BLDG 12, 17, 19, 21, 23 BENGAL LANE - BPA-16-665 BLDG 12 ROOF � f
The Commonwealth of Massachusetts
Department of Public Safety
C Massachusetts State Building Code(780 CMR)
L(1 Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section.EOr Official Us¢Onl )
Building Permit Number: Date'Appbed k B41Iding Official + _ o-
( ,-SECTION 1:LOCATION(Please.indicate Block and Lpt#,for locations for which a street'adrlress is notava 1e) _ _
Bldg 12 17,19,21,23 Bengal Lane Salem 01970 Sanctuary Condominiums c3?_ `
No.and Street City/Town Zip Code Name of Building(if applicabklj
SECTION 2 PKOPOSEDORIC „i
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below"X�
Existing Building❑ Repair❑ Alteration M I Addition Cl Demolition ❑ (Please fill out and submit Appe=ix 1) C?
L 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 1Y
Is an Independent Structural Engineering Peer Review required? Yes ❑ No f$
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION,3:::COMPLETE THiS SECTION iF EXISTING-BU{LDING-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): FiesidentiaiProposed Use Group(s): Residential
- SECTION 4;BUILDING HEIGHTAND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5a=USE'GROUP{Check as a likable}
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ 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❑ I-3❑ [-4❑ M: Mercantile❑ R: Residential R-10 R-2❑t R3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'TYPE(C•`hick as a likable), .
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
* SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details"oa each item) `
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
Private❑ 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 ❑
SECTIONS:CONTENT OF CERTIFICATE OF=OCCPPANCY,.
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 O", Eli A1QTIHORIZATI9N
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 outAppendix 2) r r
If building is less than 35,000 cm It of enclosed space and of not under Construchpn Control then check here 6�`and sk( Seaton 101
10.1 Registered Professional Res onsible for Construction Control,"'
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
I0.2 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 603231 1677 tara@ktmproperties.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:wo Etzs�-COMPEiv n2 ON INSUI't1N('E nr•Flu YIT .G;L:c.i52§ 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 0
SECTION 12 CONSTRUCTION COSTS,AN;O PERMIT_FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$ 20,000.00
1.Building S 20,000.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $ _
4.Mechanical (FiVAC) $ - 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 13 SIGNATURE OF BUILDING PERMIT APPLICANT
r
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 accur to to the est of my knowledge and understanding.
President 603-895-0400 6f7/16
Please print and t name unaries vinasaiii Title Telephone No. Date
25 Spaulding Frd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to,fill out this section upon application approval -
- Date