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0488 REAR HIGHLAND AVENUE - BPA-13-1032 =kfDBuilding The Commonwealth of MassachuseDepartment of Public Safety Massachusetts State Building Code(780 CMR) Permit Application for any Building other than a One-o wo- ily Dw (This Section For Official Use Only) Building Permit Number Date Applied BuddmgOffici. SECTION 1':ILOCATION(Please indicate Block#.and Lot#for locations for which a street.address is not available) Ltt,� G,,,V [Ask« Ave f4,e,, lull 1721a No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:.PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check a6 that apply in the two rows below Existing Building Z Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other Specify: u.4 Are building plans and/or construction docuuients being supplied as part of this permit application? Yeses No ❑ Is an Independent Structural Engineering Peer Review required? f Yes ❑ No ❑ Brief Description of Proposed Work: i-.�ran U11 �o\ ) t A-Ilhvl t t0[,..+-P 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) ❑ 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.) s SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I4❑ 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 ❑ HA ❑ IIB ❑ IIIA ❑ IIIB ❑. IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Z=Information: Sewage Disposal: Licensed Dis osal Site❑ Public❑ Check if ouIndicate municipal❑ A trench will not be Prequired❑or trench or specify:Private❑ or indentior on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \tA hstoi a C om mi-w n Rcvv,� 1 r yss: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OFOCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: S SECTION-9: PROPERTY OWNER AUTHORIZATION Name and Address of M at- Property Owner 1 (� , r. . B(.1GN �_I�rq �rr �(/p— Vt V-" jk�(— IG.�GWt `t� -6 Name(Pr—peCfv,Gftk- No.B,nd arbb 32— City/Town Zip Property Owner Contact Information- Title - Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes I 1 C Og,6?tS CYLS4-- ISgunabadlt k �.y dtfh I� 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), If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor C Omui3 Con0�41url Company Name 2, vtall ( o ar CS 6 0�� (z3 Name of Person Responsible for Construction License No. and Type if Applicable 3 W ou1,let,� Ott, 11 )66G_J 3 &M o�� Street Address City/Town State Zip z_ C n-s Telephone No. business Telephone No. cell e-mail address SECTION 11:bVO KFRS'CONY ENSA 1101 INSURANCE AEF'ID•NVIT 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? YeA5, No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT.FEE Item Estimated Costs:(Labor U and Materials) Total Construction Cost(from Item 6)=$ �...I 0 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ 1. Mechanical (HVAC) $ Note:Minimum fee=$ contact municipality) 5.Mechanical Other S (Enclose check able to 6.Total Cost $ 12 0 U o contact municia pay and write check lumber 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 best of my o vI lge and understanding. m kCkae( 0- Grr,tVle / C(,AjF ManC,3W- Please prr''nt and sign na�'1� Ti le Telephone No. Date (,.(19 Lf �nviCuIt S� t N Vs, UL$ Street Address City/To t State Zip Municipal Inspector to fill out this section upon application.approval: . Name - Date CITY L OF Ja .tit, t.�Ws.�cHtrsEres t' � BC'tLD4YG DEP.IRTJLE�iT W UNLNGTON STitEET, 3 ILL (978) 145-9595 Q.%(0E.RLEY OUSCOLL F.Lt(178) 7•I0-9344 � UYO.Z TFlOSCL9 ST.P1ERit8 Dt2ECTOR OFpt:OUC PROFERTy/OL=LVG CmallssiONER Construction Debris Disposal A117davit (required for 311 demolition and renovation work) fn accordance witli the sixth edition of the State Building Code, 730 C1dR section 1 l 1.5 Debris, and the provisions of MGL a 40, S 34; Building Pernit N is issued with the condition that the debris resulting from this wurk shall be disposed of in a properly licensed waste disposal f 111, S 150A. acility as defined by L o Tha debris will be transported by: C (Hama ut'haular) The debris will bo disposed of in : -- (Hamra(facility) ,i-suamra of permit applicant ---1 Tuvl.e Zfil3 . It i CITY OF S.-1L&Nf 'NaSSACHUSETTS BLIMMG DEPARTSMDiY 120 WASHINGTON STREET,3r'FLOOR TEL (978) 745'-959,5 FMC(978) 740.984b Kl\fBEILLEY DRISCOLL MAYOR THoNtAS ST.Fili1. m DIRECTOR OF PCBUC PROPERTY/BI:TLDING COSL%IMIONER Workers' Compensation insurance Affidavit: Builders/eontractors/Electricians/Plumbers Antilicant Information Pleage Print Lelitibly Name(Busines&Organization/Individual): C 1) A,Ut S Cr-, n (YL fUuh,", Address: (5 11 P_)L) 1 a.z-z-o t i A-y-P City/State/Zip: t, UAJ Yr rtM?4 Phonehl: Are you an employer.'Check the appropriate box. Type of project(required): m a employer with; 4. 1 am a general contractor and I employees(fbll'andlor part-time). + have hired the sulteomtractors 6. ❑New�construction 2.0 1 am a sole proprietor or partner= listed on the attached shaet.,t 1• []'Remodeling ship.and have no employees These subcontractors have;' S. []Demolition workinr.far me in any capacity:t. workers'comp tnstrtance:. 9, 0 Building addition (No worker comp.insurance S. 0 We are a eorpomtion and itat required.i ot7icen have.exercised their"- 10.❑EfectricaFrepairs or additions 3.0 I am a.homeowner doing III work right ofcxempatin per MGL `' I L0 Phim bing repairs or additions myself':[Noworkers'comp. c.,152,*§1(4),and wehaveno ; 1101(oofrepairs itnurancb rcquked.)? cmployeda:[No worfrers': t n�K C .t[, comp,insurance required:) -;Any oppllrum that chucks,box kl-most also fill uui ihn seclluo below showing ihoir vwkas mmpenadon policy mfurmation I hvneowcerf who submit this r'fldavit indicating then am doing all work allien him oiniide cantrxthrs most submit a new affidavit indicating such :Consmoton thus check this box most ailaehcd an additional shout shoving iho name of the sub sorscton and thairwotkem`comp;pal lcyinformadoe:. st_. : : !rem un ertrplaye►shut Ir pro4iding Ivorken'romprnsatlon hraurunce jot raga empluyerx'Below sat the policy and Job size Inxurance Company Name. a. ✓J..f L., V f ,)t V 4,�pp Policy 4 or Self-its. Lic,Al:_V�1 C S 11--�I S- �`h I QirS l —p t L Exphalloo Datc-_7117, 11y t 3 - Job Site Address: L{ (ei I F t c �`^^� CitylState/Zi Su a �n kv 6 D l Attach a copy,of the workers'compensation policy declaration pa (showing the poky number and-explranon date). Failure to secure coverage as required under Section 25A orMGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form eta STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Ile advised that a copy of this statcmeni may bx furwrrded to the Office of Investigations ul'the DIA for insurance covcraga ven icahon - _ - f do hereby t erto under Mop I r d peau11 ojperfury that the fnjormetlon prpvldrd ubuvs is true and correct Stsnatvre 4 (gtyr,1 Mon 1; OJrcid use onlyy. Do not write in this area,to be completed by city or li:6v'n of Ual City or Town Permitflicense N Issuing Authority(circle one): 1. hoard of licalth 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other._ Contact Person: - ---.__.-----__ Phone 8: / J ® DATE IMMIDDIYYYYI -°►v CERTIFICATE OF LIABILITY INSURANCE 03-05-2012 THIS CERTIFICATES 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 ADDITIONALINSURED,the policy(ies)must be endorsed. If SUBROGATIONIS WAIVED,subject to the terms and conditions of the policy.certain policies may require an endorsement. A statementon this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: HARTFORD FIRE INSURANCE COMPANY PHONE EINC,No): 250760 P: — F. — A:C No Est): AI ADDRESS: PO BOX 33015 SAN ANTONIO TX 78265 CUSTOMERID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Twin City Fire Ins Co INSURER B PAGLIARO ELECTRIC, LLC INSURER C: 35 OAK ISLAND ST. NsuRER D: REVERE NIA 02151 INSURER E INSUflEfl F: J COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE i1NSRi WVD! POLICY NUMBER I I MM/DO/YYYYI I IMMIDD/YYYY1 I LIMITS GENERAL LIABILITY i I ;EACH OCCURRENCE S i J 1 COMMERCIAL GENERAL LIABILITY 1 I �PREMISES IEa occurrence) ' 3 I CLAIMS-MADE I i OCCUR I MED EXP(Arty one Person) I $ PERSONAL&AV INJURY ! B GENERAL AGGREGATE $ GEWL AGGREGATE LIMIT APPLIES PER: 1 ! I PRODUCTS-COMPiOP AGG $ E �'POUCy I jRCT J LOC 1 I I $ 1 AUTOMOBILE LIABILITY I I I ' COMBINED SINGLE LIMIT ; g I (1 IEa xcidentl ; ANY AUTO i I J I BODILY INJURY(Per Person) 5 I—I ALL OWNED AUTOS BODILY INJURY(Per xcid.rn) $ H SCHEDULED AUTOS ' PROPERTY DAMAGE B 1 j HIRED AUTOS j IPer acciden0 , 1 NON-OWNED AUTOS I I $ UMBRELLA LIAB I OCCUR I I I ' J EACH OCCURRENCE 5 EXCESS LIAO I 1 CLAIMS-MADEI I I I AGGREGATE S L-21 DEDUCTIBLE I I ! $ I RETENTION $ ! 'I I Is WORKERS COMPENSATION I I I X I ORY LIMITS I 'DER i AND EMPLOYERS'LIABILITY ANY PROPRIETOR•PARTNERrEXECUTIVEIY/N' I I E.L.EACH ACCIDENT IS 100, 000 A OKFF�,nmyin NNNflEXGLUOED7 u'"'AI 176 WEG H03101 I03/17/2012 03/17/2 013 1 E.L.DISEASE-EA EMPLOYEE $ 100, 000 if S describe under D ESCRI P T ION OF OPERATIONS Mow i I E.L.DISEASE-POLICY LIMIT IS 500, 000 I 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Anar ACORD 101.Additional Rernarks Schedule.if more apace u raprdred) Those usual to the Insured' s Operations . 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. AUTHORIZEQ ft pgESE�NTATIVE/�/ � -• / 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) - The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Publ[c Safety: € c Board of Building Regulations and Standards s _ CumYvurdnnSupen}�r - Ucensc CSb78123 _ -. BRIAN S COGAN„ r ? 3 WOODVIEW HUBBARDSTON^lNA'� I 2 `.%.�►•� �x��+'& Expiration Commissioner NI27I2014 L Unrestricted'-Buildings of any use group which. contain less than 35,000 cubic feet (991 m')of enclosed;space. .Failure to possess a current edition of the Massachusetts State Building Code is cause forrevocationof this license.For DPS licensing information visitt' -www.Mass:Gft/DPS cd avis ASSOCIATES LETTER OF AUTHORIZATION APPLICATION FOR LAND USE/BUILDING PERMIT To Whom It May Concern: I, Brian Logan,a registered Construction Supervisor in the Commonwealth of Massachusetts,do hereby appoint C.Davis Associates, its attorneys,agents or representatives as authorized agent for the purpose of including a copy of my MA Construction Supervisor registration in any land use and/or permit application necessary to ensure the ability to use and/or construct improvements or modify a wireless communications facility. Please do not hesitate to contact me with any questions or should you request my presence at the submission or approval of any land use and/or permit application. Thank you. Very truly yours, Brian Logan Construction Supervisor MA Registration Number: 78123 (508) 962-9275 blosanna cdavisassoc.com L _ The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Corntpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informlation Please Print Legibly Name (Business/Orgaiiization/Individual): C Davis Construction Address: 15 Bonazzoli Avenue City/State/Zip: Hudson, MA 01749 Phone #: (508) 962-9275 Are you an employer ? Check the appropriate box: Tgr2e of groitct(Feapired),:. 1.7 I am a employer uvith 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full a md/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprii etor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme iurdmry•cdpad-ey: nwcrkzau,caw'n a:ts. nzmw Y. U t3uifding addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No wo6cers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance require-d.]1 employees.[No workers' 13.®Other Modify equipment. 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 most attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that Ls providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Corporation Policy#or Self-his. Lic- #: WC5-31 s-381889-012 Expiration Date: 7/22/13 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 coveralge 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 andUor 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 DLA for insurance coverage verification. I do hereby ify u der the pains and penalties ofperjury that the information provided above is true and correct Si ature: Date: 13 Phone#: (508)962-9275 Official use only. D"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 LMG 8/2/2012 9: 40:20 AM PAGE 2/002 Fax Server LM INSURANCE CORPORATION P.O.Box 9090 Dover NH 03821-9090 LibertyTelephone:(800)653-7893 m7®/��¢�w ® Pax: (603)334-8162 tl.�.It Email:IMS@LibertyMutual.com August 2, 2012 C DAVIS CONSTRUCTION INC 66 H CONCORD STREET WILMINGTON MA 01887 RE: WOREERS COMPENSATION INSURANCE Insured: C DAVIS CONSTRUCTION INC Policy Number: WC5-31S-381889-012 Effective Date: July 22,2012 Due Date: August 17,2012 Dear Insured- This confirms that as of the date of this letter,the above named entity C DAVIS CONSTRUCTION INC has a valid workers compensation policy,with coverage for the state of MA,effective from 07/22/2012 through 07/22/2013. The policy number for this coverage is WC5-31S-381889-012. Sincerely, Maria Anderson Commercial Service Operations cc: DAVIS CLARK&LATHAM INSURANCE AGENCY IM 0023.1010 WC5-31S-381889-012 .Page I of 1 ACC)RV CERTIFICATE OF LIABILITY INSURANCE DATE(w;BQ-f""' 3 21/13 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 TIE 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(ies) must 1: indorsed. If SUBROGAIiO 1 IS WAIVED,subject to the terms and conditions of the policy,certain policies my require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorseIren s). PRODUCER CONTACT NAME: Davis, Clark 6 Latham IRS Agen PHONE (7811 944-6171 FAX N (T81) 946-6360 One Pleasant St EMML Reading, MA 01867 AOORESs: kc@dclath�.com _ INSUPEPoSIAFFORDING COVERAGE NAICA INSURERA:James River Group INSURED INSURER8:Pil rim insurance C. Davis Construction Inc INSURERC:Great American 66 H Concord St INSURERD, Wilmington, MA 01887 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE(NSLRED 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_ANDCON_DTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR Y�W SUB, POLICYEF PO EXP LTft TYPE OF INSURANCE POUC MINBER N/DO/Y MN,DdYYYY LIIATS A GENERA-LABILITY 00045637-2 11/6/12 11/6/13 EACH OCCURRENCE _ S 1 000 000 X CONNIERCIALGEN=RALLIABILITY DANAGETORENTED $ 10 000 CIAWMAGE OCCUR MED E1m(AW..Pew I S PREM PERSON4-8 ADV INJURY $ 1 000 000 GENERALAGGREGATE $ 2 OOO 000 GGEENTAGGREGATE LMITAPPUES PER PRODUCTS-COWIOP AGE $ 2 ODO 000 1 X POLICY PRO- LOC S B AUTOMOSILELIASIOTY PGOOOOIO06969 11/6/12 11/6/13 o '— 1 E $_ 1 -COO OOO ANYAUTD BODILY INJURY(P.,person) S ALLOWAUTOS NfO X AUTOS SULED BODILY INJURY(ParaccioenD $ X HIRED AUTOS R NON-0WNED PROP RTY ONMGE AUTOS er earien�__ $ 3 A UMBFEW LIAB X OCCUR 00045636-2 11/6/12 11/6/13 EACH OCCURRENCE S 5,000,000 X ��$LIAB CLAIMS-WOE AGGREGATE $ 5 OOO OOO BED RETENTIONS S NORHERS COMPENSATION WC STATU- 1": ANDEMPLOYER S'UgBIUTY YIN ANY PROPRIETOR/PARTNER/EXEWTHEOFACE RMEMBER ECCL I.DED? NIA EL.EPCH tlOEMSEL.D EASE-EA EMP DYYRIPTIOEL DISEASE-POLICY $ DESCRIPTON OF OPERATIONS below C Builders Risk n4P3067315-01 9/2/12 .9/2/13 50,000 LE$CRWTION OF OPERAl1ON5/LOCAnONS/VEHICLES (Attach gCORD 10H.AtrBlionel Renenu ScheauM,if more epera lsregJnpl ,' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED PODC[ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR RFPRES TATWE ©1988-2011DACOM CORPORATION. All nghts reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: �I F � • 488 REAR HIGHLAND AVENUE 361-13 COMMONWEALTH OF MASSACHUSETTS - CITY OF SALEM >> BUILDING PERMIT 1 de 1 PERMISSION IS HEREBY GRANTED TO: ^• �' t r Contractor: License: Expires: E' t. '.B ' =q - ' n -�`.' • Tower Resource Management Inc of 4 D Owner: CAMP LION OF LYNN MASS INC,C/O SPECFRASITE-MA0032 any ;' Applicant: Tower Resource Management Inc max._ ^n AT: 488 REAR HIGHLAND AVENUE IN re - ISSUED ON.- 22-Oct-2012 AMENDED ON: EXPIRES ON. 22-Mar-2013 TO PERFORM THE FOLLOWING WORK: APPLICANT PROPOSES TO SWAP OUT(6)PANEL ANTENNAS WITH NEW MODELS THAT ARE SIMILAR IN SIZE jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plunrbin Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: - Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Meer: Oil: Insulation; House# Smoke: Final: Water: Alarm: Assessor Treasury: Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIO N OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUIBDORTANT:OWNER OR CONTR.4RIE042MR0101476 22-Oct-12 9238 $137.00 AFIRANGE FOR PERIODIC INSPECTICNS"RING CONSTRUCTION.SEE CURRENT BtU!I DING CODE CHAPTER 1 FOR LIST OF REQUIRED INSPECTION& CALL 9M-618-5641 TO SCHEDULE AN INSPECTION GwTMS®2012 Des Lauriers Municipal Solutions,Inc. TOWER RESOURCE MANAGEMENT June 17, 2013 City of Salem Inspectional Services Building Inspector 120 Washington St 3`d Floor Salem, MA 01970 RE: T-Mobile Site number 4BN0038B BP#361-13 Building Inspector, I hereby authorize the transfer of the General Contractor information on Building Permit# BP#361-13 for 488 Rear'Highland Ave. Salem, MA issued on 10/22/2012 to: C. Davis Associates 66-H Concord Street Wilmington, Massachusetts 01887 978-621-1381 (Mobile) mike.eranese(acdavisassoc.com Sincerely, d• Andrew Roy TRM 781-929-6150 TRM, Inc. 17 Friars Drive, Suite 8 Hudson, NH 03051