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EP-76170 0TOWN OF DARTMOUTH - BUILDING DEPARTMENT R CEIP F— 61. �' 0 f`� � HONE: 508-910-1820 FAX,.508-910-1838 r�, ' _;f "'�� „,, i /_ 1:'% iii„ V Name, I / ?( + j Property ' wner:<— i'` r ''- 1 bate. Job Location: fd '' 14 4 p: r 47 Lot: Description General Ledger#'s Ref. # Amount Building & Building Misc. 01000-44105 Electrical 01000-44106 /s .i //j / 1/. C / Plumbing & Gas 01000-44107 ; 1 Trench Safety 01000-44129 \ _ c`r ti Other Department Revenue 01000-42420 row N ccx-` � //�� White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received Byi e,,-'' f''V' THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS • C��JJ Print Form A/�// // Offi ' Use Onl (..ommonwealth o��a�achu�ett.! / y n' Jiepartmeni o/Sire&evice� f 1 i a 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),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 12/29/2014 City or Town of: Dartmouth,MA 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) 9 Medeiros Lane,North Dartmouth,MA 02747 Owner or Tenant Frank Evangelho Telephone No. 774-201-9260 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 Ove rhead n Undgrd n 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 [ 27 panels] rated 6.885 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. otal No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans To.of TVA Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ '0.o mer.gency tg I 'ig grnd. grnd. Batte 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 Initiatin• Devices No.of Ranges No.of Air Cond. Total No.o f AlertingDevices Tons No.of Waste Disposers "eat'ump `umber ons ' " `o.of Se I ontame i Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipalonnect io n ❑ Other, C No.of Dryers Heating Appliances KW ecurity stems: No.of Water No.of No.of No.of Devices or Equivalent KW 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: 17000.00 (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 El 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 Signature "f ef 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. I am the(check one)❑owner ❑owner's agent. Owner/AgentPERMIT FEE:$ SignaturetuneTelephone No. Inspections: Aaron Birkett Lic# 10843B 4- `,„,_,v..0.. of Coesamcr Muir,&ttusioesc Reguie ioe �s! E�5aRpV�CRRENTCONTRACTOR ,.: 168572 Type E. ,:: ..': 3►&201ti Supplement PL1\ ) SOLARCITY CORPORATtON MATTHEW MARKH.�M 24 ST MARTIN STREET MA 01752Bi 2UNI ILludersccreun } �� \ t t�It E"!sl „L' .tT a ' I ASS ,, Edit= �`` iiE1.ttZirIAL' I' SUES TH F Ctl.OWING LICENSE A.. A REGISTERED MASTER ELECTRICIAN a i SULARC I TY CARPOHAT I ON �l MATTHEW T MARK HAD 14 SAINT MARTIN DR BLDG 2 UNIT 11 MARLBOROUGH MA 01752-3060 # . .ram. ( '(.c^ `A ;:::...�L .A.°•L ti ,�hu:{ F: iOPE I r . CICEnin!Vi Eotu C • 5r7N ,- TRt > .fi• tJE$ tt FOL1. � tlCEN . _ :1CC� C NlrM6N9 A i tRT r 6,, : ERt L. ui1EEri The Commonwealth of Massachusetts 11 Department of Industrial Accidents •InaLJ iMactsilk"7-. t Office of investigations 1 Congress Street, Suite 100 .r = Boston,MA 02114 2017 '...1, v www.mass.govldia 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. I am a employer with 7000 4. D I am a general contractor and I 6. New 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. LI Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition {No workers' comp.insurance comp. insurance.t required.] 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions 3.D 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.❑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 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 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 employee& 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: 9 Medeiros Lane City/State/Zip: N Dartmouth,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: ✓jam^ A/14.k? X Date: 12/29/2014 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#: x . ACCORD CERTIFICATE OF LIABILITY INSURANCE °A�`M""°°"""'('08/29/2014 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 lieu of such endorsement(s). PRODUCER CONTACT MARSH RISK&INSURANCE SERVICES NAME: 345 CALIFORNIA STREET,SUITE 1300 PNJCNNo.Exty FAX No): CALIFORNIA LICENSE NO.0437153 E-MAIL SAN FRANCISCO,CA 94104 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC X 996301-STND-GAWUE-1415 INSURER A:Liberty Mutual Are Insurance Company 16566 INSURED INSURER S:Liberty Insurance Corporation 42404 Ph(650)963-5100 SolarCity Corporation INSURER C:NIA N/A 3055 Clearview Way San Mateo,CA 94402 INSURER D 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 CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE MR SUBR POLICY NUMBER i POLICY EFF POLICY UP LIMITS (MMIDDIYYYY) (MMIDD/YYYV) A GENERAL LIABILITY T62-061-066265 014 109/01/2014 09/01/2015 EACH OCCURRENCE $ 1,000,000 I DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY I PREMISES(Ea occunence) $ 1()D'OOt) X CLAIMS-MADE X OCCUR i MED EX (Any One P -- person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 _GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGG $ 2,000,000 I ) X POLICY I AFT I LOG Deductible $ 25,000 A AUTOMOBILE LIABIUTY AS2-661-066265-044 09/01/2014 09/01/2015 COMBINED SINGLE LIMIT 1,000,000 (Es accident) �.----...-----._. X ANY AUTO BODILY INJURY(Per person) $ALL AUTOVVNED SS SCHEDULEDAUTOS BODILY INJURY(Per accident) $ X x NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) X Phys.Damage COMP/COLL DEC: $ $1,000/$1,000 UMBRELLA UAB OCCUR EACH OCCURRENCE $ - EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION S - $ B WORKERS COMPENSATION 1WA7-66D-066265-024 09/01/2014 09/01/2015 X we STATU- OTH- AND EMPLOYERS'LIABILITY I TORY LIMITS ER B ANY PROPRIETORIPARTNER/EXEGUTIVE Y/N i WC7-661-066265-034(WI) 09/01/2014 09/01/2015 1,000,000 B OFFICER/MEMBER EXCLUDED? N N/A EL EACH ACCIDENT $ (Mandatory in NH) 'WC DEDUCTIBLE:$350,000' EL DISEASE-EA EMPLOYEE $ 1,030,000 if yes,descrbe under 1,000,000 DESCRIPTION OF OPERATIONS belowEL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SolarCity Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 3055 Clearview Way THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo,CA 94402 ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE of Marsh Risk&Insurance Services I Charles Marmole)o ,C.. . /-'-7�i{---e-- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD