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HomeMy WebLinkAboutMiscellaneous - 5 BOSTON HILL ROAD 4/30/2018 6 �hhb �—N•tl Ria BUILDING FILE 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§31,,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed "I on the prescribed forin.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.01 c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of.ongoing construction activity,and may be-deemed-by-the-Inspector_of-Wires abandoned-and-invalidafhe—. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or.the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Cliapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. ule 8—Permit/Date Closed: e•!> —l 'k Note:Reapply for new permit ❑Permit Extension Act—Permit/Date Closed: r 0 r, v 41 Date......�.:. f NORT1�� 3r;•t:�`"-:•_�.."�O� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING s i + r �1 •O��r�°'�,y'h SS US This certifies that ......... ........... ............................. has permission to perform ........ � v Y�1�n ..... ..... .. .... ................. ..................... wiring in the building of.......... "..1 .....00--� ...................................... at.....41$ 7q-4v.. .....t C(i.......2�...........14 1jorth Andover,Mass. ve Fee...[.n. ... Lic.No..... 91 f 1 ..... /11;tICAL INSPECTOR ....... . .. / - Check # v 4 -Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �DL3" � BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. l/07] ( -- leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: y- l s— j f City or Town oh NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 130 Rdaj Owner or Tenant /� hip p C S Telephone No. a6l-?3 e /F)7 Owner's Address f�;11e<- R a Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Buildinge-(I r v v l e K f Utility Authorization No. Existing Service D,00 Amps 1 to / a yd Volts Overhead ❑ Und rd g 'No.of Meters New Service Amps /_Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: n 1 eec�l Com letion othe ollowing table may be waived by the Inspector of Wires. f No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No,of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above r-1In- o.o mergency ig tingrnd, rnd. ❑ Satter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. TotaTons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number .Tons........ KW No.of Self-Contained Totals: ................. Detection/I'll lertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent �' Ballasts Data Wiring: ` Signs Ballaass ts No.of Devices or Equivalent No.lrIydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring; / pp No.of Devices or E uivalent OTHER: (� tj v� ce a X� Cq 6,'n e I . Attach additional detail tf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: a SC O. �" (When required by municipal policy.) Work to Start: L/- /5-, I r Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the mins and penalties of erjury,that the information on this application is true and complete. FIRM NAME: s P ,C ie -�r%'c ,� LIC.NO.: Licensee: Q r vi c e V c,c soy, 5 SignatureLIC.NO.: 9s 3-x'1 --�-- � (Ifapplicable, enter "exempt"in the license nurr�be line.) S 1 Address: ) So (A le 1• -8 l(�yl 1.:,' J_, L Alt.Tel.No. a o?-Q 3 k-7`7 3 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one Owner/Agent )❑owner El owner's agent. Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSP_ ELECTRICAL INSPECTOR-byECTTON REPORT: , SMALL I.ROUGHINSPECTION: Passed— Failed—[ ] Re-inspection requirecT($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION, Passed—[ I Failed—r .] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) . Date 3.UNDERGROUND INSPECTION: , Passed—[ ] Failed—( ] Repection required($50.00) Inspectors'comments: f (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAY : Passed—[ ] Failed—[ j Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date e 5.INSPECTION-OTHER: Passed—( ] Failed—[ ] Re-inspection required($50.00) inspectors' comments: (Inspectors Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TFdE ARTA TO BE INSPECTED IS NOT ACCESSIBLE AND A -INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): j S P F le c Ac L Address: City/State/Zip: 1 5�- ,� 1` Phone#: oZd 7- 3 - I I 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 shget.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its t required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12,❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other • comp.insurance required.] Any applicant that checks box#I 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. tGontractors thatcheck this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �r- Insurance Company Name: �O e l'A k-eJ Policy#or Self-ins.Lic.#: Expiration Date: r 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 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 under Tains andpenalties ofperjury that the information provide//d//above is true and correct Signature: Phone#: 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#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' r compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or n town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture S (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia 21�, �76orne Technologies June 12, 2013 I North Andover Building Department Attn: Mr. Brian Leathe 1600 Osgood St North Andover, MA 01845 i Verizon.Site: N Andover MA HD Site Address: 5 Boston Street, North Andover MA 01845 RE: Final Construction Inspection and Affidavit Dear Mr, Leathe; A site visit was conducted for a final inspection of the wireless telecommunications installation as part of the required CCA. The visit took place on 6/12/2013 to inspect the completed site. The site work consisted of installing internal radio equipment in an existing shelter, replacing antennas with pipe mounted antennas, fiber cables and related hardware. The site is complete as per construction drawings(Rev 0)dated 02/01/2011 by Aerial Spectrum, Inc. i Construction of completed work is,from the inspection site, allowable access and ground observation, satisfactory to the best of my knowledge, in accordance to the following standards: • ANSIMA/EIA-222-G-"Structural Standards for Steel Antenna Towers and Antenna Supporting Structures". • Massachusetts State Building Code, 8t1 Edition If you need further information, have any comments or questions, please do not hesitate to contact our office. Sincerely, PALIL NAL Paul Paul L.Mucci, P.E. MA Lic. #40619 PO Box 875 Westford MA 01886 rI-SOS-71-0141 1711 Location C, No. 3 7 �� Date 2 C/A 4 NpRTh TOWN OF NORTH ANDOVER 041 e 9 �o ;�. Certificate of Occupancy $ ..: cMusBuilding/Frame/Frame Permit Fee $ s•► a 9 Foundation Permit Fee $ Other Permit Fee $ p TOTAL $ Check # 2396 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: / Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATIONS _ Print PROPERTY OWNER J d n - �0,n A P < < 6eco0�= Print MAP NO: 10'7 C PARCEL:_ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other S ep u ❑S}Wate�r./. �t„ry.. 4 c '. t?_-.. :`=3+r c1 �E erxs0Vbill W .r hetS d^{fIDtjsU,t�i}ict4y ewes z. , t ` . DESCRIPTION OF WORK TO BE PERFORMED: Sw� exp ��4 ��e� ��,-1�, new at�e5. o ax�QQ Ong Identification Please Type or Print Clearly) OWNER: Name `12a c t�,Ce kes5 Phone:-7 I `iSN-9I 3y Address:Hoo Fc fV N( uW— —` gGro�g ►-, m CONTRACTOR Name: abn M C- 11.1 CUCI 4 Phone: b 11 - Addressj-(��P �. noA� Supervisor's Construction License: -11331 Exp. Date: -7 Home Improvement License: Exp. Date: ARCHITECT NGINEE \ w Phone: -M - 9 ;k-o�00 I Address:;" Q 6lQ 00-V\Q (6 12d bv(I n4 Reg. No._ y0 (0 0 FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ Q Q O FEE: Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ----------- - --_ --- .,,;: ------ 1 Signature of_Agent/O ner, 1 1 F ORTH Town of Andover 0 No. A K Edover, Mass., COCHIC HE W ICK RATED BOARD OF HEALTH v P'ERMIT T D Food/Kitchen Septic System BUILr > ' ' DING INSPECTOR T THIS CERTIFIES THAT....... M ........ O`me``� ... .. ...... ... . . . Foundation p T/ has permission to erect........................................ buildings on ..........�.P..S.....4?.�Y............................. c.........:................... Rough �CvG� /{ 1 /� �F'�/��S !' �ciyrtWin rr� Chimney to be occupied as............................ .. ........}�.... ......... ...�� ..................:........:....../�s`..........l........provided that the person accepting this permit shall in every respect conform to the terms of the applica on file i -Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations-Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST T ELECTRICAL INSPECTOR Rough .................................... .......... . ....... .... ......N .......................... Service B LDING PECTOR " Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the- Premises — Do Not Remove Final No Lathing or Dry wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans)b TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools Well ❑ Tobacco Sales ❑ Food Packaging/Sales 0 Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ d COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date CONIMENTS Dimension Number of Stories:_Total square feet of floor area, based on Exterior dimensions. Total land areasq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use F I I ® Notified for pickup - Date Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed osed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products i'OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals fat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording . ust be submitted with the building application Doc: Doc.Building permit Revised 2008mi f NORTH A Town of North Andover p Office of the Planning Department Community Development and Services Division �''9sSAOHUS�S'� 1600 Osgood Street North Andover,Massachusetts 01845 To: Jerry Brown,Building Inspector Re: Building Permit for Bell Atlantic Mobile of Mass Corp.Ltd,d/b/a Verizon Wireless Antenna Swap at 1275 Turnpike St. (a/k/a Boston Hill)&401 Andover St. V Rafe: March l6,2011 cc: Carl Gehring, Gehring&Associates,LLC Jerry, At the March 15,2011 Planning Board meeting, the Board voted to allow the applicant, Verizon Wireless, to replace their existing wireless antennas located at 1275 Turnpike St. and 401 Andover St., with new antennas without the need for a Special Permit. The Board's vote was as follows: On a motion made by R. Glover and seconded by C.LaVolpicelo,the Planning Board votes that the replacement of existing antennas with new antennas at 1275 Turnpike St. (a/k/a Boston Hill) & 401 Andover Street, as requested by the applicant Verizon Wireless, does not meet the criteria spec'if'ied in the Zoning Bylaw Section 8.9.7, and therefore a Wireless Special Permit is not required. The vote was unanimous. If you have any questions,please let me know. Judy Tymon',AICP Town Planner I I III i "dc 11 use Its Uc 1:u'!nu'nl nl'Public .ti;lt'cl� 13111"r11 fit'Buildin" k1L,ulaliu ; . Construction Su1!111 �t:uld:Ir11. pervison. r License License: CS 78888 I JOHN G MCGILICUDDY 14 BENNINGTON STREET QUINCY, MA 02169 A Expiration: 7/11/2012 Tr-9 207 I The Commonwealth of Massachusetts --� Department of Industrial Accidents -- Office of Investigations 600 Washington Street - Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -A ,j Address: U City/State/Zip: ; I cr�c �`���� G� , ` Phone i 'J Are you an employer? Check the appropriate box: Type of project(required): IJX I am a employer with 30 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 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 133M Other_�P� comp. insurance required.] *Any applicant that checks box 41 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 must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r_ Insurance Company Name: IU Tn-s C ( 04 r� OL; o Policy#or Self-ins. Lic. #: Expiration Date: j Job Site Address:`] &nAn � W, I City/State/Zip:M,'A()dove( I'Y1A 01$t/S 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 certi n er the pai s an penalties of perjury that the information provided above is true and correct Signature: Date: Phone#:�o 1-1 J 7 r J5 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#: V i7L ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D 01/24/20112011) 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 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 SUBROGATION IS 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 such endorsement(s). PRODUCER CONTACT NAME: VP, CIC,LIA, Michael Tarpey Tarpey Insurance Group Inc A/CNo Ext: 617.527.6070 ac No:617.527.1980 343 Washington St. E-MAIL ADDRESS: Newton, MA 02458 PRODUCER CUSTOMER ID#: VP, CIC,LIA, Michael Tarpey INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Norfolk & Dedham 23965 Structure Consulting Group, Inc. INSURER B: Twin City Fire Insurance Co 29459 49 Brattl a Street INSURER C: Arlington, MA 02474 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2011-2012 Term 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD MM/DD GENERAL LIABILITY R010555510/0512010 10/0512011 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISES Ea occurrence) ccurrence) $ 50,000 CLAIMS-MADE T OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL 6 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY 91022321 01/06/2011 01/0612012 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ j X NON-OWNED AUTOS $ i UMBRELLA LIAB OCCUR U0908417 10/05/2010 10/05/2011 EACH OCCURRENCE $ S,000,000 EXCESS LIAR A CLAIMS-MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION 08WECNN659 01/03/2011 01/03/2012 X TORY A ITS OTTH R AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) 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. AUTHORIZED REPRESENTATIVE I For Illustrative Purposes Michael Tarpey, VP, CIC,LIA ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD A CORA, AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Tarpey Insurance Group Inc Structure Consulting Group, Inc. POLICY NUMBER Arlington, MA 02474 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: ACORD Certificate of Liability Insurance Garage Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MM/DD/YY) DATE(MMIDDNY) LIMITS AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ Automobile Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MM/DD/YY) DATE(MMIDDIYY) A Excess/Umbrella Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE(MMIDDIYY) DATE(MMIDD" LIMITS A $ Other Liability INSR POLICY EFFECTIVE POLICY EXPIRATION LTR POLICY NUMBER DATE(MMIDDIYY) DATE(MMIDD/YY) LIMITS ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commercial Property Record Card PARCEL_ID:210/107.C-0011-0000.0 MAP:107.0 sLOCK:0011 LOT:0000.0 