1 CLAREMONT RD - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts INSPECTIONAL s
° Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR 1015 DEC 3?evAd CV2111
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date AppliW.
1�41,11 ' /
Building Official(Print Name) Signature Da e
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 Claremont Rd
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Municipal ❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Amber and Tim Glod Salem, MA 01970
Name(Print) City,State,ZIP
1 Claremont Rci 781-346-1955 '
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ FExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) IN Addition ❑
Demolition t] I Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': Renovate second floor bathroom. Plans attached
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 38,100 1. Building Permit Fee: $ ..Indicate how fee is determined::
2.Electrical $ $3400 ❑Standard City/Town Application Fee
❑Total Project Cos 3 Item 6)x multiplier _ x
3.Plumbing $ $6500 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$. .
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 48,000 0 Paid in Full 0 Outstanding Balance Due:
t« SECTION 5: CONSTRUCTION SERVICES
5.1 Co.nSti,,6ctj6*9i iTieCvis`or•License(CSL)
CSFA-064574 5/10/2017
Geoffrey Shafer License Number Expiration Date
Naim of'CSLA,.F-[ol�e1, List CSL Type(see below) R
610 Main St
No.and Street Type .Description
Melrose, MA 02176 U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coveting
C rr/ WS Window and Siding
SF Solid Fuel Burning Appliances
781-662-1593 gshafer@pegdesign.net I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 137663 12/13/2016
PEGASUS Design-To-Build LLC HIC Registration Number Expiration Date
RIC Company Name or HIC Registrant Name
610 Main St gshafer@pegdesign.net
No. d Street Email address
Melarose, MA 02176 781-662-1593
Ci /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation insurance affidavit 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.
Signed Affidavit Attached? Yes .......... Cf No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize PEGASUS Design-To-Build LLC
to act my behalf,i all�m/atttteerrs relat*etg worX authorized by this building permit application.
Print Owner's Nakc4lAedronic Signature) I Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.eov/ocaInformation on the Construction Supervisor License can be found at www.mass.sov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
v
o
m
rr
0 0 o 0fM
` S62721_ j�j"�SB2621R_
b..m
i
36" HighW IIs
N N
ri=
A
O
2
i
81.1 011
sure �eatr,na
NTS FLOOR G lod Bath 11 610 Main Street
z ome PLAN Melrose, MA 02176
11/30/2015 1 Claremont Rd tib 781-662-1593
,,,,;m;ralPlans onty, Salem, MA 01970
not for cons(NCM1on
UJ
U)
cr
CID
m:
S62721. SB2621 R
00 ,
i
\ 36" High W IIs
N N
A
O
0
2
Scale: SheafTif.:
NTS FLOOR Glod Bath 610 Main Street
o„a, PLAN Melrose, MA 02176
11/30/2015 1 Claremont Rd i(t( 781-662-1593
P,a,;maa',P,aaa only. Salem, MA 01970