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37-077 (9)
790FLORENCE RD COMMONWEALTH OF MASSACHUSETTS BP-2021-1787 Map:Block:Lot:37-077-001 Permit: Alts Renovations CITY OF NORTHAMPTON Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1787 PERMISSIONISHEREBYGRANTED TO: Project# Contractor: License:Est. Cost: 35000 3-0l 6 11,11CL art Ott a 74/3 7 Const.Class: Exp.Date: CONTINENTAL CABLEVISION OF WESTERN NEW Use Group: Owner: ENGLAND INC Lot Size (sq.ft.) Zoning: SR/WSP Applicant: TILSON TECHNOLOGY MANAGEMENT INC Applicant Address Phone: Insurance: 16 MIDDLE ST (413)822-1712 PORTLAND, ME 04101 ISSUED ON:08/25/2021 TO PERFORM THE FOLLOWING WORK: ANTENNAS INSTALLATIONS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I �� 1,. • Fees Paid: S245.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner rEivg0 AUG Z 5 2021 T e Commonwealth of Massachusetts Office of Public Safety and Inspections I Massachusetts State Building Code(780 CMR) Fpt of uilding Pe it A plication for any Building other than a One-or Two-Family Dwelling NaRTHAMIPUr'c r'INS PFCT1oN (This Section For Official Use Only) Building Permit Number. ate Applied: Building Official: SECTION 1:LOCATION 790 Florence Road Northampton MA 01062 No.and Street City/Town Zip Code Name of Building(if applicable) 37-077-001 Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here®or check all that apply in the two rows below Existing Building 0 Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy 0 Other ❑ Specify:Ca Uoc J c.t o-♦t Anft•ryas a�dE�H,y,,,,••f Are building plans and/or construction documents being supplied as part of this permit application? Yes ® No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 111 Brief Description of Proposed Work: Dish Wireless Proposes to install 3 Antennas, 3 Antenna Mounts, 6 RRH's 1 OVP, 1 Hybrid Cable, all to be install on the tower. Dish Wireless ground installation will consist of installing 1 metal Platform, 1 Ira Rrirtgn, 1 PPC Cahinat, 1 Frluipmant Cahinat, 1 Powar Cnnrtuit, I Talon Conduit, 1 Talon Fiber Box, 1 GPS Unit, 1 Safety Switch if required, 1 Fiber Nid If required, 1 Meter Socket all to be install in our existing lease area. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): U Proposed Use Group(s): No Change SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2❑ H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4❑ S: Storage S-1 0 S-2 0 U: Utility® Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ HA 0 IIB ® IBA IIIB ❑ IV VA 0 VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable RI Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No la Yes 0 No $ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): U Type of Construction: IIB Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Continental Cablevision 1 Comcast Ctr 32nd Floor Philadelphia PA 19103 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address 1 City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) ,Inshua RrndAr 9r17-.53 -0573 jhrndfr a@tilsnntech r.nm CS-108437 Name(Registrant) Telephone No. e-mail address Registration Number 16 Middle Street 4th FL Portland ME 04101 9-10-2022 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Tilson Technology Management Inc Company Name Richard Buker Name of Person Responsible for Construction License No. and Type if Applicable 16 Middle Street 4th Floor _ Portland ME 04101 Street Address City/Town State Zip 413 -R99 -1719 rhuker@tiI nntvch cnm Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ 30,000 Building Permit Fee=Total Construe' st x (Insert here 2.Electrical $ 5,000 appropriate municip actor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee= a 4-(6ct municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 35,000 (contact municipality)and write check number here 13'7 ejl SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and a ate to th t f y knowledge and understanding. Darryl Gresham Agent 267_304 _ 1349 8 18 21 Please print and sign name Title Telephone No. Date 1 777 sentry nkwv w veva 1 7 eta 40Q _Blue Bell PA 19492 dgresham@nbcllr corn _ Street Address City/Town State Zip Email Address gaMunicipal Inspector to fill out this section upon application approval: i 'I/ 11 ,,2 � i r I Name + Da e City of Northampton oatH.7M o S - -5� /? Massachusetts s� c,� 1 i V-•i!A. ) ,� DEPARTMENT OF BUILDING INSPECTIONS : per, ` 41; 212 Main Street • Municipal Building 1.J� ta Fl O, �, ,r�,,;"^ Northampton, MA 01060 sf361.o CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: 79 Dow Rd Bow, NH 03304 The debris will be transported by: Name of Hauler: Tilson Technology Signature of Applicant: Date: ' ii—Z Z The Commonwealth of Massachusetts V Department of Industrial Accidents Office of Investigations 1'17)1--" 47, Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 e•`�t www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Tilson Technology Management, Inc. Address: 16 Middle St.,4th Floor City/State/Zip:Portland, ME 04101 Phone#:207-591-6427 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 515 4. ❑ I am a general contractor and I employees(full and/or pait-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. (j Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.x 9. El Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 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 13.El other Telecommunications employees. [No workers' 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 employees. Below is the policy and job site information. Insurance Company Name:Liberty Mutual Fire Insurance Company, 175 Berkely Street, Boston, MA 02116 Policy#or Self-ins.Lic.#:WA2-65D-291916-031 Expiration Date:4/1/2022 Job Site Address: 790 Florence Road Northampton MA 01062 City/State/Zip: Northampton MA 01062 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 cent � tt/pgins and penalties of perjury that the information provided above is true and correct. Signature: /' Date: Jun 11,2021 (207)613-7346 Timothy Schneider,General Counsel Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.DOther Contact Person: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty Mutual. INFORMATION PAGE t75Sir INSURANCE �+fr o� olosta".M►02114 Issued by Liberty Mutual Fre Insurance Company (a stock company) 18588 Policy Number WA2-85D-291916-031 Issung Office Lewiston. ME Renewal Of WA2-85D-291916-030 Issue Date 03124;2021 Account Number 5-291918 Sub Account 0001 1 Insured and Mailing Address FEIN 01-0509537 Tolson Technology Management. Inc. NJ TIN 010509537000 18 Mdd'e Street 4th Floor Portland ME 04101 Risk ID 913719433 Association 9004 Status Corporation Other workplaces not shown above:See Item 4. Premium-Extension of Information Page 2 Pojcy Perod The policy period is from 04101i2021 to 04r01 2022 12:01 A.M standard time at the Insured's mailing address 3. Coverage A Workers Compensation Insurance Part One of the policy applies to the Workers Compensation Law of the states Isted here AL AZ AR CA CO CT FL GA ID IL IN IA KS KY LA ME MA MI MN MS MO MT NE NV NH NJ NM NY NC OR PA RI SC TN TX UT VT VA VA/ B Employers Liability Insurance. Part Two of the poi cy applies to work in each state I sted in Item 3 A The '.mmits of our I ab.lity under Part Two are Bodily Ir.ury by Accident 5 1.000,000 each accident Bodily Injury by Disease 3 1,000,000 policy limit Bodily Injury by Disease 5 1,000.000 each employee C. Other States Insurance Part Three of the policy apples to the states, if any, listed here All States except those listed in Item 3 A and the States of: ND OH WA WY D. This polcy includes these endorsements and schedules See Item 3 Coverage D- Extension of Information Page 4. Preni um: The premium for this policy h-ll be determined by our Manuals of Rules. Classrficat-ons, Rates and Rating Plans. An information required below is subject to verification and change by audit. Classifications Code Premium Basis Total Rate per 5100 Estimated Annual Number Estimated Annual Rem&uneraton of Remuneration Prerraum See Extension of Information Page Minimum Premium Total Estimated Annual Prenrum $ Premium MI be bil'ed Monthly Deposit Premium $ Deposit Tax.'Surcharge,iAssessment S Producer 0002 000008 Countersigned by Authorized Rep (FL) MARSH USA INC 99 HIGH ST FL 13 BOSTON MA 021 105021a .0 41�u -1 WC 00 00 01 A 1987 National Counc'on Compensation Ins,/a^ce, n: WC 00 CO 01 B (CA) Ed 07.01,201 MI Ripr.ts Reserved Page ' of 1 / 1 ® DATE(MMIDDIYYY`) A`COR,� CERTIFICATE OF LIABILITY INSURANCE 07r2v2021 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 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). PRODUCER CONTACT PHON: MARSH USA,INC. FAX 99 HIGH STREET PHONE (A/C,No.Extl: _(A/C,No): BOSTON,MA 02110 E-MAIL Attn:Boston.certrequest@Marsh.com Fax: 212-948-4377 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN130061406-wIXS-GAWUX-21-22 INSURER A:Liberty Mutual Fire Insurance Company 23035 INSURED INSURER B:Endurance American Specialty Insurance Company 41718 Tilson Technology Management,Inc 16 Middle Street,4th Floor INSURER C: Portland,ME 04101 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NYC-010819194-07 REVISION NUMBER: 6 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 ADDL.SUER POLICY EFF POLICY EXP LIMITS LTR INSD,WVD, POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY TB5-651-291916-021 04/01/2021 04/01/2022 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED 000OOD, 1 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 1, _ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: A AUTOMOBILE LIABILITY AS2-651-291916-011 04101/2021 04101/2022 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ - OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) $ B UMBRELLA LIAB X OCCUR ELD30001012502 04/01/2021 04/01/2022 EACH OCCURRENCE $ 3,000,000 X- EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED RETENTION$0 $ A WORKERS COMPENSATION WA2-65D-291916-031 04/01/2021 04/01/2022 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y F RM OP ORIPAR NER/E?ECUTIVE N N N/A E.L.EACH ACCIDENT $ 1,000,000 OF (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION Tilson Technology Management,Inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 16 Middle Street,4th Floor THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Portland,ME 04101 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee .-.M.ixunesiu. I ©1988-2016 ACORD CORPORATION. All rights reserved. -E. ■ ■ TOTALLY COMMITTED. August 18, 2021 RE-CE. I VET City of Northampton AEG 2 3 2021 Building Department Qua 212 Main Street Northampton MA 01060 N�RrH"Pro/v.4"38Crio 01060 NS Re: ATC #209215— Dish Wireless BOBDL00200A —790 Florence Rd Northampton MA-Collocations Dear Building Department, Dish Wirelessis proposing to install 3 Antennas, 3 Antenna Mounts, 6 RRHs, 1 OVP, 1 Hybrid Cable, all to be installed on existing tower. Dish Wireless ground equipment will consist of installing 1 proposed metal platform, 1 Ice bridge, 1 PPC Cabinet, 1 Equipment Cabinet, 1 Power Conduit, 1 Telco Conduit, 1 Telco —Fiber Box, 1 GPS Unit, 1 Safety Switch if required, 1 Fiber Nid if required, 1 Meter Socket, all to installed in our existing lease area. Included for your review and approval are (3) sets of construction drawings,(3) copy's of the Structural Analysis and the Building Permit Application. Please let me know if you require additional information, and once the application is approved please notify me, so I can make arrangements for payment. I can be reached at 267-304-1349 or dgresham@nbcllc.com. Thank you for your assistance. Sincerely, Darryl Gresham Site Acquisition Associate Agent of Dish Wireless 1777 Sentry Parkway W, Veva 17 + Suite 400 + Blue Bell, PA 19422 + 267460 0122 + www.networkbuilding.corn