HomeMy WebLinkAbout12x12 Shed Town of Montville
Building Department
310 Norwich-New London Tpke.
Tel. 860-848-3030-, Ext382 Uncasville, CT 06382 Fax. 860-848-7231
RESIDENTIAL PERMIT APPLICATION FORM Permit No.:
Type of Work Occupancy Type Permit Type
❑ New Construction ❑Single Family ❑ Building
❑Addition ❑Two-Family ❑ Plumbing
❑Alteration ❑Townhouse ❑Mechanical
❑Accessory Structure ❑ Electrical CRS#:
Property Address: 2-1 -Pc-Eer A
(Number) (Street) (Unit)
Job Description: Cc,.As}f- A \ Z 1-L Sid l44St e-I�
Owner: mor r-,e I - 1t±)c�r��,L�S
Address: Z-� t E-I e r A J f
City: '1 c r,Sv . \ C State: C- Zip Code: O(J 2- Telephone( o ) lcO - X5`3 La
Applicant: Sc-r-, R •
•
DBA:
Address:
City: State: Zip Code: Telephone( ) -
Contractors -Complete the Following:
License Type: 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
of Montville and further 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 work as described above.
❑ 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: Date:
Construction Wlue Permit Fees
Building Value: Building Fee:
Plumbing Value: P Plumbing Fee:
Mechanical Value: `` ,� Mechanical Fee:
Electrical Value: ,�l` / Electrical Fee:
Total Value: � Penalty Fee:
�b i� ' C of O Fee:
� G Plan Review Fee:
�� State Ed Fee:
�V �( Total Fee:
cyily
Revised August 23,2007 .I
State of Connecticut
r Workers' Compensation Commission Ff.., 7A
1UI ff r Please TYPE or PRINT IN INKtow
o:
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 Permit
Property located at
in the City/Town of
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 reuired si•natures are obtained.
07 / 7e /4(.2e-
Property Address
al_5"Tat,'cr- /?X/a
Job Description
Required
Department
Approval Permit Issuance Approval
Tax Collector /, C:C�V ��C �Lr e " 5/13
" Signature/date
Comments: t.t/( C1 lC'>/ „S
$ Planning & Zoning 7.425 V/ '3
Signature/date
Comments:
$ Fire Marshal c// 3I,
_
Signature/date
Comments:
❑ Health Department
Required for properties with private septic or well
Comments:
WPCA, Administrative 7It 3 /
Required for properties on sewer tignature/date
Comments:
❑ WPCA, Operations
When Required by WPCA Signature/date
Comments:
f l 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
Re•uired for Structures over 100 000 s•.ft or with more than 200 •arkin. s•aces-Official co• of STC Certificate of O•eration re•uired—.er
CGS 14-311
Signature/date
Building Department Review Complete
Signature/date
74.visedMay23,2011