HomeMy WebLinkAboutStreet Cut Permits 9999 Bancroft Lane (2) 1100070 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER STREET CUT PERMIT
DATE: 06/24/11
GIS ID: 07200080 FEE: 00
MUNIS APPLICATION# 201100659 EXPIRATION DATE: 06/23/12
APPLICANY : LOCATION
NAME: A G BUILDERS ADDRESS: tk BANCROFT LANE
ADDRESS: 85 RIDGECREST CIRCLr , OVER; "
WETHERSFIELD,CTBANROFT LANE
= SOUTH ViINDSOR,CT 06074
PHONE
WORK DESCRIPTION: SIDAN A Y,35,FEET FOR BAI&&T I ANE- GORSKI ORIGINAL
DEVEF CSPERI OR FaREST VIA LASE NO FEE = ,.
APPLICANT AGREES TO FURNISH THE TOWN bF-80UTH WW NNT3S(3R TIDE AMOUNT bF BOND REQUIRED AND TO REIMBURSE
THE TOWN OF SOUTH WINDSOR FOR ANY EXPIjNSES INCURRED BY THE TOWN FOR MAINTENANCE OR REPAIR WORK IN
CONNECTION WITH THIS PERMIT AND THE APPI ICANT-lS FAM LIAR WITH AND WII L ABIDE BY THE RULES AND REGULATIONS
FOR PERMITS AS OUTLINED IN THE TOWN OF SOUTH WINI? R'S-STREET CUI''PERIvIIT MANUAL.
ISSUED BY DATE SPECTED INSPECTED BY
6/24/20113:28PM *** PERMIT TO BE KEPT ON JOB SITE AT ALL TIMES***
TOWN OF SOUTH WINDSOR INSPECTION REPORT
PERMIT NO.: I o6D 7 d CONTRACTOR: �' r (otel
LOCATION: �ra. r L0 r"i
TYPE OF WORK:_ 'fi Qf�c,ik,7
DATE INSP NEEDED: DATE INSP: 7 It
INSPECTED BY:
WORK IN
PROGRESS: � y,
v ��,- PCcA j ,.l 'S goc?o nsz® C.eilL.� 4 4"k
�,{
3 V�l �L 4T r C3 IPJc�v1G 1'T�^ L.+��fp 4%ll l� 7[J!3 /k O
G-ea'r'��! 1.)l'v f �ir►c�S /S�l /�X154-5114 E�� �..��p� �$ �bwt
24 �c�ss b s � � t.� Plated �
SEPTIC TANK PUMPED, SMASHED, FILLED WITNESSED ❑ YES ❑ NO
AS-BUILT:
INPUT: DATE:
W/2007 Town of South Windsor INPSECTION REPORT 07
APPLICATION FOR STREET EXCAVATION PERMIT _ llado 7/5
Appl. No. TOWN OF SOUTH WINDSOR Permit No.
PUBLIC_WORKS DEPARTMENT
.1640 SULLIVAN AVENUE Date:
SOUTH WINDSOR, CT 06074
FEE $25.00
Name of Firm
Phone No. t��' 7 :5
Address of Firm ys - in Code
Location of proposed work
Describe fully nature of permit requested ,.nr -•�
Starting date - Approx.time for completion `
Cali Before You Efig No. Existing Water Supply: ❑Public Water ❑Well
Existing Sewage Service; ❑Public Sewer ❑Septic
PLEASE NOTE: THE DEPOSIT FOR THE PERMANENT PAVEMENT PATCH AND CURB REPLACEMENT IS A
PRELIMINARY ESTIMATE. THE APPLICANT IS RESPONSIBLE FOR THE FULL FINAL COST OF THE
PERMANENT PATCH AND CURB REPLACEMENT,INCLUDING ANY INCREASES IN PATCH AREA,CURB
LENGTH,-TRAFFIC CONTROL AND THE TOWNS CONTRACT COSTS. THE PERMANENT PATCH IS TYPICALLY
COMPLETED WITHIN A YEAR OF THE TEMPORARY PATCH BUT IT COULD BE LATER THAN A YEAR.
Show sketch of proposed work or furnish This section to be filled o by
tworco
opies of separate drawing Indicate.North . Town of South Windsor
ut
�Z� n -
�%�/% No.cuts' J-
- Est.Patch Sizes) = sf .
Est.Pvt.Thickness in.
Est.Patch Unit Price$ /sf
Est:Patch Cost$
Est.Curb Replacement ft
_ Est.Curb Unit Price
Est,Curb Cost-$,
Est.Traffic Unit Cost$ /hr
Est.Traffic Control$
Amt.of Deposit$
Total Due$ 19
( )Cash ( )Check#
Applicant is responsible for contacting Paid B
the Police-De t.and C.S.Y.D. Y
-1 AGREE TO FURNISH TO THE TOWN OAF 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 FAMILIARWITH AND WILL ABIDE BY THE RULES AND REGULATIONS FOR
PERMITS AS OUTLINED IN THE TOWN OF SOUT INDSOR'S STREET CUT PERMIT M4NUAL.
Signed: Date:,
/ _
Title: II 1� �9 7 Gf
Driver's Li nse.#:
PLEASE ALLOW AT LEAST TWO WORKING 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 08 REV 10-22-08 Qj f
(6�0)55 7,3 -- &01
06/27/2011 16:50 8605292182 AJC INSURANCE AGENCY PAGE 02/02
�� DATE(MM/DD(YYYY)
CERTIFICATE OF LIABILITY INSURANCE 6/27/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIPICATE HOLDER.
IMPORTANT: It the certificate holder Is;an ADDITIONAL INSURED,the pollcy(fes)must be endorsed, If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may reclutre an endersemem A slotement on thlR certificate does not"wet rights 10 the
certificate holder In lieu of such endorsement(a).
