23D-107 (7) 548 ELM ST BP-2017-0104
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D- 107 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: TENT BUILDING PERMIT
Permit# BP-2017-0104
Project# JS-2017-000176
Est.Cost:
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Grotto: MICHAEL'S PARTY RENTALS LLC
Lot Siae(sn.ft.): 53143.20 Owner: 548 ELM STREET LLC C/O 548 ELM ST OPERATING CO RE TAX DEPT
Zoning: URB(l00)/WP(I)/ Applicant: MICHAEL'S PARTY RENTALS LLC
AT: 548 ELM ST
Applicant Address: Phone: Insurance:
409A WEST ST (413) 589-7368
LUDLOWMA01056 ISSUED ON:7/26/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 40 X 80 TENT ON 7/28/16
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 it 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 7/26/2016 0:00:00 $30.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
)6,
'. Massachusetts yrs F.
N b Fl x
t. ltp- $a B DEBARMENT OP BUILDING INSPECTIONS
a�y. ;Isar �
in Street • Municipal. Building �s
Northampton, MA 01060
. L272016
TENT PERMIT APPLICATION
wommflmmokow
('or Tents over 120 square feet) 1
Permit Fee: $30.00 Check # `1 1)6
/,� PLEASEpTYPE OR PRINT AL1..INFORMATION
1. Name of Applicant. 1 'C'1V-C g S@T'�td Rur (� i.
Address:)0-kh\ 5oL h M P,✓i Pcl,v�,p•Telephone.
(_I 0.
,�i S�<PFS} Telephone:�7i - (e Fr
2. Owner of Property: Cp{ Q. C0A.2 rU(dd`l't-r nrv�0 fry, 1
Address:5 iv,:Irri }�<e {tortVc e]r Telephone: kit 3-2-i7 -0313
3. Status of Applicant. Owner Contractor 9 ,t '
4. Tent Location Address): 5-9 Oen <3 k'(e �F ilk/0,1Q\Q rvC
Parte:JIM Zoning Map# Parcel#: Diamd(s)
(TOSE FRtEt ettrt"7HE WILDING DEPARTMENT)
5. Use of Property: Residential:_ Commercial: ✓
6. DescriptionofL/of/T�1ent
, : '
Size: "! Sig
0
Occupant Capacity: ,
Dates of Use: b- 5
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.7
DATE: l/) / 1 APPLICANT'S SIGNATURE r"
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.
St\ The Commonwealth of Massachusetts
}i ts f Department of Industrial Accidents
' �'• i8 "g I Congress Street,Suite 100
(WTI 5 Spswn,MA 02114-2077
? a? wwutmassgov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Electddansiplumbers.
TORE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Bnizat
usiness/Orgaio/rndividual):Michael's Party Rentals, Inc.
Address.4O9A West Street
City/State/Zip:Ludlow, MA 01056 Phone#:413569-7366
Are you an employer?Cheek the appropriate box:
Type of project(required):
con snipes wit 15 mgSeyas Null=Pm pert-tuner 7. 0 New construction
70 sus a sole proprietor or partnership and have no employe=working (or me in g. ❑Remodeling
any capacity.[No workers'comp.insurance required.] �r--II
3.01 am a homeowner doing all work myself.No workers'coop.insurance required.l' 9. Ll Demolition
4.01 am shammy/my and will bebias contractors to=ma=ell k
woroa my pxeperry_ Iwai 10 O Budding addition
ensure that alt conaatton tither hart waken'compensation sisuurance or ere sole 11.0 Electrical repairs er additions
pmprietors with no employees. 12. Plumbing repairs or additions
50IamageneralconvectorandIhavehiredthesubcontractorslistedontheattachedsheet. 13.❑B. oft
epairs
sub
-contractors have employe=and have workers'comp.msuraneet
a.�wu mca=nation and its have eaveisedtheir tight ofexe� tion
area14. ✓ OtherTent
Meic
352§t e),and we have w employees.Wit workers'comp.&waawe requests
*Any applicant that checks hes PI must also III cut the section below showing their workers compensation policy im*mmtion.
t Homeowners who submit this affidavit indicating they are doing alt work and thew hire outside wuhucmm must submit a new affidavit Indicating such.
tCono-aetote Mat check this box must attached en additional sheet showing the name of the subcenawtvrs and sue whether or net these entities have
cmpioycts. If the sub-conrnetors have employees,they moat.*vide their workers'camp.policy camber.
I am an employer that is providing workers'compensation insurance for my employees Below is the polity and job site
information.
Insurance Company Name:Amentrust Insurance Corp.
Policy a or Sel€ins..,Lie.#::wC0640375 Expiration Date:,A�1tt7 ,
Job Site Address: J IJ Elm , J'I.(Q p) City/state/Zip: f V 0{` ray p {o,v 14tt 1� — Cap 1(.lsiseiss
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement'nay be forwarded to the Office of Investigations of the DIA for insurance
coverage verifica n.
I do hereby cern'%% rad{r the pains and penalties of purply Ebonite information provided above Is true and correct
Stanattue: it Clot e� Pate:
Phone,#i Lii� — p � - 13(Pi)
Official use only. Do not write in this area,to be completed by city or town official.
Ctty or Town: Permit/License b__
Issuing Authority(circle one):
I.Board of Health 2.Building Depart/neat 3.City/roan Clerk 4.Electrical Inspector 5.Plumbing Inspector
6,Other
Contact Person: Phone H:
�,..+ MICHA-B OP ID: SH
Ammar CERTIFICATE OF LIABILITY INSURANCE DA04418/2016 i
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 Che certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, SLOWS(to
the terms and conditions of the policy, certain poRkies may require an endorsement. A statement on tWs certificate does not confer rights to the
certificate holder in lieu of such endorsamenUs).
PRODUCER NAME:`T James N. Rodman
Rodman Insurance Agency,IOW ° 'E 781-247-7800 rSAX
145 Rosemary St.,Bldg.A Till
Ens.' ... i wo No,781-444-0090
Needham,MA 02494-3238 A&SESS.
James N. Rodman
INdURERtaIAFFORDWGCOVERASE • NAP
JNURERAAXIS Specialty Insurance, Co. 26620
INSURED Michael's Party Rentals,Inc. INSURER B Amentrust InsuranceCorp
409A West St.
INSURER C:
Ludlow,MA 01056
INSURER
.. _. .. .......,
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR Pete _.... ' SOOT EeF GR157— LIMrTS
LTR TYPE OF INSURANCE ,.+ POLICY NUMBER : MWDESYYYY MMNWYYW
A ,X COMMERCAL GENERAL LIABLITY - -EACH OCC RENCI:: Is 1,000,000
i' "6A4A:,trOH=N,-L
c_A.Iac.NIALE EX OCCURAI MIMA00200431201 BIH 512018 04/15!2017 NEM SELEa(Ea oaurtlria) 100,000
EDEAOn',CAA rhe n! s _ 5,000
4 X Per Project Aggro [PERSONAL&A DV INJURY $ 1,000,000
BEN Ar eve NJNI-APPL ES FEIN � N L -GRED. s 2,000,000
_PO c .P.O. Loc I ✓c o T _O +IOp ADO 4 s 2,000000
R 15
i AUTOMOBILE LIABILITY L.i ? ""
1.MIT Is 1,000,000
A ANY AUTO A?MIMA00200431301 0411512016 l 0411612017 I ;Bocl N.10Rv ipeu n i
ALL OWNED X CHEDUED iL by PeO aY. 3
tt''XX 'k4N-OWNED HI OPS LMAe.. I
^HIRED AUTOS qL.D. . P
I`X tpiaPELLa.mars X CCC.A EACHOC JP EIV 1$ 1,000000
A EXCESS Lua La ins-vnoE A5MIMA00200431601 04/15/2016104115/2017 .x. cR re 1,000,000
, IEE J kT_NTIONAT.
'WORKERS COMPENSATION `�T-
ANDEMPLOYERS LIABILITY I X A.UTE I
B NYPRcP ETovm R'IJE ESSUTIVE YIN WC0840375 04/01/2018.04/01!2017: L -ACCDExT $ `500,
ANY w{l6E.EC UO&' 1 I:NIA
Me a I Ty HRH) El. DISEASE-EA EMPLOrEE a 500,000
IES d aro Cder EL DsEase-oOury uvT:E 500,000
r=caessiONe o-(DPERATDNs below •
A quipmEt Floater AiMIMA00200431201 0dti 5/2tti8'.04115/2017
4115/2017 .
905,000
$1000 Ded
--..L.
DESORPTION Or OPERATIONS I LOCATORS r VEHICLES (ACORD 101,Addition RemvMt Schedule,may Lammed re emu Vacs Is re dredl
CERTIFICATE HOLDER CANCELLATION
BLANK—
SHOULD ANY OF THE ABOVE DESCRIER)POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE REFERENCE ACCORDANCE WITH THE POLICY PROVISIONS.
PROVISIONS.E WILL BE DELIVERED IN
x«s.rvv««....«.»«+n+v»+ AUTHORIZED REPRESENTATYE
uve +».rv...++
®1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
IMPORTANT DOCUMENT
Certificate of FCamesistance
ISSUED BY Date of Shipment
03/28/12
•
Registration Number `IND TRIESN R
ibi
F444.19NC. Tent Identification
16042462
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:
MICHAELS PARTY RENTALS
409-A WEST STREET
LUDLOW, MA 01056
r
f_.;:o* CAC/,
Oh •S•.,
.... RE.Tp4.
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#
8108986C(2)
Description of item certied
CENTURY MATE EXPANDABLE END
40INX20#602 FERRARI WHITE VI
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
602 FERRARI MFG FRANCE 7�� D
Name of Applicator of Flame Resistant Finish ,_. A /
Signet /V L
ANCHOR INDUSTRIES INC
IMPORTANT DOCUMENT
Certificate of Tame Wcsistance
ISSUED BY Date of Shipment
03/28/12
Registration Number
F444.19
Tent Identification
F444.19 t j,l�✓ 15042462
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:
MICHAELS PARTY RENTALS
409-A WEST STREET
LUDLOW, MA 01056
X
Au SI,
(70
•tLb.ss k
1 • $7RE
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#
8108976C(3)
Description of item certified:
CENTURY MATE EXPANDABLE MIDDLE
40WX20#602 FERRARI WHITE VL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
602 FERRARI MFG FRANCE
Name of Applicator of Flame Resistant Finish -'
Signed: Xtu ^
ANCHOR INDUSTRIES INC