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Home My WebLink AboutWindow Replacements, Door, Siding 2002 Town of Montville BUILDING DEPARTMENT 310 Norwich-New London Turnpike Uncasville,CT 06382 860-848-3030, Ext.82 Building Permit Permit Number: B2002-560 Permit Date: 27-Sep-2002 Permit Code R4 Job Location: 200 RAYMOND HILL ROAD UNIT: MAP/LOT: 087/001-00B Job Description: re-roof,replace windows,move door,Siding Owner Contractor Stacey Terrial&Michael Frank Pittisinger Tom Giroux 161 Vergason Avenue 200 Raymond Hill Road Unit: Norwich,Ct.06360 Uncasville,CT 06382 Telephone: 887-6800 Lic/Reg Type: HIC Use Group R4 Lic/Reg Number: 569589 Code 1995 CABO Construction Type 58 Exp Date: 11/30/2002 Construction Values Permit Fees Building Value: $15,000.00 Building Fee: $88.00 Plumbing Value: $0.00 Plumbing Fee: $0.00 Mechanical Value: $0.00 Mechanical Fee: $0.00 Electrical Value: $0.00 Electrical Fee: $0.00 Other Value: $0.00 Other Fee: $0.00 Total Value: $15,000.00 C/O Fee: $10.00 Comments: Plan Review Fee: $0.00 State Ed Fee: $2.40 Total Fees: $100.40 It is the owners responsibility to schedule the following required inspections(minimum 48 hours notice requested); ❑ Footing-Prior to pouring concrete ❑ Rough HVAC ❑ Backfill-Footing drains and waterproofing ❑ Fireplace Throat ❑ Concrete Slab-Prior to pouring ❑ Fireplace Final ❑ Rough Framing ❑ Chimney-One flue above thimble ❑ Rough Electrical ❑ Firestopping/draftstopping ❑ Electrical Service ❑ Insulation ❑ Rough Plumbing and Leak Test ❑ Final Inspection ❑ Gas Piping and Pressure Test Certificat; . •S. P or to use or occupancy Building Official's Signature: Town of Montville • Building Department Permit# 310 Norwich-New London Tpke. Tel. 848-3030,Ext 82 Uncasville, CT 06382 Fax. 848-7231 One & Two Family Building Permit Application Form New Construction ❑Addition kAfteration Accessory Structure ['Other Job Location a(30 R/4)/1'r10 N `1i// RoA.D l»u C./ S V i//r.- e'T O(03$'02 Job Description/Materials E Roar '/a o5 8 n1/4)37PL 30 '/ER2 Asp/10 L7 RooF QUEfL is FELT ///v.SiA// /'% Cu/NDowS/innutoofL/ /NsT/9/1 NEIL) ,3/13/A36 - Owner Midi/Xi' PITT(,)6E/Z Mailing Address arm RAynioni /,//// RIS City [JAU c AS 11, /lam State �T Zip 0 6 3 R.02. Tel k60 / / 8 90 vl" Contractor To rr /Roo ) Mailing Address /(o/ VERG'/1SQAJ /)UF. City /U0R(Ai ICJ State CT Zip p6260 Tel SCO / $87 / 62oO Contractor's License/Registration Type&Number vr6 qv9 Exp.Date / / CoSTon CoRpEIJT1 / of Norton li 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 G ) 4rifi - Date 1 / / / aoo? Construction Value Fee Building $ - 2c — $ �7 Plumbing $ $ Mechanical $ $ Electrical $ $ Other $ $ Certificate of Occupancy $ / — Plan Review Fee $ State Education $ a,y o Total $ k6-000 $ /o o ,yo STATE OF CONNECTICUT WORKERS'COMPENSATION COMMISSION Bufldin Permit Affidavit for Pro e Owners or Sole Pro rietors (Conn.Gen.Stat.§31-286b) Property located at In the town of A.C. C�3�� Name of building permit applicant Please check cyte: I. t I am the owner of the abovero 2. I am the sole proprietor P PAY. P prietor of a business.. -2A.Name of business 2B.Federal Employer Identification Number contractor Pursuant tom�c 6b,pal'�IrDp�y owner or sole proprietor[who]intends...............act as a...n... --- Poyer'may provide either a to ase general Insurance or a"sworn notarized affi c�ficatc of worker'compensation compensation insurance for all davit--• stating that he will require proof of workers' those employed on the job site in accordance with this chapter." Please check on intend I do not to act as a general contractor or principal empl [Sign and stop here] oyer. / �%� Si• •ture of applicant 2. I intend to act as a general contractor orrinci provide a certificate of workers' mpenP �coemployer.Applicant must either below compensation insurance or sign the affidavit Affidavit .....................- I hereby swear and attest that I will require proof of workers'com contractor,subcontractor,or other worker before he/she en n n workon inet a ov for every accordance with the Workers'Compensation Act(Chapter 568). on the above property in I understand that pursuant to§31-275 C.G.S.,officers of a co partnership may elect to-be excludedge corporation and partners is a District Office;and that a sole proprietor of bus ness is noby gt a waiver to with have coverageappropriate unless files his intent to accept coverage. required unless he Signature of applicant Subscribed and sworn to before me this day of ,200_ (Notary Public/Comm issioner of the Superior Corti Town of Montville Building Department Receipt Date 0) / ,iS / oZ No. 02177 From: Job Address: Zoe' /2AYM0,,j,) N/Lk /Z30 Amount $ /Oct . y o C Cash Check Check # E' (Circle one) { Received by . cl Permit #E2 z U ACORD CERTIFICATE OF LIABILITY INSURANCgu OP ID PB DATE(MM/DD/YY) STO 2 09/16/02 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bailey Agencies, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 178 Bridge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Groton CT 06340 Phone: 860-446-8255 Fax:860-448-1608 INSURERS AFFORDING COVERAGE INSURED INSURER A: Hartford Casualty Ins. Co. INSURER B: Custom Carpentry of Norwich, LLC INSURER C: 161 Vergason Avenue INSURER D: Norwich CT 06360 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING 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,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $300000 A X COMMERCIAL GENERAL LIABILITY 02SBMNI6448SB 06/30/02 06/30/03 FIREDAMAGE(Anyonefire) $50000 CLAIMS MADE X OCCUR MED EXP(Any one person) $5000 PERSONAL&ADV INJURY $300000 GENERAL AGGREGATE $ 600000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 600000 7 POLICY PRO- JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ — $ WORKERS COMPENSATION AND X TWC ORY LIMITOER A EMPLOYERS'LIABILITY 02WECJNO018 06/25/02 06/25/03 E.L.EACH ACCIDENT $100000 E.L.DISEASE-EA EMPLOYEE $ 100000 E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Proof of Insurance for work performed by insured for roofing, siding and replacement windows. Issured: 9/16/02 CERTIFICATE HOLDER N ADDITIONAL INSURED;INSURER LETTER: CANCELLATION PITTSIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Mike Pittsinger 200 Raymond Hill Road IMPOSE NO OBLIGA '; . BILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Uncasville CT 06382 REPRESENTATI S. AUTHORIZED R •RESENTAT Patricia r�l ACORD 25-S(7/97) ACORD CORPORATION 1988