0038, 0040, 0050, 0052 CAVENDISH - BPA-15-864 kn/
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
WE Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For official Use'
Building ro,t Permit Number: Build
SECTION I-WCATION(Please indicate Blo&*and Lot*for locatons for which a'street� ddress is jqt,-ayAoab le)
Bldg 166 38,40,50,52 Cavendish Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(i�plic;rble)
7
"'SECTION 2:PROP0SEDWORK ,
Edition of MA State Code used_ If New Construction check here 0 or check all that apply in th0two relow
Existing Budding 0 Repair 0 1 Alteration 15 1 Addition 0 1 Demolition 13 (Please fill out and subZ ApIR2,1)
Change of Use 0 Change of Occupancy 0 1 Other 0 Specify: w
Are building plans and/or construction documents being supplied as part of this permit application? Yes V N
Is an Independent Structural Engineering Peer Review required? Yes IJ Now
Brief Description of Proposed Work: Remove and replace roofing shingles
SECTION-3:COMPLETE THIS SECTION IF EXISTING, G BUILDING UNDERGOINRENOVATION;ADDITTION.OR,
P
USE OROCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) [1
Existing Use Group(s): "esicential Proposed Use Group(s): Residential
'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 Si-USE.GROUP,(ChecVas Applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 El- A4 El A-5 13 B: Business D E: Educational 0
F: Factory F-1 0 F2 0 ii, H'gh Hazard H-1 0 H-2 0 H-3 El H4 El H-5 0
1: Institutional 1-10 1-2 0 1-3 13 14 13 M.. ercantile 0 F—R: Residential R-10 R-2 9 R-3 0 R-4 0
S: Storage S-1 0 S-2 1:1 U: utility 0 Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA [3 HT [3 IIA 13 HIT 0 IIIA 0 THE 13 1 TV 0 IVA 0 VIT 13
tails on each item)l...SECTldT47-.:SITE iNtbkMA�TION(refer'to780!CMR ill.o:for,details
Water Supply: Flood Zone Information: 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 13
Private 0 or inclentify Zone:— or on site system 0 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 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed E3 Yes 0 or No 0 Yes 0 No 0
SECTIQN,.S:CONTENT,,OFCERTIFicATE,OF,OCCUPANCY,,,,�,-',.��
Edition of Code: Use Group(s):— Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
gSECTIONA:',PROPERTY OWNER AUTHORIZATION ,r
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 if.CONSTRUCTION CONTROL(Please.fill out Appendix 2)� !
It buildin is less than 35,000cu,ft.of enclosed<space and o`x not under Construchoti Control ttienicheck here Cand ski �Sechon
-1�1 Re istered Professional Res onsible fox Construction Contro] `
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10,2 GeneralxContractot
KTM Properties LLC -t
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 60&231 1677 tara@ktmproperties.com
Telephone No. business Telephone No. cell e-mail address
r ^ SECTION 11:.Wt RKfR+'COMPE' SATION INSURANC . FFIDAVII' M.G.L:L 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 L( No ❑
m� iz im t '
S CT10N12;`COZZI6TREICTION COSTS ANR 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 $ -
6.Total Cost $ 20,000.00 Enclose check payable to
(contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILpING=EERMIT 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 ao accurate to the best f my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and ign n e unamesunasalli Title Telephone No. Date
25 Spaulding Rd St 7-2 Fremont NH 03044
Street Address City/Town State Zip
Mumeipal Inspector to fill out this section upon application approval .
,1 a •""7, ->� a rJ,:;.. , s „a. :'_Name