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32A-043 (3) . r r,. . _ ACHUSETTS ► DRIVER'S LICENSE NUMBER .im.. 539 1404 ; , fli EXP 008 I 1- 29.2012 11-29° 1964 C S REST LAS � HST SE A 6-°° M u CZUPRYNA M STEVEN T 1. ` s cc .w s r i ' . - E °r 178 WHEATLAND AVE CHICOPEE, MA 01020.1761 k rtasassa ' 3/14. C di, .�il@ f MO 1/fi 8'fl/fh , / , f 4,i iflXCAii,,,{i'�41 B oard of Building Regulati and Standards License or registration valid for individul use ((� HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to H' 121,,4i 1' ' Board of Buildin Re ulations and Standard: t l Registration: 161442 g Expiration: 10/20/2010 Tr# 276508 One Ashburton P ce Rm 1301 Type: Individual Boston, Ma. 02108 ' -' STEVEN T CZUPRYNA STEVEN CZUPRYNA 178 WHEATLAND AVE. 1 .. 4 ,..__ CHICOPEE, MA 01020 Administrator Not vaticl without 4ignature Nt.t achusetts - I)cirartntcnt t t Public satct� 1 Bnart1 of t3ailtlinv, R 1ulationv and ltantlard, ,' Construction Super !_,cease License: CS 80726 Restricted to 00 STEVEN T CZUPRYNA 178 WHEATLAND AVE CHICOPEE, MA 01020 cam,._ --- -- E x t3 r at Io n : 11/29/2011 ( , 1 1 11 0 . 1 r T r . = 12445 ACCRA. CERTIFICATE OF LIABILITY INSURANCE OP ID JU DATE(MM/DDMNY) XCZUPRY 05/28/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE First American Insurance Agy., HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 510 Front Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chicopee MA 01013 Phone: 413- 592 -8118 Fax: 413- 592 -0995 INSURERS AFFORDING COVERAGE NA1C # INSURED INSURER AL__ Liberty Mutual Ins. Co. INSURER B: Arballa Protection Insurance 41360 60 Steven T. Czu ryna INSURER C: _ 178 Wheatland-Avenue INSURER 0: Chicopee MA 01020 INSURER E: _ COVERAGES 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 i MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN " — "j'OUCY EFFECTIVE PO�CY EXPIRATION ��' LTR NSRE _ TYPE OF INSURANCE POLICY NUMBER DATE (MMIODJYY) DATE (MMIDDIYY) LIMITS GENERAL. LIABILITY ( EACH OCCURRENCE i$ 1000000 [JAMALit r CrREN 1 t!J B X ICOMMERCIALGENERALLIABILITY 8500030850 05/03/09 05/03/10 PREMISES(Eaaccurence) 5 100000 J } r• i CLAIM MADE I Xl OCCUR ' MED EXP (Any one person) S 5000 j PERSONAL SADV INJURY $ 1000000 lll _ f GENERAL AGGREGATE $ 2000000 PRODUCTS - .CDMPlOP AGG GEN'L AGGREGATE LIMIT APPLIES PER: i I . S 2000000 I i POLICY i JECT I I LOC I AUTOMOBILE LIABILITY 5 COMBINED SINGLE LIMIT � I ANY AUTO I f (Ea accident) { 1 1 ALL OWNED AUTOS 80011? INJURY 5 I SCHEDULED AUTOS ( (Per parson) HIRED AUTOS BODILY INJURY S (Per accident) — NON -OWNED AUTOS __ PROPERTY DAMAGE S (Per accident) {( {( GARAGE LIABILITY 1 AUTO ONLY - EA ACCIDENT $ ANY AUTO ( j j OTHER THAN EA ACC } S { I I I AUTO ONLY: AGG $ I EXCESS/UMBRELLA LIABILITY I EACH OCCURRENCE $ _ f OCCUR ` !CLAIMS MADE j I AGGREGATE 1 $ 5 f ' DEDUCTIBLE — S I I RETENTION S ( ; 5 WC STATU- I 1OTH- WORKERS COMPENSATION AND TORY LIMITS t 1 ER EMPLOYERS' LIABILITY A WC1 -31S- 367000 -018 I 05/17/09 05/17/10 E.L. EACH ACCIDENT 5100000 ANY PROPRIETOR/PARTNER /EXECUTIVE t OFFICEPJMEMBER EXCLUDED? I E.L. DISEASE - EA EMPLOYEE S 100000- S Pdescribe S SPECIAL PROVISIONS below E.L. DISEASE - .POLICY LIMIT . 5500000 EC OTHER 1 i l r DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT 4 SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA1 DATE THEREOF, THE ISSUING INSURER WILL. ENDEAVOR TO MAIL 30 DAYS WRITTE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHP IMPOSE NO-OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZE REPRESENTATIVE y . ( r) ACORD 25 (2001(08) CI ACORD CORPORATION 1 The Cortmrnonwealth of Massachusetts Department of Industrial A ccidents Office of Investigations 2- 600 Washington Street • Boston, MA 02111 www. rnass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information PIease Prrint Legibly Name ( Business 'Organization/Individua1): fiLpfAJV (.L. /A)f,(J L) – 7c i/1T ✓ > � �eileP ,(;/ Address: / 7g ,Qvc ?