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CAVENDISH CIRCLE # 2, 4, 5, 7, 9 & 11 - BUILDING INSPECTION 3 c) t= 3 FIZZ.- .1 r_-2 loq 4 GE4YED SERVICES The Commonwealth of Massachusetts . Q o Department of Public Safeth pIN 24 A & Ov VVVVllllllllUUUU Massachusetts State Building Code(7 ��vlliY Building Permit Application for any Building other than a One-or Two-Family Dwelling -- (This Section For rOfficial UseDnly) Building Permit Number: Date Applied Building Officiate SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) Cavendish Circle#2,4 5,7,9,& 11 Salem 01970 Green Dolphin No.and Street - City/Town Zip Code Name of Building(if applicable) .+. t .L -�;-SECTION 2: )WORK r 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 Ix Addition❑ 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 EX Is an Independent Structural Engineering Peer Review required? Yes ❑ No IN 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) 13 Existing UseGroup(s): Residential Proposed UseGroup(s): eSl en la ' "SECTION 4:"BUILDING HEIGHT AND AREA n, v Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) ' - SECTION 5:USE GROUP(Check as.Applicable) .a ' A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 EK R-3❑ R-4❑ S: Storage S4❑ S-2❑ U: Utility Utility[] Special Use❑and please describe below: Special Use: TN9 ,."SECTION 6:CONSTRUCTION TYPE(Check as applicable) IB II ❑IA 13 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB�❑ SECTION 7:SITE INFORMATION(refer to 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❑or trench or specify: 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,CERTtFICATE'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 Green Dolphin Salem 01970 Name(Print) No.and Street City/Town zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) a-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 ro er owner's behalf,in all matters relative to work authorized bv this building permit application. ^` s SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) zed, E building is less than 33,000 ea'ft.o£enelosed's x ace and ocnot index Constmcnon Contro]then cheek here(jCand sla Secuon 10.1 101,1le '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 , " ';„ l _ ,.;�,, t s , KTM Properties LLC Company Name Charles Minasalli 160139 HIC Exp. 6/25/2016 Name of Person Responsible for Construction License No. and Type if Applicable 25 Spaulding Rd. Suite 17-2 Fremont NH 03044 Street Address City/Town State Zip 603 895 0400 601231-1677 tara@ktmproperties.com Tele hone No.(business) Tele hone No. cell e-mail address "SECTION 11:WORKERS''COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.1152.§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 si ed Affidavit submitted with this application? Yes 13 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMITFEE` Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 30,000.00 1.Building $ 30,000.00 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) $ 6.TotalCost $ 30,000.00 Enclose check payable to - (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT.APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained m this application is nd a ur a to the b t of my knowledge and understanding. President 603.895-0400 6/23/14 Please print and.si name arles Minasalli Title Tele hone No. Date 25 S auldi Rd. Suite 17-2 Fremont NH 83044 Street Address City/Town State Zip �/"� Munrcipal-Inspector to fill out thissection upon application approval: �'� -� ! tP Appendix 1 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) #2,4,5,7,9,11 Cavendish Circle Salem 01970 Green Dolphin No.and Street City/Town Zip Name of Building(if applicable) ' 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 ® Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No Q Provider notified and Release obtained? Yes ❑ No ❑ Other(if applicable) Yes ❑ No 19 Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) The Commonwealth ofMassaehusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): KTM Properties, LLC Address: 25 Spaulding Rd - Suite 17-2 City/State/Zip: Fremont, NH 03044 Phone #: 603-895-0400 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 25 4. ❑ I am a gen7sub-contractors ctor and I employees(full and/or part-time).* have hiredntractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on tsheet. 7. Q Remodeling shi and have no em to ees These subs haveP P Y 8. ❑Demolition working for me in any capacity. employeesorkers'[No workers' comp. insurance comp. insu9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152,§1(4),and we have no 12.❑Roof repairs employees. [No workers' 1311 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Union Insurance Company Policy#or Self-ins.Lic.#: WCA51 5231 6-1 0 Expiration Date: 6/16/2015 Job Site Address: Cavendish Circle#2,4,5,7,9,11 City/State/Zip: Salem, MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify !� /yerrttiify under the pains a a/ndpenalties ofperjury that the information provided above is true and correct. Signature' �/w Z Date 6/23/14 Phone#: 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#: KTMPR-1 OP ID: PP CERTIFICATE OF LIABILITY INSURANCE 06/16/2014 DATE(MMIDDmYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER Phone:603424.9901 CONTACT Brown&Brown(Merrimack) NAME: 309 Daniel Webster Highway Fax:866-848-1223 PHONE FAX Merrimack,NH 03054 9 y e MAIL Ex1 AIC No: Chris McPhail ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURED KTM Properties LLC INSURER A:Union Insurance Co mpany 25844 25 Spaulding Road INSURER B: Fremont,NH 03044 INSURER C: INSURER D: NSURE2 E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADW SUM LTR TYPE OF INSURANCE POLICY NUMBER MMIDDOYEFF MMDprff LIMITS GENERAL LWBILIr; EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CPA5152308-10 06/16/2014 06/16/2015 _ffAMA E ftENTEO PREMISESIreENTED $ 100,00 CLAIMS-MADE FXIOCCUR MED EXP(My one person) $ 5,000 PERSONAL A ADV INJURY $ 1,000300 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,000 POLICYFX_1 PRO- LOC $ AUTOMOBILE LIABILRY COMBINED SINGLE LIMIT Ea accident 1,000,00( IDED O CAA5152308-00 06/16/2014 06116/2015 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS BROPERNJURY(Pera¢itlenQ $ HIREDUTOS X NON-OWNED PROPE ld Ymt) AGE AUTOS $ Per accitlent LA LIAR X OCCUR EACH OCCURRENCE $ 53000,00 UAB CLAIMB-MADE CUA5152314-10 06/16/2014 06/16/2015 AGGREGATE $ 51000100 X RETENTION 10000 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X A ANY OFFIOERIMEMBER EXCLUDED?ECUTIVE Y� NIA CA5152316-10 06I76/2014 06/16/2015 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe antler DE SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000100 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Adach ACORD 101,Additional Remarks Schedule,if more space is required) t CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i i Office of Consumer Affairs nd Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement,Contractor Registration Registration: 160139 . . Type: Supplement Card Expiration: 612 512 01 6 KTM PROPERTIES, LLC. CHARLES MINASALLI 25 SPAULDING RD SUITE 12-2 FREMONT, NH 03044 _- li Update Address and return card. Mark reason for change. Address ❑ Renewal ❑ Employment Lost Card SCA 1 G 20M-05/11 /TJ/[�e [(ovb-s�urrugrrtnlJ����n/ ii6iac%rme�/G LLLcccaaa free of Consumer Affairs& Business Regulation License or registration valid for indi eu use only — i ME IMPROVEMENT CONTRACTOR before the expiration date. found return n to: Office of Consumer Affairs and rc and Business Regulation egistration: 160139 Type: 10 Park Plaza-Suite 5170 r Expiration: 6/25/2016 Supplement Card Boston,MA 02116 KTM PROPERTIES,LLC:..- I CHARLES MINASALLI`.:.� 25 SPAULDING RD SUITE 12-2 --- FREMONT, NH 03044 Undersecretary Not valid without signature Zell, i44Y�. Office of ConsumerAEaus d Business Re4uldtwn r !z ff , 4 1 Q I rk 'it �e t, Eioston MassaC setts 42i16 Ian Home prowement�ontraetorReeisiriticn 4 = 1 E Registmtjon. 1601o8 A Of YRa SpDPlemenl G=�d KTM PROPERTIES LLC. ,4y" Expiration e.7srzdaa CHARIES M'1 NASALL14 25 SPAULDING RD SUITE 12 2 -, P FREMONT, NH 43044 .#' H- h µ d U�daYc dddrust end Yetarn curd Nark raasan ° t�rbT ' Addrea� F' Renef nt `"' hmplopmtn29 Laq Car¢ { )tile ry[r nr �a dlTmn kltvs Hera Rcyolm „: LiGenseorrwis ktxan valid tai ntd�s idol uae only a d c ME1MARdV2M ENT CORTR4CTOR y; f before the"Idmdpn dwe.H f4und return to sRngistretion 160t3@ d�. " Gff7ce pt Canauaicr ,AHnlrs and Buaineas Regulation `>1 0x iradon '� E- Ypo HId FRrk Plec,i-WW5276 a P. 429r2Q15 ;S.iRple"',O ar o 1 �* R Stan 51n U2ll 6' pp �_ �KTM PRCP'eRTIE9 is 3 r �;3C11gRLES MINASA 11s � + e_ ti assPAuLdmr�,Ro uf�Eaz2 s...r ` t `. 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