0002,0004,0006,0008 CAPTAINS LANE - BUILDING PERMIT APP The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
�- - - (This Section For Official Use Only),
_ Building 'Date Applied: Building Official:
00 '
SECTION 1:.LOCATION.(Please
indicate Block#and Lot#for locations for which a street address is not.avail*e)
Zl� Lp� f Salem 01970 41,1-(:
No. and Street I City/Town Zip Code Name of Building(if applicable)
5EC 1ON 2:PROPOSED WORK
�(1 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
I Existing Building❑ Repair❑ 1 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 If
Is an Independent Structural Engineering Peer Review required? Yes ❑ No B
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION 3:COMPLETE THIS SECTION iF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,-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 ---T—proposed Use Group(s): Residential
SECTION4: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 applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ Ho Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 Clt R-3❑ RBI❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION_ &CONSTR_UC ITON.TYPE.(Check as applica¢le)
[A ❑ IB ❑ IIA ❑ HB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(ieferto 780 CMR 111.0 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 ❑permit is enclosed
trench or specify:
❑
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 ❑
SECTIONS:CONTENT OF CER IFICATE:OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SpV T TD C-4 C, B- (�
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 prope owner's behalf,in all matters relative to work authorized by this building permit apElication.
SECTION 10:CONSTRUCTION CONTROL(Please-fill'out Appendix 2). - -
tiuildin' is less than 35,000 cu.ft of enclosed s ace and/or'not-under Construction Control then:check kere:CYand ski 4Sectiomlo.l
10.1 Re `steredPiofessional Responsible for ConstructionCControl - - -
Name(Registrant) Telephone No e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
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,VVORKEW COMPk:NSATIOMINSURANCE AFF07AVrr , .G.L.r..152. 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 15 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$ DD9'
1. Building $ �'O B,W. &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 $ �� ��- (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my nam below,I hereby attest under the pains and penalties of perjury that all of the information contained in this ,
application s true ac m to the best of knowledge and understanding.
President 60389895-0400 �S
Please print an sign name ar es if
Sa I Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town A State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date