/7 /Ce9 j /1°o- at Dat City /State /Zip: (.t41 r 1110 C (c.) Phone #: 4 -2y6 Are you an employer? Check the appropriate bo - Type of project (required): 1. ❑ I am a employer with 4. I am a general contractor and I I employees (full and/or part- time).* have hired the sub- contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner—listed on the attached sheet. 7. Remodeling ship and have no employees These sub- contractors have 8. n Demolition any for me in aci employees and have workers' 5 Y ca P 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11 _❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[] Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 13. Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing alI work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the nacre of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L/ FgiV ()977 ?e- ,Z'../s _ Policy # or Self-ins. Lic. #: t' C 1 – 3/ 706 G7 ,. ri / Expiration Date: ,..5l i 7 1 0 Job Site Address: /5 / 9 OE"F/2/Lt S AlC7/2 rH4 tPiZZ J /i7t2 City /State /Zip: A m / 4 4 ,p pw m4 C9 <OCc 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 fotut of a STOP WORK ORDER and a fine of up to 8250.00 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 ce- f3' n. er the p i penalties of perjury that the information provided abo e is tr • and correct. Signature: Date: >' r 1 Phone#: 3 " a`lG'`t�� Official use only. Do not write in this area, to be completed by city or town official 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 #: Version 1.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT F 121_ , as Owner of the subject property isim--(7-t- 9 Coem:-/ hereby authorize At.r)eA)4/i 0-4.0P0.4.1 T 0.2..)Przq t 0- to act on my behalf, in II matters relative to work authorized by this building permit application. Signat of Owner Date 1 , C( C- , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Fa,c, PTint Nam- ign ,Kre of Orner/.... 9-7 Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not A plicable 0 . . Name of License Holder : ) CZ.i...7er2s/A/K2 S 9C77C9--C License Number 7 . IAlii64FLIONO tiZ CeP6.6 149 ( • 11-0 1 2-011 Address "iv f Expiration Date 445: 2 Y6 A Signat re Telephone SECTION 13 -WORKERS COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 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 build' g permit. Signed Affidavit Attached Yes No 0 • Versionl.7 Commercial Building Permit May 15, 2000 S. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by ,j/ g/V6L N0 0/(41/er Building Department Lot Size Frontage Setbacks Front Side Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parkin g) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW er YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW �. / YES 0 IF YES: enter Book Page and /or Document it 8. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued C. Do any signs exist on the property? YES 0 NO er IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO IF YES, describe size, type and Location: E. Will the construction activity disturb (clearing, grading, exca ion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Version1.7 Commercial Buildintz Permit May 15. 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor a L0EA.!4(-IG4. . tti, GGV__. _.._ ........w Not Applicable ❑ Company Name: c Responsible > rf l alp4yp/i' l _ _. �... In Charge of Construction 11: o)ifI s Air I 6. _ „it.; . tkvz Address Si. Telephone . . . . ~ VroioolJ Commercial Building ycnnm Ma) 15, 2000 SECTION 4- COSTRUCT1ON SERVCES FOR PROJECTS LESS THAN 35.000 CUBC FEET OF ENCLOSED SPACE 1 Interior Alterations [] Existing Wall Signs [] Demolition Repairs 0 Additions [] Accessory Building 0 Exterior Alteration [] Existing Ground Sign 0 New Siqns Roofing Cxangrpf Use [� Other �� ____ - _ Brief Description brief Eotora�efdescription berc. Of Proposed Work: ' _I4,. v i- '- Si (7),NG SECTION 5 - USE GROUP AND CONSTRUCTION TYPE . USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A-1 0 A-2 10 A-3 10 1A | [] 0 A-4 0 A-5 0 ' 1B [] B Business 0 2A 0 E Educational 0 2B ` | F 0 F Factory [] F-1 0 F-2 [] ' 2C [] H High Hazard 0 . 3A 0 | Institutional D 1-1 0 1-2 0 1-8 0 ' 3B [] M Mercantile 0 ' � ` 4 [] R Residential L� R-1 i' ~ � F-2 [] R'3 [] 5A [] S Storage [] S-1 [] 8-2 0 | 5B [] --- U Utility tility � � ----- - ---- - '---� -� -�-- --------�-- -- --�� -'- �] /x� -`----------------- ``-------------' ------`-- `- - M Mixed Use [] Specify: ----- ----�------- ---�------ --- ------ ---- S ��� C3 S��- -----�-�-----------�—� COMPLETE THIS SECTION F EXISTING BUILDING RENOVATIONS, AND/OR CHANGE IN USE Exsting Use Group: - Existing Hazard ng�aza|ndox7O8CMR34): ------� - - Proposed 34): pose�Hazanj|ndex70JC�R34-- --- ---'---- SECTION 6 BUILDING HEIGHT AND AREA OFFICE USE ONLY 8UILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floo (sf) /V'n ,. l -- ' * ' --------'----- ___ _ _-___- ---- 2 = 2" - -- -- -- -- - __, __-_____- 3 rd � � 3rd m --'----'---------------- --------------------- 4^ 4~ `----- — Total Area (sf) -' -- _ Total Proposed New Construction (sf) - --- Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) z��op� 7.3 Sewage Disposal System: Public El Private El Zone ______ OmsideFloodZoneD Municipal LJ On site disposa system[] • Versionl.7 Commercial Building Permit May 15. 2000 Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability ,- Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413 -587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 7k17A 19 cii(yz2y 0, Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Lti j ' - 9 j) s ,//j 4-y /n ..©ia if Name (Print) Current Mailing Address: ,. �/3 -_ ... -G/ 7 7`� _... _ _.... ........ .... Signature �/ ` /� Teiephone 2.2 Authorized •, a nt: 4/ 7 s _ s - Hot-yo. 01 Name (Print) F4_ e some Current Mailing Address: • q —0�77 r y Signature Te lephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 000. Ufa 2. Electrical (b) Co struecttionn from (6 of 3. Plumbing C23eI Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) El, 000, CC Check Number i5 ' $55" lr This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner /Inspector of Buildings Date BP- 2010 -0798 ow- GIS #: COMMONWEALTH OF MASSACHUSETTS Mati:131ock: 32A -041 ' . ` CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP-2010-0798 Project # JS- 2010- 000641 Est. Cost: $8000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEVEN T CZUPRYNA 080726 Lot Size(sq. ft): 5183.64 Owner: BIAPITA LLC Zoning: URC(100)/ Applicant: STEVEN T CZUPRYNA AT: 15 CHERRY ST Applicant Address: Phone: Insurance: 178 WHEATLAND AVE (413) 246 -8801 () WC CH ICOPEEMA01020 ISSUED ON:3/12/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL SIDING POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 3/12/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo