0026, 0030 CAVENDISH - BPA-15-865 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
I J °;(This Section For Official'Use.�Only)"= ,
Building Permit Number ' '%:Date Applied. Building�Official -
'SECTION I-EOCATION(Please indicate Block#.and Lot#for locations for which a atreetaddres"s is;not available)
Bldg 169 26,30 Cavendish Salem 01970 Green Dolphin
(� No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2rP.ROPOSEU WORK,
` Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
EPxisting Building❑ Repair❑ Alteration 13 Addition❑ Demolition El (Please fill out and submit Appendix 1)
L
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 lY
Is an Independent Structural Engineering Peer Review required? Yes ❑ No I%
Brief Description of Proposed Work: Remove and replace roofing shingles
rn
1$1
CJ
om
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING.RENOVATION,P�DTTIQS OR,
a, _ „• t , :' ' . CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ en
Existing Use Group(s): tiesicientiai Proposed Use Group(s):
"'SECTION 4:'BUILDING HEIGHT AND AREA . c�
Existing =PropbSed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
-SECTION S:,LrSE GROUP°(Check as`appI cable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ElF2❑ H: High Hazard H-1 ElH-2❑ H-3 ❑ H-4 ElH-5❑
1: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 9 R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:`CONSTRUCTION TYPE(Check,as applicable) -
IA ❑ IB ❑ HA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(referto 780 CMR 111.0 for detaila on each item)
Debris Removal:it Perm :
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site El
❑ 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: VIA Historic Commission Review Proccss:
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 CERTIFICATE OF OCCUPANCY ,x
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
&ECTION9: PROPERTY GINNER 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.
x SECTION 10:.CONSTRUCTION CONTROL(Please fill out Appendix 2),
if buildui fs less than 35,000 cu ft of endosad s 'ace and/or not udder Construction Control then lchk0i' re CYand sld Sechon 1Q1
10.1 Re 'ster'ed Professional=Res onsible f6r Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General;
Contractor.:
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 I1:.Wf) FRS'COMIsFN' T1F)N INStiR NCF AFfti)AUl M•G: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 signed Affidavit submitted with this application? Yes Cal No ❑
777777 SECTION 12s CONSTRUCTION COSTS AND'PERMIT FEE
Item Estimated Costs: (Labor 10,000.00
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 10,000.00 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 $
1000000 Enclose check payable to
, .
6.Total Cost $ (contact municipality)and write check number here
`SECTION 13:SIGNATURE,OF,BUILI7ING PERIYIIT 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 and accur a to the best of my knowledge and understanding.
41,,11 President 603-895-0400 8/18/15
Please print and s' ame urr (r eS Inasa Title Telephone No. Date
ld 25 Spauing to 17-2 Fremont NH 03044
Street Address City/Town State Zip
Mumetpal Iiiepector to,fil]ouk tlussectton upon application approval ` ` kM
>, s ,NffiTte. .. �' n i tS� � � Date"r' �s'