47,49 CAVENDISH - BPA-15-872 �¢ 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 Secfion For Official Use-Only)
Buildmg Permtt'Number Date Applied Building Offic a1.
'ti-,SECTION 1:LOCATION(Please indicate Block#and Lot#'for locations for which a street address is not available)':
Bldg 186 47,49 Cavendish Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
" `5_ SEG'I'ION 2:PROPOSED=WORK ,,
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 121 Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes l}^ No rrd
Is an Independent Structural Engineering Peer Review required? Yes Cr= No-iy,
Brief Description of Proposed Work: Remove and replace roofing shingles otE.^3
Ct 2 r-t
r<
N�
4�=
SECTION 3.COMPLETE�HIS�SEC ON IF EXISTING BUILDING UNDERGOING RENOVATION,AWDI N,OR .,
CHANGE TN USE OR OCCUPANCY .2 ..� ,
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): mesiaentiai 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 5:USE GROUP.(cii c, as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F. Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5 ❑
I: Institutional I-1 El 1-2El 1-3ElI-4❑ M.
Mercantile❑ R: Residential R-10 R-2 Cat R-3❑ R4 ❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(check as A 'plicable)`;j; .
IA ❑ Ill IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:STTE INEORMATION,(refer to,78b CMR IILo for details on each iterit): ._ �a
Debris Removal:i Permit: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: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
,�F;SECTIOIVS:CONTENT;OFCERTIFICATEOFOCC[JPANCY`;"'` , '� _
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
'`k r t ? 4 " ' '.SECTION 9: PROPERTY OLYNER AUTF[ORIZATION
i<. .
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 lfe`CONSTRUC170N CONTROL¢'lease fill out Appendrz 2),
If,lmildin >s(ess,Bian 35,000 eu.E#of eneloseds ace and o`r nobunder Construction Control'then iheek here C an "ki Seehon 101
10.1'Re 'stered Professional Res onsible for:ConstrueHori Control , `< � y,;-
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Coniractor. P,
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 60a231 1677 tara@ktmproperties.com
Telephone No. business Telephone No. cell e-mail address
;, "� •lZ `SECTION-1L• RKGRS^C(OMP:NSAP'ON INSU 2A: Z'E ARF[ISAVIT�M.G;ttc.152. CSC 6 `<� < 7
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 ❑
SEION12CN S AND PERMIT,FEE,C
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ 10,000.00
1.Building $ 10,000.00
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (IT VAC) $ - Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
1000000 Enclose check payable to
, .
6.Total Cost $ (contact municipality)and write check number here
E, SECTION I3-SIGNATURE OF BUILDING;PERMITAPPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application accurate o the best of my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign me InaSa I Title Telephone No. Date
25 Spaulding Rd a 17-2 Fremont NH 03044
Street Address City/Town State Zip
�Mumcipal Inspector,to fill out this section upon apphcahon approval
Narne '� Date, 't'