HomeMy WebLinkAboutGas Main Street Cut Permits 81 Commerce APPLICATION FOR STREET .EXCAVATION PERMIT
TOWN OF .SOUTH: WINDSOR �
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt: on-Fire TOV,11N -HALL Permit ' 'VOL.
Date of Expiration 1 540 SULLIVAN AVENUE bate
ins, on File O Yes t } No SOUTH WINDSOR9 CT Permit Expires .
Expiration. Date FEE $25:00
Name of Firm T0.d�I�.CLQ. �?a5 Sa_ti y �La.. :_
Address of Firm l\2 Ord Phone No. 7-012 Z_ii S�
Location of proposed work 81 Cory-)m / e_ VA/6-V 4
Describe fully nature of permit requested Q r V iit
Starting date 7-Z-7 1 5" Approx. time for completion 1 ye a e-
Cali before you dig No. Traffic Services Control No. I
Show sketch of proposed work or furnish To be tilled a A by Town of South UVicxlsor
two copies of separate drawing
Pavement Cut
Indicate North
r Prop. size of cut
No. cuts
Amt. of Deposit $_ by
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 Windsif 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: F/gn 0-.1)) Title: 14Iect n
D.LL.# Date:
PENtff SMALL BE KEFr ON JOBSITIE AT ALL TII M
APPROVED: DATE: '
Pi✓ TOWN ENGINEER
FOR INSPECTOR: Date Work started Date Completed
Signed _ . __ Date
WHITE = PERMIT PINK - ST. SERVICES
YELLOW ENGINEERING GOLDENROD FPNANE
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