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149,151 WHALERS - BUILDING INSPECTION Ss Tb- 15-gam t S U0 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 ctionForOff icialUgere Building'Permit Number [Date Applied].�.' Building Official0; SFCTIO -��A r(Please iridicate,.Block,#'aj�l,d Lot f for-locations foi'which isfteetaddressis'�not available) ,� Bldg 177 149,151 Whalers Salem 01970 Green Dolphin No.and Street City/Town Zip Code Name of Building(if applicable) �`777777TTSiCTIOT4 2: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 Re pair 0 1 Alteration IN I Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1) Change of Use 0 1 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No EY Is an Independent Structural Engineering Peer Review required? Yes- 0 No [Z Brief Description of Proposed Work: Remove and replace roofing shingles E2 PO C) > SECTION, COMPLETE THIS SECTION IPEXISTING BUILDING UNDERGOING RENOVATION,"A TION r R, CHANGE MUSE OR OCCUPANCY:., Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13 � Existing Use Group(s): mesiaential Proposed Use Group(s): 77777777777� ......� SECTION 4i BUILDING HEIGHT AND AREN,�f"",, Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) app, z,"Sl�CTI()N5--'USEr—ROVP'((ttiickis' liable) A: Assembly A-1 El A-2[3 Nightclub 0 A-3 0 A-4 El A-513 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 1.- High Hazard H-1 0 H-2 0 H-3 13 H-4 0 H-5 0 I 1: Institutional 1-10 1-2 0 1-3 0 1_4 E3 M. Mercantile 0 R: Residential R-10 R-2 11 R-3 13 R4 0 S: Storage S-1 0 S-20 U: Utility El Special Use 0 and please describe below: Special Use: SECTION 6:CONSTRUCTION I' "b PE,.(che(Check app ica le) Lk 13 IB 0 IIA 0 1111 0 IIIA 13 IIIB E3 IV [3 VA 1:1 VB 0 SECT on each SECTION SITE for Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone D Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private El or indentily Zone: or on site system 0 required El or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Cement to Build enclosed❑ Yes 0 or No 13 Yes Q No 0 Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor: Does the building contain an Sprinkler System?:—Special Stipulations: ',!xSECTION9i PR_OPERTY04VNER`AiITHORIZAT'ION �.,� (s. 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. SECTION 10•CONSTRUCTION CONTROL(Please;fill out Appendix 2), < _. ,.. If buildin is less'than 35,000 cu,ft of enclosed s ace and/or not under Construction Control thencheck here Lund ski Seehon 10.1 I0.1 Re istered Professioital Re's onsible fonConstructiorcContro t;; Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 102 General"Contra ctor 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 603-231 1677 tara@ktmproperties.com Telephone No. business Telephone No. cell e-mail address ", SECTIION 11:YJbRKPRS'C MPE?PISA7�i�N' �iI `12.4 . .'AFP[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 ❑ 7 r ,SECTION12:CON5TRLICTI9N COSTS AND PERMIT FEE ' Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 15,000.00 1.Building $ 15,000.00 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 $ - 1500000 Enclose check payable to , . 6.Total Cost $ (contact municipality)and write check number here SECTION13:SIGNATURE OF BUILDING•PERMIT . . - _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 an ccurate t the b st of my knowledge and understanding. President 603-895-0400 8/18/15 Please print and si me a Minasalli Title Telephone No. Date 25 Spaulding Rd a 17-2 Fremont NH 03044 Street Address City/Town State Zip Municipal Inspector tmfrll out fhis'sechon upon application approval, �' p, Date Name „- .�- 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) 65 Cavendish 149,151 Whalers Salem 01970 Green Dolphin No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No B Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No d 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) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations VJ 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organimtion/Individual): KTM Properties, LLC Address: 25 Spaulding Rd - Suite 17-2 City/State/Zip: Fremont, NH 03044 Phone #: 603-895-0400 Are you an employer? Check the appropriate box: Type of project(required): 1, x❑ I am a employer with 25 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑x Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I L❑ 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 most also fill out the section below showing 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. tContractors 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: Union Insurance Company Policy#or Self-ins.Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016 65 Cavendish 149,151 Whalers Salem, Job Site Address: City/State/Zip: MA 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 hereby certify under the pains a penalties ofperjury that the information provided above is true and correct. Signature Date: 8/18/15 Phone#: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: IROWCER Phah� 643 34-Sgfl9 AesE •' t " .�..� 3rowr+8 Brawn(MrrlmBek) Fa 868 848 1228 "PHONE FAX Koh , 'Og DOnkel 4YebsteF Ae nock,NH03056 " ,e 6S,a,*, „� _._.. .hds McPhali , , - fG��NAIGW _ _ y. $URkTiISl AFFORGPiG C�1iVERA6„g ;_,,,,_,.t IwsuIRERA Vn n Insurance Compah NsDRE¢_ KTM properties'LLC eNs eREes ' _ r `-t _ 25 Spaulding Road ws , Fremont,`NH R3.04h - tNSVRFRD f MF417RERE _ 'T t �r CQYEIYAGES CERTIFICATENtlMBER REVISINNtfM13ER s THIS iS TO CERTIFY THAT THE-POLICIES OF INSURANCE LLSTED BEi.¢YJ HAVE tSSUED TO THE INSURED NAMED AHOVE FUR THE POtic , tmm INDICATED NOTWITHSTANDING ANY REQUIREMENT„TERM OR C15NOMiON OF ANY CCIVTRAGT,OR,OTHER DOCUMENT WtfH RESPECT TQY±!HECf?s THIS CERTIFICATE MAY BE IBSUELM.OR MAY f'ERTAjN,;THE`iNSORANCEsAFFORDEO:BY THE PC 1E5 DESCRIBED HEREIy i5 SUBJECT TO ARt�f1'}"TERMS E?{CLUS)QNS AND CONbIT,tONS;OF SUCH POLIGIFSLIM5T95HOWN MAYHAVP WrN'kEDUf-E.0'F3YPA1®•CLAIM5 .iC?E%P T �T TYPS�aP INRURANCE'. ! 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'Supplement Card•' Ezpiraban: 6t25 20.16 KTM PROPERTIES, LLC. CH , RLES ivt1NAS6,kLLt; 25 S:PAID ING RP SUITE 117`-2 FREMONT, NH 03044 A5 k Update Address'and return card.Mark reason for rtiange. Address f"j Renewal Employment ,_t Uast Card Al °' ttICC 0 {i0IL9ue9eP,4rlaifb 4.$useless:RC$ultlnOn Lloenseu� registration valid For individul use poly !!• before tht expirattan date It found return to; pM£iMPROYEM£NTCONTRACTOR s , pate of Consumer Affaus and Business Regulutsan RRegistra6an T60139 % TYpe.. -10 Park Nara.-Swta,517t1; f a' Exptrab4nc• 612016 t- .. . Sdpplement Card ,'llostdn,,MA QU M rPf PROPERTIES:LLC. ; -iARLEL INGMIN RD ILI µ•��"' i GPl#tLpING RO SUtTE 17 2 REMON7 NH 03044 Uaderucretary 'tint dt+'ittinn r I i { i zi j a A 1 1 5 �i ' i