CAVENDISH CIRCLE # 45 - BUILDING INSPECTION ', ' 7&4-�
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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
.. (Phis Section For Official Use Only)
Building Permit Number. = (Sate A lied `_` .
PP Building Official:,
SECTION 1:LOCATION(Please indicate Block N and Lot#for locations for which a street address is not,avai1able)'<r`
Cavendish Circle # 45 Salem 01970
No.and Street Green Dolphin
City/Town Zip Code Name of Building(if applicable)
-� - SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply inthe two rows below
Existing Building❑ Repair❑ Alteration I-K Addition❑ Demolition ❑ (Please fill out a d submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Sec'
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No [I
Is an Independent Structural Engineering Peer Review required?
Brief Description of Pro osed Work: Yes ❑ No ff
Remove and re race roofin shin les
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION ADLiITION OR',x
CHANGE IN USE OILOCCUP O I I
Check here tf an Existing Building Investigation and Evaluation is enclosed(�80 CMR 34) ❑ t
Existing Use Group(s): eSl en la Proposed Use Group(s)7 eSl en la
SECTION 4:BUILDING HEIGHT AND AREA
4
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
g. `7°tSECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ .
F: Facto F-1 ❑ F2❑ B: Business ❑ E: Educational ❑
H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Instit6ti3nal I-1 ❑ I-2❑ I-3❑ I4❑ M: Mercantile❑
R: Residential- R-10 R-21X R-3❑ R-4❑
S: Storage S-1 0 1-1)❑ U: Utility Li
Special Use: Special Use❑and please describe below:
SECTION6i'CONS,TRUC17I0N TYPE(Check`as applicable)
IA ❑ IB ❑
IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
,SECTION 7.'SITE INFORl IATION`(refer to 780 CMR 111.0 for details on each tem)
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:
Not Applicable❑ g MA Historic Commission Review Process:
PP Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑
,, — ;; Yes❑ No ❑
'v SBCTION 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:
-.SECTI0N9: PROPE'RTYOWNERAUTHORIZATION`
Name and Address of Property Owner
Green Dolphin Salem
Name(Print) No.and Street 01970
City/Town Zip
Property Owner Contact Information:
Title Telephone No.
If applicable,the roe P (business) Telephone No. (cell) e-mail address
PP property rty owner hereby authorizes
Charles Minasalli 25 Spaulding Rd Ste 17-2 Fremont NH 03044
Name Street Address City/this Town
Ste Zip
to act on the ro er owner's behalf,in all matters relative to work authorized b buildin ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)If buddin is less than 35,000 cv.ft,of enclosed s ace and/or not under Construction Control then check here GCS nd slax Section 101., �.
10!1 Re 'steied Professional Res onsible for Constnicfion':Control.. 0 r
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Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address City/Town
State Zip Discipline Expiration Date
10.2 GeneralContractor - -
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KTM Properties LLC
Company Name
Charles Minasalli 160139 HIC Exp. 6/25/2016
Name of Person Responsible for Construction
25 Spaulding Rd Suite 17-2 License No. and Type if Applicable
Fremont Street Address NH 03044
603 895 0400 City/Town State zip
Tele hone No. business
603o taraQktmorooerties com
Telephone N No. cell
SECTION 11:WORKERS'COMPENSATION NSURAIVCIi AFFIDAVIT e-mail address
A Workers'Compensation Insurance Affidavit from the MA Department of Industria[Accidents must be s
submitted with this application. Failure to provide this affidavit will result in completed and
the denial of the issuance of the building Is a si ed Affidavit submitted with this a permit.application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 5,000.00
I.Building $ 5,000.00
Building Permit Fee=Total Construction Cost x
2.Electrical $ _(Insert here
3.Plumbing $ -
appropriate municipal factor)_$
4.Mechanical (HVAC) $ _ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
6.Total Cost $ 5,000.00 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 in this
application is true and ac rate to the best of my knowledge and understanding.
President 601895-0400 6/27/14
Please print sign name arles Minasalli Title
25 S aul n Rd. Suite 17-2 Tele hone No. Date
Fremont NH �3044
Street Address
City/Town State Zip
Municipal Inspector to fill out this section upon application approval: l
'
.� Name . .. t s;�,-- _.
7
M.Date
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)
#45 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 ® Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No 121 Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No IN Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable) Yes ❑ No Q Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No IN Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UIF 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/Organizatiomgndividual): 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. 1 am a employer with 25 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
shipand have no employees These sub-contractors have
8. ❑Demolition
working for me in any capacity. employees and have workers'
insurance.x 9. ❑Building addition
comp.[No workers' comp. insurance P•
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I1.❑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.]
'Any applicant that checks box#1 most 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 most submit a new affidavit indicating such.
;Contractors 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: #45 Cavendish Circle 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 under the pains and penalties ofperjury that the information provided above is true and correct.
Signature` A IGr/W Date: 6/27/14
Phone M 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#: