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78,80,82,84 CAVENDISH - BUILDING JACKET The Commonwealth of Massachusetts Department of Public Safety V� Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling `-- s'^,(TMs'Section Foi Official'Use Building Permit Number ` Date Applied '`' -:Building Offictai: '0. SECTION 1:LOCATION(Please in$icate Block'#andLoti#for locatonsfor which"a street addiess is not available) Bldg 162 78,80,82,84 Cavendish Salem 01970 Green Dolphin No.and Street City/Town Zip Code Name of Building Itapplkable) -a Edition of MA State Code used If New Construction check here❑or check all that apply in t r�a two'Sws below Existing Building❑ Repair❑ I Alteration 1t Addition❑ Demolition ❑ (Please fill out and sultipit A i Qix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: M rn rn Are building plans and/or construction documents being supplied as part of this permit application? Yes Mo 5 Is an Independent Structural Engineering Peer Review required? _ Yes N4:T1 Brief Description of Proposed Work: Remove and replace roofing shingles SECTION 3i COMPLETETHIS=SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR. CHANGE IN US&FOR OCCUPANCY'" Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Kesidemial Proposed Use Group(s): SECTION 4: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 S:-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❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2 CY, R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: sEcnO_N 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB O IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CIVItM.0 for deta ils on each ifem) r Debris Removal:i Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑ Public❑ Check if outside Flood Zone El Indicate municipal ❑ A trench will not be P 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:CONTgNT 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: , r <.SECTION9: PROPERTY OWNER AUTFIQRIZATIO14 , 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 owner's behalf,in all matters relative to work authorized by this building permit application. SECTIO,N 10:CONSTRUCTION CONTROL-(Please`frll ouY Appendix . If build&t is less than 35;000 eu.£t:of enclosed ace and/oxnot under Construcuon Conh'oI then PSection 101 40A Re isiered Professional It6slionsible for_Constr'uction Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 16.2 General Contractor s, 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:WURKFRS'Cl1MPENSATIC)N NSUR'ANCE AFF[D UIT M.G:L.c 152. 25C 6 . r 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 ❑ ?' $ECTION 12 CONSTRIJSTION COSTS AND PERMITFEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 20,000.00 1.Building $ 20,000.00 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 $ 2000000 Enclose check payable to , . 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OE 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 wd accurate to the best of my knowledge and understanding. President 603=895-0400 8/18/15 Please print an si me InaSa I Title Telephone No. Date 25 Spaulding Rd Ste 17-2 Fremont N 03044 Street Address City/Town State Zip ;. k "Mummpal Inspector to fill out this�sectmn upon appbcaton approval Na Date. . i<. it 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) 78,80,82,84 Cavendish 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 0 Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ Nod Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No IN Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 91 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organiz tion/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 ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' y P ty 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ 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 I LF] 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' 13.0 Other comp. insurance required.] Any applicant that checks box 91 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 jab site information. Insurance Company Name: Union Insurance Company Policy#or Self-ins. Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016 78,80,82,84 Cavendish Sa em, Job Site Address: City/State/Zip: 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 ccje/rrttify�under r the pains andpenaldes ofperjury that the information provided above is true and correct. SignaturCe /:L1'�(,h Pi �i1.4�1k Date: 8/18/15 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#: ` 10 Park Piaz 70 $ostcriAlassachusetts 02116 ; Home Imprpverne t C6ntractl Registr�tior� Re9ustratiom .160138 Type: .SupPlemenl Card.= Expiration:.- 612512 0 1 6 KTM PROPERTIES, LLC: CHARLES NIiNASALL! 25 SPAULDiNG RD SUITE 17-2 FREMONT, NH OP44 Update A dreas;and raturn card Mack reason foe chai ige. mfdress �tenewal <-- , Emptoytnent `—;GosF�ard ' ri;Zr /t7#"e a.�ync�+2u��lf GEl s:1�Y*rd�n{>4uif_ .. ; dice of Consumer ntltLirs 8 HUAliess-Regutaxwa Gte@ase ar registration;:solid for individul use only - ppfore the dxpiratjon dates un 1":od,return to; tM ; . fMEPR©VEMENTCONTRACTOR• u ; t3tfitc of Consumer,Affairs and Business Regufatjan P aitegisiwat!oh: 16b136 - `TYpe= 10 park•Plaza-Su�te,5t?0' Exp'6ation: 6f15i2(7T8 Sa plement Gard 3osmn .lot. -02116 rM PRQpERTlES.-CLC. _ - ` -' r iAALES MINASALU i i SPAU6ING RO SUME 17-2 S'.�.s•��,, ._—' ` 2EMO NT NH 03044 V`3iy rri t t7udersrrretary ' tiou $ 1 t I t i ti I i I 21 I t �RobUC,fR 'i T e" g15Grse 0 3.Ei2�-589t1 ;rowii:$8rawnSlMlerrimxk), vNaNe t ---------,----- O6,Dapfei 44eEsiet wghway' Rax 586a$d5 i223 'g , 1�� Ilerrintaak,NN 03054 " ' L`3 r ---r- 'Rt3UREIX(S)AFFaRBrNG C4Vi:'RAeE NA4Cs! ItSI p@R A Union insurance Company 14 r+auRgp KTM ropeMas;LLC ` NsuRiRa'� 25 Soaulding Road Ns r Fremont NH6304d COVERAGES CERTIFICATE Ntlmi3ER REYfSK9N NtiNIBER .,THIS IS TO CERTIFY THAT THE POLICIES OF iNSuRANCE L1STED 6 LE1W HAVE AFE0 188VE0 TO THE INSURED NAMED ABUVE FUR THE i?ORYGY[PEftfQD z INDICATED NOTWITHSTANDING ANY REQUIREMENT„TERM OR CO,iODITAON OF,ARY,cpNTRACT OR.,SICR R DOCUMENT WtTN ftE`S€'EC'i'TO CFNHGCN CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,`THE�.INSUFL4NCE?AFFOROFO„.SY?lHir p?C,t134"+tE$.DESCf2iBED"HEREIN }S SUBJECT 70,ALL'fltt>^`TERMS i ESSCLUS10N5 AND EOND1T14N6 OF SUCH POLICIkS LIMB iSHOW3J"41A7 NPvt�Ea �RE"QUCF„OBy PAIDCLAIMS _ - T P�GI�CI'rF.I�R _m. r b �t NSti TYMOF RMURANC@ FaGiGY UM f YWI - UIIRlT6 1 cs NERAl waumEACH accuR c $ 1600 0b A X CCMMPRCtA G@NERA uA@mxry P.R51 3061t 06t41112015 -0611612418�RYt� a r m 100,OQ, .Ey3ELs. 1 , CLAIM 5,MADE X �i16t z (' Rt 7!_ SNiYwie WN>v%A�, S � ; 5-OQ, 'PERSONAL 5 ADV fFWURY Y t,606 U6D GENEFLFi AGGREGATE' 5 r 2 2� lope GENT AGGREGATELIMft APPLIES MR: � � � u... 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X wC STA frTH• •r ANa h4PLaYER9`UA81L114'.,' A A.nF'6RaPas:rcgmARTwERn:7�cuTN@ YIN wra C5_1A51323'i&11 W18,gQ15 8614812016 EL.EAC�HIECCaENr $ « F' 4flki0,00 fE%CLUCE4Y - n aamatEo wtlo+ f - 1,660,Q , ; a 5 IPrtON CP OPERAitOt3S fletaw - EI IXSFA$E POL-0C'C7 UAiT R pEBCRdVTION,OF UPERATIONSfLgCATfaNS ItIEMCLES (A11aChACon iB1 tg3e@RdnePliEmeMs; dmur�gpscs lsmeiuhed) 4 4 t a jW.a tt t �` 4, t; ,, dy F• 1 r' CE971F{CATE14 LDER �'CANCELC�ON 'Skit i"ANY4OF I*HE,;ABOVE DESCRIBED POliCiES flE CAA7GEi:F;Eti BEFOR'8 For i1F40Rnafjor atl?u OSPS Tije .F;C7IKATiDN .1?AT,€: 'THEREOF,_Nt7�ileE- ,Y11CL a£ 6Eti1>fERF.U. Ni rp ACCORDAN_E LVfT#1 TJiE'POLiLY PRO,V15IONS, DnIX1 f f a A4I79IaR.R30 REPRE$ENTATNE' Chris IM'C all x "A"f cg.}aeBs�6BacDRa,coloRarrata niir�gil4s, saraaax' Act 25{201It%05) The ACORD name ari¢ksOtYare Ta{ligfere�d SrtBjeks ofi ACORD , ° `: + at l _