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BLDG 10, 1, 3, 5, 7 BENGAL LANE - BPA-16-663 ROOF BLDG 10 \ 0 � The Commonwealth of Massachusetts 0 Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling � ;l- (This Sec Fbr Official Use Only) _-`'E tion Building Permit Number: �' Dete Appbed Bmlding Offx�al „' ' r } 9 ,SECTION 1:LOCATION(Please indicate Block#and Lot#,for fgc4iions for.which a street address is not avalF£ble) &11 Bldg 10 1 3 5 7 Bengal Lane Salem 01970 Sanctuary Condominiums : F No.and Street City/Town Zip Code Name of Building(if applicab a SEGTION'2 PROPOSEDWORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows elow R' Existing Building❑ Repair❑ Alteration [ Addition❑ Demolition ❑ (Please fill out and submit ApperfM 1) I_ 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 11' Is an Independent Structural Engineering Peer Review required? Yes ❑ No 13 Brief Description of Proposed Work: Remove and replace roofing Shingles SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITIQN,OR .CHAN66N USE OR-OCCUPANCY +s `' Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Hesidential Proposed Use Group(s): 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 56 USE GROUP'(Checkas a'" licabe) 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❑ I: Institutional I-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2[1, 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 lieable +" IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 78Q CMR 111.0 for details oit each item) - 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 Private❑ or indentify Zone: of on site system❑ required El or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Co+nnussion 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 S:CONTENT OF CERTIFICATE OF.00CUPANCY. 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 tlWNER 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:CONSTRUCTION CONTROL(Please fill out Appendix 2) If b Iding is less than 35,000cu.ft.of enclosed space and ai hot underCon'struction Control then cheek here['`and ski Section 101 10A Re '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. 6125/16 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'-COMPENSATION NSURANCE'AL Vrr .G L.c.152.9.2SC 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 [21 No ❑ SECTION.12•CONS TRUCTTON 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 $ - 2Q00000 Enclose check payable to , . 6.Total Cost $ (contact municipality)and write check number here SECTION 13:S IGNATURE OF BUILDING PERMIT APPLICANT e w,. Ih e u 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 ccur e to e bes f my knowledge and understanding. 7/ President 603895-0400 6/7/16 Please print and sign e 'Charles \71inasalli Title Telephone No. Date 25 Spaulding Rd Se/1 7-2 Fremont NH 03044 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name . _. Date CITY OF S.U.E,NI, T%Lkss kcHUSETTS ' BL'ILDLNGDEPART E&NT 120 WASHINGTON STREET, NO FLOOR \ TEL. (978) 745-9595 FAX(978)740-9846 lU1%f9ERLEY DRISCOLL MAYOR THo&w ST.PrERRH DIRECTOR OF PUBLIC PROPERTY/BUILDING COWNUSSIONER 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 a 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shalt 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 o rmtt applicant snizoi s date Jchrial'f.Jor 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) 1,3,5,7 Bengal 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 13 Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No 1:1 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 UV 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/Organimtion/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 g. ❑ 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 11.❑ 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 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 and job site information. Insurance Company Name: Union Insurance Company Policy#or Self-ins. Lic. #: WCA5152316-10 Expiration Date: 6/16/2016 1,3,5,7 Bengal 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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains dpenalties ofperjury that the information provided above is true and correct. Signature / / sue�/g�� Date7 6/7/16 Phone#: 603-895-0400 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4 .. I I l a i i I Massachusetts-bepartment of Public Safety Board of$uilding Regulations and Standards Cnn:trurtion 5unervi%ar License: C5471477 . F` C ri hq CBARLES IN l'JM t- 25 Spa riding Rd Sh I Tremont NH 03074 y r ti, a S Commissioner W25=17 F. 1 d i y i a i t i i a v i i c If?, r Ottice of Consf men flf�airc y id�4 s}Hess Regul tior ; 10 Park PW4- Suite 5170 13oston> Massachusetts:02 i 16 lone zmpruvement Ccnitraetorj[ egistratiott Type; SuiK,�s07ent.^.urd r � KTM PROPERTIES, LLC. CHARL.ES MINASALLF 25 SPAULDING RD SUITE 17-2 '.... _ ". •- -. = -.- .__. ,,�_.. . FREMONT, NH 03044 UpuWcAdJretwued egtumtard.m.rkmsup for rkan$Y. - scn C av+->vt>, ,:�Adlfrxss ;' Regtry xi ""`a�'iuFrYburoot "1 4nxafcasrJ 4 } _ T, nM i�,.arrw✓/d rvja.. t YuerNr� j _ ... W _ tnttgf o ou""Miv Nudfiw R0,01 f on, i.ivease W';glfbm wa vadd Wr in MdulUse e04 tlleWPR0lZMVNTCONT0CTOR' ltidr Mifie Gapireftnn dntau l!'kund relucu rn: q Offfse nfCaaeumar AOn4ls find 6U5Fna5s$egulsl}an ' �s4aauan; iGQ134 jypa" }p Q'Aeki'tbr?-Su1tO3tTd .�` fzpvraiion:-6Pd&26'S btipalei*anl Ggrtl yn�tan.AfA 691 16 KW PROPERTIES LLC - CHARtEg MINASAW ? HPAVM)lNGRP8U17E 172 ^'...u....C3a�,. d FREMONT,NH p30Ma Uhd<ea<SnWry � Ot` uiiadY 5{dnd re hl i i s KTMPR-1 OF 10.MMR CERTIFICATE OF LIABILITY INSURANCE DAT61 g9rar2o1s1=015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY'AND CONFERS NO FIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the carulk ate holder is an ADDITIONAL INSURED,the policy#")must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an andomement. A statement on this certificate does not confer"Oft to the certificate holder in lieu of such ando s . POWI/DISk Phone:603.424-9901 � um(Merrimack) 3309 Dan Webster HlgM.my Fax:888-M-122 Merrimeck,NH 03054 Chris McPhail DISURB 8 AFFORDIMa CP/6RNeE ___ NAte NahMERA:Unlon Insurance Com n 259" INSURED KTM Properties LLC WINSUIRD: 25 Spauldlr�g Road mwrmRC, Fremont,NH 030" NsuReao: COVERAGES CERTIFICATE NUMBER' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 1SBUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREW IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IYIEOFIXERMANCE BR LWITS eCRERILI LNSLm' EAENOCCURRENCE S 1,000 A X ssuwAclALm mE uAMurY PAS152308-11 08/1612015 OBM6/2016 $ 100,00 CLNMS4AAOE QX OCCUR NEDEXP on. S 5. 0011 MREowu.sADVINA S 1.000,00 GENERAL AGORECATE E 2400010 GENT AGGREGATE LINT APPLIES PER PRODUCTS-Couplop OG 6 2,000, POLICY 7X IAG S AuroroesE hJA91LIiY 1,000, A ANYAUTD AA5152306-11 010116=15 08116t2016 RGULYJWURY P Pamr,) E ALLOwNTA :XSCHEDUL RY ED 8OOLYINN (Pbr�nh) S X ALIT HIREOSAUTOR X NEG S E X ItYRWELLA LWB X OCCUM EACHOCCURRENCE S 5.000,4160 A CUAS162314-11 011110*015 88H6/2016 AacRECATE s 5A00. X R 10000 E elGpx gcpyP�yA X W STMT ,O AxD EBPIDTEIIS'LIABILITY A ANYIMGPRIhTORMAJSTNERIE%EGLnNE Y/N CASIUS1S-11 06H 6%6=15 0612016 EL EAcrIAxmENr 9 1A00.00 GFFCfRAfrMBERE Dsw ® N/A tt ELs�uuM L DISEASE-FAENPLOYEEE 1,000,000 F EL.NSEABE-POLICYLIAAT S Lb 1000.00 I�BCRIPTIGN OFOPeRATtONeI IOC,UIONB/tlEIICLEB IAmcn ACGRD tM,AeeRbnU Rm,nM BNWUY,a mse epem b rpuAH) CERTIFICATE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Irdormatlonai Purposes THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN tpD ACCORDANCE WITH THE POLICY PROVWONS. Only AUn10R®REP"Ses"ATNa Chris McPhail 019864010 ACORD CORPORATION. All rights reserved. ACORD 25(WiMS) The ACORD name and logo are registered marks of ACORD