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BLDG 14, 18, 20, 22, 24 BENGAL LANE - BPA-16-662 ROOF BLDG 14 t The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) 9 Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use.Only)r 7 i Building Permit Number. Date Applied: SECTION 1:LOCATION(Please.indicate Block#and'Lot#forloeations foNwluch a street address is not av"�able) _ Bldg 14 18,20,22,24 Bengal Lane Salem 01970 Sanctuary Condominiums .J r— No.and Street City/Town Zip Code Name of Building(if applicaa>e) can l r�S ... SECTION,2r ?ROPOSM WORK .. , < . +, 5 .r% . Edition of MA State Code used If New Construction check here❑or check all that apply in the two roM below., „ I_ Existing Building❑ Repair❑ 1 Alteration E 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 EY Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: Remove and replace roofing Shingles SECTION 3:COMPLETE THIS SECTION IFEXISTING UILDING UNDERGOING�RENOVATION;ADDITION,OR 'CHANGE IN USE OROCCIIPANCY #. Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Hesidentiai 71 Proposed Use Group(s): SECTiONt4:BUILDING HEIG A HT AND REA ' t Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.R)and Total Height(R) `SECTION5:,USE&GIIOUP(Glieck'asap Iieable) ^° A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F-2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 tY R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6yCONSTRUCTTONTYPE(Check as a `licable)+ IA ❑ IB ❑ IIA ❑ iIB ❑ IUA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR lll:-0 for details on each Item) =' Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ 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 Historic Commission Revi,.,,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 OFACCUPANCY ',.: Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 4: PROPERTYOWNER°AU,THOAIZATIOIV ' 'x� �' ,� - 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:C©NSTRUMON CONTROL(Please fill out Ag 2) "' ;x, buildingis less than 35,000 cu.it of enclosed s ace and or`ndt under Construchori Control theft check here f `arid ski Section 10.1 10.1 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 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 t677 tara@ktmproperties.com Telephone No. business Telephone No. cell e-mail address SECTION 11;WORKERS':COMPENSATION WsURA.NCE AFFIDAVIT= .GL.c.157_§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 Lf No ❑ SECTiON�12:CONSTITCTION£09TS^AN,D.PIIiMI3`�FEE, Item Estimated Costs: (Labor 20,000.00 and Materials) Total Construction Cost(from Item 6)_$ 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 $ Enclose check payable to 6.Total Cost $ 20,000.00 (contact municipality)and write check number here SECTION 13LS/GNATITRE OF BUILDING PERMIT,APPLIG", ;i _ By entering my name below,I hereby aft t under the pains and penalties of perjury that all of the information contained in this application is truxA acc rate o the b 't of my knowledge and understanding. President 60389895-0400 6 7/16 Please print and si me a BSMinasalft Title Telephone No. Date 25 Spauldinq R to 17-2 Fremont NH 03044 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval ti - �7 �_ ,;. Name Date