32C-341 :AR WCIP , � Liberty
'ISSUING OFFICE 181 r� Mutual,- Workers Compensation and
INFORMATION PAGE Employers Liability Policy
ACCOUNT NO. SUB ACCT NO. Liberty Mutual Insurance Group /Boston
1- 339540 0000 LIBERTY MUTUAL FIRE INSURANCE CO. 16586
POLICY NO. TD /CD SALES OFFICE CODE SALES CODE N/R 1ST
WC2 -31S- 339540 -029 XX X WESTON 102 REPRESENTATIVE 3000 2 YEAR
ASSIGNED 2002
Item 1. Name of ABUZA BROTHERS MANAGEMENT INC
Insured FEIN 04- 3305487
Address 181 MAIN ST
RISK ID 000067613
NORTHAMPTON, MA 01060
Status 03 - CORPORATION
Other workplaces not shown above: SEE ITEM 4
Mo. Day Year Mo. Day Year
Item 2. Policy Period: From 12 -31 -2009 to 12 -31 -2010
12:01 AM standard time at the address: of the insured as stated herein.
Item 3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are:
Bodily Injury by Accident 500,000 each accident
Bodily Injury by Disease 500,000 policy limit
Bodily Injury by Disease 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Premium Basis Rates LINE 110
Per $100 Estimated
Code Estimated of RE- Annual
Classifications No. Total Annual Premiums muneration Premiums
SEE EXTENSION OF INFORMATION PAGE
Minimum Premium $ 282 (MA ) Total Estimated Annual Premium $ 1,432
Interim adjustment of premium shall be made: ANNUAL
This policy, including all endorsements issued therewith, is hereby countersigned by
Authorized Representative Date 01 -14 -10
Loc. Code Term. Oiler. Audit Basis Periodic Payment Rating Basis Pol. H.G. Home State Dividend RENEWAL OF:
01 -14 -10 NR MA WC2 -31S- 339540 -028
GPO 4030 R1 Copyright 1987 National Council on Compensation Insurance WC 00 00 01 A
Insured Copy
,. The Commonwealth of Massachusetts
Department of Industrial Accidents
l Office of Investigations
E
7 - 41 111117 7 600 Washington Street
"`�� Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/individual): o P8 �1�P�`S AN e#,,Q4l . NC.. _
Address: I U( Malti St Q s eft) fj w%. 2 Y
City /State /Zip:PO PEG via. A 4- 0 (060 Phone #: 4 (3 S N & 0
Are you an employer? Check the appropriate box:
,.,�,� 4. I am a Type of project (required):
1. L' I am a employer with 3 ❑ general contractor and I g
employees (full and/or part- time).* have hired the sub - contractors 6. Ell 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. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.I
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 11.0 Plumbing repairs or additions
. [No workers
myself. ' com right of exemption per MGL
Y [ comp. 12.0 Roof repairs
insurance required.] 1 c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all 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 name 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: 1,60-6 14.40 . a (
Policy # or Self -ins. Lic. #: W C.2- 3 (.S 3395 - O'2.. Expiration Date: 12- 3 (- 2.0 to
Job Site Address: if ( Di ki\lQ .h,S St City /State /Zip: /0a t:("kd i oi 114 Q ok
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 cert • • t 0 • • s and penalties of perjury that the information provided above is true and correct.
Si nature � � Date: ( r
d
g 3
Phone #: L t 13 (,3 81 6'6 (
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
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, - as Owner of the subject property
hereby authorize. . eF'...v2G ..-? Q�t !/ Ittltlo QA�� r ... __
-ct • my . •h. atters relative to work authorized by this building permit application.
r
2 _._
Signature of Owner Date
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.
Signe. der-the , ains and alties of perjury.
Prim - 0 , 10 ,
Signature of Owner /Age Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 1 " - , r F � 2C.
License Number
Addr:111p 0 46 Expiration Date
molt- dir"
Signature Telephone
SECTION 13 - 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 buildi ermit.
Signed Affidavit Attached Yes No
•
Version 1.7 Commercial Building 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
_ � 0 T
�GxQ�/
d Not Applicable ❑
Com n Name:
l ar
Responsib In Charge of Construct n St) 4 if poig44, mil-- Occ•
A s
..0.01A•44 ' tte stia
Signat - Telephone
r;
•
Version1.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
N a C keitjez Building Department
Lot Size lc �Y . 1 0
Frontage...
Setbacks Front
Side L: R :.. - 3 .. L: ' R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding a er been issued for /on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book ; Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav on, 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 Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations (rJ Existing Wall Signs ❑ Demolition Repairs Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use ❑ Other ❑
Brief Description Enter a brief description here. 1 Q c Q ce. side a krt 4' (de wa( lc, pe W l vu, .
Of Proposed Work: t(d a closet f'e f (LCQ le_ ifeAek 1-1,a4 & cab Ipr rt:1c‘ ' y'FuR4 s
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ / 4 ❑
R Residential I R -1 ❑ R -2 E l R -3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ _ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group: "
Existing Hazard Index 780 CMR 34): ; Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE'ONLY
Floor Area per Floor (sf) Po C-IkeiN -e.
1St 2c.,,s a 1
2 nd
2nd IQ S
d
4 m _ _
4 th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft) 35
Total Height ft
7. Water Sy+ ply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage D ' p osal System:
Public �' Private ❑ Zone _ _ Outside Flood Zone El Municipal On site disposal system El
•
Version!.7 Commercial Building Permit May 15, 2000
Deparinlent use only
City of Northampton Status of Permit:
Building Department bCutlDnvewayl rmit `'" -
212 M ain Street %;,
�, Sewer/Septic Availability �' } _ — 9 L Q�t� Room 100
Northampton, MA 01060 Two Sets of �o Plans
phone 413.587 -1240 Fax 413- 587 -1272 Piot/Site Plana
tiff'er t , d s#
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
_.. ..._
At[ W l a t Nt,S v t ��� �r1�(/l Map Lot un
/t` tetrt4 e friA fi /1- o(o 6j Z one O verlay D i tr
` . Elm St District' GB Qistrict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
W t t t 4 n $ iaaet 'ft'S yv w t S &k( o. -. ..f' e / . o " i _
P
Name (Print) Current Mailing Address ( 1 _...48:4, 86e
Signature cVfC2__(,Ze.- Teleph
2.2 Authorized Agent:
- -- da AU 2 f.
Name (Print) Current Mailing Address:
4 f f3 \ e6e
_ ,..
Signature Telephone
SECTION 3 - ESTIMATED CONS UCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building $ „ `00 , (a) Building Permit Fee
V V
2. Electrical ` ( b) Estimated Total Cost of
Construction from (6)
3. Plumbing 3 sa ° Building Permit Fee
4. Mechanical (HVAC) ._._.. _ _ ..., ...
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 'ef s Check Number /J7;3 ,T5 —
This Section For Official Use Only
Building Permit Number Date
issued
Signature:
Building Commissioner /Inspector of Buildings Date
•
File # BP- 2010 -0784
APPLICANT /CONTACT PERSON RICHARD ABUZA
ADDRESS /PHONE 181 MAIN ST NORTHAMPTON (413) 586 -8681
PROPERTY LOCATION 41 WILLIAMS ST
MAP 32C PARCEL 341 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid / / /o
Typeof Construction: RESURFACE SIDE ENTRY SIDEWALK,REPLACE WINDOWS, BUILD BR
CLOSET,REPLACE KITCH/BATH CABINETS/FIXTURES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 019062
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
( pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
�., ---� 3 i91 tC
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
i4T ... BP- 2010 -0784
GIS #: COMMONWEALTH OF MASSACHUSETTS
,. :mock: 32c - 341 " CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0784
Project # JS- 2010 - 001171
Est. Cost: $8800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD ABUZA 019062
Lot Size(sq. ft.): 6708.24 Owner: WILLIAMS ST LAND TRUST C/O ABUZA BROTHERS MANAGEMENT
INC
Zoning: URC(100)/ Applicant: RICHARD ABUZA
AT: 41 WILLIAMS ST
Applicant Address: Phone: Insurance:
181 MAIN ST (413) 586 -8681 Workers
Compensation
N O RTHAM PTO N MA01060 ISSUED ON :3/19/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: RESURFACE SIDE ENTRY
SIDEWALK,REPLACE WINDOWS, BUILD BR CLOSET,REPLACE KITCH /BATH
CABINETS /FIXTURES
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:
3// 9/i 0 0 --
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo