HomeMy WebLinkAboutReplace 3 existing fire hydrants Street APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond Required PUBLIC WORKS DEPARTMENT
Amt. on File TOWN HALL Permit N.0 2107
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 readtrhar� Wallet
Address of Firm i _r - f Phone o �
Location of proposed work a/ � C�( � Lt1t'r ��.
Describe fully nature of permit requested !17 r
Starting date 6,4qq Approx. time for completion
Call before you dig No. V. SP Traffic Services Control No.
Show sketch of proposed work or furnish To be IINW out by Town of South VAndsor
two copies of separate drawing
Pavement Cut
O Indicate North
h ! Prop. size of cut
No, cuts
�t} Amt. of Deposit $_. by
Y1 O Cash O Check #
Cut size after Perm Patch
No. Cuts
Final Billing $
i
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 w�iitthh and will ,abii�de by the rules and regulations four+ permits as outlined in the Town of lSouth Windsor's Street Cut Permit Manual.
Signed: Irll l7�C (4.�,/t Title:' fL/ L.���f" /[J l �J f//;4—,� l of ,
D.L.L.# Date:
PEFUff SHALL BE KEPT ON JOBSrrE AT ALL TOMES
Q
APPROVED: 10E 134 DATE: S' J
27A�?TOWN ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE - PERMIT PINK - ST. SERVICES
YELLOW - ENGINEERING GOLDENROD - FINANCE