PRODUCER u c,
NAME,
A.JC INSURANCE AGENCY PHONE ary (860) 721-0922 I (wc,N�}(860)529-2182
1850 Sx1,as Deane Hwy ADDRESS; _
Rocky Full, CT 06067 _ M WWREals) AFFONDINO COMP-RACE NArca
INSURER A!M01`TTPELIER US INSURANCE CO. A
INSURED DARIUSZ KLi]If HOME IMPROVEMENT INSURER B: _
INSURER C:
158 PRESTON ST INSURERD: -
HARTFORD, CT 06114 INSURER E: -
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 19 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-p TYPE OF INSURANCE ADMwvo POLICY NUMBER D MM POLICY BUSH POLICY EFF LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1, 00,000
R COMMERCIALGENERALLIABILITY PREMISES Eaecaurrence S 100 000
CLAIMS-MADE u OCCUR MED EXP(Any oneperson) $ 5•.000
A MP0006001005838 02/28/1102/28/12 PERSONAL aADVINJURY S 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEOL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s 2,000,OOO
POLICY PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea ?'Odnnt}
ANYAUTO BODILY INJURY(Par parzan) s
ALL OWNED SCHEDULED
AUTOS AUTOS SODILY INJURY(Paracckkwd) $
HIRED AUTOS NON-OWNEDPRO ITY
AUTOS Per accident)DAMAGER
3
UMBRELLA UA9 OCCUR
�_jEACH OCCURRENCE_ S
EXCESS LIAB CLAIMS-MADE AGGREGATE S
0ED RETENTIONS; M S
WORKERS COMPENSATION WC STATU- OTH
AND EMPLOYERS'LABILITY Y/N TOgY UMI:TS ■
ANY PROFRIET0A1FARTNERIEXECUTNE E•L,EACH ACCIDENT
OfFlCERNEMeEn EXCLUDED? El
N/A
IIIYnQNOry M NFn E.L.D19EASE-EA EMPLOYE S
M ee deecrlbe under �.
D Su�RIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addltienal Remarke Schedule,if more spews le required)
HOME IMPROVEMENT CONTRACTOR
CERTIFICATE HpLDER CANCELLATION
TOWN OF SOUTH NINDSOR SHOULD ANY F T ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXP)RAT N ATE 7HEPriw. NOTICE WILL BE DELNERED IN
1540 SULLIVAN AVE. ACCORDANcymrrl THE P7,LICY PROVISIONS,
SOUTH WINDSOR, CT 06074
AUTHORIZED R UEESTATI
- 19 8 2 10 ACORD CORPORATION. All rights reserved.
ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD
TILL N CONNECTICUT* Iwn An Oldoastle Company
p Y
www.tilconct.com
301 Hartford Ave.•P.O. Box 310903•Newin ton,�"f 66131-0903
9 CONTROL NUMBER
CONCRETE PLANTS TEL: P ®:•NEW BRITAIN,CT •EAST GRANBY,CT •NORWICH,C�'`"� .. (860)225-7801 ��� ���� N
•PORTLAND,CT •HARTFORD,CT •BROOKLYN,CT TOLL FREE 1-888-TILCONN ..
•OLD SAYBROOK,CT •ENFIELD.CT •,GROTON,CT
DATE TIME ORDER NO. CUST.NO. JOB NO. TRUCK NO. PLANT NO. TICKET NO.
it"I f`7f. .. _ .: . 'y t I', :�� r., ,. ,, t,? l ,,,.ya; .r
' l CUSTOMER NAME/INFORMATION JOB NAME/INFORMATION LOADS TO JOB
1 TIr1Y) f!t'iPfil_ j.�,ict-j!!i: f-,'f!"Pi#.
I �113k�f�;�iCII- T L..I'•# ;C1!J rji l�,i 1.I••#7.-'�;�1( QUANTITY ORDERED
r.of_!_. GTF,`f::jNG RI:1., '1 i::S I:"I:) i jf_i.V C'(4 ..
1 SPECIAL INSTRUCTIONS QUANTITY DELIVERED
L.[::: T, #')�.;fit? .j:`',- i'�" �:,
t'.i-(111.! f. ';,. t")r•) �'.•.(,°Ij£,.°- }.,,. ,-..r,tl. 1.'i._•1-{1':.:'L"i ?. .1 jcy r "i"y
E:_A-jL_RC C'. SUFj ;t:H(3 f.2. ;r_t
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wry ifVL) r a , ,I , i 1 I l f: t I i1 l'Ra l
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.. ;:yf raf ':y
f ... j
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..#• 7t:?i r„y
"WATCH THAT CHILD"
per 15 min.
Dela ed truck time be and 5 min./C.Y.to be billed at a rate of
MIXER ARRIVED MIXER DISCHARGED DELAYED TRUCK TIME I ,
Minimum Haul Rate: I1:r#'•I. i .,at=i ; 1t.;,. c:?t::;
f
I authorize the driver of this truck to add: gallons Hot Water Use Rate:
- � I
of water to this load of concrete for which I assume complete
J responsibility. "Caution:IRRITANT,avoid contact with skin and eyes." Sub-Total
f The undersigned agrees to indemnify and hold harmless the driver of the truck
1 and TILCON CONNECTICUT INC.from any and all damage,losses and/or Sales Tax ;_15, ... _
( y .r s
injury to the premises and/or adjacent property which may be claimed by anyone ^ INSPECTED,APPROVED&RECEIVED BY Total°•$ ,-e
to have arisen out of the delivery of this order. "°_g, t
READ REVERSE SIDE FOR FURTHER CONDITIONS OF PURCHASE. EXTRA COPY