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14-021 (3) 4 r. - as` ,sue a?i-"t.F } e- �e - :r, � . � � '? "►-, `.s pap 1 r „ j M r }} ,. fit±; +.�:' ,a`.� ASHFIELD MA 0130 ` S _ S - S S S - S S 5 S - S - S S ' S Certification is hereby made that: S �*, The articles described on t1his Certificate have been treated with'a flame-retardant approved, chemical and that the application of said chemical was done in conformance with California mA _. 5 Fire Marshal Code_All fabric has been tested and passes NFPA 701-99, CPA] 84, S S Serial tt 810898S(2) ` S S Description of item certified= CEWMV y mnTE Exrnl+onaLE ENO S S40WX20 SNYDER WHITE VINYL S S S S Flame Retardant Process Used Will Not Be Removed By S sNVOERr+FC:NFWaShincl And Is Effective For The Life Of The Fabric S ,. Signed: n a S S Y Name of Flame Rcs�stant finish. ANCHOR INDUSTRIES INC. S n nnnr�nnnnnnnnrnnnrrr nnnnrr)nnnnnnnnPfc)PC fC)Sf'cJ'c1'cPcl'cl'cl'cl'cl'cl'cl'cl'cl'cl'c1'c Pcl'c T'cl'cl'cl'cl'cl'cl'cl'c1 'c r'cf'cl'cl'cl'cic�l'I l'cT'c l'cl'cl' O The Commonwealth of Massachusetts Department of Industrial Accidents b Office of Invesfigations I Congress Street, Suite 100 W Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/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) 628-4577 Are you an employer? Check the appropriate box: Type of project(required): 1.Q I 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. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These sub-contractors have g, F-1 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 10.0 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.F-1 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.MR Other Tent Rental employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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: Hartford Underwriters Insurance Company/Mirick Insurance Agency Policy#or Self-ins. Lic. #: 6S60UB-0746N82-0-14 Expiration Date: 05/20/1 Job Site Address: City/State/Zip: 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 imprisonnient, 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 underlto pains and pen 'es of perjury that the information provided above is true and correct Si ature: «� Date: Phone#: (413) 628-4571 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#: NIUN IJLU Utt'l 4311 UY City of Northampton Massachusetts 2 in Steeet • Municipal BlatuUng OX060 0'�QfNs C'bs'�S98 cj�(3 TENT PERMIT APPLICATION (For Tents over 120 square feet) Permit Fee: $25.00 Check 4k_. 077�O PLEASE TYPE OR PRINT All,INFORMA 710 N All Telephone: 2. owner of Property-- Addrm'1F8'F6?4r---1---rMeld Telephone: "3) 3. status of Applicant-Owner —1--1/contractor A. Tent Location Address). 5. Use of Property, Residential• Commercial: 6. Description of Tent: Size: �/o Occupant Capacity: Dates atUse: 7. ALL INMRANATIONJM BECOMELM -PERMIT CAN BE QUilEODUE M LACK OFINFDR-MA312 B. Certification:I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: APPLICANT'S SIGNATURi� NOTE-199uwm of a parnit does not m5w ►an appumnes burden to cmi*with all zarft requirements and obtain&I required pwmb from the ConservmW C;ommhow,Dapwknwd of Public Wbdm and other appocw*porm worev a*wtm&— 888 CHESTERFIELD RD BP-2015-0307 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 14-021 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-2015-0307 Project# JS-2015-000577 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HILLTOWN TENTS Lot Size(sq.ft.): Owner: GUERKE ERIC Zoning: Applicant. HILLTOWN TENTS AT. 888 CHESTERFIELD RD Applicant Address: Phone: Insurance: 1592 BUG HILL RD (413) 628-4577 WC ASHFIELDMA01330 ISSUED ON.9/1712014 0:00.00 TO PERFORM THE FOLLOWING WORK.-ERECT 40 X 40 TENT 9/20/14 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 9/17/2014 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner