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Roof over Mobile Home 2003 Town of Montville BUILDING DEPARTMENT 310 Norwich-New London Turnpike Uncasville,CT 06382 (860)848-3030, Ext. 382 Building Permit Permit Number: B2003-0501 Date: 09-Sep-03 Map/Lot: 016/T29-000 Owner ID 122526 Job Location: 61 RAINBOW DRIVE Unit Job Description: Aluminum Roof over-mobile home Owner: Contractor: Richard L Murdock R&R Mobile Home Service P. 0. Box 553 61 Rainbow Drive Moosup Ct. 06334- Uncasville CT 06382 Telephone: (860) 564-5658 Lic/Reg Type/No. HIC 527990 Exp Date: 30-Nov-03 Tenant: Self Telephone: Construction Values Permit Fees Construction Information Building Value: $3,000.00 Building Fee: $16.00 Use Group: R4 Plumbing Value: $0.00 Plumbing Fee: $0.00 Code: 1995 CABO Mechanical Value: $0.00 Mechanical Fee: $0.00 Construction Type: 58 Electrical Value: $0.00 Electrical Fee: $0.00 Permit Code: R4 Other Value: $0.00 Other Fee: $0.00 Comments: Total Value: $3,000.00 CO Fee: $10.00 Plan Review Fee: $0.00 State Ed Fee: $0.48 Total Fees: $26.48 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 ❑N Final Inspection ❑ Rough plumbing and leak test ❑ Certificate of Occupany ❑ Gas piping and test Building Official's Signature: , 411, Town of Montville Building Department Permit# 310 Norwich-New London Tpke. Tel. 848-3030,Ext 382 Uncasville, CT 06382 Fax. 848-7231 One & Two Family Building Permit Application Form New Construction El Addition fl Alteration D Accessory Structure 0Other /1O 6 i 1 C Ho.--e Af Ur+ yv✓•.. i2O o1u.rc t- Job Location 6 j + y Ott V`C va'uf 14 Ile Cl— Job Description/Materials Moho,I 4 /A(o,.., 24:7o Lo ie -. c,.,,`n, �l /NSvlare 0-, U"61 /too(. Owner RI Clun-1AA VA-010 C k— Mailing Address 6 do., Wit 1'4- City V N ca State ek Zip b g g3 a Tel 860 / a VY, 31 03 Contractor R4-i ,06iif 44--e SVf."• Mailing Address p 0 /30x SS 3 City /110 OJ°P State Zip O) 3 3 y Tel rW /S6 7 / Sip 54-) Contractor's License/Registration Type &Number Hh C. 5a7 9 S0 Exp. Date if / 30 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 r Date ) / 6) / °"? Construction Value Fee Building $ / 6 Plumbing $ $ Mechanical $ $ Electrical $ $ Other $ $ Certificate of Occupancy $ / ) Plan Review Fee $ State Education Total $ 3� 1700. $ (See Reverse side for additional requirements) STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION Building Permit Affidavit for Property Owners or Sole Proprietors (Conn. Gen. Stat. § 31-286b) Property located at: 6 / r 60 In the town of Nl i v //C Name of building permit applicant: /14 /1215 i ' S V, `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) 0 VC— 6c) -- Y.12 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 c eck one: 1. I do not intend to act as a general contractor or principal employer. [Sign op er 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 Building.Department Receipt Date 7 /___y___/___47_3 No. 03133 Lyol t From: 7 // We,h4E'' C� rV i c''. e. Job Address: (6D 1"4 ' Amount $ Cash `� �+� • — Check # �"�"��, f Received by 1• i �, , ' l / Permit # (� -- I