23B-077 (5) 74 SOUTH MAIN ST BP-2017-0156
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23B-077 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-2017-0156
ProjectJS-2017-000252
Est. Cost:
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: HILLTOWN TENTS
Lot Size(sq. ft.): 7623.00 Owner: WEISMAN EDWARD N&SIMONA POZZETTO
Zoning: URB(I00)/ Applicant: HILLTOWN TENTS
AT: 74 SOUTH MAIN ST
Applicant Address: Phone: Insurance:
1592 BUG HILL RD (413) 628-4577
ASH FI ELDMA01330 ISSUED ON:8/3/2016 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 8/3/2016 0:00:00 $30.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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4
City of Northampton
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TENT PERMIT APPLICATION
(For Tents over 120 square feet)
Permit Fee: $26.90 Check iF 519`43
PLEASE TYPE OR PRINT ALL INFORMATION
I. Name Di Applicant At
•
/7 /tz(_{gy, •r6/Ge a'-Ae ` ?
Address: AS1-)//ooa mA O/ Telephone: 05 b.df-qs'! 2
2 Owner of Prcga}y Al"i_'/ h 2./9fymor /
Address: roc/ocFnr ATha/n 0/0‘,9\ relephpne�/ '/4J 31-it - 3t/701,
3. Status of Applicant_Owner ` .Coneaelor
4. Tent Location Address): lt/ !/"1
tecrehee_ /J')/ brb& a
5, Use of Property: Residential' Commercials
8. Description of Tent
Size: 3 b 36
occupant Cad Sb
Dates of Use 6/LciI/4
8. Certification:I hereby certify that the information contained herein is true and accurate to the beat
of my knowledge. ) �/
DATE: --// /1
Cc
APPUCANT'S SIONATU-' / e y „Lei/
NOTE:imoace of a pees*doers not relieve an anslicnoteburden ti eampywfth I ming fegiiarrlalts
and obtain M rORu>ted psrrnfis tam the cdlteavallon Can dal.Depasesm emihe trial aid otter
applicable permit eranang atoress
e'uordrardr3
IMPORTANT DOCUMENT"'tinc.u'„ruPcS'OP-„JS
5 Certificate of Flan?e Resistaipce 5
5 REGISTRATION ISSUED BY Date of Shipment 5
APPLICATION 1 C
NUMBER k I SIM" 5/30/2006
_t�• iN0 TRi INC.
5 •
r, ... •
. EVANSVILLE, INDIANA 47725 . Tent Identification 5
Itti MANUFACTURERS OF THE FINISHED 04292246
FI40.1 TENT PRODUCTS DESCRIBED HEREIN
5 This is to certify that the materials described have been flame-retardant treated(or are inherently noninflammable) and were supplied to: S
L5� HI72LLTOWN TENTS 15
1592 BUG HILL RD 55
5 ASHFIELD MA 01330 inl
pi
5
5 5
5 Certification is hereby made that:
The articles described on this Certificate have been heated with a flame-retardant approved
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, CPA! 84, ULC 109. 1 i
5 Serial# 8108885(2)
Pi
Description of item certified: CENTURY MATE EXPANDABLE END
3OWXI5 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MRD NEW PHILAUULPHIA.OH - A�
Name of AppSigned: ' "- LXOlicator of Flame Resistant Finish ANCHOR INDUSTRIES INC.
EIRWO_I IRSI PcPEPLI PrPcPcPcPcPcPLINTO PcPcYe PPLL)r7f@Pc1WOPL MPIPcPcPcPr.PcncPrPcf ineraargroncPcPrJccPcncicPdwaraarouggrozcPcPCPccam
2..`a The Commonwealth of Massachusetts
Department ofIndustrial Accidents
I Office of Investigations
'ii1_ 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 (Basines 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)6284577
Are you an employer? Check the appropriate box:
Type of project(required):
1.❑Q t 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. ❑New construction
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g, 9 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 10.9 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
insurance required.] t c. 152, §1(4),and we have no 12.9 Roof repairs
employees. [No workers' I3.❑� Other Tent Rental
comp. insurance required.]
*Any applicant that checks box 41 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.
7 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.ic #: 6S6OIJB--007446N82-0-16 Expiration Date: 05/20/17
Job Site Address: /��fl"" ' > t, City/State/Zip: Dre/V-e— Da a
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 pains an y�aides of perjury that the information provided above is true and correct
Signature: L.CLO r `-I Date: FA Ii b
Phone#: (413) 62845'77
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#:
VDAG
IIATTFORD WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S60UB-0746N82-0-1 6)
RENEWAL OF (6S60UB-0746N82-0-15)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE; 10456
1.
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INS AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST.
1592 BUG HILL RD SHELBURNE FALLS MA 01370
ASHFIELD MA 01330
Insured is A PARTNERSHIP
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-20-16 to 05-20-17 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
EEE
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
= item 3.A. The limits of our liability under Part Two are:
-1=
Bodily Injury by Accident: $ 1000000 Each Accident
Bodily Injury by Disease: $ 1000000 Policy Limit
Bodily Injury by Disease: $ 1000000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
auma
D. This policy includes these endorsements and schedules:
_
EEE
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 05-04-16 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 0%
PRODUCER: MIRICK INS AGENCY 73LGB
007645