HomeMy WebLinkAboutSewer Installation Street Cut Permits 28 x
APPLICATION FOR-, STREET EXCAVATION PERMIT
- TOWN OF SOUTH WINDSOR
Amt. Bona Required _mS--Ow PUBLIC WORKS DEPARTMENT
. Amt. on File TOWN HALL PermN'
it222
Date of Expiration
d 1540 SULLIVAN AVENUE Date
Ins. on Fug (.rfOYes ( No SOUTH WINDSOR, CT Per
Expires
Expiration Date--' �` FEE $25.00
Name of Firm
Address of Firm —Phone No. 649' j
Location of proposed work 57 CAJ tAl 0 4L C 'T c+Q7 %(
Describe fully nature of permit requested {.IN pi*
�+�
—00
Starting date Approx. time for completion
Call before you dig No. Yeampa Traffic Services Control No.
Show sketch of proposed work or furnish To o be iced out by Town of South VAndsor
two copies of separate drawing
Pavement Cut
O Indicate North
Prop, size of cut J�2i if3�J.A
No. cuts
Amt. of Deposit $ pIr �• ;rCby T
O Cash O Check #
5
�\jontf
Cut size after Perm Patch
No. Cuts
Final Billing $
Anit:" Due Payee $
Amt. Due Town $Applicant is responsible for contactingthe Police Dept. and C.B.Y.D.I agree to funish to the Town of South Windsouired and to reimburse the Town of South Windsor
for any expense ;urred y the-Tow or maintenance or repair work in connection with this permit and that I am
familiar with e`"b and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual.
SignedTitle: 0190
- .
D.L.L.# Date:_ ,//�jt f* 1r� CA 40x#//
PERMTr SFW1 BE ITT ON JOBSITE AT ALL TIMES /.re
APPROVED: +
y. DATE: so
� N�ENGIN�EER
.�F
FOR INSPECTOR: Date work started Date Completed
Signed— Date
WHITE - PERMIT PINK - ST. SERVICES .
YELLOW - ENGINEERING ""'""" GOLDENROD - FINANCE