HomeMy WebLinkAboutDrain Layers Permit 240 Diane Drive 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: c 0 �P`9-N C /R_ Lot #
Street No. Street Name
Premises owned by: d- Nen, Spy,
Name of Firm: 6'k( p-S YE P77C
Phone: 79 7 S-Z 3 3
Address.of Firm: �� 0 _ odx AJ ramp
TYPE OF WORK:
Lay House Drain Repair House Drain
Lay Main -
Building of acres
Lateral-For Commercial/Industrial
acres
Connection will be made with n t q C
Existing Water Supply: Public Water Well
Proposed Start Date 3 /�04_ Estimated time for completion Z �
ALL WORK TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR STANDARDS ALL OSHA REQUIREMENTS AND CONDITIONS ATTACHED TO THE PERMIT
Permit-is to be issued to -OLt-t
Layer's License No. PC ?2z _ the holder of Drain
Only.holders of P-1, P-7 or W-9 licenses
will be issued.a permit. PERMIT WELL EXPIRE THIRTY(30)`DAYS AFTER
DATE OF ISSUANCE. The undersigned Drain Layer hereby agrees to all the terms
and conditions set forth in the permit and attached thereto. Applicant has received
Town Street Excavation Permit No.
. and/or ConnDOT Permit No.
CBYD No. .o o C d q a . /ZO
Signed: Z�_ Print Name: -7—dYLi
Licensed Drain Layer
Date:
Standard Forms\Permits\APPLICATION FOR DRAIN LAYERS PERMIT.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATER-AL FIELD LOCATION
DATE OF CONSTRUCTION: __ 1 d Co
BUILDING ADDRESS
STREET (panty
D
SUBDIVISION:
NORTH ARROW
T_T_
ell
a_
fer
CONTRACTOR (PRINT) NAME OF CONTRACTOR'S SUPE OR (PRINT)
STREET ADDRESS SIGNATURE
3 104-e DATE
TOWN STATE ZIP INSPECTED BY TOWN
(P U — DATE
TELEPHONE;NUMBER
WHITE TOWN PINK — CONTRACTOR YELLOW CONSULTING ENGINEER / DEVELOPER