Loading...
HomeMy WebLinkAboutMiscellaneous - 374 SHARPNERS POND ROAD 4/30/2018 (2)N O O c0 O W b 'P 0 P-10 61 m W 0 a Z 0 z LL 0 z 0 m W IL IC J 0 Commonwealth of Massachusetts ' YDepartment of Fire Services as BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 Occupancy and Fee Checked Lev. 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 ININK OR TYPE ALL INFORMATION) Date: ) / — / dam'— ,-., City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her Location (Street & Number) 3—)f' Owner or Tenant _ To the Inspector of Wires: to perform the electrical work described below. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El 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 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 ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecN . o Devi es 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 E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated "Value of lectr' al Work: r (When required by municipal policy.) Work to Start: r Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O G : Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such co v age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM N E: 71tycrlgle, LIC. NO.:, /,S�f ` D _ Licensee: Signature LTC. NO.: d (If applicable, enter " empt 'in the licens number line) Bus. Tel. No.: 6Yii— —o iT Address: -0 Alt. Tel. No. "a *Per M.G.L c. 147, s. 57-61, securi 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's agent. Owner/Agent ,PEtiMIT.FEE. $ Signature Telephone No. v ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § + 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 r 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 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed EN Re- Inspection Required ($.) ❑ Inspectors Comments: aa ir/C)W/Al� on Inspectors Signature: Date: FINAL INS CTION: Pass IN S/ Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature:Date: on x . DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com S The Commonwealth of Massa chusetts Department of IndustrialAceidents t i X Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address:�6eR 6� City/State/Zip: Are you an employer? Check the appropriate box: C_ Phone #: o?d) - 5 -?6- a /Q 1.[] 1 a employer with employees (full and/or part-time).* 2. [ff 1 QL1 a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ 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): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submif 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, ley 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 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer "der the pains andpenalties ofperjury that the information provided abovgrs'true and correct. Phone #: c26%— 576— 0 / 5�L 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 #: r 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 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 Depaftment of Industrial Accidents fof 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' compensatiori'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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia L.1 W- j _" 1 1 GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: GENERATOR kw_ q/ NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: CTRICAL RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: �X/s7`/% v/rP *ZONING DISTRICT: yza_ "'PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL f '11 k t w _ ay' w v. NOW V AN { "Co-.Vg,� ��,!!,`, iS55 '�`•F7 _ aPPr 'Wt�k�,• "C �.� ✓� �'�, �i � l '�� -� Ay t,,,'ry ,.+�1 �" � :� -... r* �� a :��•v - x;';'� ���SA' �,�!"�.. ��Y. , S 1 r �i yr %�I lT d r' P a 4P 14 - t.17 All • Rte;. i FAL AREA OF ENCROACHMENT HIN 75 FOOT VERNAL POOL -FER ZONE IS 64 S.F.f MAP 90B PARCEL 52 tRIAN FITZGERALD iARPNERS POND ROAD VP2 VPP33 VERNAL POOL PROP. STAKED SILTATION FENCING L OF PAVEMENT TO BE REMOVED AREA). EX. PAVEMENT AND SUBSOIL -MOVED TO A DEPTH OF 6" BELOW )€-_":-_6"--0P- LOAM -'1S` THEN -70 -BE AND A WILDFLOWER MIX IS TO TED. CSE SEPTIC TANK I 10 FOOT. HORIZONTAL DED BETWEEN THE -PTIC TANK. AKE CARE TOANSURE ON VEHICLES .TRAVEL "/ -r....— –– - WETLAND AND VERNAL POOL DELINEATION PERFORMED BY ARROW ENVIRONMENTAL ON MAY 19, 2010 + MARCH 30, 2011 TAX MAP 90B PARCEL 51 ROBERT MULCAHY 350 SHARPNERS POND ROAD 1 ?UFFER ZONE TAX MAP 9013 PARCEL 46 BASIL COUGHLIN, III Nwo 2211 SALEM STREET 24"T 136 ti m d ZONE 'ONE I sot�ce ® MAPFRE The Commerce Insurance Companyw Citation Insurance Companyw 11 Gore Road, Webster, Massachusetts 01570 Commerce INSURANCE" 508.949.15001 www.commerceinsurance.com April 29, 2015 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall N ANDOVER MA 01845 RE: Our Insured: Property Address: Policyk Date of Loss: Filek JAMES FARO / MARIE FARO 374 SHARPNESS POND RD XP5968 03/02/2015 KCJP88-HTVWP3 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. OLGA ROMEO Telephone: (508)949-1500 Ext: 11482 CLAIM SPECIALIST, CASUALTY Toll Free: 1-800-221-1605, Ext: 11482 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. April 29, 2015 ice/snow damage CIC 254 (Rev. 4/95) MAIL I70 I., + Date.....2......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that / .... � t� N �CMILO�vv� .......... ....... . .... ................................................................... has permission to perform ........S�'(C,^ ()A,�, . ......)................... T ................ . ....... wiring in the building of... —T�- D ............................................................................................................ ....... j GLth Andover, Mass. Fee. Vr:�O� ....... Lic. No. all.A0 ..... ...... b fi'* LE*' C* T, R** 'I C"A*L' INSPECTOR Check I elmmomvea(Ilt. o/ Va.MaclIaJetb 2aparimenl o/ Jwe Service. BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I71fT 41 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: L1 ta,q t t 4 City or Town of. 00" ABX 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) 4c 3'l`l 5hk 12r1Pn ?pro f . Owner or Tenant (_ia ql'f� , Telephone No. Owner's Address Is this permit in conjunction with a building/ permit? Yes No ❑ (Check Appropriate Box) Purpose of Building _ ScSio�,r / pV Utility Authorization No. h �� 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: �N �(�,,� �d (��►�%e��icxi }�q�r AVj� �, �> C. �1=W�iAi •s k1*1- ©C, fit �.T. C... =rd - Tr e-& Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ccil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool gAbove ❑ n- El rnd. rnd. o Emergency Lighting Batten, 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Sel - outained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Connonneecctiotio n ElOther No. of Dryers Heating Appliances g pp KW Security stems: No. of Systems:* or Eq uivalent No. of WaterK,,i, leo. of No. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications 'firing: No. of Devices or Equivalent OTI-IER: Attach additional detail ifdesired, or as required by the Inspector t�f Ifires. Estimated Value of Electrical Work: ►3600 (When required by nawicipal policy.) Work to Start: A, g„ 4,, 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 ❑ OTHER ❑ (Specify:) 7 certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: - Ic-r-c'J.t Como rdk �- LIC. NO.: 11 3,(.,o KF, Licensee:bC "T' j,/{rk u,� Signature j/ xP LIC. NO.: (If applicable, enter "exempt " in the license number line.) 13va a Bus. Tel. No.' Qom~ +its' - d s$$ Address: AIA S4-. %A.o.w�-C" D^,. Alt. Tel. No.: MR SS�aS *Per M.G.L. c. 147, s. 57-61, security work requires DepartmenYof 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's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ V b f ZR10- I J �I fnaTt �14 _ COMMONWEALTH OF MASSACHUSETTS • • ••• • BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED MASTER ELECTRICIAN SOLARCITY CORPORATION MATTHEW T MARKHAM 24'SAINT MARTIN OR BLDG 2 UNIT 11 MARLBOROUGH MA 01752-3o6o The Con►nionivealth of Massachusetts Department of Industrial Accidents Z Office of L►vestigations I Congress Street, Suite 100 Boston, MA 02114-2017 www. nmss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): SOlarCity Corporation Address: 3055 Clearview Way City/State/7,in: San Mateo /CA/94402 Phone #: 650-963-5100 Are you an employer? Check the appropriate box: 1. ❑Q I am a employer with 3000 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. employees and have workers' [No workers' comp. insurance comp. insurance.+ 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all 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' come. insurance required./ Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑■, Other Solar I PV 1 *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. lConlractors 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 ane an employer float 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. #: WA766DO66265023 Expiration Date: Job Site Address: All Locations City/State/Zip: 09/01/2014 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 Irerebf certify under the pains rued penalties Pf rjyiy that t!X information provided above is true and correct. 9782152359 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 ACOR,1 0 ` (:> CERTIFICATE OF LIABILITY INSURANCE DATE (MMfDDtYYYY) 06/21/2013 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(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 Quinlan Arthur J. Gallagher b Co. Insurance Brokers of California, Inc., License #0726293 PHONE J - FAX No.EXl):415-536-4020 _ IIMP, NO;_ 1255 Batter Street #450 Y E-MAIL brendan inlan@a' com ADDRESS_ 9u, J4- San Francisco, CA 94111 _ __ �NSURERIS) AFFORDING COVERAGE _ NAIC It 09/01/1 INSURERA: LIBERTY MOT FIRE INS CO 23035 INSURED INSURER B: LIBERTY INS CORP 42404 SolarCity Corporation INSURER C INSURER D: 3055 Clearview Way INSURER E : _ San Mateo , CA 94402 INSURER F: COVERAGES CERTIFICATE NUMBER: 35272277 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 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. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDD(YYYY LIMITS A GENERAL LIABILITY TB2661066265053 09/01/1 09/01/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAI. LIABILITY DAMAAiE TO RENTED 100,000 _PREMISES (Ea occurrenco 111 10,000 CLAIMS -MADE OCCUR MED EXP (Any one Ton) $ X Deductible: $25,000 , PERSONAL 6 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGG $2,000,000 X POLICY PRO- __ LOC $ -- A AUTOMOBILE LIABILITY AS266106628504 COMBINED SINGLE LIMIT _(Ea accident) 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAS OCCUR EACH OCCURRENCE_ $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION WC7661066265033 (WI Retro) 09/01/109/01/14 XOOTH- I ER AND EMPLOYERS' LIABILITY YIN E.L. EACH ACCIDENT $ 1,000,000 B ANY PROPRIETORIPARTNER/EXECUTIVE WA766DO66265023 (Ded) 09/01/1 09/01/14 OFFICERIMEMBER EXCLUDED? � NIA '— — E.L. DISEASE - EA EMPLOYEE $ 11000,000 (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Proof Of Insurance. CERTIFICATE HOLDER CANCFLLATInN ACORD 25 (2010105) satyasan 35272277 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE AA ��fLn.z— �,y✓�. ACORD 25 (2010105) satyasan 35272277 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD vc���azaoc�c� _r��y--Sc�c�c�m^mpc�ooDD mcg z �i 2 X Of -<--aNC�<OrC�-�mZ p*<� 0 ozmDKm Odor-o �-0 N'U C'� S NC�z� D G)O0rr-I"n ZO m Z ri Z «G C N N N O Z Z Z r T T N C) C) 2 G� O G� m m m p C7 m D D omgg��� p maOOOZ-<��0=0;UmOmmZCFF=CCOMMDrr-XrJ35OCrK z G7 ��rrrZ�aaSp2O ��� a0O0���00rnV) CmmF-im ;�Qv,n'��I p a�DD�r-i* D0Zp0_4mm-�� Cpm<�mmOccD�� �c�np m inmo^' > j c M mm ;D r- 1-1 �CO m 0-zi�mo2PJ0 :z r�Ti�Dm Q n-, pqQ--z p a z - C o N m r �_ m N a :O m z m a z C Zilrn�m o id^'� z D _0 � N D z r D z K C O m O r M p -+a= TT7 m m z d r H z m Ln n m frT'I m� K D f l m �p Z Ci r �SeA m n X r m m y r n C� C /rn ^'yon 4�ag N n z •• = Z m r O D m C X D r z \ z r �� r O x�+Z4 ��� a =o rn - O o n z r o Z o n z z D �NRsp K C)OO z nm O n Zm rN*, m G7 M. co N �Cn ,^ C� O �� n n Cl) N � N V, N � Z Z Z Z AW§oN=.-.� n� 0 m rn O O G) O O = s � � z c_- = c X 3 c CD N � N O O z C) z N a M X C-) 0 00 m r L m N Wo CD n CDCD rQ CD � O v O O n a K-ALn0-P.0 WNC r mcn coG7W m a-,Ic mpci mm no �(7r W -omK) >K I I DS• TI' M r CDS' MO' aar-* rm, N zc' O Oa'=(--* a m c N Nr m O I OD OZ xz I onF K K: CO Dr r.,cna cI N DN z n v� amm -qN N-n O o ro mM mg M=o W � S�rmr-•mOSm2 W =m OMnmOZDrI? CC)�� �z8DaMy� m= rn C r�rprNON mO�pm OOG7�rn g nn OZzmC-) Dm C NZmD D N C• = C• m0C7--I Cm�Dpm=�r-<X r— m mom O �--Im ��0N rn m nD�r mor �M� -N1a�D cun9NZ�Dz�mmD rn O U) a� omr p =oma D� mN� OmC� OmDD�nOD r 58m c �m z c c� z ���mr a w n Z� I K n O m g D N O D � N m =;p -I - m r r� O-I M Z MM Zmr-�CO M C)(A rn n z��m C)�cmi� ��czn mZNN-�r�-090(n��� O C)>m `LFm � X z" r- 0 N N' Nim O—� H �n0—p +1N 2 0 --ix rON �ODm Nzmio 0 C-) Co�omZ m-ijuz0 �z=�p Gz) mmc)> rSy Omx �K_� <OaOa�n�l O> l`! Nn�nm �W?Z r �mnOr NOrnr- °D-oDDMmNOWrZ�gZ >-N > >z ODpo N-lom Z O nl�zZ 11 1 Opm O�� m�p0 C) OmN�O ZO r 0r-- D �C-M:z; O a MC7Op N- N-O ca � C Na 0 o W C7 zm M fg I�T7 mfTllTip �DOO 020 cai>Uo ��O W z �m�m� O0M O z0 -INM N zzN cmc w mD�vp Z� OO -nZp 1 � m = D M a M, C-) Z 0 p= m C-) � z = Z C) -d =-0 n z� m m D C O S O O C N -< M r M m� z puD o= o cn o0 N� oD OM r com oc v Z7-P�iR z �0 acro co z ; z=1 O o m m Lo- rn o�rn � v CD oma i C � =(n D> �Z — 0 0 • f"'i 00, O i z z O I < � j -Tl rn Mrn M M M 3 � D Z .< m i • < `D N Co « « > ca W N * Z s \!-I m < •�•S�NO m << Cn a x o N m (-- m �I N D rt+mnmZ7 m o zmz= m mr- m O- -I 3 3n r<-H / m X� Z Z + z rn u"gam 0 ;4 a 0 V � ANN a � w �■ � y a� v V) LLJ ir -4N M N N J J Q j N 2 2> S 2 J (n W LL)m J J p V ^� m o ¢ ¢ N w � a y %i F- O M O J U J J X LLLJ Q w W >_N[n rN(/) C) O Z_ Z_ m Q J W S'S. Q Q � ��N-n QQ QQ Z � Z Z J C� OO p t�0 O o30^ Z - (/) c a l Q of 0 ¢ ¢ Q w -d Z z Q w 0) Q w N Z Q 3 Z J Q Z x Z ~ Ln I CT D1 C 7 N m w W- Z in � LLJ Cn � Z m � a '� > cn Q OO Z a A•• N ~ (D afJ U U U U 7 E m E W w 3c� Z Z zo o �' � L U 0 00 MN U wz O O L ? W ��Wcr- S' J ±=-j H (n Cn Z m U Q p 2 2\ _O S�Q SH Q O I..V ~ CrQ D D O U Z D O W N L� ~mw~mow �� U U U Q m QZZ�Q F -'I W 3 P4_ F_ aNH O Z� m Q O D w c- OU0CQ�2 Z L �n Q Q r Q � Q molimmolomool'i I p o N V) > �a- � N zTs o a� z 0 8Y>'e * c C 0 Vol z 7, N rn�� 0 0 o w U 0 Z � W Q Q W Q OY LLJ ° Q LO l I� (n 8 e e le -e-- CL TdW o� r--- 00 O Q O crW Lr) W> O ---- V)LjjZ O � �crZ CI Q Q Q O m ck� Q 0- Q O � cn �L�r7Z co > a� o Q - w7a N m O O i 0 m i 0 _Q_ N Z:) 2 00 o 0 U U7 O O �, " C) O �/yyI� LU +. Z J Lu �7 C' Q O LL Hg >_w a F E 'Jp g Z O =jC) O sU v�N _z 2 i7� 6.OV W T�z _�-dF25�a­�?u- _C5 >-m Cz' oS y K - V W H i U.zzaW UKF_ O � � 44fi mzm 4��Z� �ryAbxryW � cnZI� Z �� S C o o_ _ _ ^ O I o �� `� v 3 D z c� ° ao aD • N Q � n D � O On On rn I I Co H x m N I m O o O o 'T1 S -n a m � � A A LA cn n n r N ? xx m z = ' z (�/1 O m o o n a ujw� -ZI m rn In G vLn N OD C7) Z C A -1 N p �I D - _ it Z7 -P O o C C� _ �' tn Z � o�rn C) p m Cn cr rn�* ��. D p Z p� p _0 V W r+ lQ CJl ® IV ^ Cn v' ;p �. �► JI N \ P,4 \_ O g i =� f^� I .mi M N m rD A • \ m Tt "� ` Nmo c� M o -a m mO D— o z Cn $ ,j -Tl W < Z °°OD D D �� < =o � czi ;;;z c m o ��� C) m n 0 �� N0 m c rn rn y <o r D rn < Z m O rn r C) O m ^ cn V 1 � �..1 0 M ^ 1 mvv� V7 W v D z N o c m @O N rn c� o R z CD N UJ = O II 0 CA � C fD r m � to 0 � a N o Z rr LwnM,)D>>,- OO r m Or � N C r O -i �m rr D m� zD r m z m m r0 =D m D gSern rt %,.y r C-)D>D-i OZf�* ;s DZ �O D m2 rmO cn O D W O Cn O o z R5 O mO TO Z mm -D 0 nNi°oN°�j NO m 00 o' --- r rNa N n 2 ITI 2 ` .'c. ■ Q N V Y • � � v 3 X X m � � x � o � X � N Z �oD � T ►nr � � ci Z T� m� '(on (�1 n fn N l0 t� D Z p � O rn p vmi N 11LJ JC:JU Z O (a CJ m m s � O• 3 I I I I I I EN � ��p Q ^p ■� V 7 ��, �� ^ W ^ ��•I I a a f �.,J, II II II II O. O. IQi Lf) Z LO 00 M c I p I N � 5 r<vrn W o I I d3m"� J Zw pa Z ��; u Uv ;; M W Z d O v; J �wv 0o : O1c2 �� vF w X II II U1 21°a c I I '► `O LLJ 1 I I I I Wa o �» :� a : » i / v CL Iw.l I I I I I o o wi o o w� « CL xoc v comZ m 2d Z F58 w w Y I I U' z� al Q3Q a �Y a a p m 0 N d Z LO'. z�SO.N� OC SW y�rnmE m M L 2 .W d r m N m I I V Nix iII4 c_ v v Lil o I I N 1 m W� x z° W a WO `IL `g `$ F Q + c Z c ie : w u E o I I ^ x W13- Lf) LD z 1 1 } I v l< v40ft 2 Y W x 1 I 40ft c J p a I I I I > Q Q O:O 00 U 0 i Z — 3 N L L, N I I I I I I r7 0 u O �N Z I I Y QQ :QQ I E � I I 1 m 0 �0 � � -O LO NN = 1 c a II n u ci W �5 I I ua:uG E E *ko Q n I I -a ^ M Z I I I I 80 :00 C) LO v Q I I 1f)M II II II II : O > y I I U � Q v Q I w. W W. I � (nom Z J U tSS 0 a o o w1 m w �*,mz < = I N N N:N Cr N: Q Y Lu W I iiiii�c a �� z o UJ j >� I L I� a cu Q Q z 5n��► Sid�i. i5Qk 55Wh S5;�u 5"k 3Q 3Q 3Q : 3Q i? 3Q Q._ > JO OO r (n o C V)o I--1 W a L' I � Q w N I 5Oft v5Oft (n J� =D 3 7 z LIW V 8:: U.1I ml\ WIC 1 LO U u Ia >�� . ^ - I Q V 00 z o a oCD C) C4 1 z Q LLLJ1 N I OL LLJO 1 .. C � W C3ui .. 1 n LCA CD c . I p �' •iF � Wzc fl � Q Q Q > (' o 6v) F N M .-I 1 ti U. z z Iz- 1 �• W r7 zo cfl mrd a CZ Z w. O lQ � �S W 0° j I a N N N N. Z c �d"'QTZd •"C �' J o I Q I _ O I c �� O ~_m° 0 3393' Z JU W > Lin ... � o 10ft I I 1 U O O O W (n w o Q c 00 m U x p N I s y wI N Ln x ri m I ry I O O J .cam. V I U = w 1 O a> C14 C) Q (D 52-ca Z a`) a`) i ----- -- r----t---------�II W N =#ZM I-+ a �� > > 11 I I IwI ,ECJ C 0 J Z W ZZ -1I D W v y t c .r a� Ic�l wl a m z W O m a i Q 5 <if Q a O w N I Y 1 1 a -- O ONJ -� `� ?i z = O �V �-. '� p ��zN J 1 O o� z w w LO 1f13N a n d =D U J m PO Q H d W a d Z U Z ZS1ZZ- L7 m ZN W V ~cr rmj° "&. W _ (n u III 3"w V N Z 41 M. 4JZ Q Na mc lcr X N 2 8 aOFW Z� 5EI+AUW� V)ZW9W CL FLJ S < = Z C:i N Q I.) O 1- G� V w s 0 H QN �' U I LLim W owMHoZ_is#� Z u LLI� ��� p aQ W LIaC w�� Z-WdFn- oma wZZwo ��L.9 OOW NNv �6S X ^mf �OmHw�a.N (7Q W oa .N.. Q~Om La —CL W QF Z WK OQW O to oN= 0m�� -<oc m0 0 Wa L w O c w N O Cl) '0 U) -CDPD 3�w�n-I rt 7 2' (D -0 (D E:w w O 6 CD m p� 3mo-CD o(0m3(n amu, ^om-;: o" - —I:°_3 C, - w , m m N CD -•ca O " w y :3 (D � ° N n g Z =M ma �'3 w CD a = o E.� Q�nc3 °�'�o Qom�Q��CD o m a 3 3 w w 0 (D u, 'a r.3.�w 3cZCCDr-. 000-00 ,. m g cD 3 3 < Q' Q 7 0 w (D 70' 00 N. CD C w „F Q (o — r« (C) -0 7< O C rt O 0. =r CD a (nO Q (n � D jm.�v3cnn- �o�.w O O n C CD 3 Q w w O O� �O Q n _ N' °3_3_Q°' -�_q JD c p 3° uOjco 0 0 0 (D (D (D w ti O �• Q Q _► F O O 7 ° c(D O' :3 w � ° CD 0 Q� QM � I 1 Q Q @ nag 0 O — "Icc) 0 00 (D n C v�0 � C) CD - 0 0 M (o m � co O a ° v c° °3 w �m _ w» • mC S 3 CD rn p} O. w (n O m a s -o o CC O T S C C D Cl. OOo (� O C xx Oa C mQa Om 0 O n 0 T ° ° Z ° w f° ( a w C w 3 m rt '. o N iD o ° 3 ni a a : a r =, -° T w CD m rt < N 0 ° N c n' r O rva vO _ a o a v ((D 3 ° V1 � = m a mw =o wo cow 5 (o 0 C m (nCD u, m a a Ma � a m ND � :3 o m m r- N O (fl O. a to C)C) ° C 2) CD 0 0 o c ms (gy m m C0 c c 1 ° a Imo' 0 w SC F 3 Q 7 CD O y cn w w 0 0 (fin V r 3 w C N cwn V C. C) r a � I 1 I f @ nag 0 O — "Icc) 0 00 O O A 0 0 O — "Icc) 0 00 (D n C v�0 � C) CD - — o a v � O CD (a � co O m O C—) O O d S 3 cn O p} O. (n O w C (D (D N (D (D O T S C C C �, (� O — 0 O n 0 3 Z O Z m 0 U) O - N CD (@D 7 (O N C n 0 CD 7 AOl 7 '0 p' a v ((D 3 0 C GW O IV W ND � \l I LOY n O 3 Liu n O 3 00 N. L cc co L V fr t C i O O L z i O lJ_ O C 0 C Q W w O � CA O O .:Zr 0 - co M O.. O 0 M CL m c v m t m F a o v a a � r j v o m c > .. N � m v a a � v. a y . 9 E V y E c o a V O "' > W N m a O' ta E V W epi N: .y E ±+ x V m - _ O O �0 LLI'• m > o ° - " v E .O > I !� o, y e m _ c N w� t7 3 O CL N � C m ° .� � 'x �.. x o a • a 7 N u i Z 2 .o.< o �t 0: O:. => S. N N L 9 Q Z W N, N Vp .N o p �!o'. m': oa00= Z �:� oa •� YI �:m vo,E �. m :o. �U. CL- a: o O o - ai Q > O LLi a. y Nl 3 z � OCD a r °i ui m Z p — 'C M Q W a- W Cc "Q O �: 3 W o' NSM d` •O' W v �_ Q N O F op co o. v W. Z,l Z LL E / 2 C m J U : - (i O0 T ° Z u E 4 W ° - c o =' L n---.-6 0, o E'er u a c V O o 3 v °in °c E� E o Lo: ° E E rco£ j r Q v' a E E. E v 7 -. Qu o °� JI F Q E s? n n; F % W C > r o f E' E m Z..j E:x 7 v f :r w a :�.9 o:0 2•.� >a Z O > o;n m p:3:n 0 p.O a N L cc co L V fr t C i O O L z i O lJ_ O C 0 C Q W w O � CA O O .:Zr 0 - co M O.. O 0 M CL m c v m t m F a o v a a � r j v o m c > .. N � m v a a � v. a y c o f z y E c o a V O "' > Z m a o "; o o ta E V Y .y E ±+ x C E ao v 3 O � E m m m > o ° - " v E .O > E u > F D N y e m _ c N w� t7 3 O CL N � C m ° .� � 'x �.. x o a • a 7 N u i Z 2 a Z 3 v v - � 39 ^ 3 0 Z. 0 a c o��g� 0o o jfilm oc z o D a p N • N N O lip v3 3 m 5 - O I ® � S D m (p r•..�D1 (D!1 i n3 �. a ` 3 a m Oy J A 0 m'�i� + wE (D uCi N rt m ® I *JID ° N N m J o (D 00 m O ■ _ o -o T u, N (D T O ID (( 4 F, ° N O, m O m O N j y v f" m m O� n• 3 (� r-0 c m 0 n 77, :' ('p O N N 7 d Z 3 v ' �O D O (D O 6 — O a? = O N m (<D m v m 0° (o' T (D N(Q O Oi tip a;•'m 0 a o (D 0 v(D (D o n Q � n "< (D 3. 0 3 ' 3 0 3 O O 0 m N z Z9 (n@ o m (D a_ 3 N n I'0 U m m C) o0 N = 0 0 O �(D I I ^ (� O_ y s°u^i DC A 2 La' — a 0 (o 11 =I" w m O F y c'N Oh 04 a c r -3 .' Vi ' o N rtw 0- - o 0 0) a o° C) F o � O O {.,y o n " c u' (D m N N m (fl u F ID< N 00 v n (D v N p v m O m m - 00 0 a m t• O n O << (D O N $'AuO F41' o d Q Q C p O CO u' O O 3 v v - � 39 ^ 3 0 Z. 0 a c o��g� 0o o jfilm oc z o D a p N • N N O lip v3 3 m 5 - O I ® � � j• J N Z 1.81 (46) O J A 0 m'�i� + wE (D uCi N rt G) —5. J ' v 0 m J r 00 I c N N _— ` O 3 � o a f" m m O� n• 3 (� r-0 m n 77, :' m N' M 00 to N (A%< 3 v ' �O D O (D O 6 — O fD (p •y+. w J aC, d m N o� y C 3 ti m m y n N o Z j IW 3 O O 0 m N z Z9 (n@ o m w 0, D DIo I'0 U (D m rcf• r i O d N /A 1.81 (46) J� S J A 0 m'�i� , i O (D uCi N rt p m (WD N +S < "'' (D N ' v 0 �; N 0 0 (� r O N 3 c N N N n" N �< �\ z n !n ((Dj W< tn' (p \ Q O 3 (� r-0 m n 77, :' m N' \ 0 d 3 o(D, 3 v n v m O (D O 6 H Z "cgyN (D (p •y+. w J aC, v3 I O y o� p -� jD � N i a p y- j O 3 O O 0 m N I ' I P O jo (n@ T� to � ut I Q ca c = 0, D DIo E C (D • rcf• N I 0D � _ = w I I ^ (� O_ y La' cu cr c ID j S.ZF rCj O v @ 04 a c O 3 rtw 0- N fl - w 3 ma 'c j (o On 3 3 N O S (p d (fl u 3 3 I (Q h(D c O a v 0 D W° 3 O ID 3 O N0 N m I I O << • NN (D n p 3> > (D Q O_ n v v N � S O (D Qc 3 Q I 7 m • ` 1 I r �IIIJJJ ro m !� m 0, cr cr tr cr cr --I S V� ID O d C J d C /A 1.81 (46) J� S J A 0 m'�i� , i O Id , m w S J' xCD H n O 9 1 V 0 ^ m!'.I'4 C J W d C 33 0 3" �\ z n 4 0 c S N m 9 C i �. 01 A N N a J oID \ 0 d V s �v la'd m � 2 to a m 3 o 0 m S 6 J N H Z Z (D p l p, J •y+. w J aC, v I O y o� a -� K, d i m C0 D � I I D (V c O 0 m N I ' I P O jo O T� to � ut I Q ca c = o D DIo r A n 3 Q N I � _ = w I I ^ (� O_ y y 0 c ID � o m a 3 No F ?. ',. 3 o n D 3! 0 cJ 3 ? 3 m l 3 �. m �' � a c m m �' 3 3. 3 N w N .•mo N co ° N w 3 ma f I A i 3 a l d 13 s 0 I N O N 3 3 I c I I fT I O 0• W a v 0 D W° 3 O ID 3 O m I I I m I I I I 3 k 3 k 0 1 3 Q 1.81 (46) 9 m l f 9 Id , m o J ^ o « m a l o: 0 am 0. v m m 3 �\ z n m I(Gm s C J Y! ,d a J oID a X 1 9 e z f i to o N A m C^) Y! m Z 0 I : 0- v I O o_ y a I d i Z I I � � I I D I N 3 NNp O 0 m N I ' I P O jo O T� to � ut I Q �3w o D DIo A n N I n I ^ 2.17 (55) 3 3 3 m 3 o 1.81 (46) 9 9 9 9 3 ID 5 m 4 m l o: 0 am = \ O m m 0 �\ z n � s 0 � a J oID X 1 9 e z f i r N A m C^) Y! m AA f ° 2.17 (55) 3 3 3 m 3 o 9 9 9 9 3 m l o: 0 am m o m m 3 "9.a m s N c � X 1 9 e z f i r N A m C^) Y! = AA f ° : 0- 3 = o_ y a � d � ` D 4 A n n n ^ N Q a c m m �' 3 3. N N w N .•mo N m 64.96 (1650) P C s 3 3 n Iz c le o 1310.9 3 O nZ 'a d la If f 'a to o im !� �1= ^ Ao ori J _ w3 D 9 3 3!D 27 (0 •O 41 .O '. O S z 0 , O ?O T' O V •Ap O V( i N D N Z' P fN! P N o N P b W W I} O I IW N } I I iP :mW IDD N � IN cr I f P I < IOD W I j N �N V V d A I N AA ' I N IS ul N ". � FI o F m! 3 A a '°• I 3 s310 l o: 0 am A D o m m 3 a; °a N c � X 1 9 e z f i r N A m C^) Y! = AA f 0 ala 2 o_ y a m a m A P V Q a c m m �' 3 3. N N w N .•mo N 5' 3 3 I I 3 ul N a% Q O N cC O O O `��erte� • -. m : E:�; m: m NAG ; to LU o cn =Cc ob c a =i U �L OO ■� CA a) O O 00 0 W W Q M LU LU N N v N W L.. a i' ca r-. r O OO o O03 - O co r - WW A cn C/5 c Y co a v V iWI c O x . m' oD N . V: 100, O V V I N V E: \ O v:: •; N T rA Q of O @1.:@J C O cn W Y A Ii rI : OO: :1: 3, r+ m N O I 1 ISI @J O o N 0 @Jl : N; �: 00 .��'. : M O. M : N �. Vf E. E 7 N C I�O m 0 : O V Q :Cw O. Vl: d•V. � i Imo. I .. G� Z G Cl w n o c O � J o L W O c W a > Y F p: to O OV N : Vi 00 O p O L O 3 C : w cc O O N p In W Q -o -- -- �. -0: Q -0—r. r�l a 'a d Off.___—.�-- O N s ". c' o ". o, v. y. M: .w. [N �: U, �' o'Z:LO u N o W W ,7 Qp'i O O o::... : S., N : v o 'rin;>: } I oo .y '+ :3:oo. m: m i m� m L •I d'.w. n.l W L' : V m' _n ..:r: '. U X x; o (/J N 100. I 1 _ f` : O: :O: LLI N: 00 : m in O : lOD _:Nr��. L J� 'IOD: N� 3 C Qry N: �. N d c CL E :1mW c O LL a r -o o NI z! la D .� I� .N vi.v�i: a� O OO N 7 >» > >: >: C: N:> >: �:N a, gyp: co V .N m nN� N tD 1 \ a" o I� o. I, �: o0 m �: .o. �/• O O O V:O N. Nw rN: v ,VViI !D�. O c DD O_ . O N W W in O N O O: O O: p N.O O. N M: r1 N: 01 N'. O: E. N U: v Z . W N N• ID O: �' I E �' E" O :Z. o' N; ap m 17' N: E Qg O Q N rl W v ' j I M: N X: N: E : - �. o cD O' oo ry N. �. « - x W W W Lam- m x x:,ti: r C m E _ Q O oo ` m m % t O t`0 : C : . { A N • c_ j e N G v u: O C W I :'fin N o. V Q vl a) y3j V Q; o N T E O °�' 3 E E ca : -�": DD 7 O c m Id C- :U: o. c; v' d: E WI O 21 DCS m Q -�. tL1 �.0 :u � V O .F v>- _ c ' ? o o u Z '. Z u O. O -Z o T � ;N w— W 1 - N UO: m c mE. n_ . n I a:�,� : C c O n 'Z —vmr — I��: a:'—. 0,a+: v. a'm:«. w uaij �: ti• O' p Z �:= '«_ u; d .•p: „oE - O j V. V' O y R. N ta' C C C < '^. �'>. ,.. 0 !.':=: a): a)I :O: J E' V•, a. OI C-� :; X" .o. O al �R�wd IM O>: t«�a>"�_ 7 : 3 7 "O SV :O: N•p: 3: 7 ,:>. n; U L >- N N: O: �:C L O• QIU 01u :C' r O al: 3.L JI J:N C:O=.'>i. N :u' O N N:o'TTL j N > N. C. C I"O . ''� c cv�i v w. �. _. � : E: � d' w: E: m v•2I-0W1 O Y Q. c: EI► --I ,pI co C J. �1._ O ti: m: c s: c. G W d t 2 ru V o d ..y I% 7 W'aC O O o �'G o'f�E o.. u; no-: o: c: O. c o v c. N:. C: � I� a�21 w: U: Q O;n F' c W m_• �: o.._ �: E ' v $, N; m. C a: of - .°1.tL 0* oEoa, CL v'� p�j. x�:>to.m-. 0: w L D :ooOl�,Fim NIN:V wZlQ.upQ".0v3i.3:u:ZP m. E m >I M0:o u: '�Zlz o �,r Z. �:g u ZiQjN o :0 ' a a% Q O N cC O O O `��erte� • -. m NAG ; to LU cn =Cc ob c a =i U �L OO ■� CA a) O O 00 0 W W Q M LU LU N N v N W L.. a i' ca O z O OO o O03 - O co r - WW A cn C/5 3 3 a a a J W a a Z_ S U to r v N a E c Y a v c O O V T rA " C O cn W Y A r+ m _ 0 Q C4 � C dLu Z >O O w Cl w n o c O � as o c W a > Y F to O OV N O p O L Q C : w cc O O N p In Oy y., 2co -o C Q am c v O d s > v o, > a O 3 c c c -0 i .2 w 3 o c v 2 `O 0° :° E r- E" o v W O C O > N Y �7 d c CL E :1mW c O LL a r 3 3 a a a J W a a Z_ S U 7 s ` ► Date . ,o .411 .......... TOWN OF NORTH ANDOVER i : + PERMIT FOR GAS INSTALLATION This certifies that . Z 11q ..... .. ` has permission for gas in stallation in the buildings of .... �l / 0 .Aqiro . . at ...?-�ryQ!/.'�l. �'a'?Cl.�. , North -Andover, Mass. Fee..y?� v Lic. No:304dG� / rhoirteA, .4-A... GASINSPECTOR Check # 1Z Z / MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: /aNr1oVg,.o2 , MA. Date: /0- b C - Z o ji Permit# Building Location:_ t' 2 Lhov ►-ya�" Owners Name: _ il/ dyt Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New:� Alteration: ❑ Renovation: 4 Replacement: ❑ Plans Submitted: Yes ❑ No OWNER'S INSURANCE WAIVER: 1 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 ❑ Signature of Owner or Owner's Agent Owner E] Agent By checking this box ❑; 1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Cod _ in Chapter 142 of the General Laws. By Type of License: ❑ Plumber Title ❑ Gas Fitter Si a of Licensed Plumber/Gas Fitter ❑ Master City/Town ❑Journeyman License Number: APPROVED (OFFICE USE ONLY) ❑ LP Installer 0 A,14/ 11;0-�4444111z-' FIXTURES co IX Lu w Z vi IX cd In m= 0 U W W L) !4 H x 0 x CO CO in w w W > z W ~ IX Q W w m 0 ~ 1- Q w z = CO a � 0 w 0 W 1- 0 w F. _ X Z V W Z 0 J u) H F- O Z --I 0 u- l' x f= W ❑ Iw- W t 0 Q 0 o❑ a O O W m> O z x x 0a. O u� H>>> x O IY SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 TH FLOOR 5 FLOOR 6 FLOOR 7FHFLOOR 8 FLOOR Installing Company Name: �Nf G (� Check One Only Certificate # Address:_ �.�'l (/Lf �� El Corporation City/Town:Dli✓G. State: 40- Business Tel: % � % yyZ - /f3 G Fax: ❑Partnership CT-Firm/Company Name of Licensed Plumber/Gas Fitter:Lj f jt1-6 c (A INSURANCE COVERAGE: I 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 indicate the type of coverage by checking the appropriate box below. A liability insurance policy R-�- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 ❑ Signature of Owner or Owner's Agent Owner E] Agent By checking this box ❑; 1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Cod _ in Chapter 142 of the General Laws. By Type of License: ❑ Plumber Title ❑ Gas Fitter Si a of Licensed Plumber/Gas Fitter ❑ Master City/Town ❑Journeyman License Number: APPROVED (OFFICE USE ONLY) ❑ LP Installer 0 A,14/ 11;0-�4444111z-' I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: r)'1/ /►�D,) V MA.- Date:_ 10 S 2/ / permit# Building Location: 3 7% ,5 a,,otvr p�,, o wners Name: Itm� Type of Occupancy: Commercial[] Educational ❑ Industrial ❑ Institutional ❑ Residential 4i�- New: ❑ Alteration: ❑ Renovation' Replacement ❑ Plans Submitted: Yes ❑ No . FIXTURES Date ...101-h/. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform plumbing in the buildings of at ....%S!,�'�q�y�,. 4o1J/ 4�/ North Andover, Mass. Fee. . •P Lic. No.,V Check # PLUMBING INSPECTOR /2z/ nave a current lia_ bility Insurance policy or ifs substantial equivalent which meets the requirements of MGL. Ch. 142 Ye No If you have checked Yes, please indicate the type of coverage b checking the ❑ g y g appropriate box below. A liability insurance policy. 1&� Other tvnn of in.lom.u.- n 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 applicatlon waives this requirement. Check One Only >i nature of Owner or Owner's A ent®'nep ❑ Agent E] I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true andx Knowledge and that alf plumbing work and installations performed under the permit issued forthis application will be in compliance with all Pertinent provision of a Massachusetts State Plumbing Code and Chapter 1 Gener ' accurate a the best o, my e" Type of License: f (umber tgnature of Licensed Plumber `y/Town ❑ Master 'PROVED (OFFICE USE ONLY) urneyman License Number: The Commonwealth ofMassachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, M,4 02111 yY www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers )Ulicant Infnrrn of in -n Name (Business/Organization4ndividual): Address: 16 City/State/Zip:_ ?EA,01NF 67 Phone #:-711- Contact :_71/• Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I 1017iployees (full and/or part-time).* have hired the sub -contractors 2• C, 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, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing .officers have exercised their 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. ❑ Demblition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Any applicant that checks box #1 must also fillout the section below showing their workers' compensation policy information. et 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 sheshowing the name of the sub -contractors and their workers' comp. policy information. -ram an employer that is providing workers' compensation insurance for my information. employees. Below is tlae policy and job site 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 uhder 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. ado hereby certify r the pains andpenalties ofperjury that the information provided above is true and correct. -90 // 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 6.Other Clerk 4. Electrical Inspector 5. Plumbing inspector 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 apartinents 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 shallnot 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 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 referencd number. In addition, an applicant that must submit multiple permit/liceuse 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 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: Due Collumonwealt'a of Massaenusetis Depaftent of Industrial Accidents Office of Inv. esfigations 600 Washington Street Boston; M- 02111 Tel. # 61.7-727-4900 ext 405 or 1.-877-MA.SSAFE Revised 5-26-05 Fax # 617-727"7749 ww I� I" 111 %01 i :Ups LL �PLUMPCKQ Amu wap'Wrl't a AN. AS A JOURNEYMAN. MBE J I I§SUES THE ABOVE LICENSE TO: ROBERTO CANNELLA ltr JELM ST in A "0' a as -4 - 4 .057,01,/12 02 . . . . . LICENSE NO. EXPIRATION DATE SERIAL NO. DEPARTMENT OF. Pit7iBLIGSAFETY 'Oil'Burner Technician Certificate Number:BU V9766' Expires 12/28/2009 Tr. no: 3054.0 Re 00 tp ROBE!RTO CANN,ELLA 16ELM ST READING, MA 01661 Commissioner —T V -T %0 V Year Month Day �:- COMMONWEALTH OF MASSAACHUSETF '° Rk SHE META 4.WOR KERS 'AS A MA STE R4JURESTRICTED ---'188UES THE AB.O.VK u $!�E T ;t4 ......... "M CrAu '4 � � REAI,I.Nf ;'�"�'k d..� MA . 018b 7 273+5 g " ` ," ... .. .... 12/28/12 . . . . . . . . . . LICENSE (�;:� EXPIRATION DATE SER 9'1 57 Date ../�/. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .A.k ..6;/1 In6?11eq, ................ has permission to perform ..��''--7�--(�� X -0 -Al ..................... plumbing in the /buildings of ................. at ... ,�orc North Andover, Mass. Fee. +�. T, 00 Lic. No PLUMBING INSPECTOR Check # — /ZZ1 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: J/, /4P'0i) V E I?-- MA. Date2-of: / o -- S - � permi.t# Building Location: 3 7 9 S�ja,, ✓ID^s p o---_ wners Name: _ �� /� . Type of Occupancy: Commercial[] Educational ❑ Industrial ❑ Institutional ❑ Residential' New: ❑ Alteration: ❑ Renovation: Replacement: ❑ Plans Submitted: Yes❑ No FIXTURES a DEDICATED z z SYSTEMS 5V w En w z cn VO j Z n W Z !- Y Q U F- W ° O W _z Fes- w _2 F¢- Q vwi = cr Z O m in w 0 } a Q Cn O v p-. N v¢i L=. w p O Q Q Z [C a N L7 -' X Q , F - Q s p= c] n w J _Z U x Q¢ w u ►- T a O ¢ m m o otg��u �O vi nw QS �1 I -SUB BSMT. �� 0 w Q3 BASEMENT 1sT FLOOR ND FLOOR 3RD FLOOR 4' FLOOR 5' FLOOR 6' FLOOR 7T" FLOOR 8T" FLOOR (;)5:' aiijr, � t ;,A�. iti8lii?: _TogyzrD V+NNI L L.Ei Address: f ( f �yf 1 A ST- City/Town:/ �- State: _ Business Tel:' 711 - 9 Cf L l �J 3C Fax: Name of Licensed Plumber: INSURANCE r'rnrGonr•�. N 0rl9 ❑ Corporation ❑ Partnership Firm/Company have a current liabi►hy Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 942 Ye No If you have checked Yes, please indicate the -type of coverage b checking the ❑ g y g appropriate box below. A liability insurance policy- Other type of indemnify ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does have the insurance coverage required by Chapter 942 0 Massachusetts General Laws, and that my signature on this permit application waives this requirement. p of the Check One Only >i nature of Owner or Owneres A ent Owner ❑ Agent ❑ ! hereby certify that all of the details and Information I have submitted (or entered) regarding th!s application are true and ac '� Knowledge and that a!1 p!!'r''Lii!lg work and installations performed under the permit issued for this application will he in compliance with all Pertinent prov!s!on of a Massachusetts State Plumbing Code and Cha ter 9 cz•ate to the best o, my A General ✓ G G Type of License: dumber ignature of Licensed Plumber `y/Town ❑ Master 2�,, 'PROVED (OFFICE USE ONLY) urneyman License Number: C ' D c 0654 Date .................................. li� -7 / / 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING Q. 4 � This certifies that ................................................ ...... has permission to perform . ......... iwiring in the building of ........./.. ......... o ..................................................... at.... .................... ... North Andover, Mass. North "I" " '4 y 7- -; 33 D 6 5y Fee..................... Lic. No. .......... .................... .. ... ........ Check # /ECrRIC L INSP CTOR/ V .I Commonwealth of Massachusetts Department of Fire Services 0 k BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. L 3 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 EC) 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: o /,-, el� � City or Town of: NORTH ANDOVER To the Insbec.t6r of Wires: By this application the undersigned gives notice of hips or her intention to perfmV the electric work described below. Location (Street & Owner or Tenant Owner's Address Telephone No. Is this permit in conjun n with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building i Ip t' Utility Authorization No. Existing Service Amps / Volts Overhead [A�Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and.Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires '(� No. of Ceil: Fans Susp. (Paddle) F No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators _ AISA No. of Luminaires Swimming Pool Above ❑ In- ❑ nd. grnd. o. ot Emergency Ligating Battery Units No. of Receptacle Outlets No. of Oil Burners FTRF ?.LA.RMS No. of Zones No. of Switches /\ No. of Gas Burners No..of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .Tons "- KW - _ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security of Devices 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: Attach additional detail if desired, oras required by the Inspector o. Wires. Estimated Value of lectrical Work: (When required by municipal policy.) Work to Start: Z041 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: 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 covers 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 pains and penalties of erjuat the information on this application is true and complete. FIRM NAME: LIC. NO.: U Licensee: ` Signature IC. NO.: E De)p (If applicable en "ex p zn the li erase numb 1 e.) Bus. Tel. No.:��7 t R V62— Address: 6 Z Address: v d x v� oXX v Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Depart=4 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's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. .� The Commonwealth o Massachusetts ._. f Department of Industrial Accidents E•:i, • Office of Investigations r 600 Washington Street ; � i1 Boston, AM 02111 www.nsass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractorsxleetricians/Plumbers At plicant Information Please Print Legibly Name (Business/Orpani7at;nn/r„f4;.,,A,,.,tl• Address: City W, 0 Phone �� Are yo::: employer? Check -the appropriate box: loyer with 4. ❑ I am a general contractor and I I . ❑�amay Type of project (required): (full and/or part-time),* have hired the sub -contractors 6. ❑ New construction 2. I .sole proprietor. or partner- listed on the attached sheet. � �• ❑ Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for me .in any capacity, (No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g (� Building addition required] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions myself. (No -workers' comp. c. 1.52, § 1(4),'and we have no 12,Q Roof repairs insurance required.] t employees, [No workers' 13'❑.Othe;r comp, insurance re required.] , ­.1 -FF• • ., n. U11"K3 ooz ff i must also tilt out the section below showing their workers' bompensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy inforsnadon. I am an employer that is providing:worhers' conrpensadon insurance for my employees: Below is the policy and jab 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. Ido hereby 5t� u der thins and ' s of perju at the information provided above is true and correct use only. Do not write in this area, to be con -doted 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 S. Plumbing Inspector 6. Other V I� Contact Person: Phone #: L3 i 0 SILVERWATCH ARCHITECTS, LLC Architecture Engineering Land. Planning Design Wednesday, November 09, 2011 To: Inspector of Buildings Town of North Andover, Massachusetts RE: Faro Residence 374 Sharpners Pond Road North Andover, Massachusetts To Whom It May Concern, As architects of the addition to the residence at 374 Sharpners Pond Road we have observed the construction to date and certify that it is in conformance with the plans prepared by this office and in conformance with the requirements of 780 CMR Furthermore we have closely observed the installation of the steel beam and find that it is also in conformance with the plans and calculations found on permit plans prepared by this office. Following are picture of the steel beam that we have designed, observed and approved. f Joel David Silverwatch, Architect AIA Si erwatch Architects, LLC 224 Main Street Unit 3B Salem, New Hampshire 03079 Licensed: NC, NH, NY, MA, ME � h No, 9671 S SALEM NH ate` i 603.894.4450 UnDate ... . ... ....................... 4, ' 6 ,) 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING --,w9r- e' This certifies that ............................. . ....................... ....... ........ has permission to perform.................................................. wiring in the building of ........ ....... j'......::..................................................... ....... ...... North Andover, Mass. Fee/,/ /) ............... Lic. No . ...... ;X ............... ............ ............ ........ I ......... 1 i1 V ELECTRICALINSPECTOR 08/10/99 15:06 40.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TRE COMWO ' THOFAR alUSE77S Office Use only DE199RTY1E7VT0FPDBLICSAFEIY Permit No. / h BOARDOFFMPREVEMONREGGADONS527CM12./ � �Q O o� Occupancy &Fees Checked APPLICATTONFOR PETIT TO PERFOW ELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date CJ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. MAP PARCEL Location (Street & Number) 42 Owner or Tenant Owner's Address .� o r/ Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building Utility Authorization No. _ Exist' Service y2%� Am �i /dolts Overhead -Under ound No. of Meters � p p � D New Service Amps / Volts Overhead Underground r-1 No. of Meters Number of Feeders and Ampacity LoAtion and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground and No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bumcrs FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW r7 Conncctions [7 No. of Water Heaters KW No. of No. of Signs Bailasis No ;4 Hydro Massage Tubs No. of Motors Total HP V'-,, fim=Cmaaga Rzmntto&=ugttitana sd1V tsCaxraILaws1 Ibawaamalliablityh�su=Pbbcy rdxkgCo C y� airs% alegiv, et YES[n' NO Ibawst>l nhedvandprocfofsazmto#rOffim YES F1 E)uubawchoc�YES,plea9 mic&tre Fofwxrjgebydtadmgthe INK CSE M' BOND OMER Rase Spedy) ,�2 ✓ /=�` ✓-� -3 irk �/ ` ���—,-9 F�pirafionl�te �\ E irna1BdVakrdElechical Wcxk $ WcdctoStMt IrWe6IDAeRegt� Ra# Final SigrrdunckrTEPertal&scfpetjuiy: L G FHOA ANE �i���%/' 1= Lia�serlo. f6p & T'7 1X=SX SignatLm �'� „ 1,4,,,r--) �� -0.92 A o ; � / C.�J ! / (� r Alt Tel OWNERSINSURANCEWAIVFIZ,lamawatethattheLioensedoesmthaw1hcmrd=o critsStksMr>tialeqrulefasregL=dbyMassadnsetLsCvnmdLaws and that my sig -otim m this pt�nit apphcaticn waives this tegmalnrt (Please check one) Owner ® Agent O Telephone No. PERMIT FEE $ Y Signature of Uwner or Agent Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................... ................... r......... 1.............. t........... has permission to perform ......' ................:.................. / ................................ wiring in the building of at .......�.�............ �........;:............... ............ �... �I ... , North Andover, Mass..0 Fee..--.. ............. Lic. No.......`...... ............... .......... ........................... f ELECTRICAL INSPECTOR ! - -_—.,r-- WHITE: r— — WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Office Use Only�-3 2 / 014t Lfamnwnwralo of - I FIBscaL prfts Permit No. GG (� _ 13partattnt of Public -afPtq Occupancy & Fee Checked 4 BOARD OF FIRE PREVENTION REGULATIONS 527 Ch1R 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Q K or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to �perform the electrical work described below. / Location (Street & Number) �7 , gi n h� "-;�vi-' �rA Owner or Tenant Owner's Address S "�— Is this permit in conjunction with a building permit: Yes No L (Check Appropriate Box) Puroose of Buildina Utility Authorization No. Existing Service ZGO Amos �� , e/ Voits Overhead '� ndgrnd LE No. of Meters I New Service Amps Vcits Overhead r Undgrnd r No. of Meters Number of Feeders and Amoacity Location and Nature of Pr000sed Electrical 'NorK G✓ `' a 4 INSURANCE COVERAGE: Pursuant to the reauirements of Massacnuserts general Laws I have a current Liaoiiity Insurance Policy inclucing Ccmo:etea oerauons Coverage or its suostantial equivalent. YE!— I have suomirtea vaiid proof of same to the Office. YES � — If you have checked YES. please indicate the type of coverage ey checking the approc to aox. INSURANCE ✓ SVNO — OTHER = (Please Scec:fy) (Expiration Date) Estimated Value of Electrical Work // Work to Start —� y3 Insoecaon Date Recuestec: Rough Final J9 7— SS Signea under the Penalties of perjury: FIRM NAME G �" l� G LIC. NO. Licensee S�'z s Signature LIC. NO. Sus. Tel. No. ,5 G �� to �7 _ L Address s ov ^� a Alt. Tei. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee toes not have the insurance coverage or its suostantial equivalent as re- auireci by Massachusetts General Laws. aria that my signature on ;nis permit application waives this reauirement. Owner Agent (Please Checx onel Teieonone No. PERMIT FEE 5 iSignature of Owner or Agent) x-6565 Total No. of Lighting Outlets I No. of at7ucs I No. of Transformers KVA No. of Lighting Fixtures i Swimming Pool grna. — arnd. _ I Generators KVA No. of Emergency Lighting No. of Receotacie Cutlets I No. of Oil Burners Battery Units No. of Switch Outlets I No. of Gas Surners FIRE ALARMS No. of Zones No. of Detection and ictal No. of Ranges No. of Air Cana. ;ons Initiating Devices No. Disposals Neat Total Total No.of ?ur^ps of Tons KW No. of Sounding Devices No. at Self Contained No. of Dishwashers ! Space/Area Heaura I(bV Oetac;,oniSounoing Devices . Municipal Local _ Connect;on _Other Heath Devices KW No. of Dryers g No. of No. of Low Voltage No. of Water Heaters KW I Sicns Bailasts Wiring No. Hvaro Massace Tubs No. of Motors / Total HP OTHER: 4 INSURANCE COVERAGE: Pursuant to the reauirements of Massacnuserts general Laws I have a current Liaoiiity Insurance Policy inclucing Ccmo:etea oerauons Coverage or its suostantial equivalent. YE!— I have suomirtea vaiid proof of same to the Office. YES � — If you have checked YES. please indicate the type of coverage ey checking the approc to aox. INSURANCE ✓ SVNO — OTHER = (Please Scec:fy) (Expiration Date) Estimated Value of Electrical Work // Work to Start —� y3 Insoecaon Date Recuestec: Rough Final J9 7— SS Signea under the Penalties of perjury: FIRM NAME G �" l� G LIC. NO. Licensee S�'z s Signature LIC. NO. Sus. Tel. No. ,5 G �� to �7 _ L Address s ov ^� a Alt. Tei. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee toes not have the insurance coverage or its suostantial equivalent as re- auireci by Massachusetts General Laws. aria that my signature on ;nis permit application waives this reauirement. Owner Agent (Please Checx onel Teieonone No. PERMIT FEE 5 iSignature of Owner or Agent) x-6565 HOTELS • RESORTS • SUITES U L /-olllz CUl rn7 ^t4 wl--- C-711, The Commonwealth of Massachusetts Department o•' Public Safety BOARD OF F;RE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION Office Use Only Permit No. O—ft,-. / Occupancy & Fee Check 3/90 (leays blank) FOR PERMIT TO PERFORM ELECTRICALVORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date�� 3 7� ,A A City or Town of_ua cl� /-T/L/ DC) U eL& _To the Inspector of Wires: -The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)? S �'���.���t F� �)t��•f� �(' Owner or Tenant f AJG"Q Owner's Address Sq'G12� Is this permit in conjunction with a buildin permit yes ❑ no (Ch -;k Appropriate Box) Purpose of Building�� j�a �, I Unlit; Authorization No. I Existing Service Atnps_J_ Volts Overhead ❑ Undgrd ❑ No. of Meters Now Service _..--Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity / Location and Nat-fe of Proposed Electrical Work----!--,- 0A- Cr L7. -Amp mvt<o✓ No. of lighting Outlets No. of Hot TubsTOTAL No. of Transformers KVA No. of Lighting Fixtures Above Swimming Pool gfnd. 4JJgVrnd ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Batte Units 1610. of Switch Outlets No. of Gas.Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Municipal Local ❑ Connection ❑ Other No. of Ranges _ TOTAL No. of Air Conditioners TONS iJa_of Disposals HEAT TOTAL TOTAL No. of Pumps TONS KN/ No. of DishwashersSace/Area Heating Kw No. of Dryers Heating Devices KW No. of Water Heaters KWNo. of No. of Signs Ballasts Low Voltage Wiring No. of Hydro, Massae Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuam to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I heave submitted valid proof of same to this office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ Work to Start Inspection Date Requested: Signed under the penalties of perjury: FIRM N License Address Rough Final AME y IC. NO._ e� Si nature l g _ LIC. NO. k J Pe Bus. tai. No. Alt. Tal. No. OWNER'S_INSURANCEWAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Ma.ssachusahs-Ge,ne at "Raw•s, and that my signature on this application waives this requirement. Owner Agent (Please check one) 9 N, Telephone No. r e –�� ?EHMIT FEE $ S �' (Signature of Owner or Agent) i r C Date.................... ........... t kORT" 1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING �7S$,,CMUSEt Thiscertifies that ....... ...:..........:..!.................................................................. has permission to perform wiring in the building of .......... ::.aj .................... r............................................. at....... :........................ !..!...:........... ......................... , North Andover, Mass. Fee..................... Lic. No . ..?.`— ..... ................................................................ ELECTRICAL INSPECTOR '?' 04/04/95 11:47 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 0 a c 1 F/ 0 0 Ri c z Crr7 C/) \ / O O z Cn H Z z O i m � y ?7 n C C `C H �C �� CD �1 T �t ut to -n 2-7 'a Com� O tz M-0 n� m O � r m t � d 5 c y O n '00 o � CD O Z c O H Ca C7 p CD o W CL cr r� E CDo� A Cly CDCD y� D �. �; a y O � CD 7 CM z � C p a CDIt 1 CD � Z rh • CD T H 0 r CD F/ 0 0 Ri c z Crr7 C/) \ / O O z Cn m CIO d H O i m � y ?7 n C O C Z H �C �� CD �1 T �t ut to -n O � IS tz M-0 n� m O 0 0 o = O m H m O n O m CC2 O O Z c O H Ca C7 1►1 W m n m CL A ,..... o =a CD h m m 7 CM a CDIt m H d y a 0 Q g CL C42 CD 1`,;� i ^. ? m y4 o V1 m m s CD 0m Aom. 0 o s. o Sr .. . A � O CD o m m CIO d n3 CA CD ?7 CIO 92 O ?7 03 'J7 C a CD T d m O 7 CL o Q7 C O � l a p0 .p tz M-0 n� 0 0 o c o � O m m CIO d CA o ?7 CIO 92 n ?7 03 'J7 C a r cn to T p O 7 CL o Q7 C Cn y l a p0 .p tz 0 c