HomeMy WebLinkAboutWater Street Cut Permits Deming Street, APPLICATION FOR STREET ,tXCAVATION PERMIT
TOWN OF SQ_UTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit • 2 2170
Date of Expiration 1540 SULLIVAN AVENUE Dater FBI a/;
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires
Expiration Date FEE $2"0"_
Name of Firm 11 0 -' e-t ie 1 t
Address of Firm C' h_1 ` L� �'_-cx: UN ~ 't- u S* 1A.2``+•� f` t'Phone No. 72`'l 12'�
Location of proposed work
Describe fully nature of permit requested �-'�3" t- �'` `� � `�c..t. ✓t��k'\
Starting � 1 � c:� �"
date i Approx. time for completion
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Nlindeor
two copies of separate drawing
Pavement Cut
Indicate North �
O P
Pro . size of cut
i 7;:. r�,f {t I"I- / �"7' No. cuts
Amt. of Deposit $_ Z, �0� by
rZ ( ) Cash (Check # r: -�
Cut size after Perm Patch
No. Cuts
Final Billing $
Amt. Due Payee $ —
K ►�1C- 1415.- (tiE' Amt. Due Town $ -_
Applicant is responsible for contacting
Zl r_
the Police Dept. and C.B.Y.D. �, G��jei2cQ�/� 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 incurr d by the Town for maintenance or repair work in connection with this permit and that 1 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:,/, ) } i V l" " ` Title: C4►la< tie✓ e,4 otr:?S
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