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1 message
Victoria Junck <v)unck@solarcity_coma Tue, Jun 7, 2016 at 12:11 PM
To: "Charles Miller(cmiller@northamptonma.goy)" <cmiller@northamptonme gotta
Good morning Cheri, tv
iti
1 am emaling you in regards to severe!permits that we have open with the City o£Pyield We need to get the
CSL information changed on the buiding permits for the following addresses:
60 Lake St(Florence)
11 Acrebrook
386 Bridge Rd
25
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
Conten number: 774-279-7650
Victoria Junck
Permit Coordinator SolarCity
of
6-7 'Mi F 19') PM
i e70/t15 QCT
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Homar:SOLAP.CIT`(/JEREMY GRAVES 108706
License Number
604 SILVER ST AGAWAM MA 01001 02/23/2019
Address Expiration Dale
774-279-7650
Signature Telephone
9.RemsteredlHonie Improvement Contractor: Not Applicable ❑
SOLARCITY CORPNICTORIA JUNCK 168572
Company Name Registration Number
604 SILVER ST AGAWAM MA 01001 : 03/08/2017
Address I Expiration Date
Telephone 978-215-2367
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.o.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wiii result
in the denial of the issuance of the building permit.
Signed Affidavit Atached Yes. ❑ No.. ❑
11. -'Ramo Owteer Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or rwo(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,an which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or fanu
structures.A person who constructs more than one home in a bun-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 he
responsible for all such work oerlbrmed under the buildine permit.
As acting Construction Supervisor your presence on thejob site will be required from time to time,during and upon
completion a£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 Annoeated.you may be liable for person(s)
you hire to perform work for you under this permit
'Ilio 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.
Homeowner Signature
The('ommnonweallk ofMussac'husells /i
Department o f Industrial Accidentst•agir ion r
VI
1r -` Quire of f n'cslignlinns' I -4.62s
EI lily 400 Wmhingtru StreetrO, erdt
3°_� Basion, MA 02!11 / 001 ' �d
wee nian..goiVJ'l
Workers' Compensation Insurance Affidavit: Buiklers/Conlracturs/Electricials/Plumbers
Annlicaal information Rhine Print Leaibiv
Name IRoshle<'organirrlint✓Individualg SOLARCITY CORP.
Address: 3055 CLEARVIEW WAY
city/slate/zip: SAN MATEO, CA 94402 phone it: 888-765-2469
Are you an employer?(:Leek the appropriate box: Type of project(required): ---
I.❑+ I and a employee with -`lana _ 4. LI I sin it genentI comruclor and I 6. n New cnnstrucliau
employees(lull and/or purl-lime).' have hired the soh-conlmrIon
2.❑ I uma sole propuielot or pnrincr- listed on the attached sheet. 1 7. ❑ Remodeling
ship and haw no employees These sub-contrlctors have H. ❑ Demolition
working forme in any capacity. workers comp. insurnnu:. 9. n Building addition
[No workers' coup. insurance 5. 0 We area ctn porulion and its
required.] oflcels have exercised Ilwir 10.0 Electrical retails uI additions
3.CiImnaIWlllewellO1doing all wink right or exemplion pee M61. 11.0 Plumping repairs or aildilioles
mi self.I Nn winter(comp. c. 152,41(4),and we marc nn 12.0 Roof repairs
insurance niquired.l' employees.INo workers'
comp.insurance require] 17.0 Other
-Aas apolicam Bin chocksh el IITOSIAMI Ill OMnOW - II t WIIM 410tlitIVo 1 t policy ( t
11 rfirei It.,®Boil ari.v nitint iiinkin i(chi) uie clie4all twin,all Ulildien hirt.cmisnk lea ta(uwcsI sianit diino'allnhn)hilletay such
1(onxmm1.Jiadad.Iai.box'MINI mmtkal it,,xdliliuud Jka alkiwioglik.BMW III Ihrvdemwn.amn.:ma Ikea wwker:onus Inlit inlivaitukin.
I mon cart)/over Mai is prodding umbers'eorrrpentatien inwarant'.'for per employees. Melon'ix the pollee and job site
informatimb
Insurance Company Nance: Zurich /l/Y/lI'eri Qat ' nee Cortipw '
Policy i/or Sell-ins n. I.ie. 11: W CI-I DlSZOJ74 -00 Expirmion Dale: 0"1-0J 'i IO
Joh Site Address:, � ri � S�_-- ('ilyisia,tgip_' ))I l+ (sOsafV ' It ^lQ
Attach it copy of I hr worker: compensation policy declaration page ishowing the policy mailer and ex pion duo date).
Failure to seem¢enornre ax Irgoired under Section 15A of kM(iI.e. 152 can lead In the imposition of criminal penalties ora
line tip In$1.500.011 and/or ouo-your imprisonment,as well as civil pcnmhios in the loan old STOP WORK l Ill Uh.l(and a line
or oil It'$150.0U n day against the violate'. lie advised Ihni a coin of this statement nap he forwarded to the I)Oke or
lavexlig:Inions of 1110171A far insurance emerni;v verilical ion.
I do hereby certify ander
/the pato-.ar''woollies c4 perjure Mal a see information provided above is true and Carat<9.
Sit;musn c_ / _ Si�/2t-xl^_ - -6d lam•-. .. I kite: .
ga
(1(lic'k/axe Iall'. Douanwrite in Ihk num,to be completed by rib:or town official. - - ---- -_-_-
ISI Cily or'town: 1'e'ndl/License/I . _..-.
Issuing Au lhoriis (circle tow),.. . . .
' I. Board of 11en11k 2. 13mildinp Department 3.frit)/low)clerk d. Electrical Inspector 5. t'huuldng Inspertnr
ft.other_- _
I
('anlxel persnat. __ .._ ___.__._ — I'honr ll: -.. .
4CO d CERTIFICATE OF LIABILITY INSURANCE OATE(MwoONYWI
06111/2615
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS •
CERTIFICATE DOES MOT 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
REPRESENTATIVEOR PRGDUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must he endorsed. If SUBROGATION IS WAIVED,subject to
the tame and conditbos of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu 6fsuch endorsememis).
PPam,CER CONTACT
MARSH RISK t,WSNUNCESERVICES mum
'.FAz..
345 CALIFORNIA STREET,51111E 1300 DRETW.FW: hMATAM
CALIFORNIA LICENSE NO 0437153 EMIL
SAN FNANCISCO.CA 94104 AOQ $S'
AJth Sheaon Soff415143.331 'NS PE151AFiG11nNGfAYERnGE _ 1 NNC11
998301SENOG4WUi-1516 igEggeIA ZwIkh/Endow InsuranceCon:pry
165E
INsuREED Y EaWfilal __. INSURERS:RIA INIA
&tr3055Cheiv'ew Way INSURER C:NIA N/A
Ss Mateo,CA 94401 xsURE0.C:American Zurich lmwenaecunpay 440142I
_
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: SEAS0171353606 REVISION NUMBER:4
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BETON HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEBOVEFOR THE POLICY PERIOD
CERTIFICATE
INDICATED. NOTYAOING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE CED BY S DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID MAWS.
WV TWE OF INSURANCE ADDL MB 1... � PQICYEFFT PWCVEXP ,..
POIICYNIMREA IQ0l5 1 NJ4OLY1S UMTS
A 1 X 'COMMERCW.GENERAL LMaairY R1E0192016E0 09/01/7615 00912016 EACH OCCURRENCE S 1000,01
iCLvus.NaOE %occla -MMAD£TO RENEW s 3,1001
1 PREMi 5E51Ee ocamicel
X SIR$250,500 _.... . um FEIMAnvme Pew"!_ 3 501
PERSONALBP➢VINJURY3 3.D]O.DW
_
GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 BLG3P66
L 1
X i1 ORoom?THER I. Pia L LOC iTECIXCiS OOMPNP PGO,5 6010 W0
Iorlan I IS
A Rumex:eai Da me BAI01601SCO 0101/015 noinai6 cOMB1NEOSINOLE LIUIr s 5,C00,L00
LET e¢ m0
e
X MF/EEO EMIT INJURY ITA MxnI 3
K'ALT� Ell A SOREMEIT Uowty mum Iver cemmen0.5.
AUTOS
K Pn PGE S
MREOAUTL6 X ANDS rEO 5
ME99
UMBRELLA WB 'OCCUR EACH OCCURRENCE 3
J. AGGREGATE �5
EXCESS U.SY LW36-MADE ..
CED I I RETENTIONS I I S
D WCRREw OCT xG� VIC018201d4w(ADS/ GH91R615 1901/016 X I PEN nr I I OIH
A ANY PRwRr1aPARTNEPJEXEcurvE Yj,I�.NI N1a 04B�t5DI 'q1 109.UtR015 i1991YAt6 1`ELECHACDENT 'S 1.000000
PFIIC£RAEMESR WOLPEEDI I' i+1C DE DUCTIBLE:5500.0W
IMy s.&sryln MX/ 1 E®52052•EA EMPLOYEES
1,060110
I OESCP1PTIN OFOPERATIONSWON 1 1 VEL LSEASE 4CY LIMA I5 1.1610
VESCRPPSON OF OPERATIONS,LaunDN5!VEHICLES IACORO,M.Amlumw NW/marks Scheme,my tic amn,m nwre Wrs m re venal
Evidence of I1 UFMtt
CERTIFICATE HOLDER CANCELLATION
SOLUOIEGAWI51On SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
X55 Chaves My TEE EX%RATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Gan MAeo,CA 99402 ACCORDANCE MENTHE POLICY PROVISIONS.
AU-MORPH]REPRESENTATIVE
or March RCM I Insurance Swims
Charles Maimolai 0 c- . i46— TS
®1988-2014 ACORD CORPORATION. All righh reserve,_
ACORD 25(2014/01) The ACORD name and logo are registered marks of AGGRO
//r %/: 1,,/, , , !�// 77': . ,
Office ofConsumer Affairs and Business Regulation,. 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 168512
Type Supplement Card
SOLAR CITY CORPORATION Expiration: 3/8/2017
JEREMY GRAVES
3055 CLEARVIEW WAY
SAN MATEO, CA 94402
I:pdate Address and return card. 'lark reason for change.
Address Rearm-al Employment Lost Card
ulna ofronamer ARtln N Ruthless ReRaWlfnn License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return In:
• Office of Consumer Affairs and Business Regulatkm
Registration: 168572 Type: 10 Park Plaza-Suite 51711
Expiration: 3/8/2017 Supplement hard Boston,MA 02116
SOLAR CITY CCHP•J+t.I n•N
JEREMY GRAVES
•
24 ST MARTIN STREET BLU ZONI --
MARLBOROUGH.MA 01752 ' Entlermortary Net valid 6itbout signature
CS-108706 ggf 1
JEREMY GRAVES +tom
179 BRIGHAM STREET
Marlborough MA 01757
•
92.• -tll/Sea"-
02/23/2019
c ft r. (// /?u;j„�'/ 'rl;
Office of Consumer Affairs hnd 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.
N Address Renewal Employment _..I Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
wmf10ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ALC-qe atratlon:
Office of Consumer Affairs and Business Regulation
8i 168572 Type: 10 Park Plaza-Suite 5170
Expiration: 3/8/2017 Supplement Gard Boston,MA 02116
SOLAR CITY CORPORATION
VICTORIA JUNCK '
24 ST MARTIN STREET BLD 21.11,11 4-i--, _
.—
ttkkBOROUGH,MA 01752
UndersecretaryNot valid without : store