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TOWN OF SOUTH WINDSOR INSPECTION REPORT
Permit No. 3169 Contractor CUSTOM PAVING
Location „ Address JOHN F JURGELAS
Type Work DRIVEWAY P.O. BOX 178
SOUTH WINDSOR CT 06074
F!hcie . fro. (860)528-2684
Date Insp Needed
Time Insp Needed
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Inspected By /
Work in Progress
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Input . l/ Date _Z- d 'C�
Permit No. 3169
Town of South Windsor, CT
Date 08/09/2001 Street Excavation Permit
Ekpi:ratfon Date 08/09/2002
Dsscrip
Applicant Location
Name CUSTOM PAVING 9 0545 ` RAhAM ROAD
Addr. JOHN F JURGELAS
SOUTH WINDSOR CT 06074fi ype of.Wor,k DRIVEWAY
Phone (860)528-2684 ;;
Applicant agrees to furnish- irh f C,aut -,'Windsor the amount of bond
required and to reimbut`-�e„Ipe `?awn South �ixid ar'-`for any expenses
incurred by the Town fQ mdtzntenat�c , orr repair w rk..in connection with this
permit and that app l i cart ; ami 1 i ar and, w,1 1., abide by the rules and
regulations for permits' a�.,pi�tli.; n Tows" af South Windsor's Street
Cut Permit Manual .
,
* * PERMIT TO E KEPT ON JOB.`:SSTE�AT ALL TIMES.
Issued by J, �F(Z.QA Tit,ie
/z z �'C
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 $25.00
Name of Firm C u 5 6 *+�. �s�%n Phone No. .
Address of Firm
Location of proposed work jr-U S:
Describe fully nature of permit requested d
Starting date iA G 1�C Approx.time for completion S m P7
Call Before You Dig No. Traffic Services Control No.
C 0 1pc, COY c
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North Prop.size of cut
No.outs
�Amt of Deposit$ by
OCash()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: Date: ,eA Ls
Title: Q'� D.L#• <0 ! 21,17 1 93Q
PERMIT SHALL BE KEPT ON]OBSITE AT ALL TIMES .
Standard Forms\Permits\Street Excavation Permitdoc