05-063 (3) The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
fit 1 Congress Street, Suite 100
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.❑■ I am a employer with 3 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
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. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. ' right of exemption per MGL
y �o workers comp. 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.❑■ 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.
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. Liic. 4:6S60UB-0746N82-0-15 Expiration Date:05/20115 c.
Job Site Address: / 911 a-Ca,,4e /A& 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 un r hepains a;dpalties ofperjury that the information provided above its true and correct.
Si Date:ature: � /
Phone#: 413 628-4577
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#:
10/03/2012 11:12 14135871272 NTGN BLD DEPT PAGE 02/02
City of Northampton
DEPARIWAIT OF BUTLDTIW INSFS=ZONS
212 Ma;Ln street * Municipal Building E Ne-thampton, M& 01060
JUN 10 2015 U TENT PERMIT APPLICATION
Electric. Plumbing&Gas lnspeciicns
Northampton. k1l 1,!',:_s0 (For Tents over 120 square feet)
Permit Fee: $25.00 Check
PLEASE TYPE OR PRINT ALL,INFORMATION
Address.
2. Owner of Property:
Address;1-16 rl )4jtcYc,6o,1 �f�'d- [Ze--IS _Telephone:
3. Status of Applicant_Omer —)e Contraftr
4. Tent Location Address):. V9'I a 6 kz-v'z'/0u"-)"-)
5, Use of Property, Residential: Commercial:
6- Description of Tent:
Size:—
Occupant Capacity,
Dates of Use:
7. ALL IUMBANATION MV-3-1 BE COMPLMD:PERM CAN BE QgNlr=r►01 ME MI.ACK OF INEDIRMT10N.
B. Certification:I hereby certify that the information contained herein is true and accurate to the best
of my knowle0ge.
�lell 5� I It -
DATE- APPLICANT'S SIGNATURE
-I- s
NOTE:Issuance of a permit does not relieve an appfioarWs burden to comply with an zoning requiremerift
and obitein d required perm from the CorwrvWon 104mmissim,Deparlmeint of Public Works and other
appkmble pwr*Wan"a*wfthw_
487 AUDUBON RD BP-2015-1282
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05-063 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-2015-1282
Project# JS-2015-002350
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HILLTOWN TENTS
Lot Size(sq. £t.): 222591.60 Owner: KRAUTH JEFFREY B&DIANA L
Zoning: RR(100)/WSP(100)/WP(32)/ Applicant: HILLTOWN TENTS
AT: 487 AUDUBON RD
Applicant Address: Phone: Insurance:
1592 BUG HILL RD (413) 628-4577 WC
ASHFIELDMA01330 ISSUED ON.611012015 0:00:00
TO PERFORM THE FOLLOWING WORK.ERECT 40 X 60 TENT 6/20-6/22/15
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 Sisnature:
FeeType: Date Paid: Amount:
Building 6/10/2015 0:00:00 $25.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner