The URL can be used to link to this page

EP-76027 T TH - BUILDING DEPARTMENT RECEIPT 76027 te 1 %27 :1 10-t 20 -F : 508.910.1838 cf Name: <C . , co, p Property Owner: L/J ! 7<�� Date:242f// Job Location: 6/1 7q C{ TeLet /aVeI ✓y,"f Map: -7/ Lot: / Description General Ledger#'s Ref. # Amount Building&Building Misc. / N°F8 Oo 105 Electrical 01u00-' 6 c o„-- 47 ) J 0 Y umbing & Gas EL 10116t30-441 7 Trench Safety „..n 4)1000-44 29 Other Department Revenue NC0[O--f-6 -42420 s White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By ' THIS IS NOT A PERMF TILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS V - - . Print Form Commonwealth m Official Use Only l,ommonaealth of/r/allac�et�i �,.�� ' - li -'1/ rryye� c7 n Pemmt No. -7Viv � apt_ d.3eparimenl o/.-tire&pvcced r, l' 1 j Occupancy and Fee Checked `+ .. > BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5j7 CM 12.00 (PLEASE PRINT IN INK ORTYP�' 4fLINFORMATION) Date: /2//Z�ZD/y'/ City or Town of: q`/it.coa7 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) OPT? o`P r,n- . -zone XL:? Owner or Tenant /f 4.7bIlJ /FF44D Telephone No Sob 495^$SV5 Owner's Address same as above Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building w/Solar-PV Utility Authorization No. n/a Existing Service Amps / Volts Overhead n 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 [ice panels] rated (ti7 kW-DC @ S.T.C. Grid Tied. In conjunction with a Building Permit. Completion ofthe following table may be waived by the Inspector of Wires. Total No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No. f Trano KVAsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool.`clove ❑ 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 Initiating Devices No.of Ranges No.of Air Cond. Total No.o f AlertingDevices Tons No.of Waste Disposers 'Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Monnectiunieipalon 0 Other C 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. Estimated Value of Electrical Work: /,DDO (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 0 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: SOLARCITY CORPORATION LTC.NO.: 1136 MR Licensee: Matthew T. Markham Signature Sit LIC.NO.: 1136 MR (If applicable,enter"exempt"in the license number 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. 1 am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. Inspections: Aaron Birkett Lic# 10843B 1 r J C tenet of Consumer Affairs Q Bacinea Regulation :N.:3-2) urIMPROVEMENTCONTRACTOR vi v c.,;L:._. 168572 Type �.: ..;..: L&2015 Supplement ( /c''J� -SOLARCITY CORPORATION v MATTHEW MARKHAM 24 ST MARTIN STREET BL02UNIK4M LBOROUGH,MA 01752 Undersecretary CfMMONW'EA1_Tt4 9l MASvitylir l T z:: iiEL,RirIAN' ILSUES TB FOLLOWING LICENSE Az. A REGISTERED MASTER ELECTRICIAN t s SOLARCITY CORPORATION '• rx MATTHEW T MARKHAM 24 SAINT MARTIN DR BLDG 2 UNIT it MARLBOROUGH MA 01752-3060 D!''ISIOIu Or PROFESSIONAL LICEMSURE tiS'90I* t}i>f FCLL41_t .T'£ Tfu :F d Ji "1 L LTRIClA • Pa FEEKETT 905 StTief# � 5T • : 00413y'B 71�f6 .1S3 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations airi 1= M 1 Congress Street,Suite 100 -_111_ Boston,MA 02114-2017 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): SolarCity Corporation Address:3055 Clearview Way City/State/Zip:San Mateo, CA 94402 Phone#:888-765-2489 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 7000 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' P ty. 9. ❑Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We arc a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152,§1(4),and we have no Solar Panels employees. [No workers' 13.�Other comp. insurance required.] *Any 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 him outside contracto's must submit a new affidavit indicating such. :Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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 Company Policy#or Self-ins. Lic.#:WA7-66D-066265-024 Expiration Date:09/01/2015 Job Site Address: (a/3 OGD met 2!d£t2 42D City/State/Zip: ,ThlEm.tou7l? ti14 OZ7417 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:�� — /ram < M,«ex Date: /2-72 2-0/ty/ Phone#: 7818167489 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#: S • �`v CERTIFICATE OF LIABILITY INSURANCE DATE oa `"14 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 poliey(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 MARSH RISK&INSURANCE SERVICES NAME: 345 CALIFORNIA STREET,SUITE 1300 - PaNXo.EMI- WC E-MAIL .No): CALIFORNIA LICENSE NO.0437153 SAN FRANCISCO,CA 94104 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL R 998301-STND-GAWUE-14-15 INSURER A:UTrerty Mutual Re Insurance Company 16586 INSURED INSURER s:110VInsurance Cmp6ra&n 42404 Ph(650)963-5100 SolarCity Corporation INSURER C:N/A N/A 3055 Clearview Way INSURER D: San Mateo,CA 94402 • INSURER E: 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 CONOmONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE MR VIVO POLICY NUMBER M SUER [ POLICY EFF POLICY EXP LIMITS (MOLIC YYYYI IMMIDDIYYYY) A GENERAL LIABILITY TB2-661-066265-014 09/01/2014 09101/2015 EACH OCCURRENCE $ 1,000•000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO REM FED 100000 PREMISES(Ea omnence) $ CLAIMS-MADE X OCCUR LIED EXP(My one per) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2•000•000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY' ^ .7g fl LOC Oeduelitie $ 25,000 A AUTOMOBILE LIABILITY AS2-661-066265044 091012014 09/01/2015 COMBINED SINGLE UMIT 1,000,000 (Ea accident) .$_.-__._. X ANY AUTO BODILY INJURY(Per person) 4 ALL SCHEDULED BODILY INJURY(Per accident) $ X HIRED AUTOS x NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) $ X Phys.Damage COMP/COLL DELI: $ $0000 41,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ LIED .RETENTIONS $ B WORKERS COMPENSATION iWA7-86D-066265-024 09/012014 09/01/2015 X we STATU- OTH- AND EMPLOYERS'LIABILITY TORYI NITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN IWC7-061-066265-034(WI) 09/012014 09/01/2015 EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N NIA B (Mandatory in NN) 'TTIWC DEDUCTIBLE:$350,000 EL DISEASE-EA EMPLOYEE 5 1.000.E EveA desvaouneer DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Ramada Schedule,If more space M request) Evidence of Insurance. • CERTIFICATE HOLDER CANCELLATION - Solargty Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Clearview Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San MaBD,CA 94402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of marsh Risk&Insurance Services I Charles Marmoll)io c-C—— --le--(--It ©198B-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo am registered marks of ACORD