Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
EP-86862
TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT < 'C ` 32 PHONE: 508-910-1820 FAX: 508-910-1838 Name � / f/� i9 V//i (�e-y- ✓' P open wner: /JC Dat@:% oa f Job Location l ,/0/6/- /`Map: 7/ Lot:W Description General Ledger#'s Ref. # Amount Building & Building Mi ,�ofD�ART .1000-44105 Electrical PA 0-T000-44106 a X 7cf?) Plumbing& Gas OCT 2 4 201701000-44107 Trench Safety 01000-44129R N ,,- Other Department Rev la. 6 00-42420'e ' COL-EC 9 • ey t 4.White-Collector's Office Yellow Copy Customer's Receipt Pink Copy-BuddingDcpanment L.:Received By Cri THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS p� �/i� �/ ��qqqq /7/ ce i Commonwealth o/fYladdacLiadetto Office sg1; i'-° c'y �7 Permit t,o. I=,. 2epartment o/Jire Serviced Ovc BOARD OF FIRE PREVENTION REGULATION [Rev l/07]07] and Fee Checked(leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC).5 7 CMR I .00 (PLEASE PRINT IN INK OR TY ALL INFORMATIONDate: 1 o p•74 I l City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of h's or her intention-to perform the electrical wo escribed below. Location(Street&Number) },�s�-�` Owner or Tenant f � t_ IC Telephone No.SO(CO LIS Owner's Address .MC �f� . / Is this permit in conjunction' � with n a building permit? Yes 1q No ❑ (Check Appropriate Box) ...) Purpose of Building (A( _t 1 f Utility Authorization No. Existing Service aCf)Amps .O /...'4O olts Overhead n Undgrd ❑ No.of Meters QCT/A, New Service Amps / Volts Overhead n Undgrd n No.of Meters • Number of Feeders and Ampacity n VI Location and Natureu o_ft_Proposed Electrical /Work: t flSt l `cj t \'( l t� moi- `m'/�` 3nt-A/ c <U 1 Completion of the following table n y be wa ved by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.Trano KVA f cq sformers 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 1 No.of Receptacle Outlets No.of Oil Burners I FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection-and Initiating-Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices 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❑• Municipal ❑ Other Secrrit Connection J iems:* No.of Dryers Heating Appliances KW 'No o Sf 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: \AC1` i s , 1 O Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lectric I Work: �{ • -i (When required by municipal policy.) Work to Start: I 23 } Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERA E: 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 ap /ication is true and complete. FIRM NAME: V1 V Inc SUta.v .0.. ii-- et1_r'tY `-"`, l LIC.NO.: �� Licensee: Li C--ja 2-- SW(CI Li Signature t C. _Sri _. c7 LIC.NO.: l S D al/ (If applicable. enter exempt"in the license number.line.) Bus.Tel.No.:'12I1 Lin'0.,30 Address: (0'1R— M1/44 le.s Stan at&Y\ Rt • -TQ.C.InICXN met Alt.Tel.No.:(003g8tU rP8-rS *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 ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ACO on9/2017 Dl9 on ® CERTIFICATE OF LIABILITY INSURANCE DATEYYY) 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 MARSH USA INC. NAME: FAX 1225 17TH STREET,SUITE 1300 INC NE No.Ext) (NC,No): DENVER,CO 80202-5534 E-MAIL Attn:Denver.CertRequesl@malshcom I Fax:212-948-4381 ADDRESS: - INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Axis Specially Europe INSURED INSURER a:Zurich American Insurance Company 16535 Vivint Solar,Inc. Vivint Solar Developer LLC INSURER c:American Zurich Insurance Company 40142 Vivint Solar Provider LLC INSURER D:N/A N/A 1800 W.Ashton Blvd. - Lehi,UT 84043 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: SEA-002920277-18 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR- ADDL SUBR LTR TYPE OF INSURANCE NW WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIUOIYYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY 3 7 7 6 50011 7EN 01/29/2017 11/01/2018 EACH OCCURRENCE $ 1.000,000 CLAIMS-MADE ' X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) 5 1.000.000 _. MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 X POLICY I PRO- JECT LOC PRODUCTS-COMP/OP AGG 'S 1,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAP509601502 11/01/2016 11/01/2017 COMBINED SINGLE LIMIT $ 1,000,000 IEa accident) X ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) 5 X HIREDAUTOS x NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ Comp/Call Ded $ 1,000 A X UMBRELLALIAB X I OCCUR 3 7 7650021 7EN 01129/2017 11/01/2018 X EXCESS LIAR CLAIMS-MADEEACH OCCURRENCE ,5 5,000,000 GL Only AGGREGATE $ 5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WC509601302 11/01/2016 11/01/2017 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE AZ,CA,CT,FL,HI,MA,MD,NJ, E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) NM,NY,PA,SC,TX,UT • E.L.DISEASE-EA EMPLOYEE 5 1,000,000 B DIf ESCRIPTION under WC509601402(MA) 11/01/2016 11/01/2017 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 • DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Town of Dartmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 400 Slocum Road THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dartmouth,MA 02747 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Kathleen M.Parsloe uuo-7y(, alti ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts tea. JY Department of Industrial Accidents -!' Office of Investigations 600 Washington Street Boston, MA 02111 s='' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information y�prPllease Print Legibly Name (Business/Organization/Individual):` I V t 1 , ` , I At �l�` y i`7 • �� Address: I oW V'J • q\-1.kor iy,\ud aufaztke Ctatt \ City/State/Zip: UT ? -2' Phone #: (1 acl Cog S�1 Are you an employer? Check the appropriate box: Type of project(required): 1.N- am a employer with ear- 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 working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.LJ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof� repairs insurance required.] ' c. 152, §1(4), and we have no 13.Ly ether,� �1 Cul'employees. [No workers' 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 hire outside contractors must submit a new affidavit indicating such. tContractors that check 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. p� • Insurance Company Name: nn` ' ' e \ Can E Jr 1 ZNsJ1� /CQ� Q(`(1(YLf^�C Policy#or Self-ins. Lic.#: k C SCR COO t 1/4 (�— n n Expiration Date: �1� yII I 11�� C/J\ Mer Job Site Address:kV,I C Id HA I I i U l.V I2�l�/ City/State/Zip:J a i I 1 16J C 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 unde they ins nd penalties oof perjury ,that lthe�information provided abovecorrect / is true and Signature: �s (V • Vilt �ll(AA� UP__. Date: 1 73 I Phone#: ZSl JI a QU4 S9 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#: Fold,Then Detach Along All Perfainhone o COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE :Y. r. ELECTRICIANS ISSUES THE FOLLOWING LICENSE REGISTERED MASTER ELECTRICIAN LLOYD R SMITH VIVINT SOLAR DEVELOPER LLC 100 NEWPORT AVE EXTENSION QUINCY.MA 02171 16688 A 07/31/2019 326883- ) DATE 'SERIAL NUMBER