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30B-045 (4) City ofNo :hamaton Mail CSL Information hcss 3u20.poste mimai'.0 u= 2&'il.= c I fc d&vt v t&sa... 3oe_ oy5 a at cz?cf I'tor, Tera-x. r�yz:;i, _hart trite;c,:cw .a :.n — n . ,.go' s- CSL fnferne.Von .... ...,_ 1 message Viatorla Ju wok <gjunck@solarclty.corn> Tue, Jun 7, 2015 at 12:11 PM To: "Cliches Miller(cmiller©northemptonm a.gov)" somiller©anorthamptonma.00v> iti Good morning Cheri, /,�/y`'t aFi I am emailing you in regards to several permits that we have open with the City of Pit' field_We need to get the CSL information changed on the budding permits for the following addresses: 60 Lake St(Florence) 11 Acrebrook 386 Bridge Rd ......L52.12ikley 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!usok Permit Coordinator l SolarCity rf2 5 ? 9p1F 1 Phi A6 The C'awnooweollk oJ'Masxachusrlfs o1� b , �1� �_— Department of Industrial Accidents k( \�' N,.=, (Wire to/investigations -_•I 4;�`}, 600 Washington Street C0 Boston, MA 02111 If'unp.n)uxx.genVdia Workers' Compensation Insurance Affidavit: Baiklers/Cont enetursfEleclricians/Plumbers Annlicani Information Please Print Legibly Name(nuskless4)rganirmiimindividuapl SOLARCITY CORP. Address: 3055 CLEARVIEW WAY City/slate/Zip: SAN MATEO, CA 94402phone ID 888-765-2489 - Are you an employer?Check the appropriate box: —_. Type of project (required): 1.0 I and a employer with 5000 _ 4. LII am a genera aaaraclor and I 6. [l Nesv cmbdvdiml employees(lull and(or par-Time).' have hired the subconlincors 2.❑ I ion a sole proprietor or wilier- listed on the attached sheet. 1 7. 0 Remodeling ship and have no employees These soh-contractors have K. D Demolition working lig me in Any minority. workers'comp. insurance. 4. n Building addition INo workers'comp.insurance 5. [1 We Are a vapornlion and its tenni-oldoltcers lin\'l'exert ISI'd hien 10.0 Electrical irpairi Ill additions 3.L) 1 not a homcownet doing all won Is right orcxeInpl ion ler MCd. 11.0 Plumping repairs or nddidous in)sell I No wod;ats'eon c. 152.*I(4),and we baro no 12.0 Roof repairs insurance rcyoi red.I r employees.I No worker'` 17.0 011ier °quill.l llSllml%Y I NUi ictl.I 'Ara xn,lieml dist Maria It,, NI awn carr till tel the veliwr nti Ii Jury Lep Ilan lire s mtgnnlaalmr mutt)intuit t hal. IDuniiiimS him ORA n111 h.v'''MINIuilivaiininenw>m:•rhdir:ar0nil.mdrn a L.111wknit!on.t.l..11,midNiaanrllrr' .up.i iltwavmnyliidr K omnlnw.ILol Mrs(ILi.lm.umlm mmdrcJ nil rnLlilimml.Lor elxnr inp Nr may u111n aWrtnuA.mwn mid dude xrxkn •..xap.ludin inlimn:xinn. I ant an employer Thal is proehling'lottery'compensation in ura,,c a for sap employees. Rehm,Lc the policy mid joh the l/Ilnr,natiou. ,�L /{,,� Insurance Company Nam.:: `Ort x�1 Angel eri eaten J ace. Ogino Palin Yl or ser-ins 1.iv. ii: TV C- D!€ZQLH —IN Iixpirmian Ua(lc�: ,Iter-�0(l'—taRp,y1 Wig Q Joh Site Address:, _2.j 1-\ 11/1 C,1(,I11 II_. ('iry_ltil:avlLip_`V V114''tk,i('r4'Wtr((�°l'1 Attar n copy of the workers' eonynmsalian pLlin'declaration (urge(shoring the policy number And expiration noirh failure to S'tllit enwrap°as required older Scatino/5A or MOI. e. b2 con lead to the imposition or criminal penalties Miro 1111e rip in S1.i111E011 and/or ono-year imprisonment,as well as civil penalties in the limn oro S'IOI' WORK ORDER and a liar of lipid$2..50.W a day ltgairvt the violator. He advised dol a rap) or this smlcmeill nm) he linvearded lo the(Mice of hrvcsligal ions of the DIA for insurance coverage cerineaiion I da bereft,'ttrrttifr tatter the pato".%Ili r penaltiesss✓f perjury that the information provided above is taw Mod c urren. Simms., "..j / _. iO4'^'!^_ /s - �Z— .. 1)nnu: . 1'honr 6.(//l Official use may. Do not mile in(hit anl,to 7 completed hl rite or mous official. -- -_ _ SII City or'town: I'ermit/I Arrow if Issuing A athoril) (circle env): I.Board of Health 2. Bottling- Department A. City/Davit Clerk 4. Electrical Inspector 5. Plumbing lnspechir h.Other (-onlacf Pe-ta"t: Phone II: ACORDN CERTIFICATE OF LIABILITY INSURANCE Aretrm s al THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If tMNcerti icate holder is an ADDITIONAL INSURED,the poem/Des)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on the certificate done not confer rights to the certificate holder In 11eµof such endorsement(s). PROEM/CFR CONTACT MARSH RISS&INSURANCE SERVICES .WAIF; - . 345 CALIFORNIA STREET,SURE 1300 INC ap.EW: . . _ .. _ONE liF.:1 _ . . . . - . CALIFORNIA LICENSE ND.0437153 E-MAL SANFRANCISCO,CA 94100 NN'Semnon$mi41$143Ab4 NSVRE�SI AFFoRnms enKRAGE _ NA1Cr _ 4981%-STIN- 15MSVPLR R:2YIkM1 PmercTi Insurance Company 1696 inisuRED sd r ity CaPYd401 INSURER II:NNIA H ... . .. _ .. ..... i 3O6%GBa'OW Wey INSURER C:NH NIA Sac Mato,CA 94402 NER SURU American beech Insurance Compan 1140142 NSURER E MSURERF; COVERAGES CERTIFICATE NUMBER: SEA-OZ113B36-08 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID COWS.ascO oom_suSR -FPac.eFF-FPOUCYEr> [TR TYPE OFAYSURANCE ?Nin VNO1 POLICY NUMBER )11NOOXYYY1 I 0AOI/WYY1'YI LIMITS A X !GIMINERCTLL GENERAL IMMURE '0300162016-00 09/01201$ 0001/2016 EACH OCCURRENCE $ 3,000,000 j CIAMBMPOF I X OCC:L4 •1 PRE SFS? �INenQl I 3,000.000 X SIR.B250.000 I I MEG SEP(ART one porton) s 5400 PFASONALanVINJVRY s 3,000,000 _ --_ GE NL AGGREGATE FLIMITRO.AERIES PER GENERAL AGGREGATE 8 6,000,800 XFVLICI"l :Yeti i ftp F FACIXGTSCpA PIOP PGOF - fi.Qq WB ICIER • I •• 13 A AVmMOBRE LIASLm EAP01e20ITi30 09,01/2015 OM810D1a 1c1 NO�NCGLE LIMIT A X j ANY AUTO I BODILY INJURY(Pm ARsml 8 X ALL OWNED X SCHEDULED BODILY INJURY(Per at aen0 I SN°NerNEO PROPERTY DAMAGE EW XREDPmOS X Mn0I 1PxaEATRA1. 8 COMPICOLL EEO. $5,000 cwi(B4AADE S UMBRELLA MAB CLOW I EKNOCGLRREGE S EXCESS LMB I J AGGREGATE ES. OI 'PETERSON'S )8 D WORRERS CORIPENSATION HCO14320140(AOS) osonoi5 rogowale `XI ERiuiE I _L0 AND E ovErtNBRITY • A YPROpPETDRTARTNER/E%ECuiuE N D1 Z15.00(WA) 00.OIR015 IBN1RDlb E L a/GRALY]DE/4T tit 1,OI GOO OFFICER/MEMEER SECLUDED? n NIA 1- - I - I�NyMa��nnxEN Inti DEWCTIELE1500,W] EI DISEASE EA FUPLOYE5y! 1,000,000 DFSCRPTIDN OF WE RATIONS Mery IE L DISEASEPODGY LIMIT I$ 1400,1100 1 DESCH/ANON OF OPERATIONS/LOCAnDn„VEI; ES(AGGRB,et,aossolal Rem,,,.kReaie,nsm be attached If more Emma Is IeM.,I Evidence a ke:renae. CERTIFICATE HOLDER CANCELLATION Sda1C1y Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 34155 CIMS Way THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED W San MRMo.CA 99402 ACCORDANCE WITH THE POLICY PROVISIONS. AU1HA RED REPRESERTATVE o1 Marsh Rl*t Insurance Servkes Charles Marmolejo C. /'0'- 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Y / //7• ( . /fr Office of Consumer Ailhirs and Business Regulation 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 I:pdate Address and return curd. %lark reason for change. Address Renewal Employment Lost Card Omreof(Mummer Affairs d Bushmen Regulation License or registration valid fur individul use only HOME IMPROVEMENT CONTRACTOR before the expiration dole. If found return to: 1 . Office of Consumer AlTnira and Rosiness Regelatkm Registration: 168572 Type: 10 Park PIara-Shite 51711 Expiration: 3)8/2017 Supplement'Said Benton,MA 02116 SOLAR CITY CCRRA:A I InN JEREMY GRAVES 24 ST MARTIN STREET BM)MINI -- PvtMLBOROUGH.MA01)52 Ibdemerremm ,Not valid Mirhout signature CS-108708 I f JERE MY GRAVES 4h 179 BRIGHAM STREET Malborough MA It1752 0V2312019 re ( (' » i?(t'n//// 1 A Office of Consumer Affairs hand Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 168572 Type: Supplement Card Expiration: 3/8/2017 SOLAR CITY CORPORATION VICTORIA JUNCK 3055 CLEARVIEW WAY ---- - -- - -- SAN MATEO, CA 94402 ----- - --- - -- ---- - Update Address and return card.Mark reason for change. u - Address Renewal –] Employment —i Lost Card Dmee of Consumer Attars&Business Regulation License ar registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiation date. If found return to: Office of Consumer Affairs and Business Regulation C Registration: 168572 Type: 10 Park Plaza-Suite 5170 Expiration: 3/8/2017 Supplement Card Boston,MA 02116 SOLAR CITY CORPORATION VICTORIA JUNCK 24 ST MARTIN STREET BLD 2UNI a..®/ _ e. IAAALBOROUGH,MA 01752 Undersecretary Not valid without attire SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of license Holder SOLARCITY(JEREMY GRAVES 1108706 Deanne Number 604 SILVER ST AGAWAM MA 01001 02/23/2019 Address Expiration Date 774-279-7650 Signature Telephone 9.Renistered',Honte Improvement Contractor: . Not Applicable 0 SOLARCITY CORPNICTORIA JUNCK 168572 Company Name Registration Number 604 SILVER ST AGAVWAM MA 01001 03/08/2017 Address Expiration Date Tereohons 978-215-2367 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be comp;eled and sobmitteo with this application.Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 0 No ❑ 11. - Home Owner ExeniptiOn The current exemption For"homeowners"was extended to include Owner-occupied Dwellines of one(I) 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 780. 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 fart 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 Oficial,on a form acceptable to the Building Official.that he/she shall he responsible for all such work performed under the building 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 maV he lin bio for person(s) you life 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,Slate and Local Zoning Laws and State of h4assachusetts General Laws Annotated. Homeowner Signature