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1871 MAIN ST./RTE 6A(W.BARN.)
�meauQ�, w1u., UPC 12543 No. 53LOR NCc--O yu Town of Barnstable . Bdflding . ., P�osted�i F ni al Inspe Lion Has.Been Made. o�ed" 1Nh'ere a Certi icate of Occupanry is Required,such�Buildmg shall Not be Occupied until a Finalulnspection;has`been mad'e., Permit Permit No. B-17-1301 Applicant Name: KEVIN J FARRELL Approvals Date Issued: 05/16/2017 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 11/16/2017 Foundation: . Location: 1871 MAIN ST./RTE-6A(W.BARN.),WEST Map/Lot: 216-030 Zoning District: RF Sheathing: Owner on Record: UMSCHLAG,JANISt Contracto Name: KEVIN J FARRELL ` Framing: .1 Address: 1871 MAIN ST $-096560 2 WEST BARNSTABLE, MA 02668 x EstP�roJecf Cost: $12,500.00 Chimney` Description: UERIZON WOULD LIKE TO'MOUNT WIRELESS ANTENNASAND Permit Fee: $313.75 Insulation: rANCELLARY EQUIPMENT ON EXISTING UTILITY POLSE#73:75-LOCATED NEAR 1871-1881 OLD'KINGS HIGHWAY SEE DO P RMIT� FeePald $213.75 � Date . 5/16/2017 Final: Project Review Req: VERIZON WOULD LIKE TO MOUNT WIRrELE�SSA�NTENNANDryk ANCELLARY EQUIPMENT ON EXISTING UTILITYPOLSE=#T375 fr �— Plumbing/Gas /K. . LOCATED NEAR 1871-1881 OLD KINGS HIGHWAY$Ef DOT � 4 Rough Plumbing: PERMIT i3 Building Official g Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. � .- �:�a a Rough Gas: All work authorized by this permit shall conform to the approved applicatiosn�yand the approved construction documenyyts fOKWhlEh this permit has been granted. , �,a Nyr-uM� L..h`x h.,�' - All construction,alterations and changes of use of any building and structuresshall�be in compliance with the local zonihif I laws and codes. Final Gas: This.permit shall be displayed in a location clearly-visible from access street orirdS&and shall be maintaine6open for public inspection for the entire duration of the work until the completion of the same. ` � y z a Electrical The Certificate of Occupancy will not be issued until all applicable signatures by;the Bwl ling and,Fire Officials are:provided�on thmpermit., Service: '- . Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing - � Rough - 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection S.Prior to Covering Structural Members(Frame Inspection) Low Voltage,Rough: 6.Insulation 7.Final Inspection before Occupancy tow Voltage Final: " Where applicable,separate permits are required for Electrical,-Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the.various stages of construction. r = Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department, Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-"ISSUED RECIPIENT , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ff;0 TONN Orril�I'dSTABI� �� Map Parcel Application Health Division ! ; , " ate(Issued ®�'�/6 27.7 a 17 Conservation Division Application Fee Planning Dept. ._ »- Permi"twee Date Definitive Plan Approved by Planning Board ICY � �01 N Historic - OKH, _ Preservation/ Hyannis Z56 — Project Street Address I - IIR81 A 1 Village 1A9�1� �nCYI` G I')CSL Owner Z t:,z,olcme Address , roq' Telephone _M- LA IA I—3VSI Permit Request y017M u3p, Qr2 Mk i ydr wiAp P l LIB qxt amWf) QMS CUn Q 00 aY, 0_1c l l nc o aZ� o g17S l occ&o Square feet: 1 st floor: existing 6proposed 2nd floor: existin02W Proposed JGJRj Total newYM� Zoning District Flood Plain Groundwater 1Overlay Project Valuation -S Construction Type I� O-C) Lot Size Grandfathered: ❑ es ❑ No If yes, attach supporting documentationo Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes 14No On Old King's Highway: Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other 100►T_ Basement Finished Area(sq.ft.) ,n Basement Unfinished Area (sq.ftYl ft Number of Baths: Full: existing new n N ktf�= Half: existing new 9 Number of Bedrooms: existing _new y C Total Room Count (not including baths): existing ' ► r ` new �(11 A- First Floor Room Count Y1 � � TTT� ► M Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New n Existing wood/coal stove: ❑Yeses Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size} Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: n Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use 1AA1 4 , Proposed Use U, l 4(a -t)LO APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name hpn �Fwrf_<< Telephone Number- Address License # q 15(00 CMUFX , YYI� (5�3?a Home Improvement Contractor# Email -I-rm Corn QdYY1 Worker's Compensation # kig- a 4ak ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO �arr�S SIGNATURE DATE sl I FOR OFFICIAL USE ONLY I APPLICATION #' DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION - FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL-BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 1 VWI�Onwireless July 2,2015. Dear Sir/Madam: Re: TRM, Inc.. Please accept this letter as notification that TRM, Inc.,of Foxborough, Massachusetts has been engaged i to perform research on certain prop.erties:and real estate including submitting;for zoning approval, building permits and negotiating real estate agreements.as well:as engage in certain engineering I analysis and construction for Verizon Wireless'.ongoing network.enhancement. TRM, Inc.., i5 authorized to act on Verizon Wireless' behalf for the purpose of filing•and consummating any zoning and/or building permit applications necessary to obtain approval of the applicable jurisdiction for the installation and/or modification of Verizon Wireless'communications facilities. Should you have any,questions regarding any TRM, Inc's•activities on behalf of Vei'izon.Wireless, feel free to contact me a:t 508-820-2017'or Via email at sean.conway@verizonwireless:com.. Resp tfully, Sean.`Cbnway Verizon Wireless Project Manager—,Real Estate i VerIZOI;wire!ess May 1,2017 Dear Sir/Madam: Re: Kevin Farrell/NEEC Please accept this letter as notification that Keven Farrell working for NEEC, of Kingston, MA has been engaged to perform research on certain properties and real estate including submitting for zoning approval, building permits,and construction for Verizon Wireless' ongoing network enhancement. Keven Farrell / NEEC is authorized to act on Verizon Wireless behalf for the purpose of filing and consummating any zoning and/or building permit applications necessary to obtain approval of the applicable jurisdiction for the installation and/or modification of Verizon Wireless' communication Facilities. Should you have any questions regarding this please contact me at 508-942-7503 or via email at npelletier@trmcom.com. Respec ully, Sean Conway Verizon Wireless Project Mamanger—Real Eastate i Hudson Design Gtoupuc 2-C CERTIFICATION Client: Verizon Wireless 118 Flanders Rd. Westborough, MA 01581 Site Name: Barnstable_SC06 .MA Site Address: 1871-1881 Old King's Hwy West Barnstable, MA 02668 Type of Survey: X GPS Survey X Ground Survey Horizontal Datum: NAD83 -expressed in degrees of Latitude and Longitude Vertical Datum: NAVD88 -expressed in feet Above Mean Sea Level (AMSL) Structure Type: Self-Support Tower Monopole Tower Guyed Tower Wood Pole Water Tank Smoke Stack Roof Top Church Steeple Temporary Site --Silo X Other. Utility-Pole Center of Proposed Antenna Array: Latitude 41°41'45.95" N Longitude 70°20'42.68"W Ground Elevation at Structure: 0' (AGL) 52'-0" (AMSL) Top of Structure(Top of Utility Pole): 29'-0" (AGL) 81'-0" (AMSL) Center Line of Proposed Verizon Antennas: 34'-6" (AGL) 86-6"(AMSL) Overall Height of Structure,Including appurtenances (Top of Proposed Verizon Antennas): 36'-2" (AGL) 88'-2" (AMSL) Certification: I certify that the latitude and the longitude are accurate to within+/-50 feet horizontally,and that the ground elevation is accurate to within+/-20 feet vertically. The horizontal coordinates are based upon the North American Datum of 1983 (NAD 83)and are expressed in degrees of Latitude and Longitude.The elevations are based on the North Americ ,er 'cal Da 'f'198 pressed in feet Above Mean Sea Level(AMSL). cO oF! , DEREK J yGm Signature: CREASER Derek J.:Crea er; P.E. CIVIL N y No.49195 Date: February 09,2017 p:978.557.5553 f:978.336.5586 a:1600 Osgood Street,Bullding 20 North,SuRe 3070,N.Andover,MA 01845 p:413.588.8139 f:413.517.0590 a:116 Pleasant Street,Ste 302,Easthampton,MA 01027 l ' i I ubl* Safety Board of Building ul ion and Standards �' - License. Construction Supervisor WIN J FEE 42 O C RVi IAA 0330 f' �r-.- -j i i .fir _ ion: 018 cc) missioner is IM-02 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): New England Electrical Contracting Corporation Address:21 Marion Drive City/State/Zip:Kingston MA 02364 Phone#:781-585-0040 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 48 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' y p �'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance:* required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below shoving 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Zurich American Policy#or.Self-ins.Lic.#:WC0161691 Expiration Date:11/13/2017 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 hereb certi un thc� ains and enalti o er'ur that the information provided above is true and correct. Si ature: 4z v / Date Phone#: 0 '— 5� i `mo oV o Official use only. Do not write in this area,to be completed by city or town official. I 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#: Client#:23780 NEWEN16 f ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYI� 11/1s/2o1s 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 NAME: J Smith Sullivan Insurance Group,Inc. PHONE 508 791-2241 FAX s08 797-3689 A1C No Ext: AIC No 1 Mercantile Street E-MAIL Jsmith Sullivan rou ADDRESS: g p•com Suite 71 O INSURER(S)AFFORDING COVERAGE NAIC# Worcester,MA 01608 INSURER A:Gemini Insurance Company INSURED INSURER e:North River Insurance Company New England Electrical Contracting Corp INSURER CZurich American 21 Marion Drive INSURER D:Hanover Insurance Company Kingston, MA 02364 INSURER E INSURER F: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY x x VCGPO81520 1/13/2016 11/1312017 EACHOCCURRENCE $1 000000 X COMMERCIAL GENERAL LIABILITY PREMISES?ER ENT ence $5O OOO CLAIMS-MADE a OCCUR MED EXP(Any one person) $10 000 X BI/PD Ded:5,000 PERSONAL&ADV INJURY $1 000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X jRa LOC $ MBINE D AUTOMOBILE LIABILITY x x AWNA947880 1/13/2016 11/13/201 EaaccideDISINGLELIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOSNON-OWNED PROPERTY DAMAGE $ AUTOS Per accident B X UMBRELLA LIAB X OCCUR x x 5811075702 1/13/2016 11/1312017 EACH OCCURRENCE s5,000.000 EXCESS LIAR CLAIMS-MADE AGGREGATE s5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION x WC0161691 1/13/2016 11/13/2017 X WCSTATu- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1 000 000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Cert Holder named as additional insured.Policies are primary and non contributory.Policies include Waiver of subrogation. 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 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #303267 KMD APPENDIX IV Form 1 APPLICATION AND POLE ATTACHMENT LICENSE Licensee Verizon Wireless Street Address One Verizon Way,Mail Stop 4AW 100 City,State and Zip Basking Ridge,NJ 07920 Date 11/2/15 In accordance with the terms and conditions of the Pole Attachment Agreement,application is hereby made for a license to make 1 antenna,RRH/Cabinet and meter attachments to poles and 1 Power Supply(ies)and other attachments located in the municipality of Barnstable in the State of MA This request will be designated Pole Attachment License Application Number BarnstableSC06MA-388902 Attached are my power supply specifications if applicable.The cable's strand size is 0.5 and weight per foot of cable is 0.2. o Communication Space X Power/Supply Space Licensee's Name(Print)Barbara Kassabian Signature Barlla ra,Ka41ab%a w NSTAR d/b/a EVERSOURCE Power Company Title Site Acquisition Tel.No. 603-303-8001 Fax No. E-mail bkassabian@trmcom.com *********************For licensor use,do not write below this Pole Attachment License Application Number is hereby granted to make the attachments described in this application to attachments to JO'poles, attachments to F02 poles, attachments to JU3 poles, Power Supplies and other attachments located in the municipality of in the State of as indicated on the attached Form 3. Licensor's Name(Print) OwRof Signature (AGREEMENT ID#) Title 0-f('V lS u• Date �/� 1i`'t ((( Tel.No. The Licensee shall submit an original copy of this application to Verizon New England Inc.and NSTAR Electric Company d/b/a EVERSOURCE ENERGY. Revised 02/23/2015 NSTAR d/b/a EVERSOURCE Form 2 AUTHORIZATION FOR FIELD SURVEY WORK Licensee: Verizon Wireless In accordance with Article III&Appendix I of the Pole Attachment Agreement, following is a summary of the charges which will apply to complete a field survey covering Pole Attachment License Application Number Barnstablesc06MA-388902 in the municipality Of Barnstable in the State of MA FIELD SURVEY CHARGES Field Survev #Poles Unit Rate Total Field Survey Application Fee I pole $139.00 $ 139.00 (includes 1st pole) Field Survey 2-200 Poles $ 13.45 per Pole $ Additional Travel Time* $200.00 per Day $ TOTAL Charges $$139.00 * Based on average of 75 poles surveyed per day,add$200.00 travel time for each additional day required to complete survey. Please note, if you calculated the cost incorrectly,your check will be returned and a new check for the correct amount must be received by this office in order to schedule the survey. If you need assistance,please call the HOTLINE on 800-340-9822. The required field survey covering Pole Attachment License Application# Barnsrablesc06MA-388902 is authorized.I am enclosing an advance payment in the amount of$ 139.00. Licensee's Name(Print)Barbara Kassabian Signature 13cwb- waXa Sabicaly Title Site Acquisition Address 16 Chestnut St, Suite 420,Foxboro,MA 02035 Tel.No. 603-303-8001 Date 11/2/15 Revised 03/06/2015 Eversource Energy FORM 3 Definitions SURVEYORS: Name of Representative attending Survey from VERIZON,EVERSOURCE,and Licensee Date of Survey: Date Survey is performed CWO#: EVERSOURCE Custom Work Order Number Munic: Municipality where pole is located State:State in which pole is located Licensee Name: Name of Company or Entity applying for Pole Attachments Exch Code:Verizon's Exchange Code=the Exchange in which the Municipality is located. Munic Code:EVERSOURCE Municipality Code=the code for the Municipality in which the pole is located(tax purposes). Application#:The number of the Licensee's Application=sequentially numbered by municipality. ELCO NAME:The name of the Electric(power)Company in whose service area the pole is located. Location: List each individual pole(ONE POLE PER LINE)you wish to attach to(multiple sheets may be used)and provide the following: Street,Route,Circuit#and other information which indicates location of poles. Indicate location by providing name of street,highway,route,etc.,e.g.,South Street, north of(N/O)Jones Road. Private Property Poles should be identified as such e.g.,P.P.(Lead off pole 1234 South). Pole#: Tel=Telephone Company pole# El=Electric Company pole# ATT: Type of Attachment:F=Fiber C=Copper or Coaxial P.S.=Power Supply Riser=Riser Pole Ownership: JO=Joint Owned 50%-50%Tel-Elco,JU=Joint Use- 100%Tel or100%Elco,FO=100%Fully owned by Tel or Elco(Other company not on pole) Charge: Y or N=Y=Yes,there are make ready charges,N=No,there are no make ready charges to the Applicant. Work Description: Short description of work operations required. Task#should also be included and is defined as the number of the task or tasks required for make ready work. The Task#is associated with a Unit Price from the ' "Make Ready Unit Price Schedule"located in Appendix 1 of the new Pole Attachment Agreement. Revised 03/06/2015 FORM 3—EVERSOURCE ITEMIZED Pole Make-Ready Work Charges PAGE OF RCE to Complete: Total Poles Surveyed Total Poles Requiring NSTAR Make-Ready Appendix IV Form 3 •�I$ ,�SURVEYf,'/�':r.�MAKE"READYWORK��ORM.- SURVEYORS: DATE OF SURVEY: CWO #: Verizon JU MC: Barnstable STATE: MA Exch Code: Munic Code: Licensee James Burgess LICENSEE NAME: Verizon Wireless LICENSEE APPLICATION#:BamstableSC06MA-388902 EVERSOURCE ELCO NAME:EVERSOURCE NSTAR APPLICATION # :i TION• ATT` i wt i' OWIITEIZS$IP' . :' wGE: LOCA. s. ,3... ,; aW;ORI{D'ESCRIPTI:O;N . TEL RTE/STREET NAME Tel El F/C J.O. J.U. I F. IYES NO TASK#S " Height List one pole per line P.S. Tel El Tel El Tel El REMARKS of Att. Rise r 1871-1881 Old Kings Highway N/A 737S i TOTALS: • Height of Attachment=Height of Licensee Attachment shall be 40"below ELCO MGN unless otherwise noted here by Verizon and EVERSOURCE surveyor. Revised 03/06/2015 • Licensee to complete bold italicized areas on Provide ownership irtformation if known I I Revised 03/06/2015 EVERSSURCE - Work Order Application FOR KEN KENDRICK: Customer Request In-Service Date:2ni16 WO Received Date: Service Address:Street: 1871-1881 Old Kings Highway Suite:_Town:Barnstable zip:02668 Customer Of Record., Customer Responsible for Payment of Monthly Electric Bills Name to appear on Monthly Bill:Verizon Wireless DBA—C/O Name: Billing Address: One Verizon Way, Mail Stop 4AW100, Basking Ridge, NJ 07920 Telephone: 508-320-2017 Tax ID Number: TBD Existing Account or Meter Number(if applicable): Property Owner Name (if different from above): Owner Address: Owner Phone Number: Party Responsible for Construction costs associated with work order(if different from above) Name:Verizon Wireless Address:400 Fribera Parkway,Westborough, MA 01581 Phone Number: 508-320-2017 Please Note that Articles of Incorporation are required for new commercial EVERSOURCE Customers Type of Service Requested: (Circle Appropriate) X New Service Service Upgrade Service Relocation Temporary Service Pole Relocation Disconnect/Reconnect Service Removal Metering Only OH Service from Pole, Pole#: UG Service from; Riser-Pole#: Padmount#: Customer Loading Brief Description of Work Attach (1) antenna, (1) RRH/Cabinet and (1) Type of Load New Connected Load in KVA meter to the pole. Will require 60 amp single Lighting le Sin Phase Three Phase phase service. Electric heat Air Conditioning Refrigeration Cooking Electric Dryer Water Heater Computer Process Equip. 14.4 Motors/Elevators Miscellaneous Totals 14.4 Number of Meters Required: Residential: Commercial: I Public: Main Switch Voltage: Amperage: Phase: Service Voltage: Amperage: Phase: Facility Type(ie: school, hospital): Telecommunications New Building Square Feet: ALL 480V SERVICES REQUIRE COLD SEQUENCE METERING(DISCONNECT SWITCH ON THE LINE SIDE OF THE METER If more than 1 meter is required, how will meters be labeled?(ie: Unit 1,2,etc, Unit A, B,etc.) i Additional Equipment: Generator: KW: Phase: Purpose: i Motor(S) : Total#: Largest HP: Phase: Locked Rotor AMP: Type of Starting Compensation(choose one): Hard Soft Capacitor VFD *See Article 802 of EVERSOURCE Information and Requirements Book for Maximum LR current and Three Phase Protection Contact Name (circle appropriate): Customer/Contractor/Consultant: James Burgess Street Address: 16 Chestnut Street, Suite 420 City, State, Zip: Foxboro, MA 02035 Telephone: 617-549-2800 Best Time to Call:Monday-Friday 9:00 a.m.to 5:00 p.m. Pager: Fax: Cell: Electrician: TBD License Number: Business Name:Verizon Wireless Street Address:400 Friberg Parkway City, State,Zip:Westborough. MA 01581 Telephone: 508-320-2017 Best Time to Call: Pager: Fax: Cell: Please note that by Interconnecting with the EVERSOURCE Distribution System the Customer of Record acknowledges that they have reviewed and are in compliance with the EVERSOURCE Information & Requirements for Electric Service(Blue Book). For New Commercial Services, New Residential Developments, New 13.8 kv Two Line Station Electric Service, please provide (2) copies of City/Town approved site plans that illustrates the new facility location and the proposed location of the new utilities(electric, gas,water, sewer,telecommunications)and a One-Line Diagram. For Service Increases at existing facilities, please submit a One-Line Diagram if available. For New Residential Services where a pole must be set, please provide(2)copies of a site plan that illustrates the proposed location of the new facilities. For Temporary Service Requests,please provide(2)copies of a site plan illustrating service location. You may Fax this Form or mail any additional correspondence to: EVERSOURCE ENERGY Electric and Gas One NSTAR Way Westwood, MA,02090 Tel: (781)441 —3851 Fax:(781)441-3194 Cell: 339-987-7059 H. Kendrick SW340 FOR NSTAR USE ONLY EVERSOURCE Revenue Allowance: EVERSOURCE Rate: KVA or KW rating of Existing Loads(if applicable): Existing Winter Peak Demand: Month/Date/Year: Existing Summer Peak Demand: Month/Date/Year: J EXISTIUD lRl'_'v=31,E 1 07,7 PROPOSEO L_rE ANf`N.0 Wf1T1 E>rR�NN C A� MOLNTEJ 10 EX.;.T I V�'i UfIUTY POLE FJO>Tiw6 UTILITY POLE)/ PROPOSED LESSEE rRM:: - ;/ t.A ED UNT TO EASING Un"JTY POLE ...`. o000 BARNSTABLE MA ao�o �71 0 y� Ira Fxwan H AN ANALYSIS OF THE CAPACITY OF ME E7OSTNO THIS LEASE PUN IS OUGAANNOIO N 11ATURE AND m STRUCTURE 70 SUPPORT THE PROPOSED LOADING IS TRENDED 70 FRONDE GENERAL NFORYRION _ HAS NTH am COMPLETED of HUDSON CESFRI RECAroac THE LD1'Amom AD SDE OF TW X CROUP.U.C.DRA1N1D5 ARE SUB=TO C1A14fE PROPOSED WIRELESS COM MUNTCAON FACEIri: THE W PENDING ME O OUTCOME OF A STRUCTURAL ANIL OUT YSM STTE LRI WILL BE PNNDFD UPD11 COMPLETION OF SIZE SURVEY AID FACLITY DES OML W APPRMaMXfE LAM. N41'41'489S Q COORDINATES: LONG IF7P 2Y 42_B8• W J Hudson O TOP aF PFOPOSI:D ANIEIOIA iva�cs+aa°mcxn amNwmP Br-N•x cmm) r FROPosm a wanwm.0 w�n� �►N tx PROPOSED ANIdNA PROPOSED LESSEE(1) 'SBCOMOOM POUTER aav ANrmu 1210 z 3RT1 FTOY UP 34•-V&(ANLI s(t+EEr PROPOSED S-0T1 FIBERGLASS ✓ TOP of ExiSnNO Lmlm POLE ExTv67DN PROPOSED SEDCDW POWER x - Bl'-O• (AMLSL) PROPOSED FM ACROSS STREET FF PROPOSED WEADIEAHFM n6Vr m ., Ba-0'x D(SnNO LMLItt POLE EXLMNO CLW WIRE PROPOSED 07375 PROPOSED FIBER FADY FBER FA0M1 LIP/7S7 ACROSS SHEET AgM55 SITiQf w PROPOSED FIBER ak PROPOSTD(1)1/2.OW 74'-lE•x N Y OOMDUR FROM RRH 10 ANTENNA ,1 PROPOSES ROS CO DUFT 10 METER- PROPOSED FIBER IN Exurm 1M.Ifv.PoiE memm Ern ,Dc APPROVED Br DPH I DUSTING CUY YIBRE ' .H PROPOSED FO'R DBMAIO OV .�'- SUBMITTALS FIBER PROVIDER O 1W AOL i PROPOSED_ PROPOSED ACroC CONVERTER EXISTING GUY YA 6 WEPan v (PRD11TM1AUL B/O01ATA) PROPOSED RIS CONDUrr PROPOSED LEASE (1)AMS RRN PROPOSED LESSEE BOA FUSEDv-DJ (CUBE-,SCtO41W94) PROPOSED SAR-O OtSDONXECT A SURGE ARRESIM PROPOSED IESSfE METER PROPOS D BRD7H' >mc wyCB SARNSTABLE MA SC06 5 TO LC >m mORM NUTIITY CO NY MPA iWEST IBA RN EST MA 028M REOUNtEM NTS 41 b - aAa rnlc GROAN EZDv.-o-ox c r sz'-o•t(AMLSL) ELEVATION & PHOTO PROPOSED CROU7D ROD sm■Aea CRAP1 1'�•Ya',r SCALE ELEVATIONY-f Cd 22c74 SCALE 3/ .1-0. L_2 EXISTING PHOTO DETAIL_�21 L-2 7LC7 SCALE 3/1e•-r-o• SCALE.TEES L-z I I CLIT FYIIINf �• j. THIS Mr m PLAN IS oIAGRABUM IN NATURE AND' AN ANALYSE OF THE CAPACITY OF THE D4SIN0 /L, m IS INTENDED TO PROYOE GENERAL WMM 4noN STRUCTURE TO SUPPORT THE PROPOSED LOADING r .f� S REGARDING TILE LOCATION AND SIZE OF THE HAS NOT BEEN COIPI£IEO BIT HUDSON or., d 1* K FROM PROPOSED WIRELESS C0MMUNICATION FACILITY. THE GROUP.LLC.DRAMNGS ARE SUBJECT TO CHANGE / SIPW SITE LAYOUT WILL DE FINALIZED UPON COMPLETION PENDING OUTCOME OF A STRUCTURAL ANALYSIS, OF SITE SURVEY AND FACILITY DESIGN. d W d' `PROPOSED F1.FROM UTILITY POLE rPOWER , J 37 ACROSSSTREET Hudson©O o.NJal golpueO pf6RNG UT_ �p POLE 1737S umor�m m \J' .1u00V14 waIW 40 11 M9fCNv NLMIIDML PROPOSED LESSEE(1) ANTENNA 12*Ntr3B.7 H WITH Fl8Q2L1AS5 l7lTDISION PROPOSED LESSEE (1)AWS RRH 155A' y g RRH DETAIL PLAN • p C 1'ti' r-0' N'o' . x 22+34 swE:3/4-1-0 12.0•0 11,17 SCALE PROPOSED ANTENNA — Comm fM: aK SECONDARY N APPROVED BY: DPN RDIM RA010 LEAD ) ANANi�u 12.0�o,,s 7 HIL Flees SUBMITTALS z FIBER GRO. BACAn e9t oDwml m :z SAR-0u . �a�j1�MNT-TOP1 BARNSTABLE MA MOUNTING KR AC SCO6 GO 1871-1881 OLD KIND'S HWY, COMIAMC-M T-75OOPIE EG WEST BARNSTABLE.MA 02688 MC-MUR-E1M OUNTING KITs=RE)AGME RADIO HEAD PROPOSED IEXTENSION EL LUCENT EQUIPMENT DETAILS •GI L AM., 2Y/Q1.8•HNH360OM—OG-2MN DIMENSIONS:120'0■3B7'H IDS WEIGHT:33.7 LBS 61Qi 1111mfR ANTENNA MOUNTING ANTENNA DETAIL ! + \ 700 REMOTE I D 2 IL 3 GENERAL WIRING DIAGRAM 5 SfJ1LE N.T.S L-3 SCALE:N.T.S L-3 SCALE N.T.S L-3 SCALE N.TS L-3 Product Specifications COMMSCOPE° POWERED BY TMORBW. CommScope-Proprietary and Confidential. Preliminary specifications are for illustrative purposes only and will be updated prior to publication. NH360QM DG2XR Andrew@ Dualband Quasi Omni Metro Cell Antenna,698-896 and 1695-2200 MHz, ! internal RETs with manual override,Internal diplexer and active GPS Li band antenna i i it Electrical Specifications Frequency Band,MHz 698-806 806-896 1695-1880 1850-1990 1920-2200 Gain,dBl 5.9 7.0 9.7 9.7 9.7 Beamwidth, Horizontal,degrees 360 360 360 360 360 Beamwidth,Vertical,degrees 28.2 25.4 11.6 10.9 10.3 Beam Tilt,degrees 0-20 0-20 0-14 0-14 0-14 USLS,d6 13 13 10 13 10 Isolation,dB 25 25 25 25 25 VSWR ( Return Loss,dB 1.5 1 14.0 1.5 1 14.0 1.5 1 14.0 1.5 1 14.0 1.5 1 14.0 PIM,3rd Order, 2 x 20 W,dBc -153 -153 -153 -153 -153 Input Power per Port,maximum, watts 125 125 125 125 125 Polarization t450 f450 1450 1450 f450 Impedance 50 ohm 50 ohm 50 ohm 50 ohm 50 ohm Electrical Specifications, BASTA* Frequency Band,MHz 698-806 806-896 1695-1880 1850-1990 1920-2200 Gain by all Beam Tilts,average,dBi 5.3 6.3 9.2 9.3 9.3 Gain by all Beam Tllts Tolerance,dB f1 f0.9 t0.6 f0.7 f0.7 0015.1 0016.6 0019.2 0a19.2 0. 19.1 Gain by Beam Tilt,average,dBi 10° 1 5.4 10- 1 6.5 7° 1 9.2 7" 1 9.6 7- 1 9.7 20- 15.3 20a 15.7 14019.3 14° 19.3 14- 19.2 Beamwidth,Vertical Tolerance,degrees f3.2 f2.3 10.7 ti +1.1 USLS,dB 14 13 12 12 12 t CommScope@ supports NGMN recommendations on Base Station Antenna Standards(BASTA).To learn more about the benefits of BASTA, download the whitepoper Time to Raise the Bar on BSAs. General Specifications Antenna Brand Andrew@ Antenna Type Metro Cell Band Multiband Brand DualPol@ Operating Frequency Band 1695-2200 MHz ( 698-896 MHz Internal GPS frequency band 1575.42 MHz Internal GPS VSWR 2.0 Performance Note Outdoor usage ©2015 CommScope,Inc.All rights reserved.All trademarks identified by @ or TM ore registered trademarks,respectively,of CommScope. page 1 of 2 All specifications ore subject to change without notice.See www.commswpe.com for the most current information.Revised:July 20,2015 July 20,2015 i I Product S pecifications cOMMSC( PE° NH360QM-DG2XR POWERED BY �Nnliriw. Mechanical Specifications Color Light gray GPS Connector Interface 4.1-9.5 DIN Female GPS Connector Quantity 1 Lightning Protection do Ground Radiator Material Aluminum I Low loss circuit board Radome Material ASA Reflector Material Aluminum RF Connector Interface 7-16 DIN Female RF Connector Location Bottom RF Connector Quantity,total 2 Wind Loading,maximum 225.0 N @ 150 km/h 50.6 Ibf @ 150 km/h Wind Speed, maximum 200.0 km/h 1 124.3 mph Dimensions Length 982.0 mm 1 38.7 in Outer Diameter 305.0 mm 1 12.0 in Net Weight 15.3 kg 1 33.7 lb Remote Electrical Tilt(RET) Information Input Voltage 10-30 Vdc Power Consumption, idle state, maximum 2.0 W Power Consumption, normal conditions, maximum 13.0 W - Protocol 3GPP/AISG 2.0(Multi-RET) RET Interface 8-pin DIN Male RET Interface,quantity 1 male Regulatory Compliance/Certifications Agency Classification RoHS 2011/65/EU Compliant by Exemption China RoHS S]/T 11364-2006 Above Maximum Concentration Value(MCV) ISO 9001:2008 Designed,manufactured and/or distributed under this quality management system i'_�v * Footnotes Performance Note Severe environmental conditions may degrade optimum performance @2015 CommScope,Inc.All rights reserved.All trademarks identified by @ or TM ore registered trademarks,respectively,of CommScope. page 2 of 2 All specifications ore subject to change without notice.See www.commscope.com for the most current information.Revised:July 20,2015 July 20,2015 "APPL'ICATION AND POLE ATTACHMENT LICENSE-FORM 1 Licensee VERIZON WIRELESS Agreement No. AMA140012 Pole Attachment License ANIA1400120703 Customer License Number BarnstableSC06MA-388902 State of MA IMunicipality IBARNSTABLE Type of Attachment Number of Attachments Billing Description Anchor 0 Antenna 1 MA CAE-ANTENNA-JO Cable/ADSS 0 Cable/Strand 0 Decorative 1 MA CAE-POWER METER-JO Drop 0 ERUV 0 Misc 1 MA-JOINT OWNED URBAN TELECOM Overlash 0 Power supply 1 1MA -PS URBAN TELECOM Riser 10 Total Attachments 4 Total Attachments Billable 4 Total Attachments-No Bill 0 Licensor's Name (Print) DEBORAH TOWN Signature Approved by DEBORAH TOWN on 01/29/2016 Date 01/29/2016 Title SUPERVISOR Phone 617-743-4511 EVERSSRCE One NSTARWay..NWBED0I 620 Westno6d,Massachusetts 6 90 ENERGY M G-1 R W Deiceimbeir 1.6,7015 Attentioni Rate and Municipal Permitting Authorities MAR 2 2 2017 PERMITS OFFICE Re:Initial Authoriz66oif for WAZOn Wir6tess to Attach to NSTAR.pqles To Whom It May Concern: Eversoure Efic d/b/a NSTAR Electric("NSTAR")is,aware that Verizon Wireless is in the process of permitting. 'forthp.installation of necessary telocoinifitinicat.ions equipmenfand"correspbindihigaerial fiber optic cable. ml Various.locations:on NSTAR owned poles throughout our service territory. As.part ofthe approvatprocess,we understand that-there.JR a requirement for NSTAR-to.revibW these l6cation$and provide the Towns with confinnafton of its approival inadvance of V rizon Wire.less's proposed attachment. Accordingly;NSTAR hereby sbbihits its initial ikuthoNzati�n for Veidion Wir.0less to:install its eq4ipmept on and coffesp6nding.aerial�lb-er,rouCe's io"N.S,TA,k.,pole's in the geographic lopations;as depicted ' ith plans subm—itted by Verizdn Wireless and on file with the.ToWat. The installations on NSTA.R.poles will be subject to the underlying terms and conditions of agreements by and betWiefiNSTAR and Wriz'o' n .. ; .eiffe ct from time: Wifolles%'.as the sate'!m n�.time to ime. be in .effect is anyt4irig further that I can pyov ide ypu with for your analysis;please do not.hesitate to contact meat 508-441-588.1. Sincerely, Steven M;Owens Supe't4y.1sor-Rlghts',Pdhbits&Public Works Eversource EnerZy,(NS;rkR, 13,leefri6) One NSTAR Way,NWBED180 Westwood;-MA 02090 Ph: (508)*441*-5881 F .(5,09)441--5842 MAR 2 2 H17 ij i �I<arCharles O.Baker, Governor MAILED 11!74ighway yn E.Po:iro.Lieu[eruant Governor Stephanie Pollack,Secretary&CEO 'Thomas J.Tinfin,Administrator , assachusetts Department of Transportation R� 8��2�ti7"" Division DISTRICT' 5 Permit#: 5-2017-0119 PERMIT—BARNSTABLE . Subject to all terms,conditions,and restrictions printed or written below,and on the reverse side hereof, permission is hereby granted to VE4 RtZON WIRELESS,Sean Conway, It 8 Flanders Road,Third Floor, Westborough,,MA 01581 and EVERSOUR.CE ENERGY,Steven Owens,40 Sylvan Road, Westwood,MA 02090 to enter upon State Highway in the Town of BARNSTABLE on Auto Route 6A, locally known as Main Street(Old Kings Highway), for the purpose of installing telecommunications equipment on an existing utility pole. The work will.be performed on existing Utility Pole 4737S,'located on the northerly side of Route 6A Main Street(Old Kings Highway),adjacent to the property located at 4187141881 Old Kings Highway,at approximate Station 190+00. Any telecommunications equipment that is being installed under this permit must be at least 9'(ft)vertically above the ground to ensure proper clearance for pedestrian and vehicle."safety and in accordance with MassDOT, Highway Division's Utility Accommodation Poliey;.as well as any State and Federal regulations. AIL work shall be done according to the National Electrical Safety Code. All,work, including the traffic management plan,shall be done as described herein and as shown on the attached plans entitled "Lease Exhibit"as drafted by Hudson Design Group,LLC, 1600 Osgood Street, Building 20 North,Suite 3090,North Andover, MA 01845,tcl.:(978)557-5553,and last revised February 3, 2017. Issuance of this Access Permit has been expedited at the request of the Grantee(s). Be advised that MassDOT, Highway Division reserves the right to ask the Grantees)to obtain additional agreements,as necessary,with MassDOTs Office of Real Estate and Development(DREAD). The Grantee(s)of the Permit,Cellco Partnership dba Verizon Wireless, is responsible to acquire all proper documentation(license agreement/approvaWothers)with the owner of the utility poles in order to install their telecommunications equipment on the poles. The following documentation is attached and is made an integral part of this Permit: Letter from Verizon Wireless designating Daniel D.Klasnick of Duval &Klasnick LLC as their agent, dated March 28,2016. Letter from Eversource Energy signed by Steven M.Owens,phone:(509)441-5881,giving authorization to Verizon Wireless to install equipment on their poles,dated December l6,.2015. *A Pole attachment agreement(Application#: BarnstableSC06MA-388902)between Verizon and Eversource Energy dated November 2,201.5. PRIOR TO ANY WORK BEING DONE V►qTHN THE STATE HIGHWAY LAYOUT,THE GRANTEE MUST CONTACT THE DISTRICT PERMIT ENGINEER AT(508)884-4306 TO OBTAIN APPROVAL FOR THE PROPOSED WORK SCHEDULE. DURING THE.DURATION OF THE PROJECT,THE GRANTEE MUST CONTINUE TO CONTACT THE DISTRICT PERMITS OFFICE,BY THE CLOSE OF BUSINESS OV THURSDAY OF EACH WEEK,TO REQUEST APPROVAL FOR THE FOLLOWING WEEK'S WORK SCHEDULE q r "FOLLOWING CONDITIONS APPLY TO PERMITS" Conditions Relating Particularly to Permits for the Laying of Pipes,Conduits,etc. Mier any pipes,conduits,drains or other underground structures are laid,or any excavation is made in the roadway,the trenches or openings shall be properly backfilled with suitable material,the back-filling shall be thoroughly tamped,and the surface of the road over said structures shall be left even with the adjoining ground. If the work is done in cold weather no frozen material shall be used for back-filling. Wherever the hardened surface of the roadway,gutters,or any part of the surface of the highway is disturbed it shall be replaced in as good condition as before it was disturbed,and if new materials are required they shall correspond with those already in place on the road. Where service pipes are to cross the highway the connections shall be made without.disturbing the hardened surface of the roadway,by driving the pipes under the roadway,or the service pipes shall be carved under and across the road in a larger pipe,unless otherwise ordered by the Director. The Grantee shall maintain the surface of the roadway over said structures as long as MassDOT may deem necessary,until all signs of the trenches shall have been eliminated. Conditions Relating Particularly to Permits for the Erection of Poles,Wires,and Overhead Structures,and the Cutting and Trimming of Trees In the erection of pole lines,unless otherwise herein provided,no trees located within the limits of the State Highway shall be cut or trimmed. No guy wires shall be attached to trees without a special permit from MassDOT,and in no event shall they be so attached as to girdle the trees or in any way interfere with their growth. The wires shall be so protected at all time and places that they shall not interfere with or injure the trees either inside or outside the location of the highway. Where the cutting or trimming of trees is authorized by this permit,only such cutting and trimming shall be done as may be designated by the Director. I In the construction or reconstruction of pole lines no guy wires shall be erected nearer to the surface of the ground than six feet;provided,however, that the owners of such lines may maintain such guy wires at a lower elevation than six feet from the ground until such time as MassDOT shall notify them to remove said wires or to the elevation first stated. In order to protect the trees through which any wires may pass,said wires shall be insulated and such other tree guards used as may be directed by the Director. Where high tension wires are erected under this permit,they shall be so located that,under conditions of maximum severity as regards a coating of ice or snow,there shall be a space of at least eight feet between such high tension wires and other wires. The Grantee shall,within sixty days from the date of completion of the work,file in the office of MassDOT a plan showing the location of each pole erected in accordance with the permit,said plan to be of such size and in such form as MassDOT may direct. General and Additional Conditions Whenever the word "MassDOT' is used herein it shall mean the Massachusetts Department of Transportation of the Commonwealth of Massachusetts. Whenever the word"Director"is used herein it shall mean the District Highway Director or other authorized representative of MassDOT. Whenever the word"Grantee"is used herein it shall mean the person or persons,corporation or municipality to whom this permit is granted,or their legal representatives. During the progress of the work all structures under ground and above ground shall be properly protected from damage or injury;such barriers shall be erected and maintained as may be necessary for the protection of the traveling public;the same shall be properly lighted at night;and the Grantee shall be responsible for the damages to persons or property due to or resulting from any work done under this permit. Except as herein authorized,no excavation shall be made or obstacle placed within the limits of the State highways in such a manner as to interfere unnecessarily with the travel over said road. If any grading of sidewalk work done under this permit interferes with the drainage of the State highway in any way,such catch basins and outlets shall be constructed as maybe necessary, in the opinion of the Director,to take proper care of such drainage. Wherever the hardened surface of the roadway is disturbed and the Director may consider it necessary or advisable to do so,said surface will be restored by the employees of MassDOT,at such time as MassDOT may direct,and the expense thereof shall be bome by the Grantee,who shall purchase and deliver on the road the materials necessary for said work if and when directed by the Director. All payments to the supplier and to laborers, inspectors,etc.,employed by MassDOT for or on account of the work herein contemplated shall be made by said Grantee forthwith on receipt of written orders,pay rolls,or vouchers approved by MassDOT. IF THE GRANTEE DOES ANY WORK CONTRARY TO THE ORDERS OF THE DIRECTOR,AND,AFTER DUE NOTICE, FAILS TO CORRECT SUCH WORK OR TO REMOVE STRUCTURES OR MATERIALS ORDERED TO BE REMOVED,OR FAILS TO COMPLETE WITHIN THE SPECIFIED TIME THE WORK AUTHORIZED BY THIS PERMIT, MASSDOT MAY, WITH OR WITHOUT NOTICE, CORRECT OR COMPLETE SUCH WORK IN WHOLE OR IN PART, OR REMOVE SUCH STRUCTURES OR MATERIALS,AND THE GRANTEE SHALL REIMBURSE MASSDOT FOR ANY EXPENSE INCURRED IN CORRECTING AND/OR COMPLETING THE WORK OR REMOVING THE STRUCTURES OR MATERIALS. ALL OF THE WORK HEREIN CONTEMPLATED SHALL BE DONE UNDER THE SUPERVISION AND TO THE SATISFACTION OF THE MASSACHUSETTS DEPARTMENT OF TRANSPORTATION,AND THE ENTIRE EXPENSE THEREOF SHALL BE BORNE BY THE GRANTEE. On the completion of the work herein contemplated all rubbish and debris shall be removed and the roadway and roadsides shall be left neat and presentable and satisfactory to the Director. MassDOT hereby reserves the right to order the change of location or the removal of any structure or structures authorized by this permit at any time,said change or removal to be made by and at the expense of the Grantee or its/their successors or assigns. This permit may be modified or revoked at any time by MassDOT without rendering said MassDOT or the Commonwealth of Massachusetts liable in any way. The Grantee shall pay the salary, subsistence and travel expenses of any inspector appointed by MassDOT to supervise the work herein contemplated. All of the above conditions shall be applicable to the work herein authorized,unless the same are inconsistent with the conditions on the face of the permit,in which case the conditions written or printed on the face of the permit shall apply. The acceptance of this permit or the doing of any work thereunder shall constitute an agreement by the Grantee to comply with all of the conditions and restrictions printed or written herein. I VERIZON WIRELESS& -2- 5-2017-0120 EVERSOURCE ENERGY(Cont.) The Grantee(s)shall be responsible for all litter and debris generated from their property during the work as described herein and/or from all prospective residents,visitors or patrons of all existing or proposed facilities mentioned herein. This responsibility shall remain in effect for the entirety of all current or future owners of said property. The Grantee(s)shall perform routine inspections and upkeep within the State Highway Layout. If conditions warrant an individual to enter in or within the proximity of a travelled way,the Grantee(s)shall assume all liability and responsibility for the removal of all litter and debris or the hiring of an appropriate party to perform such duties. Significant work within the travelled way may require a police detail. In consideration to all abutters,the Grantee(s)must take notice to the drifting of debris and the removal thereof. If it is'found that this requirement is not being fulfilled in a satisfactory manner,MassDOT, Highway Division may decide to clean the area at the Grantee's expense. TIME RESTRICTIONS AND NOTIFICATIONS DUE TO HEAVY SUMNMR TRAFFIC,NO WORK SHALL BE PERFORMED ON THIS PROJECT BETWEEN MEMORIAL DAY WEEKEND AND LABOR DAY WEEKEND WITHOUT PRIOR APPROVAL FROM THE DISTRICT HIGHWAY DIRECTOR. No work shall be performed in the hardened surface of the roadway between November 15th and April 1 st of any year without prior written approval from the District Highway Director. Special attention shall be given when performing work that will impact MassDOT,Highway Division,snow and ice operations. No work shall be performed on this project on Saturdays, Sundays,and Holidays,or on the Friday after a Thursday Holiday. Work is also restricted on the day before and the day after a long Holiday weekend without prior written approval by the District Highway Director. No equipment,trucks,etc.,shall occupy any part of the travelled way except between the hours of 9:00 a.m. and 3:00 p.m.,Monday-Friday. In no case will operations exceed the specified hours. This includes the placement of traffic control devices,equipment,or anything that restricts the flow of traffic through the construction zone. Any change in work hours will require prior written approval by the District Highway Director. The 12.minute rule will remain in effect for the duration of the permit. GENERAL TRAFFIC MANAGEMENT AND SAFETY REQUIREMENTS If applicable,any and all variable message boards(VMBs)utilized as part of the approved traffic in plan under this permit must be properly secured with regards to hacking and unauthorized tampering prevention. The Grantee(s)shall adhere to all appropriate security specifications,and take all necessary precautions to mitigate the risk of the boards being hacked. All VMBs shall be stored in a secured area and shall have a lockable,weatherproof enclosure for the operator interface,removable local keyboards which shall be removed whenever possible,and a password protected controller with local administrative passwords changed on a regular basis. When any portion of the roadway will be blocked with equipment to facilitate the proposed work,the Grantee(s)will be required to adhere to the attached Traffic Management Plan(TMP)or submit a proposed TMP to MassDOT,Highway Division,to be reviewed and approved by the District Traffic Maintenance Engineer prior to working within or impacting the roadway. The plan must include information relating to proper signing,traffic control device placement and police details. o, ' ♦ r VERIZON WIRELESS& -3- 5-2017-0120 EVERSOURCE ENERGY(Cont.) It is imperative to maintain two-way traffic at all times(where applicable)and these operations are managed so that motorists travel"delay" is minimized. At any time during the operation when a traffic delay of over twelve(12)minutes occurs and the situation is worsening,the Resident Engineer,Contractor,or Police j Detail will begin to suspend operations. Continuously increasing"delays" of over twelve(12)minutes are not to be permitted. If traffic must be"stopped",the duration shall not be more than five(5)minutes. Uniformed State/Local Police Officer(s)and their official vehicle(s)shall be present and utilized to provide protection for those installing and removing all temporary traffic warning signs and devices and to perform all traffic management as required. The Grantee(s)will monitor the flow of traffic during peak traffic volumes and if necessary,shall suspend all operations. Work will resume at the discretion of the Police detail officer and/or to the satisfaction of the supervising MassDOT,Highway Division Engineer. In the event of inclement weather or dense fog,which lessens the visibility of advanced warning signs, vehicles and workers,the Grantee(s)will suspend all operations so as not to interfere with the safety of the motoring public and the operations of work. In the event of snow or icing conditions,all vehicles and equipment must be removed from the roadway and/or shoulder area so as not to interfere with Snow and Ice Operations. The Grantee(s) shall provide safe and ready means of access and egress to all public and private roads and drives 24 hours per day. Every effort must be made as not to interfere with or inconvenience all abutters throughout the duration of this project. Signs and traffic control devices are required for advanced noticed of the work and within the work area. The Grantee(s)or Applicant will supply all required signs and traffic warning devices and shall be in accordance with the Massachusetts Manual on Uniform Traffic Control Devices. The number and location of all signs and devices shall be as deemed necessary by the Engineer for the safe and efficient performance of the work and the safety of the travelling public. All warning devices shall be subject to removal,replacement,and/or repositioning by the applicant as often as deemed necessary by the Engineer. Cones or non-reflectorized warning devices shall not be left in operating position on the highway when the daytime operations have ceased. If it becomes necessary for MassDOT,Highway Division,to remove the construction warning devices or their appurtenances from the project due to negligence by the applicant,all costs for this work will be charged to the Grantee(s). All vehicles,except passenger cars,which are assigned to the permitted project and which operate on the site at speeds of 25 MPH or less,shall have an official SLOW MOVING VEHICLE emblem displayed. All vehicles and equipment on this project must be equipped with back-up alarms. All personnel who are working on the travelled way or breakdown lanes shall wear approved safety vests and hard hats. i VERIZON WIRELESS& -4- 5-2017-0120 EVERSOURCE ENERGY(Cont.) GENERAL CONDITIONS AND APPROVED PROCEDURES Unless otherwise stated,no hardened surface of the State Highway may be disturbed. If the integrity of any existing sidewalks,catch basins,manholes or any other underground structures or equipment is compromised,the Grantee(s)will reconstruct and/or replace all items according to MassDOT, Highway Division,Standards at the cost of the Grantee(s)and to the satisfaction of the Engineer. The Grantee(s)must not disturb or remove any MassDOT,Highway Division,Bound(s)(MHB)associated with this project. If so disturbed or missing,the bound(s)must be reset/replaced by a Registered Land Surveyor: All procedures and materials must be in compliance with Massachusetts Design and Construction Standards. A copy of the paid bill must be submitted to this office upon completion of said work. All traffic safety lines if disturbed shall be replaced in kind. All disturbed areas within the State Highway Layout must be graded,loamed,and seeded to the Engineer's satisfaction. All debris and litter remaining from the proposed construction shall be removed by the Grantee(s)and the area left clean daily. ENVIRONMENTAL LIABILITY AND COMPLIANCE The Grantees)assumes all risk associated with any environmental condition within the subject property and shall be solely responsible for all costs associated with evaluating,assessing,and remediating, in accordance with all applicable laws,any environmental contamination(1)discovered during Grantee's work or activities under this Permit to the extent such evaluation,assessment or remediation is required for Grantee's work,or (2)resulting from the Grantee's work or activities under this Permit. The Grantee(s)shall notify MassDOT, Highway Division of any such assessment and remediation activities. The Grantee(s)is hereby held solely responsible for obtaining and maintaining any and all environmental compliance permits required by local,state,and federal laws and regulations when regular or emergency work is proposed within,or in close proximity to,any wetland area. These environmental compliance requirements include,but are not limited to,a Negative Determination of Applicability or Order of Conditions from the local Conservation Commission,a Water Quality Certificate from the Department of Environmental Protection,and a Programmatic General Permit from the U.S.Army Corps of Engineers. The Grantee(s)shall forward to MassDOT,Highway Division a copy of each such environmental compliance permit. CLOSING CONDITIONS ALL OF SAID WORK SHALL COMPLY WITH THE TERMS AND CONDITIONS HEREIN,AND MUST BE DONE AS DIRECTED BY AND TO THE SATISFACTION.OF THE ENGINEER. All work done under this contract shall be in conformance with the Massachusetts Highway Department "Standard Specifications for Highways and Bridges"dated 1988 and the"Supplemental Specifications to the Standard Specifications for Highways and Bridges"dated July 1,2015. All construction shall conform to the December 2016 edition of the Massachusetts Department of Transportation,Highway Division "Construction Standard Details(English Edition)";the latest Manual on Uniform Traffic Control Devices with Massachusetts Amendments;the latest edition to the following:the 1996 Construction and Traffic Standard Details(as related to Traffic Standard details only);the 1990 Standard Drawings for Traffic Signs VERIZON WIRELESS& ' -5- 5-2017-0120 E,VERSOURCE ENERGY(Cont.) and Supports;the 1968 Standard Drawings for Traffic Signals and Highway Lighting;the latest edition of American.Standard for Nursery Stock;the Plans and these Special Provisions. The Grantee(s)shall indemnify and save hariuless the Commonwealth and MassDOT,Highway Division agauist,all suits,claims or liability oi'eV er ,name and nature arising at the-time out of or in consequence'of the acts of the Grantee(s)in the performance of the work covered by this Permit and/or failure to comply with the terms and conditions of this Permit whether by themselves or their employees or subcontractors. THE GRANTEE(S)SHALL CONTACT TBE,PERNIMTS SECTION AT(508)8844306 WHEN THE WORK REQUIRED UNDER THIS PERMIT HAS.BEEN COMPLETED KORDER FOR A FINAL INSPECTION TO BE-PERFORMED BY MASSDOT,I-HGI RVAY DIVISION. A COPY OF THIS"PERNIIT MUST BE ON THE JOB SITE AT ALL TIMESTQR INSPECTION. FAILURE TO HAVE THIS PERMIT AVAILABLE AT THE SITE WILL RESULT IN SUSPENSION OF - THE RIGHTS.GRANTED BY THE PER1441T. No work shall be done under this Fermit until the Grantee has communicated with and received 'instructions from MassDOT,High way re' or at 100.0 County Street, Taunton;MA.02780. .The Permit shall be void unless the work herein contemplated.shall have been completed before APRIL 6,2018. Dated-at TAUNTON this.6TH day,orAPRIL,2017. MassDOT-Highway,D ivision, Ayl Mary- " '!Perry District Highway tor. F J `fsjJ ce:Foreman MasrsDQT-ligh►vay,Division—District S•1000 County Street Tatmton,JW 02780 (508)824-6633 W20-7 or W20- BUFFER . W20-4 100FT 1 OOF7 W13'-1 p (30m) WORK' 100-15OFT (30rra) MAX. .ZONE, 30-45V MAX, A g f r B A - •OFFICAt�: �p ONE LhNE' W20-7b or W20-7 W20-4 W13-1 . Ao=bL T Standard FIGURE TLR-5 or Details and Drawings ue TWO LANE ROAD ' &SAUAChusenz De for me pRrmoenrat TrAnypartaUor+ 'ONE.LAN E;ALTERNATI NG TRAFFIC Highway'Dtvislon Development of TemporaryTrefiic.CoMrol Plans NOT TO.SCALE r I ' MAR 2 2 2017 p� ,iT' assDOT Missethvt�tu orpanirn rnt o r Trnirsp of(Acton �} rfighviw iy Olvisian � RMITS OFFICE Application Permit fik'4ae"Perm/tAppllcat102lncludirtg the8trachesdAcicearPermltSabr la&M/RmuacDecomlpleted#2Wbyffic, pJlcant kx0rut&OmforM&paye&elocaledonp.%M2 and t+edcet eeelrrLQcaard onMe 1. MasxDOT tmfllmaiYe the llnal dl rrnlnttro»irgaMHrgAcLrrsPFnmRApp!/catlgntype ertd ahegay= s 1 Town/City.Town/Clty. West 8ametabte,MA t. State Highway route number and/or name: Route BA(Old Ifts Highway) " WARh I✓I 3. Locus/PropertyAddress: Adjacent 1871-1881 Old King's Highway(Route 8A),West Barnstable,MA 4. Description of property and/or fadilry for which access Is sought(attach additional sheets if necessary): . . Utility pole#737S located within the state highway layout for Route BA,West Barnstable,4A 5, Description of work to be performed vtrlihin State Highway Layout(attach additional sheets if necessary: Proposed Wireless Antenna and.Remote Radio Head wth cabling and fiber oonneellonmounted to existing utility pole. Please we attached plans. i? Telecommunications(wireless or wlreflnel of Renewable Energy(Solis,Wind etc)-Agreement Process and OREAD* coordination required 111see pg 2Instruction) 6. Dig Safe number. Not Applicable 7. Applicant Information I(See footnote below.) S. Properly Owner Name Cellco Pertnership-dlb/a Verizon Wireless Name Eversource Energy Mailing Address 118 Flanders Road,Third Floor Mailing address 40 Sylvan Road Westborough,MA 01681 Westwood,MA 02090 Telephone (761)673-0021 Telephone 608-40-5881 Fax Fax 608-441-5842 &Map E-mail 8teven.triligns ev4ii6Urce. M Signature Signature . Print Name 3eati ConiNey.° Print Name Steven.* 40S Date fL f 114 Date Renurrrc�wrnpkYed�itarsat;btM�aOotgst�durNs��clmntltrtronc�nfsirkthvyhwayorecrarlbryo�vrowryr/(yc IPefrrrol�vie.,'dervr�uadaar� Four o/f�fice use only. Do not write below this litre. 90 I. Appilcadon number: 5- - 6 H 6, Section 61 Finding date: 2. Date recelved I 1 7. Mass.Historic Action(yes or no):; 3. Fee amount(non-refundable): e. Plans returned to DHD: 4. Completeness Pre-Review date; 9. Permit Type/Category., S. MEPA requfred(yes or no): 10L Applketlon complete date: ENFEOEEA Cert tY t i. Permit written dace: Aftft EIR•EOEEA Cent,N 12. Permit issued date: Other-EOEEA Cert. 13. Permit denled 1 14. Permit Recording date at Registry of Deeds r If an Is representing an AppKcant the applcmion must tnitude a notarized better from the Appicant outl�ing the spedtted Buttes and responslblittes of the agent Where vrork Is proposed oo"a LdIty.the utility deWment mist sign the application as theApplkwtlsl. l Page i of 6 l LSLGs_Lj;. T Llnstructions forltComplt'iting) Apphcaton�for Pe rmitao�Access;State"Highway j MAR2 2 17 General instructions PERMITS OFFICE MassDOT's Highway Division is granted authority.to Issue State FEES: Highway Access Permits by M.G.L.Chapter 131.:Sec,2I.MassDOT A Check payable to MassDOT for the appropriate .adopted 720 CMR 13.00 under the authority of M,G.L c 81. permit application fee mustaccompany the permit. §21 and M,G.11 c,85§2. 720 CMR 13.00 supersedes the application. Fees are non-refundable, Standard Operating Procedures for Review of State Highway Access Permits dated November 30,1971,and board vote of Fee schedule for access and UtilltyPayrnents: September 17, 1991. Residential Access Permits ACCESSIsgeneiW4rdefined,butnor#m/ted1o.• 5 Units orless .............................:............. $25.60 Any physical Work performed within the State Highway Layout. From 6 to 49 Units ................................. S 1 o0.0o Greater than 49Links. ............................ S2000.00 This Application governs issuance of the two types of access Non-Residential Access Permits permit Applications,Norl-Vehicular and Vehicular,which are Less than 25,000 square feet ..................... 5500,00 lssued.under three categories: From 25,000 to 300,000 square feet ......„.— $1006.00 From 300,000 to 750,000square feet ......... S2000.00 Category.l Minor VehlcleAccess Permits Greater than 750,600 square feet ............... S3000.00 Category II Major VehlcularAccess Permits Category III Complex Vehicular Access Permits NomMunidpal Utility Permits not in conjunction With Access Perm6: Please refer to the Mass DOT Highway Access Permlt.Sub mittal -Checklist for details regarding permit types Annual blanket utility permit ...,.................... $500.00 and submittals required. Capital improvements to a utility $500.00 Specific Instructions(p�intor type} Line 1: Line 7: List name of municipality in which access is sought. Individual or business making application must complete Line 2. the required information,Including application'date and signafure. List name or number of State Highway Route(s)to which access Issought. Line 8: Line 3: Complete this section only P the individual or business List LocuVProperty address. making application 1s other than the property,owner of Line 4: the land for which the permit applies. Describe property and/or facility. If access.is sought under Category II above,,brteflydescribe facility for which access- Is sought, Return completed application,submittal checldist and fee'tso appropriate Dlstrictoff ce ilsted befow. Please Ekzmpk C Private single family resideme at 100 State Road contact the Permit-Engineer at this address If AppioXimate size of proposed bullding,4, 00&f.Approximate lot additional information Is required. she 0.75 acre. E7rartrplt 2-5 X0 00 sfi enclosed shopping mall adjacent to '0istrictOne District F.aLir Ram Rovte 1.290 and Route20.,Approx:lorsize'67 acres 270 Maln Street 5 19 Appleton Street Lenox,MA 01240 Arlington,MA 02 t 74 Line 5: Tel. 14131637-57M Tel 1781)641-8300 Briefly describe the proposed work to be performed, Fax.14131637-0309 Fax.1781),640.51 15 within the State Highway Layout. 'Office oP Real Estate and Development(OREADJ 01strict Two District Five Example f:Remove 50 feet of ex$Hng granite cure 06 south side of $]'i North King Street 1000 County Street hl9hvcyInorocrtocorsthxrddvewayaccets and modg(thee Northampton,MA01060 Taunton.NSA 02780 riiadwaygeometryto accommodate ieltFianacum, Tel. (413)582-0599. Tel 1508)824-6633 Eramplel•:Excavate 10footx l0fooj". 10norroadvreyat Fax:1413)5824596 Fax.1508)880-6102 station I00+00 in westbound lane in order to Instal I water service to res(dence at l0o stare street. Distriot Three District Six; 403 Belrr ont Street 18$Kneeland Street Line 6: Worcester,MA 01604 Boston,MA 02111 A Dlg Safe number must be provided if the work will commence Tel.'1508)929-3800 Tel. (8571368-6100 urithin,30 days of the filing,of the permit. NOTE:A Dig Safe Fax.115061 799.9763 Fax.(857)368.0106 number must be obtained by tailing 1-888-DIG-SAFE (1-898.344-72331. If construction within the State Highway Division Website: Highway Layout does norcommence within the period allowed by Dig Safe•a new number must be obtained wwjv.massdoLstate.rna.us/highway .prior to beginning construction.(vrww.dlgra�.fe ccml onaAoor oa.t l Page 2 of 6 �� OT Mir 2 2 z017 Matrachuroetr Dopsrtmcrrt of fYarisporeatlon Highway Division PERMITS OFFICE Access Permit Submiffal Checklist i GREY: OCT USE_ This checklist provides the Applicant with a list of required submittals to obtain-an Access Permit However,additional submittals may be ONLY required to Issue an Access Permit.Ali Applicants.must fili out Part and one additional part that correlates to the selected application type. To help Identify the application type,please seethe descriptions on page 6. Check each.box that pertains to your applicadon. MassDOT will make the final determination regarding Access Permit Application type and category. PARTrA, ''ALL APPL16ANTSiMUSTrFILL,OUT 1. APPLICATION TYPE CHECK ONE ❑ NON-VEHICULAR: M Nan Vehicular-Fill out Part B ❑ VEHICULAR l❑ ❑ Category I-Minor Vehicle Access Permits: Fill out Bart C-1 1❑ ElCategory II-Major Vehicle Access Permits: Fill out.Part C=1 and Part C-II ;❑ ❑ Category 111-Complex Vehicle Access.Permits: Fill out Part C-1 and Part Gill 2.APPLICATION TYPE(Check all applicable boxes) ❑' ❑ Application Complete ( ❑ Permit corresponds,toappropriateMassDOTDistrict )Q' ❑ Non-refundable check or money order on correct amount payable to:MassDOT ❑ Evidence certifying property owner(s)consent �0; ❑ Notarized Applicant Letter outlining agehes;duties and responsibilities(if applicable) 1, , ❑ Utility department sign-off as the Applicants)(if applicable) PART"B• NON:`wW UL'ARZPERMI,TSt ❑ IF NO PHYSICAL MODIFICATION to state highwwylayrwt-le parade•roadrace Ira iccount�etc iWalredsubm/tta/x pd Q Map of route ' ❑ Traffic Management Plan(designed in accordance:with the Road Flag der&Police.Regulations:701 CfAR 7.001 ❑ Detour Plan(s)with municipal approval(if-applicable) ❑ IF DRAINAGE. m❑} ❑ If requesting connection or discharge to..anyMassDOT drainage:system,contact District Personnel for additional information regarding required submittals. IF CONSTRUCTION,RELOCATION OR REPAIR OF UTILITIES: Requlnedsubml ❑ EXISTING PROJECT: reference(sj to the documents and plans already filed with MassDOT for the affected project ❑■ kW PROJECT/U rIL(TY WORK, Requ/redsubmittals• Q. M Engineered Plans)including method of crossing Highway 0; ❑ Traffic Management Plan(if applicable) (Designed In accordance with the Road Flagger&Porice Regulations:701 CMR 7.00) ❑ Detour Plans)Wth municipal approval(If applicable) Q, ❑ Tree Cutting or Landscaping Plan(If applicable) 'Vegetative Plan Including plant species and maturity size(if applicable) ❑; ❑ Blasting Plan(contact District Personnel for additional information) MassDOTrevO4.11 Page 3 of 6 ate, PART C-1:`VEHICUL:AR PERMITS' h 1OFFICE USEUONLY CATEGORY I — Minor Vehicular Access Permits MARRequiredsubmittals.'0 ❑ Engineering PlansU, ❑ ENF-(Environmental Notification Form)Certificate(if applicable) PEFit I IF RESIDENTIAL DRIVEWAY: ❑ ❑ Detailed plan/sketch showing the drive location in relation to the property lines.MassDOT baselines, i distance from nearest mile marker,and an easily identifiable fixed object(distance from telephone poles, mail boxes,other drives,etc.). jQ' ❑ If severe topographic conditions exist,an engineered plan showing the driveway layout,profile and storm water management may be.necessary to show that the edge of the proposed drive is protected during and after construction to prevent sediment and debris from entering upon the State Highway layout(SHLO). IF COMMERCIAL DRIVEWAY: (where no MEPA review is required♦ Required submittals. �. ❑ Two(2)40 state plats that Include. ❑; ❑ A. Route Number,Road Name,Property Address ❑ ❑ B. Property Corners and Bounds ❑: ❑ C. Lot Line Dimensions,Bearings and Distances ❑; ❑ D. State Highway Layout lines(both sides)and Nearest Massachusetts Highway Bounds(If found). 0 ❑ E. State Hlghynay Baseline and both edges of roadway including any sidewalks and type of edging,if any, and shoulder information(grass;gravel etc). [], ❑ F. Any existing drive to be altered or closed shall be indicated. Existing and proposed dimensions should be included for altered drives. ❑ G. Information on all proposed drives including.radii,widths,handicap ramps,etc.must be shown: ❑ H. Alf existing and proposed buildings,utilities,trees,stonewalls,fences etc.,should be labeled and shown in their correct location. ❑ I. it is required ihat all stands.buildings,gasoline pumps and structures of any kind be placed at least 12 feet back from the State Highway Layout Line since conducting of business within a State Highway Layout is forbidden. ❑ ❑ J. Complete detail on drainage,all drives should be constructed on a downgrade from the edge of the highway surface or moulder to the State HighwayLayout Line. ❑, ❑ K. Engineered plans will be required to show that storm flows are not directed into the SHLO.using contour lines,where applicanyownerproperty elevations are raised from the edge of the highway. ❑' ❑ L The.plansshould identify measures to protect the edge of the:proposed drive during and after construction to prevent sediment and debris from entering upon the SHLO. IF NEW STREET/SUBDIVISION ROAD: Minor Intersection and Roadway Reconstrudion(where no M EPA review is required) Requiredsubm/tta& ❑1 ❑ All"Commercial Driveway requirements(above)apply Irf addition to the following: Evidence of acceptance.including its line,grade and proposed drainage,by a local planning board,or other City of Town official wkh such authority. [� ❑ A street/roadprofile from Its nearest high point.and plan of drainage. Please beadvisea- • It vvili be required that all such future street approaches be constructed on a downgrade-where possible, from the edge of highway surface or shoulder to the State Highway layout Line. • Common driveway criteria may apply and must be shown on plans as mentioned above. N.zssDOTrc+04.i i Page 4 of 6 ate: PART C=11: VEHfCUI-AR`PERMITS 1 DOT - — - - —USE ONLY CATEGORY 11 —Major Vehicular Access Permits Requlredsubm/tra/s- ❑, ❑ Engineering Plans.based on the standards in the Manual On Uniform Traffic Control Devices(MUTCD), MassDOTS Project Development&Design Guide or its successor,MassDOFs Standard Specifications for Highimay and Bridges,and any current technical policies or engineering directives Issued by MassDOT. All PS&E design submissions must be both In hard copy(one set)and electronic format. Electronic format includes PDF files transmitted to DHD or designee via USB Flash Drive, CD or posted to a FTP site. �`, ❑ In cases where a proposed access is to be shared by multiple development sites,theApplicant(s) will provide evidence of the rights of access between the parties Involved prior to the issuance of the Access Permit. LQd❑' ❑ MEPA Certificate - p _ (], ❑ Section 61 Finding MAR 2 2 2017 C 1, PERMITS OFFICE CATEGORY Ill — Complex'Vehicular Permits RequfiedsubInlMls, ❑. ❑ tngineering Plans based on the standards in the Manual On Uniform Traffic Control Devices(MUTCD), MassDOT"S Project Development&Design Guide or its successor,MassDOTs Standard Specifications for Highway and Bridges,and anycurrent technical.policies or engineering directives Issued by MassDOT. All PS&E design submissions must be both in hard copy(one set)and electronic format. Electronic format includes PDF files transmitted to DHD'or designee via USB Flash Drive, CD or posted to a FTP site. ❑ in cases where a proposed access is.to be shared by multiple development sites,the Applicant(s) will provide eyidenc_e of the rights of access between the parties involved prior to the issuance cf the access Permit. ❑ ❑ jMEPA Certificate. E] ❑ Section 61 Finding Recording o(Access Permits Applicants must,record,any,WhicuJar Access Permit and;phns:or.any Non7VehicularAccess; Permit and,plans involvirig;drainage at the.aRpropriate fte9istry of Deeds Any'Permit tsst red by:. MassDOT chat requires recordingAwilI not be effective until recorded at th&appropriate.Registry of Deeds andFatnogce of recording is sUbixtitted to theDistrict Highway Director(DHD).Changes, may require the re-,6 cordng of permitsan,,d'related,documents.-ln'those cases,.permits`will riot be,effective,until'fie-recorded,atthe'RegistT,y gf,geeds and a nonce of recording,is;submltted to,. the _HD. tilassoQTra:•04.++ Page 5 of 6 THERE ARE TWO TYPES OF ACCESS PERMIT APPLICATIONS: MAR 22 2p17 VEHICULAR, ISSUED UNDER THREE CATEGORIES&NON-VEHICULAR 1. VEHICULAR ACCES$'PERMITS: _ PERMITS OFFICE Category I—Minor Vehicular Access Permits: Access Permits for Projects that require entry to the State Highway Layout(SHLO),require little to no non-signalized modifications,and do not significantly alter the operating characteristics of traffic, These Projects ordinarily do not exceed the Massachusetts Environmental Policy Act(MEPA)transportation thresholds beyond the filing of an Environmental Notification Form(ENF). Category 11-Major Vehicular Access Permits: Access Permits for Projects that require significant non-signalized modifications that may alter the operating characteristics of traffic at residential or commercial driveway intersecting with the SHLO;that require significant non-signalized modifications that may alter the operating characteristics of traffic at or upon any other intersection or roadway under the jurisdiction of MassDOT,- that require the installation of a new traffic signal at a residential or commercial driveway Intersecting with the SHLO or at any other intersection or roadway under the jurisdiction of MassOOT;or that require modification of structures,equipment or hardware at an existing traffic signal at a residential or commercial driveway and its intersection with the SHLO or at any other intersection or roadway under the jurisdiction of MassDOT. Category III—Complex Vehicular Permits Access Permits for Complex Projects requiring actions similar to major Projects,but which require a new or altered SHLO;that require significant non-slgnalized and/or signalized modification within the SHLO over an extended distance or at a number of intersections that significantly alters the operating characteristics of traffic along a corridor,or that require the construction of a new,or modifications to an existing,bridge. These Projects generally require MEPA review and may require Federal review. 2. !NON-VEHICULAR-ACCESS PERMITS: Access Permits for Projects that require access to the SHLO that do not involve physical modifications such as a parade or road race;construction,relocation or repair of utilities within the SHLO;tree cutting or landscaping within the SHLO;the use of explosives to remove material from within 250 feet of the SHLO;or connection to or discharge to any MassOOT drainage system (in cases�nrhere it can be shown that no practical alternative exists). CONDITIONS REOUIRING AN ACCESS PERMIT Vehicular Access Permits are required for: • New residential or commercial driveways or streets Intersecting the SHLO;.or, • Physical modifications to existing residential or commercial driveways or streets at their intersection with the SHLO;or, • Change in use of an existing residential or commercial driveway onto SHLO that results In a Substantial Increase in or Impact on Traffic(as defined below)over the current use;or • Construction of new or change in use of existing,residential or commercial driveway from properties that abut the SHLO to serve a building or facility,or expansion of a building or facility,that generates a Substantial Increase in or impact on Traffic: Substantial Increase In,or Impact on,Traffic as referenced above Is defined as: A Project that meets or exceeds any of the following thresholds: (il Generation of 2,000 or more new ADT on roadways providing access to a single location;or, (ii) Generation of 1,000 or more new ADT on roadways providing access to a single location and construction of 150 or more new parking spaces at a single location:or, (ill) Construction of 300 or more new parking spaces at a single location;or IN) Creation of a change in the type,pattern,or timing of traffic that is determined by MassDOT to generate a significant Impact on traffic flow and safety. Non-vehicular Access Permits are required for. • Access to the SHLO for Projects that do not Involve physical modifcations:or • Connection to or discharge to any MassDOT drainage system(in cases where it can be shown that no practical alternative exists);or • Construction,relocation or repair of utilities within the SHLO,or • Tree cutting or landscaping within the SHLO;or • The use of explosives to remove material from within 250 feet of the SHLO. In cases where a particular Project or.activity may seek both vehicular and non-vehicular access, separate and distinct Permit Applications must be filed. fAairDOTrev0q.11 Page 6 of 6 APPENDIX IV APPL`ICAUQN AND POLE ATTACHMENT LICENSE O Licensee Verizon Wireless MAR 2 2 2017 Str�eet.Address One Verizon Way,Mail Stop 4AW1.00 City,State and Zip Bashing Ridge,NJ 07920 c p p A Datenn is PERMITS OFFICE In accordance with the terms and conditions of the Pole Attachment Agreement,application is hereby made for ti license to make I antenna,RRIVCabinet'and metes attachments to poles and 1 Power Supply(ies)and otlier attachments located in the municipality of Barnstable in the State of MA This request will'be designated;hole Attacltntent License Application Number•.BernstableSitObMA-308902 Attached are my power supply specitleations If appltcablc.-The sable's strand slze is 0;5 and weight per foot o[.cable Is 0.2. ❑Comm anleatlon Space X Power/SUDPIY Snace Liechsee'sName(Print)Barbara lcassabian t�°' Signature'a0Wba*VL Xa"a.ZtLatti NSTA .0 EVFRSQVRCE L� �.; MAR .? Z 2017 d Power Company Title Site Acquisition Tel.No. 603-303-8001 - E-mail•bliassabiant&rmcom.com licensor use,-do notwrite below this PolvAttachment License ApplicationNumber is hereby granted to make the attachments described in this application to attachments.to JOI pp.les;, attachments to FO, poles;. attachments to JUa'poles; Power Supplies and other attachments located in the municipality of .'in the,$,tate'of as indicated on the:attached Form 3. LicensoesName:(Print). Signature: (AGREEivIE P ID#)' Title i r11 Out Date Tel,No. The Licensee-shall submit an original copy of this application to Verizon New England Inc.and NSTA,R Electric Company.d/b/a EVERSOURCE ENERGY. Revised P23/2015 NSTAR d/bla.EVERSOURCE EVERSmURCE One NSTAR Way.NWBEs026 WesFaood;Massachusetts 02030 ENERGY D L16 December 1.6,2.015 Attention:Stateand Municipal Permitting Authorities MAR 2 2017 PERMITS OFFICE Re:Initial Authorization for Verizon Wireless to Attach to NSTAR poles To Whom It May Concern: Eyersouree Energy d/b/a NSTAR Electric.("NSTA10 is:aware that Verizon Wireless is in the process of perrukiing for the.installation of necessary telecommunications equipment.and corre'sponding'aerial fiber optic cable in Various locations on NSTAR_owned poles throughout our service territory. As part of the approval.process,we understand that there is.a requirement for NSTAR to.review.these locations and provide.the Towns with confirmafi;on of its approval.in a Wireless's of Verizon reless's proposed attachment. Accordingiy;NSTAR hereby subm' 'ifs its initial authorization.for Verizon Wireless to:install its equipment and corresponding aerial fiber routes to NSTAR.poles in the geographic locations as depicted oh the plans. su6ni tied.by Verizon Wireless and on file with the Towns. The installations onNSTAR poles will be subject to tlae�underlying.teems and conditions of agreements by and betweei fiNSTAR and Verizon VViroless,.as the same may be in.effect from time to time: Ifthercis anything further that I can rovide you with for your.analysis;please do not.hesitate to.contact Yt .. g .. p. .. me.at.50.8-441-5881. � Sincerely, i Steven K Owens Sup'tN.so Rights;Permits&Public Nygrks Eversource Energy.(NSTAR Electric) One.NSTAR Way;NWBED180 i.. Westwood,N1A 02090 -i i Ph: (508)441-5881 ' paxi.(5A8)441-5842 .` ,.. MAR 2 2 2Q17 u ' Y { r 1 Match 28,2016 r= District Highway Di rector MassAchitsqtts Depeftlmdiit of Transportation Highway Division MAR 22 2017 Re: Application.for-Permit to.Atcess State High�vay Vtltty Pole Small Cell Wireless Attachment: Aplilitajiti Ceff'co,PArtnerthip'd/b/A V rkofi Wiiblcsis To WhomItMay.Concern. 1,-As the duly autho ized manager of Cellco Partnership dtb/a Verizon Wireless,hereby authol'lzesDaiiidlD. kias-m'ckof.buva &lK-las'ni* LLC as,duly designated agent of V6rizon Wireless,to 'mike application. for any perniks, including hg but not lltnil�d to an Application for Permit to. Access State Highway, which is necesseqy,.for the installation, maintenance and upgrades of the proposed vii1ity pole small cell Wireless attachment. .A copy dthig,letter 8hill be regarded ps hAyjgg.tlie same effect as the origitial. Thari1c,you fbi your attention to this matter. Very tr*your So 8qi6 Coif - M v ,4zon led ,8 Vi.aAd,dlfs Road..3,"floor We4 oyougb MA*O,.Is 81,1 p � CC � MAR, Z 2 2017. PERMITS OFFICE, i NCO Og o�Toiro2=16 '1 CERTIFICATE OF LIABILITY INSURANCE r 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(les)must have ADDITIONAL INSURED provisions or 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 endorsoment(s). PRQDU14R mm-WCT Aon Risk Services Northeast, Inc. FAX New York NY Office (AIC.N`o.Exl. (866) 263-7122 (Pic.No. (80)} 363-Gras 199 water street nooRE88: _ New York NY 10038-3S51 USA iNSURER(S)AFFORDING COVERAGE NAiC Al INSURED MSURERA: National (union Fire Ins Co of Pittsburgh 19445 Verizon ve reless, LLC LNSURERIT: New Hampshire Ins Co 23841 109S Avenue of the Americas LNSURERC: Illinois National Insurance Co 23817 New York NY 10036 USA INSUREAD. Lloyd's Syndicate no. 1969 AA1120106 CLsURER E: 94SURER F. COVERAGES CERTIFICATE NUMBER:570062907761 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.NOTLVITHSTANDINO 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. Umlts shown are as requested R TYPE CF IHBURAIrCE ADDD POLICYNUMBER I LIMITS X COAMRCdEF P EACH OCCURRENCE $5,000,000 CIAIIAS-A%OE E OCCUR PREMISES En r c ca SS,000,000 MEDEXPWryalcpanen} f10.,000 PERSONAL&ADV INJURY $5,000,000 OWL A30REOATE LIVIT APPLIES Pfit GENBRAL AGGREGATE SS,000,000 r X POLICY ❑PRO-JECT 1:1LOC. PRODUCTS-C7MPMPAGO SS,000,000 OTHER: A AUTOMOBILE UABILITY CA 774-21-38 06/30/2016 06/30/2017 COMBINED SINGLE LIMIT $2,000.000 A.OS a 4ecidwfl A. X. ANY AUTO CA 774-21-39 O6/30/20.16 66/30/2017 BOOILY INJURY(PerPerwri) Z O�,WaD SCHEOULEO HA BOOLLYiWuRY(ParaeddeW) IS AUTOSONLY A R AU CA 774-21-40 06/30/2016 06/30/2017 8 HIRED Avm NON-OWNED eraccl YDMIAOE orllY AUTOS ONLY VA maaldeM ;E 4! D X UTABRELLAUAS K OCCUR will 600439 06/30 201 0 / 17 EACH occuRR?NCE S3,000,00 U EXCESSLIAB CWNS•MADB AGGREGATE S3,000,000 DIED I X PETENTiON110.000 8 WORKERS OOMPENSATIONAND WC 81.: 1 X s0 u O EMPLOYERS'L IAe1LITY aNr PR6PPoETORl PARTNER/E%ECMIVE 1 ADS E.L.EACH ACCJDENT $1,000,000 A 0MCCIUMEMBER EXCLUDED? N NIA WCO20681872 06/30/2016 06/30/2017 (Mandatary toNK) CA E.L.DISEASE-EA EMPLOYEE S1,000,000 11 Yyes;detafitio imdar D laPIT10710F0PERATIONSbetary E.L:OISEASE.POLICYUMIT Sl. 000,000 DESCRIPTION OF OPERATIONS 1 L.00ATIO14S I VEHICLES(ACORD 101,Additional Remarlls Schedule;may beatlached 8 more cpact Is V6II01 ad) _ RE: Small Cell installations within the State Right of Way. Ha4SDOT is included as Additional nor t_ es t General Liability policy. MAR 22 ZQI] CERTIFICATE HOLDER t 1 CANCj ILLATION it L' i�k p ���� � HOOLb ANY OF THE ABOVE DESCRIBED P - D BEFORE THE 1 MAR aION OATS THEREOF,NOTICE MALL eE DELIVERED IN ACCORDANCE WITH THE T pOUC PROVISIONS. Mas5DOT t, ��ti- AUTNORIJ*VREPFtESENTATIVE '. 10 Park P102a -�-. j' Boston NA 02116 USA � 01988-2015 ACORD CORPORATION.All rights reserved. ACORN 26(2016/03) The ACORD name and logo are registered marks of ACORD i r AGENCY CUSTOMER ID: 570000027366 LOC#- ADDITIONAL REMARKS SCHEDULE Page _ of _ AGEVCY NAMEDINSURED Aon Risk services Northeast, Inc. verizon wireless, LLC POLICY NUMBER See Certificate Number: 570062907763. CARRIER NAIC CODE See Certificate Number: 570062907761, EFFECTIVE DATE: ADDITIONAL.REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD25 FORM TITLE:Cerlilleate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# f` WSURER INSURER MAR 2 .2017 hNSURER t INSURER F ADOMONIAL POLICLES Ifa policy belot�'does not include limit information,refer to the corresponding policy on the ACORD certificate forin for policy lilnits. POLICY, POUC1' IV,SIt ADDL SUDR MUCY.Ive 1:XPIRATION LTR TIRFOYi 1Sl nANCE INSO Wt'D PDLICYNUDIDER DATE DATE LL�11TS J[ttPo 1'K TI�IlDD 'Y\ WORKERS COMPENSATION C N/A v(CO20681873 06 30,2016, 06 30 2017 FL g N/A WCO20681871 06/30/2016 06/30/2017 NN g N/A Wc020681876 06/30/2016 06/30/2017 NA.N0.l71.WA.WI,WY g N/A WCO20681875 ST3V2TIT 06 3O/2017 N7.NY,TX.VA g N/A WCO2068-1674 06 30 2 16 06/30/2017 NE rin 1-2 MAC 2 2 ZO17 , ERMI S OFFlt E ACORD 101(2068101) 0 2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are regWored marks of ACORD t D' ,t• nrr-,zr---r--Tr-7..1113 • 1 ,,'+,f� !:it �,�,� 1 f G � _ I 1 J - � � �•���� �l N _-n . r ` ice. N-4't 2V-04.! M 1 I 0 1 _ . 94 = PIN ta o I a R � list 4- 1 'rri r LEASE EXHIBIT .... , ca led z O YOB■ 7 3 t m i �r 1 o I " i I fl t 1 • I ' {' i I ,z� �S � " u loll, um � 1 1 1 b 1 C All IN%IIIt41w IIII4'11 �1,,�1411 r�-� anrnuau+n ulhpnot +n nunwOl lnull�J11�IIltulf lhul41�tu1u ' �t e !loin IIYI1�1sq 11 0� � l.OW11�,rrrirl lltilllllta��IIIIUNII- � �: �.ti 1�aununutuwtatmulurnnalwir I m a n Eii i lB iar r8 c 0. , x a mop .� aa Ail i LEASE EXHIBIT ! CA. 1 r Rill ! o g .e.g y m i F_, _ .y,: .i:.. '- :Il-L• F`: C ':YAl'.., .•� �l r' ,(.�v� �`'•rY� f'i' 7'�;'� �_ _ ,/ �v �:'�t :(t 4v 1,'• S%``;1�'. r.•..': 's �r_ f j` ,ya °�' jr0 Z n h a try ,. bow t » ... � 4�i .:tv >?J�' 2O�ESSH)$ 'ffi�S�r`M%0� 0>t -. Y;'.S`` .g:.!+ 4....'•.'. b�R�ATING ACCOUN . t 210 BROADWAY SUITE 204 53J055%211'3, LYNNFI�LD;'MA 0.ti1Y a"0¢rj . ,����J'`=t:�•t',:�k",�.. �'rl'•s,t r:t_ 7Yyi��s 4�<°`..:o'�, March 21, 2017 Sox'. ? pt s, ' o4, W O'vOO — v $ SOO F @40 *-* FIVE HIINI)RED .**** *# ***�t* �e*at**�r �e****�t �e r pest* and O(WPO DOLL,4RS.a :W i ;:MEMO Application.:Fee ;= Barnstable SC06 UTHORIZEDSIGNATURE'= ' 006669i1' 1: 2113 ?0SSIP: 00 5 29 10 6 9 7110 ' • I i i - Town of Barnstable Expires 6 mon fi fss at ����11 egulatory Services Fee - � lT&M� homas F.Geiler,Director Building Division Q� Tom Perry,CBO, Building Commissioner 0� / 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us a Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY Nat Valid without Red X-Press Imprint [ap/parcel Number a / b 0 3U 34, roperty Address 7 4-Residential Value of Work ��0(� / Minimum fee of$25.00 for work under$6000.00 wner's Name&Address ontractor's Name Ct �C�-� Telephone Number ::j 2YE$—.a a ci a ome Improvement Contractor License#(if applicable) f/,-?S,23 6 onstruction Supervisor's License#(if applicable) Work Compensation Insurance Check LAVCC 1 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner FkL I have Worker's Compensation Insurance surance Company NameGt� 'orkman's Comp.Policy# Dpy of Insurance Compliance Certificate must be on file. xmit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to 5C.A-i (')6 ./e ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance of this pemut does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. e Improvement Contr=ors License is required. GNA 'orms:expmtrg vise071405 The Commonwealth ofMassachusetts Department of Industrial Accidents - Office of Investigations a 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluxnlbers Applicant Information Please Print Leg bly Name(Business/Organization/Individual): Address: �t ® Q 6 City/State/Zip: • Co Phone#: V�,e Are you an employer? Check the•appropriate bog; Type of project(required): 1,9 I am a enVloyer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(fall 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. . g, ❑ Building addition [No workers'Comp.insurance 5 ❑ We are a corporation and its required,] officers have exercised their 10,❑ Electrical rcpaizs or additions 3.❑ I am a homeowner doing an 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' wrap.imurancerequire&] 13,0 Other *Any applicant that checks box#l-=ust also fill out the section below showing their workers'oompeasation policyinfoanation.' t Homeowners who submit this affidavit indicating they are doing a work andtheu hire outside contactors must submit a new affidavit indicating such =Contractors that check this box must attached an additional sheet showing the name ofibe subcontractors and their workers'comp,policy information. I am an employer that Is providing workers'compensation Insurance for my employees. Below is thepolicy andjob site Information. Insurance Company Name: Policy#.or Self-ms,.Lic.#: -7!2 k ,6 f 1 /0 __S_ Bxpiration Date: l Job Site Address:_ City/State/Zip: w / lam 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$1,5M90 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 the pains a enalties ofperjury that the information provided above is true and correct. Sig ature: Date: /` D 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 Realth 2.Building Department 3.City/Town Cleric a.Electrical inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: .Ri.i1 V i. iii"vi.V♦A "JLA%,& JULAP&A v vi v i�17 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, p express orimplied,.aial 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 eomcmonwealth 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 requireme=of this chapter have been presented p 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-contractors)name(s),address(es) and phone numbers)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' compensation policy,please call the Departznent at the number listed below. .Self-insured con3paiues should tier(heir 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 permitllicense 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 town)."A copy of the affidavit that has been officially stamped or marked by the cityor 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 eacb ' year.Where a bbme owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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. f 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#W-727-7749 www.mass.gov/dia Fraser Construction Roofing & Siding Specialists P.O. Box 1845, Cotuit, MA 02635 Phone: 1-508-428-2292 & Fax 1-508-428-0123 RE-ROOFING PROPOSAL July 26, 2006 Ms. Janis Umschlag 1871 Main Street 6A W. Barnstable, MA 02668 Phone: (508) 362-9519 FRASER CONSTRUCTION hereby proposes to perform the following services in a neat and professional like manner and in accordance with the manufacturer's specifications and local building code. -Remove and Haul away all of the old Asphalt Shingles -Re-nail all plywood sheathing as needed. Supply and Install- CERTAINTEED WINTER- GUARD: (ice &water shield) Waterproof Underlayment System (3ft on eves and valleys, 18" on rakes, walls and skylights) Supply & Install- Roofer's Select Underlayment Paper (recommended by CerTainteed) Supply & Install- Hick's Ventilated Drip Edge. Supply & Install-Aluminum & Neoprene Soil Pipe Flashing Supply & Install-AIR Vent Ridge Vent. (recommended by CerTainteed) Clean & Remove - Debris from work area daily. Supply and Install CERTAINTEED XT AR-25: 25 -Year Warranty, 5 year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self- Sealing, Multi-Layered 3-Tab, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10 Year Warranty against ALGAE Containment. -\ PRICE - $7,360.00 Color. Initial Fraser Construction Roofing & Siding Specialists Possible Extra -After the shingles are removed from the roof, we will lift one sheet of plywood to make sure that the insulation be not up against the plywood sheathing, preventing ventilation from the eaves to the ridge. If it is, ventilation panels will be installed by; removing the plywood sheathing, installing the panels, turning the plywood over and then re-installing the plywood. If needed, this would be charged for as an extra at the rate of$4.00 per panel including Materials & Labor. There are 6 panels per sheet of plywood. Possible Extra-Any rotted or otherwise deteriorated trim boards, plywood sheathing, lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$45.00 per hour, plus materials, plus 20%overhead mark-up on total extras. FRASER CONSTRUCTION Warranties the labor for 10 years FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years. CERTAINTEED Warranties are as explained in the enclosed brochure CERTAINTEED Warranties the shingles to be ALGAE resistant for a full 10 years. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner'should carry fire, tornado and other necessary insurance upon the above work. We, if not accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION: Carries Workman's Compensation and Public Liability Insurance on the above work. DATE OF ACCEPTANCE: SUBMITTED BY: Homeowne C. %a ruction ACGRA CERTIFICATE OF LIABILITY INSURANCE pATE(MM,DDm PRODUCER (508)588-1260 FAX (508)588-7236 09/22/200S Wise & Quinn Insurance A enc Inc, QNICY ��tFiCATE IS ISSUED AS A MATTER OF INFORMATION t 9 y CONFERS NO RIGHTS UPON THE CERTIFICATE 449 Pleasant St. ALTER THE CO Brockton, AFFORDED BCERTIFICATE DOES OY THE POLICES BELOW_ Brockton, MA 02301 CISR, Paul Crowley INS' URERS AFFORDING COVERAGE INSURED Dean Fraser NAIC# INSURERA: E'I.ar'tford insurance Company DBA: Fraser Construction Co. IINSURERB: 71 Tarragon Circle INSURER C: Cotuit, MA 02635-2443 INSURERCL !INSURER E: COVERAGES "�— THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A,3OVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDIN( ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VNHICH THIS CERTIFICATE 1,4AY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDEED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS O POLICIES.AGGREGATE LIMITS SHOWN GAY HAVE BEEN REDUCED BY PAID CLAIMS. F SUCH IN SR FDD TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION — POUCY NUMBER GENERAL LIABILITY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED S CLAIMS MADE Q 'OCGUR MED EXP(Any one person) $ PERSONAL 6 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY CO- jE LOC PRODUCTS•WMP/OP qt`,G 5 AUTOMOBILE LIABILITY — ANY AUTO C OM�B`NdEDerst SINGLE UMIT(Ea I $ ALL OWNED AUTOS SCHEDULEOAUTOS BODILY INJURY S HIRED ANDS (Per person) *ANY "WNED AUTOS BODILY INJURY (Per accident) 5 PROPERTY DAMAGE $ (Per accident) IABILITY AUTO AUTO ONLY-EA ACCIDENT $ OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS/UMBR0.lA LIABILITY —"' EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ DEDUCTIBLE S RETENTION $ $ , EMPLOY RS'LIA BUTT ONAND 6560t{B-794X619-1-05 09/26/2005 09/26/2006 XRYI1MrTS $ EMPLOYERS'LIABILITY WC STATU- OTH- ANYCERIMEMBER/PXCLUDEIEXECUTIVE E.L.EACH ACCIDENT_ S SOD,000 OFFICEWMEMBER EXCLUDED? U yes,describe under SPECIALALPROVISIONS E.L.DISEASE-EA EMPLOYE S Soo 000 PR elow OTHER E.L.DISEASE-POLICY LIMIT $ 500 r 000 ICRPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPWAL PRO•q$IONS the operations usual to carpentry. IC A TE UMDER A L SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 6E CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO(BAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Fraser Construction Co. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABIUTY 71' Tarragon Circle OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. i Cotuit, MA 02635 AUTHORMED VE c ; I )RD 25(2004/08) FAX: (508)428-0123 ©ACORO CORPORATION 1989