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18 WILLIAMS ST - BUILDING INSPECTION (5) $ 50p9 Commonwealth of Massachusetts Sheet Metal Permit Date: J 30 2 9 Permit l# 2( s5,q y Fstimated Job Cost: S2, 00000 Permit Fee: $ Plans Submitted: YES NO Plans Revicwcd: YES NO Business License 1 � 7 Applicant License f# V. LIV .S rAu $ Business Information: \1 E V G� �/SDI Property Owner/Job Location Information: Name: / n fD rZ / I U�t� Name: O/� Vas 6 Street: hJ/W Lof— S� Street: I g W I I—Lt PSfn S City/Down: \/ 4%K q 7"y1 City/Town: -G /e / ms Telephone:/ g�l((/"f —��� Telephone: i 0 ,2,f—00 q2 Photo I.D. required/Copy of Photo I.D. attached: YES_ NO J-1 / N11-1-unrestricted license J-2 / rM-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq, ft. / 2-stories or less Residential: 1-2family >� Multi-family_ Condo/,rownhOnSOS_ Other_ Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. _ over 10,000 sq. tt. _ Number of Stories: Sheet metal work to he completed: New Work: _ Renovation: 11VAC Metal Watershed Roofing_ Kitchen ExhauSt System Metal Chinmey i Vents_ Air Balancing Provide detailed description of work to.be done: INSURANCE COVERAGE: I have a current liability Insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes❑ No❑ If you have checked Yes, indicate the type o/coverage by checking the appropriate box below: A liability Insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct Inspection required prior to insulation Installation: YES_NO_ Proeress Inspections Date Comments Final Inspection Date; Comments Type of License: ©y_ ❑ Master fine _ ❑ Master-Restricted CoyrTown ❑Journeyperson Signature of Licensee Pernul Z ❑Journeyperson-Restricted License Number: roe$ ---- ❑— -- Check atw,v.v.m,c;s.rlovhilrl Inspector Signature of Permit Approval J CITY OF SAI.EM, UxsSACHUSETTS • Bu=LNG DEP.kI MENT A 130 WASHINGTON STREET, 3 °FLOOR TEL (978) 745-9595 F.kx(978) 740-9844 KINtigFRT FY DRISCOLL THouas Sr.PIERRs TNLI�YOR DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSION Elk Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of N1GL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by N1GL c I It, S 150A. 'fhe debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) i s ature of permit app ' n .g 3 O ZD13 date T Li t . Yevgeniy V Livshits has been certified as a Type-il Type-III technician as required by.40 CFR Part 82,Subpart F. �RSES® ID EPA Proga?m+ Educational Foundation Apprd;al:9/30/93 COMMONwr;LTH'4F MASSACNUSE7T SHEET METAL WORKERS AS A MASTER-UNRESTRICTED' fi ISSUES THE ABOVE LICENSE TOEr. e.. ;YEVGEN;IY 'V,' LIVSHITS� WILMINGTONa� 01887 3-802� 11793i, bl/28/15 327853 Co ►vL 00a CITY OF sm.E%1) NLISSACHUSETTS BUILDING DEPARTM&NT 120 WASHQVGTON STREET,3''FLOOR 'ILL (978) 745-9595 Fmt:(978) 740-9846 N(gFRt EY DRISCOLI ']'wmAsST.P1ERa8 MAYOR DIRECTOR OF PUBLIC PROPERTY/HhII.DLYG C01L\11SS10NEA Workers' Coinpensation Insurance Affidavit: Builders/Contractors/Electrfelans/Plumbers Anolicunt ln(ormatlon Please Print Legibly Nulne t0usiii's OrganiiatiaNlndividual): Address: &2 S�i� 1?y city/state/zip: o�d�lnone rE: ��/ 7©�f—SrDg'7 Are you an employer?Check the appropriate box: Type of project(required): I.El I am a employer with 4. 0 I am a gores al contractor and 1 b. Nevv conatnlction employees(full and/or part-time).* have hired the subcontractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet.t ?. El Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working.forma in any capacity. workers'comp.instrance. 9. 0 Building addition (Na,workers'comp.insurance 5.0 We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions ).❑ I am a homeowner doing all work right o(exemption per MOL 11.❑Plumbing repairs or additions myself.(No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs insurance required.]t employees.(Na workers' comp:insurance required,). ME]Olher, •Any applicant char chcdrs box t 1 must ahw rill uut the scaloa below showing tha4 worker'compansarlua pulley infii matlom 1 hsmuuwnxs whosulmdt thin affidavit indicnino ihey ar doing all twrk and thaa hlra outside cantrctm must submit a raw anidavit indicting ruck =(',mtmvtan that chcsk this box must attwhud ern adslitfunul+hats showing iho matte of the sub-contractar and their wurkaW camp.pullry Infamatioe. I um an employer that is providing)vorkert'c omprasadon htsuranae for my employee.% Below Is thr policy and Job site iuforuru!lan. Insurance Company Name: Policy 4or Self-iris. Lie. 0: Expiration Date: Job SittsAddress: ,X t.v //�G7.JLfS ' � City/State/zip. ,\ttacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failuru to secure coverage as required under Section 25A of NIOL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,at wall as civil penalties in the farm of STOP WORK ORDER and a line of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the 011ica of Investlg-Aone of fife DIA ror insurance Coverage veriilealiun I du hereby ctrtily ider the punts and penu/lira p ry shut(/re h furmullon provided above/s true uud correct. Date. 5 3o zor Pho r ii• UJJiriui use ar/y. Ou not writr in t/r/s area,to be completed by city err town aJJletal I Cityor'I'uwn: _-__ Pcrmit/IJccnsa,y _ _-__ Issuing Authurily(circle one): 1. Board of Ilealth 2. ❑uilding Department J.Cilyffown Clerk A. Electrical Inspector 5. Plumbing Inspector 6.Other -- _-- Contact Person: ._ i'hone it: t (