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HomeMy WebLinkAboutMiscellaneous - 25 EMPIRE DRIVE 4/30/2018a �2 ✓/- / r t. Date..............:.............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING f This certifies that ..........��1.�( C...!.k...................:................................................... has permission to perform ..,....: a/— ................................................................... wiring in the building of .......... 1.).. J........ ....:�.................................................... at........... ...... ........................ P f /L....... � .. .............. Zo/ h Andover, Mass. Fee. 3 ........... Lic. Not. r : ��;,% ......---................ ELECTRICAL INSPECTOR Check # ! 7 Q l2 7 12 :' 4 � 'r Co►nr+aorsruoada o� Illaadacir•uae Official Use Only Permit No. _ _ eLJapar�nanE o��ira �aroico9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11071 (leave blank) t APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CME? 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 a l l o //� City or Town of: Nos(t-k htj 8<)1/W To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfonn the electrical work described below. Location (Street & Number) �P. E If P.I(J1 it ej -�;L Owner or Tenant [ , z',v 'j V's � Telephone No. (:P-1 + ^ U'" T433 Owner's Address � i Is this permit in conjunction with a building permit? Yes Purpose of Building Existing Service Amps I Volts New Service Amps / Volts Number of Feeders and Ampacity No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ OverheadEl Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system [ panels rated [ 5 ,), 1 kW Cad STC Grid Tied. In conjunction with a Buildina Permit Cbnrpletiou of1he_jollonvug table may be waived by the Inspector of Cyires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Total Transformers of- KVA No. of Lum"rnaive Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above Ei In-'No' Swimming Pool rnd. rnd. El o Emergency Lighting BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o• o etectton an luitiating Devices No. of Ranges No. of Air Cond. Toota nsl No. of Alerting Devices No. of Waste Disposers heat imp Totals: umber 'Pons JKW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating IM' Local ❑ C Ennec ioln ❑ Other No. of Dryers Heating Appliances KW ecurity yystems: No. of ©eviccs or Equivalent No. of Water KW n o, of o. o Data Wiring: Heaters Signs Ballasts No, of Devices or Equivalent No. I•Iydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail Ifdesired, or as required by the Inspector of h!'ires. Estimated Value of Electrical Work: 11 l G 0c) (When required by municipal policy.) Work to Start: ASAP Inspections to be requested in accordance with MBC 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 A BOND ❑ OTHER ❑ (Specify:) I certify, under thepains rind penalties ofperjui); that the it formation on this application is true and. eanTlete. FIRM NAME: SOLARCITY CORPORATION LIC. NO.:1136MR Licensee: MATTHEW T. MARKHAM Signature LIC. NO.:1136MR (If applicable, enter "exempt" in ilia license nuniber line) Bus. Tel. No.. 774-258-818D AddreSS" 24 ST MARTIN DRIVE (BUILDING 2- UNIT 11) MARLBOROUGH, MA 01752 Alt. Tel. No.: 774-258-8505 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public 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) 0 owner owner's a ent. Owner/Agent PERMIT FEE.' $ Signature Telephone No. cit CSLInicr AffiaiE4,'a4nd Business R10 Off Ce eg4u#'1afion 10 Park Plaza -!write 5170 Boston, Massachusetts 021 i 6 f lomc Improvement Contractor Reglistration SOLAR CITY CORPORATION MATT MARKHAM 3055 CLEARVIEW WAY SAN MATEO, CA 94402 Repistration, 168572 Type. Supplement Card Expiration: 3/8/2017 � jLd '% .,, Update Address and return card. Adark reason for change. Address Renewal Employment Lost (:ard Office ofCossanirr A fthirs A llusinv-4 Rrgul4tinn License or rtgistrAtioll Valid r0r indiVidul OW ORIV HOME IMPROVEMENT CONTRACIOR before the expl"tion date. If found return to: Office of Consurner Affairs and Business Regulation R691xtrMfl0n7 16R512 Type, 10 Park Plaza -Suite 5171) I-XVifAVOW Supplement Card Roston, NIA 02 116 MATT MAR01,AO-A 24 ST MARTIN S'l ALL i 31-0 2UNI rANLBOROUG! I, WIA 01752 11FPdtr.wcretar) lKet valid without signature TTS 90AM or ClICTRI t1l *16 ISSUES THE rOtIDW$N(; LICENSE AS A- RLGISI[Rf,V MASTER ELECTRICIAN !,(',I ARC I TY CORPORA"I I ON MAIT1,41W T 1101k)(HAM SAIN'T KAN'TIN DR ON YAOLOOR014H MA 0_11;2 3060 I L Wtfi JWXW� 134 I ti The Commonwealth of A fassachusetts Deparmsent of ladustrialAccidents Drce of In vesidgatxons I Congress Street, Suite 100 Boston, MA 02114-29J jvww. m ass.gol1dM Workers' Compensation Insurance Affidavit: Builders/Contracters/Electricisns/Plumbers Applicant Information Please Print Le ibl Name i6usincss/Organization/individuaD: SolarCity Corp. Address: 3055 Clearview Way CitylState/Zip: San Mateo CA. 94402 Phone #: 888-765-2489 Are you an employer? Check the appropriate box: Type of project (required): 1.0 am a employer with 5,000 4_ I anti a general contractor and I b. n New construction emplayees (MI and/or tart-tirne).v 2. ❑ I ant a sole proprietor or partner, have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g_ ❑ Demolition -working for the in any capacity, cmployees and have workers' 9. Q Building addition [No workers' comp. insurance regttired.j comp. insurtmce. We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I ant a homeowner doing all work officers have exercised their ILEI Plumbing repairs or additions rnyboll. [Net workers' comp. ii tit7i excutptivn tier MGL I2.❑ Roof repairs insurance roquired,] t c. 152, §1(4), and the have no employees. [No workers' l3 then Solar/PV corner. insurance reouired.l *Any applicant that checks box N [ must also rdl out the section below showing their workers' contpcuaatian puticy infamtatinn. I Homeowners who submit this affidavit indicatingibey are doing all work and then hirq outsitte contradws mast submit anew ati«davit ladicoingsuch, iCoatractors that check this box must attached an additional sheet showing the naime of the sub -contractors and state whtther or not those entities have employees. If the sub•conttaeiors have employees, they must provide their workers' comp policy number. I am ant employer titan isproriding tWtrkers' Compensation insurarteelor »ty ¢ttrployees. Below is the policy and job site irrjornration. Insurance CompanyNarne: Zurich American Insurance Company Policy -9 or Soil -ins. Lic. #: WC0182015-00 Expiration Date: 9/1/2016 Job Site. Address: City/State/zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure ra secure coverage as rcquired undcr Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year itnprisonmen% as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip 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. I do hereby cert& under the pithis andpertaitles ofperjary that Ilse lttformatlonprovided above is trete arta correct Phone 0 Ofriciul usr only. Leo not write in files area, to he completud by city or town official. City or Town: Permis/Livgnse ;i Issuing Authority (circle one): I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone A Q® CERTIFICATE OF LIABILITY INSURANCE DATEIMMfDOlYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, oer17/zals 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 endorsement(s). PRODUCER CONTACT MARSH RISK & INSURANCE SERVICES PHONE FAX 345 CALIFORNIA STREET, SUITE 1300 ..................................... CALIFORNIA LICENSE NO. 0437153 E-MAIL SAN FRANCISCO, CA 94104 _noPR) ss :........... .......................................................................� Attn: Shannon SCott 415-743.6334 INSURERIS� AFFORDING COVERAGE._ ... - . .. ,. MAIC # _0 000..__ 000 0..... IN ... 0000.... ...........} ... 0 000 .... ......... 898301-STND-GAWUE-15.16 INSURER A: Zurich American Insurance Company '16535 —.. _00_00 _ ..._ 00 00 .. . ......... ... INSURED ......_...._... ..........._. 0000 .......................... 0000.. 0000 INSURER 0: NIA NIA SolarCity Corporation _ ........... +.. ......... 0000 3055 Clearview WayINSURER C : NIA NIA ............. ............................ .......................+0000._. ............ _ San Mateo, CA 94402 INSURER.D : American Zurich Insurance Company 40142 r INSURER E: . ... 0000 ... ......... ... ..................._._...... ...................... 3,600,00D .............. 0000.. INSURER P: COVERAGES CERTIFICATE NUMBER: SEA -002713836.08 REVISION NUMBERA THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. San Mateo, CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS. AUOLSIIBR 0000 — ................._ . _._............... ... T POLICY EFF '. POLICY EXP 1 gkj ...........TYPE 0 000.. 0 000._ ................_. ..LIMITS .................. ............ OF INSURANCE LTR I POtfCY NUMBER I MMIDD MIDDI Y Charles Marmolejo-�! A X COMMERCIAL GENERAL LIABILITY IGLOO182016-00 09101(2015 0910112016 OCCURRENCE $ G 3,000,006 r x I I _EACH DAMAGE TO RENTED .......... � ........ 3,600,066 CLAIMS -MADE I OCCUR I PREI{ARES LEA pccurrence} .._*_$_ ..- 0 ,.,. ,., X. SIR s25a,DOD 0000 ... .. .............. ... I D EXP (Any one person) $ �±€.......... _ . 0_ 00on ... 5,aoa 0000. 0000. _ ............................ 0000 __................. 0000 r PERSONAL & A0V INJURY $ . .. ............ 0000.. 0000. 0000._. 0000. ........ 3,600,00D .............. 0000.. GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 6,000,000 lPRO- x I POLICY I JECT LOC PRODUCTS - COMPIOP AGG $ ......_....__ ................ ............ 0000.. 0. 000 6,D00,0OD ......... . • OTHER S A ' quTOMOBILe uaawrY13AP0182017-00 i . :0910112015 09101/2010 COMBINED SINGLE LIMIT $ SEa Pcctdent) .......... 0000 ............ 5,000,000 0000 ... _. x ANY AUTO .; BODILY INJURY (Per person). $ ..... .. ........ 0000... , .....r ALL OWNED SCHEDULED X AUTOS I xAUTOS ' 0000. .. 0000. ...� s BODILY INJURY(Peraccident): $ ;.....� )0000 NDN -OWNED X •� X HIRED AUTOS AUTOS � . .....�..� ........ ~ PROPERTY DAMAGE � (Per accident) ... .. 0000.. 0000.., I.. .. . , , t }.. .. ........... COMPICOLL DED: $ .. ... .0000. ... ._ $5,000 UMBRELLA LIAB OCCUR I...... ; .. I 'r EACH OCCURRENCE S ............._....................... EXCESS LIAR ': CLAIMS-MAOE:AGGREGATE, ,......... .._......... DED RETENTIONS $ D WORKERS COMPENSATION '.WC0182014-00 (AOS) :0910112015 :0910112016 x 0TH- ; •AND EMPLOYERS' LIABILITY A Y r N :WC0182015.00MA .09101 015 09101/2016 PROPRIETORIPARTNERIEXECUTIVE i STA ACC1pENT 1.000,000 .ANY EREXCLUDEt]� N . N I A I Ff L EACH { 5 OFFICER/MEMS (Mandatory In NH) NIC DEDUCTIBLE: $500,000 E.L DISEASE - EA EMPLOYEE: S _................ 0000. 0000... ._ .. 1,000,000 N es. descnCe under DESCRIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT I S 1,000,000 i I I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD. 101, Additional Remarks Schedule, may be attached It more space Is required) Evidence of insurance. CL"R1"IKIf`A't-F Hall r]FR CANCFI t ATInW SolarCity Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Clearview Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo, CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo-�! ©1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD A •C 1 O ■� � � m to a �OtO v m pj X W Q(/7 z?- <it w Q CD O o w J U O U U W Q J W L = Z o Q Z U W (n J� C..± J O o H F- " Q N o = W Fw Q 0 m _ a- u (n(n=)H m ¢ a N Z * O t � N M --t Lo - > � a > t LL LL LL O_ LL LLJ OwC * Q r N F- > v C.D �F i C W W 4 LTJ > w f p 2 N H W Of V) I--1 (-D N O W z Lri C) O Z Z O H U0O ,_, o Cn � S LLJ C/) O p ~ Wz ��¢ N W 7 CD LLJ ~�� Z Z m m ZO W� LIQ O Q = zo =� J �o NLLJ � Q c� =o 0 3Z ZNZ O z_ 0 O _w F- W = � < . 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