0001, 0002, 0003, 0004, 0005 0007 MAYFLOWER LANE - BUILDING INSPECTION Cam 15� 5y $ 5CD
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
bo Building Permit Application for any Building other than a One-or Two-Family Dwelling
/� (This*tionF.or OfficialUse-Only) -
I1 / Building PernutNumber: Date Applied: Building Official: - $-
SECTION.1:LOCATION(Pleaag indicate Block#and'Lot#for locations for whicha street address is not.gvailab',le)
a, 3, V SC�K,� `y Salem 01970
No. and Street ity/ own Zip Code Name of Building(if applica le)
lh1— SECTION 2:.PROPOSED:WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration n I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No C�
Is an Independent Structural Engineering Peer Review required? Yes ❑ No CS
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION_,OR
CHANGE.IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Residential Proposed Use Group(s): Residential
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels) &Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 11H-5❑
I: Institutional 1-1❑ I-2❑ I-3 11I-4❑ M. it
❑ R: Residential R-10 R-2 C; R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special U'se:
SECTION'6;CONSTR_UCTION TYPE(Check.as applicable)
IA IB E3 IIA ❑ TIB Cl IIIA [3 IIIB ❑ IV ❑ VA E3 VB 13
SECTION 7:SITE INFORMATION(refer to 780 11 1.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system El permit
❑permit is enclosed
trench or specify:
❑
Railroad right-of-way: Hazardsto Air Navigation: MA Historic Commission Review Precess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:.CONTENT OF CERT.MCATE.OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
PAYa1tom() Tb G , C- 3
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Mariner Village Salem
01970
Name (Print)
No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Charles Minasalli 25 Spaulding Rd Ste 17-2 Fremont NH 03044
Name Street Address City/Town State Zip
to act on the propeowner's behalf,in all matters relative to work authorized by this building permit ap2lication.
SECTION.10:CONSTRUCTION CONTROL(Please filtout Appendix 2)
buildin' is less than 35,000 cu.ft.of enclosed ace and ror'not under Construction Control thencheck here d(7Number
10.1 Re 'stered:Professiorial Res onsiSle for Constructions Control �Name(Registrant) Telephone No. a-mail address RegistratioStreet Address City/Town State Zip Discipline
10.2General Contractor
KTM Properties LLC
Company Name
Charles Minasallli 160139 HIC Exp. 6/25/16
Name of Person Responsible for Construction License No. and Type if Applicable
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
603 895 0400 604231 t677 tara@ktmproperties.com
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATIONINSURANCEAFFIDAVIT .G.L.c.-152.§ 25C(6)y,
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit
Is a signed Affidavit submitted with this application? Yes rY No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ -.4-dam.. dfl
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate munici al factor =$
P )
3.Plumbing $
4. Mechanical (HVAC) $ _ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ `,�.U� 6di'J. 69 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my na a below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is ac to to the best of my knowledge and understanding.
President 603=895-04005
Please print
and President
name Charles masa Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town VSttatte- Zip
Municipal Inspector fo.fill out this section upon application approyal: "'r'eF 4.4✓ r/ /r/;y_
Name Date
I
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
f�Salem 01970 _ G V
No. and Street City /Town Zip Name of Building (if applicabl
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No 0 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No Cl Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Department of Industrial Accidents
Office of Investigations
600 FVashington Street
- =-/ Boston MA 02111
1 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): KTM Properties, LLC
Address 25 Spaulding Rd - Suite 17-2
--ity/State/zip: Fremont, NH 03044 Phone #: 603-895-0400
re you an employer? Check the appropriate box:
❑x 4. I am a general contractor and I Type of project(required):
I am a employer with 25 ❑
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.[ 9. E] Building addition
[No workers' comp. insurancecomp.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
❑ I am a homeowner doing all work officers have exercised their I I.[] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
y applicant that checks box WI must also fill out the section below;how ing their workers'compensation policy information.
mieowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
atractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
loyces. If the sub-contractors have employees,they must provide their workers'comp.policy number.
'n an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
3rmation.
urance Company Name: Union Insurance Company
icy# or Self-ins. Lic. #: WCA5152316-10 Expiration Date: 6/16/2016
Salem, MA
Site Address: r City/State/Zip: 4,0 7o
ach a copy of the workers' compensatio olicy declaration page(showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
e 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
ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
r hereby certify under the pains an penalties ofperjury that the information provided above is true and correct
nature r� � ��A.�7t-t��e � i1.F%C�`C"-'r—/� Date
me#: 603-895-0400
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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
121. Of of Consumer Affairs And Business Regulation
1.0 Park Placa - Suite 5 170
B(,}ston, Nfassachus.e-tts 02116
Home Improvement Contractor Registration
Registration- 160139
Type Supplement Card
KTM PROPERTIES, LLC. Expiration 6/25/2016
CHARLES MINASALLI
25 SPAULDING RD SUITE 17-2
FREMONT, NH 03044
Update Address and return card. Nfark reason for change.
Address Renewal Employment LositiCzrif
A J
W-fficr o[Consurricr Affairs& business Re-ularjou License or registration valid for individul use mil)
N -'.
a before the"expiration date. If found return to:
'OME IMPROVEMENT CONTRACTOR
Office of(-unsumer Affairs and Business Regulation
Registration: 160139 Type 10 Park Plaza
-Suite 517)
Expiration: 6,72512016 Suppiemen:Card Boston,klk 021 L6
PROPERTIES,LLC,
,RLES MJ,',LASALL1
PAULDING RD SUITE t7-2
MONT,NH 03044
�� n rmrm I yr fu. morn
>' � DATE ItAEUL(W'/'rYYt.
CERTIFICATE OF LIABILITY INSURANCE 061sziz015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND-CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS i
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND E P
EXTEND OR ALTER THE COVERAGE AFFORDED BY THOLICIES
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 pollcy(Ies) must be endorsed. If SUBROGATION IS WAIVED;subje:t'to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not carrier rigtits:,to-the
certificate holder in lieu of such endorsement(s).
.ODUCER Phone: 603-424•$901 +tAONML-TACr
Brown. --
own&BrowMerrimack t
Merrimack)
9 Daniel Webster Highway Fax: 866-848-11223 ArC�N,',yFE:L_. . _ —_-- — ._ 1 lac,NPL
rrimark, NH 03054 I atAIL
ins McPhail
INSURERS)AFFORDING COVERAGE NAL,J
Union Insurance Company _ 25944
SORES KTM Properties LLC
25 Spaulding Road -- _ - -- - ---- --- -- ,--
Fremont, NH 03044 Nsuar:R r
h5URE0.U
IfJ3URER F
OVERAGES CERTIFICATE NUMBER: REVISION.NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW-HAVE SFZN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLCY_PERI✓D
INDICATED. NOTWITHSTANDING ANY RECUIREMENT, TERM OR CONDITION OF ANY co rRAC" OR OTHER DOCUMENT WITHRESPECTTO'WHICH .HIS
CERTIFICATE MAY BE ISSUED OR MAY PER 7AIN, THE NJSURANCE AFFO^' E:- 9, "rdF P!"[CIES DESCRIBED HEREIN' IS SUBJECT TO ALL THE TERPa3
EXCLUSIONS AND CONDMONS OF SUCH POLICIES-!IMiTS SHOWN MAY HAVE E'� _N RED JC': D 9Y P4ID CLAIMS.
TYPE CF INSURAN4E—��OI.Sl1Bh -- ---�-FOLIC EFF
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CLAIMS-MAOE FX—1I MED EXP(Any doe Person). 6 5.�
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GEN-1-46 REGAiE LIMIT APPLIES PER: j PRODUCTS-COMP OP 1GG 5 -2,00,QQ
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WORKERS COMPENSATION ^----* X TC4v L MTS
AND EMPLOYERS'LIABILITY YIN �iW CA., a231b-11 f 06,116,12015: 0611612016 j 06/16/2016 EACH G
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DESCR1PnON:OF OPERATICNS heb•x
ESCRIPTION OF OPERATIONS I LOCADONS I VEHICLES (Attach ACORO 101,Additional'.Remarks a r educe,if mare apo:..is requimd)
;ERTIFICATE HOLDER
CANCELLATION. .
SHOULD ANY OF THE ABOVE DESCRIBED-POLICIES-BE CANCE"11,BEFORE
THE: EXPIRATION DATE THEREOF, NOTICE YVILL :BE DEGN_EREO IN
For Informational Purposes ACCORDANCE WITH THE POLICY PROVISIONS,
Only
AUTIIO'e:ZED REPRESENTATIVE
Chris McPhail
fr1988-20f0ACORDCORPORATION. All rights;r®seneed.