57 CAVENDISH CIRCLE - BUILDING JACKET 11/1J�2�®
UPC 90333
No.153L•3 ts,w,e'
HASTINGS, UN
_ 9800 Fredericksburg Road
San Antonio,TX 78288
t.
USAA®
04664 . 3D1TF . JSS1293276730 . 01 . 01 . 2953
SALEM CITY August 14, 2016
93 WASHINGTON STREET
SALEM MA 01970-3527
Reference: sent MA Notification of Structures required letter
Dear Builidng Commissioner,
I am writing regarding the claim referenced below.
Policyholder: Betsy A Ostroff
Reference #: 008306793-17
Date of loss: July 26, 2016
Loss location: Salem, Massachusetts
Loss Address: 57 Cavendish Cir. 01970
A claim has been made involving loss, damage or destruction of the property referenced above,
which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143,
SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139,
SECTION 3B is appropriate, please direct it to my attention and include the reference #.
You may submit correspondence or questions to me using one of the following options:
Address: P.O. BOX 659468
SAN ANTONIO, TEXAS 78265
Fax: 1-800-531-8669
Phone: 1-800-531-8722 ext 79335
Sincerely, r (� (� {�
V,&X��4 1 `016 e
C. Michelle Rodriguez
Property - CVA Unit 7
USAA Casualty Insurance Company
PO Box 33490
San Antonio, TX 78265
Phone: 1-800-531-8722 ext 79335
Fax: 1-800-531-8669
REM/CMN
008306793 - DM-04664 - 17 - 7338 - 06 - 54577-1215
Page 1 of 1
0057 CAVENDISH CIRCLE 1337-2000
GIS#: 10141 COMMONWEALTH OF MASSACHUSETTS
Map: 07
Block: 873 CITY OF SALEM
Lot: 0081
Permit: Building.
Category: 102 New single famil BUILDING PERMIT
Permit# 1337-2000
Project# JS-2000-0192
Est.Cost: $100,500.00
Fee: $1,014.81 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Fafard Development Corporation General Contractor-052848
Lot Size(sq.ft.): Owner: MARINER DEVELOPMENT CORP
Zoning: R3
Applicant: Fafard Development Corporation
Units Gained:-
AT: 0057 CAVENDISH CIRCLE
Units Lost:
ISSUED ON. 22-Jun-2000 EXPIRES ON: 22-Dec-2000
TO PERFORM THE FOLLOWING WORK.
Bldg rust UnitD. Ultra Coach Style VQ,II 101 Permit t® uccuoy
Construct 4 unit condominium as per plans. T.J.S. �l(J 1.1 I" I I 1� U P
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: L Service: Meter: Footings:
Rougho/( �� 'puvd( Rough://3//e, House# Foundation:
Final:i�� (�,/0 --d-10/ Final: y/�!!p/���� Rough Frame: 0-/O r �O
r
Fireplace/Chimney:
Gas Fire Department Board of Health
Insulation:
� t �
Rougb:y(.J�34 Oil: /
t 0 Final: Q rC
Final:C) ( y-(o-P7-1 Smoke: (/,(�/�./
awl- � Treasury:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF
ITS RULES AND REGULATIONS.
Signature: ••9
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2000-000190 22-Jun-00 11166 $1,014.81
GeoTMS®2000 Des Lauriers Municipal Solutions,Inc.
:tt
YSQVE AD
CITY OF SALEM
BUILDING PERMIT
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
his SktiofiForbfficialuse�Ooi
fujIddig Permit Ntunbe : - Date Applied. ' Building Official ;'`
;SECTION li LOCATION(Please,in$icate Block#and Loft:#'for locations for which a street':addresg is not available)� `
Bldg 187 57 Cavendish Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 7_-,PRQPO,�
PROPOSED WORK" ........
Edition of MA State Code used— If New Construction check here 0 or check all that apply in the two rows below
Existing Building 0 Repair 0 1 Alteration 0 1 Addition El I Demolition El (Please fill out and submit ApWdix 1)
Change of Use 0 Change of Occupancy 13 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes [a-- No
Is an Independent Structural Engineering Peer Review required? Yes 19 N,gi�
Brief Description of Proposed Work: Remove and replace roofing shingles c_�
C:) r -�:Z:IV iTt
.SECTION 3:'COMPLETE-THIS,SEtTI01NIF EXISTING BUILDING UNDERGOINGAE OVATION.ADDITION,OR ",
CHANGE INUSE OR OCCUPANCY-
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13
Existing Use Group(s): mesidential Proposed Use Group(s):
j 1 SECTION 4:]BUILDINGHEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
„SECTION 5,USE,,GgOPP(Check'agappi(eab
A: Assembly A-1 0 A-2 0 Nightclub 1:1 A-3 0 A-4 EJ A-5 0 B: Business 0 E: Educational 0
F: Factory F-I 0 F2 0 H: High Hazard H-1 0 H-2 El H-3 11 H-4 11 H-5 11
I: Institutional 1-10 1-2 0 1-3 0 1-4 0 M: Mercantile 0 R: Residential R-10 R-2 EX, R-3 0 R-4 13
S: Storage S-1 0 S-20 U: Utility [] Special Use 0 and please describe below:
Special Use:
.SECTION 6:WNSTRUCTIONjTYPE,(Chcck as applicab
IA 0 IB [3 IIA 13 IIB [3 IIIA 0 IJIB 0 IV 13 VA 0 VB 13
r I' J80tMIftli'Ofor�dc 11 ncac4ifte I , - -,�z
e' 6; nir,
", ,N� �,, 4,�'SECTION7,.�S1,TE,�INFOPIMIA*-rtOlf-�1(i��f,�r, 0 1 — 1, I I ' ' S'o Ir
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private Cl or indentify Zone:— or on site system 0 required 13 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 1:1 Is Structure within airport approach area? Is their review completed?
or Cement to Build enclosed 0 Yes 0 or NoD Yes 11 No 0
,SECn qN,9.1CONTENT OF tE TIE OCCUPANCY'.).,A'�,--.,-,'
9 ICATEOF�OC
Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
l
SECTIONi9: PROPERTY'OWNER AUTHORIZATIOI_V�-'
Name and Address of Property Owner
Green Dolphin 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 property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTIONN 16.CONSTRUCTION CONTROL(Please Pill out Appendix 2)"
-- if in ildin is Cess than 35,000 cu.'ft of enelosed`s aceand or not"under Construction-Control then cheek here d(and ski' Section iD 1) '
10.1 Re 'stered Professional Res onsible fo"r ConsfrucNon Control ,�:«--_� �h„,: ",` t' '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General';Contractor u
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
6038950400 603-2311677 tara@ktmproperties.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:W(JRKE s'.CCdMPE SATIOi `INSURANCE AFF DAVIT M.G.L:c,152. '25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 15 No ❑
-" SECTION'12 CONSTRUCTION COSTS AND PERMIT FEE , 'I
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ 5,000.00
1. Building $ 5,000.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ - Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
5,000.00 Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT,,,
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and iocurate to t best of ny knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign naCri r S I asa I Title Telephone No. Date
25 Spaulding Rd Ste 7-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to fill out thrs'sectmn upon application approval° ✓ '§" °'� `,
,� 'i �, ds-; Ea`C 4 '• ( ; ,v � i,+ Ey E �: �'� �*t "Name eq �' =F� F i tom, A� d� Date i.` ��:.