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37 UNION ST - BUILDING INSPECTION 73 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 (This Section For Official Use Only) 1 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) bo c3 7 Union Sf Salem b l 97v No.and Street City/Town Zip Code Name of Building(if applicable) `^ SECTION 2:PROPOSED WORK Edition of MA State Code used if New struction check here❑or check all that apply in the two rows below 1 Existing Building❑ Repair❑ Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Er- Is an Independent Structural Engineerin Peer evfew required? 1 Yes ❑ No Brief Description of Proposed Work:'�A: t f1 CA An Sl a G d e CI L 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): I I 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 ❑ Alf❑ A-5❑ T B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-40 H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2 R-3❑ R-1❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ 11B0 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer 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❑pemut is enclosed trench or specify: ❑ 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: sir �S(zo ib cpNT SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Corners4aneC / ryO Suife 203 �ar�er5, NA D/9a3 , , Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 41G5.san m /Z,I e4wl MWO-ger 1510S'509. 704q COrnC/"51j')12d / LC7@a 91.Cora Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes 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:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control lqfchord 029,s S g'7f qO✓a_ /71/ C/o55c�nsfvucnJ4@J / 70q�;41 e e tstrant lephone No. a-mail address ��qq � egistration Number ui ,F/lfl�tf St crxnvers D19a3 J a3 /(v Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Cro5S C'on,5-lruaf7on Company Name R f Chard Goss C s /v J 8aa Name of Person Responsible for Construction License No. and Type if Applicable 379 E/lfolf (5t bonv/enrS M9 0/0/,23 Street Address City/Town State Zip _ 9x-40(0_ /77/ Cro55conshychoi-) vrldrl. com Telephone No.(business) Telephone No. cell e-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 most 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❑ No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (I-IVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ '� (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. Ple pr sicn n e Title Telephone No. Date a e 9�� Strees City/Town State Zip �Q Municipal Inspector to fill out this section upon application approval: Name bate i Details Page 1 of 1 ,4 !,.a Of iaa,weuwlil of:he Execu:�Of c^of FAI,safety and sc unty IEOPSsj Masa.Gev Fiore Stai©Agetictea ensee Details �,,,L���,.,�.,�p,.i� ull ame: ^ R�C D W CROSS Gender: Owner Name: dress: ddress 2: ty: DANVERS fate: MA pcode: 01923 o nt U 'fed fates iy icense o: S- 2 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/31/2014 Issue Date: Expiration Date: 1/18/2017 License Status: Active Today's Date: 8/20/2015 condary License: Doing Business As: e Doing Change: Lic se Renew I o rere uisite Information No Discipline Information ocumen um I Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=290754& 8/20/2015