Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 91 SECOND STREET 4/30/2018
N O O c0 Q O N v g 0 0 0 6/23/2016 20675 This is an e -permit. To learn more, scan this barcode or visit north a ndoverma.viewpointcloud.com/#/records/20675 OF NORT i 4y m o � 5 �QSSAC H UsES� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Date: June 23, 2016 This certifies that William A Logan has permission for gas installation Installing two new natural gas lines for stoves and future boilers: piping only in the buildings of RASKOW FAMILY REALTY TRUST at 91 SECOND STREET, North Andover, Mass. Lic. No. 23957 1/1 r �• �. rA httpfr£nortl,an9werma.virwpoinecloud.comrairetaKt>t4J6r° P - d ��-Gas Permit#10675-YevA... 4*7 x 0 Town of North Andover, MA Q. search... - 20675 *Gas Permit - Renovation/Alteration/Addition (Commercial or Residential NOT in conjunction with a Building Permit) 77MELINE ®Submission received jun 21, 2016 at l l:37am ®Gas Permit Review fn Progress [Vi 0 Permit Fee GE}'n+YY�4 0Permit Issuance r¢cu " Tuesday, Jun 21, 2016 12:00 PM Your request is in progress We'll letyou know of any updates via email. Feel free to check the status at any time by coming back to this page. rycar' C Pn:x A tlQN St Michael's School!! Location 91 SECOND STREET, NORTH ANDOVER, MA Ohmer RASKOW FAMILY REALTY TRUST Attachments s up, -J 'N7 -OTT7FJI001F_Tuejun 21_2Di6_15:59:.PDF UgA sdedlune 27, 2016 by V2i;;lam Logan Amite, Piueaa 11, Union St 2nd SI � l Ppplimnt William Logan rycar' C Pn:x A tlQN St Michael's School!! Location 91 SECOND STREET, NORTH ANDOVER, MA Ohmer RASKOW FAMILY REALTY TRUST Attachments s up, -J 'N7 -OTT7FJI001F_Tuejun 21_2Di6_15:59:.PDF UgA sdedlune 27, 2016 by V2i;;lam Logan JF TH OF PLUMBERS .AND::GASF[.T-T.E R.S . 'IHATION DA i ..'r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ - 1 Congress Street, Suite 100 Boston, J11A 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):� Address: �Q //_ —1112411KO U.ty/Mate/GIp:Z 7tj/a�f J/G ( ///,V ( j(aL Phone #:� Are you an employer? Check theappropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors ,pfnployees 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 $ required.] q ] �• ` r-1Weare a corporation and its 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' comp. insurance reouired.] Type o: project (required): 6. ❑ New construction ?. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electri-,al repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that check box I1 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 b -m rm_ist Fttached an _dd:t?onal sheet sl:owi^g the name of the sub -contractors and state whether or rot those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I nm an employer that is proY-=ding wor�!-.err' compensation insrirance fcr my ea:-rployees. Below is the policy and;ob site information. Insurance Company Name: Policy # or Scif-ins. Lic. #: Expiration Date. Job Site Address: Cif;/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 uu 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 Ofice of Investigations of the DIA for insurance coverage verification. I do hereby certij�y under the pains and penalties of perjury that the information provided above is true and correct. 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 #: 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 oi` on the grounds or building appurtenant thereto shall not because of such employment be deemed to be art employer." MGL chapter 152, §25C(6) also states that 'every state or local licensing agency shall withhold the issttance or renewal of a license cr permit tc operate a business or' o construct buildings in the commonwealth forany 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 work=ers' compensation affidavit compleiely, 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, afe not required to carry workers' compensation insurance. If an LLC or LL•F 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 &,at the application for the permit or iicense 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 die Department at the number listed below. Self insured companies should enter their self-i_nsurance license number on th? 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, reed only submit one affidavit indicating current policy irfon—nation (if necessaiy) and udder "Job Site Address" the applicant shouid write `=all locations in (city or town):" A copy of the. affidavit that has been officially stamped or marked by the city or tow^.i 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 citizzen 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 parson is NOT required to cumplete 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 Coammonwealth. of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax # 617-727-7749 www.mass.gov/dia 06/21/2016 10:58 FAX 9783569651 ' ,I American European Insurance Co 2250 Chapel Ave. West Cherry i ill, NJ 08002 GENE"AL LIABILITY cy Number SKP 2001234 11 Renewal of SKP 2001234 saction RENEWAL Named Insured and Address WILLIAM LOGAN 321SIXTEENTH AVE HA�ERHILL MA 01830 Business Description INDIVIDUAL IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND WITH YOU TO PROVIDE THE INSURANCE AS STATED IF LIMITS OF INSURANCE General Aggregate Limit (Other than Products -Co rJ Products - Completed Operations Aggregate Limit Each Occurrence Limit Personal and Advertising Injury Limit Medical Expense Limit, any one person Fire Damage Limit, any one fire i AMENDED LIMITS OF LIABILITY (Refer to attached schedule, if any. LOCATIONS OF ALL PREMISES YOU OWN, REP Refer to attached schedule. CLASSIFICATIONS Refer to attached schedule. Forms and Endorsements Ap licable to this Polic\ See Forms And Endorsments schedule See Forms and Endorsements Schedule These Deg'larations together with the common policy condit endorsemnts, if any, issued, complete the above numbered Countersigi ed this 18th day of March, 2016 _ Issued Date 03/18/2016 GLDECM 0696 COECM i INSURED Q0001/0004 Policy Period From 04/29/2016 To04/29/2017 12:01 A.M. Standard Time at the tJa ��n<,«�+w-nor--"' Agent DOOLEY INSURANCE AGENCY INC 0003816 PO BOX 264 IPSWICH, MA 01938 Telephone: 978 -356 - 0581 T, pe of Business Audit Period PLUMBING CONTRACTOR Annual iUBJECT TO ALL THE TERMS OF THIS THIS POLICY. POLICY, INE AGREE Operations) $ 2, 00o,000 $ 2,000,000 $ 11000,000 $ 1,000,000 $ 5,000 $ loo, 000 OR OCCUPY POLICY PREMIUM $ DEPOSIT PREMIUM $ TAXES AND SURCHARGES S TOTAL DEPOSIT PREMIUM $ 1,674.93 9-93 , coverage declarations, coverage for andform(s) and cy. ✓�G` Authorized Representative Page 1 of 4 06/21/2016 10:58 FAX 9783569651 American European Insurance Co 2250 Chapel Ave. West Cherry Hill, NJ 08002 COMMERCI FORMS AND EN [�7 0002/0004 Policy Number: SKP 2Gv1234 11 RENEWAL Named Insured: WILLIAM LOGAN PACKAGE POLICY RSEMENTS SCHEDULE - .,.,vCrage Line Form Nbr. d. Date_ -� Description i All Lines All Lines IL0017 IL0935 (11/98) _ _-- Commercial Policy Y Condition All Lines AE0029 (7/02) (3/08) Exc of Certain Cmpter Rel Loss All Lines AE0028 Roofing Exclusion All Lines AEO096 (3/08) Asbestos Exclusion General Liability AE0004 (12/09) Terrorism Disclosure Form General Liability CG2134 (10/07) Discrimination Exclusion General Liabilit Y CG2139 (1/8`) axcl-Designated Wor)•c General Liability CG2142 (10/93) 1/96) Contractual Liab. Limitation General Liability CG2146 7/98) Exc-Expl, gCollps/Und rnd PD Haz ! General LiaY bilit CG21 Abuse or Molestation Exclusion General Liability CG210 7 -9/99) 11/02) Total Pollution Excl. Endorse. General Liability CG2186 12/04) Cap on Loss fm Cert Acts Terr General Liability i CG2279 4/13) Excl-Exterior Insul & Fin Sys General Liabilit y MU6721 (12/99) Exc-Contractor-Prfessionl Liab General Liability CG0203 Roofing Exclusion General Liabilit (3/08) CG3199 (12/04) MA Changes -Cane and NonrenewalY General Liability CGO068 (5/09) Broad Form nuclear Energy Liab General Liability ! AUDIT4 (12/09) Record/Dist Mtr in Viol of Law General Liabilit Y AE8183 Voluntary Audit General Liability (15/07) CG0001 /131 Contractors General Liab End General Liability( AE0003 ( /07) Comml Gen Liab Coverage Form General Liability AE0002 (E/07) Fire Arms Exclusion General Liability AE0006 (E/07 Assault and BatteryE xclusiori Excl of Injury to Emplo;rees Issued Date: 03/18/2016 SCHED 06q16 Fap„A INSURED Copy Page 4 of 4 06/21/2016 10:59 FAX 9783569651 American European Insurance Co 2250 Chapel Ave. West Cherry dill, NJ 08002 COMMERCIALI GENERAL LIABILITY EXTENSION OF DECLARATIONS LUCATION OF PREMISES Location of All Premises You Own, Rent or Occupy: 00001 321SIXTEENTH AVE HAVERHILL MA 01830 lum Q0003/0004 Policy Number SKP 2001234 11 RENEWAL Named Insured: WILLIAM LOGAN .ocabon Classification Code No. Premium Basis Prem.Ops Ratprod/Comp Prem.Opsance Prod/Comp 098483 $ 1 - T 0 0 I i01 Ops. Ops. PLUMBING - NO SPRINKLER WORK $1,365.00 Extension of Declarations --Total Advance Annual Premium $1,365.00 Includes copyrighted material of Insurance Services Office, Inc., wit its permission. Copyright, Insurance Services Office, Inc., 1994. Issued Date: 03/18/2016 GLDEC 061 i INSURED COPY Page 2 of 4 06/21/2016 11:00 FAX 9783569651 • Ameri an European Insurance Co 2250 Chapel Ave. West Cherry 'ill, NJ 08002 TI COMMERCIAL ADDITIONAL CO IN OF PREMISES of All Premises You Own, Rent or Occupy: 00001 321SIXTEENTH AVE HA�ERHILL MA 01830 UM DDITIONAL COVERAGES Contractors General Cert Act of Terr - Premop Additional Coverage Declarations --To Incl ides copyrighted material of Insurance Services Office, Inc., v✓i Issued Date: 03/18/2016 GLDEC 0696 INSURED Q0004/0004 Policy Number SKP 2G01234 11 RENEWAL Named Insured: WILLIAM LOGAN GENERAL LIABILITY ERAGE DECLARATIONS PREMIUM $300.00 $9.93 I Advance Annual Premium $309.93 its permission. Copyright, Insurance Services Office, Inc., 1994, Page 3 of 4 D-Ekztrkd perms s20196%- E- = C https:,IJrrortier overma.vlewpointcloud.comj#/records/2'0196 9 � .... ...... ... ....... --- - ---- . .......... .......... _ _.. _...... ...... _.. _.,-------- --.-.-...... Town of North Andover, MA 4 Starch,... E), 20196 *Electrical Permit- IN conjunction with a Building Permit (commercial or Residential) TIMELINE Wednesday, May 04, 2016 09:40 AM Your request is In progress We'll let you know of any updates via email. Feel free to check the status at any time by coming back to this page. Submission received May 4, 2016 at 9:30am ®Electrical Review Jn:0x1 St 2nd St Review by departmental staff Pemtit fee V Payment Permit I;suante 0 DOC I:'ne r.t Wednesday, May 04, 2016 09:40 AM Your request is In progress We'll let you know of any updates via email. Feel free to check the status at any time by coming back to this page. Attachments -OTBFWNI001 F:_Wed_May_04 2016-13:39:.PDF L.J Up!„e'.^dF?ay I, Nl5b Aik—Nc;lca Amia'c Pizzeria y1 4 4j a4 Jn:0x1 St 2nd St A - � st nlichael'v Sehaol $� P Applirant Allison Kelley Location 91 SECOND STREET, NORTH ANDOVER, VIA (...— James Nyette Attachments -OTBFWNI001 F:_Wed_May_04 2016-13:39:.PDF L.J Up!„e'.^dF?ay I, Nl5b Aik—Nc;lca The Commonwealth of Massat^h usetts .Department of IndustrialAecidenfs Orke of In vestigations I Congress Street, Suite 100 .Boston, MA 02114-21717 ilVtu w. mass.goV1d1 a Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A }leant In€vnuatian Please Print Legibly MaMe (6usincsdOri anization/individuai): SolarCity Corp. Address: 3055 Clearview Way Gi:ty/State/Zi : San Mateo CA. 94402 Phone it: 888-765-2489 Are you an employer? Check the appropriate box: - Type of project (required) - 1 . I r P am n employer with 5, 000 4- D I air a general contractor and I Q Neto construction ernpinyees (Full arworpart-there).* 2. ❑ I am a sole proprietor or partner.- have hirer} the sub -contractors listed on the attached sheet 7. ❑ Remodeling ship and have no employees These sub -contractors have S. 0 Demolition working for ane in any capacity. emplayees and have workers' 9. Q Building addition �Ia Wt3rli@rS' comp. insurance required.] camp. instutmce? 5. We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I aut a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions rnysoli: [No workers' comp. right of exerrrp�tiaii per i'M I I2.❑ Roof repairs insurance required.] t c. 152, §1(4), and the have no employees. [No workers' 13 Fuer Solar/PV cortin. insurance reouired.l *Any applicant that cheeks box N l must sten rtlt out the section below showing thtir wot*m' compcuantion pollay information. t Homeowners wba submit this affidavit indicating they are doing all work and then hire oulsittt contractors must submit a new affidavit indicating such. ;Contactors thol check this box must attached an additional sheet showing the aortae of tate sub•cornactors and state whetbet or not those antities haVC employees. If the sub•contraelors have employees, they must provide their workers' comp policy number. ,rain an employer chat isproridtng workers' compensation insurance far my employees. Below is Ike policy and jab site information. Insurance CompanyNmne: Zurich American Insurance Company _ Policy -9 or Self -ins. tic. #: WC0182015-00 Expiration Date; 9/1/2016 Job Site Address: 5 l Second tro- Jr City/State/Zip: O r Jjaftnd GV e—( 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 MOL c. lag can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year itnprisoninent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to $250A0•a day against the violator. Be advised that a copy of this staternew maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby aerIJO under the pains and penalties cif perjur,I, that the byermaden provided abom is true and correct. Phone ti:. pf,ftlal uwa only. Do not funic in tieis area, to U completed by city or lawn. offieial. City or Town- Permit/Llegase 0 Issuing Authority (circle otie): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #t A114 R CERTIFICATE aF LIABILITY INSURANCE ATE 0W17/2015Dnrscro� CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 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 CONTACT A: MARSH RISK & INSURANCE SERVICESNME -...... ..T FAX 345 CALIFORNIA STREET, SUITE 1300 !Arc. No, e): .................................... ...., . ,. ,, .lA!c. No); . ,.................................. CALIFORNIA LICENSE NO. 0437153 {E-MAIL SAN FRANCISCO, CA 94104 -go©REss:......... .. . ... ... Attn: Shannon Scott 415-743-8334 INSURERIS] AFFORDING COVERA<iI: NAIC # 998301-STND-GAWUE-15.16iNSURER A; Zurich Arnerican Insurance Company 116535 - INSURED IrosuREa B; NIA N!A SolarCity Corporation ................. 3055 Clearvlew Way INSURER C.: NIA !NIA -. ... .... ...... ......................................... .......................+....._. SanMateo, CA 94402 ................ _INSURER D : American Zurich Insurance Company 40142 INSURER E: GENERAL AGGREGATE g INSURER F: COVERAGES CERTIFICATE NUMBER: SEA -002713836.08 RFVISION NUMRFR:4 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 REOUIRI_MENT, 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- ...... ..... AbF1L'SIIBR ._.—........,........._ .-.-............... ... Ii15iZ ... ...........TYPE T POLICY EFF '. POLICY E%N .... ...... ....._ ........._. ..LIMIT$ .................. ............ OF INSURANCE... LTR POLICY NUMBER I WDDNYYY : Mo IYYYY A X COMMERCIAL GENERAL LIABILITY 'GLOO182016-00 0910112015 .0910112016 ,EACH OCCURRENCE X I DAMAGE TQ RENTED CLAIMS-WDE OCCUR3,000,000 PREt}AISES fEaaocurrenceT....t_$...- ..._. X.. SIR, $250,000MED EXP (Any one person) $ 5,OOD ..... . ..........._................... _-................. .... I PERSONAL&ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE g 6,000,000 r .... , I X POLICY . I PRO- JECT L. ... LOC PRODUCTS • COMPIOP AGG ; $ 6,000,OOD OTHER a $ A AUTOMOBILE LIABILITY 'BAP0182017-00 '09ID112015 09/01/2016 COMBINEpSINGLELIMIT $ 5,000,OOD ,.ifa accident)........... X ANY AUTO BODILY INJURY (Per person) ': $ .....r . X : ALL OWNED f X SCHEDULED ; AUTOS AUTOS ... .. .... ...�..... .. , BODILY INJURY (Per accident) ; $ ........ ....... ... ,. X F..Z . NDN -OWNED HIREDAUTOS AUTOS `. ~Jiit0?ER1YlAMAGE . .....�........... Perac.' ... .. ...... :....� F...- F ent ..-+� .. ...... _...-._......... COMPICOLL DER: S $5,000 UMBRELLA LIAB ;OCCUR y.-. ..: I EACH OCCURRENCE. ..... .. ... _...._. .. ..... ...... .. .. .. .. EXCESS LIAB CLAIMS MADE! AGGREGATE $ .... DED RETENTION$ S D !WOR KERS COMPENSATION !WC0182014-00 (AOS) 09101/2015 :0910112016 X , STARU DTH• :AND EMPLOYERS' LIABILITY A Y r N WC0182015-00 MA ,ANY PROPRIETORIPARTNERIEXECUTIVE N NIAI F-.--.1.__ .... _ TF . ,......L �R ..... j. _ . :09101P2015 09101!2016 EACH • E.L H ACCIDENT $ - ........ r-.....-------..._ ............... 4- 1,000,000 .... .... :oWCEROMEMBEREXCLUDED? (Mandatory In NH) WC DEDUCTIBLE $500,000 (Man Hes. dsscnbo E.L DISEASE - EA EMPLOYEE S _....._- ...... .. .. ......... ....... .... . 1,000,000 DESCunder RIPTION OF OPERATIONS below E L DISEASE -POLICY LIMIT I S 1,000,000 I I i DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (ACORD 101, Additional Rnmarks Schedule, may be attached If more space is required) Evidence of insurance. SolarCity Corporation 3055 Clearview Way San Mateo, CA 99402 SHOULD ANY OF THE ABOVE OF -SCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 1N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo- p 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2094101) The ACORD name and logo are registered marks of ACORD -0, Office of Consumer Al sit and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 f lomc Improvement Contractor Registration SOLAR CITY CORPORATION MATT MARKHAM 3055 CLEARVIEW WAY SAN MATEO, CA 94402 HOME IMPROVEMENT CONTRACTOR 114 Rogluratlow 1F.jfj572 Type- fx0rZItl0n: 1,,,2V!7 Supplement Caid K)LARC.t it ')RF-0R/-:1JN1 MATT MARJ,,JtA!A 24 ST MARTIN S'JRLLr 13LU?UNI WNI-BOROUG) i, MA 01752 Re,giStratiot-l- 168572 Type'Supplement Card Expiration:31812017 Update Address and return card. Mark reason for change. Address Renewal rmployment Lost (:ard I,irense or rigistration valid For individul use only belbre the expiration (late. If found ititirn to: Office of (:onsumer Affairs and Business Regulation 10 Prark Plass- Suite 51711 Boston, MA 02116 Not valid without signanwe ISSUES T44E FOLLOWINC LKENSE AS AN,i, REGISTWO MASTER ELKTIRICIAN SOLARC I TY CORPORAI ION hAT'THtW T MAAWHAh 24 SAINT MART414 DR OLD� 2 UNIT it PtARLBOROIPGN MA 01752-3,00,0 t�nrarraariTuaadlii o� Iila�aacir•uae Official Use Only Permit No. . _ a ar �a o ere arvica9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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: City or Town of: N 0 f rh ff n C) GVe_r- 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) 9 (_SC CQ h dj— Owner or Tenant 3o, S tsj kA , r+ -e, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 1W No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Fceders and Arnpacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system panels rated R.I 1 kW (cD STC Grid Tied. In conjunction with a Building Permit Cont letiott of ilio follon ut table Wray be ~mired by the Ins .ector• of Cyires. No. of Recessed Luminaires No. of Ceil.-Sisp. (Paddle) Iran$ No. of Transformers IC to No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above Ei In -0. Swimming Pool rnd. rnd. ❑ o Emergency Lighting Butter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o eteD and Initiating novices No. of Ranges g No. of Air Cond. "Iota Tons No. of Alerting Devices 1; Na. of Waste Disposers Hestpump Totals: umber 'Cons K o. of elt ontained Detection/Alerting Devices No. of Dishwashers Space/Area Heating IM' Local ❑ ConnecctioMunicipal n ❑ Other No. of Dryers Heating Appliances KW Security ystems: No. of Devices or Equivalent No. of Water KW Heaters o. 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, or as required by the Inspector of ll'ires. Estimated Value of Electrical Work. 0 (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. Cl-IECK ONE: INSURANCE A BOND ❑ OTHER ❑ (Specify.) I certrfj,, under the pains card penalties ofperjut}p, that the htfortttation on this application is true and coutplete. FIRM NAME: SOLARCITY CORPORATION LIC. NO.:1136MR Licensee: MATTHEW T. MARKHAM Signature LIC. NO.:1136MR (If applicable, enter "exempt" in they license nrtmber line) Bus. Tel. No. :774-258-alao 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 ot'Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: l 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 eat. Owner/Agent PERMIT FEE: $ Signature Telephone No. k qob- 7Aiy co X17 �• � a CL +w M F F W 0 C— D uM TW�}� F H c O 0 N C� G O C CO C 180 150 990 al << c-,:oo-io N M 00 M P o � P N0 +�i m M n m a M + O N N M M W W m M W Z w � m o - h O Up W - P N N M n C o I Q � o i L o p N M M h O ^ a0 M t0 c M < o Q V 0 O W N h N p N d M n < Q O C 0,10 O r E N 3 J d E O O'v`a L U x v3 O E p C o > Q 00 no E o a > E� ' o o a s 3 J: f a �2Q `o O £ Q s? u U o u}'� c , `o 0 3 rn c j: < O N U o y O E N U N m j o �, 3 u Q a y o D S O O o 3 } U o d b i ? } U E o E O o E p -6. Y. o` t n I O>? a 0 E V E v oo m > j E E U E c V 0 3 0 0 0 =� u 0 0 0 0. u, a a° �� 0. O N 0 f N .a u 0 i f 0 �n < 180 150 990 al << c-,:oo-io o gal 4 ......... ......... OS9L 00 0 CL Q 0 0 c '0 o � a N V o E z - c 'v m o d N N U U 0 .O C Q rn ° U f 3 o mo S m U U s Q - d SIOZ UDJOW N3 WS1 6 ......... ......... � i N a O oS h C Q- E C o I c i L o t u 6 O U _ O o 0 c < Q O C � N 3 J d E O O'v`a L U x O H O E p C o o N W= E o a E E o a _ J: rn L _7a O V x LC - E o _ o� `o 0 = E < c O_ O 9 C QI O N N � i O' U O y .� W ?" o �, _ o C d. O u u v `k El 'O �- i p E o E Q o U o E p -6. o d u ,n o o P d d GSL 6J j • • m Q 0 0 c '0 o � a N V o E z - c 'v m o d N N U U 0 .O C Q rn ° U f 3 o mo S m U U s Q d U Q O � U � � y c C Z N U 0 o z o Q Q u a a d 0 0 B 40!! W cot,e: U 'd�fl a zD zv o� �r z O1 OQ D hE Oc po- a1., N '0_ _ . d � h o, UpU c O - d SIOZ UDJOW N3 WS1 ......... ......... � i N on o � O oS h C C o I c i O Z o V _ 3 0 O C � 1019 3 J d O O O'v`a � a o O d U Q O � U � � y c C Z N U 0 o z o Q Q u a a d 0 0 B 40!! W cot,e: U 'd�fl a zD zv o� �r z O1 OQ D hE Oc po- a1., N '0_ _ . d � h o, UpU c O c � i _ a O C C o c O O c O Z o V _ 3 0 C Q 1019 3 - O O O'v`a c Q a s O O G O o o N W= J: v ,- c c LC G Z, O j L t O � i O' U O y .� W ?" o �, _ o C d. O u u v `k El 'O o - a j -C 0 >- O �•- -r f `) cLU° P d d GSL 6J j • • U U • • („ 0 , 041, 1 OSI le,Hod pae1u0i0nU I IV 4� :J LU z � O � I .y- � S'!i U m uj {j a�.5r u�s �) LU F- z w O r 0 oc c 0 0 O �- ,�� �. s Q �p uj 3 �o-Z .L v a,c s a O 3 w ac3o a' ora' U-62-3)0 O O `r Z34 N O ` O H�ooa� a> 5 or �� �> 9L d a, O a O a �Ci ' ? J � O O. D - O _0 'J s 4 y T O_ W 2 a O OJ � S ~ � 2 Z ~ J W W Z H W p w r DO O O �� C) cZ JON L�2 oho ZEN w �oJ C)C:) ¢ c�� z3 O roe ooh o V- < azo �a '� W acs J 0_ o W w \ J w Q O~ ~ J Z m N U - J m M J Q d w 0-' Q J J W. (n N N U Q H I—' N N J w J J d Z O V Z F -a W J Z (~ N J m Q oo0 CL C Up (n0 Z C) Z^ N m W OJ J Z_ O 00 W ^ N l/i ICL � \ O N M C^O O Cn � W \ S N ^ a F- Z m Z N _ 6 ll7 W O J -4 O- � pp II o 1 of W O ( � - Y F V ==3> ZD Or O ��p N M W U J M O V' J N Z �� W Q w W z LL 3:N w z U- 0 0 N LLJ cn p0 ,--i wLLJ o " N - J Off' Cj p TI Ln L'i W NN Z W �I In U _ (n \ W z M O / W O� J a Q N W:2,- Un wJO w W O WQ W mww F- � �� a W" m � � z � �w� ^ o ¢ J Of w a oOf m �--1 J F- U U w c' w V) d J w 0 0_ J Z (n SM w Z I— �z� <M J Q U r = 2 W Z J� 0 c NY i� -p0 �_ > m� z a M Na v' o �pom ^ �� � �yJ w J W M W (n O_ CD > Q W p0 Q 0 \ W ---1 0_ OU ui OU O J W s Ifs W a W N ^ ^ s J V)\ W N W W W CD W 2 N N \UJ ~ N X) V) Lo S v Z 00 _CD Z O N 4 Wm 0 = H�'� �U Q W D ui = Z J W r Q d Q as � r I to mints J i M CW�Ny _jLLj W y' ° Q' 1. Z d' — `--' Q � V O 04 a z z Q O F- ul�_CnW= arr a Cn L; J O O 0 W N� CD 00 < ZZia d C) Zo I :1 " O w 3 Q w Im U. V) W fn 2 J N U CL I M V) W a N d' L � Z- Q a C) C> v7 O O r� w� o N O U V) ui 0 �U O (V ( N w LZ I U) (� ii 3 C9 0 M io w U) w 00 z 'cin- FFw�w I X W NQ^. -.r0 Q aQ N I..L '- 2Z WZW LU [1 N CJva j I Z J � a~M O a Z a L LU CN i t I o o Z CL a Cn O c.D O N d I LL Lo � N O o } I Q N U F- CD o O L 0 0 I Z 0O U O C7 s I �— t ¢ I I w O Q w N I V) 00 I O (n CL to H W V V 69N W JJ z O X S a U Z z c 3 N �" O Z 0 �)c S �- H� o: w a oo -H F_ _ O E ° = GS_ z Q �o °v z �� u V) _ = o o' < 0r _�I_ Z T� � MU g�Z(n N 3 Z O i � Z Z I O_ • i z W Qz N zo�W� / \ U X U V Fwz Wzw� d 0 0 N / W z 7 00 Q U _ _ /N�' �Nj' N N 00 CN cq ��/ � 1 a I 7 V V Z W N V W W U /Y X 10 10 X X = p w '^ / W QW N N 1 QZO�jm C W S=1= {l{yey K a A CL FC�� OF z wF o Z O 1QQ� W M -rM ~Za ~U'_ W JC mza �F)ia I 1I1 Q w Z a s _ N N� I O w U) ■� m w P�� I Z I I N v v" ELU U x J W J ,:i Z Z Z O >> O WI 0_ I I d U oN 2 yLi a{.� O O E vd6. N O W C.DZ ' > ArA U V C> O CU71 O O WI = W Z ni3 Q Q D W m CO WI N I ¢r�i o Z v _ p 0 ao d' d > n o o ~' O N = I c,4,: ` H x E5 O t0 W: \ CV c Qm m CL' c °° Q Ln w_ C _ LL W I I O t�pp W 4p IL V 0 O de a •�. L vi Y O _ w I C OQ c m c Y wm O I N fJ O>- 0- Ln z I V v uj a w C> o U!o H: 90ft o N °Oc; I > Q o� m Q O I I 1-0 a ^LU Z .... w WI __...._......_. ._..,..,.......,_...__. O � I C14- :z X I �o E I 'N .. i-j-2 I 7 L I N o Q I Z� N E I w M Q u')LLJ I Z I > N I I� o < Q I CD N Q � Q Q W >,a z Za_ J w Cn CD 0 N I a W $ Y W W rIjm ,4 w o I O CC� Q'� 2 co L (, O pOLLJ U) z W c 7 as v N > a l O ® z r N (nWD M C N O I N W j p I Q V) N c � I F- __j O - rwl0 �d I O O W lz p M N In > I , Uu 00 d0> I ¢ O wN I co Q �Wl�I W I n LLJ j I Q U% J d I > Y' O I bj M N> M N c. Z 4 I ^ Z o z c a s ���..+ U > > I' LLJ c w~ > > i T o Q�.� o H I I � Q Z W: r ¢ 0-) Z mm mmZ(j U O Q N C mmLLJ h N. Z c I�o0i S S.` J p =d LU I F,-"p!� LU > I I im I IN Q N O o o z o 0_C) O < Q d CD O O LJ = c o N N N LU a 0 I W D ZD Q I N I— Q J LU O m0 N rn « c U I I 00 U O 0O0 Q � W I Q a> -j w am� ON V)z Q k; y N -----� r---- t--- - - - - -- �II I I I M�I W +J g>> v ISI -------- I L- �I Q j o Q Z W LD ZZ o a�dL IQI Iwl I �I W �n O c �mo am Z o w W o oK aK a� -, m =o='JO om v w m O 1f13N a p Z v N T 0_ . . Z Z L' W C.7 J Q H7 dO m W C Nob ti N� IL- ZWZF51-'f. W Cr JT ~ CN (a� C 1'- WWJ W 3 V UJ il.,�W.I 0T> SU l'uj C14Z U qG kj �� yn� Su-=OUuWW T�a1 �S �ZN� F� N¢ o H YQ cS Q2�n5_w Ci O� Z m O < ]N•a-. Em�oo?��� z �N� v �x tae zowtna = Wy \� O > v�� Ori C' Q Q W W O �m S 2 Z W G U W W J F m W as Z=z N O O V) S >G Q C�� O W N W 1 N I �ZZZZm CL WW p�N ,. v Zc?W �NJ�OZ Wcv m �Q p I zw :; c WL0 J i--1 M n 00 �yF �aLEw I LL, m0 j � Uumzio�vmia E 0 N O u A � C momg 3 O w��^ U Mn zgLL� O cO N p NCW^ U C s o N O �o 00 � � C C O o U X c U p i O m c c pp a > ° cch °' c O o U ° U co U c p o Q O U• N O C J a. cc U —0 Q —Co U? � d ,0 ���• r z w C) o - -0 LU M U U>N W JG°c0W 0�w m - �UUmWU -�az0?� . , -�, LL .■ wzw . ; • , • ■ •' • • . .1 • .• 0 rn m U W Z o w o a o m g m o m cu _ r U— 00 -°� � r C.) 00 -0O y M CD U 00 10O co (D L) (=; co U 00 -0O J CL O O J O J °co J --O Oco J °co U C) -�U� U d a� ., Qaz Ja-dZ Ja Z J�dZ JaaZ ■■ ®6 zo-W ■ - . • • • Lu .® e • - - • 1 ■ e , • - ' ■ • • • - . • • • • •' ■ • 1 ■ • . • • ■ • .. ■ ■ ® b ..' ■ w • • • N N cu J M N N co U o U co c c j c M a) C, > Np 'D°)Z'O 0> Np N >N "-_ co 00 O M LO 0Oa) aO Z -O (O OZ 'a O Om"6 O(O OD0 Ja Jd6 O CO O(p z c8 p0(p vF U U U U U V U V U U �V U �V U w U JUdZ J�dZ Q U J�a.Z a) U a) LUU J-dZ J-dZ CD JQa.Z JQa.Z mmzFc3 z~a`''� W W O • ■ ■ ■ ■ w C_ LL i . ■ ~ Z W N d • ■ WWT 11 W z 1 . • W ~ 3 .� • ' 1 ■ • 1• ' 2 O , N • . . ® - ■ ® . • ■ • . . ave • 0 • • ® + • • �Q G.WMW • ■ / . . 1 ��Z=s • •® ® LLI . • . ocO.�w • , - 0 • .FL MW CD G 2W TM�p C1�?W O CL J. V 0 Ln cq O N M V Ln E 2 O O M O m CDr- E U a1 a n N pJ N !6 41 � a � N 7 ON W � O EO p. a) O � co 7 N J O 0 O U N N N C Op Y y0 O Or d � � N C ca L 6 L Q m CDr- E U a1 a n N pJ D 41 � a � 7 ON U O EO p. a) co 7 N J O U N N N C O CO @ ca CL Or C ca M N 3 0JO w 3 O O 0' Cj @ C 3 m D 0- U) 0-0 O y c O U @ —0 .p O Q) N ` T U) CO. O a) O , 2 a3 ._ _O -_ O N y L.L O .@. n J y C 0 CO O 7'D Q CL -C N 7 5 U O N .- O U_O. E O-0 cu of N C N J U) O 4.1 y �. O~ C N a .N-. m@ N cL 30' CL @ E a 3 U v U N N V v a) 1� 7 7 D U a) N O 'O 'O 'O U O` "O - O` in 0 C L 00 N 0 U) O. O O. `L J c o y o 5 cp y °oCL0o ?a �U 47 J y N t�6C, .U. !� n 0 7 C t N Cl) N N 7 L U .a c� D. n o O c.0 m N O) .f] w0 E a3 cL9E� a� 7 Z5aEa>EEococ d c d d E c• c N 7 3 c co o c c a> C Ey�� O CD U) �� c•3 'y . O yr M i 0 7 d C p a Q N a) V •` CL CL co a) y a) C a) a) C) a) � O S N N N W N Q w 4) 'L V/ • Q N0 om U N fpn N r I E m: n ' < 75 Cal 1 iQ 18 w:o iM m o� 2.ti .Z •� M C p 1 Q W�� o: £ (7: C C 3z d Oi �' �' al Q CL cCL W Ol iZ: F: ro O` ue Zv>Z vLKov m> £ [m u C v 6 d = '^Zq.Ozcu D. �ti o w 0 0 0 Oi :0- _ o O r1E o f E. £ �, E E O�arE £. a 3 3 °' ` s ; N r� E E E ;n . N O€ao~EEx r,x ZhE ��-n�wc ~_ N Eoa o o Zia-3�no'o'oa eny E'xx°i. aZ2:2:a >! �. em m 4 ' Iil�ll 11 j m G v m f R j o C6 L U ai N i N ps m � N � E q a Q. L i p — 1 dig O E r w Lj— CD E3 CD O a QV CD M� i� Q.. W d -4 z O CD3 2 y H O I N C O s 0 N 0 c 0 i N N p o 'O M O W M P O N O OM N s f j G � I3o0.10 Qm _ h P P N d M N h h G> p � M W6 ^3 6 O d w � U_ 14 G O N �0 •- � M n I M > a O C O. w � o a_ I n 0 a cr c E 'C3 _ W o � O Z � N M OM o P a0 f`M') n1 M ^3 <U o UO d d 0^ O h .o N p z c E U n E UJ L O '^ 43 d_ON17, O O U U E'3 Q h V U Lf- C Q I > : O r n0 Z-5. icq�ik 1 Q >Q 3 E > Q U C E se U p j J i „ H u 0) a00 . N rr W u° 0 Z a 3 0 0> Q j E E c E a' a o ] W c U > U O E 0. O N > U o y 6 3 0 3> U �_ o `� O 3> O U u o 0>> E w ° U E E E > U 0_ N E U U N oc] E ] ] X V a a° : O f O �J W u F f f _ N O H c w C3 180 ISO 990 —I i _ Qi ca 0591 co O CL CL O s f j G � I3o0.10 Qm _ U til C O � N ca 0591 co O CL CL Q Q C 0 0 c ' C Q O O U a E Z 5 c 'v 0 Q N N 4) V U O- V E TO O c C, i- U f a O m� m U U LL a V SIN 4»oW N3 WSl r U'= U U V N e O U a 0, `0 0 H — C C Z ` ' rnU E OO U U U CL N O N N 02] 9 5 < o 0 0 0 `o dQ d Q O Z r F 8 O _ U til C O � N 0�' G N L > a O C O. LL.Z I n 0 a cr c E 'C3 _ W 0 O Z W 'O O -2 > U ci E d o c > z c E el UJ L O '^ 43 d_ON17, O O U U O Q h V U Lf- C Q U U . _ ' Cfl - o Z-5. icq�ik r v o Z E U C x '^ > o )- ar0 O O 3 > U p camv , D O E 0 N rr W E o Q ° E E V v a ] rn U _ E 0. O N E N E ] II N L L C n O O .fl V U C O - O N N O M h JK O v N O- > N o c= c a o f y p f E V 0 00 Q _ a d N L d- vi 3 -m a E N V x � Q Q C 0 0 c ' C Q O O U a E Z 5 c 'v 0 Q N N 4) V U O- V E TO O c C, i- U f a O m� m U U LL a V SIN 4»oW N3 WSl r U'= U U V N e O U a 0, `0 0 H — C C Z ` ' rnU E OO U U U CL N O N N 02] 9 5 < o 0 0 0 `o dQ d Q O Z r F 8 x 8 8 8 8 8 8 8 8 0 8 Idh�e„no 0 W _ 0 til C O � N 0�' G L > a O C LL.Z I n 0 a cr c c 'C3 i W W Z W O O -2 > 8 ci E o �v0 u i v > z c E x 8 8 8 8 8 8 8 8 0 8 Idh�e„no 0 W _ 0 til C O � N 0�' G L EV O C LL.Z 0 a cr c c 'C3 6 G 6 c. � W Z W O O -2 > 8 o �v0 u i v V) a a o c el UJ -+` '^ 43 d_ON17, �3 0 O Oxo n_ SCO U a x10 C Q h V U Lf- inQ U U . 0 U y Ot Oa a p rD Z� Oo a i �eMod paaluoion0 W W U G? L 1 LL.Z V uj J O O c O 6, ci E 0 .0 = W Z W O > > "L) .0 L Y;� p 2 3:3 ; N C O O O c'1. O '4 - .[-- j C .^ -q U) c UJ -+` �„"tau > �, o e a ^, inQ ' Cfl - o Z-5. icq�ik Z Clq > o )- ar0 O O 3 > U camv , U r ~ rr W � _e:.L,cl, 0 O C G GC o 0 La 3 m,o0— rice $ if 0 2 ...... . . . .. . ............................ CL x a 0 O 0 '0 u x z a ko Q:0 0 0 G T :3 a 0: -5 0 ci IV Z U: u0 <:Q C) 0 u .2 (U LU > >: W> >1 -0 :> >: V W 0:I m a UJ :L 0 E CDi oo c Zv t0 > 4- O�O 0 =0 r -> @j d` 0 0: .0 1.: 6:0 0- 01 0: w M v 0. . ................ . 0 u. a 0 C.0 LLJ 0: No: 0: 0 >: . . . 0. .... ... --- LW Cn 0 0 0 0 0 S.: 0: 0: io E: 0 :Ml 0 .. ...... ..... .. ................ CE, > >: :0:. C', L 0 :@1 @ : .6: (ai V) cn C) zo C) ML a 0 1U C/) C/) m 0 u c . . 0: . . . . vmWi Vi.:. . . . . . . 0 E xm: 10 0 0 Z z 0: v1:E: Z� �E cc ; ' ccr Z: u < m� m ��: ? 3:: :�: & -0 w u 'U z E: 0 >. >. : �tf � � 2: , : 0� :.s : 8 0: -:.2: t�: �: " E: V >: .-6. c : -: �� 0 U. E: E: u - 1, :� E: I 4z -0i T� 0 0 u < a 0: . — , 0 - -: - u 5: 8: S &: E: Y 'L. E CL: - E .0 :u :,U: E: x: E- m >i: >: o' >: 0 zo u < wl; < 0 :Z: .: 2: (D: u z if 0 2 ...... . . . .. . ............................ CL x E E 0 '0 u x z a ko Q:0 G T :3 0 0: -5 0 ci IV Z U: u0 <:Q C) 0 u if CL E E ko 0 u LU ci IV Z 0> ro q .2 (U LU 0 UJ :L qj 0 P E CDi oo c Zv t0 > r- 04 w Lab =0 r -> d` 01 w M v CA Ln co 0 u. a 0 if Date . 2 ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING � r! Are — Thiscertifies that ....... Q 1/1.!�!:�� ................................................................................................. has permission to perform ,,... k "k -VA- ...................................................................................... wiring in the building of,.,,..,...,.`!.Q .............................................................................................. ` �f'... �`-k"........S. "U , North Andover, Mass. at ................................................ ........... . Fee...`.�..�....�....... Lic. Nd().144 ELECTRICAL INSPECTOR Check #'-12 1J • Commonwealth of Massachusetts iOfficial Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL .INFORMATION) Date: —)5-)57 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention top form the electrical work described below. Location (Street & Number) 1 " 13 S� 5� �Mwner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) j Purpose of Building Utility Authorization No.�Q L1,3 0.d G/ lam_ - Existing Service %G U Amps %ZU / 240 Volts Overhead Undgrd ❑ No. of Meters Z New Service L90 U Amps I& / Z4KO Volts Overhead Undgrd ❑ No. of Meters �— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:Pru { rP I - d C'1,0 Cmmnletinn nfthe follnwinQ table may be 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- E] rnd. rnd. No. o Emergency Ug ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 Disposers 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 .oo. Devi es or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or E u valent OTHER: Attach additional detail f desired, or as required by the inspector of wires. Estimated Value of Electrical Work: 91 O (When required by municipal policy.) Work to Start: 9- a6 " t l` 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 tk BOND ❑ OTHER ❑ (Specify:) I certify, itnder the pains and penalties ofperjury, that the information on this app licatio sis true anti complete. FIRM NAME: _ LIC. NO.: Licensee: Signature LTC. NO.: pi (! 3 ` ( p (If applicable, a to "exem No.S �n ) Alt. Tel. No.:n Address: : Bus. Tel. U G7b *Per M.G.L c. 147, S. 57-61, security work requires Department of Pfiblic 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: $ 55 -- Signature Telephone No. 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 §Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed JW 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 Y electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has detennined 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 M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE SPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: o -Z PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com I VF. Y The Commonwealth of Massachusetts Department of [ndustrialAccidents 1 Congress Sheet, Suite 100 Boston, MA 02114-2017 www mass.gov/dia d'b 5V. V9 Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/klumbers. TO BE FILED WITH THE PERMITTINI ATJTHORI' y, Name Addr( City/State/Zip:r Ile, r `c �� �� �a Phone #: Are you an employer? Check the appropriate box: 1.[] 1 am a employer with employees (fill and/or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3.Q i am a homeowner doing all work myself [No workers' comp. insurance required.] � 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.t 6. ❑ We are a corporation and its. officers have exercised their right of exemption per MGL c- 15?_ § 1(4) and we have no employees. [No workers' comp. insurance required.] Type of project (required); ' 7. ❑ NOW'constriiction 8. [] Remodeling 9. ❑ Demolition 10 0 Building addition 11. Nlec#ical repairs or additions 12xfj Plumbing repairs or additions 13,. [] Ro6f repairs 14.El Other *Any applicant that check's box #1 must also fill out the section below showing their workers' compensation policy information. I homeowners who rb,drUsub •this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached'an additional sheet showing the name of the sub -contractors and state whether or not (hose. entities have employees. If the sub contractors have employees, they must provide their workers' comp. policy number. ,. ,.. , I am an employer that is providing workers' compensation insurancefor my employees. below is the policy and job site information. Insurance Company 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)- Attach Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fnie up to $1,500.00 Pena in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil p 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 certi der, thepainLandpen al ' of perjury that the information provided above is true and correctDate:Si ature:Phone #: Off tial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone +v y 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 deflated 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 6fan 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has uotproduced-acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(1) 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 ofthis 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 nece6sary, 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 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 numbor. In additio , applicant thai 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 MO Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia s.. 4,' / COMMONWEALTH IF -MASSA S TTS BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE W AS A.'REG JOURNEYMAN ELECTRICIAN a N KEVIN R ALLARD W i N _ Z i 59 DOTHAN ST U ARLINGTON MA 02474-1342 2103 B 07/31/16 66366 j i ._L ,V �'O G. < Ia vC"'. !a ro:� I• � iQ• I Az Q. N CD mo `i00 v' o �.CD �xCD41m n o as � N O O� w CDpr !y NI o c o' O : � I � fNvjrr��n � .� -t r I j I � 1 a fD C O III -- ._L ,V