PARCEL ADDRESS--5 BOSTON HILL ROAD FY:2011 PARCEL INFORMATION Use-Code: 432 Sale Price: 0 Book: 00000 Road Type: T Inspect Date: 08/06/1997 Tax Class: T Sale Date: 12/31/99 Page: 0000 Rd Condition: P Meas Date: Owner: Tot Fin Area: 13072 Sale Type: Cert/Doc: Traffic: M Entrance: X FARNUM,JOHN C Tot Land Area: 9.49 Sale Valid: N Water: Collect Id: JEL Address: Grantor: Sewer: Inspect Reas: R 426 FARNUM STREET NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% / Comm-B/LWO/100 Indust-B/L% / Open Sp-B/L% / COMMERCIAL SECTIONS/GROUPS LAND INFORMATION Section: ID: 101 Use-Code:432 NBHD CODE: 33 NBHD CLASS: 3 ZONE: VR Category Grnd-Fl-Area Story Height Bldg-Class Yr-Built Eff-Yr-Built Cost Bldg Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class 3 1296 7.0 C 1950 1975 191,900 1 P 432 S 130680 3.000 522,740 Groups: 2 U 432 A 0 6.490 Y 12,980 Id Cd B-FL-A Firs Unt DETACHED STRUCTURE INFORMATION 1 432 1296 7 0 Str Unit Msr-1 Msr-2 E-YR-BIt Grade Cond%Good P/F/E/R Cost Class Section: ID: 102 Use-Code:432 SE C 100 0.00 1983 A A ///84 200 Category Grnd-Fl-Area Story Height Bldg-Class Yr-Built Eff-Yr-Built Cost Bldg SE C 192 0.00 1983 A A ///84 500 3 4000 1.0 S 1980 1980 113,000 AN F 100 0.00 1984 A A ///84 46,400 3 Groups: C4 F 130 0.00 1984 A A ///84 1,200 Id Cd B-FL-A Firs Unt AN F 100 0.00 1984 A A ///84 46,400 3 1 432 4000 1 0 AN F 100 0.00 1984 A A ///84 46,400 3 AN F 100 0.00 1984 A A ///84 46,400 3 AN F 100 0.00 1984 A A H184 46,400 3 AN F 100 0.00 1984 A A ///84 46,400 3 VALUATION INFORMATION Current Total: 1,025,700 Bldg: 490,000 Land: 535,700 MktLnd: 535,700 Prior Total: 1,025,700 Bldg: 490,000 Land: 535,700 MktLnd: 535,700 w Parcel ID:210/107.C-0011-0000.0 as of 3/22/11 Page 1 of 2 Commercial Property Record Card PARCEL ID:210/107.C-0011-0000.0 MAP:107.0 $LOCK:0011 LOT:0000.0 PARCEL ADDRESS35 BOSTON HILL ROAD FY:2011 SKETCH PHOTO N o P 1"'ct u re 'A Available Parcel ID:210/107.0-0011-0000.0 as of 3/22/11 Page 2 of 2 i I VerfZ. 11 wireless 400 FRI BERG PARKWAY WESTBOROUGH,MA. 01581-3936 (508)330-3300 v t A E R I A L SRPERCTRUM I C O 20 Blanchard Road,Suit0e 4 Budington,MA 01803 tel:(781)272 6200 fax:(781)272 6225 e-mail:sgumey@aedalspectrum.com k SITE NAME: N ANDOVER MA HD CONSTRUCTION EXHIBITS M PROPOSED VERIZON PIPE MOUNTED ANTE (TYP. OF 3 PER SECTOR, TOTAL OF 9)T REPLACE EXISTING ANTENNAS (SEE ANTENNA CONFIGURATION CHARTS) s EXISTING SUBJECT BUILD/NG 1 0 02/01/11 FOR CONSTRUCTION PROFESSIONAL STAMP TING PANEL ANTENNA (TYP.) �Sli OF PALM LL I c4 I �DNA1L� I VERIZON WIRELESS ANTENNA y (TYP. OF 9) DRAWN BY: DFR PROPOSED VERIZON PIPE CHECKED BY: PLM MOUNTED ANTENNA (TYP. h OF 3 PER SECTOR. ` TOTAL OF 9) TO I! SECS TORc REPLACE EXISTING PROJECT NUMBER: 3154 26T CONFIGURATIONANTENNAS CHARTS)A I SITE ADDRESS: j IG G sue✓Ecr BUILD5 BOSTON STREET I BUILDIN IZ NORTH ANDOVER, MA 01845 SHEET TITLE: ROOF PLAN 0 ROOF PLAN SCALE:Y4'=1'-O" - & ELEVATION SHEET NUMBER: NOTES: 1. CONTRACTOR TO VERIFY AVAILABLE 40 N. 2. AN 2. ANTENNA SECTOR r0 BE/NSTALLEO IN ACCORDANCE WITH TOWER MANUFACTURER RECOMMENDATIONS AND STRUCTURAL ANALYSIS 'RENT f J. CONTRACTOR TO FIELD VER/FY ALL n N SCALE: THIS PLII EX/STING CONDITIONS/PROPOSED DESIGN AND SCALE WHEN PRINTED AT AN AN xTO 8 100%SCALING NOT/FY ENGINEER OF ANY DISCREPANCIES , VerfZQnwireless BETA & GAMMA 400 FRIBERG PARKWAY WESTBOROUGH,MA. ANTENNA CONFIGURATION 0330936 (508)33001581-3936 330-3300 PCS A E RI A L SPE C TRU M 20 Blanchard Road,Suite 4 Burlington,MA 01803 tel:(781)272 6200 fax:(781)272 6225 e-mail:sgumey@aedalspectrum.com SITE NAME: 2 0 EX/STINC TOP OF LATT/CE TOWER _ e w CELL EL. IJO't A.G.L. N ANDOVER MA HD F CONSTRUCTION EXHIBITS PROPOSED VERIZON PIPE MOUNTED ANTENNA Q. (TYP. OF 3 PER SECTOR, TOTAL OF 9) TO REPLACE EXISTING ANTENNAS tion (SEE ANTENNA CONFIGURATION CHARTS) VERIZON WIRELESS ANTENNA EX/ST/NG SUBJECT (TYP. OF 9) ' BU/LO/NG a EXISTING W/4/1- ANTENNA H/PANTENNA (TYP.) LTE 0 02/01/11 FOR CONSTRUCTION PROFESSIONAL STAMP EXISTING CONCRETE- EXISTING PANEL WALL ON ROOF ANTENNA (TYR) �ytN OF EX/ST/NC MA/N ROOF LEVEL PAUL L G EL. 75t A.G.L. ^ f OF PROPOSED VERIZON ANTENNAS EL. 71=10't A.G.L. OF PROPOSED VERIZON ANTENNAS NOTE: ��_ _ _ - _— ANTENNA CONFIGURATION IS LOOKING FROM BEHIND SECTOR. EL. 6Tf A.G.L. I fes" EXIST/NG 55.t LATTICE TOWER ON ROOF ALPHA Q OF PROPOSED VERIZON ANTENNAS I ANTENNA CONFIGURATION EL. 57'-1073 A.G.L.— LVERIZON WIRELESS ANTENNA EXIST/NC CONCRETE LTE CELL PCS (TYP. OF 9) DRAWN BY: DFR ., WALL ON ROOF PROPOSED VERIZON PIPE CHECKED BY: PLM MOUNTED ANTENNA (TYP. OF 3 PER SECTOR, TOTAL OF 9) TO sECr TOR c �o REPLACE EXISTING PROJECT NUMBER: 3154 26T ANTENNAS (SEE ANTENNA CONFIGURATION CHARTS) SITE ADDRESS: EXIS771VG SUBJECT BUILDING 5 BOSTON STREET a NORTH ANDOVER, NOTE: MA 01845 ANTENNA CONFIGURATION IS LOOKING FROM BEHIND SECTOR, SHEET TITLE: ROOF PLAN 1 0 z a a 16 ® ROOF PLAN SCALE:Y4"-1'-O" _ & ELEVATION EX/S_ANG GR_AOE _ £L. 0't A.G.L. SHEET NUMBER: NO 1. CONTRACTOR TO VERIFY AVAILABLEo s A 1 LOCATION. ELEVATION z to to zo ao 2. ANTENNA SECTOR TO BE INSTALLED IN ACCORDANCE WITH TOWER MANUFACTURER SCALE: 1"=10'-0" _ RECOMMENDATIONS AND STRUCTURAL ANALYSIS TH/S PLAN SHEET/S TO BE USED IN CONJUNC77ON WITH CURRENT SCALE: J. CONTRACTOR TO FIELD VERIFY ALL N THIS PLAN TO SCALE WHEN EXISTING CONDITIONS/PROPOSED DES/GN AND PRINTED AT 24"x36"xO 8100%SCALING NOTIFY ENGINEER OF ANY DISCREPANCIES. VerfMnwireless BETA & GAMMA 400 FRIBERG PARKWAY WESTBOROUGH,MA. ANTENNA CONFIGURATION 01581-3936 (508)330-3300 PCS A E R I A L SPE C TRU M 20 Blanchard Road,Suite 4 Burlington,MA 01803 tel:(781)272 6200 fax:(781)272 6225 e-mail:sgumey@aedalspectrum.com SITE NAME: �? $EX/ST/NC TOP_OF[ATT/CE TOWER _ �w CELL EL. 1JD t A.G.L. N ANDOVER MA HD CONSTRUCTION EXHIBITS PROPOSED VERIZON PIPE MOUNTED ANTENNA (TYP. OF 3 PER SECTOR, TOTAL OF 9) TO Q. REPLACE EXISTING ANTENNAS hOA ✓ (SEE ANTENNA CONFIGURATION CHARTS) VERIZON WIRELESS ANTENNA EXISTING SUBJECT I`— OF 9) BUILDING • EX/S77NC WHIP ANTENNA (TYP.J LTE 0 02/01111 FOR CONSTRUCTION PROFESSIONAL STAMP EXISTING CONCRETE EX/STING PANEL WALL ON ROOF ANTENNA (711P.) �SH OF EXISTING MAIN ROOF LEVEL PALL" F' EL. 1A.G.L. .� E OFFP PROPOSED VERIZON ANTENNAS EL. 7t=10 f A.G.L—-—-— NOTE: OF PROPOSED VERIZON ANTENNAS ANTENNA CONFIGURATION IS LOOKING FROM BEHIND SECTOR. EL. 67'f A.G.L. I EX/STING 55'1 LATTICE TOWER ON ROOF ALPHA (Z OF PROPOSED VERIZON ANTENNAS I ANTENNA CONFIGURATION EL. 57'-10"1 A.G.L.— VERIZON W/RECESS ANTENNA EXISTING CONCRETE LTE CELL PCS (-P. OF 9) DRAWN BY: DFR WALL ON ROOF PROPOSED VERIZON PIPE CHECKED BY: PLM MOUNTED ANTENNA (TYP. OF 3 PER SECTOR, TOTAL OF 9) TO S REPLACE EXISTING Ec 267�_ ANTENNAS (SEE ANTENNA PROJECT NUMBER: 3154 CONFIGURATION CHARTS) SITE ADDRESS: s, EX/STING SUB✓ECT 5 BOSTON STREET BUILDING NORTH ANDOVER, NOTE: MA 01845 ANTENNA CONFIGURATION IS LOOKING FROM BEHIND SECTOR. SHEET TITLE: �� ` ° z ` B 16 ROOF PLAN ROOF PLAN SCALE:Y4"=1'_O" _ & ELEVATION EX/S_TINC GRADE _ �EL. O't A.C.L. SHEET NUMBER: NO 1. CON7R4CT0R TO VER/FY AVAILABLEA 1 LOCATION ELEVATION 2 10 o s to 20 ao 2. ANTENNA SECTOR TO B£INSTALLED IN ACCORDANCE WITH TOWER MANUFACTURER SCALE: 1'-10'-0' _ RECOMMENDATIONS AND STRUCTURAL ANALYSIS. J. CONTRACTOR TO FIELD VERIFY ALL THIS PLAN SHEET/S TO BE USED/N CON✓UNCRON W/7H CURRENT SCALE: WEN EX/STING CON0177ONS/PROPOSE0D DESIGN AND / PRINTED AT 24'6"&REFERENCING TVC PROPOSED THIS PLAN TOA100%LE SCALING NOTIFY ENC/NEER OF ANY DISCREPANCIES.