29-084 (4) City of Northampton Mail-CSL Information https://mail.google.com/mai1/u/0/?ui=2&ik=39211afc3d&view=pt&se...
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Northampt= Charles Miller<cmiller5nor thamptonma.gov>
CSL Information
1 message
Victoria Junck<vjunck@solarcity.com> Tue, Jun 7, 2016 at i . 1,PJ�11
To: "Charles Miller(cmiller@northamptonma.gov)"<cmiller@northamptonma.gov> `7
Good morning Cheri,
l// i
I am emailing you in regards to several permits that we have open with the City of Pi ieid. We need to get the
CSL information changed on the building permits for the following addresses:
6C Lake St (Florence)
11 Acrebrook
-:- -.
2� Hinckley St
20 Fruit St
The CSL information that the above need to be switched to is:
Jeremy Graves
604 Silver St
Agawam, MA 01001
CSL# 108706
Type: U
Expiration Date: 02/23/2019
Contact number. 774-279-7650
Victoria Junck
Permit Coordinator I SolarCity
l of 2 6/7/2016 1:32 PM
AThe ['ulntnonwealtlr of Ma sachuselts
Department of Industrial Accidents a
:..- t;rh :WI office of Investigations
��
; ►.� /
+ �!1�4..., 600 j��ff51liR�'trt113trec►t
Boston, MA 02111 C,,,'fes'
+Ire'', WII11te. /14.1..gOIVditr
Workers' Compensation Insurance AIl'idavit: liniklers/Contractors/Electricians/Plunibers
Applicant Information Please Print Legibly
Nam a(ptlsin s'or(;ynizxtiutlil)xlividuxl): SOLARCITY CORP.
Address: 3055 CLEARVIEW WAY
C ily/S1;tIc/%il): SAN MATEO, CA 94402 Ilion, fi; 888-765-2489
_
Are you an employer?? (.heck the appropriate box: — _ Type of project(required): I
1.0 1 ant a employer with 5000 _ 4. III I no a general contractor and 1 6 n New construction
employees(lull and/or purl-tittle).* have hired the sub-contractors
10 lam a sole proprictot or partner- listed on the attached sheet. 1 7. Itentexle{ing
ship and have no employees "these sub-contractors have ft. [] Demolition
working tier me in any capacity. workers'cutup. insttrinice. O. n Building addition
(No workers' comp.insurance 5. 0 We are a cot po alien and its
miquired.J elffisects have•exercised their i0.❑Electrical repairs an additions
3.LI I am a licancownel truing all wort; right of-exempt ion 1 er 1.1(.il. 11.0 Plumbing repaint or additions
Inti self. l\o' tiers comp. e. 152,§I(,1).and%\e have•no 12.0 Roof repairs
insurance required.'` employees. I No worker.'
Cutup.insurance Lewis-W.1 13.0 Other
`Au)applicant II►iil t9Krt.y txtr,al into ectal,till vat the see•litn helms dlttttiuv their ttnrl.el:coni itbIlllgn lad icy illrtnnlatittn.
t t lewucniwlLT5"Ini.nigrlit ails aRitlai it intlieutiug the) the ekn,r all Walt,and then hirer—outside ermitii•ttu•s luuct si,Nmit a new itITid,n iI iudieutiiu such
ICwnrattur,(hut thiol.tali,itln elia.l;AlnrtIill Int midi tieuild,brit NIkW,innfie namc Iaithe:41•crnlirat1us and;heir talrkers'comp.tx.lie) infirm:Rion.
I am an employer that it providing waders'compensation insurtnlce fur toy entplo)'res. Be/nw ix the polirt'and fob site
information.
Insurance Company Name: Crich ASV r,Qa.n I tiSO' tnCe COM!'
Policy fl or Sell-ins. Lie. Y: We- Dig2.0 -06 - Fspiratiun Date: 0^01-UD
b "�IL
Job Site Adttrt'ss:. I_I Pk/IL ('ty/Slaitilip:_ _ V 0atklottn,kutt. Li
Attach a ropy of the workers' compensation policy do iaration page(showing the policy number anti expiration Beat4
l:aillne to secure coverage as required under Section 25A of?Mil.c. 152 can lend In the imposition of crhuina{ pt•nall'tes ora
Zinc up In $1.5/(1.00 and/or one-year imprisonment,as well as civil penalties in the limo ufa SI'UI' WORK Olt D1-.11.and a line
of up to S25U.tt(1 a day against the violator. He advised that a coil of chi,statement ma) he forwarded to the t)I'lice of
Investigations of the I)IA for insurance ccrvcr:)kl,e veriliCatin)t.
I do hereby certify Roder the pair-.wrr pruultier o/perjure that the information provided above is true ant!correct.
SiRanoIe;... -44-442-`_ _.,..--ed-�e`er--- . .. I)rae:
1 t,
)It01.r'ti.
Official use only_ Do trot write in this arra,to lit'completed ht•r•i/l•or tutrn VOA
('it)-or'1'own: T - T_ l'crtuit/hieenoe II '
Issuing Authority (circle one):
I. hoard of stealth 2. Building Hepartntcu! 3.('ity/town('lar k 4. Eiectricatl Inspector 5. (Nunmlbing Inspector i
6.Other
('unhurt Vei•ca,ln:. __.._ �� _�__ _. Thune II: -
a.
A�� e
CERTIFICATE OF LIABILITY INSURANCE D88 v1 -
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: Ir the certificate holder is an ADDITIONAL INSURED,the policy(les)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 PHONE. ...__.._...rte...... ......._..._--_._......_
345 CALIFORNIA STREET,SUITE 1300
CALIFORNIA LICENSE NO.0437153 E-MAIL
SAN FRANCISCO,CA 94104 RE :—...... ... .. ........ .. ....-.._ ..........t6535
...... .......
Attn:Shannon Scott 415-743.3334 INSUNERtSIAFFORUNGCOVERAGE.... -..--_. 0.._..
Zurich American Insurance Company
998301-STND- 15-16 .... _....... --.NsuNEaA: ...__. .... ............. ..- .... .. ..MA
WSURED N91AtHEB: ......... ............_.SdarO ty Corppapat .....`-... .3055 CfemiswWay INSIRER C: t........
Sm Mateo,CA 94402 idSURER p_Atmed=Zurich IIIMITOCO Cowart, 0142
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: SEA-00271383€08 REVISION NUMBER:4
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PCUCY PERIOD
INDICATED. NOTATTHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 3E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.OARS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-INSR ...----...-..- - - ADM SUER j_... POUgryW POLICY EXP
LTR TYPE OF INSURANCE INSD yvD t POLICY NUMBER IMNYODJYYYYI fMMIDOIYYYY) LIMITS
A I X 'COMMERCIAL GENERAL LIABILITY �+LO0182016-00 09.91/2015 1!09D1,2016 EACH OCCURRENCE S 3,000,000
LX,
X I {)AidAxiE TO RENTED $...._ . . ..3,000,ODO
.._-SI-1k
..j CL.JMs-MADE 1... :OCCUR ( PR,�MISE$.t�4owrrr?reel._............._..-. .._.__.
X SIR:i250.000 uEo.exP{Any ane pasorti_-_s.__-- --._.. 5,000
—
I PERSONAL&ADV INJURY $ 3,1)O♦O.OIXI
GERLAGGREGATELIMIT APPLIES PER' ; GENERAL AGGREGATE $ E.
r 1AAO• r� .
.X POLE C...J JECT I._.. LOC fPRooucTS-COEEPlOPACia.�.s..... .... ... .6,000;WO
OTHER ! I S .
A AUTOMOBILE uASLTrc 3AP011?2017.00 C'J101Q015 10901/2016 COMetNED SINGLE LIMIT $ 5,000,000
X I ANY AUTO j BODILY INJURY(Per person) S
._ ..1 Au.OWNED Sf DULEC I I .__......... ... .....__.._..__ ....._....._.__..._
__ 'AUTOS X sCHEo BODILY INJURY(Per acUdal) $
t PROPERTY DAMAGE _.. ..._._..._._ ...__ ....
Autos
X_' I'I REC AUTOS .X.. .uias EO 3P SL.- .......... $
COMP/CO'.L DEO: s $5,000
UMBRELLA LIAR I I OCCUR I I EACH OCCURRENCE s ..
EXCESS UAB 1 ct. us-MADEI AGGREGATE 6
T
OED I RETENTIONS I I I.x c�Tli7Ur6�.-_ _...ta_...._. _ ._._...
r p WORKERS CONVERSATION yVC018201d-00(AOS) 09A'I2015 OQ'D1/2016 I Dit� ! 1,000
OFYICER:LOYI ORILMar.ITY L-�_-� -^
A ANY PROPRIETORIPARTNEWFJCECUTIVE Y!N WUU78'10trt-ILO�) Cd,9'.12015 09'0112016 E EACH ACCIDENT S �_
ANOEMPNSMBEREXCLUDED+ n NIA I DEOl1CTIBLE:5500,000 EL DISEASE-EA EMPLOYEE 8 1,000
;Mandatory In NH)
ryes.RIPTIONunder + EL DISEASE•POLICY Lean $
l..ESCR1PTtGN CFOPERAI•IOhS Dafox 1,000,000
•
F1
3
DESCRIPION OF OPERATIONS 1 LOCATIONS I VEHICLES IACORD III,Additional Remark Schedule,may be attached If more space Is required)
EvGs rce of insu'ance.
CERTIFICATE HOLDER CANCELLATION
SolarCil COTOreke SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
3056 CIearvrewWay THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
San Mateo,CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh Risk&Insurance Services
Charles Marrnolejo ,—�, � --,---C—=
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
.'t /lfe ( /Ir f—: /sft't r !//!! e j (1, : . ,e/r ,/1 / , , f! .
Office of Consumer Affairs land Business Regulation
t.:1'
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
• Registration: 168572
Type: Supplement Card
Expiration: 3/8/2017
SOLAR CITY CORPORATION
. JEREMY GRAVES
3055 CLEARVIEW WAY
SAN MATEO, CA 94402
Update Address and return card. Stark reason for change.
Address Renewal Employment Lost Card
Unice of foasamer Affairs&Business Regulation License or registration valid fur individul use only
,. NOME IMPROVEMENT CONTRACTOR before the expiration date. if found return tn:
i Office of Consumer Affairs and Business Regulation
Registration: 168572 Type: 10 Park Plaza-Suite 5170
Expiration: 3/8/2017 Supplement card Button,MA 02116
SOLAR CITY CCI-t-u.0tA I KIN
JEREMY GRAVES
24 ST MARTIN STREET BID 2UNI • -a. .._ . ! ;
ITAMLBOROUGH.MA 01752 t'adersecretary .Not valid without signature
•
Maesaenusetls Depart' ._. . 7 ,'••''
Board of Bu;idfng 4egurat.:;,:s 1 ,• t - : e :,
cense CS-108706 1.1111)
JEREMY GRAVES ok 16
179 BRIGHAM STREET
Marlborough MA 01752
02/23/2019
I
w.' Q`'/O rt»rl»oi/it,c(i/l4 n/ ��.r,;.;rrr� tUUJ �/(; >' Office of Consumer Affairs sand Business Business Re ulation
` 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 168572
Type: Supplement Card
Expiration: 3/812017
SOLAR CITY CORPORATION
VICTORIA JUNCK
3055 CLEARVIEW WAY
SAN MATEO, CA 94402
Update Address and return card.Mark reason for change.
SCAG 201.1 as as Address Renewal _-1 Employment `-I Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
a ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
registration: 168572 Type: Office of Consumer Affairs and Business Regulation
-'iz
10 Park Plaza-Suite 5170
Expiration: 3/8/2017 Supplement Card Boston,MA 02116
SOLAR CITY CORPORATION
VICTORIA JUNCK
24 ST MARTIN STREET BLI)2UNI �+��---i6LQ�— `/1" /
I IAF�LBOROUGH,MA 01752 410/.
Undersecretary Not valid without ature
ee VI 5 a
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. ' Not Applicable 0
Name of License Holder:SOLARCITY/JEREMY GRAVES 108706
License Number
604 SILVER ST AGAWAM MA 01001 02123/2019
Address Expiration Date
774-279-7650
Signature Telephone
9:Registered Borrie ImprovementContractor Not Applicable 0
SOLARCITY CORPNICTORIA JUNCK 168572
Company Name Registration Number
604 SILVER ST AGAWAM MA 01001 03/08/2017
Address Expiration Date
Te°ephcne 978-215-2367
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and sabrn:tted with this application.Failure to provide this affidavit will result
in he denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No ❑
11. - Hine Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofone(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 7801 Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildinc permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Norneovttier Signature