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HomeMy WebLinkAbout100 Gal. LP Tank and Line to Logs 2005 TOWN OF MONTVILLE Building Department 310 NORWICH-NEW LONDON TURNPIKE UNCASVILLE, CT 06382-2599 TEL. (860) 848-3030 X382 FAX. (860) 848-7231 MECHANICAL PERMIT Permit Number: M2005-0002 Date: 13-Jan-05 Map/Lot: 103/044-000 Owner ID: 5614000 Project Location: 40 POLLYS LANE Unit: Job Description: Set Tank,install gas line to fireplace logs Owner Name: George T and Carol E Wood Tenant Name: N/A Careof: 40 Pollys Lane Uncasville CT 06382- Telephone: Contractor Name: Mark Martin Telephone: (860)859-9070 DBA: Advanced Gas Lic/Reg Type: G1 Lic/Reg No: 386875 183 East Haddam Rd. Exp Date: 31-Aug-05 Salem Ct 06420- Construction Value Permit Fees Construction Information Building Value: $0.00 Building Fee: $0.00 Use Group: R-4 Plumbing Value: $0.00 Plumbing Fee: $0.00 Code: 1999 State Building Code Mechanical Value: $450.00 Mechanical Fee: $8.00 w/2004 Amendment Electrical Value: $0.00 Electrical Fee: $0.00 Construction Type: 58 Total Value: $450.00 Penalty Fee: $0.00 Permit Code: R5 C of 0 Fee: $0.00 Comments: Plan Review Fee: $0.00 PERMIT REQUIRED FOR GAS LOG INSTALLATION-SPECIFICATIONS State Ed Fee: $0.07 MUST BE SUBMITTED FOR PERMIT Total Fee: $8.07 APPROVAL- It shall be the owners rensonsibility to schedule the following inspections a minimum of 2 business days in advance: Field set of approved construction documents shall be available onsite during all inspections. BUILDING PERMIT INSPECTIONS PLUMBING,MECHANICAL, ELECTRICAL PERMIT INSPECTIONS ❑ Footing -Prior to pouring concrete ❑ R Plumbing and leak test ❑ Deck Piers ❑ R Electrical ❑ Backfill-Footing drains and waterproofing ❑ Elec Trench-with conduit installed ❑ Concrete Slab - Prior to pouring concrete ❑ Pool Bonding ❑ Anchor Bolts-with sill plate and prior to floor framing ❑ Electrical Service CRS No: 0 ❑ Framing ❑ R HVAC ❑ Masonry Fireplace Throat or Chimney Thimble ❑d Gas Piping and leak test ❑ Fireblocking_Draftstopping INSPECTION REQUIRED UPON COMPLETION ❑ Insulation 0 Certificate of Approval • ertificate of Occupancy Building Official's Approval: 9 — J Town of Montville Building Department 310 Norwich-New London Tpke. Tel. 848-3030,Ext 382 Uncasville, CT 06382 Fax. 848-7231 Residential LP-Gas Permit Application Form ❑Single Family [] Two-Family [] Townhouse Permit# Job Address Pp y 1_,Nioe (Number) (Street) (Unit) Job Description I I ► ► i re 1 a Cz LD S Owner 0,--e-be,(sem 07)0 b Mailing Address 0 Pr ' L. City Ito eas V i l /Q State Cf- Zip O 23ica Tel Std / Ng?' 00(0 Contractor A N 1,7M C E D C Mailing Address ()nom p ki n City � ( _E7 State C r Zip elotha0 Tel ao/ / 9 '7 6 Contractor's License Type&Number N re,2g6,g 75— Exp. Date Qg /3./ / ZODS C©P90 4777 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 make application for a permit for such work as described above. Separate applications are required for electrical. Owner/Agent Signature Date b I l Cc/ / a 6 Construction Value Fee Mechanical $ 1-150 °Q- OO Electrical $ $ Plan Review Fee $ State Education $ 0 Total $ LI 5-b QQ. $ ��0 9cvireiSeptem6er9,2004 Town of Montville Building Department Receipt DateNo. 04564 From: r Job Address: Amount $ 7 Cash Check Check # R (Circic one) Received by Permit # Advanced Gas Sales & Service, LLC 11'` 183 East Haddam Rd Salem, CT 06420 (860) 859-9070 I. ; I designate(name of authorized person) agent. as my authorized This work is to be performed in (name of town) Li fICAS C This work is to be performed at (street address) q( ?Q l ( !S L�ro G I Our anticipated start date is (expected start date) — y —C) I' V fl KJ , am the licensed contractor. My license number is .3(6(2 g 7L)_- (type) H P The license number/s of the contractor/s performing the work is S 0—ME This request is made pursuant to Connecticut General Statute, Sec. 20-338b. )1-15 Signature •f licensed cont?tor I gr —To co n O g 04\-to V- 14-voi 1v, 1ohmt ver L I ctt::otf oa: v::,t1J — 1oov t :o ILL y M i , 11 State of Connecticut department of Consumer Protection LICENSE VERIFICATION This Is to certify that the Connecticut Department of Consumer Protection's records Indicate the following Information regarding: MARK MARTIN 67 FORSYTH RD — — — — _ — - - .._ SALEIV, CT 06420 ' 'rf'sj : : :: 4yog:,'Y . ; ti �'. 4 `om:1 .:Vrt fr, •.: vti •L fv: tri t $h _�t't;i {•t•' 40:••VAr;. .al :. t '4 (, f•`;h � t:i;e?F:.e;ktiFK:,Rt vk £ ? * } tk : •1 •p :• •. k ' . . W. rf.i A , x'•. ' ? tN, i __� ` _ ,i < , ... fi _ _- -f ^t•- .:- _ —.—. .-w _, -_ 7_.• . _ ._ 44 CONNECTICUT + DEPARIMEn OV CONSUMER PI 4TECTION r I ..'10Be it known-that , ri �A .MARTIN +„ ::• 67`F �Y' hl RD I x`f :_, [��TTO7*�R� ref.. S1r1 $i- -r A t 4)6420 Imo„ a'r : i has been certified byF� �� the) �.k,, .���•of C er.ProtectionI ,% AIX :j ,. ? as a licensed t � HEATING, PIPING 8e1aN' ,� '= int . I , �� I ,- .Yom, t \ :..._ \\ y, i ; �.Ii. ! � 3_ ---- . -. lksvati-..... -::--='.. I r. .,*'' rRANST t` ': w �[�� : Vii;„ ..., : *gm: 'i I Effective: £.. 09/01/2004 • ,. Expiration: 08/31/2005 I ""' PrP.-z--s' ,.:= _._. Edsvau, g:odagu �.}} tt a Co ::,: f 3, i \� �'{Vh k, tai}''";•: ?=4,•qC 54,j A1111 .i' t¢ d yy�t�� f1 _ r. ,,3, i`f;.:;••!�`.,. `F 1f :•£-k fk i�St•'••• s f s: . _- -�. ..... ✓,,,,_I nvLJIVILJ 114,, DJ: 14.U1 p.m. U-V/-LGUq L lL ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID PB DATE(MWODr yy- PF?�UCEA ADVAN-6 10/07 OS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bailey Agencies, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 178 Bridge Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Groton CT 06340 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone: 860-446-8255 Fax:860-448-1608 INSURED INSURERS AFFORDING COVERAGE INSURER A NA1C Ranger Insurance Advanced Ga Sales & Service INSURER B: American H yStacay Marti ome Assurance 183 EdBt Ha am Road INSURER C: Salem CT 064 0 INSURER D: COVERAGES INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHS- TANDING 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,EXCLUSION POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��1t:fa.T SAND CONDITIONS OF SUCH �• TYPE OF INSURANCE POLICY NUMBER DATE MINDi , •' e]j! GENERAL LIABILITYDATE MM/D• _ © COMMERCIAL GENERAL LIABILITY R/ENG023753200IIIII cLEACH OCCURRENCE $ 1000000 10/01/04 10/01/05 ��••" ' 'CLAIMS MADE �X I OCCUR �-- .� s 10 0 0 0 0 II I II EXP(Any one person) $ 5000 MIPERSONAL&ADV INJURY $ 1000000 GENL AGGREGATE LIIMIT APPLIES PER: GENERAL AGGREGATE $2000000 ■ POLICY a !,,T8-. II LOC PRODUCTS•COMP/OP AGG 52000000 IIIIIIIIIIIIIIII AUTOMOBILE LIABILITY IN© ANY AUTO R/SBA0364746 COMBINED SINGLE LIMIT ALL OWNED AUTOS 10/01/04 10/01/05 (Eaecadent) $ 1000000 ■ SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (Per person) 111111111111 II NNON-OWNED AUTOS (Per den d URY f ■ PROPERTY DAMAGE GARAGE LIABILITY (Per accident) f II ■ ANY AUTO AUTO ONLY-EA ACCIDENT ■ $ OTHER THAN EA ACC f EXCESS/UMBRELLA LIABILITY AUTO ONLY; El AGG f OCCUR CLAIMS MADE R/CUP0421934EACH OCCURRENCE s 1000000 10/01/04 10/01/05 AGGREGATE ■ DEDUCTIBLE $ 1000000 RETENTION f 1 Q O Q O S ell IIIIIIIIIIIIIIII WORKERS COMPENSATION AND IIIIIIIIIIIIIII f EMPLOYERS'LIABILITYiiiiiirlriMMMEMf ANY PROPRIETOR/PARTNERiEXECUTIVE TORY LIMITS ■'�-� OP CIAL ROVISI NSbeloEXCLUDED? 10/01/04 10/01/0$ E.L EACH ACCIDENT It yes,describe under $ 500000 SPECIAL PROVISIONS below E.L.DISEASE•EA EMPLOYE $ 500000 OTHER E.L.DISEASE-POLICY LIMIT $ 500000 IIIIIIIIIIIIIIIIII DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Proof of insurance with regards to the named insured. Original Issue Date 10/07/04 CERTIFICATE HOLDER CANCELLATION ADVANCI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1.0 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Advanced Gas Sales & Service Stacy MartinIMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 183 East Haddam Road Salem, REPRESENTATIVES. CT 06420 Fromm) . / ACORD 25(2001/08) m ACORD CORPORATION 1988 Town of Montville Building Department 848-3030, Ext 382 RESIDENTIAL LP-GAS PERMIT CONSTRUCTION PERMIT APPROVAL Property Address Job Description The applicant is responsible for obtaining all of the required approvals checked off on this form. No building permit will be issued until all of the required signatures have been obtained. Required Approval Department Permit Issuance Approval ® Tax Collector eran,.� k\s`o S tutu e dt '► WPCA at- / / S D Si<gnature, date ❑ Planning&Zoning Signature'date ❑ Health Department Signature/date ❑ Fire Marshal Signature/date Comments/Conditions: Revrse6Septem6er9,2004 • 7A ' 7B 7C wr C State of Connecticut ', Workers' Compensation Commission =� 4=* =) DIRECTIONS tZfre, /�o"� DIRECTIONS for FILING FORMS 7A,7B and 7C w SJS Building Permit Requirements for Workers' Compensation Section 31-286b of the Workers'Compensation Act requires anyone who requests a building permit to first submit"proof of workers' compensation coverage for all of the employees who are engaged to perform services on the site of the construction project for which the permit was issued." The only exceptions to this law are the sole proprietor or property owner who will not be acting as general contractor or principal employer. What to give to the Building Official to obtain a Building Permit: 1. The General Contractor or Principal Employer must provide a written certificate of workers' compensation insurance for all of the employees on their project.This certificate may not be for liability, disability or any other type of insurance. 2. The Sole Proprietor or Property Owner who will not act as a general contractor or principal employer is not required to have workers'compensation coverage. In order to obtain the building permit, a FORM 7A should be completed and given to the building official. 3. The Sole Proprietor or Property Owner who will act as a general contractor or a principal employer must provide a written certificate of workers'compensation insurance for all of the employees on their project and must file a FORM 7B with the building official—OR he will sign a sworn notarized affidavit on FORM 7B, stating that he will require proof of workers' compensation insurance for all those employed on the job site. 4. The General Contractor or Principal Employer who has properly excluded himself from coverage using the appropriate WCC form (see NOTE below) must file the FORM 7C with the building official.This form certifies that they have properly excluded themselves, and attests that they will require proof of workers' compensation insurance from every employee that works on the designated job site. NOTE: The general contractor or principal employer may exclude himself from workers'compensation coverage by filing one of the following forms with the appropriate Workers' Compensation Commission district office: Form 6B for employees who are Officers of a Corporation or Managers/ Members of an LLC Form 6B-1 for employees who are Members of a Partnership