9,11,13,15 ECLIPSE - BUILDING INSPECTION 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 SectionFor Official Use Only),
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7777
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Building Perrriit Number *'Da te.Appled {Buil'dtng Official
11 SECTION 1:-LOCATION(Please indicate Block#'and,Loh#for locations for which•a stceetaddress is not available)
U Bldg 179 9,11,13,15 Eclipse Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION2:PROPOSED.WORK
I� Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
l Existing Building❑ Repair❑ Alteration 121 Addition❑ 1 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 ❑ No M,
Is an Independent Structural Engineering Peer Review required? Yes ❑ o [%
Brief Description of Proposed Work: Remove and replace roofing shingles "' m
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SECTION 3 COMPLETE T1IIS SECTION IP EXISTING BUILDING UNDERGOING RENOVATION,AIIT16rT;OR " -
CHANGE IN USE OR OCCUPANCY ." ,,, er
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ w�
Existing Use Group(s): hesidentiaiProposed Use Group(s):
_ - SECTION4:,BUILDIN;O 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(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ❑ B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ R. High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4 ElM: Mercantile❑ R: Residential R-10 R-2 EY 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 applicable)'
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA 0 IIIB ❑ IV ❑ VA ❑ VB ❑
`-. ,. .e ,„ "-�.SECTION 7i SITE INFORMATION(refe`,r;to 780.CMR 111.0 for,detailaon each item) , _
Debris Removal:
Water Supply: Flood Zane Information: Sewage Disposal: Trench Permit: Licensed 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 ❑
;+ ,�. ..,^ -` :_: SECTION 8:CONTENT OF'CERTIFICATE OF OCCUPANCY °g:_
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
J
SHCTIONz9i" �
PROPERTY°OWNER AUTHORIZATIOIit
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) a-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 11'k CONSTRUCTION CONTROL(Please-fill outAggendix 2) y % -
>' If bmldin 'is less than 35,000 m ft of endoseds ace,and or,not under Construction,Control then check here l and ski Section 101
10.1 Re istered Professional Res" onsible forlc6hstructiodContml'
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 11rwURKFRs'e°F)MPE S&T
-ION INSL:RANCE AFFfQAV1T M.G L.'e.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 13 No ❑
�S CTION 12:CONSTR CTION COSTSAND PERMIT FEE
G
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ 20,000.00
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 $
2000000 Enclose check payable to
, .
6.Total Cost $ (contact municipality)and write check number here
-SECTION 1 SIGNATURE OF BUILDING,,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 ccurate to the best f my knowledge and understanding.
President 603-895-0400 8/18/15
Please print and sign e rmanesimasain Title Telephone No. Date
25 Spaulding Rd S 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to_fill out this section upon apphcation777777777
r§- ,Name �,s"= t+ 'k = Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
9,11,13,15 Eclipse Salem 01970 Green Dolphin
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No 0 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No Cl Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No C3 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/Organintion/Individual): KTM Properties, LLC
Address: 25 Spaulding Rd - Suite 17-2
City/State/Zip: Fremont, NH 03044 Phone #: 603-895-0400
Are you an employer? Check the appropriate box: Type of project(required):
1. x❑ I am a employer with 25 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑x Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.#
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp, right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box At must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
[Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Union Insurance Company
Policy#or Self-ins. Lic. #: WCA51 5231 6-1 0 Expiration Date: 6/16/2016
9,11,13,15 Eclipse Salem,
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the p�ainss nd penalties ofperjury that the information provided above is true and correct.
SienaturcL'�t '�t-ri '� Date: 8/18/15
Phone#: 603-895-0400
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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Regititratign: 1601E8 --
,Type: _Supplement Caid
Expiration: 612 6�j'2016
KTM:PRQPERTIES, LLC;.
CHARLES "M'INASALLt. ' _
25 SPAULDlNG RQ SUITE 17-2 j — - — - m
FREMONT, NH 03044 w --
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