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9 HERBERT ST - BUILDING INSPECTION / I ti 12 J 3 52 The Commonwealth of Massachusetts Ci'wrJ Board of Building Regulations and Standii'tc 'E� AL Sf R t l0VCITY OF 60ult Massachusetts State Building Code, 780 CMR SALEM l �''''''uu A ' ,l�ojsed Mar 2011 l�p Building Permit Application To Construct, Repair, Renov.�U> �d �ish a c..J' One- or Two-Family Dwelling f This Section For Official Use Only `Q Building Permit Number: Date Applied: �7 l� 1 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 9 Herbert St. Salem, MA 01970 1.1 a 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(It) 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: Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Sarah Siepierski Salem, MA 01970 Name(Print) City,State,ZIP 9 Herbert St. 617-359-2180 ssiepierski@partners.org No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 10 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work':Remove and replace decks on all 3 floors and remove and replace stairs. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 32,802.85 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑ Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 32,802.85 ❑ Paid in Full ❑Outstanding Balance Due: u ho3 2- ,3 g21ro SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-086605 12/05/17 Daniel Stock License Number Expiration Date Name of CSL Holder U List CSL Type(see below) 405 Liberty St. No.and Street Type Description U Unrestricted(Buildings u to 35,000 cu.ft. Braintree, MA 02184 R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF 781-844-2370 d178@ I comcast.net Solid Insulation FueBurning Appliances Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 179378 7/25/16 Storm Guard of SW Boston A(2iA My klkOo V. HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 639 Granite St. LL-15 d178@comcast.net No.and Street Email address Braintree, MA02184 781-519-8687 City/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 .......... 0 No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Storm Guard of SW Boston to act on my behalf, in all matters relative to work authorized by this building permit application. Sarah Siepierski 06/14/16 Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering inng my myy name below, I hereby attest under the pains and penalties of perjury that all of the information contained; in this 'on is true and accurate to the best of my knowledge and understanding. l/(�� A, Print Owne s e u orized genes 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 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" MUKHIND-01 DMCDONALD A`oRo• CERTIFICATE OF LIABILITY INSURANCE DATE(M�o 5YY) 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 POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Deland,Gibson Insurance Associates,Inc. PHONE (]81)237-1515 FAUX No:(781)237-1805 36 Washington Street A/C No Ezt` Wellesley Hills,MA 02481 ADDRESS.E-MAIL info@delandgibson.com INSURER(S)AFFORDING COVERAGE NAICI INSURER A:COIony Insurance Company INSURED INSURER B:COmmerCe Insurance Company 34754 Mukhooy Industries LLC dba Storm Guard of SW Boston INSURER C: 639 Granite Street LL-15 INSURER D: Braintree,MA 02184 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICYEFF PiwCMOLICY XP LIMITS LTR INSD WVD POLICY NUMBER MMIDD/YYY MM1VDD/YVYY A X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FRI OCCUR 103GL000559301 08/08/2015 Oa/0a/2016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY❑ PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER $ AUTOMOBILE LIABILITY (CEO BINED SINGLE LIMIT 0 $ 1,000,00 a a.0. B ANY AUTO BBPL72 08/12/2015 08/12/2016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ I HIREDAUTOS X AUTOS Per accident UMBRELLA UAB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOWPARTNERIEXECUTIVE E El N/A L EACH ACCIDENT $ OFFICERNEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yyes,describe under DESCRIPTIONOF OPERATIONS below E.L.DISEASE-PDLICV LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more apace is required) We to follow CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City 0}Salem THE EXPIRATION DATE THEREOF,ACCORDANCE WITH THE POLICY PROVISIONS. CE WILL BE DELIVERED IN Salem City Hall 93 Washington Street Salem,MA 01970 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letrib►v Name(Business/Orgmivatior✓Individual): S�orM IJ/'llo rA .Sw 6,0 , v1 Address:_ (93c wll l 6rcv t to- 5J City/State/Zip: brut i'^tvtz,t elA, O 2 ($ It Phone#: —, g [- 5-1 c l . 58 G 13 Are you an employer?Check the appropriate box: Type of project(required): 1.