The URL can be used to link to this page

25 CAVENDISH - BUILDING JACKET 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 Use brd Official DateApobeq:�, [Buildij I"i : al'. SECTION I.'-LOCATION(Please iiulkate.Blo&,*and Lot#for.locations for i0iichir streefaddie�ss is tot avaflable), Bldg 183 25 Cavendish Salem 01970 Green Dolphin No.and Street City/Town Zip Code Name of Building(if applicable) Edition of MA State Code used— If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair 0 1 Alteration 15 1 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1) Change of Use 0 Change of Occupancy 0 1 Other 13 Specify: =i_; Are building plans and/or construction documents being supplied as part of this permit application? Yes &.! N o'4$ff', M Is an Independent Structural Engineering Peer Review required? Yes [g, NoceIN Brief Description of Proposed Work: Remove and replace roofing shingles C= r-j Zm CD SECTION 3,COMPLETEIMSS'ECTION417 EXISTING BUILDING UNDERGOING RENOVATION, DIT!��OR, j "- OiO; CHANGE '&si Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): mesiaenval 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.) . ... USE GROUPSECTION 5: (Check as applicable,)pplicati e A: Assembly A-1 El A-2 0 Nightclub 0 A-3 1:1 A-4 El A-5 1:1 B: Business 0 E: Educational El F: Factory F-1 El F2 0 i gh Hazard H-1 0 H-2 0 H-3 0 H-4 13 H-5 El I: Institutional 1-10 1-2 0 1-3 0 14 0 iml'.. icantile 0 rR: Residential R-10 R-29 R-30 R4 0 S: Storage S-1 0 S-20 U: utility 0 Special Use 0 and please describe below: Special Use: SECTION&ICONST'RUCTIO I __N TYPE(Check as applicable)l IA 13 IB [3 IIA [3 IIB 0 IIIA 0 IJIB 0 1 IV 0 IVA 13 VB 0 : .SECTION 7:SITE INFORMATION(refer to-780 CMR 111.O'for details'on a ch item) - Water Supply: Flood Zone Inform Sewage Disposal: Trench Permit: Debris RemoInformation: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private 13 or indentify Zone:— or on site system 0 required 13 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: VIA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed7 c3 or Consent to Build enclosed❑ T YesD orNoO Yes 0 No 0 'i SECTI9N,&.-CONTENTOTCERTIFICATE,OF.00CUPANCY-,---�'�� % Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor: Does the building contain an Sprinkler System?:—Special Stipulations: �-�� 's 'r '?SECTIONR: PROPERTY OWNER AUTRORIZATION :`r,r{ ,?, ,1 •-v 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. �,; SECTION i0: N CO ,STRUCTION CONTROL�(Pleaie fill out Appendix 2) If buildin is Less than 35,OOD cu fE of encloselis ace'Snd ornoY under ConatrucHonConhol themeheck heie,Cand ski Seehon 10.1 = 101 Re isteied Piofeieional Res arisible for.Construction Contml-'?� ;+a` - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date '120.2 Gerierai Contraceor' - 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:WOR FRS'COMPENS TIO, N, RA CE AEEID wiT M:GiL.c.152: i25C 6 E ' 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 Cal No 0 SECTION 12 CONSTRU_l TnON,COSTS AND;PERMIT-FEE Item Estimated Costs: (Labor 5,000.00 and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 5,000.00 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 $ $ 5,000.00 Enclose check payable to 6.Total Cost (contact municipality)and write check number here 7777 " SECTION 13.SIgNATUREtOF BUILDING.PERMIT APPLICANT, .'s 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 and ccurat to e best of my knowledge and understanding. zz_ President 603-895-0400 8/18/15 Please print and sign n crizurlewm i nasal li Title Telephone No. Date 25 Spaulding Rd Ste 2 Fremont NH 03044 Street Address City/Town State Zip Murucrpal Irspe@or t6'fill out this^sechon upon appheation approval r`"` -S l .. Name -_s x E - Date„ r f. 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) 25 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 ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No Cl 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 ofMassaehusetts Department oflndustrial Accidents Office of Investigations vi 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/Organimtion/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 workingfor me in an capacity. employees and have workers' Y P ty 9. ❑Building addition [No workers' comp, insurance comp. insurance.t required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions 3.[_1 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors 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 thepolicy and job site information. Insurance Company Name: Union Insurance Company Policy#or Self-ins. Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016 25 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains an$ enaldes ofperjury that the information provided above is true and correct Sin ature Date: 8/18/15 Phone M 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#: PRODUCER _I ptiOnti 643,�t24�$807 ? E .i 1a 4y irowm$8rokan(OAarrimack} _ ""East.866 Bq:E 92� P� e _sHcc ?l—..» ,..;..w DO Daniel WebstarHighway Aerrimack,NH 03064 :guesscc " y NSURF.42(5)gFFRROMCa CpylkOE =,.�NA4�C INs c iA klriign Insurance Company mouno KTMProperttas'LLC roasurceRa �y _ 25SE�aoldl6g- Rbad uaa ' cc — Fremgnt NH 03044 lNSURERE � _ ` COVERAGES . �l . = OERGIFICA7ENI6MBER: ' <- �, : REVtBION NOMBER TMtS-l9 TO CERTIFY THAT T3 'PQUCIES OF iNSURANCE L2yTEWBE OW NAVE FJ- PJ ISSS!>wq`TO THE INSURED NAMED ASOVE'FOR THE POLtLsY�S'RftfODt INDICATED. NOTWITHSTANb(NC ANY REOWREMENT,»TERM OR CONOrTION OF ANY CONTRACT OR OTHER DOCUMENT,Yl?RN RESPECT t 'WHkCH THIS C'EkTIRCATE MAY"BE ISSUEL OR MAY P,ERTAIN,°,THFs--1NZIORANCEiAFE'ORpEgeBY 1}4E PoLICIE$:OESCRIBED HEREIN MSUBJECT,TO riLi.;TAEl"TERt.4S,z, EXGLUS)ONS AND CONDrr;bws OF SUCH POLICIES."LIMITS�SHOWN 44AY htAVEt�'fiN:Eir•T1�U"CE.CS''fiY:PADpCthiMS `. L• _ Wsd !O S r"' p Y P TYPEEINSURANCE- �1, cNERu uABnrir EAcxlpdcuRgENcr __r t 000 bit A X ecmann:RCIA`tGFNUR UABlUTv Ptj5t52346 tt- D31481PQt5 0611612016 ,� a T ; t#iD,04_ .` CWMS.tAARE tlCCilk y A'.ER DD' YoneIF'Side.. PERSpNA!6 Apv{NlURY S Astldgv�q�i AGGREGATE 2,edke , }-i3—EKL AGGREGATE LIMf7;APY41E5 PER: 7I PRUC( X; m , d.RC , G(MaEN U9i LE,L ¢UTOMBILE I--` tdiYtq>0[f A ANYAVTp ! AN1#45E344.t#' dl6fiFlt4tS 46dte12646 90RPY NRNEYIPB pgson a AIL AWNED' SCxEUULEO. }. .aORft.YiJl.l41Ry(P6tarr.'Jeni1 5 '� AUTO; X NClN-friVNER e a. PeW. AGF S � ...�•.:. X I MImbAUTOS "AUTOS E Wiz.` U46REI.tA GAB X OCCUR - EACH OCpJRRENC KE S � y 5r pti'�O_a4. . A ExeEssL C{ateAcs� nc CliA31523141t ltGfti`Y2015 46195Y24tS AGGREGATE S ' q?, 77 DED X TENlIOCk t0000 - S _ WORKERS EpDAgENSATWN; .- - +S STAT2! p fi- a AND FAROYERT UABD.trY. � A aglYPRotrtlEi'ONPwzTNEruExEeuTlvEY ,CA5t�;3tgt!!i5g6tSt2tlt5 8S11St2g16 ELEn,Cr1aGGT s ` : 9G!#Ktdlf OFPICER7MCRa8h13£%CLUA26T L .J MIA, }4 _ tAAs�Matm in Nx ' EL RISEASE £A EMPLOY s ,�. P t,,00q{04 R s dustriHeur , : : t ' ;R.SCRIP(I 0.6PERATlO 9 hobo. - - e - E.L R13EfuSE POLtCk'UMIT $ rQ cc OESCRiPSWNOP OPERA110NStLOCA�WNSivExICLFs9 IAtmchAC0�010tl AtldglquuPRMb+Ma.SrfigUtke-rl mgnr�ac0 is mquiredTi f "j, '_ � . i 3s a t CERTIFiCA ER CEL 'FION �_^y , n ,SHOULI)AOYE OF'ME ABOVE DESCRIBEDPOLICIES:BE GANCEI',tiRGI,# .FfpRfn ! _Tt(E EXPIRAADN IDATi, THEREOF'=NPTICE Y11F.L BT D'liiVF3dEl1_ IN For lnioml3tlprpaj 1?Uri705QS _ ACCORDANCE W7R T,HE•�LICY OROYISiDNS �r � 4lltyi I y :'Y 5. _ 1{ t A7fT'NOF72�0 RERRESENTA?NE'-'. r x � Ghria MaPtai1 6 ! crF-: a S ?�4988a26tUACORDCDR,P,C7RAYtOfr AdEnghYSSatvatl ACORO,25(20te)g5} Ttse A.CCttq name aqd logo areiiagitered darks bf•ACORD s e ° , � 10.Paxk Pbz4 - 5tute 517Q 1364ton, M,assuhusetts 02116 . Iom� Tn�pravetnent C ontract&'Registration ° Registration: .t60t38 Type. .SuPPlemenY Car! Expiratlom% 612 5 20t6 ' KTM PROPERTIES, LLC. CHARLES tUIINASALLI= 25.SPAULDING RD SUITE 17-2 , FREMONT, NH 03044 ' - �� ' I UpdOte.Address::and return car¢.Mark reason f6r•etiange. ix +-osn Address t .Renewal A c> + , 'i Frmptoytneni '-i Lost 4rard ('J1',pn YlY Ll)r[*E?/!f &J pf(, - `^ free of Copsamer Atrairs R BuianeSs R_ egulanon` '_ 'Lteense•or regastration:sattd for individui use Doty °bofnre the expfratian date- ] found'.return to: ME IMPROVEi'&ENTCONTRACTOR - - 1 a - Of ice o1'Cansumer4ffairs and flusiness RBgutatsan, I Aegistratian 160139 Typo: -10ParkPlarn Suite5170. „y ExPiratiort.,-6f2512©i SupPlemancGarcl . fBostoo„NA'01116 fM PROPERTIES LLC. ' i -IARLES MINASALLI - i SPAULDING RO SUITE 47-2 2EM4tw7 NH 03044 Uaiferstcietery ' ;`.ut d without signature l l ,I l n t i i i i r 1