25C-251 (120) 54 FAIR ST-EXTRAVAGANZA BP-2019-1135
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:25C-251 CITY OF NORTHAMPTON
Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Gategorv:TENT BUILDING PERMIT
Penmt4 BP-2019-1135
Proiect# JS-2019-001845
Est.Cost:
Fee:$60.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor. License:
Use Group: MICHAEL'S PARTY RENTALS LLC
Lot Size(sp ft.): Owner. HAMPSHIRE FRANKLIN&HAMPDEN AGRICULTURAL SOCIETY
Zoning: SC(100)/URB(1)/ Applicant: MICHAEL'S PARTY RENTALS LLC
AT. 54 FAIR ST- EXTRAVAGANJA
Applicant Address: Phone: Insurance:
409A WEST ST (413) 589-7368
LUDLOWMA01056 ISSUED ON:411612019 0:00:00
TO PERFORM THE FOLLOWING WORK:2 - 30x25 band tents
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspectorof 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:
FeeTvoe: Date Paid: Amount:
Building 4/16/2019 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
City of Northampton
Massachusetts
{" 'I DEPARTMENT OF BUILDING INSPECTIONS SV jh
/ 212 Ham Strut a Hunicipal aullding
Northav ton, HA 01060
tia RECEIVE- -
TENT PERMIT APPLICATION � --
(For Tents over 120 square feet) AP
3 20191
Permit Fee: $30.00 Check# I 7
PLEASE TYPE OR PRINT ALL INFORMATION
M\ s�iarr
1. Name of Applicant: a \o(
Address: t ) Telephone:�-� �T�O"/� l 2�,(OV
2. Owner of Property: U\VAS`\ 'AT�'tYIQ(St �11Nil'J I` R(l�'F'1 c�G2�I/,.'Yl u�l
Address:\' D �JIC (S 13C1,Q� OIb�',&Telephone:
3, Status of Appllcant:_Owner Contractor –Font [.o/
4. Tent Location Address):--n nt I O
�LI &nlr EJWCk K6h6AQ)`z✓t MA UCXrC
5. Use of Property: Residential:— Commercial:
6. Description of Ten (`�
Size:l 2) �X Z5 NQU V- RaM1)�-
Occupant Capacity: �CN1c\ TQ1
1 �
Dates of Use: cir ((X I \ i 17c\C,
7. ALL INFORMATION MUST BE COMPLETED; PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION.
B. Certification: 1 hereby certify that the information contained herein is true and accurate to the best
of my knowledge.
DATE: Ll I I\ APPLICANT'S SIGNATURE
NOTE: Issuance of a permit does not relieve an applicant'a 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 euthodlies.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
IF Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERxIITTING AUTHORITY.
Applicant Information h !�,, Please Print Legibly
Business/Organization Name: \�\V,� ha6 K� lq
Address: X77 � J-�'�/1 I"I�t��, �`"� ek-t 9
City/State/Zip: 1u IQ� `li�L"� Phone#:C11_)�, -��5�
AT °on an employer?Check the appropriate box: Business Type(required):
1.E I am a employer with employees(full and/ 5. ❑Rerail
or part-time).' ti. ❑RestaurantBar(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.
[No workers' comp.insurance required] R. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have I O.❑Manufacturing
no employees. [No workers'comp.insurance required]' I1 ❑ Heath C."
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 1 12.❑Other
-Any applusn,Ihel checks box 51 mua ve.fill oat the seen..below showing their worker,compensedco policy infnovan,n.
'9fthe eoeporele officers have exempted themselves,bot the,.,oration has otbea employees,a workerscompensation pollcv is requiredend saoh an
argaMvafion ebouW check bas#I.
I am an employer that is providing workers'compensation insurance for my employees. U/e�faw is tFe policy information.
Insurance Company Name: MQj )&C`i' S' �A xJ�I �� l ��"s� lliTf_,)0
Insurer's Address:n 11� 1,�,,,, M) IU 1 y,�,� L (r �`� r t
City/Statc/Zip: 1\)�) ✓ M
Policy#or Self-ins.Lic.N ()\t-�o JdLL Expiration Date:
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 it
fine up to$1,500.00 and/or ane-year imprisonment,as well as civil penalties in the form of S'rOp 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 ceph the pains and penalties of peciary that the information provided above is true and correct.
Sugn m Date' Wil liq
Phone ( - Wr
Official use only. Do not write in this arm,to be completed d by city or town offinial.
City or Town: Permit(Lie ase It
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
fi.Other
Contact Person: Phone 4:
w ccaess.gov/din
ia
AC"R CERTIFICATE OF LIABILITY INSURANCE
WSBrzDls
THISCERTIFICATEOE13ISSUED OTAFFASAMATTEROPINFORMATIONONLY AND CONFERS NO RIGHTSUPONTHE CERTIFICATEHOLDER.THIS
CERTIFICATE DOES FIC AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR RAALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS LVE ORPROCUATE FINSURD THE
HOLDER, 0.CONTRACT BETWEEN THE ISSUING INbUREft(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certit".—Man".a a,ADOITIONI I.INSURED,the POlicy(iee)..at have ADOITIONAL INSURED pmLkd.M,or be endorsed
u SUBROGATION IS WAIVED,subject t the terms and conditions of the polity,cartel,pohni he may require an aTMomami n, A aUtomant On
this cegiRcate does not PonfaT d Me to In.certifioeie holder in lieu of such endorsement(s).
Pne Lar. NAM 1. MlcheIn Amenault
USiinwranceS111 OLLC
T11EMain 9lRet AR .A {-01dj5G33536 (t13}6A3-Gtfi3
AODHE55. metolle.an MR,fteo .'Ran
_ Yt6PREMORAFFp DA04LOVENAfE gp}CY
Chlpopee MA 0102. WeU.FN A: MA Retail Merchants MJGrkers Comp Group
INSURED ""
NSURER B:
Mtehaeie Harty Ranlaic,Ina.
1221 6.Mein St INSURER 0
6 naDEC:
Palmer MA 01008
NE0.F:
COVERAGES CERTIFICATE NUMBER: . 201e VJC Can REVISION NUMBER:
iM5I5 TO CERPGYiF{pT THE PO4CIES OF INSURANCE LISTED BELOW HAVE 6EEN ISSUED TO THE INSURER NAMED ABOVE FOR THE'
P£RIOC
INDICATED. NOTWI'MSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WIT IT RESPECT TO NMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND CONOTION5 OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCER BY ps D CLAIM&
IN TYPE or WSV gANCE I(iSo NFHCYNUMBER MMmUMNY NMppryyyy WMIT5
COMMERCIAL GENERAL UABUTY
,.0 =JARENCE S
CUIMSMPOE ❑GCL'JN
PRFIA5E9 E gryuneropl 5
MFp E%P(Ary o 5
PFry(ytIILdADY INJURY 1—J
GEN'LA@AEGATE LIMIT APTYFASFEN. GENERAL AGGREGATE 5 '_
Fmmy O J.i 17Im
PRPOli'i6-C'$MRY A6_G 5
aTMEP. 5
AUTOMOBILE LIABILITY IF 7
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,AND,p aCpILY rzNVMtPorpwm 5
pT" BCNEDDLEn —
UTULONLY UTOS PNYYb WIVRY(h vtlWN)
NIRM f .,NEO j
AUTLA'D'Sv A(irpSpeX 5
UMNPELLA WB rca EACH CCCUPR_ENCE j
E%4ES Lt CIAIMEMApE
AGGREGATE $
DAP PETENTION 4 $
WOM(CNS
AN EMPLOYERS'UANIpiY X M7A TN x Min'
A ANY PLURAIETONIpANTNERIE%ECUFVE E.L EACH ACCIGENi S 500000
OFFICWMEMBEREXL en' ❑N NIA 01<00503d018i19 00/oik018 01,0112020
1,-.,.u ' Lt.6.RRa -EAEMR(YVEE S 900,000
7FNCAUFFI "N"'
nlE L PIGFAAN.PLHIIOMIT 1500000
nFuLanion.OFePE Pone(LOCAMNfrf VEM0.F84COR0 tOi.AYdtlIXW RmnMUSctgpNS myW WrtMMVmmapq s NNNAMI
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL SE DELIVERED IN
Michii Party Rentals Inc. ACCORDANCE WITH THE POLICY PRQRRQNS.
1221 S Main Street
ll1Np MirfrtSENTATIYE
PAn", MA 01069 4
pY 1966-2016 ACORD CORPORATION. All rights,served.
ACORD 25(2016103) The ADDED Be..and logo are registered marks of ACORD
MICHA-8 OP ID: SH
�`Ukv CERTIFICATE OF LIABILITY INSURANCE OA04ns@018
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 PGIICYNBS)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 endorsements).
PROCUCEM ry NEAcrAMJames N. Rodman
Rodman Insurance Agency,Inc. PHONE 781-247-7900
Neeuc rv°'. 781-044-0090
145 Needham,MA 0249RosemaSt., Bldg.A c Na E
, 4-7238 ADDRESS
James N. Rodman
INSURERS)AFFORDING COVERAGE NAICI
_ INSURERA'Axis Specially Insurance,Co. _ 26620
INSURED Michael's Party Rentals, Inc. INSURER B:
1221 South Main Street INSURER C:
Palmer, MA 01069
INSURER D'. _
AUET RE'.
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.
ILmSR TYPE OF WSUMNCE PLICYNUM
OBER MMNOnYYY MM,➢WYYYY LIMne
A X COMMERCIAL GENERAL LIABILT' ER H IN t LL2 S 1,000,0
xANns MnOE �cccua IAIMIMA00201982905 011152018 104/1512049 4rL E 100,000
rat
Mm ERP(Anymepes°n) $ 5,00
X I Per Project Aggre PERSONAL S ADV INTJRr $ 1,000,
GEN'LAGGR-GA:E L MIT APPLIES PER RENEIAL AGGREGATE $ 2,000,00
POucr❑SER Loc PRODUCTS-COMROEARC $ 2,000,00
AUTOMOBILE LABILITY COMB/aeO SNGI uMrt g 1,000,00
A ATMIMAO0201983005 .041152010 041152019 (P......
wxlev(P...... s
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IX UMBRELLA Lne X CCCUR EACH OCCURRENCE t 1,00D,000
A EXCESS LM,B CIARIS411DE *5MIMA00201983205 041IW2018 041152019 AGGREGA-E 1,000,0
UEJ I I REErI10N$
WORKERS
rvr PR P [To GN r
(Men LITV TAT TE EP
AW EMPLOYERS LIABI
F66^•PK YF MIA ELEMAG D IT +v
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UCRnTONOFOPERAOCN56el°w EL DISEASE POLICYUMiT $
A Equipment Floater iMIMA0020IM2905 04115/2018 041158019905,000
I
$2500 DeDe
d
DESCRNTION OF OPEMT O W I LOCA9ONS I VENCLES (ACOR0101,Aadtl°ml RemeA°9[hetlulq mry ee vtb[I,eG tt mma epete le meube0i
uilding Limit $2,040,000 w/$1000 ded
PP $162,180
CERTIFICATE HOLDER CANCELLATION
BLANK—
BHOULDANYOPTXEAM THEREOF,
N TICE POLICIESBE CANCELLEDBEFOREIN
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
REFERENCE AccoOuxcE WITH 1xe poucr PRowsroxe.
rrr+:nrr++rr++r«rrrr.rer++xr ALRWmZEOREPRESENTATSE
L//J�ry/J®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
IMPORTANT DOCUMENT
Certificate of flame T§sistance
ISSUED BY Date of Shipment
AMHo 08/08/13
Registration Number ImUSTRIES INC. Sales Order#
F140.1 15209813
EVANSVILLE,INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described are inherently flame retardant and were supplied to:
MICHAELS PARTY RENTALS
409-A WEST STREET
LUDLOW, MA 01056
CAC/p
iy F
P
'r �7RE d` q
F BE'C pQ`
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701-04, ULC 109.
Serial# 8046025(l)
Description of item certified: NAVI-TRAC LITE MIDDLE 30W%10
VINYL WHITE SNYDER
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
, f
/Gr
SNYDER MFG NEW PHILADELPHIA.OH
Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC
10/05/2012 10:49 812-867-0547 ANCHOR IND PACE 01/01
IMPORTANT DOCUMENT
Cemjuate of IFlavis f$SJSt nce Dale Of shMnMl
ISSUED By 0110&12
Reglsre9on Num ® Tont WenW.Mn
91WIN
ANG.
F1d0.1 15030692
EVANSVIUA INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
Thio N t0 Dolly Uml the meteriN,~bed have Men eeme•reradartt pwad(arm eWererlay w0relommi Wo)and
ware supplied W:
MICHAELS PARTY RENTALS
400-A WEST STREET
LUDLOW, MA 01056
Cerfificatlon is hereby made that
The articles described on this Cerafiaate 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 701-04, ULC 109.
Serial a
8018023(2)
Dam npdon of item cera8ed:
NAWTRAC LITE NIP ENO 3 15
VINYL WHITE SNYDER
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER WG NEW PHILAOELPHOLOH
Nom of ApOcalor of Flame Resistant Finish / A
Signed: ANCHOR INDUSTRIES
USHUES INC