10-12 FIRST STREET - BUILDING INSPECTION (3) � S
The Commonwealth of Massachusetts
Department of Public Safety
State Building Code(780C MR)Seeenth Edition
f1ludding
City of SalemBuildin Permit A lication for an Buildin other than a I- or 2-Famil Dwellin(This Section Fur Official Use Only)
Permit Number. Dale Applied: Building Inspector:
SECTION I: LOCATION (Please indicate Block 0 and Lot a for locations for which a street address is not available)
v-12 first steer t Sa.to %,UA 0IR,7o �cu of s
Nu. and Street Citv /Town Zip Code V4.1me of Bwlding(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that gpply in the two rows below
Existing Building O Repair O Alteration (i( Addition O Demolition O (Please fill out and submit Appendix 1)
Change of Use O I Change of Occupancy O Other O Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes 0 No ❑
Is an Independent Structural Engineering Peer Review�re•quired? y'• 1 �� Yes ❑ No Q
Briefpe�c ri tii of Prop��is�eai Wurk: /Y�Lzrl' l�l t.CF(-�lh�� ,W,(� 91[tt.[T Aid
17.11.l.Lf� �.a�a.nd' UTLI ll ����u i9/IOLf Gr�lvru .
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,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): r
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(s+ft.)and Total Height(it.)
SECTION S:USE GROUP(Check as applicable)
A: Assembl A-1 O A-2r ❑ A-2nc❑ A-3 O A4 O A-5❑ B: Business ❑. 1 E: Educational ❑
F: Facto F-1 ❑ F2❑ T H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
h Institutional 1-1 ❑ 1.2❑ 1.3 O 14 O 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
S: Storage S•1 ❑ S-2 ❑ - U: Utility❑ Special Use O and plvase describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIAO 1180 IIIAO 111813 1 IV ❑ I VA ❑ - VB ❑
SECTION 7:SITE INFORMATION Irefer to 780 C,%fR I11.0 for details on each item)
CA Water S pply: Flood Zone Information: Sewage Disp a : Trench Permit: A Debris Removal:
I ul+hc ❑ C heck it uutadal9und Lune E3' Inaliratr mumcipol ❑
A trench will not be Licenwd Di..pi,..il Site❑
required❑oi licnJi m �)lYllc:
1 riaaty O or mdcnlih Zone: ur on air.r.lrm ❑ permit i,enclo e i ❑
Railroad right-of-way: Hazards to Air.Navigation: CIA I Inb n, l-• nniu�•i,•n Ilrur„ 1'r.,..-a
\ul \)•i•hcable l7 I��Irurltoe,rnhin.uri+urt ep+nocharea' L their reel we completed'
a l' m�a•nl In liu JJ vncL+vJ ❑ Ye. nr..\u( 1'v. ❑ \o ❑ -
SECTION 8:CONTENT OF CERTIFICA-rE OF OCCUPANCY
I do ni of l ��Jv: L-a• L'nmlrticliun: Occupant Load per I-hor:
I>.v,the building cantain.in Sprinkler?t.tcm': Special Sopulaunn.:
k
1
SECTION 9: PROPERTY OWNER AUTHORIZATION e
me son . ddresn of 'n' ,erty Owner Q, _ e_.J pry-/
�I/1TI l �0-lZ Fil�i- A4'• Y�tA�GT,t r .� Q1 /6
NamILI
e(Print) Nu.end Street City/Town Zap
Property Chcner Contact Information:
I'VVImoti,Y•f TQ4mRU(ACW U1'�_ ((1(a�'f___n ' ��7?-_(2p3•S12gc}(,c�
Title Telephone No. (business) Telephone No. (cell) a-mad addrnos
Il.tp dicablr, the pruprrh• oiicnrr hrrrbv.tuthunzrn
A p�pQ'1,c LI f1Sc� ,ht/.�,,,�ILlr- � 811t O,f1/a91 Pd 3¢( 'FL C*JnQMd
Name Street Address City/Town State Zip
to act on the +ro part owner'.behalf, in ell matters rel atice It,work authorized by this buddin • •ermat a + alication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,0W cu.it.of vndos.J s ace and/ur not under Construction Contrul than check here O and�Iup Section I0.1)
10.1 Rejaistered Professional Responsible for Construction Control
Wrier, Clw rvl -An( 394 2402) MC Wh 1A® 4U31 b
Nine(R •istrant) T r�huw Nu. e-mail a rrss Re is(ra ion Number
,s'nff oxlo�u�1J� P, t xt [J1J(f /Ic2 s —
Street Address V City/Town State Zip Discipline Expi Ilion Date
10.2 General Contractor
crj�eAqICeyl C's 71(03
I,y.Tr t+(Prrw_ _n Ric gsiblr for Construction J G__, License No. and Type if A,{lplicable,,,O
yr—k 8D —— LtfCliStYy!/]Town State (Zip(J(/
.L�1`t ��
Telephone No. (business) Telephone No. cell - e-mail address
SECTION 11:WORKERS'COMPETIO QJ5 A D V (M.G.L.c.152.§ 25C(Q)
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completejand
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin
Is a signed Affidavit submitted with this application? Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Gusts: (Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building $ Building Permit Fee=Total Construction Cost x_(Ins2. Electrical $ appropriate municipal factor)3. Plumbing $
4. Mechanical (HVAC) ti Note: Minimum fee=S (contact municipali
5. Mechanical (Other) 5 Enclose check payable to
6. Total Cost 5 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bv entering my name below, I hereby attest under the pains and penalties of perjury that,ll of the information containedjIh,4,,
.application is true,and.acc rate h, the brit of my knowlecige and understanding.
62, VjIdAf� U 17t� 0 I' ase ant and si •n nam itle rela phone.No.�th'crt Addres. CnciTown State Zip
114
lunicipal Inspector to fill out this section upon application approval:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
v
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organimtion/Individual): SBA Network Services,Inc.
Address: 117 Precourt Street
City/State/Zip: Biddeford,Maine 04005 Phone#: 207-2824200
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I 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.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑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' 13.0 Other
comp. insurance required.]
'Any applicant that checks box#I most 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 lure outside contractors mast 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: The Travelers Indemnity Company
Policy#or Self-ins.Lic.#: TRKUB466K472610 Expiration Date: 3-15-11
Job Site Address: (U `�2 fi'Ifiz;+ C,4T)2't City/State/Zip: S (P a ( d q�0
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 certify pains and enaldeso'rjury that the information provided above is true and correct
Simature t ar Date:
—�
Phone#: �o7.�2B2 -9r7-ov
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 M
Nlassachu•:etts Department of Public Safety
Board of Building Re,ulations and Standard.
Corso uctloin Sup-erviSor License
License: CS 71639
Restricted to: 00
RICHARD D AIKEN
163 NEW COUNTY RD :
HOLLIS, ME 04042
Expiration: 6/7/2011
16882
i
C CERTIFICATE OF LIABILITY INSURANCE OP ID KB DAT"MMmwry"
SBACO-1 03/15/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Henderson Brothers, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
920 Ft Duquesne Blvd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pittsburgh PA 15222
Phone: 412-261-1842 Fax:412-261-4149 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: The Travelers Inrierunity Cmpan
INSURER Br Travelers Prop Cas of Amerim
SBA Communications Corporation INSURER C: st Paul mrs F Marine ins Co 24767
Thomas Hunt, Esquire
Boca Broken
RatonFSound
Parkway NW INSURER D: Steadfast Insurance Cc 26387
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.
CM
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMND DATE MMIDO� LIMITS
GENERAL LIABILRY' EACHOCGQRRENCE $1 OOO ODD
A X COMMERCIALGENERALLIABILITY TC2JEXGL466K4775 03/15/10 03/15/11 PREMISES
(Es
orcur..) 11,000 000
CLAIMS MADE OCCUR MED EXP IAnYo Parson) $N/A
X $100,000 SIR BLANKET ADDL INSURED PERSONAL B ADV INJURY $1 000 000
LESSORS S LANDLOPDS GENERAL AGGREGATE s2 000,000
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG s2 000,000
POLICY X JECOT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
B X ANY AUTO TJCAP466K476310 03/15/10 03/15/11 (Ea accident) $1000,000
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
X HIRED AUTOS BODILY INJURY $
X NON-OWNED AUTOS (Per ardent)
X $100,000 HIRED PROPERTY DAMAGE 1
CAR PHYS DAM 4500 COMP/COLL (Per arriderd)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANYAUTO OTHER THAN EA ACC $
AUTO ONLY: AGO S
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE s25,000,000
C X OCCUR � CLAIMSMADE QK03700177 03/15/10 03/15/11 AGGREGATE s25,000,000
S
DEDUCTIBLE $
X RETENTION $10 000 $
WORKERS COMPENSATION X ITORY LIMITS ER
AND EMPLOYERS LIABILITY YIN
A O�CERaIEETOR(PA(CLUDEE CUTIVISO TRKUB466K472610 03/15/10 03/15/11 E.L.EACH ACCIDENT S1,000,000
(MarMatory in Ni xzmlaaeaKal3910 !noel 03/1$/10 03/15/11 E.L.DISEASE-EA EMPLOYE $1,000,000
It yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S1 000 1,000
OTHER
B PROPERTY QT630977OM75ATILIO 03/15/10 03/15/11 PROPERTY SEE NOTES
D PROFESSIONAL EOC937920406 03/15/10 03/15/11 CLAIM/AGG $5 000 000
DESCRIPTION OF OPERATIONS I LOCATION5I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Jobs for metroPCS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
MMOPC DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
metroPCS IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
Attn: Nick Scarfo REPRESENTATIVES.
285 Billerica Road AUTHORIZED REPRESENTATIVE
Chelmsford MA 01824 Clem J. Wandrisco, III
ACORD 25(2009101) 91988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
.--.�,,, ..INSUS°NAtJIE,� 3BA ommun ca 'cne orpora ��' OP,ID�;RCB A . Orv��,lt!x
'INSURER D: PROPERTY POLICY:
$10,000,000 ANY ONE OCCURRENCE - TOWERS
$25,363,000 BUILDING A BUSINESS PERSONAL PROPERTY
$10,000,000 FLOOD ANNUAL AGGREGATE
$10,000,000 EARTHQUAKE ANNUAL AGGREGATE
$10,000,000 BUSINESS INCOME/EXTRA EXPENSE
$ 3,000,000 BUILDERS RISK CONSTRUCTION SITE
$ 3,000,000 BUILDERS RISK TRANSIT
$ 3,000,000 BUILDERS RISK PERSONAL PROPERTY IN YOUR CARE, CUSTODY, CONTROL
$ 2,500,000 ORDINANCE OR LAW
$ 2,000,000 DEBRIS REMOVAL
$ 2,500,000 CONTRACTORS EQUIPMENT-OWNED EQUIPMENT
$ 250,000 CONTRACTORS EQUIPMENT-LEASED OR RENTED
$ 500,000 VALUABLE PAPERS
$ 100,000 FINE ARTS
PROPERTY DEDUCTIBLE: $15,000
CELL TOWER DEDUCTIBLES:
$150,000 PER OCCURRENCE/300,000 ANNUAL AGGREGATE/$25,000 MAINTENANCE
$100,000 FLORIDA WINDSTORM
NAMED INSUREDS:
SBA COMMUNICATIONS CORPORATION
SEA TELECOMMUNICATIONS, INC.
SBA NETWORK SERVICES, INC.
SBA SUBSIDIARY HOLDINGS, INC.
SBA COMMUNICATIONS INTERNATIONAL, INC.
SBA TOWERS, INC_
SBA PROPERTIES, INC.
SBA PUERTO RICO,INC.
SBA SITES, INC.
SBA TOWERS USVI, INC.
SBA TELECOMUNICACOES DO BRASIL LTDA
SBA NETWORK MANAGEMENT, INC.
TCG ACQUISITION LLC
SBA SENIOR FINANCE, INC.
SBA CMBS-1 HOLDINGS LLC
SBA CMBS-1 GUARANTOR LLC
SBA CMBS-1 DEPOSITOR LLC
SEA SENIOR FINANCE II LLC
SBA TOWERS USVI II, LLC
TCO LAND LLC
SBA INFRASTRUCTURE HOLDINGS I,INC. (DE)OPTASITE ACQUISITION HOLDINGS CO INC
SBA INFRASTRUCTURE, LLC f/k/a OPTASITE TOWERS LLC
SBA PUERTO RICO II LLC
SBA ADVANCED WIRELESS NETWORKS LLC
MCF ACQUISITION 2008 LLC
SBA COSTA RICA, LLC
COSTA RICA QUOTAHOLDER, LLC
COSTA PACIFICO OPERACIONES LIMITADA (COSTA RICA)
COSTA PACIFICO TORRES LTDA (COSTA RICA)
SHARED TOWERS PA, LLC
SBA CANADA HOLDINGS, INC. (BRITISH COLUMBIA CANADA)
SBA CANADA, ULC (f/k/a JADE TOWER, ULC) (AT ERTA CANADA)
TRISTAR INVESTORS, INC. SBA TOWERS II LLC
REDBUD ACQUISITION 2009, LLC SBA STRUCTURES, INC.
BIG HORN ACQUISITION 2009, LLC SBA STEEL LLC
BIG BEND ACQUISITION 2009, LLC AAT COMMUNICATIONS LLC