7 FORTUNE WAY - BUILDING INSPECTION (2) C-Poi 0\,3 0 1 S 14
The Commonwealth of M�a-s—sachtise s
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
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'Tor Offlcial'Us&Only)�_
dj Ins'Section'
Permil
Building tNumberIDAteA Applied Offici
al
SE indicate Block#�and,Ldt#for.locations for which a streetaddiess is not available),
Bldg 173 7 Fortune Way Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
Edition of MA State Code used— If New Construction check here 13 or check all that apply in the two rows below
Existing Building El: Repair 0 1 Alteration [5 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1)
n Change of Use 0 Chang, of Occupancy 13 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 �X� o lc�
Is an Independent Structural Engineering Peer Review required? Yes El zwo QP
Brief Description of Proposed Work: Remove and replace roofing shingles
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SECTION 3-.,COMPLETE-THIS SECTION IF EMSTING-BUILDING'UNDERGOING RENOYATTON;iAVDITIQN,OR,
�
C14ANGEINV E ROC FANCY,S 6 OCCUPANCY,
it, ,t �,�i� ,,,__
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13
Existing Use Group(s): Residential Proposed Use Group(s): Residential
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 5,USE GRbUP,(Check as applicable)
A: Assembly A-113 A-20 Nightclub El A-3 0 A-40 A-50 I B: Business El E: Educational 0
F: Factory F-1 0 F2 0 I gh Hazard H-1 El H-2 0 H-3 11 H-4 0 H-5 0 r,
I: Institutional 1-10 1-2 0 1-3 0 1-4 0 M.. i`ercantile 0 R: Residential R-1 13 R-2 E R-3 0 R14 0
S: Storage S-1 0 S-2 El U: utility 0 Special Use 0 and please describe below:
Special Use
g SECTION 61 CONSTRUCTION TYPE(Cheek'as APPIicable,IA 13 IB [3 IIA 0 1113 0 IIIA 0 im r3 IV 0 VA E3 VB El
-a.SECTION-7:SITE ltqtORMA:tOf4' eierto780CMA!11,.01orde '
0 tailson each. em),v,* :
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 13 Check if outside Flood Zone 0 Indicate municipal El A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify:—
I permit is enclosed El
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable El Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed El Yes 0 or No El Yes 0 No 0
OF:CERTIFIC WCONTENT. ATgOF OqCVPANCY'.,,'
Edition of Code: Use Group(s): Type of Construction:— Occupant Load per Floor:
Does the building contain an Sprinkler System?:—Special Stipulations:
T
SECTION 9:,PROPERTY OWNER A`UTHORIZATTON
-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.
SECTION 104CONSTRUCTTON CONTROh'(Please`fili,out Appendix
If buildia is less than 35,000 cu.ft'of enclosed ace and- or not under ConshuchonControl thesicheck here:[ and skipSection 10.1
10.1 Re 'stered Prafesstinal Res onsible fo'r Construction Controls{'
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor_ z"-
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 11:WOR ERS':COMP U SATION INSURA- .AFI'DAM 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 L3 No ❑
Item Estimated Costs:(Labor ,000.00
and Materials) Total Construction Cost(from Item 6)_$ 10
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 $ Enclose check payable io
6.Total Cost $ 10,000.00 (contact municipality)and write check number here
' s -' ;. _�,c ; ' 3ECTION.13c SIGNATURE OE BUILDING PERIl3IT:4PPLICANT ..' `
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information co o
ntained in this
application is tru and accura to the best of my knowledge and understanding.
r President 603-895-0400 8/18/15
Please print d name s inasa i Title Telephone No. Date
25 Spaulding to 17-2 Fremont NH 03044
Street Address City/Town State Zip
4
Matncrpal Inspector,to fill out this�sectton upon application approval
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 Cavendish
7 Fortune Way 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 121 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No d Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No E3 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 oflndustrial Accidents
Office of Investigations
VJ 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organimtion/hidividual): 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 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ 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' 13.0 Other
comp. insurance required.]
Any applicant that checks box 91 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.
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. Lic. #: WCA5152316-10 Expiration Date: 6/16/2016
7 Fortune Way 6 Cavendish 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 ceru under the pDains and enal�ry that the information provided above is true and correct
Sienature7( �/W 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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-'Type• ,Supplement Card `
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KTM PROPERTIES, LLG.'.
CHARLES MINASALLf --
25 SPAULDING .RD SUITE 17-2 - -
FREMONT,'NH 03044 -
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