0002, 0004 ECLIPSE - BUILDING INSPECTION The Commonwealth of Massachusetts
CDepartment of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
777 ,(This ecti6nPor-CifficiAlts 777 (,T s�..S. ebAy
00 Building Permit N e drrub 0�Buildur* fficlal
SECTION,I."�,0CATIQN(P ease indicate Block and Lot
kfor locations for whicliva,street address ii,mot lable):',4vai
r Bldg 181 2,4 Eclipse Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION
E
Edition of MA State Code used If New Construction check here 13 or check all that apply in the two rows below
Existing Building 0 Repair EJ I Alteration IN I Addition 0 1 Demolition 13 (Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy El I Other El Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No
Is an Independent Structural Engineering Peer Review required? Yes 0 No IN
Brief Description of Proposed Work- Remove and replace roofing shingles
rn
- .SECTION 3:,COM SECTION IF VaSTING BVILDIN6 UNDERGOING RENOVATION,ADDnf0N OR
ET CHANGE IN USE OR OCCUPANCY,
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13
Hesiclentiai Resideril fid!
Existing Use Group(s): Proposed Use Group(s):
SECTION4.'BUILDINGHEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
-,, $ 5
-V :,USF,GROUP;(djecka_a able),
A: Assembly A-1 D A-2 0 Nightclub El A-3 0 A-4 13 A-5 0 B: Business 0 E: Educational El
F: Factory F-1 0 F2 0 1_4 0 M.h High Hazard H-1 El H-2 0 H-3 0 H-4 0 H-5 0
1
1: Institutional 1-10 1-2 0 1-3 1:1 Mercantile El [R: Residential R-10 R-2 IY R-3 0 R-4 El
S: Storage S-1 0 S-2 El U: utility 0 Special Use 0 and please describe below:
Special Use:
SECTION 6'.-eONSTRUCTIONTYPE,(Checkas Applicable)
IA El IB [3 IIA 0 IIB 0 1 IIIA 0 11113 0 1 IV 0 IVAO VB 0
SECTION,7iSITE
INFORMATION(refer to 78pCMR Ill:O for details on'each item)' 'i
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 0
Private 0 or indentify Zone:- or on site system 0 required El 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 0 Yes 0 or No 0 Yes 0 No 13
;SECT
-ION 8-,`C'PNTENT1?Fq1TI,
Edition of Code: Use Group(s):_ Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:-Special Stipulations:
<SECTIOIV�9`PROPERTY"bWNEk 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.
SECTION1tr.'CONSTRUCTION CONTROL(Please-fill"outAp'pe'ndtx2)'
r of enclosed` - `- � It buildin �s leas than 35,000 cu ft .s fee and or not under Constmet[ori ControCthen check here Clltand ski' Section 101 '. --
10.1 Re 'stered Professional Res onsiblefor Construction Control' -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
162 General Contract&" t �'
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
,n'SECTION ll*.6WORKER4'COMPE.N' 3r€ N INSURA "CE AEEg2 NI1' M.GaL.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 15 No ❑
'SECTIONI2"CIONSTRUCTION COSTS_AND PERMIT EE `
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 $
10,000.00 Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
,:FSECTION 13:SIGNATURE OP BUILDING,PERMIT•APPLICANT, ry `
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 accurate to phe best of my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign n e rOs&minasalli Title Telephone No. Date
25 Spaulding Rd St 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval { RO �-''• i'