HomeMy WebLinkAboutDriveway Street Cut Permit 250 Abbe Road APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
AmV,,Bond Required ) ►� PUBLIC WORKS DEPARTMENT
Amt. on File TOWN `HALL Permit ' No ,' '�'"�
Date of Expiration 1540 SULLIVAN AVENUE Date
`Ins. on File O Yes (W"No SOUTH WINDSOR, CT Permit Expires I
Expiration Date FEE $25.00
Name of Firm ►L
Address of Firm �� �� Phone No.
Location of proposed work �+
Describe fully net a of permit requested ! i f+� 'i
1 YCC CE �ti, k C.
Starting date 2 D/VcyApprox. time for completion
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be idled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North r `
Prop. size of cut
No. cuts
i Amt. of Deposit $ by
tZL vf'- t Cash O Check #
Ems---� Cut size after Perm Patch Y
New
No. Cuts
Final Billing $
! !Amt. Due Payee $ —.
Amt. Due Town $ _—
Applicant is responsible for contX
g
the Police Dept. and C.B.Y.D. lil+ffr(�(.t1�tJj//U4 by date
i h,
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_.,exp-pnses incurred by the Town for maintenance or repair work in connection with this permit and that I am
fa7flar with ~arid will abide by the ruts and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Si ed:L'4z Title: d4`
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D.L.L.# Y ��LO nDate: f
PE AArr BE KEPT JOBStTE AT TIMES
APPROVED: DATE:
T WN-E ER
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FOR INSPECTOR: Date work started Date Completed
Signed Date
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