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44-014 (19) BP-2022-0182 254 OLD WILSON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 44-014-002 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0182 PERMISSIONIS HEREBY GRANTED TO: Project# ANTENNAS Contractor: License: Est. Cost: 35000 HEIDREA COMMUNICATIONS LLC 109212 Const.Class: Exp.Date:04/17/2022 BROADBENT, ERICSSON & SUSAN LEIGH Use Group: Owner: MACRAE MAIL: SBA COMMUNICATIONS CORP Lot Size (sq.ft.) Zoning: SC Applicant: HEIDREA COMMUNICATIONS LLC Applicant Address Phone: Insurance: 1 WILLIAMS WAY WC-14220923 BELLINGHAM, MA 02019 ISSUED ON:03/01/2022 TO PERFORM THE FOLLOWING WORK: ALTERATIONS TO EQUIPMENT AT CELL SITE 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I f4 • • )2 • .I • Fees Paid: $245.00 212 Main Street, Phone(413)587-1240,Fax:(4l3)587-1272 Office of the Buildine Commissioner 6 -- c_F--;.if i :7-ii-.-----, „ gj F�� 2 4 ?Q2 / The Commonwealth of Massachusetts �' 2 1 Office of Public Safety and Inspections ��`',_ —.__ Massachusetts State Building Code(780 CMR) �TF;;,'A r".,I;yu1ding Permit Application for any Building other than a One-or Two-Family Dwelling r , 7, ) Q (This Section For Official Use Only) Building Permit Number:i"'22-J04"Date Applied: Building Official: SECTION 1:LOCATION 254 Old Wilson Road Northampton, MA 13219 SBA Existing Monopole Tower No.and Street City/Town Zip Code Name of Building(if applicable) 440014 44 -014-002 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 RI Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other ® Specify: No Change Proposed. Are building plans and/or construction documents being supplied as part of this permit application? Yes IR/ No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No fil Brief Description of Proposed Work:Remove existing (12) antennas and replace with (6) L TF antennas on dual mourn: and (3) MT6407-77A antennas, and (3) CBRS RRH with clip on antenna. Remove (9) RRH and replace with (6) dual RRH's. No ground disturbance proposed. Removing and replacing of existing equipment at an existing cell site. 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): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) N/A Total Area(sq.ft.)and Total Height(ft.) N/A 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 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2❑ 1-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special.Use El and please describe below: Special Use Description: Communications facility. Note facility is existing. Proposing minor modifications. SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ HA 0 IIB ❑ MA IIIB ❑ IV CI 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 N/A Check if outside Flood Zone RIIndicate municipa A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system�A required❑or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable I]a Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No® 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 SBA Communication Corp. 8051 Congress Ave. Boca Raton, FL 33487 Name(Print) No.and Street City/Town Zip Property Owner Contact Information George O'Neil Site Manager - _ 5t6-244-4689 goneil@sbasite.com 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 0. 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 Heidrea Communications LLC Company Name Russell E Cates CS-109212 Name of Person Responsible for Construction License No. and Type if Applicable 49 Valley View Road Leominster MA 01453 Street Address City/Town State Zip 508-473-1990 _ - rcates@heidrea.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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor $35,000.00 and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Total Construction C.: x•I I(I - here 2.Electrical $ appropriate municipal factor) $ $245.0.0 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=0100.00(contact municipality) 5.Mechanical (Other) $ $35,000.00 Enclose check payable to City of Northampton 6.Total Cost $ $35,000.00 (contact municipality)and write check number here -2 R 73(2 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 accurate to the best of my knowledge and understanding. Anne McGuinnes Consultant (857) 928-6276 Please print and sign name Title Telephone No. Date SAI 12 Industrial Way Salem NH 03079 Anne_Mcguinnes@SAI-Comm.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: �O� , ) � Name babe City of Northampton oatMnM �5...'. -�"� Massachusetts �S - c'<< p 1-1 ( DEPARTMENT OF BUILDING INSPECTIONS w. • • 212 Main Street • Municipal Building Jb, Ca rai Northampton, MA 01060 rs 1` 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: The debris will be transported by: Name of Hauler: Signature of Applicant: Date: The Commonwealth of Massachusetts t^r Department of Industrial Accidents _ s Office of Investigations Lafayette City Center ILL � 2Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Heidrea Communications, LLC Address: 1 Williams Way City/State/Zip: Bellingham, MA 02019 Phone #:503-473-1990 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 50 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ElRemodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p 9. [' Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 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 Telecommunication employees. [No workers' 13.