifon xequzzecT(��0.00) � j � �nspectprs' comme�afs: - (Xnspectoxsyzgnature - uoiiaTs) Iry a77 Slate 6� / Z- 2. +xNA�,Nsp,gC3CIOl�; passed- •�+`afTecT--�) � ate^�ns�ectionxe0uixed($50.00)~[ � . n i Olemm ads: (Gisiectors' zgna e ~ no islztiaTs) plate 'LtmyR CROD" II'�.' e TION. sed- j ] +azled- [ Ete-inspeetionxeguixed($ 0.40)~ j 1 spectors' comments: (fns ectoxs} aignatuxe ~ no iniiials) Date DATE, CALLER -0 STA IONAIj ON 31: Passed --j I xnspectoxs' conmmeph: railed-- (.cusp ectors' �'ignatnre � na f J.V'.A16�E: . te-3nspectionx� 'asset-•[ � �+,azled--j )- 'Re�nspecti asp ectoxs' coiAm.ents: ..j � Date ,specfox§'zgnatuzeuoxnifials} Date I)OOR TAGN .ASE TO 13E T OUT.AO MFT ON RITE IF TM .ADEM. TO 3E INSFECTED xg Wor .A.CCESMEE .AND .A. RE••J,'SDECTION Off` $50,0 0IN TO BY, CMRGED. . P .s Commonwealth of Massachusetts U9, Department of Fire Serv/ces BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. l/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK X111 work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT NINK OR TYPEALL .WF0AW TI0A9 Date: , G, --- J City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intenti n to perform the electrical work described below. Location (Street & Number) I � N a f" < -7— Owner Owner or Tenant -ram ,9 Owner's Address Ro I Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing table may be waived by the Inspector nfWmp.e_ No. of Receised Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers RVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires L Swimming Pool Above ❑ In- ❑ o. o mergency ig mg nd. rnd. Battery Units No. of Receptacle Outlets 12, No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Tons Total No. of Alerting Devices 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 ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: I. No. of Water No. of No. No. of Devices orE uivalent Heaters KW of signs Ballasts Data Wiring: No. of Devices orE uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Eauivalent 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: 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 ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thel�awns` �an�d enn_lties ofperjl , that the infortna+ion orytliis application is true and corp�Ete. FIRM N : ��uvtG�. j°) ri_ L°f'1/I( LTC. NO.:� dLJ Licensee: 10 L C �'>—Signature_ ZC - - LIC. NO.: 2 �/( g, h4 (Ifapplicable, a er "exe% in the license number line.) Bus. L�IC. N • � 1 %7 9 � 1116 Address: rQ� �Q 7 14 ���,,, D ��i 7 Alt. Tel. �'o.: 'Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic 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 ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 3—a ry-CXThe Commonwealth of Massachusetts Department oflndustriqlAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers Name (Business/Organization/Individual): Ckiai ler rl eG+rl Co,( ,�erLl% CLQ J Address: P-0 ,y 7� /B ? 2— City/State/Zip:.. City/State/Zip:a44 `ell d11-1 Phone #• q 7/ Are u an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. [:11 am a sole proprietor or partner- have lured the sub -contractors listed on the attached sheet. T• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3. [:11 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions o workerscomp. myself � ' Y p c. 152, , and we have no 4 § 1() 12.E] Roof repairs insurance required.] t employees. [No workers' 13.❑ Other 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 ire 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and joh site information. Insurance Company Name% Merz_-" Policy # or Self -ins. Lic. Job Site Address: Expiration Date: 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 requiredunder 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 o£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 DTA for insurance coverage verification. Ido hereby certi under the pains�9and penalties ofperjury that the information provided above is true and correct. - Simafore: T)atP- Phone #: q -z g —,/-? q a 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 L Information and Instruction's 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 hire, express or implied, oral or written." An employer is defined 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 a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 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 be 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 applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" 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 certificate(s) 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 maybe 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 Accidents. 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 orpermit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance. for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Coxru. onwealtil of Massa- -tts - Dep.artrnent of Zndustda1,Accidents Office of Iuvestigatitons 6.00 Washingto>a. Street Boston? MA 02111 TO, # 617-727-4900 eyt 406 or 1.-877,:MASSAFB Revised 5-26-05 Fax # 617727-7749 www mass,govldza . The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): 66t)lery` ecJ Gest,( Se/-L/I Ci J Address: P-0 , 820� l6 7 2— city/state/zip: ; � l el_y W `` 1 o iTy'7 Phone #: AreKuu an employer? Check the appropriate box: 1.1 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or parkime).* have lured the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. x ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 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 insurance required.] t 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 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:. / L�%�G�'il�l!✓t J Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. X do hereby certi under the pains and penalties ofperjury that the information provide/d above is true and correct. Simature: Cl/�� Z, Date: b ,6/0 /Z Phone #: q-7 9 q-2 t � c 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: