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I am a eneral contractorand 1 Type of pruj"t(required): I.t.ld 1 ant a employer wither 6. [](yew construction employees(full and/or part-time).'" have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attnehed sheet. 7. [❑Rentodelinb shi and have no em to ees These sub-contractors have p p y 8. �Dcrnolition working for me in any capacity. employees and have workers'(No workers'comp.insurance comp.insurance.l �• ❑Building addition regtrired.J 5. We;ve a corporation and its I ll.Q Electrical repairs or ad1 ,far;+hnnu:uwnf r dialog aEl work offirurs have exercised 11161. I I.( .(t'lombing rr teals nr adri ht of excrtt tion x r INtGL nays+:lt: (Nv wnrkcrs'comlz. g p� 1 � I"l. Roof re insurance required.)f c. 152,§1(4),and we have no employees.(No workers' --- ------- -LLcornp,insurance required.) ► - �l't 'Any-opplicanl that checks tux A 1 must also tilt out the section below showing their workers'conga:nsotun policy inlornYHtion. I llumcowrrefs who Submit this attldavit indx:nnmg(hcyarc doing alt work on it there hire oulside conimciors most submit it new aaidacit indicating stash. 'Cuniroctun lhal check this box must altached an mlditional short showing the name or the sob-cont mmtors and slate whether or not those entities have employees. If the sub-eoniraclurshave employees,they must provide their workers'comp.policy numties, ` `l aul,an rnqplover that is provlding workers'conrperisadon insurance for roy employees. ,below is the policy and job site iaforrnution. Insurance Company Name:, Q(�GO� ,i�.._�- ,F,� (i --- �(�,(1ttf(•G---(;C2___._—_�._.. Policy tl or-Self-ins.Lic.N:—, /,,/ x! ►y3 =2�l .__ Expiration Date: l Ci istotdzi O�t.1G�, Q�OG 2 Job Site Address: 1-•D��ah c�_�'� L&°� - h p-t� - e-- 1� Attach a copy of the workers'compensation policy declaration page(showing;the policy number and expiration date). V C'ailure to secure coverage as required under Section 25A of MOL c. 152 can toad to the imposition of criminal penalties Orel fine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded w the ORlce of Invcsti charm of the DIA for insurance coveraz;e verification. i do berefiy certify under the pins and penatries of per jury that the information provided above is true and correct. ��unl u.te only. Donut write in t us area,to be cortrpletrd by uty or rower u rare City or Town' Issuing Authority(circle one): �I Board of Health 2. Building;Department J. City%Cawn t;lerk 4. Glccfrical inspector S. Plurnbind Inspcclor Phone -- Contact Person:__ - AERIWIR-01 MCLA CERTIFICATE OF LIABILITY INSURANCE DAT DIYYYY) 9//27/227/2013 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 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). NT PRODUCER (248)433-1466 NAMEACT Lauren M. McCann Oswald Companies-Birmingham,MI HO" AX No 700 Forest Avenue E-MAIL Birmingham,MI 48009 ADDRESS:lmccann@oswaldcompanies.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:North American Capacity Ins Co INSURED Aerial Wireless Services LLC INSURER B:Allmerica Financial Benefit Insurance Comp 120 Forbes Blvd. INSURERC:Nat'I Union Fire Ins Co of Pittsburgh PA Mansfield, MA 02048- INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 POLICY EFF POLICY EXP LIMITS LTR 1 POLICY NUMBER MMIDD/YYYY MMIDD/YYW GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY PNG100195500 919/2013 9/912014 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PROT- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00 Ea accident $ B X ANY AUTO AWB A091249 00 91912013 919/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 C EXCESS LIAB CLAIMS-MADE BE026217626 9/9/2013 919/2014 AGGREGATE $ 5,000,00 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE � E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information Purposes ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD j. Massachusetts-department of Public Safety , �✓ Board of Building Regulations and Standards Construction Sripervisor License: CS-088703 KL+VIN CUNNINGAA1Y1 29 HALE RD STOW MA 01775 Expiration Commissioner • Unrestricted•-Buildings of any use group wwcli a contain less than 35,000 cubic feet(9911n3)Of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: wvnv.Mass.Gov/DPS C.r o �.s Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): r Registration Number Address M. Expiration Date i Signature Telephone 9.2 Registered Professional Engineer(s): Scott N. Adams 'Civil Name Area of Responsibility '500 North Broadway East Providence, RI 02914 _ =4_6006 _ Address t�(J(w .v Registration Number (401)354-2403_1 igna Telephone Expiration Date I Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date d Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Aerial Wireless Services Not Applicable ❑ Company Name: .Kevin Cunningham Responsible In Charge of Construction 29 Hale Road Stow, MA 01775 Address S� «,� (781)964-7010 Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 'American Tower Corp as Owner of the subject property hereby authorize[Amber Debole _m_ _ ..m.......... _. . _ _. _.._ ao act on my behalf, in all matters relativ rk authorized by this building permit application. 05/08/2014 re of Owne Date Amber Debole as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed underthe pains and penalties of perfury Amber Debole Print Name .-.- _ - . -- .�-P —-• -- [ Sig a of Ov;nerAggin:17 Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable El e em Name of License Holder.' -_ Above_ License Number Address Expiration Date Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit 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. Signed Affidavit Attached Yes G) No 0 Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size __ ;No Change �NoeChange _ Frontage _' 'No_Change _ No„Change Setbacks Front L 4 Side L R. L: WIJ Rear Building Height Bldg. Square Footage % j Open Space Footage _.__, n (Lot area minus bldg&paved _ . _J parking) #of Parking Spaces (volume&Location) `No Change p�No Change_ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES IF YES: enter Book Page` and/or Document#, � B. Does the site contain a brook, body of water or wetlands? NO 01” DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description ;Enter a brief description here. Of Proposed Work:ELL TO UJ F(L_. A N 1 E N N �S SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ( ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: 'Existing Wireless Communication Facility M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: `wireless Facility Proposed Use Group: Change Existing Hazard Index 780 CMR 34) `NSA Proposed Hazard Index 780 CMR 34). NA SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 St __ ._. St 2nd , 2nd 3`d N 3 A14 f/" n 4m A/� 4t Total Area(sf) /)� Total Proposed New Cot uction(sf) ✓v �jl._ Total Height(ft) �T Total Height ft NA 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 414 7.3 Sewage Disposal System: Public ❑ Private ❑ MA--- Zone Outside Flood Zone❑ Municipal ❑ On site disposal system E3 Versionl.7 Commercial Building Permit May 15,2000 Inr. I y of Northampton �� f I� //� A B [ding Department1[ rluiiy� a - � MAY 1 2014 � � Aft 12 Main Street ;�, Room 100 01 m ton MA 01060 b � Electric, Plumbmc E Gas fns p North .Y ric r. h oftm(&1 - 7-1240 Fax 413-587-1272 � d� 1 k APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office m. e '170 Glendale Road Map Lot unit t 'Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 'American Tower Corporation 16 Chestnut Street, Foxborough, MA 02035 .._ w Name(Print) Current Mailing Address: x(781)424-9253 Signature I e 2.2 Authorized Agent: ;Amber Debole i16 Chestnut Street,Foxborough, MA 02035 _ Name(Print) Current Mailing Address: (781) 424-9253 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee $17,500.001 t 2. Electrical � (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1201 APPLICANT/CONTACT PERSON TOWER RESOURCE MANAGEMENT INC ADDRESS/PHONE 16 CHESTNUT ST FOXBORO (781)929-6150 PROPERTY LOCATION 170 GLENDALE RD-T MOBILE MAP 42 PARCEL 089 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: ? f New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 088703 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay ol. 41�lj 1 Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 170 GLENDALE RD-T MOBILE BP-2014-1201 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma:Block:42-089 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ANTENNAS BUILDING PERMIT Permit# BP-2014-1201 Project# JS-2014-002029 Est.Cost: $17500.00 Fee: $105.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: AERIAL WIRELESS SERVICES LLC 088703 Lot Size(sq.ft.): 2265120.00 Owner: NORTHAMPTON CITY OF LEACHATE TREATMENT FACILITY Zoning-: Applicant. TOWER RESOURCE MANAGEMENT INC AT. 170 GLENDALE RD - T MOBILE Applicant Address: Phone: Insurance: 16 CHESTNUT ST (781) 929-6150 WC FOXBOROMA02035 ISSUED ON.512212014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL EQUIPMENT &ADD ANTENNAS 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. Certificate of Occupancy Sienature: FeeTvpe• Date Paid: Amount: Building 5/22/2014 0:00:00 $105.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner