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MFH 2002 O 0 N N r., I t, N I) --o z Q) C/) vl U W � a] O t 73 CCS O >' Uami td) co 5 = U cn" U+-+ a) 4] iCS., V 0r4 0 o •+' o Cil cil 0 4) - y a ' aa) 0 �O E = w E °U U .� f° c Q 0 O 3 4) C �a timl A 0 do 04 Z1 = c - V 4..., .a? 0 C, — •mi cs y o V o C E--. IS1 ax U >, o 00 .n 7., O aO by , p_n o 2 o •° ., C � nciTU ti U ,.+ gE . a f • U 0 p 0 . U to o a ¢. U U 1 ;5 :5 I1 _ c' E 4 '- E-4 ° o E-• o�.1 0 VD m. Town of Montville Building Department 848-3030, Ext 82 ONE&TWO FAMILY CERTIFICATE OF OCCUPANCY SIGN-OFF SHEET Property Address Job Description: 1./1 The owner/agent shall be responsible for the completion of the form, no certificate of occupancy will be issued until all signatures below have been obtained. HEALTH DISTRICT 848-3030-882 Approved ❑ Permit#: Not Applicable Septic System Date Approved ❑ Permit#: Not Applicable Private Well Date WPCA DEPARTMENT 848-3030,Ext.881 ?// ❑ Approved Permit#: ❑ Not Applicable Municipal Sewer Date House Trap ❑ Outside ❑ Inside Approved ❑ Permit# ❑ Not Applicable Municipal Water Date DEPARTMENT OF PUBLIC WORKS 848-7473 Approved ❑ Permit#: f Not Applicable Director Date PLANNING&ZONING DEPARTMENT 848-3030.Ext.81 In-Compliance E Permit#: 200—29 7 El Not Applicable Zoning ate In-Compliance ❑ Permit#: ❑ Not Applicable Inland-Wetlands Date &vised 6/28/2002 Town of Montville Building Department Date r/ F, deq Field Inspection Notic Permit #��a4D��-��Q Job Location Relkiproved Type of Inspection l 1/ / Not Approved - Please call for re-inspection when the following corrections have been completed: ceding : ' cial / Town of Montville 4;-4 Building Department Date / / p5 Field Inspection Notice Permit #,U0412 _%1 Job Locatio 5-7 i N �� ,✓ Approved Type of Inspection S Not Approved - Please call for re-inspection wh the following corrections have been completed: /7 1.7%.41,4(-re Building e cial Town of Montville Building Department Date 7 / 3 /0 Z Field Inspection Notice Permit # Job Locationf7 /-.D 1 N ►. a C).AApproved Type of Inspection 5 ( Not Approved - Please call for re-inspection when the following corrections have been completed: Building Official Town of Montville Field Inspection Notice Permit # Location: ,67 l2z7i,i So i,. Type of Inspection: 1PGc h Fy'&i j Issued to: Delivered to: NOT APPROVED The following orders are hereby issue or their correction: Please call for inspection when corrections have been comps- -d 860-848-7166 Date: Ot-j/o z- By: c Building Official . Town of Montville BUILDING DEPARTMENT 310 Norwich-New London Turnpike Uncasville,CT 06382- 860-848-3030, Ex.t 82 Electrical Permit Permit Number: e2002-133 Permit Date: 04-Jun-02 Permit Code R5 Job Location: 57 RAINBOW DRIVE UNIT: MAP/LOT: 016/T29-000 Job Description: Electrical&Eloectrical Service Owner Contractor JENSEN'S INCORPORATED John Morton 85 Green Hill Road P.0. BOX 608 Unit: Madison, Ct. 06443 SOUTHINGTON CT 06489-0608 Telephone: 203-245-3644 Lic/Reg Type: El Use Group R4 _ Lic/Reg Number: 101835 Code 1995 CABO Exp Date: 9/30/02 Construction Type 5B Construction Values Permit Fees Building Value: $0.00 Building Fee: $0.00 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: $0.00 C/O Fee: $0.00 Comments: Plan Review Fee: $0.00 Included on Building Permit State Ed Fee: $0.00 Total Fees: $0.00 Jt 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 E] Electrical Service ❑ Insulation ❑ Rough Plumbing and Leak Test ❑ inal Inspection ❑ Gas Piping and Pressure Test Certific. e of O anc - •rior to use or occupancy Building Official's Signature: ' ,���/ 1 : 0 Town oaf Montville i Building Department CO Date 6 / 3 / Field Inspection Notice Permit # Job Location 0 7 gfct-- ` Jo 02- !i:I Approved Type of Inspection - ` ° Not Approved lease call for re-inspection when the following corrections have been completed: v (�!1� 1,U3 PQvIf .0/7+--) NQr Bo. MovP 1 O /..) /4 oS)Lt? Jr ,- 0-C- fi5 o-zi� c z i , f / Building Official i Town of Montville • Building Department Permit# 7DO a? - 433 310 Norwich-New London Tpke. Tel. 848-3030, Ext 82 Uncasville, CT 06382 Fax. 848-7231 One & Two Family Trades Permit Application Form 0Plumbing ®Electrical U9vtechanical (eating Air Conditioning Gas Piping DOther Job Location .S -7 eRq lu�Evw Job Description/Materials 4-1\2T57411 200 j4.Kip F f,e‘.._7 c..s-L St-(LU t C e Owner -31--,05e,u_ ZUG. Mailing Address p, [,: _ 6,c2 g City _570.M 1 IAc'tz k" State G7- Zip 0 b y cr ce" Tel / / Contractor jun ti 11//6 y76.) Mailing Address 'i V epi tit t (/ ( City /(A A4ci tS a ti State Cr Zip D&V y3 Tel 2-0_3 / z /r/ 76- V/Y Contractor's License/Registration Type&Number C / - /Of ? 3j Exp. Date 8 7 / 30 / D L 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 C92 'y/i Date 5 12-1 / e Construction Value Fee Building $ $ Plumbing $ $ Mechanical $ $ Electrical $ //b o a-) $ Other $ $ l J/IlTVA Certificate of Occupancy1 Plan Review Fee ihk$ il'`�rei�r1,� State Education $ 4 Total $ $ V STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION Buildin: Pet-mit Affidavit for Pro.e Owners or Sole Pro•rietors (Conn. Gen. Stat. §31-286b) Property located at 7 In the town of /QC) I Name of building permit applicant: \A• L' 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 §3I-286b,"a ....................... property owner or sole proprietor[who]intends to act as a genu contractor or principal employer"may provide either a insurance or a"sworn notarized affidavit... stating that he�will' a uirecate of pr workers'compkers' compensation insurance for all those employed on the job site iniac require with this chap" Please check one: 1. I do not intend to act as a general contractor or principal employer. [Sign and stop here] 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 contractor,subcontractor,or other worker before he/she engagesn workinsurance above for propertyy accordance with the Workers'Compensation Act(Chapter 568). work on the above in I understand that pursuant to§31-275 C.G.S., officers of a co partnership may elect to be excluded from coverage by filingcorporation waiver and thetapps in a District Office; and that a sole proprietor of a business is not d with coverage unless files his intent to accept coverage. N to have unless he 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 Type:E1 JOHN W MORTON 85 GREEN HILL RD MADISON, CT 06443 LIC./REG.NO. EFFECTIVE 101835 10/01/2001 0/01/2001 09/30/2002 .1 SIGNED: ,r/ �G • Town of Montville Building De,. -tment Phone: 848-7166 310 Norwich New London Tpke Fax: 848-7231 Building / Trades Permit Permit Number BP2001-690 Permit Date 11/15/01 Permit Type Building Permit Code R6 Job Street# 57 Job Location RAINBOW DRIVE Map/Lot 016/T29-000 Job Description Manufactured Home Owner Contractor Jensen's Inc. P& H Construction Address P. 0. Box 608 Address P. 0. Box 164 1 City Southington State Ct. City Uncasville State Ct. — Zip 06489 Telephone 860-793-0281 Zip 06382 Telephone 860-848-2372 Lic/Reg Number 113 Lic/Reg Type NHC Exp Date: 9/30/03 Use Group R4 Code 1995 CABO Type Construction 5B Building Value $12,514.00 Building Fee $76.00 Plumbing Value $400.00 Plumbing Fee $10.00 Mechanical Value $4,719.00 Mechanical Fee $28.00 Electrical Value $691.00 Electrical Fee $10.00 Other Value $0.00 Other Fee $0.00 Total Values $18,323.00 C/O Fee $10.00 Comments: Plan Review Fee $7.60 State Ed Fee $2.93 tates $144.53II Building Official's Signature _U,p2 -jT� 2)7,, ---- Date //10T, /6�' It is the owners responsibility to schedule the following required in ctions (minimum 24 hours notice required): Footings -prior to pouring concrete Backfill -footing drains and waterproofing C I Fireplace Throat "Concrete Slab, prior to pouring ❑ Fireplace Final ❑ Rough Framing ❑ Chimney -one flue above thimble E. Rough Electrical ❑ Firestopping/draftstopping ®Electrical Service ❑ Insulation VRough Plumbing and leak test ❑ Pool bonding ® Gas piping -pressure test and installation ❑ Final Inspection ❑ Rough HVAC V Certificate of Occupancy - PRIOR to use or occupanc 05/18.01 20:36 FAX 8487231 BUILDING DEPT IZI01 Town of Montville Permit # j'e e,/-- 6 pa 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 ❑ Nein Constnutian ❑AccissoryStructure OSPlumbing 1__ Itec/ranira! ❑Addition ❑eDemnftion ®q frctrical )0 bleating ❑Alteration ®Other ? of 1�.etwi(,.,t,\ r Air C tioning !t " ging Q Job Location 51 ..AA.:ti Dur A'1vC. P IGA5 vi I/G/ (1 Job Description/Materials gebo: d la�- -„ sce �»+oh � � / �«a wllI4.h/A4 Fdo) d e Owner er s ...2"-AL., Mailing Address PO- o16- 60S 1 I City 500411 -0 A. State C r Zip QG y8 J/ Tel gGe / M /0.249 Contractor P}/4�ivtS4fa t.21"C Mailing Address P6. gOlo / g .. City P/1445 v ne State C l Zip Ca3eeZ. Tel 866 / 85'8 /0?3}, Contractor's License/Registration Type&Number /Vey A.6e- '///3 Exp. Date 9 / 30 Aril New Home Construction Contractors: Have you entered into a contract with a consumer for the proposal new home?❑ Yes EPNo I hereby certify that the proposed work will conform to the Basic Building Code and all other cedes 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 SSignature �.� Y. 0. Date /. / ok7, /O/ Construction Value Fee Building $ oZ $ Plumbing S / D $ /c Mechanical $ ' -- $ .7e f Electrical $_ 6 ? / $ 7e Other $ $ Certificate of Occupancy $ /O i Plan Review Fee $ 7.6 v State Education $ n i 9 5 Total $ /,9 3,2 ? / V " ,.,-3 Town of "Iontville Building Department Receipt w. p Date _-- —/ -/ L, : Q No. 61272 From: Job Address: r► Amount $ ---_ACash Check # 1 ?57� (Circle one) Received by *,21,404t ZID ' 012t4,,, Permit # l--o?e, Permit Fee Calculation Spreadsheet RESIDENTIAL PERMIT CALCULATION (MANUFACTURED) QTY $/UNIT TOTAL Site Work Slab on Grade 924 SF ;3 Foundation SF .;9 Anchors SF 6,37 Garages Attached, 1 car EA $ 8,926.00 Attached,2 car EA $ 14,548.00 $ Attached,3 car EA $ 20,246.00 $ Detached, 1 car EA $ 10,547.00 $ Detached,2 car EA $ 15,809.00 $ Detached,3 car EA $ 21,072.00 $ Breezeway/Decks Open 176 SF $ 15.00 $ 2,640x1. Enclosed SF $ 25.00 $ Porches Open SF $ 37.25 $ Enclosed SF $ 45.35 $ Sheds No Electric SF $ 25.00 $ - With Electric 100 SF $ 25.00 $ 2,500.00 TOTAL BUILDING $ 12,513.52 Electrical New Service EA $ 1,250.00 $ - Tie-in 1 EA $ 200.00 $ 200.00 Misc. Electric $ 491.00 Plumbing New Sewer EA $ 1,250.00 $ - Sewer Tie-in 1 EA $ 200.00 $ 200.00 New Domestic EA $ 1,200.00 $ - Domestic Tie-in 1 EA $ 200.00 $ 200.00 Mechanical Oil Heat EA $ 500 $ - LP-Gas 1 EA $ 450 $ 450.00 Y IIs air conditioning included(Y/N)? $ 4,269 I PERMIT FEE Building $ 12,514 $ 76.00 Y Plumbing $ 400 $ 10.00 Y Mechanical $ 4,719 $ 28.00 Y Electrical $ 691 $ 10.00 Other $ - CO Fee $ 10.00 Plan Review $ 7.60 State Ed Fee $ 18,323 $ 2.93 Total Fees „ - $ 144.53 Based on 2000 RS Means Square Foot Costs 10/31/01 ACORD. CERTIFIG TE OF LIABILITY INSI„ ANCE. OP�2 NK DATE(UM/DONT) PRODUCER 0/29_/01 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mathog & Moniello Cos. , Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 433 South Main Street, Ste 116 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR West Hartford CT 06110-2815 ALTER THE COVERAGE AFFORDED BY THE POLICIES 6ELOw, - Phone: 860-313-2000 Eax:860-561-2882 INSURERS AFFORDING COVERAGE INSURED '._- .. .. _... .._.—.... INSURER A'. Federal Insurance Company.___ -♦ INSURER fi Jensenr ITT Hartford Insurance �/ Inc. A an Krieger INSURER C' "'-" "--' 246 Redstone St- PO Box 608 ---- Southington CT 06489 INSURFRD. "- '— - I COVERAGES INSURER E. --- ----. THE POI(CIES 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 Sy PAID CLAIMS. INSR .... _.. LTR TYPE OF INSURANCE POLICY NUMBER GieV EFFECTIVEPa{itTTj�XpIR4TRUI -" -- --- GENERAL LIABILITY DATE(MM/DID/YY) DATE{MM/OD/YY) OMITS F•ACH OCCURRENCE S 1,000,000 A X COMMERCWLGENERAL LUBRITY 35374717 01/01/01 OZ/O1/OZ FIRE DAMAGE(Any or* $ 100,000 ]CLAIMS MADE l OCCUR - -. MED EXP(Any one Par$on) $ 1 Q,000 -- -- ' PERSONAL Y AWN/INJURY $ 1,000 000 GENERAL AGGREGATE --- $ 2,000,000 OEN'L AGGREGATE LIM(r APPLIES PER: --- POLICY— JCC I ]LOC PRODUCTS_COMP/OPAGG $ 1,000,000 AUTOMOBILE LIABILITY _ ANY AUTO COMBINED SINGLE LIMIT Y (Ea accident) ALL OWNED AUTOS ---•y- _—.._.._ __ SCHEDULED AUTOS SPOIrL,INJURY (Per Pr en) $ HIRED AUTOS ----. —_ NON-OWNED AUTOS BODILY INJURY • (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ''jj AUTO ONLY•EA ACCIDENT $ _IAN?AUTO OTHERTHAN EA ACC $ ! AUTO ONLY. ACG $--- EXCESS UABIUTY EACH OCCURRENCE $ ` -- OCCUR I ! CLAIMS MADE -_ -- —. AGGREGATE _- ___ - $ I DEDUCTIBLE -— _ RETENTION $ - --- ---$ ..... $ WORKERS COMPENSATION AND WC SIATU- DTH- t EMPLOYERS LIABILITY X I TORY LIMITS i I ER __ 31WBG06691 01/01/01 01/01/02 E.L.EACH ACCIDENT $ 100000 f; B E.L.DISEASE•EA EMPLOYEE $ 100000 E L DISEASE-POLICY LIMIT a 500000 OTHER t DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS i' CERTIFICATE HOLDER N ADDITIONAL INSURED:INSURER LETTER:_ CANCELLATION MONTVI Y. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE THE EXPIRATION p DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 14—DAYS WRITTEN Town of Montville NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Building Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 310 Norwich-New London Turnp. REPRESENTATrvES, Uncasville CT 06392 AUTHORIZED REPRESENTATIVE Kathy A. Bellemare I ACORD 25-S(7/91) OACORD CORPORATION 1988 T00/T00'd 8T££# O'PISINOI. OHZVW 70R7Tocnno en• , r r,,,.-, 05/18%01 20:36 FAX 8487231 BUILDING DEPT 03 Town of Montville Building Department 848-7166 CONSTRUCTION PERMIT SIGN-OFF SHEET /02 9 Property Address Map/Lot Job Description- 4014,4e a ///D,g,/L///yy// [(11 „..,/ ,/,‘„pit 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. HEALTH DISTRICT 823-1189 ❑ Permit#: ❑ Not Applicable Septic System Date ❑ Approved ❑ Not Applicable Plans for Food Service Establishment Date ❑ Permit#: ❑ Not Applicable Private Well Date WPCA DEPARTMENT 848-7094 ❑ Permit#: ❑ Not Applicable Municipal Sewer Date ❑ Permit# ❑ Not Applicable Municipal Water Date DEPARTMENT OF PUBLIC WORKS 848-7473 _ O Permit#: ❑ Not Applicable Director Date POLICE DEPARTMENT 848-7510 O Plan Reviewed ❑ Not Applicable Officer in Charge Date PLANNING & 2 NTNG DEPARTMENT 848-8549 7 r 2-//0l [a Permit#:ZQI - Z 97 ❑ Not Applicable Zoning Date 0 Permit#: Not Applicable Inland-Wetlands Date FIRE MARSHAL'S OFFICE 848-1175 Plan Review U Approved El Not Applicable Fire Marshal Date Joe S RC. „,,' YC. JENSENS, INC.246 Redstone Street SHEET NO. 0F___ P.O. Box 608 SOUTHINGTON, CONNECTICUT 06489 CALCULATED BY DATE (860) 793-0281 \ FAX (860) 793-6909 CHECKED BY DATE SCALE • .„,As 3 x3 cps( o n °P o(-- Pr Apron (96ca Pr- lus-cys• 3/4/7 S PAC, • 5/4.x.1, rPr. .c,kl g Lc2� Joisr (16' Cd--,v,--1) it V` ,„ 2”QCx,c,fe c, P,jo,;(;?4l1Srq'SKea1105-I thud) JENSENS, INC. JOB S Jac:^tow` OK w_ 246 Redstone Street SHEET NO. OF P.O. Box 608 SOUTHINGTON, CONNECTICUT 06489 CALCULATED BY DATE (860) 793-0281 FAX (860) 793-6909 CHECKED BY DATE I 'I1 y SCALE `� • / 1 • f• ir . • II • • . , IIMiiiiiiii . 4.. Owv,c. . • , , il . • a� il� l WM • • . • • • b II • • • • • w� a � 'aC3uCI 204.;Isopia Shee61205-I PharkE • 1— I Ni O03 O -i Cp cip CO IP° , ;EPS ID i a CO ■ p .4 X111 li>.,.,_,,_t__L 1 Off-; ti \ INTI A 111111 oYJ I 1Il\ 110 • Qy J a' oy I IMI 01 'T ■■■■ .■■n ■i�■ri 1 1—NEN a-Y- 1•I,� q (on 1-c...1_,-6-J J■/■ 1 \■■'.41,!■■■■■■■■■ y�-- — --{ c 1 E'li 3 /-z-‘ >. ...„,,,\ 3 / ,.._. \ tipC -I \N �qA I j \l � \r � .: , , , ., _ _ , � I ■ NITIRIffikPlinillir 'M1t innunionsgi Imuipalf moramovramomut unr- rk mom if „ nil rp. : ,, 1•••••••••• mil ill Ild 1111.411 .0 I ,D,. :3i 000 ,t0 iF ? Town of Montville BUILDING DEPARTMENT 310 Norwich-New London Turnpike Uncasville,CT 06382 860-848-3030,Ext.82 Plumbing Permit Permit Number: P2002-098 Permit Date: 06-Aug-02 Permit Code R5 Job Location 57 RAINBOW DRIVE UNIT: MAP/LOT: 016/T29-000 Job Description: plumbing Owner Contractor JENSEN'S INCORPORATED Efficient Plumbing P.O.Box 608 P.O.BOX 608 Unit: Montville,Ct.06353 SOUTHINGTON CT 06489-0608 Telephone: 572-0571 Lic/Reg Type: P1 Use Group R4 Lic/Reg Number: 204880 Code 1995 CABO Exp Date: 10/31/02 Construction Type 5B Construction Values Permit Fees Building Value: $0.00 Building Fee: $0.00 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: $0.00 C/O Fee: $0.00 Comments: Plan Review Fee: $0.00 Included on Building Permit State Ed Fee: $0.00 Total Fees: $0.00 It is the owners responsibility to schedule the following required inspections(minimum 48 hours notice requested): ❑ Footing-Prior to pouring concrete L; 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 V. Rough Plumbing and Leak Test ❑ Final Inspection ❑ Gas Piping and Pressure Test Certifi - - . r..-., . -Prior to use or occupancy Building Official's Signature: Town of Montville Building Department Permit# Qr 310 Norwich-New London Tpke. Tel. 848-3030, Ext 82 Uncasville, CT 06382 Fax. 848-7231 One & Two Family Trades Permit Application Form lum6ing DECectricaf 0Wechanica. .7feating Air Conditioning —Gas wiping []Other Job Location 5 7 X a ,,ti .,., 1 v Job Description/Materials ✓ 7---x?.., L e-.L,p�R.,-- . Owner n,..eiv 5 Mailing Address R ,j i,,.2_, Sk— p_0 .1- .)e �(�� City, State Zip OGL{ZS/ Tel 3----60 / 73i (Jos/ Contractor --7--= c,�tiT Ay, Mailing Address d. c 6 City V) bv.-CV(L..L.e. State Cit- Zip (_)6.- Tel S'il U /.e-32„)/ 637( Contractor's License/Registration Type&Number PI )„,Y 8 b V Exp. Datef O / 3/ / G 7 i 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 { ,0 Date / / )5 / CZ, Con ion Value Fee Building $ $ Plumbing $ $ Mechanical $ $ Electrical $ $ Other $ $ Certificate of Occupancy $ Plan Review Fee $ State Education $ Total $ $ STATE OF CONNECTICUT WORICEpS'COMPENSATION COMMISSION Buildin: Permit Affidavit for Pro.e Owners or Sole Pro.rietors (Conn. Gen. Stat. §3I-286b) Property located at In the town of Name of building permit applicant_ Please check one: I. 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(F Pursuant to §31-286b," "'-'•---•••- .......... property owner or sole proprietor .. ..--c•a --contractor -'- or principal employer"mayP P [who]intends to act as a general insurance or a"sworn notarized provide either a certificate of workers'compensation insurance for athose employed on the job site in compensation irequire proof of workers' 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 orrinei provide a certificate of workers'compensation employer.Applicant must either below. insurance or sign the affidavit ............ I hereby swear and attest that I will Affidavit ............. of contractor,subcontractor,or other workerubefore he/she hdsh men compensation insurance for every accordance with the Workers'Compensation Act(Chapter 68)_ges in work on the above property in I understand that pursuant to§31-275 C.G.S. partnership may elect to be excluded from co, officers of a corporation and partners in a District Oflice vcragc by filing a waiver with the appropriate 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 BUILDING DEPARTMENT 310 Norwich-New London Turnpike Uncasville,CT 06382 860-848-3030, Ext.82 Mechanical Permit Permit Number: M2002-19 Permit Date: 09-Aug-02 Permit Code R5 Job Location: 57 RAINBOW DRIVE UNIT: MAP/LOT: 016/T29-000 Job Description: LP-Gas piping and tank Owner Contractor JENSEN'S INCORPORATED Spicer Gas Co 36 Thames Street P.0. BOX 608 Unit: Groton,CT 06340 SOUTHINGTON CT 06489-0608 Telephone: 860-445-2436 Lic/Reg Type: G1 Use Group R-4 Lic/Reg Number: 308503 Code 1995 CABO Exp Date: 8/31/02 Construction Type 5B Construction Values Permit Fees Building Value: Building Fee: $0.00 Plumbing Value: $0.00 Plumbing Fee: $0.00 Mechanical Value: $500.00 Mechanical Fee: $10.00 Electrical Value: $0.00 Electrical Fee: $0.00 Other Value: $0.00 Other Fee: $0.00 Total Value: $500.00 C/O Fee: $0.00 Comments: Plan Review Fee: $0.00 State Ed Fee: $0.08 Total Fees: $10.08 It is the owners responsibility to schedule the following required inspections(minimum 48 hours notice reauested): ❑ Footing-Prior to pouring concrete ❑ Rough HVAC ❑ Backfill-Footing drains and waterproofing ❑ Fireplace Throat ❑ Concrete Slab-Prior to pouring ❑ Fireplace Final ❑ Rough Framing ❑ Chimney-One flue above thimble E Rough Electrical ❑ Firestopping/draftstopping ❑ Electrical Service ❑ Insulation ❑ Rough Plumbing and Leak Test 0 Final Inspection ❑d Gas Piping and Pressure Test J Certificate o •-..,;ancy-Prior to use or occupancy Building Official's Signature: f )1f Town of Montville Building Department Permit# 310 Norwich-New London Tpke. Tel. 848-3030, Ext 82 Uncasville, CT 06382 Fax. 848-7231 One & Two Family LP-Gas Permit Application Form Job Location S � ;�cG� i36\ RS:��=;GN�s Job Description/Materials e �Qla'�r� Owner���$�•J S T, Mailing Address �t State Zipic.,t(1°-‘ Tel /sn'3 / Contractor �i���CO Mailing Address "\C... . City CA..INState moi". Zip' C'.54 Tel '\ /C44S / Contractor's License/Registration Type&Number Cr- `�D$ S b3 Exp. Date $ /%1 /4 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 ..,, Date ' / / Construction Value Fee Building $ $ Plumbing $ $ Mechanical $ S�o ,a c $ /U. Electrical $ $ Other $ $ Certificate of Occupancy $ Plan Review Fee $ State Education $ o•d 8 Total $ /c� o� 0 Town of Montville Building Department Receipt Date < - / Z / c 1 4;;;) No. 01997 From: 15-0 C g2 /� Job Address: / I : Ark) Amount $ /0 . O q ( CasID Check (Circle onc) Check # f; Received by �• ccii-r•rt,-e, ------ Permit #)y7�oZ-//� STATE OF CONNECTICUT I)EPiiRT41E.A'7 OE( )VS'(':bIER PROTECTION r HEATING,PIPING&COOLING LIMITED CONTRACTOR Type:G1 HAROLD E EVERETT JR 80 GEORGIA ROAD OAKDALE, CT 06370 LIC./REG. NO. EFFECTIVE EXPIRES 308503 09/01/2001 :• 0/31/2002 SIGNED: