BLDG 13, 25, 27, 29, 31 BENGAL LANE - BPA-16-664 ROOF BLDG 13 The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR) _
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
- - ' (This,Section For-Official Use`Onl )
Building permit Number Bwldiug Official.
SECTION 1:LOCATION(Please:indicate Block#and Lot*,for locations for which a sheet address is riot available) tb,
Bldg 13 25,27,29,31 Bengal Lane Salem 01970 Sanctuary Condominiums
No.and Street City/Town Zip Code Name of Building(if applicaTjI )
�+ SECTION 2;PROPOSED WORK i 4*-!
( Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows belo,
( Existing Building❑ Repair❑ Alteration Cif 1 Addition❑ 1 Demolition ❑ (Please fill out and submit AppLadix 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 BCTILDINGIUNDERGOINO`RENOVATION,ADDITION,OR
CH AL GE,IN'USE OROCCYiPANCY„ Y
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Hesicientiai 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 GROUP(Check`as a plicable)'
A: Assembly A 1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ T B: Business ❑ E: Educational ❑
F: Facto F-1 Cl F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑t R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6;COIVSTRUCTION,TYPE{Check as a -licaIII ;
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7i SITE INFORMATION(refer fo*:CMR 111.11'fo;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 be P
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Histnric 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.00CUPANC)(
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
5f, SECTION 9: PROPERTY OWNER t1UTHORIZATION
Name and Address of Property Owner
Sanctuary Condominiums Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Tide 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 propertv owner's behalf,in all matters relative to work authorized by this building permit a ication.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If bwm ldg is less-than 35,000 cu.it of enclosed s ace dor an not under Construction Control then check here Lund ski "Seetton 10 Y
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-1
KTM Properties LLC
Company Nance
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 II:WORKERSS.CUMVENSATIbN 1i .Ui<ANCE AFFQAVIT,(M.G.L.a 252�§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:12:CONSTRUCTTON COSTS AN,D 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 Co t 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 11 SIGNATURE OF BUILDING PERMIT"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 t ue and ccura ,to twn�
st of my knowledge and understanding.
. President 603 895-0400 617/16
Please prin and ' n name a lnasa� Tide Telephone No. Date
25 Spauldin d Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
d 1
Municipal Inspector to fill out this section upon appllcation''4 ppirov
-al
Name . Date