1,3 MARINERS WAY - BUILDING INSPECTION C- 151P5� I10
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 Dwelling
(TTriaSection For Official,Use Only).
Building Permit Number: . Date Applied: Building Official: 3
15 , SECTION 1h:LOCATTON.(Please indicate Block#and Lot#for locations for which a street addiess is not a—,y `le)
3 /1 �L nLUSalem o1s7o
No.and Street City/Town Zip Code Name of Building(if applicab�— le).--
SECTION 2:PROPOSED-WORK
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 L# Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
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 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): Resiclential 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 5aUSE GROUP(Check asapplicable)
A: Assembly A-1 ❑ A-2❑ Nightclub Cl A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1 ❑ I-2❑ I-3❑ 14 ❑ M: Mercantile❑ R: Residential R-10 R-2 f31 R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION fs:CON3TREICFION.TYPE(Check:as applicable)
IA ❑ IB ❑ IIA ❑ HB O IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(tefer-to 780 CMA 111.0 for details on each.item):
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:,
Licensed Disposal Site 13Public❑ Check if outside Flood Zone 11 Indicate municipal❑ A trench will not be
Private❑ or indentify Zone: or on site system❑ required E3permit is enclosed
trench or specify:
❑
Railroad right-of-way: HazardstoAir 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:
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Mariner Village Salem
Name(Print) 01970
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 prope5y owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please_fill-out Appendix2): -
If building is less than 35,000 cu.ft.of enclosed.- ace and/or.notunder Construction Control then check hereffand ski pSectiors10.1
- 10.1 Re 'stere3.Professional Responsible for Consfrucfioi Control
Name(Registrant) 'telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2General 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 $i-p
603 895 0400 603.231 1677 tara@ktmproperties.com
Telephone No.(business) Telephone No. cell e-mail address
SECTION ll;-WORKERS'.COMPENSATION�INSURANCE AFFOTAVIT
aG.L.:ciT52." 2506'.
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit
Is a signed Affidavit submitted with this application? Yes EY No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$ �Jt - _,Q, 00
1.Building $ /0. w . O O 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 I $ /0/")0C1-00H (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering in,y name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicatione and ac ate to the best of my knowledge and understanding.
President 603=895-0400
Please print and sign name a eS masa 11 Title Telephone No. Date
25 Spaulding Rd Ste 17-2 Fremont NH 03044
Street Address City/Town State Zip
Municipal Inspector tofillout this section upon application approval:
Name V
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)
J /y/x4zt yea o �CGy Salem 01970 /O/QiLI�CP�fQ yj�
No. and Street y City /Town Zip Name of Building(if applica e)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No D Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No D 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)
-� Department of Industrial Aecidents
— Office of Investigations
600 Washington Street
;^ Boston, NIA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): KTM Properties, LLC
Sddress: 25 Spaulding Rd - Suite 17-2
--ity/State/zip: Fremont, NH 03044 Phone #: 603-895-0400
.re you an employer? Check the appropriate box:
x 4. 1 am a general contractor and I Type New
(required):
❑ [ am a employer with 25 ❑
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
❑ 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'
comp. insurance.,
9 ❑ Building addition
[No workers' comp. insurance p
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
r_1 officers have exercised their I am a homeowner doing all work I L Plumbing repairs or additions
myself. ' right of exemption per NIGL
Y �o workerscomp. 12.[:J Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
y applicant that checks box X I must also till out the section below showing their workers'compensation policy information.
rmeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
loyees. ff t e subcontractors have employees,they must provide their workers'comp.policy number.
it an employer that is providing workers'compensation insurance for mV employees. Below is the policy and jab site
2nnation.
urance Company Name:
Union Insurance Company
icy# or Self-ins. Lic. #: WCA5152316-10 Expiration Date: 6/16/2016
2 tin
Salem,
MA
Site Address: 1 3 1 1 1 C21u�t-Q�l_ /� Wg= City/State/Zip: 0 / C/7 t/
ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification,
z hereby certify under the pains an penalties of perjury that the information provided above is true and correct.
/- / ry
nature_`_�� / C� !� Date:
me#: 603-895-0400
Official use only. Do not write in this area, to be completed by city or town offrciaL
City or Town: _Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
-----------
Office of Consumer Affi rrs And Business Regulation
K 1.0 Park Nam - Sui-te 5170
Bo:ston, Massachusetts 02116
Home frapjovement Contractor Registration
Registration 160139
Type Supplement Card
KTM PROPERTIES, LLC. Expiration 6/25�2016
CHARLES MINASALLI
25 SPAULDING RD SUITE 17-2
FREMONT, NH 03044
UpdAte Address and return card. Nfark reason for change.
Address Renewal —, Employment Last,Card
11F(lite oF 1, & Business 11 -ulation License or registration valid for individul,use only
_61VIE IMPROVEMENT CONTRACTOR before the expiration,date. If found return to:
, Office of un-sumer Affairs and Business Regulation
Type:
egistratiom 160139 1OPark Ylaza -Suite5170
Expiration: 6,2512016 Suppietnert _-wo Boston,KA,021 t6
PROPERTIES, LLC.
RLES M1;'qASALLJ
PAULDIN: RD SUITE 17-2
MONT, NH 03044
��1 n I mrtc-I yr lu.. noun
R �i217 CERTIFICATE OF LIABILITY INSURANCE Dosl4uz Sr
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POL[GIC-S
BELOW. THIS CERTIFICATE OF INSURAJNCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. _
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ie>) must be endorsed. If SUBROGATION 1S WAIVED,.subject to
the terms and conditions of the policy, terrain policies may require an endorsoment. A statement on this certificate does not corner rights to the
certificate holder In lieu of such endorsement(s). -
Phone:603-424-9901 con
tOOUCER HAMLAcr
own&Brown(Merrimack) F 'HOne FAX
FA
3XI 866-848-1,223
---—
9 Daniel Webster Highway Nat
erdmack. NH 03054 -h..9AIE
;;is McPhail -ADDRESS-. ----- __-
VJSURERISI AFFORDING COVERAGE NAa:Y
INsuRERA Union Insurance Compaannn�__
5URED KTM Properties LLC INsuaer+.e
25 Spaulding Road --
Fremont, NH 03044
INSURER.0 _
UISURER E
OVERAGES CERTIFICATE.NLIMBER: - REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FORTHEPOLICY:`PERICO
INDICATED. NOTWITHSTANDING ANY RECUIREMENT, TERM CR CONDI.'TON OF ANY C!;NTRACL OR OTHER DOCUMENT WITH RESPECT TOWHICHTHIS
CERTIFICATE MAY BE ISSUED OR MAY PER'-AIN, THE INSURANCE AFFORDED J( TaE POLICIE=S DESCRIBED HEREIN IS SUBJECT TO ALL THE T-ERFdS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE F'.=N RE7JC_D BYRAO CLAIMS.
R -.----T–POLIO EFF FGLtGV EXP
R . TYPE CF INSURANCE I i@*$l:! POLIO,NtIM1IBEft �jMM DC YYYYI INMfDD/YYYYI' LIMBS
I GENERAL LMutiurY ii EACH OCCURRENCE 15 1.1000.000
I X I .^,CAf tEV f-!.LL.GF_N RAL L:Aa"�LITY
1 �GPA51.a2308-11 06116f2015 06/1612016 PREMISES Eaorcu+rerce 5 100,00
_J CLAIMS;MADE F OCCUR f MED EXP(Any perVf). F_ 5.011
PERSONAL.a ADV INJURYEll
S -1,000,00
GENERAL AGGREGATE if 2,000,00
r NI GGREGATE LIMIT APPLIES PER: PRODUCTS-COMP'OP AGU
PRO.
�'--I— COMBINED SINGLE J RT 1 QOQ,00.
AUTOMOBILE LABILRY
AN� AUTD iCAAS152308-11 i7611612015-i06/16/2016rBODILY INJURY(Pec persem
ALL OWNED �i SCH'_pUIE BODILY INJURY(Pe,auicanl)-''^5 — – --�_
_ AUT OS X I AUTOS
!I–
HiREDAUTOS xq AUT05
I
L( UMBRELLA LLID X j OCCUR - EACH OCL'URPENCE S
1 EXCESS LAB I I CL^UM&MADE! I jCUA5152314.11 1 OW16i2015 0Bill 6/2016 AGGREGATE 5 ^$:OOO+O00_
5
I I D'cD � X RETENPON,S 1...0000! --
WORKERS COMPENSATION ! -- -T :
Y .M.r
AND EMPLOYERS'LIABILITY Y r NIW CA5152316-11 ! 06'lfi2015 06116/2016 L EACH ACCIDENT JT 1.000.00
ANY PROPRIETOWPARTNER£XECUTNE N,Al
–
.OF CERVEMBER EXCLJOEOT E.L.DISEASE-EA EMF OYEEI_S 1,000,00
(Mandatary In NH)
R les.desznDe under E L DISEASE-PGf:GY.L LIMIT S 1,000,00
DESCRIPTION OF OPERATIONS
I 1
i I I I
I I
I
ESCRIPTION OF OPERATIONS)LOCAMONS I VEHICLES iAtuch ACORO Mi.Addifi nal:RemarksSeiletlule:'rf mare apaRe srequired)
:ERTIFICATE HOLDER CANCELLATION.
SHOULD-ANY OF THE ABOVE DESCRIBED-POLICIES.BE CANGEIL40 BEFORE
THE: EXPIRATION DATE THEREOF,- NOTICE WILL BE owl i.ER£O' IN
For Informational Purposes ACCORDANCE WITH THE POLICY PROVISIONS.
Only
AUTiIOS ZEO REPRESENTATIVE
Chris McPhail
r5 1988-2010.ACORD CORPORAT[ON. All tigh Xis raid.