0026 NEW DERBY STREET - B0A-09-561 TAVERN ON THE SQ I_'ll\\ \.III\i.11 lam,plltlll • \'.L', '.L\I\..\I III .I : I-nl'l 11
APPLICATION FOR PLAN EXANIINAT ION AND
BUILDING PERMIT
kLL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT; .% t lic:mts must complete all items on this page
SITE INFORMATION
Location Name / J! GI/ '�d✓�D'LI TrjWgii ing 5� WAII ')//
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Poperty Address t
Located in: Conservation Area Y/N Historic district
APPLICATION DATE T�6 GI
Use Groups
(check one)
Group Homes 123 124_
Residential (3 or more Units) 112_
Type of improvement Residential (hotel/motel) RI
(check one) Assembly(Theaters) A 1 _
New Building Assembly (restaurants & clubs) A2r_A211cy
Addition Assembly (churches) Al _
Alteration Business B
Repaid Replacement_ Educational E_
Demolition_ Factory (modera(e hazard) Ft _
Move/Reloc:ue Factory(low hazard) F2_
Foundation Only High Hazard H_ �!
Accessory Building Institutional (residential care) 11
Institutional (incapacitated) 12_
Institutional (restrained) 13_
Mercantile M _
Storage St _MuJer;nc II:¢;uil
Slorase S2_L0w llaz;ud w 1
OWNI•:RSI III' INFORMATION(Please Ivue or Print It rh) �V
ONV\ER Name WuSitnl�v, �t LLG (r GG G
Address G n
Telephone
Signature
I)h:Sl'RII'"f1ON OF F%oRI:'1'O BE 1'F:ItFOR\IFD N60V AVER- I tN tu,
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FSF1:NIA FED CONS"CRL'CITON COST
CO\'I ItACTOlt INFORMAL ION ,
Name /IJ0, 1 M11t1z0Iqq
Address 3l CCU /N/G 1/G at o s G�
Telephon
Construction Supervisor's Lic # g 3 23
Home Improvement Contractor #
.v4CIIIT :C'PEACINEER INFORMATION
Name Sous r s�
Address
,.Telephone 6 �E ✓� �e0
Mass. Registration #
rERntrr FEE CAI.CUI.ATION
Estimated Cost x $1151,000 + $5.00=
COiNINIEWI'S
The undersigned applicant does hereby attest that all informatioit stated above is trite to the best of my knoivledge
ittider the p/enn Ities of perjury // I
Signed /T (owner) (agent)
APPROVED BY :
1)ATE APPROVED:
ARCHITECTURAL CONSTRUCTION CONTROL
(Design Only)
In accordance with Section 116.2 of the Massachusetts Building Code,I,STEPHEN A.SOUSA being a
registered professional engineer/architect,hereby certify that I have supervised the preparation of the
architectural design plans for the Tavern in the Square Restaurant and that,to the best of my knowledge,
such design plans;materials and specifications conform to the provisions of the Massachusetts State
Building Code,all acceptable practices,and all applicable laws and ordinances for the proposed use and
occupancy.
MA REGISTRATION #: 9587
PROJECT TITLE: Tavern in the Square
PROJECT LOCATION: Salem, Massachusetts
NAME OF BUILDING: Washington at Derby
NATURE OF PROJECT: Interior Restaurant Ft Up
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No. 9587 C
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�YF.a�rH DF to PSS ��
Architects Stamp *] Signatu Date
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BRISILDA HYSENAJ
Notary Public
Commonwealth of Massachusetts
My Commission Expires OGt 8,2015