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TOWN OF SOUTH WINDSOR INSPECTION REPORT
Contractor CUSTOM PAVING
Permit No. 3119 , Address JOHN F JURGELAS
Location woe, T DR!Vt'-'� P.O. BOX 178
Type Work DRIVEWAY SOUTH WINDSOR CT 06074
Phone No_. (860)528-2684
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Permit No 3119 Town of South Windsor, CT
Date 05/24/2001 Street Excavation Permit
Expiration Date 05/24/2002
Descrip:
Applicant Location
Name CUSTOM PAVING 0042 ROBERT DRIVE
Addr. JOHN F JURGELAS
SOUTH WINDSOR CT 06074Type of Work,., DRIVEWAY
Phone (860 )528-2684
Applicant agrees to f,Urn sh the T.awn .',of South Windsor the amount of bond
required and to reimburse 1rhe Town -of South 4W.ihdsor for any expenses
incurred by the Town fq'r, m4--t j,,qo or. repai r.,work i n connection with this
permit and that app 1 i cant',,�i s farm"'l"i ar `wl"th and, Wi l'l ' abide by the rules and
regulations for permits tfw as._ tlir� 1,1h the. Towns of South Windsor's Street
Cut Permit Manual .
* * PERMIT TO BE KEPT ON JO8 .SITE AT ALL TIMES.
Issued by _ -' -� _ Title
Date Completed J� 81 U� _ Inspected By
3«4
•- APPLICATION FOR STREET EXCAVATION PERMIT
TOWN Of SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
Name of Firm Cu 7-® rr, IPa -, Phone No. "r ® J-a �? q 4
Address of Firm �—
Location of proposed work_
Describe fully nature of permit requested S,-,-, P . R eC"Ats P
Starting date_ I l-9 X) ► Approx.time for completion
Call Before You Dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North Prop.size of cut
No.cuts
" ''Amt,of Deposit$ by
U4677 -
()Cash(�)CheckCut 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:
Title: Q Y'e D.L.#: 0 3 L 2 2
PERMIT SHALL BE KEPT ON]OBSITE AT ALL TIMES
Standard Forms\Permits\Street Excavation Permit.doc