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�*, The articles described on t1his Certificate have been treated with'a flame-retardant approved,
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5 Fire Marshal Code_All fabric has been tested and passes NFPA 701-99, CPA] 84, S
S Serial tt 810898S(2) `
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S Description of item certified= CEWMV y mnTE Exrnl+onaLE ENO S
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S Y Name of Flame Rcs�stant finish. ANCHOR INDUSTRIES INC. S
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The Commonwealth of Massachusetts
Department of Industrial Accidents
b
Office of Invesfigations
I Congress Street, Suite 100
W Boston,MA 02114-2017
www massgov/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. [:] I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
ship and have no employees These sub-contractors have g, F-1 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9. Building addition
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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.F-1 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.MR Other Tent Rental
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I 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: 05/20/1
Job Site Address: 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 imprisonnient, 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 underlto pains and pen 'es of perjury that the information provided above is true and correct
Si ature: «� Date:
Phone#: (413) 628-4571
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#:
NIUN IJLU Utt'l 4311 UY
City of Northampton
Massachusetts
2 in Steeet • Municipal BlatuUng
OX060
0'�QfNs
C'bs'�S98
cj�(3
TENT PERMIT APPLICATION
(For Tents over 120 square feet)
Permit Fee: $25.00 Check 4k_. 077�O
PLEASE TYPE OR PRINT All,INFORMA 710 N
All Telephone:
2. owner of Property--
Addrm'1F8'F6?4r---1---rMeld Telephone: "3)
3. status of Applicant-Owner —1--1/contractor
A. Tent Location Address).
5. Use of Property, Residential• Commercial:
6. Description of Tent:
Size:
�/o
Occupant Capacity:
Dates atUse:
7. ALL INMRANATIONJM BECOMELM -PERMIT CAN BE QUilEODUE M LACK OFINFDR-MA312
B. Certification:I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: APPLICANT'S SIGNATURi�
NOTE-199uwm of a parnit does not m5w ►an appumnes burden to cmi*with all zarft requirements
and obtain&I required pwmb from the ConservmW C;ommhow,Dapwknwd of Public Wbdm and other
appocw*porm worev a*wtm&—
888 CHESTERFIELD RD BP-2015-0307
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 14-021 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-2015-0307
Project# JS-2015-000577
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HILLTOWN TENTS
Lot Size(sq.ft.): Owner: GUERKE ERIC
Zoning: Applicant. HILLTOWN TENTS
AT. 888 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
1592 BUG HILL RD (413) 628-4577 WC
ASHFIELDMA01330 ISSUED ON.9/1712014 0:00.00
TO PERFORM THE FOLLOWING WORK.-ERECT 40 X 40 TENT 9/20/14
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 Signature:
FeeType: Date Paid: Amount:
Building 9/17/2014 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner