HomeMy WebLinkAbout12 D.I.P. Street Cut Permits Foster Stre APPLICATION FOR STREET EXCAVATION PERMIT
TOWN OF SOUTH WINDSOR
Amt. Bond 'Required PUBLIC WORKS DEPARTMENT
i
Amt. on File OWN HALL Permit a 0
Date of Expiration 1540 SULLIVAN AVENUE Date 9-1
Ins. on File O Yes O No SOUTH WINDSOR, CT Permit Expires .I
Expiration Date FEE $25.00
Name of Firm T• Y Yr+ V\
Address of Firm �'}'� ASS �h �✓ Phone No.
Location of proposed work }" i
Describe fully nature of permit requested d• See- LAckyN S.
Starting date Approx. time for completion �%+ e
Call before you dig No. Traffic Services Control No.
Show sketch of proposed work or furnish To be 19W out by Town of South Windsor
two copies of separate drawing
Pavement Cut N /A-
Ste.O Indicate North Prop. size of cut gv\S No. cut§
Amt. of Deposit $_ by
�jNN.W,��"'?�.GO, /`•' �ES�A/5/IC3L� FbF� ( ) Cash
lZ J 6 0-M � �L AL.E W /f�1/IAA u�/U ( ) Check #
j9AJ 7L hrJ Cut size after Perm Patch
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No. Cuts
C-v?,( c� �—' T* of�ovw I t �j F
mat 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 inthe Town of South Windsor's Street Cut. Permit Manual.
Signed: Title: W ) Kirin f`kCAV .c.tC✓ Cj VPSO
D.L.L.#_1 4 Z R S 156 L.I Date:
PE*AIT BE ON J0QP7 AT ALL TWS Q
APPROVED: DATE:
T ENGINEER
FOR INSPECTOR: Date work started Date Completed
Signed Date
WHITE PERMIT PINK - ST. SERVICES
YELLOW ENGINEERING GOLDENROD - FINANCE