HomeMy WebLinkAboutReplace broken water service Street Cut APPLICATION FOR STREET EXCAVATION PERMIT
Amt. Bond Required O
_ N OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT _
Amt. on File TOWN HALL
Date of Expiration__
1 S0 SULLIVAN AVENUE Permit '
Ins. on File Oyes O No UTH WINDSOR CT Date��
Expiration Date E $25.00 Permit Expires
Name of Firm
Address of Firm It
Location of proposed work Phone No. O( a-
Describe fully nature of permit requested
hill
r`_.5�1 ✓/C'C.l
Starting date
Call before you dig No. Approx. time for completion �I
Traffic Services Control No.
Show sketch of proposed work or furnish
two copies of separate drawing TO be idled °� Town of South Wirxfsor
Indicate North Pavement Cut
- ` �Air 1
Prop. size of cut /A G y aw
No. cuts W /
Amt. of Deposit $ by
i
O Cash O Check #
r Cut size after Perm Patch
No. Cuts
rr, Final Billing $
b �
11 ce i.i `+ ' Amt. Due Payee $
Applicant is responsible for contacting "7 Amt. Due Town $
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 by the Town for maintenance or repair work in connection with this permit and that I am
familiar with and will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed:lh/ �A, f �(
Title:
D.L.L.#
Date:_
PERLGT SWLLL ON AT ALL TRAES
APPROVED:
DATE:
TO GINEER
FOR INSPECTOR: Date work started
Signed Date Completed
Date
WHITE - PERMIT
YELLOW - ENGINEERING PINK ST. SERVICES
GOLDENROD - FINANCE