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EP-77335 I • 1 ARTMOUTH - BUILDING DEPARTMENT RECEIPT 7733E, ' { 1 C i 1' 1' -1820 FAX: 508.910.1838 Nam`efithib 7 . fit Owner: DatJob Location: SI)t Map: 2C9 Lot:/3 — -;ire Description General Ledger ti's Ref. il Amount Building & Building Mise-0E mArA. t 1000-44105 Electrical / MD R it 1 1 0-44 1 06 sd, r;, 1---( cly& G U r Plumbing & Gas NAY 1 9 20,5 01011-44107 Trench Safety s 01010-44129 Other Department Rev b `caLtEC 000-42420 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received.By,. ---'c " :' ----..._ THIS IS NOT A PERMIT/LICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS .: _ Commonwealth of Massachusett �,' P Offtc�s�°3 Ste. I•= it �/� Permit No. ?— =.111 , Department of Fire Services? �i�/� �]) tCS ! Occupancy and Fee Checked /((° 0 •.-- r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C..e(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: •/14/15 City or Town of: Dartmouth To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform t e electrical work described .• ow. Location(Street&Number')?it Millers Dr Owner or Tenant Greg Potter Telephone No Owner's Address Is this permit in conjunction with a building permit? Yes ISI No I (Check Apt opriate Box) Purpose of Building Residence Utility Autho .tion No Existing Service Amps / Volts Overhead Und_ . No.of Meters New Service Amps / Volts Overhead Undg t No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Instaling a 10.5 KW photovoltaic system. Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures 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 Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices 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 0 Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: 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. 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 IN BONDn OTHER❑(Specify:) (Expiration Date) Estimated Value of Electrical Work: '0 Si I (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and comple1070 A FIRM NAME: SunBug Solar LIC.NO.: Patrick McDonough ilaatii /J /y 21070-A Licensee: Signature v� LIC.NO: (If applicable n er "yx t"i t lic e,nemb crime.) Bus.Tel,No.. Address:41 1 A Hlgnr nd Ave suite 31merville Ma 02144 Alt.Tel.No:` -85b 8Ub2 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the liabilit} ine trance cnvenge normally required by law. By my signature below,I hereby waive this requirement. I am the(check one owner _wner's agent. Owner/AgentP�ERtYIIT FEE:$ Signature Telephone No. The Commonwealth of Massachusetts _— Department of Industrial Accidents lh= t Office of Investigations _eeti c 600 Washington Street rismeire I— a Boston, MA 02111 me www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SunBug Solar Address: 411A Highland Avenue, Suite 312 City/State/Zip: Somerville, MA Phone #: 617-500-3936 Are Jou an employer? Check the appropri to box: Type of project(required): 1 1 I am a employer with 10 4. II am a general contractor and I 6. Ni ew construction employees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. 7. ■.emodeling ship and have no employees These sub-contractors have 8. Eli emolition working for me in any capacity. workers' comp. insurance. 9. ■iuilding addition [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised their 10■i lectrical repairs or additions 317I am a homeowner doing all work right of exemption per MGL 11.1 lumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.r'oof repairs insurance required.]t employees. [No workers' l3Ither Solar Installation comp. insurance required.] 4Any applicant that checks box#1 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 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. Insurance Company Name: Liberty Mutual Insurance Group Policy#or Self ins.Lic.#: WC31 S381595-014 Expiration Date: 4.30.16 Job Site Address: 82 Millers Driver, City/State/zip: Dartmouth, MA, MA 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: d', 12 i f Phone#: 61 - 0-3936 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#: ACC PR CERTIFICATE OF LIABILITY INSURANCE DATE T/(MM;Dm Y) 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 NAME: T. Edmund Garrity & Co. , Inc. (NC No EXt) (617)354-4640 FAXfAic No):(617)359-5828 545 Concord Ave. gOORe55.annie@garrity-insurance.com INSURER(S)AFFORDING COVERAGE NAIL# Cambridge MA 02138 INSURER A:Sentinel Ins Co. 11000 INSURED INSURER B:COImnerce Ins. Co. 34754 SUN BUG SOLAR LLC INSURER C:Liberty Mutual Ins. 411A HIGHLAND AVE INSURERD: INSURER E: SOMERVILLE MA 02144 INSURERF: COVERAGES CERTIFICATE NUMBERMASTER COI 2015 REVISION NUMBER: 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR SUEW TYPE OFINSURANCE ADDL POLICY EFF POLICY EXP LTRINSD WVD POLICY NUMBER (MM/OD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE I X I OCCUR DAMAGE TORENTED 1,000,000 PREMISES RENTrnence) $ 08SBANN6974 4/30/2015 4/30/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BOGVYR 4/30/2015 9/30/2016 BODILY INJURY P AUTOS AUTOS ( eraaitlen0 $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE 085BANN6974 9/30/2015 4/30/2016 AGGREGATE $ 1,000,000 DED RETENTIONS $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 000,000 OFFICER/MEMBER EXCLUDED? Y N/A C (Mandatory in NH) WC2315381595015 4/30/2015 4/30/2016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 D yes, TN under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION O OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) The Workers Compensation policy does not include coverage for Cheney Brand, Benjamin Mayer and Lisa Raf fin. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE William Garrity/ANNIE —`----- `--� 7 ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r,r11ant) $ ate*.�Z�mc7 z Za - CO 3•e�5m^.am D Og. Oco 0Nco n w nC N 0 o 3 N O O p O j 0 N z N U � o ma)' ca.0 O9 , (Dana) a CO' m � 32. yo'D.a cmmm i� amo vv aaa -I == ..m o o co-c^ 3 3•N m a0 0 9 N _ � m x 3 Fa. a m d� co s -- N m o + co a o a A av o_' I r c 0 -- m co N A < � O ofp' -O 50 v - C O M o N N o-, O 2 0 N o ® O0 N,� 71 �v O CO F �'-p 0 a00 KoN D<D a 3 �' �m 0 N 0 m c O [.1 < * N a cn rp a o or 3a • O Z -o A y O o 0 /� _,N --® J c c Doo m is °c 3. w J 3a CD N �. N D 3 O N V N N(((��� O co CO CD (((Op N y y a O = 0 W 3 F iv 2 CD coO a 0.1 s N N co NJ N O {�j D N N • T WV 0_ d C 40.co m Z Da H co 0 -0 a) m -—I z 1 a r # Date Revision rn : o [ a _ R1 ASimms 4/8/15 Greg Potter c N m Electrical Drawing 82 Millers Drive .a o IQ 411A Highland Ave,Suite#312 v o Dartmouth, MA 02747 c„ Somerville,MA 02144 I u