BLDG 101, 61, 63 AURORA LANE - BUILDING INSPECTION Q ,_ 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 Dc4Rging
__S( (This Section For Official'Use Only) ' rst
Bui(dmg Permrf'Number. Date Appbed.,` ,. ; ", _ 'Boilding QfBctaL'
SECTIO '. TI N Pleaseindicate,Block.#and Lot#for locations for which a street address is not available)
Bldg 101 61,63 Aurora Lane Salem 01970 Sanctuary Condominiums
i No.and Street City/Town Zip Code Name of Building(if applicab
1 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rods below S
Existing Building❑ Repair❑ Alteration 0 1 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Cf
Is an Independent Structural Engineering Peer Review required? Yes ❑ No IB
Brief Description of Proposed Work: Remove and replace roofing Shingles
SECTION 3 COMPLETE THIS SECTION IF EXISTING=BUILDINGVNDERGOING,RENOVATIONy ADDITION,OR
CHANGE IN USE
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): hesidentiat Proposed Use Group(s): Residential
" SECTION�4: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.)
- tSECTION 5:USE GROUP(Check as a plicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2 Cl H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑t R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
- SECTION 6:CONSTRUCTION;OPE(Checkas a' hc`able)",TM= '+
TA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 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❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not c P
Private❑ or indenti Zone: or on sites stem❑ required❑or trench or specify:
�' }' permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Yrncess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTTON 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION,
Name and Address of Property Owner
Sanctuary Condominiums 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:C.ONSTRUCTION CONTROL(Please fill out Appendix 2) ' s"
If buildin is less than 35,000 cu.ft.of enclosed s ace and or iiot unde3 Construcuofi Control then check here:C)`and ski Secbon 10.7
10.1 Registered Professional Res onsible-for Construction ConttoT "` " ' e s '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor
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 60a2311677 tara@ktmproperties.com
Telephone No.(business) Tele one No. cell e-mail address
SECTTON21:WORKERS"`O.MPf,NAT SiON 1NSUi2ANCE APF DA 1T .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 IN No ❑
SECTION:I2 CONSTRUCTION COSTS,AND PERMIT FEE x'z
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 $ 20,000.00 (contact municipality)and write check number here
`SECTION 13SIGNATURE OF BUILDIWG PERMIT,APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that allof the information contained in this
application is tr and a curat to the st of my knowledge and understanding.
President 603-895-0400 6/7/16
Please print and s name ar inasa i Title Telephone No. Date
25 Spauldinq Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipat Inspector to fill out this section upon application approval - "f^ L+'✓
",Name. Date
CITY OF S'U.&%l$ INLAISSACHUSETTS
BuumLNG DEPARTNxN f
I-V WASIQNGTON STREET, Vo FLOOR
TEL. (978) 745-9595
FAX(978) 74"W
KIMSERLEY DRLSCOLL
MAYOR THOWS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/8L'ILDING COMMMIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A_
The debris will be transported by:
MA Waste Systems Inc.
(name of hauler)
The debris will be disposed of in :
300 Centre St _
(name of facility)
Holbrook, MA
(address of facility)
siRnatur 'permit applicant
smz0ts
date
d�br�utrdce
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)
30,32 Whalers Lane
61,63 Aurora Lane Salem 01970 Sanctuary Condominiums
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 0 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No 0 Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No E1 Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No E3 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 oflndustrial 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/Organization/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. 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.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ 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.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
-Any applicant that checks box#1 must 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.
tContraetors 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.
I Union Insurance Company
Insurance Company Name:
Policy#or Self-ins. Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016
Job Site Address:
61,63 Aurora Lane and 30,32 Whalers Lane City/State/Zip: Salem, 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
yc P�
c�le_rttify��under
�thee pailn/s nand penalties ofperjury that the information provided above is true and correct.
Sitmature_ / '�t/[�Y/I //� Date' 6/7/16
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#:
Office of Consumer Affairs end Business Regulation
10 Park Plaza Suite 5170
Boston;Massachusetts 02 t 16
Home Improvement Contractor Registration
Regiat Type: upplar
Type: SupR:err;en!Curd
Explration. 9r252WS
KTM PROPERTIES, LLC.
CHARLES MINASALLt
25 SPAULDING RD SUITE 17-2 "-
FREMONT, NH 03044
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