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17A-072 (3) The Commonwealth of Massachusetts Department of IndustrialAccidents 9j7, Office of Investigations o I 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 Comer Road City/State/Zip:Ashfield, MA 01330 Phone#: (413)628-4577 Are you an employer?Check the appropriate box: Type of project(required): 1.IN I am a employer with 3 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 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.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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' 13.- Other comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. f 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 isproviding workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Hartford Underwriters Insurance Company/Mirick Insurance Agency Policy#or Self-'ins. Lie.#:6S60UB-0746N82-0-15 Expiration Date:05/20/16, Job Site Address: f br. �� --- 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 t ains andpen es ofperjury that the information provided above is true and correct. Sip-nature. Date: Phone#• 413 628-457° 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#: }}.i .+yiy+yy,.yd lbfbif1b1'1 11:11 141i5ti/1'11'1 NIL" bLJJ Vtt'I tlAut UziUY C Dv CE Ci of Northampton OCT ,X 201 Massa�hus�tts �'s'�' s'cF� c Plumbing&Gas OF BPZLDnw nt"v zo" _ �. uric,Mumb on,MA 01 street • manicipal Htaildlnq thattm, >dL 03.060 `m TENT PdRMIT APPLICATION (For Tents over 120 square feet)) Permit Fee: $2540 Check# v j PLEASE TYPE OR PRINT ALL,INFORMATION �' 1. Mame o`Applicant �� Ir� ` ! ( I e� H i (� �flLy=) l C 11 11-141 p .1 WIS jpgl? V S 17 7 Address: sG,.��,c r� �✓� l�l�-3c� Tele hone- � �� 2. Owner of Property: ��r,� Address;"�'/ Telephone 3. Status of Applicant_Owner Contractor 4. Tent Location Address): 6 e- 5. Use of Property: Residential; Commercial: 6. Description of Tent: Size: 30 x-' 3 0 Occupant Capacity, �P Dates of Use: 7. AU—NF9BV&j1ON riLW HE COMELEETED-PERMrr cAN In n>arteo om To LAoK of mOmg.a•r N B. Certification:I hereby certify that the infoRnation contained herein is true and accurate to the beat of my knowledge. DATE: A/// APP11CANT'S SIGNATURE G / �� l NOTE:Iowa=of a permit does not mime an wt's burden to comply wkh an zcnm8 req*ements and obtain 91 required pAnnfS korn the Conn vavm Conmris M,Depertmwt of Publa Works and other appNrmbls pern t audxwlW&_ 21 MOUNTAIN ST BP-2016-0473 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-072 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-2016-0473 Project# JS-2016-000783 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HILLTOWN TENTS Lot Size(sg_ft.): 11020.68 Owner: WALKER STEWART Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: HILLTOWN TENTS AT: 21 MOUNTAIN ST Applicant Address: Phone: Insurance: 1592 BUG HILL RD (413) 628-4577 WC ASHFIELDMA01330 ISSUED ON.101712015 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT 30 X 30 TENT 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 10/7/2015 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner i n090� E21ORPRE01M� 0 1 �J��'��'��1 M P O RTA NT DOCUMENT . S Cer un ieate of Flan?e Resi8iapce 5 :- S S REGISTRATION ISSUED BY Date of Shipment 5 S APPLICATION R S 5 NUMBER s EVANSVILLINDUSTRIEE, INDIANA®NA 47725 5/30/2006 rj Identification Tent S S S 5 S e MANUFACTURERS OF THE FINISHED 04292246 S F110'1 TENT PRODUCTS DESCRIBED HEREIN 5 5 This is to certify that the materials described have been flame-retardant treated 5 S (or are inherently noninflammable) and were supplied to: S 5 HILLTOWN TENTS S S1592 BUG HILL RD 5 5 S SASHFIELD MA 01330 5 S 5 5 S S 5 5 5 Certification is hereby made that: 5 5 The articles described on this Certificate have been treated with a flame-retardant approved 5 5 chemical and that the application of said chemical was done in'conformance with California SS Fire Marshal Code. All fabric has been tested and asses NFPA 701-99 CPAI 84 ULC 109. p , S Serial # 8108885(2) cS S Description of item certified: CENTURY MATE EXPANDABLE END 30WX15 SNYDER WHITE VINYL S 5 S Flame Retardant Process Used Will Not Be Removed By 5 5 Washing And Is Effective For The Life Of The Fabric f Signed: Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC. � c1[J[J�cP�PcJ cJ�[.!Cf[PrJ�c!rJtP[J�[1�c1[.ici[![JcPcJ'[1�cPc.J�cft1[J�[J[.f�J'r.(�cf[nc1rJ�cJcJ�rJ�t J�cl�[l�rf7cfcl�Gf[J�t Pc1�[P[.f[1cPcl[J'ct c?[.![�.1�[J�cP[.I[.JrfrJ�cl�.l[.![JPrJ�r_f[.n[.J� � R 21 MOUNTAIN ST BP-2016-0473 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-072 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-2016-0473 Project# JS-2016-000783 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HILLTOWN TENTS Lot Size(sq.ft.): 11020.68 Owner: WALKER STEWART Zoning: RI(100)/URA(100)/WSP(100)l Applicant: HILLTOWN TENTS AT.• 21 MOUNTAIN ST Applicant Address: Phone: Insurance: 1592 BUG HILL RD (413) 628-4577 WC ASHFIELDMA01330 ISSUED ON:101712015 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 30 X 30 TENT 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: A� Final: Smoke: Final: l� THIS PERMIT MAY BE REVD T TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND I Certificate of Occu anc Si nature: FeeTe: Da(Pa d: AmountDa d: Amount: Building 10/7/2015 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner