2,4,6,8 ADMIRALS LN - BPA-15-856 ROOFING A ZZ O
The Commonwealth of Massachusetts
VVVVU��ff 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 For Official Use Only). ...-. . ,n,`.
Building:Permit Number: Date Applied: ' -Building Official:
SECTION 1::LOCATION(Please indicate Block#and Lot#for locations for which a street address is not i'Klab
2, 4, 6, 8 Admirals Way Salem 01970 Mariner Village a c-->
No.and Street City/Town Zip Code Name of Building(if app ble) om
SECTION 2:PROPOSED WORK, O D— -
Edition of MA State Code used If New Construction check here❑or check all that apply in the two Dws bmgG
Existing Building❑ Repair❑ Alteration C Addition❑ Demolition ❑ (Please fill out and submit tlpendiX,--')
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 Cat
Is an Independent Structural Engineering Peer Review required? Yes ❑ No [X
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): Hesiclentiai Proposed Use Group(s):
SECTION A: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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2 ET R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
- - SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
-- SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site El '
Public❑ Check if outside Flood Zone[I Indicate municipal❑ A trench will not be P
Zone: or on sites stem❑ required❑ cl trench or specify:
Private❑ or indenti
f3' y 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 OFOCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
- SECTION 9: PROPERTY OWNER AUTHORIZATION: -�
JName 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 property owners behalf,in all matters relative to work authorized by this building permit application.
�SECTION 10:CONSTRUCTION'CONTROL(Please fill=out Appendix 2)
rtx,
o If buildingis less than 35,000 cu.H. Construction of encloseds ace and/or not under Control then check here lfand ski' Section 10.1
10.1 Registered ProfessionaLRes onsible for Construction:Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
'102,GeneralContractor
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
".. SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 ❑
r SECTION 12i CONSTRUCTION COSTS AND:'PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 20,000.00
1.Building $ 20,000.00 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 $ Enclose check payable to
6.Total Cost $ 20,000 (contact municipality)and write check number here
s - _ SECTION 13:SIGNATURE 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 accurate to the best of my knowledge and understanding.
President 603-895-0400 7/15/201
Please print and i name Charles inasa li Title' Telephone No. Date
25 Spaulding Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Muntctpal.Inspector to-fill out this:section upon application approval: _-
-,.::, Name
III