HomeMy WebLinkAboutStreet Cut Permit 55 Chapel Road 1000179 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER STREET CUT PERMIT
DATE: 08/31/10 _
GIS ID: 18000055 �' � ��� � '�/� � FEE: 25.00
MUNIS APPLICATION# 201001145 j IRATION DATE: 08/31/11
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APPLICAN " LOCATION
NAME: H W LEVACK CO. 1'�— _ ARERED 55,CHAR-EL EL ROAD
ADDRESS: 452 MA STREET
IN
IZABETH L/U&
SOUTH WINDSOR,PTO L APL ROAD
y �*JWI INDSOR,CT 06074
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PHONE ee
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WORK DESCRIPTION: NEWy
APPLICANT AGREES TO FURNISH THE TQVUF` OJTH= 5 � OND REQUIRED AND TO REIMBURSE
THE TOWN OF SOUTH WINDSOR FOR AI� P N�1 tJ � �VIJ �AINTENANCE OR REPAIR WORK IN
CONNECTION WITH THIS PERMIT AND THE�PAJII,SAM IAR = AW L ABIDE BY THE RULES AND REGULATIONS
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FOR PERMITS AS OUTLINED IN THE TOWN OF -LrT� I D �3'I " IT MANUAL.
ISSUED BY DATE ECTED INSPECTED BY
8/31/201010:51AM *** PERMIT TO BE KEPT ON JOB SITE AT ALL TIMES***
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TOWN OF SOUTH WINDSOR INSPECTION REPORT
PERMIT NO.: J 0601 7 9 CONTRACTOR: 1/.4 G
LOCATION: {'1 0��SZ
TYPE OF WORK: 0-
DATE INSP NEEDED: DATE INSP:
INSPECTED BY: BD
WORK IN
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PROGRESS: L Gr�C
SEPTIC TANK PUMPED, SMASHED, FILLED WITNESSED ❑ YES ❑ NO
AS-BUILT:
INPUT: DATE: I _)A_ �
S/FORMS/TOWN OF SOUTH WINDSOR INSPECTION
APPLICATION FOR STREET EXCAVATION PERMIT �ba 9
Appl.No. TOWN OF SOUTH WINDSOR Permit No.
PUBLIC WORKS DEPARTMENT
1540 SULLIVAN AVENUE Date:
SOUTH WINDSOR,CT 06074
FEE $25.00
ff Name of Firm ��— —✓ `'� Z ,C--=' � Phone No Z,, b 9C1
Address of Firm Zip Codea4.6
Location of;proposed work
Describe fully nature of permit requested
Starting date�Dig
/ Approx.time for completion <�
Call Before Y . �� ai Existing Water Supply: Public ater ❑Well
Existing Sewage Service:` [I Public Sewer ❑ Septic
PLEASE NOTE: THE DEPOSIT FOR THE PERMANENT PAVEMENT PATCH AND CURB REPLACEMENT IS A
PRELIMINARY ESTIMATE. "THE APPLICANT.IS RESPONSIBLE FOR THE FULL FINAL COST OF THE
PERMANENT PATCH AND CURB REPLACEMENT,INCLUDING ANY INCREASES IN PATCH AREA,CURB
LENGTH,TRAFFIC CONTROL AND THE TOWN'S CONTRACT COSTS. THE PERMANENT PATCH IS TYPICALLY
COMPLETED WITHIN A'YEAR OF THE TEMPORARY PATCH BUT IT COULD BE LATER THAN A YEAR.
Show'sketch of proposed work or furnish This section to be filled out by
two copies of separate drawing Indicate North Town of South Windsor
No.cuts
Est.Patch.Size(s) sf
Est.Pvt.Thickness in.
Est.Patch Unit Price
Est.Patch Cost$
Est.Curb Replacement ft
Est.Curb Unit Price$ /ft:
Est.Curb Cost$
Est.Traffic Unit Cost$ /hr
Est.Traffic Control$
Amt.of Deposit$
Total Due$
Cash O Check#
Applicant is responsible for contacting Paid By
the Police Dept.and C.B.Y.D.
I AGREE TO FURNISHTO 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 WI THIS PERMIT AND THAT I AM FA ILIAR WITH AND WILL ABIDE BY THE RULES AND REGULATIONS FOR
PERMITS AS LIN IN THE TOWN Cffl SOUTH W DSOR'S STREET CUT PERMIT MANUAL.
Signed: Date: - �
Title: Driver's License#:ol`7 1 40
PLEASE ALLOW AT LEAST TWO WORK G DAYS AFTER APPLICATION FOR ISSUANCE OF PERMIT
WORK MAY NOT BEGIN UNTIL A-PERMIT HAS BEEN ISSUED
PERMIT SHALL BE KEPT ON JOBSITE AT ALL TIMES
Street Excavation Permit U8 REV 10-22-08