BLDG 89, 22, 24, 34, 36 AURORA LANE - BPA-16-657 REROOF BLDG • r �I
The Commonwealth of MassachusettsP
Department of Public Safety
�
\y4 i Massachusetts State Building Code(780 CMR) .
Building Permit Application for any Building other than aOne-or Two-Family DwrtHin g
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i. '(This Section For Official Use Onl yi I.'
Building Permit Number; Date Applied. Building Official----", ' -IiiE "
9 SECTION 1:LOCATION(Please indicate Block#arid Lot#for locations for which`a street addiess`isot avaz le) ,
( Bldg 89 22 24 34 36 Aurora Lane Salem 01970 Sanctuary Condominiums
No.and Street City/Town Zip Code Name of Building(if applica e)
' SECTION 2:PROPOSED"N'ORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two ror73 below"
Existing Building❑ Repair❑ 1 Alteration 0 1 Addition❑ 1 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 a
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION 3 COMPLETE THIS SECTION IF EXISTING BtRLDING UNDERG ENOVATION,ADDITION;OR i
CHANGE IN USH OR OCCUPAN&I,
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Hesidentai 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.)
SECTION 5:USE,GRO:0(Check as a licable)
A: Assembly A 1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ 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 TYPE(Check as
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIiB ❑ IV ❑ VA ❑ VB ❑
. SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 fon3ewls on each item)';
q
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
required El or trench or specify:
Private El or indentify Zone: or on site system❑ 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 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: PROL'ERTY,O"tRAUTHI�RIZATI(jN• r "°
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:CONSTRUCTION CONTROL(Please fill out Appendix 2)'_ ^ ,t
buildingis less than 35,00 cu ft of enclosed s ace and or not under Construction Control then check here 4and ski'p Section 1Q.1
10.1 Registered 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. 6/25116
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',coMPE:NSATION INSURANCE AFF13AVIT(M.G,U 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 si ed Affidavit submitted with this application? Yes Eel No ❑
SECTION12:CONSTRUC}'ION;COSTS ANU 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 $ -
20,000.00 Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
:SECTION 13'SIGNATL1I;E OF.BUILDIIVGPERMIT 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 d accurate o the bes f my knowledge and understanding.
President 603-895-0400 6/7/16
Please print d sign e ariErs ToTnasalli Title Telephone No. Date
25 Spa Idin Rd,04e 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application appni'ya ib
Name Date
CITY OF Si .&%I, NLkSSACHUSETTS
BUUMLNG DUARTMUNT
120 WASHINGTON STREET, 3'FLOOR
TEL (978) 745-9595
FAX(978) 740-98"
IU.NtgF t F.Y DRISCOLL
MAYOR THomAS ST.PrERM
DIRECTOR OF PL SUC PROPERTY/SUMOiNG CON[ARSSIONER
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
I 11, 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)
sig *omi(applici&
6/7/2016
date
JcbriulT.Juc
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)
22,24,34,36 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 121 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ Noll Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No CF 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
wi 600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgmimtion/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.❑ 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.t
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 I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12Z 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 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 most submit a new affidavit indicating such.
•Contractors 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 andjob site
information.
Insurance Company Name:
Union Insurance Company
Policy#or Self-ins. Lie. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016
22,24,34,36 Aurora Lane Salem, NIA
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 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 ands enalties ofperjury that the information provided above is true and correct.
en Siature: ^ 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#:
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%fie `f:(1))eI in,rr)e�r�i`fr a `Gft�lcrlirzt rr:nl�`i
��. Office of Consumer Affairs dnd Business Regulation
AN 10 Park Plaza- Suite 5170
=' Boston,Massachusetts 02116
Home Improvement Contractor Registration
'RegistrType: Suopte
Type: SuvPlament.^.ard
x - £xphation.. &n_Sij2()'IB
KTM PROPERTIES, LLC. -
CHARL.ES MINASALLI
25 SPAULDtNG RD SUITE 1.7-2
FREMONT,NH 03044
Update Addr aZ1 and return=n Alark raw"far rh40Xe.
Address -1 E.Pk-..Mt i_ Last Curd
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KTM PROPERTIES.LLC.
CMAPLES MLWSALLI ,
25 SPAL6ENNG RO SUI:E 17-2 .`'�F--}
FftEMONT,NH 0304E UnJan:erePry ' r'Nnt
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards 3
Constructirp Supervisor
License: CS-071077 i
CHART ES J.=, 'ry I
25 Spaulding Rd Sf_ - IF L i
Fremont NH 03074 I
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Expiration
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CERTIFICATE OF LIABILITY INSURANCE
THIS CERTOICATE IS ISSUED AS A MATTER OF INFORMATION OIRrAND CONFERS NO ROM IUFON 111E SATE HOLDER'HIS '.
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEMATIVELY AMNIEN% EKMW OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INEURAINCE DOES HOT CONSTITUTE A CONTRACT BETTPE@N THE ISSIHNO BNSUMAIR p, AUTHORED
REVIMENTATM OR PROWCER MW THE t pTE ROIDER
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SHOULD ANY OF THE ABOVE OESCRISED POLICIES BE CANCELLED BEFORE
For INdorNrmtlonel Puryasea aADoo �1wla TTHHEEPauCYt fi BILL BE OEAaII6D IN
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Chile McPhaE
01988.2010 ACORD CORPORATION. AB rlShm meerved.
ACORD 25(21110" The ACORD nomme and 6W are m btered molt of ACORD