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25C-251 (2) City of Northampton 807.li ,5 . . 'S,. o� Massachusetts �,? •- '•, is -;' A. DEPARTMENT OF BUILDING INSPECTIONS ��, ‘ 212 Main Street • Municipal Building s0,t C�� n O`; ` -. Northampton, MA 01060 -s'Nky '-1.�•� 66 ___k -.: L-.., 1 , go-.)...)--"5 71 'O'i \2P4 APR 1 1 2022 iTENT PERMIT APPLICATION 4.CY . 1 L____ . ,,.._ nrPT.OF BUILDING INSPECTIONS (For Tents over 120 square feet) NOS?THAMP/ON.MA01060 �^ _ Permit Fee: $30.00 Check # ( C I PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: 1!LC -S 9 ( K c -eS - - t `S Address: /(9,3I .3 • (‘'\0t.4A.5)-- .Patwas1 t 0l O(09 Telephone: toS 89- 7 Yee if 2. Owner of Property: '! 4(�- 1 Go<<CQ COu-4S Address: Z( G'-tC 3 -4-- Telephone: 41/ 3 -5-6y- 0 3 7 3. Status of Applicant: Owner Contractor 4. Tent Location Address): GI c-I _Lc 5 N D(- 01_,,,-c0-6✓` / /IAto DkOtoO Parcel ID: Zoning Map# �17( . Parcel# 1 S I District(s) .C) 2— (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Use of Property: Residential: Commercial: 10(3 22 6. Description of Tent: OIL 7 Size: ti O ' X Y O' ) Occupant Capacity: l/ of ►'��k- Dates of Use: i) I l I 1 00 -- LI) / l a a 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. k- _ DATE: LdliI as APPLICANT'S SIGNATURE 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 Massachusetts Department of Industrial Accidents is � --- Office of Investigations - Lafayette City Center �'r : 2 Avenue de Lafayette, Boston,MA 02111-1750 - .... www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/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? Cheek the appropriate box: Type of project(required): I.Q I am a employer with 18 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. 0 Remodeling 2.ID I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in anycapacity. employees and have workers' p tY 9. ❑Building addition [No workers' comp. insurance comp. insurance.* 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 q ] employees. [No workers' 13.1I Other Tent comp. insurance required.] _ *Any 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. #: 014005034819121 Expiration Date: 1/1/2023 Job Site Address: 1 ( 1 ;f 54" , City/State/Zip:pbroke ..,0'a. , M If I b lots 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 cer ,u der the pains and penalties of perjury that the information provided above is true and correct. Signature: 1 Date: ill 1 as Phone#: 413-589-7368 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3ElCity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6E:Other Contact Person: Phone#: DATE(MM/DD/YYYY) ACORD® CERTIFICATE OF LIABILITY INSURANCE 4/13/2021 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 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 ARA Insurance Services, Inc. PHONE Kerry Barton_ FAX 102 N.W. Parkway (A/C,No,Ext1 800-821-6580 I(NC,No):816-474-1931 Kansas City MO 64150 ADDRESS: Kbarton@arainsure.Com INSURER(S)AFFORDING COVERAGE NAIC aY INSURER A:AXIS Insurance Company 37273 INSURED MIMA002 INSURER B: Michael's Party Rentals, Inc. 1221 South Main Street INSURER C:_ Palmer MA 01069 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 142433697 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MM/DDIYYYYI (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY AIMIMA002-029336-08 4/15/2021 4/15/2022 EACH OCCURRENCE $1,000,000 DAMAGE TO CLAIMS-MADE I X OCCUR PREMISES(EaENTED occ rrencel $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY L I F,Tei LOC PRODUCTS-COMP/OP AGG $2,000,000 i OTHER: $ A AUTOMOBILE LIABILITY A7MIMA002-029338-08 4/15/2021 4/15/2022 COMBINED SINGLE LIMIT e (Ea accident_ L(I D00 _ ANY AUTO BODILY INJURY(Per person) $ _ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X PROPERTY DAMAGE $ NON-AWNED (Per accident) AUTOS X HC Cd$1000 X HC OTC$100 $ A UMBRELLA LIAB X OCCUR A5MIMA002-029339-08 4/15/2021 4/15/2022 EACH OCCURRENCE $Loan ono X EXCESSSSLLIAB CLAIMS-MADE AGGREGATE $ DED ! RETENTIONS _ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? n .L N I A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ _ A Rental/Sales Inventory ! AIMIMA002-029336-08 4/15/2021 4/15/2022 Actual Loss Sustained Special Form/Theft Deductible 2,500 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Building Limit$2,081,000 w/$2500 ded BPP$165,424 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Reference AUTHORIZED REPRESENTATIVE ARA Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Client#: 1740037 MICHAPAR6 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDVVVY)02/23/2022 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 pollcy(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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Kylie Kirkland USI Insurance Services LLC PHONE FAX WC,No,Eel):877 396-3800 (A/c No): 877-775-0110 333 Glen Street, Suite 302 EMAIL kylle.kirkland@usi.com Glens Falls, NY 12801 ADDRESS: y 855 874-0123 INSURER(S)AFFORDING COVERAGE NAIC• INSURER A:MA Retail Merchants Workers Comp.Group 00000 INSURED INSURER B: Michael's Party Rentals,Inc. 1221 S. Main St INSURER c: Palmer, MA 01069 INSURER D: INSURER E: 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. INSR ADDL SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POUCY NUMBER IMM/DD/YYYY)'(MM/DD/YYYYI, LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE PR $ CLAIMS-MADE OCCUR EMISES(Ea ocaprence) $ MED EXP(Any one berson) $ PERSONAL&ADV INJURY $ GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE UABILrrY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY P PE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS _ S A WORKERS COMPENSATION 014005034819122 01/01/2022 01/01/2023 STATUTE OT AND EMPLOYERS'UABH.ITYER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L EACH ACCIDENT s500,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Michael S Party Rentals Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 1221 S Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Palmer, MA 01069 AUTHORIZED REPRESENTATIVE (c)1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD #S35030344/M35030338 KZKZS IMPORTANT DOCUMENT Certificate of Flame l sistance ISSUED BY Date of Shipment 03/28/12 NCH Registration Number INDUSTIFI I ® Tent Identification F444.19 t 15042462 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and were supplied to: MICHAELS PARTY RENTALS 409-A WEST STREET LUDLOW, MA 01056 C>> T E�? �'_-;`4,F CAL jco�•� `.s r4 9,- 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# 8108976C (3) Description of item certified: CENTURY MATE EXPANDABLE MIDDLE 40WX20#602 FERRARI WHITE VL Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric 602 FERRARI MFG FRANCE Name of Applicator of Flame Resistant Finish Signed: ANCHOR INDUSTRIES INC IMPORTANT DOCUMENT Certificate of Flame Wcsistance ISSUED BY Date of Shipment 03/28/12 rini, Registration Number INDUSTRIE INC.® Tent Identification F444.19 15042462 EVANSVILLE, INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and were supplied to: MICHAELS PARTY RENTALS 409-A WEST STREET LUDLOW, MA 01056 4';`�,F CAL/p��Q I .' T•a z�. •'.' Pi O 4 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# 8108986C (2) Description of item certified: CENTURY MATE EXPANDABLE END 40WX20#602 FERRARI WHITE VL Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric 602 FERRARI MFG FRANCE Name of Applicator of Flame Resistant Finish Signed: i1--- ANCHOR INDUSTRIES INC