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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: E2003-0019 Date: 22-Jan-03 Map/Lot: 037/002-045 Owner ID 2503
Sob Location: $ ANDERSEN LANE__ Unit
Job Description: Electrical & Electric Service
Owner: Contractor:
Cyr Construction Inc Wayne R. Thompson, Jr.
31 Lisbon Heights
135 Providence Street Lisbon Ct. 06351-
Taftville CT 06380 Telephone: (860) 859-6601
Lic/Reg Type/No. El 181667 Exp Date: 30-Sep-03
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
Plan Review Fee: $0.00
State Ed Fee: $0.00
Total Fees: $0.00
It is the owners responsffi ity to schedule the followingjnsp ion (minimum 48 hours notice required):
❑ 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
0 Electrical Service ❑ Final Inspection
❑ Rough plumbing and leak test ❑ Certificate of Occupany
❑ Gas piping and test
Building Official's Signature:
Town of Montville
Building Department Permit #/~~3~ 9
J
310 Norwich-New London Tpke.
Tel. 848-3030, Ext 82 Uncasville, CT 06382 Fax. 848-7231
One & Two Family Trades Permit Application Form
F]Ph mbing nErectrkaf nMechanicaf
l .~feating
Air Conditioning
GasPcpang
Other
job Location So, "A
Job Description/Materials
Owner Cry e. S4-poi C~ Mailing Address i Prf j ~ n ~e SI t
City %ac~srJ ~I State G_ Zip Tel frO / 61rT
Contractor k lko" 5-O'l OP- Mailing Address 9/ 1-,'5 An 6--P-5
City State C' Zip v (v ~S E Tel F60 l 37/v/ (Gf $
Contractor's License/Registration Type & Number Exp. Date 9 / ?,-)I
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.
? / J
Owner /Agent Signature Date L)
Construction Value Fee
Building $ $
Plumbing $ $
Mechanical $ $
Electrical $ `/vaC7 $
Other $ $
Certificate of Occupancy $
Plan Review Fee $
State Education $
Total
ELECTRICAL>UNTLlNllTED GONTRA.CTOR
I WAYNE RTHOMPSON JR
31 LISBON HGTS
1 LISBON, CT 06351
TYPE: FA
LIC.JREG N0. EFFECTIVE EXPIRES 1
].81b(77 10/01/2002 09/30/2001
SIGNED ~
J* ,
.
Fir
STATE OF CONNEcnaw
WORKERS' -COMPENSATION COMMISSION
BuiIdine I'erwit Affidavit for Prope rty ()UVng~ or Sole Proprietors
(Conn. Gen. Stet. § 31-2866)
Property -located -at C-5-aA
-
In the town of n f r~((
Name of building permit applicant: G,,)a y n e_
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 IdentificatioaNumber (FEIN} .
Pursuant to § 3I 286b, "a property owner or sole proprietor [who] intends to act as a general
contractor or principal employer" may provide either a c ofworke & compensation
insm.nce.or a "sworn notarized affdav' _ _ stating that he wiiH =Vim proof of workers"
compensation insurance: for all those employed on the job site in accordance with this chapter."
Please check one:
I . X I -do not intend to act as a general contractor or prineipaj employer:
[Sign and stop here]
Signs of applicant
2. I intend to act as a general contractor or principal employer. Applicant mast either
provide. a certificate of worker' compensaton insurance-or sign the affidavit
below.
Adavt
I km* swear and-attest that I will require proofof. workers' con
contractor, subcontractor, or other worker before hefshe en8a8a pct} work on work the insurance above for per every
-acootdanec with the Workers' Compensation Act (Chapter-568a. -
I undOstaud*tkat pursuantto § 31275 C.G.S., officers ofa cmpomtion and
Putnership may elect to-be excluded from cove ra anen is a
- ge by 8 a waiver with the appropriate
-District Office ; -and that a sole proprfetor of a business is not mquired-to have Coverage Unless he
files his-intent to accept coveram
Signature of applicant
SnbsM'bed and sworn to before nii~ this -,day of
.:(Notary PubW Cmmis sionw-of the Superior Ccuat)