37,39,43 BRITTANIA CIR - BUILDING INSPECTION G 1 5 Sq $1 bS
The Commonwealth of Massac
husetts
Department of Public Safety
Massachusetts State BuildingCode 780 CMR
( )
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
. (This Section For Official_,Use Only),
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION Please indicate Block#p0 ( and Lot#for locations for which a,street address is not availal)le)
�73y3 Salem 01970
v l No. and Street �` Town Zip Code Name of Building if a li a
h'/ P g( PP c ble)
4 SECTION 2:PROPOSED WORK
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 Ctl Addifion❑ 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 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 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): Hesiclennal 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.)
SECI_TON S.-USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h 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 Cat R-3❑ Rh❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SEC nON`6s CONSTRUCTION TYPE-((heek:as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB O
SECTION 7:SITE INFORMATION(refer.to 780 CMR111.0 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 El
required ❑ 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 ❑
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:
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 pro2erty owner's behalf, in all matters relative to work authorized by this building ern-it ap2lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
buildin`is less than 35/000 au.ft.of enclosed ace and/ornot under Construction Control then=check here,1Yand ski :Section,lo.l i
- 10:1 Re 'stered.ProfessiunaI Responsible for CoristructioniCoritro(
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline ExpirationjDate
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.corn
Telephone No.(business) Telephone No. cell e-mail address
SECTIONII:.WORKERS"COMPENSATION-INSURAN€E-AFF[DA rr.( .G.L.c:152. 25C6 . 3
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:CONSTRUCTION COSTS AND PERMIT'FEE
Item Estimated Costs: (Labory���
and Materials) Total Construction Cost(from Item 6)=$ L.�l{r/U-!/..L0_Z:)
1. Building $ ����. 45,0- 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 $ /5 4Da,. 60 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my namoelow,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true ac rat o the best of on knowledge and understanding.
Ad President _603-895-0400
Please print and sign name ar eS a t Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town- State Zip
Municipal Inspector to.fiR out this section upon application approval:
Name Date