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HomeMy WebLinkAboutCB, man hole and 15 pipe Street Cut Perm .APPLICATION FOR STREET EXCAVATION PERMIT TOWN OF SOUTH WINDSOR Amt. Bond R ire ,:'oaa PUBLIC WORKS DEPARTMENT - Amt. on Fily ©© 0 TOWN HALL Permit . No ► Date of Expiration 1540 SULLIVAN AVENUE Date Ins. on File Yes O No SOUTH WINDSOR, CT Permit Expires Expiration Date FEE $25.00 Name of Firm J 4`5 GutTl Address of Firm t^� Phone No. 43Z-9"S Se' Location of proposed work Describe fully nature of permit requested Jkrwk) tNEP(r A IT _M I05t7• k CAATt::A &X.!Q . , J - Starting date 14 - C)S Approx. time for completion Z 3 Call before you dig No. 9 ()GZ Traffic Services Control No.:x Show sketch of proposed work or furnish To be irked out by Town of South Whrdsor two copies of separate drawing Pavement Cut Indicate North {� Prop. size of cut No. cuts Amt. of Deposit $�,7� by 41� { i O Cash (itiT Check # �^v"' x�o i Cut size after Perm Patch por No. Cuts x� Final Billing $ ��tit? IL 1G VJ mT Am#. Due- Payee $ G 011 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 it and will abide by the r les anp regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual. Signed: `Title: � 1064 t D.L.L. lo 1 i(C,I 16sl Date: E PEEWIT SHALL BE IItEff ON JOBSRE AT ALL TIMES �" 01 APPROVED- t� �i^ ,� �� �l�I DATE: -" 3'" 2 TOWN ENGINEER (ram FOR INSPECTOR: Date work started Date Completed .N Signed Date WHITE - PERMIT PINK - ST. SERVICES YELLOW ENGINEERING GOLDENROD —FINANCE