HomeMy WebLinkAboutWater Street Cut Permits 994 Pleasant Va (2) �¢4, APPLICATION FOR STREET` EXCAVATION PERMIT
.4 TOWN OF SOUTH WINDSOR
Amt. Bond Required S7200 PUBLIC WORKS DEPARTMENT
Amt. on Fite 5' oa TOWN HALL Permit
Date of Expiration lo- S 1540 SULLIVAN AVENUE Date
Ins. on File cwYes No SOUTH WINDSOR, CT Permit Expires _
Expiration Dated FEE $25.00
Name of Firm •m l C�n��• s �A c.
Address of Firm 5 E I I a-r ^ j•' Phone No. ���B-L►OS�{
Location of proposed work qq 0 y 4 1d9kAft. P\QG.a..+ UG��Z
Describe fully nature of permit requested Y�UJq�r� lM ('� �nS'�Gl� Y1f�J U,\ eIf., WG}tl
Seru:co 4ts 00k ft& .1,_Ua
Starting date (fl -(1 "C s Approx. time for completion
Call before you dig No. 0153 9 O Z22 4 Traffic Services Control No.
Show sketch of proposed work or furnish To be filed out by Town of South Windsor
two copies of separate drawing
Pavement Cut
O Indicate North LC� /�
Prop. size of cut
No. cuts
Amt. of Deposit $_ ' �' by
O Cash X
Check #?jeuSQA4 J(AN)
r Cut size after Perm Patch
No. Cuts
Final Billing $ over l o f
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St t v,(.0 Amt. Due. Payee $ -�
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Amt. Due Town $ ._
Applicant is responsible for contacting Y7he
Police Dept. and C.B.Y.D. by date r'
I agree to funish 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 will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual. "
Signed: ILI, Title: r<c a J ti 4 to r M
D.L.L.# Z'Z 3 2 "1'9 20"1 Date:PEFUIT SHALL BE ON AT ALL Td1AES
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APPROVED: DATE: /O_ l— / r
T ENGINEER
)FOR INSPECTOR: Date work started Date Completed
Signed- __-_ _ __.-__ ___ _-____Date_
WHITE - PERMIT PINK - ST. SERVICES —
YELLOW - ENGINEERING GOLDENROD - FINANCE
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1540 SULLIVAN AVENUE • SOUTH WINDSOR, CT 06074
r�OSOx CO TELEPHONE (860) 644-2511
June 20, 2006
Certified Mail
JMJ Construction.
658 Ellington Road
South Windsor, CT 06074
Re: Street Excavation Permanent Patch Fees
Permit#2156, 994 Pleasant Valley Road
To Whom It May Concern:
When the Town of South Windsor issued the above referenced permit to you, it collected a total of$118.80
for the permanent patch deposit based on available estimates at that time. The roadway had been overlaid
however, so the permanent patch fee deposit of$118.80 is being refunded to you.
If you have any questions, please contact me at (860) 644-2511, extension 244.
Sincerely,
Jeffrey Doolittle, P.E.
Town Engineer
cc: Melanie D. Crucitti, Director of Finance
SAENGINEER\Joy\2006 Cut Patch Laras\Cut Patch Joy JNU Refdoc
♦ M
s
REFUND OF DEPOSIT REQUEST FORM
STREET EXCAVATION PERMIT
Request Date: --(,ZZ DG
Issue Refund in the amount of $
From Account# 001-0300-0205-059
To:
Permitee: Cbn-5+ ud-lC)r)
Address
�. G3- rn l r, CT 0(60- y
Permit C IfLp 994 Pl + Val k?a
Number Location
Number Location
Number Location
Number Location
Number Location
Submitted By:
Narn6 Date
Check Issued:
Number Date
Processed by Finance
Name Date
SAENGINEERIFORMS\Office FortnslPatch Refund Form.doc