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Roof Overlay 2002 Town of Montville BUILDING DEPARTMENT 310 Norwich-New London Turnpike Uncasville,CT 06382 860-848-3030, Ext.82 Building Permit Permit Number: B2002-535 Permit Date: 26-Sep-2002 Permit Code R4 Job Location: 19 RANDY LANE UNIT: MAP/LOT: 039/044-000 Job Description: Roof Overlay Owner Contractor NORBERT+ROZOLIA ORZECHOWSKI Norbert Orzechowski 19 Randy Lane 19 RANDY LANE Unit: Uncasville,Ct. 06382 UNCASVILLE CT 06382 Telephone: 848-8981 Lic/Reg Type: Use Group R4 Lic/Reg Number: 0 Code 1995 CABO Exp Date: Construction Type 5B Construction Values Permit Fees Building Value: $3,500.00 Building Fee: $22.00 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: $3,500.00 C/O Fee: $10.00 Comments: Plan Review Fee: $0.00 State Ed Fee: $0.56 Total Fees: $32.56 Jt is the owners responsibility to schedule the following reauired 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 0 Final Inspection Cl Gas Piping and Pressure Test = ificate of 0 -:..•.cy-P 'sr to use or occupancy Building Official's Signature: �� `= Town of Montville Building Department Permit#16,06 '-,f ' 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 0 Addition cg Alteration 0 Accessory Structure OOther Job Location /q', PQ 14 c{ LOW( Job Description/Materials '/j/A.) 7. iLo Die‹.1.— h, CL Aye Owner p/ fl&r? ( O I2 2 L-Ckt21.4(e Mailing Address / 9 �Q/v cJy 6y 1 City ,/ Ca_/) S Ni//e State— L Zip Tel 1 ti1lf''Cj / Contractor 6 'ff‘ Mailing Address City State Zip Tel / / Contractor's License/Registration Type&Number 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 _do /. _ � . . ,1 Date q / 1, / 200 'z___ Construction Value Fee Building $ 3 S-e 0 / $ cRa Plumbing $ $ Mechanical $ $ Electrical $ $ Other $ $ Certificate of Occupancy $ f 4 ,--- Plan Plan Review Fee $ State Education $ 5_4, Total $ \3_0(`) $ \s_5. ' . (,/��"'/" Permit Fee Calculation Spreadsheet MISCELLANEOUS PERMIT CALCULATION Pools&Spas Above Ground Round EA $ 3,000.00 $ - Above Ground Oval EA $ 5,000.00 - In-Ground EA $ 18,000.00 $ - Heater EA $ 3,300.00 $ - Hot Tub EA $ 5,000.00 $ - Roofing Strip&Reroof :SQ $ 210.00 $ - Overlay 20 SQ $ 175.00 $ 3,500.00 Sheds With Electric SF $ 25.00 $ No Electric SF $ 25.00 $ - Deck SF $ 15.00 $ - Porch SF $ 23.00 $ _ TOTAL BUILDING CONSTRUCTION COST $ 3,500.00 PERMIT FEE Building S 3,500 $ 22.00 Mechanical S - $ . - Electrical S - $ - $ $ CO Fee $ 10.00 Plan Review $ - State Ed Fee S 3,500 $ 0.56 Total Fees $ 32.56 Based on 2000 Average Construction Cost 9/10/02 Town of Montville Building Department Receipt Date / , jd„ No. 02136 , 410 � , From: /..� , ice- _ .. ......."_ Job Address: /111,NriAr 'Mr 11 Amount $ ,?, Cash Check Check # ((ircle one) Received b s�'�, is •.ri _ �/. Permit is/110\7000 �'' i� STATE OF CONNECTICUT WOE'COMPENSATION COMMISSION BuiIdin• Permit Affidavit for Pro.e Owners or Sole Pro.rietors (Conn.Gen. Stat. §31-286b) Property located at In the town of ig/ 4 4117 Name of building permit applicant: i/'� _ 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 PPuisuantcontractotoo§31- 86b,"aproperty owner or sole proprietor[who] ntend.....-c-.s._...n..._ r principal employed'may provide either a intends to act as a general insurance or a"sworn notarized affidavit... �of workers'compensation compensation i fit'-- stating that he will proof of workers* insurance for all those employed on the job site in accordance with this chapter" Please check one: 1..X1 do not intend to act as a general contractor or principal employer. [Sign and stop here] A, ' / c12.9C' Signature of applicant 2._I intend to act as a gen 'contractor ori rincI provide a certificate of workers'compensation p � employer.Applicant must either below. pcnsation insurance or sign the affidavit Affidavit ........ --- 1 hereby swear and attest that I will require contractor, subcontractor,or other worker before he/she he/sh�of �compensation insurance for every accordance with the Workers'Compensation Act(Chapter 68)_ work on the above property gages in in I understand that pursuant to§31-275 C.G.S.,officers of a co partnership may elect to-be excluded corporation and partners in a District m Office; and that a sole from coverage by filing a waiver with the appropriate files his intent to accept coveragcpnctor of a business is not required to have coverage he Signature of applicant Subscribed and sworn to before me this day of 200 . (Notary Public/Commissioner of the Superior Cot