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CAVENDISH CIRCLE # 55 - BUILDING INSPECTION 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 Permit Number: 'Date Applied: Building Official: SECTION 1:LOCATION.(Please indicate Block:#and Lot#for locations for which a street address is not available)' Cavendish Circle # 55 Salem 01970 Green Dolphin No.and Street 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 in the two rows below Existing Building❑ Repair❑ Alteration �; 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 Pro osed Work: Remove and rep�ace roofing shingles SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR < CHANGE IN USE OR OCCUPANCY P s my` Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing UseGroup(s): esi en la Proposed UseGroup(s): Reside5tial 4SECTION4:'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.) SECTION 5:USE GROUP(Check as applicable) - . . : A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto ' F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2 0 1-3❑ I-4❑ M: Mercantile _ R: Residential R-10 R-2 CK R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: i `SECTION 6:CONSTRUCTION:TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA0 VB0 SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) 777 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 0 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: l ` SECTIONS 9: PROPERTY OWNER AUTHORIZATION , =t 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) 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 proper owner's behalf,in all matters relative to work authorized by this building permit application. ` - SECTION 0 COTRUCTIO Appendix 2)CONTROL(Please fill out n„ f buildin isles han 35 000 cuft ofeclosed x; ? s pace and/or not under Construction Control then check here Cxand skr Section to 1 $1 Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General-Contractor 3�a,% '<.., �,;;+??, '-*;.;. ish z. -�;. �- .. ,t KTM Properties LLC Company Name Charles Minasalli 160139 HIC Exp. 6/25/2016 Name of Person Responsible for Construction License No. and Type if Applicable 25 Spaulding Rd. Suite 17-2 Fremont NH 03044 Street Address City/Town State Zip 603 895 0400 603-231 -1677 tara ktmproperties com Telephone No. business Telephone No. cell e-mail address SECTION II:-CNORKERS•COMPENSATI©N INSURANCE AFFIDAVIT M.G.L,c.152.§25C 6 :rc A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes EX No ❑ fr SECTTION 12:CONSTRUCTION COSTS AND PERMIT FEE w. Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 5,000.00 1[22. Building $ 5,000.00 Building Permit Fee=Total Construction Cost x_(Insert here Electrical $ - appropriate municipal factor)=$Plumbing $Mechanical (HVAC) $ _ Note:Minimum fee=$ (contact municipality) Mechanical Other $ Enclose check payable to Total Cost $ 5,000.00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUItiDING PERMIT APPLICANT ,�r. .. .. ,. .- ,. .. Via,..;Q 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 a and ac ate to a best of my knowledge and understanding. President 603.895-0400 6/27/14 Please pnntan gnname arles Minasalli Title Tele hone No. Date 25 S auldi Rd. Suite 17-2 Fremont NH 83044 Street Address City/Town State Zip Mtiructpal Inspector to fill out this se ton upon apphcahon approval; C t s:'Rit es f t5:rttf a t t..;s ..a a ,, Name: 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) #55 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 M Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No Gt Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations k9i 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/Orgmization/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. x❑ I 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑x Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' comp. insurance.$ 9. ❑Building addition [No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ME]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 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. $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.M WCA51 5231 6-1 0 Expiration Date: 6/16/2015 Job Site Address: #55 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 ce under thepains andpena/ties ofperjury that the information provided above is true and correct Suture` f �(2�0 �j) /�-7/ z� Date 6/27/14 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#: