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TOWN OF SOUTH WINDSOR INSPECTION REPORT
Permit No. 3297 Contractor CUSTOM PAVING
Location f1�� Ti lit,L�� .ROAa Address JOHN F JURGELAS
Type Work Dt�IVEW P.O. BOX 178
SOUTH WINDSOR CT 06074
e (860)528-2684
Date Insp Needed
s Time I nsp Needed f ., a �-3- dl'lq
Inspected By
Work in Progress
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Permit` No. 3297 Town of South Windsor, CT
Date 05/23/2002 Street Excavation Permit
Expiration Date 05/23/2003
Descrip:
Applicant
Location
Name CUSTOM PAVING R ILL ROAD
Addr. JOHN F JURGELAS
SOUTH WINDSOR CT 0 0 DRIVEWAY
Phone (860)528-2684
Applicant agrees d hiftd required and to re i or the amount of bond
m u : o ` th r any expenses
incurred by the Town I e` an pai U
connection with this
permit and that appli t an ide by the rules and
regulations for permi 1 f th Windsor's Street
cut Permit Manual .
k
* PERMIT T T LL TIMES.
Issued by 'P-QA
R
Date Completed Inspected By ~ _
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSORf CT
FEE $25.00
Name of Firm U -C,T n Phone No.
Address of Firm o u W_
Location of proposed work /' OA a--r Al i ii tQ
Describe fully nature of permit requested r v
Starting date Approx.time for completion
Cali Before You Dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North Prop.size of cut
No.cults
I/O S ie "Amt.of Deposit$ try
{)Cash O Check#
Cut size after Perm. Patch
No. Cuts
Final Billing$
AmL Due Payee$
Amt.Due Town$
Applicant is responsible for contacting by date
the Police Dept.and C.B.Y.D.
I AGREE TO FURNISH TO THE TOWN OF SOUTH WINDSOR THE AMOUNT OF BOND REQUIRED AND TO REIMBURSE THE TOWN OF
SOUTH WINDSOR FOR ANY EXPENSES INCURRED BY THE TOWN FOR MAINTENANCE OR REPAIR WORK IN CONNECTION WITH THIS
PERMIT AND THAT I AM FAMILIAR WITH AND WILL ABIDE BY THE RULES AND REGULATIONS FOR PERMITS AS OUTLINED IN THE
TOWN OF SOUTH WINDSOR'S STREET CUT PERMIT MANUAL
Signed: . Date: ' Y .
Title:— D.L#•
PERMIT SHALL BE KEPT ON 306SM AT ALL TIMES
Standard Forms\Permits\Street Excavation Permit.doc