FORTUNE WAY # 3, 5, 9 & 11 - BUILDING INSPECTION Lr, ( Z2.-) 1 $1 t S
C4 — I O c Z RECEIVED 2-
Al
ICES
The Commonwealth of Massac usetts
Department of Public Safety �M�11 p nn'� r�4 A ^
Massachusetts State Building Code(780 CMt[1r Ju% `
08
Building Permit Application for any Building other than a One-or Two-Family Dwelling
,... (This Section For Official Use Only)
Building Permit Number:`�: -Date Applied: 'Building Official'
SECTION 1:LOCATION(Please.indicate Block#and Lot#for locations for which a street address is not available)
Fortune Way#3, 5,9,& 11 Salem 01970 Green Dolphin
No.and Street City/Town Zip Code Name of Building(if applicable)
,a >. SECTION 2:PROPOSED WORK J <.
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 I% Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No EX
Is an Independent Structural Engineering Peer Review required? Yes ❑ No D(
Brief Description of Pro osed Work:
Remove and rep ace roofing shingles
SECTION 3:COMPLETE THIS SECTION IF EXISTING'BUILDINGUNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY '
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Hesidential Proposed Use Group(s): esl en is
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 GROUP.(Check as;applicable)
A: Assembly A-1 ElA-2❑ Nightclub ❑ A-3 ElA4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: institutional 1-1❑ I-2❑ I-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2 IT, R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION:TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION refer to 780 CMR 111.0 for details on each`ii m( ) .i t ;, .
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
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
Edition of Code: Use Group(s):- Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
c0�,ArrQ-A-c✓ 7
SECTION 9: PROPERTY 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 ermit application.
� SEC' N 10:CONSTRUCI'ION:CONTROL(Please fill out Appendrx 2)
- If buildm is less than 35,000 cu.ft of enclosed"s ace and or not under Cons Control then check here Cland skipSection 101
10:1 Registered Professional Res onsib1,for Construction.Control,," :`
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor 1=11
KTM Properties LLC < I
Company Name
Charles Minasalli 160139 HIC Exp. 6/25/2016
Name of Person Responsible for Construction License No. and Type if Applicable
25 Spauldinq Rd Suite 17-2 Fremont NH 03044
Street Address City/Town State Zip
BD3_K 0400 -231 -1677 tara@ktmproperties.com
Telephone No.(business) Telephone No. cell e-mail address
m" SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDRVIT 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 R No O
_>• , z' ` 4.; h, '""' SECTION 12 CONSTRUCTION'COSTS AND PERMIT FEE
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 m}uunicip ity)
5.Mechanical Other $ (contactmunicipality)Enclose chec payable
write check number here��
6.Total Cost $ 20 000.00
" ',, {'h'SECFION 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�_,e and cc ate to a best of my knowledge and understanding.
President -6- cM-0400 /623/14
Please print an s' name harles Minasalli Title Telephone No. Date
-25 03044
Street Address City/Town tate Zip
V, fezr � "� i�, r .x of r x eMi ,fxf'; -k - �n�
Municipal-Inspector to fill out this section upon application approval:
TN, ame "€ '" ' Date
N
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)
3,5,9,11 FOftUf1P W2y 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 23 Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Other(if applicable)
Yes ❑ No 12 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
9 600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/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.i] I am a employer with 25 4. ❑ I am a general contractor and I
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. x❑ 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.❑ Electrical repairs or additions
3.❑ I 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' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 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 the policy and job site
information.
Insurance Company Name: Union Insurance Company
Policy#or Self-ins.Lic.#: WCA51 5231 6-1 0 Expiration Date: 6/16/2015
Fortune Way#3,5,9,11
Job Site Address: 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 the pains an�.l(perjury that the information provided above is true and correct
Sitmaturre� Date: 6/23/14
Phone M 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 10:PP
CERTIFICATE OF LIABILITY INSURANCE O6116/2014
DATE(MMIDD/YYYY)
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 CNTACT
Brown&Brown(Merrimack) NAME'
309 Daniel Webster Highway Fax:866-848-1223 PHONE FAX
Merrimack,NH 03054 9 y EJANL° EX° AIc No:
Chris McPhail ADDRESS:
INSURERS AFFORDING COVERAGE NAIC0
INSURED KTM Properties LLC INSURER A:Union Ins LiranceCom parry 25844
25 Spaulding Road INSURER B:
Fremont,NH 03044 INSURERC:
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 DL SUB
LTR TYPE OF INSURANCE POLICY NUMBER MMDDYEFF POLICY EXP MMIUDIYYYY LIMBS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A X COMMERCIALGENERALLIABILITY CPA5152308-10 06/16/2014 06/16/2015 PREMISES IEa°c urrenu $ 100,00
CLAIMS-MADE OCCUR MED EXP(my one person) $ S,DDD
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,00-0
POLICY X pRO 00(
LOC
AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT
Ea accident 1,000.00
JAEXCESSLUUI
NY AUTO CAA5152308-10 06/16/2014 06/16/2015 BODILY INJURY(Par person) $
ALLOWUTOS NED X SCHEDULED BODILY INJURY(PeraccidenQ $
IREDAUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS $
Per accident
S
MBRELLA UAB X OCCUR EACH OCCURRENCE $ 5,000,000
CUA5152314-10 06/16/2014 06/16/2015 AGGREGATE $ 5,000,00ED X RETENTION 10000 $
ERS COMPENSATION -
AND EMPLOYERS'LIABILITY X WC STATU DTH-
A ANY PROPRIETORIPARTNERIEXECUTIVE YIN WCA5152316-10 06/16/2014 06116/2015 E.L.EACH ACCIDENT $ 1,000,00
OFRCERIMEMBER EXCLUDED? � NIA
(Mantlaloryln NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 ll yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00
DESCRIPTION OF OPERATIONS/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
-/
01988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
i
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-: Affairs
Business Regulation
_ . r Affai
Office of Consume I
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10 Park Plaza - Suite 5170
I
Boston, Massachusetts 0211
6
Home Improvenient,,Contractor Registration
Registration: 160139
Type: Supplement Card
Expiration: 6/25/2016 li
KTM PROPERTIES, LLC. or.
CHARLES MINASALLI
25 SPAULDING RD SUITE 12-2
FREMONT, NH 03044
Update Address and return card. Mark reason for change.
Address n Renewal Employment ❑ Lost Card
SCA 1 Ca 20M-05/11
P�o tponnncnoitocal/�rr>����inllncluitt.•!G �.
- ffice of Consumer Affairs& Business Regulation License or registration valid for individul use only
r ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation I
egistratiop: 16o139 Type: 10 Park Plaza-Suite 5170
-C Expiration:. 6/25/2016 Supplement Card Boston,MA 02116
I
KTM PROPERTIES, LCe
I
CHARLES MINASALLf
25 SPAULDING RD SUITE 12-2
FREMONT, NH 03044 Undersecreta Not valid without signature
ry I
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Office of C unsurrlec r�Ifaus}and Business Regulation , ;i,
10 Park Plata; Suite
Boat an, vlassacliusetts 0'2116
Romelmprome entContractor;Registrati
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`ym Su;lpiement case
KTM PROPERTIES, LLC. "F t i Ex0�4atlon: ar25r2o.a
CHARLES MINASALLI,z t e
25 SPAULDING RD SUITE 13.2
EREMOM, NH03044= � t
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te. [feard return to: ,7xr tAd:
kRegrstradon tWZ3g,; 1 TYPa OfSeb of Con{umer'ARaln vjnd Bamne5v Reguia(wn $ ,+I 33° 4.
Expiration 10 Park Piazy-Suite 5170 f S `! 1`
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