10D-003 73 WATER ST BP-2020-0026
GIS#: COMMONWEALTH OF MASSACHUSETTS
Me.-Block: IOD-003 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:REPAIR BUILDING P E R M I T
Permit# BP-2020-0026
Project# JS-2020-000042
Est.Cost: $15700.00
Fee:$100.00 PERMISSION IS HEREB Y GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK R DILL 106171
Lot Size(sg.ft.): 11630.52 Owner: TUPERKEIZSIS MARGUERITE M
Zoning_URB(I00)/ Applicant: MARK R DILL
AT: 73 WATER ST
Applicant Address: Phone: Insurance:
PO BOX 287 (603),352-4447 WC
KEENENH03431 ISSUED ON.7/12/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR ROOF AND SIDING DUE TO FALLEN
TREE
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 Sianature:
FeeTyim Date Paid: Amount:
Building 7/12/2019 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2020-0026
APPLICANT/CONTACT PERSON MARK R DILL
ADDRESS/PHONE 78 GAP MTN RD TROY (603)3524447
PROPERTY LOCATION 73 WATER ST
MAP IOD PARCEL 003 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction:_REPAIR ROOF AND SIDING DUE TO FALLEN TREE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106171
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
at, r
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.
06-26-'19 11 :49 FROM- Bergeron Cons. 16033572672 T-141 P0002/0013 F-419
De�artrp�nt use only
City of Northampton Status of Penult
'
Building Department Cp CulDrlveWay Rer`r
pii;
� 7t 212 Main Street Sewer/Sepia gv�il�blltly " :'T� '
Room 100 '
Wata�IWell„Qyallpillty
Northampton, MA 01060 Two S®ts of structtir �`Plans `
phone 413-587-1240 Fax 413-587-1272 Plat($ite plans
Other SlieCif� ''
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
73 W4-)-"0– s4 Map—A0 9 Lot d 3 Unit
(^()A
' /,�/)A 01OS-2 zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
L”/-3- sN- sy�9
Telephone
Signature
2.2 Authorized Agent: I ,pT. en P,
Ra—me lL �j�(LdJn �'vnr�RUG77aY7�„ t�y• .(�P 94'y b 7 Kea, ly,
�1
(Pri lt) Current Mailing Address; 03 4 ��!
Signak e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 1f o o (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
a. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+ 3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature;
Building Gommissionedlnspector of Buildings I Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
06-26-'19 11 :49 FROM- Bergeron Cons. 16033572672 T-141 P0003/0013 F-419
Section 4. 70N ING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing proposcd Required by Zoning
This column to be filled in by
Building Npattment
Lot Size
Frontage
Setbacks Front
Side L E= R:E--. L:=t
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot arroa minus bldg&paved W I.—D
parking)
#of Parking Spaces
Fill:
volumc&Location) ---
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOWtPr
YES 0
IF YIES, date issued
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES_0..
IF YES: enter Book T-W _,.,..,........ Page _ and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
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 0 NO i
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
1F YES, describe size, type and location: -- .� .,��_...._y..�_._......��._.,V...W..
E. Will the construction activity disturb(clearing,grading,excavation,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-
06-26-'19 11 :50 FROM- Bergeron Cons. 16033572672 T-141 P0004/0013 F-419
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 [p] becks [M Siding [da Other[qi
Brief Description of proposed �lJ
Work: me'eHI2 leoov Sir. l'l Due- 4-o � e fki 7' ly0C.�.
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes 4-"*No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, Complete the followina:
a. Use of building: One Family 11'� Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? N D
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 APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
L r' /�/4)ie /� J
/`f4'n ' 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.
Print Name
Signature f Own®r Agent Date
06-26-' 19 11 :50 FROM- Bergeron Cons. 16033572672 T-141 P0005/0013 F-419
City of Northampton
Massachusattn
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street 6 Municipal Building
Northampton, MA 01060
AFFIDAVIT
Rome Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Horne Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, nepair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
done by registered contractors,
Note. If the hoineowner has contracted ivith a coiporation or LLC, that entity must be registered.
Type of Work. Est. Cost. /-r
Address of Work: /�W,�e'(Z'
Date of Permit Application:
I hereby certify that-
Reeistration. is not required for the followinv renqnn(0,
Work excluded by law(explain);
Job under$1,000.00
Owner obtaining own permit(explain)-
Ruilding not own ex-no0o pi ed
Other(specify):
0'WNER,Q, ORTAINING Tff FAR OWN PRRMIT OR P.NTF.RTNG INTO('ONTR A(-TI;"7TT14
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
TTNDFR M.G.L.("harmer 1d7.A. FTTf Ti OWVPWP� AVIQ:0 Aq.'ZTTk1R TNF.RFr%PnNSFR'FT.TTFS FOR ALL WOP-1Z
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
31gIIVLI UILLIUL (11C.PCilahkZ�of pOijtUy,
I hereby apply for a building permit as the agent of the owner:
Date Contractor'Name t)?, 'V HTC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property-,
Date Owner Name and Signature
06-26-'19 11 :50 FROM- Bergeron Cons. 16033572672 T-141 P0006/0013 F-419
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �i 01.))
f� f l Not Applicable ❑ / /
Namo of License Holder. �k;,�yaJ�1�.. 01 J J C_c," /d G 1 7 f
Liconse umber
hLZ 019
Address Expiration Date
ig tura Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
�
d 1s0Y �
Address Expiration Date
Telephone 0 "sus-2"'WY 7-
SECTION
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(AM.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 uilding permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
06-26-'19 11 :51 FROM- Bergeron Cons. 160335726722/ T-141 P0007/0013 F-419
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, N� s� chusetts 02118
Home improvemd*,Gwtractor Registration
Type: Corporation
BERGERON CONSTRUCTION COMPANY -�- m Registration: 161160
e is Expiration: 09/28/2020
P.O.BOX 287
KEENE,NH 03431 = i
PCA 1 C 20M-05117Update Address and Return Card.
.� �".�arreo�aubi�g�✓Z��war�ai
Office of Consumer Affairs R Business Regulation
HOME IMPRQMENT CONTRACTOR Registration valid for Individual use only
Torporation before the expiration date. If found return to:
e is` 'a o Expiration Office of Consumer Affairs and Business Regulation
_ 09/28/2020 1000 Washington Street•Suite 710
8ERGERON COMPANY,INC, Boston,MA 02118
r�
EDWARDBE Jytl,.
27 MATTHEW S ROPb, r
KEENS,NH 03431 s"Undersecretary' Not vali ithoUt Lure
f.,
C)
rn
I
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commonwealth of l'9assachusetts co
Divi
sion of Professional Licertsur
Board of gu+�ding�Regulations and Sia dards
Const r r
r isor
CS-106171 , ;' T
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A"K R DILL
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06-26-'19 11 :51 FROM- Bergeron Cons. 16033572672 T-141 P0009/0013 F-419
4izy or NOrtnampton
"s Massachusetts
DEPARTIaNT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building01
�`i •. 'a
Northampton, MA 01060
Massachusetts Residential Building Code
Section 110.85.1.2
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.
Section 110.85.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 11 0.85, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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 (W'orkers' 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.
06-26-'19 11 :52 FROM- Bergeron Cons. 16033572672 T-141 P0010/0013 F-419
4j-r.y or vorLnampton
Massachusetts
A
DEPARTMENT OF BUILDING 1'NSF9CTIONS
212 main Strcct *Municipal Building
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c:40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at-
---73 Waje(c
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from,
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
06-26-'19 11 :52 FROM- Bergeron Cons. 16033572672 T-141 P0011/0013 F-419
Information and Instructions
Massachusetts General saws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number;
The Corntnonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.rnass.gov/dia
06-26-'19 11 :52 FROM- Bergeron Cons. 16033572672 T-141 P0012/0013 F-419
The C'oninronwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 0.2114-2017
wwmaiass.gov/dia
kvi� Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIulnbers.
TO BE FILED WITH THE PE22MITTING A'UTHOMITY•
Applicant Information please Print Legibly
Name (Business/Organization/Individual): Re 4 P�P e,a n.SH/ _'�A, r1 -A G..
Address:_Po GOX 08 7 Z 7 M io4hewS /Z 0-
City/State/zip: JX e-e- h e-; -Al. 14J 0-3 VfJ phone#: 603- 34-Z
Are you an employer?Check the appropriate box: 'Type of project(required):
1.EdI am a employer with 11Y employees(fUll and/or part-time).` 7. New construction
2.❑I am a sole proprietor or partnership and bave no employees working for me in $, Remodeling
any capacity.(Aro workers'comp,insurance required.]
9. Demolition
3.O I am a homeowner doing all work myself.[No workers'comp,insurance required.]t
❑
4.F11 am a homcotvncr and will be hiring contractors to conduct all work on my property. 1 wilt 10E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11_❑Electrical repairs or additions
proprietors with no employees. 1 ❑
Plumbing repairs or additions
5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
Those sub-contractors have employees and have workers'comp.insurance.; 13.[gAoof repairs
6.r1'We are a corporation and its officers have exercised their right of exemption per MGI.c. 14. Other 5),01 OZ
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomtation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outaidc contractors must submit a now affidavit indicating such.
tContraetors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
cmploycea. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ant an erltployer that is providing workers'compensation insurance for my employees. Below is tire policy and job site
information.
Insurance Company Name: 140t 4 .1 p1S(jje4C er
Policy#or Self-ins.Lie.#: C 10A 908 Gj0I 1 )I� — Expiration Date: il-l -� 2 0
Job Site Address: • !�7 e c 94, G eco. 144, City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(s owing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK OIWER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby Cert' der the p �'ryls an d peLnahies of perjury Mat the information provided above is true and correct.
i n tune' /` Date: �
Phone#: 3 2-r e-IV
Oficial use only. Do not write ter this area,to be completed by city or town ofcial•
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
06-26-'19 11 :53 FROM- Bergeron Cons. 16033572672 T-141 P0013/0013 F-419
AeGORH CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
6/26/2019
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(les) 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 CONTACT
ClarkJJAML-
-Mortenson Insurance pH ONE ��,603-352-2121 _ FAX 003-357-8491
P.O. Boxe N 606 @'MA1L . Gsr24admin clark-mortenson_com
Keene NH 03439 _.,....�
INSURERS AFFORDING COVERAGE NAIC IF
w�w INSURI9RA,Acadia Insurance 31325
INsuREo BERGERON7 INSURERS:Westchester Surplus Lines Insurance Co. _
Bergeron Construction,Co.,Inc. _
PO Box 287 INSURER C
27 Matthews Road INSURER O:
Keene NH 03431 IN5URERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER:597177896 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 WIiICH 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 Or SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER IUMIOpY EFF MMLIG EXP LIMITS
LYIt
A X COMMERCIAL GENERAL LIABILITY CPA508991116 41'112019 411/2020 EACHOCCURRENCE __$_1,000,000
DAMAGE TO CN7
CLAIMS-MADE 1KOCCUR Fa occuflencel $300000
X 250 MED EXP(Any one person) 8 to ODD
PERSONAL 8 ADV INJURY $1,000,000
GEN'L AGGREGAYE LIMIT APPLIES PER; GENERAL AGGREGATE $2,000,000
POLICY❑X PES F]LOC PRODUCTS-COMPIOPAGG $2000000 _
OTHER, $
A AUTOMOBILE LIABILITY CAA508901216 411(2019 41!!2020 COMBINED SINGLE LIMIT $
IEd> rlr)
X ANY AUTO BODILY INJURY(Flee person) $
ALL OWNED SCNEOULED BODILYINJURY(Pcraaidenl) $
AUTO`: AUTOS
NON-OWNED PROPERTY DAMAGE $
X HIREDAUTOS X. AUTOS
A X UMBRELLAUAG X OCCUR CUA5089U151& 4/1/2019 411/2020 EACH OCCURRENCE $1,000,000
EXCESS LIAR CLAIMS-MADE AGGREGATE $1,000,000
DED RETENTION$ I $
A WORKERS COMPENSATION WPA508901616 4111L419 4/112020 X R7A71 ITE FORH
AND EMPLOYERS'LtAeILIYY Y I N
ANY PROPRIETOWARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000
OFFICERIMFMBER EXCLUDED? a N I A
(Mandatory in NH) E.L.DISEASE-EAEMP(AY'E $50DOOD
It Yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
B Contractors Pollution GZ4297755007 7/612018 7(612019 $2,000,000 General Aggregate
Liability $2,U9U,000 Per OcrAgrence
$10,000 ded
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 191,Addlhanal R9markp Schedule,may be aHached If more apete 18 required)
Workers Corrlpensation Statutory limits for the States of NH,VT 8r MA
There are no Excluded Officers
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