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31C-047
BP 2022-0958 88 VILLAGE HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31C-047-001 CITY OF NORTHAMPTON Permit: Temp Structure (Tents) PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0958 PERMISSION'S HEREBY GRANT I TO: Project# Contractor: License: Est. Cost: MICHAEL'S PARTY RENTALS INC Const.Class: Exp.Date: CONWAY SCHOOL OF LANDSCAPE DESIGN INC Use Group: Owner: UNIT 2G Lot Size (sq.ft.) Zoning: PV Applicant: MICHAEL'S PARTY RENTALS INC Applicant Address Phone: Insurance: 1221 SOUTH MAIN ST (413)589-7368 014005034819121 PALMER, MA 01069 ISSUED ON:08/10/2022 TO PERFORM THE FOLLOWING WORK: 20X40 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: 1. j/ 47-2Z2_ 4Q THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: (� - )i • I Fees Paid: $30.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildine Commissioner City of Northampton w Massachusetts c I. ' � 1 t k DEPARTMENT OF BUILDING INSPECTIONS , ��. 212 Main Street • Municipal Building / ~ - Northampton, MA 01060 Ci_1(..._!I `� :I J �� ,- °5s� 4.1J TENT PERMIT APPLICATION / �0 /PP?. (For Tents over 120 square feet) �'`-.4qT qM�o S Permit Fee: 530.00 Check# 1��q� .oFrpNS 0 (�,� /� PLEASE TYPE OR PRINT ALL INFORMATION� t�c 1. Name of Applicant: `y t.\C p� -c1 I--€J l v Address: I ( 11. (\Ap i.(\ 04-. fillier QC W\ OtO bRTelephone: (4 13-S gR--7 8 b$ 2. Owner of Property Tt' C O r L-. j 5C CIO() Address: K`tS \/,1 to y. rT t I 1 (6 Telephone: O[',-5 3 i- 7( 7 3 3. Status of Applicant:_Owner XContractor 4. Tent Location Address): R$ V I(ICZC� I-ra.t 0 pOf wte+—n "tn Z'\c.,..c n Parcel ID: Zoning Map# Parcel# District(s) ._ (� (TO BE FILLED IN BY THE BUILDING DEPARTMENT) /�'� 1,2�2 5. Use of Property: Residential: Commercial: k 1� v 6. Description of Tent: // (� 1 D' Size: aO' k R o ' f V�e �-en A Occupant Capacity:q to 9 Dates of Use: !/i — t 1 I I ID 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. 9° ,(its, DATE: 10 APPLICANT'S SIGNATURE /� I��\\ 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 Commonwealth of Massachusetts Department of Industrial Accidents a,....--, = s,L ►- s Office of Investigations Lafayette City Center _.• t 2 Avenue de Lafayette, Boston, MA 02111-1750 wwx.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Michael's Party Rentals, INC. Address: 1221 South Main Street City/State/Zip: Palmer, MA 01069 Phone tI:413-589-7369 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 18 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 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 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no Tent employees. [No workers' 13.® Other comp. insurance required.] *Any applicant that checks box#1 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: MA Retail Merchants Workers Comp. Group Policy#or Self-ins. Lic. #:014005034819121 Expiration Date:1/1/2023 Job Site Address: V V l(lay_ fit.U I2J City/State/Zip:136( Wwy `6 r-j JVt il B \O(e C) 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 certi under the pains d&enalties of perjury that the information provided above is true and correct: Signature: Date: l 73 sa-es- Phone#: 413-589- 368 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Eluntbing Inspector 6.0Other Contact Person: Phone#: AC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDlYYYY) 4/13/2022 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 CONTACT NAME: Kerry Barton ARA Insurance Services, Inc. PHONE FAX 102 N.W. Parkway UV_C-No.Extr 800-821-6580 l uvc.No),816-474-1931 E-MAKansas City MO 64150 ADDRESS: Kbarton@arainsure.com INSURER(S)AFFORDING COVERAGE NAIC A INSURER A:AXIS Insurance Company 37273 INSURED MIMA002 INSURER a: Michael's Party Rentals, Inc. 1221 South Main Street INSURER C: Palmer MA 01069 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 1036983667 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR IN SD OF INSURANCE AI D[UBR POLICY EFF POLICY EXP UMITS LTR SD W /Y VD POLICY NUMBER IMM!DDYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY Al MIMA002-032737-09 4/15/2022 4/15 2023 EACH OCCURRENCE_ , $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $100.000 MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- POLICY JJECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: A AUTOMOBILE LIABILITY A7MIMA002-032738-09 4/15/2022 4/15/2023 COMBINED SINGLE LIMIT $ (Ea accident) 1.000.000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED x SCHEDULED BODILY INJURY(Per accidents $ X HIRED AUTOSAUTOS AUTOS X AUT SEED (PePRr accidentDAMAGE X HC Col$1000 X HC OTC$100 $ A UMBRELLA DAB X OCCUR A5MIMA002-032739-09 4/15/2022 4/15'2023 EACH OCCURRENCE $1,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED , RETENTIONS $ ... _... WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE ERA Y/N .L ANY PROPRIETOR/PARTNER/EXECUTIVE N 1 A E EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ A Rental/Sales Inventory Al MIMA002-032737-09 4/15/2022 4/15/2023 Actual Loss Sustained Special Form/Theft Deductible 2,500 it DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Building Limit 52,081,000 w/$2500 ded BPP$165,424 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. Reference AUTHORIZED REPRESENTATIVE ARA Insurance ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Client#: 1740037 MICHAPAR6 ACORD - CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YVVV)ov23/2o22 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(les)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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Kylie Kirkland USI Insurance Services LLC PHONE iAX (A/c,No,Eat):877 396-3800 I(Aec,No*877-775-0110 333 Glen Street, Suite 302 ADDRESS: kylie.kirkland@usl.com Glens Falls, NY 12801 INSURER(S)AFFORDING COVERAGE NAIL a< 855 874-0123 MA Retail Merchants Workers Comp.Group 00000 INSURER A: INSURED INSURER B: Michael's Party Rentals, Inc. INSURER C: 1221 S. Main St INSURER D: Palmer, MA 01069 INSURER E: 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 AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LT RR TYPE OF INSURANCE INSR MD POUCY NUMBER (W YYYY) (MM/DDJYEYXY) LIMITS . COMMERCIAL GENERAL LIABILITY pEAACCHHQOECCCUURRENCE PR CLAIMS-MADE OCCUR EMISES(Es occu ence) S MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEPR $ POLICY JEC LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABILI Y COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acddenq $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ A WORKERS COMPENSATION 014005034819122 01/01/2022 01/01/2023 'MUTE OTN- ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L EACHArl'4nmNT $500,000 OFFICERIMEMBER EXCLUDED? N N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE $500,000 It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) CERTIFICATE HOLDER CANCELLATION Michael's PartyRentals Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 1221 S Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Palmer, MA 01069 AUTHORIZED REPRESENTATIVE 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S35030344/M35030338 KZKZS r ,10;":21,1 . Waln/e/ G 'a/4a/we/e ISSUED BY Manufactured by Date treated or manufactured Burl an Corporation Fred's Tents &Canopies 1-704-867-3548 7 Tent Lane Stillwater,NY 12170 03/2007 This is to cert that the materials described below have been flame-retardant treated(or are inherently nonflammable) FOR Michael's Party Rental 409 A West Street Ludlow, MA 01056 Certification is hereby made that:(Check"a"or"h") a)The articles described below this Certificate have been treated with a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. Name of chemical used Chem. Reg.No. Method of'application _ X (b)The articles described below are made from a flame-resistant fabric or material registered and approved by the State Fire Marshal for such use. NFPA-701 (large scale) Trade name of flame-resistant fabric or material used _Blockout_ Reg.No. F5350t The Flame-Retardant Process Used WILL NOT Be Removed By Washin (1464% Fred's Studio Tents & Canopies, Inc. Plant Supervisor Product Description 20x40 Center Peak Unit Customer Invoke# 17719