Reimbursement Application
Application Data
| First Name |
Robert
|
| Last Name |
kelly
|
|
lkelly05@snet.net
|
|
| Phone |
860-836-3896
|
| Mailing Address |
4 Jacobs Hill Road
Ellington, CT 06029 |
| Tested Home Address |
4 Jacobs Hill Road
Ellington, CT 06029 |
| Date Home Built |
1995
|
| Date Home Addition Built |
|
| Addresses which Share the Foundation | |
| Test Date |
2021-09-13
|
| Type of Test Performed |
Visual Inspection
|
| Total Invoice for the Test |
650.00
|
| Lab/Engineer Contact |
Michael Plickys
|
| Lab/Engineer Phone |
860-549-6190
|
| Lab/Engineer Email |
|
| Test Lab Name |
Macchi engineers,llc
|
| Is the Engineer Licensed |
Yes
|
| Engineer License Number |
17241 (unverified)
|
| Prior Reimbursement |
|
| Number of Cores Tested |
|
| Test Result Files |
image2021-10-13-081534.pdf |
| Proof of Ownership Files |
image2021-10-11-080938 (2).pdf |
| Additional Photos and Documentation |
image2021-10-11-080822 (1).pdf |
| Documentation of Payment |
image2021-10-13-081708.pdf |
| Waiver Request: Unsigned | |
| Waiver Request: Approved | |
| Application Status |
Paid
|
| Date Application Submitted |
2021-10-13 20:28:08
|
| Last Modification Date |
2022-03-25 09:50:36
|
| Application Last Reviewed By |
Laura Quintiliani
|
| Signature |
|
| Date Paid |
2021-10-18
|
| Check Number |
17308
|
| Check payable to |
Robert kelly
|
| Check Amount |
400
|
| Voucher Amount |
400
|
| Was Damage Present? |
1
|
| Was Pyrrhotite Present |
0
|
| Pyrrhotite Percent |
0
|
| Damage Level |
Minor to moderate (repair suggested/recommended)
|
| Damage Location |
Wall only
|
| House Features |
Gutters - With Extension;Finished Basement
|