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42-079-002 (6) BP-2024-0367 114 GLENDALE RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 42-079-002 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-2024-0367 PERMISSION IS HEREBY GRANTED TO: Project# MODIFY CELL SITE 2024 Contractor: License: Est. Cost: 50000 ERIC KUKLINSKI 97447 Const.Class: Exp.Date: 01/06/2025 Use Group: Owner: AMERICAN TOWER CORPORATION Lot Size(sq.ft.) Zoning: SC Applicant: ERICSSON Applicant Address Phone:, Insurance: 1086 MAIN ST WLRC67813509 WEST WAREHAM, MA 02576 ISSUED ON: 04/08/2024 TO PERFORM THE FOLLOWING WORK: MODIFY 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 172- Fees Paid: $350.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner 4Pq 4.@ The Commonwealth of Massachusetts ,� * I--;` ��• % / Office of Public Safety and Inspections e I f i �'f :+ ;��rn, / a Massachusetts State Building Code(780 CMR) i ,�g4Permit Application for any Building other than a One-or Two-Family Dwelling \boo Ng r` (This Section For Official Use Only) Building Permit Number:a 240 / ate Applied: Building Official: SECTION 1:LOCATION 114 GLENDALE ROAD No.and Street City,/rTpwna Zip Code Name of Building(if applicable) Assessors Map# Blooccfk#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❑ Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other D Specify: T-MOBILE CELL SITE MODIFICATION 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: ON BEHALF OF T-MOBILE THE PROPOSED WORK INVOLVES MODIFYING THEIR EQUIPMENT AT THE EXISTING CELL SITE. PLEASE REFERENCE THE ATTACHMENT FOR FURTHER DETAILS. 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.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub ❑ A-3 ❑ A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 ❑ H-2❑ H-3 0 H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ® IB0 IIA0 IIB0 IIIAO IIIBO IVO VA 0 VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site 0 Public El Check if outside Flood Zone El Indicate municipal 0 A trench will not be P Private Elor indentify Zone: or on site system 0 required®or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable® Is Structure within airport approach area? • Is their review completed? or Consent to Build enclosed 0 Yes 0 or Noy❑ 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 AMERICAN TOWER CORPORATION 10 PRESIDENTIAL WAY-WOBURN MA 01801 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 617 _375 _7500 Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: AUTHORIZED COMMUNICATIONS LLC AGENT 750 W CENTER ST STE 301-W BRIDGEWATER MA 02379 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 ERICSSON INC Company Name ERIC KUKLINSKI CS-097477 Name of Person Responsible for Construction License No. and Type if Applicable 1089 MAIN ST-WAREHAM MA 02576 Street Address City/Town State Zip 508 - 742 - 8472 - - eric.kuklinski@ericsson.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 and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ 50000 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$_ _ _kcontact municipality) 5.Mechanical (Other) $ • 6.Total Cost $ 50000 Enclose check payable to �t O"L (contact municipality)and write 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 accurate to the best of my knowledge and understanding. ADAM WOLFREY-CENTERLINE COMMUNICATIONS LLC 4//► AUTHORIZED AGENT /[r (/ 508 -867 -3100 0322.24 Please print and sign name Title Telephone No. Date 750W CENTER ST STE 301-W BRIDGEWATER MA 02379 awolfrey@Clinellc.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: //' -Z- L zZ it Name Date File #BP-2024-0367 APPLICANT/CONTACT PERSON:ERICSSON 1086 MAIN ST WEST WAREHAM, MA 02576 PROPERTY LOCATION 114 GLENDALE RD MAP:LOT 42-079-002 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $350.00 Type of Construction: MODIFY CELL SITE New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan Driveway Grade% THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: I/ Approved Additional permits required(see below) For all projects that need additional reviews E ci.x;0 as checked below,please see the Office of Planning& Sustainability Permit page or scan here - 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 i/& - 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. CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton str. Massachusetts "'�; DEPARTMENT OF BUILDING INSPECTIONS '; - 212 Main Street • Municipal Building Northampton, MA 01060 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: 6300 Legacy Dr,Plano,TX75024 The debris will be transported by: Name of Hauler: Signature of Applicant: ,4,daa.,z 0)& AGENT Date: 03.22.23 Re: Building Permit Application - 114 GLENDALE ROAD - 4SH0213C Kevin Ross <kross@northamptonma.gov> Fri 3/22/2024 11:21 AM To:Adam Wolfrey <awolfrey@clinellc.com> Cc:Kim Carson <kcarson@northamptonma.gov> Hi Adam, The permit fee is $7 per $1000 of estimated value of work, so $350 will be the fee. No paper filling is required, we have everything in the email. Any questions, please let me know. Thanks, Kevin On Fri, Mar 22, 2024 at 11:11AM Adam Wolfrey <awolfrey@clinellc.com> wrote: Hi Kevin, Attached to this email is a copy of a building permit application that I'm submitting on behalf of T- Mobile. Can you please confirm the amount of the permit fee? Also, do you need a copy a paper copy of the filing? Thanks, Centerline has a new look.For more information about our rebrand,click here. �� Adam Wolfrey I Site Acquistion Consultant Fa_ 750 W Center St, Suite 301 I West Bridgewater,MA 02379 Mobile: 508-667-3100 awolfrey_@clinellc.com www.centerlinecommunications.com Building a better network. Smart design. Quality construction.Reliable maintenance. •. `79 - S GL,lv Co n ir ul—Srr 7 i' � X� Kim Carson <kcarson@northamptonma.gov> S 4SH0213C-BP-2024-0367_114 GLENDALE RD_42-079-002_CROCKETS M&S COI/WC 1 message Stephanie Gladys <steph.g@crockets.com> Tue,Apr 23, 2024 at 3:09 PM To: kcarson@northamptonma.gov Cc: Ivan larygin <ivan@crockets.com> Good afternoon, Kim and thanks again for taking the time to speak with me today. Please find attached, our COI to satisfy the Sub-Contractor requirements for BP-2024-0367 located at 114 Glendale Road. Thank you! CRDCK :TS Steph Gladys Construction Project Manager Crockets Materials and Services inc. Address:3430 Progress Dr,Unit C,Bensalem,PA 19020 o Phone:(315)567-3328 E_3 Email:steph.k@crockets.com °'Site:crockets.com NATE STAR amum 2 attachments 4SH0213C -BUILDING PERMIT&ZONING ADMIN APPROVAL.pdf 23K �'_ CROCKETS_COI_EXP03.23.25.pdf 64K ACcRD® DATE(MM/DD/YYYY) Cc CERTIFICATE OF LIABILITY INSURANCE 03/26/2024 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 CONTNAME: Andrea Andrea Pigott MICHAEL•PIGOTT AGENCY (A/�No.Est): (215)245-7900 FAX Not: (215)245-7970 2008 State Rd. E-MAIL d anrea I ADDRESS: @Pottins.com 9 INSURER(S)AFFORDING COVERAGE NAIC C Bensalem PA 19020 INSURER A: Selective Ins.Co.of South Carolina 19259 INSURED INSURER B: Berkshre Hathaway Direct Insurance Company 10391 Crocket's Material and Services Inc. INSURER C: Scottsdale Ins.Co. 41297 6 Erin Dr INSURER D: Mesa Underwriters Specialty Ins.Co. 36838 INSURER E: Richboro PA 18954 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 ADDL SUER POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A S 2329501 03/23/2024 03/23/2025 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X 1,(118i LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A AWNED AUTOS ONLY SCHEDULED AUTOS S 2329501 03/23/2024 03/23/2025 BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE S 2329501 03/23/2024 03/23/2025 AGGREGATE $ 3,000,000 DED X RETENTION$ 0 $ WORKERS COMPENSATION X STATUTE ERH pa,md,va,wv,de,ct AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? y N/A N9WC809423 12/15/2023 12/15/2024 (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 EXCESS UMBRELLA OCCURRENCE $5,000,000 C QX-04394143 03/23/2024 03/23/2025 AGGREGATE $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) A Installation Floater S 2329501 03/23/2024-03/23/2025 Limit:$250,000 D Excess Liability UM35847 03/23/2024-03/23/2025 Ea Occurrence:$2,000,000 Aggregate:$2,000,000 ELECTRICAL APP INSTALLER Excluded on WC:Aliaksey Yeskin 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. FOR BIDDING AND INFORMATION To request a specific certificate of Insurance AUTHORIZED REPRESENTATIVE please email:andrea@pigottins.com �Q ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD