01 ,03 , 05, 07 ECLIPSE LANE - BUILDING PERMIT APP 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
{Thison'For Official'.Use
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,J) SF_CT10N'1LOCATION'(Please indicate Block,,*and L44,for locations for which astreet address isnot available)
Bldg 180 1,3,5,7 Eclipse Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION PROPOSED WORK
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 El I Alteration IN I Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy 0 1 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No EY
Is an Independent Structural Engineering Peer Review required? Yes 0 No IR
Brief Description of Proposed Work: Remove and replace roofing shingles
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CHAN,
GEINVSEOR !CCU
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13 rTi
Existing Use Group(s): Hesioential Proposed Use Group(s):
, SECTION*,BUILDIMS HEIGHT AND AREA2,
Existing Yroposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5iUSE GkOUPjCheck Is applicable).
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 13 E: Educational El
F: Factory F-1 0 F2 0 1 H: High Hazard H-1 El H-2 0 H-3 0 H4 0 H-5 0
1: Institutional 1-10 1-2 0 1-3 0 14 0 1 M: Mercantile 0 R: Residential R-10 R-2[Y R-3 El RA 0
S: Storage S-1 0 S-2 El U: utility [3 Special Use 0 and please describe below:
Special Use
SECTION.6.'CONSTRUCTIQNTYPE,((;ke,ckas applicab
1A 13 IB 13 HA 13 1111 0 IIIA 0 111B VA 13 VB [3
SECTI 0
�-.,SITF,jNFQRMAf16T;�(refer to.780.1cNIA 111,01ordetails-
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Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Q Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone:— or on site system 0 required 0 or trench or specify:
permit is enclosed El
Railroad right-of-way: Hazards to Air Navigation: TNIA Historic Commission Review Process:
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No El
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CTON'9.,CONTENT-
Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
i
SECTIONS: PROPERTY OWNERAUTHORIZATION
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.
�ti%SECTION I0'CONSTRLICT tON CONTROL(Pleaseefill out'A'—dix 2)'
Ifbuildin is less than 35000 cu.ft of enclosed ark and cir not under Con'structiori-Co-I'then eheckhere C and sld sechon lo.S'
s, _ _.
=10.1 Re 'steed Professiorial`Res`ottsible far Gonstruetior.Control � 4, :..
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 ll:.w K=F s cC3MPF I,AI'iON auRANc .AFFIDAVIT M.G.L.,c.152.§25C(0))
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 si ed Affidavit submitted with this application? Yes L( No 17
P .SECTION i2r CONSTRUCTION COSTS AND PERMIT FEE , r
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 $ -
$ 20,000.00 Enclose check payable to
6.Total Cost (contact municipality)and write check number here
:' SECTION 13.SIGNATURE�OF,`BUILD
ING PERMIT 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 urate to th best of y knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign not e r a Title Telephone No. Date
25 Spaulding Rd Ste -2 Fremont NH 03044
Street Address City/Town State Zip
Munwrpat Ixispector to fill out thts sedmn upon application approval l ` rM ` n k r r ,�-,
0T Name-