10,12,14,16 GOOD HOPE LN - BUILDING INSPECTION The Commonwealth of Massachusetts
444D�� Department of Public Safety
Massachusetts State Building Code(780 CMR)
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: o ✓t
SECTION 1:LOCATION°(Please.indicate Block.#and Lot#for locations for which a street address is"n avail e)
10 12 14 16 Good Hope Lane Salem 01970 Mariner Village om
No.and Street City/Town Zip Code Name of Building(if ag'cabld�r2
. .`: SECTION 2:PROPOSED WORK �rn
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the tw row below
Existing Building❑ Repair❑ 1 Alteration IM I Addition❑ 1 Demolition ❑ (Please fill out and submit�ppenk 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: N
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Ey
Is an Independent Structural Engineering Peer Review required? Yes ❑ No IB
Brief Description of Proposed Work: Remove and replace roofing shingles
'SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑ Ptuddential
Existing Use Group(s): Hesiclential 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'5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
I: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 EY 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IHB ❑ IV ❑ VA ❑ VB ❑
- SECTION 7:SITE INFORMATION(refer to 780 CMR111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zo=Info�ation: Sewage Disposal: Licensed Dis osal Site❑
Public❑ Check if outIndicate municipal❑ A trench will not be Prequired ❑or trench or specify:
Private❑ or indentifyor on site system❑ 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'S: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:
$: - 'SECTION 9: PROPERTY OWNER AUTHORIZATION.
Name and Address of Property Owner
Mariner Village Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Charles Minasalli 25 Spaulding Rd Ste 17-2 Fremont NH 03044
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
.: '^�11 SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building'is less than 35,000 cu.ft.of enclosed-s ace and/or not under Construction Control then check here Lund Air,Section 10.1)�-
10.1 Registered Professional Responsible for Construction Control ?+
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
KTM Properties LLC
Company Name
Charles Minasallli 160139 HIC Exp. 6/25/16
Name of Person Responsible for Construction License No. and Type if Applicable
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
603 895 0400 603-231 1677 tara@ktmproperties.com
Telephone No. business Telephone No. cell a-mail address
.SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152., ,25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes LY No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT.FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$ 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 municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 20,000.00 (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 accurate to the best of my knowledge and understanding.
President 603-895-0400 7/15/201
Please print and s' name umarieS Minasalli Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Mumcipal Inspector tofill out this section upon application approval:
>. .. .- n _ s _.
.z. .- '. - Name... ; i -. Date �` '
r'
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)
10, 12, 14, 16 Good Hope Lane Salem 01970 Mariner Village
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 19 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 CI Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No 13 Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Department of Industrial Accidents
Office of Investigations
600 Washington Street
1 Boston, MA 02111
www.mass.gov/dia
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. x❑ I am a employer with 25 4. ❑ I am a general contractor and I
s have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees These sub-contractors have S, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp.insurance.t
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.]
"My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
'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
:mployees. If the subcontractors have employees,they must provide their workers'comp.policy number.
ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
%reformation.
Insurance Insurance Company
Company Name:
Policy#or Self-ins.Lic.#: WCA51 5231 6-1 0 Expiration Date: 6/16/2016
Job Site Address:
10, 12, 14, 16 Good Hope Lane City/State/Zip:Salem,
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
3f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
r do hereby certify under the pains an penalties of perjury that the information provided above is true and correct
Signature�� � i1 A?�sdA�J Date, 7/15/2015
Phone#: 603-895-0400
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
C
y
And
,lam office of Carnsumer AffLls nd Business Regulation
t0 Park Plaza - Suite 5170
Bastoq� Massachusetts 02116
Name lrntIrav{ ment Co
ntracttir-Reg stratiaii ' '
2 t _ % Registration' 160139 _
Type:, .Supplement Card,'., -
Expiration. 6!25t2016 - -
k<TM PROPERTIES, LLC.
CHARLES MINASALLI
25 SPAULDIN'G RE) SUITE 17-2 ___._. __. --- --
FREMONT NH 03044 _.... ".r _ ---_ .._ ...;_
- d F.'pdate Address and return curd.Mark.reason for change,
Address , ' Renewal ' 3 Enpilovtnent i Lost Card '.
3A 4 0: 1<0M oal: n
1 `^`r x, n<r.,iu, ,�11 r ^-7�fir rrrltrt r t'J , �� _ • _ -•
K '4Jiifice ui Caasamcr AiYaIrs& Business R"ut,lti00 F,ict use.or registration valid for IndividoI use only
3�1� � 6efort the esgrration date. If found return to:
� {t7MEt[v1PROYEh7ENT CONTRACTOR,
g�;� - QfGce of Consumer Affairs and$usiness Regulation
A'; V,tftegistratiow 160169 Type: 10 P1rkF'Ie= Suite fl/0
---r_r Expiration: 6p'25im6- x Suppleme,ml Card Plosion, NrIA 12116
:TM PROPERTIESrCtC.
-
)HARLES Ml,,ASALL4
.5 SPAULDIN6 RD SUITE 17-2 `'ti 2`*��-
=REMON7 NH 03644 Cndcrsecrarriry :A`pi. d wiihout signature -
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rt tTYlt'rc-+ we yraau rrpngq -i
,.•^"","1 _ . k�:' *'r c.1T" � ' f= ` - URANCEL RnTstM�eiuxv°��i
00t t21; 01 a
THIS-CERTIFICATE fS 15SUED AS A MAI"TER OF FNFORMATION ONt.Y ANQ COt3FERS NO RIGHTS UPON THE CERTIFICATE HOLDEN,Tifl$
CERTIFICATE DOES NOT AFFIRfAATkVEG:.Y OR NEGATIVELY AMENQ, EXTEND OR ALTER THE COVERAGE.AFFORDED BY THE PL)LICIES
BELOW. THIS.CERT(FICATE'OR INSURANCE QDES NDT CONST.ITUT£. A StlN'I'RACT. BETWEEN THE ISSUING-iNSURER{S), AUTHORIZED�,
REPRESENTATIVEflRPRODUCER,'•AND't'HECERTIPICATEHOLDER. "'_ ,,, - .._
IMPDRTANT: If floe certificate holder is still ATiDIT{ONAL INSURED,the po0cy(Ic87 must be endorsed. if SUBROGATION IS WAIVED-,subject to
the terms and conditions of the policy,certain polIda<.may reyufra art endnrsemenT. A sta4ement on this certificate does not confer t')ghts tom e'
.certificate holder In lieu of such endorsement{s).
PRODUCER I 'Phone:603-424-9,901 NAME
Brown&Brown{Merrimack}: PH�e � No 'e -
309 Daniel Webster Highway "Fax:$66-848-1223 tAL�u - - ...�t_.._L `
Merrimack,NH 03054 ; ` -j
Chris McPhail - ° `y z �'- ki4SURERS AFFORDING C44ERAfiE " ' r'tW i.U__,_,_
Nsua ftA_Union insurance Company 25F24$
'INSUR`cD KTM Properties LLC INSRRkR
255paulding Read tN"UREF u
Fremont, NH 03044 - -- --- ---- __
rISSU{E F, _ Ti
z x
Dt9UgEk F
COVERAGES - CERFI ICATE NUMBER. - x ` . ` REVISION NUMBER: _T -
( THIS IS TO CERTIFY THAT THE POLICIES OF. INSURANCE LSTED BELOW HAVE 3,. N 16SUED TO THE INSURED NAMED ABOVE FOR THE?IQIX`t,PERIOD
INDICATED. NOTWITHSTANDING ANY REOC[kREMENT, TERM CR CONDI""ION Or AHY P—ONTRACT OR-OTHER DOCUMENT VJR`H RESPECT TU viliick,"I`MIr4
.CERTIFICATE MAY ISSUED OR MAY PERTAIN IHE INSURANCE AFFORvCTz BY T NC POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL'THE TERMS,-
I EXCLUSIONS ANDCONDITIONS OF SUCH POUCIE&LIMITS.SHLNN MAY t'AVE KEN 2 DUC cD BY PAID CLAIMS _ _�
POLICY E€T POLICYT_x LIMITS !
TR d TYPE OF INSURANCE INSU 1�^ HQLIC"�}yrffdeER m oCAj';S'Y I MM+DnMlYY
s;`uRRALUAstUTY I; EACHOC+r.6uYS{ CE 5 1 f100,000
A X- COIAMERO:ALGEN ITA3 L.3,A81i.+TY GPAE'13230811 _ Q611ߟ O6f1612016 NR„EI�i@'-�Eaonc,arpl lit@,00
CLtiMS MADk "OCCUR ( 1AED I XP(AnY one(mcs,m) S $tip
d' PERSONAL B ACM INJURY
y e .i . ENERALAGG' ATE -,„ _32,000,00
�' _ - * PRODUcr5 ;O?B? t.!AuC 6 _
GYM( AGGREGAfFi1M€T APPLIES PER .-._. '$
: y S S
POLR Y Fx _l i ti.00 '- lT COMEINED 11 tkLIlUT .M1 B00
AUTOMOBILE UAIMUTY i i �� —•--%-•,..-T.... fEa accitl,7?ILL ._
. 1 CAA.�152308-11 DEf1612015 06116/2016 SOULY IrUJRY(Rat xmn) a
i
A ANY AUTO
ALL UWNED x71 SCHEDULED BQC LY NJURYQ 9r 8rN.1a411OI 5
ALTOS j ' �Pf GPkRT�'DAAfAr` y
{tSP 1-6WNE6 jRee aamami {
i HIRED AU COS L _I AUTOa 7 •.
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UMBRELLA UAB .,Y, OOGUR f s�~ ° "e a [ EACH OCCURR9fV
A , EXCESS LIAR. CIUMSMADE ' 16UAb152314-11 z '^ 00 W2015 0611612016 AGGREGATE
DED RECENT ORS 10000
NC5 ATU -
WORXERSCOMPENSATION a?;,Qh"T
ANp EMPLOYERT LABILITY Y I { IWCA5152316 I1= O6t16'2015 06116/2016 F_EACH Acc+bFLx 3 1,0V0,000
.
A ANY PROPR+CTORPARTNc,2PYEi:44NE ( - :- 1000,000
'i OkFX;:R'MEMB=R EXCL'JOED'° ®IN .E >' - Et DISEASE Eh EA4't0. 8 t _
IrdBnaae4rYto NH) a { Y i
If a¢acAt¢md¢t - - EL o+sfA.eE 1POLICYurnT 53 1,090,00. .
DES,..RPYnOR OFflPFRATiONS lfelor' i __..---f-- ;E
y.
DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLE (A[tatM1-ACORDIQ1,AadAlonXlRe'narksSLtledn4¢,+fnmre aRAtis(s r¢Rwroa; ". _`
ky
f t
CERTIFICATE HOLDER' _- CANCELLATION '
r s. SHOULD ARY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEfORE-
-- :. THE E1tPLtA-nON DATE THEREOF, NOTICE WILL' BE DELIVERED iN
For informational Purposes ACCORDANCE WITH THE POLICY PROVISIONS r
Only
I a AUT1I0 1Z90REPRESENTAnVE
Chris McPhail
e
-
. i 3)1988-2010 ACORD CORPORATION. All rights>raserv#:1d_
arnion 2R(7n-r m5) The.ACORD name and loco art n reaiatered marks of ACORD