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TOWN OF SOUTH WINDSOR INSPECTION REPORT K s
Permit No. 3170 Contractor CUSTOM PAVING
Location ` , STt f' Address JOHN F JURGELAS
Type Work DRIVEWAY P.O. BOX 178
SOUTH WINDSOR CT 06074
P'hon.e, No. (860)528-2684
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Date Insp Needed Date nsp Z 07
Time Insp Needed
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Inspected By
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Work in Progress
Input
Date �--
3170
•� Town of South Windsor, CT
Dade w' '` O8/09/2001 Street Excavation Permit
-Expiration Date 08/09/2002
Descr.ip: CK#6053 FOR 7 PERMITS
Applicant Location
Name CUSTOM PAVING 6SS `F0$TER STREET
Addr. JOHN F JURGELAS
SOUTH WINDSOR CT 06074 Ty156 of Work DRIVEWAY
Phone (860)528-2684
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Applicant agrees to furn7 s the Tcn of Scui;n Wndsor the amount of bond
required and to reimbwr , tp� � 7gw oaf , h Wor for any expenses
incurred by the Town foraixenan"der r40
ar ' gt"k� in connection with this
permit and that app 1 i canft. 1i~a�m1 an�,'Wl 7�1,--- �i de by the rules and
regulations for permits-*, o��li�ne� i�z � Town,,,Of 'South Windsor's Street
Cut Permit Manual , a
* PERMIT 'TO BE fE1T >: ?(+i„Jt � STET ALL TIMES.
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Issued by
Date Completed �' �� U-7 Inspected By �i/ ~'
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
Name of Firm -C 710 rn A A to Phone No. —1-D 5 3-G, Y
Address of Firm fad 5•. o*7;P
Location of proposed work :B �--
Describe fully nature of permit requested R r-
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Starting date A:% s A n Approx.time for completion ~JO:4
Call Before You Dig No. Traffic Services Control No.
;::04 -74'C GAO
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North Prop.size of cut
No.arts
Amt.of Deposit$ by
()Cash()Check#
Cut size after Perm. Patch
No. Cuts
Final Billing$
Amt. 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: �� =-. L Date: /:)U Q r
Title: D.L#: 0 7T f '7f
PERMIT SHALL BE KEPT ON 70BSITE AT ALL TIMES
Standard Forms\Permits\Street Excavation Permit.doc