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APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit ' 2220
Date of Expiration 1540 SULLIVAN AVENUE Date z
Ins. on File ( es O No SOUTH WINDSOR, CT Permit Expires—,12=Z7—
Expiration Date FEE $25.00
Name of Firm
Address of Firm C D bCi Phone No. J� p'
Location of proposed work ANJ 14:114 + _
scribe fully nature of permit,requested �ac y®1 `�c1 a r +D�
Starting date Approx. time for completion
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be fled out by Town of South Minds"
two copies of separate drawing
Pavement Cut O Indicate North G � /I
Prop. size of cut
�'} I No. cuts +
,i Amt. of Deposit $_��-�v bye.
O 4!!�J-
Cash (� Check #- -' ' •
Cut size after `Perm Patch
No. Cuts
!n V j Final Billing $
r0
�f� /fj/) �, • ,� Amt. Due Payee $ —.
Applicant is responsible for contacting
r Amt. Due Town
the Police Dept. and C.B.Y.D. by date
I agree tQ'>..f4nish.,t6 the Town of South Windsor the amount of bond required and to reimburse the Town of South Windsor
for, any ex fie" `'i icurrgd'by the Town for maintenance or repair work in connection with this permit and that I am
familiar wit '':and w" `bide th rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
Signed Title: .
D.L.L.t Date /5,•
PEAMr(;�FiALL ON JC T 4su TUNES
APRRQV °'+s DATE:
xS'
GINEER
b } !�
0148:R
u sr b<� at4 w r}o•;stpp�rted —des - 1"� Date Completed
Signed w - to
WHITE PERMIT' PINK ST. SERVICES
YELLOW E NRfNG GOLDENROD - FINANCE