HomeMy WebLinkAboutRepair gas leak Street Cut Permits 35 Fe i APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR 326�t
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $25.00
Name of Firm J' Phone NQQ. 6 -0
Address of FitAr D t d
Location of proposed.work
Describe fully nature of pemWt requested 1 A'
Startir)g date Approx.time for completion
Lail Before You Dig No 2 02 1 FD 2 2 10 Traffic Services Control No.
Show sketch of proposed work or furnish To be filled out by Town of South Windsor
two copies of separate drawing
Pavement Cut
Indicate North Prop.size of cut
No.cuts
' Amt.of Deposit$ by
O Cash O Check#
Cut size after Perm. Patch
No. Cuts
Final Billing$
Amt. Due Payee$
Amt. Due Town$
Applicant is responsible for contacting by date
the Police Dept. and C.B.Y.D.
I AGREE TO FURNISH 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 BY THE RULES AND REGULATIONS FOR PERMITS AS OUTLINED IN THE
TOWN OF SOUTH WINDSOR'S STREET CUT PERMIT MANUAL.
Signed: Date:
Title: ' 'I Ar d1I` D.L.#•
PERMIT SHALL BE KEPT ON 3OBSITE AT ALL TIMES
Standard forms\Permits\Street Excavation Permit.doc