42,44,46,48 CAVENDISH - BPA-15-860 TZi7-
The Commonwealth of Massachusetts
Department of Public Safety
Q � Massachusetts State Building Code(780 CMR)
S Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section Por:Official Use;Onlp)
Building Permit'N,umber: Date Applied '` . Biiildim Official: '
n SECTION 1:LOC'ATION(Please indicate,.Block#and Lot;'#for locations for which-a street address is not available)
_ Bldg 167 42,44,46,48 Cavendish Salem 01970 Green Dolphin
1 No.and Street City/Town Zip Code Name of Building(if applicable)
7 SECTION 2•PROPOSED 4NORK
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 0 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
Is an Independent Structural Engineering Peer Review required? Yes ❑ zNo
Brief Description of Proposed Work: Remove and replace roofing shingles "' �'
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1„,SECTION 3^.COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,APPITIQN OR,
` s'" t : CFIANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Hesidential Proposed Use Group(s):
SECTION 4:BUILDINs 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:`ilSE,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❑ M. High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4 ElM: Mercantile❑ r R: Residential R-10 R-2 Cat R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility ❑ Special Use❑and please describe below:
Special Use:
sECTIQN 6:CONSTRUCTION TYPE;(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ I1I13 ❑ 1 IV ❑ VA ❑ VB ❑
e •'=:�, 4 4 a' SECTION 7:SITE INEORMATiON(referfo 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site ❑
Public❑ Check if outside Flood Zone❑ 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:CONTENT OF CERTIFICATI` OP OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTI0N'9: PROPERTY OWN
BRAUTHORIZATION
Name and Address of Pr- operty 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.
SBCTION'10 CONSTRUCTION CONTROL (Please fill!out Appendix 2)`_
If building is less than 35;000 cu:ft of enclosedfs ace and 3rnot under Construction Control then-check hereOand ski Section 1D 1
10.1;Re 'stei'.ed Piofessional,lies onsible for Construction Contr`oI �. ' "'' ' ` ' . . '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
16.2 General=Contradoi
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
" -,SEC3'ION 11:WOPKCRS'CC7NIPRNS 'I'lON NSCR 'NC .A'FF[D��'VI`l" KC.L.C.152. ,25C 6
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 a lication? Yes M No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor 20,000.00
and Materials) Total Construction Cost(from Item 6)_$
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:SIGNATURE,OF BUILDING PERMIT APPLICANT
By entering m name below,I hereby attest under the pains and penalties of perjury that all of the information
y g y y p p p t7 y motion contained in this
application is true accurate to the est of my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and si me inasa Title Telephone No. Date
25 Spaulding Rd to 17-2 Fremont NH 03044
Street Address City/Town State Zip /
Municipal-Inspector to"fill out this-section upon application approval
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