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Name STATE LINE SEVER & CONST CO, OT 2 DART HIL-L ROAD
Addr . 238 SHAKER ROAD
ENFIELD CT 06082 Type of -Worm 'WATER
Rhone (860 . 49-6176
Applicant agrees to furnish the iowht of Soiich, Windsor the amount or bond
required and to re,imbur. Se tire", Town of ,�pu:th vVitlds.or forar;y e,;penses
incurred by the Town for` rrt�xrtte,la'r iair' 'wi `(. 311 connection with this
permit and that applicant i 8 `earn."+ '1 #ar with 'and. W111 1 abide by the r u 1 es and
regulations for permits as U+jt,,Iined ir, 1he. Town Jr= South Wi dsor s St,,, eet
;ut Permit Mai,ua t .
1 PERMIT T(✓ BE KEPT ON �,�� S°I T L-' A? ALL T%P'tE
Issued uy
itfe
Date Comp 1 ete)b Inspected By
APPLICATION FOR STREET EXCAVATION PERMIT
APP TOWN OF SOUTH WINDSOR
PUBLIC TOWN DEPARTMENT
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
Name of Firm Phone No. ftc"7`Y(-to 17
Address of Firm
Location of proposed work On
Describe fully nature of permit requested
Starting date — — Approx.time for completion S
Call before you dig no. C!7�66 06 47-CT9 Traffic Services Control No.
Show sketch of proposed work or,furnish To be filled out by Town of So. Windsor
two copies of separate drawing Pavement Cut
Indicate North
Prop.size of cut 4�Y(O J = Z446
No.cuts_
Amt.of Deposit S Ub/6 by
O&ash Check# 7,4'
Cut size after Perm. Patch
No.Cuts
Final Billing,S
Amt.Due Payee S
Amt.Due Town S
Applicant is responsible for contacting
the Police Dept.and C.B.Y.D. by date
I AGREE TO FURNISH 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 ASIDE BY THE RULES AND REGULATIONS FOR PERMITS AS OUTLINED IN THE
TOWN OF SOUTH WINDSOR'S STREET CUT PERMIT MANUAL.
Signed: Date: 'c�)q
Title: [��)��_� D.L.!!
PERMIT SHALL BE KEPT ON JOSSITE AT ALL TIMES