13,15 FORTUNE WAY - BUILDING INSPECTION 7 -7 1 1 -7 1 W vkr-\ue-R-s I- ) -k5 - 6 6Z
1 :5 L t5 to V_:R)KZ _T 15- 15 �(O''
The Commonwealth of Massachusetts
Department of Public Safety
W Massachusetts State Building Code(780 CMR)
.60 Building Permit Application for any Building other than a One-or Two-Family Dwelling
This ' UseOnly)Section
'3 Building Pe
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Buildft� fii
rout um' cia :
( I SECTION ON4, Please indicate Block'#'ind 1.4"For 1—fion's for which a streeta4diess isnotayailable) ,'
Bldg 172 13,15 Fortune Way Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
- S �K
SECTION UCTION I,PROPOSED WORK
02 Edition of MA State Code used— If New Construction check here 0 or check all that apply in the two rows b.elow
Existing Building 0 Repair 0 1 Alteration 15 1 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy 13 � Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes U N;a:Y
Is an Independent Structural Engineering Peer Review required? Yes N44Z
Brief Description of Proposed Work: Remove and replace roofing shingles — :o
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"`SECTION&COMPLETE THISSECTIONJF EXISTING MUSE OR OCCUPANCY BUILDING UNDERGOING REN ,�r N,
lyf_ TION Dl R
9 I 'HAi-;GE
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13
Existing Use Group(s): Hesidential Proposed Use Group(s): r1Ub1UUr1L1d1
SEC71ON4:18UILDING,HEIGHTANDARF-A-
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SE
'(Che k a ' l5li )"
�GROUP, c a ap iable)c
SECTION�-_LSE
A: Assembly A-I 0 A-2 El Nightclub 1:1 A-3 1:1 A-4 13 A-5 El B: Business 0 E: Educational 0
F: Facto Ey F-1 13 F2 0 ii,il_'gh Hazard H-I El H-2 0 H-3 13 H-4 0 H-5 El
1: Institutional 1-10 1-2 0 1-3 El 1-4 1:1 M. Mercantile 0 R: Residential R-10 R-2 EY R-3 El R-4 0
S: Storage S-I El S-2 El U: utility 0 Special Use 0 and please describe below:
Special Use:
T
,$9CITON6.CONSTRUCTION TYPE(Cliecklas.applicable)IA 13 IB 0 IIA 0 IIB 0 IIIA 0 IJIB 13 IV 0 VA 13 VB 0
;:isECTIO'N,7-.'siTE,iNFbRA4AtioN"(ref-"i itcM 111.0 for details each er 6��8 item) i�
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site El
Private El or indentify Zone:— or on site system 0 required 0 or trench or specify:
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 13 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed[3 Yes 0 or No 0 Yes 13 No 0
PAN ( 11�11 1, i9l, 711, - 101 1
�s]�CTIqNg-.,,�:PNTENTOY!;ERTIFIC-ATEOFOCCU 0.�i:l�",!"i i'3'A�
Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
'SECTION'S: PROPE$TY OWNER 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.
y i<+ SECTION 10:�ON¢TRUCTIOIV CONTROL (Pleasefill out,Appendiz 2)"" r -
;t,'- Jfbu31dm is iess than 39,000 cu.fE'of endbo eds ace and or not under Construction-Control th`4rahedc here Land sla Section
1Q.1 Re istered Ptofessional Res onsible for Construction Control< . a* '' .+� ;`" '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
'-1U.2General`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) Tele hone No. cell e-mail address
SECTION,I1:> LQ_R RC',CEliUIPENSAtiI. N tNSL*RANGE AFF[U'. V1' 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 I21 No 0
SECTION 12:CONSTRUCTIONCOSTS AND PERMIT FEE
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 $
2000000 Enclose check payable to
, .
6.Total Cost $ (contact municipality)and write check number here
[ 'SECTIONI3:SIGNATURE OF BUILDING;PERMLTAPPLICANT
.,
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 ar�accurate t the best of my knowledge and understanding.
President 603895-0400 8/18/15
Please print and si me L-manearminasalli Title Telephone No. Date
25 Spaulding Rd e 17-2 Fremont NH 03044
Street Address City/Town State Zip
°Munterpal Inspector to fill out this sed>'on upon application approval ' • `'�= W�_
Name + q�FJE FDate..'`'q,i