® 1 am a employer with 4(:� _ 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner. listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.KOther Cl�t S comp. insurance required.] d f� 4 *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new andavit indicating such. :Cuntracters that chock this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that it providing workers'compensation insurancefor my employees. Below is the policy and job site Information. ^ Insurance Company Name: R .^1_. t r�/v t M 66 t l V�S1AluN�c-e- ��vy.rGarl N�- Policy#or Self-ins. Lic. #: q A t tn�IJC- 1. DO--40% 1001.2 -�2 -201-9 A Expiration Date: JI(( Job Site Address: I 11mu JI . City/State/Zip:_ ,<� km YA OR 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 hereby cetvify under the pains and penalties of perjury that the informailan provided above Is true and correct. Signature: e� — — Date: Ig Phone#: lg ::�- Official use only. Do not write in this area,to be completed by city or town of/Iciai City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: CITY OF S.u.Em, NLkSSACHUSETTS • Bu LDLNGDEPkRT!*[&NT 120 WASHLNGTON STREET, 3'0 FLOOR T EL- (978) 745-9595 FAx(978) 740-9846 KI%C3ERLEY DRISCOLL MAYOR T HoKu ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUILDING cowNaSSIONER 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: Barry Bros Disposal (name of hauler) The debris will be disposed of in : PO Box 650040 (name of facility) Newton, MA 02465 (address of facility) 4W�I%a signs re of permit applicant date dibri.Jfrdm I Massachusetts-Department of Public Safety Board of Building Regulations and Standards Conarucnon Supcni%or jtY License:CS5" r '• STOCK VILLAGE DRLVE �c '6�aisry lllA 02169 n F. : -fie -M401 APbsue of The& Wj!ive Otf+ce of Public Safety and Security(EOPSS; h1a55.Coo':Home State Aae9ce. Demographic Information Full Name: Daniel J Stock Gender: Owner Nam: icense Address information Address: Address 2: City: Braintree State: MA pcode: 02184 o nt : United States icense InTormation License No: CS-086605 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/1/2015 Issue Date: Expiration Date: 12/5/2017 License Status: Active Today's Date: 5/3/2016 Secondary License: Doing Business As: tus Change: R Prerequisite n oma ion No Prerequisite Information Discipline No Discipline Information ocumen um Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us Office of Consumer Affairs and Business Regulation W 10 Park Plaza - Suite.5170, Boston, Massachusetts 02116 P � Home Improvem�ent„Contractor Registration Registration: 179378 Type: Supplement Card MUKHOOY INDUSTRIES LLC iR 4`-u Expiration: 7/25/2016 DAN STOCK - 639 GRANITE ST LL-15 -- --- -- BRAINTREE, MA 02184 `fP Update Address and return card. Mark reason for change. scn+ n zoM-ovn .7 Address J Renewal r-1 Employment fir ! Lost Card 6/14/2016 Your Proposal Print storrim EXTERIOR RESTORATION 639 Granite St LL-15 • Braintree, MA 02184 • PHONE: 781-519-8687 Siepierski,Sarah 9 Herbert Street Salem, MA 01970 IIWe the Owner(s) of the premises described above, authorize Storm Guard ("Contractor")to furnish all materials and labor necessary to conduct the scope of work below. Zero-down,low-interest financing options available to eligible homeowners. Attached Files: ) Terms&Cord_. Price Breakdown Price: $32,802.85 R&R Deck R&R Deck and Ceiling w/Preserve PT Micropro Pine Wood- Materials include: Pressure Treated Framing, Tongue& Groove, 3x Decorative Beam, Pressure Treated Pine Railing -This estimate assumes a full deck replacement(including code upgrades)as recommended by our carpenter- If the scope of work is reduced once we start working we will deduct the final price by a pre-agreed amount i Quantity Unit Price Price L3 _ _ $5,710.40 $17,131.20 R&R Deck Remove and Replace Concrete Stairs w/Preserve PT Micropro Pine Wood Quantity Unit Price Price 2 $1,430.83 $2,861.65 R&R Deck Dumpster Fees(assuming we can place in your driveway) Quantity Unit Price Price $714.00 $714.001 Painting - Exterior J Sand, Prep&Paint(2xCoats; Limited to 2 colors) -Staging is not included. Price will increase if staging is necessary. Will submit invoice for reimbursement Quantity Unit Price Price I https://buildertrend.net/Leads/LeadProposalExtemal.aspx?leadlD=ASUoJyD-_Mc&proposalld=x-b6w450JHk&openPrint=True 1/2 6/14/2016 Your Proposal I —�1 -- - --- - $10,667.00- -- - -- $10_667.00 R&JR Deck Footing Replacement(If Required By Building Inspector) Quantity Unit Price Price 1 $1,429.00 $1,429.00 R&R Deck Will submit permit invoice for reimbursement Quantity Unit Price Price i I 1 $0.00 $0.00 Total Price: $32,802.85 Signature Approved by #4 Siepierski,Sarah Date: 6-9-2016 https://buildertrend.net/Leads/LeadProposalExtemal.aspx?leadlD=A8UoJyD--Mc&proposaild=x-b6w450JHk&openPrint=True 2/2