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EW Service Permit App APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 City or Town of: __________________________________ Date: ___________________ To the Inspector of Wires: By this application, the undersigned gives notices of his or her intention to perform the electrical work described below. Location (Street & Number): ____________________________________________ Unit No.: ________________________ Owner or Tenant: __________________________________________ Email: ____________________________________ Owner’s Address: ____________________________________________________ Phone No.: ______________________ Is this permit in conjunction with a building permit? (Check appropriate box) Yes Purpose of Building: _____________________________________ Utility Authorization No.: ___________________ Existing Service: _____________ Amps _____/_____ Volts Overhead Underground No. of Meters: _____ New Service: _____________ Amps _____/_____ Volts Overhead Underground No. of Meters: _____ Description of Proposed Electrical Installation: _____________________________________________________________ ______________________________________________________________________________________________________ Completion of the following table may be waived by the Inspector of Wires. No. of Receptable Outlets: No. of Switches: Generator KW Rating: Type: No. Luminaires: No. of Recessed Luminaires: No. Wind Generators: Wind KW Rating: No. Appliances: KW: No. Water Heaters: KW: No. Transformers: Total KVA: Space Heating KW: Heating Equipment KW: No. Motors: Total HP: Total KW: No. Heat Pumps: Total KW: Total Tons: Fire Alarm System No. of Devices: Swimming Pool: In-Grnd. Above-Grnd. Hot-Tub No. of Self-Contained Detection/Alerting Devices: No. Oil Burners: No. Gas Burners: Video System No. of Devices: No. Air Conditioners: Total Tons: Telecom System No. of Outlets: No. Energy Storage Systems: KWH Storage Rating: Security System No. of Devices: Solar PV KW DC Rating: Solar PV KW AC Rating: No. of Modules: Roof-Mount Ground-Mount No. of Electric Vehicle Supply Equipment: Level 1 Level 2 Level 3 Rating: OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _________________________________ (When required by municipal policy) Date Work to Start: _________________ Inspections to be requested in accordance with MEC Rule 10, and upon completion. FIRM NAME: ___________________________________________________ A-1 or C-1 LIC. No.: ____________ Master/Systems Licensee: __________________________________________ LIC. No.: __________________________ Journeyman Licensee: _____________________________________________ LIC. No.: __________________________ Security System Business requires a Division of Occupational Licensure “S” LIC. S-LIC. No.: __________________________ Address: ____________________________________________________________________________________________ Email: __________________________________________________________ Telephone No.: ________________________ I certify, under the pains and penalties of perjury, that the information on this application is true and complete. Licensee: ____________________________Print Name: ________________________________Cell. No.: _______________ INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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: _____________________________________ 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: _______________________________________________ Tel. No.: ________________________________ Signature: ____________________________________________________ Email.: _________________________________ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.: __________________________ Occupancy and Fee Checked: ____________ [Rev. 1/2023] Residential No Permit No.:_________________ TBD Trinity Solar Inc.4434 A1 Brian K. Macpherson Brian K. Macpherson 21233 A 32 Grove St, Plympton, MA 02367 applications.westma@trinity-solar.com 413-203-9088 508-577-3391Brian Macpherson X X 12525 B SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 5/26/2023 Arthur J.Gallagher Risk Management Services,LLC 4000 Midlantic Drive Suite 200 Mount Laurel NJ 08054 856-482-9900 856-482-1888 CherryHill.BSD.CertM@AJG.com Gotham Insurance Company 25569 TRINHEA-03 National Union Fire Insurance Company of Pittsburg 19445TrinitySolarInc. 4 Open Square Way,Suite 410 Holyoke,MA 01040 Endurance American Specialty Ins Co 41718 Liberty Insurance Underwriters Inc 19917 129732996 A X 2,000,000 X 100,000 5,000 1,000,000 2,000,000 X GL202100013378 6/1/2023 6/1/2024 2,000,000 B 2,000,000 X CA 2960145 6/1/2023 6/1/2024 A C D X 5,000,000 X EX202100001871 ELD30006989101 1000231834-06 6/1/2023 6/1/2023 6/1/2023 6/1/2024 6/1/2024 6/1/2024 5,000,000 Limit x of $5,000,000 19,000,000 B XWC135881076/1/2023 6/1/2024 1,000,000 1,000,000 1,000,000 B Automobile Comp/Collusion Ded.CA 2960145 6/1/2023 6/1/2024 All Other Units Truck-Tractors and Semi-Trailers $250/500 $250/500 Evidence of Insurance Evidence of Insurance