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Windows 2001 Town of Montville Building Department Phone: 848-7166 310 Norwich New London Tpke Fax: 848-7231 Building / Trades Permit Permit Number BP2001-343 Permit Date 6/27/01 Permit Type Building Permit Code R4 Job Street# 12 Job Location RAINBOW DRIVE Map/Lot 016/T29-000 Job Description Windows Owner Contractor Mary Whitehead Yost Home Improvement Address 12 Rainbow Drive Address P. O. Box 263 City Uncasville State Ct. City Waterford State Ct. Zip 06370 Telephone 848-0430 Zip 06385 Telephone 442-8032 Lic/Reg Number 500250 Lic/Reg Type HIC Exp Date: 11/30/01 Use Group R4 Code 1995 CABO Type Construction 5B Building Value $6,000.00 Building Fee $34.00 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 Values $6,000.00 C/O Fee $10.00 ---------- Comments: Plan Review Fee $0.00 State Ed Fee $0.96 Total Fees [ $44.96 1 Building Official's Signature // , Date E It is the owners respo 1 o schedule the following required inspections(minimum 24 hours notice required): Footings -prior to pouring concrete ❑ 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 ❑ Pool bonding ❑ Gas piping-pressure test and installation ❑ Final Inspection ❑ Rough HVAC V Certificate of Occupancy- PRIOR to use or occupancy Town of Montville Permit #spud -343 Building Department 310 Norwich-New London Tpke. Tel. 848-7166 Uncasville, CT 06382 Fax. 848-7231 Application for Building or Trades Permit Building Permit Trades Permit ❑ New Construction ❑Accessory Structure ❑Tfum6ing ❑9Kechanical ❑Action ❑Demotztion ❑Electrzcal Hfeating ❑Alteration ®Other C yrs r,. Air Conditioning Gas'Piping Job Location /Z jE5 kt/ *1Q ) Jrrf Job Description/Materials P/ "o'er L%xc.frr*e-C Owner itlPfiI W , Mailing Address City U kl State C-r Zip 06 38 z Tel ,6o /files / OSt3O Contractor Yu ST lie---tcr /c uP/tv✓er-L.-re Mailing Address e 0 . &,) 263 City W OTi`r " i State 0--7— Zip ex38 J Tel & O / y45e./.1 &01 Contractor's License/Registration Type&Number 500 2 5 Exp. Date /l / 34 12,00 / New Home Construction Contractors: Have you entered into a contract with a consumer for the proposed new home? ❑ Yes ❑ No 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 � � �a L� r.2 /�' Date / 2 1 / Q / ruction Value Fee Building $ ���� $ Plumbing $ $ Mechanical $ $ Electrical $ $ Other $ $ Certificate of Occupancy ' $ /v Plan Review Fee $ State Education $ o.94 Total $ y4/. .5 STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION Building Permit Affidavit for Property Owners or Sole Proprietors (Conn. Gen. Stat. § 31-286b) Property located at 4/K &4.,./ V In the town of U 4 .5 E.7 Name of building permit applicant: t�Q ' YO ST-- Please check one: 1. I am the owner of the above property. 2.X.s I am the sole proprietor of a business. 2A. Name of business `/CS % /mac- /1 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 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: I._I do not intend to act as a general contractor or principal employer. [Sign and stop here] Signature of applicant 2. 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 c7-raJ. Si:. :Iof a...11(11"."- Subscribed a . worn to before me this 2 / day of 11/17 ,200/ . (Notary Public/Commissioner of the Superior Court) t Town of ontville Building Departm. Receipt Date 0 4;)‘ 6 / Z, / o, No. 00821 rGr_C - From: --- ----- Job Address: /Z /?A/kJ iZvw DT2 JV j i A C Amount $ 4-/4/ . 96 C Check Chcck # (Circle one) Received by *1 • Sv r,•.i-",e(j Permit # gpZoo 1-?y3