70,72,74,76 CAVENDISH CIRCLE - BPA-15-859 44-
�Z-2_�_ 15120
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
. .... . (Thts Section For Official Use
-,Building,Pe,r"h i—tN-u, nb,e,r--,1 - - 'Building
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SECTION I-LOCATION(Please indicate Block f and1of#for locations
which,,a'rtr0t'addre'9s is not av�ai ble)
Bldg 163 70,72,74,76 Cavendish Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if atplicab
SECT lo)K-2:PROPOSED WORK 'I"' J
Edition of MA State Code used— If New Construction check here 0 or check all that apply in the Q rowtZimv
Existing Building 0 Repair 0 1 Alteration 0 1 Addition 1:1 1 Demolition 0 (Please fill out and submit Qppen4i ?)
Change of Use 0 Change of Occupancy 0
I Other 0 Specify: (,n
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 (340 Ey1j;
Is an Independent Structural Engineering Peer Review required? Yes 0 No [3
Brief Description of Proposed Work: Remove and replace roofing shingles
P`: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING;UNDERGO ADDITION,OR
CHANGE IN USEOR OCCUPANCY :,
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) 13
Existing Use Group(s): hesiclential Proposed Use Group(s): nubluelitial
'--,'<''SECTION UILDINGHEIGHT,AND-AREA`
'�,���-"��
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft)
' 'SECTION5:USE,GRbLTP,(Clieckasapplicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 E]_ A-4 El A-5 0 B: Business 0 E: Educational El
F: Factory F-1 0 F2 0 H: Hi Hazard H-1 0 H-2 0 H-3 El H-4 El H-5 0
1 M. TR: Residential R-10 R 1: Institutional 1-1 El 1-2 0 1-3 0 1-4 0 . Mercantile 0 -2 9 R-3 0 R-4 1:1
S: Storage S-1 13 S-2 El U: utility El Special Use 0 and please describe below:
Special Use:
4-SECTION 6:1 CONSTRUCTION (Check al§applicable)'
IA 13 Ill 0 IIA 13 IIB 0 IIIA 13 IIIB]E:3 :�VA 13 VB 0
SECTION,7..SI-TE INFORMATION(refer to.,78O.CM]k,.'1,11.0.i6r,details on,each item), ,,
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone El Indicate municipal 0 A trench will not be Licensed Disposal Site 13
Private 0 or indentify Zone:- or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: _N4A Historic Commission Review Process.
Not Applicable 11 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No 0 Yes 0 No 0
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:
-SECTION'S:.PROPERTY-OWN ERALITHORIZATIOIV
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.
"+ik SECTION SR CONSTRUCTION CONTROL(Pleaso:fil]out Agpen`dix 2) j
rr ..;,�. . . -., .
If buIldin is Less than'35,000 cu"ft of enclosed ace and/or not under GonstcuetlonConttol th'exi;rheekbere,land sla Sechon101
10.1 Registered Professional Res onsible for Construction Control l:
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 GenerahContractor"
}a a;
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
':',SECTION11:WoR CRS^@'OMPGN' 'Cf(JN t.�VSL A CFAFF(i3 V3T M.G:L.c.152: 35C 6 s .. r t " �
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 L( No ❑
iy-, S'OCTION 11 CONSTRUCTION COSTS ANDTERMIT' EH
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 $
20,000.00 Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATUREOF iloL NG'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 cl ac ur to to th best of my knowledge and understanding.
li
Zzl.1 President 603-895-0400 8/18/15
Please print and si ame unweS minasalli Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
'Municipal Inspector to,fill out this,sechron upon application approval
v
& 3.( a . : r Name „to.` a 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)
70,72,74,76 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 M 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 d Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No 13 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 oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
up www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organimtiordlndividual): 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 general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hived the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity, employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
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 11.❑ 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 most also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew 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.
I Union Insurance Company
Insurance Company Name:
Policy#or Self ins. Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016
70,72,74,76 Cavendish Salem,
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 cceertrtify�u�nder the pains and penalties ofperjury that the information provided above is true and correct
S'nnatureC / Nfit" 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#:
nRabaCkR I IT Phone 603
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CERTiFiCATE MAY BE ISSUED.OR,MAY_ PERTAIN,xt THE-1NSUR44CE-AFFORDED:f3Y 1HE pQ,,,P6 t}ESCRI9F.fl`HEREIRt i5 S,UBJECT TO LL?fkiE
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KTM PROPERTIES, :LC. ' 1
CHARLES' M'INASALLI .c '
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25 S,PAULDIN,G RD SUITE 1,7-2
FREMONT, NH d3b4:4 - -
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