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Jul -13 -2009 04:12 PM Remillard insurance 14133300LUV Li
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP ID LL °"'E 9
BERBB -1 07/13/09
PRODUCER THIS CERTIFICATE M ISSUED AS A MATTER OF DFORMATION
ONLY AID CONFERS NO RIGHTS UPON THE CERTIFICATE
Remillard Insurance Agcy, Inc HOLDER. THIS CERTIFICATE DOES NOT AMA, EXTEND OR
79 Lyman Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
South Hadley NA 01075
Phone: 413 - 538 -7862 Fax: 413 - 538 -7179 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURsRA Safety Insurance Company 39454
Bergeron Builders Inc INERB: Western World Ins., Co.
Tyler Bergeron INSURERC: Hartford Ins., Co
7 School Street INSURER D:
Granby NA 01033
_ INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I DICATEC. 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 AFFORDS) BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POU AGGREGATE LIMITS SHORN MAY HAVE BEEN REDUCED BY PAID CLAIMS_
MR TYPE OF III PAY susses l ai l kW701 11 YI LIMITS
GENERALUADTUNY EACH OCCURRENCE 1500000
B X cOMMERCIM. GENERAL LwauTY NPP1063865 -2 09/12/08 09/12/09 PIS s' 'mss au.I s 30000
CLAMS MADE fl OCCUR MED EXP (Pay ono person) S 5000
PERSONAL BADVINJURY s 500000
GENERAL AGGREGATE s 1000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMPIOP AGG s 500000
T POLICY n JECi n Lac
AUTOMOBILE UAIM JTY
SINGLE LIMIT
A, RNA= RNA= 2432163 07/14/09 07/14/10 (EreodNler*
ALL OWNED AUTOS BODILY INJURY s 100000
X SCHEDULED AUTOS p pete
X HOED AUTOS BODILY
X NON•OWNEDAUTOS s 300000
q
(Pm/
Z )DAMAGE s 100000
mejOrs
GARAGE LIABILITY AUTO ONLY - EAACCIDUNT S
_._ ANY AUTO OTHER THAN EA ACC S
AUTO ONLY AGO s
EXCESBNIBBRBLLA LwBI1 T17 EACH OCCURRENCE S
OCCUR n CLAIMS MADE AGGREGATE -
s
DEDUCTIBLE _ $
— RETENTION S S
WORKERS COMPENSATION AND I L@ I I E
C 6S60UB5126C36408 07/23/09 07/23/10 E.L.EACSACCIDENT s 100000
ANY PROPRETORPARTIMEREXECUTIVE
OPFICERAUVABEREXCLUDED? E.LDEEASE EAEMPLOYEE $ 100000
IM IYes, dettYA u ndo
IA-PRASIONSWow EL DISEASE - POUCYLIMIT S 5 00000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES/ EXCLUSQNS ADDED BY ENDO /T I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYIODR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CAHCEUED BEFORE THE EXPIRATION
City of Northampton 0/EMINENCE,. THE IS3UING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
F:413- 587 -1272 NOTICE TO THE CERTIFICATE HOLDER NATO THE LEFT, BUT FAILURE TO DO SO SHALL
Electrical Inspector
IMPOSE NO OBLIGATION OR LIABILITY MANY IMO UPON THE INSURER. ITS AGENTS OR
212 Hain Street
Northampton NA 01060 REPRESENTATIVES.
AMTI �IG'r r _ pv
ACORD 26 (2001108) ��GGyy 0 ACORD CORPORATION 1988
t76£91. 401 )
Ltozigza
CCM VW . A8NV80
13381S 100HOS L
NO830838 8 2:131M.
00 :14 papiilsaN
VIZOR so :asua311
asuaDr) JosIniadns uollonilsuop
sp.irptirN pup stio9ritinm "flti!ppriti in pima
z)imri jo Itrattwerlau - 4.)0...nrpe■selk
i4e eammo4uveald
Board of Building Regulations and Standards
* -
9 Agiwi HOME IMPROVEMENT CONTRACTOR
Registration: 147679
Expiration: 7/28/2009 Tr# 132236
Type: Private Corporation
BERGERON BUILDERS INC.
• TYLER BERGERON
7 SCHOOL STREET
GRANBY, MA 01033 Administrator
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ 1
Name of License Holder : l p
11 r.c v e ��P..l�j ✓� `J eo �"7 9
(,�
License Number
7 ���► ,( s� ieJ �r�ln / 14A O�0R3 7 —a-8 — )0 ti
Ad dr s Expiration Date
yl3 - "1) 7- go ti
ignatu Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
13erb (0,4 6
Company Name Registration Nu ber
7 6( 420( 61irri C /yl tI 01033 E iratio� Date
Address 91)1m-63034
Telephone
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 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on %Ntich 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 Fob site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also he advised that with reterence 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 Er Replacement Windows Alteration(s) n Roofing U
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Des iption of Proposed . j ,(
Work: uX 4, t., 1N X If, Co rAiI4 54i�arc. c� ( J G .1Vt <vt L1OUSe •04/1 e..'re.+b+c -
Alteration of existing bedroom Yes %-- 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? l G/� 1 I
d. Proposed Square footage of new construction. a.(1 Dimensions / / A 16
e. Number of stories? 1
f. Method of heating? c�ott., / /1 n4 wrn .i r F ireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction ,.ti. UUf1 \,.)0j eCe. vHt—
i. Is construction within 100 ft. of wetlands? Yes ✓No. Is construction within 100 yr. floodplain Yes ----
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building andd Zoning regulations? t/ Zoning No .
I. Septic Tank City Sewer V Private well City water Supply L./-
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
. j, I, ti l tat , as Owner of the subject
property N Q �,✓
hereby authorize �y . { � e ' q e --- 9r.
\
to a m
'7/i
behalr II n .tters relativ to work authorized by this building permit application.
7/10/0/
Sign ure of Owner Date
I, I -0.(-- g e"c -eA-12 , as Owner /Authorized
d b
Agent hereby clam 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.
l e -- 'p MIA
Print Na e
Signature of Owner /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 17 , 300 1
Frontage
Setbacks Front 3 0 3 5
Side L: 5 R: SS L: R: S
Rear if 0 27
Building Height /
Bldg. Square Footage /937 % 2.16 1 ).
Open Space Footage % e `
(Lot area minus bldg & paved 15;30 g Q 1 /5 BS /� y0R
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Fin ever been issued for/on the site?
in
NO 0 DONT KNOW `� / YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Cr YES
IF YES: enter Book Page and /or Document it
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 ,Date Issued:
C. Do any signs exist on the property? YES Q 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 ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex ion, 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
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413- 587 -1240 Fax 413 -587 -1272 s itePIen,, --- (
OttRrr1sp v ti ,i l� 1 r'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
JUL 1 5 2.009
SECTION 1 - SITE INFORMATION
This- section to , be comply* by office
" '
1.1 Property Address: ,a
Map Lot...._ _ Unit
�? NO�WOOCI t k •
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
LO 51u5 ML D>1jc t pc^ 141A , oo mci9egu..(d 57 Nay O4
Name P "nt) Current Mailing Address:
O 44/1/ Telephone
Siva ure
2.2 Authorized Agent:
liffi — 6etirDe te el 7 n ( 64 + 61`, A DI03)
Nam4 1.______________ Current Mailing Address:
93- t / 7 go
SignTelephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building OO (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0047
APPLICANT /CONTACT PERSON TYLER BERGERON
ADDRESS /PHONE 7 SCHOOL ST GRANBY (413) 427 -8034 0
PROPERTY LOCATION 57 NORWOOD AVE
MAP 30B PARCEL 005 001 ZONE URB(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
Typeof Construction: BUILD 210 SO FT CONNECTOR BETWEEN GARAGE AND HOUSE
New Construction
Non Structural interior renovations
Addition to Exct t r
Accessory e PO (/fI1df 5/S7? `Z
ccessory Strucure 6�'
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved 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
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.
57 ; BP- 2010 -0047
oft' COMMONWEALTH OF MASSACHUSETTS
Ma s :Blo CITY OF NORTHAMPTON
Lot: -0151!-' ' "'" " PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP- 2010 -0047
Proiect # JS- 2009 - 000113
Est. Cost: $20000.00
Fee: $112.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TYLER BERGERON
Lot Size(sq. ft.): 17293.32 Owner: MCDONALD DOUGLAS S &
Zoning: URB(100)/ Applicant: TYLER BERGERON
AT: 57 NORWOOD AVE
Applicant Address: Phone: Insurance:
7 SCHOOL ST (413) 427 -8034 0
GRANBYMA01033 ISSUED ON:7/21/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: BUILD 210 SQ FT CONNECTOR BETWEEN
GARAGE AND HOUSE
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 $112.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo