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HomeMy WebLinkAboutSFR - Mechanicals Town of Montville wk: Building Department 310 Norwich-New London Tpke. Tel, 848-3030, Ext 382 Uncasville, CT 06382 Fax. 848-7231 Residential LP-Gas Permit Application Form Singfc'FamlC Ej Two-Eamlfy Townhouse Permit # ig 1 Job Address OLLISo ►''1~ 0A q )DPib , C_+ 0 (o 3,7 L) (Number) (Street) (Unit) Job Description_ 'DSbI L U n DeIZ G,~t l i'1 i~ t n eS hPRibX 7D,C U 1 ena 11 boo qt~ J ~Ij Pr(~ ~p►2 : ~z A>~v>~ - c~►rrea~ L a+ - Dr -e r - Coo kr - - ida ( 4et Owner FYl 1C a rlsDr~ Mailing Address IQ PLU So r) W o w city k< 1 , i✓ State L' Zip 0(b3")0 Tel ROD / c93 J`-/ J~_ Contractor mm Cj Is Mailing Address 193 L~. Donyn pcoy-) 1,~) City ~SM fe-M State Zip O Co (-IaO Tel RoD/RV/ Contractor's License Type & Number 6~T 3969' r)S 4. PC Exp. Date d 3 f / ,3?©p 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. Separate applications are required for electrical. qf2L~~~~...~Date Owner /Agent Signature d / / 0 / 200 CP Construction Value Fee Mechanical $ j~ D . D7~ $ l Electrical $ $ Plan Review Fee $ State Education $ . o Total $ 0 ° $ F, O 5 RtvisedSeptem6er9, 2004 Town of Montville Building Department File Receipt Date: 09-Jan-06 Receipt No: 967 Received From: Advanced Gas Job Address: 12 Allison's Wa Fees Collected State Educational Training Fee Cash: $0.00 Cash: $0.00 Check: $8.05 Check: $0.05 Check No: 3531 Construction. V lue: $300.00 Demo' ' n V $0.00 P Received By Joseph Summer r-fc-vJ,itVt 7.0^hI, VVh' L I l VIt4 4V+yr~vo ,OOV fIJ flCy v State of cone e tl Dopartmer)t of c u ConsuMor Protection _ L1CE N.S. E~RIFJ iC~ AT1 0 N This is to ce y >1that tha Connecticut Department of Indlcpte the >f0110WIng. lnformaflpn regardln,. g Con-tsU.mer Protection's rec MARK MART/N 67 FOR$YTH (gip 0620 STATE OF CONNECTICUT + DEPARTMENT OF T CONSL1`VViiE~ PROTECTION Be it known that MARK A MARTIN 67 FORSYTH RD SAL.ENj CT 06420 has been certified by'ilie Department of Co psi mer Protection as a HEATING, PIPING & COOLING LIATUED CONTRACTOR G3 Lxcens`e # c Effective: 09/01/2005 Expiration: 08/31/2006 H Edwin R Rodriguez, Cot "`"nmissionet From: Pat Barrett At Bailey Agencies Inc FaxID:860-448-1608 To: Anne Made Date, 10/28105 03:07 PM Page: 2 of -cow. CERTIFICATE OF LIABILITY INSURANCL' orin p DATE (MM/DD/YYTN) ADVAN-6 10/28 05 FRooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bailey Agencies, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 64 Plaza Court, PO Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Groton CT 06340-0001 Yhone:860-446-8255 rax:660-448-1608 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Range= Insurance INSURER B: A..saoan Znc.zdtaonaa Co Advanced Ga Sales & Service INSURER C: Stacey Martin 183 East Haddam Road IN$URERD: Salem CT 06420 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N4AE0 ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMEW, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURMCE 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 BY PAID CLAIMS.. LTR NS TYPE OF INSURANCE POLICY NUMBER PATE MM/p DA MMRT LBNTS GENERALIaABILtTY EACH OCCURRENCE SSOOOOOO COMMERCIAL GENERAL LIABILITY ZNG0238284 10/01/05 10/01/06 PREMISES Eaoccu.nc. $ 300000 A X CLAIMS MADE X OCCUR MEO EXP (Any p pv n) $ 50 O O PERSONAL B ADV NJURY $1000000 GENERA. AGGREGATE ;2000000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG 1$200000 F-1 PRO- f7 ' I POLICY LOC AUTOMOBILE LIABILITY COMBINED EeD I,INGLE LIMIT $1000000 A X ANY AUTO SBA0364746 10/01/05 10/01/06 (ED a ALL OWNED AUTOS BODILY INJURY j SCHEDULED AUT04 (Pw p.rson) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per OwIdoru) i PROPERTY DAM•IAGE j . (PIN eCdldanq GARAGE LLuLay AUTO ONLY - CA ACCIDENT AVN A j ACC ; O A~Y AGG i R ESS/UMBREU.A LIABILITY EACH OCCURRENCE j ~,Q 000 Q Q A X occlrR CLAMSMLADE CUP0421934 10/01/05 10/01/06 AGGREWTE $ 1000000 j DEDUCTIBLE X RETENTION $10000 _ FLOYER$ corn COM LIABILITY AND X R B UTY NC7 7 62 S O O 10 Ol WoR k / /OS 10/01/06 j 500000 ANY,PROPRIETOTLPARTMERIE)(ECVTIVE OFFICER&O'eER EXCLUDED? YEE s500000 If SPECIAL AL PRO PRO wwx LIMIT VISIONS below OTHER A Property Section ENG023.8284 10/01/05 10/01/06 O SCWPTIO O NS H C E S D RS >iP PR ProoSioB insurance with regards to the named insured. Original Issue Date 10/28/05 CERTIFICATE HOLDER CANCELLATION ADVANCI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSVRER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 80 SHALL Advanced Gas sales & service Stacy Martin IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR • ' 183 East Haddam Road REPRESENTArnBS. Salem, CT' 06420 AUWORMD PRESENTATIVE ACORD 25(2D01108) CORD CORPORATION 1988 ADVANCEQ: GAS SALEM, , CT 08 183 E. CT 06ROAD 420 hone 860- 0-8 9-362 8597-9070 SALES & SERVICE Faxe 88 BUILDING DEPARTMENT RE: BUILDING PERMIT APPLICATIONS PROPERTY ADDRESS: A LLl sore Uojj AK DAL( C-,f 0(,3170 OWNER: CSO DESCRIPTION OF JOB: sfail u n u 0 d L-vi flS a0lor0k fteet U S b , e . ~ t ~e T ) k - C~ 0 wa - Dr' f-e,)r - Coo STARTING DATE: LICENSED CONTRACTOR: MARK MARTIN HTG.386875 LICENSED CONTRACTOR'S AGENT: rs~) PLEASE ALLOW MY EMPLOYEE TO PULL OR DELIVER THIS PERMIT. Sincerely, !jar HEATING, PIPING & COOLING LIMITED CONTRACTOR V G1 ' MARK MARTIN MARK A MARTIN PRESIDENT 67 FORSYTH RD SALEM, CT 06420 LIC. / REG NO. ~FFOE/2005, IVE EXPIRES 386875 ' ' ~08/31/2006 SIGNED OFCONNECTiCU ArcC l FINANCING.STATEML,aT Follow Instructions Catoui Requesting Party Oust ID Space for filing office use only Name Addrase. City State . t • DEBTOR'S CT FULL LEGAL NAME - Insect only QM debtor name (1a or 1b) -do not abbreviate or combine namea 10. WMW%NtZATIQK8 NAME 1 I DNID $ LAST ME aFIRON NAME MI DLE NAM to MAILIN A D SSSTATE POSTAL CODE COUNTRY F RE 1TYPE 1e. JU 1 I OF O ON 1f. R TION a P N ORGANIZATION DE$TOA 2, ADO OVAL EgTOR'S EXACT FULL LEGAL NAME -Insert only og debtor name (As or 2b) - do not albbTvfste or cotMihe names 2a OAGANIZATICNIS N OR 2b.1 IVi0UA1'S LA T NAM FIRST AME MIDDLE NAME SUFFIX 2c, MAILING AD RESS CITY S TE POSTAL CO E COUNTRY A 01 IN R" 2d. TYPE OF R RATION J ' ktISDICTION F OR IZATI N RQANI T AL t0 tl OP 10 ORGMIZAT16N DNAL EBTOR 3. SECURED PARTY S NAME (or NAME of TOTAL ASSIGNEE of ASSIGNOR S7P) -Insert oNy Qm secured party name (3a. or 3b,) Sa. MT E F~jT:~~ OR (IR N E MIDDLE NAME SUFFIX f CITY 8 P08TAL CODE COUNTRY ~t 4. This FINANCING STATEMENT covers the tottovaing coitateral: C) (Do 0 ~ ~ b 1 s L) nr ~ C CAP-LS O vIJ 6. AL NATIVE DESI ION (t aWft ble) Q LESSEWLESSOR Q cONSIGNEE/CONSIGNOR Q 8AILEeM,-jL0R Q SEUMSUYER OPTIONAL FILER REFERENCE DATA FILING OFFICE COPY - CONNECTICUT UCC FINANCING STATEMENT (FORM UCCt) (REV. 08128/2001) y., Town of Montville Building Department 548-30.30, Ext 382 RESIDENTIAL LP-GAS PERMIT CONSTRUCTION PERMIT APPROVAL f f gin: - /f-f/~t e4l ( -'f 7,0 Proper(y Address Job Description The applicant is responsible for obtaining all of the required approvals checked off on this form. No building permit will be issued until all of the required signatures have been obtained. Required Department Permit Issuance Approval Approval Tax Collectors .rae g /0 J WPCA Si.gnaW:rc dish Planning & Zoning `signature! kkite Health Department ig), awl' O" lots-, Fire Marshal .'i<gnaftire' dater Comments/Conditions: P,p*eds"m6er9, 2004