BLDG 13X, 33, 35, 37, 39 BENGAL LANE - BPA-16-661 ROOF BLDG 13X IP—N The Commonwealth of Massachusetts
Department of Public Safety
�•<y / Massachusetts State Building Code(780 CMR) .�.
Building Permit Application for any Building other than a One-or Two-Family Dwgling ' ..
(This Section For Official Use Onl ) c--
Building Permit Number: Date Applied.,,, '` Building Offiptal ' -
SECTION L LOCATION(Please iindicate Block 4 and Lot It,for^locations for which;us treet address is not avai,)jrle)
Bldg 13X 33,35,37,39 Bengal LanE6alem 01970 Sanctuary Condominiums r -
No.and Street City/Town Zip Code Name of Building(if applicable ?J
t
SECTION 2:PROPOSED WORK �` • e
.--Q Edition of MA State Code used If New Construction check here❑or check all that apply in the two rov"elow-i
Existing Building❑ Repair❑ Alteration 15 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No If
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION 3:COMPLETE THIS SECTTION IP EXISTII,*IG"BUILDING�•U_ NDERGOING RENOVATION,ADDITION;OR '
'CHANGE IN US.
E OB OCC[fPANCy
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): KeSidentiai Proposed Use Group(s): Residential
SECTION:4:.BUILDIN.G 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.)
9HCTION-5:USE GRQUP(Checkias a •licable)-
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ IT ❑ H-3 ❑ IT ❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 f$ 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 INFORMA'_t'IO1V(refer to780;CMR111.0 for details on eachi tem
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public El Check Disposal Site❑`Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
Private Clor indentiEy Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: VIA 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_CONTEN %OF CEI TT.MCATE 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 OWNER 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 propertv 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 biuldm is less than 35,000 cu,ft of enclosed s are and or not under Construction Control then check Here:CYand ski% Section 10.1
10,1-Registered Professional Responsible for Construction Control. t
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
102 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 603-231 1677 tara@ktmproperties.com
Telephone No. business Telephone No. cell e-mail address
SECTION lY:LNORKERS':COMPENSATION NSOftANCE AEE[tUA 1T .G•L.'c-152.$-25C u��
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION:11 CONSTRUCTION COSTS�AND PERMITFEE `
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ 20,000.00
1. Building $ 20,000.00 Building Permit Fee=Total Construction Cost x (hisert 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 13 SIGNATURE OFEUILDING,P,ERMIT,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 actor to t the bes of my knowledge and understanding.
President 603-895-0400 6!7/16
Please print an sign e are Hasa 1 Title Telephone No. Date
25 S auldin Rd 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal.Inspector to fill out this section upon application approval �'16y'u atr . .r(J,v '.l(
-s .; 'Name .