HomeMy WebLinkAboutWater Street Cut Permits 113 Beelzebub R APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit
Date of Expiration 140 SULLIVAN AVENUE Date
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date FEE $25.00
Name of Firm
Address of Firm �` I- ef 7'-' Phone No,
Location of proposed work / F,7 t` G
Describe fully net re of Kermit requested �.:�� r ' (h./® s
Starting date Approx. time for completions•/ 5'
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be Med out by Town of South VYind301r
two copies of separate drawing
Pavement Cut
O Indicate North r r
Prop. size of cut
No. cuts 2/Z 79�
Amt. of Deposit $_ by
Cash -•2,19 40
(� Check #-
evemoo; c Cut size after Perm Patch
t %
i/< d-,,: '{/r✓J No. Cuts
Final Billing $
fAmt. Due Payee $ —
Amt. Due Town $
Applicant is responsible for contacting
the Police Dept. and C.S.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 wit nd will abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
i'
Signed:
D.L.L.#- 1,20 % Date:
PERMIT SHALL BE KEPT ON JOBSITE AT ALL TIMES
APPROVED: >ilf +-��jf�•9!
DATE:
TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
'Signed Date
WHITE - PERMITS PINK - ST. SERVICES
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