07-027 (12) 0c) R
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City of Northampton 60 LR ��,Zpnq
wf^ Massachusetts '` =- "i.
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'I DSPAa1'N6NT OF aDIIDINO INSPECTIONS
\ 212 Main Street • Municipal Building
NortRa�ton, Na 01060
ry� EIVEn
TENT PERMIT APPLICATION Mqy
2019
(For Tents over 120 square feet)
Permit Fee: $30.00 Check#, % -
gv- 19-1.ai
� A PLEASE TYPE OR PRINTALL INFORMATION
1. Name of Applicant: f lP.i Qei11-l4 �C,J�AS
Address: tali Se, E.44h �A arVs S t Telephone: L4 3
pp
2. Owner of Property: � cI ' �n I�n�
Address: S-49 aaN Fr Lm, QM Telephone: -SG I -
3. Status of Applicant_Owner Contractor
4. Tent Location Address): 54 cl nl Fn M < 2
Percat;iP:^Zart�ti�Nl§Tk# .. ameltl`^" ,.• pk9>�TTs? " ,
(T6' `Eba St1E8' LI�A Y1A�Nry
5. Use of Property: Residential: V Commercial'_
6. Description of Tent:
Size: JC2 kLl S
Occupant Capacity: -10
Dales of Use:- {o I
7. ALL INFORMATION MUST BE COMPLETED:PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
s. Certification: I hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: t' -)U IVf//,�, 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.
The Cnrrlxlonn'rxlUr nfMnrcnehusrhs
Department of7xdusMalAecidents
_ I Congress Sheet Suite 100
Boston, MA 02114-2017
B,fTntmassgot/din
�•`U •/ Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED MITI I'THE PExMITTING AUTIIOBITY.
Applicant Information Please Print Legibly
Business/Orgaanization Name:
Address: / Z SGy CCA
City/State/ZiptQ C Phone
Are you an employ,.'?Check the appropriate hoc: Business I ype(required):
L.M I am a cnrplaycr with _cmployecs(full mid/ 5 ❑germ'
or part-time)" 6. ❑Rs+tauranc43ar.Rmting Hstuhlishmm�t
20 1 it,,a sole pmprictor or partnership and hnvc nn 7. ❑Office and/or Sales(inclreal cerate,.,,in,etc.)
cmployccs working for me in any capacity.
[No workers'cony+. insurance squired] H. ❑Nun-profit
3.❑ We oro a corporation mrd its officers have esercised 9. ❑Urn,ndinmcnt
their right ulexemption per e, 152,§114).and we have Io.❑ ,mauuthc(uring
no cmployccs [No worker,'comp.i....u➢nce required]' H. I 'all i(Sec
4.❑ We as a mor-profit orgmi.tinns
,smMd by voluntcu . 11
with no cmpioyosI2,. [No workeri comp_insurance req.] 6lhcr \'Q
•A.,:,di,; lhai chmlca box 41 nwvt nL..tillora Nt.mdh.bvlwv ub tiig fncir murkav'moite, ai—ry,1k,infumimiu
"I I'rhe r.,gxnamtifik rely,, ,x,oatkd rbnmclrvs,bur ala<wpmmmn 1—uVity noaluyae.a worker:mmpensai,m PA.y Is mit...l and s.h'ov
orpnirai,m should,Fick Ma 4I.
lnm an rmlrlgrr Thar it prmJding rvnrkers'rnmpenxaa/o7n iuewrancefnr rap rmPl Jre, Be/naisthepnl 'pinfbrmannn.
�m I l l (,-!, C 11)
Insurer's Address: 549 �M Fa(M S 1A��
City/slam/zip: LAA __
lLc � ._ .
c ( I_ '!� l[ JInlic NnrSelf-ins.Iic.1 (V�LI ] J �� a ___..
Attach a copy of We workers'winpensatimr policy declaration page(shirring the policy nmuber and espirntlun date).
Failure 10 secure eovemge.1 L,4.ircd under Section 25A or NIGI.c. 152 can lead ro the imposition oferiminal penalties ora
line ap m it�Ut1.Otl and/or mro-ywr imprismnnenLos well a,civil penalties in the form of n STOP WORK ORDI 11 nod a line
of tip to b250.00 a day against the viulanr. Be advised that s copy of this statement may be IlrwaNed to the 011ie,of
Investigal ions of the DIA for insurance coverage vert ticanol.
I da herebp ee/r(`f�(/p, derrhe pain.,and penaldes ofperju,y that the inforamnian proeidedd idwee is true
and correct.
Si nnlure "/ Dam' 1 ��V�
torero:/_ 413
Iii 5 — 7 7 617
Offirta/use only. Da not write in IFis arra,to br rmrydnrd by riq nr town official.
City or Town: Permit/License q
Issuing Authority(circle one):
1.Board of tlealth 2.Building Department 3.City/Town Clerk 4.Licensing Board 5-selectmen's Office
6.Other
Contac( Peron,: phone N;
vwva ov/Aiv
MICHA-6 OP in-SIM
4�ORD CERTIFICATE OF LIABILITY INSURANCE -0-411Nm°"" '
OQH 7/2019
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(los)must have ADDITIONAL INSURED provisions or 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 cedRicate hostler In lieu of such endorsement s.
PRODUMN 781-247-7800 cT James N. Rodman
Rodman Insurance Aggenc -"""—'— --
145RosemarySt. Bldg AY °iQ Na,E :787.247-7800 .No:781-444-0090
Needham,MA IIN94-3238 ea
Jame.N. Rotlman
W.Ua6RA:Axis Specialty Insurance Co. 25820
INsunal Michael's Party Rental s,Inc. RUNNER III
1221 South Main Street '
11 _— - ---___-- - ----
Palmer,MA 01069 leeueaRc
INSURER D'.
PIBURER E:
N.WER F:
COVERAGES CERTIFICATE NUMBER' REVI I N
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REWIREMENT, 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 AND CONDIPONS OF SUCH POLICIES.LIMITS SHOWN WYHAVE BEEN REDUCED BY PAID CLAIMS,
LIN TYPE OFWMUNCE MUCY NUMBER PoLICY EFF POLCYEXP UNITS
A X COMNERCIAL(ulamK LIIBRI1 'All 1111IIRRRF T S 1,000,000
('A NMSM&F u occUR AiMiMA00202299006 04/15/2019 04/1512020 DanAGe r:.ueNiec r 100,000
M 5,000
PERSONAL 6 ADV IN,RiY 5 1,000,000
GENT AGGREGATE OMIT APPLIES PER GENERAL AGGREGATE Y 2'000'000
Poucr❑X jRo-j Loc PRooua6.n>NmIOP AGGI 2,000,000
.T1.QR
AADrowBIEuAmury CONDNEDISINGLL OAT s _1,000,000
?nv no 7MIMAD0202299206 041151201904H52020 Fain .nIL r �„
I nlrt� ^N'r X A'iin�um ROnitl nI lP.nnlw^I f .�
XIn(,� oNLe X usi'N'iAi P�unNt �I AMAOE T
X $1000 Dods I X Comp/Coll
A X UMBRB.LA WB I X I OCCUR EACH OCCURRENCE . 1,000,000
EXGR"LIA6 r rI AIM[NU:F MIMAD02UM9308 04/15/2019 04/152020 AGGREGATE S 1,000,000
�p(HFog �ypFGNPgTIR111THi
PIDEMPLOYER4'LIA IM YIN ...CTAT F F?� ......
.rYTE q' 022PMMER .EWTYE NIA ELEACH ACODENT 1 —. . �.
npppp x. I[Y
IMmMWtlI rIHI El GGEAaE_EA_E111101EF t
n 3:aas�wo Iwo-
I..j IZNATI N1-1- L W A WUCY MIT $
p q pm a er0411fif2olo X202011,200,000
$2500 Ded
DEBCR VNOFOPETUTOMILOCMMIWHCLES UCORD M1,AGStlmY RamvXF 9srMWe,mNCe MYNretl Aman peLe IF nOUYafl
Building Limit$2,122,620 w/$2,500 ded
BPP$168,732
CPRTIFJrATP Will nFI? CANCELLATION
BLANK--
6HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THS
E%PINYON DATE THEREOF, NOTICE WILL BE OELIVEREO IN
Michael's Party Rentals, Inc. ACCORDANCE WITH THE Poucr PnowBloas,
1221 South Main Street
Palmer,MA 01069 AUTHORRRnEDREPRESENrATIVE
&22
ACORD 25(2018/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
AcoRaP CERTIFICATE OF LIABILITY INSURANCE
Mi I
Denm2D19
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 ME 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: It Ne om ificat holder is an ADDITIONAL INSURED,ger pWiry(ias)must have ADDITIONAL INSURED prouklone or he endorsed.
If SUBROGATION IS WAIVED,MUB(eCl to the term.and conditions of the policy,caNaln pp6Cies may require an endmema A statemem on
Nis certificate does mt confer dgM1t t Ne certificate holler in lieu pf.ucM1 endor.emeM(c).
PRODUCES, NAMB. Michele Araenauft
USI Ina nnace Be.LLCE E (413)5433534
AOtIF65: a, (H 3)54N153
711 EMain Street mcneft,alxreWl®usi.mm
IxslmFa(a uFtroMG COVERAGE NUC.
CFknpee MA 01020 wwrank A: MA Relal MMUenR Worka2 Comp Group
XI wo
MSURER B: _
Michael'c Party Rentals,Inc. xLsuaER c:
1221 S.Main St wsURFR H
INSUflER E'.
Palmer MA 01069 WSURER,.
COVERAGES CERTIFICATE NUMBER: 2019 W'C Can REVISION NUMBER:
THIS IS TO CERTIFY THAT WE POLICIES OF INSURANCE LISTED BELOW NAVE 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 NMICH THIS
CERTIFICATE MAYBE ISSUED OR MAY 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 CLAIMS.
LTR TYPEC£INSURANCE INSID paUCYNVMBERMW
MMmO mJWYY) tins
COMMERCIAL GENERAL UAB0.IT' EACHOCCURRENCE 1
CLAIMSMALIE OCCVR PREMISEe e F
M EB tAL P,me Pi I
PE0.5CNgL8 AoV IHJIIRV S
Gon-AGGREGATE Lear ARGUES PER'. GENERAL AGGREGATE {
Pcucv❑IE T ❑LCD PRGODCFM-CwproPAGG c
mH
AumMa"LB uAe1LJry S
Euwd
ANYAUTO RCdLY INJURV(PorpReon) E
OJlcn OLv F7 S M."a" .11 wlwY aie .me„,n
HI TEONONDVMED PROPERTY AG {
.ONLY AIJTne ONLY
UMBRELLA LAS OCOUR EACHOCCURRENCE S
ENCESSUAR CLAILAOE AGGREGATE 6
GEO I I RETIN71I 5 S
NCANE43COMPRNSATiON X .TANTE x ER
ANDEMPLOYERS'Lµ®LILY
ANY PRCPRIEFWIPARTNEWExECVirvE IN 500,000
A OFFlCEWMBABER G.L.IE. O N/A 014005034819118 04/O V2019 01/01/2820 EL FACX ACCIDENT {
Mpan4Mwy In NHl E.L.DISEASE-DEMPLOYEE A Soo 000
IDFSCRIWION OF OPERATIpYSEelw EL psEASE-PpICV LIMIT 6 500,000
OESCWPn WOFOPERArONSIWCA9ON5/WHMLE5 ACpi91m,A44ieonY RemvMa ScMCulq may lecryaWEHmvn.paw IamyWn4l
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Micheal'{Party Rei Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
1221 S Main Street
TI.m RPPREaEN1ATVF.
Palmer MA 01059 r
01983-2015 ACORD CORPORATION. All right reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
IMPORTANT DOCUMENT
Certifwate of Flame &sistance
ISSUED BY Date of Shipment
/o� 0326/12
RF140.11;:IMNDS%Segistration Number g 9 ® Tem Identification
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
Q CALF
H Z5
2
y �P
E'Ir
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#
6106675(1)
Description of item certified.
CENTURY MATE EXPANDABLE MIDDLE
30WX15 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILADELPHIA OH
Name of Applicator of Flame Resistant Finish 944
J�,Q
Signed: /Y t.�w4
ANCHOR INDUSTRIES INC
IMPORTANT DOCUMENT
Certiate of Flame &ststance
ISSUED BY Date of Shipment
A{,� 03/28/12
Registration Number Y ® Tent Identification
__
F140.1 ,I��� 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
� Z
N
* 10-
E E
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#
8108885(1)
Description of item certified:
CENTURY MATE EXPANDABLE END
30WX15 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILADELPHIA OH
Name of Applicator of Flame Resistant Finish
Signed: uc��
ANCHOR INDUSTRIES INC