Loading...
HomeMy WebLinkAboutRoad Crossing of N.U. Street Cut Permits APPLICATION FOR STREET EXCAVATION PERMIT Pr TOWN OF SOUTH WINDSOR Amt. Bond Required PUBLIC WORKS DEPARTMENT Amt. on File TOWN HALL Permit 2133 Date of Expiration 1540 SULLIVAN AVENUE Date Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires� Expiration Date FEE 25.00 Name of Firm rA I% '� t Address of Firm C w0 S eo r N 'Phone No. Location of proposed work buj Rb . (:Z.. �n1 i `JS• Describe fully nature of permit requested a -sc: Startin date �� q� 9 Approx. time for completion ' Call before you dig No. S• 9 4'C f. Traffic Services Control No. Show sketch of proposed work or furnish To be tilled out by Town of South Windsor two copies of separate drawing Pavement Cut O Indicate NorthG� r Prop. size of cut No. cuts Amt. of Deposit $_. by O Cash V� Check # f l p ttkta Cut size after Perm Patch �x No. Cuts Final Billing $ - _ Amt. Due Payee $ 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 with and will abide the rules and regulations for permits as outlined in the Town of South Windsor's Street Cut Permit Manual Signed: Title: 7r r S D.L.L.# ©S 17 y9 / f Date: PERMfr SHALL BE KEPr ON JOBSITE AT ALL TIII4ES APPROVED: g) DATE: `•"" "� � 7j4 TOWN ENGINEER FOR INSPECTOR: Date work started 7 S Lj�' 9 S Date Completed �^Zy'"9 Signed Date 7�ZH Y WHITE - PERMIT PINK - ST. SERVICES - YELLOW - ENGINEERING GOLDENROD - FINANCE