HomeMy WebLinkAboutGas Line for Fireplace
Town of Montville
BUILDING DEPARTMENT
310 Norwich-New London Turnpike
Uncasville, CT 06382
(860) 848-3030, Ext. 382
Mechanical Permit
Permit Number: M2003-0085 Date: 12-Jun-03 Map/Lot: 043/009-007 Owner ID 49533
Job Location: FORSYTH ROA~_ Unit
Job Description: gas line for fireplace
Owner: Contractor:
Rtt Development Inc Robert Giusti P & H
P. 0. Box 482
35 Blais Rd Waterford Ct. 06385-
Uncasville CT 06382 Telephone: (860) 444-7062
Lic/Reg Type/No. S1 388724 Exp Date: 31-Oct-03
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: $250.00 Mechanical Fee: $10.00 Construction Type: 5B
Electrical Value: $0.00 Electrical Fee: $0.00 Permit Code: R5
Other Value: $0.00 Other Fee: $0.00 Comments:
Total Value: $250.00 CO Fee: $0.00
Plan Review Fee: $0.00
State Ed Fee: $0.04
Total Fees: $10.04
It is the owners responsibility to schedule the following inspections (minimum 48 hours notice reauired)•
❑ 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 ❑ Certificate of Occupany
Q Gas piping and test
Building Official's Signature:
Town of Montville
Building Department Permit # AL0a 3 Ok S~
310 Norwich New London Tpke.
Tel. 848-7166, Ext 82 Uncasville, CT 06382 Fax. 848-7231
One & Two Family LP-Gas Permit Application Form
Job Locations
Job Description/Materials 77T~
Owner 1~~\ De, -l u l',4, t Mailing Address ~2j
city State Zip Tel. 9,
Contractor Mailing Address
E Zip, _ (C Tel C7 l 70 ~v 0<
City StateC
Contractor's License/Registration Type & Numbe 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 Aj Date /i ! d
Construction Value Fee
Building $ $
Plumbing $ $
Mechanical $ _b $ ZO -
Electrical $ $
Other $ $
Certificate of Occupancy $
Plan Review Fee $
State Education $ - 6
Total $ $ /c~
STATE OF CONNECTICUT
WORKERS' COMPENSATION COMMISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § -31-286b)
Property located at r
In the town of
Name of building permit applicant:
a
Please check one:
] . _ 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 MMq)
Pursuant to § 31-286b, "a property owner or sole proprietor [w pr. _ho] as general
contractor or principal employer" m intends to acct as a general
may provide either a certificate of workers' compensation
insurance or a "sworn notarized 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 sto ere]
Signa 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 ro
accordance with the Workers' Compensation Act (Chapter 568). P PAY
I understand that pursuantto § 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.
Signatum of applicant
Subscribed and sworn to before me this day of
,200
(Notary Public/ Commissioner of the Superior Court)
Town of Montville A
Building Department =
848-7166, Ext 82
ONE & TWO FAMILY
LP-GAS PERMIT
SIGN-OFF SHEET
Property Address
Job Description:
The owner/agent shall be responsible for the completion of the form, no construction permit will be issued until all
signatures below have been obtained.
Installations over 120 gallons shall require Fire Marshal approval.
Buried tank installations require departmental approvals.
HEALTH DISTRICT 848-3030, Eat -339
❑ Permit ❑ Not Applicable
Septic System Date
❑ Permit ❑ Not Applicable
Private Well Date
PLANNING & ZONING DEP. 848-8549, Eat 7
❑ Permit ❑ Not Applicable
Zoning Date
❑ Permit ❑ Not Applicable
Inland-Wetlands Date
FIRE MARSHAL'S OFFICE 848-1175, Ext 82
Plan Review
❑ Approved ❑ Not Applicable
Fire Marshal Date
Montville- Building Department Receipt
Town of Mon u
No, z -,f Q
Date
~77-
From: /
Job Address:
Cheek
{ Amount Ic one)
~ Permit
Received by°
V
CTU~
Iatt:coNTItA
ul~o
pLUriBING 1J'Fk~ : 1~* ' fi
l1 P E: I' 1 i" 1 EXPIRES 11
-ivFF
16. 1 REG Na f. , 10/31/2003
279284
SIGNED
1TEV CONTRP'CTORl ;
COOLING IJN?M~
ING, PIPING
~AT gOP~F:R"~ ~ GY135'TI
LEA ~~~ENUE
NEW ,ON DO C1 06320-3412 1
TYPE: Sl 11
EXPIRES 1,
EFFECTIVE 08/31/2003
REG Nfl 09/012002
LIC.1
388724
'SIGNED
Town,"of Montville
Building Department
Date Z. 023 Field Inspection Notice Permit #
Job Location //a ?ZSY?'~'f T
Approved Type of Inspection 6-1-V LAN
❑ Not Approved - Please call for re-inspection when the following corrections have been completed:
Ir
r.:
E
Building Official