32A-043 (2) . .,
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID ,JU DATE(MM/DD/YYYY)
XC2UPRY 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 1 NAIL #
INSURED j INSURER A. Liberty Mutual Ins . Co .
INSURER B: Arbella Protection Insurance ( 41360
Steven T. Czupryna INSURER C:
178 Wheatland Avenue INSURER 0
Chicopee MA 01020 -- -- - - - - -- -- --- .- ---- -- ______
1 INSURER E 1
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
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.
IR CT S R Rt NS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE I POLICY EXPIRATION I — — -
+ �' DATE (MMIDDlYY) I DATE (MOONY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
I I f UAMAG'E 10 KEN f EU
B I X 1 OMMERCIALGENERALLIABILITY 8500030850 05/03/09 05/03/10 PREMISES ((Eaoccurence) $ 100000
i J CLAIMS MADE r X i OCCUR MED EXP (Any one person) $ 5000
I I ( i PERSONAL &ADV INJURY i $ 1000000
i — GENERAL AGGREGATE I $ 2000000 _
1 GEN L AGGREGATE LIMIT APPLIES PER rPRODUCTS_COMP/OP AGG I $ 2000000
1 POLICY I 1 JECT j j LOC ____
I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
1 1 ANY AUTO (Ea accident) $
I I
ALL OWNED AUTOS I
I i BODILY INJURY
1 J SCHEDULED AUTOS (Per person) $
I I HIRED AUTOS
� BODILY INJURY $
I NON - OWNED AUTOS i (Per accident)
I I —
1 -- ._- - - _ —_ - -__ — ._- .- ---�-- i PROPERTY DAMAGE $
1 ( (Per accident)
- GARAGE LIABILITY AUTO ONLY _EA ACCIDENT _ $
I -I i ANY AUTO OTHER THAN EA ACC $
—,_ I l I ._.
I } AUTO ONLY. v AGG $
1
EXCESS/UMBRELLA LIABILITY ! I - EACH OCCURRENCE $
j I OCCUR 1 1 CLAIMS MADE AGGREGATE $
-
I-— i { $
I I DEDUCTIBLE I I —_ —` _ $ . _ _
! I RETENTION $ $
WC STATU- iOTH
WORKERS COMPENSATION AND TORY LIMITS 1 ER
EMPLOYERS' LIABILITY
A ANY PROPRIETOR /PARTNER/EXECUTIVE WC1- 31S- 367000 -018 05/17/09 05/17/10 EL. EACH ACCIDENT $ 100000
OFFICER /MEMBEREXCLUDED? E.L. DISEASE- EA EMPLOYEE $ 100000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500000
OTHER
j I
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZE REPRESENTATIVE O 4 i
ACORD 25 (2001/08) 0 ACORD CORPORATION 19£
"AcImasemok - • MASSACHUSETTS v
DRIVERS LICENSE
NUMBER
co ono
-N-2012 -29-1964 •
CLASS REST MIT liEX
6-00 M
CZUPRYNA
STEVEN T
178 WHEATLAND AVE ...
CHICOPEE, MA
01020-1761
diri
ard of BliiidingRegulations and Stinnturns
Construction Supervisor License
License: CS 8072
Expiration: 11129/21)09 Tr# 16290
Restriction: 00
STEVEN T CZUPRYNA
178 WHEATLAND AVE
CHICOPEE MA 01020 Coaimisiioner
rh Ni ,
Board of Building Regulations and ▪ Standards
HOME IMPROVEMENT CONTRACTOR
▪ . 4f Registration: 161442
• Expiration: 1012012010 Tr# 276608
Type: Individual
STEVEN T CZUPRYNA
STEVEN CZUPRYNA
178 WHEATLAND AVE.
CHICOPEE, MA 01020 Adnii nistralm.
The Commonwealth of Massachusetts
Department of Industrial.4ccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information PIease Print Legibly
Nance ( Business /Organization/Individual): /94061jf/L. ,e a,n/g- Y1dero/l/
Address: 7 J� af 14rA 'EF tLl <31coc
City /State /Zip: 04fa COOP_ F_ /VW b/ GZO Phone #: 11 - — 8 8" dl
Are you an employer? Check the appropriate box; Type of project (required):
am a general contractor and 1
1.1 i am a employer with 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
=. ❑ I am a sole proprietor or partner-
listed on the attached sheet. 7, modeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. [] Building addition
[No workers' comp. insurance comp. insurance.$
required -] 5 • ❑ We are a corporation and its 10. ❑ 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. E Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
z 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 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!,/,e3r_ i 7i ,4,77usfy?. T,
Policy # or Self -ins. Lic. [.t�CZ -� 3! - ?'� --C a �C Expiration Date: en
Job Site Address: /5-- / 7 CH, '1 67: City /State /Zip: , grihk '7z'4 mQ b t
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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 certi r- a er the pains and penalties of perjuty that the information provided above is true and correct.
Signature: � ----� Date: AitAtle )-
Phone #: 3- ''WO/
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 4:
Version1,7 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
i
1. 1 ol»--16(L , as Owner or the subject property
hereby authorize, - cjrACAJ 7 C2,200 et .--//v 42 to
act on my behalf, in all matters relative to work authorized by this building permit application.
.....-----------\_____
Signature • •wner Date
4., 06'4 , 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.
.6,ei/e c gvwc2
Print Name
str,
Sig ature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
._.. .
Name of License Holder : ..,,cir—ii&J r cz.optzwyw cs V D7,9- 8
License Number
/713 44)17 19/6 eiliCac?Lee Me' 4 11 tea` /
Address Expiration Date
Signat ..•-•"'#m----- 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 bui ' g permit.
Signed Affidavit Attached Yes No 0
..,
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bide & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO LJ DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document if
B. Does the site contain a brook, body of water or wetlands? NO ®DONT KNOW Q YES Q
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 Q NO
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, excava on, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Versionl .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
,LO 1/1u_& a34057 ,c
_. .__ ................ Not Applicable ❑
Company Name:
Responsible In Charge of Construction
/78 600 -leR► NO A/6- ..Qrit,c 64" __ ira9. _ O191.0
Address
./ 4 857o1
Signatur: Telephone
Versionl.7 Commercial Buildin` Permit Ma 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35.000 I
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing ❑ Change of Use El Other ❑
Brief Description Enter a brief description here. RefIiie Maur F,,ri/ — AO") Acesla16 - NEW ROILS
Of Proposed Work: 01l 4 . 1 0 , 9 / R o t A1464.1 1 # ? N 3 1 - A ` & if /Cs reirfatrAl Cate/M0 rs Aw0
/ UA Nl l3iQl I - _44i- gralZ4 ,-
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A -2 ❑ A-3 ❑ 1A ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A p
E Educational ❑ 2B ❑
F Factory ❑ F -1 ❑ F -2 ❑ I 2C ❑
H High Hazard ❑ I 3A ❑
1 Institutional ❑ i -1 ❑ 1 -2 ❑ 1-3 ❑ 33 ❑
M Mercantile ❑ 4 ❑
R Residential ti' R-1 ie - R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ 3-1 0 S -2 ❑ 5B ❑
U Utility ❑ Specify..
M Mixed Use ❑ Specify:
S Special Use 0 Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: Proposed Use Group: No,/q/✓6r.
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)
NO G'l,6 1 S ,
1 s,
2nd _
2nd
3 rd
3 ro
_ 4 cn
4
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft)
Total Height ft
7. Water S ly (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public p Private ❑ Zone Outside Flood Zone Municipal On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of orthampton Status of Permit:
c Building epartment Curb Cut/Driveway Pen
21 gin Street Sewer /Septic Availability
Room 100 Water/Well Availability
Nt 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 At This section to be completed by office
1¢ „ j7 1[9 CO Qy / Map Lot Unit
.J �T Zone Overlay District
Eim St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ,.
g - ° ^ ,t iri EI' P j t - -C. 4 /7 .. s as ► aW _ ®t 0 y a
Name (Print) Current Mailing Address.
,�/
1 1 1 3 -. 559.— 07716...
Signature p Telephone
2.2 Authorized Agent:
'-f 7 „7 Sr J/ .9 ',Cv °tes a
Name (Print) / a J e y,Ela Current Mailing Address:
Signature - Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building doe, . (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of Ci /' yeb•
Construction from (6) /
3. Plumbing Building Permit Fee
Yoo..Qo
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 +3 +4 +5) 1 /l .Q0 Check Number 41, «0
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings , Date
File # BP- 2010 -0463
APPLICANT /CONTACT PERSON STEVEN T CZUPRYNA
ADDRESS /PHONE 178 WHEATLAND AVE CHICOPEE (413) 246 -8801 0
PROPERTY LOCATION 15 CHERRY ST
MAP 32A PARCEL 043 001 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 ` r/ Q�
Fee Paid (O�f
Typeof Construction: INSTALL KITCH CABINETS & BATH FIXTURES IN UNITS 15,17,17R & 19, REPAIR
FRONT PORCH (DECK,RAILS,STAIRS & COLUMNS)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 080726
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
do
Demolition Delay
L� fJ'
L -
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.
l
41
e - 1
viois t it
` .
15 CHERRY ST BP -2010 -0463
GIS f: COMV ONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 043 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WTTH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit BP -2010 -0463
Pro,ect if JS- 2010 - 000641
Est. Cost: $11400.00
Fee: $68.40 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
ATE 15 CHEP.RY ST
Applicant Address: Phone: Insurance:
178 WHEATLAND AVE (413) 246 -8801 0 WC
CHICOPEEMA01020 ISSUED ON:10/29/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL KITCH CABINETS & BATH FIXTURES
IN UNITS 15,17,17R & 19, REPAIR FRONT PORCH (DECK,RAILS,STAIRS & COLUMNS)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
n ii6e0.154- tt;
Underground: Service: Meter: /` - '
Footin g s: ,
Rough: 62.. t �/ t
Ro gh: ! ' v /
Rouse# Foundation: ` ?J
�
AA- fil t i,. ii r.5 t -� Driveway Final:
Final:3 ..„7 �C: '" Fin s al (,2 c . 1` t k
t� ` -` .3 / /r Rough Frame: O l t " - c t
.IN(IPE iz /"/d' 1� icy 1 t?.k
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Cic `
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATJ N OF
ANY OF ITS RULES AND RE .. ,A_ , 1 S. / .0...,,,e,,,,.. 4G� / �s
Certificate of Occu • c / / Si ature:
FeeType: ..- Date Paid: Atnount:
Building 10/29/2009 0:00:00 $68.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
p