❑� Other 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: Granite State Ins CO Policy#or Self-ins. Lic. #:WC 14220923 Expiration Date: 3/15/2022 Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Da `.!)e,Lean Date: 3/15/2021 Phone#: 508-473-1990 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): 10Board of Health 2❑Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: B CITY of BOSTON Martin J.Walsh, Mayor MATTOCKS-HIGGINS AFFIDAVIT OF WORKPLACE SAFETY 1, Diana DeLeon ,do hereby declare the following to be true and accurate to the best of my knowledge. I. Occupational Safety and Health Administration(OSHA) &has not issued / o has issued any notice or violation against my company,as a sole proprietorship, limited partnership,and/or limited liability partnership/corporation,and/or any affiliated business or subsidiary of which I am an owner, manager,officer and/or director in the last five(5)years. If you selected"has issued", please disclose the following information: Company Date of Violation Address of Violation Total Fines, if any Check if: _Serious _Willful _Repeat _Failure to Abate Named violation: Company Date of Violation Address of Violation Total Fines, if any Check if: _Serious _Willful _Repeat _Failure to Abate Named violation: **Attach additional pages if necessary If any violations are categorized as Willful or Repeat, affidavit must be accompanied by a copy of the Site Safety Plan for the project seeking permit. II. Is the company currently on the OSHA Severe Violator Enforcement Program(SVEP)Log? o Yes an No Companies in the SVEP are not eligible to receive a permit from the City of Boston III. Company's Experience Modification Rating: 1.01 Available from the MA Workers Compensation Rating and Inspection Bureau The Licensed Contractor must disclose any subcontractor's OSHA violation history or SVEP designation to the permit reviewing department. Signed under penalties of perjury: 8/3/2021 Z, i)¢Z21219Jt Heidrea Communications, LLC Date Name Company The Permit Reviewing Authority,or designee,shall have the discretion to issue a stop work order for any open permits and/or deny the issuance of a permit due to failure to disclose any and all OSHA violations or demonstrated history of unsafe, hazardous or dangerous practices. Published October 18,2017 Aco° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 41.—/ 3/16/2021 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 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: Kristin Hollander The Driscoll Agency PHONE FAX 141 Longwater Drive Suite 203 t c4 Lo,En):781-681-6656 I(A/c,No):781 681-6686 Norwell MA 02061 ADDRESS: khollander@driscollagency.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Admiral Insurance Co 24856 INSURED 5801 INSURER B:Granite State Ins Co _ 23809 Heidrea Communications, LLC Heidrea Communications NY, LLC INSURER C:Selective Insurance Co of Southeast 39926 Heidrea Communications CT, LLC INSURER D:Berkley Insurance Co 32603 1 William Way INSURER E:The Charter Oak Fire Ins Co 25615 Bellingham MA 02019 — INSURER F: Merchants Mutual Insurance Co. COVERAGES CERTIFICATE NUMBER:519384839 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 POUCY EXP W UMITS LTR ,INSR VD POLICY NUMBER IMM/DD/YYYY) IMM/DD/YYYY) A GENERAL LIABILITY CA000017499-09 3/15/2021 3/15/2022 EACH OCCURRENCE $1,000,000 X ' DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) 5300,000 CLAIMS-MADE LX OCCUR MED EXP(Any one person) S 5,000 __ X Contractural PERSONAL 8 ADV INJURY S 1,000,000 X X,C,U _ GENERAL AGGREGATE S 2.000,000 GEM.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 —I POLICY X JF? LOC S C AUTOMOBILE LIABILITY A9107087 3/15/2021 3/152022 COMBINED SINGLE LIMIT (Ea accident) S 1.000.000 X ANY AUTO BODILY INJURY(Per person) i ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOSPROPERTY DAMAGE S NON-OWNED ED (Per accident)HIRED AUTOS AUTOS - Comp 8 Col ded S$500 each F UMBRELLA UAB X OCCUR CUP0001200 3/15/2021 3/152022 EACH OCCURRENCE $5,030,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION S S g WORKERS COMPENSATION WC 14220923 3/152021 3/152022 x WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY UMITS ER ANY YI R/MEMBER PROPRIETORPARLNERE ECUTIVE N N/A E.L EACH ACCIDENT S1,000,000 OF(Mandatory in NH) E.L DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT S 1,000,000 D Professional Liability PCADB-5013992-0321 3/15/2021 3/15/2022 $2,000,000 ea.claim $7,000,000 egg. E Pollution Liability 660-6K535893 COF 20 3/15/2021 3/15/2022 $5,000,000 ea.occ. S7,000,000 egg Builders Risk DESCRIPTION OF OPERATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of Insurance AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural X 2 Foundation 3 Structural x 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Mustapha Assi 561-995-7670. 50322 Name(Registrant) Telephone No. e-mail address Registration Number 8051 Congress Ave. Boca Raton FL 33487 Structural 6/30/22 Street Address City/Town State Zip Discipline Expiration Date Jesse M. Moreno 47315 Name(Registrant) Telephone No. e-mail address Registration Number 4 Bay Road Blg. A, Suite 200 Hadley MA 01581 Civil 12-29-21 Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals.