22B-067 (2) 215 SPRING ST-CRIMSON&CLOVER FARM BP-2016-1382
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man.Block:22B-067 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-2016-1382
Project# JS-2016-002377
Est. Cost:
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PETERSON PARTY CS-060219
Lot Size(sq. 11.1 3936647.88 Owner: TRUST FOR PUBLIC LAND THE C/O GROW FOOD NORTHAMPTON INC
Zoning:URA(103)/WP(100)/WSP(10o)lA—Blicant: PETERSON PARTY
AT. 215 SPRING ST - CRIMSON & CLOVER FARM
Applicant Address: Phone: Insurance:
36 CABOT RD (782) 729-4000 WC
WOBURNMA01801 ISSUED ON.•5/23/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.-40 X 80 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 5/23/2016 0:00:00 $30.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
Massachusetts �
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
TENT PERMIT APPLICATION
pFproFau;;.DENGiNsr GnGta9 (For Tents over 120 square feet)
NGFiTNAthi'TGN tr1A01460
Permit Fee: $30.00 Check # d 7z?
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: / C�� r
Address: J 6740/� �K WObd 12 h, G)FO/Telephone: 7 f 7d 9- KU D a
2. Owner of Property: (96c1.2 t5a Alo6 M N 4 //�
Address: ,,?,VS- 17741t? sf' x",;10.7 /ydrL(f 40k,!?�iTelephone:_ 6/�- 360 - j7
3. Status of Applicant: Owner ✓Contractor
4. Tent Location Address): o2/,_ �IJ21h It 5r. �/Z1 Ih S 0'11 f C/o V« 64 2m
Parcel ID:, Zoning Map# Parcel# istnct(s}': .
(TO BE FILLED IN,BY THP BUIL„,INQ DEPARTMENT)
5. Use of Property: Residential: Commercial: /
6. Description of Tent:
Size:_ �1'0 y-?0 -2o 3O
Occupant Capacity:
Dates of Use:— // 6
7. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
8. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: cS��/ /(0 APPLICANT'S SIGNATURE_
NOTE: Issuance of a permit does not relieve an applicant's burden to comply with all zoning requirements
and obtain all required permits from the Conservation Commission, Department of Public Works and other
applicable permit granting authorities.
40x80
V0��R�
0 .0-16,x24 Dance Floor
r .
0
OCCUPANCY 160 People
CERTIFICATE OF LIABILITY INSURANCE F DATE(MMiDDlY
9/24/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONT
Michael Bonacorso
Bonacorso Insurance Agency, Inc. PHONE -781)937-3200 FAX
AfC.Not:(761)937-3202
10 Cedar Street E-MAIL
ADDRESS:michael@banacorsoins.corn
Unit # 32 INSURER(S)AFFORDING COVERAGE NAIC 9
Woburn MA 01801 INSURER A Acadia Insurance Co.
INSURED INSURER B AIM Mutual Insurance Co.
PPC EVENT SERVICES INC / PETERSON PARTY CENTER INSURER C:
TABLE TOPPERS OF NEWTON INSURER D:
36 Cabot Road INSURER E: I
Woburn MA 01801 NSURER F
COVERAGES CERTIFICATE NUMBER:2015 / 2016 Master REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE POP,THE POLICY PERIOD
G
INDICATED. NOTWITHSTAND!NANY REQUIREME.NiT, TERM OR CONDITION OF ANY CONTACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR PAJAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIIMS.
iNSR TYPE OF INSURANCE ADOL SUER' POLICY EFF POLICY EXP
LTR N' WVD POLICY NUMBER fMMIDDIYYYYMh1rDDfYYYY} LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $� 1,000,000
�Mco
MMERCIAL GEVERAL•LIABILITY DAMAGE TO RENTED
RREMISES iEa occur ercel S 250,000
10/9/2015 10/912015 lACLAINIS-PytADE x OCCUR PA5061025-13 IhtEDEX?IArycn=ce;sonj g 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
'L AGGRE+GATE WAITWAITAPPLIES PER: PRODUCTS-COMROP AGG $ 2,000,000
GEN
PCLICY X GRD– LOC I
AUTOMOBILE LIABILITY j i COC tBlNED S(NZLE LIP.II'
1,000,000
• A a UiO � � 180CHY!NnRf(nAr r
( h7 S t,ECii_E_ L?k 0-8173 13 11C/3{2015 ;..CS,9 2016 1 B._'.'
°=C,,AL–CS X .....—
I i ( uki!uIxI
X UMBRELLA LIA3 `� 1,000,000
X I OGG.R
f EACH ocC+SRR'=racE S 10,000,404
EXCESS C'4E+gAGGREGATE ATE S 10,000,000A MAD&
CED RETEN'[ION3 I UA 5173415 10/9/2015 10/9/2016
S
B WORKERS COMPENSATION411C STA-U- O T H-
AND EMPLOYERS'LIABILITY YIN X _TOR wit t�TS ( ER
ANY PROPRETOR`PARTNER'EXECUT€VE
OFFiC 'P,tEMBER EXCLUDED? n N/A � E.LEACH ACCIDENT �3 1 QQQ QQQ
(MandaERtory in NH) 10/9/2015 10/9/2016 S
If�•as,deacribe coder
E.L.DIrAaE-Era EP�:PLOYEE'S 1 000,000
DESCRIPTION OF OPERATIONS belcv 1 E-L.DISEASE-POLICY LIPA!T S 1,000,000
i
I
DESCRIPTION OF CPERATIONS t LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Michael U. Bonacorso
ACORD 25(2010105) x-1998-2014 ACORD CORPORATION. All rights reserved.
INSl1 rSrtt^n=.'rC:.� Th. AC()Prl marl c of At-nPn
The Contmonwealth ofMassrtchtrsetts
h rY Department of Industrial Acchlents
t� 1 Congress Street,Shite 100
eta Boston, AM 02114-2017
www.mtiss.a ov/diff
Workers'Compensation Insurance Affidavit: Builders/Ct)ntractorsltJiectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organizatiot-t/lndividuai):Peterson Party Center
Address:36 Cabot Rd
City/State/Zip:Woburn,Ma Phone #:781-729-4000
Are you an employer'Check the appropriate box: Type of project(required):
[Tv-1 t am a employer with 200 employees(full and/or part-time).' T, []New construction
2.M I am a sole proprietor or partnership and have no employees workirsg !'m me in 8. ❑Remodeling
any capacity.[No workers'comp,insurance required.]
4. ❑Demolition
1[j I am a homeowner doing all work myself: [No workers'comp.insurance required,]'
10 Q Building addition
4.M I am a homeowner and swill be hiring contractors to conduct all work on my=property. I will
ensure that all contractors either have workers'compensation insurance or are sole I Ln Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
4.❑1 am a general contractor and I have hired the sub-contractors Ifisted on the attached sheet. 13 Roof repairs
These sub-contractors have employees and have workers'comp,insurance.*
14.P1 Other Temporary Tent
6 11 etre are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box 41 must also fall out the section below,showing their workers'compensation policy inrormation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the stab-contractors and state whether or not those entities have
employees. If tltc si,ib-contractors hake emplo}ees,they must provide their workerscomp,policy number.
I ant an entployer Haat is providing workers'compensation insurance for my employees. Below is the policy and jolt site
information.
Insurance Company Narne:A l M Mutual fns Co
Policy#or Self-ins. Lic.#,WMZ8008006586 Expiration Date:10/9116
Job Site Address: da- 5�/Zt� �S /-- ity/State/Lip;�/Z
Attach a copy of the workers' compensaitt}n policy declaration...Page._(showing..the_pohcy..number-anti-expirattiion date) _.____.. _._......
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 tip to$250.00 a
day against the violator.A copy of this statement may be tbrwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cent;fy tinder the pains and penalties of perjury that the information provided above ' tru and correct;
Si nature. ----F Date �rd� /,6
Phone#:781-729-4000
(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
f.Other
Contact Person: Phone#:
5 �ij)4j f-111 111�It ?�Ytit-1 + f�1�1
C's-060219
33 Hanford Romdiem*
04/2712017
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Certification is hereby made that:
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IMPORTANT DOCUMENT
Certi-Cientc of Ftaair�e ctze�;]'*Usetapee
REGISTRATION ISSUED BY Date of Shipment
APPLI ATION 5/12/2005
NUMBER *0F
EVANSVILLE, INDIANA 47725 Tent Identification
F 140.1 MANUFACTURERS OF THE FINISHED
STENT PRODUCTS DESCRIBED HEREIN
5This is to certify that the materials described have been flame-retardant treated
or are inherently noninflammable) and were supplied to:
657150 5
Iu PETERSON PARTY CENTER INC
139 SWANTON ST
WINCHESTER MA 1890
a S
5
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved 5
chemical and that the application of said chemical was done in conformance with California
Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109.
Serial # s I OSIM (2)
Description of item certified:
U-NFURYNIA FE EXPANDABLE END
4oWX20 SNYDFR W1 11TE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric 5
SNYDER MI'Ci Ni0
EWPHILADIAT111A,011 d-
�_')SPECIAL EVENTS DIVISION-ANCHOR INDUSTRIES INC. 5