54,56,58,60 CAVENDISH - BPA-15-863 ff, 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 UseOnly)
Building Permit Number. - Date Applied : 'iBuilding Offctal. `�' r '''
SECTION 1-.-LOCATION(Please indicate-Block#and,Lot*for locations-for which a sheet address isipot available)
Bldg 165 54,56,58,60 Cavendish Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED-4yOI*- `
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 Cri Addition❑ Demolition ❑ (Please fill out and subn 0 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ 10
Is an Independent Structural Engineering Peer Review required? Yes ❑ o CIO
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION 3:COMPLETE THIS'SECTTON IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY `
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Kesiaential 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'5rUSE GROiIP(Check'as'a plicable) , ,.
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ ICI❑ M: Mercantile❑ R: Residential R-10 R-212C R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
' SECTION 6:CONSTRUCTION TYPE(Clreck ae applicable) ;; ;„., -> >
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
.. :SECTION 7:SITE IhIFORMA 'ION(refer to 780 CMR 13i.D fordetails on each item)'-.f
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
A trench will not be Licensed Disposal Site❑
Private❑ or incientify 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 Nc ❑ Yes❑ No ❑
�SECTION'6:CONTENT OF CERTIFICATE OP OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION. ,:.PROPERTYOWNER 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 owner's behalf,in all matters relative to work authorized by this building permit application.
w 'SECTION 10.'CONSTRUCTTONOONTROL(Please fill"out Appendix 2).`
-"`, ff buildin' ei less than 35,Q1HI cu.ft.of enclosed a ace and or not under Construction Control then check hYre Cand la Section 101
lo.l Re 'steied Professional Res onsible foi Construction Control=
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
0.2 GeneraicConiractor'� '`'. z«
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 11E.VV(JR PR4,comP.EN' 'ft0 INSURANC . FFID'.VIT M.Gri.: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 signed Affidavit submitted with this application? Yes 13 No ❑
SECTTON.I2, _OIVSTRUCTION'COSTS AND PERMIT FEE
Item Estimated Costs: (Labor _ 2Q,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 $
2000000 Enclose check payable to
, .
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNi1TURE OF BUILDING.PERNIIT.APPLICANT <.
'E _. .
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 an accurate the b t of my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign ne inasalli Title Telephone No. Date
25 Spaulding Rd S e 17-2 Fremont NH 03044
Street Address City/Town State Zip
.Mumcrpal Inspector to,fill out this-section upon applxeef on approval
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)
54,56,58,60 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 ❑ No EJ 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)
Aft The Commonwealth ofMassaehusetts
Department oflndustrial Accidents
Office of Investigations
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/orgariimtion/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):
1.0 I am a employer with 25 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).` have hired the sub-contractors
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. ❑ 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 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 41 most 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 most 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 andjob site
information
I Union Insurance Company
Insurance Company Name:
Policy#or Self-ins. Lic. #: WCA5152316-10 Expiration Date: 6/16/2016
54,56,58,60 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 certify under the pains ndpenaltieess ofperjury that the information provided above is true and correct.
Cirm re: // "y`ffitd 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#:
�RoouBa _ .424 01
'Phone:
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*p I`mprovernent ContractO Registration
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Type: ,.SupPiement,Card`
€ Expiration. 6/25�b1 fi
KTM PROPERTIES, LL,C.
CHARLES M'INASALL! -
25 5PAULDlNO RC? SUITE 17-2 - - -
FREMONT, NH 03G.44 - - -
Update z#ddresseaad return taro Mark r¢ son for Change.
-i '7' Address --I Renewal 7} Emliloym¢n4 a L,pst Card
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ffite of Copsvmer Affairs&Busmess:Regulation' : ,ieense,or registration:valid for individul us¢only _
�r 'beforellie-eipiration date: CS found return to'. ;
ME.IMPRDYEMENT 6DNTRACTpR - 4tf+te oFCtfnsum¢r A.ttairs and Business Regatation
eReglstration: i6p139 s �TyPe. 'lppaekflaYa•rSaite,3t7tt` _
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fM PROPERTIES,:LLC.
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i SPAULDING RD SUITE 17-2
2EMOM'T NH 03044 �.r �+y`''
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