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TOWN OF SOUTH WINDSOR INSPECTION REPORT
Permit No. 3568 Cont„r,..act'br""ANDR2:'CHARBONNEAU & SONS
Location 0025 RUSTIC LANE
Address 125 :F'DWlN ROAD
Type Work MISCELLANwOUTH WINDSOR `^CT 06074
Phone No ( ; }
Date Insp NeededDate-;::: sp
Time Insp Needed �� CA
Inspected By
Work in Progress — { — C .LTY ar /
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Date
Permit No. 3568 Town of South Windsor, CT
Date 08/11/2003 Street Excavation Permit
Expiration Date 08/10/2004
Descrip: REPAIR APPROX. 60 0P SI D:Et+f41-K' ..
Applicant Locat<ian
Name ANDRE CHARBONNEAF- & SONS RUSTIC T,ANE
Addr. 125 EDWIN ROAD
SOUTH WINDSOR, or�s 'II$CETrLAN
Phone
Applicant agrees to "furnish the T w q 5d�tth Windsor toe amount of bond
required and to rei bur'se the'Ta*„tz� f tlu h Wia1.e S0r fsr any expenses
incurred by the Town p:r m in: enance esr repaYr 0a 'Yk sn r?rin 'cti n with this
permit and that appllc� t :is apt il; :ar jai h az�d., abide' by the rules and
regulations for permits a 'i The Toz11 tlf South Windsor's Street
Cut Permit Manual.
* * PERMIT To BE ktn 0Y3 30$ SITE AT AZ$ TIME5
Issued by -------ewA --
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Date Completed _— --- Inspected By -- — —
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APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00 r
Name of Finn "��� � '�ai�' S�VsC ��` J ��
Address of Firm Phone No.
Location of proposed work c dl„e
Describe fully nature of permit requested I I e
t)kuw fucks,
Starting date Approx.time for completion_ F S
Call Before You Dig No. _JTraffic services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut ,
Indicate North Prop,size of cut
No.cats
Amt.of Deposit$ by
f ()Cash()Check#
� I t� Cut size after Penn. 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 JAM 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: 1 )
t Date:
Title:
PERMIT SHALL BE KEPT ON 3OBSITE AT ALL TIMES
Standard Forms\Pennits\Street Excavation Permit cloc