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WINRR ISLAND PARK - BUILDING INSPECTION The Commonwealth of Massachusetts ® Department of Public Safety Massachusetts State Building Code(780 CMR)Seventh Edition 1 Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) uIINZR txf�"-tt� pAat- ?4Oc-EAAtMA .N/,4 --v No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ 1 Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other m0151)ecify: M V Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Me' Is an Independent Structural Engineering Peer Review required? Yes ❑ No iS' Brief Description of Proposed Work: ea Ecr-10A— O rr 'IEn+Zv✓uiR+/, u��6-TE2 Y<Lt,L , 7e3uEy� �02 �`iyE g�.9RAOSi= OF ClJGLFc�G- L✓/.CID .i�RT.it 'Ti7/E ?ociBc� r�/LL �3t Ln� EB.c-D �/SAs�SZ:7�'1BL�-D r�^,fiv't� GeE�I-c✓� �D/-� t�/� �'T�" SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: 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-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5 ❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ - F2❑ H: Hi h Hazard H-1❑ H-2❑ ' H-3 ❑ 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 Sl❑ S-2❑ U: Utility❑ 1 Special Use M amend please describe below: "n Special Us¢`�- t! SECTION fi:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public, '� Check if outside Flood Zone X Indicate municipa(.$,( A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required gor trench or specify: permit is enclosed❑ 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 ❑ Yes❑ or No A Yes❑ No Q� SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY ,. Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 3 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Cl" of oArt%M 50 woke- t5gAo 2V SAL&,Mf . MA q p i Name(Print) No.and Street City/Town Zip Property Owner Contact Information: WILL1W PI'SOsAP- f70 _7HS-_143D =_ Title Telephone No. (business) Telephone No. (cell) e-mail address applicable,the property owner hereby authorizes - 4oMA--t#%ov&44F=9E /SZ— Name Street Address City/Town State Zip to 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 2) - f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 101 10.1 Registered Professional Responsible for Construction Control ��NFHI-HA.v/�ARk4ii5y -7�49 © 7 vrt-nrlGea/�meri ✓14ssaL• !"lcn �Q� ` Name(Registrant) -�_ — Telephone No. e-m il address 40 Registration Number /5Z t^ts v�/�Sr 0 /ity/Tow State xpr gnl- Gt/n� �� F Street Address C Zip Discipline ation Date - 10.2 General Contractor - - _S.c C,�(/ _any Name: Name of Person Responsible for C--struction License No. and Type if Auplicahle OTC/ Street Address �'�'J ^� City/Town - State Zip Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'CONWENSATION 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❑ No 0 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 municipal factor)=$ 3.Plumbing $ P _ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ 6b NA nclose check payable to 6.Total Cost $ (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 be s�s m knowledge and understanding. ,oNATZ",J � - MAd�x. C� `7 _ZF7 - oV47 1x2lq p• ` -07 Please print and sign name Title Telephon No. e _15y CoJLwT 3T• i Vr1L�-y MFk UFt Street Address - City/Town State Zi Municipal.Inspector to fill out this section upon application approval: Name D Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 116. The checklist below is a compilation of the documents that may be required for this. 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 Re uired 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression OL 5 Fire Alarm(may require repeaters) X 6 HVAC X 7 Electrical pc 8 Plumbing include local connections X 9 Gas Natural,Propane,Medical or other) - DC 10 Surveyed Site Plan Utilities,Welland,etc. a( 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program X 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation �C 16 Energy Conservation Report pt, 17 Architectural Access Review 521 CMR of 18 Workers Compensation Insurance DC 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) >L `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.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information L�.vyr2��✓ -i �"y-� zzS �� Name(Re istrant) Telephone No. e-mail address Registration Number G aelG�S Iz,( /> v�s8vx6r- V1, Street Address City/Town State Zip Discipline Exp' atio Date 'Scuawt a,� m,Uz,Cer lit?y Name(Registrant) ephone No a-m�a' ad. —V address Zehl Registration Nu ber Lri Z �it/ffAll � /X ( ow— Street Address City/Tows State Zip Discipline f xpii�r b�oon Date Nar^ "'"^+��'�nhl +A Telenhnna N� ���J -mail Adrl-ess � /R�.aoict�r(af�in�n Nur• .s-,�.,/y� ' SIP --,;)4 —/IA.cN iFF +NFF1 � _ _`v i�N ['.7Y. —1 cni/�"o— Street Address city/Town State Zip Discipline Expuatig(n Date Appendix 1 I For the demolition of structures the building code requires action on service connections. 780 CMR 112.0 DEMOLITION OF STRUCTURES 112.1 Service Connections. Before a building or structure is demolished or removed, the owner or agent shall notify all utilities having service connections within the structure such as water, electric, gas, sewer and other connections. A permit to demolish or remove a building or structure shall not be issued until a release is obtained from the utilities, stating that their respective service connections and appurtenant equipment, such as meters and regulators, have been removed or sealed and plugged in a safe manner. All debris shall be disposed of in accordance with 780 CMR 111.5. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot# for locations for which a street address is not available) No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) The Commonwealth of Massachusetts Print Form U Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Mt�tnlAN A5,Sor_iAit�S� i r✓r` Address: t5z cwu IU'i Srt City/State/Zip: t3 v �l rot F1- o is t-5_ Phone #: `i 78 zS9_ Olt 4-7 Y z-'`t Are you an employer? Check the appropriate box: Type of project(required): 1.C&I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.® Other -MHP• M6� fTu dL 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 time 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 isproviding workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: /-4ea(1D00 _b { t�d�Nato>uc 104 MAW ST 10, Ati11k)6 ttZ , 1.4 A-- 019c4 S Policy#or Self-ins. Lie. #: 08 W 6 KL-2106 Expiration Date: 7 ' ( Ito Job Site Address: V I en1T+d2 `cA�J-Z) City/State/Zip: 5&_C-X4 t MA 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' and the aims and penalties ofperjury that the information provided above is true and correct. Signature: Date: i 2.1 Li'Oct Phone#: 97?,-- 2-95- 0447 x 2-14 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. 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O] UpBaJe8Mk0 In ' M KKS �mwSS`° _ a M NRG SYSTLMS INC N rrYe.W(me pp wcgq ' Wv+Rx w a 110� 00,S r9N 16 E50UAG.1.. 051 m- 1bdl NaWon mx owas ..nrs wurw°Ar:.Kere' on Po, Ah Large Foat?:inr t.000.000 Pofale /,p 1_.oy LSCi mn°'r,K r .x',,re " 60(.SOjmHU_60m ., kLL t.OWUS pwnrA :ax� Ma ePP6p.'AL$ DaIC 203 1 U0 .m W- oa pawkepr'uxT' w r:Or scv[wuays &AZia, h)'ne f. .nele Icx mldl'MDm perpwr - C,vF -.-.sniNr .x r 0-Oianleb � eiE �w/orNt _ m•e 144344 �"' NTS T 1 ai i 50m XHD TalftwerTm Small Footprint ± Max.Anchor Load Imperial Units 8,000 I IL 7,000 -- � 3t4 Ice i 1!2 Ice 1!4'Ice 6,000 t .� I I I l � - �a No Ice c 5,000 1"Ice lf60d CON 5UXI '5 4,000 ....... I .. o -- c I I _. c E 3,000 X 2,000 - — I —T— 1,000 L_......... -.. I i i i i I 0 1 30 40 50 60 70 -MIk%80 90 100 110 120 130 33 Foot Fastest Mile Wind Velocity(mph) Release[late:&01107 Rev A All material and format are copyright of NRG Systems Inc and may not be reproduced w1hout permission. 128 NRG_60m_and_50m_XHD_TallTower_Installation_Manual_and_Specifications_Rev_1.05.pdf 15 January2009 Site Layout TOWER r T�TA-L �N BACK ANCHORS SHOULD BE UPHILL OR DOWNWIND ti ��ILLIIUf✓CHo� UPHILL Cr//+ DOWNWIND SIDE GUY ANCHORS IRS SIDE GUY ANCHORS BASE PLATE (INNER, OUTER) 13.7m (45') 30 48m (100') 14.94m (49') ' ` 33.53m (110') TURNING BLOCK 46 1.5') TYP ►� BRIDLE ANCHORS WINCH ANCHOR I DOWNHILL GUY ANCHORS I I NRG_60m_and_50m_XHD_TallTower_Installation_Manual_and_Specifications_Rev_1.05.pdf IS January2009 R' Install the doublers on the vertical pieces as shown below. Carefully align the "saddle" cutouts with the large holes in ` the vertical pieces so that the pivot tube can pass through. Make sure the bolt and nut are oriented as shown, nut on the outside. �1 e k,. J F.: 4` a. a a � x^f� Place the baseplate at the installation site, orienting it with the gussets closer to the winch. At the beginning of a lift, particularly for the gin pole, the winch forces are largely horizontal. These forces tend to (slide the baseplate toward the winch and/or tip the baseplate up on edge. To counteract these forces, if is highly recommended that the baseplate be anchored against;lid1a and tipping. There are several possible techniques _ depending on the terrain, soil, and subsequent operations under the tower. • Ro s { the baseplate into the soil Nti m, eep soil,drive several pieces of rebar through the holes ' e in e' le them away from the winch and place as many as ' pr along the baseplate front edge.(farthest from the — I* Rock anchors to the baseplate—On rock,or shallow soils,attach rock anchors tot a aseplate, particularly along the front edge. These should be positioned and attached to hold the edge of the baseplate down as well as keep it from sliding. • Cable to the Guy Anchor—A cable made up as a bridle connected to the tower tube pivot pipe can be run to the inner anchor opposite the winch or to an anchor nearer the baseplate. See below for details. I 25 1 N RG_60m_and_SOm_XHD_TallTower_Installation_Manual_and_Specifications_Rev-1.05.pdf 15 January 2009 r (V .v L O m - m m m m PP m a- I Figure 4 Drive ground rods through the baseplate holes so they can provide additional anchoring for the baseplate. - s r � g Install the Anchors See Appendix H: Anchoring Guidelines at the end of this manual for more information on installing anchors. Depending on the soil type, anchoring can take varying levels of planning, effort and time. Be sure to know what sod ' types you are dealing with as part of your pre-installation planning process. Leave the eye of screw-in anchors about 150 mm (6 inches) above ground. 26 ' NRG_60m_and_50m_XHD_TallTower_Installation_Manual_and_Specifications_Rev_1.05.pdf 15 January 2009 m� e —�--�ynnyunl•�.r� ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MDNY)D00 1022/29 9 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MacDonald &Pangione Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. BOX 428 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, 104 Main Street - INSURERS AFFORDING COVERAGE North Andover, MA 01845 INSURED Meridian Associates, Inc INSURER A:The Hartford Group 152 Conant St. INSURERS Beverly, MA 01915 INSURERC: INSURER D. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTft TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRATION DATEIMM1DDNYI DATEI LIMITS AGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY 08 SBA VY0439 08/03/2009 08/03/2010 FIRE DAMAGE(My oneflre) $ 300,000 CLAIMS MADE OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY �' $ 1,000,000 GENERAL AGGREGATE I$ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO 1$ 2,000,000 POLICY jpTPRO PRO- LOG AUTOMOBILE LABILITY 08 MCP TD7354 08/03/2009 08/03/2010 (Ea aBINED SINGLELIMIT ANY AUTO $ 1,000,000 ALL OVA®AUTOS BODILVINJURY 'SCHEDULED AUTOS (Per person) $ HIRED AUTOS NON-OWNED AUTOS (Per at) n)RY $ PROPERTY DAMAGE $ (Per acaden0 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGO $ Aq EXCESS LIABILITY 08 SBA VY0439 08/03/2009 08/03/2010 EACH OCCURRENCE $ 10,000,000 OCCUR CLAIMS MADE AGGREGATE $ 10,000,000 $ DEDUCTIBLE I$ RETENTION $ 10,000 1$ A WORKERS COMPENSATION AND NC STATU- OTH- EMPLOYERS'LIABILITY 08 WB KL2108 07/01/2009 07/01/2010 X TORYUMITs ER EACHACCIDENT $ 1,000o0o E L.DISEASE-EA EMPLOYEE $ 1,000,000 _ E.L.DISEASE-POLICY LIMIT 1$ 1000_0 00 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLEWEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS I CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL - DAYS WRITTEN Meridian Associates NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 26S(7197) 0 ACORD CORPORATION 1988 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MNUDD/YYYY) M 06/16/2009 PRODUCER (781)233-9050 FAX (781)231-8151 THIS CERTIFICATE IS ISSUED AS A MA'S PER OF INFORMATION Tarpey Insurance Group Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 347 Central St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 990 Saugus, NA 01906-0304 - INSURERS AFFORDING COVERAGE NAIC# INSURED Meridian Associates, Inc. INSURERA: Naxum Indemnity 1S2 Conant Street INSURERS: Beverly, MA 01915 INSURERC: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NS OATE MM/DD DATE MM/DD GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTE15— COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS MADE ❑ OCCUR MED EXP(Any one Person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Y AUTO (Ea accident) $ AN ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPESATION AND EMPLOYERS'N LIABILITY './N TORY LIMITS ER ANY PROPRIETOR/PARTNEWEXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,desce under SPECI rlh AL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER PFP600550101 02/13/2009 02/13/2010 Limit- $1,000,000 A Errors & Omissions Retention- $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Hartford Insurance Stephen Tarpey, CPCU CIC VP ACORD 25(2009/01) - ©1988-2009 ACORD CORPORATION. All rights reserve: The ACORD name and logo are registered marks of ACORD �7 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. I ACORD 25(2009101) / Uv r; ,will it r�� Kit» .J� °t�,` �x� � ,,.r• � i B s •'1 't ' �� _ ,Y.a ha` $ 4 y''14.t°,�Z !f s b �•lla xn e� yq �+• r �� �^'a,�. ' i,. �f b+f.• T x 4'.4 y� F' � �¢7 r x:Y"q tr P4,'r� � m k''.k "� �s 7.•".'�`.p,_.. � ' . '�+F .�`#41 ;. r( n 4• �J ' 4yG 5 f1A '�W� w Wit/� .{' S" ry�` i �` �{}yI J l,� y e•I ' evi- 41 zL t ,L s� Braintree Electric Light Department Woodard&Curran Warehouse Design December 3, 2009 Braintree, Massachusetts Bid Set ii. If any previous violations or complaints have been filed against the facility; and, if so, provide a brief statement describing the violation(s), how it was addressed, and its current status. iii. Proposed use of soil or material (i.e., reuse, treatment, disposal, or other) at the facility. iv. Description of quality assurance/quality control chemical sampling (QA/QC) that may be conducted on materials proposed for transport to the facility. V. Any limitations on soils or materials proposed for transport to the facility based on material consistency (i.e., granular soil, organic soil, or cohesive soil, debris content, slurry excavate, etc.). vi. Whether the facility is an EPA Superfund site or part of one. vii. Describing any remedial treatment systems that are in operation at the facility. viii. If any releases have occurred at or adjacent to the site, if they have been reported to the DEP,the Release Tracking Number and the status of the release. e. Facility information necessary to complete either Section E of DEP Bureau of Waste Site Cleanup Form BWSC-012A Bill of Lading or to complete Section E of DEP Bureau of Waste Prevention Material Shipping Record an-d Log. f. For facilities or locations that are not licensed by the State, provide the following: i. A letter of permission from the local Board of Health and other governing authorities (e.g., Conservation Commission) authorizing the facility or location to receive soils of the descriptions proposed by the Contractor. ii. Background chemical test data on soil and groundwater representing conditions at the proposed facility or location. i iii. A statement indicating whether or not the facility or location is in an aquifer recharge area. For Group IV facilities, provide a copy of the DEP-approved waste ban compliance plan. Y g. For Group IV (Solid Waste) facilities, provide a statement from the facility indicating the following: s" r' i. That the facility is operating in accordance with its waste ban compliance plan, ' permit, consent order(s), and/or other applicable documents. ii. If any previous violations or complaints have been filed against the facility; and, if so, provide a brief statement describing the violation(s), how it was addressed, and its current status. iii. Proposed use of material (i.e., reuse, recycling, treatment, biomass, or other) at the facility. iv. Description of quality assurance/quality control chemical sampling (QA/QC) that may be conducted on materials proposed for transport to the facility, EXCAVATED SOIL. AND MATERIAL MANAGEMENT PLAN 02220-4 r sus; The Commonwealth of Massachusetts w y, Department of Public Safety Massachusetts State Building Code (780 CMR) Seventh Edition y\ a Building Permit Application to Construct, Repair,Renovate or Demolish any Building other than a One-or Two-Family Dwelling CODE REQUIREMENTS FOR BUILDING PERMITS • 780 CMR(The State Building Code),Section 110.1 indicates that"It shall be unlawful to construct,reconstruct,alter, repair, remove or demolish a building or structure; or to change the use or occupancy of a building or structure; or to install or alter any equipment for which provision is made or the installation of which is regulated by 780 CMR without first filing a written application with the building official and obtaining the required permit therefore." • Section 110.2.1 indicates that "A building permit shall be required for temporary structures, unless exempted by 780 CMR 110.3. Such permits shall be limited as to time of service,but such temporary construction shall not be permitted for more than one year." • Section 110.5 indicates that "Application for a permit shall be made by the owner or lessee of the building or structure, or agent of either. If application is made other than by the owner, the written authorization of the owner shall accompany the application. Such written authorization shall be signed by the owner, or shall grant permission to the lessee to apply for the permit. The full names and addresses of the owner,lessee, applicant and the responsible officers,if the owner or lessee is a corporate body,shall be stated in the application." • Section 114.1 indicates that"A permit to begin work for new construction, alteration, removal, demolition or other building operation shall not be issued until the fees prescribed in 780 CMR 114.0 shall have been paid to the department of building inspection or other authorized agency of the jurisdiction, nor shall an amendment to a permit necessitating an additional fee be approved until the additional fee has been paid." FILING INSTRUCTIONS 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications,fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application.The check is to be made payable to the local city or town where the work will be done. �%