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ECLIPSE LN # 6, 19, 21 - BUILDING INSPECTION
z o F 3 OK 122I 1 $ I S. Ti t I S 6R-m t-1 The Common eealth�WMARN��JCES UlfDepartment of Public Safety Massachusetts State Buildi *djI ff fRA & 08 Building Permit Application for any Building of er than a ane-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number.' ' ' Date Applied '- a' ". Building Official: - s SECTION 1:LOCATION(Please indicate Block:#and Lot#'for locationsfor which astreet address is not available) Eclipse Lane #ti 19 21 Salem 01970 Green Dolphin No.and Street CityTown/ Zip Cade Name of Building(if applicable) SECTION 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 M Addition❑ 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 IN Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑C Brief Description of Proposed Work: Remove and replace roofing shingles as; SECTION 3 COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATI N ADDTTION OR e t) CHANGE IN USE OR OCCUPANCY "''"" Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): _ Besiripntlal Proposed Use Group(s): SECTION 4:.BUILDING HEIGHT;AND AREA ' Existing Proposed NoVS: Storage of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Area(sq.ft.)and Total Height(ft.) "" SEC'I'ION5:USEGROUP:(Checkasapplicable)sembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ Alf❑ A-5❑ B: Business ❑ E: Educational ❑to F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑titutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 IX R-3❑ R4❑ S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: f SECTION 6:CONSTRUCTION:TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ ry ❑ VA ❑ VB ❑ ~?:, '' SECTION 7:SITE INFORMATION(refer to 780'CMR 111.0 for details on each item) ' As a_ Water Supply., Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Private❑ or indentify Zone:Tor 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 ❑ SECTION8:CONTENT OF CERTIFICAT&OF'OCCUPANCY- - r - . .w FD ,, on of Code: Use Group(s): Type of Construction: Occupant Load per Floor: the building contain an Sprinkler System?: Special Stipulations: 88ClION 9: PROPERTY OWI�BR�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 95 Spaulding Rd Ste 17-9 hremant 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. 'r SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f build I ing is less than 35,000 cu.ft`of enclosed s ace and/or not under'Construction Control then check here M.d slu Section 101 r 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date KTM Properties LLC Company Name Charles Minasalli 160139 HIC Exp. 6/25/2016 Name of Person Responsible for Construction License No. and Type if Applicable ?aS a llding Rd tit 17-2 Fremont NH 03044 Street Address City/Town State Zip 602 895 0400 603231-1677 faraCo�ktmprnpp0iac rnm Telephone No.(business) Tele hone No. cell e-mail address SECTION 11:WORKERS`COMPENSATION INSURANCE AFFIDAVIT M.G.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 Q No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 15,000.00 1.Building $ 15,000.00 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 $ Enclose check payable to f,� ;� ev 6.Total Cost $ 15,000.00 (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 accurateAo the b st of my knowledge and understanding. f 603.895-0400 President /2 /14 Please prfn and si name Char es Gllnasalll Title Telephone No. Date 25 Spa Fremont NH 03044 Street Address City/Town State Zip 2" sts ;`s" .:: Municipal Inspector to fill out this.section upon application approval: s Name -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) #6,19,21 Eclipse Lane 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 13 Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No 12 Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No 11 Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ulr� 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/Orgmization/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): 1.0 I am a employer with 25 4. ❑ I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' comp. insurance.t 9. ❑Building addition [No workers' comp. insurance P� required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.❑Roof repairs employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also till 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. tContractors 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 the policy and job site information. Insurance Company Name: Union Insurance Company Policy#or Self-ins.Lie.#: WCA51 5231 6-1 0 Expiration Date: 6/16/2015 Job Site Address: Eclipse Lane#6,19,21 City/State/Zip:Salem, MA 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 thepainsand �/ynauies ofp�erjjmrry that the information provided above is true and correct. Suture'. /Y - /�I�Q U �W Date: 6/23/14 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#: KTMPR-1 OP ID: PP ,a►�Ro CERTIFICATE OF LIABILITY INSURANCE D06/16/2014Y) osns/zola THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER Phone:603.424.9901 CONTACT Brown&Brown(Merrimack) PHONE FAX NAME 309 Daniel Webster Highway Fax:866-IB48.1223 we No Eat: A No: Merrimack,NH 03054 EMAIL Chris McPhail ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Union Insurance Company 25844 INSURED KTM Properties LLC 25 Spaulding Road INSURER B: Fremont,NH 03044 INSURER C: INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUBR LTR TYPE OF INSURANCE POLICY NUMBER MM1010YEFF MMIDUVIY VY LIMIT GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CPA5152308-10 06I16/2014 06I1612015 DAMA E RENTE PREMISES Ea occarrenoe $ 100,00 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,00 PERSONAL It ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 POLICY GEN' AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,00 A ANY AUTO CAA5152308-10 06/16/2014 06/1612015 BODILY INJURY(Per person) $ ALLOWAUTOS NED X SCHEDULED AUTOS BODILY INJURY(Per accident) $ X HIREDAUTOS X NON-OWNED PROPERTY AUTOS $ Per accitlenl X UMBRELLA LAB X OCCUR EACH OCCURREK$ 5,000,001(( 00,00 A EXCESS LAB CLUMS-MADE CUA5152314-10 06/1612014 0611612015 AGGREGATE00,00RETENTION 10000MPENSATION WC STATURS'LUU3ILITY XETORrPARTNERIEXECUTNE YIN WCA5152316.10 06/1612014 06116/2015 E.L.EACHACCID00,000 ER EXCLUDED? � N/AH) E.L.DISEASE-E00,00( a underON OF OPERATIONS below EL DISEASE-P00,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A Y 41-k ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD too"fvt Consumer Affairs nd Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 160139 Type: Supplement Card - Expiration: 6/2 512 01 6 KTM PROPERTIES, LLC. CHARLES MINASALLI 25 SPAULDING RD SUITE 12-2 FREMONT, NH 03044 Update Address and return card.Mark reason for change. ❑ Address ❑ Renewal Employment n Lost Card SCA 1 C, 20M-05/11 _ = trice of Consumer Affairs& Business Regulation License or registration valid for individul use only /. ME IMPROVEMENT CONTRACTOR re the expiration date. If found return to: befo Office of Consumer Affairs and Business Regulation egistration: 160139 Type: 10 Park Plaza-Suite 5170 Expiration: 6/25/2016 Supplement Card Boston,MA 02116 KTM PROPERTIES,LLC. CHARLES MINASALLI 25 SPAULDING RD SUITE 12-2 FREMONT, NH 03044 Undersecretary Not valid without signature I. f x.x x r /f7U (!'f�•l)G'�Nf'7'fft'G`flu'L ,L(�St7f 111C'.i/�/f� $ , '` Oflce ofiConsumer AEFaarsd Business Ttegulatfon ,•.,,, park Plaza'-, 5iiite 5 sc Boston, Ma'sac usetts 02116 [some lmptovemt<nt ConCcactor;Aegistration l t r r � fte9+slratraT 1$Q736 "p� ', o- i 2 ! 7 ype, Supplement drd KTM PROPERTIES,LLC. ri o6"re ` Fzp atE9n &"2s'?9 a i J CHARLESIMINASALLd.+i: 25 SPAULDING RD SUITE 12 2 O E FREM,ONT,,NH 03044 A ,. y Up 4ddriss..it return anrd Mar ¢n ..h k r �oq fiyz x+pe._ s x <,..+ti-, + 3 e t Add AdOass - ILell"ii . 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