23A-146 (25) BP-2024-0745
130 PINE ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-146-001 CITY OF NORTHAMPTON
Permit: Temp Structure
(Tents)
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2024-0745 PERMISSION IS HEREBY GRANTED TO:
Project# TENT 2024 Contractor: License:
Est.Cost: 0 HILLTOWN TENTS
Const.Class: Exp.Date:
Use Group: Owner: FLORENCE CONGREGATIONAL CHURCH
Lot Size(sq.ft.)
Zoning: URB Applicant: HILLTOWN TENTS
Applicant Address Phone: Insurance:
1592 BUG HILL RD (413)628-4577
ASHFIELD, MA 01330
ISSUED ON: 06/11/2024
TO PERFORM THE FOLLOWING WORK:
20X40 TENT FOR USE ON 6/15/24
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final: (U 6,-14 Zy e,12
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAiNIPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 7
2-
Fees Paid: $30.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
c. 117/b:i/YNl'1 11:1'1 141.308 f l Z!'1 N I UN t3LIJ Utr l NAtat eZ/t7Z
{t, ..„ City of Northampton
Massachutsetts aY' ;
t" ,• t: DEPARTRENT OF BDILDTRCJ INSPECT/MS 1'
r 212 Haan street • Municipal Building •--.. S.s.p
NostbamBton, lak 07.060 F'„' .
(`—ke—Cerc�� ,
JUN 1 0 TENT PERMIT APPLICATION
2024
(For Tents over 120 square feet)
WEPT OF SUILOING INSPECT! �� D�
NORTygMp7 ON$ Permit Fee: Check# o 6
Ov,MA01pfip
PLEASE TYPE OR PRINT AU.INFORMATION
1. Name of Applicant /I J�1//tip L121Th J gl) 1
Address: f1SAibe id ./n / Tete hone:
/ /-3) 6 V- I/67-7
L. Owner of Property. / Orm b l'nn 1-Gr
Address: .45 P tip 5/-� Juno F}r) Telephone:7'i/3) ' ?C2 - Fyg�
3. Status of Applicant: Owner Contreator
4. Tent Location Addreass): /3 a /nt'fl . 6- e--rL
JOi1 'a,»p /V /4
.S' �S. . :::".4:•.:-.:. C:.
.. . . . . . ikD71QC et)
2
5. Use of Property: Residential: Commendat: X
6. Description of Tent
Size: ,70 r t 1/0 occupant Capacity: V el-r i 5 - e D X" " vim'7,4_,1
Danes of Use: (D // 5/0'
7. ALL 1 MATION ML ST RE CON(PI.ETED-PERMIT CAN 6E QENIED DI, TQ LACK OF 1NFQRMATION,
B. Certification:t hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: 6f V/d5/ APPLICANT'S SIGNATURE L'.i-e.J
NOTE:Issuance of a permit does not reeve an i
it's burden to comply with all zonirrg requirements-
and obtain ail required permits from the Conservation Commission, Department of Public Works and other
applicable permit granting authorities,_
Ce1r1ifL&i4z of F& wtz Re4iMi.c1e
ISSUED BY Manufactured by Date treated or
• •`�•, a, Snyder Manufacturing,Inc. Fred's Tents&Canopiesf c
tured
�:= .,1 3001 Progress Street 420 Hudson River Road 2/2015
NA, os , r, Dover,OR 44622 Waterford,NY 12188
This is to certify that the materials described below have been flame-retardant treated
(or are inherently nonflammable)
FOR Hilltown Tents
1144 Watson Spruce Corner Road
Ashfield,MA 01330
Certification is hereby made that:(Check"a"or"b")
a)The articles described below this Certificate have been treated with a flame-retardant chemical approved and
registered by the State Fire Marshal and that the application of said chemical was done in conformance with the
laws of the State of California and the Rules and Regulations of the State Fire Marshal.
Name of chemical used Chem.Reg.No.
__ _ Method of application
X b)The articles described below are made from a flame-resistant fabric or material registered and approved by
the State Fire Marshal for such use.
x
NFPA-701-2015 (large scale)
Trade name of flame-resistant fabric or material used White Blockout Reg_No. 140.01
The Flame-Retardant Process Used WILL NOT Be Removed By Washing
Fred's Studio Tents & Canopies, Inc. `
Plant Supervisor
Product Description Customer Invoice# 30161
20x20 Center Peak
20x30 Center Peak
20x40 Center Peak
The Commonwealth of Massachusetts
Department of Industrial Accidents
_ 1- Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
www mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Shirley A. Lilly& Gregory A. Lilly, Partners, dba Hilltown Tents
Address: 1144 Watson Spruce Corner Road
City/State/Zip: Ashfield, MA 01330 Phone#: (413) 628-4577
Are you an employer? Check the appropriate box: Business Type(required):
1.11 I am a employer with 5 employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 120 Other Tent Rentals
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Hartford Underwriters Insurance Co./Mirick Insurance Agency
Insurer's Address: 28 Bridge Street
City/State/Zip: Shelburne Falls, MA 01370
Policy#or Self-ins. Lic. # 6S60UB-7H9236-A-24 Expiration Date: 2/15/25
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under§25A of MGL c. 152-can lead to the imposition of criminal penalties of a fine up
to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to
$250.00 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 certify, under a pains and pen ' of perjuty that the information provided above is true and correct.
Signature: a./Acy /��� Date:
/�/aV
Phone#: ( 1/ ) 64cP" %/6 /7/7
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
1.DBoard of Health 2.❑Building Department 30 City/Town Clerk 4.0Licensing Board
50 Selectmen's Office 6.DOther
Contact Person: Phone#:
www.mass.gov/dia
VDAC
IIARTFoRo WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S6OUB-7H79236-A-24)
RENEWAL OF (6S60UB-7H79236-A-23)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
A STOCK COMPANY
NCCI CO CODE: 10456
1.
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INSURANCE AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST.
1592 BUG HILL RD SHELBURNE FALLS MA 01370
ASHFIELD MA 01330
Insured is A PARTNERSHIP
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 02-15-24 to 02-15-25 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
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 06B
..11111
C3111
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
— 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 01-25-24 WC ST ASSIGN: MA
OFFICE: RMD HTFD 05G
PRODUCER: MIRICK INSURANCE AGENCY 73LGB
011826