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VDAC
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S60UB-0746N82-0-13)
RENEWAL OF (6S60UB-0746N82-0-12)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1.
NCCI CO CODE: 10456
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INS AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST
1592 BUG HILL RD PO BOX 375
ASHFIELD MA 01330 SHELBURNE FALLS MA 01370
Insured is A PARTNERSHIP
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-20-13 to 05-20-14 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
ONWWWW
MIEWEIWO
—"' B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
WOMEN •
MIMEEP
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
MEMO Plans. All required information Is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 04-29-13 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: MIRICK INS AGENCY 73LGB
008093
10/03/2012 11:12 14135871272 NTON BLD DEBT PAGE 02/02
City of Northampton
Massachusetts gym'
*
16, DEPAR22M'N2' OF Bra UMW ZNS?EGTTONS • 's
\ f: 212 Main Street • xuoicipal Building vk�•
2013 Northampton, X& 0X060 hq" 154 .%�
�o-�CT10Na
pEpT OF Rut`pTON MA 01060 ` •
NnRTNAM TENT PERMIT APPLICATION
(For Tents over 120 square feet)
Permit Fee: $25.00 Check# c?‘-‘5.
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: A/r l i7 (-1//L/ f/I/1 fOC4=24."; C!A'/S
/i4-AZ SPA cz ee_
Address: A , e /7-1/4 Telephone: (z//.3 3 ) 64? --7 6'7'7
2. Owner of Property: 6:7 F� � �°/L� •
Address: Li_7:26'/`- 6/-/c- flues zz Telephone:
3 Status of Applicant Owner Contractor
4. Tent Location Address): C/n ( /4;
8ff)E,i- recer-trlyiep:, ;' ',p,gT t:4 4 n{'r s t �1 c; �•'. ; >
('f'd' E`ril:LED1tV9Y .tfUlt'D1f egmmiT
5. Use of Property: Residential: Commercial:
6. Description of Tent:
Size: G `7U
Occupant Capacity;
Dates of Use: 7/27/i3
7. ALLI •RM T •. 44 UST : •„• _T •• - ■141 :h _ • i • • LA e , •- • .
B. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: `Z` '` APPLICANT'S SIGNATURE -et6-4'
NOTE: Issuance of a permit does not relieve an applicant's burden to comply with all zoning requirements
and obtain all required permits from the Conservation Commission.Department of Public Works and other
applicable permit granting authorities._
300 NORTH MAIN ST-LOOK PARK BP-2014-0146
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A-002 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Tents BUILDING PERMIT
Permit# BP-2014-0146
Project# JS-2014-000276
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HILLTOWN TENTS
Lot Size(sq. ft.): Owner: LOOK PARK
Zoning:URA(51)/WP(20)/URB(2)/HB(0)/WSP(0)/ Applicant: HILLTOWN TENTS
AT: 300 NORTH MAIN ST - LOOK PARK
Applicant Address: Phone: Insurance:
1592 BUG HILL RD (413) 628-4577
ASHFIELDMA01330 ISSUED ON:8/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 30 X 40 TENT ON PINES THEATER
STAGE 7/27/13
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 8/8/2013 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner