HomeMy WebLinkAboutConnect sanitary sewer from street to bu ' a
g - APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required s PUBLIC WORKS DEPARTMENT
-Arnt� on File 1` TOWN HALL Permit 2221
-.Date of Expiration 1540 SULLIVAN AVENUE Date-_ «.
Ins. on File vo�es O No SOUTH WINDSOR Permit Expires
Expiration Date , f`e^.� FEE $25.00
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Name of Firm ! '► L lA C f 1 r✓ �`
Address of Firm -73 /11 _r,�t� �"}' f� 7- .. -�..Z"�
� .�-r�v-�1 Phone No. F V�,
Location of proposed work C 0 h, oyi a ,-Gt I-J A _
Describe ^fully nature of permit requested L�w w• C Aly r �A�' �•^� o✓V-N �t u
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Starting date Approx. 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
Prop. size of cut
f No. cuts
L
Amt. of Deposit $_ by
O Cash O Check #—
C
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 an wi abide by the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed: iv i` Title: - +
D.L.L.# Date:
PERAAfT SHALL ON AT ALL TIMES
APPROVED: DATE: 1/Ca( I —
T ENGINEER
W_FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE
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