HomeMy WebLinkAboutMeter Replacement 2003 e
Town of Montville
Building Department Permit#
310 Norwich-New London Tpke.
Tel. 848-3030,Ext 82 Uncasville, CT 06382
Fax, 848-7231
One & Two Family Trades Permit Application Form
DPfumding t(ectrical []1fechanicaf L71T
.5feating 1
Air Coraktioning O ccJu F,rL ('W
C, ____.❑Other Gas Piping /N�tsr—✓K F-1, C, ____.
Job Location 3( /�/I ad ZIjM5o/e__C C r
JobD scrition/Materials
P 1V4(X27 /A9 /fit/ -X 7-141(, S,g,-- /C 1
( �
Adr
Owner.._) yj�S' ez,, ,L__ Mailing Address 7/ r /1'JeG ---
City ���%�(./Ia,� �7`' �+, �y- l �y�
State (-tom Zip O 3 Tel gX6 / 15 / g e:'72
Contractor (..C1---7/C Mailing Address AS no'<jK
City State Zip Tel /
Contractor's License/Registration Type &Number
Exp. Date / /
I hereby certify that the proposed work will conform to the Basic 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 a ae :pplication for a permit for such work as described above.
Owner/Agent Signature / 2f /mt._
Date/( / //` `cf J
AIIIIIIIVAIV
Construction Value Fee
Building $
Plumbing $
Mechanical $
Electrical $
Other $ 1,4(.), \
Certificate of Occupancy
Plan Review Fee it 1 i
State Education
Total $ it / i e
1 / e
STATE OF CONNECTICUT
WORKERS' COMPENSATION COMNIISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at:
In the town of
Name of building permit applicant:
Please check one:
1• I am the owner of the above property.
2. I am the sole proprietor of a business.
2A. Name of business:
2B. Federal Employer Identification Number(PUN)
Pursuant to § 31-286b, "a property owner or sole proprietor [who] intends to act as a general contractor or
principal employer" may provide either a certificate of workers' compensation insurance or a "sworn
affidavit...stating that he will require proof of workers' compensation insurance for all those employed on the
job site in accordance with this chapter."
Please check one:
1• I do not intend to act as a general contractor or principal employer.
[Sign and stop here]
Signature of applicant
2. I intend to act as a general contractor or principal employer. Applicant must either provide a
•
certificate of workers' compensation insurance or sign the affidavit below.
Affidavit
I hereby swear and attest that I will require proof of workers' compensation insurance for every contractor,
subcontractor, or other worker before he/she engages in work on the above property in accordance with the
Workers' Compensation Act(Chapter 568).
I understand that pursuant to § 31-275 C.G.S., officers of a corporation and partners in a partnership may elect
to be excluded from coverage by filing a waiver with the appropriate District Office; and that a sole proprietor
of a business is not required to have coverage unless he files his intent to accept coverage.
Signature of applicant
Subscribed and sworn to before me this day of
200_.
(Notary Public/Commissioner of the Superior Court)