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22 ATWOOD DR COMMONWEALTH OF MASSACHUSETTS BP-2021-1857 Map:Block:Lot:39-060-001 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-2021-1857 PERMISSION IS HEREBY GRANTED TO: Project# ANTENNA Contractor: License: Est. Cost: 70000 QUALTECK WIRELESS 088703 Const.Class: Exp.Date: 10/09/2021 Use Group: Owner: OXBOW PROFESSIONAL PARK LLC Lot Size (sq.ft.) Zoning: GB/WP Applicant: QUALTECK WIRELESS Applicant Address Phone: Insurance: 29 HALE RD (339)205-5017 WC6-63 1-5 1 0650-020 STOWE, MA 01775 ISSUED ON:09/16/2021 TO PERFORM THE FOLLOWING WORK: INSTALL 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. Signature: • i, 1 f Fees Paid: $490.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner August 5,2021 BOBDL00174A Building Department Northampton,MA RE 22 Atwood Drive,Northampton,MA 01060 To: I, Kevin Cunningham as an employee of QUALTEK WIRELESS authorize my Massachusetts construction supervisor license CS-088703 to be used for the building permit application at 22 Atwood Drive,Northampton,MA 01060 by Crown Castle. Please feel free to contact me with any questions or if you require additional information. Sincerely, KitAr— Kevin Cunningham QualTek Wireless 339-205-5017 kcunningham@qualtekwireless.com Z -a� File #BP-2021-1857 APPLICANT/CONTACT PERSON:QUALTECK WIRELESS 29 HALE RD STOWE, MA 01775(339)205-5017 PROPERTY LOCATION 22 ATWOOD DR MAP:LOT 39-060-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $490.00 Type of Construction: INSTALL ANTENNAS ,it . New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 7( Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Perm it With Site Plan MajorProject: Site Plan AND/OR Special Perm it 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 494,A„..., 9/I� I Sigyture of Building Official II 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. CROWN 4545E River Rd,Suite 320 West Henrietta,NY 14586 Phone: (585) 445-5896 www.cmwncastle.com al% woe CASTLE September 2,2021 MA-CITY OF NORTHAMPTON Building Department Puchalski Municipal Building 212 MAIN STREET NORTHAMPTON,MA 01060 Via FedEx **********NOTICE OF ELIGIBLE FACILITIES REQUEST********** RE: Request for Minor Modification to Existing Wireless Facility—Section 6409 Site Address:22 ATWOOD DRIVE,NORTHAMPTON,MA 01060 Crown Site Number:800530/Crown Site Name:MA NORTHAMPTON II CAC 800530 Customer Site Number: BOBDLoo174A/Application Number:553297 Dear Building Department: On behalf of DISH Wireless L.L.C. ("Dish Wireless"or"Applicant"),Crown Castle USA Inc. ("Crown Castle")is pleased to submit this request to modify the existing wireless facility noted above through the collocation, replacement and/or removal of the Applicant's equipment as an eligible facilities request for a minor modification under Section 64091 and the rules of the Federal Communications Commission("FCC").2 Section 6409 mandates that state and local governments must approve any eligible facilities request for the modification of an existing wireless tower or base station that does not substantially change the physical dimensions of such tower or base station. Under Section 6409, to toll the review period, if the reviewing authority determines that the application is incomplete, it must provide written notice to the applicant within 3o days, which clearly and specifically delineates all missing documents or information reasonably related to whether the request meets the federal requirements.3 Additionally, if a state or local government, fails to issue any approvals required for this request within 6o days, these approvals are deemed granted.The FCC has clarified that the 3o-day and 6o-day deadlines begins when an applicant: (1) takes the first step required under state or local law;and(2)submits information sufficient to inform the jurisdiction that this modification qualifies under the federal law4. Please note that with the submission of this letter and enclosed items, the thirty and sixty-day review periods have started. Based on this filing, the deadline for written notice of incomplete application is October 2,2021,and the deadline for issuance of approval is November 1,2021. 1 Middle Class Tax Relief and Job Creation Act of 2012,Pub.L.No.112-96,§6409(2012)(codified at 47 U.S.C.§1455). 2 Acceleration of Broadband Deployment by Improving Wireless Facility Siting Policies,29 FCC Rcd.12865(2014)(codified at 47 CFR§1.6100);and Implementation of State&Local Governments'Obligation to Approve Certain Wireless Facility Modification Requests Under Section 6409(a)of the Spectrum Act of 2012,WT Docket No.19-250(June 10,2020). 3 See 47 CFR§1.6100(c)(3). 4 See 2020 Upgrade Order at paragraph 16. The Foundation for a Wireless World CrownCastle.com CROWN 4545 E River Rd, Suite 320 (585) 445-5896 Phone: West Henrietta,NY 14586 wwwcrowncastle.com v CAST L E The proposed scope of work for this project includes: Install antennas,ancillary tower and ground equipment etc. at an unmanned wireless facility with no change to structure height or ground space. At the end of this letter is a checklist of the applicable substantial change criteria under Section 6409.Additionally,please find enclosed the following information in support of this request: (1) Completed permit application; (2) Certificate of Insurance; (3) Workers Compensation Affidavit; (4) Initial Construction Control document; (5) Letter of Authorization from GC license holder; (6) Construction Drawings—2 sets; (7) Structural Evaluation;and (8) Section 6409 Substantial Change Checklist. As these documents indicate, (i) the modification involves the collocation, removal or replacement of transmission equipment;and(ii)such modification will not substantially change the physical dimensions of such tower or base station. As such,it is an"eligible facilities request"as defined in the FCC's rules to which the 6o-day deadline for approval applies. Accordingly,Applicant requests all authorization necessary for this proposed minor modification under Section 6409. Our goal is to work with you to obtain approvals earlier than the deadline. We will respond promptly to any request for related information you may have in connection with this request. Please let us know how we can work with you to expedite the approval process.We look forward to working with you on this important project,which will improve wireless telecommunication services in your community using collocation on existing infrastructure. If you have any questions, please do not hesitate to contact me. Regards, Richcvtd Zajac Richard Zajac Site Acquisition Specialist Crown Castle Agent for Applicant (585)445-5896 Richard.Zajac@crowncastle.com The Foundation for a Wireless World CrownCastle.com CROWNCAST L E 4545 E River Rd, Suite 320 Phone: (585) 445-5896 West Henrietta, NY 14586 www.crowncas8e.com Q,,,,,� Section 6409 Substantial Change Checklist Towers Outside of the Public Right of Way The Federal Communications Commission has determined that a modification substantially changes the physical dimension of a wireless tower or base station under 47 U.S.C.§ 1455(a)if it meets one of six enumerated criteria under 47 C.F.R.§ 1.6100. Criteria for Towers Outside the Public Rights of Wav YES/NO Does the modification increase the height of the tower by more than the greater of: NO (a) 10% (b) or,the height of an additional antenna array plus separation of up to 20 feet from the top of the nearest existing antenna? YES/NO Does the modification add an appurtenance to the body of the tower that would protrude from the NO edge of the tower more than 20 feet or more than the width of the tower structure at the level of the appurtenance,whichever is greater? YES/NO Does the modification involve the installation of more than the standard number of new equipment NO cabinets for the technology involved or add more than four new equipment cabinets? YES/NO Does the modification entail any excavation or deployment outside the current site by more than 30 NO feet in any direction,not including any access or utility easements? YES/NO Does the modification defeat the concealment elements of the eligible support structure? NO YES/NO Does the modification violate conditions associated with the siting approval with the prior approval the NO tower or base station other than as specified in 47 C.F.R.§ 1.6100(c)(7)(i)—(iv)? If all questions in the above section are answered"NO,"then the modification does not constitute a substantial change to the existing tower under 47 C.F.R.§1.6100. The Foundation for a Wireless World Crown Castle.com The Commonwealth of Massachusetts ,tqr Office of Public Safety and Inspections Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number9 p�•Zl-'SS/DateApplied: Building Official: SECTION 1:LOCATION 22 Atwood Drive Northampton 01060 No.and Street City/Town Zip Code Name of Building(if applicable) 39-060-001 Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair 0 Alteration ® Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy 0 Other El Specify: telecom alteration 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 0 Brief Description of Proposed Work: Install antennas,ancillary tower and ground equipment etc. at an unmanned wireless facility with no change to structure height or ground space 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) ❑ Existing Use Group(s): telecom Proposed Use Group(s): telecom 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.) 162' 162' SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5❑ B: Business 0 E: Educational ❑ F: Factory F-1 0 F2 0 H: High Hazard H-1❑ H-2 0 H-3 0 H-4 0 H-5❑ I: Institutional I-1 0 I-2❑ I-3 0 I-4 0 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 ❑ IIA ❑ IIB ❑ IBA ❑ IIIB ❑ IV 0 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❑ 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 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: 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 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 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 El. 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) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Qualtek Wireless Company Name Kevin Cunningham CS-088703 Name of Person Responsible for Construction License No. and Type if Applicable 29 Hale Road Stowe MA 01775 Street Address City/Town State Zip 339-205-5017 - - kcunningham@qualtekwireless.com 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 Cl No 1] SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate m pal fac . =$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum f:- =$ a (c ntact municipality) 5.Mechanical (Other) $ Enclose check payabl: to t 6.Total Cost $ 70,000.00 (contact municipality)an. ' -check number here 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 accura to the st of my knowledge and understanding. Richard Zajac Site Acquisition Specialist 585. 445_ 5896 9/2/2021 Please print and sign Title T lephone No. Date 4545 East River oaed,Suite 320 West Henrietta NY 14586 richarci.zajac@crowncastle.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: . • 9 leo 'CIN3:61:Name Da e City of Northampton Win°^3ro�; S`s '°`,.s, e �;. Massachusetts ��? ;< w: 11 DEPARTMENT OF BUILDING INSPECTIONS 9' j c. ,,,.--:ti' - 212 Main Street • Municipal Building Northampton, MA 01060 ssbyi.. f�� 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: 22 Atwood Drive The debris will be transported by: no debris expected Name of Hauler: 9/2/2021 Signature of Applicant: ( Date: ACORE, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ‘...—/ 8/4/2021 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 NAME: Daisy Braun Arthur J. Gallagher Risk Management Services, Inc. PHONE FAX No):856 482-1888 4000 Midlantic Dr, Suite 200 (AIc.No.Extl:856-675-1334 Mt. Laurel NJ 08054 ADDRESS: CherryHilI.BSD.CertM©AJG.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:First Liberty Insurance Corporation 33588 INSURED QUALUSA-01 INSURER B:Liberty Mutual Fire Insurance Company 23035 QualTek Wireless LLC 475 Sentry Parkway E INSURER C:AXIS Insurance Company 37273 Ste 200 INSURER D:Navigators Insurance Company 42307 Blue Bell, PA 19422 INSURERE:Liberty Insurance Underwriters Inc 19917 INSURER F: American Guarantee and Liability Ins Co 26247 COVERAGES CERTIFICATE NUMBER:1240826275 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 ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTRINSD VD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) B X COMMERCIAL GENERAL LIABILITY TB2-631-510650-040 11/30/2020 11/30/2021 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED _ CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY X jEa X LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: 1 $ B AUTOMOBILE LIABILITY AS2-631-510650-030 11/30/2020 11/30/2021 COMBINED SINGLE LIMIT $2,000,000 (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) - Comp/Collision Ded $$1,000/1,000 CC UMBRELLA LIAB X OCCUR P-001-000073672-03 11/30/2020 11/30/2021 EACH OCCURRENCE $30,000,000 E• X EXCESS LIAB NY20EXCZO3HAGIV 11/30/2020 11/30/2021 F CLAIMS-MADE 1000324565-03 11/30/2020 11/30/2021 AGGREGATE $30,000,000 AEC 8761755-02 11/30/2020 11/30/2021 DED I RETENTION$ $ A WORKERS COMPENSATION WC6-631-510650-010 11/30/2020 11/30/2021 X AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Yn N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? I I (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 F Installation Floater 1 13 UUM BK0148 11/30/2020 11/30/2021 Limit 5,000,000 Deductible 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Cyber Liability(Primary) P olicy#CYB-1004358-01 Policy Period: 11/30/2020-11/30/2021 Carrier:Hudson Excess Insurance Company Limit:$10,000,000 Cyber Liability(Excess) Policy#C-4LP8-001024-CEPMM-2020 See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton 22 Atwood Drive Northampton MA 01060 AUTHORIZED REPRESENTATIVE ,f (—� st7_&,_) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: QUALUSA-01 LOC#: ACCPRO® ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED Arthur J.Gallagher Risk Management Services, Inc. QualTek Wireless LLC 475 Sentry Parkway E POLICY NUMBER Ste 200 Blue Bell,PA 19422 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Policy Period: 11/30/2020-11/30/2021 Carrier:Certain Underwriter at Lloyds Limit:$10MM x$10MM Property Policy Policy#13 UUM BK0148 Policy Period: 11/30/20-11/30/21 Carrier:Hartford Fire Insurance Company Leased/Rented Equipment: Limit:$1,500,000 Deductible:$5,000 BPP Limit/Deductible:$4,190,000/$5,000 Professional Liab/E&O/Pollution Policy#0311-0596 Policy Period: 11/30/2020-11/30/2021 Carrier:Allied World Assurance Company,Ltd Occurrence/Aggregate:$5MM/5MM Hartford Fire Insurance Company Inland Marine Policy Eff Date: 11/30/20-Exp Date:11/30/21 Policy#13 UUM BK0148 Installation Operations-LIMIT:$5,000,000/DEDUCTIBLE:$5,000 In Transit-LIMIT:$1,000,000/DEDUCTIBLE:$5,000 In Temporary Storage-LIMIT:$15,000,000/DEDUCTIBLE:$5,000 RE:Scope of work being performed:Dish New Site Build ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Ff_� _. Office of Investigations 1. _ Lafayette City Center 4JtIll 2 Avenue de Lafayette, Boston,MA 02111-1750 � ,, www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: QualTek Wireless LLC Address: 1150 First Avenue, Suite 600 City/State/Zip:King of Prussia, PA 19406 Phone#:(484)804-4500 Are you an employer?Check the appropriate box: Business Type(required): I. ■❑ I am a employer with +100 employees (full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]** II. Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑� Other Wireless site development *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:Arthur J Gallagher Management Service, Inc. Insurer's Address:4000 Midlantic Drive Suite 200 City/State/Zip: Mt. Laurel, NJ 08054 Policy#or Self-ins. Lic.#WC6-631-510650-020 Expiration Date: 11-30-2021 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§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 certify, under th pains and penalties of perjury that the information provided above is true and correct. Kji c= i Phone#:Signature: = / Date: 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): I.❑Board of Health 2.0 Building Department 3.❑City/Town Clerk 4.0Licensing Board 50 Selectmen's Office 6.['Other Contact Person: Phone#: www.mass.gov/dia Initial Construction Control Document } / To be submitted with the building permit application by a Registered Design Professional '�, for work per the ninth edition of the gym °J4 Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Date:8/19/21 DISH Wireless Colocation New Site Build Site Dish ID: BOBDL00174A I Crown BU#800530 Property Address: 22 Atwood Drive Northampton, MA 01060 Project: Check(x) one or both as applicable: New construction X Existing Construction Project description:Dish 5G-proposes to add telecommunications equipment to include(3)antennas, (6) RRH,(1)OVP and (1)hybrid to the tower and a 5'x7'lease area with(1)cabinet. I Shu Sakanoue MA Registration Number:51926 Expiration date:6/30/22 am a registered design professional,and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerningl: Architectural Structural Mechanical Fire Protection Electrical Other: Telecommunications for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to --- official a'Final Construction Control Document'. cp OF MASS Enter in the space to the right a"wet" or `•�'' S HE CyG electronic signature and seal: o .A. C CIVIL 0 2y21 'o Phone number: 201-819-4493 Email: •.1r. om `SSIONAL ENS\ Build = ►se Only Building Official Name: Permit No.: Date: Note 1.Indicate with an'x'project design plans,computations and specifications that you prepared or directly supervised. If'other' is chosen,provide a description. Version Ol 01 2018 an% CROWN Date: 4/28/2021 v CASTLE Crown Castle 2000 Corporate Drive Canonsburg, PA 15317 (724)416-2000 Subject: Structural Evaluation Carrier Designation: DISH Network Co-Locate Site Number: BOBDL00174A Site Name: MA-CCI-T-800530 Crown Castle Designation: BU Number: 800530 Site Name: MA NORTHAMPTON II CAC 800530 JDE Job Number: 645103 WO Number: 1952360 Order Number: 553297 Revision. 0 Site Data: 22 ATWOOD DRIVE, NORTHAMPTON, Hampshire, MA Latitude: 42° 18' 9.77" Longitude: -72°37' 30.74" 162 Foot—MONOPOLE Tower Crown Castle is pleased to submit this "Structural Evaluation"to determine the structural integrity of the above- mentioned tower. The purpose of this evaluation is to determine the suitability of the tower structure to support the proposed equipment configuration listed in Table 1. Based on a comparison of loading listed in the previous analysis dated 11/27/2018, the proposed loading change will not have significant impact on the overall tower stress rating. Therefore, the final proposed equipment configuration listed in Table 1 is structurally ACCEPTABLE. Table 1: Proposed Equipment Configuration Mounting Center Line Number Antenna Antenna Number Feed Line Level Elevation of of Feed (ft) (ft) Antennas Manufacturer Model Lines Size(in) 121 1 MOUNTS Commscope_MC-PK8-DSH 121 1 RAYCAP RDIDC-9181-PF-48 121 121 3 FUJITSU TA08025-B604 1 1-1/2 121 3 FUJITSU TA08025-B605 121 3 JMA WIRELESS MX08FRO665-20 Respectfully submitted by: 014 OF MgSS9cyG Jamal Huwel, P.E. JAMALA.HUWEL Director Engineering `" ° CIVIL 0)) igitally signed by NO.51270 ;Jamal A Huwel %NAL EN •' Date: 2021.04.28 22:39:36-04'00' Structural Evaluation