71,73 WHALERS LN - BUILDING INSPECTION CA�- t 5(o g Li $,//o
The Commonwealth of Massachusetts
ti Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Tlus SectiomFor Official Use Only).. - --
Building!permit Number: Date Applied: Ij Building Official:
SECTION 11:�L)OCATION(Please indicate Block#and Lot-#for locations for which a street address'iss not.availab`Ie)
O,X-R Salem 01970
t No.and Street City/Town Zip Code Name of Building(if applica le)
_ SECTION.2:PROPOSED:WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
(11-- Existing Building❑ Repair❑ Alteration Li( 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 pemut application? Yes ❑ No ly
Is an Independent Structural Engineering Peer Review required? Yes ❑ No C8
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): esl en Ia Proposed Use Group(s):
SECTION 4:B,UILDING.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.)
SECTION S:•ELSE GROUP(Check.as,applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ All❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1 El ❑ I-3❑ Ill❑ M: Mercantile❑ 1 R: Residential R-ID R-2 Cat R-3❑ RA❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use ❑and please describe below:
Special Use:
SECTION&CONSTRUCTIOIN TYPE{Check_as applicable),
IA ❑ IB ❑ IIA ❑ IIB ❑ IIL4 ❑ IHB ❑ IV TVA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 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❑ required❑ or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process
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 CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
rnt� tt_k-D $ � 1 3 ri C71
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Mariner Village Salem
Name (Print) jaddress
No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-ma
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 proj2e5y owner's behalf, in all matters relative to work authorized by this building permit ap2lication.
SECTION 10:CONSTRUCTIONS CONTROL(Please fill outAppendix.2).
If buildin`is less than35,000 cu.&..of enclosed act and/orpot under Construction Control then check here I.Yand ski Section.10.1 t
_ .
10.1.Re 'stcred.Professional Res onsilile for ConstrucHontConfrol
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
KTM Properties LLC
Company Name
Charles Minasalili 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 603-231 t677 tara@ktmproperties.com
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:480AKE2S'COMPENSATION[NSURANCE�tSFFIDA4IT: .G.L.cl 152. 25C 6 . � .-
A WorkersCompensation 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 EY No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$ IPZl9_ �•-��
1. Building $ ZO, ""D 20 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 $ 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 elow,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true accu the best of m knowledge and understanding.
President 603=89895-0400 '.L!
i
Please print an 'gn name Charles I a I Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to:fill out this section upon application approval: .�3
Name Date:
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)
I,�Salem 01970
No. and Street City/Town Zip Name of Building (if applica e)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No 13 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 IJJ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No IN Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Department of Industrial Accidents
Office of Investigations
'- c 600 Washington Street
ti Boston, ALL 02111
4 www.tnass.gov/dia
Workers' Compensation Insurance Aflidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibiv
,Name (Business/Organizatiordlndividual): 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 1 Type New
(required):
❑ [ am a employer with 25 ❑
employees (full and/or part-time).
have hived the sub-contractors 6. ❑ New construction
❑ I am a sole proprietor or partner- listed on the attached sheet. 7. x0 Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
❑ 1 am a homeowner doing officers have exercised their all work t 1. Plumbing repairs or additions
t£m se ' o workers' right of exemption per N[GL
Y � coo P 12.0 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 XI must also fill out the section below showing their workers'compensation policy information.
tmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
loyees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
vn an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
grmation.
urance Company Name: Union Insurance Company
icy#or Self-ins. Lic. #: WCA5152316-10 Expiration Date: 6/16/2016
J /J Salem,
Site Address:�I 573 GU1�a � e_ City/State/Zip: MA
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
e up to S 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 D[A for insurance coverage verification.
z hereby certify under the pains am1 penalties of perjury that the information provided above is true and correct.
p0 pp
nahve7 ,� ��I(�e. is i1�72 wt�`—'�l� Date:
me#: 603-895-0400
Offteial 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#:
J'
Office, of Consumer Affairs And Business Regulation
1.0 Park Place - Suite 5 170
Bcistor, Massachusetts 02116
Home Improvement Contractor Registration
Registration 160139
Type Supplement Card
KTNI PROPERTIES, LLC. Expiration 6/25t2016
CHARLES MINASALLI
25 SPAULDING RD SUITE 17-2
FREMONT, NH 03044
Update Address and return card. Mark reason far crruinec.
"Jill Address Renewal Employment Lost Card
all
Ile—11
.�L
h"
ffirc'o[C,)nsumtcr affairs& Business Re-ulation License o; re-istration valid for individul use only
befure the,expiration date. If found return to:
ME IMPROVEMENT CONTRACTOR Off-ke of Consumer Affairs and Business Regulation
5"WE egistration; 16C139 Type -10 Park Flaza Suite 5170
Expiration: 6i25i2016 Supplement Cary Boston,IVIA OZI 16
I PROPERTIES, U C.
.RLES MINASALLI
P4ULDIN,3 RD SUITE 17-2
MONT, NH 03044 Cuderse-retary 4 d without siKnaturc
-!�144 n I IYIrR•I yr ILL..InYu.
CERTIFICATE OF LIABILITY INSURANCE ans1tuz 5r
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFEKS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE:PGGICIES
BELOW. THIS CERTIFICATE OF INSURANCE ODES 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..subye�t to
the terms and conditions of the policy, certain policies may require an endarsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
cooucER
Phone:603-424.9901 NAAsTA;Gr
'own &Brown(Merrimack) Fax: 866-B48-1223 retire --1 -- -- : FAX —'-----
9 Daniel Webster Highway Nc,N�rg _�--_—_— .— FAX
-refmack, NH 03054 EMAIL
iris McPhail
BJSURER(S)AFFORDING COVERAGE NA(C G
---"-,—------------._._ ------------_-- INsu,EB A Union Insurance-Company_—_--... 25Q44
;URED KTM Properties LLC msuRena _ __
25 Spaulding Road
Fremont, NH 03044 INSURER c
It BUREP o
INSURER F:
OVERAGES CERTIFICATE NUMBER: - - REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BF=N ISSUED TO THE INSURED NAMED-ABOVE'FOR THE POLICY PERICO
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIC-i THIS
CERTIFICATE MAY BE ISSUED OR MAY PER`AIN, THE INSURANCE AFFOPDE: 3'( LIE. P"!iaES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS5
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES JAIITS SHO'hN MAY HAVE G ti RIiDUCED BY PAID CLAIMS.
-rAa0L�5UBR _ F OLIL EFi�PO EXP.0 LWRs
R; TYPE aF INBDRANCE�Iyµryn. POLIO NUMBER I'HM DC YY Yl'IMM OCIYYYYI
GENERAL LIABILITY i EACH OCCURRENCE S _1rv000,000
i--. AIw,-ZTO'-FEN fEn.
rX l co+.r..IERCIAI.GENER�:i.L.AB�Tv -CPA5152306-11 i t}6(16i2D1$�06116/2016 �PREMI ESIEa'o .wre w 5 "1QQ,oQ
00
CLAPAS+MDE LJ.OCCUR i MED FXP(A V,ana persanl 5 5,00
J _ t PERS�WJURY s 1:.000,00
(GENERAL AGGREGATE _ a,pQa'.QO
! -- -- -" -- i PRODUCTS-COMP OP iG
- GENL',GGREGATE NINUT APPDFS P%R: -
1 r^PRO- I^I_CC j 5
COMBINED SINGLE LIMIT t._000 QQ
LAUTOMOBILE LIABILITYactlde^ti__
ANY AU.D '.CAAS 152308-11 J6116,2015 j 0 6/1 612 01 6 rBODILY INJURY leer pelvm:. s _-
AL! NNED X SCM_DU''-ED j ! BODI YINJURY Ire,awc.,Q 5
AUTOS AUTO' - I ~PROPERTY DA.4wG
X i HIRED AVTOB ^X AUTOS"N-co j i IPeramdenrl
S
EACH OCCURRENCE
�( UMBRELLA LABX 1 OCCUR
EXCESS LIAR {CLVMS.W.DE: ,CUA51.52314-11. i-_66}16f2Q1$ 0611612016 AGGREGATE 5 41000r
! DEO X RETElITION,S 10000! s
WORKERS COMPENSATION ! ! * _ X - YPSTATU- IDTH-:, _-
TOR LATU - , +
AND EMPLOYERS LIABILITY YIN e- 1,000,00
ANY PROPRIETORIPMTNEREXECUTNE I 'W CAS152316-11 ! 0616'2015 06I16/2016 EACH ACCIDENT _
CFFC=rU AEMe`R�XU% Y NN -N I A I i - 9,OQ0,00
(Mandatory In NH) -- E L DISEASE-FA EMP OYES
_--
d Yes.descdhe under E L DISEASE.'Pc�EY LMrT I.4 1,000,OQ
OESCRIPr1ON OF OPER,`,TIONS'veW I .--
i
ESCRIPTION OF OPERATIONS LOCAOONS I VEHICLES Uuui.h ACORD 101.AddihonalAo;nads Schedula,if mare uPa...is required)
;ERTIFICATE HOLDER CANCELLATION _
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED:BEFORE
THE: EXPIRATION DATE THEREOF.- NOTICE WILL BE 04NERED` IN
For Informational Purposes ACCORDANCE WITH THE POLICY PROVISIONS.
Only
AUTIIOfifVt6 REPRESENTATME
Chris McPhail
,b 1988-2010 ACORO CORPORATION. All rights4roOrved.