HomeMy WebLinkAbout208 Old Farm Road (7)3 3 TO THE BUILDING INSPECTOR
s. of the APPLICATION FOR
PLAN EXAMINATION ANOTOWNOFWIIrDSOR, COW
PLAN
PERMIT
IMPORTANT — Applicant to complete all items in sections: 1, It, /it, IV, and IX.O
ZONINGI• AT (LOCATION) l/ 4-f"1 RC51 DISTRICT
LOCATION NO.) STREET)
OF BETWEEN AND
BUILDING CROSS STREET) CROSS STREET)
LOT
SUBDIVISION SJLLINILIhd. (E USTA LOT ` BLOCK SIZE CP_ V,
N
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D v
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking' most recent use
1 New building Residential Nonresidential I2Addition([/residential, enter number 12 One family 18 Amusement, recFeationa!
o/ new housing units added, if any,
in Part D, 13) i 3 ':wia or more family — Enter 19 Church, other religi us
number of units— — — — -0- 20 Industrial3 Alteration (See 2 above)
14 Transient hotel, motel 21 Parking garage4 Repair, replacement or donfiito y — Enter number
5 Wrecking(//multifamily residential, o/units ——————— — —1 22 Service station, repair garage
enter number o/ units in building in 15 Garage 23 Hospital, institutional
Part D, 13)
16 Carport 24 Office, bank, professional
6 Moving (relocation)
p
17 Other — Specify 25 Public utility
7 Foundation only 26 School, library, other educati nal
B. OWNERSHIP 27 Stores, mercantile
8 fA Private (individual, corporation,28 Tanks, towers
nonprofit institution, etc.) 29 Other — Specify
9 Public (Federal, State, or
local government)
C. COST Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g., food
processing plant, machine shop, laundry building at hospital,elementary
10. Cost of improvement,,,,,,,,,,,,,,,, S school, secondary school, college, parochial school, parking garage for,
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed, enter proposed use.
in the above cost
a. Electrical......................
b. Plumbing ...................
c. Heating, air conditioning.......
d. Other (elevator, etc.)............
11. TOTAL COST OF IMPROVEMENT I$ V+
III. SELECTED CHARACTERISTICS OF 60,.:ILDING — =or new buildhn;s and additions, complete Parts &E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS
30 Masonry(wall bearing) 40'Public'or private company
48• Number of stories................
31 Wood frame 41 El Private (septic tank, etc.)
49• Total square feet of floor area,
all floors, based on exterior
32 Structural steel dimensions .....................PtJ
33 Reinforced concrete H. TYPE OF WATER SUPPLY
34 Other — Specify 42 Public or private company 50• Total land area, sq. ft. ...........
43 Private(well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
F. PRINCIPAL TYPE OF HEATING FUEL 1. TYPE OF MECHANICAL
51. Enclosed ....................
3515-Gas Will there be central air 52. Outdoors....................... r
36 Oil conditioning?L. RESIDENTIAL BUILDINGS ONLY
37 Electricity 44 Y s 4r$ No 53. Numb r of bedrooms.............. 4
38 Coal
39 Other— Specify Will there be an el votor? Full..........
54. Number f
46 Yes 47T N both( ms
Partial........
IV. IDENTIFICATION — To be completed by all applicants t
Name Mailing address — Nurnlrrr, sfrrrt, cil v, star/ .Glaze ZIP code Tel. No.
1. az3 s
Owner or
Lessee ICtDWI 1 V
2.
Contractor
3.
Architect or
Engineer
The owner of this building and the undersigned agree to conform to all applicable laws of this jurisdiction.
Xre.
fopplicant Address Applicati n dot
i 7 d
00 NOT WRITE BELOW THIS LINE db
V. PLAN R EVI EW RECORD — For office use
Plan Review Date Plans Date PlansPlansReviewRequiredCheckFeeStartedBYApproved BY Notes
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Permit or Approval Check Date
Obtained Number By Permit or Approval Check Date Number ByObtained
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building
Permit number 13281
Bui Iding
Permit issu d June 14 14 83
Building
Permit Fee $384 a 00
Apt
TITLE
E
i
I
TOWN OF SOUTH `iVINDSOR
BUILDING PERMIT
I
Date .hrnp 14 19 83
l
Fee Paid $.3.84..00 Est. Value $. .63.,7 00
Permit 13287
on the Side of
Lot #20 Old Farm Road Save
Street No. 208
Owner Southridge - Rene Vellleux
Apoimt Rene Veilleux
i
CERTIFICATE OF OCCUPANCY ISSUED:
i Date
No..6396
Fee Paid $ 3.00
CLASSIFICATION
Dwelling
BU=ING PMUWr
i
I
N° 1328'7
OFFICB OF
I
THE BUILDING INSPECTOR
of the
Town of South Windsor, Conn.
I
South Win Jim& 14 19 83Conn.
I
I
That Southri_dgp EstA 8 ?n.94is is to (fiertif;,
is hereby granted permission to Dwelling
i
at estimated value of
I
on the side of Lot #20 Old Farm Road Street on land
owned 6y Rene Ve i l leuxx
Said Work to be as described in Application
No. 1,3587 . and to conform to specifications and plans filed with said Application, and Building By-
Laws of THE TOWN OF SOUTH" WIMSOR.
Issued June 14- _ 19 830
Building Inspector.
Streets and sidewalks, obstructed by excavations or building materials, must be guarded by barrios
during the day and by both barriers and colored lights by night.
SECTION 1343, GENERAL STATUTES OF CONNECTICUT: "When any person shall place
or keep building materials, or any obstacle in any highway (or any sidewalk) either with or without a
license therefor from the city or borough in which such highway may be situated, he shall pay said city,
t wn or borough all cats and damages which it shall sustain, or be compelled to reason therefor."
Dwelling - Lot #20 So.Ri 6/14/83
Southri'dge Estates, Inc. r
208 Old Farm Road
Permit # 13287
Electrician A. Mozzicato 8055
Heating Contr. Ace Mello 5660
Plumbing " Ace Mello 6169
Oil Burner
Certificate of Occupancy 6396
Plot plans apprd. per Engr.
Permit No. TOWN OF SOUTH WINDSOR
SOUTH WINDSOR, CONN.
Permit N 6396
Certificate of Occupancy
that-theTCERTIFY, 14
at No.'''" A"4''` in the o`vn of South Windsor, Connecticut, has
been erected and completed in accordance with :dBuMing Code and Zoning Regulations of
n of South Windsor, and is hereby approl o occupa ncytheTow
y Building Inspector
caner, Builder
Date 19
Fee Paidi
i
t
N / - ;JO L I( N / F W D COMPANY
166.E 5710
0*0
h i
LOT 21 LOT \2O, Q
0 m
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NQ \
250 cv 4J O
V)40
sf V
f;:a
o
4% LSw-
SO .L o t' - LNL
Rs25.001
L =39.2T
10 . 00
N T - OT - V
AV\
0 L D \\ FARM ROAD
24T.8 \
L.239.8 I
MAP REFERENCE TAKEN FROM A MAP ENTITLED S EC TI&4 SY PROPERTY DO SOJTN RIOGIC ESTATES A88Y
ROAR 9 NEVERS ROAD SOUTH WIN DSOR, CONN. PLOT PLAN SCALE: 1 40' DATE: 12 '27• 78 REV.8- 2818, ••18- 80
10-21-84 41 - 81. 12-2-82 DRAWN: A.V. H. CHECKED E.W.L. PROJJICT: 711-48 SHEET 2 OFT EMIL W. LUCEM,
ASSOCIATES 5 OAK LAND ROAD SOUTH WINDSOR, COMM,
NA
V y. /C DF COHN(,,
W.
A
ti
ORAL h
yWMtuiH•uM
8055
ELECTRICAL APPLICATION
Application No. 9166
on the side of
Lot #20 Old Farm Rd. Street
i
i
Street No. 208
Owner Southridge Estates
Electrician Anthony Mozzicato
i
FILED IN OFFICE Or-
The Building Inspector
Aug 3g 19 83
INSPECTION.
rsr No Electrical Work shall be started until a Per-
mit is granted by the Building Inspector.
In New Buildings no wiring shall be started
until the plumbing and heating pipes, and the fire
stops (if of wood) are installed, without a special
permit from the of5ce of the Building Inspector.
APPLICATION FOR PERMIT TO DO ELECTRICAI. WORK.
No. ......9/.61...... .. ......
Permit No. . . 8 . .... . ...
TO THE BUILDING INSPECTOR
of the
TOWN OF SOUTH WINDSOR, CONN.
1... . hereby make application to. perform Electr cal Work according to detailed description below. All
provisions of the Rules for Electrical Installation, Section 48, Building By-Laws, shall be complied with
whether specified herein or not.
ZSouthWindsor, Conn., 2 — 1JPAign here 2' C-l`
Address Jj C' = .!].'.. ................:..
Location .... ... ... ' Side of ..1. .............
Nature of Building 5' How many stories ... ....... ............ ............................................ ................
New or oId Building . .. . ... .. How many families ................................ ........................................................
Kind of Installation How many Stores ....................... ........................../..../........
T.....c.........................
Owner C.. .. Address
Architect Address
Builder L- l L'h .S. ... Address L=',S,....... &t0q. .-,,ems/ ..... ....
Electrician Qw adz..........Address %' ` G..... ...L... '.C' '........ /9........_.......S Z
Size of Main Wires .. _#......;7..........
No. of Light Loops ... .... ........ No. of Heat Loops .. ,. No. of Power Loops ........................._._...
No. of Light Outlets . . .. .. ... No. of Heat Outlets . . No. of Power Outlets ............. . ...........
NoP of Light Circuits ... 2 . .... . . ... No. of Heat Circuits No. of Power Circuits
No. of Sockets . ... . . ../ .. .. No. of Heat Receptacles No. of Motors
No. of Panels ............... ..... . Size of Heat Circuit No. of Power Receptacles
No. of Switches .. ..... . .... . Total Wattage Size of Power Circuit ..
Total Horsepower
No. of Straight Electric Fixtures ....... . ... .. .............. ..... .... . No. of Combination Fixtures .... . ...
No. of Receptacles ....................... ........ ........ ................. .... . No. of Cord Drops ...... ........................................................ ..... ... ...
Remarks: For other kind of Installation .. .. ..... v f-•..•••••. .w,,,,......1 ... Y............
I.................9? l ........
I....................... _............................................................................................................ .............. ... ...... ..
Estimated Cost
6169
i
PLUMBING APPLICATION
Applica on ram. 9
on the _..._._ sick of
Q Qld Farm Rd. Sant
Street No. 208
Owner ...S thridee Estates
ply _...__ Ace Mello
i Filed in Office of
The Budding
June 2 8 ig 8 3
n cana
I
No person shall f m - In f- add m or aloar at1
portion of the dra mp symm of say 6oWmg
e=oept to repair labs) uma a Peer- it is Sraooed
by the B
Application No. .......69.48................. Permit No. ...61-69..................
TO THE BUILDING INSPECTOR
of the
TOWN OF SOUTH WINDSOR. CONN.
hereby make application to perform plumbing according to detailed description below. All
provisions of the Rules for Sanitation, By-Laws, Sections 33 to 47 inclusive, shall be complied with whether
specified herein or not.
South Windsor, 23 .June........1993 ... sign here .... . .. ... ..... ... ..... . . ....... ......... .. ..... ...............
Address .16...qq4y..Ptreet West Hartf.. ..Street ...... ......4 ...........
20 Old Farms RoadLocation ...IP9t... .. -- .......... . .......rm........................................side of ... ................................... ................................................. Street
Nature of Building ... residential.............................. How many stories . ................................................. ..................................
Owner .......Rene VPi leux & ;59n .............................. ...... Address ....23....Che3_ton.--kv-e-_-W*zt..Hartford.,. .CT
Architect ..................... . .......... . . ..... ... ........................... .................... Address
Builder . ......................... Address ................. .........................................................................................
Plumber .4e Mello Plumbi49....&. ReatiAg................. Address ...16..cody. ...zt....-We-st...Hartgordl. ..........Mello.. ......................
DRAINAGE
CESSPOOLS, How many Where located .. .... .. .. .. ........................................................................
Are they water tight Of what materials are they built ...... .................... .. ..............
Size of pipe from house to cesspool Kind of pipe -... - ................ ......................................... ................
MAIN DRAIN IN CELLAR, Material ABS. ... ... Diameter ............4.11... ...................................................................... ..........
Aboveor below cellar bottom below...................
SOILPIPES, Material . ABS ...... Diameter .......3"..........................................................................................
WASTE PIPES, Material .... OS.. ................. Diameter 2!!..............................................................................
TRAPS,Type proposed to use is
RAINWATER LEADERS, where do they run to .. . . ... ... ..................................................................................................................
REFRIGERATORWASTES, where do they run to . ... . . ......... ..................................................................................... ...............................
TANKOVERFLOWS, where do they run to
FIXTURES
WATER CLOSETS, How many . .... ...3.................... ......... Where located ... bathrome............................................................
Distance from trap to vertical soil pipe ................. ................... Pattern
WASHTRAYS, How many .. . . .. ... ....................... .............. Where located .. ... ........................................................................................
SINKS, How many ................... ......... ................................................... Where located . -kit.chen...................................................................
BUTLERSSINKS, How many ....................................................... Where located. ..................................................................................................
REFRIGERATOR SINKS, How many .. ................................... Where located ..................................................................................................
LAVATORIES,How many . ............5_5 Where located ..........bA:kJ=Q.Q=. ........................................................
BATH TUBS, How many l tO.A...I....Ohwex............... Where located ..........bathrooms..........................................................
URINALS, How many ........ .... ........ ........................................... Where located ....... ......................................................................................
Are water closets and urinals to be local vented If not, is there a window in outer wall
ofroom where same are to be located .
Estimated Cost. 2..9.00.0..00 ...................... Licens #202526
r TK— FSh
n
f qqy LL
PERMIT #
Application For 6761 5660
DEPARTMENT DECISION Hewing Permit
APPLICATION IS HEREBY:
DEPARTMENT OF LICENSES AND INSPECTIONS
4
i APPROVED DISAPPROVED
TOWN OF SOUTH WINDSOR
was a OA1 NIEF rspff11`tfowr APPLICATIONS MUST BE PRINTED OR TYPED. BEGIN WITH NUMBER ONE BELOW
71 1. LOCATION OF JOB
Old Farms Road #208
Ld
V4 NO. STREET
aO
fy
LOT NO. FLOOR APT. NO.
3.z
f,--
xi s. OWNER Rene Veillenz it, Sons
Sf S. ADDRESS 23 Chelton Avenue
m Want Hartfori. OT a PHONE 522-5224
a&f `„c it
r_ ,
S. APPLICANT Aee Mabl n Plumbing P, Heating
e. ADDRESS - _Cody rye _
ford 522-oi 1_ 7.PHONE _9090
s. LICENSE NO.
II- EXPIRATION DATE OF LICENSE-10=1 83
210. ESTIMATED COST s '
11. IS THIS A CONTRACT COSn YES No
Permit 132871s. FEE ENCLOSED s
r is. TYPE OF BUILDING-
COMMERCIALCOMMERCIAL
4-5
1 . TYPE F JOB: INDUSTRIAL
RIIGINAL ALTERATION
INSTALLATION ADDITION
REPAIR
APPLICATION FOR HEATING PERMIT (Continued it m Reverse Sid )
11. LOCATION OF JOB 20 Old Farms Road
NO. STREET FL OR APT.NO.
12. TYPE OF INSTALLATION: OIL BURNER ELECTRIC Cl VENTILATION SPRINKLER
GAS BURNER STACK INCINERATOR MISCELLANEOUS
IDENTIFY
SIZE LOCATION SIZE SIZE
13. OF TANK OF TANK OF FILL OF VENT
14. B.T.U. EQUIP. AT REGISTER FURNACE MAKE AND NO. AT BONNET FIRING RATE
BOILER OR FURNACE MAKE AND NoLAlOORe._cO B.T.U. OR SQ. FT. NET 84• T.U. OR SQ. FT. GROSS FIRING RATE
FLOORS TO BE HEATED NEW OR OLD BUILDING new INSULATED - YES OR NO yes
TYPE OF WALL frame INSULATION ROOF OR CEILING INSULATION
AVG. SYSTEM WATER TEMP. m* B.T.U./SQ. FT./HR. EMISSION
INDOOR-OUTDOOR TEMPERATURE DIFFERENCE 0 - 70* FAHRENHEIT
MAKE OF RADIATION: BASEBOARD. COPPER CONVECTORS. OR C.I. RADIATION. OUTPUT PER SECTION OR LINEAL OF RADIATION. SQ.
FT. OR B.T.U. $hntemp
DESCRIPTION OF WORK Complete heating system for single family dwelling15. TO BE DONE:
16. HEAT LOSS SCHEDULE. (TO BE INCLUDED FOR ALL JOBS):
ROOM SIZE wlNoows AREA - SQUARE FEET B.T.U. B.T.U. < DISTRIBUTION INSTALLED
AND DOORS VOLUME TOTAL TOTAL yl
ROOM NO.GROSS GLAS! NET WALL CEILING FLOOR CU.FT. AT 70•F CORRECTED J j I-LL REGISTER
L w N AND TEMP. TO 6 TYPE AND SIZE RAO. OR LEADER
SIZE < WALL
f'Lto INFILT.) DIFF. F O N SO' FT' FREE AREA
TOTALS
A. HEAT LOSS FROM BUILDING B.T.U./HR.
B. DOMESTIC HOT WATER DEMAND B.T.U./HR.
C. PIPING. OTHER THAN NORMAL B.T.U.!HR.
ALLOWANCE FOR HEAT VALVE OF FUEL (A B C) FACTOR
17. ELECTRICAL WORK BY:
NAME ADDRESS
SUBCONTRACTORS AND
18. THEIR TRADES
ALL WORK COVERED BY THIS APPLICATION HAS BEEN AUTHORIZED BY THE (OWNER) OR (AGENT) OF THIS PROPERTY AND WILL
BE DONE IN STRICT ACCORDANCE WITH THE BUILDING CODE.
APPLICATION TO BE COMPLETELY FILLED IN. 04,0 71
DATE SIG ATURE OF APPLIC
R CALCULATION SHEET 1503 (Moder Methods1w- rl— CRO Copyright 1977 by Th Hydr nits Institute
C' v jzOWNERADDRESS DESIGN TEMPERATURE DIFFERENCE 22—F. DATE la...Z y
COL.A COL.B COL.C COL.O COL.E COL.F COL.0
1 .ROOM
E 2/h a L L •
Dash•wet T•snp.O H W H IN H lee
2 ROOM DIMENSIONS,FT. U d P BTUH per Fo t of
3 LENGTH EXPOSED WALLS, FT. Q Jr Radlati Is Sel•ctes1
4 WINDOW AND OUTSIDE DOOR AREA LL
BTUH BTUH BTUH BTUH BTUH
5 WALL CONSTRUCTION ROOM LIN.FT.OF
Table 9, Lu a 3 x H) U 0 U l a s
FR M LINE I2 <
DIATIO
6 TYPE OF GLASS z Q LD
1 Bottom of table used for Line 51 X1 Q J U U 0` 0& 5' v
7 CEILING CONSTRUCTION w C 1 0V
Table 9, L x W)
B FLOOR CONSTRUCTION?
ITable 9, L x W r Lin. Ft.)
9 1 COLD PARTITION CONSTRUCTION P l p y
Table 9, L x H) r
O ,f- p p
10 :c 1 wan fwi:n Dw Wined t10 H 7-- v
2 walls twith Openings)
3 Wells(With Openings)or Ent. Hall 6 0-O O
11 TOTAL BTUH AT 70F TEMP. DIFFERENCE• j Q j-0 Q p p
J
1
12 TOTAL BTUH AT DESIGN TEMP. DIFFERENCE >I K y p v
COL.A COL.B COL.H COL.1 COL.J COL.K COL.L T TAL BTUH T TAL
1 ROOM r a.- OF BUILDING RADIATION
QAT SSLSCTIRD
O H &e WI- H { H W H LWO" H I Jr DESIGN TEMP.•
DIFFERENCE
2 ROOM DIMENSIONS,FT. u 1` 2 O
3 LENGTH EXPOSED WALLS, FT. 3 3 y 8
4 WINDOW AND OUTSIDE DOOR AREA U.
BTUH 9 H BTUH 9TUH BTUH
6 WALL CONSTRUCTION p- INCREASE BATHROOM
Tabl 9, Lin 3 x H) U U (} U 3 a v O o G t/ Q Q TOTAL 30%
4 TYPE OF GLASS
B ttom of tabs used for Line 5) i 7 0 6 Ulf: j U U j` 0 d
tFOR CONCRETE FLOOR ON7CEILINGCONSTRUCTIONGROUNDORFILLAT
T ble 9. L x W) U5 00 6 500 Y 0 a 7 U 0 GRADE LEVEL,USE LINEAR
B FLOOR CONSTRUCTIONt FEET OF EXPOSED EDGE
Tobl 9, L x W r Lin. Ft.) 700
9 COLD PARTITION CONSTRUCTION
Table , L x V0
10 _c 1 Wail(With Op•aings) O; /Y Q U Q d D d
0 2 Wells(With Upeningsl n X .o y 006.7 d
3 Walls(With Openings)by Ent. Hall
11 TOTAL BTUH AT 70F TEMP. DIFFERENCE• 3
12 TOTAL BTUH AT DESIGN TEMP. DIFFERENCE —1 j
FORM 1503
This form is available fr m The Hydronics Institute, 35 Russo Place,Berkeley Heights, N.J. 07922
G 62
1 = B = R CALCULATION SHEET 1503 (Modern Meth Copyright 1977 by The Hydronics Institute
OWNER ADDRESS Q U''r
DESIGN TEMPERATURE DIFFERENCE -&.F. DATE IfL. rJ
COL.A COL.B I COL.C COL.O COL.E COL.F COL.O
1 ROOM
E
O H 4,/ W H I`,- vYr H L W H L W H L W 0"Na Water Telup.
2 ROOM DIMENSIONS, FT. v S L BTUH Per F of of
3 LENGTH EXPOSED WALLS, FT. Q Radlatl a Seloolled
4 WINDOW AND OUTSIDE DOOR AREA U.
STUN STUN BTUH STUN BTUM
S WALL CONSTRUXTION Room LIN.FT.OF
Tab1 9,Lino 3 x H) 0 0/
0 d G T TAILS RADIATION
11 TYPE OF GLASS FR MLINE IS =RLECTEQ
S ttom of table used for LIna 6) X11 jo f Q
7 CEILING CONSTRUCTION
7
C j—
Tabi 9,LxW) U V v
g FLOOR CONSTRUCTIONt
Tabl 9, L x W or Lin. Ft.) r 00 E
9 COLD PARTITION CONSTRUCTION F
Table 9, L x H) r
G
10 :C 1 Wall(With Qp ninge) o; 6 i Y CTQ H
2 Walls(With Openings)ex ,0 y) n
3 Walls(With Openings or Ent. Hall i.
or J11TOTALSTUNAT70FTEMP, DIFFERENCE' O
12 TOTAL STUH AT DESIGN TEMP. DIFFERENCE K
COL.A COL.B COL.H COL. 1 COL.J COL.K COL.L TOTAL TUM TOTAL
1 ROOM OF BUILDING RADIATION
pC AT SELECTED
O H L W H L W H L W H L W H L W DESIGNTEMP.•
r DIFFERENCE2ROOMDIMENSIONS, FT.
U
3 LENGTH EXPOSED WALLS, FT. J-
4 WINDOW AND OUTSIDE DOOR AREA L
STUN BTUH STUN STUN STUN
5 WALL CONSTRUCTION INCREASE 13ATHROOM
Table 9.Line 3 x H) TOTAL 209E
6 TYPE OF GLASS
B tt m of table used for Line 6)
11> tFOR CONCRETE FLOOR 0111' "7 CEILING CONSTRUCTION GROUND OR FILL AT
Table 9, L x W)GRADE LEVEL,USE LINEAR
e FLOOR CONSTRUCTIDNt FEET OF EXPOSED EDGE
Tabl 9. L x W r Lin. F t.)
9 COLD PARTITION CONSTRUCTION
Table 9,L x H)
10 -c 1 Wall(With Openln s)
2 Walls(With UpenU-tg4 X
3 Walls(With Openings)or Ent. Hall
11 TOTAL STUH AT 70F TEMP. DIFFERENCE'
12 TOTAL 6TUH AT DESIGN TEMP. DIFFERENCE
FORM 15 3ThisformisavailablefromTheHydronicsInstitute. 35 Russ Place.0 rkeley Heights, N.J. 07922
TO THE BUILDING INSPECTOR
of the APPLICATION FOR
TO" OF SOUM WINDSM COW PLAN EXAMINATION AND
BUILDING PERMIT
IMPORTANT — Applicant to complete all items in sections: 1, 11, III, IV, and IX.o
Y
ZONINGI• AT (LOCATION)- Q L a DISTRICT R R
LOCATION NO.) STREET)
OF BETWEEN AND
BUILDING CROSS STREET) CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
II. TYPE AND COST OF BUILDING - All'applicants complete Parts A — D
A. TYPE OF IMPROVEMENT D. PROPOSED USE - For"Wrecking" most recent use T
1 New building Residential Nonresidential
2 Addition([/residential, enter number 12 One family 18 Amusement, recreationalo/new housing units added, if any,
in Part D, 13)13 Two or more family - Enter 19 Church, other religious
3 Alteration (See 2 above)
number of units- - - - - 20 E:] Industrial
14 Transient hotel, motel,
4 Repair, replacement 21 Parking garageppordormitory - Enter number
5 Wrecking ([/multifamily residential,of units ------- - -p. 22 Service station, repair garage
enter number of units in building in 15 Garage 23 Hospital, institutional
Part D, 13)
24 Office bank6ElMoving (relocation)
16 Carport professional
17 (j'6ther - Specify 25 Public utility7 Foundation only
26 School, library, other educational
B. OWNERSHIP C t-AAL SZ'yV LL' 27 Stores, mercantile
8 Private (individual, corporation, 28 Tanks, towers
nonprofit institution, etc.) 1N 12LOW PLAS4' 29 Other - Specify
9 Public (F deral, State, or
local government)
C. COST Omit cents) Nonresidential - Describe in detail proposed use of buildings,e.g., food
processing plant, machine shop, laundry building at hospital,elementary
10. Cost of improvement,,,,,,,,,,,,,,,, Ss 0 school, secondary school, college, parochial school, parking garage for,
department store, rental office building, office building at industrial plant.To be installed but not included If use of existing building is being changed,enter proposed use.in the above cost
a. Electrical......................
b. Plumbing ......................
c, Heating, air conditioning.........
d. Other(elevator, etc.)............
11. TOTAL COST OF IMPROVEMENT j$1'00-
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS
30 Masonry (wall bearing) 40 Public or private company
48• Number of stories................
31 W ad frame 410 Private (septic tank, etc.) 49• Total square feet of floor areq,
all floors, based on exterior
32 Structural steel dimensions ....................
33 Reinf reed concrete H. TYPE OF WATER SUPPLY
34 Oth r - Specify 42 Public or private company 50. Total land area, sq.ft. ...........
43 Private(well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL
51. Enclosed .......................
35 Gas Will there be central air 52. Outdoors.......................
36 Oil c nditi ping? L. RESIDENTIAL BUILDINGS ONLY
37 Electricity 44 Yes 45 No 53. Numb r f bedr ms..............
39 C al
39 Other- Specify Will th re be an I vat r?
54. Number f
Full..........
46 0 Yes 47 No batter ms
Partial........
IV. IDENTIFICATION — To b compl t d by all applicants
Nam Mailing address — Number, street, city, and State ZIP code Tel. No.
ANOR :w LYG19 a OLD FARM RD . o o y
44414 -owner or
Lessee S W I AJ D S Q R C_?-.V-7 q 41
2. 02 r ca,f Co'I'b'~
Contractor o(/o o V/qj O Amr_
3.
Architect or
Engineer
The owner of this building and t-he undersigned agree to conform to all applicable laws of this jurisdiction.
Sign ure of applican Address Application date
0 NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plans Review Re uired Check Plan Review Date Plans By Date Plans By NotesqFeeStartedApproved
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Permit or Approval Check ae
ObDa.
t
ed Number By Permit or Approval Check Ob
ateDained Number By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building
Permit number
Building
Permit issued / 19
Building A.f1
Permit Fee $
prov d y:
1
TIT
i F
TOWN OF SOUTH WINDSOR
BUILDING PERMIT
Date Nov. 2 2 1983
Fee Paid .4..00 Est. V 500.00alues$
Permit NV 13581
on the side of
Old Farm Road Strea
Street No. 208
Owner Andrew Lvga
Applicant Andrew LXQa
CERTIFICATE OF OCCUPANCY ISSUED:
I
Date
No.
Fee Paid $
I
CLASSIFICATION
Coal stove/existing
fireplace
BUILDING PERMIT
N? 13581
OFFICE OF
THE BUILDING INSPECTOR
of the
Town of South Windsor, Conn.
South Windsor, Conn.Nov. 22 1983
X#ta to to (ferttf-U, That Coal stove and Energy Stowe, Inc.
is herebyanted ion to
Install coal stove into existing fireplace
8t' P
at estimated value of $ 500.00
on the side of 208 Old Farm Road Street on land
owned by Andrew Lyga
Said Work to be as described in Application
No. 13881 and to conform to specifications and plans filed with said Application, and Building By-
Laws of THE TOWN OF SOUTH WINDSOR.
I ued No . 2 19 830
wading Inspector.
Streets and sidewalks, obstructed by excavations or building materials, must be guarded by barriers
during the day and by both barriers and colored lights by night.
SECTION 1343, GENERAL STATUTES OF CONNECTICUT: When any person shall place
or keep building materials, or any obstacle in any highway (or any sidewalk) either with or without a
license therefor from the city or borough in which such highway may be situated, he shall pay said city,
town or borough all costs and damages which it shall sustain, or be compelled to reason therefor"
ra.*,•-
a "' '-' Bl'. . 'J • s ctir-. '` ,''`., r- -
y''._.met,-.-,n*rem-{
I
F 1
l{
1
Pursuant to Permit No. ' R
This Certifies that the Wood/Coal Stove installation for which the above named Permit was j
granted has been duly inspected and is hereby approved.1
j
Owner Andrew Lyga a
Street SOS old Farm Road
r 19 Building nspector
MARCH 15, 1991
TOWN OF SOUTH WINDSOR
BUILDING DEPT.
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT '6074
ATTENTION: JAMES EMERY
DEAR SIR:
THE COAL STOVE YOU INSPECTE- THE OTHER DAY
AT 208 OLD FARM ROAD IS HE ORIGINAL STOVE
WE HAD INSPECTED WHEN WE MOVED IN THE HOUSE.
SINCERELv .
TO THE BUELDING INSPECTOR
of the APPLICATION FOR
TOWIN OF SOUTH WIMSO , COS. PLAN EXAMINATION A N D
BUILDING PERMIT
IMPORTANT — Applicant to complete all items in sections: 1, It, 11I, IV, and IX.
y I O D PA 0? 1 RV -ZONINGI• AT (LOCATION) DISTRICT
LOCATION NO.) STREET)
OF BETWEEN AND
BUILDING CROSS STREET) CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
to
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking' most recent use n
1 New building Residential Nonresidential
2 Addition(1/residential, enter number 12 One family 18[:] Amusement, recreationalofnewhousingunitsadded, if any, 13 Two or more family — Enter 19 Church, other religiousinPartD, 13)
number of units— — — — --op- 20 Industrial3 Alteration (See 2 above)
14 Transient hotel, motel,
D
21 Parking garage4 Repair, replacement or dormitory — Enter number
5 Wrecking (1/multifamily residential, of units ——————— — -- 22 Service station, repair garage
enter number of units in building in 15 Garage 23 Hospital, institutional
Part D, 13)
16 Carport 24 Office, bank, professional6 gniMovrelocation)
7 F (
relocation)
ion only
17[ ther — Specify AIsoy' 25 Public utility
26 School, library, ther educational
B. OWNEr%SHIP C3 2QVN 0 Pdoc- 27 Stores, mercantile
8 Private (individual, corporation, r 1 28 E] Tonks, towers
nonprofit institution, etc.) 2. 29 Other — Specify
9 Public (Federal, State, or
local government)
C. COST Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g., food
Processing Plant machine shop, laundry building at hospital, elementary
10. Cost of improvement................ S bd0 OC 0 school, secondary school, college, parochial school, parking garog for,
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed, enter proposed use.
in the above cost
7. a. Electrical......................
b. Plumbing ......................
c. Heating, air conditioning.........
d. Other (elevator, etc.)............
11. TOTAL COST OF IMPROVEMENT $ 50 00-00
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS
48. Number of stories................30 Me* my (wall bearing) 40 Public or private company
49 Total square feet of floor area,31 Wood frame 41 Private (septic tank, etc.) all floors, based on exterior
32 Structural steel dimensions ....................
33 Reinf reed concrete H. TYPE OF WATER SUPPLY
50. Total land area, sq. ft. ...........34 Other — Specify 42 Public or private company
43 Private(well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
51. Enclosed .......................F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL
35 Gas Will there be central air 52. Outdo rs.......................
36 011 c nditi ping?L. RESIDENTIAL BUILDINGS ONLY
37 Electricity 44 Yes 45 No 53. Number f bedro ms..............
38 Coal
39 Other— Specify Will there be on •levot r? Full..........
54. Number of
46 Yes 47 No bathrooms
Partial.......
IV. IDENTIFICATION To be compil t d by a// applicants
Nam Mailing address — Number, street, city, and State ZIP code Tel. No.
wi Y-
owne.
Q P. 2,ol& oi-o r-Aiem r2b
Lessee G A 1 4-1 za 4.1L
Contractor C?
L0 w . A 01 C),!;"(.
3.N-may I
Architect or
Engineer
Th owner of this building and the undersigned agree to conform to all applicable laws of this jurisdiction.
Sign of applicant Address Application date
DO NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD For office use
Reate la Date Plands
Plans Revi w Required Check PlanFeeviow DStarPtedns
y ApproveB By Notes
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER S
V1. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Date ote
Permit or Approval Check Obtained Number By Permit or Approval Check ObDtained Number By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACg-,STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building
P rmit number
Building
P rmit issued 3,aa- 41 19
Bui Iding
P rmit Fee
Rpprrov d y:
C
TITLE U
op
J
TOWN OF SOUTH WINDSOR
BUILDING PERNUT
Date Mar•22 1984
Fee Paid 30..00 Est. Value $5.,000
Permit NV 13722
on the side of
Old Farm Road Street
Street No. 208
Owner Andrew P. Lyga
Applicant A. P. Lyga
CERTIFICATE OF OCCUPANCY ISSUED:
Date
No.
Fee Paid $
CLASSIFICATION
I
Above ground pool
BUn DING PERMIT
N ' 13'722
OFFICE OF
THE BUILDING INSPECTOR
of the
Town of South Windsor, Conn.
South Windsor, Co.. Mar. 22 1984
94is is to Certifg, That F.nta s Pools
is hereby granted permission to Above around pool 16' x 24'
at estimated value of
on the side of
r
208 Old Farad Road Street on land
owned by Andrew P. Syga
Said work to be as described in Application
No.14022 and to conform to specifications and plans filed with said Application, and Building By-
Laws of THE TOWN OF SOUTH WINDSOR.
IsudMar. 22 10.
f',',--Building Inspector.
Streets and sidewalks, obstructed by excavations or building materials, must be guarded by barriers
during the day and by both barriers and colored lights by night.
SECTION 1343, GENERAL STATUTES OF CONNECTICUT: "When any person shall place
or keep building materials, or any obstacle in any highway (or any sidewalk) either with or without a
license therefor from the city or borough in which such highway may be situated, he shall pay said city,
town or borough all costs and damages which it shall sustain, or be compelled to reason therefor."
iNSPECTION'REPORT Gf Permit ,# CJ Job If
1 Footing 0.0
2 Foundation
3 Framing
4 Wiring yjD
5 Plumbing
6 Heating
7 Lathing
8 C.O.
6 IM-MINU PUUL U I ILI I Its UUN I HAU I
Name A i t w f Job No.
Address d. .__ f- F G., Date
City S`-.i l!i -, %.-i Size
Ph.(A. '`YN-t-y----------V171'j -_•.f -S- _ Best time to call=-=---
SPECIFICATIONS
1.LOT GRADE
0-12"
0-18"
0to2ft.
Over 2 ft.
I
LABOR
TAX
TOTAL t v
DIRECTIONS TO JOB SITE
HOUSE s
9 K G 1 f S c) u `rH
L
RrcNT
y Ai Lr2 t4AMtl
9
TA Ic Lr
S U L C V A S R V t-r) -t- L FT-
61 tl rr
A P R s oA .i`o o L-L
IZA9 jr,
DELIVERY INSTRUCTIONS: 'AROP STAINING: CONTRACTOR
o HAND CARRY o OWNER
BUILDING PERMIT: o CONTRACTOR MACHINE ACCESS: YES
QZWNER MINIMUM 8') NO
LOT STAKE OUT: CYCONTRACTOR HAND DIG
YbWNER OBSTACLES TO BE REMOVED: CONTRACTOR ( )
SOD REMOVAL: NORMAL OWNER
SPECIAL fi- • NONE
DECK SIZE: NORMAL DATE y
SPECIAL OWNER X
a J--
OWNER X
8301
ELECTRICAL APPLICATION
Application No. 9407
on the side of
Old Farm Road Street
Street No. 208
Owner Andrew Ly&a
Electrician H me owne r
FILED IN OFFICE OF
The Building Inspector
Mar. 22 1984
INSPECTION.
m No Electrical Work shall be started until a Per-
mit is granted by the Building Inspector.
In New Buildings no wiring shall be started
until the plumbing and heating pipes, and the fire
stops (if of wood) are installed, without a special
permit from the office of the Building Inspector.
Electrical Permit No. .......9de/
Master License No.,
TOWN OF SOUTH WINDSOR Building Permit No.
BUILDING DEPARTMENT Date Filed
Date Final Approval ...... ........ ......... ...........
APPLICATION FOR ELECTRICAL WORK
Electrical Inspector
Y ;;AI. .. ............R ..... .JOB LOCATION: a0i OL-13 JOB OWNER: . 1 ......................
Sideof Between ... ..... and .................................................................................
Name of Building Owner Address -
If work is for Lessee—Give name Address ....................... .... .............. . ... ...................
Building now occupied as (unless new) No. of family units now . . .. . ........ ..
Building to be occupied as Number of family units to be .. ................
Is this work included in a Building Permit? Permit Fee .. ......... ........... ...... ........................................................... . ... .............
47 If no Building Permit)
Permittee Business Address Telephone
COSTOF JNSTALLATION:V. O.c=.)........................ . ..................... .............................................................................................................................
TO BE FILLED OUT BY PERMITTEE
TO BE WIRED EXISTING APPLIANCES
Number of light outlets to be installed
Number of convenience outlets to be installed Number of present Appliance Circuits .. . ....... ................ ........
Number of switches to be installed Do these include Range Water Heater Number of appliances to be installed
as listed below) Dryer Ej Air Conditioner Oil Burner
TYPE RATING NO.
Dish Washer E] Gas Burner
Range
Well Pump E] Elec. Heaters E]
Range Top . . . . . .
Oven . . . . . . . . REMARKS:
Water Heater
Clothes Washer . . . .
Clothes Dryer . . . . .
Dish Washer . . . . .
Air Conditioning Motor .
Oil Burner Motor . . . .
Gas Burner . . . . . .
Circulator Motor . . . .
Attic or Large Fan . . .
Well Pump . . . . . .
Electric Heat
Other . . . . . . . . .
Number of new Lighting Circuits . . . . ............................
Number of new Appliance Circuits . . . ............................
Number of Heating Circuits . . . . . . ..........................
Number of Motor Circuits . . . . . . . ............—...--
Size of present service ............... ...............................................
Size of service to be ....................................................................
DARMENT DECISION APPLICATION FOR PLUMBING PERMIT PERMIT#
ation is hereby:TOWN OF SOUTH WINDSOR lar-33
BUILDING DEPARTMENT
PROVED 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230 a y
Building Inspector
Application must be printed or typed
Location of Job:
FEE SCHEDULE
r S
0-$1,000=$13.00 Street No. Street Lot No.
Over$1,000='3
13.00 per$1,000
or any fraction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS
Ae
APPLICANT PHONE# GO
f
D 3 y4—
0000, 10 N S OWNER 1,4 61
q< OWNER ADDRESS O 00
OWNER PHONE
C ESTIMATED COST$r CO
IS THIS A CONTRACT COST? PXes D No
FEE ENCLOSED$
TYPE OF JOB:
Roc O New Installation
teratio Addition/Repair Revised 8/99
APPLICATION FOR PLUMBING PERMIT (Continued from reverse side)
TYPE OF BUILDING IS THIS APPLICATION ASSOCIATED WITH A
BUILDING PERMIT APPLICATION? YES NO
RESIDENTIAL
BUSINESS CURRENT USE AND OCCUPANCY
ASSEMBLY
MERCANTILE FUTURE USE AND OCCUPANCY
EDUCATIONAL
INSTITUTIONAL ENGINEER'S NAME PHONE
FACTORY
STORAGE ADDRESS
GARAGE
MIXED USE CITY STATE ZIP
TYPE OF INSTALLATION SIZE OF MAIN DRAIN
NO.OF TOILETS STYLE NO.URINALS STYLE
NO.OF BATHTUBS NO.OF SHOWERS NO. OF LAVATORIES
NO.OF CONDUCTORS SIZE NO.OF STACKS SIZE
AREA OF ROOF NO.OF CATCH BASINS NO.OF FLOOR DRAINS
NO.OF OTHER FIXTURES KIND
ARE TOILET COMPARTMENTS VENTILATED TO OUTER AIR BY A WINDOW YES NO
SIZE OF WINDOW IF NONE C.F.M.OF VENTILATOR
SIZE OF DUCTS SEWER OR SEPTIC TANK
SIZE OF WATER MAIN SIZE OF WATER PIPING&RISER
WATER HEATER: TYPE MANUFACTURER
DESCRIPTION OF WORK
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANX DATE 3 c72 576
i
DEPARTMENT DECISION APPLICATION FOR HVAC PERMIT PERMIT#
Application is hereby:TOWN OF SOUTH WINDSOR
BUILDING DEPARTMENT
APPROVED 1540 SULLIVAN AVENUE Bldg.Permit#
644-2511 ext. 230 IC2
Date Building Inspector
Application must be printed or typed
Location of Job:
Fo
EE SCHEDULE I D /
1,000=$13.00 Street No. Street Lot No.
Over$1,000=
13.00 per$1,000
ny fiaction thereof Tenant Designation Apt.No.
APPLICANT
APPLICANT ADDRESS /3 G'`i•
o • W c u ror UGo7y
APPLICANT PHONE# g6 O
OWNER 1.4 614 o/, g`i/
C OW N S F,4 gOWNERADDRESS
OWNER PHONE
O
ESTIMATED COST$ ODC
IS THIS A CONTRACT COST? s 0 No
FEE ENCLOSED$
TYPE OF JOB:
SORB Co 13 New Installation
Puleration/Addition/Repair Revised 8/99
APPLICATION FOR HVAC PERMIT (Continued from reverse side
TYPE OF SYSTEM: TYPE OF BUILDING:
EATING RESIDENTIAL
A/C COMMERCIAL
VENTILATION INDUSTRIAL
HEATING
STEAM LOW PRESSURE LIMIT LBS. HIGH PRESSURE LIMIT LBS.
DRONIC WARM AIR UNIT RADIANT HEATER
EXISTING RADIATION ADDITIONAL RADIATION TOTAL RADIATION
DESIGN TEMP. OUTSIDE OF INSIDE OF DIFFERENCE OF
TOTAL HEAT LOSS(BTUH) OF(HEAT LOSS SHEET MUST ACCOMPANY
APPLICATION)
DESCRIBE ALL HEATING EQUIPMENT(INCLUDING MAKE&MODEL NO.)
GROSS HEATING CAPACITY(INPUT-BTUH) NET RATING(OUTPUT-BTUH)
TYPE OF FUEL
OIL-GPM OIL TANK LOCATION:INSIDE OUTSIDE CAPACITY
GAS-INPUT LPG TANK CAPACITY ELECTRIC-KW
AIR CONDITIONING
DESIGN TEMP.OUTSIDE OF INSIDE OF DIFFERENCE OF
TOTAL HEAT GAIN(BTUH) HEAT GAIN SHEET MUST ACCOMPANY APPLICATION)
DESCRIBE ALL COOLING EQUIPMENT(INCLUDING MAKE&MODEL NO.)
TONNAGE COOLING CAPACITY(BTUH)
VENTILATION
DESCRIBE ALL AIR HANDLING EQUIPMENT(INCLUDING KITCHEN EXHAUST EQUIPMENT)
1
c;ti 5 5 0 J
TOTAL SIZE OF SYSTEM(CFM) FRESH AIR INTAKE(CFM)
PLANS MUST ACCOMPANY APPLICATION)
FURTHER DESCRIPTION OF WORK
THE UNDERSIGNED HEREBY APPLIES FOR A PERMIT TO PERFORM THE WORK DESCRIBED AND IS TO
COMPLY WITH ALL LOCAL ORDINANCES AND STATE OF CONNECTICUT BUILDING CODES IN THE
PERFORMANCE OF SUCH WORK.
39?9g-C-) 5 - / C
CONTRACTORS LICENSE NO. TYPE STATE
SIGNATURE OF APPLICANT DATE 7 2 5