HomeMy WebLinkAboutElectrical Permit for Solar Panel Installation - Permits #11791 - 38 TURNPIKE STREET 8/14/2013 0
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com4wnweaft4ol MaJ6aC4Wetb Official Use Only
Permit No.
IF
�e ar�m.en o r+
Occupancy and Fee Checked
BOARD FIRE PREVENTION [Rev. 11 7 (leave
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code MEQ,527 CMR 12. ¢�
(PLEASE PRINT IN IN- K OR TYPE 4 LL INFO 'ION Date*
City or Town of: TO the Inspector of Wires.
By this application the undersigned-gives-notice of his r her int ration t per-formthe electrical work described below.
Location(Street&Number) v
Owner or Tenant R. Tele hone No. Q
Owner's Address V � �e
s this permit in conjunction with a building permit? Yes No ❑ Check Appropriate Box)
Purpo a of Building Gi n gve (Y\6 Utility Authorization No.
Existing Service Z0 AmpsI'LO/IAOVolts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps Volts Overhead❑ Undgrd No.of Meters
Number of Feeders and Amp city
Location and Nature of Proposed Electrical Work: U\.<zh3A1QA�-0Y\- 0-� ro moqr\j-
CoMletion!?ZlheLollowingtable mav be waived b the ins eotor of Wires.
No.of Recessed Luminaires No,of Cell.-Susp.(Paddle)Fans No,of Total
ITransformers. KVA
No.of LuminaGire Outlets No.of Hot Tubs Generators KVA
Above In- No.of Emergency Lighting
No,of Luminaires Swimming Pool rnd. grnd.. lBatte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of was burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Fond, Total Tons No.of Alerting Devices
No.of waste Disposers Heat Pump .... .... r Tons..,..,. I ......... No.o Self-Contained
Totals: Detection/Alerting Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security stems:
No,of Devices or Equivalent
No.of Water �,� o.of l o.of Data Wiring:
Heaters Signs Ballasts 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 ofh Wires. k
Estimated'value of Electrical Work: � hen required by municipal policy.)
Work to Start: L' —I— 3 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 licensed 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 D ❑ OT R ❑ (Specify:)
I r c� ,under the pains and malt �. r�juror,that the in r�rnatio�on this mil � i s true rr and o et , �
FIRM NAME: i tjd_ jvzJ LIC.NO.: �3 t-q
Licensee: * - 03 Signature I r N r• I 'S I
1. licable, eater "'exempt"in the license number lire. Bus.Tel.No.;-Tj _k-_�. 53 6
Address: Alt.T'el.No.¢
*Per M.G.L.c. 147,s. -7-61,security work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAIVER: I am aware1hat the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,l hereby waive this requirement. I am the(check one D owner El owner's a ent.
Owner/Agent P
Signature Telephone No.
V7
� �
v jr
CERTIFICATE OF LIABILITY
01114013
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 OIL ALTER THE COVERAGE AFFORDED BY THE POLICIES
F
BELOW, THIS CERTIFICATE OF INSURANCE DOES MOT CONSTITUTE A CONTRACT BETWEEN! THE ISSUING Il SUREI S), AUTHORIZED
REPRESENTATIVE.NTATIV R PRODUCER,AND'' H CERTIFICATE HOLDER.
IMPORTANT: 1f the oe0ficate holder is an ADDMONAL INSURED,,the p lio les must be endorsed. It SU13ROGATION IS WAIVEE$3ub_jwt t
the terms and conditions of the policy,certain policies may require an endorsement A statement on this Oertificate does not confer rights to the
ceittlimte holder In lieu of such end r e er s.
PRO I CONTACT
MARSH USA 114 . r+�AI 1
122 '17TH STREET,SUITE 100 "M=*, lKwo:
OnA
�rx; ��ar, I�req�est, rl�a .corrl,Fa�� 1 , 4 .4 �1 Ac -
INSUREftffi AFFORDING VERA E N
4627 -V"PIE 13-14 Wobu I R :Eras Insurance CompanyF 7'
INSURED Commerce And Industry Ins Co
1ivi t Solar,Inc. INSURER E: 1 410
41 N 300 W INSURER
Provo,UT W04 INSURER D
INSURER E
INSURER F
COVERAGES CEFrriFICATE M SEA-002366024-05 REVISION NU E :I
FTHIS 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,T, TERM OR CONDITION OF ANYCONTRACT ACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED CFI MAY PERTAIN.. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS A D CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED# BY PAID CLAIMS.
