26-005 (3) OLD FERRY RD BP-2015-1071
GIS It COMMONWEALTH OF MASSACHUSETTS
Mao:Block:26-005 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-2015-1071
Project# JS-2015-002023
Est.Cost:
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Gmuo HILLTOWN TENTS
Lot Size(su.R.): 33541.20 Owner: WILLARD HAROLD F&DORIS A TRUSTEES
Zoning: Applicant: HILLTOWN TENTS
AT: OLD FERRY RD
Applicant Address: Phone: Insurance:
1592 BUG FITT L RD (413) 628-4577 WC
ASHFI ELDMA01330 ISSUED ON:5/5/20I5 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 40 X 40 TENT 5/22- 5/26
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: Dm Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. eIcue m' V/Alma
.rL a
Certificate of Occupancy signature: /
FeeType: Date Paid: Amount:
Building 5/5/2015 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
IMPORTANT DOCUMENT
Certificate of cF&me Resistance
ISSUED BY Date of Shipment
2/2/2015
Registration Number C�
F-140.01 INDUSTRIES INC. Sales Order#
60-6
SO-615202
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described are inherently flame retardant and were supplied to:
72961
HILLTOWN TENTS
1592 BUG HILL RD
ASHFIELD MA 01330
USA
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-CAL);;,,
4/6
71,4
y r
9''.. F/RE 1t.
RE.t pa.
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, ULC 109.
Serial# 8109101 (1)
Description of item certified: CENTURY MATE aoW X 60 SNYDER WHITE VINYL 160Z
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MANUFACTURING INC PHILADELPHIA PA fu.:.w Code/xfi
Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC
The Commonwealth of Massach usetts
Department of Industrial Accidents
l = i
Office of Investigations
al
1 Congress Street, Suite 100
_
o!_I� Boston, MA 02114-2017
"1/4+w-�" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busineorganiza onnnai ianap: 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:
contractor and I 6. of project(required):
L D I am a employer with 3 4. ❑ I am a general
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. Er Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑ 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.❑ 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 Rental
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they am 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. #: 6S6OUB-0746N82-0-16 Expiration Date: 05/20/17
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 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 certify under pains and pe l s of perjury that the information provided above is true and correct.
Signature: 'Lite -E-L' Date: 7 (t0
Phone#: (413) 62845 r/`1
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#:
ANDVDAG
I burf-govpWORKERS COMPENSATION
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (656008-0746N82-0-16)
RENEWAL OF (6S60UB-0746N82-0-15)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
1 NCCI CO CODE: 10456
INSURED: PRODUCER:
LILLY, SHIRLEY AND LILLY, MIRICK INS AGENCY
GREGORY DBA HILLTOWN TENT 28 BRIDGE ST.
1592 BUG HILL RD SHELBURNE FALLS MA 01370
ASHFIELD MA 01330
Insured is A PARTNERSHIP
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 05-20-16 to 05-20-17 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
Ski B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In
item IA. 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 03 068
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy 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: 05-04-16 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: MIRICK INS AGENCY 73LG6
007845
1t1(M3/Y111Z 11:12 1413 df1ZIZ NIUN DW 1/tYI frMS MZr OZ
City of Northampton
w "y Massachusetts �-
.ter.,. (�t
rllt 4 D2rOF e•IDDaap DOSPOCTIOAS
I�—' ..r 31212 Main Main S street • Mwiel0el Stu-Ulan;
1 TENT PERMIT APPLICATION
I ,
Ll „ I (For Tents over 120 square feet)
O
I , 'c , Permit Fee: $25.00 Cheek* 479(7
j PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant �`MII1-1-E'ci ( Ale Eli l l c,�(.Len ell
Address: I I Litt t i -r "4, i lit e. LiA2P' 1 T.wh c(, m.9 O/33'/'
2. Owner of Property. ✓7/d- c '�C 1/21.13cs I, •i t l/i 101) �a�-!�-�•r�
Address: Olci 1"�''f r1-1 IC/ X� Telephone:
3. Status of Applicant_Owwe/t I AContreetor
4. Tent Location Address): (�/�U1 �f/per e`T(-( 1'n—
l�i-or` Al t rrn.0 tan 01/9-
Patotclatizot c!itpiaicod3"x-: n. 13- ;.. 4t-t. .,y<..
5. Use of Property: Residential:X Commercial:_.
B. Description of Tent
size: ,30. )( & 0
Occupant Capacity6/0
/
Datesot Use: 1 7471 -, - ific(iG
7. ALL INFORMATION MUST RE CO/an-TED:PERMIT CAN Rs fFNIPf MW Tri LACK of INEPRMAIION
B. Certification:I hereby Certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: (17 1z< APPucANT's swam:- — Lv-i-e'f et'(
NOTE:Issuance of a permit does not relieve an applicant's burden to needy with all zoning raqukarrwt
aro obtain Y regrind ponds from the CanservellOn Commietdd DepsVnetof Pubic Wale and other
applicable pante grating Whoa_