HomeMy WebLinkAboutWiring Permits - Correspondence - 777 GREAT POND ROAD 6/11/2015 Date :.. e ..................
ORT
'TOWN OF NORTH I p,1�1®OVER
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o a PERMIT-FOR
WIRING
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has permission to perform ct . ...
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wiring in the building of ...... ..
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ELECTRICAL INSPECTOR
Check# __w___----
Print Form
Commonweak of///amacLieffe Metal Use Onl
ct�-yy�� cc Permit No.
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eCJePa►•fmaartl o�...tire�grvicee
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07j (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfornied in accordance with the Massachusetts Flectrical Code(MI C),527 CMR 12.00
(PLEASE PR1AIT IN INK OR TYPE ALL INP-ORMAI-ON) Date: l 1
City or Town of: dG(Jiv- To lire Inspector or Wires:
By iliis application the undersign gives notice of his o her intention to perform the electrical work described below.
Location(Street&Nu ber)
Owner or Tenant 4'fit Telephone No. J(1
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[J 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 panels]
rated/26/rkW-DC @ S.T.C.Grid Tied. In conjunction with a Building Permit.
C'am�lctinn a the i>llotvitt tnhle nrcry he waived 6•t/u Lie ce7vr a 'Wirev.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans r o Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above mer enc mg
No.of Luminaires Swimming Poo l El
tacle Outlets No.of Oil Burners nd. rnnd. ❑
Battery Units
No.of Receptacle FIRE.ALARMS No.o p f Tones ,—
No.of Switches No.of Gas Burners n•a electron and
Initiating Devices
Tota
No.of Ranges No.of Air Cond. Tans No.of Alerting Devices
No.of Waste Disposers eat Pump I Number ons o,oSelf-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW I ocul❑ untc pa
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems,.;No.of Devices or E uivalcnt
o.of Water KN, o.o o.o Data Wiring:
Heaters g; ns Ballasts No.of Devices or E uivalcnt
No.Ilydromossage Bathtubs No.of Motors Total HP Telecommunications ring:
No.of Devices or Equivalent
OTHER: 71
Atlach additional detail if derired.or as required h.v the fimpector nj'Wires.
Estimated Value of Electrical Work: $ TZ.4000 (When required by municipal policy.)
Work to Star(: 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 the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: SOLARCITY CORPORATION LIC.NO.: 1136 MR
Licensee: Matthew T. Markham S@;rtat��re «t�'��i L IC,NO.: 1136 MR
1/0ppficahle,enter"exempi"in the license aianher line.) 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.57-61,security work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee doer not have the liability insurance coverage normally
required b law. B m signature below,I hereby waive this requirement. I am the check one C owner's a gent.
q Y Y Y•�g Y 8 � ( _
Owner/Agent
Signature Telephone No.
PERMIT FE._r.$ ,_�2-SE-2—
1
¢)f19Ce of Consomer Af!'Airs&Bavinm Regatatian
[pME IMpROVEMENT CONTRACTOR
Registfation: 168572 Type
Expiration: 3I8i263Ti Supplement
SOLARCITY CORPORATION
MATTHEW MARKHAM
24 ST MARTIN STREET 8LO 2UNI —
IlAhLBOROUGH,MA 01752 Undersecretary
(,-()MLqoV4WEALTk-v OF p t
ELELTRICIANS
ISSUES TliE FOLLOWING LICENSE AS x
REGISTERED MASTER ELECTRICIAN
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SOLARCITY CORPORATION
MATTHEW T IiORO P HAM
24 *SAIN'r MARTIN DR
-µ< BLDG 2 UNIT I
t1ARL BOROUGH MA 01752--3060
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Cx The Cononenhealth ofMassuchtisetrs
Deptirinient of InditstrittlAccidents
Office oflnvestigations
UIV 1 Congress Street,Stifle 160
Boston,ALL e021144 20f7
wow.massgou/dirt
Workers'Componsaiion Insurance Affidavit;Bttildelrs/Camfltact€rrs/ lectt�ieia>nslPium>;+crs
A lie nt Inlforination Please Frint Le ibI
Name ([Iusincss/Orgattixatian/lndtviduel): SolarCit COr
Add.ess: 3055 Clearview Way
CitylState/Zi : 402 Pbotie#: 888-765-248
Are you as employer?Check the appropriate box: Type of projeet(required):
1,E)1 an a employer with 4. 10111 a ge:iterftl aontraator and I
employees(fill)and/or part-time.).* have himd the sub-+contrxetors 6, 'Blew consmedon
2,❑ T am a sole proprietor or partner- listed on the attached sheet, 7. Remodeling
ship and have no employees These sub-contractors have g. [ Demolition
working for the in any capacity, employees and have workers' g, []Building addition
[Novvorkery' comp, insurance comp.msurmice.
required.] 5.{ We are a.corporation and its MD Electrical repairs or additions
3.[] l ant a horlreowtter doing all work officers have exercised their f LE)Plumbing repairs or additions
myself.[No workers' comp. 3 ight of exemption per 1 rtGL 12.0 hoof repairs
insurance required,)t e. 152,§1(4),and we have no 13 Other
employees.[No workers'
camp,insurance regttired,f
*tiny applicant that checks box 91 mast aiso fill out the section bolow0awitts!heir tvorltcrs'comrycnsation ponoy inronnation,
i Homewvnets who submit this aflidwit indicating lacy are doing all wark and then hire oulside canuudors mnst submits new af0devit indicating stick.
lcowraoom that check(Iris hox must attached to additiond sheetslowing Ilia molt oriha sub-contractors and stato whether or not those enruics have
amployo". if the sub-cgntraetbrs have emphryccs,lhoy must pravlde.their warkels'comp.policy number.
-atlt ern em fo er t/rat is rovidinl t;orAers�om sattorr sue�cc pr rn eel► to gees. Below�s the rtlt nrtd o6 sste
p J' P 8 pe 1 y P J p cy }
information.
Insumnce Company Name: Liberty Mutual Insurance Co
Policy#or Selr-ins, t,ic,#:WA766D06Q265024 Expiration Date: 9/1/15
Job Sito Address: 6( �6n ' 9d City/State/zlp: ;Z �L`j �I 1� t6 �1 �'��
Attach a copy af the workers'compensation polity deelnrution page(showing the policy number and expiration date).
Failure to secure coverage as required under Surtion 25A of MOL c. 152 can lead to the imposition of crminal penalties of a
fins;up to$1,500.00 and/or ane-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250,0U-a day against the violator. Be advised that a copy of this statement may be fanvarded to the Office of
investigations of The DJA for insurance coverage verification,
X do hereby Certifyuw tt., the pants and penalties ofperiu.31 that the itrformaden prortidad above is tare anti correct.
Pha� e4:
0jj Fei0i_use rrtrlJ. Do tsar write ire this area,to be campleted by city or tower ofciot
City or Town: Izcrtrriill.iet itse
Issuing Authority(circle oov);
1..Board of 111calth 2,Building Department 3,City/Town Cleric 4.Llectrical Inspector 5.Plumbing inspector
+6. Other
Contact Person; Phone#t
+W` CERTIFICATE E �r/OF LIABILITYINSURANCE $084=1 14
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THISC f,T0CATE its ISSUM AS A MATTER OF'INFORMAVOK ONLY AND CONFMS NO 810liTS UPON THE CIERTIFiCATE HOL.MR,THIS
CERTIFICA-Te VOES NOT AFI-1f(MATNEL,Y OR NWATIVELY AWND, EXTEND OR Al-TER THE COWRAGE AfFOADVO 13Y THE POLICIES
fkgi,;1W. TI•LIS CeRTfRCA.TE OP INSURANGE DO56 NOT CONSTITUTE A CONTRAOr j3j '1r EEN THE WSU.iNG INSURERS), AUT6It3R17, D .
REPAESU TATIVE OR PRODUCER,AtlO THE CERTtFtCATE HOLDER.
IMPORTANT, If tha oortifiCate.holder IS an ADDtTiONAL INSURED,tha polloy(loal moat bo endonaari. If SI18tZOOATION IS WAIVE,itubjact to
tile tems and conditions of the policy,certaln policies may taquim an endarssawfil, A s3tatemOnt On this crortificate does not confer rightxt to the
GeTtlfscate hDidev In lieu of such attdorsemant(ea.
PRi3UUCER _ .. ... __ ....
MARSH RISK$INSUM9SSERVICE$ �H E �t
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345 CAL150RO STREET,SUITE 13M WG_,r Jiv,AM];
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SANFRANCESCO,CA M104 tNSEs
_ WlNAff*AvM1GCOVERAGE 3EASCE#
99t3Ot•STNA-GAyyU!~i#15 IEEsuEEEOA;UbotfMvluotFu suelr, ranca"My 16586
INSURED tF3St}fEER$:LIt70(Fj(1Mw1w'.tftC.omuakn _ ... . . T _M .
Ph{65D?863 510q SHsu(tEk c:WA NEA
3Q55a6WYIaw WAY EH5URER D, -
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COVERAGE CERTIFICATE NUMBER-. SEA424402PP REVISION NUMBER:4
THIS IS TO EC Wft TNRT THE POLICIES OF INSURANCE LISTED 9Ei,OW HAVE BEEN ISSLIeD TO THE INSURSD NAMED Ai OVt~r0R"THE Poucy i F-R(OD
INDICATED. NOTWTHSTANDING ANY RFQLt4REMENr,TERM OR COMOITION OF ANY C[SNTRACT OR OTHPR DOGUMEf4T WITH RESPECT To'"'CH THIS
CERTIFICAT9 MXY Be ISSUED OR MAY FFA'1AIN•THE INSURANCE AFFQRDI tD BY THE t'QLICteS I}ESCRIB@L7 HERr jH IS 5UBjEOT To ALL THE TERMS.
EXCLUSIONS AND CONTIITIONS OF SUCH POLICIES,fwIMI-rS SHOtMN MAY HAVE aEEN REOU.CED&Y PAW CLAIMS.
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wit0ty colpoovo SHOULD ANY ESP THE AJ4QVEE 09SCRIEED POLICIES 05 CANCELt,ECI BF-FORE
1055Gl-w"ewWay ii•rc VPIW,,'ou CA'ry �.',LiL^vF, NOVICE 'OLL BE 1351.3:�PED t!1
Sw M�CA D4402 ACC.QRPANM 1NYfH UW VILCY PROVISIONS.
AUTHORIZED RH N"WnAT(YE
nt r,1llrale Rksk&EnanratlCa Se[vEtes
L'tttutes Marmote;a .�•�,""�"��~"'•'"�.
1098,2010 ACIORn CORPORATION. All Mhta feseeved.
ACOVO 25(7010105) The ACORD Rant and logo artt regiitererl mar"of ACOR13