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0488 REAR HIGHLAND AVENUE - BPA-15-1386
1 C WEO ICES The Commonwealth oPWAM se s UlfDepartment of Public Safe t c A � ' O Massachusetts State Building (014S) 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 Official: �. SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) q9SW�,ltAtA- Sd6w MA of910 P JA No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK IEdition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below JJJ�1(11 l� Existing Buildinj�Q Repair❑ 1 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No 91 Brief Description of,J'roposed Work: .�OD��cti,�- Its puycSl✓vl 4u rzdw C3) I�QLJ ciw4klbtGS 9 C3� I wvi le_ kacl Iv arAC �Ct �C fXtS�lrvl menta 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) Cl 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.) kJ U C SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F20h 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❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB Cl IIA ❑ IIB ❑ IIIA ❑ HIB ❑ 1 IV O I 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: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone 13 Indicate municipal❑ required❑or trench or specify: Private❑ or indentiifytv 1A �Z qe: or o�site system❑ ✓'r pe nclosed❑ Railroad right-of-way Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable♦� Is Structure within airport appro h area? Is their review com I ? or Consent to Build enclosed❑ Yes❑ or No( Yes❑ No 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: Lr-\w 2�1vc� r 95 Ryan Drive,Suite 1 Raynham,MA 02767 CENTERLINE 781.713.4725 COMMUNICATIONS 617.249.0819 January 15, 2016 Thomas St.Pierre Inspection Services Director City of Salem 93 Washington Street Salem MA 01970 Dear Mr. St. Pierre: Re: Building Permit at 488 R Highland Ave T-Mobile recently pulled a building permit to add antennas at the above referenced site. Construction has not commenced on this permit and T-Mobile would like to change the Contractor listed on the application. The new contractor is Tilson. I have enclosed a new building permit application reflecting this change. Please reach out to me if you have any questions or need anything additional. Sincerely, By: Joh awre e Site ition Centerline Communications, LLC Mobile: (781) 715-5532 jlawrence@clinelle.com Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. 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) N t�l�ti laid �"` �4I2 AAA- 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 CT� Provider notified and Release obtained? Yes ❑ No LK Gas Shut Off? Yes ❑ No 8'� Provider notified and Release obtained? Yes ❑ No M-- Electricity Shut Off? Yes ❑ No 09 Provider notified and Release obtained? Yes ❑ No C9^ Yes ❑ No b� Provider notified and Release obtained? Yes ❑ No M— Other (if applicable) Yes ❑ No ('9 '�- Provider notified and Release obtained? Yes ❑ Noe Other (if applicable) !EMj Massachusetts - Department of Public Safety Board of Building Regulations and Standards �';.n+trtiti;;n Su(serti ,;;r License: CS-108437 . ' JOSHUA BRODER' 245 COMMERCIAL ST SUITE 203_ Portland ME 04101 10 Expiration Commissioner 09/10/2018 Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet (991m3) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS 1 r SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner AMe�ta,, —16tdaL– 3f`t Q(f4rn' Name(Print) No.and Strand et /Town Zip Property Owner Contact Information: 1^ 3az -zw_ Is _-_- Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes /� I � A,, taw rt Ace- IEK/o— or 41 a hr� WX MA 0Z,-?b� Name — I Street Address Ci /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) building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control 1A , S4evews �(S-6f(J_6WO I y96 C,/ Name(Regi grant))_� '� Tel hone No. e-mail address Registration Number 163 Vw ✓u rl!rQcl HtYJQN 1 nI�_ 1 1 Street Address City/ own State Zip Discipline Expiration Date 101 General Contractor -T. I S01\j 1_�CAA . IMG(MT L 0 U. Company Name Jo5k-t, 2rc,ct✓S-Z�SV37 Name of Person Responsible for Construction I.fcense No. and Type if Applicable 2\-S Cor WVroalS-}- P,AI _ Mt7 M,4 Street Address City/Town State Zip IL/_?E_ s� =_ 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 13 No ❑ 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 $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose 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 istrueand accurate to the best o my knowledge and understanding. (1 �Wt nCC- Srrtr prWak, I Pshf, Please print and sign name �t" Title Telephone No. Date 9 T_ divan Py IU Pr Cl z7 to l Street Address s City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 1/14/2016 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 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(s). PRODUCER CONTACT Amanda Ziegler Cross Insurance-Portland PHONE (2O7)780-1677�AX . (]07)'190-6377 2331 Congress Street gh-,E,.,Wazi'egler@crossagency.com INSURER(S)AFFORDING COVERAGE NAIC 4 Portland ME 04102 INSURERAAtlantic SpecialtV Ins Co 27154 INSURED INSURER B:Zurlch—_American Ins Co 16535 Tilson Technology Management; Tilson INSURERC: Wireless LLC; Tilson Fiber Technology LLC INSURERD: 245 Commercial Street, Suite 203 INSURERS: Portland ME 04101 INSURERF: COVERAGES CERTIFICATE NUMBERCL1532734013 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. ILTR NSR TYPE OF INSURANCEJUM POLICY NUMBER MMNDY EFF POLICY M DONM I LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Me TE6 $ 1,000,000 A I CLAIM&MADE .00CUR 711014383 /1/2015 /1/2016 MED EXP(Any one Penson) $ 15,000 X Contractual Liability PERSONAL S ADV INJURY $ 1,000,000 X XCO GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRI LOC 1 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S e..dm) 11000,000 A X ANY AUTO BODILY IWURY(Perpe,sm) $ ALL OWNED SCHEDULED 11014383 /1/2015 /1/2016 BODILY INJURY(Per acddent) $ AUTOS AUTO$ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Underinsured motorist $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 OED I X I RETENTION$ 10,00C 1711014383 /1/2015 /1/2016 1 $ B WORKERS COMPENSATON X WC SLIMIT OTR AND EMPLOYERS'LIABILITY y/N ANY OFFICER/MEMSER EXCLUD Dp ECUTIVE ON-] N/A E.L.EACH ACCIDENT $ 11000,000 (Mandatory In NH) 5746855 /1/2015 /1/2016 E.L.DISEASE-EA EMPLOYE $ 1,000,000 I ddescrifl beunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000,000 A Tech E 6 O 711014383 /1/2015 /1/2016 EaO-Dedoobbl"25,000 3,000,000 A Employee Dishonesty 711014383 /1/2015 /1/2016 Um9 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (AMch ACORD 101,Additional Remark.Schedule,N more spate is myulred Illinois Union Insurance Co. - Contractor's Pollution Coverage ef£ 5/15215-5/15/17 - $5,000,000 Per Pollution Condition Limit of Liability/$5,000,000 Aggregage Limit with $25,000 Per Pollution Condition Deductible. The Worker's Compensation Policy contains an "all states: provision that provides coverage for all states excluding monopolistic (ND, OR, WA, WY) . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Centerline Communications, LLC. ACCORDANCE WITH THE POLICY PROVISIONS. 95 Ryan Dr. , Suite 1 Raynham, MA 02767 AUTHORIZED REPRESENTATIVE Luke Goodine/BD7 _ ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS625 mmnnss ni Tho Arnran na...o a..A I,..._sr..re..loeereH_,aa,e,.f arnon 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/individuat):Tilson Technoloqy Management Inc. Address:245 Commercial St.,Suite 203 City/State/Zip:Portland,ME 04101 Phone#:207-591-6427 Are you an employer?Check the appropriate box: Type of project(required): LQ I am a employer with 135 employees(full and/or part-time).- 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. tContractors 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:Zurich-American Ins Cc Policy#or Self-ins.Lic. #:5746855 Expiration Date:04/01/2016 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 ofperjury that the information provided above is true and correct. Signature: 1 7 t&_ Tilson-Site Acquisition Coordinator Date: Phone#:207-358-7454 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.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: