62,64,66,68 CAVENDISH - BPA-15-861 a-1217
The Commonwealth of Massachusetts
lU Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
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_'SECTIONJ:LOCATION(Please indicate Block,,f and Lot f.for locations for which'a sheet address i4not available)
Bldg 164 62,64,66,68 Cavendish Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(iZpplicAe)
SECTION 2.PROPOSED WORK
l " , - ,
Edition of MA State Code used— If New Construction check here 0 or check all that apply in thobvo r!E�.�elow
Existing Building 0 Repair 0 1 Alteration IN I Addition 0 1 Demolition 0 (Please fill out and submit AppTRC�1)
C7-
Change of Use 0 Change of Occupancy 0 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No:ff
Is an Independent Structural Engineering Peer Review required? Yes EV- No15_
Brief Description of Proposed Work: Remove and replace roofing shingles
-COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION;ADDITION;OR
Check here if an Existing Building Investigation and Evaluation is enclosed(Seel 780 CMR 34) 0
Existing Use Group(s): Hesidential 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)
1 -7
SEC ION Si USE, heck as'aI;plicable)
GRO A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 El. A-4 13�A5❑ B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 D H-2 El H-3 El H4 11 H-5 0
1: Institutional 1-111 1-2 0 1-3 0 14 D M: Mercantile 0 R: Residential R-10 R-2[I R-3 0 R4 0
S: Storage S-1 0 S-20 U: utility 13 Special Use 0 and please describe below:
Special Use: -
SECTION 6i CONSTRUCTIONTYPE(ChitIc ag-applicable),
IA 11 . IB 13 IIA 13 IIB 13 1 IIIA 0 IIIB 13 1 IVO JVAO VB 0
-SECTION 7:SITE INFORMA iO&,(referto,786�tmR.iiiio,,for deWls!ori each iiem)
Water Supply: Flood Zone Inf omation: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site Cl
Private El or indentify Zone:— or on site system El required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 13 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed E3 Yes 0 or No El Yes 0 No El
','F 9 4,"--- SFCTIOK B'--iPpNTENT 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:.PROPERTYOWN'ERAUTHORIZATION
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.
,SECTION10:CONSTRUCTIONCONTROL'(Please fill Opt Appendiz2)
If budditi "s Less than 35;p00 cu.2t.of enclosed's ace and/pr not under Construction Control then clferk he're,f;Kand sla S�eti m 101 -
10.1 Registered Professional Res onsible for.ConstrucHoir Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 GerieraPContractoc - `
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
SECTIONAL WORE FRS"COMPENSNI'ON INS ` ANC ;AFF DAVIT M.CiL" 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 signed Affidavit submitted with this application? Yes CY No ❑
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 (f VAC) $ - Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ -
2000000 Enclose check payable to
, .
6.Total Cost $ (contact municipality)and write check number here
I' t f.. ; , SECTION 33:�SIGNATURE.OF BUILDING PERMIT APPLICANT +; r +I•
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 accurate o the best of my knowledge and understanding.
� President 603-895-0400 8/18/15
Please print and si me L;rMTWS InaSaVl�-�I Title Telephone No. Date
25 Spaulding Rd a 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to�fill out thissechon upon application approval f .I " ""'
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