12C-002 VDAC
I Tr 5
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S6OUB 0746N82 - 0 - 12 )
RENEWAL OF.(6S60UB- o746N82 -0 -11)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 80411
1.
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INS AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST
1592 BUG HILL RD PO BOX 375
ASHFIELD MA 01330 SHELBURNE FALLS MA 01370
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 -12 to 05 -20 -1 3 12:01 A.M. at the Insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the pollcy applies to the Workers
Compensation Law of the state(s) listed here:
MA
0=
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:
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 06A '
•
D. This pollcy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
-- 4. The premium for this pollcy 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 -10 -12 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: MIRICK INS AGENCY 73LG8
00780
•11'
q } t. >¢ 'cy f'', A rc t Y
yz ., The Commonwealth Of Massacl ` ° 1.A i-.` : �' 1:`> �, `r a :f.," ° + . =1
' Department of Industrial Acad A k'
c = ` --- ,; ,,. tt. Office of Investigations . , r`
_'mi 1 Congress Street, Suite 100
_':� � Boston, MA 02114 -2017
:,:,•, w ww.mass.gov /dia
.' - Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business /Organization Name: Shirley A. & Gregory A. Lilly, d /b /a HllltoWn "'eats . `
Address: S 92 Bug Hill Road
te r:: .
City /State /4: A MA 0 1330 Phone #: (4131628-4577 ,..
Are you an employer? Check the appropriate box: Business Type (required):
1. El I am a employer with 2 employees (full and/ 5. ❑ Retail
or part- time).* 6. ❑ Restaurtutt/Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
8. ❑Non -profit •
[No workers' comp. insurance required]
3. ❑ We area corporation and its officers have exercised 9. ❑ Entertainment
their right'of exemption per c. 152, §1(4), and we have 10.0 Manufacttu'ing
no employees. [No workers' comp. insurance required] ** 11.❑ Health Care'
4. ❑ We are
a organization, st by volunteers, Tent Rental
with no employees. [No workers comp. insurance req.] 12. Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
**If the corporate officers have exempted themselves, but the corporation has other employees, a workers' Compensation policy is required and such an
organization should check box #1.
.,
I am an emplo that is providing' workers' compensation insurance for my en ployets. Below is the policy information.
Insurance Comflany Name: Hartford Underwriters Insurance Company /Mirick Insurance Agency
Insurer's Address:' 28 Bridge Street, P.O. Box 375
City /State/Zip:
' ° $helburne Falls, MA 01370
Policy # or Self-Ins. Lic. # 6S6OUB- 0746N82 -0 -1 Exp D ate: 05/20/1$
Attach a copy ' of the worker's' 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 forth 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 s .,i,
I do hereby certify, under pains an/ra lties of perjury that the information provided above is true and correct:
Signature: l�L.Ey�)..;�t `J Date: ' /0/, 7 z �:
Phone #: ( 413 528 - 457 7
Official use Wily. 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. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone #: ,
K www.mass.gov /dia
'SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [D] Other [
Brief Description of Propose
Work: 4 • sL P't -6" e° '/' 04il>A
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family , Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, irk` ,4 L. / /'f A f h (f/ -oc ." I eft , as Owne thorized
gent • - reby declare that the statements and information on the foregoing application are true and accurate, to the best of my kn edge
and belief.
Signed under the pains and penalties of perjury.
A/r /e / /1 /1y
Print N me !L /
Signature of Owner /Agent Date
s `
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW O YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
J DECEIVED ' - Department use only
% Cit of Northampton t
Status of Permit:
Buildin Departmen Curb Cut/Driveway Permit
OCT - 3 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
DEPT. F BUILDING
NORTHAMPTON NSP INSPECTIONS Northampton, MA 01060 T wo Sets of Structural Plans
13 587 -1240 Fax 413- 587 -1272 Pl ot/Sit e Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
, / Lar{j ,- r S 1 Map Lot Unit
. � /caren C e (r),‘ Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: .
(7 / //leg,-) /.SGJ_t,4?! /c-_ 6 / /J1 m.S /LI = f' Y' �i iie-
Name (Print) Current Mailing A dress: �a( a
(V/ 3) S/ - ' / ' O/ 7
Telephone
Signature
2.2 Authorized Agent: y
��/►� ,- ie 4 1 A-. La!/', ( f,! &-,, ?�/, /6 A &:4 /...b // 4,4 M! ed Id 177 •d/3
Name (Print Current ailing Address:
.4_,i .4,7 641 e: //5) 62J ` VS 7 7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. 11gild+Rg / 2 / /) / c (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 160 --' Check Number J3 � -0-04...
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
P
61 NORTH FARMS RD BP- 2013 -0391
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C - 002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Tents BUILDING PERMIT
Permit # BP- 2013 -0391
Project # JS- 2013- 000631
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HILLTOWN TENTS
Lot Size(sq. ft.): 67082.40 Owner: ISABELLE COLLEEN MARY
Zoning: RR(100)/WSP(100)/ Applicant: HILLTOWN TENTS
AT: 61 NORTH FARMS RD
Applicant Address: Phone: Insurance:
1592 BUG HILL RD (413) 628 -4577
ASHFIELDMA01330 ISSUED ON:10/4/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 40 X 40 TENT - 10/12/12
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 10/4/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner