HomeMy WebLinkAboutElectric for AG Pool
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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: E2003-0257 Date: 11-Aug-03 Map/Lot: 030/043-043 Owner ID 2001
Job Location: 4 AMANDA CO Unit
Job Description: Electrical for pool
Owner: Contractor:
Michael J and Charyl L Fleener Michael J and Charyl L Fleener
4 Amanda Court
4 Amanda Court Uncasville CT 06382-
Uncasville CT 06382 Telephone: (860 367-0668
Lic/Reg Type/No. 0 Exp Date:
Tenant:
N/A
Telephone:
Construction Values Permit Fees Construction Information
Building Value: $0.00 Building Fee: $0.00 Use Group: R-4
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
Plan Review Fee: $0.00
State Ed Fee: $0.00
Total Fees: $0.00
It is the owners resoon ibilitV to schedule the following ins ion (minimum 48 hours notice requumd)i
❑ 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 W Final Inspection
❑ Rough plumbing and leak test ❑ Certificate of Occupany
❑ Gas piping and test
Building Official's Signature:
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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Air Conifitioning
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Job Location
Job Description/Materials '?o L ~~~;rc • co. d si P
Owner Mic+4n L ~zi),:*~z2 Mailing Address_ 7
City "ncca.S,41!.{ State c r ' zip ol6.36Z Tel B(oo 13o / oWeS
Contractor, 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 Date ~8 I t / v
Construction Value Fee
Building $ $
Plumbing $ $
Mechanical $ $
Electrical $ $
Other $ $ .
Certificate of Occupancy $
Plan Review Fee $ .
State Education $
Total' $ $
6
! STATE OF CONNECTICUT
WORKERS' COMPENSATION COMMISSION
Building Permit Affidavit for Property Owners or Sole Proprietors
(Conn. Gen. Stat. § 31-286b)
Property located at: y
In the town of ~t/1o 1,1,711
Name of building permit applicant: _ ~1«t,~~ ro~~~R
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 § 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 clue k one:
1. 1 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 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)
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