10,12 ECLIPSE - BUILDING PERMIT APP CK
SIX 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
f '{TM$Eection Poi Official Use�Only)
Building Permit Number ; `IDate Applied --Building Offical.. -
; `r 'SEC I'ION,1d LOCATION(Please•indieaIte Block*and Lot'#for locations for which'a street address is not available)
Bldg 188 10,12 Eclipse Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION'2PROPOSEbWoRK
_ - -..
Edition of MA State Code used_ If New Construction check here❑or check all that apply in th5awo r taws below
Existing Building❑ Repair❑ I Alteration l3 1 Addition❑ 1 Demolition ❑ (Please fill out and subtiii}Appac 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: O
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0-0 Not p
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work: Remove and replace roofing shingles
tV rn
SECTION 3:COMPLETE THIS SECTION IF.EXISTING BUILDING UNDERGOING.RENOVATION,ADDITION;OR
CHANGE INLISE OR OCCUPANCY.:.
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Kesidential Proposed Use Group(s):
. 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(Checkas ap licable)
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 ❑ H-4❑ H-5 ❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑t R-3❑ R-4 ❑
S: Storage 5-1 ❑ S-2❑ U: Utility ❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION, ,I! (Chcc as ap"licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
t a '..SECTION 7:SITE INFORMATION(refer fo 780 CMR 111.0 for details on each
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: ed Disposal Site❑
Public El Check if outside Flood Zone❑ Indicate municipal ElLicens Dis 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: %M 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,Si CONTENT OF CER•TIEICATE,OF OCCUPANCY ; fi
Edition of Code: Use Group(s): Type of Construction:- Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY•OWNER AUTHQRIZATION
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.
k SECTION IP CONSTRUCTION'CONTROL (Please"frll out Appendix 2)', '
,.
burldtri is less than 35,0002u.'fE of er'slosedls'aeeprid czr not under Constxueuon=Corilrol there check bete E a`nd ski Sec i6n 10.1 +i,
.101 Re istesed ProfessonahRes oirsible for Construction Control' - -- '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General-Conicactor� � `'"
KTM Properties LLC
Company Name
Charles Minasallli 160139 HIC Exp. 6/25116
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 11:WbR £RS"CCJMPHNS T O+ NSUR CE AFF[IY' Vt " NLG L,.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 CAI No ❑
SECTION SZt CONSTRU_CTION COSTS'AND PERMIT FEE
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
SECTION•13: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 ace rate to e b st of my,knowledge and understanding.
/ Aw Z President 603-895-0400 8/18/15
Please print and sign name a eS a I Title Telephone No. Date
25 Spaulding Rd Ste 17 Fremont NH 03044
Street Address City/Town State Zip
Mumcrpal Inspector to.fill out this section upon application appioval
=�Namex tiu i� Date.