1,3,5,7,9,11 BRITTANIA CIR - BUILDING INSPECTION cK i 50s 4 �33�
The Commonwealth of Massachusetts
Department of Public Safety
\UP) Massachusetts State Building Code(780 CMR)
�a Building Permit Application for any Building other than a One-or Two-Family Dwelling
ThisSection.For Official Use Only) -
Building'Permit Numben Date Applied: Building Official
l n SECTION.1:LOCATION(Please indicate BIocl�#and Lot#for locations for which a street
_ adnot.availa'Ie)
)'la
_43 Y /, -1 /9
No. and Street City/Town Zip Code Name of Building(if app' able)
- SECTION.2:PROPOSED WORK i
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration 0 1 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 Ef
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'IF-EXISTING BUILDING 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): Residential 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.)
SECTIONS,USE GROUP(Check as applicabte)-
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑
IHh Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ Ha❑
C:IM.
Institutional I-10 I-2❑ F3❑ Mcantile
❑ R: Residential R-1❑ R-2 a R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6 CONSTRUCTIQN,TYPE(Cheek:as applicable) '
IA ❑ IB 0 IIA O IIB ❑ IIIA ❑ IIIB ❑ IV 13 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR.111.0 for details on each item)
Trench Perrmt: Debris Removal•
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone 11 Indicate municipal 11A trench will not be P
required ❑or trench or specify:
Private 11or 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 ❑
SECTION 8:CONTENT OF CERTIFICATE:OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load"per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
rnRt�� iD U .C. (I3
SECTION 9: PROPERTY OWNER AUTHORIZATION -
Name and Address of Property Owner
Mariner Village 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 buildingpermit application.
SECTION 10:CONSTRUCTION CONTROL-(Please-fill out Appendix 2).
buildin' is less than 35,000 cu.ft.of enclosed ace and/orpot under Construction Control then check here,dan7Secbtiomjo.j
10:1Re `stered.Professior al Res onsible for Coustruction[ControlName(Registrant) Telephone No. a-mail address Registration NStreet Address City/Town State Zip Discipline
10.2 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 603-231 1677 tara@ktmproperties.com
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS`COMPENSATION-INSURANCE-6HIDAVrr"- .G.L.r 152. .250(6)Y,
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 ❑
SECTION 12:CONSTRUE'FION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$ 34Q, ltD4
1. Building $ -30 "5, D. 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 $ 50, (contact municipality) and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name low,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is truean ccurate o the best of my knowledge and understanding.
President 603=895-0400
Please print and sign naame ares I I Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
-7Appendix 1 i
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)
5 / G?LSalem 01970
No. and Street City /Town Zip Name of Building (if applicab e)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No 0 Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No CJ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Deparbnent of Industrial Accidents
" ~ �! Office of Investigations
75 1 c� 600 6Vashington Street
Boston, MA 02111
rvww.raass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/0,anizatimdlndividual): KTM Properties, LLC
Address: 25 Spaulding Rd - Suite 17-2
'—ity/State/Zip: Fremont, NH 03044 Phone #: 603-895-0400
.re you an employer? Check the appropriate box:
M 4. I am a general contractor and 1 Type New
(required):
❑ I am a employer with 25 ❑
employees (full and/or part-time).
have hired the sub-contractors 6. ❑ New construction
❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑x Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers'
com insurance.[ 9. E] Building addition
[No workers' comp. insurance P�
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
❑ 1 am a homeowner doing all work officers have exercised their I L❑ 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.❑ Other
comp. insurance required.]
y applicant that checks box'I must also fill out the section below ihowing their workers'compensation policy information.
)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
atractors that check this box must attached an additional sheet showing the name of the subcontractors and stale whether or not those entities have
loyees. If the subcontractors have employees,they must provide their workers'comp.policy number.
in an employer that is providing workers'compensation insurance for my employees. Below is the policy aid job site
zrmatimr.
arance Company Name: Union Insurance Company
icy # or Self-ins. Lic.#: WCA5152316-10 Expiration Date: 6/16/2016
m
Salem, �
Site Address: S 7 9r ] �` �� (...(�[% — City/State/Zip: t9lq /r�
ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
rp to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
z hereby certify under the pains an`1penalties ofperjury that the information provided above is true and correct.
nature � ��A� �- i" i1.6�L�`Z"=�—// Date: 7�S
me#: 603-895-0400
Official use only. Do not write in this area, to be completed by city or town official
City or Town: _Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
0f Ftce of Consumer A ir
(fit s end Business Revulation
C7,
V-MM—tt 1.0 Park Mata - Suite 5 170
Boston, Nlassachus..eus 02116
Home Improvement Contractor Registration.
Registration 160139
Type Supplement Card
KTM PROPERTIES, LLC. Expiration 6/25/2016
CHARLES MINASALLI -
25 SPAULDING RD SUITE 17-2
FREMONT, NH 03044
Update Address and return card.Mark reason for change.
7 .
I- Address Renewal -7 Employment LaqCttrd
of Consumer Affairs& Business Re"Ulfatioo License or re-wration valid for individul use only
MIPME IMPROVEMENT CONTRACTOR before the expiraqon date. If found return to:
Office of Consumer Affairs and Business Regulation
egistration: 160139 Type: 10 Park Plaza -Suite51711
Expiration: 6j2512016 Supplement --dro Boston,M.-k 021,16
PROPERTIES. LLC.
.RLES M1111ASALI-1
PAULDIN3 RD SUITE 17-2
MONT, NH 03044
�...�i nlmrn-1 yr ru....nunn
aca��zG CERTIFICATE OF LIABILITY INSURANCE DATE(Mf2ii0YYY
✓�,.- �O61f213045
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY .AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEN. -'NIS"
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE.PUFICIE$
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE:. .A CONTRACT BETWEEN THE ISSUING INSURERS} AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND'I-HE CERTIFICATE HOLDER.
IMPORTANT: If the certificate Holder is an ADDITIONAL INSURED, the poficy(ies) must be endorsed. If SUBROGATION IS WAIVED,sybiectto
the terms and conditions of the policy, Certain policies may require an endorsement. A statement on this certificate does not comer rightsto the
certificate holder In lieu of such endorsement(s).
tODUCER Phone:603-424-99,31 Na�Col Act - -
t:
own 8 Brown(M11ercimack) rnme-"------- — I FAA' --�----
9 Daniel Webster Highway Fax:866-848-1'223 Ajq.h�10111._
errimack, NH 03054 I MAIL
iris McPhail LDogess .. .. -- --_— __
e1SVRER(Si AFFORDING COVERAGE _ NAR,4 -
__ msuREa Unron Insurance Com_an_ 257l4i_
- ----
5UREO KTM Properties LLC I InsueeRe __
25 Spaulding Road __ ---._ - ---
Fremont, NH 03044 USURER c _.
Ih.SURER D _
NSURERE
NSURFR F
OVERAGES CERTIFICATE.NUMBER: - REVISION,NUMBER:
THIS IS TO CERTIFY THAT T'HE POLICIES OF INSURANCE LISPED BELOW HAVE BEEN ISSUED TO 'rHE INSURED NAMEDABOVE'FOR THE POLIC(,PE'RvDD
INDICATED. NOTWITHSTANDING ANY RECUIREM1IENT, TERM OR CONDITION OF ANY C I NITRAC' OR OTHER DOCUMENT WITH RESPECT TO SYHIC.-i THlS
CERTIFICATE MAY BE ISSUED OR MAY PER AIN, THE RSURANCE AFFORDED 3'r' T-iE.. P/"-I'.T-IES DESCRIBED HEREIN IS SUBJEC7 i0 ALL THE TERPAS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. IAtTS SHOWN MAY HAVE°r'= y RED`UC"D BY PAID CLAIMS.
_
ADOL,SUBR ?IN.IL EFF POLICY
rt! TYPEOFINSURANCE �: +Yn POL_C'NUMBEF FNM�O.YY"YI tM___T M�DDIYYYYI LttdRS
GENERAL LIABILITY EACH OCCURRENCE b 1,000,000
lw�FXIIJ—ro �. 1616!2015,I01112016 104„00cEmeaA. L.vr_ry ; 5•�--I ; A;MS.WilE MED EXP(Anydnep—)
IPERSONAL
a ADV INJURY
GENERAL AGGREGATE 5 2,0W00
cN'I.Ab REGATE'LIMHAPPUESPER: I ',f PRODUCTS-COMPOPIG 'S 2,000,00
I PGI i.Y� X '.' IF ^�LGc _ 5
---i-- COMa.NEo-SINGLE LIMIT ! 1,000;00
AUTOMOBILE LIABILITY T L(Ea aclitlen,i__ —_L�
I -'I A"AUTO CAA5t52308-11 i )6i16i2D15j 0 6/1 612 01 6 BODILY-NJURY(Per Pear; 15 _
AL: O,YNED SCH`Dl --E: I ! aOCII Y INJLRY(Pe aWcenl);b
_�•: ALTOS X AUTO: i - ___. __._-. _-__
1 PROPE/iTV DAMP.G
NON-010.1NED j !Per acnaonn _5 -
.Y HPFDAUTOB [�X AUTno
r^I
I:
.X I UMBRELLAtIAB X I OCCUR I r L EACHOCMRP.ENCE 5 5.000.DO
i FXIESS UAe -r,L NISAM�E GUA5152314.11 1.06;-1612015 06/1612016 AGGREGATE 5 5.x00.000_
100001 I � 's
DED ; X RETENTIONS
—'T 'NC-STATLL 10Tlf-
; WORKERS COMPENSATION
EMPLOYERS
IIASILRY
I AHO YIN ' j I R I 16/2016 I -�_ ACODEN 1 5 1,000,00
AN-r PROPRIETORIPARTNEREXECU Iry= W CAa1.2316-i t 0&16'2015 O6! .EACH ALc DEN_--_
1 GFFLERME?J8EREXCLJOEO? N N1Gj I ,000�00
TiE L.DISEASE-EA EMPLOYE
! (M deory.In NH) I
If yes.describe under I E.L.DISEASE Po� CY UM:r L b 1,000,00
DESCRIPnON:OF OPERATIONS Veb'x I I - -
i
F RIPTION OF OPERATION-I LOCA'DONS/VEHICLES iAttech ACORG tel,Additlanal;Remmrks Swedote,if mem apace Is required)
;ERTIFICATE HOLDER CANCELLATION .
SHOIILD'ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE"O'SEFOR£
EL'N
THE EXPIRATION DATE THEREOF, NOTIOE WILL .BE D _EREd'- IN
For Informational Purposes ACCORDANCE WITH THE POLICY PROVISIONS.
Only
AUTHOR'ZEU REPRESENTATIVE
Chris MCP11211
C,)i988-2010.ACOROCORPORATION. All righlsir®sorved.
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