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05-001 (28) IMPORTANT DOCUMENT Certificate of T&me 1esistance ISSUED BY Date of Shipment 04/11/11 Registration Number E NCH0R ®INDUSTRIES INC. Tent Identification F140.1 • j..� 14943281 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and were supplied to: HILLTOWN TENTS 1592 BUG HILL RD ASHFIELD, MA 01330 G� STEM CAC (!J tRE M p E't p'¢ Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-99, ULC 109. Serial# 8108975(4) Description of item certified: CENTURY MATE EXPANDABLE MIDDLE 40WX20 SNYDER WHITE VINYL Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric SNYDER MFG NEW PHILADELPHIA OH Name of Applicator of Flame Resistant Finish Signed: ANC HOR INDUSTRIES INC IMPORTANT DOCUMENT Certificate of Flame &sistance ISSUED BY Date of Shipment 06/03/11 Registration Number CHOR INDUSTRIES nt Identification INC.. F140.1 14973321 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and were supplied to: HILLTOWN TENTS 1592 BUG HILL RD ASHFIELD, MA 01330 G15 T cati,�o� o N q jr Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109. Serial# 8108985(2) Description of item certified: CENTURY MATE EXPANDABLE END 40WX20 SNYDER WHITE VINYL Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric SNYDER MFG NEW PHILADELPHIA,OH Name of Applicator of Flame Resistant Finish Signed: J4 AL AN HOR INDUSTRIES INC - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations w d 1 Congress Street, Suite 100 .w` Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Shirley A. & Gregory A. Lilly, d/b/a 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: Type of project(required): 1.Q I am a employer with 3 4. F� I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, E]Demolition working or me in an capacity. employees and have workers' g Y p h'• � 9. E] Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no Tent Rental employees. [No workers' 13A Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Hartford Underwriters Insurance Company/Mirick Insurance Agency Policy#or Self-ins. Lic. #: 6S60UB-0746N82-0-14 Expiration Date: 05/20/14 Job Site Address:��a efaer f( Leers City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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 epains andpenalties ofperjury that the information provided above is true and correct. Signature- '� � '`� Date: Phone#: (413) 628-4572 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1l7{ti{�{1b1'G 11:1'1 141 ibti�i'L t'1 N i UN BLU Utt'I t'Hlat ►�lI bL ,`v City of Northampton .�- �� rfassacxtusetts x:' � -c • �ja5p�0 212 Main street smtnicipal Building t TENT PERMIT APPLICATION (For Tents over 120 square feet) Permit Fee: $25.00 Check# ` LS PLEASE TYPE OORR PRINT AU.iNFORMAMN 1. Name of Applicant �/ UG�� / ��1 45 � Address: //4V ?'j ef lee.-4��r�'Cd / .9 Telephone_��3 6�' "4/��'7 2. owner of Propperty: Address: / 6dX &13 P),,q Telephone:A�/3 .5e7- S4 7 3. Status of Applicant Omer x Contractor 4. 'Tent Location Address: -' <l l cs Pl s<r _ j'..It ':aar:,, Iatl1E111 5. Use of Property: Residentfal: Commercial: 8. Description of Tent: ? Size: `1-0 J�- /(f lE, l C'ri Occupant Capacity: Dates of Use• i. ALL INFL3R •°TIQN MUST aE COMPLETED•PERMIT CMBE l7E[JlEQ aUE TO LACK OF INEDR ATION s. Certification.I hereby eertity that the information contained herrein is true and accurate to the best of my knowledge. 1 DATE: �` APPLICANT'S SIGNATURE C NOTE:Inumm of a pernwt does not relieve an applicant's burden to cmn*with a8 Zord ng mquirer+r>lerft and aobiain all requited pmft from the Cor ort Corr de im,Depwknw t of PLhk Works and oilier aapplble pwn*g �— 222 RIVER RD BP-2014-1314 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 05 -001 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-2014-1314 Project# JS-2014-002211 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HILLTOWN TENTS Lot Size(sq. ft.): Owner: OVERLOOK HEALTH CENTER AT NORTHAMPTON INC zoning: RR(101)/WP(7)/ Applicant. HILLTOWN TENTS AT. 222 RIVER RD Applicant Address: Phone: Insurance: 1592 BUG HILL RD (413)628-4577 ASHFIELDMA01330 ISSUED ON.61912014 0:00:00 TO PERFORM THE FOLLOWING WORK.ERECT 40 X 60 POLE TENTS 6/13/14 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: FeeType: Date Paid: Amount: Building 6/9/2014 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner