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HomeMy WebLinkAboutPre-submission Materials LOCATION:OFFICE MAILING ADDRESS: Town Hall Annex P.O.Box 1179 5 37 See Route 25 ) � zv Southold,NY 11971 (cor.Main Rd. &Youngs Ave.) � Southold,NY Telephone: 631 765-1938 www.southoldtow-nny.gov June 8, 2022 PLANNING BOARD OFFICE TOWN OF SOUTHOLD Ms. Lois Rightmeyer inRange Solutions, LLC 695 Route 46 West, Suite 300 Fairfield, NJ 07004 Re: Wireless Co-location DISH Wireless @ Baxter 415 Elijahs Lane, Mattituck SCTM#1000-108-4-11.3 Zoning District: LB Dear Ms. Rightmeyer: The Planning Department has received a report from our Wireless Technical Consultant, Cityscape, Inc. (CityScape) and has determined the building department application as complete for review based on the provided Structural Analysis dated April 11, 2022 and a RF Exposure Analysis dated January 16, 2022. Pursuant to §280-71(B)(2)(b) of the Southold Town Code, site plan review and approval by the Planning Board is required for the proposed co-location. A complete site plan application for a wireless communications facility is required to be submitted to this office for review and approval. The full requirements for this application are included in the Town Code §280. Upon receipt of a complete site plan application, the Planning Board will conduct their substantive review, including reviewing a report from their technical consultant CityScape. We will do all we can to expedite the review as quickly as possible. If you have any questions regarding this site plan or its process, please do not hesitate to call this office. Respectfully, Brian Cummings Planner OFFICE LOCATION• MAILING ADDRESS: Town Hall Annex So P.hold, NY 1179 11971 54375 State Route 25 ��"a"a � „ (cor.Main Rd. &Youngs Ave.) , Southold, NY � Telephone: 631 765-1938 www.southoldtownny.gov .w x. PLANNING BOARD OFFICE TOWN OF SOUTHOLD MEMORANDUM To: Michael J. Verity, Chief Building Inspector From: Heather M. Lanza, AICP, Planning Director. Date: June 8, 2022 Re: Planning Department Report Wireless Co-location DISH Wireless @ Baxter 415 Elijahs Lane, Mattituck SCTM#1000-108-4-11.3 Zoning District: LB The Planning Department has received a report from our Wireless Technical Consultant, Cityscape, Inc. (see attached report) and provides the following: 1. CityScape has determined the application as complete for review. The applicant has provided a Structural Analysis dated April 11, 2022 and a RF Exposure Analysis dated January 16, 2022. 2. Pursuant to §280-71(13)(2)(b) of the Southold Town Code, site plan review and approval by the Planning Board is required for the proposed co-location because it causes a visible change to the exterior and is not an interior mount. A site plan application for wireless communications facility is required to be submitted to this office. Thank you for your cooperation. Town of Southold, New York Telecommunications Site Review c ON s U L T A N T s , 1 N C Collocation Application 2423 S.Orange Ave#317 Orlando,FL 328062806 Tel:877.438.2851 Fax:877.220.4593 April 18, 2022 RECEIVED [13; O Mr. Brian Cummings, Planner u ZZ Town Hall Annex Building butlao Town 53095 Route 25 Planning Board Southold,NY 11971 APPLICANT/PROVIDER: Dish Wireless LLC PROVIDER SITE ID: NYNYCO2191A OWNER SITE ID: BU#843211 /Mattituck ADDRESS: 415 Elijah's Lane, Mattituck,NY 11952 LATITUDE: 40° 59' 57.79"N LONGITUDE: 720 30' 40.17"W SCTM#: 1000-108-4-11.3 STRUCTURE: 107.5' Existing Monopole Tower(110.5' including appurtenances) Dear Mr. Cummings, At your request, on behalf of the Town of Southold ("Town"), CityScape Consultants, Inc. ("CityScape"), in its capacity as telecommunications consultant for the Town, has considered the merits of the above-referenced application submitted by Crown Castle on behalf of Dish Wireless ("Applicant") to collocate new equipment on an existing one hundred and seven and a half(107.5) foot monopole tower. The tower, owned by Crown Castle, is located at 415 Elijah's Lane, Mattituck, New York, see Figure 1. T-Mobile, Verizon and AT&T also operate at this site. In emails sent to the Applicant between December 20, 2021 and March 11, 2022, CityScape directed the Applicant to resolve the following completeness deficiencies in its equipment collocation application: 1) Provide a full structural analysis report verifying that the proposed loads will not exceed the maximum permitted stress rating of the tower. 2) Provide an RF exposure study as required in §280-70K of the Town Ordinance, demonstrating that the RF emissions of the proposed Dish operation, together with the RF emissions from the other carriers at the site, will not cause RF exposure levels at accessible areas to be in excess of FCC limits. 3) Explain why the proposed feed line cannot be mounted inside the monopole as is normal practice instead of on the exterior surface of the monopole. As of April 12, 2022, the Applicant has submitted all information needed for CityScape to fairly review the application. Town of Southold—SCTM#1000-108-4-11.3 %miRrva%cape Dish Wireless/NYNYCO2191A April 18,2022 C O N S U L T A N T S , I N C . Page 2 supportstlqcture tai n1I nt The Applicant proposes to install a new collocated wireless facility on the tower for Dish Wireless by adding the following equipment at the eighty-eight (88) foot above ground level, illustrated in Figures 2 and 3: TOWER EQUIPMENT # ADD 1 Commscope MC-PK8-DSH Antenna Platform w/Support Rails 3 JMA Wireless MXOFRO665-21 Antennas w/Mount Pipes 6 (3)Fujitsu TA08025-6604 RRUs&(3)Fujitsu TA08025-I3605 RRUs 1 Raycap RDIDC-9181-PF-48 Overvoltage Protector 1 1-3/8"Hybrid Cable(installed inside monopole) Engineering staff for Dish Wireless confirmed that there is an entry port available to install the one proposed Hybrid cable inside the monopole shaft, as is indicated in Figure 2. At ground level in the compound, the Applicant proposes to install a new metal 5-foot by 7-foot equipment platform and a 12-inch wide waveguide bridge between the proposed platform and the monopole. Equipment on the platform will consist of a site service cabinet, a telco fiber enclosure, a power protective cabinet and a utility H-frame. All indicated ground-level changes will be within the fenced compound except for new fiber lines in conduit and a fiber vault, both of which will be underground and within the utility easement. Structural Analysis The Applicant submitted a structural analysis report prepared by Crown Castle, dated April 11, 2022, based on ANSI/EIA/TIA-222-H, Risk Category II and Exposure Category C standards. The analysis indicates that, after the Applicant's proposed modifications, the tower would be at 86.2% of maximum usage capacity (out of an allowable 105%) and the base foundation would be at 83.2% of maximum usage capacity (out of an allowable 110%). Thus, it is determined that the structure, with the proposed modifications, would be structurally compliant,see Figure 4. The Applicant did not submit a mount analysis; however, as this is a new collocation, a full mount analysis is not deemed necessary, and since the platform mount is designed for up to nine (9) antennas and only three (3) antenna positions will be occupied, it is assumed the mounts to be used will be sufficient for the proposed equipment. RF Exposure Safety To verify RF exposure safety, the Applicant provided an RF exposure assessment of the proposed installation based on mathematical worst-case calculations, prepared by Henry Gultom Aft Town of Southold—SCTM#1000-108-4-11.3 %Mikyscape Dish Wireless/NYNYCO219 1 A April 18,2022 C ON S U L T A N T S , INC . Page 3 and dated February 16, 2022. The information provided within the study was found to be consistent with FCC guidelines and takes into account the operations of the Applicant's proposed/existing facility and those of Verizon, AT&T and other personal wireless facilities known to operate at this site. The ground level analysis indicates that the maximum RF exposure level is only 15.3%of the general public MPE level,see Figure 5,thus meeting the FCC exposure requirements in ground-level areas that are unrestricted. Summary The Spectrum Act, which is found within the Middle-Class Tax Relief and Job Creation Act of 2012 ("The Act") and administered by 47 CFR §1.6100 of the FCC Rules, states that a personal wireless facility collocation, modification or upgrade is considered an eligible facilities request if it meets six criteria, most notably (1) it does not increase the structure height by 10% or 20 feet, whichever is greater, (2) it does not involve adding an appurtenance to the body of the tower that would protrude from the edge of the tower more than 20 feet or more than the width of the tower at the level of the appurtenance, whichever is greater and (3) it does not require any excavation outside the existing ground compound or leased area. 47 CFR §1.6100(c) further states that if an application meets the criteria, the application should be approved and not denied. Cityscape has determined this application meets the requirements of an eligible facility and recommends approval for streamlined processing and administrative approval, with the understanding that the proposed Hybrid cable will be installed inside the monopole shaft. The Al2plicant is reminded that any planned equipment changes that differ from the submitted Construction Drawin s must be filed with the Town for review and a royal.. I certify that, to the best of my knowledge, all the information included herein is accurate at the time of this report. CityScape only works for public entities and has unbiased opinions. All recommendations are based on technical merits without prejudice per prevailing laws and codes. CityScape verified that the proposed appurtenances shown by Applicant's construction drawings were listed in the structural report, but we did not independently verify the calculations, statements or the appropriateness of the analysis criteria contained therein. Town staff should verify compliance with applicable building and fire codes prior to issuance of a permit for this modification. Respectfully submitted, B. Benjamin Evans Senior Project Engineer CityScape Consultants, Inc. Town of Southold—SCTM#1000-108-4-11.3 AM Dish Wireless/NYNYCO2191A April 18,2022 coNSU1, TANTS , INc . Page 4 i• DeLorme Street Atlas USAO2011 i i ti Sit � et...m � c +W ru a cauur�n � ROAD a p ma p T P 8 o m � " r�uwn5ua<rDLrcAw�, „ ,_.; 8 + O D A M µ8 f O A is P A 1pVYj .: ,�, jry'Ad.P o mirk Bury"COW AN CEtnE0. Data use subject to license }.�• 5CM0 I IUM ©DeLorrne DeLorme Street Atlas USAO2011, wiucwl�l 1NMNm m — m „', vw,wdelorme com 1 mI'ab fft m Data Zoom 14 Town of Southold—SCTM#1000-108-4-11.3 Dish Wireless/NYNYCO2191A % S cape April 18,2022 C o N s U I. T A N T s , 1 N C ,. Page 5 Figure 1 — Site Location Map %S7IAG -AA--. An A%S i w w A .. ,.. 5 AC:'- - I{y %5-I\C -AN L_A1 E\VAS ni ryV °e rrm. R�C C=n 98' C" AG- OM*Aim MnWM AIK OM POW PRGOM'-R J 1�IMY�wr L.1� .....�.. _InCr N_l A\T NNAS� ......I IT .,..,., AGGL r r , r ...Mae r w w r r r r r N � �a r r �...m_%III:NG YONGPo__ r r� r r r r ON P rAPbOM SEM r r r PFA OM CM WAVWW iic r CE MMM r VSUW %IS..0 EN =Y ,,GAT r, °■ 1! V :. w . . o7 ca -i Figure 2 —Elevation Drawing of Structure & Proposed Equipment Town of Southold—SCTM#1000-108-4-11.3 Aft 01001URIk Dish Wireless/NYNYCO2191 A %0ikySca*jRW April 18,2022 C O N S U L T A N T S I N C . Page 6 PROPO®DISH WMulm L.L.C.ANTENNA (IYP 1 PER SECTOR 70ML 3)-- PROPOSED DISH 1-1 1 LL.O. RRH pYP 2 PER SECTOR 70ML E) PROPOSED DISH 7NW41110 LUL MACK—ter-ewe~Orr OP I PER:SWICK,TOM 3) At I - _._ .. =x 5 N3 ,fo "01 •' .'^.F PROPOSED DISH W11611M LLM GYP DEVICE +fir Cl *P� 7d 0"�� // �a k at 12• B•_..0 2' 3. ANTENNA LAYOUT 3/4 •`1„c' 2 ANTIEN N 711N1SMISSM7N CABLE SECTOR POSITION VOSTNG OR MANINAMIMIOI-MODEL TECH OLDCI` SOM(WiW) AZIMUTH HAD IBM LIE TYPE PROPOSED NULRF31 cow AND EEDDIN ALPHA Al PROPOSED M7O WBELESS/IOOIOf�21 SC... 120•s 20.0` UTEIIBMLA BC1t PPRRODFPO09SFEDD . 3' • (1) R - I 0 � WElESS/MOMHOOOF21 OD 72.6 2D. ltww- w CDHEPIYM-121 (12t'LOC WOEIESS/MOMROBEB-21 EC 7Z0•at 2DcrT RRH SECIOR PO4DION MODELNIJMIMR 1. CONIRECOR 70 REFER 70 FINAL 0ONSTRI CIION RFOS FOR ALL RE '..... At FU M/1A011025- w Bc DE7ALS. ALPHA 2. ANTENNA AND AN AY MODELS L CHARGE DUE 70 EOUFTIEM BISO At FIE /TAINIOW-BOB O ... 50 RAIBABTY ALL EDUPNENR GWDES MAT BE APPROVED AD RENMN IN CNIPLNNOE WIN THE PROPOSED DESIGN AID Bt RA nw/TA08025-01104 OD STRLCRINAL ANALYSESS, EE111 Bt FIMOTSU/TA0028-81105 90 C1... FWrFMJ/TAOWZS-BO04 OO OAWA C FILBISMI/TA0002O•-BO06 00 ANTENNA SCHEDULE ND SCALE 3 Figure 3 — Overhead View of Proposed Equipment Configuration Town of Southold—SCTM#1000-108-4-11.3 Dish Wireless/NYNYCO2191A " April 18,2022 C O N S U L T A N T S , I N C . Page 7 CROWN Date: April 11,2022 CASTLE Crown Castle 2000 Corporate Drive Canonsburg,PA 15317 (724)416-2000 Subject: Structural Analysis Report Carrier Designation: DISH Network Co-Locate Site Number: NYNYCO2191A Site Name: NY-CCI-T-843211 Crown Castle Designation: BU Number: 843211 Site Name: MATTITUCK JDE Job Number: 640434 Work Order Number: 2081886 Order Number: 549093 Rev.2 Engineering Firm Designation: Crown Castle Project Number: 2081886 Site Data: ELIJAH'S LANE,MATTITUCK,SUFFOLK County,NY Latitude 40°59'57.79",Longitude-720 30'40.17" 107.5 Foot-Monopole Tower Crown Castle is pleased to submit this"Structural Analysis Report"to determine the structural integrity of the above-mentioned tower. The purpose of the analysis is to determine acceptability of the tower stress level. Based on our analysis we have determined the tower stress level for the structure and foundation,under the following load case,to be: LC7:Proposed Equipment Configuration Sufficient Capacity This analysis utilizes an ultimate 3-second gust wind speed of 128 mph as required by the 2020 New York State Uniform Code.Applicable Standard references and design criteria are listed in Section 2-"Analysis Criteria". Structural analysis prepared by:Jared Koski,El Respectfully submitted by: OF NEW I ,���ttT acryx Rohit Soni,P.E. Senior Project Engineer OEESSI itySca a Comment: Structural Usages determined to be 86.2% of Maximum Tower Capacity and 83.2% of Maximum Foundation Capacity. tnxTower Report-version 8.1.1.0 Figure 4 — Structural Analysis Summary A"h,ftSCaW,l Town of Southold—SCTM#1000-108-4-11.3 Dish Wireless/NYNYCO2191A April 18,2022 CONS ULTANTS , INC . Page 8 0 Statistical Summary X r Statistical Summary / copy Data 1600 100.00 D/o of Total R Area 0 - OHO ' 1600 .. Area 100.0 - 500 Q 0 % of S i Area 500.0 - 5,OOC 01 , 0.00 % of�1 Area > 5 OO�O Area R66f Area 10° s ft, Max %MFE 15: Min %MFE Q % With FCC 1997 Public Standard There is noF�Lf exposure(%100%)on the gror�n�l level. CityScape Comment: Maximum Exposure at ground level determined to be 15.3% of the FCC general population Maximum Public Exposure Level (MPE). 8 Confidential and P(OpFietary >2021 DISH WIRELESS Figure 5 —RF Exposure Assessment at Ground Level TOWN OF SOUTHOLD Purchase Order# 3 4 94 4 -------------- Datew . Account# ndcr ........................... . ..............---------- Deliver and send billing to: Ve Department P�Okx,\rwl� Address VENDOR "Return this copy and Town of Southold voucher itemized and signed for payment" ITEM QUANTITY DESCRIPTION UNIT COST TOTAL A C -VIA THIS PURCHASE ORDER IS NOT VALID WITHOUT THE SIGNATURES OF THE DEPT. HEAD AND THE SUPERVISOR I CERTIFY THAT THERE ARE SUFFICIENT FUNDS AVAILABLE IN THE ROI`q LION CHARGL Dept. Head I CERTIFY THIS TO BE A JUST AND TRUE P CHASE ORDER Supervisor VENDOR cKyscape2423 S.Orange Ave,#317 Orlando, Florida 32806 CON S U LTA N 'I` S , I N C . Tel:877.438-2851 Fax:877.220-4593 LETTER OF AGREEMENT December 6, 2021 Brian Cummings, Planner Town of Southold 53095 Route 25 Southold, New York 11971 Re: Agreement between Town of Southold, New York (Town) and Cityscape Consultants, Inc. (Consultant) Dear Mr. Cummings, As per the above referenced Agreement between Town and Consultant, Consultant agrees to provide a review and analysis for a DISH Wireless application to modify and/or upgrade equipment at a wireless communications facility located at SCTM#108-00-04-011-003, 415 Eliiah's Lane, Mattituck, NY 11952. Review services for the Application will be performed at an agreed upon rate of four thousand, dollars ($4,000). There will be no additional costs of fees associated with the review of this Application and/or follow-up letters relating to this Application. Consultant will provide the services as outlined in Exhibit A, Scope of Services, of the Agreement. Sincerely, Elizabeth Herington-Smith Government Relations Manager CityScape Consultants, Inc. Michaelis, Jessica From: Michaelis, Jessica Sent: Monday, November 22, 2021 10:38 AM To: Elizabeth Herington-Smith Subject: Quote for colocation Attachments: Dish Wireless Colocation at Baxter.pdf Good Morning Elizabeth, The Planning Department is in receipt of a new application to modify and/or up-grade equipment at an existing wireless facilities. Pursuant to §280-74(A)(4) of the Southold Town Code, the Planning Department is seeking to provide a brief report to the Building Department concerning the proposed wireless communications up-grades and whether or not this application warrants full Site Plan review. Please provide an estimate for the cost of your consulting services to determine whether the applications meet the General Requirements in the Southold Town Code for maximum permissible exposure. Should the Planning Board approve your estimate, a purchase order will be provided authorizing this application's review to begin. Please, do not start any review until you are authorized to do so in writing. All the application materials are attached. We have not received a check from the applicant, so please do not start any review until you are authorized to do so. Thank you. If you have any questions or comments,please contact me. Thank you, Jessica Michaelis, Office Assistant Southold Town Planning Department 54375 NYS Route 25 P.O. Box 1179 Southold,NY 11971 Phone: 631-765-1938 Email:JessicaM&southoldtowrinvgoov i INRANGE s o a ar r i rr ra s 695 Route 46 West, Suite 103 Fairfield,NJ 07004 �. October 28,2021 ��� �•-� RECEIVED Town of Southold - Building Department C)V2 2 2(3 21 Town Hall Annex 54375 Main Road PO Box 1179 ....w.........._. i�..�at.rair"i.c°,.��t�a�.".m .._._............,... Southold,NY 11971-0959 RE: Request for Minor Modification to Existing,Wireless Facility—Section 6409 Site Address:415 Elijah's Lane Mattituck,NY 11952 Crown Site Number:843211 Customer Site Number:NYNYC2191A Dear Building Department: On behalf of DISH Wireless Ll C. y("Applicant"), collocation,( ,)is pleased tea submit this request to equipment odif the existin wireless fa ilit oted above through err"; era eli hale C:`raawn Cr r y g " *facrlrtics r uest for a✓minor �m odifica tion under Setioreplacement 091/or removal es the Applicant's 4ea,tton 6401 srnal flee rides of tire. Federal Section Communications Commission(""l°C,':O.a Section 6409 mandates that state arid local governments must approve any eligible hicilrties request for the modification of mi existing wireless tower or base station that does not substantially change the physical dimensions of such tower or base station, Under Section 6409,to toll the review period, ifthe reviewing authority determines that the application is incomplete,it must provide rea►snotice related to cant within 30 clay*, which clearly and specifically delineates all missing documents or government, a Additionally, if' lure e written notice to the applicant wit flea, request rrrec�ts the. federal recluireraaents. a. starts or local has vernment,fail the issue an ad appr60-dovals deadlines f, pp . ) pp � �.. f I l�re FCC C " required for flue request within 60 days„dress approvals are deemed granted. l� ,eand dal that submits information ulflcrerrt�ltorrnforrnrtlie k�0sdi applicant:(1 takes flee first step regarirc<l under stave or local j than this modification qualifies under the fMeral laww . Of'this filing,that with the.submission of this letter arid enclosed items„the t started,Based a the deadline f 11 hirty,and sixty-da yrevie,w periods have Please recite t e for written notice of incomplete application is November 26 20�21,and the;deadline tier issuance of approval is December 26,2021, The proposed scope of works for this pr qje ct includes. Install antellnazs,ancillary tower and ground equipment etc,at an unmanned wireless facility with no change to structure height or ground spaccas per plans. At the end of this letter is a checklist of the applicable substantial change criteria under Section 6409.Additionally,please find enclosed the following information in support of this rcgtlestP (i) Building Permit Application (2) Section 6409 Substantial Change Checklist. As these documents indicate,, (i)the rriodi!"rcatiorl invoIve,s the coHocation,rcmov€al Or rcplaicenlent of transmission equipment; arid(ii)such modification will not substaaratla.11y change the physical dimensions of such tower or base station, As such,it is an "eligible facilities request" as defined in the l CC,"s miles to which tlac 60-day deadline for approval applies, Accordingly, Alaplrcaait requests all authorization neccss<aiy for this proposed ruirfor Modification under Section 6409, Our goad is to work with you to obtain approvals Cirlier than the deadline, We will respond promptly to anyrequest for related information you may have in Connection with this request.Please let us know how we can work witt,you to expedite the approval 1 Middle Class Tax Relief and lob Creation Act of 2012,Pub.L. No. 112-96,§6409(2012) (codified at 47 U.S.C.§14SS). Acceleration of Broadband eplci rrre nt by 1111f roving Wireless Facility Siting Policies,29 FCC Rcd.1286S l 4 ,c0 Wireless § lit Modification al l iCe q ests Uncle 5ectitm 6409(a)J f t ie Sp,s t"1 un,i Act o to 1 (codified -1""crcr ertlorr Requests rtrrrasa ' f',tac^al . t cct il�q 20 at 47 C FR 1.61.00 •and 1 � � ,ov rraera Approve Certain � y .. � r � � o ,. �l Actof2012, wC Docket No. 1.9-250 (Junes 10„2020). 3 See 47 CFR§ i.6�100 (0(3). i See 2020 Upgrade Order at paragraph 16. process. We look forward to working with you on this important project, which will improve wireless telecommunication services in your community using collocation on existing infrastructure. If you have any questions,please do not hesitate to contact me. Sincerely, �-° JMQ-s', aP-+ aw of G%raw�l Pik inRange Solutions,LLC 695 Route 46 West, Suite 300 Fairfield,NJ 07004 Mobile: 973-865-0983 Fax: 973.860.24 4 E-mail: lg @inrange-LLC.com RGE S0LUT10NVS errs TOWN OF SOUTHOLD-BUILDING DEPARTMENT 1 Own Hall Annex 54375 Main Road 111. 0. Box 1179 Southold,NY 11971-0959 Telephone (631) 765-1802 Yax (631) 765-95021-114)s://Www.southolcit,ownI APPLICATION FOR BUILDING PERMIT Date Received For Office Use Only D C PERMIT NO, Building Inspector: r—% MIT NOV 0 12021 d" them ent,irety, )D I eb I BUILDING DEPTaPlillcatlott wi�pot be TOWN OF SOUTHOLD h-Applicant t accepted 61, W141,11111 "o, (Page shall D ate:10/8/2021 *V,N,"N"V/0-fir OUV NER(S)" 'FPRO'PERTY- "mof Name:SBA Towers IX, LLC SCT M#100'0-108-00-04-011-003 Project Address:415 Elijah's Lane Mattituck, NY 11952 Phone#: Email: Mailing AddressM51 Congress Avenue Boca Raton, FL 33487 Attn. Site Admin 77,77 CONTACT PERSON Name:Lois Rightmyer, Agt on behalf of Crown Castle/ Dish Wireless Mailing Address:695 Route 46 W Suite 300, Fairfield, NJ 07004 Pho I ne I tt:197311-18651-10983 11 Email:lg@inRange-11 C.com IESICiN PROFESSIONAL INFORMATION: Mailing Address:2500 W, Higgins Road Suite 500 Hoffman Estates, IL 60169 Phone tt:847-648-4068 _J Email: CONTRACTOR INFORMATION: 4" of Name:NW Management Mailing Address:55 Commercial Street Freeport, NY 11520 Phone#:516-779-3226 Email:generaloffice@nwmanagment.net DESCRIPTION OF PROPOSED CONSTRUCTION DNewStructure OAddition ElAlteration E]Repair ElDemolition Estimated Cost of Project: Eil0therAdd (3)Antennas, (6) RRH (1)OVP and one Hybrid to existing tower $33,000 .......... Will the lot be re-graded? E]Yes F*-No Will excess fill be removed from premises? []Yes *NO ............... PROPERTY INFORMATION Existing use of property:Cell Tower Intended use of property:Cell Tower Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to this property? ❑Yes BNo IF YES, PROVIDE A COPY. XCheck Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by Chapter 236 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code, housing code and regulations and to admit authorized inspectors on premises and in building(s)for necessary inspections.False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law „, sa�„ ,,, >u ✓„ii,leu/,ai„ .,«;.Lei„ G''lliW.„i, ✓; .u.,,�r/ y ,,,,.:;,,. Application Submitted B riWme): is htm erPP Y(p � 3' .Authorized Agent Downer Signature of Applicant: Date: „ STATE OF NEW YORK) Meld 1er SS: COUNTY OF Is _ being duly sworn,deposes and says that(s)he is the applicant (Name of indivi I signing cntrlct)above named, (S)he is the.— (Contractor,Agent, Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application;that all statements contained in this application are true to the best of his/her knowledge and belief; and that the work will be performed in the manner set forth in the application file therewith. Sworn before me this day of ("�c}ab e 2 20 .... Notary I t F PROPERTY OWNER AUTHORIZATION or . ti (Where the applicant is not the owner) Kimberly My] Crown y ( Castle, Tower Owner) 1200 MacArthur Boulevard, Suite 200 residing at Mahwah, NJ 07430 inRange do hereby authorize to apply'on my behalf to the Town of Southold Building Department for approval as described herein. 10/13I2021 ....... .... www_ .. ... Owner's if.Wi ture Date Kimberly Myl Print Owner's Name 2 CERTIFICATE OF LIABILITYDATE(MM/DDA-m) INSURANCE 10/11/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CERTIFICATE DOES NOT A CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS FFIRMATIVELY OR NEGATIVELY BELOW, THIS CERTIFICAT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES E OF INSURANCE DOES NOT CONSTITUTE A REPRESENTATIVE OR PROD CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED UCER„.AND THE CERTlFlCATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(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 endorsements), PRODUCER Twin Forks Insurance Agency NAME Ita (31trllan0 16 Station Rd,Suite#7 `FAIL Bellport,NY 11713 I li�31 224 1000 nSUran 1 224 1800 �a L,�� elena�tu�ai. ce.colTl NAIc I �1 F INSURED INRA Travelers Indemnity Co of Ameri a E N.W. Management Inc RB Travel .Ty„ Ins Co of Am ri ca 55 Commercial Street INsu T _ 37362_ „ .w INSIIIRC General rStarsIndemnity Company Freeport, NY 115202831 " ^" ` rPoint Life Ins Ins Co 23850 IN$IIlI w6CE.�Shel to urine �Srlec�I r .. INSmERF; Hart Ford all Insurance c e.... _.. .__..._._". COERAGEI Ire Insurance Co CERTIFICATE NUMBER. THIS IS 'TO CERTIFY TFIAT TINE PC,ILII�IES OF INSURANCE.LI STE4T BELOW HAVI: BEEN IaSh.IEC}TO"G`C-IE IN aURE NAIIt�iECDDNABC7 NUMBER: THE POLICY I�EI�kC)I INDICATED, NOT�IPITIISTANI IN AIRY REt�UIREMENT, TERM OR CONCINTION of ANY CC3NTRACT OR OTHE,'R DC?CUMED ABOVE ITH RESPECT TO ICYPWHICH THIS LRT URANCE AFFCIRDEO BY THE POL6CIES DESCRIBED HEREPN IS SUBJECT TO ALL THE TERMS, INSRXRI EXCLUSIONS AND CC3NCII'IICINS O SUCH deSL � I'LIMIT _ .._.._- N RECIUCE AIN THE INS D BY PAID I,.t AfM . GENERAL LIABILITY D M D YY LIMITS EACH OCCURRENCE CLAIMS-MADE _."... OCCUR X X 6 - - - �_ 300.000 LIABILITY 1 000 A coMMCRc�wA�.oErat�RA�L�.qAB 000 80 6K115641 18 42 _. p 1...._ " 1,000,0005 __�. 2/1/21 2/1/22 MI~D tw.xP Arr one arson 00 PFRONALSAI)VINJURY $ 0 ontractual Liablht �. GEN'L AGGREGATE LIMIT APPLIES PER: _•..._._"_„ TE $ 2,000,000 POLICY PROr LOC RODUC I_fs OMGAOPAtnG .,.-_. .. ✓ $ 2,000,000 AUTOMOBILE LIABILITY .m._ MUIN SINGLE LIMIT ✓ ANY AUTO ALL OWNED _. �CEa B ✓ A TOS AUTOS ✓ AUTOSSCHED X X BA-2N16120A-21-42-G 2/1/21 2/1/22 BODILY RY(Perperson) $ __. AUTOS ✓_ ED BODILY INJURY NON-OWNED INJURY(Per accident) $ _ AUTOSPERTYDAMAG _..... „ ✓ Hired UMBRELLA LIAB OCCUR _....,$ .._.. ..... _..�. ...".. ... .....--. "✓ C EXc.Ess uae ORRENCEµ 00CIAMS MA F X IXG929776B 2/1/21 2/1/22 AGGREGATE $ 5 000,0OODED REEN"oN _ ` WORXFRS COMPENSATPON ""^- AND EMPLOYERS,LIABILITY WC STAfU OTH- ANYPROPRIEIOPUPARTNr"R�ExECLITiVE Y/°N - T�Y.LT E.L,EACH ACCIDENT.... (M F(Mandatory Exr LIJLJE,D� � N/A $ (Marwctirrtor^Ir In III) _. � Iyas,d DESCMRiPTtON OF under P„tA'rIONS Wgow E _ . .,$ _- ..w_...... E"B..DISEASE-POLICY LIMB $ D Excess Liability X X PU6698603 $5,000,000 2/1/21 2/1/22 Insurer E ShelterPoint-DBL policy# D226216 Statutory DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Certificate holder is included as additional insured if required by written contract or agreement CERTIFICATE I(OLDER CANCELLATION Town of Southold 53095 Route 25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO Box 1179 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Southold, NY 11971 AUTHORtZED RE.PRESE"''""" -" ©1500-cuium ,vrw _umrur%Atrvrv. mii rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD rcrrkers - CERTIFICATE OF INSURANCE��.��' Compensation COVERAGE Board DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW PART 1.To be completed by Disability and Paid Family Leave Benefits Carrier or Licensed Insurance Agent of that Carrier 1a.Legal Address of Insured(use street address only) "`"" --~- N.W. MANAGEMENT INC s Telephone Number of Insured 55 COMMERCIAL STREET 432-8700 FREEPORT, NY 11520 Work Location of Insured("Only roqujred it coverage i specifrcally limited to 1 c.Federal Employer Identification Number of Insured or Social Security Number certain laacatlrans in New York Mate„f.e.,wrap-up policy)s 201330499 2.Name and Address of Entity Requesting Proof of Coverage 3a.Name of Insurance Carrier (Entity Being Listed as the Certificate Holder) ShelterPoint Life Insurance Company Town Of Southold 3b.Policy Number of Entity Listed in Box"la" 53095 Route 25 DBL226216 P O BOX 1179 3c.Policy effective period Southold, NY 11971 12/01/2020 to 11/30/202 4. Policy provides the following benefits:: A.Bath disability and paid family leave benefits. 0 B.Disability benefits only. Ej C.Paid family leave benefits only. 5. Policy covers: © A.All of the employer's employees eligible under the NYS Disability and Paid Family Leave Benefits Law. Fj B.Only the following class or classes of employer's employees: Under F perjury,I certd y that I am an acsthorized representative or licensed agent of tl rri �e'insurance caer refdrer�oed above and that the named insured has NYS Disability and/or Paid Family Leave Benefits insurance coverage as described above. Date signed 10/11/2021 By -� (Signature of insurance carrier's authorized.. representative or NYS Licensed Insurance Agent of that insurance carrier)_ Telephone Number 516-829-8100 _ Name and Title Richard Whit Chief E ecUtive Officer IMPORTANT: If Boxes 4A and 5A are checked, and this form is signed by the insurance carrier's authorized representative or NYS Licensed Insurance Agent of that carrier, this certificate is COMPLETE. Mail it directly to the certificate holder. If Box 4B,4C or 5B is checked, this certificate is NOT COMPLETE for purposes of Section 220, Subd.8 of the NYS Disability and Paid Family Leave Benefits Law, It must be mailed for completion to the Workers'Compensation Board, Plans Acceptance Unit, PO Box 5200, Binghamton,9 NY`13902-5200. PART 2.To be completed by the NYS Workers'Compensation Board (Only ifBox 4C or sB of Part 1 has been checked) State of New York According to information maintained by the NYS Workers'Compensation otaO�rt the Board ve-named employer has com lied with the NYS Disability and Paid Family Leave Benefits Law with respect to W of his/her employees, p Date Signed By (Signature of Authorized NYS Workers'Compensation Board Employee) P Telephone Number �� Name and Title _ lease Note:Only insurance carriers licensed to write NYS disability and paid family leave benefits insura nce policies and NYS licensed insurance agents of those insurance carriers are authorized to issue Form DB-120.1. Insurance brokers are NOT authorized to issue this form. DB-120.1 (10-17) �Il�l��l�ll��l��l����lllll��l�lll�l�n���ll IIIIIIIDB-120.1 (10-17) 1111111 4;!� NYSIF New York State Insurance Fund 8 CORPORATE CENTER DR,2ND FLR,MELVILLE,NEW YORK 11747-3166 1 nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE AAAAAA 201330499 TWIN FORKS INSURANCE AGENCY 16 STATION RD STE 7 BELLPORT NY 11713 SCAN TO VALIDATE POLICYHOLDER AND SUBSCRIBE N W MANAGEMENT INC CERTIFICATE HOLDER 55 COMMERCIAL.STREET TOWN OF SOUTHOLD FREEPORT NY 11520 53095 ROUTE 25 P0 BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER CERTIFICATE NUMBER H2371 659-0 1903 POLICY PERIOD 09/29/2021 TO 09/29/2022 DATE THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE 10/12/2021 FUND UNDER POLICY NO, 2371659.0„ COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLNSURANCE DER FOR WORKERS" COMPENSATION UNDER THE NEW YORK WORKERS` COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK„ TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY,. IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY,INCLUDING ANY NOTIFICATION OF CANCELLATIONS OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WESSITE AT HTTPS:i YOLK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURENTOIGIVE SUCHTNOTIFICATIONS. NEW x THIS POLICY DOES NOT COVER CLAIMS OR SUITS THAT ARISE FROM BODILY INJURY SUFFERED BY THE OFFICERS OF THE INSURED CORPORATION, PRESIDENT WALTER DAHLEM(1 OF 1) N W MANAGEMENT INC THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NY'SIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNT; WE PAID IN WORKERS"COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT„ THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY, NEW YORK STATE INSURANCE FUND •26.3 VALIDATION NUMBER:283226902 DIRECTOR,INSURANCE FUND UNDERWRITING CROWN Date: 8/13/2021 CCCAST'LE Crown Castle 2000 Corporate Drive Canonsburg, PA 15317 (724) 416-2000 Subject: Structural Evaluation Carrier Designation: DISH Network Co-Locate Site Number: NYNYCO2191A Site Name: NY-CCI-T-843211 Crown Castle Designation: BU Number; 843211 Site Name: MATTITUCK JDE Job Number: 640434 WO Number: 2009145 Order Number: 549093 Revision. 0 Site Data: ELIJAH'S LANE, MATTITUCK, SUFFOLK County, NY Latitude: 40° 59' 57.79" Longitude: -72°30'40.17" 107.5 Foot—MONOPOLE Tower Crown Castle is pleased to submit this"Structural Evaluation"to determine the structural integrity of the above- mentioned tower. The purpose of this evaluation is to determine the suitability of the tower structure to support the proposed equipment configuration listed in Table 1. Based on a comparison of loading listed in the previous analysis dated 6/9/2021, the proposed loading change will not have significant impact on the overall tower stress rating. Therefore, the final proposed equipment configuration listed in Table 1 is structurally ACCEPTABLE. Table 1: Pro ose�L�ine' ment Confl uration Mo"Un lr CenterNumber Antenna Antenna Number ale din Level Elevation of Manufacturer Fee Feed Lin ft ft Antennas Model 88 1 MOUNTS Commscopa_MC-PK8-DSH 88 1 RAYCAP RDIDC-9181-PF-48 88 88 3 FUJITSU �TA08025-13604 1 1-3/8 88 M... 3 FUJITSU TA08025-B605 88 3 JMA WIRELESS MX08FR0665-21 Respectfully submitted by: It is a violation of the law"section 7209 of the Article 145 I of the State Education Law"for any person to alter any �" QF NEW b document that bears the seal of a professional engineer. / y 0 EN M 'nl eI Dentinger P.�. unless the person is acting under the direction of alicensed Sr Project Engineer professional engineer. 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