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Town of Montville
Building Department
848-3030,Ext 82
ONE&TWO FAMILY
CERTIFICATE OF OCCUPANCY
SIGN-OFF SHEET
� 0 /P7 �� /5
Property A dress
Job Description: -C C(
The owner/agent shall be responsible for the completion of the form, no certificate of occupancy will be issued until all
signatures below have been obtained.
HEALTH DISTRICT
848-3030-339
Approved
❑ Permit#: ❑ Not Applicable
Septic System Date
Approved
Private Well ❑ Permit#: ❑ Not Applicable
Date
WPCA DEPARTMENT
848-3030,Ext.376
Approved
Municipal Sewer Date ❑ Permit#: ❑ Not Applicable
House Trap ❑ Outside
0 Inside
Approved
❑ Permit# ❑ Not Applicable
Municipal Water Date
DEPARTMENT OF PUBLIC WORKS
848-7473
Approved
Director ❑ Permit#: ❑ Not Applicable
Date
PLANNING&ZONING DEPARTMENT
848-3030.Ext.379
In-Compliance
Pn /WO3 ❑ Permit#: 2U0�-Z97
Zoning ❑ Not Applicable
ate
In-Compliance
Inland-Wetlands ❑ Permit#: 0 Not Applicable
Date
2Zpvised 6/28/2002
N
I
1) Town of Montville
Building Department
Date: /J�
Zi0 3 Field Inspection Notice Permit#:
Address: iv., .2:7oL_/.._i' fj ( /))4,-) --- — '
--171eLP
Not Comments/Corrections Required—re-inspection required:
Inspection Approved Approved
❑ Footing 0 0
❑ Backfill
o Concrete Slab 0 0
❑ Framing 0 0
❑ Rough Elec 0
o Elec Service 0 ❑
❑ Rough HVAC 0 0
❑ Rough Plumbing 0 0
❑ Gas Line 0 0
❑ Fireplace Throat 0 0
❑ Chimney 0 0
o Fire/Draftstopping 0 0
❑ Insulation 0 0
• Final Inspection 0 0
om C of 0 '. 2S 0 _ ---- .
0 ❑ /,
fors Signature
P
Town of Montville
BUILDING DEPARTMENT
310 Norwich-New London Turnpike
Uncasville,CT 06382
(860)848-3030, Ext. 382
Building Permit
Permit Number: B2003-0599 Date: 16-Oct-03 Map/Lot: 102/036-000 Owner ID 120037
Job Location: 100 POLLYS LANE Unit
Job Description: Shed
Owner: Contractor:
Daniel G Johnson and Thea M Kallan Daniel Johnson&Thea Kallan
100 Polly's Lane
100 Pollys Ln Uncasville Ct. 06382-
Uncasville CT 06382 Telephone: (860)848-8664
Lic/Reg Type/No. 0 Exp Date:
Tenant:
Self
Telephone:
Construction Values Permit Fees Construction Information
Building Value: $6,300.00 Building Fee: $40.00 Use Group: R4
Plumbing Value: $0.00 Plumbing Fee: $0.00 Code: 1995 CABO
Mechanical Value: $0.00 Mechanical Fee: $0.00 Construction Type: 5B
Electrical Value: $0.00 Electrical Fee: $0.00 Permit Code: R9
Other Value: $0.00 Other Fee: $0.00 Comments:
Total Value: $6,300.00 CO Fee: $10.00
Plan Review Fee: $4.00
State Ed Fee: $1.01
Total Fees: $55.01
It is the owners responsibility to schedule the following inspections(minimum 48 hours notice required):
❑ Footing -Prior to pouring concrete ❑ Rough HVAC
❑ Backfill-Footing drains and waterproofing ❑ Fireplace Throat
❑ Concrete Slab-Prior to pouring concrete ❑ Chimney-One flue above thimble
❑ Rough Framing ❑ Firestopping/draftstopping
❑ Rough Electrical ❑ Insulation
❑ Electrical Service ❑ Final Inspection
❑ Rough plumbing and leak test ❑d Certificate of Occupany
❑ Gas piping and test
Building Official's Signature: ��
.
Town of Montville
Building Department Permit#/ 2ô5
310 Norwich-New London Tpke.
Tel. 848-3030,Ext 382 Uncasville, CT 06382 Fax. 848-7231
One & Two Family Building Permit Application Form
C]Jew Construction C]Addition C]Alteration Accessory Structure
['Other
Job Location too Pot j 'S 1--n
t2')( ZOO
Job Description/Materials Clej ve r -+- ()Igo p C1St D\E=&
iO�t1
Mailing Address IOC) PCn.
CityL 1 (X)3\l t \f'. State CX ZipO..C3 2Tel `cam/6 / a(D CaLl
Contractor SQ \e1 \ S,,if"rt--- - Mailing Address
City E3 (rC\ State *CT-Zip O t Tel J Q
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 make application for a permit for such work as described above.
Owner/Agent Signature \ ,1 Date / /
Constructio Value Fee
Building $ $
Plumbing $ $
Mechanical $ $
Electrical $ $
Other $ $
Certificate of Occupancy $
Plan Review Fee $
State Education $
Total $ $
(See*verse side for additional requirements)
Town of Montville Building Department Receipt
Date /o / V / 03 No. 03236
From:
Job Address: /OD PoL L Yf L.-,O 7•1 L-T`
Amount
$ �� o 1 � Check Check #
(Circle one)
Received by J u � Permit #
•
Permit Fee Calculation Spreadsheet
MISCELLANEOUS PERMIT CALCULATION
Pools&Spas
Above Ground Round EA $ 3,150.00 S
Above Ground Oval EA $ 5,250.00 $
In-Ground EA $ 18,900.00 $
Heater EA $ 3,465.00 S
Hot Tub EA $ 5,250.00 S
Roofing
Strip&Reroof SQ $ 207.20 S
Overlay SQ $ 127.05 $
Plywood SQ $ 101.85 $
Sheds 240 SF $ 26.25 $ 6,300.00
Electrical Service
100 Amp EA $ 816.43 $
200 Amp EA $ 1,519.19 $
400 Amp EA $ 6,039.29 $
Breezeway/Decks
Open SF S 22.31 $
Enclosed SF S 94.76 $
Porches
Open SF S 62.69 $
Enclosed SF $ 123.90 S
TOTAL BUILDING CONSTRUCTION COST $ 6,300.00
PERMIT FEE
Building $ 40.00
Electrical $ -
S -
CO Fee $ 10.00
Plan Review $ 4.00
State Ed Fee 6,300 $ 1.01
Total Fees $ 55.01
Based on 2003 RS Means Residential Cost Data
10/8/03
•
STATE OF CONNECTICUT
WORKERS' COMPENSATION COMMISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at: i(7 C {DO' t
In the town of ( f i \\-€' Q'r C k 3 Z
Name of building permit applicant: ---1--re._ca1 QJ lC-f
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(FEIN)
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. ,V 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 Covera e u es he files - intent \cc; •t age.
\ •
,
Signature of applicant
Subscribed and sworn to before me this c;1—r\k day of L� J `�"-�- 2003
(Notary Public/Commissioner of the Superior Court)
JOYCE W. FINN
NOTARY PUBLIC
MY COMMISSION EXPIRES JAN.31,2004
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