8 ECLIPSE LANE - BUILDING JACKET •
No 15330 'gT
HASTINGS. NN
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O. COPY
CITY OF SALEM
Issued. it 4.
CRY of Salem WNW Dem.
SALEM, MASSACHUSETTS 01970
DATE OCTOBER 29 e 99 PERMIT NO 72 -1999
uppuu^w --------_auvnESv ---- -'-T-T STREET _-'
(NO) tSTREET) (CONTRS LICENSE)
CITY ASHLAND --STATE MA z|poODE01721 nEL.wn. 508-881-16q0
PERMIT To NEO BU7LDING � NUMBER OF
_� TWO OR MORE FAMILY �E���Uwnn 4
nY, op/mpR^vcwcwo NO r"vr"Sn.o^w
ZONING
AT(LOCATION) 0006 ECL I PSE LANE U 1. 6c",Q DISTRICT-2--31—
LOT
SUBDIVISION IYAP 1217 LoT_,!�_0_8] BLOCK SIZE I.S. 7.) ACRES
BUILDING mToas,_---_---_-__'prWIDE ov-__------_---'pruowaov FT./wooaoTAND SHALL CONFORM/wCONSTRUCTION
TOnPEUSEBASEMENT WALLS OR FOUNDATION
newxnxs: B OF
� psnwPERMIT
VOLUME' emwm��� 00- FEE
(CU81CISQUARE FEET)
FAFA8D R. E
nwwsn " D. C. BUILDING DEPT.
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�Z\ 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
(This Section.1of,01ficial Use Ofil Building Permit Number.
uilding
'd&'SECTION 1-'LOCATION jekas6 indicate Block#'and Lot#I or locations for which a street a essis not available) a,
"Lc' 01970 Green Dolphin
Bldg 182 8 Tip's'e......... Salem
No.and Street City/Town Zip Code Name of Building(if applicable)
"S RK ON2:�Plk P SED
ECTI 0
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 12S TAddition 0 1 Demolition 0 (Please fill out and submit Appendix 1)
Change of Use El Change of Occupancy 0 1 Other 11 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Cy
Is an Independent Structural Engineering Peer Review required? Yes 0 No [2
Brief Description of Proposed Work- Remove and replace roofing shingles
c�
f',,SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITIOM OR
CZ)
CHANGE lNiVSE bR"OCCUPANCY J
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13
Existing Use Group(s): Hesidential Proposed Use Group(s): �
,SECTION,4,BUILDING HEIGHT AND ARE]A
Existing (n Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft)
" lf6ckLas I appncab,31iCT16N 51.'USE,GROUP(C A: Assembly A-1 0 A-2 0 Nightclub El A-3 E] A-4 0 A-5 0 B: Business El E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-I 0 H-2 0 H-3 0 H-4 El H-5 0
1: Institutional 1-10 1-2 0 1-3 0 1-4 0 M: Mercantile El R: Residential R-10 R-2 IT R-3 0 R-4 0
S: Storage S-1 0 5-213 U: utility 0 Special Use 0 and please describe below:
Special Use:
SECTION6,CON_ STRUCTIPNapplicable)TYrE(Chetkas Lk 0 IB 0 IIA 13 IIB 13 IIIA 0 IIIB 0 1 IV 13 IVA 0 VB 13
SECTIO
N SITE INFORMATION(ncferto,,78WCMR llt.016rdetafls,on each
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone El Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone:— or on site system 0 required 0 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 Consent to Build enclosed 0 T Yes 0 or No 0 Yes 1:1 No 0
7
OF NCY-_SECTION ff_-' NTENT-CfCERTIFICATE OCCUPANCY
Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
,t: 4 ":SECTION?9: PROPERTY OWNER`AUTT30RIZATTON . ,
'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.
^ti SECTION 10 CONSTRUC'ITON CONTROL(Please fill out Appendix 2} t
`
If•buildm �s less than 35,000 cu.ft"of encloseiis ace and'or not under�onsteuc i rn trot`theti-check here�E' and ski' Secuon 101
1Q.1 Re 'stered Profes'sanat'Res onsilile for Constructioir`Contml.!. .�.,:�rh ,y�.
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
'ID.ZGeneral_Confractor�
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 60a231 1677 tara@ktmproperties.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:Wt7R FRS'CQMPFNSAT Q1N NSUR NCE AF I7AVI1' M.GsL.c:152. �i25C 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 1221 No ❑
SECTION i2d CONSTR(_ICTTON COSTS ANI)>PERMIT FEE
Item Estimated Costs: (Labor 15,000.00
and Materials) Total Construction Cost(from Item 6)_$
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 $ -
$ 15,000.00 Enclose check payable to
6.Total Cost (contact municipality)and write check number here
<.: PSECTION43: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 ccurat tot best of my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign e a Title Telephone No. Date
25 Spaulding Rd S 17-2 Fremont NH 03044
Street Address City/Town State Zip
a E72
Mumerpal Inspector to fill out this section upon application approval
"rx a 7
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