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doo° of o APPLICATION FOR STREET EXCAVATION PERMIT
Appl. No. TOWN OF SOUTH WINDSOR Permit No.
-+ PUBLIC WORKS DEPARTMENT
TOWN HALL
1640 SULLIVAN AVENUE
SOUTH WINDSOR,CT 06074
FEE $25.00
Name of Firm ,6 "�'z Phone No. '26- 0.2—
Address of Firm 1 �f Zip Code
Location of proposed work eVe 97,1
IC
Describe fully nature of permit requested / 1`!S 91,E/J
Starting date `7- /D a Approx.time for completion
Call Before You Dig No. ;2001 '.2<7)D 7�
PLEASE NOTE: THE DEPOSIT FOR THE PERMANENT PAVEMENT PATCH AND CURB REPLACEMENT IS A
PRELIMINARY ESTIMATE. THE APPLICANT IS RESPONSIBLE FOR THE FULL FINAL COST OF THE
PERMANENT PATCH AND CURB REPLACEMENT,INCLUDING ANY INCREASES IN PATCH AREA,CURB
LENGTH,TRAFFIC CONTROL AND THE TOWN'S CONTRACT COSTS. THE PERMANENT PATCH IS TYPICALLY
COMPLETED WITHIN A YEAR OF THE TEMPORARY PATCH BUT IT COULD BE LATER THAN A YEAR.
Show sketch of proposed work or furnish
two copies of separate drawing This section to be filled out by
Indicate North Town of South Windsor
No.cuts
sE Patch Size(s) sf
Est.Pvt.Thickness in.
Est.Patch Unit Price$ /sf
Est.Patch Cost S
Est.Curb Replacement ft
Est.Curb Unit Price$. /ft .
Est.Curb Cost$
Est.Traffic Unit Cost$ . /hr
Est.Traffic Control$
Anrt:of Deposit$
Total Due$
( )Cash ( )Check#
Applicant is responsible for contacting Paid By
the Police Dept.and C.S.Y.D.
1 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 O IN THE TOWN OF SOUTH WINDSOR'S STREET CUT PERMIT MANUAL.
Signed: Date:
Title:/. .,® Driver's License M
PERMIT SHALL BE KEPT ON JOBSITE AT ALL TIMES
Street Excavation Permit 08.doc
TOWN OF SOUTH WINDSOR INSPECTION REPORT
PERMIT NO.: CONTRACTOR: '/ ct n '
LOCATION S a- J 9 S-
TYPE OF WORK:_ 10 51a 11 -] S b Y` Gas -Ina yv
DATE INSP NEEDED: DATE INSP:�[ 2v 0
INSPECTED BY:�;�
WORK IN
PROGRESS:
Dot VA6
AS-BUILT:
INPUT: _ ( VV\ DATE: j, ® q
W/2007 Town of South Windsor INPSEC HON REPORT 07