10-12 FIRST ST - BUILDING INSPECTION (2) CH OF SALENT
PUBLIC PROPERTY
DEPARTNIENT
APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT] AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name P�;-A I A IQuilding P]2�
Property Address to-12 Fit—
Map 9 1:3
Located in: Conservation Area W-)--I-Iistoric district
Use Groups
(check one).
Residential q3 or more Units) R2 ✓
Type of improvement Residential(hotelhnmel R11
(check one) Assembly(churches) ,kI
New Building_ Assembly(nightclubs etc) -V
Addition Assembly(restaurants,recreation) A3—
Alteration Busibcss 8 —
Repair/Replacement_ Edttcational E
Demolition Factory(moderate hazard) F
Move/Relocat6 Factory(low hazard) F2
Foundation Only High Hazard 14
Accessory Building Institutional(residential care) 11
Other(describe) Institutional(incapacitated) 12
Institutional(restrained) J3
Mercantile M
Storage(moderate hazard) SI
Storage(low hazard) S2—
OWNERSHIP INFORMATION(Please type or Print Clearly) IA ell: ec 12CS, T-tnL-
OWNER, Naine U 0 L—IP IQ- f>k: S Sakswt
Telephone
DESCRIPTION OF WORK TO HE PIEW"ORIVIE'l
4
ar
ES11MATED CONSTRUCTION COST
WELLMAN ASSOCIATES, INC.
70 BROADWAY STREET
P.O. Box 738
WESTFORD, MA 01886
PHONE (978) 589-9870
FAx (978) 589-9421
MOBILE(978) 828-3264
KRISTEN LEDUC
I
CONTRACTOR INFORMATION
Name C�10.V w�VA
Address Zl /} vi el(7 V G✓ S •. Wi Jm i slat 61r, NSF} QI f7
Telephone 9 16- 8310-7 53
Construction Supervisor's Lic# 70 7
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name Tan "s 1 1 A•yti,rv,
Address ilaoo Csg)cod Sk. 00. 4rn,inyer. MA 010K
Telephone 97 - 55 2Ss53
Mass. Registration # IV-0 720
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 = -
Commercial est. cost x $11/$1,000 + $5.00= 9V rJ•°0
COMMENTS
The undersigned does hereby attest that all information stated above is trite to the best
of my knowledge under the penalties of perjury
Signed C,/,G
Date «� 1 .•
`JJl.0 T/JO'IJJOJiIY/6LlNlfldllG i/!!/.l10.1(dC11UfN':�
Hoar of6uilding Reguiatian and,Standards
Construction Supervisor License
License: CS
70740
` Slithdate:- 3f30/1968
K- Expiration: 3/3012009 Tr# 11416
Restrictiot : 00'
CHARLES R WING^JR
84.ANDOVER STD
WILMINGTON, MA 018873tmmiSsioncr
05/-18/2007 02:03
7816907474 r<c`u. u•••••-
3 Commonwealth of Massachusetts
' Department of Industrial Accidents
oerbsrr a 600 Washington Street
Boston,Mass. 02111.
workeWC�ompensation Insurance Affidavit
(Lieaaedl'amittec)
with a principal place of business ac
Mallstewzro)
do hereby certify under the pains and penalties of pedury,that:
I am an employer providing workers'compensation coverage for my employees working on this job.
Insurance Company Policy Number
(} I am sole.proprietor and have no one working for mein any capacity.
() I am sole proprietor,general contractor for homeowner(circle one)and have hived the
contractors listed below who have the£ollowing workers'compensation policies:
I
Contractor Insurance Company/Policy Number
Contractor hun ance Company/PolieyNumber
Coatraeror lasurance CompartoolicyNumbs
(j lam a homeowner perfarming all the work ntyscl£
I undmtlmdttutn o[tids statement willeefoltaetdWta the OBFee orTavatirPAom Mats DAA fhr t
cce eavmp vexiR�nad[rat aye t,kgwootaagc
nutted®de9saioa the Inhrof ir2am feed to deniatpa=dn rot ofeei0.60 Pea againaSe.a5mofapmS(500.00 andPormoyeaea'io:wevemrnt ac
we0 as tfivtl paeaiea in the form uta STOP wp,R�K OItDAAoade nee ofSA00.00 n Any op�Lm�q x. •
Signed e_/G �Z dayof
ew
Litxtnsoe/Peratittce anilding Dt:ptutmaln
. Licensing Bosrd
sdoamea'e office
Health Department
TO VERIFY COVERAGE WORMATION CALL 427-7274900 X 403,404,405.409,375
E
ACORD CERTIFICATE OF LIABILITY INSURANCE o%ia/2D0 8
PRODUCER' (978)223-4037 FAX (978)223-4038 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
CFR Ins Agency LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
153 Andover Street Unit 208 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers, MA 01923
INSURERS AFFORDING COVERAGE NAIL S
INSURED Infinite Solutions, Inc INSURER Scottsdale Insurance Company
214 Andover Street INSURER II Safety Insurance 39454
Unit M1 INSURER C:
Wilmington, MA 01887 NsuRIR D:
NSURER E
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.
RISR AWL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE ►OLLY EXPIRATION llYffB
GENERAL LUBRITY REM OF CLS1371696 03/19/2008 03/19/2009- EACH OCCU�E $ 1 000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED f SO DD
CLAIMS MADE a OCCUR HIED EIIP(My one ie w) $ 5 DD
A PERSONALAADVINUURY S 1.000.00(
GENERAL AGGREGATE S 2 OGENL AGGREGATE UMIT APPLIES PER PRODUCTS-COMP/OP AGG S 2
X POLICY JPRO- LOC
FECT
AUTOIaOBLS LIABILITY 6200922 09/29/2007 09/29/2009 COMBINED SINGLE UMrr
ANY AUTO (Ea aeda ) S 1 000
ALL OWNED AUTOS BODILY INJURY
X SCHEOULFDAUTOS (�P�R) S
B X HIREDAUTOS
BODILY INAJRY S
X NON-OWNED AUTOS (PariNVenl)
PROPERTY DAMAGE $
(per x Iftm)
GARAGE LIABILITY AUTO ONLY-EAACGDENT S
ANY AUTO OTTER THAN EA S
AUTO ONLY: AGO S
EXCESSIIIMBRELUUASLOY REM OF XLS0040495 03/18/2009 03/19/2009 EACH OCCURRENCE $ S 000
X OCCUR CLAIMS MADE AGGREGATE S S 0W
A $
DEDUCTIBLE
s
RETENTION $ $
WORKERS COMPENSATWN AND WCS LIABfIT\' STATLL EMPLOYERS'
ANY PROPRIEfORMART ERMXECUTIVE EL EACH ACCIDENT f
OFFICEWMEMDFR EXCUIDEDT EL DISEASE-EA EMPLOW�I S
N yeC CLPRO PROVISIONS
EL.DISEASE-POLICY UMTT f
SPECIAL PROVISIONS EMory
OTHER
DESCPoPIONOF OPERAl10N6/LOCATIONS I VEHICLES/EXCLUSONqAQD�BYEN��E�IENTI BPECLLL 8
e Workers Compensation Certificate will be mailetl directly by Lberty Mutual Insurance Company
nder Policy 8 WC231S3S112S018 effective from 3/20/08 to 3/20/09.
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE
EX-RATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL
Metro PCS 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOUXER NAMED TO THE LEFT,
Matthew P Granese BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LRIBILITY
28S Billerica Road OF ANY FUND UPON THE INSRFR,ITS AGENTS OR REPRESENTATIVES.
Chelmsford, MA 01824 AUTHOWMD RFPIIESENTATNE
Nicholas Consoles GAIL 414?u
ACORD 25(2001108) (DACORD CORPORATION 19118
l
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 terns and conditions of the policy,certain policies may
require an endorsement.A statement on this certificate does riot confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this forth 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.
ACORD 25(2001108)
i CITY OF S.U.ENI, NI LksSACHUSETTS
• BUILDLNG DEPARiN(&NT
120 W ASHINGTON STREET, Yo FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
1Q\ffiERL EY DRISCOLL
MAYOR THOdtAS ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BLHM04G CONWISSIONER
CONSTRUCTION CONTROL DOCUMENT
Project Title: AAT: Pequot Apts., MetroPCS Inc. Date: 5/30/08
Project Location: 10-12 First Ave., Salem, MA
Scope of Project: Attach 6 wireless antennas to the facade of the building and place
related equipment on the roof of the building.
In accordance with SECTION t116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code
I, V�' (
, I T 1 ! ,t! ,- Mass.Registration Number 1" 74- V
being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
mire Project [ ] Architectural [ ] Structural [ ] Mechanical
( ] Fare Protection [ ] Electrical [ ] Other(specify)
for the above named project and that to the best of my knowledge,such plans, computations and specifications meet
the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore,I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit, and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed in
a manner consistent with the construction documents.
1 shall submit periodically, in a form acceptable to the building official,a progress ogether with pertinent
comments. Upon completion of the work,I shall submit to the building official Alk o the
satisfactory completion and readiness of the project fo cupanc Sso 4
;o DANIEL P. �E >
Eivp':t A
Signature and Seal of registered professional: o C!V;< < �
vo t
9F�1 � R_
c STD .
F,f+J �C\ty
. •. o - IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
CITY OF SALEM 2051400310 Bk.21115 Pg,494 ite MAY 1 4 2009
008
J ' n 05/14/2008 14:05 00 OTHER P8 111
I hereby certify that 20 days have expired
PLANNING BOARD from the date this instrument was received,
and that NO APPEAL ha&b.: filed in this
Wireless Special Permit n
R9' 1� LEt..r�ass.
The Petition of Metro PCS for the Pro "c�te , � � K, 5al�c.
,10-12 First Street "C iUia s.
A Public Hearing on this petition was held on April 17, 2008. The following Plat ring Board
members were present: Charles Pule6,,.-.Tim Kavanaugh, Tim Ready, John Moustakis,.Gene
Collins, Pam Lombardini and ChristiYie Sullivan. Notice of this meeting was sent to abutters and
notice of the hearing was properly published in the Salem Evening News.
The petitioner is requesting a Wireless Communication Facility Special Permit under Section 5-
3, Special Permit Uses, of the City of Salem Zoning Ordinance, to allow for the installation of six
panel antennas, and three equipment'cabinets on the roof of the building at the Pequot
Apartments, 10-12 First Street, Salem, MA (Map 13, Lot 6). This equipment will replace
existing Metricom equipment. The proposal also includes the addition one GSM antenna, and
one GPS antenna.
The Planning Board reviewed the application and plans submitted and found that the petitioner
addressed the requirements of this section for the issuance of a Special Permit.
On April 16, 2008, the Board closed the Public Hearing and the Planning Board voted by a vote
of seven (7) in favor (Puleo, Kavanaugh, Ready, Moustakis, Collins, Lombardini and Sullivan),
and none opposed, to grant the Wireless Communication Facility Special Permit for the location
stated above, in accordance with the application dated April 1, 2008 and site plan last dated
January 15, 2008, titled `BOS0097A .ATT Pequot Apartments, Salem, MA", Sheets T-1, Z-1,
Z-2, Z-3 drawn by Hudson Design Group LLC, submitted and now part of the file.
�;:
YI _
The Special Permit was approved witdlthe following conditions:
1. The equipment shall be painted'red to reduces its visibility and allows it to blend with the
existing brick penthouse; the applicant, his successors or assigns shall maintain the
appearance of the rooftop equipment.
I hereby certify that a copy of this decision is on file with the City Clerk and that a copy of the
decision and plans is on file with the Planning Board.
-/AL
Charles Puleo, Chairman
This endorsement shall not take effect until a copy;of the decision bearing certification of the City Clerk that twenty(20)days
have elapsed and no appeal has been filed or that if such appeal has been filed that it has been dismissed or denied, is recorded in
the Essex South Registry of Deeds and is indexed in the grantor index under the name of the owner of record or is recorded and
noted on the owner's certificate of title. The fee for recording or registering shall be paid by the owner or applicant.
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 • TEL: 978.745.9595 FAx: 978.740.0404 ♦ WWW.SALEM.COM