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31C-047 TENT
BP-2023-0709 88 VILLAGE HILL RD COMMONWEALTH OF ASSACHUSETTS Map:Block:Lot: 31C-047-001 CITY OF NORTH MPTON Permit: Temp Structure (Tents) PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0709 PERMISSION IS HEREBY GRANTED TO: Project# TENT 2023 Contractor: License: Est. Cost: MICHAEL'S PART RENTALS INC Const.Class: Exp.Date: CO AY SCHOOL OF LANDSCAPE DESIGN INC Use Group: Owner: UNIT'G Lot Size (sq.ft.) Zoning: PV Applicant: MIC I' L'S PARTY RENTALS INC Applicant Address Phone: Insurance: 1221 SOUTH MAIN ST (413)589-7368 014005034819121 PALMER, MA 01069 ISSUED ON: 05/30/2023 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: jj Smoke: Final: V� �' iI; kilo THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ' s ,2 . TAIT Fees Paid: $30.00 212 Main Street,Phone(413)587-1240,Fa : (413)587-1272 Office of the Building Commis ioner City of Northampton „iowrrrlP' Massachusetts YlkW , `• � DEPARTMENT OF BUILDING INSPECTIONS St ' 41 $ 212 Main Street • Municipal Building S` .' ,a,e;or,• 0 Northampton, MA 01060 �y TENT PERMIT APPLICATION MAY 3 0 2023 (For Tents over 120 square feet) DEPT.OF BUILDING INSPECTIONS ��Q/� NORTHAMPTON.MA01060 Permit Fee: $30.00 Check # /4- ( PLEASE TYPE OR PRINT ALL INFORMATION r 1. Name of Applicant: ke1a.��S Address: /aa-t Baal-(„ 1A'l&(Asf. &tow-1 r/IA- Telephone: 913-58. 1 73 , S 2. Owner of Property: I l ( Ova�� ScluDo Address: V 1 t IQc-e 4(:t( Telephone: -1 /3 'S3 7 - 7 17 3 3. Status of Applicant: Owner X Contractor 4. Tent Location Address): g g \/t ta,9i e 4( t (kJ Parcel ID: Zoning Map# Parcel# District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Use of Property: Residential: Commercial: 6. Description of Tent: 1 Size: (90' X `1 01 pa - € tty �T Occupant Capacity: I ab Dates of Use: t,(a3)aoa3 — co Ia(n )r30 a3 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: j I �1J,� APPLICANT'S SIGNATURE t� - l 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 Massa husetts j Department of Industrial Ac idents • t_ wi Office of Investigation V A' _.- P= W -4 �xI INN Lafayette City Center C Ili r; 2 Avenue de Lafayette, Boston,M 02111-1750 � s. .•�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ ontractors/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 #:413-589-7369 Are you an employer? Check the appropriate box: Type of project(required): 1.❑� 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 .❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, 0 Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.1=1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no Tent employees. [No workers' 13.0 Other comp. insurance required.] *My 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. #:014005034819122 Expiration Date: 1/1/2024 Job Site Address: l, City/State/Zip:),)6Attavteriv,t KiA'olve20 Attach a copy of the workers' compensation policy declaration page(sho ing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can ead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties ' 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 stat ment may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 6J,V "' ' Date: ---1:2-(4) 1 a3 Phone#: 413-589-7368 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): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: AC€ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) `,...-----. 04/19/2023 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 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 certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Daniel McDonald NAME: PHONE FAX Brown&Brown of Massachusetts,LLC (A/C,No,Ext): (781)455-6664 (A/C.No): 980 Washington Street E-MAIL Daniel.McDonald@bbrown.com Suite 325 INSURER(S)AFFORDING COVERAGE NAIC# Dedham MA 02026 INSURER A: AXIS Insurance Company INSURED INSURER B: Michael's Party Rentals,Inc. INSURER C: 1221 South Main Street INSURER D: INSURER E: Palmer MA 01069 INSURER F: COVERAGES CERTIFICATE NUMBER: 23-24 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGERENTE CLAIMS-MADE X OCCUR PREM SESO(Ea occur ence) $ 100,000 MED EXP(Any one person) $ 5,000 A Al MIMA00203617910 04/15/2023 04/15/2024 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO 0000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $OTHER Network Security& $ 50,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED X SCHEDULED A7MIMA00203618110 04/15/2023 04/15/2024 BODILYINJURY(Peraccident) $ AUTOS ONLY HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 A u EXCESSLIAB CLAIMS-MADE A5MIMA00203618210 04/15/2023 04/15/2024 AGGREGATE $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.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 $ Equipment Floater A Al MIMA00203617910 04/15/2023 04/15/2024 $1,500,000 $2,500 Ded DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mare 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 Michael's Party Rentals,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 1221 South Main Street AUTHORIZED REPRESENTATIVE Palmer MA 01069 Air y1 26Ay0101h.....—_ I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Client#: 1740037 MICHAPAR6 ACORD,, CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD;YYYY) 1/06/2023 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 ha'e 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: Amanda Hanson No): USI Insurance Services LLC PHONE, 845-383-5960 FAX 610-537-2231 (AC No,Ext): WC, 12 Gill Stret,#5500 E-MAIL ADDRESS: amanda.hanson@usl.com Woburn, MA 01801 INSURER(S)AFFORDING COVERAGE NAICar INSURER A:MA Retail Merchants Workers Comp.Group 00000 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 —O THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRAC'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 RooEDCCUyyCi�D BYppPAID CLAIMS. LTRR TYPE OF INSURANCE ADDL R INSR WVD POLICY NUMBER POLICY OF (MM/DO//YICY EYYY) UNITS COMMERCIAL GENERAL UABILTTY EACH $ _ —1 CLAIMS-MADE OCCUR PREMEaE urrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO POLICY JECT LOC PRODUCTS-COMP/OP AGO $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ 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 RETENTION$ $ A WORKERS COMPENSATION 014005034819122 01/01/2023 01/01/2024 X STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANYIPROPF PROPRIETOR/PARTNER/EXECUTIVE EXRTNER E ECUTIVE Y/N N/A E.L.EACH ACCIDENT $500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) CERTIFICATE HOLDER CANCELLATION informational purposes onlySHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE p p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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 #S38680502/M38680496 UXYZS Cr1ifitate of FLe ISSUED BY Manufactured b Date treated or •xi'j"L� manufactured • 4.* •It Snyder Manufacturing,Inc. Fred's Tents & Camies t,, . 3001 Progress Street 420 Hudson River ad or- Dover,OH 44622 Waterford,NY 121 8 04/2021 F 140 This is to certify that the materials described below have b-enflame-retardant treated (or are inherently nonflammable) FOR Michael's Party Rental 1221 South Main Street Palmer, MA 01069 Certification is hereby made that:(Check":"or"b") a)The articles described below this Certificate have been treated 'th a flame-retardant chemical approved and registered by the State Fire Marshal and that the application of salt chemical was done in conformance with the laws of the State of California and the Rules and Regulations of le 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 fa ric or material registered and approved by the State Fire Marshal for such use. x NFPA-701-2015 (large scale) Trade name of flame-resistant fabric or material used White Blockout eg.No. 140.01 The Flame-Retardant Process Used WILL NOT Be R moved By Washing Fred's Studio Tents & Canopies, Inc. ' Plant Sup rvisor Product Description (5) 20x40 Frame & Cable Customer Invoice# 46180