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Town of Montville
BUILDING DEPARTMENT
310 Norwich-New London Turnpike
Uncasville, CT 06382
(860) 848-3030, Ext. 382
Electrical Permit
Permit Number: E2004-0066 Date: 16-Mar-04 Map/Lot: 043/009-022 Owner ID 1760
WS WAY Unit
Job Location:
Job Description: Electrical & Electric Service
Owner: Contractor:
RTT Development Millovitsch Electric
43 Lisbon Heights
35 Blais Road Lisbon Ct. 06351-
Uncasville CT 06382 Telephone: (860) 376-2153
Lic/Reg Type/No. E1 104995 Exp Date: 30-Sep-04
Tenant:
Self
Telephone:
Construction Values Permit Fees Construction Information
Building Value: $0.00 Building Fee: $0.00 Use Group: R4
Plumbing Value: $0.00 Plumbing Fee: $0.00 Code: 1995 CABO
Mechanical Value: $0.00 Mechanical Fee: $0.00 Construction Type: 5B
Electrical Value: $0.00 Electrical Fee: $0.00 Permit Code: R5
Other Value: $0.00 Other Fee: $0.00 Comments:
Total Value: $0.00 CO Fee: $0.00 Included on Building Permit
Plan Review Fee: $0.00
State Ed Fee: $0.00
Total Fees: $0.00
It is the owners responsibility to schedule the following inspections (minimum 48 hours notice reguired)•
❑ 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
F-/~ Rough Electrical ❑ Insulation
Q Electrical Service CRS 317507 ❑ Final Inspection
❑ Rough plumbing and leak test ❑ Certificate of Occupany
❑ Gas piping and test
Building Official's Signature:
.S 5 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 Trades Permit Application Form
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Job Description/Materials
Owner r-2,-\-\" ; Mailing Address
City V: Stated ' Zip Tel I I
Contractor CN\\\ %fr\-,)~ Mailing Address
State \ Zip c010 Tel 366/3? /,zI 21 5
Contractor's License/Registration Type & Number ki,\ \5 Exp. Date/ 3 /04
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 $ $
Electrical $ $
Other $ $ .
Certificate of Occupancy $
Plan Review Fee $ .
State Education $
Total' $ $
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ELECTRICAL UNLiNUTED CONTRACTOR
jo$B-pH N MILLO` ITS>~H JR
43TISBON I-ILTCHTS
LISBON, CT 06351
TXTE: El
EFFECTIVE EXPIRES
I C. r REG NQ ,11.-.
104995 10/01/2003,
SIGNED _
J
STATE OF CONNECTICUT
WORKERS' COMPENSATION COMMISSION
Building Permit Affidavit for Froperty Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at:~
In the town of 01J~7
Name of building permit applicant:
Please checJ one:
1. I am the owner of the above property.
2. I am the sole proprietor of a business.
2A. Name of business: y~ CSC l i
2B. Federal Employer Identification Number (FEIN) d(z,
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 chec one:
1. I do not intend to act as a neral contractor or principal employer.
[Sign and stop here]
Signature of applic t
T-
2: I intend to act as a en al contractor or principal employer. Applicant must either provide a
certificate of workers mpensation 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)