TYPE OF INSURANCE A � POlt�ll#�ulk�sER Y E Y xp LAM
Fri GENEML UABIUTY 13PKGVV00029 01101/2 1 '0110112014 EA H O CUR M ARI EMI E 1100�}, 00
7
O MEI IL EI E#AL LIABILI D � � �e�ce 0,000
CLAIMS-MADE OCCUR MED EXF(Any one ) 5100
PERSONAL&ADV INJU Y 110 0,000
GENERAL AGGREGATE 20000,000
GE L AGGREGATE LIM IT APPLIES PER. � PRODUCTS-COMPIOP AGG S 20000,000.
7X POLICY Pik - El LOO ~
AUTOMOBILE L ILITY COMBINED INGLE LIMIT
Ea id
ANY AUTO BODILY INJURY(Per person)
A OWNED AUTOSLE BODILY INJURY(Per accident)
NON-OWNED PROPERTY— AMAGE
HIRED A AUTOS
UMBROL AVAIR X OCCUR 13EFXVVOOOI1 1101/2013 1101/2014 EACH OCCURRENCE $ 10,000,000
EXCESS LIAB CLAIMS-MADE #
I AGGREGATE 10,000,00
DED RE NTION
WORKERS ER OMPMATI l 66W 01114/201311/012 1 TAT 1 0TH-
AND EMPLOYERS'UAEIU7Y
ANY PRO PRI ETORMARTNERWECU I I V E_ YID E.L.EACI-I ACCIDENT 'I,0001C000
DFFICEf�NEMSER EXCLUDED?
I4 nda W in NFL) E.L.DISEASE-EA EMPLOYEE S I A004000
II` ss d"cAbe under '1,000t00D
DINIPTION OF OPERAMONS below E.L.DISEASE-POLICY LIMIT
A Errors&Omissions13PKGWOG029 011 1/01 11 1l2014 LIMIT 11000,000
Ca*a*I"s Polluffon DEDUCTIBLE 610001
I)EG UMON of ••••P■RATI N I LOCATIONS!VEHICLES A#s A ORD 101,AddWomW Remo rks e,hedu more spaw is mqulr *
RE: ■Norma I NTH}■ obum,MA.
1+01801
CERTIFICATE HOLDER CANCELLATION
1
Quincy Wobum,E.LD SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
ck Ndo:nal Devefopment THE EXPIRATION DATE 'THEREOF, NOT.IDE WILL BE DELIVERED IN `
2310 Washington SL ACCORDANCE WITH THE POLICY PROVISIONS.
Dori Lower Falls,to 0242
AUTHORIZED REPRIESENTATWE
of Marsh USA Inc.
Kathleen M.Pardon �.
1 - 1 R CORPORATION. All rigs rewrved.
ACORD 25(2010/06) The ACCORD name and logo are registered mirks of ACORD
r `*
Depa rhn en t of'In d stria I A c ciden is
Office of Investigadons
Congress Street,Suite 100
Boston,." 02 -20 7
ww.mas .gola
Workers' Compensation Insurance Affidavit: tiers Con rae oars l rici nslPl x bers
scant Information Please Print Lezi
Address. 24 Normac Load
wo um, Mo ' -7 - 00City/State/Zip. oe # ;
Are you an employer?Check the appropriate box: Type of project(required):
1.R1 I arm aemployer with
I am a general contractor and
employees(fall and/or part-time).*
have hired the sub-contractors • El New construction
. I are a sole proprietor or partner- listed on the attached sheet. 7. EJ Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for nee in any capacity. employees and have workers' . Buildingaddition
[No workers' comp. insurance comp.insurance.
re aired. , El we are a corporation and its I .El Electrical repairs or additions
, I am a homeowner doing all v oark officers have exercised their I LO plumbing repairs or additions
myself. [No workers' comp. gbt o exemption per MG 1 Roof repairs
C. i p
u�ra�ac required.] � � � ' ,and we have o
employees. workers' 1 .[D otherSolar
comp.insurance required.]
Any app tic a t that checks box#I must also fill out the section below showing their workers'compensation poI icy infbr ation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
+ ontr►et is that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not these entities have
employees. if the sub-contractors have ernpIoyees,they must provi a their workers'comp.policy number.
I am an employer r that is providing workers compensadon insurancefor my employees. Below is the policy and job site
l formutlon.
Insurance Company Nance: Marsh USA Inc.
Poker#or Self ins,Lic.#:66454896 Expiration ]ate: 11#01/20 3
'T
Job Site Address �
/Stater
� p
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 cr ina penalties of a
dine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fora 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 o
Investigations of the DIA for ftw rance coverage verification.
do h erebyceMfy un der the Palos and Pealtls oCzerury that theinformation prosided above is true and correct.
Si Mature-
ohe : - 9- 900
Official use only. Do not write in thi'sarea,to be completedcity or town offleW
City or Town: Permit/License t
Issuing o y(circle one):
1.Board of Health 2.Biding Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Lnspector
.other
Contact Person: Phone
k