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HomeMy WebLinkAboutDrain Layers Permit 498 Buckland Road (2) APPLICATION FOR DRAIN LAYER PERMIT TOWN OF SOUTH WINDSOR PUBLIC WORKS DEPARTMENT TOWN HALL 1540 SULLIVAN AVENUE SOUTH WINDSOR, CT FEE $60.00 . Location of proposed work:_ Lot# Street No. Street Name Premises owned by: Name of Firm: cJ__ Address.of Firm: �S TYPE OF WORK: Lay House Drain Lay Main Repair House Drain - � ; Lay Lateral for CommerCial/Industrial Building of acres Connection will be made with VC-, Existing Water Supply: Public Water_ Well________ Proposed Start Date ©7 Estimated time for completion ( t� ALL WORK TO BE IN ACCORDANCE ALL OSHA WITH-TOWN.OF SOUTH WINDSOR STANDARDS, REQUIREMENTS ANDNpITIONS ATTACHED TO THE PERMIT Permit-is to be issued to Layer's License No. 6- the holder of Drain will be issued.a permit. PERMIT WILL EXPIRE THIRTY Only �Olders Of _i' D or W-9 licenses DATE OF ISSUANCE. The undersigned grain Layer. hereby agrees to AFTER -and conditions set forth in the perm4.1t�nattached thereto. theterms* Town Street Excavation Permit No. Applicant has received and/or ConnDOT Permit No. CBYD No. Signed: Print Name: ame: - se Drain Layer Date: Standard FomskPerMIMAPPLICATION FOR DRAIN LAYERS PERMMdoc TOWN OF SOUTH WINDSOR SANITARY' SEWER LATERAL FIELD LOCATION DATE: OF CONSTRUCTION: BUILDING ADDRESS Ad STREET ,r3vc%L�,hoJ �d1, SUBDIVISION: /I NORTH ARROW i T-;qqq 1 4-4— /1 s /0 1peT41 ,77 Cc,,, S� fa CONTRACTOR (PRINT) NAME OF CONTRACTOR'S SUPERVISOR (PRINT) STREET ADDRESS SIGNATURE o l6w r ; 04 a 7 r g��IaG DATE TOWN STATE ZIP INSPECTED BY TOWN 06 a '2 - S'2 s' DATE TELEPHONE .NUMBER WHITE - TOWN PINK CONTRACTOR YELLOW CONSULTING ENGINEER / DEVELOPER