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35-197 .s •ha1 r l 901 4._ Si ' ;t£ of Y ,,SO d c. kce t 3 ,tip 4-7/s/ eE rni "[ s k '" Q j r"d cf a� Und fc� , . Massachusetts - Department of Public Safet3 Board of Building Regulations and Standards # Construction Supervisor License License: CS 80274 Restricted to 00 TYLER R BERGERON ' "•,,,, 7 SCHOOL STREET _ , I GRANBY, MA 01033 CZ;_ ----....---, , Expiration: 7J28/2011 ,... ( I I nitii is■i4 flier Tr#: 18394 ... - 6iiitilto , upea/th a‘ ita,k3aCk4$04 Office of Consumer ' Affairs & wines, Regulation , r-- HOME IMPROVEMENT CONTRACTOR r =4 - t --- _ - --177--: - f V - :wa ---,- t Registration: 147679 . ' : Expiration: 7/28/2011 Tr# 287232 - -<,\,„• - •+77 • Type: Private Corporation • BERGERON BUILDERS INC. TYLER BERGERON 7 SCHOOL STREET ..-- GRANBY, MA 01033 Undersecretary Sep -14 -ZU1U U3:dd PM Remillard Insurance 14135386010 1/2 R VP CERTIFICATE OF LIABILITY INSURANCE OP ID LL DATE(MM/ODIYYYY) 09/14/10 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 UWVIAW NAME: PHON Remillard Insurance Agcy, Inc NC, N• FAX No): 79 Lyman Street ADDRESS: South Hadley MA 01075 PRODUCER CUSTOMER BERGE -1 Phone:413- 538 -7862 Fax:413- 538 -7179 ItSURER(S) AFFORDING COVERAGE NAIC INSURED INSURERA: Safety Insurance Company 39454 Bergeron Builders Inc INSURER e: Peerless Insurance 18333 Tyler Bergeron 7 School Street INSURERC: Guard Insurance Group Granby MA 01033 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INTR TYPE OF INSURANCE AUDI. UMW " POLICY EFF - POLiICY !XP INSR WVD POLICY NUMBER (MM!DDAYYYY) (MWUVOIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE 5 500,000 B COMMERCIAL GENERAL LIABILITY CSP1421404 09/12/10 09/12/11 PREAN S 100,000 I I CLAIMS -MADE C OCCUR MED EXP (Any one person) _ S 15,000 PERSONAL IL ADV INJURY _ $ 500,000 _ GENERAL AGGREGATE _ S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 1, 000, 000 POLICY n 1&: n LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) A ■ ANY AUTO 2432163 07/14/10 07/14/11 BODILYINJ ■ ALL OWNED AUTOS BOOIYINJURY(P�penon) $ 100000 BODILY INJURY (Per accident) S 300000 ® SCHEDULED AUTOS PROPERTY DAMAGE S 100000 X HIRED AUTOS (Peraccided) — © NON -OWNED AUTOS S S UMBRELLA UAB OCCUR EACH OCCURRENCE _ S ■ EXCESS LIAB CLAIMS-MADE AGGREGATE S ■ DEDUCTIBLE S RETENTION S S C WORKERS COMPENSATION BEWC123246 07/23/10 • 07/23/11 XI T OR WC Y LIMI -1 1 TS ER IOrH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXEC EL EACH ACCIDENT S 100000 OFFICER/MEMBER EXCLUDED? UTiV� N/A (Maennedatory inNH) E.L DISEASE - EAEMPLOYEE S 100000 DESCRIONO OF below EL DISEASE - POLICY LIMIT 5 500000 l _ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I more space is required) carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYNOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS, F:413- 587 -1272 Electrical Inspector AUTHORIZED REPRESENTATIVE 212 Main Street Northampton M. 0I060 0, t 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 7y lr.r 6r t f) n C.5 8 ( "l /' License Number 7 3jLoo 5 -- ( ‘' MI 01033 7- 0 Address Expiration Date /8 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ d)cC�,n (6,114- /7 � 0 7� Company Name Registration Number � Jdepot 5t-fel tivAol MA 81(33 7 -)8- )0i Address Expiration Date Telephone L 1i3 - � 1 I) -8o34 SECTION 10- 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 ❑ No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 1083.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) [] Roofing Or Doors 0 Accessory Bldg. Demolition ❑ New Signs [D] Decks [L Siding [DI Other [O] Brief Description of Proposed Q Q 1 1 Ll l Work: U (ni l 0 N el C.Ac -G � a o I 1 3 0& Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPUES FOR BUILDING PERMIT I, ROHM G I Peon, c , as Owner of the subject property �(' Q� hereby authorize > > I Gr" t)Cr B co v1 to act on my behalf, in all *iatters relative t�work authorized by this building permit application. Signature of Owner Date 1 66 ('.f cb Y► , as Owner /Authorized Agent here declare that the tatements 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. Print Name Signatu er/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size / O 176 /0, 9 75 Frontage Setbacks Front stn 33 Side L: 3i R: 15 L: 15 R: 15x Rear 5 y a` Building Height ?-u Bldg. Square Footage 616 % 1681 / i r e Open Space Footage 0 i 59 4 4 1 3 % 9' 31/ (Lot area minus bldg & paved y g4 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO lJ DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES © NO lJ IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit � 212 Main Street Sewer /Septic Availability SE? 2 2 Room 100 Water/Well Availability _Northampton, MA 01060 Two Sets of Structural Plans phone 41 587 -11240 Fax 413 -587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 11 1 1(0 IIUCA S P: cc•°\ Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 2 j� �oV1A'!�1 'R , a< 1160 1J rnt'� Pi l� d Name (Print) `,, Current Mailing Address: i a - on-IALA f ��®OVJ�_ Telephone Signature 2.2 Authorized Agent: 7 ic 3ef PVoh 7 SuLor.I Si i«f f rtiri {. MA c io3) Name (Print) Current Mailing Address: 7 V A, A - 1 113 - 8o3 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ),v, Coy (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 3- Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 30.000 Check Number 50 . , /o:3 C o This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0270 LP _ APPLICANT /CONTACT PERSON TYLER BERGERON 0 �C ✓ 1 ( ; \, ' �, ADDRESS/PHONE 7 SCHOOL ST GRANBY (413) 427 -8034 Q '4 k� PROPERTY LOCATION 1160 BURTS PIT RD a lC MAP 35 PARCEL 197 001 ZONE SR(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid �J Typeof Construction: CONSTRUCT 24 X 32 DET GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 080274 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON e liw -'z!') INFORMATION PRESENTED: eft c 1/2-7! ((? V Approved Additional permits required (see below) L.�u + 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 9 /Z ?/k 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. 1160 BURTS PIT RD Y o/ 6 e BP-2011-0270 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -197 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- 2011 -0270 Project # JS- 2011- 000442 Est. Cost: $30000.00 Fee: $153.60 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TYLER BERGERON 080274 Lot Size(sq. ft.): 10977.12 Owner: PEASE RONALD Zoning: SR(100) //WSP II Applicant: TYLER BERGERON AT: 1160 BURTS PIT RD Applicant Address: Phone: Insurance: 7 SCHOOL ST (413) 427 -8034 () WC GRANBYMA01033 ISSUED ON:9/27/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 24 X 32 DET GARAGE 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 9/27/2010 0:00:00 $153.60 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner