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B-16-1448 CELL TOWER EXTENSION Commonwealth of Massachuse s Citv of Salem 120 Weshingbn St,3rd FloorSelem,MA 01970(978)746.8599 1 Return card to Building DWision for Certificate of Occy nay Permit No. ' 1346-140 FEE PAID: $275.00 PERMIT i . LD DATE ISSUED: 12211120116 This certifies that LORING 1NERS SALEM AIMCO/TTA MS 236 has permission to erect, alter, o demolish bui d' UE Map/Lot: 200007-0 as follows: Other Building ermit Pq$ES REMOVING & REPLACING 3 TENN NAL.RRTTS ON ITS I EXISTING ROO OP Contractor Name: DAVID COOI±ER DBA: Contractor License No: 108961 12121/2016 i Date This permit shall be deemed abandoned a6d invarrd u after Issuance.The Building Offficcial may grant one or more extensions not to exceed six All work authorized by this permit shallco�orm to the and the approved construction do permit has been granted. All construction,alterations and changes use of any, res shall be in compliance wkh the codes. This permit shall be displayed in a location: vis t or road and shall be maintained for the entire duration of the work ung the completion of the same. The Certificate of Occupancy wig not 6e Is' ad until a res b the Build a permit. HIC#: 'P Myfune(as set forth in MGL 042A). Restrictions: f Building plans are to be available on site:' All Penmit Cards are the property,of the PROPERTY OWNER. EMPIRE telecom Date: March 14, 2019 To: Salem City Hall 93 Washington Street Salem, MA 01970 Via: Letter VIA USPS Michelle Scharath, Empire Telecom USA, LLC Re: Permit No. B-16-1448 Building Permit Extension for AT&T Proposed work on existing wireless communications structure at 1000 Loring Ave (AT&T Site ID MA3354) Dear Mr. St. Pierre: We are writing to request an extension to the above referenced Building Permit. Unfortunately construction was delayed due to materials not being available. We anticipate starting construction this spring. For your reference I have enclosed: a copy of the Building Permit, an updated COI and Workers Comp Affidavit. I have also enclosed a prepaid USPS return envelope if you are able to mail the Building Permit to me. This can be dropped in any mail box. If you have any questions or require the Permit be picked up in person, please don't hesitate to contact me at the email address or number below. Thank you for your attention to this matter. Sincerely, 'nlcciceffe S6444a Michelle Scharath Site Acquisition Specialist Empire Telecom USA, LLC 16 Esquire Rd Billerica, MA 01862 Phone: 978-935-6913 mscharath(cDempiretelecomm.com D�,v ► p Co c�.p�. t,xP . z( zttlZo-z The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/individual):Empire Telecom USA, LLC Address: 16 Esquire Road City/State/Zip:Billerica, MA 01862 Phone#:617-6394908 Are you an employer?Check the appropriate box: Type of project(required): I.[Z]I am a employer with 100 employees(full and/or part-time).' 7. New construction 2.E]1 am a sok proprietor or partnership and have no employees working for me in 8. Remodeling any capacity (No workers'comp.insurance required.] 3 D 1 am a homeowner doing all work myself (No workers'comp insurance required l' 9, ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 50 1 aro a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E:]Roof repairs These sub-contractors have employees and have workers'comp insurance E✓ Other Wireless site 6.a We ane a corporation and its officers have exercised their right of exemption per MGI.c. 14. eVe Opm@n 152,§1(4),and we have no employees [No workers'comp insurance required] Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. ?Homeowners who submit this affidavit indicating they arc doing all work and then hue 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:First Liberty Insurance Corporation Policy#or Self-ins. Lic.#: WC6-631-510650-018 _ Expiration Date: 11/30/2019 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 pet: rjury that the information provided above is true and correct. Signature: I. /iJ f C�)W a!n Date: Phone#:617-639-4908 Oficial 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.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AGENCY CUSTOMER ID: _ LOC#: AC4 RE® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Arthur J.Gallagher Risk Management Services,Inc. Empire Telecom USA,LLC 1150 1 st Avenue,Suite 600 POLICY NUMBER King of Prussia,PA 19406 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 Environmental Insurance(Contractor's Pollution Liability) Policy#0311-0596 Policy Period:11/302018-11/302019 Carrier:Allied World Assurance Company,Ltd. Occurrence/Aggregate:$5MM/5MM Hartford Fire Insurance Company Inland Marine Policy Eff Date:11/30/18-Exp Date:11/30/19 Policy#13 UUM BKO148 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 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Ac R® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/29/2018 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(les)must have ADDITIONAL INSURED provisions or be endorsed. H 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(*). CONTACT PRODUCER NAME: Cassie Burke Arthur J.Gallagher Risk Management Services, Inc. PHONE g5s-482-9900 FA/AX,No):856-482-1888 4000 Midlantic Dr,Suite 200 (AIQ Nm Ext), Mt.Laurel NJ 08054 ADDRDRELSS: Che Hill.BSD.CertM AJG.com INSURER(S)AFFORDING COVERAGE NAIL 0 INSURERA:First Liberty Insurance Corporation 33588 INSURED INSURERS:Liberty Mutual Fire Insurance Company 23035 Empire Telecom USA, LLC INSURER C:AXIS Insurance Company 37273 1150 1st Avenue,Suite 600 King of Prussia, PA 19406 INSURER D:Liberty Insurance Underwriters Inc 19917 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:111597710 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 ��8UBR POLICY NUMBER APOLIC/EFF POLICY LILY EXP LIMITS TR B X COMMERCIAL GENERAL LIABILITY T62-631-5106504048 11/30/2018 11/30/2019 EACH OCCURRENCE $2,000,000 DAMAGE REN CLAIMS-MADE X OCCUR PREMI S Ea occurrence) $300,000 MED EXP(Any one $5,000 X XCU PERSONAL 8 ADV INJURY $2,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 JEST FX]LOC PRODUCTS-COMP/0P AGG $4,000,000 POLICY� OTHER: $ B AUTOMOBILE LIA UrY AS2-631-510650.038 11/30/2018 11/30!2019MEIN D SINGLE LIMIT $2000000 Ea acrid nt 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 ecddent C UMBRELLALIAB X OCCUR 0-001-000073672-01 11/30/2018 11/3012018 EACH OCCURRENCE $5,000,000 X EXCESS LU16 i CLAIMS _E AGGREGATE $5,000,000 DED I X RETENTION $ A WORKERS COMPENSATION WC6-631.510650-018 11/30/2018 11/30/2019 X STATUTE ERR AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXECUTIVE NIA A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED7 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $1,000,000 Kdescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1000000 D Excess Liability 1000324565-01 11/30/2018 11/30/2019 Each Occurrence 10,000,000 Aggregate 10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addkkmal Remarks Schedule,may be attached H more space Is required) Property Policy Policy 11113 UUM BKO148 Policy Period:11/30/18-11/30/19 Carrier:Hartford Fire Insurance Company Leased/Rented Equipment: Limit:$1,500,000 Deductible:$5,000 BPP Limit/Deductible:$6,825,000/$5,000 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. Evidence of Insurance AUTHORIZED REPRESENTATIVE s"II I-C> ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD