320 LAFAYETTE ST - BUILDING INSPECTION (8) lth
'p/ ! ;•'—.r- The ComDepartment of Public`Safelyachul9i�{#�TIONA�SERVIC -
l../�� .% \IaNsachu,rtts titatr Budding Code 1780 C\IN)Seventh MC
rC ES
City of Salem ((J IUJ F B
BuildingPermit Application for an Buildingother than a 1-or 2-Fami1 Dwe-IYi Jr4
(This Section For Official Use Only)
Budding Prrmn Numbvc Date Applied: Building Inspector:
SECTION 1:LOCATION(Please indicate Block M and Lot 0 for locations for which a street address is not available)
320 Lafayette St Salem 01970 Lafayette St Apartment Bl g.
No.and Street City /Town Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 1 Alteration Qi I Addition❑ 1 Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes IN No ❑
Is an Independent Structural Engmeerini-Pe r Ri:� nived? Yes ❑ No IX
Brief Description of Proposed Work: WW 1 Be constructing a wireless communications
facility on the existing rooftop within a stealth enclosure that will
include 3 panel antPnnaa 1 hac•khaaal antenna and "I erntirment enclosure
__with l frnai i ment rahi nar in 1-ha i ntari nr of the hllilrliSlrj'
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,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): t
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(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5 Cl
B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 Cl 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 O 5-2 ❑ U: Utility 0, f,._ .. Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as Applicable)
IA ❑ too IIA ❑ IIB Cl IIIA ❑ III0 0 1 IV ❑ 1 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:
Public❑ Chuck if ou INide Flo,0 Zone❑ Indicate municipal ❑ A trench will not be Liccmed Di.poeal Site❑
reyuared❑ur trench „r Il+ecdv:
Ih ivate❑ or inJentdc Zone:_ or un ate Nv.tem ❑ permit iN enclo,ed ❑ _
I Railroad right-of-way: Hazards to Air.Navigation: Ilnt,an <-.•nnnn....n R., ,", Pr.•,,.,,;
\,d \ diiablc. 1 I ❑ I,then tea icac complvlyd'
„r l ,nnrnt to Rudd end,,,ed ❑ Nv,11 ,a No❑ NV,❑ Nn ❑
j SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I.Jown ,d (,.de -..__L,e(doupi,) rt pv of(1,n,ructwn: Occupmit l o.ni pvr Il„ur
I1,•r, the bmldin�;nuatain.ua Spnnkler}t.k•m'' spec i,al>upuLauun.
sT
14*qw--hV0 D/ 7W/
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nomeand Addressol Property 8erLafa Lafayette St. Salem
Thomas Carpi Y 01970
Name Wrint) No.and Street C ih/Town Lip
Vropvrty 0%%ner Contact Information: parktowersmgmt@aol.com
Owner of Record 617-548-2156
Title Telephone No. (busmen) Telephone No. (cell) a-mad address
If applicable,the property,mner hereby authorizes
Patty Masterson/Goodman Networks 30 Main St. Ashland MA 01721
Name Street Address City/Town State Zip
to act tin the pro pert%owner'.behalf, m all matters relative to work authorized by this budding permit a > plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It building is lass than ii,t%A)cu.Met enclosed s ace and/or not under Construction Control then check here O and skip Sechun lust)
10.1 Registered Professional Responsible for Construction Control
Ron Jackson 781-686-5727 27127
Name(Registrant) Tele phone No. e-mail address Registration Number
21 B Street Burlington MA 01803 Structural 6/30/10
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Clearwire Corp.
CUwayfteaStott CS 67205
Nrlmrpiiiei Ow PlaceleLta Construction Beverly License No. and Type if A__pplica6101915
Street Address City/Town State Zip
781 603-2792 __ wstott@clearwire.com
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 IN No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 10, 000 . 00
and Materials) Total Construction Cost(from Item 6)=$
1. Building g 10, 000 . 00
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 $ $10, 000 . 0 0 (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 is true and acairate to alh,�f my knowledge and under«anding.
Patricia MastersonI site Acquisition Manager 214-534-7276 2/17/ 0
Pleo.c print and sign name L title relephone\'o. Dale
Goodman Networks/30 Main St . Ashland MA 017
l itrret lddrv, llh-/Town titate ip
j >tunicipal Inspector to fill out this section upon application approval:
\time Dale
�. CITY OF Sm.E.m LA SSACHLSEM
• BCILDLNG DEPARTJmNi
�` 120 W.AiHNGTON STREET, 3w FLOOR_
TEL (978) 745-9595
FAX(978)740-9946
j KItfBERLEY DRISCOLL
j MAYOR THoNw ST.Pw-m
DIRECTOR OF.PL'BLIC PROPERTY/SIIIDLNG:CONa(ISSIONER,
SECONDARY CONSTRUCTION CONTROL DOCUMENT
'(for Professional;Engineers/Architects responsible for only:aportion of'a,controlledproject).
Project Title:; Clearwire Corporation 'Daie. 2/7/10
Project'Locapon: 320 Lafayette Street, Salem, MA 01970
Scope;of Project: telecommunications
MA-BOS7155
In accordance with the sixth edition Massachusetts-State
Building Code,780 CMR SECT10141.16A
I, onaldCso�.I G Mass.Registration Number 2 {r 2f7 m.
W
^being a registered professional EngineerlArchitect hereby CERTIFY that I have prepared or:directly- supervised
'the`preparatton of aj design plans,computations and specifications concerning:
[ ] Entire Project (1,Architectural (,Structural [ ].Mechanical'
[ ],"Fire_Protection< j[ ] Electrical [ ] ther(specify)
for"the above,anted project andthat to thi�besi of my knovrledge,such plans;computations and specifications meeti
the applicable provisions of the Massachusetts State Byilding Code,all acceptable engineering practices-and all;
,applicable;laws foi tlie.proposed project.;
Furihermore,j understand-and AGREE:tliat I;shail perform-the necessary:professional:services toedetermine that
the�abovejmentioned portions of the work proceed in accordance with the documents approved for the buildings
'permit
Upon..completion of ilie work,:1"shall:submit a iinatreport as'to.the satisfactorycompletion;of the;above
mentioned,,portiurr of the work:
_ � A Of MA C
Signature and Seal of registered professional: RO
v
No.
9FQ1StEQ
t
,^ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/lndividml): LL642i'i(Zl= cc e,
j{ Address: !qqO0 kf L1,,A; PotA/_r
City/State/Zip: WRKUWD l 04 99-033 Phone#: at-A 7yd/ y8bo
Are you an employer?Check the appropriate box: Type of project(required):
1. ix''1 am an employer with II$CO 4. f] I am a general contractor and 1 6._I New construction
employees(full and/or part time):" have hired the sub-contractors 7,0 Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. 11 Demolition
working for me in any capacity._ employees and have workers' 9. 0 Building addition
[No,workers'comp.insurance comp.insurance.$
3 required] 5.0 We are a corporation and its 10. ❑Electrical repairs or additions
3.U I am a homeowner doing all work officers have exercised their
jltltlt myself [No workers'comp. right of exemption perm MGL 11. n Plumbing repairs or additions
insurance required]t c. 152,§ 1(4),and we have no 12. I.J Roof repairs
employees.[no workers' 13. I_i Other
comp.insurance required.]
i
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy Information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContactors that check this box must attach 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.
s
I am an employer that Is providing workers'compensation insurance for my employees.Below is the policy and fob site
information.
I Insurance Company Name: A01V RISK twtsuRA L�„S f.Js:s r . 1 AM
i .�
i Policy#or Self-ins.Lic.#: 0 3W E Z L,/sE(o /Ex�p�iration Date: f�l '/�ilO
Job Site Address: 37�7 �{J � `. City/State/Zip: ty,rd o q /c)
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 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 farm of a STOP WORK ORDER and a fine of
$250.06 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify
nA1 tin-der the pains and penalties of perjury that the information provided above is true and correct.
Signature: /W Date: 7iI111I in
Print Name: W A`I Jf_ sn r.-'". Phone#: 6 o 3 a fZ 0,
Official use only Do not write its this area to be completed by city or town official
City or Town:met('P�n Permittlicense#:
Issuing Authority let one):
I.Boru of Heath Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other D
Contact person: 2107N A 5 bS ' 9 i�r� Phone#:
'41C R� CERTIFICATE OF LIABILITY INSURANCE DATE11/09/2009Y)
PRODUCER ADD Risk Insurance Services west, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
Seattle WA Office AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
1420 Fifth Avenue CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE
Suite 1200 COVERAGE AFFORDED BY THE POLICIES BELOW.
Seattle WA 98101-4030 USA
PHONE- 206 749-4800 FAX- 206 749-4860 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Hartford Ins Co of the Midwest 37478
Cl earwire Corporation INSURER B: Zurich American Ins Co 16535
4400 Carillon Point z
Kirkland wA 98033 USA INSURER c: American Guarantee & Liability Ins Co 26247
INSURER D: �
u
9
MSURER 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. LIMITS SHOWN ARE AS REQUESTED
INSR ADD'
LTR MSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTFVE POLICY EXPIRATION LMTTS
DATE MM/DD DATE MM/DD/YYVY
CGENERAL LIABILITY GLA 6555971-GO 11/01/2009 11/01/2010 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $500,000
CI-MMSMADE ® OCCUR PREMISES(Ea ocemrence)
NED LAP(Any one Person)
O
PERSONALffi ADV INJURY $1,000,000 v
n
GENERAL AGGREGATE $2,000,000 n
GE'N I,AGGREGATE LIMIT APPLIES PER:
PRODUCTS-COMP/OP AGO $2,000,000 m
❑X POLICY ❑ PRO- ❑ LOC 00
JE
n
rn
B AUTOMOBILE LIABILITY GLA 6555971-00 11/01/2009 11/01/2010 COMBINED SINGLE LIMIT O
X ANY AUTO (Ea accident) $1,000,000 z
N
ALL OWNED AUTOS BODILY INJURY u
SCHEDULED AUTOS (Per Person) C
HIREDAUTOS b
BODILY INJURY V
NON OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT
ANY AUTO
OTHER THAN EA ACC
AUTO ONLY:
AGO
C EXCESS IUMBRELLA LIABILITY UMB655596700 11/01/2009 --11-7-5172=EACH OCCURRENCE 5 rz=
X OCCUR ❑ CLAIMS MADE AGGREGATE $5,000,000
OC
O C
BDEDUCTIBLE
RETENTION
tD R
A WEZL X WC STATU-I OTH- C
WORKERS COMPENSATION AND TORY LIMITS ER tt
EMPLOYERS'LIABILITY C
IN I E L.EACH ACCIDENT $1,000,000 n ccANY PROPRIETOR/PARTNER/EXECUTIVE O tt
OFFICER/MEMBER EXCLUDED' E.L.DISEASE-EA EMPLOYEE $1,000,000
lo(Manderyia NH) N
If ,describe muter SPECIAL PROVISIONS bebw E.L.DISEASE-POLICY LIMIT $1,000,000��
n
OTHER o H
M C
M r
M u
m u
LO�
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
See Attached List of Named Insureds. Evidence of insurance.
c
m c
Cl C
O�
CERTIFICATE HOLDER CANCELLATION
clear wireless LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION p�
4400 Carillin Point DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL PP
Kirkland WA 98033 USA 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, O^C
BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY O U
OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. O
/' �/� r C
AUTHORIZED REPRESENTATIVE �7/s'Lf✓es fuNnm vd X? r-C
hU
ACORD 25(2009/01) 01988-2009 ACORD CORPORATION.All rights reservedn n
The ACORD name and logo are registered marks of ACORD r r
INSURED
Clearwire Corporation
4400 Carillon Point
Kirkland WA 98033 USA
List of Named insureds
Clearwire Corporation
Clearwire Us LLC
clear wireless Broadband LLC
clear wireless LLC
ClearMedia, LLC
Certificate No: 570036777440
N tssochus tts- Dcp:utmcntof Public Safet
Board of Building Regulations atol Standards
1 Coisfruction Supervisor License
rt License: CS 67205 `r:�+,
ReStncted to:.00 •"P`t ,fa __""
kw
fxI w, t
WAYNE P STOTT }
*2 PILLOW LACE LN E .
BEVERLY;MA 01915
0 Expiration: 8/29@O11
\� C'onunisgiunrl'.;S S'W+ Tr#: 10029
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Jan 18 10 03:49p p,2
LETTER OF AUTHORIZATION
Date:January 19,2010
Clearwire Site ID:MA-BOS7155
Property Located az: 320 Lafayette Street,Salem,MA 01970
To the City/County of.Salem/Essex
APPLICATION FOR ZONING/USEBUILDfNG PERMIT
This letter authorizes Clearwire and its authorized agents to file for all necessary zoning,planning and
building permits(local,state and federal)for the purpose of installing,operating and maintaining a
telecommunications facility on the rooftop of our property referenced above_
All approval conditions that may be granted to Clearwire in connection with this facility relating to this
specific application are the sole responsibility of Clearwire.
Property Owner: i Date:
Tom Carpi
_(Please ease print name)
44 1Pointdearw rem Kirkland,WA98033 1a42mu5u:2 16.7600 1144245.2/8.7900 Iw...
clearwire.com
February 9, 2009
4I4
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Re: Clearwire LLC-Leasing,Zoning and Permitting Authorization
To whom it may concern,
I
Please be advised that Goodman Networks is performing work for Clearwire US LLC
("Clearwire") in the Boston, MA market. Clearwire hereby authorizes Goodman
Networks to act on behalf of Clearwire for the sole purpose of leasing and acquiring
zoning and permit approvals to ensure Clearwire's ability to construct and operate its
broadband services network. This authorization shall not be construed as a commitment
of any type, and all final terms will be subject to Clearwire's approval.
Sincerely,
CLEARWIRE US LLC
C_-��
John A. Storch
VP Network Deployment
4.
I
HIGH-SPEED INTERNET MADE SIMPLE. WAY SIMPLE.
I
v CITY OF SALEM
PLANNING BOARD
Wireless Special Permit Decision
For The Petition of Goodman Networks 1;
For The Property Located At 320 Lafayette Street t i Y f, -11 11.r;`,'S-
A Public Hearing on this petition was held on January 21, 2010. The following Planning Board
members were present: Chuck Puleo, John Moustakis, Nadine Hanscom, Tim Kavanaugh, Tim
Ready, Christine Sullivan, Randy Clark, Helen Sides and Mark George. Notice of this meeting
was sent to abutters and notice of the hearing was properly published in the Salem News.
The petitioner is requesting a Wireless Communication Facility Special Permit under Section 6.6,
Wireless Communication Facilities, of the City of Salem Zoning Ordinance, to allow for the
installation of 3 panel antennas and 1 backhaul antenna enclosed in a new stealth closure located
at 320 Lafayette Street, Salem, MA.
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 January 21, 2010, the Board closed the Public Hearing and the Planning Board voted by a
vote of seven (7) in favor(Puleo, Moustakis, Hanscom, Kavanaugh, Ready, Clark and George),
and two (2) opposed (Sides and Sullivan), to grant the Wireless Communication Facility Special
Permit for the location stated above, in accordance with the application(dated November 20,
2009) and site plan last dated November 30, 2009, titled "MA-BOS7155-b Park Towers, 320
Lafayette Street, Salem, MA 01970" (Sheets T-1, C-1, A-1, A-2, and A-3) and prepared by EBI
Consulting, submitted and now part of the file.
The Special Permit was approved with the following conditions:
1. The stealth tower shall be painted white rather than constructed with the proposed brick
finish; the applicant, his successors or assigns shall maintain the appearance of the
equipment.
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.
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 Plamring Board. 2" f 11 o-//3m
Charles Puleo, Chairman
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 . TEL: 978.745.9595 FAx: 978.740.0404 ♦ WWW.SALEM.COM
f
Date FED 1 7 7nt2_
I hereby certify that 20 days have expired
from the date this instrument was received,
and that 14t0 A-. ,CAL has been filed in this
office.
ATrue Copy . . .
ATTEST. CITY , �El lfi, Salem, iJiass.