HomeMy WebLinkAboutStreet Excavation Permit 224 Carriage Dr _ APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required 1_00� PUBLIC WORKS DEPARTMENT —
Amt. on File , 000 TOWN HALL Permit 2160
• Date of Expiration ---' 1540 SULLIVAN AVENUE Date
ins. on File Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date '7~�~g(, FEE $25.00
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Name of Firm Lj e A VV s
Address of Firm— C ro vr;? Phone No. y a 0 C'b
Location of proposed work 21JL _�RA 46 Lr �Q
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Describe fully nature of permit requested /N S '`C-�. �� �� �,f.1n•t �' b
Starting date U 3 f�` �' Approx. time for completion
Call before you dig.No. Traffic Services Control No.
Show sketch of proposed work or furnish To be filed out by Town of South VWKIFor
two copies of separate drawing 16 X a-",
Pavement Cut
O Indicate North
Prop, size of out
our No. cuts
Amt. of Deposit $�� by
- O Cash ( } Check #
Cut size after Perm Patch
Pt1(_ No. Cuts
Final Billing $
I r"u C_ ® Amt. Due Payee $ —
Amt. Due Town $
Applicant is responsible for contacting
the Police Dept. and C.B.Y.D. by date
I agree to funish to the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for any expenses incurred b he Town for maintenance or repair work in connection with this permit and that I am
familiar with and will bi the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: Title: sy. c.v
D.L.L.# a Date: J
PERMrr BE ON AT ALL TIMES
APPROVED: ' DATE:-
T NGINEER
• FOR INSPECTOR: Date work started Date Completed
Signed Date
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