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EP-78317
TOWN OF DARTMOUTH BUILDING DEPARTMENT RECEIPT 73317 Ji PHONE: 50EI '10- ;FAX: 508-910.1838 j re, / Name: 'd ' " Property Owner: t il— DateG'•/� Job Location: /04ahr G() / Map: `�`'& Lot:/1 ,////9 Description ,,,ge ettLedcer#'s Ref.# Amount Building& Building Misc. 41000-4416i5 7 Electrical 01000-44100 3lj /,9-iC 54',".6, 1 Plumbing & Gas 01000-4 07 Trench Safety 071}11O44129 �a,, ( '' ® � . 5`„ Other Department Revenue 01000-42420 \I White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received MT/ � THIS IS NOT A PERMIT/LICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS �' I I �rint Form /� t7� q� / (1. t j ip C,onunomosalU.a f t/ia&achu4eits 11 `t `' ,. `'/ ry�/ vv..tt Permit No. ///t �,/ ' j t in :'a, heparimeni oiJire�eruicee •.IA / •` iI ,� )BOARD OF FIRE PREVENTION REGULATIONS Occupancy 1/ leave blank). dFeeChecke //S�� ,,.... APPLICATION FOR PERMIT TO PERFOR irr CTRICAL 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: 8/4/2015 City or Town of: Dartmouth 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) 14 Warbler Way Owner or Tenant Matt Rose Telephone No. 508-934-9918 Owner's Address same as above Is this permit in conjunction with a building permit? Yes n No ❑ (Check Appropriate Box) Purpose of Building w/Solar-PV Utility Authorization No. n/a Existing Service Amps / Volts Overhead n Undgrd n No.of Meters New Service Amps / Volts Overhead❑ Undgrd n No.of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install Solar Electric- Photovoltaic(PV)system [44 panels] .i< rated11.44 kW-DC @ S.T.C. Grid Tied. In conjunction with a Building Permit. Completion of the following.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- ❑ No.of Emergency Lighting grnd. grnd. Battery 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 I Initiating Devices No.of Ranges No.of Air Cond. Total No.of AlertingDevices Tons No.of Waste Disposers heat Pump I Number I Tons I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security S stems:* No.of Devices or Equivalent No.of Water KW No.of No.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 of Wires Estimated Value of Electrical Work: 28,000 (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 0 OTHER 0 (Specify:) I certify,under the pains and penalties ofperJury,that the information on this application is true and complete. FIRM NAME: SOLARCITY CORPORATION LIC.NO.: 1136 MR Licensee: Matthew T. Markham Signature e r LIC.NO.: 1136 MR (If applicable,enter"exempt"in the license nnnther line.) Bus.Tel.No.•781-816-7723 Address: 160 Corporate Park Drive,Pembroke.MA,02359 Alt.Tel.No.:774-258-8505 *Per M.G.L.c. 147,s. 57-61,security 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 D owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Inspections: Aaron Birkett Lic# 10843B . / • : .!..i; * .4' ' '.414. 1'W• i' ;.• ;,..f''...;, -. . , • .ma of Consumer Albin&Ruainew Regulation A , .,.,9-rrnopnvEMENT CONTRACTOR ' -* .,• ,.i Ji..i • 16S572 Typt t:,.::.• : . 318120 i 5 Supplement SOLARCITYCORPORAHGN MATTHEW MARKHAM — . 24 ST MARTIN STREET MD 2UNI ' AmusoRouGH.MA 01752 Iladersteretary , t 1 rnicANCRONWFAI TI f or MASpA; /!Pig I , ts- z. :-. ;., , ".•,,„.7gUL kPc (- 7 1:.SUES TH I CI LOWING LICENSE A.;', A ,.., REGISTERED MASTER ELECTRICIAN /SOLAR('TY CORPORATION _--"- MATTHEW T MARKHAM -. L .. : 24 SAINT MARTIN DR BLDG 2 UNIT 11 'I, MARLBOROUGH MA 0 1752-3060 a. 1'-'CI.'"*.'77F.'1,''''7. ' nN.,.'.:47,1.ri47 .mr.."'-y.-rc-...•.:Hq;-4,-;??:-.::] 4112.1•44.',J.!, .LLEP- .z.. g9 ,.. ..-.1i7Li.g.1L .. ?Latta*?('-t. • , DIVISION OF PROFESSIONAL LICENSURE . ..::::::;;:. E.:: :.,,..:fi ::.-„.:., 411%"::: :1•;Y?.:: ::::'..::.,7:1 •ittiitS:'1,..O.C'-FtitLefittifikiltatagie.. 1,44-.1ittr-atuRttgovigh4wri i crAftc,.-4,::, .\,...411_::: :..- ..t.**Th4,-::E1:1.',..l...-:,'2-4kAlli*Alinaktn:::::':.--..:: :;,-.2.L.sr„T..;'..:.':,:„:!;...:-,--:,c.'..iNC..:CA.,?:-..:::::::-.:::i.Y.::::C:' :- ; :‘-c-.:-..:7•( ' -..: 4 .:1';;.€:;.::2:1i;:rf:.:,:::;,:;Ni.l.:.'4'.:.%- ..:::-::::...•::;,..,::::'4..-2.:::,:- .);.: . ': '..t]it-1::.. •.:„:_...t.:i ..::300.1.04.1#411:12:-:•!'JY5::::;663:-.:-: :.1:: .-. ''f. -. 1-,.: .!:::',N:Z.: '..:',iitT4?';:e0:: ::::.:::-..-:.;-.'-;,;:::-.,..'::;:.:::iitl.::;:-.... .''-.:;•:::,':-:R1.:-!;-1147:4 0*#:4041till:.14...:.;:''1.:::'!:144::00,39. 500::.1.(Cb:;....1 :-N t;7: &421#4,14446Rn;--41-5,1C?il....% ::::? I • The Commonwealth of Massachusetts h Department of Industrial Accidents . Ell lilt!- Office of Investigations or _Mr 1 600 Washington Street " -R.kile..li - = Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Bohm:.,t'tg;uiz:niou taw,itluani SolarCity Corporation —I Address: I3055 Clearview Way City/State.Zip: 'San Mateo CA 94402 Phone#: 188e-765-2489 Are you an employer?Check the appropriate box: Type of project(required): 1. £t I am a employer with 5000 4. El I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2.cI am a sole proprietor or partner- listed on the attached sheet. t 7. ®Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition ;) [No workers'comp. insurance 5. ID We are a corporation and its • required.] officers have exercised their 10.�Electrical repairs or additions 3.I] 1 am a homeowner doing all work right of exemption per MCI. 1 I.Q.Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.r1 Roof repairs ' insurance required.] t employees. [No workers' 13. © Other Solar comp. insurance required.] 'Any applicant that checks box 41 must also fall out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating thcy am 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. pp Insurance Company Name:, 1I'berry Mutual Insurance Company Policy#or Self-ins. Lie.#: WA766D066265024 Expiration I)ale: t 9/01/2015 —I Job Site Address: I 14 Warbler Way J Dartmouth/MA/02747 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. I do herehr certif'under the pains and penis 'es of perjury ro a information provided above is true and correct Signature f', .f� -/ �:�r; I8/4/2015 — I tale. Phone rr: 1888 765-2489 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#: ii A ROC oe CERTIFICATE OF LIABILITY INSURANCE °OM/2014 " ' �2014 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 Ileu of such endorsement(s). PRODUCER CONTACT MARSH RISK&INSURANCE SERVICES NAME: 345 CAUFORNIA STREET,SUITE 1300 PHONE FAX CALIFORNIA UCENSE NO.0437153 PHONE_Mit. Imo,No): SAN FRANCISCO,CA 94104 AMRFcc: INSURER(S)AFFORDING COVERAGE ?WON 996301-6TND-GAWUE-1415 INSURER A:Literty Mutual Fre Insurance Company 16566 INSURED INSURER B:Liberty Insurance Corporalon 42404 Ph(650)963-5100 SolarCity Corporation INSURER C:N/A NIA 3055 Gearview Way INSURER 0: San Mateo,CA 94402 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002440269-02 REVISION NUMBER: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 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 CONDITK)NS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LNIR TYPE OF INSURANCE PIER inn' POLICY NUMBER aMMEYEFF POLICYEXP LIMITS (MMIDDIYYYY) IMMIDDIYYYY) A GENERAL LIABILITY TB2-651-0 56265-014 '09/01/2014 09/01/2015 EACH OCCURRENCE $ 1•000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MEDEXP(Any one person) $ 10,000 ' PERSONAL S ADV INJURY 5 1,093,000 GENERAL AGGREGATE $ ___ 2,000,000 I GEN'L AGGREGATE�I LIMIT APPLIES PER' PRODUCTS-COMP/OP AGG $ 2.000,000 ( I POLICY) A I LOC Deductible $ 25,000 A AUTOMORRE LWBIUTY AS2-661-086265044 09/012014 0991/2015 (CoOMBI SINGLE LIMIT $ 1,�,� X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS AUT NON-OWNED ( OPP Per (DAMAGE S X Phys.Danege COMP/COLL DED: S $1,000/$1,000 UN9RELLA LIAR OCCUR EACH OCCURRENCE $ I EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED 1 I RETENTIONS $ B WORKERS COMPENSATION iWA746D n"'065424 09/012014 09A12015 X WC STATU- oTH- AND EMPLOYERS'IJAMLRY TORY IIMmS FR B Y/N ANY PROPRIETOR,PARTNERIEJ(ECUnVE :1WC7�61-0 6 626 6()34(WI) D9f(1120,4 5911)i/2615 EL EACH ACCIDENT $ 1,�+� B MaFnddatory In NW EXCLUDED? N N/A VC DEDUCTIBLE:$350,000 1,000,000 DtSCRr 11DN OFO EL DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATION$below EL.DISEASE-POLICY LIMB $ 1,000,000 DESCRIPTION OF OPERATIONS,LOCATIONS/YFNaT ES(Attach ACORD 1e1,Additional Remade Schedule,If mom space Is requires) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION Sob/City Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 CleaMew Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo,CA 94402 ACCORDANCE WITH WE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk&Insurance Services I Charles Marmolejo C. :- --:t ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo am registered marks of ACORD