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Town of Montville
Building Department
848-3030, Ext 382
RESIDENTIAL
CERTIFICATE OF OCCUPANCY
SIGN-OFF SHEET
ci L,� �C'
Property Address
Job Description: !✓/L
The applicant is 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,Ext.339
Approved No Permit
❑ Permit#: ❑ 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
House Trap ❑ Outside ❑ Inside
Approved No Permit
❑ Permit# ❑ Required
Municipal Water Date
DEPARTMENT OF PUBLIC WORKS 848-7473
Approved No Permit
❑ Permit#: ❑ Required
Director Date
PLANNING& ZONING DEPARTMENT 848-3030,Ext.379
Z‘el'atia • !) In-Compliance No Permit
Wil' 9/057 Permit#:g)y./i'y ❑ Required
Zoning Date
In-Compliance No Permit
❑ Permit#: ❑ Required
Inland-Wetlands Date
Town of Montville
Building Department
310 Norwich-New London Tpke.
Uncasville,CT 06382
Tel. 860-848-3030,Ext. 382 Fax. 860-848-7231
12/26/07
Donald and Annette Woodmansee
116 Polly's Lane
Uncasville Ct 06382
Dear Donald and Annette
During a resent review of our files it was established that permit#B 2004-0373 dated July 12 2004 for
construction of a sunroom has never been closed out because all the required inspections were never
done. In order to maintain our records please contact our office between 8:00AM and 4:30PM to schedule
the required inspection.
Please be informed that the use of this sunroom without the required inspections and issuance of a
Certificate of occupancy would constitute a violation under the Connecticut Building Code.
Respectfully yours
Charles Corell
Building Inspector
cc: File
Town of Montville
Building Department
Field Inspection Notice
Address: 116 Polly's Lane
Job Description: 14x18 Sunroom
Permit Numbers: B2004-0373
Footing Not Approved: Approved:
Comments: 1.
Backfill Not Approved: Approved:
Comments: 1.
Framing Not Approved: Approved: 7/22/04 JS
Comments: 1.
Rough Electric Not Approved: Approved: 7/22/04 JS
Comments: 1.
Electrical Service Not Approved: Approved:
Comments: 1.
Rough HVAC Not Approved: Approved:
Comments: 1.
Rough Plumbing Not Approved: Approved:
Comments: 1.
Gas Line Not Approved: Approved:
Comments: 1.
Fireplace Throat/ Not Approved: Approved:
Chimney Comments: 1.
Fire/Draftstopping Not Approved: Approved:
Comments: 1.
Insulation Not Approved: Approved:
Comments: 1.
Certificate of Not Approved: Approved:
Occupancy Comments: 1.
Not Approved: Approved:
Comments: 1.
Not Approved: Approved:
Comments: 1•
Not Approved: Approved:
Comments: 1.
Comments:
Page 1 of 1
Town of Montville
Building Department
•
310 Norwich-New London Tpke.
Tel. 860-848-3030, Ext 382 Uncasville, CT 06382 Fax. 860-848-7231
CERTIFICATE OF OCCUPANCY APPROVAL
P (( t `s ct ((le*_
PropertyiAddress
aLn rQ c,✓Yl
Job Description
No Certificate of Occupancy will be issued until all of the required signatures have been obtained.
Required Department Certificate of Occupancy Approval
Approval
WPCA _Jt-' J i //
Required for all occupancies on sewer Sicina ur l that..
Comments:
Planning &Zoning l // �vL
Required for all occupancies / itla: is 3'ei
Comments: -:f1 �� `��1
Health Department
Required for all occupancies with septic systems Signature/date
Comments:
❑ Department of Public Works
Required when project includes driveway work or certain drainage requirements date
Comments:
❑ State Dept. of Transportation
Required when STC Certificate of Operation is applicable
Comments:
❑ Police Department
Required for all occupancies-except one&two family Jata
Comments:
❑ Fire Marshal
Required for all occupancies-except one&two family vi nate`C/ date
Comments:
Revised August 5,2005
Town of Montville lid
Building Department
Date: i/i 5/06' Field Inspection Notice Permit#:
Address: i/G /--75/// ,, L4, ,e
Not Comments/Corrections Required—re-inspection required:
Inspection Approved Approved
❑ Footing 0 0 sem ,,
,? p.0,ill Pi th/ II Al S 1 o r!
❑ Backfill 0 ❑ /'�E'�fi
❑ Concrete Slab 0 0
o Framing 0 0
❑ Rough Elec
❑ Elec Service 0 0
❑ Rough HVAC 0 0
❑ Rough Plumbing 0 0 /
ID Line 0 0 /e -ce
S c`i ec�, �e 447e k.6e,4y,s�,
❑ Fireplace Throat 0 0
/D m e 7Zj c ./Ar
o Chimney 0 0 w / 1/ b e yn
❑ Fire/Draftstopping 0 0
h /
❑ Insulation 0 0l // Bye- 1.0 3 d i xf, 3B a
❑ Da
al Inspection 0 0
res-T 0 ❑
❑ 0 Pc,A,444?) .-__,____
Inspector's Signature
•
Town of Montville
Building Department
Date: 1/iV/o2 Field Inspection Notice Permit#:
Address: // /Ol/js Lz;,,t
Not Comments/Corrections Required—re-inspection required:
Inspection Approved Approved
OFooting ❑ El Apr j,"ova- 4/' c/e2 ,
Backfill
0 Concrete Slab 0 0
❑ Framing 0 0
❑ Rough Elec 0 0
❑ Elec Service 0 0
❑ Rough HVAC 0 0
❑ Rough Plumbing 0 0
0 Gas Line 0 0
❑ Fireplace Throat 0 0
❑ Chimney 0 0
❑ Fire/Draftstopping 0 0
❑ Insulation 0 0
C of Onspection K.,
of O
❑ 0 0,.....„:4 O " ;
Inspector's Signature
TOWN OF MONTVILLE
Building Department
310 NORWICH-NEW LONDON TURNPIKE
UNCASVILLE, CT 06382-2599
TEL. (860) 848-3030 X382 FAX. (860) 848-7231
BUILDING PERMIT
Permit Number: B2004-0373 Date: 12-Jul-2004 Map/Lot: 102/040-000 Owner ID: 5640000
Project Location: 116 POLLYS LANE Unit:
Job Description: 14x18 Sunroom
Owner Name: Donald P and Annette Woodmansee Tenant Name: N/A
Careof:
116 Pollys Lane
Uncasville CT 06382- Telephone:
Contractor Name: Property Owner Telephone:
DBA: Lic/Reg Type:
Lic/Reg No: 0
Exp Date:
Construction Value Permit Fees Construction Information
Building Value: $10,491.00 Building Fee: $88.00 Use Group: R-4
Plumbing Value: $0.00 Plumbing Fee: $0.00 Code: 1999 State Building Code
Mechanical Value: $0.00 Mechanical Fee: $0.00 w/2000 Amendment
Electrical Value: $525.00 Electrical Fee: $8.00 Construction Type: 5B
Total Value: $11,015.00 Penalty Fee: $0.00 Permit Code: R3
C of 0 Fee: $10.00 Comments:
Plan Review Fee: $9.60
State Ed Fee: $1.76
Total Fee: $117.36
It shall be the owners repsonsibility to schedule the following inspections a minimum of 2 business days in advance:
Field set of approved construction documents shall be available onsite during all inspections.
❑ Footing-Prior to pouring concrete ❑ R Plumbing and leak test
❑ Backfill-Footing drains and waterproofing ❑ R Electrical
❑ Concrete Slab-Prior to pouring concrete ❑ Elec Trench-with conduit installed
d❑ Framing ❑ Electrical Service CRS No: 0
❑ Fireplace Throat-One flue above throat ❑ R HVAC
❑ Chimney-One flue above thimble ❑ Gas Piping and leak test
• Firestop Draftstopping
❑ Final Inspection
❑ Insulation 11 Certificate of Occupancy
Building Official's Approval: Ade `
Town of Montville
Building Department
310 Norwich-New London Tpke.
Tel.848-3030,Ext 382 Uncasville,CT 06382 Fax. 848-7231
Residential Building Permit Application Form
Permit#
❑New Construction ®Addition ❑Alteration ❑Accessory Structure
❑Single Family ❑ Two-Famity ❑ Townhouse
Job Address \\ (7„L L Y ,5 L N E
°timber) (Street) (Unit)
Job Description (k 7 g S v nJ cc Y,-`
Owner \Jour c3 L7 k.A_ oo,0.,„,SE,c Mailing Address ‘\ V€,L t. 's L Ptx•c
City V rJG fkSji i Ll State C_-t- Zip 04.:),S1- Tel 60 / cf't$ / S-481
Contractor\ , OwNE tL Ve-Krrk\'T Mailing Address \1L., 401_H s L.v E
City 0 N c R sv\L-L State CrZip Fs 2— Tel V /554%-- / 7
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.
Separate applications are required for electrical,plumbing,mechanical, etc.
Owner/Agent Signature � W , �,,, Date
Construction Value Fee
Building $ $
Plumbing $ $
Mechanical $ $
Electrical $ $
Certificate of Occupancy $
Plan Review Fee $
State Education $
Total $ $
(See averse side for additional requirements)
Town of Montville Building Department Receipt
Date C� / 3v / ay
From: 4%,i, /()_odO41i4 5,c,r
Job Address: G� ACcr,5 /y,
Amount $ / 3G 'ash heck Check # S'C�2
one)
Received by j i� 3'�
- _ Permit #7i-400(-/—""
Permit Fee Calculation Spreadsheet
MISCELLANEOUS PERMIT CALCULATION
Address:
Pools & Spas
Above Ground Round EA $ 3,150.00 $
Above Ground Oval EA $ 5,250.00 $
In-Ground EA $ 18,900.00 $
Heater EA $ 3,465.00 $
Hot Tub EA $ 5,250.00 $
Roofing
Strip & Reroof SQ $ 225.00 $
Overlay SQ $ 130.00 $
Plywood SQ $ 105.00 $
Plumbing
Full Bath EA $ 4,230.00 $
Half Bath EA $ 2,690.00 $
Garages
Attached, 1 car EA $ 8,885.00 $
Attached, 2 car EA $ 15,114.00 $
Attached, 3 car EA $ 20,914.00 $
Detached, 1 car EA $ 11,657.00 $
Detached, 2 car EA $ 17,456.00 $
Detached, 3 car EA $ 23,256.00 $
Sheds SF $ 26.25 $
Sheds with Electrical SF $ 26.25 $
Electrical Service
100 Amp EA $ 825.00 $
200 Amp EA $ 1,500.00 $
Siding $
Windows & Doors $
Decks/Porches/Sunrooms
Open SF $ 22.31 $
Covered SF $ 62.69 $ -
Enclosed 252 SF $ 41.63 $ 10,490.76
TOTAL BUILDING CONSTRUCTION COST $ 10,490.76
PERMIT FEE CALCULATIONS
Fee
Building $ 10.491 $ 88.00
Plumbing $ - $
Mechanical $ - $
Electrical $ 525 $ 8.00
Work Commenced before permit issuance $ -
CO Fee $ 10.00
Plan Review $ 9.60
State Ed Fee $ 11,015 1.76
Total Fees $ 117.36
Based on 2003 RS Means Residential Cost Data
6/30/2004
4
STATE OF CONNECTICUT
WORKERS' COMPENSATION COMMISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at: \1 (P
In the town of YYAr3‘,ri11
Name of building permit applicant: `✓oar c o Q- rn F S€ C
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. V I do not intend to act as a general contractor or principal employer.
[Si 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)
Town of Montville
d3Cielf Plan Review Form
Date:Street Address: ,/6 715 IN
Job Description: 5-G '6 Qui
We have received a building permit application for the above referenced property. In accordance with Connecticut General Statute
29-263,your application is being rejected for the following reason(s)that are checked-off or commented on:
• Supporting Documentation
Plans are to be drawn to scale including dimensions of rooms and spaces and all framing information
Building permit ap lication not completed,signed,dated
X, Permit fee$ N 7.3(4i
Worker's comp.Affidavit or worker'comp.Insurance
Copy Contractor's registration or license
Construction permit sign-off sheet
Street address of project on all drawings and documents
Field set of approved plans need to be picked up from our office
Comments:
•
Building Official
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SERIES 5500
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FEATURES
p///(' - n Vinyl construction is strong and durable. It
f ;� ;, a; will not rot, peel, flake, or corrode, therefore
never needs painting.
Supplied knocked down for easier handling
Ideal for either new construction or remodel- and transportation.
ing, the Series 5500 Vinyl Patio Door is sup- PANELS
plied K . (knocked down). The modular Fusion welded construction for a strong
packaging makes this door convenient to weathertight seal at all corners and joints.
Wtransport. . Panels are reversible, conveniently installed to
Cr
move from right to left or left to right.
WEATHERSTRIPPING
0 HARDWARE/ACCESSORIES - Double mylar fin seal woolpile helps elimi-
nate air, water and noise infiltration.
1. HARDWARE
GLASS
HANDLES VENT LATCH Standard E Standard vent i 1" insulated tempered glass for energy effi-
ciency,located safety and added strength.
li White at the sill,
Exterior Warm Edge Intercept Spacer®* reduces con-
densation, stress cracks and seal failures.
Handle
� ventilation.
t. SCREEN
Standard ' Electrostatically baked enamel fin-
h� Wood ish rolling screen is color ii. -
coordinated and durable. le %off,,*,,�E
Interior
TII'r
H Handle WARRANTY
NT�i L ,-
' - LIFETIME WARRANTY!
*Intercept is a registered trademark of PPG '�J
ACCESSORIES Industries Inc.
Optional GRILLES
_•;, BrassOptional AVAILABLE SIZES:
Plated 7171 White or
Exterior 'Beige Grilles.
Handle �'--I--- 0 = Fixed X= Moving
Optional STL RD'} SCREEN
Brass A heavy Bury Nominal Size Type Rough Opening
Interior extruded
x d eScreen 5/ 0 x 6/8 OX 60 1/8"x 80 1/4"
72 1/8"x 80 1/4"
• Handle y
is available. 6/0 x 6/8 OX
8/0 x 6/8 ox 96 1/8"x 80 1/4"
Brass handle rs supplied with a lock cylinder and key. 9/0 x 6/8 OXO 108 1/8"x 80 1/4"
12/0 x 6/8 oxo 144 1/8"x 80 1/4"
COLOR 10/o x 6/8 0)0(0 118 1/8"x 80 1/4"
White or Beige. 12/0 x 6/8 0)0(0 142 1/8"x 80 1/4"
7 0 Color reproduced as closely as 1
printing will allow. P ,
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Town of Montville
Building Department
848-3030,Ext 382
RESIDENTIAL
CONSTRUCTION PERMIT
SIGN-OFF SHEET
Property Address
Job Description: c-,\. .0 e,c Y-
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#: ❑ Required
Septic System Date
Approved No Permit
❑ Permit#: ❑ Required
Private Well Date
WPCA DEPARTMENT
848-3030,Ext 376
A. j � O Approved No Permit
• •� - -� l� �3\U y 0 Permit#: Required
unicipal Sewer IDate
Building Trap 0 Outside 0 Inside
Approved No Permit
❑ Permit# 0 Required
Municipal Water Date
DEPARTMENT OF PUBLIC WORKS
848-7473
Approved No Permit
❑ Permit#: 0 Required
Director Date
r PLANNING&ZO NG DEPARTME 848-3030,Ext.379
/ /� Approved No Permit
Ks Permit#: :d - / 97-❑ Required
Z mg Dat
Approved No Permit
0 Permit#: J)Required
Inland-Wetl ds Date
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC SAFETY s'�G
DIVISION OF FIRE, EMERGENCY& BUILDING SERVICES F P
IS'
;_b OFFICE OF THE STATE BUILDING INSPECTOR f
i
MEM V`
•
oui �/ tic
lR.y+Sry r� June 23, 2004
Mr. Donald Woodmansee
116 Polly's Lane
Uncasville, CT 06382
RE: M-896-04 116 Polly's Lane
Uncasville, Connecticut
Dear Mr, Woodmansee:
I have reviewed the referenced request for modification of Section 403.1, of the
1995 CABO One and Two Family Dwelling Code portion of the 1999 State
Building Code, which states in part that all exterior walls shall be supported on _
structural systems extending below the frost line (42 inches).
It is my decision to approve this modification, as requested, to allow a 252
square foot sun room to be supported by an existing 24 inch thick slab. This
decision is based on the condition of the existing 35 year old slab.
If you have any questions, please contact Daniel Tierney, Deputy State Building
Inspector, at (860) 685-8310.
R=•- ds
• • 'so• - - •. Laux, A —
State Building Inspector
CRL:DT:pm
cc: Vernon Vesey, Montville Building Official
Telephone (860) 685-8310
1111 Country Club Road P.O. Box 2794
Middletown,CT 06457-9294
http://www.state ct.us/dps/cifebs
An Equal Opportunity Employer
STATE OF CONNECTICUT FILE#
DEPARTMENT OF PUBLIC SAFETY
OFFICE OF THE STATE BUILDING INSPECTOR
P. O. BOX 2794
MIDDLETOWN, CT 06457-9294
TELEPHONE: (860)685-8310
FAX: (860) 685-8365
REQUEST FOR MODIFICATION
OF THE STATE BUILDING CODE FOR OFFICE USE ONLY
1. Name and Location of Building 5� 7 Cr.t 7 1,A ____ ,M o Iry v�1 ��
\
(P\ a•LA—\/' L.perr e Q„tca v r t,L:C LT
No. Street Town State Zip
2. Building Owner Oc,,NQ,L® � �� ,N SSE
3. Applicant's Name c)w..i tLQ e ��^b7�iNN Telephone C y civ.A
Applicant's Address `` c. ec,Lt.\)1 Lqr.l E U,kTc+Acv tL ' 3t
(Include Firm Name if Applicable) No. Street Town State Zip
Name of Person to Contact'CL•letL0 Q. G t;..oMAtJS•CE-Telephone � g C6) y g S k4g-7
(For information if required)
4. A.Date of Application for Building Permit ,V A/ti (.
B. Applicable Code(Title and Date) l ? 9 3--- (,4 O
5. Use Group f` ``
A. Was there a change of occupancy: El Yes (( Pt No
B. If yes from to
6. Building Construction Classification 5‘3,0.) % e
7. Square Foot Area of Building(Total) 14 X ' 5
Maximum Square Foot Area per Floor
8. Number of Stories
9. Check Applicable Designation:
❑New Building 0 Existing Of Addition 0 Other(Explain)
SuN Ro�M
10. Fire Protection at subject premises(Check appropriate headings)
r �
La Smoke Detection ❑ Heat Detection
® Extinguishers
❑ Sprinklers
0 Standpipes ❑ Other(identify)
REQUEST FOR MODIFICATION OF'THE STATE BUILDING CODE Page 2
11. Describe alarm system(s)at premises
12. Building Code Section that modification is requested from Li d3, t
C.,. SuQP L
13. Modification Sought SEE ‘rt)c, .Rct.t R,ECi,vr2,cmEyo..c- c kit„
C--G;oST- Cora\C. k-1/43 6L3 1'l�, �Q CivS ' Li--) e.-.c)
C'42,Av'et�G SVa\I �ic5uvvt ayl CXtST LrjG 2L TF-tikCK 3 'IEANR CA-9
Co��,�rrC CAT, .. Ct10,02 J'-rt. Jr,Stko NSic j czar
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14. Applicant's Signature CD. Q._ Date Signed C2 ''Z'oy
15. Important Requirement Failure to provide the following information will delay modification
process. The Building Official must comment below on the modification request as per Connecticut
General Statute 29-254(b). *Note: Must be signed by Chief Building Official,Acting Building
Official or Provisional Building Official.
❑ Support Request
❑ Do Not Support Request
The decision on this request is left to the Office of the State Building Inspector.
❑ Please contact the undersigned.
Building Official's written comments, if desired.
T!//cam" �w -t /, G)
Building Official(Printed) ! Town * uilding ne
g fficlal Sign4Jrre Date Signed
e60 —gve -3v3v A / —ylPi4
Building Official's Telephone Number Best Time to Contact
MODAPP
Rev.8/21/00
L_ POLLY'S t ANE _
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ELECTRICAL By Owi R
PHoHE _48-0640
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SERIES 5500
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'! 11 ._, -
f. I._ .. FRAME
..
',r if b Vinyl construction is strong and durable. It
- -� will not rot, peel, flake, or corrode, therefore
never-needs painting.
• S plied-knocked down for easier handling
Ideal for either new construction or remodel- a c$tation.i; : h=
ing, the Series 5500 Vinyl Patio Door is sup- PANELS
plied K.P. (knocked down). The modular
Fusion we a eentrttehien-isr z,.U1
packaging makes this door convenient to weathertight seal at all corners and joints.
Wtransport. a Panels are reversible, conveniently installed to
c.)
3� moveifrom�lright to leftTor left to right.
Y'ij t 1 dERS A RI2 ± �.L'N 3
O HARDWARE/ACCESSORIES • Double mylar fin seal woolpile helps elimi-
nate air, water and noise infiltration.
a..4 HARDWARE CLASS
I CANDLES VENT LATCH Standard $ Standard vent • 1" insulated tempered glass for energy effi-
ciency, safety and added strength.
l li White at the sill,
Exterior Warm Edge Intercept Spacer®* reduces con-
Handle allows partial densation, stress cracks and seal failures.
ventilation.
SCREEN
Standard Electrostatically baked enamel fin-
F• •4 Wood ish rolling screen is color
Interior
coordinated and durable. f.! "t%�'°y
E
f Handle WARRANTY P:>,„
• LIFETIME WARRANTre
Y! , F',,
,74
*Intercept is a registered trademark of PPG C..
ACCESSORIES Industries Inc.
Optional GRILLES
li ,lraats: optional AVAILABLE SIZES:
d .■
1 White or
Exterior ■■ a Beige Grilles.
Handle • 0 = Fixed X= Moving
Optional STURDY SCREEN
Brass A heavy duty Nominal Size Type Rough Opening
Interior ,,,f extruded
' } Sturdy Screen 5/0 x 6/8 OX 60 1/8"x 80 1/4"
Handle is available. 6/0 x 6/8 OX 72 1/8"x 80 1/4"
8/0 x 6/8
OX 96 1/8"x 80 1/4"
Brass handle is supplied with a lock cylinder and key. 9/0 x 6/8 OXO 108 1/8"x 80 1/4"
12/0 x 6/8 OXO 144 1/8"x 80 1/4"
COLOR logo x 6/8 OXXO 118 1/8"x 80 1/4"
do
White or Beige. 12/0 x 6/8 OXXO 142 1/8"x 80 1/4"
' 0 Color reproduced as closely as
priming will allow.
Town of Montville
Building Department
Field Inspection Notice
Address: 116 Polly's Lane
Job Description: Electric Service
Permit Numbers:E2004-0161
Footing Not Approved: Approved:
Comments: 1.
Backfill Not Approved: Approved:
Comments: 1.
Framing Not Approved: Approved:
Comments: 1.
Rough Electric Not Approved: Approved:
Comments: 1•
Electrical Service Not Approved: Approved: +, t)4 1 1
Comments: 1.
Rough HVAC Not Approved: Approved:
Comments: 1.
Rough Plumbing Not Approved: Approved:
Comments: 1.
Gas Line Not Approved: Approved:
Comments: 1.
Fireplace Throat/ Not Approved: Approved:
Chimney Comments: 1.
Fire/Draftstopping Not Approved: Approved:
Comments: 1.
Insulation Not Approved: Approved:
Comments: 1.
Certificate of Not Approved: Approved:
Occupancy Comments: 1.
Not Approved: Approved:
Comments: 1.
Not Approved: Approved:
Comments: 1.
Not Approved: Approved:
Comments: 1.
Comments:
Page 1 of 1
Town of Montville
BUILDING DEPARTMENT
310 Norwich-New London Turnpike
Uncasville,CT 06382
(860)848-3030, Ext.382
Electrical Permit
Permit Number: E2004-0161 Date: 23-Jun-04 Map/Lot: 102/040-000 Owner ID 120042
Job Location: 116 PO i v5J eNE Unit
Job Description: Electric Service
Owner: Contractor:
Donald P and Annette Woodmansee J. L. Gifford&Sons Electric
P.O. Box 352
116 Pollys Lane Montville Ct. 06353-
Uncasville CT 06382 Telephone: (860)848-9058
Lic/Reg Type/No. El 125552 Exp Date: 30-Sep-04
Tenant:
Self
Telephone:
Construction Values Permit Fees Construction Information
Building Value: $0.00 Building Fee: $0.00 Use Group: R4
Plumbing Value: $0.00 Plumbing Fee: $0.00 Code: 1995 CABO
Mechanical Value: $0.00 Mechanical Fee:
$0.00 Construction Type: 56
Electrical Value: $1,500.00 Electrical Fee: $10.00 Permit Code: R5
Other Value: $0.00 Other Fee: $0.00 Comments:
Total Value: $1,500.00 CO Fee: $0.00
Plan Review Fee: $0.00
State Ed Fee: $0.24
Total Fees: $10.24
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
0 Electrical Service CRS #: 343953 ❑ Final Inspection
❑ Rough plumbing and leak test ❑ Certificate of Occupany
❑ Gas piping and test
Building Official's Signature:AidlirF
kir
i., G R 5 10 o • 3 y3 553 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
DPlumbingelectrical []Mechanical
9feating
Air Conditioning
❑Other _Gas PiPing
Job Location / /G 0 /1 y 15 GANe-
Job Description/Materials Ale‘,...d /O A Ser v)c..-c
/liCv.-- 1''x'1...(., 00 k V�nn
y -flu AJ-t t.-
-
— -c-- X60 v . . c L :as v, t _ _ 4 t., e
Owner b0 Ai WOqZ hi )../Sec Mailing Address /J! Pelt,/ •3 44 Pe—
City
tomCity t4A'casK , /I-c._ State Cr Zip o4(3Fr Z Telgrio /drj - / ?yr
Contractor T 1-• G i-}(4 nA ♦ So,J i l -Mailing Address /20* gS'Z
City moA.;TV 1 LLt Statecr Zip 0G3S3 Tel geo /Fyh• / 96S8'
Contractor's License/Registration Type &Number 6 1 /z, -Z
Exp. Date 61 / . a / Z D O y ,
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 Signatureaf A AO,
._.1-,AI
Date t( / Z / 0 y
Construction Value Fee
Building $ $
Plumbing $ $
Mechanical $ $
Electrical $ / 560 $ /d
Other $
Certificate of Occupancy $
Plan Review Fee $
State Education $
Total $ 7 Cti›.-- -
}
Town of Montville Building Department Receipt
Date ±z_L
From: No. 03898
',
Job Address: �r
i
Amount I
$— c Cash. ,,Check Chcck
one) k # I
Received by / 1
„ y
--- .0!„.', Permit #
STATE OF CONNECTICUT
WORKERS' COMPENSATION COMIVIISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at: / /6 Po 11 ys L A Xi-e_ bn - 43 VI /).e al-
In the town of mo* 1/I //e
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(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. lK.I do not intend to act as a general contractor or princi.al employer.
[Sign and stop here]
a., g
Signature of applic t
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)
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
ELECTRICAL UNLIMITED CONTRACTOR
JOHN L GIFFORD
242C MAPLE AVE BOX 358
MONTVILLE,CT 06353
TYPE: El
LIC./REG NO. EFFECTIVE EXPIRES
125552 10/01/2003 09/30/2004
SIGNED