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TOWN OF SOUTH WINDSOR INSPECTION REPORT
Permit No. 2698 Contractor M.J .D. CONSTRUCTION CO.
.Location 0555 NUTMEG ROAD Address 26 MONROE ST
Type Work MISCELLAN HARTFORD CT 06106
Ph6,ne.,No. (860)953-8025
Date Insp Needed
T i me I nsp Needed
Inspected By
Work in Progress ' 'tl a ,r
Input Date
Pe vit No. 2698
A Town of South Windsor, CT
Date 05/.25/`1999 Street Excavation Permit
Expiration Date 05/24/2000
Descrip: PERM. PATCH FOR M. D.C.
Applicant location
Name . M. J . D. CONSTRUCTION C ;t 5 W`TMEG ROAD
Addr . 26 MONROE STD '
HARTFORD CT 06106 Type. of 4of , MISCELLAN
Phone (860)953-8025
IN
Applicant agrees to , u r ;sh th� '1`Qi � °F c��r �Vsor the amount of bond
required and to reimbuIrsW" a-, o -,�o .uth r d �r fm
wr� r any expenses
incurred by the Town ;f crr m zl n, connection with this
permit and that app 1 i;caraEt and !fit ;,�i de by the rules and
regulations for p e r m i t tae 4tl `w � To�tph�f., uth Windsor ' s Street
Cut Permit Manual . "
* * PERMIT T av`6 r % ,,� " A'tWAtL TIMES.
,
Issued by ., � TA",lop
f�
Date Comp 1 eted ���� �� fihspected By
d
APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
Name of Firm roVls ro . r ti Phone No. o 3 — o -eY—
Address of Firm
Location of proposed work
Describe fully nature of permit requested
Starting date Approx.time for completion
Call Before You Dig No. 9 9 q 10 Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North Prop.size of cut r S
— No.cuts
°1 M:f�• Amt,of Deposit$ by
F'.4 r W {)Cash{)Check#
Cut size after Perm. Patch
No. Cuts
final Billing$
K. . ._. �/Nl�ei..STF/_
f I ' 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: 2�
Title: Arl D.L.#•
PERMIT SHALL BE KEPT ON 30BSITE AT ALL TIMES
Standard Forms\Permits\Street Excavation Permit.doc
THE METROPOLITAN DISTRICT - PAVEMENT CUT DATE:
BILL JOB YES ❑ NO.0- # WO #
ADDRESS' TOWN STATE HIGHWAY YES❑ NO❑ PROD. #
DRAW SKETCH SHOWING LOCATION AND SIZE OF CUTS AND CUT MADE IN:
CROSS SECTION OF PAVEMENT
STREET BIT. CONC.❑ CONCRETE❑ PREMIX❑
SIDEWALK BIT. CONC.❑ CONCRETE❑ FLAG❑
CURB BIT. CONC. ❑ CONCRETE❑ STONE❑
DRIVEWAY BIT. CONC.❑ CONCRETE❑
i GRASS
REASON FOR CUT:
NUMBER OF CUTS:
DATE OF FIRST CUT:
IS JOB COMPLETED: YES❑ NO❑
FOREMAN:
REPLACEMENT PAVEMENT CONTRACT NO.:
_ \Q BIT. CONC.❑ CONCRETE❑ PREMIX❑
DATE COMPLETED:
ACCOUNT NUMBER: -
1 CALCULATIONS
NO.
OF CUT ITEM # ITEM # ITEM # ITEM #
i
ORIGINAL TO PAVING INSPECTOR
COPY TO MDC OPERATIONS
COPY 1 TO CONTRACTOR
PRESS HARD, 3 COPIES
COPY TO TOWN OR CITY: