1000 LORING AVE - BUILDING INSPECTION (6) GK L ��'s 9 �SSo� �
� � The Commonwealth of Massachu
��\����,�' /� Department of Public Safery�l�RE`����RV1GE5
��\yu/�! Massachusetts State Building Cod�C1R21t���
�� Building Permit Applicarion for any Building other than a One-or Two- a ' y�l�Zvelling
� � (This Secflon For Official Use Only) . �
Building Permit Number: Date Applied: Building Official:
.O SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
� I(7 0 0 (-a c'�r�a i�ve ��,M t`n fl �'c�,lc�c�o��12eio-P-lo� �i_ t¢
1 /� No.and Sfreet City/Town Zip Code Name of Building(if applicable)
=J SECTION 2:PROPOSED WORK
IEdition of MA State Code used_ If New Constructlon check here O or check all that apply in the two rows beloca
�`� Existing Building❑ Repai � Alteration Addition Demolition ❑ (Please fill out and submit Appendix 1)
,� Change of Use ❑ Change of Occupancy ❑ Other �Specify: U '(�40 �
Are building plans and/or construcrion documents being supplied as part of this permit applicaHon? Yes (� No ❑ I
Is an Independent Structural Engineering Peer Review required? Yes� No ❑
Brief Description of Proposed Work U� I CY�C� W i t O� £S`
�c� i3 Q.� t�v� �` f . � f-lcla 12 i0 'S 1 r�r C SP .� �1 d-
��u��+;�<-, b�,�b 1-Qe s -b 1 z.� 5�c d � bP�
'h�br �d reable5 �-n �r+5+�n� :.x 1'� r,c1�g I
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) ❑
Exisfing 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.) �
SECT'ION 5:USE GROUP(Check as applicable) �
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ i
F: Factor F-1 ❑ F2❑ H: Hi 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-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S2❑ U: Utility❑ Special Use�and please describe belo�v:
Special Use: i
SECTION 6:CONSTRUCT'ION T'YPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTTON 7:SITE INFORMAT'ION(refer to 7S0 CMR 111A for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal: !
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required O or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commission Review Process:
Not AppGcable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes O or Aio❑ 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 Sripulations:
S�lv D Q-t7 1�4z�tC�Lff S� ��v� z( �
� ��-t'I�iC Tot�
- � � SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
�6S �cc,\�m S'a f�r 1� ��9 7 �-`Q C Ca\1�o�n -r�c 75� l I
Name int) No.and Street City/Town Zip
Property Owner Contact Informarion: (P ll ,�� "` ,y
� V So
'RK �(Yl �rr r - �,n ��p�ei= � - -
Tifle� r,� Telephone No.(bu� Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
5o1�n "(`fl����iOUaC�Y y9 �ca,�-tle 6-� � � � an 1YL� C� a�(�N
Name � Street Address City/ wn State Zip
to act on the ro erty owner's behalf,in all matters relative to work authorized b this buildin ermit a licarion.
SECT'ION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin is less than 35,000 cu.ft of enclosed s ace and/ox not under Conshvcflon Conlxol then check here 0 and sM Secflon 10.1
101 Re 'stered Professional Res onsible for Construction Contcoi
'a � 1Z ____to i�-c��--3 y�,� �9 a ao
Name eei trant) Tele hone No. e-mail address Re ' iraHon Number
a� �umme�� �c�s{�r YY \�1 o a�d �� G�3o�lc�
Street Address City/Town State Zip Discipline ExpirationDate
102 General Contractor �
�C�C1uce �5��\���r��r �covD
Company Name �b u� �_ M�1 I`` CV.��N
rP-- �_s -� �88 i�
Name of Person Responsib e fo� onstruction License No. and Type if Applicable
�� C�ra�l� 5�" ��I�r��azsn t'(1'R� �4��
Street Address City own State Zip
_(�l�l 3�- c�3a�{
Tele hone No. usiness Tele hone 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 th issuance of the building permit.
Is a si ed Affidavit submitted with this a licafion? Ye No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FE �
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ �Q � � d Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Muumum fee=$ (contact municipality) �i
5.Mechanical Other $
Enclose check payable to
6.Total Cost �a 5O �� (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 penalries of perjury that all of the information contained in tMs
application is true and accurate to the best of my knowledge understanding.
—\ � �---T,����V(�i2'v �� �I`l-3a��63ay
J�hn�(' �2�•1��uc��a� - -
Please rint and sign name � itle Telephone No. Date
�1G �sa�'fIf s}. 1� �t� o��Y
Street 9ddress City/T n State Zip
Municipal Inspector to fill oat this section upon application approval: � v.�-K� �
Name Date
Appendix 1
For the demolition of structures the building permit appiicant 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 Biock # and Lot#for locations far which a street address is not
available)
��� �.E��C 1 �C � 1-2- C-�-�:YYI— �� �
No. and Street �� City /Town Zip Name of Building(if applicable)
For the above described property the following action was taken: I
/
Water Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No
Other (if applicable)
Yes ❑ No ❑ Provider notified an_d Release obtained? Yes ❑ No
Other (if applicable)
��� �'�-�
��� ��
� �
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Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where a licable
No. Item Submitted Incom lete Not Re uired
1 Architectural
2 Foundarion
3 Structural
4 Fire Su ression
5 Fire Alarm ma re uire re eaters
6 HVAC
7 Electrical
8 Plumbin include local connections
9 Gas Natural,Pro ane,Medical or other
10 Surve ed Site Plan Utilities,Wetland,etc.
ll S ecifications — �/
12 Shvctural Peer Review
13 Structural Tests&Ins ecflons Pro am
14 Fire Protection Nanarive Re ort
15 Existin Buildin Surve /Invesri arion
16 Ener Conservation Re ort
17 Architectural Access Review 521 CMR
18 Workers Com ensaHon Insurance �
19 Hazardous Material Miti aHon Documentarion
20 Other S eci i/
21 Other S ecif �
22 Other S ec'
*Areas of Design or ConstrucHon for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this applicarion has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
��G����CUI��(�u �1l-3BR -fo3c7`-� �1FS8S8'
Aiame(Registrant) � Telephone No. e-mail address Registration Number
�q b�ca�rt��e s}�. {�c 1��r�G�Cm m'� c��Y� v ]�— ��
Street Address City/Tow State Zip Discipline Expiraflon bace
e R���e�le �1���95-3yo6 �aa�
Name( gistrant) Telephone No. e-mail address Registrafion Number
2-`6b Stmnrnn.0 51- . �3�j�,� ('�1� 0 3io � (0 3o-i �
Street Address Ci /Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State ZI Discipline Expiration Date
�6� .� r The Commonwealth of Massachusetts
, Fa" `.'' a Department of Public Safety
'=J �'/ ��, Massachusetts State Building Code (780 CMR)
?�. Building Permit Application to Construct,Repair, Renovate or Demolish any
`' �'" ' Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Departrnent of Public Safety has issued these building permit applicarion forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in arder to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the buIlding permit applicarion, that no outstanding property taxes, water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work wIll be done to ensure that the city or town will accept
this applicarion form and if any addiHonal information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.A11 applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the BuIlding Permit fee. The fee may be calculated using the infarmation to
be supplied in section 12 oE the BuIlding Permit Applicarion. The check is to be made payable to the
local city or town where the work will be done.
� ' ' The Co
� �nmonwealth ojMassachusetls
DeparY�nen!ajlndystr�l Accidents
O,ijrce ojlnvesfigaiions
600 Washingyon Sfreer
Boston,MA 01111
Workera' Compensation Insurance AfHdavl�gt�fla ryCooh.actors/Electntclans/Plumbers
A Scant IntormaHost
Ptease Prtnt L 'bl
Name(Bu�ma,rorp,izatioo�tndvidus��_S}�;U c�t�t� �C��1��,1��Cl q C� t � u '�
Address: y�( ��,�.��� �� ..
Ci /Sta ' : r�C,�CI ��l `t1' Oc�`l�`� Phone#: � �S� p l�
Are you aa employer?C6eck e aPP�oP�+e bo:: -� I I ' � � � r
�� I am a cmployer with 3� 4. [� I am o g�eral contrector end I T�°�P�1�(re9ofred):
0T71P��Y�(fultaod/orpart_time).• hsve iub-contracto� ❑ hucHOa
hi�ed the b. New cons
2 Q I am a wle ptoprtetor or pa�er- listad on tbe atmehed aheet 7.
9�P aad have no employeey Thae�n�+s Lave ❑R�Ddel'mg
woiioag for me in anY eaPeciry. �P�o3'�sad heve worters• 8• Q�molition
[No woricrn'comp. insu�ance wmp.inwraaca= 9. �Build'mg addiGon
3.� 1 am a�hdomeowner doiag all work S a o�cers have�era�ixd their I 0'Q Electrical repaus or addit�'ons
myself:[No worice�'comp. rig6t of exemption pR MGL 1 I.Q Plumbing repairs or additioos
3e.� I�h mr�Rd.�f c. l52, §I(4).and we heve no 12.�Roofrcpajn
�8`t"'g e°° emP�M'ea.[No wodtrn' I�Otha�
8enael eaa4aemr(rcfa to#4)
��Y WD�ama�e cLacks 6oz pl mua�lso fill a�u tpc�ectma'bc7ow. '�CC tIXjUlrod.]
f u
7 Homoaweeaaho�uhmitt6i�.Aidavit.eidiuong:�yasedain ..lt �.���'e•.���°�Yinfmm�eion.
eDOG1CWf Ih�l e6aCk 16116oi mYG J6�C�CS Li�IFTame��aet�.i�fp���i�1C211we 66l?tl}i c00p�CtOf/mLLff Al�mil a 11CW�jdlYlt IO�
��'CYL �1�1C pi�-Lypp���yy���'�„ �ID���d1t11 Wp1}�'Or�C���ld10 W�JhC Of IIOf 16o�C tLU4q�V�h.
,..�»�
. GOIII�`�pj�r��.
/an�w r�wploye�fhat sr provJding warke�'ca �
injonnado� � '"p 74T4�p�+vanee jor wry emp/oy�a B�w v�r���fo6 ritt
Insurmce Company Narne: 1 ,��y [r'I� � 1 �� l '� �
Palicy 31 or Self-ins. Lic.#:__!�n L,U C C"� G� ��'7
_�_ ��a�D�: - 3 -I (,�____.
Job Site Ad�esn:�(�(j(} p,C� �q � rP
Aduh a copy otthe workert'compensatloe City/Staze/Zip; �
Fa+1�ae W sxure covera e as P°�Y declaratlon pige(a4owlnQ the popcy oumber and e=p[nyoo date).
g +�9��d wnder Section 25A of MGL c. 152 can lead�a ���y��bon of criminal penxlK�y of a
fine up to S I,500.00 and/or ono-Year imprisonmrn4 ay well aa civil peneltip in the form af a STOP WORK ORDER and a fine
ot up rn I]SO.pp a�y ag�yt�e violator. Bo advixd�t a ca �
Io��sogatioav of the DIA for iavuc-en�e coverage �{��eD �of this s�atement may�{o�,ard���e ORice of
!da hereb�cerd�y undn rhe pniru e� nal
Y►y thml6e infonu�n p��a a����Q�comd
i
- .� . _. �.. .- '-------. .. ,.__ _.
6/ - v8= �_ l _�`� --
U$kia!u►e only. Do noI write rn�hu artq Eo be enmplered by cJly or lown oj�cia[
Giy nr Tawn- '
Permlt/L(cenu#
lasatng Anthotity(circle onc):
1• Board ol Health 2. Bu[Iding Departmeo� 3. Ciry/I'u�yn Clerk 4. Electrical IospKyor 5. Ptumblag Inspaxyar
b.Other
Cootaet peraco-
PEooe(i:
`°�"���� CERTIFICATE OF LIABILITY INSURANCE Ros4 i�zizois��
�-
THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERiIFICATE 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(ies)must be endorsed. If SUBROGATIONIS 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 sueh endorsement(s).
GROOUCER CONTACT
NNME
PAYCHEX INSURANCE AGENCY INC
(A/qNo,En): (NC,No[ (HBH� 443-6i12
21070V5 P: F: (888) 443-6112 EnooR'ess.
PQ BQA 33015 INSIIRER�S)APFOR�INGCOVERqGE NHIGM
SAN ANTONIO TX 78265 wsuaesn: mwin City Fire Ins Co 29959
INSIlftEO
INSORER B:
INSIIRER C:
S^1RUCTURE CONSULTING GROUP� IN wsuaeao.
Y J Bt�ATTLE ST INSORERE:
ARLINGTON MA 02974 ws�aeRF:
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 POLICV PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTR4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAV 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 RE�UCED BY PAID CLAIMS.
1NSR TYP£OFINSUFANCE .1PDL SUBR PoLICYNUMB£R POGCYE£F POLICYEXP LIM/TS
/ /MM/OD
COMMERCIAI GENERAL LIA81lRY EAGH OGGURRENCE $
CI.AIMS-MADE ❑OCCUR DM1AGETORENTE� 5
PREMISES(Ea ouunence)
MEDEXP(Pnyoneperson) $
PERSONALBADVINJURY 5
GEN'LAGGREGATELIMITAPPLIESPER�. GENERALAGGREGATE $
POLICV� PR� ❑ LOC PROOUCTS-COMP/OPAGG
JECT
OTHER: 5
AUTOMOBILE LIABIIRV COMBINED SINGLE LIMIT
(Eaaccitlent) $
ANV AUTO , BO�ILV INJURV(Perpersan) 5
ALLOWNEO SCHEDULED
AUTOS AUTOS 90DILV INJURV(Geracutlem) 5
HIRE�AUTOS NON-OWNED PRwERTVOAMAGE 5
AUTOS (Peracutlent)
5
UMBRELLA LIAB OCCUR EACH OCCIIRRENGE g
EXCE55 LIAB CLAIMS-MA�E AGGREGATE 5
oEo qErEunorvs
5
WOFKERSCOM➢SN59TlO,S ' PER OTH-
ANO£llPLOY£RS'LlABIL/TY y' STFNTE ER
ANV PROPRIETORiPARTNER/E%ECUTNE YIN E.L EACH AGCI�ENT ��� O O O� O O O
OFFlCER/MEMBEREXCLU�ED9
A (MandatoryinNN) ❑ WA 76 WEG GB2651 O1/G3/[O15 O1/03/2016 E.L.DISEASEEAEMPLOVEE SZ� OOO� OOO
If yes,descfibe untler E.L.OISEASE-POLIGV LIMIT 51
DESCRIPTION OF OPERATIONS belaw � O O O� O O O
DESCRIPiION OF OPERAilONS/LOCAT/ONS/VEMILLES(ACOR0101,Aptlitional Remarks Schedule,may be a[lacM1ed i/mom space Is repuireE)
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.
T O W R O f S a 121R� MA AUTNOR2E0 REPRESENTATNE `
32 DERBY SQ �Gc.� �Q��(�,�„�_i
SALEM, MA 01970
OO 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are�egistered marks of ACORD
.��p), Massachusetts -Department of Public Safety
`� Board ot Building Regulations and Standards
Cnn�tructinnSupenizur �'I���
Lieense: CS-078888 �
```�, i i. o�..
John G McGilticud�y �]{� '
65 Governon RoaH E�{�� J s
M7Wn MA 02186 �� '';
:
.� �
�„�,,,,���. ,� �•`�' Expiration
Cormmissioner 07f11/2016
� � Dewberry
' Dewberry Englneers Inc.
280 Summer Sheet,lOth Floor
� , . Boston,MA02210-1131
� �� 617.6953400
� • . 677.695.3310fax
, . www.dewberry.com
J
January 9,2015
Mr.Tim Baker
Structure Consulting Group
49 Brattle Street
Arlingtan, MA 02474
Re: Swampscott MA
1000 loring Avenue
Salem,MA 01970
Dear Mr. Baker, ,
Verizon Wireless has proposed to replace (3)existing antennas (1 per sector)with (3) new antennas (1
per sector)and install(3) new antennas (1 per sector)on existing pipe mounts on the fasade of the
� above reference building. Additionally, (3) new remote radios heads�RRHs) (1 per sector)will be
installed on existing ballast mounts. The existing building is an Il-story residential structure, consisting
of steel frame and brick fayade structural system.
The antennas are to be mounted on the fa4ade, using existing mounting hardware as outlined.in the PCS
Drawings provided by Dewberry Engineers Inc. (Dewberry).The existing ballast mounts,for RRHs and
surge arrestors,will be modified to reduce weight. Dewberry has performed a site visit and reviewed
existing information,to assess the condition of the existing building and mounting hardware, and
concludes that they have adequate reserve capacity to support the proposed equipment as shown in
our PCS drewings.
Our assessment is based on the assumption that the existing building structure and mounting hardware
� are in good condition. If during construction any damage or deterioration is noticed on the building or
hardware, Dewberry is to be notified to assess any deviation from the assumed condition.
If you have any questions, please do not hesitate to call me at 617-531-0742
SPncerely,
Dewberry Engineers,Inc.
, P h�+'�.�:�.
` /j� ` �. �Yy Oi(.g n �1�1 .
O(i /i�i•—Z . .{`i. �'�a�,.'':�''°
� /�� ,�.;� �'��
�, . BflEI�G'cD!E. -�
Brenden Alexander, P. E. a v Fl�Gv'::"d!?rH °' 't>
>
t1;;Tl.i?„4l
- Senior Project Manager � ST� � .
Nu.4CG!2 k
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l
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R:\50002925\50070449-SWAMPSCOTT_MA�Adm\Reports\Structural\Swampscott MA Structural Letter_O1-09-SS.docx
� Initial Construction Control Document
�r
To be submitted with the building permit application by a
> Registered Design Professional
< for work per the 8`�edition of the
� Massachusetts State Building Code, 780 CMR, Section 107
Project Tide: Verizon Wireless—Swampscott MA Date: 1/20/15
Property Address: 1000 L,oring Avenue, Salem, MA 01970
Project: Cbeck(x) one or both as applicable: New construction x Existing Construction
Project description: Replace(3)existing panel antennas (i/sector) with (3)new panel antennas mounted on existing
fa�ade mounts. Install(3) additional new panel antennas on existing spare fa�ade mounts. Install (3) new RRHs (1/sector)
on existing ballast mounted frames on the roof. A structural assessment of the proposed modiFications was performed by
Dewberry Engineers Inc. dated OU09/15, Brenden Alexander,P.E.
I, Benjamin B.Revette MA Registration Number: 49220 Expiration date: 6!30/16,am a registered design professiorzal, and I
have prepazed or directly supervised the preparation of all design plans, computations and speciFications concerning�:
Architectural Structural Mechanical -
Fire Protection Electrical x Other: As described above
for the above named project and that to the best of my lmowledge, information, and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agee that I(or my designee) shall perform the necessazy
professional services and be present on the constmction site on a regulaz and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to[he stage of constmction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports (see item 3) together with pertinent comments
in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Fin 'on Control DocumenP.
Enter in the space to the right a"weP'or 916�8.
electronic signature and seal: �
. !loiL
i�o,��9� .
I �� . .
Phone number. 617-531-0800 Email: brevette@dewberry.com , ,
Building Official Use Only
Building Official Name: Permit No.: Dare:
Note 1.Indicate with an `x'project design plans,computations and specifications that you prepazed or directly supervised.If bther' is chosen,
provide a description.
Version 06 11 2013
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