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BLDG 86, 2, 4, 6, 8 AURORA LANE - BUILDING INSPECTION
• v The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) .-„- "y'"` BuildingPermit Application for an Building other than a One-or Two-Family Imi = PP Y S Y Dc� S' . ... - (This Secuon,For,OfficialUsgOnl ) Building Permit Number. Date Applied Bmldrng b4i': l i �1 SECTION.l•LOCATION(Please indicate Block#and L'ot#,foryloca$ons for which a street address is'not available) ^TZ / Bldg 86 2 4 6 8 Aurora Lane Salem 01970 Sanctuary Condominiums J r �Y No.and Street City/Town Zip Code Name of Building(if applicable) ` SECTION 2-PROPOSED-WORK;+ Edition of MA State Code used If New Construction check here❑or check all that apply in the two roc4f;rbelocl%, Existing Building❑ Repair❑ Alteration L11 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 permit application? Yes ❑ No Cff Is an Independent Structural Engineering Peer Review required? Yes ❑ No U Brief Description of Proposed Work: Remove and replace roofing shingles 'SECTION 3r.COMPLETE THIS SECTION IF EXISTING BUILDING'LINDERGOING RENOVATION,ADDITION,OR - CHANGE IN USE OR OCCIIPANGY' Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Hesidential Proposed Use Group(s): Residential -:SECTION 4;BUILDING�HEIGHT ANO 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;U§E GROUF,(Check'as'a 'licats)e) A: AssemblyA-1❑ A-2❑ Nightclub ❑ A-3 ❑ A 1❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ 13❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 IT, R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE{Check as a lieable), -:=i} TA IB ❑ IIA ❑ iIB ❑ IHA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer tq 78Q,CMR111.0 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: 1AA 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: SECTION 9: PROPERTY(IWNERAUTHQRIZATI6N 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 a lication. ` SECTION 10;CON STRUC'RON CONTROL`(Please,fill out Appendix 2), [f buildingis less than35,000 cu ft of enclosed s ace and or hot under Comu'uction Control then'check here f 'arid ski SeG4ori 101 10.1Re"stered Professional Responsible for Construction Control 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 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:WORKERS'4'OVtP$NSATION,INSLIRALcE ArnD AV 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 ❑ "SECTION11 CONS,-I2UCTION'CO$TS AIJ6PERMIT=FEEf Estimated Costs: (Labor Item Total Construction Cost from Item 6 =$ 20,000.00 and Materials) ( ) 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 $ - 20,000.00 Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLI,CANT 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 tr a and cc ate to a best of my knowledge and understanding. President 60389895-0400 6/7/16 Please print an gn name r el S Min S li Title Telephone No. Date 25 Spaulding d Ste 17-2 Fremont NH 03044 S Street Address City/Town State Zip 1 Municipal Inspector to fill out this section dpon appHcztton approval 'Name Date r CITY OF S.UENI, TNLkSSACHUSETTS BumDLNG DEPARTNmNT 130 WASHINGTON STREET, Va FLOOR TEt_ (978) 745-9595 FAX(978) 740-98" KIJtBERLEY DRISCOLL MAYOR THOKILS ST.PIERM DIRECTOR OF PUBLIC PROPERTY/BU DING CON MIISSIONER 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) signature of pe t a piicant srnzots date SebristtT.Jtu: 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) 2,4,6,8 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 11 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 11 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) The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations twl 600 Washington Street Boston,MA 02111 wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgmization/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 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, employees and have workers' 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 I LF] 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 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Union Insurance Company Policy# or Self-ins. Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016 2,4,6,8 Aurora Lane Salem, MA Job Site Address: City/State/Zip: 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 a 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 force 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 thee pains d penalties ofperjury that the information provided above is true and correct. Sivnamre�/ 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#: � . _ C�../J!C ((:`f�JTlli'[fS�f(flSl?!lt�fll• C+ .`-'—.'��L.CG:i.it.C•C.flt/iP,C�:i• Office of Consumer Affairs id Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 IJotne Improvement Contractor Registration Repisl Type: Supplfr p Type: Supptemenl Card Expiration. 6/250016 KTM PROPERTIES, LLC. CHARLES MINASALLI 25 SPAULDING RD SUITE 17-2 FREMONT, NH 03044 lipduteAddress and return mai&dark moan for tbangr. f,.• a h++cY± :;Address Rrvewal EmPlaymeat 4osi Curd • (ncr of C mumer dfmu,S Halt..,Regulxt a Laeme"re ntratlot.valid to,indMd-1"t aaly �`btE lUPROVEMENI CONTRACTOR baferuhr explrndon date. If found return lo: t q Office of Cumumer Affairs and Business Regulation MaGistmuuw le0139 Type: tO Pa'u Plates-Suite 51T0 itfi Expiration: 6MS12041 Suppiemeni Cato Bo.mn..�l4U2116 KTlA PROPERTIES.LLC. - ChWLES MIKASAi l 25 SPAL10MG RO SUITE 37-2 •:'�-f-•— r.--- �, . FREMONT,Bol 030.14 UnJrnetrearp �,'Nat ddllbout ^. L I i a Massachusetts-Department of Public Safety ; Board 61 Building Regulations and Standards ! Conaruciion Sunercisnr vets License:CS-071077 CHARLES J 6I NA -'fOR' I I 25 Spaulding Rd SFe1 Fremont NH.03044 i Expiration 1 Commissioner 07/25/2017 ! I 1 i t M I i i { i i KTMPR-+ OP ID:MMR CERTIFICATE OF LIABILITY INSURANCE ogre""�"I osn2rmIs THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONWARD CONFI RII NO ROM UPON THE CERTIFICATE HOLDER.TM CERTIFICATE DOES NOT AFFMMAWALY OR NEGATIVELY ANN. EKTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEMM THE ISBUB16 BI URU44 AUTBOIUE D REPRESENTATIVE OR PRE AND THE CERTIFICATE HOLDER. IM ORTAMP I BID owditab I ler Is an ADDITIONAL MURlD,th po0ay(los)must M oodetset N SUBROGATON E WART®,s*Dd to the tams and eondlEms of ow poBry.OwtHln Pam mBy Faqube an wWemwnart A alstoRwd an Oda awdBeals daoa not eonfw d9 to Is Bar owtlEeste holder,to Bou of sack PROPUCa1 R;IRv -BOSd2A-OB01 BrawrI&S FDIC 804114MI14221 =MIMCAW 03096 eovaRAm wacB IMMIMEM A•Union hOINOB:B DISMAN KTM Pmpwtks LLC 25SpeuldlTIg Road BDURarla: Remold,NN 030" o• E: COVERAGES Tien is TO CEtnFY THAT THE POLICIES OF DOLMANCE LISTED BELOW HAVE SEEN ISSUEEI TO THE INSURED MAIMED ABOVE FOR THE POLICY;1.000 IMICATED. NOTamHSTANDIRB ANY RECiA�B/f.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMSHf VWN RESPECT TO WHI CERrF ATE MAY BE msum OR MAY PERTAIN.THE DIMMAICE AFFORDED BY THE POLICIES DESCRIBED HMNEN m BUBdECT TO ALL THE DMUSIOM AND CONDITIONS OF 81"POLCIESI LAIRS SHOWN MAY HAVE BfEal REDUCED BY PAID C ABIB. TrrFOFmIwAIIR Lama aelatlmLLL%s I EACKOCCIAME CE a A X owaaxauLLrawTY IM+Ot>D&11 ODHOf8010 OBNEQMB a CIA ❑X m/ERALAammDAre a 2AODA OERAaaROMTEIAOTAPPIDBIAETt CHI. AGO A 2A80 MLCY X Lm a el/oeas LNaalTr 1• A � j X Allr MINB008 MOMS eeoammvYmaa Mwr/vIPw Aur1 HIRMAe X A6 x D..r�wm.Das aaaa so= eACHoccuntoCa a BAMBOO! A EF®ewe CLADMALW 6131dA1 OL46 MB 01111612016 AgOADCATE s 5.000. x +a9oD ■ WORK=Cmpgnmv R X JIM A ,sa.F aTi�s e T CA518Y378A7 OE180Ms DIVISIONS aLeWHAoemH+r s 1A00. o/ssaVeOLOEA OIa/reFm LtlJ MIA IWedAbrb reO FL meFABE.Fa a 1 .00 tl tloa+ea.me,r tear 1000 OBBC OMGFOPMtA=WILOCATMMIVBDMO(ADM AOIm W%A*MM;ad Rmmbed0dU%NlAem wmbmubao C MOULD AM OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes THE EXPIRATION DATE TNHEP. NOTTCS WDL an DELIVERED INTPaB ACCORDANCEVIMTHEPOLCYPROYiSICLM . Only AunmR®a�NmTNa Chda McPhaB 0 1980- MG ACORD CORPORATION. AD dgMs reserved. ACORD 25 P010105) The ACORD Moore and logo are registered meTlm ofACORD