HomeMy WebLinkAboutWiring Permit solar part 1 - Building Permit - 725 BOXFORD STREET 5/11/2015 Date F .....'...........................
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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> This certifies that ....................................... �......... ..... ......... :.............. z
has permission toperform .....� ...... .6. :. ... ..f.: � .. ..� !................
wiringin the building of.........:.......:. ':°:.:.. .....'......................................................................
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at ...... , rt � d �... :....,North Andover,Mass.
Fee... 4: Lic.No.�4s. .. . ............
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E�ECTRICAL�NSPECTO
Check
Print Form
o�(ramnwnweadlji ///a��ae�eu�el Official Use Only
Permit No. �)
�Llepart*ms►tl a�...tir+e.Jerviced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 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
(PLEASC PRINT IN INK OR TYPE ALL INFOR ATION) Date. S (�
City or Town of: or1dC)U{'i' 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) �T
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) "
Purpose of Building w/Solar-PV Utility Authorization No. n/a
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: Install Solar Electric-Photovoltaic(PV)system ( j' panels)
rated kW-DC @ S.T.C.Grid Tied. In conjunction with a Building Permit.
Cnar�tctina n Yltc Jn11or+•Nr talile tnak•he wuiscd b•tlrc Lrs eclor a 'Wirer.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o,of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above n- 0.0 mergency g ng
No.of luminaires Swimming Pool rnd. rnd. Batte-a Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of 7,oncs
No.of Switches No.of Gas Burners o.o etection and
Total Initiatin Devices
No.of Ranges No.of Air Cond. Tons No,of Alerting Devices r
No.of Waste Disposers eat Pump I Number rons KW No.of Self-Contained
Totals:I F Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.or Dryers Nesting Appliances KW Security S ystems;
No.of Devices or Equivalent V�
No.of Water KN, o.o o.o Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or E uivaent
OTHER:
Atlacb additinual delad if desired,or as required by t/re h►spector nj'Wires.
Estimated Value of Electrical Work: �(yC ('� (When required by municipal policy.)
Work to Start: A.S.A.P. Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑✓ BOND ❑ OTHER ❑ (Specify:)
I certify,under toe pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: SOLARCITY CORPORATION LIC.NO.: 1136 MR
a:lcettsee P1latthewT. Markham Signature LIC.RO.: 113 MR
(1('applicable,enter"exentpi"N the license number tine.! Bus.Tel.No.*774-258-8180
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.57-6 1,security work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee doer 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 age"
Owner/AgenttunePERMIT FEE:$
Signature Telephone No.
—^ I
;r ' �D6fIc�oPC:pnsumcr,Gffgtra�p�ntiness TiCe{;ulmtio�t
no, rrt �
r00ME IMPROVEMENT CONTRACTOR
Registration: 168572 Type
ExpdraVoll: g/812617j Supplement
SOLARCITY CORPORATION
MATTHEW MARKHAM
24 ST MARTIN STREET BLD 2UNI << •�� '_—
iWLBOROUGH,MA 01752 Undersecre9ury
E ,,k°I`.'fRICIAI1S
ISSUES `I"FIE FOLLOWING LICENSE AS A
REGISTERED MASTER ELECTRICIAN
^8
SOLARCITY CORPORATION
MAT1'HEW T I"di" %rh,HAM
24 'SA I NT MAD"I'I N DR
BLDG 2 UNIT )I /A
MARLBOROUGH MA 01752-3o60 �rur�
The Commonwenillt of Massachusetts
Department of InrlustrialAccidents
+" Office of Its vestigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
' www.mass.gov/ilia
Workers'Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers
Applicant Inforintition Please Print Lc ibl
Name(13usiness/Organizatinn/individual): SOLARCITY CORP
Address:3055 CLEARVIEW WAY
City/State/Zip:SAN MATEO, CA 94402 Phone #:888-766-2489
Are you an employer?Check the appropriate box: Type of project(required):
1.10 1 am a employer with 5000 4. ❑ 1 am a general contractor and 1 6.
employees(full and/or part-time).* have hired the sub-contractors . ❑New debt construction
7
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑Remoling
ship and have no employees 'These sub-contractors have g, ® Demolition
working for me in any capacity. employees and have workers' g 0 Building addition
[No workers' comp.insurance comp. insuranco.t
required.] 5. [:] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing;all work officers have exercised their 1 I D Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no SOLAR/PV
employees. [No workers' 13MM Other_,___._,..
camp. insurance required.]
*Any applicant that checks box 41 must also rill out the section below showing their workers'compeaeation policy information.
t I lomeowners who submit this affidavit indicating they are doing all wotk and then hire outside contractors must submit a new atl"idavit indicating such,
tContractors that check this box must attached an additional sheet showing tire name of the sub-contractors and state whether or not those entities have
employees. tf the subcontractors have employees,they must provide their workers'comp.policy number.
l ant an ettiployer Ural is providlti workers'compensation itrsurarice for niy employees. Below iv the policy and job site
Information.
Insurance Company Name:LIBERTY MUTUAL INSURANCE COMPANY
Policy 9 or Self=ins. Lie. 11:WA7-66D-066265-024 Expiration Date:09/01/2015
Job Site Address:�_ ��ZL_. ..,. City/State/Zip: tit"" j� ., ]�
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 tfo hereby cerl&antler the pains and Penalties of perjury that(lie i►tfornmallou provitleil above is true ant!correct.
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Phone M
Official use only. Do trot write/it this area,to be completed by city or town official.
City or Town: Permit/License N
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#:
,/��4C-a./R®� CERTIFICATE OF LIABILITY
® DATE(MMYODIYYYY)INSURANCE
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 (NSURER(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 endorsements.
PRODUCER NAME:CONTACT
MARSH RISK&INSURANCE SERVICES PHONE !FAX
345 CALIFORNIA STREET,SUITE 1300 (A/C,No,EAU: (AIC,No):
CALIFORNIA LICENSE NO.0431153 EMAIL
SAN FRANCISCO,CA 94104 ADDRESS:
INSURERS)AFFORDING COVERAGE NAIC e
99B301-STND-GAWUE-14.15 INSURER A;Liberty Mutual Fite Insurance Company 16 l)G
INSURED Ph(650)963-5100 INSURER e:Liberty Insurance Corpolation 42404
-
SolarCity Corporation INSURERC:NIA 'NIA
3055 Clearview Way INSURER D;
San Mweo CA 94402
INSURER E:
INSURER r:
COVERAGES CERTIFICATE NUMBER: SEA-002440269-02 REVISION NUMBER:4
THIS IS 10 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE. BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INITIGATEL). NO(VVIIHSIANDINCi ANY RECIUIRFMENI, TERM OR CONUIIION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 WHICH THIS
CERTIFICATE MAY HE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
E XCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCFO BY PAID CLAIMS
INSR TYPEOi1NSUFTANCE �AODiISUBRI!WVn, POLICY NUMBER MMmO�YFF MMLrDDmYY
LTRLIMITS
A GENERAL LIABILITY T62-G61 OG6265.0)4 09,10112014 WIN112015 EACH OCCURRENCE IT 1,000,000
X COMMERCIAL GENERAL OAHII ITY ( TIREMIS TO lit: 100,(10D
PREMISES IEd ac�inelco) S
CLAIMS MADE X (OCCUR I MED EXP(Any.one poison) S 10.000
I PERSONAL&ADV INJURY a 1,000000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE I IMII APPLIES PER I PRODUCTS•COMPIOP AGG S 2,000,000
X POLICY, X PRO• LOC IDeduclible S 25,000
A AUTOMOBILE LIABILITY JAS2.661.066265-044 09..10 I2014 09r01/1015 MBINED SINGED LIM 1000000
,(Co occident) 3
X I ANY AUTO I I HOD❑Y INJURY(Por poison) $
ALL DWNFG �SCHEDUEkD HODILY INJURY(Per acc.dant) S
AUTOS i AUTOS
I X 1 HIRLO A1110S X NO O5�ED (Pm u'FF 7Y OAMAOF S
X Phys Damara i ICOMPICCILI DFD: S $1.0001S1A00
UMBRELLA LIAO I OCCUR i " � LACII OCCURRLNCI. S
EXCESS LIAll I Ct AIMS MAGI. ,AGGREGATE a
OLU RETENTION3 S
p WORKERS COMPENSATION I WAI.660.OGG265.024 1ftU11'2614 ,1W10112016 X Wc:STATU o H.
AND ERAPLOYERe'LIABILI7Y .TORY LIMITS ER ,
B ANv PROnRiETORrPAR1?J Ril XI(J I IVL YIN i WC/G61 0GU265•U34(WI) 09.01l2014 09ro112015 E L LACtI ACCIDENT S 1,000,000
OFVICERJN.EMDcR EXCLUDEG'� ( N NIA 1
B (Mandatory in NH) WC DEDUCTIBLE:$350.000 E t ❑ISLASE•EA EMPLOYEE,S 1.00000
yyees dose ltoo tndw ( 1.000,000
DkSCRIPTIONOf OPEHAI(DNS :ow [t 0SFASE POLICY LIMIT I$
i
DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 1ef,Addlilonal RemArks Schedule,If more apace Is required)
1 v{1�eT i o!Insurance
CERTIFICATE HOLDER CANCELLATION
Sn!-City Cwpolatitio SHOULD ANY OF THE ABOVE UESl:kibty VULIUILb BE UAh4LVLLtU utt-ORF
3055 Clearview way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
San Mateo,CA 94407 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED RFPRESENTATIVE
of Marsh Risk&Insurance Servicos
Charles Marmolelo —=.-
C 1988-2010 ACORD CORPORATION, All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD