HomeMy WebLinkAboutGas Main Street Cut Permits 336 Chapel R APPLICATION FOR STREET EXCAVATION PERMIT
Amt. on File
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Date TOWN HALL Permit
.. 1540
Date of Expiration SULLIVAN AVENUE Date
Ins..on File OYes No SOUTH WINDSOR CT
Expiration Date FEE 25.00 Permit Expires
Name of Firm ��,< (AZ
Address of Firm Z Srwc-r Nita. R 29a��36
�+ Phone No.
Location of .proposed work ��40 �.y}I#�"'><, A�O.
Describe fully nature of permit requested -r71t4. 004i zgmwc
Starting date b // „f' --
9c�� em Approx. time for completion �y
Call before you dig No. ♦5 7 O0 ' s 7 Traffic Services Control No.
Show sketch of proposed work or.»furnish F[P
aut by Town of Soulh YYlndsor
two copies of separate drawing r
OutIndicate North f cut
�-`_ Ag
No. cuts
�L� ( ,-toss Amt. of Deposit $ by
1 �
. ,,. C O Cash O Check #
Cut size after Perm Patch
No. Cuts
Final Billing $
Amt. Due Payee $ —
Amt. Due Town $ _
Applicant is responsible for contacting
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: L Title: Y
a
D.L.L.#
Date:
PERMIT SHALL BE ON JOBSI E AT ALL TIES
APPROVED: c/ DATE: �f/ (O - /
TOWN ENGINEER
FOR INSPECTOR: Date work started ,Date Completed
Signed Date
_-WHITE PERMIT
YELLOW - ENGINEERING PINK - ST. SERVICES
GOLDENROD - FINANCE