HomeMy WebLinkAbout8x12 Shed 2015 Town of Montville
Building Department
310 Norwich-New London Tpke.
TeL 860-848-3030, Ext 382
Uncasville, CT 06382
Fax. 860-848-7231
RESIDENTIAL PERMIT APPLICATION FORM
Permit No.:
ape— of Work Occupancy Tvne
❑New Construction Perm!g Type
❑Single Family ❑Buildin
❑Addition ❑Two-Family g
o Alteration ❑ ming
❑Townhouse Mechanical❑
❑Accessory Structure 0 Electrical CRS#:
Job Address: 4
IR)c
CA
(Number) V., 4 tieve Aks v' i //r e'T ae 3 FL(Street)
Job Description: 5 /f e---, (Unit)
X / ' y� •
Owner: 'Pa e,e `JT 2
Address: an'A ' cfn
City:
State: Zip Code:
Telephone: g4, b ^ fryg-' 08' 7
Contractor:
DBA:
Address:
City:
State: Zip Code:
Telephone: License Type:YP License No.:
Expiration Date:
I hereby certify that the proposed work will conform to the State Building Code and all other codes as adopted by the State of Connecticut and the Town
ofwMontville andfurther attest that the proposed work is authorized by the owner in fee and that I am authorized to make application for a permit for such
described tabove.
❑ By checking this box, I will follow the requirements of the 2005 NEC as the alternative compliance per section E3301.2.1 of the Residential Code,
instead of the electrical requirements in chapters 33 through 42 of the Residential Code.
Owner/Agent Signature: A . / zip
Date: g —/ y -- / 5—
Construction Value
Building Value: Permit Fees
Plumbing Value: Building Fee:
Mechanical Value: Plumbing Fee: ��
Electrical Value: Mechanical Fee: SAW _ ,/ f
Total Value: Electrical Fee: !/
Penalty Fee: .Na .
C of O Fee: V
Plan Review Fee: _
State Ed Fee: `r-
Total Fee: -,-
&vise&Decem6er31,2005
State of Connecticut
IC.-
Workers' Compensation Commission �-
:�_ �j� Please TYPE or PRINT IN INK
Proof of Workers' Compensation Coverage when Applying
for a Building Permit for the Sole Proprietor or Property Owner
who WILL NOT act as General Contractor or Principal Employer
APPLICANT FOR BUILDING PERMIT
Name of Applicant for Building P A Permit e'a
p pf'•= /TProperty located at ! ry C ij �/��4 / 17--
in the City/Town of ['+5 V! C' C,
(/N! / O G 3
ATTEST
If you are the owner of the above-named property or the sole proprietor of a business doing work on the site of the construction project at the above-named
property and you WILL NOT act as the general contractor or principal employer,you are not required to have workers'compensation insurance coverage.
CHECK ONE(1) BOX ONLY and complete the following:
I am the OWNER of the above-named property.I WILL NOT act as the general contractor or principal employer.
Signature of OWNER Applicant-. .. _
❑ I am the SOLE PROPRIETOR of a business doing work at the above-named property.I WILL NOT act as the general contractor or principal employer.
Name of Business
Federal Employer ID#(FEIN)
Signature of SOLE PROPRIETOR Applicant
Town of Montville
Building Department
CONSTRUCTION PERMIT APPROVAL
Applicant is responsible for obtaining all of the required approvals. No .ermit will be issued until all the re.uired si.natures are obtained.
/G 71,4 e•C f .1 /k'.4 s✓ //co C T 0e3
Property Address
Job Description
Required
Approval Department Permit Issuance Approval
Tax Collector
Comments:
Signature/date
Planning & Zoning G \ �l-i I I
Comments: Signature/date t
® Fire Marshal
Comments:
Signature/date
❑ Health Department
Required for properties with private septic or well
Comments:
❑ WPCA, Administrative
Required for properties on sewer Signature/date
Comments:
❑ WPCA, Operations
When Required by WPCA Signature/date
Comments:
❑ Department of Public Works
Required when project includes driveway work or certain drainage requirements Signature/date
Comments:
❑ Montville Police Department
Required for all permits EXCEPT one and two family residential Signature/date
Comments:
❑ State Dept. of Transportation
Required for Structures over 100,000 sq.ft.or with more than 200 parking s.aces-Official co. of STC Certificate of 0.eration re.uired—.er
CGS 14-311
Signature/date
Building Department Review Complete
Signature/date
1ZevisedMay 23,2011