Loading...
CAVENDISH CIRCLE # 67 - 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 Perutit Number:. Date Applied: Building Official: `- E SECTION 1:.LOCATION,(Please indicate Block#and Lot#for locations for which a street address is not.available) ' Cavendish Circle # 67 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 EK Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 11 Is an Independent Structural Engineering Peer Review required? Yes ❑ No 14 Brief Description of ProPosed Work: Remove and replace roofinq shingles SECTION'3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR,�,` CHANGE INUSE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): esl en is Proposed Use Group(s): F<esidential SECTION 4:'BUILDING HEIGHT AND AREA.> Existing s Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) `x SECTION 5:USE GROUF(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: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 CK R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: .• SECTION''b:CONS'ERUCTION3'YPE,(Check as applicable) . :, IA ❑ IB ❑ IIA ❑ IIB ❑ 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: PP Y� ' 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 ❑ t 'SECTION;B: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 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 property owners behalf,in all matters relative to work authorized by this building permit application. Y � }SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendix 2) e If buildin is less than35,000 cti k=of endoseds'ace and/oi not under Construction Control thencheck h`er`e.dCand ski Section.70.1 s = 101 Re `stered Professional Res` ofisible,for Constnictio'Control "> ' ,. Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 101 General Contractor'; KTM Properties LLC (✓ 7 D7 7 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 taraQktmproperties.com Telephone No.(business) Telephone No. cell e-mail address ' `SECTION 11:WORKERS'COMPEN5ATION INSURANCE AFFIDAVIT .G.L.'c.152. 1".`. '� 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 PERMIT FEE r Item Estimated Costs: (Labor 5,000.00 and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 5,000.00 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 $ - Enclose check payable to 6.Total Cost $ 5,000.00 (contact municipality)and write check number here Y SECTION 13 SIGWAT'URE OF BUILDING PERMIT APPLICANT s` #% }Ve w r 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 andflccurate to the best of my knowledge and understanding. President 60M95.0400 6/27/14 Please pri d sign name harles Minasalli Title Telephone No. Date 25 Spa dinq Rd. Suite 17-2 Fremont NH 63044 Street Address City/Town State Zip S t'pF Municipal Inspector to fill out this section upon application approval: L ! �( Win, aate Name . 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) #67 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 B Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ER Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/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.Q 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 ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. Buildin addition [No workers' comp. insurance comp.insurance.: ❑ g required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 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.Lie.#: WCA51 5231 6-1 0 Expiration Date: 6/16/2015 Job Site Address: #67 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 tc $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 hereb certify under the pains and enalties ofperjwy that the information provided above is true and correct Signature /'Z.� 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 officiat 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#: ,; iv CamYldld - 3ULLG'J1fU Boston, N2assachuetts02116 Yy Io`meT"rzprovemen}}t Cpntracta`r Registration Ft11 t * 41S j 3 F } P } _ tt rt t Registration ;160139 -B' � Type. Supplement Card Expiration: 8725(2416 KTM PROPERTIES, LLC. CHARLES :MINASALLI PI a 4Ii l 25 SPAULDING RD SUITE 17�2 �a FREMONT; NH 03044 _ I ij% CSpdate hddress and return raf0 Mark rzasnn for changr .f Address 6 Renewal 1 ! Ergoloyment�, ,t Lost Card CAI c1 .9M o6+11 I ff Cu t ' k / f : ttiee of Oonsumer hffairs&6us Bess Regulation, - tLicense or registration valid for individul use onLY" ,. ' 4NME IMPROVEMENT CONTRACTOR' 3 `before the Expiration date,jf found return to: '- . Office of t,unsumer A#fairs and Business Regulation + .. .. - egtstration; 16d139 g i Ype to;Pa0i kiiza Exptration: 6/2 512 01 6,.. 4 ;Su lament;0ard 6 a £r f pp a pB.ostan r1,01.116, 't ' _a JM PROPERTIES.LLC 9 It t 3 ` iHARLES MW�}SALII � 5 SPAU,t DING R4 SUITE 172 ���r 'REMONT,NH 0304Ain, Underseereta f 4ot d w�thouty nature pi_ x r 1 � F i r p 1 y } Z 1' ? ; E if 'N xP. I 4.,a $ It IF E t 1 to a d g � €t r 33 s' i ,�- { & i , ]t S �. rt KTMPR-1 OP ID: PP CERTIFICATE OF LIABILITY INSURANCE D06/16/2014 ) O6/16/2014 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:603-424.9901 CONTACT NMEBrown 8 Brown(Merrimack) PNONE 309 Daniel Webster Highway Fax:866.848-1223 A/C No Eat: " No: Merrimack,NH 03054 E-MAIL Chris McPhail ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Union Insurance Company 25844 INSURED KTM Properties LLC INSURER B: 25 Spaulding Road Fremont, NH 03044 INSURERC: INSURER D: INSURER E NSURER 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 IDOL SOUR P OLICY EFF POLICY EXP LTR TYPE OF INSURANCEINSR WVQPOLICY NUMBER MM/DD MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CPA5152308-10 06/16/2014 06/1612015 PREM SE E.occumencei $ 100,000 CLAIMS-MADE IXJ OCCUR MED EXP(Any onU ) $ 5,000 PERSONALB AD $ 1r000,000 GENERAL AGGR $ 2,00"00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COGG $ 2,000,000 POLICY X PRO LOC $AUTOMOBILE LIABILITY COMBINED SINGEa accident1,OOQ000A ANY AUTO CAA5152308.10 06/16/2014 06116/2015 BODILY INJURY( n) $AALL UTOS NED X SCHEDULED AUTOS BODILY INJURY( ent) $X HIRED AUTOS X NNON-WNED PROPERTY DAMA $AUTOS Per accitlentUMBRELLA LIAB X OCCUR EACH OCCURRE $ S,000,000A EXCESS LAB CLAIMS-MADE CUA5152314-10 0611612014 06/16/2015 AGGREGATE $ 5,000,000 DIED X RETENTION 10000 S WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITYLIM A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN CA5152316.10 06/16/2014 06/16/2015 E.L.EACH ACCIDENT $ 1,000,000 OFFICEWMEMBER EXCLUDED? � N/A (Mandatory In NH) E.L.DISEASE EA EMPLOYEE $ 1,000100 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1.000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more spa"Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ForinformationalPur Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Only p ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD s - !ht n� IsSratiS'n'��d 4ai Itl$iv33td la ooal5y _ _. _ 3 i ru f anremer AYMlr e@ IMs axrRx tak;n - beim"zI ,pi m^Wn date SfN mi w ,e�IMt7fi§ITt'*OVEtNEET Cv R?,hcT".JI" tlfllcvwTtimsunifr.hftv4rs 11rld i3v31a�s Regu4vtiou�: 'v.; f4 fiaiki Ia.1.colic AF'la _ ri b:ffraxion; 5,12MN"o . - 6nNr:ia'tr nt Caw 6nstm:, i.�ti2i16. .. KrM �..�Q.m"-m.-....�.,.«..,.,,...n.�, v�i wIY7 kU t+v Sti.f_i r ..,•.r.•�.�-_ ..,.+....-.;."«,., ' m4Q3r4 .15 ."•`-- �....�� alai dx>$64 e"`""r ,m.., ;•"'" E eecnux ° f>xr s er-1 ,.,c w.m t _ FS J-Nluq sA{t[ . stv� ,•4 wa re+:e+tac�a ®..&=,r, `wM xrw .,,, .rv. ffx e } �' N � tfi �i 3 6 .. ^A A c✓ 'fit 4 '" III�£ti Vl" r HJ!..4^: ^9" 4A:,-...i^v .u*a ..g F.w A +n w 't r'F tt v .-'If- } 'Y T•>T'6 'A .le.n Y n.lM ja d: "5w w":w _ & w +s�aa"'`nt,s erne " �' »a. r �w•Trnmr wa: E o _ .+nds.+sav+ny.Resa}c�. ., ---�#+'M �.�.`t„"' +:. r+sg e. '.�•- .c .p,.:X �.:a-''�;' ^h�.,.� :n�+hxuw mk.r--.+es: .vy,._z_�.'£av+ -::.^'tee. A bR.e�-gip. ^�:.>,+'u'.... ,,p w ,vnn ,4„ 4T m�mu^.,^.�a .n pn 5�.. , ..:� .: �, MY,ay £ �w x X & r p(°•#+*i�":,.y,Y^twYS'"^ .. n i .ti. t r a S "Y�` " .� fi 4s� .e+'.:M'x,P�� nw ».,n to srn•3 ro er � & ,ua :« K ,' r= S t I � Sm