0009,0011 HIBERNIA LANE - The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
'^ Building Permit Application for any Building other than a One or Two-Family D"Wrig Lb
(This Section For Offioal Use Chily) • S -fq-
Building Permit Number. Date Apphed Banding Offioal
SECTIO CATION(Please indicate Block*and Lot 41,for locations for which a stireet'address'iS not ava .le) , t ra
Bldg 112 9,11 Hibernia Salem 01970 Sanctuary Condominiums
1 No.and Street City/Town Zip Code Name of Building(if applicabtK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two row;zlelow 1,
Existing Building❑ Repair❑ I Alteration 0 1 Addition❑ I 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 Cl No If
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 13
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) ❑
Existing Use Group(s): HeSidential Proposed Use Group(s):
SECTION 9`i 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 a licable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 R-2 CT R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility ❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Checklas a .(slicable)
TA ❑ Ill ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
I ' SECTION 7:SITE INFORMATI,ON,(re£ei to 780 CMR 111.0 for,details on each item).
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:
_a 7-(�
SECTION 4: PROPERTY I?'OWNERAUTHRIZATION a
Name and Address of Property Owner
Sanctuary Condominiums 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 10.CONSTRUCT;iON CONTROL(Please fill out Appendix
if buildin is less than 35,000.cu ft of eiultl3ed s are and' or not un{ter_Construcuori CAntrol then chetk here-[.'hand ski Secuon 101
10.1 Registered Professional Responsible for Construction Con"I
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractox r.
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
6038950400 60a231 t677 tara@ktmproperties.com
Telephone No. business Tole hone No. cell e-mail address
SECTION 11,WORIZERB':CCSMPENSATt€)N YNSUlz NC AFFIDAVIT .GL.c.,152s§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 13 No ❑
SECTION I2 CONSTRUCTION,'COS'fS,AND PERNETFEE.
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 $ -
20,000.00 Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
` Sl?CTION 13$STGNATIIRE OF SUIGDING PERMIT APPLfCANT ,
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 accu to to th est of my knowledge and understanding.
President 603895-0400 6/7/16
Please prin and n male s InaSa i Title Telephone No. Date
2525 Spaul� 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector to fill out this section_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)
10,12 Janus
9,11 Hibernia Salem 01970 Sanctuary Condominiums
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 0 Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No O Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No IJ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No Q Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
CITY OF SM EM, M.kSSACHUSETTS
• BUELDLNG DEPARTNIENT
130 WASHINGTON STREET, 3r FLOOR
a� Tat- (978) 745-9595
FAX(978) 740-9846
KINIBt xr FY DRISCOLL
MAYOR THobw ST.PIERRs
DIRECTOR OF Pvauc PROPERTY/BumDtNtG cow\mxoNER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
MA Waste Systems Inc.
(name of hauler)
The debris will be disposed of in :
300 Centre S1
(name of facility)
Holbrook, MA
(address of Facility)
si nature of r rt li�
g app cant
smz01 s
date
detfriiwlLdce
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govvdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Orgmimtion/Individnal): 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
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. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P ty 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 12.0 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.
tContraetors 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.
[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. #: WCA5 1 5231 6-1 0 Expiration Date: 6/16/2016
10,12 Janus and 9,11 Hibernia Salem, NIA
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 hereb certify under the pains and enalties ofpe-rju�ry that the information provided above is true and correct
Signal 7 - // �� —��/�) Date: 6/7/16
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:MMR
CERTIFICATE OF LIABILITY INSURANCE I °"=. .
oerl2nms
THIN CERTIFI6ATIF S MM AS A NATTER OF INFORMATION ONLY AND CONFERS NO ROM UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY A1934D. EMM OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BMW THIS CERTIFICATE OF INSURANCE DOES NOT COM ffUFE A CONTRACT BBTI GEN THE MSRWIG INSURI"S).AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
MWORTANh. N tim oWWkam holder IS an ADDITIONAL UMUIU=.Bm POUCYIIN)need M wAbMed. N SUBAOGATWX M WAIVED.;=Od to
the tmw w sad omMN clew PURCY.aeriaN Page=mmW natal a an mwdmaemmd A atatolnmd on arr orware to does not cooler dahts to the
cartlBrAe holder In Rom of such endersenterdIaL
PAmw:603424 M
88toan Fax:SB&MO-
30908 d NH 070111 maim
Chrle NeRteO Sac•
PWJMA:URdml DwsurmlN Company 258"
Qmuum KTM Properties LLC DIWAMB,
26 SpauldlnS Road cornmeal
Fannon%NH 03044
MIUMME-
COVERAGES IC11 NREVMMtJUMBMI
TIUS R TO CENTIFY THAT THE POLICES OF MIRANCE LWT®BMW HAVE SEMI WRIED TO IIM MLOIED NAN®ABOVE FOR TM POLICY PERIOD
WDICATED. NOIIVRHSTANDTAT ANY REQUSIEWNT,TERM OR CONDITION OF ANY COMRACr OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CEI"CATE NAY BE ISSUED OR MAY PERTAIN THE INSURAH M AFFORDED BY THE POUCMS DESK HEREIN Is W&EOT TO ALL THE TERMS.
IX0.USIONSAND CDICRICNB OF SUCH POLCEES.LQUTS SHOWNIAAY HAVE SEEN R®UCEO BYPNO AOAB.
Awe OF QNURAww44 Lame
am® Y 11%61 am INS Am, EACH O0DUFAtl e S 1.OW
A jXj anwlaereaulweSm PASIMINS-11 OBHSWIS OBNSIlmB s 1
aAHBuem ❑X NmFxP m f SAM
PMtSM LSADVDUURY S IA00.
avdmADmEOAre s 2"0,0001
sBILAoeemAretaeTAPPt®Pea PRODUCIs•ODNADPAOD P 2,000.
POIx.Y X tOC S
5mmaos
AAU1O AA5152308.11 OBHSIZ016 OS WMGix elalmaw" SOOLrmAIRYPbr x AINOS
N�edo 3
x 00= almocawam s swollrl
A FxKCw9d p x
WA118,100E SM441 allows OBTI8/l016 AGOFSMTE s 5,0001
X IREM tondo I 1 P
wme�omvDmATxm X
A A�w Tw3waanueYIN
CASISMS.11 Mamie 0101612018 E1EPMAOCMVNr s 1,110[1.011111
trOQLIOFJY! lia NIA
F-LOMEW-EAgUPLOVU 1
e a®eewev
EL tear St 000
pBeppP11p10FW®G1W1181tAClOWNQ/YBMA91�M01m 1m,AQ/aeetl aeaOb QdnQYb,Qmsstpmbwpob�Q
C
SHOULD ANY OF THE ABOYB DEDCRUM POLICIES 89 CANCELLED BM M
For Informational Purposes � WOHTTKEPouDYPRONu1ow.EXPIRATION 0419 THEREOF WOM 1P6i BE nM.wmED IN
Only
AYllwwt®aBPR®eTATae
cowls McPhaIF
019884010 ACORD CORPORATION. AS rights reserved.
ACORD 25 CMUM5) The ACORD seems and legs are reglals"maim of ACORD
� r-1Cff it-Cofll Consumer
s Pnd
Business Ret ulatiun
10 Park Plaza- Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Rngistrution: 180139
Type! SuOplentent Card
ExpUathn, 825Yf018
KTM PROPERTIES, LLC.
CHARLES MINASALLI
25 SPAULDING RD SUITE 17-2
FREMONT,NH 03044 -.---. ..__- ,.__.. ..,.. . ._.. ......--
Update Address and return canL Ptsrk rsason rnr Change.
Addraf ,7 Remaul -'-:EMplavMeot i_ Lost Cud
VMLIE�WZ
rCmeraQaio&emunt Regabdna Lkensebr rcgntrndan valid for iadwl t as,onlp
VEM£Ni CONTRACTOR OMc.OfrteeaPC roo9lstsauov 1£0!39 '9po:lkvlIBPurk P1ua•SuiwJi?0
+ E+pirallon: N ww!5 saWismant Cew acston.T.40''m
KRA PROPE.RTL9S,LLC.
CRARLES WNASALLI
25 SPAL1014G RO SUIT E 19-3 e%•F> c--- ��'ij'{�'yL__... ...
FREMONT,NH 0344 _._.L S'?�pt dd9[hwts(ywtura
tlnden¢Rury
E
i
i
I
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Cnnstructinn Sunervisnr c®am = I
License: CS-0 71WR i
CHARLFSJM7N y_ W-�, t
25 Spstdding Rd Sto I - F
Fremont i'IF1f 03074 � {
f
Expiration I
Commissioner 07J25MI7
l
I
i
i
t
t
i
i
I
t
i