HomeMy WebLinkAboutWindow 2004 Town of Montville
BUILDING DEPARTMENT
310 Norwich-New London Turnpike
Uncasville,CT 06382
(860)848-3030, Ext.382
Building Permit
Permit Number: B2004-0273 Date: 23-Jun-04 Map/Lot: 102/038-000 Owner ID 120039
Job Location: 108 POLLYS LANE Unit
Job Description: Install new picture wit endow
Owner: Contractor:
Theresa M McAvoy THD Home Services
345 Greenwood Ave.
108 Pollys Lane Worcester Ma. 01607-
Uncasville CT 06382 Telephone: (401)935-2633
Lic/Reg Type/No. HIC 565522 Exp Date: 30-Nov-04
Tenant:
Self
Telephone:
Construction Values Permit Fees Construction Information
Building Value: $3,242.00 Building Fee: $22.00 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: R4
Other Value: $0.00 Other Fee:
$0.00 Comments:
Total Value: $3,242.00 CO Fee: $10.00
Plan Review Fee: $0.00
State Ed Fee: $0.52
Total Fees: $32.52
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 CRS#: 0 El Final Inspection
❑ Rough plumbing and leak test ❑ Certificate of Occupany
❑Gas piping and test
Building Official's Signature:
x
Town of Montville
Building Department
310 Norwich-New London Tpke.
Tel.848-3030,Ext 382 Uncasville,CT 06382 Fax.848-7231
Residential Building Permit Application Form
Permit#
New Construction 0 Addition razglieration 0 Accessory Structure
❑Single Family 0 Two-'Family 0 Townhouse
Job Address 1 Le rPO 1\ l tig U rir t J
(Number) • (Street) �J V
(Unit)
Job Description T-41 441 l i 1 fit CZ i ' r ) ( /Xj)
Ovlizlitia I J/-)A nie‘c
Owner .-1-100._ H(.ail Mailing Address ICA a) (1 leilie-
City0645-al IL State CT Zip£3 Tel 9'(dn / /
Contractor
�jt Mailing Address S G-- posjy�/j
WarLAWCity State 1 Zip O�1,b7 Tel Lip j/ '-/
� aZ0=3
Contractor's License/Registration Type&Number b., 5av Exp. Date 1) /30 / 09-
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 requir d f. - trica D lu ' g,mechanical,etc.
Owner/Agent Signature f ir. Date l
Construction Value Fee
Building $ Z D — $ s�� oa
Plumbing $ $ LSC
Mechanical $ $
Electrical $ $
Certificate of Occupancy $ /0 519
Plan Review Fee $
State Education $
$
Total $ Lia
(See Reverse side for additional requirements)
Town of Montville Building Department Receipt
ipt
Date /
No. 03867
From: Aa' .._
Job Address: Ai-- vc ,
AN
Amount $ '`
30� • S� Cash- 4p Check # 0:
(Circ c one
Received by
"���• �-- _ Permit # ��
r STATE OF CONNECTICUT
WORKERS' COMPENSATION COMMISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at: O g Qp 1111 tA 1% nrciSii J
In the town of HO 11I
Name of building permit applicant: '--1-11) o1-1 '5frJ
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: T
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. 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)
r .
Town of Montville
Building Department
848-3030, Ext 382
RESIDENTIAL
CONSTRUCTION PERMIT
SIGN-OFF SHEET
Qo 1 U
Prope, ty Address
or
Job Description: (k)114D1.3-116 )1101^
The applicant is responsible for the completion of the form, no permit will be issued until all signatures below have been
obtained.
HEALTH DISTRICT 848-3030,Ext.339
Approved No Permit
❑ Permit#: 0 Required
Septic System Date
Approved No Permit
❑ Permit#: ❑ Required
Private Well Date
WPCA DEPARTMENT 848-3030,Ext 376
Approved No Permit
❑ Permit#: [❑ Required
Municipal Sewer Date
Building Trap 0 Outside ❑ Inside
Approved No Permit
0 Permit# ❑ Required
Municipal Water Date
DEPARTMENT OF PUBLIC WORKS 848-7473
Approved No Permit
❑ Permit#: 0 Required
Director Date
PLANNING&ZONING DEPARTMENT 848-3030,Ext.379
Approved No Permit
0 Permit#: ❑ Required
Zoning Date
Approved No Permit
0 Permit#: ❑ Required
Inland-Wetlands Date
AT-HOM Cate:
SERVICESo: loon oFHot)rl
Location: ,VA iV4 -e`
�c
y
To Whom It May Concern:
This letter will authorize the following person(s) to act as agent(s) on behalf of
THD At-Home Services, Inc., 3200 Cobb Galleria Parkway, Suite 200, Atlanta, GA
30339 to pull and sign for permits and inspections with respect to the installation,
maintenance and repair of windows and siding under Connecticut Contractor license
number 565522.
Authorized person(s):
Richard Fallone
TD
ctor of R- d David Katz
THD At-Home Se es, Inc.
STATE OF GEORGIA
COUNTY OF COBB
The foregoing instrument was acknowledged before me this 26th day of March,
2004 by David Katz.
_ (Seal)
Notary ' -blic-State of Georgia
Margaret Payne
Printed Name:
01/21/06
My Commission Expires:
Personally Known X Or Produced Identification
Type of Identification Produced
THD At-Home Services, Inc.
3200 Cobb Galleria Parkway•Suite 200•Atlanta, GA 30339
(770)779-1300 •Fax(770)984-0709•Toll Free 1-877-469-0114
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ATLANTA,GA 30339
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