HomeMy WebLinkAboutDrain Layers Permit 1475 Ellington Road (2) 76,3-4
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:
i
Name of Firm: I
Phone:
Address of Firm:
TYPE OF WORK:
Lay House Drain_; Repair House Drain
Lay Main__ Lay Lateral for Commercial/Industrial
Building of
acres
Connection will be made with
r
Existing Water Supply:Pp Y Public Water L-" Well
Proposed Start Date_/l� Estimated time for completion
ALL WORK TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR STANDARDS
ALL OSHA REQUIREMENTS AND CONDITIONS ATTACHED TO THE PERMI
T
Permit is to be issued to qv,
'
Layer's the License No. � �� holder of Drain
Only will be issued a permit. PERMIT WILL EXPIRE THIRTY holders of P-1, P-7 or W-9 licenses
DATE OF ISSUANCE. The undersigned Drain Layer hereby 3 agrees to a l the to
and conditions set forth in the permit and attached thereto. Applicant has received
terms
Town Street Excavation Permit No. ceived
and/or ConnDOT Permit No.
CBYD No. .
Signed:
r �-
g • d
Licensed Drain ayer Print Name�� d
Date:
` standard Forms\Permits\APPLICATION FOR DRAIN LAYERS PERMIT.doc